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HomeMy WebLinkAboutMiscellaneous - 36 MILTON STREET 4/30/2018zo 010 C2 tz �z R: ( cn lirl (D t- :71 C/) kl, 4w C3 "o A06 CD IM C2 CD 0.,Q C3 O cr %< — CD 0-40 =r CP CD C3 CD P. M c D CD co) M CA CD ca CD O • CD CD zo 010 tz �z R: ( cn lirl (D t- :71 C/) kl, GO CA N CA 0 It 0 c Date... //-.- dl. A-5 . . . ... .. . .... .. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This t-,-rtifss-e that .�� —0 ... I ....................................... has permission for gas installation ............ in the buildings of ............... .............. at ..... .......... North Xndover, Mass. Fee Y/. ..... Lic. No. Check GAS INSPECTO�� 5338 (Print or Type) JD0 V -V2_ Mass. Date `A / 20 O 4—Permit# 1,J Building Location-? 6, /Q A) -4--4-:1—�"Owner's Name e� i ted o9 /740 /V^ 6'8. ` Owner Tel# %7A- � " I,Z � % .S /'')_/ Type of Occupancy o 3 d New ❑ Renovation ❑ Replacement a Plan Submitted: - Yes❑ No FIXTURES Mk Installing Company Name _,LtivTG 61 t �G ,, + 41 l J Address Business Telephone # ✓ ?ZC, 3ee- 2 3 4/J"' Check one: Certificate ❑ Corporation ❑ Partnership * Firm/Co_ Name of Licensed Plumber or Gas Fitter �E ,it, INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGt Ch_ 142. Yes ® No ❑ If you have checked yes, 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 permit issued for this application will be in compliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By Type of License: & Plumber Signature of Licensed Plumber or Gy4t Fitter Title ❑ Gas fitter o Master License Number City/Town ❑ Journeyman APPROVED (OFFICE USE ONLY) a�oii� � moi MEi o�u�o oo� you Installing Company Name _,LtivTG 61 t �G ,, + 41 l J Address Business Telephone # ✓ ?ZC, 3ee- 2 3 4/J"' Check one: Certificate ❑ Corporation ❑ Partnership * Firm/Co_ Name of Licensed Plumber or Gas Fitter �E ,it, INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGt Ch_ 142. Yes ® No ❑ If you have checked yes, 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 permit issued for this application will be in compliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By Type of License: & Plumber Signature of Licensed Plumber or Gy4t Fitter Title ❑ Gas fitter o Master License Number City/Town ❑ Journeyman APPROVED (OFFICE USE ONLY) Date. _ c�HO" T.�ao TOWN OF NORTH ANDOVER ..w SAWO PERMIT FOR PLUMBING This certifies that -Yz.. ....!... ........................ . has permission to pet form >..................... . .s. plumbing in the buildings of ................ .............. at `.....f oh Andover, Mass. Fee-�'),,t..... Lic. No.,H<..`��.. -. !..... i. ...... . L PLUMBINGPECTOR Check # 6690 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) `// J-C� W =A, • 41V Do U -tp— , Mass. Date //Os - City, OS -City, Town Permit # Building Owner's AT: Location .3 6 n., i o .n.1 -�" T Name ZZA, o .4 Z,1 n Az Z7Jl,�ti tu Type of Occupancy: 'e? C, J New ❑ Renovation 21 Replacement ❑ FIXTURES Plans Submitted Yes ❑ No (Print or Type) +" Installing Company Name M t 4 Address -:r' CAJ 17` ,61 � rr -7" YS k, ti't � t Check One: ❑ Corp. ❑ Partnership Q Firm/Company Certificate Business Telephone s <t a- xs— Name of Licensed Plumber or Gasfitter /rteF,,;I —F -,L d'a kA 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 Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signature of Owner/ Agent I have a current liability insurance policy to include completed operations coverage. ❑ By Signature of Licensed Plumber Title Type of Plumbing License City/Town ,/.Z,:2 ® Master ❑ Journeyman APPROVED (OFFICE USE ONLY) License Number FORM 1240 H&W HOBBS & WARREN rM ,V, -o V m z 0 m In C A o m = � o � r N � v � � = Z -a 0 0 0 o r c 3 W z O z 0 m In Town of North Andover of NO oTM ,h ... *•. o BUILDING DEPARTMENT & INSPECTIONAL SERVICES c: •A'_ - C, Community Development and Services Divis 400 OSGOOD STREET ",.. North Andover, Massachusetts 01845s"""° a `y � cMue t hgR://www.townofnorthandover.com P (978) 688-9545 or 9534 Michael McGuire F (978) 688-9542 Building Inspector INFORMATION REQUEST Building Department Please use this form if the Building Inspector is unavailable to provide immediate assistance. Please fill out this form in its entirety to ensure an accurate and prompt response. All requests for information will be handled as soon as possible. CONTACT INFORMATION Date: Name: G'o V ch e� Phone number: %e l'1 Fax number: Address: 7—b N l _ INQUIRY - Property in question: (Please include as much information as possible) Subject: Inquiry: Thank you for your interest and inquiry. a 0.. VC6, ve, U-4 BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 d Location-3�-, No. Date NpRTh ' TOWN OF NORTH ANDOVER � 9 a ' Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL _ Check # 18716 ,�V Buildl g Inspector TOWN OF NORTH. ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING ri=g. BUR DING PERMIT /NUMBS n l DATE ISSUED: /0 SIGNATURE: Building Commissionerfl r of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Map Number Number: Parcel Number 14J. J � © 2i U2 O 1.3 Zoning Information: Zoning Dislrid Proposed Use 1.4 Property Dimensions: Lot Area Fronts ft 1.6 BUILDING SETBACKS ft Ad ssc� 4 Front Yard Side Yard / Y6 /�'� -0 Rear Yard ReqWred Provide Reqdmd Provided ReqWmd Provided 3.2 Registered Home Improvement Contractor Not Applicable ❑ 1.7 Water Supply M.G L.C.40. 54) 1.5. Public ❑ Private ❑ Zone Flood Zone Infomntion: Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record Name (Print) Address for Service: Signature Telephone 2;1 Owner of Record: Print I CRCTION 3 - [ ONCTRITV PION CF.RVICF.0 I Address for Service: 3-.-1Licensed Construction Supervisor: Not Applicable ❑ ,r2k ,f Cs— C3 y f� © 2i U2 O Licensed Construction Supervisor: License Number 41111 19 Ad ssc� 4 %D j, i� / Y6 /�'� -0 Expirdtion D ifure Telephone i j/ 3.2 Registered Home Improvement Contractor Not Applicable ❑ T�Me—,( tJv jC 4— / Company Name Registration Number n e� r MQ Li Add sse� fc J a Expirfition Aft S' re Telephone V 00 M Z O O Z M 90 O anD r M _r z G) SECTION 4 - WORKERS COMPENSATION (NLG.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check au applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify --ter Brief Description of Proposed Work: G'u -r- X (a -,)a el e- / /,C**,' �.(- L) I __ C affidavit will result Addition ❑ _ leo- /h O V Ci LJ/ -L I k Se C -7-,'d N `7- ��i✓ \% i t �j� i f� V UJ -'-J c/aw P r i SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar) to be Dollar ( 1. Building _ D a,!3 O (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing e o Building Permit fee (8) x (b) Io I c ! 4 Mechanical HVAC) 5 Fire Protection --I 6 Total 1+2+3+4+5 o A p 1 Check Number SECTION 7a OWNER AUTHORIZA ION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 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 OW R/AUTHORIZED A, -GENT DECLARATION I, Ji 0, JY► e S as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief n G, , L — �- Print I f Owner/. NO. OF STORIES I1—M "UT -1 aa1MMIM .1 SIZE OF FLOOR T MBERS 1" SPAN DRAENSIONS OF SILLS DDAENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION SIZE OF FOOTING MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 0®4 7 Z2 Date SIZE 2 ND THICKNESS X r 1� L/o fe 6 )u'r-,% W AJ J ,nl Q G- Y 3 /Vv r TV"i s i" 41t All dimensions -size designations given are subject to verification on job site and adjustment to fit job conditions. Motmini.-Blocked Window -Destiny >► 71 J This ism original design and trust not be Designed: 7/6/200 released or copied unless applicable fee has Printed: 7/11/200.` been paid or job order placed. 2 1 Drawing N; y' JAMES GOUCHER CARPENTER /-BUILDER 4.O1d Bear Hill Road Memmac MA 01860 .(978) 346-8950 Lic.# 028520 MA Reg. # 103459 TO: Linda Montminy 36 Milton St:..... _- North Andover, MA 01845 Remodeling of kitchen. Work to include: hROPO S Paee No 1 of 2 '�aees All home improvement contractors and subcontractors engaged in home improvement contracting,'unless specifically;eiempt from registration by provisions of Chapter 142 'of the general laws, must be registered with the Commonwealth i f Massachusetts. Inquires about registration and status"'should be made'to'the Director, Home Improvement Contract Registration, One Ash- burton Place, Room 1301, Boston, MA 02108 617-727-8598.Own- ers who secure their own construction related permits or deal with unregistered contractors will be excluded from the Guaranty Fund Provision of MGL c.142A. PHONE: 978-68515711—' DATE 6/13/05 JOB NAME / LOCATION: Same Gut entire kitchen and dispose. Remove partition walls in cabinet area and dispose. Remove wood flooring in cabinet area and dispose. Remove bearing wall between kitchen and dining room and install support beam. Remove section of wall at back stairwell and dispose. Install new sheetrock walls and ceiling. Prep floor in cabinet area and install new ceramic tile. Install new trim on windows and doors. Install new primed speedbase baseboards. Install new cabinets. Install new laminate counters. Plumbing, heating and gas piping allowance to be $6,000. Electrical allowance to be $3,000. Owner to supply new cabinets, counters, ceramic tile, grout and adhesive. Proposal does not include painting, structural repairs or upgrades if necessary, soffit installation above cabinets if required or cost of permit (contractor to acquire permit). r a Page 2 of 2 pages Work schedule Contractor will not begin the work or order the materials before the third day following the signing of this Agreement, unless specified here in writing. Contractor will begin the work on or about _9/15/05_ (date). Barring delay caused by circumstances beyond Contractor's control, the work will be completed by 10/30/05 (date). The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contracto shall not be considered as violations of this Agreement. Warranty The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of 1 Year following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials, or damage caused by the Contractor, his subcontractors, Employees or agents, is discovered within one year after completion of any job, including cleanup, the Contractor shall, at his own expense, forthwith remedy, repair, correct, replace, or cause to be remedied, repaired or replaced, such damage or such defect in materials or workmanship. The forgoing warranties shall survive any inspection performed in connection with the agreed-upon work. WE PROPOSE hereby to furnish material and labor - complete in accordance with the above specifications, for the sum of- Twenty fTwenty nine thousand, nine hundred eighty six dollars( $29,986.00 ) Payment to be made as follows: $8,000 when work begins, $8,000 when rough plumbing complete, $8,000 when cabinetry installed and $5,986 upon completion. All material is guaranteed to be as specified. All work to be completed in a professional manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra Authorized charge over and above the estimate. All agreements contingent upon strikes, accidents or delays Signature beyond our control. Owner to carry fire, tornado, and other necessary insurance. Our workers are fully covered by Worker's Compensation insurance. Note: This oposal may be withdrawn by us if not accepted within 30 days Acceptance of proposal- I have read both sides of this document and all attached documents and accept the prices, specifications and conditions stated. I understand that upon signing, this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above. You, the buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. Cancellation must be done in writing. Signature Date of Acceptance: Notice: No agreement for home improvement contracting work shall require a down payment (advance deposit) of more than one-third of the total contract price or the total amount of all deposits or payments which the contractor must make, in advance, to order and/or otherwise obtain delivery of special order materials and equipment, whichever amount is amount is e DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES z , ■ Or g \z 00 (. n =. \mw (De . &\_ a z0g q \ Lo S § \moi 2\ LL F- (1) \± % o z § § 0 k o D . 2 \ I a 8 << ZI SoE / i �';� • = The Commonwealth of Massachusetts Department of Industrial Accidents ;fj;, Office of Investigations 600 Washington Street F = Boston, MA 02111 �..%, f - i www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers pplicant Information Please Print Legibl, Name (13usiness/Organization/Individual): a � M e f �o Address: r 0,/W se" f- // C City/State/Zip: m e i- -'M Q G M Phone #: ?7e ?X61 e%s e Are you an employer? Check the appropriate box: . Pd 1 am a employer with / 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL 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 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other *Any applicant that checks box # I must also till out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. _ Insurance Company Name Policy # or. Self -ins. Lic. #: Job Site Address u&_ �_ Yom Expiration Date: City/State/Zip: Al. /9nl�6V a%" Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer fy under the pai and pe r /ties of perjury that the information provided above i71r aandcorrect. Signature- w r)nty• A%/ . f #: r! Official use only. Do not write in this area, to be completed by city or town gfflcial. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone Information and Instructions - Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this.chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia t tj NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: mss' is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL -11,S150A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 1 OA. The debris will be disposed of in: 6, /K Z"'//o 'V Fire Department Sign off: Dumpster Permit --Y' Pos� (Location of F, Signature of Permit Applicant Date CO) M M x CO) CO) m 0 y d C � COP) Cl) 10 0 CD n Z co) d Cl CM)� � O CZ y CD RD Ov CD dQ O Q d CD CD O CD vv w 3, C. CD H C O CO) CC2 C=D F O CD z O CD C Cp O t 0 O Z 2r ON m O C _d m CO cc0 N C 0 M N N CT .Z' c MMI Obi _. N 0 N cELI o m e m CL N' 0 h� �C Za o m o.� � -.4 o m p O H j O -00d OC N n � =- N Om C,��,.«; O =r_? m O N O O CLW m Co, d N ' O Q CL IL C F _ O. � o — �m m : .fA N n m � N m .- 00 O O o O. O m . o Wim: d d c o� CL -S: CD nd 0: CO2 C) MM M m CO) E y 0 0 c V 0 ro 's7 PP t X17 op O x 0 E y 0 0 c x A J- E c7 Z q Aw C7 � oq U W u o ;� a a a --a �+ a W I a w G t cn cn O FM4 •� m r.+ w EsN ism• � t C2 O 4.. cm O C N . m m CM s O J C � .' O 'D H O x o ~' $ uiCO c H N LU E o. CO3 N Go m ' r_... O C � Q N Ca I ' 2'.2 y c o CD Cc aw o ID c ID .r C3 cm CD c =��= CD ca .0 m 0 m c c N 0 t r 0 Z 0 s CD ON i..l a O co O Z � O y � C cm COD Q Ce O O 'ff m m 0 CD CL CD 0CD0 cc O d 2L cmQ O fr c ea CL O CO3 M, ca C CD CL V CO) O C C cc C43 Cl ir D Y+ U) It W U) y-\ MASSAt;HUst 115 Un IFURM APPLICATION FOR PERMIT TO DO GASFITTING (Prriint) or Type) Mass. Date Building Location(24 Alz_TaaJ Owner's Name—AdA.)7-A7.J L� Type of Occupan �S 7 n &Z Ifu Installing Company Name. BAY STATE GAS; COMPANY Address 55 MARSTON STREET LAWRENCE; MA 01840 Business Telephone 508-687-:1105 New ❑ Renovation ❑ Replacement Pians Submitted: Yes❑ No„a Name of Licensed Plumber or Gas Fitter Francis X. CorkPry Check one: �❑ Corporation ❑ Partnership ❑ Firm/Co. Certificate # 1862 INSURANCE COVERAGE: 1 have a curren# liability Insurance policy or its substantial .equivalent which meets the requirements of MGL Ch. 142. Yes If you have checked Vis. please indicate the type coverage by checking the appropriate box. A liability insurance policy K Other type of Indemnity ❑ gond ❑ 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 hereby certify that all of the details and information I have submitted (or entered) in abo knowledge and that all plumbing work and installations performed under the Permit i f r Plication are true and accur to to the best of my Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene app6catfon wtl n� mpiiance with all T of I nse: Title �Plumber Signature o nse umber or Gas Gasfitter Cit /T1 Master License Number 8697 iu'FVF� (OFFICE IJS�O�CYT-- Journeyman ONE mono --IMEN IMMUNE H MEN on amm; Nunn son �ison iiiiiiiiiiii:iiiiiiiiiiii Name of Licensed Plumber or Gas Fitter Francis X. CorkPry Check one: �❑ Corporation ❑ Partnership ❑ Firm/Co. Certificate # 1862 INSURANCE COVERAGE: 1 have a curren# liability Insurance policy or its substantial .equivalent which meets the requirements of MGL Ch. 142. Yes If you have checked Vis. please indicate the type coverage by checking the appropriate box. A liability insurance policy K Other type of Indemnity ❑ gond ❑ 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 hereby certify that all of the details and information I have submitted (or entered) in abo knowledge and that all plumbing work and installations performed under the Permit i f r Plication are true and accur to to the best of my Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene app6catfon wtl n� mpiiance with all T of I nse: Title �Plumber Signature o nse umber or Gas Gasfitter Cit /T1 Master License Number 8697 iu'FVF� (OFFICE IJS�O�CYT-- Journeyman Z - O + F U W a , N _Z N N W n O d t,3� n z- t - SL N J _ n Z o W F - o � - o cc 0. z p z c a ¢ .� O O ti. IL . to 3 z O c 9 O w Q a m v f- a .� a aul W � w a U. z t,3� Date. . �V-. . F'/. -. G . ! ...... TOWN OF NORTRANPOVER PERMIT FOR GAS INSTALLATION This certifies that ................... has permission for gas installation ... ............ in the buildings of ........................ at .. , (.x -z ................... North Andover, Mass. Fee.. Lic. No.5 ... ... Q, E ........ GAS INSPECTOJR Check 4 3615 MASSACHUSE;TT� UNIFUHM APPLICATION FOR PERMIT TO DO GASFITTING r� (Print or T e) A)40 , � � , Mass. Date ils(1 R "A Building Location4.1Owners Name' A�f Type of 04 Permit # 3 �i0 7/"A WAM New ❑ Renovation ❑ Replacement((g� --'` Plans Submitted: Yes❑ No ❑ Installing Company Name (Z T A • `elm MA T A r2Q Check one: Certificate Address 3C.) 0o4 C H ih r?. ry Lid . ❑ Corporation M r= T H U e tj 01 rl U 1 k g y ❑ Partnership Business Telephone 92 —5 (7 -1 1 2--Firm/Co. Name of Licensed Plumber or Gas Fitter '2 o a E?— T A 58 mm H 74 Pc"-) INSURANCE COVERAGE: I have a currennt}fability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ted' No O If you have checked rimes, please Indicate the type coverage by checking the appropriate box A liability. insurance policy Other type of indemnity ❑ - Bond ❑ OWNER'S INSURANCE WAIVER: 1 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 i 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 of License: C� Plumber n ure of cen u or atter Title der 9333 er license Number City/Town Jou ME Installing Company Name (Z T A • `elm MA T A r2Q Check one: Certificate Address 3C.) 0o4 C H ih r?. ry Lid . ❑ Corporation M r= T H U e tj 01 rl U 1 k g y ❑ Partnership Business Telephone 92 —5 (7 -1 1 2--Firm/Co. Name of Licensed Plumber or Gas Fitter '2 o a E?— T A 58 mm H 74 Pc"-) INSURANCE COVERAGE: I have a currennt}fability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ted' No O If you have checked rimes, please Indicate the type coverage by checking the appropriate box A liability. insurance policy Other type of indemnity ❑ - Bond ❑ OWNER'S INSURANCE WAIVER: 1 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 i 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 of License: C� Plumber n ure of cen u or atter Title der 9333 er license Number City/Town Jou A z > t i 7� V a 0 0 N N 2 CA W f" 0 -i �O z '�J C-1 Date—/. '/..`.! f ........ 40RTN TOWN OF NORTH ANDOVER `--, py. ,oto ,s,tiOL p PERMIT FOR GAS INSTALLATION This certifies that . Z .'.`�; .......... • • .. fU has permission for gas installation . r_.:. f .....................> in the buildings of ............................... • at .:3 � �?> ! l ...... � :.. ......... North Andover, Mass;- Fee. ass:Fee. �. �! :... Lic. No.., ... .......................... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer