Loading...
HomeMy WebLinkAboutMiscellaneous - 44 BRUIN HILL ROAD 4/30/2018 (2) BRUIN HILL ROAD 210/1/1 04.A-0097-0000.0 I I Date.... ............... TOWN OF NORTH ANDOVER PERMIT FOR WIRING SSgCHU This certifies that 11.......kA...............N.k�...+�Jv......... ..... ...... ....... ....... ............. .......... ..... . ..... ...... has permission to perform .. ...... . ..... ......;...... ............. .... wiring in the buildin 3,,of.................... ................................................................................. at ..............t....!.............................................. .. t� .... ...............................North Andover,Mass. Fee... ................. ........V 1.( ................................................................... ...........................Lic.No. ELECTRICAL INSPECTOR Check# 19-7 7 l N1. z�- Commonwealth of Massachusetts Official Use Only Permit No. 7 a Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/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 TN HK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application thesigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Nu �)�j(Z�ti-N Nc2mL & yWAQJ eVt Owner or Tenant V )j y-M k-S Q- Telephone No. Owner's Address �4w�+� Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Il/ New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity 4 �^ Location and Nature of Proposed Electrical Work: _Cr�it. �A NQ► J Completion of the following table may be waived by the Inspector of Wires. of No.of Recessed Luminaires No.of Cell: TransSusp.(Paddle)Fans Total Trsformers KVA --' No.of Luminaire Outlets No.of Hot Tubs Generators ISA Pool Above In- o.o Emergency Lighting No.of Luminaires swimming rnd. ❑ rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiatin Devices No.of 4 i Total 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 FoTHER- Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: U (When required by municipal policy.) Work to Start:U Z&s,sA\` 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: 1NSURASICE ❑ BOND ❑ OTHER ❑ (Specify:) Icertify, under thepains and lties ofperjury,that the information on this application is true and complete. FIItM NAME: Qom '' LIC.NO.: 3 SOI Licensee: _]`� � �4Kt Signature LIC.NO.: , (If applicable,enter exempt in the license number line.) Bus.Tel.No.-Q-"-7o1-3 3a cr Address: Alt.Tel.No.- "Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent --- Signature Telephone No. PERMIT FEE: $ Zj i ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the 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 shallbelimited 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 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: . Inspectors Signature: Date: ` PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Insn tors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass IN Failed(] Re-Inspection Required($.) ❑ Inspectors Comments: k Inspectors Signature: Date: r FINAL INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: liate, DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com '' TOWN OF NORTH ANDOVE-A --, ��_' MASSACHUSETTS Matthew Egge Town Planner Planning Department 1600 Osgood Street I Suite 2035 (978)688-9535 North Andover,MA 01845 Fax: (978)688-9542 megge @townofnorthandover.com a�\nv4vt SGV vs n v ,e Vi- 7 .41 The Commonwealth of Massachusetts - �' Department of Inclustritcl Accidents 07 Office of Investigations 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):vn,\ c,� N�\ Address: A 32 -c),icky S-v- `,N�i 3o City/State/Zip: ,'n\/t- Phone#: -7c) 1--3 3 2 I Are you an employer?Check the appropriate boa: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.10I am a sole proprietor or partner- listed on the attached sheet. FJ 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. El We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work rightper MGL I L❑Plumbing repairs or additions of exemption Pon myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]i employees.[No workers' 13.❑Other comp.insurance required.] *Any 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 a're 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 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:. Policy#or Self-ins.Lia#: Expiration Date: Job Site Address: LA City/State/Zip: Nc,&\-�k C �2YC Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereb ertoW under the pains and penalties of perjury that the information provided above is true and correct. Sip-nature: 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.PIumbing 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." li 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 dwellinghouse 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 em to er." p Y 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 P ,§ ( ) commonwealth nor any of its political p 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 maybe 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 contactou regarding theapplicant. Y g g Pp Please be sure to fill in the permit/license e number which will be used as a p 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 bum 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 ciuestions, please do not hesitate to give us a call. The Department's address,telephone and fax number: U r The Commonwealth of Massachusetts Department of Industrial.Accidents Office ofIaVestigafions 6.00 Washington Sire.et Boston?MA,02111 Tei,#61.7-7274900 ext 406 or 1-8777MA.SSAFE Revised 5-26-05 Fax 0 617-727-•7749 wWw mass,goVMa i fa7/0912014 819:52 9784590044 aArlm5jb 6 c ` y ttia �C .� � �!�' � t . ElR�t* twt'd l�tdle ewe ste�w�. •' +t+� r _e�-T,e - L"c t='aEoaa=gr' rawer dr-w=f- r%f— s rh r..ra r�m_w 3't�t�k-asen^�t.'ftRt t ��!!llxl4`C��i U2s lAdt�l�l1�7'[�ld fdl #t!�G@Kf��M0 }tin��rss���a��,e�s s x .+. •.€ersr„sae� a�ee�E ter}s€i�.s�ret�r ss— �*���� �,���t L �•�— � � E rir .>,.+...w.W. - .n.r.srr .•fir Figprtvwa.r V 1rAr fir_. TL[V�YGAPt'A_— er tRF �µ fif.■.fSit'Or�..fF1• iV.i�R SRV 4IA mmimmT`ti Fdd:'.••'E�tTyretF t -. ,_- .•E4Efi•T' £! E}! !2}Ls3;}F3 31 'fe5l2[3�4 - 4�1l1la!lRldwros!Nf}06f.rlein ra.rMrii�■q■�crtccc - .vW�.w Ys�tia.dN'MVlYr3g+ii£iil..t'a3iswr-344i}/Gbl4i @ ¢. K-a fd¢+.is ♦�.r—.WE.III - l�iiaS�BsEt�i►ACd;I�`iC thetC M lord� of Gsti�{r� �,�,,�}�{. �.. .r.e..w.r.char acaelos tarc s O_rc.r..l. 6 tr/ 4SG -- - - -_r._��,' :::4ilr' i� 7tr"r•r,:,t'.ytk.pq, .dit.w/.rq}}16t�!r,w+wN�'�1i`fl�'4 ►61'LI-1' ;;bQO<"�[t9� f1' ��Ht _ L6aie noww m Imu W wu4m trtitarstdlsf"=I. f - r-�.'-��ar ��s;;=-��rca� rs��--: ar� e-xt�s�r �_�•����aal�--- re�a�� �ar�a��--rt �i1/r.s'sl■ a.. wv►rvl +.wwr•srr�,ea �!d®r�T r +nom. I�11 i_ +�+4 iefiiF� -Ra-.asr.:=�+.ev sgie ;�1��'d'dfe�7?Et 61<d��' �_ - -r? f 01332 ice.. .-..-�,: .� .».•.�,.�:"� . _-_____ ►t awl. it•81 i taw w. i ;rMtn E D� ■ : e �. _ � f irt "s t d _ -ASWledttr't _. � v�w ��re^,re IIsrrs�sa>t.�rrt ar "J�'�'4"�7T[�"�� �■:�■ `r��r,—,6=n:A:,ri•-�K�'Cc A.aa i�o'f RCYfOW}*l�i/I�C7�. n;�i w^-rw TWINY simt taimy m PrM�+E�1ET�8Y THE IOUCIM�.RCIiW!¢[ZEIN!!S SMEOT"TO ALL THE 4ERMO, E �i�tt} a *}l4$ fAmOla%#SI } 'r}aNTCe rww WSW- - •rtr r= - v - t''�:'''� rr .r�»r�..�.+r�.��r�'e.tew•._ ilMn't.JVVtP.fi4.VO lt• 7 Tg E Xa�ldT7R'31�2T T!i!lAtlr t = '3�=�"��"•"' t f �r o I E i�•r�wroewrwcw.+wl.vrpw�-+ww•.•, RAEJR/NEB�OEdJAMI�Oi } t F�tl�sS'F4fw. ii 4ew+.wwr ! �4. t t►s:wr gra an �r is g. - � ;[�-ws.Wri..�Y`!./wY..« � � �. � i � l■�V Gr�Mle l�w/4 I1. `�� 114 Y W E{ 1 r vw+�.w.sT..ay.•..i®T3�2�C }= Zip 1R$ i a' 4T'a!F!A!!<n..�.'. +�ira r ► i t zzwimwwh rw ynw2gr•Ru;r Bt.F i r Y' (t��� wt_.Mr..r.Fp.•f.l�/f..�1� r{ E t YRA ! ! t t b Y iftlimf&A t'Td -__- p � 1 I.���ly�a■e9■IMM.■I t t t --YF I �"� -r-ir�■,v.� t r re-Rt� t r• 1 t E tcxrn�r �rr� �t - F—E T t9laVnrto�r f t' � � � �s1k!FR!!l�TA 4 E - } t Ir■wv-- -- t F k''S.'iP•7 rTIE.Tlcl.!'fE2lrE t t } { Iwo .r wNrurr+sr�lw• .rn S Y tie t t t 1 �.._v. .. .. - �MMYRI�..kbtgSW}^t""�t}- 1E76GOtV! d} ��t!'6R.ltCDC15'.StC6RSC t ! i !� 4 � f�Et mmr5�!fbt! rr�•c:refrtxae�rslf•af�'xFf �tiwr < ! t 5 � � -}}*�;�r}lklmlct�'t F 6 I J 4 E �.1..' itr�ee4.�+rac/wwss+v tnaeci+uxnm tetaA�e�1 a�s�es.�n�t E [ E t { eiirl�kalc sl:t�it�„�_ —• -�I�I..®,1�•�---��-i�li��ioF� -- - � -- .w/.Iw.=;Q..sa,,.dlw,•w.y.•,.sawu�rasysnmi � E &rite of C4*t m ell ww}s a rw vsrsv y 7!�l�itet'}V/4tiEddK7 6�7�trC7lE/!1'i[itw��.�.�•�w.Yw _1•!!•l�.+�■■� ,bra rir�.sc.�a�2'��c�a _LL�.2�,.�_ _3§E+PEi `�1■�--^•'w-.r :viiw s.r�wtvr.wj• .rar r.wnV ItO.lt�wrsv r rsi 1r�r=rasiw srVrt.>.¢r I�WRY pSA_CHeSE M OMMONWEa►LTH • EL::ECTRICIAN� : SE WING. LICE�.N.-.. a LO fLECT�R.I C 1 AN � ISSUES THE FOL N . Z :RI GHA:Rp MCNAMARA '`� � - 25 ;: ApT All Date. . TOWN OF NORTH ANDOVER 3? � �o� PERMIT FOR PLl,1BING s a ' s � SACNUS� This certifies that . . . ! .Ex?!'z '?l. . i'. . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . .f'.,� n,- /-. . . . . . . . . . . . . . . . . . . . . . at . . . y.�/ . .����.41.4. .� . .f. .t'. . . . . . . . . . North Andover, Mass. Fee.,-?.?. .—.Lic. No.. .5.7.7?. . . . . . . . . .4 PLUMBING INSPECTOR Check # GI)�1�G �/ ' ?370 MASSACHUSETTS UNIFORM APPLICATION FOR.PERMIT TO DO PLUMBING a� Pr'nt or Type Mass. Date r� 20 P it # t _24.�_O_ Building Locatio .Owner's ameLo KI Q Type of Occupancy New 0 Renovation 0 Replacement 63.1* Plans Submitted: Yes D No 0 FIXTURES B.P.4 'SEWER# SEPTIC# Z Z Y u1 PLO O Q Z > w Y LU uJ elf 0 .Z-i LU ¢ 111 to S tY to Z O Z .z� Z d J V) In w �yCL Lu L p N Z a LU F_ .o o = ti_ i- Q C1 tr .' j G W u_ m U) O S = vl u- c0 D Q Of m 0 O SUB-BSMT BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR Tz_ FLOOR 7TH TLOOR ' 8TH :. . nstaUing Company Name" Check ong: Certificate kd.dress 0 Corporation P l0 d 3y 3usiness Tele honeD Partnership- lame of Licensed Plumber or Gas Fitter__ Ea lw*j 'a a Arm/Co. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGLCh. 142. Yes No .0 If you have checked Yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy P---- Other type of indemnity ❑ Bond 0 OWNER'S INSURNACE WAIVER: 1 am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: Owner 0 Agent D hereby certify that all of the.detafis and-information I have submitted entered)In above-a_ppilcatlon are true and accurate to the best of y knowledge and that all plumbing work and installations perfo�me n"d r the permit isf for this application will be in compliance with .1 pertinent provisions of the_Massachusetts State Plumbing Code a t 142 of therafLaws. �By Si n arf ure of Licen ed lumber Title EE P wn APPROVED(OFFICE USE ONLY) I Type of License: fWMaster ❑Journeyman APPROI - License Number-2-8 7 007 The Commonwealth of Massachusetts Of It.* H.. afti Dcparrmcnt of Public Safety P.—it 36. BOARD OF FIRE PREVENTION REGULATIONS SZT CMR 1200 3/90 o�c„rKi r.4 o�-ca" ct.a.. at.o►1 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK AU worlt to b.Paiormed In accordance with the Mauachuscns Electrical Code, $27 CMR I2:00 (PLFI�SE PRINT ZH I2IK OR' TYPE<.ATT- 'INFORiS�T101ij;. Date . "CiEy :or:Tovu of j,. jli Or//=!d To thi"Inspecrar.of Niress The undersigned applies for a permit to perform the electrical work described below. Location (Street b Number) .PLJin� /7�iLLe �TUAO Owner or Tenant Owner's Address Is this permit in conjunction with a building permits Yes ❑ No Li (Check Appropriate Boz) Purpose of Building Utility Authoriz,arion NO. < Existing Service _ _ Amos �/- . _ _ -- - ad ❑ Undgrd❑ No, of deters �! _/L_ ad ❑ Undgrd❑ No. of Meters ° 2 � 16 Date.�...�`�. -�i� NORTI, �SPcfd fir_ �tJT s,� ���cep 0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING No. of Transformers Tj°vl *1° i ❑ Generators RVA t'��°'•����� f' No. of Emergency LL&Ating ,SSACMUSf Battery Units ' FIRE ALARMS No. of Zones This certifies that .�......, N of Detection and :.............................^..�.............................. Initiating Devices has permission to perform -�. /.. No. of Sounding Devices P pe ....................... L No. of Sel Contained wiring in the building of �-'' ,,,,,, Datection�sounding Devices 7 Ff.. ..: Local C3nipal ConeConnection❑ eT I North Andover,Mass. at.......... ..... ............................................. ................. Low voltage 4 S/irin Fee. 5............... Lic.No.•� ��! .....'I ,� .., .......:....:............................................. --'-"ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK:Treasurer i "awe a current Lia - setts General Labs Insurance Policy including Completed Operations Coverage or its substantial equivalent. TES NO a I have submitted valid proof of same to this office. YES❑ NO 0 If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE ❑ BM ❑ OMM❑ (Please Specify) - Estimated Value of Electrical Work S !J/ (Expiratio ac Work to Start Inspection Date Requesteds Rough Ficul Signed 4LAer the �-- penalties of perjury: : FIR! NAE nL LIC. NOL/ Licensee Signaeure NO. Address —' _ Bus. el. No. OtiIaER�S LNSIJRANt3 STAT s Z an aware that the Licensee does not have the insurance coverage or its su - atantial equivalent as required by Massachusetts Ganeral Laws,wand that my signature on this permit application waives this requirement. Owner Agent (Please check one) Signature of Telephone No. PERMIT FEE S Owner or Agent Date. . . /E/... . . . N° 4346 O',".0 RT:��o TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 44011 SSACNUS i This certifies that �'� `'. . . . . . . .L. . has permission to perform . . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings . . . . . . . . . . . . . . . . . . . . . . . . . . North Andover, Mass. Fee.,?>.,. -. . .Lic. No./ ?.�. .J:t: . ... . . . . . . . PLUMBING INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer J • 01 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) l i, WA/A0 WE& Mass. Date cl?-as9 aD Permit# T3 V(S r � ._ Building Location H/LOwner's Name /d A.ecs�` /n/ 'L L Fi9/�7/L c Type of Occupancy to New .❑ Renovation ❑ fle lacementl�/ P Plans Submitted Yes ❑ No (s�— FEATURES . . z z Z Y Q O W � J U) } U Q U) Z W W W Z u) Q 2 < = I- Z O 0 0 M 2 O0=U) L11 m - ¢ } Q w W Y 2 W Q Q X Z � 2 W rq Z p Q cn Cr_� Q n ¢ O - W S O 2 3 0 2 -� vi (L H Q Y a LLL tt LL1Y W Lul Q FF- Q OS MOW ¢ p Q Q 2 2 w Q O U 2 Y m 2 i- � u_ 0 Z O Q � Q m 0 SUB-BSMT. BASEMENT 1 ST FLOOR . n 2ND FLOOR 3RD FLOOR ,� 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Namel-QR�IC (5:(90 V =2��f Check one: Certificate Ste,'y�/ / ❑ Corporation ❑ Partnership Business Telephone 7 �l� ^d//��a /�� r"��©Q �m/Co. Name of.Licensed Plumber �!lz INSURANCE COVERAGE: I have a current liability 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 of coverage by checking the appropriate box. A liability insurance policyOma— Other type of indemnity ❑ Bond ❑ OWNERS 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: Si nature of Owner or Owner's A ent Owner ❑ Agent ❑ 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit Issued for this a plication will be in compliance with all pertinent provisions of the Massachusett tate Plumbing Code and Chapter 142 of the General Laws. By igna urs o icense um er Title Type of License: Mastgr 4tr'-- Journeyman ❑ City/Town License Number ;2Q2 4�!2Q2 APPROVED OFFICE USE ONLY)