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HomeMy WebLinkAboutMiscellaneous - 32 SECOND STREET 4/30/2018 32 SECOND STREET 210/030.0-0029-0000.0 i � �1�� 1 I �� �� `� �� �� i� � Q, �, �' - - -`. Datel.. �.�....fill.q............... OF NORTry,� o?; oom TOWN OF NORTH ANDOVER * PERMIT FOR WIRING sSACHUS� This certifies that ....:.;`�'�,: �.:...::...,. M ............. .............................. ............................... has permission to perform ....�y ...`F-2.lMUc? - ,................................... ............... wiring in the building of........... ..!.!.Cn ....................................................................... at ....^ 2-...^� << ✓�^c ...... .......... ,N rth Andover,Mass. Fee... ...1.......Lic.No. ............... ..�`'�. ....... ��/��/.jjjjjj.������........ .. ... LECTRICASPECTOR tCheck# o Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. U07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINTWINK OR TYPE.ALL INFORNIATIOIV) Date: City or Town of: NORTH ANDOVER 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) 3,� fe6,,r,1 / S(' Owner or Tenant C ,,all f— C�, (p Telephone No. 4D36Frt o,3 / Owner's Address _ -rc yle%-P� Is this permit in conjunction with a building p rim. Yes ❑ No ❑ (Check Appropriate)Box) Purpose of Building �p f A�-/ r.,4-1 Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA "Z No.of Luminaire Outlets No.of Hot Tubs Generators KVA No,of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting grad. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No. of Waste Disposers Heat Pump I.NyMl er I Tons I KW No.of Self-Contained Totals: I J*- ........._........]**"­­­­''' Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts 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 WYres. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: ,)p/ Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO RA E: 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of erjury,that the information on this application is true and complete. FIRM NAME: _ fic�c, �, f, LIC.NO.: 1, J r,�; Licensee: C41,a_,/ Signature L � � LIC.NO.: (If applicable,enter "exempt"in the license number line) Bus.Tel.No.: 71f cl<y Address: Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.No. 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)❑owner ❑owner's ent. Owner/Agent PERMIT FEE. $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the Q permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass n Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass[M Failed 0 Re-Inspection Required($.) ❑ 6^ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspector mments: Inspectors Signature: Date: FINAL INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comme Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustriqlAccidihis Office of Investigations 600 Washington Street Boston,MA 02111 U1V www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):_ :CA I Q,-zl/ G �,, Address: 7 1 Z/y, zze f City/State/Zip: "( �P w, � �f Phone#: 7 �� Y -G a Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and I ` ❑ * have Hired the sub-contractors 6. New construction employees(fall and/or part-time). 2. I am a sole proprietor or partner- listed on the attached sheet.1 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. Building addition [No workers' comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs 1 insurance required.]i employees.[No workers' comp.insurance required.] 13.[J Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. _I_ Insurance Company Name:. I T�1r r oo Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: 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 insurance coverage verification. I do hereby cert under the pains a d penalties ofperjury that the information provided above is true and correct. Signature: Date: O Phone#: 9 � Ee Y a �, - Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# 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 ofhire,- 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-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 maybe 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 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 permittlicense 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,telephone and fax number: Tho Commonwealth of Mossa'Usetts Department of Industrial.A,ccidents Office.of Investigations 600 Washington Street Boston,MA.02'111 Tel,#617-727-4900 ext 406 or 1-877-MA-SS.AFE Revised 5-26-05 Faz,#617-727-7749 v� .ss,g4vfdxa COMMONWEALTH OF Mo-SSACHUSETYa ^' o • ""Isla Lei BOARD OF Et :ICT ISSUES,.THE FOLLOWfNG LICENSE; R..>R£7; JOURHE,YMA;N ELCTRI`GIA EDWARD A KANKA: jk 147 MILLViLLE ST..::::::: L:t L>EM <;NH 03079-22. 2'j: ;a 10356 07/3:1/lb ;' 61010 . ., M Datel�.I,tq.............. OF NORrH,h TOWN OF NORTH ANDOVER ° 9 PERMIT FOR PLUMBING This certifies that............................................................ has permission to perform....bt4k.... .acQ.. :X................................. C hc�s� plumbing in the buildings of....................................... .................................................. at....,32.......5- c.n c...�..... .............North Andover, Mass. Feet- ....Lic. No 133?q....... ........... Check (0 PLUMBING INSPECTOR �p �� p MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK k CITY % km ov cr 11 MA DATE _ ► ( PERMIT# �� JOBSITE ADDRESS OWNER'S NAMEF— cam E POWNER ADDRESS SC�r�C;. TEL — FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL © RESIDENTIAL.0 PRINT CLEARLY NEW: RENOVATION:R/ REPLACEMENT:Q PLANS SUBMITTED: YES NO FIXTURES 7. FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 8 � DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM _._� ! i ! ! _. _! _3 _-.._-.__€ ! € DEDICATED GRAY WATER SYSTEM I DEDICATED WATER RECYCLE SYSTEM I __-----]IF-773 DISHWASHER -i --J _- DRINKING FOUNTAIN _ i 1 -_--' I _._I _ € ._-_-I __.,.._I •--___..1 ....__.._.J .__._. f . . ._._I __.....1 __ _..._ t FOOD DISPOSER FLOOR/AREADRAIN ! .-_ _� i � ___.._.� J ._......_..! —j .... -I INTERCEPTOR(INTERIOR) P -__-_-[ --__._ --.-j __.-_ i _...._._i -j _ .- ---.___! .-.____.I _ f �! i 7-7 KITCHEN SINK l I ! .--! ! _I I f .__..-_I LAVATORY ! ___J .._✓._� _.,_.-_ __ -__.___i __._._1 ____J _-.__- .._..._J .:__..._i ..____-.1 i 1 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET _-- _I -- _-_� _____.!_._^. E ? _._-_I ._._-.1 .___-. _�._I ____� .•__.__! _.�! .__-.- -! Q. URINAL WASHING MACHINE CONNECTION --_! ! + WADER HEATER ALL TYPES _I ! f ._ _ ( i —I ? - _f W/'JER PIPING T ER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES _.-. NO M r IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY R' OTHER TYPE OF INDEMNITY Di BOND O--I OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER © AGENT 10 ' SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this 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 complianc with all Pertinent provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME W,���c• c I LICENSE# � SIGNATURE MPD JP Q - CORPORATION D#=PARTNERSHIP P# ;LLC B� COMPANY NAME yJ,y,�� `m. � � A��, ADDRESSyx2A _ .. CITY ��h�� -�STATE ®ZIP TEL FAX L ( CELL��EMAIL L ` ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No Ss II THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES s AX The Commonwealth oflMlassachusetts - Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA.02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Leidbly 1 Applicant Information `` • Name(Business/Organization/Individual): �}•��\vrr� �C�tr.4 Address: �3 C'1 c 'Q - City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors �--�/ �• Remodeling 2.� 1 am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs insurance a ired.re q uemployees.[No workers' 13.❑Other comp.insurance required.] 4Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit 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 an employer that is pYoviding workers'compensation insurance for my employees. Below is ihe,policy and job site information. Insurance Company Name:. P Y Policy#or Self-ins.Lie.#: ExpirationDate: Job Site Address: 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 requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fne 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 maybe forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do hereby cert under tlz pains and penalties of perjury that the information provided above is true and correct. - Simafore• Date: g I Phone#• - C, 1 C7 —Lc,.-) ea�U Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# 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 M V Information and Instruction's 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-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 maybe 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 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" any given year,need only submit one affidavit indicating current Policy information(ifnecessary)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 orpermit 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,telephone and fax number: The Com mouwealtl ,of Y_ �usPtts Dapartrnent offndustdal Accidents Mce ofIuyestigatims 600 Washington Street BostQnt MA.02111 Tei,#61.7-727-4.900 est 406-or 1-8777MASSAFF Revised 5-26-05 Fax#617-727-774.9 M SSA MA OMmot4vv LTH OF , I TT E.R 59 RD GASF S p`LUMgERS :. L�.tENSE LLOWIN. 1� SSUES THE FO PLUMBER. LI;GENSEQ `A5 A JOURNEYMAN ;4N:. :i ►NGTON N T HARR W►LLIAM o $ MAPLE ROUGE Ro AD , 01$44 4166 ,. . MA 214636 Date . .I. 4�gv{'GHLjCaa'. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . M. . , , , ,1",I,(A � r� 1 ►f'G has permission for gas installation . . .vc?.�.IP 2� in the buildings of. C . .1� t�.`�. . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . !.�.l��.�. . . S North Andover, Mass. Fee . .:� Lic. No. .h 11 . . 00 . . . . . . . . . . . . . . . . . . . . . / GAS INSPECTOR Check# )?j`�`7 8763 -` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY ,r- „ __, J -e. _ MA DATE PERMIT# O 1 0 lY JOBSITE ADDRESS w 1 OWNER'S NAME OWNERADDRESS - _ TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL © RESIDENTIAL '— PRINT CLEARLY NEW:�Q RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YESF-1 No Ell f APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE I _1 , _ 11 FRYOLATOR FURNACEA= GENERATOR �y GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN _ - G�� T. ._ L_ I_ -. 1 1_ J i POOL HEATER ROOM/SPACE HEATER m .. ..:. I —J== __ 1 __. — . . _ ROOF TOP UNIT ( I TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER =OTHER F INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Vd NO [j IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY r OTHER TYPE INDEMNITY Ej BOND41 EJJ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER E] AGENT E SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this 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 complianc ith all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER GASFITTER NAME � � Vt, d �c.� LICENSE# SIGNATURE MP _. MGF El JP D JGF LPGI j CORPORATION Q# PARTNERSHIP0#[ LLC[A# COMPANY NAME: A_N ..�. ADDRESS CITY - STATE[ ZIP P _- .. —.-. TEL FAX 1�—:s---� _j — .— -CELL EMAIL :R ,ia.�e ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES v r t The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 10 www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/El Please Print Legibly Applicant Information Name(Business/Organization/Individual): /,° 2 Address: . City/State/Zip: c! Phone#_ 7 1 5 7 �,7 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction to full and/or .* have hired the sub-contractors p yees( part-time).*sole proprietor or partner- ) listed on the attached sheet. E]Remodeling 2. I am a ship and'have no employees These sub-contractors have 8. E]Demolition working for me in any capacity. workers'comp.insurance. 9, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their required.] 11. Plumbing repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL ❑ g p myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs employees.[No workers' insurance required.] i 13.0 Other comp.insurance required.] *Any applicant that checks box#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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.9: Expiration Date: Job Site Address: 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 requireclunder 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. Ido hereby cert'ownder thepains andpenalties ofperjury that the information provided above is true and correct. Si atur Pho e ficial use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# 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#: r Commonwealth of Mas�hssetts Division of Registrati `�� Board of P/umbi im JOSEP�1yt {[� 2CARRIq ~— ;I HAMPSTE� Master Plum` r PL15977-M 05/01/2014 004999 License No. Expiration Date. _ __ Serial No. i u054 -1�1811 Date . . . . . . . . . �rti�tn TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . . !^!`^ . has permission to perform . . �). . 2. . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of.V".4. k-'-5 at . . . . . . . 1 'A- ! r 5 -e4+ , , North Andover, Mass. Fee .`r' l�cT�Lic. No. ` .66*� . . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check# 1-;74"-7 ,S ` 4 MAS ACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Q CITY _ _S�'t_ _ +i MA DATE f l3_TI PERMIT# /6d 90 7 JOBSITE ADDRESS 3Z 3 Sr- _ OWNER'S NAME POWNER ADDRESS A I TEL FAX T I TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL RESIDENTIAL 1.1� PRINT = CLEARLY NEW; ! RENOVATION:® REPLACEMENT: 0� PLANS SUBMITTED; YES� NOD V FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 2Q, ..__..___! I _ J ____._- ._.__._.l ! _.—__ _,.__......► .._,__.....! ._..._; _.._._. ._,,. ! I - DEDICATED SPECIAL WASTE SYSTEM _ _( .-.._.._.._1 _ _ 1 _._..._! .__..__._f ...____..I € I _..-_._J DEDICATED GAS/OIL/SAND SYSTEM € DEDICATED GREASE SYSTEM ______.I ! _.___...__ DEDICATED GRAY WATER SYSTEM _! f I DEDICATED WATER RECYCLE SYSTEM I __. ! ._._ I __-� _._J I _ ( - f __._.J __. ! _ .. ! f __�..! _ _ I ..i DISHWASHER ( _..._ ___ DRINKING FOUNTAIN -.! .._......{ ! FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK _I _ ._._.J i 4 ._.._...._._i 1 __.lI _._._.-...I �-- LAVATORY ROOF DRAIN _ ! _J -1 _.--1 ..______( ____.i SHOWER STALL SERVICE/MOP SINK TOILET _ I ..__......_I _.. I URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER __._ ----._.! _.. Ill F-1 -.-Jll I E, INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ..€d] NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Q BOND Q OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER _I AGENT JE SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this 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 compli o4e with al Pertinent pr�f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# S"9 ?p7 i SIGNATURE MP JP�€ CORPORATION 0# _ i PARTNERSHIP 0# i LLC j . COMPANY NAME _ ✓j _fes. v _ ADDRESS _'Z ��/` CITY --�� —- _...__....-_.. --I STATE l ZIP ; _il TEL �/ FAX _ _. CELL I�— IEMAIL �efj _w'�. 0 _ ._.Oe�,Gy ...�'t.l�� _.. ._. . - ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES l b /_. � The Commonwealth of Massachusetts - - Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): ✓r/ �J�(� Address: -:�- ( ✓ `,a<•, k� in City/State/Zip: "1 A 1/ Phone#: !?7 2 —/755- Are S 7 /75-5-Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction ployees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.[:]Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.[]Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit 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 an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: 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 requiredunder 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert' nder the pains and penalties of perjury that the information provided above is true and correct. Sim,natur Date: Phoe#: 5- -176-Y7 77cial use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# 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 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 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 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, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of M-assachusetts Department of Industrial.Accidents Office of Investigations 600'Washington Street Boston,MA.02111 Tel.#617-727-4900 ext 406 or 1-877,7MASSAFB Revised 5-26-05 Fax#617-727-7749 __WWW-Mass,govfdia .. Commonwealth of Massachusetts Division of Registrati " "' \\� Board of Plumbi JOSEPI-t /4 2 CARRI/� _I HAMPST�~� �^ Master Plumb r PL15977-M 05/01/2014 0� �✓ License No. 004999 Expiration Date. Serial No. Date . . . .• I • y�1`TLRD 7�•, TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 1 ' This certifies that . . . . . . . . . . . . . has permission for gas installation . . ` . . , , , , , , . . . . . in the buildings of. . .(�',. <�.. . . . . . . . . . . . ... . . . . . . . . . . . . . at . . . . �. . . .S-k,,z, ,.+ . . . ,North Andover, Mass. Fee . Lic. No. A-: �Jc). . ''t . . . . . . . . . . . . . . . . . . . . . GASINSPECTOR Check# 8767 7 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE : PERMIT# JOBSITE ADDRESS g-59 OWNER'S NAME GOWNER ADDRESS TE (o11- FAX . TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL EjI- RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:Q REPLACEMENT:Eg" PLANS SUBMITTED: YES Q N0& APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1l r 1.. 1 �J11l -_ .=l .- f ___ ]--I BOOSTER ---1 —�J — . 1 J CONVERSION BURNER COOK STOVE _ J1__j ;1 _ DIRECT VENT HEATER DRYER PFIREPLACEFRYOLATOR I J ( FURNACE - GENERATOR .— GRILLEW�AL_ INFRARED HEATERLABORATORY COCKSMAKEUP AIR UNIT ( _ T---- OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 4 UNIT HEATER I UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 'NO [�1 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY © BOND �1 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. "\ CHECK ONE ONLY: OWNER 0 AGENT m SIGNATURE OF OWNER OR AGENT (� hereby certify that all of the details and information I have submitted or entered regarding this 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 P inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the Genera!Laws. PLUM BER-GASF ITTER NAME S\\1a LICENSE# 1Z'n SIGNATURE MP E2MGF[_1 JP D JGF[j] LPGI D CORPORATIONF-10#=PARTNERSHIP[D# LLC-�I# COMPANY NAME: -.1\\!2�� Fwb_ _�ADDRESS CITY - tom ----� STATE�ZIP ]TEL i -ct1 8 ^��C`►^ 1 FAX ----- ------ ..�__� CELL._ -_. _..__..__...__�EMAIL_._ �4��_---� I ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES r 29 X11,1- c � c The Commonwealth of Massachusetts Department of Industrigl Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leuibly Name(Business/Organization/Individual):� Address: Qom_ City/State/Zip: `�'`� ���� Phone Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑,New construction ployees(full and/or part-time).* have hired the sub-contractors 7 2. I am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g E]Building addition [No workers' comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3111 am a homeowner doing all work right of exemption per MGL 11.El Plumbing repairs or additions myself. [No workers' comp, c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]i employees.[No workers' 13.[JOther comp,insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. ERpirati- Date: _..__._. •. -. . Job Site Address: 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 requiredunder 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. G I do hereby certify under the pains an penalties ofperjury that the information provided above is true and correct. Si ature: V Date: y 3 801-1 Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# 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#: COMMONWEALTH OF MASSACHUSETTS PLU.1ASERS AND GASFITTERS LICE_NE D AS A- MASTER PLUMBER ISSUES THE ABOVE LICENSE TO: I WILLIAM i" HAR INGTON : 08 MAPLE T'IDGE RD I METHUEN MA 01844=4166 13.779 05/t ,./14 156:635 :: . Q ; r i 003 1 Date .. r .;:fa4�LRO�tYF TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,This certifies that . . . �, 4r!1 , t' . , . , . . . . has permission to perform . . .��r. plumbing in the buildings of. . . .� ov :>-e ., , , , , , , , , , , , , , , , at . . . . ... Z. . .�_! . . ? .. . . . . ,North Andover, Mass. Fee�( . . Lic. No. 1'7 7� . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check# k L MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _ _ MA DATE 'l ?,� ,901 —) PERMIT# JOBSITE ADDRESS a ac- I OWNER'S NAME �c,,_ P OWNER ADDRESS Y _ �,c\ S I TEL FAX — — TYPE OR OCCUPANCY TYPE COMMERCIAL � EDUCATIONAL RESIDENTIAL®� PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES© NO FIXTURES 7 FLOOR, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB Eil S H ._____� _ f __( I _-.__� CROSS CONNECTION DEVICE ______ DEDICATED SPECIAL WASTE SYSTEM $ __._.._.) ( I -...__...__1 ....___. ( .______I _........__1 DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER I FLOOR/AREA DRAIN $ INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL �( SERVICE/MOP SINK ___3 ._____I TOILET URINAL _......... _—( -- __.1 1 .._-..__i i _ ._._1 ..-__._I ..._..-. i rl WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER -_ i - I -__.._.( INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESffq'NO E IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER —+ AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this 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 complia a rovision of the / Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# IGNATURE 4.14 MP�jp D CORPORATION R# PARTNERSHIP P# LLC COMPANY NAME W,��,�>��.r� --��,;�� ��-�— ADDRESS CITY I 'STATE - ZIP Ol cam.��--� TEL �1�1 j^_(o�t1 9C FAX CELL�� f EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 7/,z - a ji i n � D a ' The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information \. Please Print Le0bly Name(Business/Organization/Individual): �?��l�tc.M �C`�r raw 1� ?,\3rnb\sy ti rti Address: g h City/State/Zip:_ Phone#: L Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction loyees(full and/or part-time).* have hired the sub-contractors 2.B11 am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.F1 Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.[i Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date. Job Site Address: 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 requiredunder 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 hereby certto under thepains andpenalties ofperjury that the information provided above is true and correct. - Si ature: Date: a �a Phone#: `1 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# 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#: Q * j 4 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-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,not the 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 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 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, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massa.,cnosetts Department ofIn-dustriai Accidents Office of Investigations 600 Washington Street Boston}MA 02111 Tel.#617-7274900 ext 406 or 1-877-MASSAFB Revised 5-26-05 Fax#617-727-7749 wwwanass.goV1dia COMMONWEALTH OF MASSACHUSETTS PLUABERS AND GASFITTERS. LICENSED ASA. MASTER PLUMBER fi i ISSUES THE ABOVE LICENSE TO: I WILLIAM. 11 HAR,, INGTDN i 08 MAPLE MIDGE RD f� METHUEN MA 01844-4166 13779 05/(1./14 156:635 . I . -') M�PN(1. 030 1 1.or.N(1. 2. R!('ORp(1FOWNLRSIII, DATE BOOK PACE Z1 IN I. Stili DIV. LOT NO. 1.0( A IIIN -7 PI INFUSE Of III III III NG OWNERS NAME NO.OF SORILS SIZIi OWNERS ADDRESS r 411-1511� BASEMENT OR SLAH ST NO AR(1111 E(-I'S NAME SIZE OF FLO()R I IKIHERS I 2 3 RD HI III DER<SN.MTE � �I SPAN DIST ANCE TO NEAREST FILM DING IXAIF.NSIONS(IF SILLS DIS I ANCE FROINA STREETDIMENSIONS(If M ISI S UIS 1'ANCE FROM IDT LINES-SIDES REAR DIMENSIONS OF GIRDERS AREA Or LOT FRONTAGE IIEIGIIT OF F(AINDATION TI IICKNESS IS BUILD11,1(iNEW SIZEOF f(XAINC, X IS BUILDING ADDITION MATERIAL OF CI IIMNEY 1S BI111.DIN(i ALTERATION 1S BUII-DIN(;ON SOLIDOR FILLED LAND WILT.BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING C(NdNECI ED TO TOWN WA'I ER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECIED TD TOWN SEWLR IS BUILDING CONNECT ED TO NA I'URAL GAS LINE LAND COST -y ES 1.H1.1 X;.CO6'r Lo tion £ � ESr. BLDG.COST 1'ER (2.FT. No y' Date EST. BLIXi.COS r 1'LR ROOM SEI'I'IC PERnlrr NO. a 04 NORTN TOWN OF NORTH ANDOVER 4. APPROVED BY: '• o.. O 3 L - 1 r c• N E F:cTCIR p Certificate of Occupancy $ ---� Bl Ir.l Itv •1 5 Building/Frame Permit Fee $ } e• <���• � • OWNERS S� Foundation Permit Fee $ (IWNERSIEI.a 1ACNU5 t Other Permit Fee $ c(mrFR.,>La C:-AyG Sewer Connection Fee o, Water Connection Fee j TOTAL i Buildinglt spector i 12 6 2 2 Div. Public Works 1� X00"pEit]ttT xo. APPLICATION FOR PERMIT TO BUIL — NORTH ANDOVER, MASS. PAGE 1 MAP "0. - -6 I LOT NO. 2 RECORD OF OWNERSHIP DATE (BOOK MAGE ZONE SUB DIV. LOT NO.' F 1 LOCATION 7 25- �'� PURPOSE OF BUILDING `p V-\` l aM OWNER'S NAME [JEL�V M f ©� NO. OF STORIES SIZE OWNERS ADDREii 3 a eCOn �`� BASEMENT OR SLAB ARCHITECT'S NAME ✓ ,f� SIZE OF FLOOR TIMBERS IST 2N0 ARD BUILDER'S NAME "7- ar-y� eC IY����t-ARp SPAN DISTANCE TO NEAREST BUILDING u\ DIMENSIONS OF SILLS DISTANCE FROM STREETPOSTS - DISTANCE FROM LOT LINES-SNS REAR GIRDERS I AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW - - SIZE OF FOOTING X '• i If BUILDING ADDITION - MATER:AL OF CHIMNEY If BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS F CODE LISBUILDING LDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY CONNECTED TO TOWN $EWER LDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS S-+��CA C PROPERTY INFORMATION S LAND COST SEE BOTH SIDES ! EST. BLDG. COST EST. BLDG. COST PER SQ. FT. PAGE 1 FILL OUT SECTIONS 1 - 2 .� EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 - 12 SEPTIC PERMIT NO. ELECTRIC METED$ MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED ■Y BUILDING INSPECTOR GATE FILED-2/ )�( ��//TT��" IUILDINO 1!{SP[L'TOR SIGNATUR OWNER OR A kI D OWNFRTELit SEE I rcRMIT ORAWMID -ciiomt=If varyl o �u > O� 5 �nO u / �O , � saYOa O' .1. c►ORTjy Town of _ Andover No. 13G 0 dover, Mass., - l 1 KE •i-y: '� w �_COCHICHEWICK '�• {i.9s Oq Oreo A 'C E BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System // BUILDING INSPECTOR THIS CERTIFIES THAT.................................... ... � ?............M+t#I S.onf....................................................... Foundation has permission to- wct........, /,T. r/.. ...�..2buil�dings on ....ti3...1........ .............SQ .......... Rough to be occupied as.............................................. ............. Z.N Q.0.W..%........... .. �0.. .......... Chimney provided that the person accepting this permit shall in every respect conform to the terms of thea Dation n file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Final Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION S S ELECTRICAL INSPECTOR Rough ......................... ................ ... . ... ............................................. Service B DING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous (Place 'on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Lc6ation No i _ �l Date A NaRTM TOWN OF NORTH ANDOVER 3?O',�`•o !•,h�0 g F Certificate of Occupancy $ _ Building/Frame Permit Fee $ • i ,SSA�I1USEt Foundation Permit Fee $ Other Permit Fee $ a Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building.lnspector 1 ? 6 Div. Public Works I I--, RMIT NO. ZZ'' APPLICATION FOR PERMIT TO BUILD***** /*NORTH ANDOVER, MA 1%1%P NO. 0 iO LOT.NO. 2. RECORDOFOWNERSHIP DATE BOOK PAGE V)NL v SUB DIV. LOT NO. LO( AlION z PIMPOSE(A=BIIIII)ING OWNER'S NAME NO.(NX SIORIUS V SIZG OWNER'S ADDRESS BASEMENT OR SLAB ARC I II I E(.-I'S NAt.IE SIZE OF FLOOR TIMBERS 1 2 3 BI IILI)ER'S NAME � I SPAN DISI ANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DIS I'ANCE FROM SfREE'1 DIMENSIONS OF I'OS IS DISI ANCE FROM LOT LINES-SIDES REAR DIMENSIONS OF GIRDERS AREA OP Lor FRONTAGE IIEIGIff OF FOUNDAll(NJ TI IICKNESS IS BUILDING NEW SIZE OF FO(YI ING x IS BUILDING ADDITION MATERIAL OF CIIIAINEY IS BOILDING ALTERATION IS BUILDING(NJ SOI.IDOR FILLED LAND W11 1.BUILDING CONFORM TO REQl11REMEN l S OF CODE IS BUILDING C(NJNECI ED fO TOWN WATER B()AND OF APPEALS ACTION, IF ANY IS BUILDING C(NdNECfED 10IOWN SEWER IS BUILDING CONNECT ED TO NA TURAI.GAS LINE INS TII('l'IONS 3. PROPE111-Y INFORMATION LAND COST ESI BI.IXi.COST PAGE I FII.LOIrrSECTIONS 1-3 EST. BLDG.COSTI'ER (j.FT. EST.BLDG.CCAS I'I'ER ROOM ELEz,rRIC ME rERS MUST BE ON OUTSIDE OF 131,111 DING SEI'TIC PERMI F NO. A T1 ACHED GARAGES MUST CONFORL.I'rO STATE FIRE REGULATIONS 4. APPROVED BY: PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR BUILDING INSPECTOR DA E FILED Azes-v OWNERS I Ell '12/ :�' �� z�� ' COKIRAELN 6/o 3 SIGNAIIIREOFOWNER(N2AlI'llNN2iL1:DAGGNT COM R.LIC# a- -'7 PERMIT GRANfED s� 19 FEAltrr NO. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. �C PAGE 1 MAP "0. LOT NO. �..� �y 2 RECORD OF OWNERSHIP DATE (BOOK 'PAGE "�. I -----�1 ZONE SUB DIV. LOT NO. LOCATION `L - PURPOSE OF BUILDING p OWNER'S NAME �CUM; Miff I ©� . NO. OF s70RiEf `7 SIZE K OWNER'S ADDRESS �2 ���� G;�� BASEMENT OR fLAScx ARCHITECT'S NAME J``` ��r / SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME "t-{---�� � Roza �t-AR p SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS - _- rOSTS DISTANCE FROM STREET DISTANCE FROM LOT LINES 51 ES REAR - GIRDERS i FRONTAGE HEIGHT OF FOUNDATION THICKNESS AREA OF LOT SIZE OF FOOTING x 15 BUILDING NEW IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND 15 BUILDING ALTERATION WILL BUILDING CONFORM TO REQUIREMENTS F CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER is BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS ��� Cf (� �� 3 PROPERTY INFORMATION �� S � LAND cosi SEE BOTH SIDES EST. BLDG. COST EST. BLDG. COST PER SQ. FT. PAGE 1 FILL OUT SECTIONS i - 3 EST. BLDG. COST PER ROOM � PAGE 2 FILL OUT SECTIONS I - 12 SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM_TO STATE FIRE REGULATIONS r-^NS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED / WILDING INSKGZOR SIGNATURE OWNER OR AUT 1 D T �f OWNER TEL/ lr E E V4aW IT ORANT90 , _- CONTR TEL1=,,-- -- --- o-27- i — Location No. i 1 % 7.— Date NORTN TOWN OF NORTH ANDOVER • s • s ; , Certificate of Occupancy $ �'�s'••°''�t�' Building/Frame Permit Fee $ s�04 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 1 Building Ins9ctor TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: O/ 2 DATE ISSUED:Agm4f ic CO 11�� SIGNATURE: Building Commissioner/I for of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: �� 1.2 Assessors Map and Parcel Number: 7S 2 -5 030 Map Number Parcel Number O 1.3 Zoning Information: 1.4 Property Dimensions: Zoning strict Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReqWred Provided RegWred Provided 1.7 Water Supply M.G.L.CAWO.. 54) 1"5. Flood Zane Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of of Record K (E 4/ �A )q tk e-S 4b Qj Name(Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Z • m Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Constrion(Zvisor: Not Applicable ❑ �te �larv0 Licensed Construction Supervisor: 0 License Number 1 Address — Zoo o Expire ion bate Sig hone 1 r 2 Registei­4 Home Improvement Contractor Not Applicable ❑ Company Name M Registration Number r Address r Expiration Date Signature Telephone SECTION 4-WORKERS COMPENSATION(M.G.L.C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building P-- Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify : Ok ; Brief Description of Proposed Work: . VINV( Qr-i (zk(S 1 N �kV1 `1oi�°t OJe-S � 7��51<NS Slp ,��j SECTION 6-ESTID4ATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY . ` Com leted by permit applicant 1. Building (a) Building Permit Fee (FO O Q Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X(b) 4 Mechanical HVAC 5 Fre Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, ®eqj l e(_ KZ,k � as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, As Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief i �e%t ,v C� Print Name (6 Si nature of Owner/A ent Date NO.OF STORIES 2 SIZE I 1J BC, C:4- BASEMENT :4BASEMENT OR SLAB SIZE OF FLOOR TINMERS 1 2ND 3 FD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE s.� •��'.Gf'1ze oma�nyyuuea� o� (j DEPARTMENT OF PUBLIC SAFETY Ik CONSTRUCTION SUPERVISOR LICEW j Humber:; : Expires :Birthdate . CS °037887.03/24/2000 03/24/196 �. Restrictp�To: 00 DANIEL,,REITANO 65 MYSTIC ST APT 224 i .� METjIUEN, MA 01844 TAORTH Town of over O y! �^ No. Y� 401 - _ �r _ - neo_ 2044 Y ZO - LA E o �` dover, Mass., COCMICKEWICK ADRAT E D S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System 08* BUILDING INSPECTOR THIS CERTIFIES THAT I.. .. Foundation has permission to erect ... ........ ........ .........:. buildings on .2.Z... .... ............ .. ....... ............. - Rough to be occupied as .. Chimney .................................................................................................................................. provided that the person accepting permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of t Codes and By-Laws relating to the Inspection, Alteration and Construction,of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION ;W., ELECTRICAL INSPECTOR Rough ..................................................................... ..................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner r Street No. x SEE REVERSE SIDE Smoke Det.