HomeMy WebLinkAboutMiscellaneous - 364 JOHNSON STREET 4/30/2018 (2)'own ot,Nori'h Andover
%ymenka'� Friday, April 06, 2016
)eposit Nugber 1604111
)perator Counter pc 1
1CR (ELECTRICAL INSPECTION) $55.00
0
'otal Paid $55.00
:ash $55.00
:hangs $0.00
teceipt Number gov00004643
49/2016 6:55:12 AM
Jame RICHARD BENJAMIN
:ashler Id. treascoll-17
Date ........:(....��2.............
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ................ �G`:�`�Y!........ �'� �............._.
has permission to perform ............ .....:................................................
wiring in the building of...........D............................... re-�''.......IF ,;. .........................,
at . .X.. ........
s.................
... J�...�............/�.r............... North dover, Mass.
f
FeeJ.�.................. Lic. No.................. .z� ... ....G... ...........
ELECTRICAL INSPECTOR
Check #
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No.
Occupancy and Fee Checked
tev. 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 ININK 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)
Owner or Tenant 1),,--> Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes L No ❑ (Check Appropriate Box)
Purpose of Building .<c,l A a4 LC--, Utility Authorization No.
- Existing Service
New Service
Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: �IAI e, A ^d
!'., of tho fnllnwina tnhlo mnv ho waived by the Inspector of Wires.
Attach additional detail if desired, or as required by the Inspector of r .
Estimated Value of Electrical Work: 11-00 , (When required by municipal policy.)
Work to Start: f'j j 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, cinder the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME:. LIC. NO.: I L q (o
Licensee: QAC A_ caq,,a ?olbn XAnAv%, Signature LIC. NO.: S C
(If applicable, enter y"e1xempt" in the li ense number line.) Bus. Tel. No.. !a -S Zg -3 Z
Address: k:--3$ 14 At,, V—e i ,60.6 2.a 6A-.� 0 t4 638 Z 3 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/AgentPERMIT FEE: $ ,y
Signature ,_Telephone No.
...,.. r..,.-.... , -• •-., ---- •. -..o
No. of Total
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above In-
Swimming Pool Ind. ❑ rnd.
o. o Emergency Lig ting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Detection andInitiating
No. of Switches
No. of Gas Burners
Devices i
No. of Ranges
No. of Air Cond. Tons Tot
No. of Alerting Devices
HeaToia P
Number
Tons
KW
No. ofSelf-Contained
No. of Waste Disposers
'•'
.•••.......•.
-......••.....
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local F-1Municipal Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or E uivalent
No. of WaterKW
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 E uivalent
OTHER:
W2 es
Attach additional detail if desired, or as required by the Inspector of r .
Estimated Value of Electrical Work: 11-00 , (When required by municipal policy.)
Work to Start: f'j j 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, cinder the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME:. LIC. NO.: I L q (o
Licensee: QAC A_ caq,,a ?olbn XAnAv%, Signature LIC. NO.: S C
(If applicable, enter y"e1xempt" in the li ense number line.) Bus. Tel. No.. !a -S Zg -3 Z
Address: k:--3$ 14 At,, V—e i ,60.6 2.a 6A-.� 0 t4 638 Z 3 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/AgentPERMIT FEE: $ ,y
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
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 M
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass n
Failed ❑'
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass 0
Failed ❑'
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Dater
FINAL INS CTION:
Pass
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
Department of IndustrialAccidents
w = d 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 AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/C rganization/Individual):
Address:
City/State/Zip:
Phone #:
Are you an employer? Checktlie appropriate box: Type of project (required):
1. ❑ I am.a. employer with employees (full and/or part-time).* 7. Q New construction
2.�am a sole proprietor. or partnership and have no employees working for me in 8. Remodeling
any capacity. [No workers' comp. insurance required.]
9. ❑ Demolition
3.FJ I am a homeowner doing all work myself. [No workers' compAnsurance required.] t
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10E] Building addition
ensure that all contractors either have workers' compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. ' ; '
12.. E] Plumbing repairs or additions
5. n I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.# 1STJ Roof repairs
6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Q Other
152, § 1(4), and we have no. eiraployees. [No workers' comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
T Homeowners who submit #his 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 . thepolicy and job site
information.
Insurance Company
Polic�# or Self -ins. Lic. #:
Job Site Address:
Expiration Date:
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
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance
coverage verification.
I do hereby certify under the pains and penalties of penury that the information provided above is true and correct.
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 #:
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 -contractors) 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 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 # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
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Date... ... ?,
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that........ -.......
WAY F-5 ........ ........................
has permission to perform .........
.. .............................
wiring in the building of .....ti. y .................................................
at ......... ...... —5,1 ............. . North Andover, Mass.
Feec?.f..'—O.F ..... Lic. No. .............
3443 CAL INSPECTOR
Check #
7862
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Imupalroy and .Raft CUOMO
BOARD OF FIRE PREVENTION REGUIX-IONS Rev. 1107 wave tank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All Wath trabc ptstfQM4t1 rn Raatlrt MOVI with the MussardImmot6 4*tvaal Fede (M9Ct. S27 CMft,12.00
(p&,eA,gE PRINT IN INK OR TYPE ALI. fNIPORJt� 770AI) Onto9 "O '7
City lar Tai- el?t 40- r 1141'0 Vey ' To the' Inspector of Wires:
Hy chis upplicotion the underAIgn vel notice (11 lis or her unRntion to porfhrni thn citta rit:ol work denribW below.
Talophono Ne,
O"Agr or'renant
Owner's Addrest
Is thin permit In at
Ptirpotlt of l3ulldlnt �1 ., , n Utility Autbortaatine No.
,�.,�.,, ..77.7.._7.-,.�...._.�..,...,.
Existing Service Arraprw _,„NMta 0vRrheA4 IJedgird ❑ No, of Metera ....
Ampa %-- —valrs overlivid undffrd No. ofmews
Number iaf Fa9dara Bad Ararltwwetty _ r —
004 Nature of
Na. of Retaeseadl Latrtlaathre
wMVM�A"'^
No. of Waolttttlr'e 090418
No. of Lumdnalras
NO. of 1Raaaptaais ontlus
No, of 9witQhe4
Na. of Range%
No. of WeNte Dtttpomers
No. of 0hbwR1IWn
Na of Dryers
MW
No, IRydromowtg* 9athtubs
tlWrlenl Work, kA i rte_ io eL-1
of CollASUSP, (PA4010) Fatal A ,M moll i
of I:lot Tul1A ». 0ofte storA XVA
tnrninp foul jT a I. I
' r "
of ill Ilurnors
/ nn AL ams No. of zonae
No, of Clos 9orners
of Air Cnnti. AMWO No, of Amlart"Ing ISnvittan
,.11low
T1
Re/Arco H980112 XW
uYMMMhn1Mv"Mvq.N.�M��
ting A,ppilances 1K'W
of Motortr Total up
❑ IitlnnaA�st 0 Oft
nan�ntrptnn
HER!
r ”' 77 Att rtQ�Awonal divati (l tinRlt a 09' 449 Iwo, fib -rid kv fk, Urapaalur Rl 11194.
13stimetad valud of $ta4pllgal ork J (When roquired by municlpRI policy,)
Wt1rk On Start, rc Inspoo done to bo t'quipowl in apoo dgaf»W widN W 8410 10, And upon CoMpI000ta,
INIi VR,ANCE COVERA09. Valess wAivod by the owner, no parmit for The parfonvanott of oloct6ml work rimy issus Wane
the licenses provide$ proof of liability inpuranco including "completed operation" oovera gr. or itz subs%ndal cquivnlont, The
trndmt•stpad aartitias that such oovergo is itt force, and has exhibiteA proof ot'Same to th Permit i®sttinµ ofllao.
CLICK ONE: INSURANCE MOND 0 OTFIU Q ($pacify:) Zur<� ln- serol -re
I sord(jii. roodor r/trtptulnH& I pntwftflos o fppfynt;r, that the on fiorttRfrltna o►t ds I'gPlIvation Is true owl eltpr#al0.
Licensee; ao x hllgttntu to _ _ LIC, N -
(1P0whi-ehly, m+tv, "arrmarlat" iu Iba 1leirn0# »anrbr!r' im r skis. Tel, Ne.• _
A dts retia s . — L�,.l"� �°FL M " �tG a �Q ,Of Alt. Titf. N o.:
"Par M.Q.L. t:. 1417'a"."37-61, at evrity work ragxures Dapeivioni of Public bfifaty "S" i. cone: Lie. No,
OWNER'S INS1.IRANCE WA.IVIi#R9 t am awsrr that tl9e Livenama rlrjvv irvt have thg debility insurnrtou uavorov nomally
tagtulred by law. By try dopa true below, I hcrl3by wulve 010 r04011e9114nt. I A l tbR (61Arawntrr ant
UwntrrlA,ttant AERwr ize
lit0lrartarrl _� __� _^_ 'i'altapltt►nalAe,r
'�IT NO. 403
I
APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
PAGE 1
MAP NO.
LOT NO.
I
2 RECORD OF OWNERSHIP (DATE
BOOK PAGE
ZONE
SUB DIV. LOT NO.
F
LOCATION 36V
PURPOSE OF BUILDINGQ _ _
�T"�'y-R
OWNER'S NAME f
NO. OF STORIES SIIZZ'EV'o-� � /��
OWNER'S ADDRESS 36
BASEMENT OR SLAB
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST 2ND
3RD
BUILDER'S NAME R
tf1
,l�J
[_
��3 ��
SPAN Q, v
��-
DISTANCE TO NEAREST BU DING
DIMENSIONS OF SILLS
DISTANCE FROM STREET S'a"'-�.
11POSTS
DISTANCE FROM LOT LINES — SIDES
�� f-
REAR, �� *
" GIRDERS
AREA OF LOT
FRONTAGE
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE OF FOOTING X
IS BUILDING ADDITION
MATERIAL OF CHIMNEY
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODEIS
BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION, IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS 3 PROPERTY INFORMATION
LAND COST
Noe
SEE BOTH SIDES
EST. BLDG. COST
PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT.
PAGE 2 FILL OUT SECTIONS I - 12 EST. BLDG. COST PER ROOM
AEP9MC PERMIT NO.
ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATE F 16LD
(/ BOARD OF HEALTH
SIGNATURE OF OWNER OR AUTHORIZED AGE/4T
F E E
PLANNING BOARD
PERMIT GRANTED
�
19
BOARD OF SELECTMEN
BUILDING INSPECTOR
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Date.
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
fly -- G
This certifies that :� ...... ...... .
has permission to perform.'.� .:.... .
plumbing in the -buildings of �C r l '-'................. .
North Andover, Mass.
at.
Feer-!'!✓L1c. No. :4��. . .
� f PLUMBING INSPECTOR �
Check H �//
H
L9
N-�
MASSACHUSETTS UNIFORM APPL
(Print or Type)
Building L^n
occatio
7 / no
New 0 Renovation �❑
SUB—BSMT,
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR
7TH FLOOR
STH FLOOR
r
FOR PERMIT TO DO PLUMBIN
ID & Permit #
&Owner's Name
— Type of Occupancy Residential
Replacement IN Plans Submitted: Yes ❑ No ❑
FIXTURES
Installing Company Name Heritage Htg. &Pig. • CO. Inc. Check one: Certificate
Address 35 Pleasant Street _ IX Corporation 714
Stoneham-, Ma 02180. ❑ Partnership
Business Telephone -781-438-7776 n Firm/Co.
Name of Licensed Plumber ' Gordon Switzer
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ® No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability Insurance policy D1 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 Uvner 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 .
pertinent provisions of the Massachusetts Stale Plumbing Code and Chapter 142 of the General Laws.
By t i n D A
ature o ceennsee u>'n e
Title
Type of License: Master [g Journeyman p
City/Town $ 3 2 2
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Installing Company Name Heritage Htg. &Pig. • CO. Inc. Check one: Certificate
Address 35 Pleasant Street _ IX Corporation 714
Stoneham-, Ma 02180. ❑ Partnership
Business Telephone -781-438-7776 n Firm/Co.
Name of Licensed Plumber ' Gordon Switzer
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ® No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability Insurance policy D1 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 Uvner 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 .
pertinent provisions of the Massachusetts Stale Plumbing Code and Chapter 142 of the General Laws.
By t i n D A
ature o ceennsee u>'n e
Title
Type of License: Master [g Journeyman p
City/Town $ 3 2 2
APP 0 IC S N _ License Number A
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Date....�31e�
.
.............................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
ff
This certifies that . ...........
has permission to perform ' ��
�.............� .......... ., ............
wiring in the building of . :i! ........... ...................................................
at . VV..44ZAA�.�. ......... , North Andover, Mass.
Fee ........:....... ...V- IV. ' �• .. ,,�'���/,.,
%(�� ELECTRICALINSPECTO�
Check #
'-7 f,ry
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P occupancy *n,,3 Fee Chcchcd r
F�c'�,�f�f10r- FlREl PRF-�I=NTInN f?Et�l'},�''.Tic'` !a Revd1199j
APPLICATION FOR PF.-FIRAIT TO P -RFORM ELECTRICAL WORK
I :,4 ,f.,s'.: Itl!';(tls Ch'rttlf ti ePtIF {�1l t"1 521 CMR 12 {1Q
00 morin to lie perlolr„c11 rn 3rGoftl:l,lcc'• �^
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City pr ') o vls (sf: �f7_f
To Meinspect0f' A� Ibi,t?s,
lmllc�
By 11),s ap}sllcahr)tt the unit rsl ur:r9 Ltvcs of I,!� t' I',(i lU pr.0,ifnl IhC elccttical work descnt>ed bit loo
j.acaliu„ (Sfrecl C 1Vtt1111scr}^�.^_...�.
1a.
Owner or 1111
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1s this pettuil 11, co,tjstrac,tiurl Iri111 bu11Ju1u l,cr 1 ;I" l c5 VO
(CkA t\I,ysro}►hvo Uox)
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Al,s ,s 1 \ uila (), c; i,C.,rl _� llttdgrtl No. of Meters•
i`f jm„ )er of F'eejcrs -md A.m aacity
t.o • t;u„ atul iYaturc of Proi)oscal
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0 THER.
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1,I'`iM.-V4C..'f>!. Cl�\'�:1tAGU.: Ulllcs'k v a,Vcd ny the 0N11cf, no pe;n1„ for the.performance performance of electrical moor, may issua unlcas
file i"'ensca provi(ks proof of Lability I„stlrallce ioclI d q. con,plrieti operal,00' corfsav of ils 1uhstantial equiY09111, 'Tile
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