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AMERICAN CLAIMS SERVICE
MULTI -LINE ADJUSTERS
BUILDING INSPECTOR/COMMISSIONER,
BOARD OF HEALTH AND/OR
BOARD OF SELECTMAN
Building Inspector
Town of North Andover
1600 Osgood Street Building 20, Suite 2035
North Andover, MA 01845
Insured:
Nguyen
Address:
33 Sherwood Drive North Andover
Policy:
PHO 0100 62 41 35
Loss Date:
April 15, 2015
Loss Type:
Ice dams
ACS File:
32010
Claim has been made involving loss, damage or destruction of the above -captioned
property, which may either exceed $1,000.00 or cause Massachusetts General Laws,
Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General
Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the
writer and include a reference to the captioned insured, location, policy number, date of
loss and claim file number.
Ned Grady
Claims Representative
On this date, I caused copies of this notice to be sent to the persons named above at
the addresses indicated above by first class mail.
Unless we hear from you within the next 10 days, we will not be obligated to pay any
portion of this claim to you.
Date 04/17/15
7 KIMBALL LANE, BUILDING C, LYNNFIELD, MASSACHUSETTS 01940
TELEPHONE (781) 245-9516 / FAX (781) 245-1077
E-MAIL — daims.acs@verizon.net
APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1
15.
MAP h�
LOT NO. I +
2 ` RECORD OF OWNERSHIP DATEBOOK
'PAGE
ZONE R`
SUB DIV. LOT NO. A
'fmi5i'���/
84,0S. Iga(,p
I3Z!Rq
LOCATION 3a !a �p �C� �RtuP
- 1
PURPOSE OF BUILDING
t] Ci
f`F�
�JY2��j �
OWNER'S NAME
NO. OF STORIES "7
!_
SIZE , "r
OWNER'S ADDRESS \ - �X �Ua N 1��
BASEMENT OR SLAB
f10Seylr�el-j j
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS
1ST ax 2ND 3RD
BUILDER'S NAME T �, ^
SPAN
DISTANCE TO NEAREST BUILDING
1
DIMENSIONS OFFT'SILLS
a J e
DISTANCE FROM STREET o� �'
POSTS
3.IT
DISTANCE FROM LOT LINES - SIDES 3-�, Co2 / REAR f/0!
GIRDERS
1 ^ S
AREA OF LOT coo RX SQ pr FRONTAGE 3TJU /
HEIGHT OF FOUNDATION
O / THICKNESS IV
IS BUILDING NEW 7_�l�Ov
SIZE OF FOOTING
O /O X `2
1
IS BUILDING ADDITION N
MATERIAL OF CHIMNEY
m . \
IS BUILDING ALTERATION ' \
IS BUILDING ON SOLID OR FILLED LAND 30L, 1
WILL BUILDING CONFORM TO REQUIREMENTS OF 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
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS 1 - 3
PAGE 2 FILL OUT SECTIONS 1 - 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CON ORM TO STATE FIRE REGULATIONS
PLANS MUST BE FIL P Y B ING INSPECT R
s
DATE 7 " /
SIGNA4trRE O R D AGENT
FEE
PERMIT GRANTED
to O
MAY 1 51997
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COSTEST. BLDG. COST
EST. BLDG. COST PER SQ. FT. CD -2 -
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BUILDING INSPECTOR
OWNER TEL. #
CONTR. TEL. # -SS3
CONTR. LIC. # 20 a 42
H.I.C. #
t
P
BUILDING RECORD
I
1 OCCUPANCY 12
SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
MULTI. FAMILY OFFICES _ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA -
APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
CONSTRUCTION
2 FOUNDATION 8 INTERIOR FINISH
CONCRETE _ 3 1 2 13
CONCRETE BL'K. PINE _
BRICK OR STONE HARDW D
PIERS PLASTER
_ DRY VJALL I
UNFIN.
3 BASEMENT_,
AREA FULL FIN. B'M'TAREA _
'h 1/2 % FIN. ATTIC AREA _
N_O BM'T FIRE PLACES _
HEAD ROOM MODERN KITCHEN
4 WALLS I 9 FLOORS
CLAPBOARDSB 1 2 3
DROP SIDING CONCRETE �_
WOOD SHINGLES EARTH _
ASPHALT SIDING HARDW D
ASBESTOS SIDING _ COMMCN
VERT. SIDING ASPH. TILE
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY ATTIC STRS. & FLOOR _
BRICK ON FRAME
CONC. OR CINDER BILK.
STONE ON MASONRY WIRING
STONE ON FRAME
SUPERIOR I I POOR
ADEQUATE I NONE
5 ROOF 10 PLUMBING
GABLE I HIP BATH (3 FIX.)
GAMBREL MANSARD TOILET RM. (2 FIX.)
FLAT SHED WATER CLOSET _
ASPHALT SHINGLES LAVATORY
WOOD SHINGES KITCHEN SINK T'
SLATE NO PLUMBING 4"
TAR & GRAVEL STALL SHOWER`.."I rr�
ROLL ROOFING MODERN FIXTURES _
TILE FLOOR
TILE DADO
6 FRAMING 11 HEATING .�
WOOD JOIST A, PIPELESS FURNACE -
FORCED HOT AIR FURN. rim TIMBER BMS. 8 COLS. STEAM E r�
STEEL BMS. & COLS. HOT W'T'R OR VAPOR
WOOD RAFTERS AIR CONDITIONING
RADIANT H'
UNIT HEATERS
.
7 NO. OF ROOMS OI L
.. .. r . 1ci crTDlr
1st 13rd I 11 NO HEATING I I _
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments 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.
****************Applicant fills out this section*****************
APPLICANT: _COB,F)e/ V ,4/iusz Phone 373- 753
LOCATION: Assessor's Map Number Parcel J�
Subdivision J A P E0 1 Lot (s) I q
StreetJle-P-U) OO I�RipF St. Number
************************Official Use Only************************
NDATI� S OF OWN AGENTS:
d �
onservation Administrator
Comments
To Planner
Comments
f� Food Inspector -Health
pt'c nspe ,or -Health
i
Comments
Date Approved 5/ 1 - ! V
Date Rejected
Date Approved`
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Public Works - sewer/water connections ,T� 7 )9 7_
- driveway permit _1216 S 7 27
Fire Department
Received by Building Inspector Date
MAY 199T-
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N0 722
APPLICATION FOR WATER SERVICE CONNECTION
North Andover, Mass. 19
Application by the undersigned is hereby made to connect with the town water main in >>Vl e✓��1� �� Street,
subject to the rules and regulations of the Division of Public Works. f
The premises are known as No. -�:3.3
or subdivision lot no. /
0.17 0 :5
Owner
Contractor
g
,373-- 753
ArMrocc
PERMIT TO CONNECT WITH WATER MAIN
l�
The Board of Public Works hereby grants permission to ��/ N h S 7
to make a connection with the water main at 154rP1—u11-19G( l J2 Street
subject to the rules and regulations of the Division of Public Works.
Inspected by
Date
B rd of Public Works
By
See back for rules and regulations
RULES AND REGULATIONS GOVERNING THE INSTALLATION OF WATER SERVICES
1. No persons shall tap or in any way tamper with water mains which are part of the distribution system of the Town
of North Andover without a valid permit from the. Division of Public Works.
2. All water services shall be installed a minimum of five feet below the finish grade.
3. No water services shall be backfilled without inspection by a representative of the D.P.W.—Telephone 687-7964.
!.'-Service connections shall be V type k copper tubing.
5. All fittings shall be brass flange type Mueller or equal
H 15202 Corporations
H 15212 Curb stops
H 15402 Three part unions
H 8185 stop and waste valves
6. Curb boxes shall 'be' installed at the property line and shall be of the Erie Type with 41/2 foot rod and brass plug
type cover.` � 1. 1/ i
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CERTIFICATE OF USE & OCCUPANCY
Town of North Andover
Building Permit Number 255 Date November 6, 1997
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 33 Sherwood Drive
MAYBE OCCUPIED AS Single Family Dwelling IN ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND
SUCH OTHER REGULATIONS AS MAY APPLY.
CERTIFICATE ISSUED TO Timberland Builders
PO Box 907 No. Andover MA 01845
ADDRESS
Building I ctor
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014t &MManwettlo of Maosar4ustas Permit No. 'f z
19epartment of public §tfetg Occupancy & Fee Checked l • u
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 .also (leave blank)
t,
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK,s
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��
(X& or Town of NORTH ANDOVER To the Inspector of Wires:
The udersigned applies for a permit to perform the electricalworkdescribed belo ry
L
�(—thT �-d' G C
Location (Street & NumberL')I �
Owner or Tenant
Owner's Address �J/r �' `�� �✓ jyP� /�� 0
Is this permit in conjunction with $ building permit: Yes ❑ No ❑ (Check Appropriate ^
Purpose of Building t /� Utility Authorization!�_��S
Existing Service Amps _J Volts Overhead ❑ Undgrnd ❑ No. of Meters
New Service Amps —J Volts Overhead ❑ Undgrnd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No. of Lighting Outlets
9 9
No. of Hot Tubs
No. of Transformers Total
KVA
No. of Lighting Fixtures
Swimming Pool Above In-
grnd. ❑ grnd. ❑
Generators KVA
__7No.
No. of Emergency Lighting
No. of Receptacle Outlets
of Oil Burners
Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of ,Zones
No. of Detection and
Total
No. of Ranges
No. of Air Cond.
tons
Initiating Devices
No. of Sounding Devices
No. of Self Contained
No. of Disposals
No.of Heat Total Total
Pumps Tons KW
No. of Dishwashers
Space/Area Heating KW
Detection/Sounding Devices
Local Municipal Other
❑ Connection ❑
No. of Dryers
^1
Heating Devices KW
g
No. of No. of
Low Voltage
No. of Water Heaters KW
Signs Ballasts
Wiring
No. Hydro Massage Tubs
No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES L' NO C I
have submitted valid proof of same to the Office. YES = NO Z If you have checked YES, please indicate the type of. coverage by
checking the appropriate box.��
INSURANCE C BOND C OTHER G (Please Specify)
(Expiration Date)
Estimated Value of Electrical Work $ _
Work to Start
Signed under the Penalties of perjury:
Inspection Date Requested: 2 Final
FIRM NAME LIC. NO.
Licensee ew I w Signature LIC. NO. 13Y�'Z
r / Bus. Tel. No. y -2 S - Z3-6
Address J AllTel. No.
�
J/�/o
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insuran a coverage or its substantial equivalent as re-
quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Ownqr. Agent
(Please check one) ` ,l
Telephone No. PERMIT FEE 5 (�
(Signature of 0wner or Agent) x-6565
�•
sr.4
Date.....
+
1673
NORTH
°f<'`°.;•�"°
-. ..
TOWN OF NORTH ANDOVER.05'
'
• -
PERMIT FOR WIRING
A
5
,SSACNUS�
S
This certifies that
......... b.Y1........�.................................................. ...t:..:..:.
has permission to
perform .......&I,P ....!I'
�'. p'1. �{.`.!
wiring in the building
of .. .......f.. .:..,� :`..
ri
at .1 - i...1 ........
...................... . North Andover, Mass.
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ruu
Fee
Lic. No. l....�Y.. .........................:......... .........
C
ELECTRICAL INSPECTOR'
WHITE: Applicant
CANARY: Building Dept. PINK: Treasurer
Date.A .... -7
N2 1915 ........2.............
NORTH
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
7SgACHU
This certifies that ......
has permission to perform
wiring in the building of ......1...........................................
K .1 ....... .............. . North Andover, Mass.
at,.%3? ..... V.J.� ......
Fee"Z:RL::-:� ......... Lic. No/'??./!... . .........
�7 — *— EL� A**L* 1* N**S' P*'E* C—T, 0**R"'
10/12/99 12:24 35.00 PAID
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
!L-� X( • Olke use Only _. ,
ahc (401nmonwtalt of MUSUC411atts Permit No. 1 !a/-6
19tyariment of Vublic %fttg Occupancy 8 Fee Checked
BOARD OF FIRS PREVENTION REGULATIONS 527 CMR 12:00 �J90 peeve blank)
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 9/29/99
City or Town of NORTH ANDOVER To the inspector of Wires:
The uderelgned applies for a permit to perform the electrl'cal work described below.
Location (Street b Number) 33 SHERWOOD DRIVE
Owner or Tenant THAN NGUYEN
Owner's Address (978) 974-9202
Is this permit In conjunction with 4 building permit: Yes ❑ No ® (Check Appropriate Boit)
Puzgose of Building - Utility Authorization No.
Existing Servk;e Am Volts Overhead ❑ Undgmd ❑ No. of Meters
Amps _. J
htew Service • /imps _,_! Wits Overhead ❑ Undgmd ❑ No. of Meters
Number of Feeders and Antpacity
Location and Nature of Proposed Electrical Work
No. of hu Outlets No. of M T1,bs No. of ltunforrnen Ibis!
o Lighting . -
No. of Lighting Fixtures Swimming Pool A�qrnd,e❑ � ❑ Oensrators KVA
No. of Emmency Lighting
No. of Receptacle Outwits No. of ON Burners • Baum Ur"
No. of Switch Outlets No. of Das Burners FIRE ALARMS No. of Zones
No. of Air 'ond. 15W No. of Detection and
7No. of Ranges tons Inidau" Devices
No. of Disposals No.d TOW
� Tions KW No. of Sounding Dsdces -
No. of Self Contained
No. of Dishwashers, SpecefArw Heating KW Do c-lorV3ounding Device*
Municipal
No. of Dryers Heatkq Devices KW Local ❑ Connection ❑ounr
No. of No. of LOW lbltape
No. of Water Heaters KW 819 Waste vnp BURGLAR ALARM
No. Hydro Massage 'Ribs No. of Motors TOW HP
OTHER:
.INSURANCE COVERAGE.• Pursuant to the requir*msnts of Massachusetts generN Laws -
1 have a current Uabiflty bwxsnoa Paley kwkx tnp Completed Operations Cove"* or its substantial equivalent. YES O NO O 1
haw submitted valid proof of same to the Office. YES O NO O If you haw c wd" YES. please Indleate the type of coverage by
ehoddng the appropriate boot.
INSURANCE 0; BOND. O OTHER Q (Pleas* SP6d1yi -- - � (Expiration Oats) .
�
Estimated Value of 214.00
Work s 10/1/99
Wbrk to Start 9/28/99 • Inspection Date Requested: Rough Final
Signed under the Penalties of perjury: 1 t r
FIRM NAME UC. NO.
Ucensee Donald A- Arnnlcrt Signature uc. No.. 123u'
Bus. W. No.
Address 111 Mora& Street Norwood, MA AII. W. No.
OWNER'S INSURANCE WAIVER: 1 am aware that the License+ doe* net have tin Insurmw4 *overage or Me substantial equivalent as re•
qulred by Massachusetts General Laws. and that my sipnature onth►— s perno application waives this requkertnnl. owner AO"
(hers* chock one)
.. Tolephon No. �_ PERMIT FEE t _35.0 _
r3lenuur•_d Owna._or AaoM1 •.ntltS
%MASSACHUSETTS UNIFORMAPPLICATION 'PLUME1
IT JD0
(Type or Print)
NORTH ANDOVER Mass.
Date:
Building Locations 3 S4eOLj'oo fD. Permit V.,V-7/i
Owners Name 'r(/ 79e4PP-D
New Q Renovation Replacement Plans Submitted 9,
7`-
F T UREq
ip
(Print or Type)
Check one:
icate"
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Installing Company Name kli& 1Y ror M Cor
Address 31 Partner.
11,0_14t ag
Firm/Co.
Business Telephone
Name of Licensed Plumber:
z -
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy `--t-'Other type of indemnity Bond 0
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of 1"!
this application does not have any one of the above three insuronce coverages.
Signature of owner/agent of property Owner E] Agent"ti,.o
I hereby certify that all of die details and information I have subiniticd (or entered) in atmove application are true and 4rugatc to thc best of Inv
knowledge and that all plumbing work and installations lictformcd under reentit ksucd for this application will be in costoptiance with all pcglinefit rsa.,4
witiOns of the Massachusetts State Plumbing Code and chapter 142 of die General Laws,
B
Title. Signature of Licensed Plumber4.
CitTown: �2 16C)<(Xype of Plumbing License �je
Y/
f.LAPPROVED TOFFICE USE ONLY) License Number ❑ Master Journeyman
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1ST FLOOR
2ND FLOOR
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31113 FLOOR
4TH FLOOR
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STH FLOOR
6TH FLOOR
7TH FLOOR
13TH FLOOR'l—n
(Print or Type)
Check one:
icate"
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Installing Company Name kli& 1Y ror M Cor
Address 31 Partner.
11,0_14t ag
Firm/Co.
Business Telephone
Name of Licensed Plumber:
z -
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy `--t-'Other type of indemnity Bond 0
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of 1"!
this application does not have any one of the above three insuronce coverages.
Signature of owner/agent of property Owner E] Agent"ti,.o
I hereby certify that all of die details and information I have subiniticd (or entered) in atmove application are true and 4rugatc to thc best of Inv
knowledge and that all plumbing work and installations lictformcd under reentit ksucd for this application will be in costoptiance with all pcglinefit rsa.,4
witiOns of the Massachusetts State Plumbing Code and chapter 142 of die General Laws,
B
Title. Signature of Licensed Plumber4.
CitTown: �2 16C)<(Xype of Plumbing License �je
Y/
f.LAPPROVED TOFFICE USE ONLY) License Number ❑ Master Journeyman
- 3471
Date.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that . 1A,, f.'.( <. F. - ... (i 4� .c. !'� ?�j'' ......... g
has permission to perform .../A, f .. (`r� !�'^ �........... . . . �
plumbing in the buildings of ......... . .
at. . 135.� e%:: t, -s-.4 x�,. c ............. , rth Andover, Mass.
Fee -'/0...- .. Lic. No.d. !. U .`% . vi
r.
PLUMBING INSPECTOR
g'
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
(Print of Type) " ^` "'�` rvry 1 -VH PERMIT TO DO QASFITTINQ
NORTH ANDOVER c�
.Mass. Date
g
Locatlo, Permit #
Locatin ��� c S� �i��d o �
Owner's
Name T7 -')Li 3 7D eq
New Renovation p Replacement t7
Plana Submitted:. Yes Q No Q
sun—ssMT.
• •ASEM,kNT
1sT FLOOR
irrO.FLOOR
311 FLOOR
ITH FLOOR
STH FL0011
4TH FLOOR
7TH FLOOR
STH FLOOR
'.
Installing Company Name G✓f1/� A� �J ye�jt�/ � dco Check one: Certificate
Address 21 P/,Tre o (3i Q Corp'
d Partnership
p Firm/Co.
Business Telephone
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:Check one
1 have a current liability Insurance policy or its substantial equivalent. Yes O
If you have checked yea, please Indicate the type coverage by checking the appropriate boxNo O
A liability Insurance policy `` Other type of Indemnity D Bond D
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not hay® the Insurance coverage required by
Chapter 112 of the Mass. General Laws, and that my signature on this permit applicallon waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner D Agent D
I hereby certify that aq 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 Installallons performed under the pewi
pertinent provisions of the Massachusetts Slate Gas Gbd nd of
enrmit Issued for this application 11 be M oom Ilan wl
eY
Title
Clty/Tgwn
IIPPr1 mo (OFFICE USE ONLY)
e a Chapter 112 the Geral LAWS. p a lh all
T of License:
PPlumber
GasOtler gna uta o cense um er or aseI r
Master
Journeyman Lkense Number 2i0 0
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Installing Company Name G✓f1/� A� �J ye�jt�/ � dco Check one: Certificate
Address 21 P/,Tre o (3i Q Corp'
d Partnership
p Firm/Co.
Business Telephone
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:Check one
1 have a current liability Insurance policy or its substantial equivalent. Yes O
If you have checked yea, please Indicate the type coverage by checking the appropriate boxNo O
A liability Insurance policy `` Other type of Indemnity D Bond D
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not hay® the Insurance coverage required by
Chapter 112 of the Mass. General Laws, and that my signature on this permit applicallon waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner D Agent D
I hereby certify that aq 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 Installallons performed under the pewi
pertinent provisions of the Massachusetts Slate Gas Gbd nd of
enrmit Issued for this application 11 be M oom Ilan wl
eY
Title
Clty/Tgwn
IIPPr1 mo (OFFICE USE ONLY)
e a Chapter 112 the Geral LAWS. p a lh all
T of License:
PPlumber
GasOtler gna uta o cense um er or aseI r
Master
Journeyman Lkense Number 2i0 0
149633 Date.. � .
�..�.. f
NORTH 1
TOWN OF NORTH ANDOVER
py`,.to ,e tiOL
p
PERMIT FOR GAS INSTALLATION
9SSAcmUSE
f`
This certifies that 1 �-2 r:...D�4 ........... .
has permission for gas installation ...! e ...0 ....
in the buildings of .................�.
at �. S1f.` �Z .�. G �........... , North Andover, M..
Fee.. j, Lic. No..'.�`f..b....... .
AS -INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
48 f ✓'V /
Date. ......... ......
_.: ,�pRTM TOWN OF NORTH ANDOVER
r3: ' PERMIT FOR GAS INSTALLATION
W /' • °oma _, . 7
`/.. . �� V `
� This certifies that ..1`:. f ................ r _
S has permission for gas installation .f- " . ........... .
in the buildings of :.0 r> .....................
tv
" at North/Andover, Mass.
Feed .`.. Lic. No��7G
.....
......
GAS INSPECTOR .
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MAP Z � �� j ��� • � � D�
_ 74:2
4ASSA CATON FOR PERNQT TO DO GAS FMING
or print) Date 19
1vUKIH ANDOVER, MASSACHUSETTS
Building Locations ��-1Z�.xx"� K� V` Permit #�
Owner's Name
New ❑ Renovation ❑ Replacement ❑
Amount S
Plans Submitted ❑
(Print or type)
Name
Name of Licensed Plumber or Gas Fitter R - .
Check one: Certificate Installing Company
❑ Corp.
armer.
❑ Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No
If you have checked ves, please indicate the type coverage by checking the appropriate box.
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:
Signature of Owner or Owner's Agent `�` Owner ❑ A2ent ❑
I hereby certify that all of the details and information l have submitted (or entered) i • ab e application are true and accurate to the
best of my knowledge and that all plumbing work and installat' F%rme n�e.DPe it Issued for this application will be in
compliance with all pertinent provisions of the Ivlassachus s Stat as a II at) r 142 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Li`:c`� ed Plumber Or, Gas Fitter
Plumber. l VAP 'i
fEl-Gas Fitter License i umoer
Master
Journeyman