HomeMy WebLinkAboutMiscellaneous - 34 OLD VILLAGE LANE 4/30/2018co Q
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that - C....�0. 1... �� /�
.. :............................,-...................................................
perform ........, . , �.. .......... .... ....:.. :.....................
has pernussion to . f.. f.:
wiring in the building of.,,...,..1
at �./ ....... UJ/...� v l � ......... ,North Andover, Mass.
Fee.....: z-�.L....... Lic. No. �70/U
ELECTRICAL INSPECTOR
Check # S�
' Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. iml (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 PRINT IN)NK OR TYPE ALL INFORMATION) 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) ?q d 1 j li i I Imo, p (u r► e
Owner or Tenant Rubef t Bar nc'h_" Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes R No El(Check Appropriate Box)
V
Purpose of Building w e l f c✓1 Utility Authorization No.
- Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Vndgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: rema,.e 0Ad re nnovn i'
5c'rvic-r0A111d �c✓' SiOddie,
Completion ofthefollowing table maybe waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- E]
rnd. rnd.
No. o Emergency Lighting
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
Tons
No. of Alerting Devices
No. of Waste Dis posers
p
Heat Pump
Totals:
Number
" '
Tons " ""
'"' "" " KW
' '
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security
Device s or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wtres.
Estimated Value of Electrical Work: I,D0d (When required by municipal policy.)
Work to Start: %_ I6 - I S Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties ofperiury, that the information on this application is true anti complete.
FIRM NAME:. ill a J1 LIC. NO.: I q0o
Licensee: ISignature LTC. NO.: 140 10 6
(If applicable, enter "exempt" in the license number line) Bus. Tel. No.: G i 7 �% J_ 00 /7
Address:1Z u S5 v.e- OAodwn / q /l 040 1 Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires D artment of Public Safety "S" License: Lic. 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 agent.
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
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed 4
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 0
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass IN
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass IN
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSP CTION:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date: > r — - / J
DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com
F
The Commonwealth of Massachusetts
_ 0 Department of IndustrialAccidents
EV I Congress Street, Suite 100
_ Boston, MA. 02114-2017
�< www.massgov/dia
Workers, Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING .A.UTHOitIT1'•
please Print Le0b
A''licant Information
�4
Name (Business/Oigai&ation/lndividual): 1 (V1 ✓1
Address:
City/State/Zip: g Ol ifU3 Phone #: C13
56 5 0 G tl
.. < ,.. . �.
Are you an employer? Check the pPropriate box:
Type of project (required):
l,�am a employer with employees (frill and/or part-time).*
�corisiruction
7. Vemode,
��,
2. F1 I am a sole proprietor or partnership and have no employees Working for me in
8, 11t1g
any capacity. [No workers' comp. insurance required.]
9. ❑ Demolition
3. ❑ lam a homeowner doing all work myself. [No workers' comp. insurance required.] t
10 ❑ Building addition
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
insurance or are sole
11. ❑ Electrical repairs or additions
ensure that all contractors either have workers' compensation
1e6` 11• oy' ees.
12TEj.pjMnbjng repairs or additions
proprietors with no mpl
5.❑I am a general contractor and 1 have hired the sub -contractors listed on the attached sheet.
have workers' comp. insurance.t
13•_ 0 Roof repairs
These sub -contractors have employees and
14.n Other
6. Q We are a corpozatiori and its. officers have exercised their right of exemption per MGL c.
152 61(4) and we Have no employees: [No workers' comp. insurance required.]
*Any applicant that check's box #1 must also 511 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 state whether or not those. entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. ' f �����
Insurance Company Name: �-(
Policy # or Self -ins. Lic. #:.
Expiration Date. 7 -10 11
Job Site Address: l
I 4 Ane 4 f{-nc/a/ -e/-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 MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a
and/or one-year imprisonment, as well
ay be forwarded to the Office of Investigations of the DIA for insurance
day against the violator. A copy of this statement m
verification.
Ido hereby certifyunderyepai ndpenalties
Phone #: CTI f
the information provided above is true and correct.
i
r,a+P• q-!/- S
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
Issuing Authorrity (circle one): i
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 trusted 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 b6 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 xequiired."
Additionally, MGL chapter 152, §25C(1) 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 wb'contractor(s) name(s), address(es) and phone number(s) along with their certificates) 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. B e 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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in(city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 61.7-727-7749
Revised 02-23-15 www.mass.gov/dia
w
/z, 2- 7—//
Date..................................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ................................... ..........
has permission to perform ...... /, i
.............. .............................
wiring in the building of ........ ........... ............
at..;V ... all.,v ...... 4,,0—
.......... ..
....... .............................. .North Andover, Mass.
Fee ... ...... ;�� Lic. ......
ELECTRICALIpEcm
Check #
-10561
i.
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. p. 143, § 3L, the
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.01.2. 143,,5 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 entitystated 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
puipose 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 trough August 15, 2012.
i
8 — Permit/Aate Closed:
0 Permit Extension Act — Permit/Date Closed:
*** Note: Reapply for new permi
Commonwealth of Massachusetts Official Use only
Department of Fire Services Permit No.
Occupancy and Fee Checked
y BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank
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 PRINT IN INK OR TYPE ALL INFORMATION) Date: DCC 27rfl X16
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)S � 62W Z-XA�Z
Owner or Tenant I� �j Telephone No. 665
Owner's Address S/C
Is this permit in conjunction with a building permit? Yes ❑
Purpose of Building L741,eu-/A16
No ® (Check Appropriate Box)
Utility Authorization No.
Existing Service ACU Amps 40 / a�Volts Overhead ® Undgrd ❑ No. of Meters-7—
New
etersNew Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
2
!CL 2! ?4w-4 �,
Comnletion ofthe following table may be waived by the Insnector of Wires_
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
o. oTotal
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ n- ❑
d. grnd.
o. o Emergency Lighting
Battery Units
No. of Receptacle Outlets ��
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
o. of Detection an
Initiating Devices
No. of Ranges
No. of Air Cond. Total Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
umber
*
TonsKW
... ......._
... ` .
o. of Self -Contained
Totals.
I
I
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municippi ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security ystems:
No. of Devices or Equivalent
No. of Water
KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or E uivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
a ecommumcations inng•
No. of Devices or Eq uivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electric Work: x700 (When required by municipal policy.)
r
Work to Start: Z // Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE VERAGE: 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 ains and pen ii of perjury, tha a information on this application is true and complete;
FIRM NAME: the
e; 77g0NN/.f �.L'/C LIC. NO.:
Licensee:G,WGC ll�/A 1*e^/,t// S Signature LIC. NO.:
(Ifapplicable, ester "exempt" in the li ense number line.) w Bus. Tel. No. -,-'%'1A C
1A e
Address: L LGI.,(,&V 1!gZZW�-?QA/ �n/9T Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's a ent.
Owner/Agent PERMIT FEE. $
Signature Telephone No.
890,0
r'
r10RTM
/°- 9
SSAOMUS�
This certifies that
Date .l./d
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
has permission toperform.../.7.Ca
plumbing in the buildings of.._�—.C6-4•.... h.�'.... .
at. fC'.. V s �.� ....fQ ...... North An over, Mass.
.rZ. . t
PLUMBING INSPECTOR
Check #
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or Print)
NORTH ANDOVER, MASSACHUSETTS
� Date
Building Location 014 &&419 U Owners NameS'd1NPIV) t ,&Y94PA,97r Permit #
�H Type of Oxupancy 01A&L i A-) 6 Amount
New ❑ Renovation ❑ Replacement El . Plans Submitted Yes ❑ No
FIXTURES
(Print or type) c Check one: Certificate
Installing CompanyName HALLO RAWU Corp.
Address &r ,(, -ST- ❑ Partner.,
1--lOaOTh,s4A1-0or!e-/L_ 14 ,4 , 01$Y5
Business Telephone 3P 7& — 0', ❑ Firm/Co.
Name of Licensed Plumber. 70-.,v 1Ioil �`i
InsuranceCove U: Indicate the type of insurance coverage by checking the appropriate box
Liability insurance policy ElOther type of indemnity 11 11❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee ofthis application does not have any one ofthe above
three insurance
Signature Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in above application ane true and accurate to the
best of my knowledge and that all plumbing work and installations perfarmed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Phrmb' Code and Chapter 142 of the General Laws.
83' r o rcens um er
Title
Type ofPlumbing License
�
City/Town cense f4amoer Master ❑ Journeyman]
APPROVED (oma usE oNLY tG-�
7 6 7,; Date. .il.10)/!t....... .
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
n • qh
This certifies that .. !../`J �.
� � P, //- . 4
has permission for gas installation ....... .. ..l . .
in the buildings of . �'!��..... �k .�% �f . 7: � ..........
at ..7� ... C'w ..V Northdover, Mass.
GAS INSPECTOR
Check # 10�
i
M"ACHUS"UNIFORMAPPLICATONFORPEBMT4DQGAS IMING
(Type or per) Date
NORTHANDOVER, MASSAOHUMM
Building -Locations AL' Permlt u
Amoumrt S
.�fi/U e4 % ,41 Pl W 47--7- Owner's Name
New f'l Renovation r-1 Replac:em"M rkl Plans Submitted
(Print or We)
O Carp.
rfa ni c o= Ceriificatabstalling Company
Name 7
Address d- 13 o X 5 7 aZ 0 Panner,
44wR tr✓ rP z
Business Telephone i7 6 b'S` 5-0 yFnnm/Co
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy orit's substantial equivalent Yes El ME]
Ifyou have checked yes, please indicate the type coverage by checking the appropriate box
Liability insurance policy -0 ' Otheriype ofindeuu ity. M Bond
OwaePs InsuranceWaivw.. 12m aware that the licensee does not have the Insurance coverage rewired by Chapter 142 ofthe
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
I hereby cer* that all ofthe details and infimnation I have submitted (or mtered) in above annunatinn ara iniP and armiraSP to +m,P
best of my knowledge and that all plumbing work and installations performed under Permit issued for this application v iill be in
compliance with all pmtineat provisions ofthe Massachusetts State Gas Code and Chapter 142 ofthe General Laws.
(OFFICE USE ONLY)
Signature ofLicensed Plumber Or Gas Fitter
10 Plumber �( V 9 33
rl Gas FittericL� ense Number
er
ItIMer
Ej Journeyman
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SUB-BASEM ENT
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BASEMENT
1ST_ FLOOR
ZND. FLOOR
3RD. FLOOR
4TH. FLOOR
STH. FLOOR
6TH. FLOOR
7TH. FLOOR
8TH. FLOOR
(Print or We)
O Carp.
rfa ni c o= Ceriificatabstalling Company
Name 7
Address d- 13 o X 5 7 aZ 0 Panner,
44wR tr✓ rP z
Business Telephone i7 6 b'S` 5-0 yFnnm/Co
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy orit's substantial equivalent Yes El ME]
Ifyou have checked yes, please indicate the type coverage by checking the appropriate box
Liability insurance policy -0 ' Otheriype ofindeuu ity. M Bond
OwaePs InsuranceWaivw.. 12m aware that the licensee does not have the Insurance coverage rewired by Chapter 142 ofthe
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
I hereby cer* that all ofthe details and infimnation I have submitted (or mtered) in above annunatinn ara iniP and armiraSP to +m,P
best of my knowledge and that all plumbing work and installations performed under Permit issued for this application v iill be in
compliance with all pmtineat provisions ofthe Massachusetts State Gas Code and Chapter 142 ofthe General Laws.
(OFFICE USE ONLY)
Signature ofLicensed Plumber Or Gas Fitter
10 Plumber �( V 9 33
rl Gas FittericL� ense Number
er
ItIMer
Ej Journeyman
Date.lele- .1 w........ .
ON
TOWN OF NORTH ANDOVER
'PERMIT FOR GAS INSTALLATIO
This certifies that ...f�.eewle.Arx..4 .1 ........... ..
has permission for gas iinstAllatiion . /sr" Anne, .
in the buildings of ..Ah? r. &'44e_h� ................
at
ort -Andover;- Mass.
Fee. XP . Lic. No.(rM�.SV . ....... .
GASINSPECT
Check #
7976
0
i
nye r-rl -- In in —M
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 Yes No ❑
If you have checked Yes, please indicate the type of, coverage by checking the appropriate box below.
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
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
c. ,��,.,.o : n,.. . ,,,._ �- ^---• Owner ❑ • Agent ❑
„a.� auu„nttvu ter encereai regaMing tnis application are true and
accurate to the best of my ybtedge and that all plumbing work and installations performed under e' milt issued for this application will be In
compliance with all Pert o ov(sion of the Massachusetts State Plumbing Qade
_ V V / -
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town: 6 MA. Date:
Type of License:
Permit#'
Building Location:34 046 LJd ll/��-E Ll� OwnersName:
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
New: (�Alteratlon; ❑ Renovation: 0 --/Replacement: ❑ Pians Submitted: Yes ❑ No ❑
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 Yes No ❑
If you have checked Yes, please indicate the type of, coverage by checking the appropriate box below.
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
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
c. ,��,.,.o : n,.. . ,,,._ �- ^---• Owner ❑ • Agent ❑
„a.� auu„nttvu ter encereai regaMing tnis application are true and
accurate to the best of my ybtedge and that all plumbing work and installations performed under e' milt issued for this application will be In
compliance with all Pert o ov(sion of the Massachusetts State Plumbing Qade
nd Chapter 14� of th General Laws.
By
Type of License:
❑ Plumber
titre
❑ Gas Fitter
❑Master
Sig ature .of Licensed lumber/Gas Fitter
Cityrrown ` '
[]journeyman
License Number:
APPROVED (OFFICE USE ONLY)
❑ LP installer
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7 FLOOR
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installing Company Name: 'Nit
Check One Only Certificate #
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Address: � � 11 icy ` ! 1`�ll T j
IN � - C1tyRown: I � bt7/-G r<�0 State: r
LJCor oration
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Business Tel: l (K ._.7711- Fax: _ � `77
El Partnership
Firm/Company
�/
Name of Licensed Plumber/Gas Fitter: c=C V I L�-
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 Yes No ❑
If you have checked Yes, please indicate the type of, coverage by checking the appropriate box below.
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
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
c. ,��,.,.o : n,.. . ,,,._ �- ^---• Owner ❑ • Agent ❑
„a.� auu„nttvu ter encereai regaMing tnis application are true and
accurate to the best of my ybtedge and that all plumbing work and installations performed under e' milt issued for this application will be In
compliance with all Pert o ov(sion of the Massachusetts State Plumbing Qade
nd Chapter 14� of th General Laws.
By
Type of License:
❑ Plumber
titre
❑ Gas Fitter
❑Master
Sig ature .of Licensed lumber/Gas Fitter
Cityrrown ` '
[]journeyman
License Number:
APPROVED (OFFICE USE ONLY)
❑ LP installer
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ESTIMATED COST OF JOB Z! 7, CSS
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IMMEMAN CA,
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14 WAYNE RD
MAL
The Cominottivealth of Massachu.s•etts
print Form
I i Depai-Intent of Industrial Accidents
Office o, j'Investigations
,.; I Con-ress Sheet, Suite 100
' 4 a Boston, iYIA 02114-2017
:.i Ivlvly 111(iss.goMdia
Workers' Compensation Insurance Affidavit: Builders/Contractoi•s/Electriciatis/Pltttnbet-s
Annlicant Information Please Print Legibly
f � j
Name(I3itsinessi0rgmtiratiotttlndividual); �'c1 j � .J� 1J�'�, �h; =�, If�4i- 1-�'r:r ���j'/,t �•
Cit} /State/Zip: �'i i / ,L -,, l .i.: > /'•� Phone #i:
A you art employer? Check the appropriate
box:
I . am a employer Nvith / H;
4• ❑ I ani a general contractor and I
employees (full and/or part-time).%
have hired the sub -contractors
2. ❑ 1 ant a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working forme in any capacity,
employees and have workers -
[No workers' comp: insurance
Collip, insurance."
required.]
S. ❑ We are a corporation and its
3.0 1 ani a homeowner doing all work
officers have exercise(i their
myself. [No workers' condi..
right of exemption per MGL
insurance required.] '`
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
I i.❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ -Other _„ r c `/ ',i. %. _It''
'Any applicuu that checks bo.x 111 must also tits out the section below showing their workers' company tion policy infornntion. !'
I W111Cnw'oers Who submit this affidavit indicating they arc doing; all wok and then hire outside coil o:aetors must submit n nem nflidavit indicating such.
'Contractors thnt check this tim must attached an addilioiml sheet showittig lite, name orUtc suh•eonntactors and state whether or not those entities hm'c
employees. If the sub. contractors hnvc employees. they must provide their workers' comp. policy number.
1 ant (tit entpinper thtit isprovi(ling Ivorhers' compensation jimirem ce for• my employees. Belmv is the policy andjoh site
itilbrtttation.
Insurance Company N
c r'
Police ii or Self-it7s. Lie. #:
l Ex �irntion Date G�%
t} C_7 I' <•
1013 Site Address: `� �, �t 11 City/State/Zip:0 _.. Jj6Jt /
Attach a copy of the. Fvor•I<ers' coil] perrsatiwr policy declaration page (showing the policy number anti expit-atiotr'dltc).
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 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a clay agatja the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIAk''fot lsurance cQyerage verification.
I(Io h
mitts
Med the iu%ortnatiort/trovided abotte is inq (111(1 eorrCC,
71.. f` ,..fir:, ,.
OJrlcial trse o» ll-. Ido not write hr t/tis rrrerr, to be completed hp Citi, or torpit official.
City or Town. Permit/License 9
Issuing Authority (circle one);
I. Board of Health 2. Building Department 3. City/T'owrl Cleric
6. Other 4, Cleetrieal Inspector .>. Plumbing Inspector
Contact Person:
__ Phone 9:
!J(
Date. �`T„"�.7 .........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........ A ...... ..............................................................
.4 tl
has permission to perform ........ -7." .............. .......
wiring in the building of.. 4-n ._v—`-
.........................................................
at—?� ................. 1% . ......... North Andover, Mass.
Fee. J .............. Lic. No.,AvIt.: .........
ELECTRICAL INSP
Check # 0700 IICTor
7288
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No.
Occupancy and Fee Checked
[Rev. 1/071 (leave blank
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 PRINT IN INK OR TYPE ALL INFORMATION) 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) 3q ow u((�6e Ln^16
Owner or Tenant
Owner's Address
Telephone No.
=W6 `3J34
Is this permit in conjunction with a building permit? Yes D& No ❑ (Check Appropriate Box)
Purpose of Building Z 3/ffr /-Ve O1 -MI VV Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑
New Service Amps / Volts Overhead ❑ Undgrd ❑
Number of Feeders and Ampacity
No. of Meters
No. of Meters
Location and Nature of.Proposed Electrical Work: Z. j prvj koy0l),4; IN
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
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑In- Elo.
rnd. rnd.
o Emergency ig mg
Batter Units
No. of Receptacle Outlets 2
No. of Oil Burners
FIRE ALARMS
[No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
InitiatingDevices
No. of Ranges
No. of Air Cond. Total Tons
g No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Number
Tons
KW
No. of Self -Contained
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
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
�Da Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: Gl/r (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: LIC. NO.:
Licensee: Signature 0,,- LIC. NO.: �� �
(lfapphcable, enter "exempt" in the license number line.) Bus. Tel. No.:
Address: 2-01 WE'CL.t W4 AfAL", / Ot771 Q&9*15W' /JVf GlFi(p3 Alt. Tel. No..93t-25-7,
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. 1 am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE. 9 -Z74 -r—
•
PAJ
TOWN OF NO
PERMIT
11
Date. 'r!,�. ?� �. .
ANDOVER
FOR PLUMBING
This certifies that . 17. �'3 �,� .4 :`• • • P!k •/-/ ......... • •
has permission to perform ... Re7 h: o. � .,(+ ............... .
plumbing in the buildings of '.—
.................
at ... 3 y . �? (. `J...'�! �. f ............ North Andover, Mass.
Fee. Lic. No. /. :?! ? .. L :..... .
PLUMBING INSPECTOR
Check # G
7338
IN
'MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print a Type)
Mass. Date Permit 7.7
Y Building Locatlon W Owners Name,=lsrf
Type of occupancyT � iT
c67 /
New ❑ Renovation '❑ Replacement Plans Submitted: Yes O No 2-
FIXTURES ,
Installing Company Name' r r a ��rr
�s��t ese' 1�-�K¢s e�r��a����ee�w
Address 272 KENOZA STREET
Business
Name of Licensed Plumber
Check one:. Certificate
❑ Corporation
.❑ Partnership
❑ hnwco.
INSURANCE COVERAGE:
I have a current ility insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes El No ❑
If you have checked yn. pleaseindicatethe 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 taws, and that my signature on this permit application waives this requirement.
Check one:
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 the permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of oral Laws.
ae df Uoenstd Firimbdt'
Title / 2"00' Type of License: Master D Journeyman 2
City/Town I.��%/�
l L License Number „ .
4
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Date ... &l..:.�
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ..1.'...�� `: • �`t 7< • �......... -�', C
............ .................. ............
has permission to perform ........ :. G ........ r ..................................
wiring in the building of ........ �..�.......
-F I- IV
at ......%/....................................... . North Andover, Ma
��... Lic. No, ......��..�.... c
Fee...?........... �'t..�' ...L..........
ELECTRICAL INSPECTOR
Check #
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
.14
The Commonwealth of Massachusetts otttee Use Durr my�
Nrait b.
Department of Public Safety
occupancy' a Pee Cheered
lug BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 12:00 3190 (leave bunt)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All .wk to be performed In accordance with the Maseaehasette EJeOrieal Code, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE AI.,L//INFORMATION) Date A) ` D /
Town of Mass. /l/0�7'`'� 144 C16 mer To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Stree
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit: Yes Lf No Lam' (Check Appropriate Box)
Purpose of Building `/0 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
Location and Nature of Proposed Electrical Work
OA7
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers Total
KVA
No. of Lighting Fixtures
No.
Above ❑ In -
Swimming Pool grnd. grnd.
Generators KVA
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting
Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection and
Initiating Devices
No. of Sounding Devices
No. of Self Contained
Detection/Sounding Devices
Local ❑ Municipal ❑Other
Connection
No. of RangesNo.
of Air Cond. Total
tons
No. of Disposals
No. of pumps Total Total Tons KW
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
Heating Devices KW
No. of Water Heaters 11W
No. of
Signs f Ballasts
Wirinoltage
No. Hydro Massage Tubs
No. of Motors T)tal HP I
OTHER: ��DD / Z l LTJ 7 In J (J— /` L . of )7L/t 7L
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Li bilis Insurance Policy including Completed Operations Coverage ori substantial
equivalent. YES EF NO []� I have submitted valid proof of same to this office. YES a NO ❑
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
INSURANCE ZBOND L-1 OTHER L] (Please Specify)
Estimated Value of Electrical Work S C% U
Work to Start �0 ' ^ V Inspection Date Required:
Signed under the penalties of perjury:
FIRM NAME
Licensee
Address
` xpiration Date
Rough / Final (�
LIC. N0, 14101 Y06Y
OWNER'S INSURANCE -WAIVER: I am aware that the Licensee does not have the insurance coverage or its
stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit
application waives this requirement. Owner Agent (Please check one)
PERMIT FEE S 3s
(Signature of Owner or Agent) Telephone No.
M Office Use Only
The Commonwealth of Massachusetts 33�
P.roit b.
Department of Public Safety
Occur'ancy 6 Fee Qrccked
BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 12b0 3/90 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code. S27 CMR 12:00
(PLEASE.PRINT IN INK OR TYPE ALL INFORMATION) Date /0 - IJ- 0
Town offtjpb Mass. ItlQ-A 14,J ppb `er To 'the .Inspector of Wires:
The undersigned applies for a pesnit to perform the electrical work described Delon.
Location (Street & Number)
Owner or Tenant
Owner's Address
— q9,f !.t rh "
Is this permit in conjunction with a building perm( : Yes ❑ No E3'0'� (Check Appropriate Box)
Purpose of Building Z' O Ll f.(__ Utility Authorization NO.
C
Existing Service Amps / Volts COverhead ❑ Undgrd ❑ No. of Meters
4
New Service Amps / Volts Overhead ❑ Undgrd ❑, No. of Meters
;Number of Feeders and
Location and Nature of Proposed Electrical Work
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers Total
KVA
No. of Lighting Fixtures
Swimming Pool Above ❑ In-
grad. grnd. UCJ
Generators KVA
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting
Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALAR+%S No. of Zones
No. of Detection and
No. of Ranges
No. of Air Cond. TotalN
tons
Initiating Devices
No. of Sounding Devices
No. of Disposals
No. of pecans Total Total
"
Tons KW
No. of Self Contained
Detection/Sounding Devices
Local ❑ Murilcipal
Connection❑Other
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
Heating Devices( KW
No. of Water Heaters KWf
prq r
Signsa;lasts
Low Voltage
Wiring
No. Hydro Massage Tubs
No. of Motors T)tal HP !
OTHER:
/��
' r
INSIJR,ANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Li bilit Insurance Policy including Completed Operations Coverage or i s substantial
equivalent. YES NO I have submitted valid proof of same to this office. YES
S Q NO ❑
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
INSURANCE 2 BOND L._J OTHER M (Please Specify)
xpiration ate
Estimated Value of Electrical Work S .0 U
Work to Start 1 Inspection Date Required: Rough Final C l
ZZ
Signed under the penalties of perjury:
FIRM NAMEf� � ;A
�`i C. LIC. NO.
r
Licensee '//eSignature %/7,2,-a E , LIC. NO.
Address -3-2 Tn(d n .J� 1 /�UCe�J4, 61 0 Bus. Tel. No. �—�/,�I- � %C� �yCi3
C Alt. Tel. No-. f=UPL =
OWNER'S INSURANC- 1AIVER: I am aware that the Licensee does not have the insurance'coverage or its sub-
stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit
application waives this requirement. Owner Agent (Please check one)
Telephone No. PERMIT FEE S �� r `� O
(Signature of Owner or Agent
(}
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTI G
(Print or Type)
NORTH ANDOVER ,Mass. Date
(Print or Type) Check one: C:ertlticate
Installing Company Name PN Corp.
Address J39 S& OrPartner.
10L P' /% t?/� S� Firm/Co.
Business Telephone: s�/7/ �/y
Name of Licensed Plumber or Gas Fitter�/'T
Insurance Coverage: Indicate the type of i')surance coverage by checking the
appropriate box:
Liability insurance policy Other type of indemnity Q Bond �(
have been made aware that the licensee of
Insurance Waiver: I, the undersigned,
this application does not have any one of the above three insurance coverages.
Signature of owner agent of property Owner D Agent M
I heteby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of MY
knowledge and that aU plumbing wort and installation pm
crfoted under Permit issaed to, this application will -
provisions
with ai! peztiaeat
provisions of tho Massachusetts State Cas Cnde and CLApter 142 of the General Laws.
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
TYPE LICENSE:
Plumber
Gasfitter'�7SignaturtetLicensed
Master PlumberGasfitter
Journeyman -� y_�
License -Number
FIY.TU
building Location
.3 4/ o4D d �// �t;e ��NE Permit
#
Owners Name
s
New Renovation
�] Replacement �] Plans Submitted
P
r CVe
a
(Print or Type) Check one: C:ertlticate
Installing Company Name PN Corp.
Address J39 S& OrPartner.
10L P' /% t?/� S� Firm/Co.
Business Telephone: s�/7/ �/y
Name of Licensed Plumber or Gas Fitter�/'T
Insurance Coverage: Indicate the type of i')surance coverage by checking the
appropriate box:
Liability insurance policy Other type of indemnity Q Bond �(
have been made aware that the licensee of
Insurance Waiver: I, the undersigned,
this application does not have any one of the above three insurance coverages.
Signature of owner agent of property Owner D Agent M
I heteby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of MY
knowledge and that aU plumbing wort and installation pm
crfoted under Permit issaed to, this application will -
provisions
with ai! peztiaeat
provisions of tho Massachusetts State Cas Cnde and CLApter 142 of the General Laws.
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
TYPE LICENSE:
Plumber
Gasfitter'�7SignaturtetLicensed
Master PlumberGasfitter
Journeyman -� y_�
License -Number
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2140 FLOOR
3RD FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR
TTH FLOOR
STH FLOOR
__ ±___ I
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(Print or Type) Check one: C:ertlticate
Installing Company Name PN Corp.
Address J39 S& OrPartner.
10L P' /% t?/� S� Firm/Co.
Business Telephone: s�/7/ �/y
Name of Licensed Plumber or Gas Fitter�/'T
Insurance Coverage: Indicate the type of i')surance coverage by checking the
appropriate box:
Liability insurance policy Other type of indemnity Q Bond �(
have been made aware that the licensee of
Insurance Waiver: I, the undersigned,
this application does not have any one of the above three insurance coverages.
Signature of owner agent of property Owner D Agent M
I heteby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of MY
knowledge and that aU plumbing wort and installation pm
crfoted under Permit issaed to, this application will -
provisions
with ai! peztiaeat
provisions of tho Massachusetts State Cas Cnde and CLApter 142 of the General Laws.
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
TYPE LICENSE:
Plumber
Gasfitter'�7SignaturtetLicensed
Master PlumberGasfitter
Journeyman -� y_�
License -Number
i
` Date .. � .. . .......... .
?4.
NORTN TOWN OF NORTH ANDOVER
p; �.ao .e 1ti0
p PERMIT FOR GAS INSTALLATION
y'SS�cHusEt - �
This certifies that .... , �' % .: '`. ±......................"I
has permission for gas installation . ! r , :... ' .. ' ............ .
in the building_ s of ..�D- �.` t . ............... .
at .... c ! ..... f . % ,!!�` ! ! <. .c.. , r' l.! :-� , _ North Andover, Mass
Fee./_ .. Lic. No. �, . � "1,� � ......................... i
<< j GAS INSPECTOR
WHITE: Applicant ATVARY: Building Dept. PINK: Treasurer GOLD: File'
7
Say State Gas Company
Ll
GAS INSTALLATION AUTHORIZATION
t-4) Qate ✓�1��
Issued to D t ao J
Address
For Installation of:
BTU Input
Restrictions
BSG Representative
PERMIT ISSUED _ BY
INSPECTOR
This Portion of Authorization To Be Returned to BSG.
Inspection Has Been Made of the Following Gas Equipment:
❑ Heating System (BTU Input ) ❑ Range
❑ Water Heater ❑ Clothes Dryer
❑ Room Heater
Location
All Work Has Been Done In Accordance With The Massachusetts
State Gas Code And Is Ready For Use.
a
NECESSARY
IF MAILEO
IN THE
UNITED STATES
NO POSTAGE
BUSINESS REPLY CARD
FIRST CLASS PERMIT NO. 721 LAWRENCE, MA
73
POSTAGE WILL BE PAID BY ADDRESSEE
BAY STATE GAS COMPANY
ATTN: SALES DEPT.
55 Marston Street
Lawrence, MA 01840
NECESSARY
IF MAILEO
IN THE
UNITED STATES