HomeMy WebLinkAboutMiscellaneous - 370 SUMMER STREET 4/30/2018�;
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT T4 DO GASFITTIKG
( Print or Type)
Mass. Date S
—Buil—ding Location -3 7D 504,A4Permit # _a Sri 3
Owners Name /4tc.N&RDJI'li.
. New - Renovation 12'Replacement EY Plans Submitted 0
Ft''TU P FS
(Print or Type)
Installing Company Name
Address
Check one: Certificate
�j Corp. /,p
Partner.
2.'D •—
f�<l L_j Firm/Co.
Business .Telephone: 4y4S9Y1L�q-
Name of Licensed Plumber or Gas Fitter i bAjq 4 '%MeAJ
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy 12_- 9ther type of indemnity ® Bond
Insurance Waiver: 1, the undersigned, have been made aware that the -licensee of
this application does not have any one of the aboye three insurance coverages.
Signature of owner/agent of property Owner 0 Agent
i haebl► artiftr that all of the details and inforn eibm t have aabmitted (or entered) in above appfieatieo are tragi and araarrato to the beat of my
knowkdgg atd that all plumbiott we* and fnwltatW= performed anda- ttrmit kwed for this sppfiWios wdl be in oompfis m with at pestsimt
pcovisiooa of the Ifasaachusetts State Cas Code and mapta 142 of the Gc ctai Laws. ..
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
TYPE LICENSE: ty) _ _
Gasfitter Signature of Licensed
Master Plumber or Gasfitter
Journeyman 7
Lice -s9 Number
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1ST FLOOR
2HD FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
STH FLOOR
(Print or Type)
Installing Company Name
Address
Check one: Certificate
�j Corp. /,p
Partner.
2.'D •—
f�<l L_j Firm/Co.
Business .Telephone: 4y4S9Y1L�q-
Name of Licensed Plumber or Gas Fitter i bAjq 4 '%MeAJ
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy 12_- 9ther type of indemnity ® Bond
Insurance Waiver: 1, the undersigned, have been made aware that the -licensee of
this application does not have any one of the aboye three insurance coverages.
Signature of owner/agent of property Owner 0 Agent
i haebl► artiftr that all of the details and inforn eibm t have aabmitted (or entered) in above appfieatieo are tragi and araarrato to the beat of my
knowkdgg atd that all plumbiott we* and fnwltatW= performed anda- ttrmit kwed for this sppfiWios wdl be in oompfis m with at pestsimt
pcovisiooa of the Ifasaachusetts State Cas Code and mapta 142 of the Gc ctai Laws. ..
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
TYPE LICENSE: ty) _ _
Gasfitter Signature of Licensed
Master Plumber or Gasfitter
Journeyman 7
Lice -s9 Number
MASSACHUSETTS URIFORM APPLICATION FOR PERMIT TO DO PLUMBING
r(,Type or Print) G'
• /" - Aft E .Mass. Date: s'
Building Location S'e//,lm E2 c -r Permit #,` 3 73
Owners Name afL RA;Z42 �f G
g New Renovation M�Replacement [� Plans Submitted ❑
,,:ti��
FIXTURE
By
Title . JUN 1 1 1997
City/Town-
APPROVED (OFFICE USE ONLY)
r
Signature of Licensli Plumber
Type of Plumbing License
License Number Master ❑ Journeyman
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BASEMENT
IST FLOOR I
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2ND FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
(Print or Type)
Check one: Certificate
- Installing Company Name ,PA11110
e1� /%%
Corp. Z5f-F
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Partner.
Address 2L�Ll�EI/�
1 ,/&
Firm/ CO.
0 L
Business Telephone
Name of Licensed Pluriber :
Insurance Coverage: Indicate the type
of insurance coverage by checking the
appropriate box:
Liability insurance policy Other type
of indemnity
0 Bond F7
Insurance Waiver: I, the undersigned,
have been made
aware that the licensee of
this application does not have -any one
of the above three insurance coverages.
Signature of owner/agent of property
Owner
❑ Agent
I hereby certify that all of die details and information 1 have submitted (os entered) in above applicatiom are tine and accurate to the best of my
-. knowledge and that all plumbing Mork and iastaltations performed under
remit issued for this application will be at compiianoe with all pertinent pto-
visiosta of the Massachusetts State Plumbing Code and Chapter 142 of the Contest Laws.
By
Title . JUN 1 1 1997
City/Town-
APPROVED (OFFICE USE ONLY)
r
Signature of Licensli Plumber
Type of Plumbing License
License Number Master ❑ Journeyman
+".+�t..,.,':-w4-q" "aiitv.,:.Fs.,:`^'',.w:*"„'"'-"'�,+r-^tJ 'r x .`' �,f:•�,.a.: �s"ar ...i..�.-.-.,d
Date7. .
z} ' 3=3-73
01 TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
,
SSS..- IS
This certifies that .
3.' has permission to perform ... RG. o L <* ................
plumbing in the buildings of k;-7 jL-e c. {' _. ..... .
at. _S ? ...J .�- . �'�� .. �. ......... North Andover, Mass.
Fee. Jf " .. Lic. No. .. �,,....... �... ... .
,r
M. 07/07/97 12:27 45.00 PAID
WHITE:, Applicant CANARY: Building Dept. PINK: Treasurer
2583 117---
Date .P.- ......
A
NORTH TOWN OF NORTH ANDOVER
pf ao ,tip
PERMIT FOR GAS INSTALLATION;
CLq
� N
This certifies that.C�. / �..... J:d� ............
has permission for gas installation .':.Jp!': Y. 5.!i.. Q
in the buildings of e .e .......................... . 0
at .... Sl ...... , Nprth.,Andover, Mass.
Fee �.U..... Lic. No.`�.� I3... t. �C. . ......
GASINSPECTO
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
� - 014t Cgommanurett4 of fftaosac4usttts Permit No.
Eepartment.of Ilublic iafetg Occupancy A Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 iso (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 r
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 2 _ __;-7-2,
�& or Town of NORTH ANDOVER To the Inspector of Wires:
The udersigned applies for a permit to perform the electrical work descnb d below.
Location (Street & Number)
Owner or Tenant
Owner's Address`-��U
Is this permit in conjunction with a buildings/ permit: Yes LJ No ❑ (Check Appropriate Box)
Purpose of Building��� �Sic��J� Utility uthorization No.
Existing Service Ado Amps�� ��U Volts Overhead Utility
❑ No. of Meters /
New Service Amps —J Vofts Overhead ❑ Undgrnd ❑ No. of Meters
N b f F d nd Am acit �- --e :—> V7_1 10(:2
�O
fn
um er o ee ers a p y
Location and Nature of Proposed Electrical Work
No. of Lighting Outlets Z z
No. of Hot Tubs
No. of Transformers Total
i VA
No. of Lighting Fixtures
g g ��
g Pool Above In-
Swimmin P grnd. ❑ grnd. ❑
Generators KVA
No. of Emergency Lighting
No. of Receptacle Outlets S 7
No. of Oil Burners �` awl/
Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection and
Total
No. of Ranges
g f
No. of Air Cond. tons
Initiating Devices
No. of Sounding Devices
No. of Self Contained
—
No. of Disposals
No.of Heat Total Total
Pumps Tons KW
No. of Dishwashers
Space/Area Heating KW
Detection/Sounding Devices
Local Municipal ❑Other
❑ Connection
No. of Dryers <
ry
Heating Devices KW
No. of No. of
Low Voltage
No. of Water Heaters KW
Signs Ballasts
Wiring
Total HP/7
No. Hydro Massage Tubs
No. of Motors
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws
I have a current Liability Insurance Policy including Compi Operations Coverage or its substantial equivalent. YES NO = I
have submitted valid proof of same to the Office. YES _ NO Z If you have checked YES, please indicate the type o cove ge by
checking the appro to box.
INSURANCE BOND C OTHER �_ (Please Specify)
(Expiration Date)
Estimated Value of Ele tric Work $
Work to Start ? 7 Inspection Date Requested:
Signed under the Penalties of pe iury:,fi
FIRM NAME�✓���V'
Licensee r� Signature %G
Rough �/�� 0c e! Final
LIC. NO.
LIC. NO. 1-2I=SES
Address Cj v �_ � � � - , - _1— � -- --
OWNER'S INSURANCE WAIVER: I am aware that the Li ensee does not have the insurance coverage or its substantial equivalent as re-
quired by Massachusetts General Laws. and that my signature on this permit application waives this requirement. Owner Agent
(Please check one)
Telephone No. PERMIT FEE $ —Al.
'.
(Signature of Owner or Agent) x-6565
�•
Location -? 2U --�
No. �A^,8 S Date
TOWN OF NORTH AN -DOVER
o _ ,
Certificate of Occupancy $
'��°''•°''t�' Buildin /Frame Permit Fee $
9
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # LIVO
15532 / Building Inspect6r
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
.�:��"'` �x,��k,.,, , . ��x; ."a, .:, . ',, ., a:.`..: a ... 4���.�'3 $ �,.. ,�z'". ,' r?c3 ^aa s,... •'.
BUILDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE: 1XM4.
Building Commissioner/I or of Buildings Date C/
SECTION 1- SITE INFORMATION,
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information:
Zoning DistrictProposed Use
1.4 Property Dimensions:
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
R aired Provided
1.7 Water SupplyM.GL.C.40. 54) 1.5. Flood Zone Information:
Public ❑ Private ❑ Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIPtAUTHORIZED AGENT
2.1 Owner of Record
kidyAs-LD -3 -7
Name (Print) Address forService:
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
11'7, /77 Lt-,
Licens onstruction'Supervisor:
Address.
/l/j %%%1lu G/ eta r 6 tB 5"
Signature Telephone
Not Applicable ❑
es 0 y Z 01;G
License Number
'
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
Ma
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SECTION 4 - WORKERS COMPENSATION (RG.L. C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ...... N No ....... ❑
SECTION 5 Description of Proposed Work check all applicable)
New Construction ❑
Existing Building J "
Repair(s) 1
Alterations(s) ❑
Addition 0
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify.
� ,! A. , A,
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Brief Description of Proposed Work: .
37� SUl&tt
. _Ja(b . mo
Z1L� - eP6l*L P 9—ID6-4 . /�GG1115yS
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Com leted by permit applicant
OFFICIAL USE (3NI:Y
r� <.-
1. Building
DQE
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) X (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, L---- , 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 OWNER/AUTHORIZED AGENT DECLARATION
1, 'e?d j, MI) Gk LE 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
gl
Print Nam
Signatufe of Owner/A ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
RD
SIZE OF FLOOR TIJVIBERS 1 2 3
SPAN
DIMENSIONS OF SILLS
D11\, ENSIONS OF POSTS
DfMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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North Andover Building Department
Tel: 978-6,88_954
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid. waste disposal facility as defined by MGL
c11,S150A.
The debris will be disposed of in:
(Location of Facility)
J
Signature of permit App►icant
-/� -0
Date
NOTE: Demolition permit from ti?e Town of North Andover must be obtained for
this project through the Office of the Building Inspector
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Print.
Name:
Location:
CRY Phone
am a homeowner performing all work myself.
�I am a sole proprietor and have no one working in any capacity
ED1-a'm an employer providing workers' compensation for my employees working on this job.
Company name: /22_/CffLC S A gD C. AUC
Address31Yo9k'� 2` 57R
Clic: Ml?/l Phone ,�k�7 _�� � 8 `p
Compam name:
Address
City:
Phone*
Failure to secure coverage as required under Section 25A or MG -L— 152 can lead to the imposition of uiminal penalties. of a fine up to $1, 500.00
and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK 0611 and a fine of ($10f) 00) a day against rrre. 1
understand that a copy of this statement may be forwarded to the Office of investigations of the DIA for coverage verification.
I do herby certify under the pains and pena&ies of perjury Mat the infmMatim provided above is true and correct
13/e2 -
Print name ("( Sig to tN? (A -C, kLE � t P Ya -a I V1r-., A)T_Phone # n? d 70 �
Official use only do not write in this area to be completed by city or town official' E] Building Dept '
OCheck if immediate response is required Building Dept D Licensing Board
p Selectman's Office
Contact person: Phone # 0 Health Department
Other
RM WORKMAN'S COMPENSATlOR
JrlPBOARD OF BUILDING.REGULA710NS t'
License CONSTRUCTION SUPERVISOR
op
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i'Expiresn02/19/2004- £Tr; o; X16590
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�RIGHARD A`'MUCKLE�
433 MARKET STS az
'LAWRENCE MA 01843 Administrator
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i'412 1037
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TOWN OF
NORTH ANDOVER
p
PERMIT
FOR :WIRING
�,SSACNUSE�
..u_
w
This certifies that .....M. a... ��........ �r
....
�% i L
has permission to perform ....K1. J.....
i_ >>
�cK...ln!../... i�
a+
wiring in the building of ....... .1A ............
.......z.................................
...... .. .
7 +z ��
at �...1.
Q
Andover,'Mass ;.
.�.4t......... .................
,North .
Fee. .0 Lic. No.� L.�13 ................
.,
- -
ELECTRICAL INSPECTOR
... L.-•". � � � �.
tet..
WRITE: Applicant CANARY: Building Dept.
PINK: Treasurer x,
Date .... g::A.1
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............ C,
............................................................
e-1, eetL�,
has permission to perform .............. N .. e.�� ..... .........-1"C.........I . .
wiring in the building of ..........
. ...........................................
at 77/1 5��f ... 16�� ..... .......... ,,North AndovetrMass.
I.... -w ..........
Fee .... Lic. Nq,114'-.3'V37 ... ............
,�Ei�CTRICAL'- INSPECTOR
Check # J,7
4338
7HECOMMOI TWEALTHOFMASS4CRUSE77S
DEPARTAflM0FPM1CS4FMY
BOARDOFFIREPREVE1VHONREGUTA77ONS527GW?12.00
Office Use only
Permit No. °??
E +5
Occupancy &Fees Cheoked
APPLICATIONFOR PERMIT TO PERFORM ELECMCAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 J —
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date �% O
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) SUS�
Owner or Tenant (Yhe
Owner's Address
Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) .
Purpose of Building j �1 Utility Authorization d .
Existing Service � Q Amps /'W / 2 bolts OverheadI:iy
nderground No. of Meters
New Service 106 Amps / ` Lq lYolts Overhead Underground � No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work _ C -r 70 n 1J 1 C-�
No. of Lighting Outlets I No. of Hot Tubs No. of Transformers Total
KVA
No. of Lighting Fixtures Swimming Pool Above Below Generators KVA
11 ground eround
No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units
r°
No. of Switch Outlets
No. of Gas Burners
No. of Ranges No. of Air Cond. Total FIRE ALARMS No_ of Zones
Tons
No. of Disposals No. of Heat Total Total No. of Detection and
Pumps Tons KW Initiating Devices
No. of Dishwashers Space Area Heating KW No. of Sounding Devices
No. of Self Contained
Detection/Sounding Devices
No. of Dryers Heating Devices KW Local Municipal Other
Connections
No. of Water Heaters KW No. of No. of
Signs Bailasis
No. Hydro Massage Tubs No. of Motors Total HP
OTHER
InsurarloeCovaage. Ptnlottieiac�ritarlaltsofNlassada>set�Ga�a�alLaws
IbawaaLdx-ityh�s==Pbhcymrin CCC CDMaW0ritsWXWntW uiVa� YES NO
>l
IhavEsilbmNedvalidploof intheOffxe YES >I}auha�ed>9cl�d 'plea9eiothetypeofco by
circidngdbre
IN Bim._ _ _ _ _ori _... 1•-_•..J-- - -- - - - . / - _ 3_
rtil C I�
Es�dvaikdElt�calWixk $
wotklDShatt h Mp C iMDratoRecp>e kd Rout F>rlal
FIRMLAME -e lc Lice MNO. 3
1~IRMNAME
[iesee's_ 'LoeeNoc6
�� CGj/ : )6ew�P � Bt>s;r>essTetrlo
kcklress—AIL Tel. No.
JWNER'SINSURANCEWAIVER Iamawaredv Lmwdoes nothavethcumancecowtageoritsaibsmtdequivala tasiegcmedbyNbssact G=TAIaws
tndthat mysipahueonthispmn*tapplicationwaives thisrequki m)`nt.
Please check one) Owner Agent
Telephone No. PERMIT FEE
Igna ure of Uwner or Agent
Date.7:./.)'.....
�
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
_`�
This certifies that ..l..�.�. �. �G!.c/
has permission to perform .....T). 4...l ....................... .
plumbing in the buildings of . J /'/ (.). C:.�', (.:'�................ .
at ..a3.?.0. . S .G ,� �_ : r. :.... , North Andover, Mass.
Fee. Z...... Lic. No. A J. ? . ........� .. `.-��^- ....... .
LUMBING INSPEC OR
Check #1 ? � } �
5660
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type)
0C1L-%q /4nC/,a Q,�Mass. Date Permit #
1 Building Locationy� /yy rnm 2 Owner's Name
Type of Occupancy Residential
New U Renovation 0 Replacement 0 Plans Submitted: Yes ❑ No ❑
FIXTURES
Installing Company Name Heritage Htg. &Plg. CO. Inc. Check one:
Address_ 35 pit -,q, ant Street MCorporation
Stoneham, Ma 02180 �.� Partnership
Business Telephone—_-__381-��=] 71�—._ F1 Firrn/Co.
Name of Licensed Plumber Gordon Switzer
Certificate
714
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 9 No U
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy M 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 or emner or owner s J+yeni -
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 Slate Plumbing Code and Chapter 2 0l the General Laws.
By --
Signatwe of icense umber
---- Type of Liconse: Hasler [-X Journeyman ❑
City/Town 8322
APPROVED FICE—TI SE ONLY) License Number___-_____
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Installing Company Name Heritage Htg. &Plg. CO. Inc. Check one:
Address_ 35 pit -,q, ant Street MCorporation
Stoneham, Ma 02180 �.� Partnership
Business Telephone—_-__381-��=] 71�—._ F1 Firrn/Co.
Name of Licensed Plumber Gordon Switzer
Certificate
714
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 9 No U
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy M 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 or emner or owner s J+yeni -
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 Slate Plumbing Code and Chapter 2 0l the General Laws.
By --
Signatwe of icense umber
---- Type of Liconse: Hasler [-X Journeyman ❑
City/Town 8322
APPROVED FICE—TI SE ONLY) License Number___-_____
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Date:
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ... c
has permission to perform ... � • Ut . 7. ..................... .
plumbing in the
buildings of ... � /t � o
at ... NortAndover, Mass.
Fee -3?...... Lic. No........ . ! ........ ....
PLUMBING INSPECTOR
Check # J
5661
1
t
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO D /pi MBING
(Print or Type)
4 Za /-M Ande i&Cmass. Date �Plermijjt #
aV. Building Location. r�i"/ L'�P,�_T Owner's Name( .� T Prt'�L, mn
Type of Occupancy Residential
New ❑ Renovation ❑ Replacement Plans Submitted: Yes ❑ No ❑
ear, .C:•'�
FIXTURES
Installing Company Name Heritage Htg . &Plg . Co. Inc.
Check one:
Address 35 Pleasant Street
Stonehani., :Ma 02180,
Business Telephone 781 -438-7776
Name of Licensed Plumber Gordon Switzer
IX Corporation
❑ Partnership
171 Firm/Co.
Certificate
714
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 01 No ❑
If you have checked Vis, please indicate the type coverage by checking the appropriate box.
A liability Insurance policy IN 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 ❑
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all .
pertinent provisions of the Massachusetts State Plumbing Code and Chapter 1 2 of they General Laws.
By
Signature o Zicens--Plum er
Title
Type of License: Master iX Journeyman ❑
City/Town 8 3 2 2
APPROVED Z01 ICE CO LN-�� License Number
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7TH FLOOR
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Installing Company Name Heritage Htg . &Plg . Co. Inc.
Check one:
Address 35 Pleasant Street
Stonehani., :Ma 02180,
Business Telephone 781 -438-7776
Name of Licensed Plumber Gordon Switzer
IX Corporation
❑ Partnership
171 Firm/Co.
Certificate
714
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 01 No ❑
If you have checked Vis, please indicate the type coverage by checking the appropriate box.
A liability Insurance policy IN 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 ❑
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all .
pertinent provisions of the Massachusetts State Plumbing Code and Chapter 1 2 of they General Laws.
By
Signature o Zicens--Plum er
Title
Type of License: Master iX Journeyman ❑
City/Town 8 3 2 2
APPROVED Z01 ICE CO LN-�� License Number
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