HomeMy WebLinkAboutMiscellaneous - 3 MASSACHUSETTS AVENUE 4/30/2018 (5)3
Re Commonwealth of Massachusetts WfiLcc Usk Only
Perrit No. -
Department of Public Safety
Occupancy & Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1ZOO 3/90 (leave blank)
I e"J
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WOR
All work to I>e performed In accordance with the Ma"achusetts Electrical Code. S27 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INYORHATION) Date
City or Town of- AtrrA J a Aler To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Stree
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit: -_ Yes n No 9 (Check.Appropriate Box)
Purpose of Building _Ut:Llity. Authorization. NO..'
Existing Service Amps Volts OverheadEl Undgrd F� Noz. of Meters
New Service Volts Overh ead _0 NO. of Meters
________,Amps Undgrd El
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work,
No. of Lighting Outlets
No. of Hot Tubs
Total
No. of Transformers KVA
No. of Lighting Fixtures
Above E] In- n
Swimming Pool grnd. gr-nd
Generators KVA
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting
Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection and
Initiating Devices
No. of Sounding Devices
No. of Self Contained
Detection/Sounding Devices
Municipal
Local 11 ConnectionD Other
No. of Ranges
Total
No. of Air Cond., tons
No. of Disposals
Ileat Total Total
No. of Pumps Tons KW
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
Heating Devices KW
No. of Water Heaters KW
No, of No. of
Signs Ballasts
Low Voltage
Wiring
No. Hydro Massage Tubs
No. of Motors TotAl HP
OTHER: Z_
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantiil
equivalent. YES[] NOD -I have submitted valid proof of same to this office. YESE] NO E]
If you have checked YES,,please indicate the type of coverage by checking the appropriate box.
INSURANCE n BOND F] OTHER [J (Please Specify)
—7—Expiration Date)
Estimated Value of Electrical Work
Work to Start
Inspection Date Requested: Rough
Signed under the penalties of perjury:
FIRM NAVE
Licensee I<C,( (, I
;1C,le'T ( 6, C i gna ture
Final
.LIC. NO. 13 7'�'Z//
Bus. Tel. No. Y�/
Address Alt. Tel. No. -710
014NERIS INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub-
stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit
apnlicat7 wa ve
i s this requirement. Owner Agent (Please check one)
e
MIT FEE S
Telephone No. PEJU
(Signature of er or Agent)
T
42 415
oolo
S CHU
Date ...... L f ........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
&C
This certifies that ............. .. ... C4�.A . ......
has permission to perform .
..............................
wiring in the building; 0
.i�llb .111'.( ...... 191
at ........
-3 ...... .. . . ... .................... . North Andover, Mass.
Fee.7 Lic. No./ ... 7..q A
................. i�E**C* T** R*'I*C* A**L* *I* N—S' P**E*C'*T* 0—R— * ...............
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
The Commonwealth of Massachusetts Wiicc us� Nly
P�r.it No.
De;>ortment of Public Safety
Occupancy & Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 Oea�c blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All veork to t>e performed in accordance wzith�the Ma"achuserts Electrical Code. 527 CMR 12:DO
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
City or Town of &112L�A 4d&er To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Stree
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit: Yes[] NO (Check.Appropriate Box)
Purpose of Building Utility Authorization NO.
Existing Service Amps Volts Overhead EJ Undg�d [] No. of Meter.,
New Serv-ice Amps Volts OverheadEl Undgrd F1 No. of Meters
Numher of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No. of Lighting Outlets
No. of Hot Tubs
Total
No. of Transformers KVA
No. of Lighting Fixtures
Above In -
Swimming Pool grnd. 0 grnd . Q
Generators KVA
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting
Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection and
Initiating Devices
No. of Sounding Devices
No. of Self Contained
Detection/Sounding Devices
E] Municipal
Local ConnectionEPther
No. of Ranges
Total
No. of Air Cond. tons
No. of Disposals
No. of Heat Total Total
Pumps Tons KW
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
Heating Devices KW
No. of Water Beaters KW
No, of No. of
Signs Ballasts
Low Voltage
Wiring
No. Hydro Massage Tubs
No. of Motors Total HP
OTHER: e z—
INSURANCE COVERAGE: Pursuant to ' the requirements of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial
equivalent. YES E] NO E] I have submitted valid proof of same to this office. YESE] NO []
If you have checked YES,, -please indicate the type of coverage by checking the appropriate box.
INSURANCE [:] BOND [:] OTHER r -J (Please Specify)
(Expiration DateT
Estimated Value of Electrical Work S
Work to Start
Inspection Date Requested:
Signed under the penalties of perjury:
FIRM NAIE
Rough_Final
LIC. NO. / � -7 �/ �7 IV
License
Address
'A L r. iei. no. ^-9-1
014NERIS INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its�ub-
stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit
app ica7t7 waives this requirement. Owner Agent (Please check one) 7
A /
31
14 J_ PERMIT FEE S
L—b—1 A r, Telephone No.
r (Signature of er or Ageht)
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REMARKS BY ELECTRICIAN:
t-.
al
LW7H_E RET9 7US I R E -S E N: �V _IR _0_� TM E �NT G G F NY E i
October 27, 2011
Via United Parcel Service
� - �11_7 S /I r/A dl/
607 North Avenue, Suite 11, Wakefield, MA 01880 tel 781.246.8897 fax 781.246.8950 www.ecsconsult.com
Susan Y. Sawyer, Health Director
1600 Osgood Street
Building 20; Suite 2-36
North Andover, MA 0 1845
RE: Notice of Document Availability
12 Massachusetts Avenue, North Andover, MA
MassDEP RTN 3-3246 and 3-21527
Dear Ms. Sawyer:
ECS Project No. 05-215837
� 0.1: N : I ITA
pmt ue, v — A- i"'u I I
TOWN OF NC DRTH ANDOVER
'HEALTH DEPARTMENT
Environmental Compliance Services, Inc. (ECS), on behalf of Global Companies, LLC, has submitted a
Release Abatement Measure (RAM) Plan to the Massachusetts Department of Environmental Protection
(MassDEP) for the above—reference Site. Release Tracking Numbers (RTNs) 3-3246 and 3-21527 were
issued for releases from a former waste -oil and fuel oil UST and presence of polycyclic aromatic
hydrocarbons (PAHs), respectively at,the property. A Class A3 Response Action Outcome (RAO)
Statement and Activity and Use Limitation (AUL) were submitted for this Site in September 2003.
As required by 310 CMR 40.1067, the RAM Plan was prepared as greater than 20 cubic yards of soil
contaminated by a hazardous material is anticipated to be generated during construction activities.
Construction activities are anticipated to: begin in early November, 2011, and will include the excavation
and removal of three existing gasoline USTs, installation of two new gasoline USTs in the same location of
the current UST field, replacement of the dispenser islands and the concrete pad over the UST and fueling
areas, installation of a roof drain infiltration system, and installation of a precast concrete stormceptor.
Copies of the RAM and aforementioned documents can be obtained by contacting the MassDEP's Bureau
of Waste Site Cleanup (BWSC), Northeast Regional Office located at 205B Lowell Street
in Wilmington, Massachusetts, 01897. This notice has been prepared in accordance with the
Massachusetts Contingency Plan section 40.1403(3)(d).
If you should have any questions concerning this submittal, please do not hesitate to contact our office.
Sincerely,
ENVIRONMENTAL COMPLIANCE SERVICES, INC.
"AlaztLy,
Matthew Carey
Senior Project Manager
I N___EjCT,1�,Q, - . - R III -
Date. .....................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
................... .........................
This certifies that ..... ............. Ile
has permission to perform—.—.. ..........................
wiring in the building of in�,
........ .................... .......................... NorthAwdover, Mass.
FeeA.�—
....................
.................. Lic. No . ............. ................. ELECTR . [CAL . INSP . E ...... 7
ClIV,
Check #
7964
i
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
20 Permit No. " 4�, /
Occupancy and Fee Checked /1-1�1571zn
[Rev- 9/05] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC 27 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL TNFORMA TION) Date: /7-
2 City or Town of- A"Jo,,&e- To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) M.4 It S q v c -
Owner or Tenant 114114ey .0s/ co Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes Er No F] (Check Appropriate Box)
Purpose of Building o Fl:t c , LSft,-- Utility Authorization No.
Existing Service JLao Amps /Zo 2 o6 Volts Overhead Undgrd [:1 No. of Meters
New Service Amps Volts . Overhead Undgrd El No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion ofthe followinjz ble may be waived by the In ector of Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires q
Swimming Pool Above
grnd. Ignr n d. E3
No. of Emergency Lighting
BafteEy Units - - �
No. of Receptacle Outlets /8
No. of Oil Burners
FIRE ALARMS I
No. of Zones
No. of Switches
No. of Gas Burners
No. of Dete( nd
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
I.Ny!pp�rjy�!M
I
J.KW
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
_
Space/Area Heating KW
LocaIE:1 Mun'c'PP' El Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water
Heaters KW
No. o No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE [Er.-BONDE] OTHER F-1 (Specify:)
I certift, under thepains andpenalties ofperjury, that the information on this application is true and complete.
FIRM NAME: -PArl It r -C, I LTC. NO.:. 10 6-3J-- 8
I
Licensee: ' 'Y1xPhdJ* PA�114C-1-4 Signature 52:�A—&L— LTC. NO.: 16 S -3S --O
af applicable, enter "exempt " in the license number line) Bus. Tel. No.: c0 A - 24S- —7ei(18
Address: ' 12o A-Iesv4yn P -D uht)- 6-D Rlalstou) V9 03S&67' Alt. Tel. No.:
*Security System Contractor License required for this work; if applicable, enter the license number here:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) El owner El owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $ 1-2 <-
9
F-2
0
0
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Mishington Street
Boston, MA 02111
www.mass.gov1dia
Workers'. Compe Insation Insurance Affidavit: ]3uilders/Contractors/Electrici"ans/P I lumbers
Applicant Information Please Print LeOblv
Name (Business/Organization/Individual):
Address: 12 o
City/State/Zip: P1,91j-Aw, t,,11: oaqo�- Phone.#: 976 - 2 C-9-- 7 E?
Type of project (required�.,,
6. M New construction
7. DICernodeling
& Demolition
9. Building addition
10. Ele ctrical rep airs or additions
11 -El Plumbing repairs or additions
12.0 Roof repairs
13. [1 Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Honicowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit . indicatina such,
lContractors that check this box must attached an additional sheet,showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their worken, comp. policy number.
I am. an employer that is providing workers'compensation insurancefor my employees. Below is the policyandjob site
information.
Insurance Company Name: 4 e F -A r 0- 1 C_
Policy or Self -ins. Lic. #:' /;;P)( '14 Expiration Date:
Job Site Address:— 2 City/State/Zip: -t1ap-1A
Attach a copy of the workers' compensation policy decla—ration page (showing the policy number and expir . ation date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties -of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations of the DIA for insurance coverag2 verification.
I do hereby certijy under the pains -andpenaldes ofperjury that the information provided above is tru e and correct
Signatuie: Date:
Phone#: jf76-249--78419
Officialuse only. Do not write in this area, to be co��Leted —by city or town officiat
City or Town: Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Departme nt 3. City/Town Clerk 4. Electrical Inspecto
6. Other r 5. Plumbing Inspector
Conta& Person:
Phone #:
Areyou an employer? Check the appropriate box:
1. El I am a employer with f 4.1 E] I am a general contractor and I
(ftffl and/or part-time).* have hired the sub -contractors
2. ZI am a wle proprietor or partner- listed on the attached sheet.
ship and have no employees These suv-coiltractors have
working for me in any capacity. employee's and have workers'
[No workers' comp. insurance comp. insurance.1
required.] 5. We are ac'orporation and its
3. 1 am a homeowner doing all work officers have exercised. their
myself [No workers' co*mp. right of exemption per MGL
insurance required.] t c.-1 52, § 1(4), and we have no
employees. [No workers'
comp. msurance required.1
Type of project (required�.,,
6. M New construction
7. DICernodeling
& Demolition
9. Building addition
10. Ele ctrical rep airs or additions
11 -El Plumbing repairs or additions
12.0 Roof repairs
13. [1 Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Honicowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit . indicatina such,
lContractors that check this box must attached an additional sheet,showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their worken, comp. policy number.
I am. an employer that is providing workers'compensation insurancefor my employees. Below is the policyandjob site
information.
Insurance Company Name: 4 e F -A r 0- 1 C_
Policy or Self -ins. Lic. #:' /;;P)( '14 Expiration Date:
Job Site Address:— 2 City/State/Zip: -t1ap-1A
Attach a copy of the workers' compensation policy decla—ration page (showing the policy number and expir . ation date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties -of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations of the DIA for insurance coverag2 verification.
I do hereby certijy under the pains -andpenaldes ofperjury that the information provided above is tru e and correct
Signatuie: Date:
Phone#: jf76-249--78419
Officialuse only. Do not write in this area, to be co��Leted —by city or town officiat
City or Town: Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Departme nt 3. City/Town Clerk 4. Electrical Inspecto
6. Other r 5. Plumbing Inspector
Conta& Person:
Phone #:
Information and. Ins'tructions
Massachusetts General Laws chapter 152 requires all employ6rs to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every p . crson in the service of another under any contract of hire,
express or implied, oral or written."
An employqr is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including.the legal representatives of a decea;sed employer, or 6e
receiver or trustee -of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more dian three apartments and who resides therein, or the.occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an e'n3ployer."
MGL chapter 152, §25C(6) also states that "every state or local licensing a
gency shall withhold- the issuance or,
renewal of a license or permit to,bperate �a business or to construct buildings in the commonwealth for any',
applicant who has not produced aic�ptable evidence of compliance with the insurance coverage required." ',�
.Additionally, MGL chapter 152, §25CO) states "Neither the commonwealth nor any of its political subdivisions shail
enter into any contract for theperformance of public work until acceptable evidence of comph . ance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other tho the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that This affidavit may'be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are requ#ed to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate lint.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Departibent has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should 'write "all -locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future perimits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permi.1, to b�rn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations w ould like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone -and fax number:
The Commonwealth of Massachusetts
DePartment Of Industrial Accidents
Offlee of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274000 ext.406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 1 1�22-06
www.mass-gov/dia-
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that
.... .. ..........
11 ..........................
has permission to perform_- a. ... .......
plumbing in the buildings of –,J .. o- ..........
at. .................. ........ n ...... North'Andover, Mass.
Fee,�*.' Lic. No.92,,P— ............
P L�U M �BN&3�'�I-NS P E C T 0 R
Check # 7-v/,,7
7627
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type)
Mass. Date
Building Location U i�, -- Owner's Name
Type Of Occupancy
Renovation Replacement Plans Submitted Yes 0. No
New - : )(
FEATURES
Installing Company Name L)19--uio t! UnO14 V /Iv-113py
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Address, 4- # 4 HIS& &,s 9, r
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Name of Licensed Plum'ber N9 U
--7;M one
Xorporation
:--- Partnership
-� Firm/Co.
Certificate
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142.
Yes �( No
If you have checked yes -,,please indicate the type of coverage by checking the appropriate box.
A liability insuranc.e_po-licy.- -.i - Other type of indeftinity -7, ' Bond -
OWNERS INSLIRANq�,�-IWAIVER: I am aware that the'licensee does not ha�e the insu[ ' I . i I . I
I ance
Chapter 142 o�-M -Caws A-nd that my signature on this permit application wa;,-e's this reqyiremen�t
e:
Owner-.- ,.-Agent
��n�atu,e of �Owner-or Owner-s-
-A-qent —
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to
the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will
be in compliance with all pertinent provisions of the Massachusetts State Plum
_>�g Code and Chapter 142 of the General Laws.
By
S—ign-aTu—reOf Ll Xns, ��. ter����
Title Type of License: MasrerX Journeyman
Ci!Y/Town-----. Licen-:! Number 0,7-n
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SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR
TTH FLOOR
8TH FLOOR
Installing Company Name L)19--uio t! UnO14 V /Iv-113py
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Address, 4- # 4 HIS& &,s 9, r
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Name of Licensed Plum'ber N9 U
--7;M one
Xorporation
:--- Partnership
-� Firm/Co.
Certificate
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142.
Yes �( No
If you have checked yes -,,please indicate the type of coverage by checking the appropriate box.
A liability insuranc.e_po-licy.- -.i - Other type of indeftinity -7, ' Bond -
OWNERS INSLIRANq�,�-IWAIVER: I am aware that the'licensee does not ha�e the insu[ ' I . i I . I
I ance
Chapter 142 o�-M -Caws A-nd that my signature on this permit application wa;,-e's this reqyiremen�t
e:
Owner-.- ,.-Agent
��n�atu,e of �Owner-or Owner-s-
-A-qent —
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to
the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will
be in compliance with all pertinent provisions of the Massachusetts State Plum
_>�g Code and Chapter 142 of the General Laws.
By
S—ign-aTu—reOf Ll Xns, ��. ter����
Title Type of License: MasrerX Journeyman
Ci!Y/Town-----. Licen-:! Number 0,7-n
01-09-'08 16:28 FROM-Byam BrosMahoney Ins +978-937-0745 T-902 P001/001 F-570
AC CERTIFICATE OF LIABILITY INSURANCE OP IDsz
I DATEIMWD-
DAVID-3
01/09/08
PROOLKew
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
I MEOF146UFOXCE
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Byom Bros-Noboncy Insurance
IV& Pawtuokot Blvd
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
LIMITS
Lowell HA 01054
Phone: 9le-434-2926 Fax: 910-937-0145
INSURERS AFFORDING COVERAGE NAIC #
1149URERA, -k%W r.�"w C..
INSURERS: Cuard Insurance
"CHqCM=V= 1 1000000
David H. Murphy Plumbing
Keating & Gas Fitting Inc.
IWAIREA 0: Commerce Insurance Company
IN6MR D.'
3 Chambers Street
Lowell, NA 01852
05/15/01
05/15/00
OAMAMTOMNTM
FIMMI193P.—P."I 1 100000
COVERAGES
TM6 POL"h OF INURANCA UKE06ELft PIAVE bEfix ISSY90 TO TmE wMib tmEO ABOVE FOR YnE FOuCYPEF*OD IHOICCATED. mONAWANIANO
ANY RMIREMENT. TERM OR CONDITION OF ANVOONIRACT OR OTHEA DOOWENT WITH RESPECT TO WhVH TWO CERTIRIDATE MAYBE ISSUEOOR
MAY PERYAW. Phi NSU"Gt AP`P`OAOfO5V'YPft IVULIfft D=R'RPKEftN 15 SUWCGT TO ALL
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05/15/01
05/15/00
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CERTIFICATE HOLDER CANCELLATION
TOWOMN
SHOULD ARYOF THE AIM DESCRAPEO FOIXIEO BE CANCEUSO BEFORE, 11116 EXPIRATION
OATt flitft'GV, "It 11WRO (IRWRtNVOILL M*AVOR TO MAIL 10 DAVOWAIM"
tIOTM TO TNECESIMWAM NOLOUNAINIES
Town of North Andover
120 Main Street
iRorth Andover MR 01865
go&
avamaros—
ACORD 2S (2001108) WAS—.4jor 9) ACORD CORPORATION 1955