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TOP FND 1r REPORMN .+T HYDPANr SCALE:1'•49 i EASEMFM I o WOE -2 1 RAIUOE / .1wea1r M01 F0.a1 IDMX 1) 1r ROFORAw omSHEET IEOF 2Gl,lu @ EAsaaD rPYEeEWR rw•,ePnDAan wv,rw•,112,L81> CONSERVATION AS—BUILT PLAN -0 TNV,r w•110.W(OA4,aB) PN 1Y M•1 W.aa(CB,) PROFESSIONAL •,11.12 wV iS M•,Wae mMxn wutrart•tvez, FOR 1rw•ta+.,s INv,rovr•1esz: ENowEER 2A'o0f•,e,.ta � CROSS�OUND2Y DRAIN_C--___- "AUTUMN CHASE” INV 1 , 1-pp— l �Twv�rw'�iW.e, �Ixv,Brw.•1BI.W ... 1DRN OW4 0RNAG E WSNT pORj :. cB,mBLaRATE7 IO VER,MASS.AND 1 B-(OBLGRATE) 1:/ \`�wV 1r0Uf•1WAO wV1rOLR•,WdR 1r GP' WM•2oLW wvtrour-,eaax _____-_ -S AN DRA'M•� - gwiM.mzn --- NORTH ANDOVER REALTY CORPORATION 914°l `•'A, ,rtPP INWN �Dg9•GO RNt2OUT•,2882 W SPRINGHILLROAD,NORTHAHDOVER.MAQ-5 eMH - ______ DMH] WHSUMMER STREET PROFESSIONAL ENGINEERSeIANDSURVEYORSOATI 1- 13'^NS IRrry it lWN.ieo.m(CBe) CB B(DBLW E) CS1CHRISTIANSEN&SERGI,INC. INVtrw•,ae.W(WV) RIM•te1.T1 S OUi•,80.], INV IY OUT•,e1.m 4E11 L t AF. m l Date.. a�.1..� ......... O�NORTH a;� ;.•�o�p TOWN OF NORTH ANDOVER o PERMIT FOR WIRING 8`4ACHU�✓� This certifies that ...........................................................................................:................................ has permission to perform ......�.P..';-� { Q— ...........................................................:............ wirin g4 the building of..: ... f a.... � iCJI 2 M I1�- ................................ ............. at ............. ...................I U�.N ..............,North Andover,Mass. ..... ........................ Fee.................."".-.....Lic.No. ................. .......44�.................................................................. ELECTRICAL INSPECTOR Check# ` e � Commonwealth of Massachusetts Official Use nOnly Department of Fire Services Permit No. a Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank \ 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 W INK OR TYPE ALL INFORMATIOA9 Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned Ives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant �,�S.,o,irs a 1 �'�� �lit ^4 Telephone No. Owner's Address u Is this permit in conjunction with a uilding permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building /�GW Utility Authorization No. Existing Service� -j Amps If' oVolts Overhead❑ Undgrd Pill' No.of Meters I 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 maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cel Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets y5 No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting rnd grnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones t&.of Switches No.of Gas Burners �f No.of Detection and TotInitiatin Devices No.of Ranges ' No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number 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 Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of 07res. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 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:) I certify,under the pains and penalties of perjury,that the information t plication is true and complete. FIRM NAME: " l! �c. 1,L-4 O LIC.NO.: ' Licensee: �- �1�41b Signature L LTC.NO.w 3 29 (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.9;?a Address: Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Departmen f 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: $ 7 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 e permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.Atter 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 IN Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSP ION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: 4, _ Date: — Zk-- / DEB WEINHOLD ...TOWN OF MERR AC,MA. .......dweinhoid@townofinerrimac.com ti The Commonwealth of Massachusetts Department ofIndustrial 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 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 6. ❑New construction ployees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet.# ?• E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. E]Building addition [No workers' comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs 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.E]Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.[i Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they Aire 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:, l 0 tj n 049AICG �vL_qfi'&A Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip:_P141=T� &L pt Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 hereby cerci unde th pair penalties of perjury that the information provided above is true and correct Signature: Date: / Phone#: J.r t+ 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-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 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 GonUAojUWeajtb,of Massarl�vsotts Department of Industrial Accidents Office of Investigations GOR Washington Street Boston?MA.02111. Tel.#617727-4900 ext 406 or 1-877rMASSAFE Revised 5-26-05 Fax#617-727-7749 �.zn�ass,go�/iia Division of Professional Licensure: License Search Page 1 of 1 The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES ................................................................-............................................................................................................................................................................................................ .......... Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency More... LICENSEE Name:KENNETH DIGUILIO REFERENCES& METHUEN,MA RELATED INFO Disclaimer Regarding ""This Licensee has additional Licenses,click here to view them." Website License Searches Glossary of License Status Codes Licensing Board: ELECTRICIANS JOURNEYMAN ELECTRICIAN More... License Type: TYPE CLASS: E License Number: 23892 Status: CURRENT Expiration Date: 7/31/2016 Issue Date: 8/1/1977 Exam Date: 6/7/1977 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Friday,March 28,2014 at 9:29:03 AM. ©2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg.state.ma.us/public/pubLicenseQ.asp?board_code=EL&type class=_E&li... 3/28/2014 1 0 , 50 Date... ... .�......` o?;•,;`'°;•�."�O� TOWN OF NORTH ANDOVER r PERMIT FOR WIRING �,SgACHUSE� This certifies that ............ .............................................. .............................. has permission to perform !l ` ........... .. ....... wiring in the building of.... !.!.rl....�..�....��.. ... ................... at..... Z......1�ir .j'rs`'•, �. .....- North Andover,Mass. ........... .. ........................ . Lic.No.............. .........� Fee. ..........- ,. .... �, .......... .... . .z.:.: ..... ... / ELECTRICAL INSPLf R ' Check 4 �� 3� ✓/ COMmonwealth of Alassachuset Official ffic�al Use Only Department of Fire Services Fev. No. AIV S C� BOARD OF FIRE PREVENTION REGULATIONS ncy and Fee Checked _ APPLICATION FOR PER 7] (leave blank Ice with l'® PERFORM ELECTRICAL ®RK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINI'•ININK OR TYPE ALL INFORMATIO City or Town of: NORTH ANDOVER � Date: %J By this application the undersigned gives notice of his or her intention to perform the To the e1e electrical wk dector of escribed be ` \ Location(Street�&Number) �v11- low. Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a b ding permit? Purpose of Building Yes NO ❑ (Check Appropriate Box) Utility Authorization No. 110g,30 7 Existing Service Amps =_Volts Overhead Undgrd No.of Meters • New_Serviceb0 Amps ps 2G / P Volts Overhead Undgrd ry Number of Feeders and.Ampacity 12 No.of Meters Location and Nature of Proposed Electrical Work: Com letion of the followin table maybe waived by the Ins ector of Wires. No.of Recessed Luminaires No.of Ceil:Sus No.of p.(Paddle)Fans Total No.of Luminaire OutletsNo, Transformers VtA of Hot Tubs No.of Luminaires Generators KVA 2rnS�unming Pool Above ❑ In- o. o mergency rg g No.of Receptacle Outlets d' nd• Batte Units No.of Oil Burgers FI EP ALALWIS No.of Zones No.of Switches No.of Gas Burners No.of Detection and No.of Ranges Total Imtiafin Devices . No.of Air Cond. No.of Waste Disposers .Heat Pump Number Tons ns No.of Alerting Devices KW Totals: _" `- - -. - .......-.-.--. __.. No.of Self-Contained No.of Dishwashers Deteetion/Alertin Devices Space/Area Heating KW Local❑ Municipal No.of Dryers HeatingAppliances Connection ❑ Other ' No.of Water pp KW Security Systems:* Heaters KW No.of Ballasts No.of Devices or E uivalent Si s Basal Data Wiring: . r No.Hydromassage Bathtubs uNo.of Devices or E uivalent No.of Motors Total HP Telecommnications Wiring; OTHER:- Estimated THER:Estimated Value of Electrical Work: Attach additional detail if desired,or as required by the Inspector of Wires Work to Start (When required by municipal policy.) 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 the licensee .provides proof of liability insurance including "completed operation"coverage or its substantial equivalent. undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office y e unless CHECK ONE: INSURANCE q nt. The ,CHEcerCK ❑ BOND ❑ OTHER g under the pains and penalties o ❑ .(Specify:) FIRM NAME• fperlury,that the information o application is true and complete. did Licensee: Q, A LIC.NO.. (If applicable, enter"exempt 'in the license umber line) LIC.NO. . Signature , Address: 6j -- �� Bus.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires D OWNER'S INS epm'tm of Public Safety"S"License: Mf Tel.No.: f INSURANCE WAIVER; I am aware that the Licensee does not have the liabilityLic.No. required bylaw. By my signature below,I hereby waive this requirement. I am the(check one msuumnee coverage normally Owner/Agent ) ❑owner Signature ❑owner's agent. Telephone No. PERMIT FEE: � S S� ELECTRICAL PERMT NO. INSPECTION REPORT: ELECTRICALINSPECTOR-DOUG SMALL I.ROUGH INSPECTION: Passed—[ j Failed—[ ] Re-inspection required($50.00) [ j Inspectors' comments: (Inspectors'Signature-no initials) Date 2.FINAL INSPECTION, Passed—[ ] Failed—[ ] Re-inspection required($50.00) Inspectors'comments: (Inspectors'Signature-no initials) Date 3.UNDER GROUND INSPECTION: a Passed—[ j Failed—[ ) Re-inspection required($50.00)-[ ] Inspectors' comments: r (Inspectors'Signature-no initials) Date 4.INSPECTION—SERVICE: DATE CALL E IONAL GRIM: Nom: Passed— Failed—[ ] Re-inspection required($50.00) Inspectors'comments: A IeIL d (Inspectors'Signature-no initials) Date ti 5.INSPECTION-OTHER: Passed—[ ] Failed—[ ] Re-inspection required($50.00)EDate Inspectors' comments: (Inspectors'Signature-no initials) DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE,AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED. The Commonwealth of Massachusetts Department of Industrial Accidents Office ofinvestigations ..600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ Ieetricians/Plumbers Applicant Information Please Print Legib Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: [2. .❑ I am a employer with 4. Ty;E] f project(required):' ❑ I am'a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 New construction ❑ I am a sole proprietor or partner- listed on the attached sheet, 1 7• Remodeling ship and have no employees These sub_contractors haveworking for me in any capacity. workers'comp,insurance. 8' Demolition [No workers'comp. insurance 5. ❑ We are a corporation and its 9' ❑Building addition 3.❑ required.] officers have exercised their 10.❑Electrical repairs or additions I 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 in required.] t employees. [No viorkers' 12.❑Roof repairs comp,insurance required.] 13.E] Other fi"Any applicant that ehedks box Yl must also fill Out the section bei-w s oviinng their ensation Poli Homeowners who submit this affidavit indicating they are doing all work and then hire outside,compontractors must submit new affidavit indicating such. Cy information. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'omp.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: Policy#or Self-ins.Lie.M Expiration Date: Job Site Address: City/State/zip: Attach a copy of the workers'compensation policy declaration page(showing the poIicy number and expiration da Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminall 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct Si ature: 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• Date. ,8 Z Nw .. .... . NORTIj o� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION s a �,SSACMUSEt This certifies that . ./T.l�?-e. . !��'� � . . . has permission for gas installation . . . A .4104tS�-. . . . . . . . . in the buildings of . . 4.!"�//. &: 41 NI MASSACHUSETTS UNIFORM A PLICATION FOR PE MIT TO DO GAS FITTING City/Town: / , MA. Date: Permit# Building Location: D� A Owners Name: /' 41711 Type of Occupancy: Commercial❑ Educational ❑ Industrial ❑ Institutional❑ Residential New: Alteration:❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES W co TV) , W W 0) z W N v � TT z I— o X co W W �-L) co Lu ~ s w C7 J O z g z O W W � W W O F- n W m W g m 0 I- W O a X W f- C0 Q W W W _z g _ Lu �o w W o x W Z W W Z O J I- (- O Z J (� LL co x Z W O a w w m W O z 0 > z 1-- X o o u_ c� O x x g o a. �° > > > o SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR Installing Company Name: /,r/ /�f Check One Only Certificate# /��/ ❑ Address: O Corporation n City/Town State: / c El Partnership Business Tel: � T Fax: Name of Licensed Plumber/Gas Fitter: El Firm/Company INSURANCE COVERAGE: I have a current liability insurance 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 ❑ Agent ❑ By checking this box❑;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 rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ' BY / Type of License: r /� C ❑Plum r Title ,l ❑ Fitter Master gnature of Licensed Pumber/Gas Fitter City/Town ❑Journeyman APPROVED OFFICE USE ONLY ❑LP Installer License Number: �i -13 - 3 9'176 Date. .��/8/��. . . MART: a TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMUS� This certifies that . 1.7!!x ' . lK . l . . . . . . . . . . . . . . . . . . . . . . . i has permission to perform . . . .14'e.'�+!., . . . . . . . . . . . . . . . . ` plumbing in the buildings of . . .a"//. . .[.c��.f�. . . . . . . . . . . . at. ./.0.T. .fo . .,/.�o,1/4 v.7,o-4:,,P. . . . . . . . . . ., North Andover, Mass. Fee. .M.�PLic. No../,�/'r'? . ./,�!����! .��,�2����. . . . . . . PLUMBING INSPECTOR f Check # 60 i 4' F I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING �y City/Town: MA. Date` \ Permit# Building Location: ) Owners Name: � Type of Occupancy: Commercia ❑ Educational r� ❑ Industrial[] Institutional❑ Residential LSI New:[Vl glteration:❑ Renovation: ❑ Replacement:❑ Plans Submitted: Yes❑ No E] FIXTURES w DEDICATED 2 2 SYSTEMS LU N w Z v� VO j En In to 9- .J = of vi 0 Z cn Z Q Q w C7 cr 2 cr O m vi a H W F=- N N a w w v Z p o LUD O w w Z a u S Q Q Q m m yLn 0 O ~ ] 00 O 00. 0 Ln �¢ = 3 d a z 0 o W -SUB BSMT. 3 0 Q 3 BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4'FLOOR ST"FLOOR 6T"FLOOR 7T"FLOOR 8T"FLOOR fns illi. v C�J,z t:G.ly. IYrp;�• / J CE; c':C�r,3 O-1,. �• a IJ" Address El CorporationCity/Town: 3 _ State: A#Business Tel: Fax: ElPartnership Nam ❑Firm/Companye of Licensed Plumber: � INSURANCE COVERAGE: I have a current liabi►Insurante policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes N If You have checked Yes,please indicate the.type of coverage b checking the ❑ g Y g 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 ter 142 of the Massachusetts General Laws,and that mysignature on this permit application waives this requirement. Check One Only >i nature of Owner or Ownet's A ent Owner ❑ Agent ❑ I hereby certify that all of fhe details and information 1 have submitted(or entered)regarding Phis application are true and + Knowledge and that f t Plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massach setts State Plumbing Code and Chapter 742 of the General Laws, a-. .a.e to the best Of my f!j/Y/—, `/ Type of License: `.le ❑PP umber Sig ature of Licensed Plumber ylTown M Master 'PROVED(OFFICE USE ONLY) ❑•Journeyman License Number: loe"7A