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HomeMy WebLinkAboutMiscellaneous - 437 MASSACHUSETTS AVENUE 4/30/2018 ` 437 MASSACHUSETTS AVENUE 210/045.A-0046-0000.0 \ I Date... ...... 1502 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SsgC"uto This certifies that........' �.�...�' j.......................................................................................... has permission to perform..... .................................................. .......... ............. plumbingthe 4bDildings of C at... ......................................................... North Andover, Mass. ................................................................................................ Fee.37......Lic. No. t..(.�P.77.... ................................................................................. ........... PLUMBING INSPECTOR Check MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE /7 �/%, � PERMIT# JOBSITEADDRESSNAME S, OWNER, ]r OWNER ADDRESS -- FAX 4 TEL A-R&ZZA TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL El RESIDENTIALP— PRINT CLEARLY NEW: E-11 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO[3 FIXTURES-1 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 GAS10JUSAND SYSTEM ............ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM ....... ..........J==== 1L DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN ----------- FOOD DISPOSER FLOOR/AREA DRAIN _.......-___I INTERCEPTOR(INTERIOR) .......... ------- F-77 KITCHEN SINK ................. ................I -----J LAVATORY ROOF DRAIN — F- 7 SHOWER STALL SERVICE I MOP SINK ............ F—,f— TOILET ------ URINAL ------ ...................... WASHING MACHINE CONNECTION WATER HEATER ALL TYPES ............ ir WATER PIPING OTHER -- ----------------- ------ ---- --- ----------------- J, ----------- ----------_- ..................... .......... INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142, YESOINO E] IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND E. 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: OWNERE.J' AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the permit issued for this application will be in compil with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. = PLUMBER'S NAME LICENSE# SIGNATURE MP JP 01" CORPORATION PARTNERSHIP 0#=LLCF1 COMPANY NAME ADDRESS V CITY Ix ze-e STATETEL ZIP FAX CELL -5 EMAIL .w i Date..... . ................ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION sSgCmu This certifies that ........p........................ ...... ......, '4 ...I.................................................... has permission for gas installation ..... . .... ........................ in the buildings of...... ... .... . !))O .................................................................... . at....... ...... w . '.....................L.............. North Andover, Mass. Fee........................ Lic. No. .. ....... ..................................................................... GASINSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE"_ . :IS .I PERMIT# M71� JOBSITE ADDRESS --- -� ._ . 5 ._._ OWNER's NAME +' OWNER ADDRESS iI --- ]FAX _^:� TYPE OR OCCUPANCYTYPE COMMERCIAL(. EDUCATIONAL „__I RESIDENTIAL PRINT [ CLEARLY NEW:l RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 0-I NOD -APPLIANCES-1 _,FLOORS--► BSM 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOKSTOVE _._.J -,.,i DIRECT VENT HEATER PRYER FIREPLACE _J FRYOLATOR1 -_1 FURNACE [�—[ _i —_1 I�Y - GENERATOR .-...._ I GRILLE ,17 I --:- l .-- _--i r - i _.l .- J INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT F 7] 1= -. }( "(�"'jF 77-1 OVEN POOL HEATER .1 ROOM/SPACE HEATER ROOF TOP UNIT == TEST UNIT HEATER UNVENTED ROOM HEATER { I :_ I --7_ _ y WATER HEATER OTHER _ __. ..1 _I(moi =-I . l NO 1 ._-t- �s�,�,r-r___--s---•--..I IT i�i .:-:.�i .T_:�J I=_r<� .: __ J -. 1 r „�,_s i . _1 I�i[-i - i �� INSURANCE COVERAGE h1le a current labilit Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES I IF Y?U CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE 60X BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY [--A 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: OWNER JJ AGENT I SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be,In complianc�'tha Pertinent provision ofthe Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAMEEj /� -S'%®��= f��$�{� LICENSE#�� I SIGNATURE MPGF(_ 11JP( { JGF LPGI Q CORPORATION[�# d PARTNERSHIP[�#� LLC D#=1 COMPANY NAME: ?OSE.A���1 ✓' - ��1i , ADDRESS CITY :., �11 STATE ZIP _4 $ S j TEL FAX[.__ CELL !EMAIL�.. . ._ T! 7 _ 'r1 a I -. k The Commonwealth of Massachusetis Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Annlicant Information Please Print Legibly Name (Business/Organization/Individual): E Address: �iSS �t City/State/Zip: (J 2fS`-Phone q!� Are you an employer?Check the appropriate box: Type of project(required): I.F-1 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2. I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.F-1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 0 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp,insurance.t 6.n We are a corporation and its officers have exercised their right of'exemption per MGL c. 14. Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I a»z an eznployez•tliat is providing worlrers'conzpezzsatioiz izzsurazzce for nzy employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby certify ii5da x4hepains and penalties of peljuiy that the inforination provided above is true and correct. Si>natur Date: Phone#: ?M t�Ae 0 4QA?g 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#: Fold,Then Detach Along All Perforations � OMMONWEALTH OF MASSACHUSETTS ml 01 ki o "INALijius 2 LemEong z I". Q i PLUMBER ASFITTERS. ISSUES f OLLOWING LI,.CENSE L1GE5EU AS A MASTER PLUMBER W r PETER xJ STONE LX a .. ........... !Z PO Box 323 `f''11 ,;)�``` J NOREH ;'ANDOVER MA 01845-03 3----: � . .. i5b77 05/01/16 223443 I i I Fold,Then Detach Along All Perforations COMMONWEALTH OF MA�SACII-IUS�7TS o ov av • PLUMBER! I ITERS 1 ISSUES THE FOLLOWINh ,LICENSE i LICENSED AS'' A JOURNEYMAN PLUMBED f I PATER J STONEDow 1 ;in Z a PO BOX 323 `';~1Lu NORTH ANDOVER MA Ol$45-032.'. `� J 1974 0101/16 sw 223444 I I l • 10000 Date... .... ........ .... ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING "CHUS Thiscertifies that ............................................................................................. has permission to perform ......... ........... ........ ... ........... ... ......... wiring in the building of...........('012 ............... .................................................. at.......14P---7......MASY....1�-4�..... North Andover,Mass. ................ Fee. ......'.0 ... Lic.No.. -Ef ECTRICAL INSPECTO�� Check # L 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: Irm accordance-with the provisions of M.G.L.c.143,§.3L,the a 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.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 ofongoing constrction.activity,and maybe deemed_bytheJnspector_of_Wires abandoned.and.invalidafhe.—. 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 Lection,179 of Chapter 240 of the Acts of 2010 andexlended 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. RU le 8—Permit(Date Closed: /j"'*Note:Reapply for new permit l J� ❑Permit Extension Act—Permit/Date Closed: "Commonwealth of Massachusetts Official UsEE Department of Fire Services Permit No. pBOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Che [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), 27 C 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: �f %�City or Town of. NORTH ANDOVER To the Inspect. By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) `X_3 s Owner or Tenant Owner's Address Telephone No._ 1����� Is this permit in conjunction w th a building permit? Yes ❑ No Check A Purpose of Buildin � ( Appropriate Box) p g-- r'S�Dula a Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No.of Meters New Service Amps / _Volts Overhead❑ Und rd g ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Comletion of the ollowin table may be waived by the Ins ector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs `Generators KVA No.of Luminaires Swimming Pool Above EJ o No.of Receptacle Outlets No.of Oil Burners .o mergency ig ting rnd. gr d. ❑ Batte Units FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and No.of Ranges No.of Air Cond. Total Initiating Devices Tons No.of Alerting Devices No.of Waste Disposers Heat PumpNumber .Tons KW.....•.... No.of Self-Contained Totals: Detection/Alertinir Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection El Other No.of Dryers Heating Appliances KW Security Systems:Y !s No.of Water No.ofo. No.of Devices or E uivalent Heaters ICS Signs Ballasts Data Wiring: No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent Cory ®p Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electr' al ork: d (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 thepains andpenalties of perjury,that the information on this application is true and corplete. FIRM NAME: Licensee: fj1�'--���/� LIC.NO.: Signature (If applicable, enter "exempt" 'n t e license J number line.) LIC.NO.: Address: Bus.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Alt.Lec.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)Elowner E]owner's agent. Owner/Agent Signature Telephone No. [PERMIT.FFEE. $ ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR-DOUG SMALL I-ROUGH INSPECTION: Passed—[ ] Failed—[ ] Re-inspection requirecT($50.00)-j ] Inspectors'comments: (Inspectors'Signature-no initials) ~ . Date 2-]FINAL INSPECTION; Passed— Re-inspection required($50.00)-[ ] � Inspectors'comments: (Inspectors'Signature-no initials) - Date . 3.UNDER,GROUND INSPECTION: , Passed— , j ] Failed—[ ] Inspectors'comments: Re-inspection required($50.00)- r (Inspectors'Signature-no initials) Date 4.IN —SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed—[ ] Failed—[ ] Re- inspection re uired _ Ins 9 q ($50.00) [ ] pectors comments: (Inspectors'Signature-no initials) Date 5.IN -OTHER: Passed--[ ] Failed—[ ] Re-inspection required($50.00) Inspectors' comments: (Inspectors'Signature-no initials) Date D 0 O TAGS ARE TO BE FILLE11 OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE-jNSPECTION OF$50.00 IS TO BE CHARGED. 77 Date. . .-J.:'. ... .... T� Of NO oA1, TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ,SSACMUsft c J �= This certifies that . �. . . . ,?�.Yv�t�.4 J : f' has permission for gas installation . Q .pl . .levy-f. . . . . . . . in the buildings of . .1��.i Q, . . C r jy J at .HI.? . .44.E North Andover, Mass. Fee.)_:5:�. . Lic. No.. }. . . . . . ./` (' . . . . GAS INSPECTOR Check# 3� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town• MA. Date: Owl/Pe it# Building Locatio Name/o�l� Ale r/o Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: Plans Submitted: Yes❑ No❑ FIXTURES IY W W U) � Z Y v1 MX 2 0O W W U U) H O = o: W O J — rn z I.- QQ _ z O L W : o Lu U)z W z m p Q� wn. j3 p Lu X a H w CWJ w O ~ = rn O w H _ z I- o a s °m w o z o N > z _ V D z i g O a z >> > o SUB BSMT. BASEMENT 1srFLOOR 2 FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6 FLOOR -TT'-FLOOR 8 FLOOR 1l Installing Company Name. Check One Only Certificate# Address: orporation ' itylTown: State: Business Tel; ❑Partnership % Fax: ❑Firm/Company Name of Licensed Plumber/Gas Fitter: �)Wl) be INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 Yes to/❑ If you have checked Yes.please indicate the type of coverage by checking the appropriate box below. A liability insurance policy fid"111" 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 1 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 Plu ing Code and Chapter 142 he General Laws. By Type of License: ❑Plumber Title �❑�Gd�ss Fitter ature of Licensed lumber/Gas Fitter El A City/Town ❑Journeyman License Number: _/ �� APPROVED OFFICE USE ONLY) ❑LP Installer t Date. . . . ... .. Of NORTH TOWN OF NORTH ANDOVER o �b0 PERMIT FOR MECHANICAL INSTALLATION t • M ^� SAGMUSES This certifies that �.. . . . ... .. .� ../. . . . . a. C- — has permission for mechanical installation . . ... . . . . . . . . . . in the buildings of . . � 7. . �� s� .��.�. . . . . .oy. ... �y6 at . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. North Andover, Mass. Fee i--. . . Lic. No.:!q . . . . . . . . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR WHITE:Applicant CANARY:Building Dept. PINK:Treasurer Commonwealth of Massachusetts Sheet Metal Permit Date: ? . /` Permit# Estimated Job Cost: $ Permit Fee: $ Plans Submitted: YES NO Plans Reviewed: YES NO Business License# Applicant License# J-966— Business Information: /J Property Owner/Job Location Information: Name: Name: Street: 7 � � f Street: City/Town:"X, �ry�(/ l�C�Cr City/Town: &'e_'�! /YfJ a Telephone: Telephone: �� J Photo I.D. required/Copy of Photo I.D. attached: YES`'1/ NO Staff Initial J-1 /M-1-unrestricted license J-2/M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. /2-stories or less Residential: 1-2 family Z Multi-family Condo/Townhouses Other Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft. _I/over 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work: Renovation:-JZ HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: i e, INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes Z; No❑ If you have checked Yes,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 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's 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 sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Progress Inspections Date Comments Final Inspection Date Comments Type of License: By Master Title ❑Master-Restricted a/ov Citylfown ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: ® Fee$ Check at www.mass.gov/dpl Inspector Signature of Permit Approval ;r :zF Fold,Then Detach Along All Perforations COMMONWEALTH OF MASSACHUSETTS �t BOARD SM AS A MASTER—UNRESTRICTED ISSUES THE ABOVE LICENSE TO: X761$0763 :I { x > '% �° Sia tl•,. TYPE JOHN C REID f w K Nz M1 150:0 SALEM ST � p�r+ o�a� ' `a f r a NORTH ANDOVER MA 01845-0000 1500 SALEINuT i ° s N.ANOOVERMA�` 964379 5806 11/28/12 964379 018454914 �jpa a I LICENSE • • DATE SERIAL Fokl.Then Detach Along All Fedorahons h COMMONWEALTH.OF MASSACHUSETTS DIVISION :.•-. . BOARD BOARD OF SHEET METAL WORKERS SM AS A MASTER-UNRESTRICTED ISSUES THEABOVE LICENSE TO: TYPE STEPHEN J MCCARTHY M1 31 GRANITE AVE ' SALEM NH 03079-31,21A1-_" 3079-3126 ..4 776152 0 /11 776152 LICENSE NO. EXPIRATION DATE SERIAL No. Fold,Then Detach Along All Pertoral,ons Date.. . .. .. . . Af 0f NORTN TOWN OF NORTH ANDOVER 40 • PERMIT FOR GAS INSTALLATION 9 �,SSACNUSEtS This certifies that . .�. !. . . . ?�. . . . l has permission for gas installation in the buildings of . . ? Vit.:. . . . . . . . . . . . . . . . . . . . . . . . . 3 at . . • • , North Andover, Mass. Fee. Lic. No.. r r ;^ c� GAS INSPECTOR Check# ? 3 5521 MASSACHUSETTS UNIFORM APPUCATON FOR PERNIlT TO DO GAS F rrING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations `�`j/ / �SS . Permit# SJ^Z �1 Amount$ 3 a� Owner's Name New Renovation El Replacement Plans Submitted o a z c H 3 a U °a a s o SUB -BASEM ENT B A S E M ENT IST. FLOOR 2ND . FLOOR �i 3RD . FLOOR 4TH . FLOOR STH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR C C1�e )C one: Certificate Installing Company (Print or type)� �A llU C � Co Name `] 1l r /�� n [ Corp. i Address ` C12 des 5 1 U . .�+1 CiY�2 Partner. I usmess Telephone 6k-0--766q © Firm/Co. Name of Licensed Plumber or Gas Fitter S Lid S�� y INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ® No❑ If you have checked Yes,please indicate the type coverage by checking the appropriate box. Liability insurance policy © Other type of indemnity Bond 0 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 1:1 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 underPermit Issued for this application will be in compliance with all pertinent provisions of the Massachus s St Gas C e ha ter 142 of the General Laws. By. Signature of Licensed er Or Gas Fitter Title Plumber City/Town Gas Fitter r1cense Numher Master t1PPROVED(OFFICE USE ONLY) Journeyman