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HomeMy WebLinkAboutMiscellaneous - 44 SAWYER ROAD 4/30/2018 44 SAWYER ROAD 210/031.0-0052-0000.0 I I I I Claim # 2592449 Advantage Claim Services Adjuster Assigned: Glenn Guarente 522 Chickering Road #B North Andover, MA 01845 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health c� Inspector of Buildings Board of Selectmen Town Hall Town Hall North Andover, MA 01845 North Andover, MA Re: Insured: David Gordon Property address: 44 Sawyer Rd. North Andover, MA 01845 Policy #: 2592449 Loss of: 2011/10/29 File or Claim No. AD 9609 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1, 000.00 or cause Mass._Gen._Laws,_Chapter_143,_Section_6 to be applicable. If any notice under Mass_Gen_Laws,_Ch _139_Sec._3B is appropriate please direct it to the attention of the writer and include a reference to the,. captioned insured, location, policy number, date of loss and claim or file number. r Glenn Guarente Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. 11-2-11 Signature and date Claim # Advantage Claim Services Adjuster Assigned: Glenn Guarente 522 Chickering Road #B North Andover, MA 01845 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 3B To: Building Commissioner Board of Health or Inspector of Buildings Board of Selectmen Town Hall Town Hall North Andover, MA 01845 North Andover, MA Re: Insured: David Gordon Property address: 44 Sawyer Rd. North Andover, MA 01845 Policy #: 2674856 Loss of: 2016/03/31 File or Claim No. AD 1987 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1, 000.00 or cause Mass._Gen._Laws,_Chapter_143,_Section_6 to be applicable. If any notice under Mass_Gen_Laws,_Ch._139_Sec._3B is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Glenn Guarente Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. ignature and date • 7 7 4� Date.. 7. . . . .. .. HOFTH °f „ro ,°,ti0 o� TOWN OF NORTH ANDOVER - PERMIT FOR GAS INSTALLATION o9q � CHOSES f This certifies that . . .Q�,U N l .1.r�. . .�✓�5. . . C q. . . . . . . . . . . . . p has permission for gas installation . .VYI. ! `�. . 4�►�!�.�=.� i in the buildings of . . . 1.L3 . . . . it-0 a-4 . . . . . . . . . . . . . . . at . . . . . . .. North Andover, Mass. Fee : �? . Lic. No. z Y.S . . G hee., .� :.!. " . GAS INSPECTOR Check# '3O y 6 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) WI R A WANE.12_. , Mass. Date 06 D 1 Permit # Building Location -4d- SAWYEr- RD. Owner's Name_1XVID $. Wtwt� � KMO ANDOUEQ. HA Type of Occupancy $f M&Lt aii IL`� I New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑ _ I N N W N 2 � z rr vi N N V U) a' W d ° N x Imo. W J N W F V m F" S Jl O x o w Q CC x � ° w o2 d m m H W W O 4 0 N N O dt V W Y N z 4 a O. O > W W W N j Q x M a (W7 � W h- W f- S Lc C1 f- Z J Ir Z I. W W O > LL H W J {f.. W a Wa W Z. Q x Na m Z O x a 0 (A = .S 010 Z W 7 G Cy J V a: y D d O SUB—BSMT. BASEMENT IST FLOOR 2ND FLOOR 1 3RD FLOOR N 4TH FLOOR N 5TH FLOOR 6TH FLOOR 7TH FLOOR t STH FLOOR ) a Installing Company Name COL.LMBIA CIAS GF MASSACHU56TTS Check one: Certificate # 1 Address 55 MARS TON STREET X7 Corporation 1862 LAWRENCE, MA 01841 - 2312- ❑ Partnership _ Business Telephone q 7 e-691- 640 6 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery _. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability Insurance policy 1K 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 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 abo pplication are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S. (/ By T e of License: Plumber Signature of Licensed Plumber or Gas Title Gasfitter Master License Number 374 5 City/Town Journeyman APPROVED O C SE ONLY IL BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE N0. ' APPLICATION FOR PERMIT TO DO GASFITTING NAME TYPE OF 13UILDING * " LOCATION OF BUILDING . t PLUMBER OR GASFITTER LIC. NO. i I • I PERMIT GRANTED DATE .19 I GASINSPECTOR Date. . p'." .o�T:1�a TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMUS� This certifies that . . has permission to perform plum/Ming in the buildings of . . . . . . 2� . . . . . . . . . . . . . . . . . . �... . . . . . . . . . . , North Andover, Mass. Fee. 30 . . . .Lic. No.13 rf . . . . PLUMBING INSPECTOR Check ,7 3� 8098 i L �. �l� � �.��2� � ��� _ _ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS ""' r� Date cc� Building Location J eKL S Owners Name ' &'OzAlij Permit# v9 Amount Type of Occupancy New Renovation Replacement 1:1 Plans Submitted Yes ❑ No FIXTURES czz E" WCn ° w a �' x x ° zLnLn 0 0 x a U w w x aCC z F x az z x SLBB%E BASE" T ISI FLOCIR M FIDC 3M ROOK 4IH FLOOR 5M FLOCR 6IH HJOOR I - 7IH FLOOR SIH Hl= (Print or type) Check one: Certificate Installing Company Name E) Corp. Address / �i t°' i� 14 Partner. Busmess Telep one Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance signature Owner ❑ Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and install"' s pe ed under Pe ' Issued for this application will be in compliance with all pertinent provisions of the Massachu is a lu in e d apter 142 of th General Laws. By: igu is se um Title er ype of Plumbing License City/Town icense u er Master �/J6urneyman APPROVED(OFFICE USE ONLY —• .% The Commonwealth of Massachusetts k� ll Department of Industrial Accidents t .. ! Office of Investigations 600 Trashing ton Street Boston, M4 02111 c z� www nzassgovldia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Pimbers APPlicant Information Please Print Leeibt Nelle (Business/prpnization/Individual); Address: City/State/Zip: Phone#: . 974OF Are you an employer?Check the appropriate box: I.❑ I am a employer with 4, ❑ I am a general contractor and IFE01 lim(requires: _ e-Miziyees(full and/or part-time).* have hired the sub-contractors construction . 2. I am.a:sole proprietor or partner- listed on the attached sheet,x deling ship and have noemployees These sub-contractors have working for mei' an workers' comp.insurance. g' ❑Demolmon Y��Ty' 9. Building[No workers'comp.insurance S. ❑ We are a corporation and its ❑ ng addition required.) officers have exercised their 10.El Electrical repairs or additions 3.❑ I airs a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself.[No-workers'comp, c. 152, §I(4),and we have no 12. Roof insurance required.] ❑ repairs 9 ] .employees. [No workers' I3.❑.Other comp, insurance required_] *Any applicant that checks ba#l must also fill out the section Wow showing their workers''compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contnrctots that check this box must an an additiouai shear showing.the name of the sub-cotrtractors and their workers'crap,p-_„?i-information. I ant as employer that is provldt►tg:worlrers' infor»�atinn. compensation insurance for my employeaL Below is the policy and job site . Insurance Company Name: ' Policy#or Self-ins.Lie.#: 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 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 c 'y u er , sins ofPedury that the information provided above is true and correct Si Lure: y�/� Date: Qr Phone#: t�ciat usewrite in this area,to be completed by city or town official City or Permit/License# Issuing one):1.Boardilding Departweut 3.City/Town Cierk 4.Electrical Inspector 5. Plumbing Inspector6.OtberContact Phone#: Information a. lid Instructions Massachusetts General Laws chapter 152 requires all emp 3 oyers 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 mom 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 slates that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or *o 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 complertely,by checking the boxes that apply to your situation and,if necessary, supply sub=contractors)name(s),address(es).arnd 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'co-rnpenzation 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,notthe 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 iiisured mmunii;ahouId Put--thP_ir self-insurance'license number on the'appropriate tine. 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 permittlicense number which A-ill be used as a reference number. in addition,an applicant that must submit multiple permittlicense 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 affidavtit is on file for fiAtm 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 questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of 13ndustrial Accidents Office of Investigations 600 Washington St j=t Bosfon, MA 0.2111 TeL#617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#61 7-727-7749 www.m2ss.gov/dia Name i Location Check# Date Note: RKS 00NTOWN OF NORTH ANDOVER of ,,.o , �ti ��-�9ti) m Sewer Mitigation Fee $ * 9 Sewer Connection Fee $ TLIL >;,unr' (97.�;) C"Us�t Water Connection Fee $ Meter Fee $ ,-210-- Other $ RECEIPT NO. TOTAL $ (� TEM PERMIT 1786 �.,V, aA,a�: io. 1��� Div.Public Works WHITE: Applicant CANARY: Department PINK: Treasurer GOLD: File LUUA 11UN INSTALLER ` PHONE Note: The Installer shall verify that there is suffici nt water pressure for the new irrigation system prior to the start of any work. General Requirements— I. Bypass Meter Set-up- A plumber shall set up a horizontal space for the bypass meter. The bypass meter shall be located before the house meter. Deduct meters are not allowed except for those homes with water booster pumps. Ball valves should be installed on both sides of the meter. H. Rain Sensor— A Rain Sensor shall be installed on all new irrigation systems. III. Backflow Preventor— The proper backflow preventor shall be installed. IV. Sprinkler Head Location— All sprinkler heads and piping must be installed entirely on the homeowner's property. Sprinkler heads will not be allowed in the Town's Right-of-Way(R.O.W.), which is typically ten to fourteen feet back from the edge of roadway pavement. V. Bypass Meter Installation and Town Inspection After all work has been completed, call the DPW for bypass meter installation. The meter installer will use this Permit to inspect for proper meter set-up, rain sensor, backflow preventor, and sprinkler head location. This Permit must be present at the location for the bypass meter when the Town's meter installer arrives at the property. For Town Use Only: B}pass Meter Rain ,Sennsor Backflow Preventor Sprinkler Heads Date Initi:.11s V b (� s S n oA cledi(-A TONt'N OF NORTH ANDOVER DIVISION OF PUBLIC WORKS 384 OSGOOD STREE'r NOR FHAN'DON1R, \1.-\SSACHUSLI FS 01845-29(11) J. WILLIA.�l fl.\4L.RCL\_K, DIRECTOR. P.E. Thitothi-J fFillell AORTH T(J(:1,,,/ionc (9 085-0950 Fax (9,-8) 688-957.3 SSACHUS AUTOMATIC LAWN IRRIGATION SYSTEM PERMIT DATE -RECEIPT NO. Jr HOMEOWNER ja&)%6 (jr- y-cAo,/\ PHONE 17 LOCATION E INSTALLER PHONE Note: The Installer shall verify that there is su�f�ficientCwater pressure for the new irrigation system prior to the start of any work. General Requirements— I. Bypass Meter Set-up- A plumber shall set up a horizontal space for the bypass meter. The bypass meter shall be located before the house meter. Deduct meters are not allowed except for those homes with water booster pumps. Ball valves should be installed on both sides of the meter. H. Rain Sensor— A Rain Sensor shall be installed on all new irrigation systems. III. Backflow Preventor— The proper backflow preventor shall be installed. IV. Sprinkler Head Location— All sprinkler heads and piping must be installed entirely on the homeowner's property. Sprinkler heads will not be allowed in the Town's Right-of-Way(R.O.W.), which is typically ten to fourteen feet back from the edge of roadway pavement. V. Bypass Meter Installation and Town Inspection After all work has been completed, call the DPW for bypass meter installation. The meter installer will use this Permit to inspect for proper meter set-up, rain sensor, backflow preventor, and sprinkler head location. This Permit must be present at the location for the bypass meter when the Town's meter installer arrives at the property. For Town Use Only: B}pass Meter Rain Sensor Backflow Preventor Sprinkler Heads Date Initi:.ils 5 S noA 60-J�J(-A-.' t : Date...!.....j oh "' NORTh TOWN OF NORTH ANDOVER PERMIT FOR WIRING �s3 C$4us� I/ This certifies that 6—ei......... : ::-.... .... J............ . ....�:... ......... f;�:��'� has permission to perform ...:...::::.^......:.:.r.-................................................... wiring in the building of., .�^ .-................................................. at. ��fy...:...:.... A ........................................ .North Andover,Mass. Fee?............... Lia:�No r?� r�-? .._.<_.: � � ...... ... '/;f.............. ELECTRICAL INVECTOIS� U// Check # n IEFAi71MENTo EEVSAFM Penult Na. �� 9 8aW0FF=PABMffl 1VRW11Xa1 M7tWAW Oaapoaoy&taxa Chord .• :• APPUCATTONFORPE]RMITTOPERFORMELECTRICAL WORK ALL WORK to BE PERFOUM IN ACCORDAHM WH THE MAssACitWHI 0.6CrW&cow,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INPORIKATION) Date_ `C3-1'C Town Of North Aadd To the IrispeAor of Wires: The undersigned applies for a permit to perfoen the electrical wort described below. Location(Street A Number) Owner or Tenant r Owner's Address .Layfl - la this permit in conjunction with a building pamdt Yes[:] No �(Chect App upridB Hoa) Purpose of Building o' G Utility Authorization No. Existing Service Amps .I.Volts Overhead Uaderpauai Q No.of Meters New Stnvit Amps Vohs Overhead U .��� Mergeotrad � No.of Melees Number of Feeders and Ampacity Location and Nature of Proposed Mecaricai Wort 6 c . Na of t.&WX OOeLu Na of Hm Tubs N&oto Tout Na d I &lUB Rawer Swbmd"Pool' Above B� KVA dstwrston KVA Na of Recgtwb ON" Na d OB Ramses Na of B=gsacy Uslains Bata Units Na of swiwb Oadab Na altar Bamws No.of Rmar Na of Air Coad. TOW FM ALARMS Na of Zaees�� Teres Na of Dispossir No•of Hat TOW Tod Na ofDemcdos srd plum Toss KW Wilabs Da lm No.of Dishwubas spsaa Am Huftd r: KW Na of Sing Davies N0.orSaifCo miasd �•�•� No:d Dryers tlesdnB DM= KW ��j DMwddpd . C� C— No.of water Hdstaes KW Na d ftat Sm Ball" AL Hydeo bfmW Tabs Na of Mown ToW HP fYTHF.R• lnatanoe�Plaatbtllere¢leirmat�fimit3®ilrsiYa Ihmacu=tLirti,Ytoe�araeIR-cy daft() iris cri 2t*ffl iegi*" YIN NO Iharesubar'ItadvammMpW((znetohe�Y$4 Iyouhen>;ctied�iYB4,Pksin3s�tbetyped by eo` BM am o dVatzdEb"W*$ WOekbSoatIt�e�erim-pl zod Sgmd--- FMNAM iot eu&- liaueNn UoaeaNb Adko Bullet TdNa W-40-1 awr,WsmakimwAmismamtoftLiaQae �he• ' s�eAkTdNa W1 tayiiagiivalmtaeaacraedbyMae®ctteetrCiQnitLa�ia ands■tmy4 tsecriftjmnitshpia,l'oWWftre (Please check one) Owner Agent w Te hone No. pWtWr FEE t Date.�..� �.'. "°RTN TOWN OF NORTH ANDOVER pt Ir PERMIT FOR PLUMBING .. SSACMUS� -I This certifies that . . . .�. . . . . . . . . . . . . . . . . .+. . '. . . . . . . . . . . . . has permission to perform . . . 4- --. plumbing in the buildings of . . . . . .�.(. . (! .�P ,. .� + at . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . North Andover, Mass. Fee. . . . .Lic. No.,-)f . .�. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check # V a 68 6 MASSACHUSETTS UNIFORM APPLICATION FOR-PERMIT TO DO PLUMBING (Print or Type) Mass. Date 20 66 Permit Building Location eRaOwner's Name Go�21 /v Type of Occupancy_ New❑ Renovation 0 Replacement-a— Plans Submitted: Yes 0 No ❑ h� FIXTURES B.P. # SEWER # SEPTIC # z Ln L] Ln z z Ln Ln z ¢ 4� LLJ ' z o z v, w O ~" w u- z w N _ to z a LLJ LU cl� LU wU Qm zLU IL ck� cnC Q o _o zo o O U¢ a m o ou ¢ D O SUB-BSMT BASEMENT 1ST FLOOR 2ND FLOOR J` 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Comp//any Name (r G 7 Check one: Certificate Address Lo L— Y I y(�cJT S/ . ❑ Corporation Business Telephone c ZS ❑ Partnership Name of Licensed Plumber or Gas Fitter C ❑ Firm/Co. Z r✓ / INSJRANCE COVERAGE: I had,e a current liability insurance policy or Its substantial equivalent, which meets the requirements of MGL Ch. 142. y Yes E-- No . ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box. 1 A liability insurance policy a . Other type of indemnity ❑ Bond ❑ OWNER'S INSURNACE 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. __Signature of Owner or Owner's Agent Check one: Owner ❑ Agent 0 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 t mit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapte 1 of the a eras Laws. By Title Signat r icensed Plumber ` City/Town APPROVED(OFFICE USE ONLY) Type of License: ❑Master O'Tourneyman License Number Date.t-')'.q Q:PL: NORTH OF t,.t� , 'O 3� i` '+ TOWN OF NORTH ANDOVER ti z . o • PERMIT FOR GAS INSTALLATION ra ISS �CHU5Et This certifies that c `?G.n... . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . .✓--�.. . . . . . . . . . . . in the buildings of . . . . . . .? e., .. . rin '-' at 6^0.4,E Yx. ... . . . . . . . . . . . . . . . . . . .. North Andover, Mass. Fee.<. Lic. No..q " ' . . . . . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR Check# 5496 MASSAGE fUSr=TTS UNIFORM I AP . ATIO FC}R PERMITIO DO GASFITTtNG tI 1.Prin`t or T.Y�(p¢) % / 1. �!� '/�>�i�C�</�12 ; Mass: Dale 2 ' �� Permit #_'; _ 1. ` Building Location .I 61 - �I 0�. 1. Owner s Name " d Type vt`Uccupartcy /� 116 � New 1. �] Renovation Q ReL.placement.(]-"' Pl'ans Submitted; .Yesp No C7 � . N a X ut N N U N y N CC' a }- ¢ .:. ", ' I ¢ ? t. ¢ y V u! d . 3, I V) O ? W $UR—$SMT, 8'A S E M.E t1T - 7:ST FLOOR . 2`.Np FLOOA '. I L, 3Rt) FLOOR ,r ,W :LTH FLOOR ` " �. S.TH FLg0R . isTH FLOOR. ..L . L . r - � , ,rr��'L,9. 9. , r 9 9L. �;: r j 9 - .r: -. 9� I I . r r �H 2TH FLOOR ,'. B:TH FLOOR Installing Compang Name G� LL.�1-1>�1/u I t� Check cane: CeriIflcate Address_ - > Ldl L `� CarpoFatlon ��__'_� DOIr / . ` -�� ❑ .partnership % Business Telephone ("� f p .fir IGo. " Name of t.Icensed Plumber or t3as Fitter, �/-L/ /' INSURANCE`COVEttAGE:.9 r , I have:e curren�,ttabl(ii}r insrr urance`policy or i1.ts substantial equivalent which meets the requtrernents of MGL Ch. 142. Yes No_O 9 9r - Il you have checked yes, please tttdicate`file"type coverage by checking the appropriate box. A liability insurance policy Q Other type vt lnderriNty CI` ' .Bond C3 OWNER'S 1NSUftANCE WA1yt=R l.am aware that the'lkensee dues not have the Insurance coverage required by Chapter 142 .r the Mass. �eneraf Laws,•and that my signature on thls permit application wa&'q- . nils requirement. Check one.. LLL Lr a Signature o!Owner or•Ovaner's Ag99. ent OwnerC Agent ❑ I hereby certify that alt of the details acid Information 3 trays submitted.(or entered)in above appliralion are°true and accurate to the bast of my knowladQe and that all plumbing work and lnstallatlons erlarmed under t►re permlt Issued far,this application wilF:be In cotnpllance wtih nit r F H 9 E perilrtentprorisiorls of'the.Massachtsseiis State Gas Co a and t�iapter 142 ot"ihe Gene ailaws. T e of,[]cense: ` Title Plumber Sig � 2 u s o ,c nee um er or Gas dieter _ asl Kar /J,, 1L;� CiiylTown aster [}Cense Number 7✓ At't'fl(7V[f1�OTj'--0 Journeyman,.