HomeMy WebLinkAboutMiscellaneous - 36 SAMUEL WAY 4/30/2018Or
7 J;f
Date .. 1.1. 7 AJ Z
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .... P/ ef7
...........
has permission to perform ..... C) 0. (
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wiring in the building of ................
at 3 to. .54W.41W. Lt*North Andover, Mass
Lic. No. �)- 3 ..K�
.
Fee , VS', . ..
ELECTRICAL INSPECTCF7
Check #
11226
Commonwealth of Massachusetts official Use only J
Department of Fire Services Permit No. j 2 t9
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07] (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 INMK OR TYPE ALL INFORMATION) Date: 1 �L
City or Town of. NORTH ANDOVER To the Inspector ofMires:
By this application the undersigned gives Rotice of his or her intention to perform the electrical work described below.
Location (Street &
Owner or Tenant
Owner's Address
Telephone No.
Is this permit in conjunction wit a b ildin permit? Yes F1 No ✓r (Check Appropriate Box)
Purpose of Building Utility Authorization No.
- Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion ofthe %llowinQ 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- ❑
o. o mergency Lighting
rnd. grnd.
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 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
No. of No. of
Data Wiring:
Heaters
Signs - Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Estimated Value of Electrical Work:
Attach additional detail if desired, or as required by the Inspector of Wires.
(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 vV BOND ❑ OTHER ❑ (Specify:)
X certify, under fiKpalns aildpenalties ofperjuty, that flee information on this application is true and comp let.
FIRM NAME:. j l LIC. NO.: 3q
Licensee: V j Signature LIC. NO.:
(If applicable nter "exmp` in the li se limber line.) 'V�� - Bus. Tel. No. -
Address: 'V Alt. Tel. No.: 3*7
*Per M.G.L c. 141, s. 57-61, security work requires Department ofpublic 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
Owner/Agent
Signature _
Telephone N
I am the (check one) ❑ owner ❑ owner's agent.
PERMIT FEE: $
❑ 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
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 ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass 151
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL, ROUGH INSPECTION:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass IN
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
FINAL IN ECTION:
Pas ?
Failed
Re- Inspection Required ($.) ❑ .
Inspectors Comments:
Z
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip:_j Q ) b)j }_ b�g�� Phone #: al
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. [(I am a sole proprietor or partner-
listed on the attached sheet. I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, §1(4), and we have no
insurance required.] i
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.E Electrical repairs or additions
11. El Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
'ontractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
zformation.
isurance Company Name:
olicy # or Self -ins. Lic. #: Expiration Date:
ib Site Address: City/State/Zip:
.ttach ro copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ne up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
tvestigations of the DIA. for insurance coverage verification.
do hereb,y-certify under thUains and penalties of perjury that the information provided above is true and correct.
zone #:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
P
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 multiplepermit/license applications in any given year,'need only submit one affidavit indicating current r
l
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
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
_evised 5-26-05
www.mass,gov/dia
Z -Z- -05�
Date......!..~.. ..... ............. t
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ......
.�4v—
has permission to perform .........
wiring in the building of .........1--4-/ ......................................
at ... ')tY&U.,a . ..... Q-.,2.A.y ..................... North Andover, Mass.
Fee4/-.�.-..� ... Lic. No.al.�' ....... . ....... .
Fee..`... Ea� 0/ -i -'CAL INSPECTOR
Check#
87't 3
r -1—
• Commonwealth of Massachusetts
C)fficial use Only I
PcrtnitNo.
Department of Fire Services Oce and Fa Checked
BOARD OF FIRE PREVENTION REGULATIONS . 1/071 eaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
s27 CMR 12.00
IN
All work to be performed in accordance with the Massachusetts Electrical Code (MECO% r l
(PLEASE PRT INWK OR TYPE ALL INFORMATION) Date: L/.-
City or Town of- NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her inte�ion to perform the electrical work described below.
Location (Street & Number) J
Owner or Tenant `;>GZv/ Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Boz)
Purpose of Building D c . 701/19 Utility Authorization No.
Eidsting Service Amps / Volts Overhead ❑ Undgr•d ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Metes
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: 'R /f . x ij"
a.. fnllnwina tnhle may be waived by the Inmeetor of Wires.
No. of Recessed Luminaires
wn
No. of Ceii.-Susp. (Paddle) Fans
O. of
Transformers
low
KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators
`,
No. of Luminaires
-Above
Swimming Pool ornd. ❑
❑ •
o. o ency Utkting
Baftery Units
INo. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
F-0.of Zones
INo. of Switches
No. of Gas Burnerstal
No. . Ioa as
Initiating Devices
No. of Ranges
No. of Air Cond.
To
Tons
No. of Alerting Devices
impose
No. of Waste Disposers
eaTotas
one
o. o ontam ed
Deteetioul Devices
No. of Dishwashers
Space/Area Heating
KW
Munial
Local ❑ Conn tion
❑ Othe
of Dryers
Heating Appliances
KW
SecuriNo. of� or Lquivalent
No. of Water KW
Heaters
o. of
Signs
No. of
Ballasts
Data Wiring:
I No. of Devices or
uivaknt
No. Hydromassage Bathtubs
No. of Motors
Total HP
No. omf cats ort
OTHER: v ref / i
-/'f
4=ch additional detail if desired, or as required by the inspector of wires.
Estimated Value of Electrical Work (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 cov a is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete
FIRM NAME: S✓ Va /lf o►rl*f LIC. NO.: B ySG
Licenam: go 4-e rf D. Su lA ver n Signature LIC. NO.: 2.2 i/ 7>
(If applicable, enter "exempt " in the license number line.) Bus. Tel. No_ V,7
Address: 02-7 /ti l D i-A/UQ SX 4AA-11e4V CE_ Alt Td No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department o 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 an the (check one) ❑ owner El owner's a ens
Owner/Agent
Signature Telephone No. PERMIT FEE: S
S
R"Yl 162�f
The Commonwealth of Massachusetts
�- j� Department of Industrial Accidents
i ! Office of Investigations
ii 600 Washington Street
Boston, MA 02111
www nuus gov/dia .
Workers' Compensation Im�' ranee Affidavit: Builders/Cont-se%rsMectricsan&/Plambers
ADDlicant Information Please Peat 'b
Name (Business/Orgaeizationnndividual): �J ��� V� /7"n �PIOI� 'V 10/-
Address:
0/-Address:
A
City/State/Zip: L—A" Phone #:. 9W- w/4) y 7 "
A2YOU an employer? Chwk.tbe appropriate box:
I aro a employer with % 4, Type of project (r'egaited):
❑ I am a general cont7andemPlo3'ees (foil and/orpart-time).* have hired the6 �'coon2. ❑ I am a.sole proprietor or par mer. listed on the attache7. ❑ Remodelingship and have no employees These sub-contracto
working for me in any capacity, $- Q Demolition
workers' comp. insurance.
[No workers' comp, insurance 5. ❑ We are a corporation and its 9 Q Building addition
required.] officers have exercised their 10. Electrical repairs or additions
3. EDI am a homeowner doing all work right of exemption per MGL 1 !.❑ Plumbing myself [No workers' comp. c. 152, § 1(4), and we have no g �� or additions
instusnce.required, t 12.❑ Roof repairs
.employees. [No workers'
comp. insurance uired.] I3.❑ Other
*An
t Ho eppiitant tlmr checks box' $ t must also fill out the section beiow showingthar workuc' o0
t liomeo an who submit this affidavit indicating they are dein M work mpeaaation policy inforrnatiott
tCaatractors that check this box mutt g and thm h6e outside `nmll rs must submit a new affidavit mdi d g n�
attached an additional cheer showiot the runno of the sublOMOMMMand their, wort' camp. Doti.. -y
r am an employer that is providertg workers' conepensation ensuraxee or
informtatiort f m1' employees: Below it ta&e P'a&T mdjob site
Dance Company Name: G Ya n
Policy # or Self -ins. Lic. #: WL Z �S'9 S9
Expiration late:
Job Site Address:
Attach a copy of the workers' cwm Cm'/Staierzip: �/�
pensstion. 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 irn
fine up to $1,500.00 and/or one-year imprisonment,position of cnmirrai penalties of a
Of up to $250.00 a y as well as civil penalties in the form of a STOP WORK ORDER and a fine
day against the violator. Be advised that a copy of this statement may be forwarded tothe p ffcc of
Investigations of the DIA for insurance coverage verification.
I do hereby cerci lender the p �
/���' P� olPerlWJ' flier the irtfnt-ntatiot: provided abovr is trtie and corned
Sit�rratttre: L�id�"1 -
/�.=--
- G L— Co '17
O}jicia! use nasty. Do not ionto l" this area, to be completed or town o
by cit]' $�[,
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of'Heatth 2 Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Pin li r
6. Other
Contact Person:
Phone #:
This certifies that .... ..........
has permission to perform ..
Date .eie ..�� !a2 ......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
-2
r. ...... ................
'... ` �...
...........................................
wiring in the building of ..... ...... .............................
. S?
at ........................... I . -N North Andover, Mass.
7....................... . .................. 0
Fee .%a%..........,? Lic. ............... i—wa ...
Check # /d
8700
Commonwealth of Massachusetts
Department of Fore Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No.
Occupancy and Fee Checked 1/
[Rev. 9/051 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code ( C , 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: O
City or Town of: Ate, /AkLo111rf? To the Inspect r of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) a47 s o jA )
Owner ori IE b F iI .� t CI ZI Telephone No.
Owner's Address L 7 S --n� 1
Is this permit in conjunction with a building permit? Yes
No ❑ (Check Appropriate Box)
Purpose of Building "Z�W E L I lJ6 Utility Authorization No.
Existing Service Amps / Volts
New Service 700Amps I-ZQ. / 2µm Volts
Overhead ❑ Undgrd ❑
Overhead ❑ Undgrd
No. of Meters
No. of Meters
Number of Feeders and Ampacity ?00 nrn to
Location and Nature of Proposed Electrical Work: 11 0 12CL X s - il.)(; LE J� M 1 4 1 11613 1 J
('mmjetion nfthe fnllnwina tnhle ma -v be waived by the Inspector of Wires.
jet
-- - - -✓ - - -
Noof Total
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
Tra.nsformers KVA
No. of Luminaire Outlets LlNo.
of Hot Tubs
Generators KVA
No. of Luminaires
Above In-
Swimming Pool rnd. grnd. ❑
o. o Emergency Lighting
Batte Units
No. of Receptacle Outlets (
No. of Oil Burners
(FIRE ALARMS No. of Zones
No. of Detection and
No. of Switches
No. of Gas Burners /
Initiating Devices
No. of Ranges
No. of Air Cond. I Total
Tons
No. of Alerting Devices
Heat Pump Number
Tons
KW
No. of Self -Contained
No. of Waste Disposers
Totals:
(Detection/Alerting Devices
No. of Dishwashers
S ace/Area Heating KW
p b
Local`E� Municipal ❑ Other
Connection
Heating Appliances,
Security Systems:*
No. of Dryers
No. of Devices or E quivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters %
Signs Ballasts
No. of Devices or Equivalent
Telecommunications Wiring:
No. Hydromassage Bathtubs
No. of Motors Total HP
No. of Devices or Equivalent
OTHER: W..
Attach additional detail tfdesired, or as required by the Inspector of Cres.
Estimated Value of El trical Work: (When required by municipal policy.)
Work to Start: d 1,
Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COQ RAGE: 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 Q'BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: Interstate Electrical Servi, s orpor.at', LIC.N .:A-5217
Licensee: Pasquale A. Alibrandi Signature I
(Ifapplicabl rater "exe n t" in the license number line.) Bus. Tel. No.: 9 7 8 — 6 6 7 — 5 2 0 0
Address: X16 Tiede Cove Rd., N. Billerica, MA 01862 Alt. Tel. No.:
*Security System Contractor License required for this work; if applicable, enter the license number here:
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.
0
Date.. r,. �.:a.? .. .
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
t�
This certifies that -.. G. r!. ........ ..........
has permission for gas installation <-.-:... ...... ..:..13 ........
in the buildin s of . ........ ,..-:...^..fir.-- ...........
at . ( . . .......: ... ..... ....... , North Andover, Mass.
Feet..... Lic. No/? �/. .. .. ...........
GAS INCE R
Check # �9
6862
i
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t_fJA -C ( d • Gaya ,• '1i�r
or, 1n >a F2•® e'�a i-' W It: - �-
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INSURANCE COVERAGE
1 have a current rhmumnespogcyorftsubsbndaiequivakmtwhich Wrests the requirementsof MGL. Ch. 142 Yes B1 No ❑
If you have chaotoed Yews please lndbwtethe type of cow by checking the appropriate boot helm.
A liabiiity insurance policy ❑ Other type Of hrdenrnSy ❑ Bond
OWNEWS MSURANCE WAMft I am aware that the licensee, does not have the durance coverage nxpdred by Chapter 142 of the
Massadumseth General Laws, and that my 819natUM on this perndi application waives this requbenNwrL
Check One Only
owner ❑ Agent ❑
Sonahme of Owner or Owner's Aaerd
accurate do to best of my Knaadedge and that aS ptmd*g was and h performed undintho pew urea tier thb app8cedon w®be he
complamewNbSUPON&M pr ovidan of the Massmhumeft Sbft Plumbing code andChapter M of the General Laws. _--y
By Pitenber
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INSURANCE COVERAGE
1 have a current rhmumnespogcyorftsubsbndaiequivakmtwhich Wrests the requirementsof MGL. Ch. 142 Yes B1 No ❑
If you have chaotoed Yews please lndbwtethe type of cow by checking the appropriate boot helm.
A liabiiity insurance policy ❑ Other type Of hrdenrnSy ❑ Bond
OWNEWS MSURANCE WAMft I am aware that the licensee, does not have the durance coverage nxpdred by Chapter 142 of the
Massadumseth General Laws, and that my 819natUM on this perndi application waives this requbenNwrL
Check One Only
owner ❑ Agent ❑
Sonahme of Owner or Owner's Aaerd
accurate do to best of my Knaadedge and that aS ptmd*g was and h performed undintho pew urea tier thb app8cedon w®be he
complamewNbSUPON&M pr ovidan of the Massmhumeft Sbft Plumbing code andChapter M of the General Laws. _--y
By Pitenber
TWO Q Gies Filter
M Faster
Of
ip ' ( Lioenm Number.
Date. Cpl. .
TOWN OF NORTH A DOVER
PERMIT FOR PLUM ING
This certifies that
V
has permission to perform ......�E'/!�! ...://.5.. .............. .
plumbing in the buildings of ...Ca'�F..�✓Q(yr:..�P:%!�"t2� ..
at ... 3 North ,Andover, Mass.
0-0
Fee%a .:.. Lic. No. 4 �3 - /. ii.....����'lr ... / .. .
PLUMBING INSPECTOR
Check N
8137
INSURANCE COVERAGE:
1 have a anent 6bi1r inswance ply or ft substanM eqdvalaM which meets the requires of MGL Ch 142 Yes � .NO ❑
If you hoe Chad" YM please bWkete the type of coverage by checUng the appropriate box below -
A liability insurance policy ❑ Ohertype of indemnity ❑ Bond ❑
OWNER'S BISURANCE WAMER:1 am aware Urat the licensee does not have the hmns rce coverage requite by Chapter 142 of the
M achuset -8 Ge:reral Lawns, and that my signadne on this permit app��tlon waives this requkennriL
Check One Only
Siwtalwe of Owner or Owner's Agent
Owner ❑ Agent ❑
t Hereby Certify trraR an of the detatis and Inforruarlon 1 have aubmlmed(or ung t� appBeation are tragi and aaarr�e to the best of my
._a. ..� ...... w. r.w.......y ..v■s ww uw.naawars Pip UROW UM
Pertinent provision of the Massachusetts State Pkmbhrg Code and Chapter 1
u0d for
ea apptiea§on will be In Om with ail
i
Z; O-%
1i
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
CWTown:/VoY4 An doye r MA. Date-_ l a Permit#
-L -E
BWWM91.,ocatlon:,3� &m u e (- WLtg --
ownrr�s Name•L' E�� i�Pm P � wi
Type of Occupancy: CommerW ❑ Educafional ❑ industnai ❑ lnsbkftnal ❑ Residential W
New.0 Alteration: ❑ Aenoration; ❑Rep�ernerrt ❑ Plans Submitted: Yes ❑ No ❑
INSURANCE COVERAGE:
1 have a anent 6bi1r inswance ply or ft substanM eqdvalaM which meets the requires of MGL Ch 142 Yes � .NO ❑
If you hoe Chad" YM please bWkete the type of coverage by checUng the appropriate box below -
A liability insurance policy ❑ Ohertype of indemnity ❑ Bond ❑
OWNER'S BISURANCE WAMER:1 am aware Urat the licensee does not have the hmns rce coverage requite by Chapter 142 of the
M achuset -8 Ge:reral Lawns, and that my signadne on this permit app��tlon waives this requkennriL
Check One Only
Siwtalwe of Owner or Owner's Agent
Owner ❑ Agent ❑
t Hereby Certify trraR an of the detatis and Inforruarlon 1 have aubmlmed(or ung t� appBeation are tragi and aaarr�e to the best of my
._a. ..� ...... w. r.w.......y ..v■s ww uw.naawars Pip UROW UM
Pertinent provision of the Massachusetts State Pkmbhrg Code and Chapter 1
u0d for
ea apptiea§on will be In Om with ail
i
Z; O-%
1i
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•
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a p, �} } }
= t1
g
Business Tel: FaxName
■ i
of Licensed } }
INSURANCE COVERAGE:
1 have a anent 6bi1r inswance ply or ft substanM eqdvalaM which meets the requires of MGL Ch 142 Yes � .NO ❑
If you hoe Chad" YM please bWkete the type of coverage by checUng the appropriate box below -
A liability insurance policy ❑ Ohertype of indemnity ❑ Bond ❑
OWNER'S BISURANCE WAMER:1 am aware Urat the licensee does not have the hmns rce coverage requite by Chapter 142 of the
M achuset -8 Ge:reral Lawns, and that my signadne on this permit app��tlon waives this requkennriL
Check One Only
Siwtalwe of Owner or Owner's Agent
Owner ❑ Agent ❑
t Hereby Certify trraR an of the detatis and Inforruarlon 1 have aubmlmed(or ung t� appBeation are tragi and aaarr�e to the best of my
._a. ..� ...... w. r.w.......y ..v■s ww uw.naawars Pip UROW UM
Pertinent provision of the Massachusetts State Pkmbhrg Code and Chapter 1
u0d for
ea apptiea§on will be In Om with ail
i
Z; O-%
1i