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HomeMy WebLinkAboutMiscellaneous - 41 BERKELEY ROAD 4/30/2018 41 BERKELEY ROAD 2101047.0 000.0 1 ' Date TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . . . . . . . . . . . . . ) �� C��p�'e-- has permission to perform . wiring in the building of . . . . . '�'!�r. . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . .AN North Andover, Mass. Fee . 1.1/ 1 . . . Lic. Nol() ��tlr . . .Mbt . . . . .. ELECTRICAL INSPECTOR Check# 11215 1- Common wealth of Massachusetts Official Use Only Permit No.—T 7 l� 161 WK 5: Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]Occupancy and Fee Checked 0 (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 PRINTWINKOR TYPEALL INFORALMO 9 Date: City or Town of: NORTH ANDOVER 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&Number) &666 Owner or Tenant ,� Telephone No. Owner's Address Is this permit in conjunction with a buildingper it? Yes No ❑ (Check Appropriate Box) Purpose of Building �j A'N1 oQ il� e-1 Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA t No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- Elo.o mergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No, of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Nber Tons KW No.of Self-Contained Totals: .............. '""" "''"" """......""""""'".. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW SecNoto Devin s or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs ((No.of Motors Total HP No.of Devices or Equivalent OTHER: �'GICA'fi(\ '2'fS f,Sw! C ��C2cjk,95 f��n►S �c�-d ,5 Ro CesS t'a S Attach additional detail if desired,or as required by the Inspector of 97res. Estimated Value of Electrical Work: 1 y(6T-- ac) (When required by municipal policy.) Work to Start: -/�L Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) Icertify,under the ains and penalties of perjury,that the information on this application is true and complete. FIRM NAME L Q 6Me Neck l C-- 4 LIC.NO.: Licensee: �Q a ��Rp,Q fl� Signature NO.: (If applicable,enter -exempt-in the license number line.) Bus.Tel.No. Address: '32?( Lde5+ tADM5 S'f 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 PERMIT FEE. $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the t Permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be fled orr l on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166, §32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑ Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass)x Failed Re-Inspection Required($.)❑ Inspectors Com ents: Inspectors Signature: d Date: ROUGH SPECTION: Pass Failed ?❑ Re-Inspection Required($.) ❑ Inspectors Comments: zu Inspectors Signatur Date: FIN L INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 UV. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization4ndividual):A N a Address: �� (�J�S� � ��/5 S City/State/Zip: Phone Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a emplo er with 4. El am a general contractor and 1 6 employee part-time).* have hired the sub-contractors E]N construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.# ? Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ IVm a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]i employees. [No workers' comp.insurance required.] 13.❑ Other xAny applicant that checks box#1 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 hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. t am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. VL0tC17?eJ L[assurance Company Name: % mC,7y Policy#or Self-ins.Lic.#: Expiration Date: fob Site Address: City/State/Zip:0)0 eA4 Agcld 't''S M-AS.3 Attach a,copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ?ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a .me 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 )f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certify under the pains ann�d peva ies of perjury that the information provided above is true and correct ii natur . / Date: ©l ?hone Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their 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 permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current F 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 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia Date. N° 9665 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ea� � This certifies that " —7 . . . . . (' . . . . . . . . . . . . . . . . . . . has permission to perform . . .l ? plumbing in the bbuiilldin s of . 1Q�. . !J�i.^�!�t". . . . . . . . . . . . . . . . . at. . . . 4�. . . .�-?�' A,. .'PIR • . . . . .ANo dover, Mass. Fee '. .Lic. No.) PLUSPE 0 Check # _e� WHITE:Applicant CANARY: Building Dept. PINK:Treasurer i i .m MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY L, — MA DATE -/I PERMIT# JOBSITE ADDRESS OWNER'S NAME OWNER ADDRESS TEL FAX _ TYPE OR OCCUPANCY TYPE COMMERCIAL ,' EDUCATIONAL Q RESIDENTIAL € PRINT CLEARLY NEW: Q RENOVATION: REPLACEMENT: Q PLANS SUBMITTED: YES� NOD FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM ( ► [ " DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN .._.._.-! FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK _I - --.-_1 ---._._! E __._-.._...f - .----._-J LAVATORY ROOF DRAIN SHOWER STALL t i ; SERVICE/MOP SINK TOILET URINAL I ..._._1 ! I _.! I _.___...J ._._._` ..__..._..( __....._( __..._._f WASHING MACHINE CONNECTION I ; WATER HEATER ALL TYPES ` , WATER PIPING -- ' " - ---- --- I 1 1 OTHER I 1 } I i " INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Ej BOND I OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT JEJ SIGNATURE OF OWNER OR AGENT 6 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ;LICENSE# SIGNATURE MP[m, JP[j CORPORATION[:]## PARTNERSHIP M# LLC Q# COMPANY NAME D/=C um b i t7 ` ADDRESS CITY ic.,-C 1 STATE JQ/If i ZIP CV,�p,j��- I TEL 7Z) elS- � i FAX CELL $ - EMAIL (1oCo",h 23 e (fiylLt, C ' Gv ,AG1- �1 S - .. - �^ U • Yr ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ / FEE: $ PERMIT# PLAN REVIEW NOTES A f The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 UT. www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. [No workers' comp.insurance 5. El We are a corporation and its 9 EJ Building addition required.] officers have exercised their 10-ElElectricalrepairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.❑Other 1. *Any applicant that checks box#I 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 hire outside contractors must submit a new affidavit indicating such. kContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. F am an employer that is providing workers'compensation insurancefor my employees. Below is the policy and job site information. Insurance Company Name: ?olicy#or Self-ins.Lic.#: Expiration Date: -ob Site Address: City/State/Zip: kttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). -ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 ,f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. mature: Date hone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.E]Inspector 6.Other Contact Person: Phone#: r -a Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their 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 permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(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 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia COMMONWEALTH OF MASSACHUSETTS ` Q= 'I:MBERo AND GASFLT>t'ERS f LICCOtED A:�. A MASTERPLUMBEW.I. I ( ISSUES THE ABOVE LICENSE TO .. DEREK - COF-.F1N 19. GARDE A DR rcFlFr.[I_u� NI-1 030.5..2-.106.7:- . . . 13:7_ 05101/14 ;15U.67, aaammm grammima @m&m CONTROL# 366963 . IMPORTANT If this license is lost or destroyed, notify our Board at the: Division of Professional Licensure, 1000 Washington' St., Suite 710,Boston,MA 02118-6100. F If your name or address shown is changed, notify your board i ' of correct name or address to insure proper mailing of next Renewal Application. Always refer to your license number. This license is subject to the provisions of the General Laws as amended.It is_a personal privilege,and must not be loaned or assigned-to any other person. Keep this license on your person or posted as required by law. 'NA8NING THIS DOCLi.V E 4T HAS E.4riANCEr)SCCLjq,_*, S ;r s . , a f� Date. . . . ... . . .. HORTN Of �4' orTOWN OF NORTH ANDOVER F P dX PERMIT FOR GAS INSTALLATION f ♦ 09 5 . SAG HUSEtA This certifies that . . . has permission for gas installation . .IIAI,.o Z,(:.,� . . . . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . .� .? . . . ..1�r'/`;f. . . . . . . . . . . . . . . .. North Andover, Mass. Fee. . >. .` . Lic. No. '.).;.-'. ��. . . . .:. . -. . . . . . GAS INSPECTOR Check# 351- 1 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS17117ING (Print or Type) Mass. Date 1,9�0�71/ Permit # 3 ,3-'t7 Building Location �,/POwner's NameJL, To V=L/� lJ� moi' Type of Occupanry New ❑ Renovation ❑ Replacement Plans Submitted: >es❑-- No ❑ N N W N Uf N U y ¢ N Q O W W tlz J O � mF' o° ' VJ < Cc + �o ¢ Srz y¢rl W (- H d C > 4 N tl W = z O W W W Yf W = < = S Q W ¢ W f. WUA W H S H Q H N m Z O 2 W O y S z < W < ¢ ¢ < W > ¢ W z, < < ¢ 'S O tl S 1L p 3 p C J U ¢ Y p a F- O SUB-BSMT. BASEMENT 1ST FLOOR 2ND FLOOR r 3RD FLOOR 9 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name m MAT A X20 Check one: Certificate Address 3 OoA C H/V%,4 ry i-N(. ❑ Corporation �1 F T N U E_ rJ of A U ( k y ❑ Partnership Business Telephone /2 92- -5 S 7 1 2--Arm/Co. Name of Licensed Plumber or Gas Fitter -R 0 A E r-T A- `5 A trm f1 i A (--) INSURANCE COVERAGE: I have a current}ability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 2' No If you have checked yes, please Indicate the type coverage by checking the appropriate box 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 g eq ed 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 pe i ed for this application ' be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ner Laws. BY T of License: t3 Plumber Mture of cen _.u of Gas Fitter Titletta< 8333 er License Number Qty/TownJourneyman N BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING i NAME • TYPE OF BUILDING LOCATION OF BUILDIN,_G PLUMBER OR GASFITTER LIC. NO, I PERMIT GRANTED DATE GASINSPECTOR