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HomeMy WebLinkAboutMiscellaneous - 373 SALEM STREET 4/30/2018 (2)MetLife Auto & Home® Homeowner Operations Field Claim Office Attention: Claims P.O. Box 6040 Scranton, PA 18505 (800)854-6011 March 19, 2015 North Andover Building Inspection 1600 Osgood St, Suite 2035 North Andover, MA 01845 Our Customer: Thomas J. Abernathy Jr Claim Number: JDF01410 OG Date of Loss: March 1, 2015 Dear North Andover Building Inspection: Pursuant to M.G.L. 139 § 313, please be advised that a property loss at the address referenced below has been estimated to have damage to the dwelling or other structures that will exceed one thousand dollars. Please let us know within ten (10) days if there is a pending or existing lien against the property as provided by M.G.L. 139 § 313, or if there is an intent to initiate proceedings to perfect such a lien. Loss Location: 373 Salem St, North Andover, MA Sincerely, Home Ops CAT Team Sarah Lackey Metropolitan Property and Casualty Insurance Company Claim Adjuster (800) 854-6011 Ext. 7440 Fax: (855) 411-6689 Email: MetLifeCatTeam@tnetlife.com MetLife Auto & Home is a brand of Metropolitan Property and Casualty Insurance Company and its affiliates, Warwick, RI. MPL MA-REGDEPT Printed in U.S.A 0698 I Date. 6.: c .4— t I TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ..O .,"A. .t? f Sn...(�,t ,r:, ? J.. , :.. _ ....... . has permission to perform ..LJ h.?kcr.. bc!;A-, ...�..t�1tS.c�,• i. plumbing in the buildings of —t: kQVA,.5 at . 3-7 ...S 5 c! vy 4 k .. , ..... , , North Ando , Mass. Fee'r30-c-o . Lic. No..-.. /w% . ...... .. . PLUMBING INSPECTOR Check # / ©U MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building S'e4l el' Z s Ow S o23'f% �(S' i/d/ 7/f yPe mit # Type of Occupancy f)1U & L iA-) 6 `M°unt New ❑ Renovation ❑ Replacement ® Plans Submitted Yes ❑ No FIXTURES (Print or type)y� CQ one. Certificate Installing CompanyName IL 4L -O RFA) fti�MjS,,-Aj Corp. Address 0-4" ST- ❑ Partner: .�� AA -14o e,t— o .q o j11,ys- Business Telephone 9 7e (� *; _ -T-0 y ❑ Firm/Co. Name ofLicensed Plumber. -70,V Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box Liability insurance policy © Other type of indemnity El Bond ❑ 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 Signature Owner ❑ Agent ❑ I hereby certify that all of the details and infom cation I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbi a Code and Chapter 142 of the General Laws. By, igA � � M "" r Title Type ofPlumbing License � 91 City/Town Master ❑ Journeyman APPROVED (OFFICE USE ONLY 7 Date...�?.��..... ` TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ++ This certifies that .... .% ......... r has permission for gas installation .LU � ��. �'`�L � ..l: in the buildings of ..... �^. _,1,., s ................ g... "........ at �--�..�. � .. � `! � e,�n � ' i ......... North And ver. ass. Fee ,Zc� U!? Lic. No.'�.3. 7 GAS INSPECTOR Check # 1 Q� MASSACRUSEM UNIFORM APPLICATO.N FORPE RMfT TO DO GAS FrrnNG (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations 3 73��l �i� sr T11,01W *5 A1T 0fWX ,7W JV - Owner's Name Date 9—d 3 _ // New Renovation f-1 Replacement Pian Submitted r Permit # Amount $ 01fint or we) one: Certificate Installing company A Name T 114 G 10 Corp. Address e-- d - 13 4 X S 7 aZ LJ Partner. G�i•tc.1 � ert/ �P rY7 �� - � /� �Z LJ Business Telephone i 7 Y5 --q So `1 ❑ FmnlCo. Name of Licensed Plumber or Gas Fitter ols Vq r+/ INSURANCE COVERAGE - Check one: I have a aurent liability Insurance policy or its substantial equivalent. Yes P1 No Ifyou have checked yes, please indicate the type coverage by checking the appropriate box Liability insurance policy Other type ofindemnity rj Bond Q Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 ofthe Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ® Agent I hereby certlty that all ofthe details and mtormation I have submitted (or entered) in above application are true and accurate to the best ofmy knowledge and that all plumbing work and installations perforined under Permit Issued for this application vnn'Il be in compliance with all pertinent provisions ofthe Massachusetts State Gas Code anal Chapter 142 ofthe General Laws. y (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber R V g 33 Gas Fitter LicenseNumber Master Journeyman U u c z o z g ai 0 H < q SUB-BASEM ENT BASEMENT IST. "-FV00R 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FL.00R 6TH. FLOOR 9TH. FLOOR 8TH. FLOOR 01fint or we) one: Certificate Installing company A Name T 114 G 10 Corp. Address e-- d - 13 4 X S 7 aZ LJ Partner. G�i•tc.1 � ert/ �P rY7 �� - � /� �Z LJ Business Telephone i 7 Y5 --q So `1 ❑ FmnlCo. Name of Licensed Plumber or Gas Fitter ols Vq r+/ INSURANCE COVERAGE - Check one: I have a aurent liability Insurance policy or its substantial equivalent. Yes P1 No Ifyou have checked yes, please indicate the type coverage by checking the appropriate box Liability insurance policy Other type ofindemnity rj Bond Q Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 ofthe Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ® Agent I hereby certlty that all ofthe details and mtormation I have submitted (or entered) in above application are true and accurate to the best ofmy knowledge and that all plumbing work and installations perforined under Permit Issued for this application vnn'Il be in compliance with all pertinent provisions ofthe Massachusetts State Gas Code anal Chapter 142 ofthe General Laws. y (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber R V g 33 Gas Fitter LicenseNumber Master Journeyman 8732 Date. /,TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that 44/. ............. . has permission to pekrm ..... 6.S ^�""1 .......... . plumbing in the buildin. s of ... ........... at .. , ...... North Andover, Mass. F.. Lic. No. ,.. A .... . . PLUMBING INSPECTOR Check # I;gVEM - F6 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town:Ajot A %idtd0d6r MA. Date: / 'a g%!S Permit#t Building Location: 37 S Ci �eea Sf- Owners Name: &e rtvat4 Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ New. ❑ Alteration: n Renovation: FIYTI IRFS Plans Submitted: Yes Residential No Installing Company Name: J70 in G CY10-r Address: G la on c,,'c. C bjcit0own• f'k , h ,-rc— f _state: -VI f , BusinessTel:Ct'.02) Fax: 200 �-,c0 02(::)3102(::)3102(::)31�� / Name of Licensed Plumber: 3—C) k Check One Only Certificate # ❑ Corporation ❑ Partnership ❑ Firm/Company INSURANCE COVERAGE: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy- Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does_ not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only ❑ Signature of Owner or Owner's Agent Owner E] Agent I 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. By Title City/Town APPROVED (OFFICE USE Type of License: ❑ Plumber Master Journeyman Plumber /3-PYCF- DEDICATED SYSTEMS MMMMMMMMMMMMMMMM MMM"MMMMMMMMMMMMMMMMMMMM MMM MMMMMMMMMMMMMMMMMMMMMMMMMMMM MMMMMMMMMMMMMMMMMMMM MM ��i�iiiiiiiiiiiiiiiiiiii�iii Installing Company Name: J70 in G CY10-r Address: G la on c,,'c. C bjcit0own• f'k , h ,-rc— f _state: -VI f , BusinessTel:Ct'.02) Fax: 200 �-,c0 02(::)3102(::)3102(::)31�� / Name of Licensed Plumber: 3—C) k Check One Only Certificate # ❑ Corporation ❑ Partnership ❑ Firm/Company INSURANCE COVERAGE: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy- Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does_ not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only ❑ Signature of Owner or Owner's Agent Owner E] Agent I 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. By Title City/Town APPROVED (OFFICE USE Type of License: ❑ Plumber Master Journeyman Plumber /3-PYCF- COMMONWEALTH OF MASSACHUS ISSUES, THE ABOVE LICENSE TO: JOHN A LEONARD m 6 TAMARACK LN AMHERST NH 03031-2261 13248 05/01/12 795817 Moouea� CERTIFICATE OF UABILR°"'� Y INSURANCE s nMtBr ►7s lsl so�+►rx�to� OT Mii 10 �lhitto�w taste CWLYiwo oo Mo RMMfT u"m7ltM�w 501 "Mumoth P4144 ALTER 1it6 edow� Ef"00dexTY lilt 03053 Phone: 603-432-2577 le::603-432-4700 OMPAUM APPOVADO CObTAM R 0 f+efee sra�e A SB 03031 f e of TMraC=aRsWAVMcsufj0nff�awh ff�rauso.a,K.o„�,�,,,®,,.ae�orctrerot,crseieao9�G�T� ygr8 +tMtl RB01AI�,QR, 719x1 ORCOI�fr�OwOMllNrooMINeTG11011ilROOU61aRMR1H 1lll�T�o�CN7�y�rflP�GITQIMYR.NpuW cra NfnPWM4TWAFrOl bf'fj PCUMBMW"WNNJM=TUALLTMIMMMXZLMCPMMOCOMfOIaw r011f,ESAOYIf�,ltEL9111S �NDYMI ff►Y HAVE �lI1�Ut>IbAV'M101XAM1S cuor umm *srs�ert Lion A 7C LammJ ctare,raer � occlse SUN fol00000t 05/16/10 fly/16/11 924000 l�eafja•pr,gq,,.pd,�„1 =5400 --- AML+A9WMAM 91000000 aw�AnowwA�uwr++�vta9�e' o+s9oalloan7s 99000004 uo� 09000000 rwnv MMM tnsaar IWAUM 81005708 09/I2/09 09/I2/10 l�R +1 i f ia04b00 Ala OWWDMPMM MCMMURIf1AUM OODlYfilfJ!!f► _ A�.•wo! x ��,u+os Z $°01.�g ' _ t�r.fsdlfo°AW1s` : � QAldn9 u�am MI AMO Au1DofLY-i14A0Godff : 71M1. a►A� s " f UAw,Mnat AM s cam ❑ w+ue wmf ao"COMWAMM a "PCs 0�011C111ti • 'er�►ion 9 s W1A7 fOwovs °'insew iLMMACCWW �• -'• E1 0 1{iE-61 -- rL b lA1AE-/�lGYlaff f s�n�nrv�wrorsoaee�rourata.Ee�rma�.�,�e�„„ eawaroi �nTMIS7ff11ffiU19 fff< Is71f1� 30 II; M04f:7D7�71�fff1'�A79M9Lr1f�flff�707!l�rT,lllrRsy,INETaloOlDMIfl1 i f1'GEIIOOR�/,tllptld7�f�I111t1ab�MOMY�f;w�lERrts�7O� Date ..`-'.fes:": F:r.. �/'1p... . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that�C I . has permission for gas installation --A '. ....... ��, in the buildings of .......................................... at .-�....�.� -�.� , North Andover, Mass. Fe� Lic. No`?�'/ .._._.._._ `�a-',�. .......... . Check # 7158 MASSACHUSETTS UNDDRM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations ,4 Owner's Name New ❑ Renovation Replacement LCJ Permit # Amount $ %/�� Plans Submitted (Print or type) Check one: Certificate alling Company Name 41',' Cpf� ' ® Corp. Address C -S ® Partner. GI�tsS usmess elephdne 0 Finn/Co. Name of Licensed Plumber or Gas Fitter / l�,•� 1'/ _ ��%�7 INSURANCE COVERAGE Check one: I have a current liability Insurance policy or. it's substantial equivalent. Yes 0 No If you have checked Les, please indicate the type coverage by checking the appropriate box. Liability insurance policy, Other type of indemnityBond13 Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent - ---- -- -----v ---. _.• �• •••� ........•� K.+u „„v„uauvu i uavc suuIII utcu kOr enTereQ) m best of my knowledge and that all plumbing work and installations performed under I compliance with all pertinent provisions of the Massachusetts Sx9b a Code an4A-;4 Title City/Town IAPPROVED (OFFICE USE ONLY) application are true and accurate to the Issued for this application will be in 142 of the General Laws. 1 ---- Signature of Licensed Plumber 5r Gas Fitter Plumber Ma Gas Fitter License Number Master Journeyman Cn V .. w oUD z a w� � � z x x a w0 w H x a a w a w° zW o z o to x o x 3 0 a U a > a a o SUB -BA MENENT BASEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLO O R 4TH. FLOOR 5TH. F L 0 O R 6TH. FLOOR 7TH. FLOOR # 8.TH. •FL00R-1 F--� (Print or type) Check one: Certificate alling Company Name 41',' Cpf� ' ® Corp. Address C -S ® Partner. GI�tsS usmess elephdne 0 Finn/Co. Name of Licensed Plumber or Gas Fitter / l�,•� 1'/ _ ��%�7 INSURANCE COVERAGE Check one: I have a current liability Insurance policy or. it's substantial equivalent. Yes 0 No If you have checked Les, please indicate the type coverage by checking the appropriate box. Liability insurance policy, Other type of indemnityBond13 Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent - ---- -- -----v ---. _.• �• •••� ........•� K.+u „„v„uauvu i uavc suuIII utcu kOr enTereQ) m best of my knowledge and that all plumbing work and installations performed under I compliance with all pertinent provisions of the Massachusetts Sx9b a Code an4A-;4 Title City/Town IAPPROVED (OFFICE USE ONLY) application are true and accurate to the Issued for this application will be in 142 of the General Laws. 1 ---- Signature of Licensed Plumber 5r Gas Fitter Plumber Ma Gas Fitter License Number Master Journeyman The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Uf 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le�bly r� Name (Business/Organizafion/lndividual): Address: City/State/Zip: Are you an employer? Check the appropriate 1. ❑ I am a employer with 4. M I am a general contractor and I employees (full and/or part-time).* 2. ❑ 1 am a sole have hired the sub -contractors listed proprietor or partner- on the attached sheet $ ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5• ❑ We are a corporation and its required.] 3. ❑ 1 am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. C. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required] * =sy a*•giieant that checks 1vc Yl must also f11 out the sectio✓ b Type of project (required): 6. 0 New construction 7. El Remodeling 8. Demolition 9. Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 R of repairs 13. Vther Ft) Onn C�P / 'm t Homeowners who submit this affidavit indicating they are doing all work and then Hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the, name of the sub -contractors and their workers' comp, policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name%-'�Nvpss cc�� a� ns()011�1_n(__�R, Cof0w) QC Policy # or Self -ins. Lic. #: V Expiration Date: �pp� Sob Site Address: City/State/Zip:Dtidt-Atl o 94 L Wil. Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a 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 her certify under the pains and penalties of perjury that the information provided above is true and correct l . > Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person: Permit/License # 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 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 ox- other legal entity,.employing employees. However the owner of a dwelling house having not more than three apartaxents and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintemance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall notbecause 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 perriiit 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 permittlicense 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 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 0.2.111 Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax it 617-727-7749 www.mass-crov/dia Date.. -/9 -v -7 ...... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that.. 'sz-. .. ............. has permission for gas installation ....... Al- ........... in the buildings of .... ........................ at .... 77?..... North/Andover, Mass. Fet� <-- Aq .. Lic. No... .. ..../w ........... 4S* INSPECTOR Check# 1?W0 I - 5916 MASSACHUSETTS UNIMIRM APPUCATON FOR PERMUT TO DO GAS FITTING (Type or print) DateZ�j,/ / 07 NORTH ANDOVER, MASSACHUSETTS Building Locations 2 `7 / �— Permit # Amount $ Owner's Name � � �P2 14/� New D Renovation 1:1 Replacement Plans Submitted (Print or type) Che k one: Certificate Installing Company Name �J ,r7stir -e s�.L /-/ u Corp. Address 8 U ro +Z j < � Partner. Business Telephone L 1rm/Co Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 13-1/ NoO If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy u Other type of indemnity D Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ® Agent 13 I hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installati s performed under Permit Issu for this application will be in compliance with all pertinent provisions of the Massachus je s ACode and Cpapter 142�the Geral Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) ,ignature of L Plumber Gas Fitter Master 0 Journeyman sel7lumber Or Gas Fitter (cense um er a A U z v; Q O w Q O O z w x O w w z d x a a w p w OF G H W C7 z F w Z > F w z x F W U > c:, F U a W z 3 a A d c7 d O O w a O x SU B-BASEM ENT a v x > B A S E M ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7 T H. F L O O R STH. FLOOR (Print or type) Che k one: Certificate Installing Company Name �J ,r7stir -e s�.L /-/ u Corp. Address 8 U ro +Z j < � Partner. Business Telephone L 1rm/Co Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 13-1/ NoO If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy u Other type of indemnity D Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ® Agent 13 I hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installati s performed under Permit Issu for this application will be in compliance with all pertinent provisions of the Massachus je s ACode and Cpapter 142�the Geral Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) ,ignature of L Plumber Gas Fitter Master 0 Journeyman sel7lumber Or Gas Fitter (cense um er