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HomeMy WebLinkAboutMiscellaneous - 378 SALEM STREET 4/30/2018i � o I V I V � • W D O r o m I O 1 A o m o m m o � o 6074 ' r Date .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING �,SSACMUs� This certifies that ................................. � ow.... ......... ow .............................. has permission to perform .............`..... F....'�Eh/....................................... wiring in the building of .........! ................. See at ............................ 5 North Andover, Mass. gc rJ "7 Lic. No.&Yki4- g -l; .................. ELECCRICALINSPECrOR Check # �a + DEPARTMENTOFPUBLICS4FEN Permit No. BOARD OFMEPREVEMTOIVMGU ATIOM527CNR 1200 Occupancy & Fees Checked APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK.f- ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSAC[iUSSTS ELECTRICAL 0 E, I (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Owner or Tenant J -T1"1 To t nspector of Wires: Owner's Address 0 1 6 ()a t, ) "f'I"ee= 1 - Is this permit in conjunction with a building permit: / / Yes No ® (Check Appropriate Box) Purpose of Building (]C cnm� � X 17r -A 2 J� Utility Authorisation No. Existing Service Amps Volts Overhead Q Underground a No. of Meters New Servi A11.4 Amps Volts Overhead r --J Underground Q No. of Meters Number of Feeders and Ampacity NIA Incation and Nature of Proaosed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA and ound No. of Receptacle Outlets No. of0ii Burners No. df Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total O Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW / No. of Self Contained Detection/Sounding Devices Local Municipal Connections a Other No. of Dryers Heating Devices KW No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Missage Tubs No. of Motors Total HP IIWrd1UBC0AMge ItmeaamentLiablkftH VeP0kYmA&9CCr1Vi e . Co w.Wcritssul3sl;NMaF1iva{at Y6 M NO Iha%eabmt advafidpjcfofs3miatteOffm YES Ifjauhmdvd BYES,pltmmffc*the4FofanmWbydakwrgft N9 ANC,'E BOND OH -&R (Pl mSpe* FxrlrabmDale WetktDStatt hgomcnD*ReWe*d Signedunde3"iePlndb sofpajW FIRMNAME EtrnakdVakxalE6McalWdk $ Rao I FEW Li=,SeNa Je 0- - /VIa -; ( 1 `a % ►� sigtlahae - Limmisb * - Btsi mTel.Na .11 Ak.Td.Na OWNER'SiNSURANCEWAIVER larnmatethAftliaensedosmt theitstraneoo►@eori�sts�>4alegld�aiatascocplQedbyMass se>tsGaiaalLaws andtisatmysigtrat enitrspamf.eppi mtknv4 d isle fait (Please eck e) er Agent Telephone No. PERMIT FEE 1 ' P,V,;4 j �� d �f -14 Date.. -. ..a. 09......... NORTH . 16 TOWN OF NORTH ANDOVER PERMIT FOR WIRING . . ....... . ........................ . This certifies that .................. has permission to perform ............ tj wiring in the building of ...... ................................................... at.Zwl.jf ........61 . ...... . ....... North Andover, -Mass. ... .... .. Fee ...... Lic. .............. Z.7i WP�69 PELEcTRicAL NSPE R Check # V L 8392 y �� (.o onwa,& o/ Y&66ac" UME= 2Tarhwd o/ -7w S'ervica! BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. g 3 -C?,2,-- . Occupancy and Fee Checked sem_ [Rev. 1/07j eave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12,00 (PLEASE PRINTW INK OR TYPE ALL INFORMAVON) Date: z, S --0, - City or Town of: ..&,t � A A ® V -di 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 & Owner or Tenant Owner's Address Is this permit in conjunction with a� building permit? yes F-1ose Parpof Building _ �es i/, Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Elec$rical Work: No ❑ (Check Appropriate Boa) Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters No. of Recessed Luminaires - -- - ----- - - - No. of Ceil.-Sasp. (Paddle) Fans rcu u -W J! d c[Vr v rr [rely. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming pool Above ❑- E3o. grud. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets o. of Oil Barriers FIRE No. of Zones No. of Switches No. of Gas Burners o. of Detection an Initiatine Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers eat Pump Totals•aD-0 I um r Tons o Self -Contained Detection/Alertin Devices .._ -1o. No. of Dishwashers Space/Area Heating KW Local ❑arncrpa Connection 0 Oiber No. of Dryers Heating Appliances KWarmy stems: Devices or uivalent No. o Water KW Heaters 0� o. o o. o Signs Ballasts Data Wirin No. of Devices or FAuivalent No. Hydromassage Bathtubs No. of Motors Total HP a ecommunicationsiring No. of Devices or nivalent OTHER: nttacn aaamonat aetatt p aestreA or as required by the Inspector of Wires. Estimated Value of Electrical Wort(When required by municipal policy.) Work to Start: 7 'Z 6 -(�(� 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 v e is in force, and has exhibited proof of same to the issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) F.tI 10 I certify, under the pains and allies of perjury, that the information on this lication is true and complete: FIRM NAME: �`�' LIC. NO.: Licensee: Signature LIC. NO.: / (If applicable, enter "exempt" in the I kepse number line.) C Bus. Tel. No.- Address: 2 Z:�© Alt. Tel. No.: .9-7e &,S 7 7,3,3� *Per M.G.L. c. 147, s. 57-61, security work requires Departni nt of Public Safety "S" icense: 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 (checkone ❑owner E] owner's agent. Owner/Agent c Signature Telephone No. PERMIT FEE: $: — r d� � � � � 1 - � � _ Qt ` ` ' , i Y �. � � � � 1 - � � , i � I I U. Date..... . .... ... ... ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... ............. ................................................................ has permission to perform wiring in the building of ........... ... . .................................................... at ... .. .... ".,,NonrthhAndd ve M Fee ..... Lic. No.,��/*/*.7 j LE k. AL N R Check # 8427 N Commonwealth of Massachusetts Department of Fire Services i BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. ore Occupancy and Fee Checked [Rev. 1/07] 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 IN INK OR TYPE ALL INFORMATION) Date: . /O; City or Town of: NORTH ANDOVER To the Inspec or of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 3Z F � �S: Owner or Tenant \ / / �1- Telephone No. (a7 q(r 77pZ.? Owner's Address 14 Is this permit in conjunction with a building permit? Purpose of Building Existing Service _ Amps 0 / ZVo' Volts New Service 2.00 Amps lZ! / Z—VO Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Yes ❑ No ® (Check Appropriate Box) Utility Authorization No. �(o� 4(c:)n 3 Overhead Undgrd ❑ No. of Meters Overhead Undgrd ❑ No. of Meters No, of Recessed Luminaires 11—JuctuwIng No. of Ceil: Susp. (Paddle) Fans abee may oe waivea oy the /ns ector of Wires. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o Emergency Lighting BattM Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiatin Devices No. of Ranges No. of Air Cond. Tonss No. of Alerting Devices No, of Waste Disposers eat Pump Totals: INumber -" "' Tons KVV No. of Self -Contained Detection/Alerting Devices No. of Dishwashers . Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers No. of Water KW Heating Appliances KW No. No. of al of Signs Ballasts . Security Systems:* No. of Devices or E uivalent Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: eiiiuca aaatrionai aetaet 1f desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: Z-&t� (When required by municipal policy.) Work to Start: / of 7 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 proofof 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 pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: r 4nr e✓ % at LIC. NO.: 3gl7L4� Licensee: Signature LIC. NO.: (If applicable, enter "exempt" in the license num er line.) Bus. Tel. No.- q78 4-22 l?7-7 Address: —Pb X03 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 agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts Department o_f'Industrial Accidents Office of Investigations . 600 Washington Street Boston, MA 02111 C-1 . www.nxass gov/dia . Workers' Compensation Insurance Affidavit: builders/Contractors/Electricians/Plumbers Applicant Information Piease Print Legibly Nallle (Business/organization/lndividual): Address: City/.State/Zip: Phone #: . Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ 1 am a general contractor and I_ Type of project (required):T T❑New employees (full and/or part-time).* have hired the sub -contractors 6. construction 2. ❑ I am.asole proprietor or partner- listed on the attached sheet. $ 7• ❑ Remodeling ship and have no employees These sub -contractors have 8. [] Demolition working for mein any capacity. [No workers' comp. insurance workers' comp. insurance. 5`. ❑ We are a corporation and.its g. Building addition required.] officers have exercised their 10.❑ Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work right of exemption per MGL l i.Q Plumbing repairs or additions myself. [No -workers' comp. c. 1.52, § 1(4),' and we have no 12,0 Roof repairs insurance required.] t employees. [No workers' 13.[] Other comp. insurance required..] may appuoe s roar c .,necxs oox F1 must also fill out the section below showing their workers' compensation policy information, i Homeowners who submit this affidavit indicating they are doing all work and then hue 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 insurancefor my. employeeL- Below is the policy and job site information. Insurance Company Name:_ Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: Ciiy/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 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 DCA for insurance coverage verification. at I do hereby certify under the pains and penaltdes of perjury that the information provided above is true and correct Signature: Date: Phone #: 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 #: Date.. l . 45-... . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that has permission for gas ins all . .............. . L in the buildings of ......................... lat North Andover, Mass. Fee -45. . Lic. No........... ......... .c.4,%......... . GAS ! TOR Check # �G/ 4/ 5006 i`' G MASSACHUSETTS UNIFORM APPLICAT)?N FOR PERMIT TO DO GASFITTING (Print /?/oar Type) od VA , Mass. Building Location 378 Y/I.t4 Telephone New ❑ Renovation FLOOR Date N 20 05' i / Owner's Name :T -Q 6.S <tH-4 % d a'1 %llp Ll-2- d ❑ i e6 °' in ' J H V O m C E _ - G C j cc ,C v L �W y V d Rf M O o N w O N Date . �� 20 05' Permit # 11506h / Owner's Name :T -Q 6.S <tH-4 % Type of Occupancy %llp Ll-2- ?pl cement ❑ Plans Submitted: Yes ® No® 12 °' ' J H V O m C E _ - G C j cc ,C v L �W y V d Rf M O o N w O N 18TH FLOOR I I I I I I I I I I I 1 1 1 1 I 1 1 1 1 1 1 1 1 1 I I Installing Company Name EnergyUSA Propane, Inc. Check one: Certificate Address PO Myles Standish Blvd. XI Corporation 132 C ,Tauton, MA 02780 ❑ Partnership i Business Telephone (800) 822-1300 X8051 ® Finn/Co. Name of Licensed Plumber or Gasfitter William Kent Corson C/ 2 f - .3 7-5' — irf P INSURANCE COVERAGE: EnergyUSA Propane, Inc. has a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch. 142. Yes X� No El If you have checked jL, please indicate the type of coverage by checking the appropriate box. A liability insurance policy D 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 Owners Agent ri 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 Code and Chapter 142 of the General taws. Type of License: By ® Plumber Title Q Gasfitter City/Town El Master APPROVED (OFFICE USE ONLY) Mioumeyman Signature of Licensed Plumber or Gasfitter License Number 3707 ,�EnergyUS/i Propane DATE PAGE N0. / A NiSource Company �j /� / ��' -J / 0�j '142 64 'S r A/. ffwod w BY i___. I ................... 1 � � I -I I I I I I- 10 TP i cl_� 370 i i Location No. �7 Date Check # uc:> TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL i 161 C�o .._ 17971 A/u 16I.-1 - Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING Number. id 3 6-00,39-" Parcel Number BUELDING PERMIT NUMBER: DATE ISSUED: C SIGNATURE: ✓V` Building Commis9i'oner/IngWor of Buildings Date 1 !SECTION i- SITE INFURMATION j 1.1 Property Address: 1.2 Assessors Map and Parcel Map Number Number. id 3 6-00,39-" Parcel Number e1 p-45 , �t� ca, /e,, 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lal Area Fronts R L6 BLTMDING SETBACKS ft Front Yard Side Yard Telephone Rear Yard Re(pired. Provide Required Provided Required Provided Namq Print Address for Service: 1.7 Water Supply M.G LC.40. 34) 13. Public 0 Private 0 Zone Flood Zone Information: Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: 0 On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT 10 LlIStflCt: Y�r.s rf o 2.1 Owner of Record j / / L 1{/PSS l�Qh1� �t� ca, /e,, Name (Print) Address for Service Signature Telephone 2.2 Owner of Record: :Gly an - Namq Print Address for Service: IL -2) SE 747 Si ture Telephone S TION 3 - CONSTRUCTION SERVICES Licensed Construction Supervisor: Not Applicable Licensed Construction Supervisor: License Number Address Signaldre Telephone Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable Company Name Registration Number Address Expiration Date Signature Telephone wo M X _r z O A� SR.CTION 4 - WORKERS COMPENSATION (M.G.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 rmit. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check a ble New Construction 0 Existing Building Y Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other 0 Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building 0/ r (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 CONTRACTORFOR BUELDING PERMIT 'APPLIES 1, V ii r leL , as Owner/Authorized Agent of subject property Here y authorize to act on My Vzhalfp allm s r lative to work authorized by this buildu►g permit application. I oS S' iat a of Ove rer Date CTION 7b OWNER/AUTHORIZE�AGE�NTDEC�LAARATION 1, 1. ,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 Pruni Name Si ature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 ND 3 r° SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIN ENSIGNS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHEVMY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE f NOeTM TOWN OF NORTH ANDOVER ;•';` .•�6 oL OFFICE OF p BUILDING DEPARTMENT 400 Osgood Street North Andover, Massachusetts 01845 D. Robert Nicetta, Building Commissioner HOMEOWNER LICENSE EXEMPTION Please print DATE: 111r10,5 Telephone (978) 688-95454 Fax (978)688-9542 JOB LOCATION: L37U c5 Pte - Number ��SSt/treet Address Map/Lot HOMEOWNER JJ les �� /�Cc i, 7l 'c �'cV —1 `1-1, 7 Nam6 Home Phone Work Phone PRESENT MAILING ADDRESS 3 7('" do, le ,tet V P - City Town a 1605 Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other Applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. /j // HOMEOWNERS SIGNATURE APPROVAL OF BUILDING BOARD OF .I TEALS 688-9541 CONS L.R V TION 6880530 I1EALTH 688-9540 PLANNING 688-9535 C O - m C O O y C C3 C.2 a� CL m ccm cc is o CF COL m O t rte+ d 44 M c�V' m a E CL y y ,m3 CM : y C y = C o m CDCLa o o, �mmCC Z= 'COD ..71 mho 0 cm -.,o CLC s= m o. E o C w �� ece _ � o F3 y o Lu m �mrc S CL _ CIO qm y M gm= O H =m$ awm F p T Me- r 0 E 0 CD � CD CD n O Q a Ccm Q■� h Q � y � � m m CL Q CD 3.0 x q a v � Cc � q cm< o =� c ca C Z C CD CL C.3 CIO c � c � CL Q w° w° U w w°' w w oo cn o cn C O - m C O O y C C3 C.2 a� CL m ccm cc is o CF COL m O t rte+ d 44 M c�V' m a E CL y y ,m3 CM : y C y = C o m CDCLa o o, �mmCC Z= 'COD ..71 mho 0 cm -.,o CLC s= m o. E o C w �� ece _ � o F3 y o Lu m �mrc S CL _ CIO qm y M gm= O H =m$ awm F p T Me- r 0 0 LLIU) W W 19 W U) E CD Z CD CD n O Q y = Ccm Q■� h Q � y � � m m CL Q CD 3.0 CD � Cc Q i o oo"„ cm< o =� c ca C Z C CD CL C.3 CIO c c c CL Q 0 LLIU) W W 19 W U) 40Rr 0 q This certifies that ...8: has permission to perform Date. . 4 -T)OWN = OF ORTH ANDOVER MIT FOR PLUMBING L-P P. . . . . . . . . . . . . . . . . . . . . j. . . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of ... ri. .11.A # z ..................... at. .........Andover, Mass. Fee,4.(!:� Lic. No .......... ....... �D,-'Ti ....... PLUMBING MBING INSP Check # 66*16 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location <� 7 d 5,4 ners New of Renovation EY Replacement 11 FIXTURES f l Date 9 /Zo As Permit # Amount Plans Submitted YesNo (Print in type) /% -� �� j�� /'�� `� Check one: Certificate Installing Company Name (�,. , , Corp.r �ls Address Sy 0 C) k ro i - Partner. <— Business Telephone �� 7 K & E-& Zj X'- 11 Firm/Co. Name of Licensed Plumber. Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy a Other type of indemnity 11 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 11 Agent 0 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massa ch tts St Plumbing ode and apter l4 the General Laws. By: Signature 01 Licenseu Type of Plumbing License Title o City/Town License um Master Journeyman ❑ APPROVED tor-McE USE ONLY Date. ........ EZTOW --OF NORTH ANDOVER IT FOR GAS INSTALLATION This certifies that ..................... has permission for gas installation .... 'f ............... in the buildings of .1f.14,4 � ................................ at .5h.1 -e ... .............. I North Andover, Mass. Fee.) Lic. No..7 ? O .? ... .... (L- ...... 'GAS INSPECTOR Check# 1,7Z L 5248 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING 3 (Print or Type) 954 Mass. Date ` v�'� 20 Permit # �( Building Location LAZ16-?7 s Owner's Name JuL,6s Telephone 9%� S(� �_9�. / Type of Occupancy A0 New Renovation Replacement ® Plans Submitted: Yes ® No� �[ O O i d .ai (n L c.i � fn = lSf L fiS :L -d a> am L Z O m C >r = N LA i w KT C O eQ md rO .O W R O > Q2 N > d N_ L. ° CC= o c m °C S �� O aC W- O X ti � 0 J UW> BASEMENT 1ST FLOOR 2ND FLOOR FLOOR FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name EnergyUSA Propane, Inc. Check one: Certificate Address /00 Myles Standish Blvd. X® Corporation 132 C �ujl/fon, MA 02780 ® Partnership Business Telephone (800) 822-1300 X8051 �7�-3� j -%,>� ® FirmiCo. Name of Licensed Plumber or Gasfitter William Kent Corson INSURANCE COVERAGE: EnergyUSA Propane, Inc. has a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch. 142. Yes l No If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy X� Other type of indemnityEl 1:1 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 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 Code and Chapter 142 of the General Laws. Type of License: By ® Plumber Title a Gasfitter City/Town ElMaster APPROVED (OFFICE USE ONLY) QJourneyman Signature of Licensed Plumber or Gasfitter License Number 3707