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HomeMy WebLinkAboutMiscellaneous - 33 COLUMBIA ROAD 4/30/2018w w n 0 r C W D .Z7 O D v Date ... !.:;�' 1.1-7.c:-3 ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..-:Ta!! M5.... `..`�.`.�.r.......I— .............................. has permission to perform ........0. � �.� A S ............................................................ wiring in the building of ........5`.'.....�h�.......................................Q!Z 7at ....X...3.... ........... .P................ . North Andover, Mass. ( � p # - Fee.... . ... Lic. No3S 66yl; ....... ... .......�I.... ... ELECTRICAL SPECTOR Check # t5 -)o 4913 Offc' I U e Permit Nd.m BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupanc7&ee Chec APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all information) , Date C) ' To the Inspectdr ofWires: Town of North Andover I The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number Owner or Tenant Owner's Address Is this permit in conjunction with a building permit Yes 0 Purpose of Building Existing Service (�C) Amps /r} Volts New Service Amps Voits Number of Feeders and Ampacity Location and Nature of Proposed Electrical Gw4� f S'�r l; c ti I' No S--" (Check Appropriate Box) Utility Authorization No. Overhead 41*�— Undgrnd 0 r No. of Met( Overhead 0 Undgmd 0 No. of Met( No. of Lighting Outlets No. of Hot fuse Total No. of Transformers KVA No. of Lighting Fixtures Above a Svvimmi Pool and a In a rnd a Generators KVA . of EmergencyLighting. No. of ReceptaclesNo. Outlets No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone _ No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No. of Diposal No. Pumps Tons KW No. of Sounding Devices _ NoJ of Self Contained No. of Dishwashers S Area Heating KW Detection/Sounding Devices _ No. of Dryers Heating Devices KW 0 Municipal 0 Other Local Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wiling No. Hydro Massage Tuds No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Lavas I have a current Liability Insurance Policy includi mpleted Operations Coverage or its substantial equivale YES NO = have submitted valid proof of same in the OffiYE = NO s If you have checked YES please indicate the type o coverage by checking the appropriate box. INSURANCE - BOND - OTHER - (Please Specify) a y ,I (Expiration Date) Estimated Value of. Electrical Work$ Work to Start Inspection Date Resquested_ Signed under the Penalties of perjury: FIRM NAME �<\ LIC. NO. . �( c LIC. NO. 211101Z Z 81x5. /'�� � Tel No. t i w `Oy � 37 Address clus ��� K Alt Tel. No. _�`��� —er74 —& } a' OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Mass General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) (Signature of Owner or Agent) Telephone No. PERMIT FEE $ w The Commonwealth of Massachusetts Department oflndustrial Accidents Office of investigations Boston, Mass. 02111 Workers' Compemation.lnsurance Affidavit Name Please Pri;rt Name: Location: City Phone # I am a homeowner performing all work myself: I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees worldng on, this joi Company name: Address Qttr Pfne Insurance Co. Policy Company name- Addrps. if Faik" to secure cooverage as required urs Sedion 25A of MGL 152 can lead tvthe i nmWon of akraw perces CCA and/or one years' FmWisornient_as_wedas::cbal-ulheSorm � 51�]P fnesa€ flQja f understand that a copy of this statement may beforwarded to the office of kn estigetiom of the DA for coverage verdJaMoh. / do hereby c&W wxAar the pans acrd pwmffies of perjwy hW #* MamabonprovA*d above is true and caomect Signature Date ► Print name Phom-# Official use only - do not write in this area to be completed by city or town official- City or.. Town Remu7/Licer�sirg.. DCheck d /rrnnede&- response is required �JaL1 p Sol Contact person: Phone # Het OU Town of North Andover Building Department 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 0 APPLICATION FOR CERTIFICATE OF OCCUPANCY I INSPECTION ADDRESS I33 (,4"" �Y'2 LOT NUMBER SUBDMSION DATE REQUEST FILED till �g 1 Da, DATE READY FOR INSPECTION a 12.1 O FIVE (S) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN OFF'S MUST BE COMPLETED WITHN THIS TIME .. FRAME. A RE-INSP O OF TWENTY-FIVE ($25.) DOLLARS WILL BE CHARGED IF DOES NOT MEET ALL APPLICABLE CODES. SIGNATURE LAr OFFICIAL USE ONLY ROUTING CONSERVATION RX"I PLANNING DATE D.P.W. — WATER METER DATE 162� D.P.W. MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED THE INSPECTION REST DATE. .0 /7 TION Location .-3 Co %M -P,/ No. 62 2 0 Date 11-a)- 0l TOWN OF NORTH ANDOVER � ` A Certificate Occupancy $ of CMUsE<� Building/Frame Permit Fee $ Foundation Permit Fee $ f Other Permit Fee TOTAL Check # f7 � 15'175 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT kPPLICATION TO CONSTRUCT REPAIR,: RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 3UILDING PERMIT NUMBER:. DATE ISSUED. ! _ ® © r iIGNATURE: ia--limn rr%mmiccinnPr/Incni--tor of BuildinES Date >L'1.11V17: 1-Jlllc uarvniat�aavi. M 1.2 Assessors Map and Parcel Number: 1.1 Property Address: 3:3 RX Not Applicable 0 License Number r 'Expiration Date Map Number Parcel Number Not Applicable 0 _ 1.3 Zomig Information: Registration Number 1.4 Property Dunensiobs: . R y�i tonin District Use Lot Area (sf) Front f `e 1 . 1.6 BUILDING SETBACKS ft Yard Rear Yard Front Yard Side Regttiired Provide *Required Provided R red Provided 1.7 Water Supply M.GLC.40. 34) zone 1:3. Mood Zone information: . outside blood Zone 0 1.8 S —raga Disposal System Municipal On Site Disposal System r 11 ?ublic Private 0 SECTION 2 - PROPERTY-OWNERSMP/AUTHORIZED AGENT 2.1 ofR�eco�rrdd % tO�w�n/e�r v, Name (Print) Address for Service WSignature Telephone 2.2 Owner of Record: dam � 1 SST - CONSTRUCTION SERV Address for Service: 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone 167-3711 3.2 Registered Home IrrtKI Company Name Address M Not Applicable 0 License Number r 'Expiration Date Not Applicable 0 M 1100 eacEmz Registration Number Expiration Date 7 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 .......0 .......0•, .- . SECTION 5 Desert tion of.Pro. osed Work `check , ,a licable) New Construction 0 Existing Building Ir Repairs) K Alterations(s) 0 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other 0 Specify Brief Description of Pro/posed Work: / �'�Y� ea � ry��'�-/ttr �57� �'�� `yam �"�1`•in ,,S"�, -CAS �'in� k,r� G SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to beNO s Completed brmit applicant 1. Building (a) Building Peimst Fee 2 Electrical b ,O estimated Total Copt of Construction 3 Plumb in _ , zs� Building Permit fee - (a) .x (b) 4 Mechanical HVAC 5 Fire Protection 1 ao 6 Total 1+2+3+4+5 i g-bkz- oa SECTION 7a OWN`TER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT L 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 OWN ER / AU T HORIZEDTION as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true accurate, to the best of my knowledge and belief rint Name / S�lature of bi'merLeIGgent Date NO. OF STORIES SIZE BASEMENT OR `SLAB SIZE OF FLOOR TIMBERS 1 2 RD 3 SPAN DR,4ENSIONS OF SILLS K ONS OF POSTSONS OF GIRDERSOF FOUNDATION THICKNESS OOTING X L OF CHIIVINEYNG ON SOLID OR FILLED LAND ING CONNECTED TO NATURAL GAS LINE North Andover Building Department Tel: 978-688-954.5 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: V (Location Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector V INiiL- r'; -I JY.. ,—sir•,,,,..,-.. s•.f� ri Loranger, Robert 165 High St. Billerica, Ma. 01862 SO I 11/5/2001 Tonnage exceeded weight limit:_ _wV 11/5/2001 ' 15238 SC I 33 Columbia Rd. N. Andover, Ma. C.O.D. 11/5/2001 10/29/2001 3.29 80.00. ! 263.20 { Do not overfill containers, they will j not be picked up. Repairs for damage on containers which are I moved will be billed to the -' customer. i$ 3 � 1 ".,� � p � it aF- x -• ` � � � XV i `�" a �h a�� � � u, � �•� �.� a�.+e.4a.,�. 14, R E bth,., N... ........ - Y Loranger, Robert 165 High St. Billerica, Ma. 01862 x T" i 110/29/2001 Pick up & disposal of 40 yard_open top container. Includes disposal of up to 6 tons. rel: ry Payment received on account%„ 5F i Do not overfill containers, they will not be picked up. Repairs for,%, + damage on containers which are moved will be billed to the icustomer. I . WE APPRECIATE YOUR BUSINESS. 5'C Dl,E BALAr t - CHARGE Ut 10/30/2001 14874 SC 33 Columbia Rd. N, Andover, Ma. C.U.D. ; 10/30/2001 10/29/2001 650.00 ; 650.00 -650.00 133 -650.00 FROM :,.JOHI-,,' MC..'BRIDE 1,10. 0"."1 !72, !.4 16", 111,(In I 1"11f I I'M I PR 1(. A,, M'i.% 01,8(' ;,.Q•p ti ';C(10010-01 v . 4w-, f'1Av3H1 1 �i IN' I . td Pi )iU OrTSM, =7- i T ' LI -� — 111;itl, ldil:d L-- .13.45. o i.4 M11 P(:bLIC)".111ERIOD,.. Thc pulli.'NImiod lis !rola Hl'/27/2001t lo IL.11 /dvL �toi!dasd hNA1. Workers compon<.ation ilic pol to Workers f. mqX'w- l I loll 1 ani' trO (hu, if tecl h'2r"'. "vh);'. achwwlts Emplr*yer5 1. iaNllty rojicv appl'ies to work in cach statc nmed III i!vlm 4 11C limit; ol'("mr liabi!ity 1.111dCl- TWO f3odfly fiijm-) 6y Accidew ,$1{I{) (11;{} accidcllt 130th}( 111jury by Di+Cat;c W(''00() poh(:" I'l-Il)f f i i slotcs hl"llt"Ince; VzIl-t I hllie: of the policy ilpf)lhes li) Out'atc"';Jfzlnvlisied lwrc: IN (A j07L; pulic.\ illdides these nini "DRE"M rfor MUNI: The prelniurl this pcl ict will be -&-tcrn-1 ncd t -,,y OLIF of ocms. Rate,; and Ratm P�ans. All 1pfmmaticm required below . i, I() V� .111 Ica I on �"md c 11a 11 L�c by —1(, —'; Min D'ask R�j(�. P�.-r Fst i n" �i 1'�d A I I n I In'l as, s" F1 C' I 1 T! sl Sce WC 00 (116 01 indicoted bdow, int)nrm �djuslments of pr-einitly'n Tni Li m for Increased 1, imits p(1m Tv,r), Ji'applical-Av iall be made— �'Otal Premium Sub jc'�t to the Fxpe1-;QT)c.f" Nif)"'Ification s Nlc-dificd to r"Cilco E-q..'erietic.Q. 'N'16d, of r --i F— Standard, Pr., mium A DIA A -ss V) Expense (-.'onstint Ch-')rge Tot al.!-:516imved Annual 'illimium I'll -l -nim -11 S13 Tol'al Esonnatcd Annual Prfl.nw jj-.7 � 112 4 ame of'P.toduccr: JI-OHN MC RRIDF I N.S'. !')','A M J" - 7— STY)(111 Y,-, TWO TIAR .M ;ON' WAY, FREEHOLD, N.J. 07-28 TIMS INFORMAiiON ' 16C, Vffli FUR (0:011LANSA I VYN �%.ND V.-IIIALON NO. I I l"O,,URANCE POL[C."Y UNDORSEMUNITS, if- A.NY, ISS(TI)TO F(-)R'il A PARly 1,11URPOI cc), ,\If LL i i-"= H* NUN16).: VOIA(:Y. COV) KKAI V 1987,1NA HCANNAL iNCIL ON YN jf\,I it NNCF. Wf 00 Fit, V I A 17; 7 L S El l -,S Ems fl, CO) 2 0: 00 �\�@ co 2 > .2 LU (L IX SIX S E C) Z z 0 < .j . } 04 0 0: I- 0) , }LL J�o 00 Oz ailb- \ ) 0 \CL x !2 z A ul W UJ he w Lu LU w \}/: �� � � � � \ . Ems fl, 0 m m m m 0 m MU0 m N CCD O CCD mm P C CD y. CL v y CO CD I S- CA O 1 Z CD O O CD O CCD cn O rD cn ry� (D m►n G a w ;u GQ ro : p w `�. � PV pGp C�i :v p ;u O � "� :v w n � Co� PO G oa ►n G cn b c O CL n dy o omi 0 9 0 c .3655 ri r 36, Date.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... T F ............................................................ has permission to perform ... kxe. r?. .4.......... . & Tt... P- r/ ... wiring in the building of ......... fv-) C k 0 6 ... ....... .................... .......... . ....... at ...... ................ North Andove S. Fee.. :.. Oj Lic. No. .......... ................. ELECTRICAL INSPECTOR Check # TIM009MMOlW WEE4LTHOFAL4MCffRI M DEPARTMFNTOFPUBLICS MY ' . BOARDOFFIREPRE EWONR gJLATIOAUS527t912-M Office Use only Permit No. S Occupancy & Fees Checked 1 u A'LICATIDNF4R J-'.ERMITTO PERF'ORMELECI'RICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat t 3. Zoo Z Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street &Number) 32 Ul,, l- i e'd Owner or Tenant AV , 777. o 7 /a 777 i Owner's Address Is this permit in conjunction with a building permit: Purpose of Building �Gr,la�/'lpj Yes Lllj No " (Check Appropriate Box) Existing Service 60. Amps Ze/ Novolts New Service Amps / volts Numbgf of Feeders and Ampacity Location and Nature of Proposed Electrical Work AP A,4 Utility Authorization No. _ Overhead Underground No. of Meters Overhead Underground No. of Meters No. ofAtighting Outlets No. of Hot Tubs No. of Transformers Total .. No. of Lighting Fixtures /7 Swimming Pod KVA Above Below Generators KVA vv - ground ground No. of Receptacle Outlets No. of oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets y� No. of Gas Burners No. of Ranges No. of Air Cond. Total FIRE ALARMS No. of Zones T - No. of Dishes No. of Dryers No. of Water Massage Tubs OTHER KW No. of Heat TOW Total No of Detectionana Ptunps T06KW Initiating Devices ` Space Area Heating KW No. of Sounding Devices No. of SelfCotttaiued Detectiun/SoitWing Devices Heating Devices KW Localconnections Municipal Other �. No. of No. of signs Bailasis No. of Motors Total HP 1lmrartoeCaer� Ptsstrantbthetat�tiarla�atMa�dit>st�C�a�aelLavus . [ha%catamotLiabkhmm=Pckyatru&g cawo=isa*amtdgmda>t yB NO [hawWb ni1WdMMp1 ofaf§M1D#C011 t Y1N NO FjcubmedtedaedMplem*tcitsiethetypeaf000Wbydukngte INSURANCE M BOND anut 0 NcdcbStatt I Z UbqxcfimDEieReWe*d e EiedvaitecalWctk$ j�DD Rough-- fM t a l , -Fret Iioamm i t�D N49 Li==]go 'd/. 44 I %J BtsrtmTd.Na - - eo g trite �� D ✓U Gli/ )/(�/t [ t�9- d l �Ll A1tTe1Na ��' / �Q �0 3 IWNF�t'SWSURANCEWANFR;Ianat�methattheLioen9ed=not ve$veinsslrmetnaaagetric et�nvalagaste db�,M Laws check one) Owner Agent ' Telephone No. PERMIT FEE Date ` ........... TOWN OF NORTH ANDOVER V. PERMIT FOR PLUMBING �.......... This certifies that ........................ . has permission to perform --'Id-.-: . ................. . plumbing in the buildings of 6.-� at. ............ , North Andover, Mass. Fee. n . . Lie. No..�2.F z^' ........... PLUMBIN"GNSPECTOR Check # 0Z-- U i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location 33 ',4 /% �fC,,04 /07r, New 1:1 Renovation Replacement FIXTURES Date +®2 %" alp Permit # Amount I Plans Submitted Yes 0 No (Print or type)�L d O/ � �f �f Check one: Certificate Installing Company Name ' �1 ❑ Corp. Address '/v��P �'V Ati • Partner. usmess a ep one 979- G 97 S:r7 S/ 01-*Firm/Co. Name of Licensed Plumber: �AL j�/� /�L Dz>/ ",j Insurance Coverage: Indicate the typ insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State. umb' Code d apter 142 of the General Laws. By:Signa u'�e�o se um er Type of Plumbing License Title 91 ea o2 City/Town icense um er Master Joumeyman ❑ APPROVED(OFFICE USE ONLY i Date ........ ............ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ;his certifies that ... . ........... . ' has permission for gas installation *i`h the buildings of ..!`..'.... /C x� at :..` ....... ......:............... . North Andover, Mass. Fee.. .... Lic. No...,,: ?-.. .::-�,� �! ........ . GAS INSPECTOR Check # . r-- 3:7LI f� MASSACHUSETIS UNIFORM APPLICATON FOR PERMiT TO DO GAS FITTING _ (Type or print) Date 7 -- 0� NORTH ANDOVER, MASSACHUSETTS % Building Locations C-0 la -17,61,f I Permit # 3 Owner's Name New ❑ Renovation Replacement ❑ Amount $ '-4r1c, s�- Plans Submitted ❑ (Print or t),pe) --, �. �GQ �/N �� c one: Certificate Installing Company Name ` �f j Corp L.J Address '�� N'v �' ❑ Partner. Business Telephone 9%k 4 el 7 J ----7k 04LCo. Name ofLicensed Plumber or Gas Fitter 7/9L %P// z0 JP/,0V INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No❑ If you have checked yes—please in ' the type coverage by checking the appropriate box. Liability insurance policy b7 Other type of indemnity ❑ Bond ❑ ,. J Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one. Signature of Owner or Owner's Agent Owner ❑ Agent ❑ 1 .---Uy a ci u y mai .u, of um uctaus anu imormanon 1 nave summuea (or enwrea) 1n auove application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. )wn LOVED (OFFICE USE ONLY) 40% SigniiGe of Licensed Plumber Or Gas Fitter Plumber C��a Cuts Fitter License Number Journeyman , ,4TH. FLOOR (Print or t),pe) --, �. �GQ �/N �� c one: Certificate Installing Company Name ` �f j Corp L.J Address '�� N'v �' ❑ Partner. Business Telephone 9%k 4 el 7 J ----7k 04LCo. Name ofLicensed Plumber or Gas Fitter 7/9L %P// z0 JP/,0V INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No❑ If you have checked yes—please in ' the type coverage by checking the appropriate box. Liability insurance policy b7 Other type of indemnity ❑ Bond ❑ ,. J Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one. Signature of Owner or Owner's Agent Owner ❑ Agent ❑ 1 .---Uy a ci u y mai .u, of um uctaus anu imormanon 1 nave summuea (or enwrea) 1n auove application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. )wn LOVED (OFFICE USE ONLY) 40% SigniiGe of Licensed Plumber Or Gas Fitter Plumber C��a Cuts Fitter License Number Journeyman y` TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that 1"Oe� ... has permission for gas installation ................. in the buildings of .. T etw tI .- ......................... at ..3.� .��.�: �1! `? ...P ....... North Andover, Mass. Fee. c? Lic. No..:?. 3-3?.... PS INSPECTOR Check # % t � � (! 4314 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING�`s (Print or Type); , 0 , Mass. G Building New ❑ Renovation ❑ Owners Type Replacement (gam )Z' Eeii ,�0CN T i Iq Submitted: Yes❑ No ❑ Installing Company Name :2r- eg T A . ` AM AAA TA �U Check one: Certificate Address 3 0 Oo A c H m A. ,%j -i -NI . ❑ Corporation M E T H U E 0 01 rl 01 ❑ Partnership Business Telephone /d,92 — 5 9 "7 f 2-,firm/Co. Name of Licensed Plumber or Gas Fitter -. r) I E P T A- 5 A m M fq i A & D INSURANCE COVERAGE: I have a current I' bility insurance policy or Its substarttial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked ve, please indicate the type coverage by checking the appropriate box A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the pe - ed for this application be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ne Laws. BY T%ler f License: C� mber rt ure of cen u or Fitter Title tter License NumberCitylTownurneyman O 1 N Y • • WOMEN Installing Company Name :2r- eg T A . ` AM AAA TA �U Check one: Certificate Address 3 0 Oo A c H m A. ,%j -i -NI . ❑ Corporation M E T H U E 0 01 rl 01 ❑ Partnership Business Telephone /d,92 — 5 9 "7 f 2-,firm/Co. Name of Licensed Plumber or Gas Fitter -. r) I E P T A- 5 A m M fq i A & D INSURANCE COVERAGE: I have a current I' bility insurance policy or Its substarttial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked ve, please indicate the type coverage by checking the appropriate box A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the pe - ed for this application be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ne Laws. BY T%ler f License: C� mber rt ure of cen u or Fitter Title tter License NumberCitylTownurneyman O 1 N NI W S 6i F- I W Y N !-A � m J d Q Z F Y. N Q. J O Z O O D W O V :F Ous O z d oc s O O z O � J ~ W a m V J d Q W W W NI W S 6i F- I W Y N !-A � m J d