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HomeMy WebLinkAboutMiscellaneous - 39 LONGWOOD AVENUE 4/30/2018 (2)Ic . / / � `ƒf O )//k7) Rmz © \ Z7 m O » � ED �n� 0\ N/ / 2 §/; �:2 q m I r- _.o C $ > \e / N m 4.t, lj� cr 4(n CC) Z 0 > ca MASSACHUSETTS UNN ORM APPLICATION FOR PERNIIT T D DO GAS FITTING (Type or print) Date NORTH ANDOVER, MASSACHUSETTS °? Building Locations Zo Ae:j ,u/t>dov Permit # L ° nJ Q E'Ol., jofdOwner's Name Amount $ 4p 3p New 0 Renovation D Replacement ® Plans Submitted ❑ (Print or type) Name /Gss+it %4&�"R4 A -";Check one: Certificate Installing Company Corp. Address /00 eUk -S-7-p— [:] Partner. gusmess, e�epnone _ g- s -G E]Firm/Co. Name of Licensed Plumber'or Gas Fitter &411611T 41,/ INSURANCE COVERAGE Check one: I have a current liability Insurance, policy or it's substantial equivalent. Yes ® Noo If you have checked Les, please indicate the type coverage by checking the appropriate box. Liability insurance policy ®- Other type of indemnity 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 13 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 installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code a Chapter 142 of the General Laws. By: Title City/Towne. APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber 12 YJ -13J Gas Fitter License Number Master ® Journeyman CA z � a Fd• O '� �' � � Fw+ C w w C7 U w x v, z OF > d G7 F < x w a w F z E- Q z w t a H. E- 'z o z w o C x a� x 'o x 3 0 0 > o a o SU B-BASEM ENT a° N B A S E M ENT 1ST. FLOOR 2ND. FLOGR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR - 8TH. FLOOR (Print or type) Name /Gss+it %4&�"R4 A -";Check one: Certificate Installing Company Corp. Address /00 eUk -S-7-p— [:] Partner. gusmess, e�epnone _ g- s -G E]Firm/Co. Name of Licensed Plumber'or Gas Fitter &411611T 41,/ INSURANCE COVERAGE Check one: I have a current liability Insurance, policy or it's substantial equivalent. Yes ® Noo If you have checked Les, please indicate the type coverage by checking the appropriate box. Liability insurance policy ®- Other type of indemnity 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 13 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 installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code a Chapter 142 of the General Laws. By: Title City/Towne. APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber 12 YJ -13J Gas Fitter License Number Master ® Journeyman -0 =r TO CD 0 Ln .4 14, 01% LA 'C' V) m 0 CIA MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Location 3% lfJAJ 5'!,y/Dc� O /? ivffJwners Name �'i L , ji�//��� %J�j L Permit #y� Amount 2,;� , 0-'- Type tiType of Occupancy I)W {.III',-) e New Renovation 0 Replacement10 Plans Submitted Yes No 1:1 U3 FIXTURES (Print or type) Check one: Certificate Installing Company Name 7 A' 1-14110'r+l x+ ❑ Corp. Address '"u IT0 >,-' 5! 7 Z E]Pager.' Z -9 A, -4 -rte e iyl ✓� 42fi S Business Telephone 4:. S- s --y % Firm/Co. Name of Licensed Plumberi� flG j iL� y . Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy �' Other type of indemnity 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 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 Massachusettstate P t bing Code and Chapter 142 of the General Laws. r By: 'SignalurcoMicenseariumber T e of Plumbing License Title �y�•_7 3 City/Town License Numorr Master Journeyman jam} APPROVED (OFFICE USE ONLY r _ -0 CD = Icc --,.V --4 0 z 0 n z 0 z a 0 m m z 0 0 0 m C)i Cl I CD roZ 0 x MS 0 F- 0 0) CD CD :3 0 0 3 CD o 3 0 CD 0 -n 3. CD m -n 0 CD '< m 4A 40 69 69 69 --4 0 z 0 n z 0 z a 0 m m z 0 0 0 m C)i Cl I TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR. RENOVAM OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/12S=tor of Buildings Date SECTION 1 -SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: � I lro lv C—, 0o --F,--) �y . 0 (2„ ` p c) �- Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: r . Zoning Distric Pr used Use Lot Areas Fronta ft 1.6 BUILDING SETBACKS 00 Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ Public ❑ Private ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT listrict: l'ns mo 2.1 Owner of Record i / k- LA M.A (Z _ Name (Print) Address for Service 0)-4 00 E — -7 '- 5 Signature Telephone 2.2 Owner of Record: CC>&,,(2 �� 1-� c, _q_ N ,o► ,game Print Address for Service: s(So(zC-->'ISA ol�� Si ature Telephone SECTION 3 - CONSTRUCTION SERVICES , 3.1 Licensed Construction Supervisor: Not Applicable ❑ 51, Licensed Construction Supervisor: License Number. Address Expiration Date Signature Telephone A 3.2 Registered Home Improvement Contractor Not Applicable ❑ tA-611� 12P r j G Company Name ;> r- 2 ' ,� Registration Number Expiration Date Signature ele hone ou rn z O v rn 0 M 90 0 rn _r G) SECTION 4 - WORKERS COMPENSATION (1VLG.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. in the denial of the issuance of the building rmit. Signed affidavit Attached Yes ....... No ....... 0 SECTION 5 Description of Proposed Work (check an aonlicable ) New Construction ❑ I Existing Building ❑ 1 Repair(s) ❑ 1 Alterations(s) Accessory Bldg. ❑ I Demolition 0 1 Other ❑ Specify ' Brief Description of Proposed Work:: I SECTION 6 - F.STIMATF.n rONSTRTTrTinN rncTQ I Failure to provide this affidavit will result Addition ❑ Item Estimated Cost (Dollar) to be Completed by permit applicant QFFiC1Ai, USE ONLY` ' 1. Building •-- (a) Building Permit Fee ! v 2 Electrical -Multiplier (b) Estimated Total Cost of Construction ` 3 Plumbing Building Permit fee (a) x tbl l 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number JGOWNERSl.11V1' isAGENv�Tl"�icOR [�v ir1v1CLGA 11Vlr 1 V IfLl;V1YlYLLlEll Wtl.N;1V I CONTRACTOR APPLIES FOR BUILDING PERMIT 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 I SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, Z ttu q 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 Print e Signature of caner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TEVIBERS 1' 2 VD 3 SPAN DIMENSIONS OF SILLS DINIENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATTON THICKNESS SIZE OF FOOTING X MATERIAL OF CHININEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE r North Andover Building Department Tel: 978-688-9545 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: t�a2C�g �/L (Location of Facility) Signature of Permit Applicant t p CJ—a5 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Installed Siding and Windows Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Reg istration,.1.26893 _Exp7ration 8/3/2006 y IT,ype Supplement Card THE Home Depo, _ - Hbh a Seni�c @UNROEUN CHH�OU ViJ- ` 3200 COBB GALLERfA-PKWY'#20 ALTANTA, GA 30339 Administrator Proudly sold, furnished and installed by RMA Home Services, Inc., a Home Depot authorized contractor. 345 Greenwood St. Unit 2 • Worcester, MA 01607 • 508-756-6686 • Fax 508-756-2859 • Toll Free 800-657-5182 Sip 25 05 03:01p lean 781 246-0299 p.6 e IIOME IMPROVEMENT CONTRACT Sold, Furnished and Installed by: Branch Name: _ _ _ Date: Z3 r� THD At -Home Services, Inc. d/b/a The Home Depot At -Home Services 13c. 345A Greenwood Street, Worcester, MA 01607 Branch Number: a�Job #: . Toll Free (800) 657-5182; Fax: 508-756-2859 Federal ID# 7 5-269 8460 ME Lie 9 C'02439 Rl Cont. Lica 16427 Cl' Lic# 565522; MA Home Improvement Contraclor Reg. #12699: 3t (Gc;yt ►WC�%�1iGZ ltcc i1' �`k lV Installation Address: of City State Zip (0id Purchaser(s): Last 4 Di its of Driver's Lie. # & Exp. Mo/Yr: Work Phone: lhmw Phone: # 6.Z3 - , Home Address: / (If different from Installation Address) ' City State Zip Project Information: I/We/You ("Purchaser"), the owners of the property located at the above installation address, offer to contract with Home Depot U.S.A., Inc. ("Home De of") to furnish, deliver and arrange for the installation of all materials as described on the attached Spec Sheet #: "43tc• , incorporated herein by reference and made a part hereof. Horne Depot reserves the right to cancel this contract if, upon re -inspection of the job, Home Depot determines that it cannot perform its obligations due to a structural problem with the home or because work required to complete the job was not included in the contract. CONTRACT AMOUNT *LESS DEPOSIT BALANCE DUE ON COMPLETION Minimum 25% of Contract Amount due upon execution f this contract. ' Indicate Payment Method For BALANCE DUE ON COMPLETION - DEPOSIT PA"4ENT OPTIONS (Subject to lbrid verification andiorcredit approval.) 1. Check, Cashiers Check or US Postal Service Money Order (\lade payable to The Home Depot). 2. Credit Card* and/or other payment options - Circle One Below Visa MasterCard Discover American Express The Home Depot Home Improvement Loan The Ilome Depot Credit Card Available Credit: S ( HIL & DCC UNL Aeetr, c(-' JJi�t JrE p. Date: _ Name as it appears on card:_A l f yy 'By my/our signature below, liwc agree to allow Home Depot to charge the above referenced credit cad for the deposit indicated. _ .. -- --T -aI C, CaYd elder's ig"� alu HIL or IIDCC Authorization Codes Deposit Final Payment # a2 I3� # 6.Z3 - , Purchaser agrees that, immediately upon satisfactory completion of the work, Purchaser will execute a Completion Certificate and pay any balance due. Purchaser also agrees to be jointly and severally obligated and liable hereunder. Entire Agreement: This agreement and its attachments, including any Financing agreement, contain the complete agreement between the partles and can not be amended or modified unless in writing in a separate agreement signed by both parties. NOTICE TO PURCHASER Do not sign this contract before you read it. You are entitled to a completely filled-in copy of the contract at the time you sign. Keep it to protect your rights. Do not sign any Completion Certificate or agreement stating trial you are satisfied with the en lire project before this project is complete. Law prohibits home repair contractors from requesting or accepting a Completion Certificate signed by the owner prior to the actual completion of the work to be performed under the contract. You may cancel this transaction at any time prior to midnight of the third business day after the date of this contract. See Notice of Cancellation for an explanation of this right. There will be a service charge equal to 25% of the contract amount if the jeh is cancelled by Purchaser AFTER the third business day. RY MY/OUR SIGNATURE BELOW, [,,1tJF. AGREE TO BE BOUND BY THE TERMS OF T-1HS CONTIZ_A C"I. DIME ACKNOWT.FI)CE RRCFIPT OF A COPY OF Ttl[S CONI-RACT AND TWO COMPLETED COPIES OF THF. NOTICE OF CANCELLATION. • r Sep 25 05 03:00p s:ean Branch Ofc: Nv Branch #: A* '31 781 246-0299 p.1 AM3367 SIDING SPEC SHEET Spec Sheet #: DESCRIPTION OF WORK Job #: CUSTOMER INFORMATION _ Customer Name: � 1"d. I 11j " KV Y`�AC� Home Phone #: M � '� ' �( WorklCell Phone #: ��7i�) % ��! �3 Installation Address: J� �O �� ��r� E-mail Address: AJ 18 St-, rddrocs L Siding Drop Location: >�'�. D�_iJr N ��n P, bi i S tS� L� Dumpster Location: n ci state DO coda VINYL SIDING AREAS to be SIDED PRODUCT PROFILE CORNERS *COLOR* Front / Left / Premium Distinction Clapboard Dutchlap e Standard Siding %qsF tFfM Outside Corners �L Back / Beaded Right Triple 3" Roughsawn Designer' INSULATION ShakeslRounds Hand Split Other Other Rounds White Only 3!8" or 3+4" SOFFIT, FASCIA, FRIEZE BOARD & GUTTERS AREAS to be COVERED New Gutters & Down Spouts 3 Front Left Back Ri ht *COLOR* Other Area Soffit & Fascia Yes P'" Frieze Board 2 LZ r Soffit Only Y Fascia Only Color: Tuck Fascia 3New Gutters & Down Spouts to be installed in existing locations, 2 Cover Frieze Board with: PVC Alum. Coil or Vert. Soffit unless noted below. CUSTOM WRAP WITH PVC COIL REMOVE & REINSTALL Windows +Doors Qty *COLOR* uJrll 1G Qt Qty Storm Windows Awnings up to 8' Z Garage !Patio Door i 11Y11�� Storm Doors Awnings Over 8' Double Garage Door Burglar Bars ' Existing Shutters Build Out Frame 'In certain markets, Burglar Bars can be removed, but not reinstalled. REMOVE EXISTING SIDING ° Yes= NoF,;'1 If Yes: Vinyl(Wood= Aluminum= 4 Only where new siding is to be installed. Home Depot will NOT remove asbestos material. FUR OVER MASONRY PORCH CEILING, BEAMS & POSTS NEW ACCESSORIES Y (N Double'' Soffit Color: GABLE VENTS Front Beaded Soffits Location: Qty *COLOR* Left s white or Canyon Tan ONLY Rectangle vtl�t Back YIN *COLOR* Octagon Right Wrap Porch Beams Wrap Porch Posts NEW SHUTTERS # of Pairs *COLOR* SPECIALTY WRAPS Y + N *COLOR* Knee Braces Louvered `1 �Z IV, A` rV ' ki Triangular Gable Vents � G Raised Panel reeig REPLACE ROTTED WOOD I Specify the locations: SPECIAL CONSIDERATIONS: C ,• i 6 r ref' 1 wJ z r Lr;, I have reviewed and agree with the job specifications described above. If rotted wood is discovered AFTER removing the existing siding, or if it could not be identified at the time of sale, there will be aadditional charge of $4100 per Sq. Ft. for Plywood and $5.00 per Lin. Ft. for Dimensional umber. Customer Signatur _ t Date: 7J0-34 5FC.S VS •` 1 CO) m m m m m m H C � d CA Cl) � O C7 Z H CL o �, =r a. C. _• y aCO �C CD CDCL o c�=rd CD CD CD w co C CD y� CL C2 y O C a v y O 'vCD Z oCD O CD g _ CA t CT N b7 `� W w C 10 �m0 m CO3 n '� O ClFL- ei n0 m tom., C7 '� ? m =r of CO) CJ (/)0 CD Cf) yO M O r4 y p 0 O x Cm �s O C 2-4 �Cl) m -Ow p O ted: O 25.E COD W c aG cD: =r 5a� s CA m ��g O H -� `: �0 c c d m y � p of N N O d d i � �_ S �' m m, �m C, �1 o . �. g _ CC/ z b7 `� W w C O ' :-f.: w '� is L' co tom., C7 '� .�.r O O m f m '17 ^� CJ (/)0 CD Cf) yO M ty CL r rD to p Cm �s d a • �Cl) s ted: CA �0 c PI o=: v Cf) o CC/ z b7 `� M ro w C ro w '� Cil L' tom., C7 '�7 n 7d aGa '17 ^� CJ (/)0 CD Cf) yO M ty CL r rD to p y 0 S THE C0*M0ATgEALTgOEA1,4SS ETIsa DEPARTNIElVTOI~`PUBucsomy Office Use onfyg ;g BOARD OFFIREPBEVEMONREGUAMONS527CMR12� F.0ccupancy ea ^heckdd A.PPI_ CA7TON FOR PEIZAKT TO PERFO_T�NI ELE�I�AL W ALL WORK TO BE PERFORMED IN ACCORDANCE WITTI THE MASSACHUSSTS R E L CODE, S27 CMR I L O� (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Town of North Andover Date `The undersigned applies for a permit to perform the electrical work described below. To the Inspector of Wire; Location (Street & Number)P- Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: --��� Purpose of Building —FF.vFJIURG -Dox) Utility Authorizati No. Y`...x.PsJ2D?lies Volts .. Overhead Underground No. of Meters �u a No. of Meters -1 I Date ..... t,-!>..... 1. ..:. TOWN OF NORTH ANDOVER . PERMIT FOR . WIRING This certifies that .....�;! ......... ''� FYI U (i -,• s ......................... has permissi . tb ... ............... perform ......r.... � rr �. � �� .... � .... ........................... w�nng.in the uil ding of .......1 dry s i.f� ........... at ........� f .� < ... Fee}'...... _• ,North Andov , M ,,.., .... Lic. No. r'.�� �/ r s: y� Check # ri / EtECTWCAl.IwspErroR 4, SVIaTK°ciia..w.ts. iawacunat I a�subnvttedvabd ds IrntuanoePblxy�g ��..�y� �:> t�� �,�� .r. a, ptoof�anetflthe0ffioe YES —' NO 4. xwmg the bDX SURANCE .. BOI�ID Pirriic�lethetypeofwby . OTiiER may) - - xictoStart hVectiMEWcRapesiDd Ratffi EMm*dVakrdEbc"W0&$ nedunder'&l ofpajuT ' Far! :MNAME !1 Total KVA KVA -s--1g naaery Units RMS No. of Zones ection and Devices nding Devices Contained Sounding Devices Municipal Other Connections �r / IicroseNo see d C// aL O l��e/fl f�J Si � �^- Li)nWNo------------- BzsinssTet No. S M)RANCE W i22 cit/ �1t5► Alt Tet No AIVER, Iam aware that thel�c�edoesnothave the' thatmysigt)&ueonihispcnnitaMhcahonvmvesthisr gaue t co `�oritsst> alequiv tasiegt>IIedbyMa�sacht s(3enetalL3ws :ase check one) Owner �._ D Agent 0Teleph" ne No. � � PERMIT FEE ignature o weer or gen $ y C) 4�b- ::r ON cr OQ INII) :4,N i -u * M Z ;u 0 z 0 0 ;u ;u z 0 M M KN THECOM1/L ONWEALTHOFMASSACHUSE77,'s Office Use only G DEPARTA1E 0T'PUBZICS4MY Eop it No. Z/ RDO BOA_ OFFIREPREVEVHONREGULAHONSD7CM12- l ancy& Fees Checked APPUCATTONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION)Date //X/.,/ Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street c Owner or Tenant Owner's Address To the Inspector of Wires: is tors permit in conjunction with a building permit: Purpose of Building Yes (� J No L L-1' (Check Appropriate Box) Utility Authorizati No. Existing Service /UU _ Amps/-/ Volts Overhead Underground No. of Meters New Service /0 C3 Amps/,70 /,27i0 Volts Overhead M Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets i No. of Lighting Fixtures F No. of Receptacle Outlets No. of Switch Outlets No. of Ranges No. of Disposals No. of Dishwashers No. of Dryers No. of Hot Tubs Swimming Pool Above ground No. of Oil Burners No. of Gas Burners No. of Air Cond. Total Tons No. of Heat Total Pumvs Tons Space Area Heating Heating Devices No. of Water Heaters KWNo. of No. Hydro Massage Tubs tT IER- No. of Motors No. of Bailasis Total HP -u. ur r ransrormers Below Generators round No. of Emergency Lighting Battery Units FIRE ALARMS Total No. of Detection and KW Initiating Devices KW No. of Sounding Devices No. ofSelf Contained Detection/Sounding Devices KW LocalMunicipal M Connections Tota! KVA KVA No. of Zones Q Other suranmCovMW- Ptnstrl lDdriewirw)ffxs ofMassadu9ftG= rallaws rave acunati-di7ityIn arrepbhcyMckidirvco ngilefie C&Xrdg--Crjls Akstanu egtnvatat YES NO �. avesubmaDdvabdprudefsarnetodroflioa- YES U 7T ff)auhawdle WYES,plemudcatethetypeofmvtr.4pby eckingthe -- box LTJ SURANC� BOND OIIIIQt �' eSpecify) EVirafionDale Esf na1od Value dUactwal Work $ �� Fidel :• �•-i .�-•tel? 1rPcc 5 `/ Ab/ i //d cl/ da (o CtA-� VJ'a r,,v oii1ql- A>t Tel No. /NER'SINSURANCEWAIVER;Iamaware Mat theLicensedoes nothavethcro ancecowr-ageoritssubganWeWvalentasr qu edbyNlassach�GenetalLaws that my signat m on this pemvt appbcah® this requitenfnt :ase check one) Owner Agent Telephone No. PERMIT FEE Signature of Uwner or Agent The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston; Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: Location. City Phone #- I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for rry employees working on this job. Company name: City: Phone # Insurance. Co. Policy # Company name: Address City: Phone#. Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penal ies of.a fine up to $1,500.00 and/or one years' imprisonment_as_well_as_ch4l penattiesjn-theinrm-ofa_ST_OP_W_ORK_ORDFRand_a fne-of ($1D0 -0Q -a lay.againsf.me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. / do hereby certify under the pains and penalties ofperjwy that the information provided above is true and correct. Signature Date Print name P_bone.# Official use only do not write in this area to be completed by city or town officiar City or Town Permit/Licensing Building Dept pCheck dff immediate response is required p Ucensin_q Board E] Selectman's Office Contact person: Phone #. it Health Department El Other ` MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00SF ING (Print or Type) NORTH ANDOVER Mass. Date / S39-- �uilding Location,?/ u/d0 17' Permit # ' Owners Name q,4 S td oL • Y New 71 Renovation �] Replacement �lans Submitted F1XT1IR=c (Print or Type) Installing Company Name Address 1 5A f 4i0_- P4 r Business Tele hone• A`kc" �-1 P Check one: Certificate (� Corp. Partner. Firm/Co. Name of Licensed Plumber or Gas Fitter �A1_1 4 h --y Insurance Coverage: Indicate the type of insurance coverage by checking the a ro rinte box PP P Liability insurance policy Other type of indemnity Q 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 coverages. Signature of owner/agent of property Owner U Agent F7 1 hereby certify that ahl of the deuils 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 Installations performed under Permit isseed for this application will be in compliance with all peztlneat provisions of the Massachusetts State Gas code and chapter 142 of the General Laws. By Title City/Town: APPROVED (OFFICE use ONLY) SPE LICENSE: Plumber* Ga s f itter Master journeyman Signature of Licensed Plumbe �r Gasfitter lS License Number "a (Print or Type) Installing Company Name Address 1 5A f 4i0_- P4 r Business Tele hone• A`kc" �-1 P Check one: Certificate (� Corp. Partner. Firm/Co. Name of Licensed Plumber or Gas Fitter �A1_1 4 h --y Insurance Coverage: Indicate the type of insurance coverage by checking the a ro rinte box PP P Liability insurance policy Other type of indemnity Q 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 coverages. Signature of owner/agent of property Owner U Agent F7 1 hereby certify that ahl of the deuils 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 Installations performed under Permit isseed for this application will be in compliance with all peztlneat provisions of the Massachusetts State Gas code and chapter 142 of the General Laws. By Title City/Town: APPROVED (OFFICE use ONLY) SPE LICENSE: Plumber* Ga s f itter Master journeyman Signature of Licensed Plumbe �r Gasfitter lS License Number TO 0 4 > cr ob 0 rA 41 cn (JQ CD '0 f. Z X cn 'JO to