HomeMy WebLinkAboutMiscellaneous - 30 SUGARCANE LANE 4/30/2018 (2)Date ...... L/ ......
. ...... .......
'0' TOWN OF NORTH ANDOVER
0
Vow PERMIT FOR WIRING
This certifies that ............................................. ......... / ...................................
has permission to perform ...
... .. . ....
wiring in the building of .............. . . ...............................
.....................
at ....... 34�.. Souee0*141415 Z-.$
.......... I/ ................. . North Andover, Mass.
Fee..! .................. Lic. Nw��
.QiD/Y ...............
. ..... ..........
Check # 2- Z-
.8 4 6:2
t
-C\- Commonwealth of Massachusetts
UVEMO Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. �Z Z 2–
Occupancy and Fee Checked
[Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts ElectricaLZ11M
e (Z1 CMR 12.00
(PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date:City or Town of: NORTH ANDOVER To the Inspeires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) —To Se19'/J2 �'.c�A a / 14 A, P
Owner or Tenant
Owner's Address
Is this permit in con
Purpose of Building
building permit?
Existing Service 200 Amps %_X / rp Yj_ Volts
New Service Amps / Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
(Check Appropriate Box)
Overhead ❑ Undgrd ❑ No.. of Meters
Overhead ❑ Undgrd ❑ No. of Meters
Colet; th 11
oo e o owtn
m
No, of Recessed Luminaires CP
n
No. of Ceil.-Susp. (Paddle) Fans
table may oe watvea Vy the Inspector of Wires.
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires ®
Swimming pool Above ❑ In -El.
o mergency Lighting
d. d.
Baotte Units
No. of Receptacle Outlets
No. of OR Burners
FIRE ALARMS
No. of Zones
No. of SwitchesNo.
of Gas Burners
No. of Detection and
Initiatina Devices
No. of Ranges
No. of Air Cond. TotTons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Number
""`""
Tons
No. of Self -Contained
Totals:
Detect1 ion/Ale Devices
No. of Dishwashers '
Space/Area Heating KWLocal
❑ Municipal E] other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of WaterNo.
of No. of
No. of Devices or E uivalent
Heaters KW
Signs Ballasts
Data Wiring:
No. of Devices or E uivalent
No. Hydromassage Bathtubs
No. of Motors Total Hp
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
nuucn uuainonat aetau y desired, or as required by the Inspector of Wires.
Estimated Value of E ctric 1 Work: (When required by municipal policy.)
Work to Start: p Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE C VE GE: 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 cov rage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the informa ' o this application is true and complete.
FIRM NAME. �Z---- LIC. NO.:
Licensee: Signature _LIC. NO.:AF �®
(If applicable, enter "exemptto the license number li e.) Bus. Tel. No.: Wig/ ��� �
Address: 00�tJ���% C f CMZ! l Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the Iiability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $
pptv, ea-< ► �- �-ag Ari
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f
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
.. I I.. 01,...;::.... .
C-1 www.massgov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aoplicant Information Please Print Leaibiv
Name
FIM
Address:
City/State/Zip: Gt-'E, Lzej/1 �Z17� Phone
Are you an employer? Check the appropriate box:
I . ❑ I am a employer with 4. ❑ I am a general contractor and I
have hired the sub -contractors
listed on the attached sheet. #
These suit -contractors have
workers' comp. insurance.
5.,7 We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 1.52, § 1(4), and we have no
.employees. [No workers'
comp. insurance required.]
mployees {full and/or part-time).*
i am e.sole proprietor or partner-
s ' and have no employees
working for mein any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No -workers' comp.
insurance required.] t
Type of project (required):
6. [] New construction
7. Q Remodeling
S. Q Demolition
9. (] Building addition
10.7 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12. ❑ Roof repairs
13.❑ Other
-AT1y applicant that checks hoi#1 must also fill out the section below showing their workers' compensation policy information,
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
4contractors that check this bolt must attached an additional sheet showing the name of the sub -contractors and their woricers' comp. policy information.
I am an employer that is providmg workers' compensation insurancefor my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy 9 or Self -ins. Lic. #:
Job Site Address:
Expiration Date:
City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration 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 i wlklde coverage verification.
I do hereby c i�ensen_alties..of-perjury that the information provided abo is aandcorrect
Si tune: Date: G .
Official use only. Do not write in this area, to be completed by city or town of iciaL
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department
6. Other
Permit/License #
3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Contact Person: Phone #:
y
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer 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 deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner- of a dwelling house having not more than 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 employer."
MGL chapter 152, §25C(6) also states that "every state or locai licensing agency shall withhold the issuance or
renewal of it license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence.of compliance with the insumnce'eoverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance 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 -contractors) 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 than 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, notthe Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,. please call the Department at the numberlisted below. Self. -insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials. .
Please be sure that the affidavit is complete and printed legibly. The Department 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 permits 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 permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, i
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
Office of investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
Date. . ...........
0.1, 40 . RT" TOWN OF NORTH ANDOVER.
PERMIT FOR PLUMBING
This certifies that ................ .
...........
has permission to perforIV--'r ........... . ................
..................................
plumbing in the buildings of
at. (I ....... .... -North Andover, Mass.
Fee e� k .... Lic. 0 ..........
............
PLUNtS,K-G INSPECTOR
Check #
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location
Date `91) p�
)wners Name Lq/�/� Permit — 9 f
of Occupancy �,�Amount
New rl Renovation Replacement 'IEJ------F'lans Submitted Yes ❑
No
Ti�TCrTTT?17nn - -
krnnr Or type) _
Installing Company Name_j U Check one: Certificate
n � Corp.
Address k� 69'
0 Partner.
* usmess Telephone
Co. L L C
Name of Licensed Plumber:
Insurance Coverage: Indicate the urance coverage by checking the appropriate box:
Liability insurance policy Other type .of indemnity F1 Bond
Insurance Waiver. I, the undersigned, have been made aware that the licensee of this applicatio
three insurance n does not have any one of the above
Signature Owner
I hereby certify that all of the details and info oh Id have su
best of my knowledge and that all plumb' work and installatic
compliance with all pertinent provisions f the Mass chusetts
By.
igrmmre or Lact
VED tom= usE oNL.r
nAgent 0
ted (or entered) in above application are true and accurate to the
?erfo�.eraP=. mit Issued forthis a ation will be in
P�rjCita of this
Laws.
Type of Plu4ng l- ec nse
ice seu oer Master Journeyman ❑
The Commonwealth of Massachusetts
! Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, 1114 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual):
bad
City/State/Zip:sa X60 b% Phone #:
Are you an employer? Check the appropriate box:
1. atn a employer with 1
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet z
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.] officers have exercised.their
3. ❑ 1 am a homeowner doing all work right of exemption per MGL
myself. [No workers' comp. c. 152, § 1(4), and we have no
insurance required.] t employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. remodeling
S. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
-rr �� • •• u �..��n� ��n n , ,,,� nso uu our me section neiow showing their workers' compensation policy information.
t homeowners wlro submii.khis afadavii indicative liiej alt eoirg rEl cvc:r:; sa. Ehea hi;- outside coirirruiorb must suomit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am ann employer that is providing workers' compensation insurance for mJ' employees. Below is the policy and job site
information.
Insurance Company Name:&/-7�/Pi
Policy # or Self -.ins. Lic. #:
Expiration Date:
Job Site Address:_ 3 6 „a't /ACity/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration 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 coverage verification.
I do he by certi under th and penalties of-,/
e� _,
q__.
that the information provided above is true find correct
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
/Oz�
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined. as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer 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 deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than 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 employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit,to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance 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 than the
members or. partners, are not required to cavy 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 lava, or if you are required 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 line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department 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 permits 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 permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would 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, teiephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents.
Office of Investigations
600 Washington Street
Baston, MA 02111
Tel. # 617-727-4900 ext 4.06 or 1-877-MASSAFE
Fax 4 617-727-7749 "
Revised 5-26=05. wwW,mass.gov/dia
Location
No. Date
40RTN
TOWN OF NORTH ANDOVEP,
0
Certificate of Occupancy
$ �g,
41
Building/Frame Permit Fee
$ ------- At
A
Foundation Pprrni t Fee
$
Other
$
Sewer Connection Fee
$
Water Connection Fee $
TOTAL
7180
$
Building Inspector
Div. Public Works
'y�
Location
No. Date
Ork?
U
7179,
TOWN OF NORTH ANDOVEFF
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Perpt F,ee $
Other Permiff--e"e�� $ (9
Sewer Connection Fee $
Water Connection Fee $
TOTAL' $
Buildind'inspector
Div. Public Works
(3 17,
Location
No. Date
TOWN OF NORTH ANDOVER
,ertificate of occupancy $
3uil�iing/Frame�Permit Fee $ "AT7.40
-oundation Permit Fee
Other Permit Fee
Sewer Connection Fee
Water Connection Fee $
TOTAL $
ilding Inspector
/4993 15:18 11667.50 pmeu
6 7,7 0 Div. Public Works
L�catlon
No. Date
11-d _112�
Tol
OF NORTH ANDOVER
Certificate of Occupancy
$6
7'.
Building/Frame Permit Fee
$
CHU
Foundation Permit Fee
$
d
Other Permit Fee
$
--------
SewerConnection Fee
$
Water Connection Fee
$
TOTAL
$
X5
Building Inspector
Div. Public Works
Location 30
No. Date
It
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
,eFoundation Permit Fee
-.Ofher Permit Fee
Sewer Connection Fee $
394 Water Connection Fee $ /->-1p
T qfSA L) ao, 0-
Smildind Inspector
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FORM U - LOT RRT7? = FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Depart --sant- having jurisdiction
have been obtained. This does not relieve the applicant and/or,
landowner from compliance with any applicable local or state law,
regulations or requirements.
************** *A pli a t fills out this
, W r s�
APPLICANT: Phone Sd ? 474
.? 7/�
LOCATION: Assessor's Map Number Parcel a
Subdivision ��/�D f6ES Lot (s)
Street ,�(/!Y/C� G,�9-,7%ei St. Number
************************Official use only************************
RECO ATIONS OF TOWN AGENTS:
71 t4 442
C reservation Administrator
Comments , ,gym-��r)� 1r7� ,
Mill
10§�Ip M ME Elf
Date Approved
Date Rejected
Date Approved
Date Rejected
zz� I,/Z3 Date Approved
Health Aae^.t Date Rejected
Comments
Public WOrks - sewer/water cannections -�--
- driveway permit 49 —27-9:3
Fire Depart=ent
Received by Building Inspector ? Date
NOV
WH(:I:; OF:
I it III .I )ING
c.ONS1:1(VA*1.1ON
I11 AI:1'11
1 !l.ANN1N( ;
ATE
`.;.�.-::�• J: IyU��'I',<I �1,Iyi�UtiTL'lZ
.t •:.. .
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1'1,.1NN1N(;. L (;t)t1lftlt,!Nl'1'1' [)l:�'1st,()1'l111?N'1'
KA ti N I I.P. Nl :l .ti( )N. 1 )Il (1:(:1(1 t
CHIMNEY AI111LICAHON ANO I'E131I r
)CATION 40 -r D- ��'U G iQG9�✓4.
Ili 1 71 illi-, -1 7!;
P E It m 1'1'. # - /-13
UNER' S NAME:./�l
1ILDER'S NAME: ' ' ' %//kf13f4o L�;,jfjrjo
iSON' S NAME: -bolus r*�X/9 ja r
kSON' S ADDRESS: oft
.SON'S TELEPHONE: —ce d,�
JERIAL OF CHIMNEY. owfa�R y
IT-ERIOR CHIMNEY: d L'XI LRIOR CHIMNLY:
11�1BER AND SIZE OF FLUES: °rAD Axl
II CKNESS OF HEARTH:___---
CIL,iiII)Ley an ().(hepbce call(I
:gu.eatiow been nece.sved:
1 ,TE:
to Vie Acqu.u.Le►nclll'.5 u() the culle cull have :u(Ce3 cunt
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CERTIFICATE OF USE &OCCUPANCY
Town of North Andover
Building Permit Number 513 (1993) Date APRIL 28, 1994
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 30 SUGARCANE LANE (Lot #28A)
MAY BE OCCUPIED AS SINGLE FAMILY DWELLING W/3 CAR GARAGE IN ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND
SUCH OTHER REGULATIONS AS MAY APPLY.
CERTIFICATE ISSUED TO Robert Janusz
4 e
/•`' +� ''`°� 40 Sunset Rock Rd.
ADDRESS Andover, MA
Building Inspector
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING�''
(Print or Type) -
f NORTH ANDOVER Mass. Date ~�
kuilding Location (-O'T q0 6 GjQ(J69rj-P ( OL)e Permit #
Owners Name j('(-(3/Ml`N-Q r3C)1'/1-)'e'_11-7s
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New Renovation D Replacement Plans Submitted
FIXTURPS
(Print or Type) Check one: Certificate
Installing Company Name Q1*jWA('1 aff-ehil`V P(U/1&PV—j Corp.
Address11,� XgNl,�M :P-7c1Pfry-g Partner.
Firm/Co-
Business Telephone: �-04
Name of Licensed Plumber or Gas Fitters (' i(r� �D8 6t /37—S
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy F�g Other type of indemnity 0 Bond Ej
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner I---] Agent El
I hereby certify that all of the dctails 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 Permit iuued for this application will -be in compliance with all pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of tho General Laws, • _ .
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
TYPE LICENSE: G%G�22/C
Plumber
Gasfitter Signature of Licensed
Master Plumber or Gasfitter
Journeyman da-, f6 O
License Number
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(Print or Type) Check one: Certificate
Installing Company Name Q1*jWA('1 aff-ehil`V P(U/1&PV—j Corp.
Address11,� XgNl,�M :P-7c1Pfry-g Partner.
Firm/Co-
Business Telephone: �-04
Name of Licensed Plumber or Gas Fitters (' i(r� �D8 6t /37—S
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy F�g Other type of indemnity 0 Bond Ej
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner I---] Agent El
I hereby certify that all of the dctails 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 Permit iuued for this application will -be in compliance with all pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of tho General Laws, • _ .
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
TYPE LICENSE: G%G�22/C
Plumber
Gasfitter Signature of Licensed
Master Plumber or Gasfitter
Journeyman da-, f6 O
License Number
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Date ................
TOWN OF 'NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
AUG 1 0 1993
This certifies that 14 - ;- " ,, 1 - I
............... f .........................
has permission for gas installation
........................
in the buildings of .... f-�. ...........................
at ................................... , North Andover, Mass.
Fee. A.; .... Liq. No—% 7.1
............ ...........
GAS INsp6c-r-oR
WHITE: ApplicaM CANARY: Building Ddpt. PINK: Treasurer GOLD: File