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HomeMy WebLinkAboutMiscellaneous - 46 FRANCIS STREET 4/30/2018 46 FRANCIS STREET 2101014.1014.=0000.0 Date. •?�,��/Z. . . 9407 V-— , TOWN OF NORTH ANDOVER ° PERMIT FOR PLUMBING w �,sSACHUs� This certifies that has permission to perform . . . .. . . . . . . . . . . . . . . . . . plumbing/in the buildings of . . . ?. . . . . . . . . . . . . . . . . . . . . . . . at . . . .Jl�t� . f'I f . . . . . . . . . . . . . . . . ,Mn7d�yer MaFee..32,5v.Lic. No..�dG. . !. . . . . . . i PLUMBING INPECTOR Check MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY ti►0 , (/U�-- ' % MA DATE l i PERMIT# 7 6, JOBSITE ADDRESS OWNER'S NAME Q 4 )V c POWNER ADDRESS I TELI JFAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL RESIDENTIAL®� PRINT CLEARLY NEW: RENOVATION:® REPLACEMENT:® PLANS SUBMITTED: YES N0[] FIXTURES Z 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 GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _ DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER -- FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: 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 a OTHER TYPE OF INDEMNITY © BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ® 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 tr nd a curate to urate !pe best ofmy knowledge and that all plumbing work and installations performed under the permit issued for this application will be in pl' nce ith II Pe ' ent pro ion of Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME S�'-t v�t kl, GT LICENSE# S116NATURE MPD JP©I CORPORATION# TS v-9 PARTNERSHIP©# LLC0 COMPANY NAME t d-Ef ADDRESS CITY U• l � -iL 04 J sft v! ZIP TEL (' b Q 8`Z0 FAX ��& d 73 EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes V THIS APPLICATION SERVES AS THE PERMIT FEE: $ PERMIT# PLAN REVIEW NOTES T The Commonwealth of Massachusetts Department of Industrial Accidents 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 LeLyibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I ' 6. 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 8. ❑Demolition workingfor me in an capacity. workers'comp.insurance. Y p tY• 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t 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 a're doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert under the pains and penalties ofperjury that the information provided above is true and correct. Simature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: r , 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 ofhire,- express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to 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 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston.,MIA 02111 Tel,,#61.7-727-4900 ext 406 or 1-877,MASSAI{E Revised 5-26-05 Fax#617-727-7749 wwwanass.govfdia. Date. S J.�?. . . . ..... . NORTH °f �r •' TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION y,SSACNU5E� This certifies that . . . . . . . . ./ . . . . has permission for gas installation in the buildings of . . . f'I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . 01; . . . . . . . . . . . . . . . .. North .Andover, Mass. wzFee.4?(99. Lic. No.903G. . . . �/. '�,��-�'�T. . . . . . GAS INSPECZ Check# ✓7 8 '139 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK lowCITY '�/l Cl - � MA DATE I— I j PERMIT# d" JOBSITE ADDRESS 'OWNER'S NAME OWNER ADDRESS _ S.✓f-ver,-C-n_ _ _ TEL TPYPPENOTR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL [ RESIDENTIAL CLEARLY NEW:Q RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES Q NO D APPLIANCES'l --FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER =j „---.,i r.._.j . .I= (^ 1 _I BOOSTER -��..._ CONVERSION BURNER .►[--I I -- -=� - - I __ —. :.__I __ J _._..� ._>._ _ __ I I .:__�I COOK STOVE ��I ! �.1 I I _T J( f . ,I _ - DIRECT VENT HEATER �.f DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER [ - C -� 1 LABORATORY COCKS MAKEUP AIR UNIT — OVEN - {- POOL HEATER ROOM/SPACE HEATER - ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER -- WATER HEATER _ OTHER ! t I �II INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO �J IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [f' OTHER TYPE INDEMNITY BOND __1 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 - J AGENT El SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are tr ac urate to the best of y knowle ge and that all plumbing work and installations performed under the permit issued for this application will be in co pli ce all Pe Hent prov' on of t Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME S�f-t�.t ' i' I,v. N _ LICENSE# 3(,N GNATURE _._. -- MP El MGF 0 JP D JGFL] LPGI© CORPORATION Q# ._J q71 PARTNERSHIP[ [# LLC E]#� COMPANY NAME: '�T' _ S l°�- e"1,44- 'e- ADDRESS CITY —nL). 6-A-14�1 C.� - _ — STATE `4 ZIP 4 ! Y TEL 1-22-L& _ G FAX -- CEL ��6-73JEMAIL M� The Commonwealth of Massachusetts Department of Indusfr al Accidents Office of 1-nvestigations ..600 Washington Street Boston, AM 02111 www mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le�bly• Name(Business/organizafion/Individual): - - Address: - -- -- -- .- _ -- — City/State/Zip: Phone#: Are yo�an employer?Check the appropriate box:1• a em to er with 4, Type of project(required):' P Y ❑ I am a general contractor and I employees(full and/or part-time).' have hired the sub-contractors 6 ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling ship and have no employees These subcontractors have 8. ❑D�moliton working for me in any capacity. workers'comp.insurance.[No workers'comp.insurance 5. ❑ We are a corporation and its9' ❑Bing addition required.] officers have exercised their 10•❑Electrical repairs or additions 3.E1.1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp, c. 152,§IN,and we have no insurance required.)t employees- 12.❑Roof repairs • [No workers' comp.insurance required.] 13.❑Other "�.ny applicant that thee:-box Pi must also IM out the section belov.•ehoe.rinb:heir wo fc;'c,•yeasat oa Policy o ation. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam 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 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 certify under the pains and penalties of periwy that the information provided above is true and correct Sienature: Date: Phone#: FFOther only. Do not write in this area, to be completed by city or town official n: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector son: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"'an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer.,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than-three apartments and who resides therein,or the occupant of the dwelling house' of another who employs.persons to do_maintenance,.construction or repair work on such dwelling-house - —-or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,'§25C(6)also states that"every state or local licensing'agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es) and phone number(s)along with their certificates)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. 116-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 trrowu that the a p hoas`.ion for the pcm&t.or license is being requested,not the D parnt:ent of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' - compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.. Please be sure to fill in the permit/license number which will be-used as a reference-number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business.or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would'like to thank you in advance f6r your cooperation and should you have any questions, please do nothesitate to give us a call. The Department's address,telephone and fax number. The Commonweal&of Massachusetts. Department of Industrial Accidents Offce of Investigations 60:0 Washington Street Boston,MA 02111 Tel. #617-7274900 ext 406 or 1-8.77 MhSSARE Fax#6.17-727-7749 Revised 5-26-OS uFwu,.mass..LYov/dia Location No. 3 C Date �� S Or MORTH TOWN OF NORTH ANDOVER ' % 41 ' Certificate of Occupancy $ MuSt<�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 0 r I I -C / Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. ) DATE ISSUED: ?F Q SIGNATURE: I✓q C Building Commissioner/InTector of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: t Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Re wired Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record a ✓ - l s �, il/cljQ Name(Prit) Address for Service Sig tore Telephone 0 2.2 Owner of Record: Name Print Address for Service: Z Signature Tele hone M SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: -- License Number 7r3 ������N �l �/,. ✓`��>D 'HT1 Address Expiraiio4 Date S rrare Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name 7 LI'-,3 6 7 't �ig.�GSC/ T Registration Number r Address / (® Expiratiog Date Sin ore Telephone SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. -Signed affidavit Attached Yes.......0 No.......0 SECTION 5 Description of Proposed Work check an applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolitiop., ❑ Other ❑ Specify Brief Desch' tion of Proposed Work: t SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building --' (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) ^t 4 Mechanical HVAC V^�J �- 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONT13ACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property C. Hereby au orize /��C 61 �'�!ti ��/il� �� to act on , My behalf,in all matters relative-to wor ut zed by this building permit application. l - -Signature of Owner Date f SECTION 7b OWNEWAUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name 7 Signature of O er/A ent Dat NO. OF STORIESSIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS 1ST 2 ND 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DRAENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 11/0912000 10:38 978`587-0149 INTERNET INSURANCE PAGE 01 • A AGCERTIFICATE OF LIABILITY INSURANCE 11/09/2000 pRppuppl; THIS CERTIFICATE ISSUED AS A NIA OF INFORMATION INTiiilidT INBVRI cx AamucT, SMC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 522 CR=CD�RING ROAD ALTER THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NORTH ANI)MR, MA 01845 INSURERS AFFORDING COVERAGE INURED INsma A. BAvgR$ pROPLRTT AND CASDALTT INSURANC;a ALL TR19)ER ONS ROOF/PD:BT to Pam= WMAER0: , 70 JBVTRJ N STRUT INauaEaC: INSURER D: SCUM ANDOV= DOL 01545- INSURER£: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDINO 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS. 1 R TYPE OF iNBDR;ANCE FOUCY NUMBER POLICY¢ UNITS OENERALI.IADILRY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILF)Y fl AMAGE Ote9ro CIAIAS MARE ]3 OCCUR MED EXp fAny or* S ❑ w PERSONAL&ADV INJURY : OENERALAGGREGATE S GENT.AO011EOATE LVAIT APPLIES PER: PRODUCTS-COMPsOP AGG S POLICY PR0 LOC AUTOMp AUT LUIBIU7YANY (ES 60000) 81lKILE LiA(R : ALL OWNED AUTOS f BODILY INA RY , SCHEDULED AUT06 I (Pa woo) HIRED AUTOS 11100ILY INJURY S NON-OWNED AUTOS (PM wad") PROPERTY( oomm) E S "PAU UABIUTY AI/YO ONLY-EA ACCIDENT t ANYAUTO OTR THAN EA ACC i AU, ONLY: AGG i ow.u/UANLIIY� EACH OCCURRENCE I OCCUR IU;CLAIMBMADE i AGGREGATE $ t � DEDUCTIBLE i $ RETENTION S S VWME142 U COMPENSATION AND EMPWYAMUTY AR0000776 11/09/2000111/D9/2001 I EACH ACCIDENT i 100,000 E.L.DISEASE•EAENPLOVE i 100,000 E•L.DISEASE•PO CYL SCO,000 OT'NER OE>iCRIPTION Of OPERATIONSILOCATtONSIVEHICLtSUCLUS)ON3 ADM 9Y I!NDORBEMENTISPECIAL FROWUMM CERTIFICATE MOLDER AD oNALINsuREa INSURER LETTER-. CANCELLATION SHOULD ANY OP THE ABOVE CEBCIImEO pOLIC1EB SE CANCELLED BEIORE THE VwIRATION DATE TNEREOi,THE IMMO NlsA9R WILL ENDEAVOR TO M=0. 010 LAYS*RITTEN , NOTICE 70'M CERTWWATE HOLOW NAMED TO TIS LEFT,BUT PAtLURE To 00 SO SHAI£ IMPOSE NO OKAIATION OR N=B0.1TY OF ANY HIND UPON THE INSURER,FT$AGENTS OR REPREBENTArnEB. TAW4 AW ACORD 263(7!87) OACORD CORPORATION 1958 w BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 0342 Birthdate: 09/30/1945 1 Expires:09/30/2001 Tr,no: 5943 Restricted To: 00 NORMAN GAY 70 JEFFERSON ST N ANDOVER, MA 01845 Administrator i q6 '11"__.. & Commercial Ro • • 'd �es` Licensed&Insured �� • Roof Leak Experts • I A (978)794-3883 • 1-800-WAIT-4-US- MMU Proposal Submitted To Phone Date Street Job Name City,State&Zip Code _ Job Location Job Phone We Propose hereby to furnish and labor in accordance with specifications below,for the sum of: 6* Dollars All material is guaranteed to be as specified.All wdrk to be completed.in a workmanlike Authorized manner according to standard practices.Any alteration or deviation from specifications be- Signature: low involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.All agreements contingent upon strikes,accidents NOTE:This proposal be or delays beyond our control,Owner to cavy fire,tornado and other necessary insurance. Our workers are fully covered by Workmen's Compensation Insurance. withdrawn by us if not accepted within days. We hereby submit specifications and estimates for: e 7- NORTH own of Andover No. A 0 dover, Mass., L COCHICHEWICK '-�ATED C) Is, BOARD OF HEALTH Food/Kitchen PERMIT T .. D . Septic System BUILDING INSPECTOR ................................................................................................ THIS CERTIFIES THAT......... .............. F Foundation has permission to erect....O.W.Y.1............... buildings on ................... ............. .............. 4-........... Rough .. ............. ... . ... co V .Per Chimney to be occupied as........ ......A.......................................... ..................................................... t t provided that the person accepting i. permit shall in every respect,conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relal:117� to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. /C/ / .� / Y SayPLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION ST TS ELECTRICAL INSPECTOR Itf a ( Rough .................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a~ Conspicuous Place- an the Premises — Do Not Remove- Final No Lathing or. Dry Wall To. He. Done FIRE DEPARTMENT Until inspected and Approved by the Building Inspector.. earner L Street No. SEE -REVERSE SIDE- Smoke Det. Location Nvj No. Date 6 MpRTM TOWN OF NORTH ANDOVER O'�•.aa y 1'ti'O Certificate of Occupancy $ # Building/Frame Permit Fee $ AS `r0 • e a ;�s "°''•t�' Foundation Permit Fee $ s.KHus� CL Other Permit Fee $ Sewer Connection Fee $ Id Water Connection Fee $ . TOTAL $ � Building ector " ~ " Div. Public Works PERMIT NO. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 + MAP h40. LOT NO. V Q- 2 RECORD OF OWNERSHIP ;DATE BOOK ;PAGE ZONE I SUB DIV. LOT NO. I — LOCATION ^ < PURPOSE OF BUILDING 0 E' " OWNER'S NAME � 4 NO. OF STORIES SIZE OWNER'S ADDRESS s S BASEMENT OR SLAB - ARCHITECT'S NAME O ( SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME /4- l tee 69-4 .0 , ^- 'C©e C-�u l" SPAN --- DISTANCE TO NEAREST BUILDING � DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS f DISTANCE FROM LOT LINES-SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION Vol MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST /.2 "p'-: C f> PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. PICGE 2 FILL OUT SECTIONS f - 12 EST. BLDG. COBT PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY • ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE F ED !N BUILDING INBP[CTOR SIGNATURE OF OW ER OR AUTHORIZED AGENT torl— dp / F E E OWNER TEL.# (O / PERMIT GRANTED CONTR.TEL.k 6 p -' '�19 CONTR.LIC. T V l �Ct H.I.C.# 1077 G(c BUILDING RECORD ' 1 OCCUPANCY 12 SINGLE FAMILY �OFF ORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY ICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION —I 8 INTERIOR FINISH CONCRETE B I 2 13 CONCRETE BL K. PINE BRICK OR STONE HARDW D PIERS PLASTER _ ORY VJALL _ UNFIN. 3 BASEMENT 11 AREA FULL FIN. B M AREA _ V, 1/2 V. FIN. ATTIC AREA _ NO B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN r 4 WALLS 11 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARD"JD _ ASBESTOS SIDING _ COMMC:N VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY _ STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. 6 FLOOR I_ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH Q FIX.) _ GAMBRELMANSARD TOILET RM. I2 FIX.) FLAT A SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC lit 13rd I NO HEATING J I rA -= 'All 4 BSc i 1 / 2-- 1� elOr } HOME IMPROVEMENT CONTRACTORS REGISTRATION ' Board of Building Regulations and Standards One Ashburton Place -- Room 1.301 Foston , Massachusetts 02108 HOME IMPROVEMENT CONTRACTOR Registration 109740 Expiration 09/24!98 Type — DBA HOME IMPROVEMENT CONTRACTOR Registration 109140 ALLEN CONSTRUCTION CO Type - D8A ROBERT W . ALLEN Expiration 09/24/98 86 ANDOVER ST N ANDOVER MA 01845 ALLEN CONSTRUCTION CO 7f BERT W. ALLEN ADMINISTRATOR 6 ANDOVER ST N ANDOVER MA 01845 PAID nrp(. Trir(,, ^r p!ir Tr' ^r.rr-r, ...i i_ ,;R i ..__N T �O C' i' 1!;. ncS pt lf-,'T � n� ^.r r n1 fit' FEB 21 95 �g aOSTON, UA 02 108-1;113 (:ONSTRUCTION SUPE1M,)IS0R I^TCrNS)F " D.P.S• Number: Expires= B.irthdat:e - CS 0409.'_7 05/04/1997 05/04/1957 is 4 s t r J_c t e d TO: 00 ROBERT lel ALLEN Detach bottom, fold sign on 86 ANDOVER ST back, and laminate iic:Pnse ward. N ANDOVER, 11A 01345 Keep top for receipt and change of address notification. �. �le [9arzrraancuealf�2 a�,.GGccrUucficc.tv/,G.' Restri:ted fo: jl DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISH '_10E!t1E 00 - "gone J Nnaher E%DiieS; B1 iid•i`e' 1A. - lIasonrY CS 04092? 05/04/1991 15/N/19�7 ANOCVER ST it ,,NDOV R, 'A 31111� NORTH F Townn ofdover O .. I.M... No.3 as rt dower, Mass., R"lSr. 14- 199 COCMICMEwICK AORATED SF BOARD OF HEALTH Food/Kitchen -PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT .................L>O.O h�!>.... G'r ..^L ,t` !..... !�!>5►.T.. !.... ... Foundation has permission to Mwt............C — - 4 4....F .14,. .I.�..............�R... 7$77w p � ... ...................... buildings on ....�.... t C . ....... Rough to be occupied as .............. �e���. . .... 370.!p.....ovotm .. 1e�.... �17i2...... chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLES CONSTRUCTION STARTS ELECTRICAL INSPECTOR • Rough ,. Service jemou4'r- tz%tvd.� OL &-Zs T7A ........................................ ..................BUILDING INSPECTOR T Final 1z.00 F144 Occupancy Permit Required to Occupy Building I GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. Smoke Det. Date...... . J . ...... ............................ RTM TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION BsgCHUS� Il, r . .�.� ✓ ` .o This certifies that .........................�........................... 'A .t has permission forgas installation(.'...( i ..��' .�� r� 0 .....�.......... in �e buildings of... J ? ..- ................. at..,...............{.`f...................... .................... .... j, North Andover, Mass. Fee(P.D.:170 ... Lic. No. .2.0 Z.�7.... (...f...' ................................................. GASINSPECTOR Check# 114 7 c P MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY _ _fly c,.�e✓ ro � MA DATE PERMIT �i -- x JOBSITEADDRESSOWNER'SNAME w(1_ OWNERADDRESS .__ — def TE -_3 go JFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL D RESIDENTIAL 53 PRINT CLEARLY NEIN:EI- RENOVATION: REPLACEMENT:® PLANS SUBMITTED: YES 0 NOO APPLIANCES-1 FLOORS- BSM 1 2 3 4 5 8 7 8 9 10 1f 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER _� J _ _( J _ .J I J DRYER - FIREPLACE FRYOLATOR j FURNACE -- ._ . I �— I J GENERATOR GRILLE INFRARED HEATER ..-_-- LABORATORY COCKS MAKEUP AIR UNIT .. ._.___ OVEN l _ POOL HEATER J ..__u.. _. _ _ _ ( I _J _ 1 ._ __ .) f . ROOM/SPACE HEATER ROOF TOP UNIT EST NIT HEATER _...... 1 _,..__..i ....._...a .__._.,I - =---1 -. . UNVENTED ROOM HEATER =. _... . _... I ...-..._ ..__._..1 .-_ _. _ _.___ _. :,_ _.,,... .► ..__- _._...... WATER HEATER OTHERI IT - INSURANCE COVERAGE I�ave a current Jlablliiy nsurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES ONO 0 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ( BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Ma s y�husetts General laws,and�thatinyslgnafure on this permit application waives this requirement. CHECK ONE ONLY: OWNER [0 AGENT 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME [Zo LICENSE# d SIGNATURE MP 0 MGF[s,;a JP 01 JGF LPGI CORPORATION®# .. PARTNERSHIPS(#=LLC[:_I#F---J COMPANY NAME:_Rb-.6 _. PzG,- -- / �----- ADDRESS -... ..0_F1we�...�._._. CITY v c.-- - _. .. . . T .STATERjjZIP I p�= EL FAXL5 0�1 EMAIL ��CELL —.fpa� The Commonwealth of fassachuyetts -• Department of fadushiccrAccidents kvOffice of Invesagations 600 Washington Street Boston,MA 02111 www.massg'ov/dia Workers, Compensationb1suxance AffZc�avit:BrgdexslContrcacfoxslElectxiezansI�'lumbe�xs Please�'x�nt I� Name(Business/Organtzaflonftdividual.): p P�✓-F `�+�h S A ,ss: 8'D r l o y ei c e_ u �� � Cary/State/Zip: e� 1 v r M O , b l 7 Phone#: (required): (re f pq Are you an employer?Check the appropriate b ox: Type oF 4, Q T am.a general contractor and T 6. Q New construction .[[ T am a employer with have hixedthe sub-contractors employees(full.and/or part ti g).• wed on the atEached sheet.r 7. ❑Remodeling 2,[ T am a sole proprietor or partner ship and'have no employees These sub-contractors have S. [[Demolition workers'comp.insurance. 9. ❑Building addition working forma in any capacity. [No workers' comp.jnsurance 5. Q we are a corporation audits 10,Q Electricalxepairs or additions required.? officers have exexeisedtheir right of exemption per MGL 1.1.1]Plumbmgrepairs or additions 3.E] X am a homeowner doing all work an l we insurancerhave no 12.Q Roof repairs myself.insurance r equired.] c. 152,§1(4),workers comp. employees.PTO workers' 13,A Other comp.insurance required.] xAny applicant that checks box#f mustaiso fill outthe section below showing their workers'compensationpolicy information. 7 gomeowners who submit this affidavit indicatingthey dre doing altwork and then hire outside contractors must submit anew affidavit indicating such. xContractors that cb eckthis box mast aifached an additional sheet showing the name ofthe sub-confractors andtheir workers'comp.policy information. ,am an employer that isproviding workers'compensation hisurance for my employees: Below is the policy and jolt site information. 11mance Company Name' Expiration Date: Policy#or Self-ins.Lie.#: City/State/Zip: Job Site Address: - ensation-poliey declaration page(showing the policy number and expiration date). Attach a Copy of the workers'comp Failure to secure coverage as requiredfine as wellaer Section 25A of sZc vilpenaltiOL o.152 es in the,£oxinlead to e imposition STOP WORSE ORDER and a fine flue up to$1,500.00 and/or one�year gator. , ofup to$250.00 a day against the violator. Be advised that a copy of fhis statement may be forwarded to the Office-of Investigations of the DTA.for insurance coverage verification. X do hereby cest�Wider the pains arad penalties ofpeiiury Haat Me infbrmadon provided akoye is true and correct Siun.ature 6 r2L Date• — Phone#: - 9 D r7 3 Official use only. Do not write in this area,to be completed by city Or town offlciaL City or Tawe: Permit/License# Issuing Authority(circle one): x.Board of health ?.BuildingDepartment 3.City/Tows.Clerk 4.Electrical inspector 5.Plumbiagl'nspector 6.Other - Phone 9. Infoirmation 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 orimplied,oral orwritten:' An employe. is defined as"an individual,partnership,association,corporation or other legal entity,or any two or mare of the foregoing engaged in a joint enterprise,and including the Iegalrepresentatives of a•deceased employer,or the receiver or trustee of as fudividual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more thm three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states`Neither the commonwealth nor any of its political mbid iops shall enter into any contract fbr the performance of public wont 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 certificates)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,apolicyis required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents fo;confumation 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 ifyou 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 tho appropriate line. ` City or Town Officials Please be sure that the affidavit iscomplete and priutedlegibly. The Depaxtmenthasprovided aspace atthebottom 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 Monnation(ifnecessary)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 fila for fatuxe permits or licenses. Anew affidavit must be filled out each year.Where ahome owner or citizen is obtaining a license ox permitnot related to any business or commercial venture (i.e.a dog license orpermit to burn leaves etc)siddperson is NOTrequired to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any gaesfions, please do not hesitate to give us a call. The Department's address,telephone and fax number. Tho CQ On-W-aalth of Mamac hmett Dapar(mD,ut QMftfdal.Acoldwtg Oxce Oflaveaugat(Ma 6Q Wa6how fte,ft �Q�tonx .QRZ Z� Ta,#617-727_4900 ext 40,6 or 1-87 ,MMSM Revised 5-26-05a 617"727"7749 w�.�aSs,g4v��ia 6 v COMMONWEALTH OF MASSACHUSETTS . . o 0 BOARD OF PLUMBER'S AN'0 6ASFITTERS . ISSUES THE FOLLOWING' LICENSE ' LICENSED As A JOURNEYMAN PLUMBER. ROBERT B BURNS v;v ul 80 FLORENCE AVE �^Z W TEWKSBURY ., . .MA 01876-4416 zozr7'; o /off/a6 214794 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER Mass. Date 1�3uilding Location 4UFir0r s V t S Permit # J c� ' Owners Name -'77-)A?Xje- �Z New '7 Renovation D Replacement Plans Submitted 0 FIXTURES Y W N LUm C) U ca f' x N LU CC tu d m H Y W W O O a � W 4 r in y W � x x o w as u 0 ; z a x W CCC: p a w t' m v x t:11 Cr. F- 2 y W w t7 ? k r W j t- w z d W < a ►' }- rn m = o z � o rr� x Q ,u > C W 2 a r- Q a x O 0 z U. o o -A v � > Q no. 1W- o SUA—BSt.IT. BASEMENT IST FLOOR 2MD FLOOR G1 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR (Print or Type) / Check one: Certificate Installing Company Name dQr� P� -F M4-( Q Corp. Address ���jl &Q �nl -- -S-( I Partner. 00- ►.- c�ti-r'r Alf�4 Firm/Co. Business Telephone: l�M ^x-33 (4 Name of Licensed Plumber or Gas Fitter Insurance Coverage_: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Q Bond Ej 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 coverages. Signature of owner/agent of property Owner 17 Agent 0 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 hnstaUations petfomied under Permit issued for this spplicatio in compliance with tl t provisions of tho Massachusetts Slate Cas Code and Chapter 142 of tho General Laws. B TYPE LICENSE By A-.)* Plumber Title Gasfitter Signat of Licensed City/Town: Master Plumb or Gasfitter Journeyman ) APPROVED (OFFICE USE ONLY) icense Number Date.. ..... ..... . ........ O NRTH Of �p ,s,,tia TOWN OF NORTH ANDOVER FO? y` a LD PERMIT FOR GAS INSTALLATION j SSACHUSE This certifies that . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . .. . . . . . .. . . . . . . . . . . . . . in the buildings of . . . . . , :.< . . . ._. . . . . . . . . . . . . . . . . . . . . . . . . at . .. . . . . . . . ... .. . . .. . . . . . . . . . . . . . . , . . ., North Andover, Mass. Fee. . . . . . . . . Lic. No.. . . .. . . ... . . . . . .. . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD:File