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HomeMy WebLinkAboutMiscellaneous - 369 GREAT POND ROAD 4/30/2018Date ........7!.`.�......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING �SACHU9c ^ "' This certifies that ....� ..C, ..............o-3 Ci .(.............................................. S�,J has permission to perform ,.,tl!1?.� `1 .......���S ............................ wiring in the building of................. 4 at ..... 1,©l 9...r%.4.....Ply�cL rJ . .......................................................... orth Andover, Ms. Fee G TRICAL ECTO Check # U i "~ `j�4-X15—I� v� IZ��s3 1 4 - kL . Commonruea(�h o� /r/��ac/u�e Official Use Unlj 2eparinwnl of }ire Serviced Permit Na. lczd ' ' .Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07) (leave blatilc 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: .�y To the nspecto of ires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 9 y —. ,Q�j 0 Owner or Tenant In Telephone No. Owner's Address /off---• ���_C�.�,�i� � 1 Is this permit in conjunction with a building permit? Yes ❑ No �� ❑ Purpose of Building (Check Appropriate Box) ,,��#r;`R. Utility Authorization. No. Existing Service Amps / �Voltst. Overhead ❑ Undgrd 13 No. of Meters New Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical WorVQ�, M '? �A -4V19. Y_ rs. � 17 \J - - -- -- kwnon required Dy 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 pain and penalties of perjury, that the information on this application is true and complete FIRM NAME: Licensee: ,a✓ LTC. NO. : R�`�' Signature / b o(Ijapplica�,enm h license mber IerJ LIC. NO.: !xeAddress: 7aw Bus. Tel: *Per M.G.L. c. 147, s. 57-61., security work requires Department of PubliAftc Safety "S" License: TeLicNo. OWNER'S INSURANCE WAIVER: 1 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) Q owner ❑ owner's anent. Owner/Agent Signnture Telephone No. PERMIT FEE: S /' Completion o the ollowin table tno be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans o' o ota Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires - Swimming Pool Above ❑ n- ❑ o o. o mergency "'lig'' tng rnd. d. Bat Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. d ' etection an Initiatin Devices No. of Ranges tal No. of Air Cond. on Tons No. of Alerting Devices No. of Waste Disposers eat ump um er .. To Is:............._........._. .. Detection/Alertin Devices No. of Dishwashers Sp/Area Heating KW Local unicipa Connection ❑ Other No. of Dryers No. WaterINo. Heating Appliances KW ecurity yystems: ofEquivalent of Heaters KW o. o o. o .Devices or Data Wiring: Signs Ballasts No. of Devices or E-6—lent No. Hydromassage Bathtubs No. of Motors Total HP a ecommunicatlons Wtriog: No. of Devices or Rn uivalent OTHER: Fstimated Vahlr niRlone.: al ��� -t.. Attach additional detail iirdesired, or as required by the Insnecrar of u';.,..• � 17 \J - - -- -- kwnon required Dy 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 pain and penalties of perjury, that the information on this application is true and complete FIRM NAME: Licensee: ,a✓ LTC. NO. : R�`�' Signature / b o(Ijapplica�,enm h license mber IerJ LIC. NO.: !xeAddress: 7aw Bus. Tel: *Per M.G.L. c. 147, s. 57-61., security work requires Department of PubliAftc Safety "S" License: TeLicNo. OWNER'S INSURANCE WAIVER: 1 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) Q owner ❑ owner's anent. Owner/Agent Signnture Telephone No. PERMIT FEE: S /' m 0 4 The commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washinvon Street Boston, Mei 02111 s'rint F.D. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): Address:% City/State/Zi 6l�YS P /f%► /� C�r�l� . Phone #:�%r � al( j Are you an employer? Check the appr 1. ❑ I am a employer with employees (full and/or part-time),* 2.2 1 am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t riite box: 4. ❑ 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.# 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have iio employees. [No workers' comp. insurance reauired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.7 Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill 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. IC ontractors 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. Insurance Company Name: Policy # or Self. -ins. Lic. #: Expiration Date: Job Site Address: 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 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 WORD ORDER and a fine 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 certify under the pains andpenalties ofperjury that the information provided above is true and correct. A /D IN 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: �) /� .tl IQ J.�.:-�701�:-COMMONWEALTH OF MASSACM LERICIANS I SSUES THE AQWJ*::`:::'I��i: LICENSE AS A REG'`JOURNEYMAN MRNEY E L E C -TR Vc j,A�N,.: r .1725 GT.,; OND Rb DOVER A 'A" 01845 2 1 0,7-/3-1 /d ?7333 J A. Claudette Bellia 369 Great Pond Road North Andover, MA 01845 April 27, 2016 North Andover Building Department 1600 Osgood Street Building 20, Suite 2035 North Andover, MA 01845 Dear Allan Paduchowski, As of April 20, 2016 John P. Thompson of 1725 Great Pond Road, North Andover, MA; decided to abandon the job, therefore I am releasing him of his electrical duties for remodeling our kitchen and 3 bathrooms at our home, 369 Great Pond Road. I, Claudette Bellia, along with my husband, Joseph Bellia, are taking responsibility and liability from here on. Thank you. incerely. laudette Bellia "1057? Date ... ......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .... Qx� �/ V , r- �- -� 1P C ri r44 I ............... has permission to perform ........ .................. ......... .... ... .... . plumbing in the buildings of .......... .......................................................... at .... ..... 9 1+- P, " ......... North Andover, Mass. Feel�� . .. Lic. No. ".4 . .............................................................. Check # S4�-ze- PLUMBING INSPECTOR UJ k9li-Iq M �kAo ,\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY 4 t v I MA DATE PERMIT # lV j JOBSITE ADDRESS ��,�,9 (z-►a���� OWNER'S NAMES _ POWNER ADDRESS _ TEL:=FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: [9- REPLACEMENT:Ell PLANS SUBMITTED: YES ® NOQ FIXTURES'l FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE ! ( __ [_ .• I �( I _ I l _^ _; DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM__I ._ J ____.I ._( __�_- _ _.. _._ _. DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM f _ ( (_ __. ( _ _ J _ ._f DEDICATED WATER RECYCLE SYSTEM [ _._.___..1 J ! _._.� .._. _J ! __..J ! i AL --j, L==j DISHWASHER DRINKING FOUNTAIN _i _.____J _-..-- 1== ____ (______ FOOD DISPOSER [ FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR)....____..I ..__.__( i . _J.____j 0 KITCHEN SINK _I .. _ .__J _jF-7-1 LAVATORY _ (_ ( _.._.__._.� ..._._� ROOF DRAIN i ( SHOWER STALL € SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION 1 _[ ( ----_ ____._( _____ _-_ _ _ _ -J —J . _i _ --..i -._.____! _... _ __ ...J ._-J F Vk ;7ER HEATER ALL TYPES WATER PIPING 2-0— -0—OVER OTHERI ___( INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Y0 D IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND 0 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: OWNER 0 AGENT E 11 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this 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 provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME3c fir. LICENSE # I Ij—t/_ q (� SIGNATURE Mpg JP 0 CORPORATION n#=PARTNERSHIP 0# � LLC a _j COMPANY NAME r,:,,,, ADDRESS 4 - CITY f STATE ZIP 6 TEL Q� FAX _ € CELL L� EMAIL �� w W LL ------------ �`�� _ I/ Date..4/7�`/****�-% TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ........................................�.fi�'' .... ............. I ................................................ has permission for gas inst lation . in the buildin W IR sof ......... = ........ . . .................................................................................. at ............................ ...... ...... . North Andover, Mass. ............ ......... .................. ...... .... Fee -6.. ... ....... C.5. ... D ....... Lic. No. h.S-1 ........ ............................................... GASINSPECTOR Check O� �� ► P.19-14 M� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY LI��r""�'� _ MA DATE-jJIPERMIT# JOBSITE ADDRESS - Q . _ OWNER'S NAME GA& OWNER ADDRESS TEL _ FAX TIWE OR PRINT OCCUPANCYTYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL CLEARLY NEW: E] RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES D NO APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR_ . FURNACE GENERATOR GRILLE INFRARED HEATER . -A LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER 1 _ ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER �a i WATER HEATER OTHER) � -- �TINSURANCE COVERAGE Ithave a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES & _ NO 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 2 OTHER TYPE INDEMNITY E] 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: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this 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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME ��C�1q( JrAti �. LICENSE _ _ I SIGNATURE '3) MP Ej"MGF E I JP ®. ! JGF LPGI © CORPORATION &r# � -- ( PARTNERSHIP 0#= LLC E]# COMPANY NAME:Mak �t ^ ADDRESS CITY _ STATE ZIP FAX CELL EMAIL LAS _ AIN M� con Z O H a w �'1 z O N rl w �- I_- W o w O H a Z LU W s a w 5 a W LU w L LU d g w a, a U J E, a CL a � LLi x w F- LL °z 0 w k� O � The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington. Street Boston, MA 02111 www.mass gov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly Name (Business/Organization/individual): Address: Z/(/ d fm-ir\ " 9 City/State/Zip:'�,%,.A „&nA . 6f JJ Phone#: 67A S`S!-VfJ � A,ree,yyou an employer? Check the appropriate box: - Type of project (required): 1. Ly' 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. I �• remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g• ❑Building addition [No workers' comp. insurance 5. FI We are a corporation and its 10.❑ Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12.E] Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showingtheir workers' compensation policy information. 1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. X am an employer that isproviding workers' compensation insurance for my employees. Below is the policy and job site information. \ Insurance Company Name: (k� &N L AJAJ lhS- Cd . Policy # or Self -ins. Lie. #:%S3 N O Y II Expiration Date: Job Site Address: 6-rYo,� PO►1d \`e' City/State/Zip: iy./yWd ov Aftach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL 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 fine 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. X do hereby cert. Wder flee pains and penalties ofperjury that the information provided above is true and correct. ME 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. PIumbing 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 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. 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 (ifnecessary) 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 ofInvestigations 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: Tho Comm onweaXth of Massoc�husPtts Depaariment ofladusWal Accidents Qface QIuestiatitoana 600 WashiVou Stropt Boston, MA 02111 TQL # 617-72 7-49 0 0 eyt 406 or 1-877,MASSAFF, Revised 5-26-05 Fax# 617-727;7749 'cw_mace ansrfri;� 3ER'EXPIRATION uc Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 60,000.00 m $ - $ 720.00 Plumbing Fee $ 90.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 90.00 Total fees collected $ 1,000.00 369 Great Pond Road 519-14 on 12/31/13 Reshingle Roof, Remodel 3 Baths Remodel Kitchen N2 I, - Date .................... `.ter.......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING is certifies that ................................................................... - ............................. haspermission to perform ... : ............ : ................ ...... ............................... wiring in the building of .............................................. . ...---- ..... ................................ D at ................... ............................................................ . North Andover, Mass. Fee .. ................... Lic. No:''.' -.—r ...a—' ....................... ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer • office ON 0w1f� '- f ` The Commonwealth of Massachusetts ►malt 3,. • Depatiment of Public Safety' occoraatt a tit O•eched tiOAilb of FIRE PREV 171011 11EGULAT10NS S27 CMR 1200 1/90 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK NI rack so lot pcelclr ntd In accordance rit6tht I•lataachasttu Elcclrlcal Code. S27 CMR 12:00 (PLEASE PRIITT Li IRK OR ME ALL IIiFORIMTI011) • - Date. 4",-L6 City or Town of �/,l ,9aba-'e- Io the Inspector of Direst 7bi undersigned applies for a permit to//perform the electrical �work des e ibed below. Location (Street L Ihmber) 3E� �j %,•�U i`" 0--ner or Tenant. 4(, QAJ Owner's Address. Is this permit in conjunction with a building permit: Yes ❑ Ito (Check Appropriate Box) yurpose of Duilding s/ /flyiZ Utility Authorization 110. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ Ile. of Ileters__ Rev Set -Tice Arps /: Volts Overhead ❑ Undgrd ❑ Ito. of Heters Ih=ber of Feeders and Ampscity Location and Nature of Froposeb Llectrical Work 67 /E?/ ao No. of Lighting Outlets b 6 No. of Ilot Tubs Total 110. of Transformers KYA No. of Lighting Fixtures Swimming Pool Above In- grnd. ❑ grnd. ❑ Generators KVA No. of Receptacle Outlets Ito. of Oil Burners Ito, of Emergency Lighting Rattery Units Ito. of Switch Outlets No. of Gas Burners FIRE ALARIIS Ito. of Zones Ito. of Detection and —' Initiating Devices Ito. of Soundln Devices tlo. of Sel( Contained Detection/Sounding Devices local ❑ lluConnect Ioncticip❑ Other Co No. of Ranges No. ofIAir Cond. Total tons Ito, of Disposals Ito. of licat Total Total PUMPS' Ions KWg No. of Dl shwa slier s Space/Area Heating K11 No. of Dryers Heating Devices KW Ito. of hater linters KW Not of No. 01— Signs Ballasts Low Voltage Hiring Ilo. hydro Itassage Tubs No. bf Ilotors Total 11P OILIER: I1ISURAt10E COVERACEt Pursuant to the requirements of Massachusetts General Laos I have a current LI a flit Insurance Poitcy Including Completed Operations Coverage orTs substantial equivalent. YES[_ 110 [i I have submitted valid proof of sane to this office. YES(+ 110 (_] It you have checked YES$ please indicate the type of coverage by checking the appropriate box. INSURANCE 0' MIM ❑ OTHER ❑ (Please Specify) Estimated Value of Electrical Work S _7 xp rat onate Ir cork to Start Inspection Date Requestedi Rough Final ,4.,:2,/,qz toed under the penalties of I•etj••-yt 1-4 FIRH NAHE (��/� Q(r �► � � i LTC. ti0. 7— l.ttenseeJ// 1/o'CAIT f 6A7 i)rnf S Signature / Qy� VLIC. •t10. a ' D Bus. rel. Ito. ; zw- n Address ..1610. /' ,410-11eC 1L1_ 01/jay ��� 86- �' oxcY Alt. Tel. Ito. 011NER'S INSURAIICE NAIVERt I an aware that ti,e Licensee does not have the insurance coverage or i7_2 i7b stantlal equlvalent as required by liasanciwsetts Cenera l Tevs� an�tliat my signature on this permit appIle atlon valves this requirement. Owner Agent (Please check one) Telephone No. Signatu �e o Omer or gent a ...I PER11If FEE S 4 3421 Date...S.-. �.1:. ... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... B G. .L � .. S...... .'.^............. . has permission for gas installation . . :( ........... in the buildings of ..., 1..:� r:. ........................ . at ..... fl • !a �4 ��• °• ` •`�• • • • • : , North Andover, Mass. ! C Fee.. 1:."... Lic. No.. 37/ �... .:- r-.:�..... . GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) i fn h y I& A, G AA1I 101/Q _ Mass. Date J --A .6000 Permit # Building Location 6,1 -ea -7- /--;,V. /tiwner's Name *6 //P,S e,.L1'Q V _ Tpe of Occ ncy �le� , c%w Ct• New C] Renovation ❑ Replacement Plans Submitted: Yes❑ No ❑ Installing Company Name Boule's Gas Address 39 Oxford Avenue Haverhill, MA 01835 Business Telephone 978-372-6783 Name of Licensed Plumber or Gas Fitter Charles H. Boule' Check one: ❑ Corporation ❑ Partnership Firm/Co. Certificate INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 90 No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy X 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 pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the G r ws. By Tof License: Plumber Signature of Licensed Plumber or Gas atter Title Gasfitter Master License Number M3z2Q;/ J355$ _ _ .. City/Town Journeyman APPRCNED I MOMEMMOMMENE No ON MEN 0 d�M■t■ V ■■t■NOMH��■Hnh IN IN M-1 � Installing Company Name Boule's Gas Address 39 Oxford Avenue Haverhill, MA 01835 Business Telephone 978-372-6783 Name of Licensed Plumber or Gas Fitter Charles H. Boule' Check one: ❑ Corporation ❑ Partnership Firm/Co. Certificate INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 90 No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy X 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 pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the G r ws. By Tof License: Plumber Signature of Licensed Plumber or Gas atter Title Gasfitter Master License Number M3z2Q;/ J355$ _ _ .. City/Town Journeyman APPRCNED I