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Miscellaneous - 45 BERRINGTON PLACE 4/30/2018
c�� — 1 1�1 ®N 1� Date �7 . ...... 11 629 TOWN OF NORTH ANDOVER ° p PERMIT FOR PLUMBING r ss�CHUS� This certifies that... "O'q ............:..........ar:........... .................................................................. has permissiofi to,�Orform. ... ....... �i�... plumbing in the buildings of............................................................................................ at..J�...I..6°2.e*...... 7vy!,-.. .................................... North Andover, Mass. Fee:l..y..� Lic. o.�N�S/..<�. ................................................................................. PLUMBING INSPECTOR Check# 2 32- & 1014- 115M 1�j1��15 �' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 2 i9 6 CITY Q w c o u 2P MA DATE�- -1 PERMIT# 4- JOBSITE ADDRESS ���1 $► {� �GG OWNER'S NAME POWNER ADDRESS S - _ TEL - ° '' - - FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Ll RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION: .. , REPLACEMENT: PLANS SUBMITTED: YES® NO FIXTURES Z FLOOR— BSM 1 2 3 4 5 5 7 8 9 10 11 12 13 14 o BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM _i _ I DEDICATED GRAY WATER SYSTEM _ I-11' I DEDICATED WATER RECYCLE SYSTEM _ I _ DISHWASHER -- DRINKING FOUNTAIN _ FOOD DISPOSER �� _ _ _-_ _ _ _ _ _ _•I FLOOR/AREA DRAIN -__--- INTERCEPTOR INTERCEPTOR INTERIOR I , KITCHEN SINK LAVATORY 2 ROOF DRAIN -- ' _ - -- - - —- -I SHOWER STALL --=C--- - -- - - - --- SERVICE I MOP SINK _- _, _ [ _ _ _ _ _ _ ! TOILET -- --€ - - •-.. __.1 _ - - --- -- -- -- -- - URINAL - WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 ° WATER PIPING OTHER { 9� 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 CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE:APPROPRIATE BOX BELOW 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 3'- Massachusetts General Laws,and that my signature on this permit application waives this requirement. '— CHECK ONE ONLY: OWNER ® AGENT SIGNATURE OF OWNER OR AGENT S 1 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 com lance wit all Perti ent pro lion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# z /SIGNATURE MP® JP ! CORPORATION®# PARTNERSHIP®# LLC®# COMPANY NAME JADDRESS CITY1 STATE ZIP 01 .4'7'(v TEL FAX sj=u g/ CELLI EMAIL_ i ��9,�� c� e ��� Y'he Commonwealth of 19�c���ach��et�s Department of1nd��t>^r��Accacle�at� I Congress Street,Sete 100 ' �Yd gostoa,MA 02114 2017 www-mass-go Mal �V'oxkexs'Caxnpen�o$�xp�'PV)_`l�T��TTx`i NGnAtxaCt OSt7[7CX.tx'xcianslPiuznbexs. please print Leeibly ;A, lxcant 1'u�oxxnation ( n n Name(Sits3ness/Organizaiiou/Iudioidual): (JL�r�dl `I L' C�z�i� l47 fha6'IV 1 C Gt'{ �J 0 Address: Y > w CIVVA0 S r- r � City/Statelzip: j jW,- �v n 'It E2--6 'hone#: S� %Sd"S Z 3 eZz ----- Are you art employer?cheekthe appropriate bo- Type of project(.Vqq x*red): I.[]I am a employer with . employees(fufl andlor part thuc)-* 1, 0 New constnzctzoXl 2.�✓Lam a sole proprietor or partnership and have no employees working for me in 8(�emo delilig any capacity.(Noworkers'comp.insurance required.] 9. El Demolition 3..E]I am a homeowner doing all work myself[No workers'comp.insurance required.]t JOE]Building addition 4.E]I am a homeowner and will be hiring contractors to conduct all work on my property.I will II.E]Electrical repaixs or additions ensure that all contractors cilerhave workers'compensation insurance or are sole _._. nbli3g-xepates.or-ad dit1o7a5— 5.E]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roofrepairs These sub-contractors have employees andbaveworkers'comp.insurancet 14.0 Other 6.[[We area corporation and its gffirrers have exercisedtheir right of'exemption per MGL c. 152,§1(4),and we have no, mployees.[No workers'eomp.insurance required.] :'Any applicant that checks li0n41 must also Tilt outthe section below showing their workers'compensation policy information. Homeownerswliosidimit hisaf(xdavitindicatingtheyaredoing all work andtheahire outsidecontractors must submitanewaffidavitindicatingsuch. iCo rnootors Haat check this box must•ait indicched an additional sheet showing the name of the sub-contractors and state whether or not those entities have . employees. lfthe sub-ebnlraetors have employees,theyhtnit provide their workers'comp.policy number. yam an erriployer that is pNovidirzgworkers'compensation insurance fox my employees'Below is the policy arid,job site information. Insurance CompanyName: Policy Mox Self-ins.Lic.#: ExpirationDate: Job Site Address: C_Z {' tom--- C:itp/State/Zip: Attack+,a copy of the vVork6rs'cbmpensation.p lacy declaration page(showingtlze polxcy7qumlOer and expiration date). Failure to secure coverage as required under MGL G.152,§25A is a criminal violation punishable by a fine up to$1,500A0 and/or one,year i mpxisonment,as well as civil penalties in the form of a STOP WORK ORDER and a�n e of up to$250.00 a day against the violator.A,copy of Ibis statement may be,forwarded to the Office of investigations of the DIA for insuxance coverage verification. X ilo hereby certif under the airs an enaltio filer ji!r�triat the inforrrtation provided above is flue and correct. Date: Z-17-16 Si nature- Phone#• 2 9 qS—'o Z 3 Official use only. Do notyvrite in this area,to be completed by city or town official. City or Town: penmit/License# Issuing Authority(circle one}: i 1.Board of health 2.Building Department 9.City/'Town Clerk 4.Electrical Inspector 5.pluanbingTnspector b.Other Contact Person' phone#' �'ar HUSETTS 40MMONWEALtH OF MSAC AS BOAR©CSF PLUMBERS A1�0 ASFITTERS 155UE5 THE FOLLOWk'Na LICENSE., ;* L 1 N6-,F `1lS A JOURNEYMAN-PLUMBER U ANTHONY M PALDINO 43 WAKE.$I T ROAD�, \,s► ate .}k TEWKiBURY MA 01876-2155 24516 05101/1 2147$2 -. Bryan Bendig 59 Berrington Place North Andover, MA 01845 Town of North Andover Building Department c/o Plumbing Inspectors Office I This letter is inform the Town that I have chosen to work with a new plumber for the final plumbing needs in my master bath remodel. I am releasing Shawn's Plumbing and Heating from the permit and have hired Anthony Paldino, License#24516, from Ultimate Plumbing and Heating. Bryan Bendig 1 i I D ........ ................. 11 2e o "SRT",ti TOWN STH- OVER PERMIT FOR PLUMBING ��88ncHU This certifies that,( �.... f���/J'g1cJ .. ........ .. ....................................................................... has permission to perform..,C� ... ...<!..alf.............................................................. plumbing in the buildings of .. .. ................................................ ............................ .............. . o rthiAndover, Mass. Feey ..kic. No.4/ . ....... -..................... .... ................................... / APLUMBING IjSSPECTOR Check# I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK }- _ _ CITY U�• f� �J ACS� , MA DATE PERMIT# JOBSITEADDRESS /t �� OWNER'S NAME POWNERADDRESS1 alne TEL Qd FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL2j PRINT CLEARLY NEW: 0 RENOVATION: REPLACEMENT:© PLANS SUBMITTED: YES Q N0[t{ FIXTURES 7 FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS101L1SANDSYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM '-j ---J=== _1 _I DISHWASHER -_..___, _.f DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINKE LAVATORY I L -- ROOF DRAIN SHOWER STALL SERVICE/MOPSINK _ �.1 { ( ( _____J TOILET URINAL __ .__ _.-•-! ___-� _._._1 -.[ _._. ___-. _l .. __.1 ..__._� .___._I __.__! _.-_1 WASHING MACHINE CONNECTION .WATER HEATER ALL TYPES WATER PIPING OTHER —L----_ __. _1 -_._-I ______I I _I INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES -Ai NO Q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ] OTHER TYPE OF INDEMNITY DI BOND El OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT I© SIGNATURE OF OWNER OR AGENT 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 compli c with all e ' ntgrovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME�rn/1/! P�(/0 �/(�JLICENSE# GNATURE MP Dl JP A CORPORATION-]J# PARTNERSHIPP# ;LLC COMPANY NAME -f ; ADDRESS _ l �I CITY yr _V -_� ----:--_..kfyJ I STATE C ' '-�J ZIP ��� ►I TEL FAX CELL��EMAIL _ Sd t!Z)i ccll CPG0 MLS ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES }7 Yes No HIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of IndustrialAceidents I 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 PERIVIITTING AUTHORITY. Applicant Information Please Print Legib Name(Business/Organizationgndividual): Lshawl, zw f lit"i Address: q q City/State/Zip: Phone Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2 VtlI am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 4.F1I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 EJ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. • 12.[]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.insLranceJ 6.Q We are a corporation and its officers have exercised their right of exemption per MGL G. 14.Q 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. I Homeowners who submit this affidavit indicating they are 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 state whether or not those entities have employees. If the sub-cori6ciors have employees,'they must provide their workers'comp.policy number. Iain 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.#: 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 DIA for insurance coverage verification. I do hereby certify der the pains and penalties ofpeijury that the information provided above is true and correct. Signature: X A, Date: ,Aza Phone#: Q�3 -? Ira- 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 thereon,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 fillout 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 foi 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Date.. //02............. .......... .......... N°RTjf _ °��•`� ` '' °9 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ,gsACMUS�t This certifies that ..... cF.......ll....,��?.. .?... ............... ELS .................................... has permission for gas installation ... ' . in the buildings of..,....:�.�1..�! Al.......................................................................... at..... .... ......�n....... �' --......North Andover, Mass. Fee4......... Lic. o. ..f/ / '... ........��. ................................ le GAS INSPECTOR Check# A 9750 `-- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY ] MA DATE - PERMIT# JOBSITE ADDRESSOWNER'S NAME GOWNER ADDRESS ___-- TE . e"��FAX TYPE OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL® RESIDENTIAL CLEARLY NEW.. 0 RENOVATION:Q REPLACEMENT: PLANS SUBMITTED: YES F_711 NO C APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER f J I _ __ . _ _ BOOSTER CONVERSION BURNER ---- -_ f ; COOK STOVE DIRECT VENT HEATER ( DRYER - FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE I I i INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN W —--I -- — POOL HEATER ROOM 1 SPACE HEATER — ROOF TOP UNIT TEST UNIT HEATER ' UNVENTED ROOM HEATER WATER HEATER 0 HER i _ i _. `r i .. -.... f _.__.._� _....__ I ..............1 -1 --� 1 . . Al INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO ❑_I I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY E] 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 � A ENT [� SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application a tr and a curate to a best of m knowledge and that all plumbing work and installations performed under the permit issued for this application will om liance w th a e i of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME David Williams LICENSE# 11719 GNATURE li MGF 0 JP EJ JGF 0 LPGI® CORPORATION L]# 2493 PARTNERSHIP Q# LLC[# COMPANY NAME: -ating Inc. ADDRESS 78 Found Street CITY Wakefield STATEMA ZIP 01880 ITEL 781-245-9200 FAX 781-245-9599 CELL 781-548-1288 JEMAILIdavid@call128.com I � ` V v �` G 128PL-1 OP ID:KW CERTIFICATE OF LIABILITY INSURANCE F DATE(MDOW YYY) Q2/255/2012014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION 1S WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Chas.F.Hartshorne&Son,Inc Chas.F.Hartshorne NAME:PHONE .781-245.4300 Fax 3 Chestnut St. Arc Nc ac No:781-246-5810 Wakefield,MA 01880 A-DMDAIL�s. Chas.F.Hartshorne&Son,Inc INSURER(S)AFFORDING COVERAGE NAIC If INSURERA:Travelers Insurance CO INSURED 128 Plumbing&Heating Inc INSURER B: 78 Foundry St INSURER c: Wakefield,MA 01880 INSURER D INSURER E INSURER F. COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, TYPE OF INSURANCE POLICY EXP LTR POUCYNUMBER MMIDO MID LIMITS FGENERALLIABILITY EACH OCCURRENCE 5 1,000,000 A COMMERCIALGENERAL LIABILITY 680-7C496868-14-42 03/09/2014 03/09/2015 D"AGE TO PREMISES Ea RENTED occurrence) S 300,000 CLAIMS-MADE ®OCCUR - M Y EXP(Anyone person) S 5,000 X Business Owners 0310912013 03109/2014 PERSONAL&ADV INJURY s 1,000,000 GENERAL AGGREGATE S 2,000,000 GENI AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG S 2,000,000 POLICY X jECT PRO II LOC S AUTOMOBILE LIABILITY COaBINEDtSINGLE LIMIT S 1,000,000 A ANYAUTo BA-5D091054-13SEL 10/18/2013 10118/2014 BODILY INJURY(Per person) S • ALL OWNED XSCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) 5 X NON-OWNED PERCIAMAGE HIRED AUTOS AOSACO S S UMBRELLA LIAROCCUR EACH OCCURRENCE 5 A EXCESS LIAR HCLAIMS-MADE TBD 01/28/2014 01/28/2015 AGGREGATE s 1,000,000 DED I I RETENTIONS Is WORKERS COMPENSATION I WC STATU- I OTH- AND EMPLOYERS'LIABILITYTORY LIMITS A ANY PROPRIETORIPARTNER/rXECUnVEY/N IEUB7C497865 03109/2014 03/0912015 E.L.EACH ACCIDENT 5 500,000 OFFICERIMEMBER EXCLUDED? N I A (Mandatory in NH) 03/09/2013 03/09/2014 E.L.DISEASE-EA EMPLOYE0 S 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below I EL DISEASE-POLICY LIMIT S 500,000 PROPERTY 20,600 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Ramarm Schedule,if more space Is required) CERTIFICATE HOLDER CANCELLATION NATIONG SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORMF REPRESENTATIVE Chas.F.Hartshorne&Son,Inc I 0 1 988-201 0 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD t ;fid �::COMMC?NWE4LTHOF M1�SSACHI�SETTS e e e • e e BOARD OF PLUMBERRS A D BASFITTERS i ^' LSSUES TNE -FOLLOWING ..LICENSE L I GE1iSIr#1 AS A MASTER_F L-UMBEI "' F Q DA_V113 M WILLIAMS- 78 ILLIAMS 78 F O UNL#RX fiT W1=F f ELD .. MA 01880-3217# 1J 6 214820 128 Plumbing & Heating Inc. 78 Foundry Street, Wakefield, MA 01880 781-245-9200 The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations I Congress Street,Suite 100 Boston,MA 02H4-2017 ,M www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizatiorr/Individual): 128 Plumbing & Heating Inc. Address:78 Foundry St CitylState/Zip:Wakefield, MA 01880 Phone#: 781-245-9200 Are you an employer?Check the appropriate box: Type of project(required): 1.Q I am a employer with 6 4. 1-11 am a general contractor and I 6. F1 New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.RN Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 1�.❑Roof repairs insurance required.] t c. 152,§1(4),and we have no 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. 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. Iain an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Traverlers Policy#or Self-ins.Lic. #:1 H UB7C497865 n l Expiration Date:3/9/2015 Job Site Address: , u&s1 q_,��`) (i'(G� 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. Ido hereby cern der pains a I d pe aloes of perjury that the information provided above is true and correct. Signature: Date: Phone#: 781-245-9200 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..../ 9.. L.................... OF N°nrH,�O o? °9 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION gB�cMus� This certifies that � ; �`' ^Sk S .... ........................—............ has permission for gas installation j.!�i. ............�-:.�A............ . !�� in the buildings ofAex ,. :.......................................................................� ,2�ti North Andover Mass. ` Fee...3u�....Lic. No.— ��`�...... . ........................................................ Gl�j GAS INSPECTOR Check# 9558 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK MA DATE[�L2i/_L�t_ PERMIT# CITY [.N.ANDOVER 71 OWNER'S NAME[ JOBSITE ADDRESS BERRINGTON PLACE OWNER ADDRESS SAME TEL[978_376"8-219 --'---]FAX[ TYPE OR — PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL[j RESIDENTIALF CLEARLY NEW: RENOVATION:,[ j REPLACEMENT:C PLANS SUBMITTED: YES[] NOE,] APPLIANCES-1 FLOORS- BSM T—1 -2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER —----- j BOOSTER CONVERSION BURNER COOK STOVE Ii- j 'c 7- --jr- L DIRECT VENT HEATER _21 J I" DRYER FIREPLACE L FRYOLATOR --------- FURNACE ....ENERATOR GRILLE J INFRARED HEATER L D LABORATORY COCKS L L MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST 7-- UNIT HEATER IF _7=E UNVENTED ROOM HEATER 11-7,D __117- J -WATER HEATER -7: OTHER L AL Ar -if 111 N 7 111 L_77i F m2JE- L__J INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Dv OTHER TYPE INDEMNITY E BOND Fj OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 11 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER j� AGENT [-] 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 b ompliaqce with, i e i nt provision of the 4_ pli Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME[BRULICENSE#5735 '�IAATURE MP[77 J P lr-- # I PARTNERSHIP[]#E— MGF JGF E] LPGI F CORPORATION FL LLC L COMPANY NAME:�NEW ENGLAND GAS SYSTEMS INC___ ADDRESS 102 LOCUST ST CITY STATEEMLI Lin FAX 978 739-�902 CELL[ 508-8434724 a�Lska� ocor� f_]EMAILlInEg� 9�_ ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE,USE ONLY FINAL INSPECTION WAS S Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES i Be Commonvealth offfassm.0useftg . , f�.flee o,ffAvesfigafeons 600 Wash ngfon Xkeet Roston,HA 02111 uf -�tv��nr��gavtc�za NQrji.O,q'Co)A.pewafon)(hsuxa)coMUM:�uui�c�erc�t�ax��ac�ox�l�vc�x�czax�sl�'��%r��iox�,� Apph orrmallon P Nv.3'n e Q3rt8iue.s3jorgaaizationl .dWdual}: \ "��' ��5�� ��� �'�'`'S ^�- ►L - Addxegs' eyoixan exaplayer?L``kchtko appxoprzate3bim Typo ofproseet(reqwxea): 1 T am a emplOyex wqh__( 4• 11 Z afar a genexal con{xactax axad 6• ❑New cbnstaxdloa F employees( anc7(oxpax time).T have ned tho sub-contracfoxS 2.E1 j am.a solepropxzetor orparbau- listed on.the attached sheet:� `�. �RettlarTeling ship and`haveno•empZoyees 'phew sulr coldmetorshava 8. Demolit[on woxking foxrne in auy capacity. S. comp.irtsnxanco. 9. Brtzding addition [No workov?eomv.anmmpo 5. ❑ We axe a coxporatzorc anclits 10.[]Electricalrepaixs ax additions xecltzixed.� ofxcershave exercisedifiak 3.Q aznaho aeownexdoingallwork rig atoiexemptioxcPer M,91, x1.. ]plumbingrepa9xsoradditiom mysels. Ivwaxkexs'comp. c.152,§1(A},andwahavw-.o I-2,pRaofzepars insara�cexe ed. i employees.[NOworkexs' � � comp.insnraxtcere0uixed.� 13,�Otliex `gplicanitbaichecksbmg mus�alsa llouitheseetionbeldgtshov�ingtheirwbzkers'compensat[onpolicyinfom�atioz. "I g'omeov,+nersvrho submirthisa£fdaYitm���g'-beY��Q�g��orlcandtLenbireoufsideceafracforsmns�snbm�anev�aFCzdapi�indica�ngsizeh. xCon[racfnrs��a�o7xeekff�sbo�'?nnsLatfacheda�zaddiiionalsbeeEsho�ingrhenameo�thasu$-eoniraeforsand�tei�vtozkers'eomp.policyinformaiion, �l�11Ztt7Z el1Z Ji`Oy�N IZfIL`l5` lNOviC1lX2 Nr�IYI�eN 'CO�f21E 29 Z0Y1IYIS�Ik271Ce fa'Yt2]T E77 J�Oj12e5 BeZ0 i� ZeP�tC�j1 t jO l t'B �zfD�xnutiorz. �`\—� mrance CompanyN'ame;_ ?o7icy 0 or �C �c-► �,�� �� Ca f�tatefG' � oaeC�� Ol� rob bite Addxess; A faclracopy eft ewoxkexS'compensatiox€p ngcleclaxatronpage(showing•tltepolicy')am hOran.r1eukatzoxtcrate), yaiiure toseo o coverage as xe cludex Sectlom.25A of M c.152 can leadto the imposition of cximinaliSenaltzes of a doze-app to$1,500,00 andfox one-Year.xmpxiso� entx asweh.as cKpennities inthe fobr_.of`a IO2 RX ORDER and afime ofupto$250.00a&,yagainstfhvmolator: Eeadvisedthat acopy ofthisstatementmaybefoawaxcledtotheOf ueof• 7nvestigatloas of the DTt3.fox ihmaace coverage verification. -'do hexa r fy aw e�tlia '�`an' i2attie,90�per uy thalthe in orcin ia�a rrovir ec a ioY s z`iue and ca rec 'Sip Date: Q eiaZ ,Se,xjry, Vp gog ayrite in Azis area,to be eornpreted ry city or tart o,fleial Czar'or Fawn: feAmitl�icezase# fSM)agAuthorzty(circle 61101- 1. n0.x.)30arj of)aealth?.BuffdWg)Deparfineei. I CxtyROM Clerk 4.Blectrzcalympetor S.Vzmabzngiuspector 6.Other Information aj.d Instructions - - massachuseffs General Laws chapter 152 xeclaattes aliemployexs to provideworkexs'compems'U'lonfo:Mokemployees. Puxstrant to this sfafafa,an e�� loyee is defared au'...evaxy Parson.zi fhe sexVIC0 of wiftex under any comfract Glk May • e�xess ox•implied,oral or-wxiuen" At eWlctyq zs defncd as"anindividual,paztmexeMp,association,coxpoxatioxt q atherlegal entify,ox any,,wo ormora ofthe idxegoiagengaged inajoimtenferpxise,andincludingtltelegal xepxesenfativesofw4aceasedp plpyex,.orfire recaiver ox�isfee o.�an.indzvzdual,pazfaarship,association,ox o'iltexlegal ezltity,employing employees. �oweverthe owner of adp�ellinghousehavTmgnaimoxethanf�xee aparfinenfs audvrha resides i�.erein,or�ie ocaupaufof'the dWeliinglrouse of amafhex who employs persons to domraintenauce,conszctiorz orrepair work ort such dweUzmg b Ouse or oxtthegrounds orbuildirig appixxtenaizttlterefo shallnot acause ofsuch employment be deemed to be an employer.,, MGL chapter 152,§25C(5)also sfatas that"every sfa�e ar to cal XZcettszug agency shall withhold the issuance ox' renewal of a license or permit to operate a bminess or to construet bu9ldings fu M3 commonWeafth for away appltcank-vh o 1203 not p�o�uced.aceeptabXa evidence of cobapliattee w�t�.the`xnsux ante co�texage r��uixed:' Additionally,MC-d,chapter 152,§25C(7)sfafes"i alther the eommonwealthnox any ofits political subdivisions shall enfexinfo any eotttractfoxtitaperfoxmanee ofpubficwoxkuntilaccaptable evidence of compliance with titaimsuxance ' xeclttixemrenfso:��thisenaPtexhavebeextpxesenfedtathecooizacfzngautborzty." } AppEcanfs Pleas'ac0 out the workers'com* pansat on affidavit completely,by checking tho boxes that apply to your slfaaUon and,if iiaeessaty',supply snb-conixacfox(s)natme(s�,addxess(es)and�homenumbex(s)alomgwith their eextif"taate(s)of insurance; LimitedLiabiiity Companies(LLC)oxLvnifadLiabilityi'atfrtexships(�T ' vTithno employees ottiextha�tlZe Membexs oxpafters,arenotregdxedto canyvtoxkexs'compensatzoninsurance. 1-anUI C orLLP doeshave employees,apolicyisxequized. Be advkvdthattbis afdavitmaybembmittedto fftaDeparft amt of industrial Accidmfs for con m mon ofinsuramce covexage. Also be luxe to sign,and date the affidavi: ate afs davitshoufcf bexetnm6dtothecitycrtown t e"he�applicagonfoxthepezoritOrlieemseisbeingxecluesfed,xto tlreDepaitmentof IndastrialAeeidemis. ShoAldyouhaveanycluesfionszegaxdingtlielavrorziyouatexec edtaabtauta*orkexs' compansa'donpolicy,pleasecalt',�.e�7epaxbnemtattSienumberlistadbelov,: Selerlcomnamzesshoufdenfaxfheir self h=auce license number on the appxoPxiafe line. ' City or Tom Onciafs 'leasebesure Itatibea,�tdavitiscomplete audpxintedlegibly. ThoDapaz'.enthas movidadaspaceattbebottomz of&0&Mdavif foxymto;U out lathe event the OBice ofXnvestigatiomsiasto comtaetyouregarag the applicamt. please be-suxeta�Iliztthe�ei�t/1lcensenumbex�liicb.v+illbeusedasaze�iexextcemtam.herr ln.additiom,axtappltcamt thatznustsubmitmvfaviePezrait/lrcamse applications itt any givenyear,need only sal mil one, davitittdicatingturrent policy inzormaiion(ifnecessaxy)and under"d'ab,SitaAddress"thaappficatttshouldv�xite"alllocafionsin (city or towir)":A:copy o�"tlie a�davlu thatfias been o�ciallys=iainped orm.axitedbythe tits!oxtovrm.maybapxovidedt0ttle applzcantasproofthatavalidazu"davit•isan le or tvxePemlitsorlicenses. AmevTonzeach year.Whare alrorne owner orcitizem is abtaimingalicextise oxpeztnitnotxelatedta auybusitress oxcomunexcial venture (z.e,a doglkemse orlier�t to burn leaves eta.)saidpexson is XOTxeoxadto complete this amda: , The O.fdce():f Pnvestigations wo uld like to thatk you in advancafor youx caoPexatim and sh ouldna have any questions, please do natbesitdte to give us a calf. The Depax�xtent's address,telephone and faxnumbex. rho CQMMQllw.cam Or ,.USSar'Ame 1)4pa c)Et OfTUCTU*dal A ccX Ofca omi ve f i ort 6Q[ asn� Devised 5 26-D5 Fax 617.727-7749 _y r1 A COMMONWEALTH OF MASSkCHUSETCS; BanRa aF PLUMBERS AN'D GASF:ITTEftS j ISSUEST,HE FOLLOWfiVG LICENSEQ REGISTE tE15 AS A GAS 'CORPORATIO meg" J LiPINSKI `/ rr ENG4:AN13 CAS SYSTEMS INC M,GF,3 Z 102 LOCUST ST �1, ,t��;' Io I .. pR1VVER5 MA 01923 2204 0 01:; 16 21022 COMMONWEALTH OF MASSACHUSETTS BOAR©i3F PLUMBERS,:040 G`ASFJTTEI�S ISSUES THE FOLLOWINfi LICENSE t'tCENSED 'AS A MASTER GASFITTE T r; r E, BRUCE J LIPINSKI 102 LOWST STREET: VER 1}A 01923 2202102 Location )`b+3 4� 45- -6�0(�rou �o S-A- No. 9 r) S Date ' r),n 3 MOR71y TOWN OF NORTH ANDOVER 9 � S Certificate of Occupancy $ s' Mus ti<t' BuildinglFrame Permit Fee $ lea S Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 6 a S d T Check # 3 E 1 6359 ` Building Inspector unt-uu-cuul) ,uL lu.-t; nu vM10i1nlY0LlY a acnu! aio )Ir- aaou F. ui YK Issulab TrAP6(A.IkQet,O q �5- LOT 3 &WVW FOUMUMN ra.f. EY. • �as.�' mss• tN� N{l i .g9iei Fd1 "� BERRINGTON PLACE �L L�� FOUNDATION ��� � r it-4AW W DW7 MW a�nrr�eacrm LOCA TION PLAN T NO Wr aerrac�ANY WW arson ar , MM/ •f►lAMpfrArl CLIENT: JIM CARROLL w awna su Mw rye ww a yw ww M AMY ^NOW 00"Trow NO OMM AYoWAMV WW rc 00 C$IPr1=TM 13 WN AM WNL! WINo" w�r w aAM r Mu#a LWA770N: LOr 3 DERRINGTON PLACE ow ONMWWor ria o' jNria NORTH ANDOVER, MA. SCALE: f60' DATE: 5/5/03 CHRISTIANSEN &SERGI W., raa aer"o►st NAw"U^ arch M M%V"ro emu a Mmuca a mar an nwo.ra aia� Location �J 3 y `r-� r•"�w���v p1. No. y _ Date 14 -1 6-b_3 TOWN OF NORTH ANDOVER Of . o ,.tiG �`?'o • pA i' ` Certificate of Occupancy $ _ cMus Building/Frame/Frame Permit Fee $ s� t 9 1 O O Foundation Permit Fee $ Other Permit Fee $ TOTAL $ � Check # 35�� i6 3 u 4 /VI Aj t,/Building Inspector Inspector TOWN OF NORTH ANDOVER -BUILDINGDEPARTMENT APPLICATION TO CONSTRUCT Ma RBNOVAT OR.DEMOLM A ONE ORTWO FAMILY DWELLING .O BUILDING PERMIT NUMBER: n Q DATE ISSUED: SIGNATURE: Btlildi Commissioner ofl)iiil&w Date Z SECTION I-SITE INFORMATION 1.1 Propetty Address: 12 Asssuaa Map and'Paroel Number.. L67 3 41s_ Fx_r1^,''1�Si'I'On �I Q'(� MapN=bc PWW Number 1.3 rli%Infommtian: 1.4 hVe"Dimeado s: ZonmtzDi9& provased Use La Area Fcnnts Q 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Repind Provide ACM&W Provided Provided © O 1,-YW&wS"lyl,30I•.Q4 54) �� r4oadTaavlatomgtm: i.a Benerge.DiipoAlSystem PA& 0 t�aiwte 0 2aee� OmReFtoad2aae t}- At=wpl a N8ikD6p"-6y*m ❑ SECTION -PROPERTY OWNERSERIAUTHORUMD AGENT M. 2.1 Owner of Record No r4x AKAovee 6(p t ob �nL. ye-4k ? N. A., .A Name Print) Address Ear Service; wrI I clan+ s;>( Gl Telephone .��e• (o�ro-��a y 22 0tvnerafReumi NamePmtt Addrassfor Senice: Z M S' re Td hone SECTION 3-CONSTRUCTION SERVICES 3.1 Incensed Conshdction Supervisor: n Not ApplicaVe ❑ Li sec iwac oft S\a&or. ro l- 5 _ (, 3,r p 3 Limen Number 5 GfeAT q rg_f_. A A. Addrm Q -7- 19 - V 3 V lrw./`C. �1G b�7Z 6 Expiration Date adore Lo Tekooft. r a 3.3 Registered tiom Improvement Contractor Not Applicabk 0 0 Company Name m Registration Number Address Expimtion Date signatuie Totophove r ` r 'f E SECTION 4=WORKERS COMPENSATION(AL(;.L C 152§23c(6) Workers Compensation Imsumcc affidavit most be oaaplaod end submitted with.tlus ap wfion.imam to provide flus at6dmvit will malt in the denial otthe issuance of the bail. it. � . ` Sigmal atHdavit Attached Yes......F No....:,d SECTIONS De`seri tionoi _ Work td)w&aD ble) New Construction' Existing Burilding 0 Repair(s) 0 Alterations) 13 Addition -111, Accessory Bldg, 0 Demolition • 0 Other 0 Specify Brief Description of Proposed Wolk: cloin 15-124C fi TWO S ro ry- w cc Cil F6� 1�o�s� •.� 1-4, vee CiAIZ 9a(4gsti urtc�ar- �D �mfns '3 A--'h5 SECTION 6-TtSTIINATED CONSTRUCTION COSTS . hent Estimated Cost(Dollar)to be OI tUIO}�il. rk" CowleW by wiftit a0ficerd 1: Building (a)S .BaildingPennitFee Multiplier 2 •Electrical (b) EstimatedTotalCostof o 0 0 :Construction 3 Plumb _.. 000 Building Permit fee t,1 x(e) 4 blabanica l rACY. 000 / y 0� S ••Fire F1;LWuon .• 0C) _ K� 6 Total 142+3 571, 1 GO CkeekNuunber SECTION Ta OWNER AUTHORMTION TO BE COMPLETED WIMN OWNERS AGENT OR CONTRACTOR APPLIES FOR BU"ING PERMIT, as Owner/Authorized Agent of subject property Hereby authorize to act on My behitt mall matters relative to work author%W by this building permit aWication.- Agnatum of Owner Date SECTION 7b OWNER/AUTIIORIZED AGENTDECLARATION r �,oJ Ge s Corm l r Pies l z n+ ,as owner/Autharized 4ent of subject Property IiMbyoeclaee that the statements and information on the foregoing appllcation are true and aecurate,to,ft best of my knowledge and belief rt},, a.ApV@rRar.X;01 Core. C xy6s PN C.e►rra rr„� ►Om Q Ce..r.,dPA a, N/ 9 3 La?�03- Simature of Om&A t Date O.OF STORIES SIZE BASEMENT OR SLAB $SftC -k1 SIZE OF FLOOR TIMBERS I 2N. 41.4 3 l•O SPAN DIMIONS ORSIGLS ... x DIIvi NSIONS OF POST'S DZEMIONS OF GMDERS HEIGHT GF FOUNDATION THICKNESS. - - SIZE OF FOOTING X MATERIAL OF CHWEY WQ 19 BUILDING ON SOL D OR FILLED LAND IlXiO IS BUILDING CONNECTED TO NATURAL GAS.LINE S FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. ****nn**APPLICANT FILLS OUT THIS SECTION ***** APPLICANT ardaVet- RAl{- PHONE ` - 68 6-7 7 R Y LOCATION: Assessor's Map Number—K—) _ S Y PARCEL SUBDIVISION & cyl LOT(S) 3 U STREET &.4 r i,'l0r'1 ��}� ST.NUMBER 415 OF IAL USE ONLY RECOM ATI OF TOW A NTS: Z-1, lif L11 162z� C SERV7WbMINIbT8ADATE APPROVED DATE REJECTED COMMENTS Cr EIVED TO N R DATE APPROVED 0 9 2003 DATE REJECTED CO MENTS 2'ATH ANDMA FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS-SEWERIWATER CONNECTIONS _oOd DRIVE77&Z:7- FIRE DEPARTMENT L " RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm I 0!"/2.3/2_63 i9:_2 9786333!4. I"; ;tl'tit.F:;\J ],I`�'� NG4-z IJI AC014D CERTIFICATE OF LIAEILMY INSURANCE --�DATF(MMIDWYr i 03/2512003 PRODUCER ����+ THIS CERiIFICATF IS ISSUED AS A MATTER OF AFORMATION �_r� M.P. Roberts Insurance Agency Inc --TONLY AND CONPER3 NO !RIGHTS UPON THE CERTIFICATE HOLDER. THIS CFRTIFICATF. DOES NOT AMEND, EXTEND OR 1060 Osgood Street ALTER THE COVERAGE AFFORDED kJY THE PCLICIES BELOW, Norte Andover Mri 01645 978 663-8073 INSURERSAFFORDING COVERAGE :NaVRV NORTH ANDOVER REA,L-TX CORP. -..._ � I;I;:�;-,SR�,� WESTFFRN WORLD INSURANCE CO — !tN+iuFEFD: HANOVER rNSURANCE CO 100 .TOI-lNNYCILKZ ROAD _Ir,sUR_F c — — - .- -" •�'' Y__- NO. ANDOVER., MA 0I845 - N b UP-ER: lee rarrzrrtr»ztuea�t ��..�T/ ;�ir�4P.1�4 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 063503 Birthdate: 07/19/19,65 Expires: 07/19/2003 Tr.no: 12903 Restricted: 00 JAMES V CARROLL 12 PIPERS GLEN ANDOVER, MA 01810. Administrator i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Please Print Name: Location: City Phone am a homeowner performing all work myself. 01 am a sole proprietor and have no one working in any capacity ® 1 am an n emplo`y1er providing workers'compensation for my employees working on this job. Company name: 1 "�-In F�oVQ,z Core - Address (00 To�n ,-v Akg Roa city: firth Arlo vktL- I M19C S Phone#: 179 C� -La 14 Insurance Co. Gud&a Ti VO QAC@ Gr'oy Y) Policy# N(o VJ C ( ,0 3 le. Company name: Address City: Phone#: Insurance Co. Policv# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of($100.00)a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and penalties of perjury that the information provided above is true and correct. signature a,,,J� a CW.0 I��y,�o�.+�C Date 3 a 7(0 Printname 6i g—A eS A CAI-ro) l Phone# J79 6-77ol Official use only do not write in this area to be completed by city or town official' ❑ Building Dept []Check if immediate response is required Building Dept p Licensing Board E) Selectman's Office Contact pe►san: Phone#: E] Health Department Other FORM WORKMAN'S COMPENSATION GROWTH MANAGEMENT BYLAW EXEMPTION STATEMENT TOWN OF NORTH ANDOVERBUMDING DEPARTMENT This form shall be used to assist the Building Department in their determination of exemption under section S 7 6 of the Town of North A>idover Growth Management Bylaw. The applicant shal l provide all of the necessary information as requested below. cvp �7fy 1 Permit Applicant Property address Map/Parcel j 7-Q &�(0 ? 137 v/ Applicant's Phone Number Single Family Two Family I the undersigned applicant for the above property attest that the AWched building per-nut for which this lurm is cumplaad docs comply with the EXEMPTION section 8.7.6 ofthe Growth Management Bylaw.l also understand providing this lornh dues nut absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance ufthe building permit.Further 1 understand that my interpretation of the exemption status is subject to review by the Building Department and is only utlicially accepted when the building permit is issued. Based un section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot,in die building permit applieauon and associated attachments,complies with one or more ufthe following sections as indicated by a check mark. This is an application for a building permit for the czrlargement,restoration or reconstruction of a dwelling in :xislence as of the etTccuve date ofthis bylaw,provided that no additional residential runt is created. The lot(s)was I were created prior to May 6, 1996 and are exempt from die provisions of section 8.7 ohdhe Zoning Bylaw. This application is for dwelling units for low and or moderate income families or individuals,where all of the cuhhditwns ,)(S.7.6 are met and or represents dwelling units for senior residents,where occupancy of the units is resuictd to senior c7uzuis through a properly executed and recorded deed restnaiun runnuhg with the land.For purposes ofthis section"senior"shall mean persons over the age of 55. This application is pan of-a development project which voluntarily agreed to a minimum 40%permanent reduction in density(buildable lots)below the density permitted under zoning and feasible given the environmental conditions of the tract,with the surplus land equal to at least ten buildable acres and permanently designated as open space or farmland.The land to be preserved shall be protected 5-om developmem by an Agricultural Preservation Restriction,Conservation Restriction,dedication to the Town,or other similar mechanism approved by the planning board that will ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 and shall receive a one time exemption from the Planned Growth Rate and Development Sdieduling provisions for the purpose of constructing one single family dwelling unit on the parcel. J This application represents a la which is ready for a building permit(all other per -Lis from all other boards and commissions have been received and the project is in compliance with those perrruts),and the Development Schedule does not accommodate issuing a building permit in that year.One building permit will be issued per year per Development until such time as the development schedule accommodates issuing building permits. Applicant must submit an approved FORM U with this E\T VtPTiON. PLE.-kSE PROVIDE ANY AND ALL INFORMATION THAT WOULD ASSIST THE BUILDING DEPARTM NT IN MAKfNG A DETERMINATION THAT THIS APPLICATION IS ALLOWED UNDER ONE OR MORE OF THE ABOVE EXEMPTIONS. BY SIGNING BELOW I ATTEST TO THE ACCURACY OF THE INFORMATION PROVIDED AND THAT THE ATTACHED BUILDLNG PER'vtlT IS ALLOWED AN EXEMiPTION AS CITED ABOVE. FURTHER I UNDERSTAND THAT THE SUBiYUTTAL OF MISLEADING OR INACCURATE INFORMATION OR TILE CHECKING OFF OF A ABOVE EXE1vGYMON WHICH DOES NOT COMPLY,WHETHER DONE TO MY KNOWLEDGE OR NOT IS GROUNDS FOR REFUSAL BY THE BUILDING DEPARTMENT TO ISSUE A BUILDING PERMIT. APPLICANTS SIGNATURE DATE THUS FORM TO BE ATTACi-IED TO THE BUILDING PERMIT APPLICATION North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: (Locatio f Facility) r V Signature of Permit Applicant 3 aI a 3 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector r I I MAScheck COMPLIANCE REPORT I I Massachusetts Energy Code I Permit # I MAScheck Software Version 2.01 Release 3 I I Checked by/Date I I TITLE: PLAN NO. 3843 CITY: North Andover STATE: Massachusetts HDD: 6322 CONSTRUCTION TYPE: 1 or 2 Family, Detached HEATING SYSTEM TYPE: Other (Non-Electric Resistance) DATE: 3-6-2003 DATE OF PLANS: 3-5-03 PROJECT INFORMATION: COLONIAL HOUSE COMPANY INFORMATION: BRUNO ASSOC. 28 BERKELEY ROAD N. ANDOVER, MA 01845 COMPLIANCE: Passes Maximum UA = 805 Your Home = 423 Area or Cavity Cont. Glazing/Door Perimeter R-Value R-Value U-Value UA ------------------------------------------------------------------------------- CEILINGS 2239 30.0 30.0 38 WALLS: Wood Frame, 16" O.C. 3522 13.0 13.0 169 BSMT: Conc. 8.0' ht/7.0' bg/8.0' insul 2510 19.0 19.0 60 GLAZING: Windows or Doors 309 0.310 96 DOORS 192 0.310 60 HVAC EQUIPMENT: Furnace, 87.5 AFUE ------------------------------------------------------------------------------- COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The heating load for this building, and the cooling load if appropriate, has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125% of the design load as specified in Sections 780CMR 1310 and J4.4. Builder/Designer ! Date ' - ,r TITLE: PLAN NO. 3843 MAScheck INSPECTION CHECKLIST Massachusetts Energy Code MAScheck Software Version 2.01 Release 3 DATE: 3-6-2003 Bldg. l Dept. l Use I CEILINGS: [ ] I 1. R-30 + R-30 I Comments/Location I WALLS: [ l 1. Wood Frame, 16" O.C., R-13 + R-13 Comments/Location I BASEMENT WALLS: [ ] 1. Conc. 8.0' ht/7.0' bg/8.0' insul, R-19 cavity + R-0 continuous Comments/Location WINDOWS AND GLASS DOORS: [ ] 1. U-value: 0.31 For windows without labeled U-values, describe features: # Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments/Location I DOORS: [ ] I 1. U-value: 0.31 Comments/Location I 1 HVAC EQUIPMENT: [ ] I 1. Furnace, 87.5 AFUE or higher I Make and Model Number I I AIR LEAKAGE: [ l I Joints, penetrations, and all other such openings in the building I envelope that are sources of air leakage must be sealed. When I installed in the building envelope, recessed lighting fixtures I shall meet one of the following requirements: I 1. Type IC rated, manufactured with no penetrations between the I inside of the recessed fixture and ceiling cavity and sealed or I Basketed to prevent air leakage into the unconditioned space. 2. Type IC rated, in accordance with Standard ASTM E 283, with no I more than 2.0 cfm (0.944 L/s) air movement from the the I conditioned space to the ceiling cavity. The lighting fixture I shall have been tested at 75 PA or 1.57 lbs/ft2 pressure I difference and shall be labeled. I VAPOR RETARDER: [ ] I Required on the warm-in-winter side of all non-vented framed I ceilings, walls, and floors. I MATERIALS IDENTIFICATION: [ ] I Materials and equipment must be identified so that compliance can I be determined. Manufacturer manuals for all installed heating I and cooling equipment and service water heating equipment must be I provided. Insulation R-values, glazing U-values, and heating equipment efficiency must be clearly marked on the building plans I or specifications. I I DUCT INSULATION: [ ] I Ducts shall be insulated per Table J4.4.7.1. I DUCT CONSTRUCTION: [ ] ( All accessible joints, seams, and connections of supply and return I ductwork located outside conditioned space, including stud bays or I joist cavities/spaces used to transport air, shall be sealed using mastic and fibrous backing tape installed according to the manufacturer's installation instructions. Mesh tape may be omitted where gaps are less than 1/8 inch. Duct tape is not permitted. The HVAC system must provide a means for balancing air and water systems. l TEMPERATURE CONTROLS: [ ] Thermostats are required for each separate HVAC system. A manual or automatic means to partially restrict or shut off the heating I and/or cooling input to each zone or floor shall be provided. I I HVAC EQUIPMENT SIZING: [ ] I Rated output capacity of the heating/cooling system is I not greater than 125% of the design load as specified I in Sections 780CMR 1310 and J4.4. I SWIMMING POOLS: [ ] I All heated swimming pools must have an on/off heater switch and require a cover unless over 20% of the heating energy is from I non-depletable sources. Pool pumps require a time clock. I I HVAC PIPING INSULATION: [ ] I HVAC piping conveying fluids above 120 F or chilled fluids I below 55 F must be insulated to the following levels (in.) : I PIPE SIZES (in. ) I HEATING SYSTEMS: TEMP (F) 2" RUNOUTS 0-1" 1.25-2" 2.5-4" I Low pressure/temp. 201-250 1.0 1.5 1.5 2.0 Low temperature 120-200 0.5 1.0 1.0 1.5 I Steam condensate any 1.0 1.0 1.5 2.0 I COOLING SYSTEMS: Chilled water or 40-55 0.5 0.5 0.75 1.0 I refrigerant below 40 1.0 1.0 1.5 1.5 I CIRCULATING HOT WATER SYSTEMS: [ ] I Insulate circulating hot water pipes to the following levels (in. ) : I I PIPE SIZES (in. ) NON-CIRCULATING I CIRCULATING MAINS & RUNOUTS HEATED WATER TEMP (F) : RUNOUTS 0-1" I 0-1.25" 1.5-2.0" 2.0+" I 170-180 0.5 I 1.0 1.5 2.0 I 140-160 0.5 I 0.5 1.0 1.5 I 100-130 0.5 I 0.5 0.5 1.0 I ----NOTES TO FIELD (Building Department Use Only)------------------------- ar Name Location # G Check 3 Date 3 —Z�'� Note: of NaRTH�� TOWN OF NORTH ANDOVER o Q ^ Sewer Mitigation Fee $ * Sewer Connection Fee $ �ss�c►,us�` Water Connection Fee $ Meter Fee $ Zea Other $ RECEIPT NO. TOTAL $ �� ' r 11. 0 12 G Div:Public Wo s WHITE: Applicant CANARY: Department PINK: Treasurer GOLD: File f gp. ZONING DISTRICT: R 1 I � \J I I O W j �\\ MIN. LOT FRONTAGE 7, 120 175SFT. MIN. FRONT SETBACK = 30 FT. MIN. SIDE SETBACK = 30 FT. MIN. REAR SETBACK = 30 FT. `\ D�3 \ \ D-5'4Nz �, �\ �•� I \ EDGE OF \\ \ \\ 2 \ WETLANDS \ \ \ vI \\ D-51 \\ \\ I \ \ \ D-49 \ \ WI I D-50 i�� \ D-45 v. \ a; \ \ f (Z' 1 f / I \ \ D�46'172 \ \ \_/ / / 1 , 174 176— — �� \ \\ \ \\ \\ OT REAS = 8 7, 1 9 SF / M \\ •.\�' ` SO/ME\NTAT!4N 1\ I 1 •'�/ L/M1T OF 100 ''• \� \CON�`ROL . \ / • I f BUFFER ZONE LOT ' ILEACfiIING \ °°\\• TEST CHAR ER1 PI T 150' OFFSET ROM WETLANDS 66' 190 -2ROPOS>vED kOUSE I I \ L0� / TeP\FN - V93.0 �) I / GAR. FL�t = 1185.0 SEWER I b 1 SERVICE. �� �w QF M SCREEN ` I INV:=: 19px PORCH / j I 183 9 (MIN) 34' I I I S m / 192 I W � IL y 192-89 / ( I No.28895 55' a tea+ I A90, �FC,1S7E�'`������2 19L� a 1v 1 I Fss/ONAL�NG j3 I o SMH (/7 RIM = 189.61' I ,� \�� PROPOSED SITE PLAN I I INV 8" PVC = 182.08 SEWERSTUB / I FOR INV a 182.8' \ I I LOT ..J BERR/NGTON PLACE Cb I . I L=27./40' I /N a .:�• I I I I I � / 0, I NORTH ANDOVER, MASS. BERR/NGTO � I 7�' �, co II � I F `�9• As PREPARED FOR: P�,ACE a ' °6• JAMES CARROLL SCALE: 1" = 40' 7 DATE: FEBRUARY 6, 2003 SMH K8 RIM 188.79* VCCHRI S TIA NSEN k SERGI PROFESSIONAL ENGINEERS RS INV 8" PVC IN 181.58' INV 8" PVC OUT = 181.54 `� LAND SURVEYORS 160 SUMMER ST. HAVERHILL, MA 01830 TEL. 978-373-0310 © 2003 BY CHRIST/ANSEN 8 SERGI, INC. DWG. NO. 01.039012 ORTFi jTown � � 6 Andover o � ` � �..Y, . , No. Al 478 F- - �qLyy __ ori ndover, Mass., T O LAKE COC r�IC F+E wiCK CJ SSACHU`���� I T FOR EXCAVATION AND FOUNDATION THIS CERTIFIES THAT 0rAydpvtr� ':/� ........Coo ............. N R has permission to excavate and pour foundation at 4� ... lr�...... . 1A 04; ......a.oaf � 'y .... � ..►�. ..� ............ for the purpose r of..' .� �. , 8 1 ... �.�...VN! ,tt`....��t�u. .��'.... ...... � The person accepting this permit must return to the office of the Building Inspector a ceried plot plan show of building thereon before Foundation will be inspected. r) VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS The holder of this Foundation 'Permit proceeds at own risk and without UNLESS CONSTRUCTION STARTS assurance that a permit for entire building structure will be granted. �PS ...... ALLSJ �D) - .......................................... DUE R,Hi ILE P-Ek:`'a;;T ti _ d BUILDING INSPI;C-FOR CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number Date 11 a 5 "b 3 THIS CERTIFIES /TT / 40,-D THE BUILDING LOCATED ON �o -0 e n n y 4a� MAY BE OCCUPIED AS S//�) G /f- FA- vh c — /D RVOM5/ 3111- f3AfGis. Sal/ vvo er- IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO lEneV� Aryilouer K�P�1j.! 001- ISD —J 0 A;,tq C A(Cc S `/, Building Inspector .AL %J V V Ab AL Va 1 ..VAL dMbsA§6'ftOWv V a"... O 478 .lN. No. o�A�oC„;� Qy lover, Mass., -�/-ago 3 �! O'?A TE D P Pa W BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT../VOPA AM44evr BUILDING INSPECTOR .... _ Foundation .�(6�-�°���'�"��� has permission to erect.............. .. 4— buildings �~ Rough p �. .. ....... ......... on . 0....3. ....... ,�...... . . to be occupied ...VRt... ..... ��r •f` �liq! h��". "P 'rh' 3 �...... . .�....... .. e� �.N ....... ... provided that the person accepting this permit shall in every respect conform to the terms of the iplication on file in Final W-tkc' ,__ fI- S—c-3 this office, and to the provisions of the Codes and By-La s relating to t e Inspection, Alteration and Construction of Buildings in the Town of North Andover. �� ' el IF O PLUMBING INSPECTOR VIOLATION �--- of the zoning or Building Regulations 'Voids this Permit. PERMIT EXPIRES IN 6 MONTHS ��� UNLESS CONSTRUC ON T TS ELECTRICAL INSPECTOR Rough o`�r ...... ......... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough a Display in a Conspicuous Place on the Premises — Do Not Remove No Lathing or Dry Wall To Be Done FIME DEPAR N Until Inspected and Approved by the Building Inspector. Burner — Street No. Smoke Det. SEE REVERSE SIDE f��v� Town of North AndoverNORTH o�ts``D Building Department 3? tit.l a 0� 27 Charles Street o 2 North Andover,Massachusetts 01845 ' (978) 688-9545 Fax (978) 688-9542 ��SSAc Hus���y APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION ADDRESS L' 'Be cr in s k n N)ck- LOT NUMBER 3 SUBDIVISION DATE REQUEST FILED )0 DATE READY FOR INSPECTION C I a 3 a 3 TEN(10)DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN-OFF'S MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE-INSPECTION FEE OF TWENTY-FIVE($25.) DOLLARS WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. SIGNATURE OFFICIAL USE ONLY ROUTING D.P.W.—WATER ME DATE l/ k- D. W. MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TOT E INSPECTION QUEST DATE. IGNATU DPW AlrfrlV61Z NORTfy Town ofAndover O a'1 No. 4719 �- � � Al-11-8003 dover, Mass. A0RATED p`P�\ ;C� TS G� 4 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.. 0 ...../ Or.............Rtoob�.. ..4 p ..... Foundation has permission to erect.............. ........... buildingson .4. *f3. 03 0~ a .. . . . ..y ............... Rough ............ ' to be occupied as.I.Q.ro. ! r himney rh.�.. ..�i1...LM .�.. ...� i�.....1�.N. ....f' ...5....... . .�....... .. .... . provided that the person accepting this permit shall in every respect conform to the terms of the pplication on file in Final this office, and to the provisions of the Codes and By-Laws relating tInspection, Alteration and Construction of Buildings in the Town of North Andover. w3f? a/ I ote (001 S O � PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUC ON T TS ELECTRICAL INSPECTOR Rough . ...... ................ . ........ .. . Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Ratner Street No. SEE REVERSE SIDE Smoke Det. Date. ..... .. HORT4 O� TOWN OF NORTH ANDOVER • - PERMIT FOR GAS INSTALLATION s o 9 SACNUSEt�h This certifies that . .i�l�•� '�l�� . . :. ;���. 1 . . . . . . . . . . . has permission for gas installation in the buildings of . .r..x4uA<.1. !. . . . . . . . . . . . . . . . . . . . . . . . . . at .1 y" . . . . . !/.'!'r� ;�. . ... . . . . . . .. North Andover, Mass. Fee.)� Lic. No.l.'. ,).- : . . . . . . . . . . . . .L". c5. . -1.. . . . GAS INSPECTOR G Check# 4415 MASSACHUSETTS UNIFORM APPLICATON FOR PERM TO DO GAS FMI NG (Type or print) _.----Date -�: n- co 3 NORTH ANDOVER,MASSACHUSETTS Building Locations LEE � � �5 Permit# Amount Owner's Name CP(1(l c3t I Cci-�-Y ULA-1 v;:�s New❑ Renovation ❑ Replacement ❑ Plans Submitted ❑ s 00 W W W roa W d W O � a a w ri) 9x z o Fx a p ' c a O w 3 a a° A a EW O SUB-BASEM ENT t BASEMENT 1 1 IST. FLOOR I F- 2ND. FLOOR 3RD. FLOOR l 4TH . FLOOR FTH, FLOOR FLOOR FLOOR FLOOR (Print or ®one: Certificate Installing Company Name �rz�� �ivYv�ac �r�1QAC� il Corp Address X33 '/• ❑ Partner. wO-• Oiba(a Business Telephone q -1� • �1S'Z-"ISOI� ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter KA i`,w M k I1Q- INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ® No❑ Ifyou have checked yes,please indicate the type coverage by checking the appropriate box. Liability insurance policy © Other type of indemnity E] Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapjofthe Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent 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 installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 ofthe General Laws. By: Signature of Licensed Plumber Or Gras Fitter Title ❑ Plumber I I�z City/Town ❑ Gas Fitter License Number ® Master APPROVED(OFFICE USE ONLY) ❑ Journeyman