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HomeMy WebLinkAboutMiscellaneous - 465 CHESTNUT STREET 4/30/2018 (2) 465 CHESTNUT STREET 2101096.C-0030-0000.0 Date...52.....�...�..................... A � W�1 Y 0 00A A4 o - " � TOWN OF NORTH ANDOVER 9 PERMIT FOR GAS INSTALLATION SBACMUg� This certifies that ............. ..---..... ✓U c leS has permission for gas installation inthe buildings of...................... f W70................................................................... at......?.�O 7��•a ,., North Andover, Mass. Fee .... ...-.......Lic. No .......................... GAS INSPECTOR Check#��� 9.306 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ?I ` �U � � —_ CITY _�Q n ' n � -.�' �-� MA DATE , PERMIT# JOBSITE ADDRESS L�p OWNER'S NAME OWNER ADDRESS TE FAX TYPE OR OCCUPANCYTYPE COMMERCIAL Q EDUCATIONAL RESIDENTIAL[, PRINT CLEARLY NEW:El. RENOVATION:L1 REPLACEMENT:® PLANS SUBMITTED: YES Ej NO 0 APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER . 1 _ . IL � . l BOOSTER CONVERSION BURNER COOKSTOVE DIRECT VENT HEATER �-1 I-- - ,__.._ . -.... DRYER - FIREPLACE FRYOLATOR FURNACE1 GENERATORI- GRILLE .r INFRARED HEATER LABORATORY COCKS I (� 1..._..._ --I MAKEUP AIR UNIT OVEN POOL HEATERI ROOM/SPACE HEATER ROOF TOP UNIT I TEST UNIT HEATER A UNYENTED ROOM H ATER I l WATER HEATER OTHER _( I [-� - I -- INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES _ NO 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE E BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY — OTHER TYPE INDEMNITY Ej 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 El AGENT O SIGNATURE OF OWNER OR AGENT 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 co lance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE# /U SIGNATURE MP 0 MGF Fj JP® JGF LPG[ CORPORATION PARTNERSHIP®#©LLC®# COMPANY NAME: ADDRESS CITY - cU/P�1 _ STATE ZIP TEL J-1 O _ FAX CELL EMAIL ,. s 1 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPE TI NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES w w f f 2 The Commonwealth of Massdchusefts Department of IndustrialAceidents Office of Investigations IN 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print Legibly Name(Business/Organization/Individual): �iq 1�1 rS Address: Tl 41_►-g�,�CAftk( c A.g City/State/Zip:��w ren c-e A4-,4 6(K q3 Phone#: Are u an employer?Chee th appropriate box: Type of project(required): 1. I am a employer with W v 4. ❑ 1 am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 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.]i employees.[No workers' 13.2r0ther r7 comp.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 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 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.Lii/c..#: ( Expiration Date: Job Site Address: 21�f`5 CAST I U r City/State/Zip: N6 MA 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 tryy under th ins and penalties of perjury that the information provided above is true and correct. Si afore: Date: c.5 a1+1� 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#: 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 employes." MGL chapter 152,§25C(6)also states that"every state or lo'eal 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 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. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to 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 for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Dopartmat of ladustrial Accidents Office of luVestigations 600 Washington.Street Boston}MA,021 It Tel,#617-727-4900 ext 406 or 1-877:"SAFE Revised 5-26-05 Fax 4 61.7-727-7749 v�vvt�axAass,go�Cd�a 4� COMMONWEALTH OF MASSACHUSETTS -DIVISIONOF PROFESSIONAL eaAfm OF I PLUMBERS. AND GAS Fl,TTERS � I ISSUES THE FOLLOWING '`LICENSE L tCEN .ED AS AN LP .GAS I NSTWGIL R .:.. THOMAS A BONACC(1RS I y W 1 .0.. PAMELA LN RAYMoN N03077 15I. 48 �. toz2 `:.. o5%ot/t>b, 216go4 �1 . i Sketch checklist: Site -k Checklist for Sketch 0 All Windows that apply 0 Tank to House o All Doors that apply 0 Scored S.�_ o Leech Bed 0 All Sources of Ig c ftegulatos o Driveway o Second Stage Regulator to-M-St s b Sec0r�o'.S«�ao 0 Temporary Tank Location o All Measurements �a Regulator o Only I temporary tanb to Doors 0 Tank to Windows 0 second Stage Regulator rneeded/atlowed o Tank to Doors to Sources of agnition 0 2 temperary tanks 0 Tank to all Property Lines 0 Second Stage Regulator needed 0 Tank to Sources of to:'ank{including Ignition ten;PorarY Mlk8 where applicable) Comments (notes from tec °clan o oi4fce�e /off f 6 3 Q2 e I:! s �� ®fce Notes/Coarespondence(custoMers/technici s/other customers): -------------- Sitewalk Drawi • —___ `1 I IG i a 1 Zr 0 R --..noon�uuacus Lieurrcar uoae Amenaments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c.166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. ` Permits shall-be limited as to the time of ongoing construction activity,and may be-deemed-by.the-Inspector_of_Wires abandoned.and_invalid_if he—_. ._ or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending"through August 15,2012. . '00 Rule 8—Permit/Date Closed: " ***Note:Reapply for new per ,t ❑Permit Extension Act—Permit/Date Closed: '10009 Date......y ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING WFIA r- *�,MACHUSEt This certifies that ........... .......... . ........ 6 his permission to perform ......IAP 0 �alv-C-". ............... wiring in the building of.......... v....................................................... at............ 5j- ................................. ......North Andover,Mass. Fee..753— Lic.No.2.3/1,;X....... ....... Check # -Commonwealth of Massachusetts official Use Only Department of Fire Services Permit No. �PL L BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked _ [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WO All work to be performed in accordance with the Massachu§etts Electrical Code(MEC),527 CMR 12.00 R (PLEASE PRINT WINK OR TYPEALL FORMATION) Date: City or Town of: NORTH ANDOVER By this application the undersigned ives notice of his or her intention to perform the electrical ctoof Wires: below. Location(Street&Number) Y t�J� ��� - 1 Owner or Tenant 9"It 1-1 Owner's Address Telephone No. 692 - � y Is this permit in conjunctio with a building permit? Yes Purpose of Building N0 (Check Appropriate Box) Utility Authorization No. Existing Service,_ Amps C -�d�olts Overhead Undgrd❑ No.of Meters New Service Amps / __Volts Overhead Number of Feeders and Ampacity Undgrd ❑ No.of Meters Location and Nature of Proposed Electrical Work: r- 5-64 Com letion of the following table a be waived Ly he Ins ector of Wires. No.of Recessed Luminaires No.of Ceil:Sus . No.of p (Paddle)Fans Transformers Total No.of Luminaire Outlets No.of Hot Tubs KVA Generators KVA. No.of Luminaires Swimming pool Above ❑ In- o.o mergency Ig ting No.of Receptacle Outlets rnd. rnd. ❑ Batter Units ti No,of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and No.of Ranges No.of Air Cond. Initiatin Devices Total Tons No.of AlertingDevices No.of Waste Disposers Heat Pump Number Toms KW Totals: •• ....................... No.of Self-Contained No.of DishwashersDetection/Alertin Devices Space/Area Heating KW Local❑ Municipal No.of Dryers Connection ❑ Other Y Heating Appliances KW Security Systems:x No.of Water No.of No.of Devices or Equivalent Heaters KW No.of ' Data Wiring- Si ns Ballasts No.of Dvices or E uivalent No.Hydromassage Bathtubs No.of MotorsTotal Telecommunications Wiring: HP OTHER: No.of Devices or Equivalent Estimated Value of Electrical Work: QD �-Attach additional detail if desired,or as required by the Inspector of Wires. Work to Start: (When required by municipal policy.) V Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pain and penalties of perjury,that the informatto n this application is true and complete. FIRM NAME: jz -' G �-p Licensee: ,�- LIC.NO.: 3� CIL c Signature LIC.NO.: (Ifapplicabl enter"ex t"in the/ice number line Address: � 0 3 f9 3 3 Bus.Tel.No.•G1- *Per M.G. c. 147,s.57-61,security work requires Department of Public Safety"S"License: Alt.Lie.No. � OWNER'S INSURANCE WAIVER:I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$ ELECTRICAL PERMIT NO.� INSPECTION REPORT: ELECTRICAL INSPECTOR-DOUG SMALL Y.ROUGH INSPECTION: Passed—[ ] - Failed—[ ] Reinspection required($50.00)-j ] Inspectors'comments: (Inspectors'Signature-no initials) Date 2.FINAL;INSPECTION: Passed—[ ] Failed—j _] Re-inspection required($50.00)-[ ] Inspectors'comments: e!27515, (Inspectors'Signature-no initials) Date E3DERROUND INSPECTION-. Failed—[ ) Reinspection required($50.00)-j I mments: (Inspectors'Signature-no initials) Date f 4.INSPECTION—SERVICE: DATE CALLED NATIONAL GRID: Nom; Passed—[ ] failed—[ j Re-inspection required($50.00) Inspectors'comments: { (Inspectors'Signature-no initials) Date S.INSPECTION-OTHER: Passed—[ ] Failed—[ ] Re-inspection required($50.00) Inspectors,comments: - (Inspectors'Signature-.no initials) Date DOOR'TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED. x The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,f M 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/OrganizatiorAndividual): Address: V }� City/State/Zip: � art �(� , (9 Ph one#: Are you an employer?Check the appropriate box: Type of project(required): 1.El am a employer with 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.K 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 working for mein any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.❑Electrical repairs or additions 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' comp.insurance required.] 13.El Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #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. wInsurance 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 f r insurance coverage verification. I do hereby certl&u r the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: !� Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Per # 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#• } . t'v 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." 4 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111. Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia Date .................................. VA40 Tol 2 TOWN OF NORTH ANDOVER PERMIT FOR WIRING us This certifies that ........ .......... ................................ .... .. ....... ... ..... ... .... ......... has permission to perform ..... 1417;�Z;zo... wiring in the building of............. .................................................. 4 ............................................................. . ....,North Andover,Mass. at........ ......... .. ..... ..... Fee..�q Lic.No... .10..... I L LEMICAL INSPECTOR Check # 8316 P + � � a �, P Date.11 NoaTM TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING s e� -• a SAGMUS� ,1/ ,� This certifies that ,= �'- :,-�-�!! .. . . . . . . . . .�:. . . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . .. . . . . . . . . . at. . ,_..,- 4i�,,���:� , North Andover, Mass. Sru Fee.-;. Lic. No.. . . . . . . . . . . . . . . . . . . . . . j PL 3I G INSPECTOR Check # 7819 r` MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) C►/f�1/ /Y)�Q I/Y'� Mass. Date g ba Permit # �7f _ Building Location C Owner's Name61�`l/ �� -79 —6v 7—' 609 Type of Occupancy. Residential New ❑ Renovation ❑ Replacement 9 Plans Submitted: Yes❑ No ❑ FIXTURES c < `4r _jo cn o w zf W ]C J V7 a 7 L7 K fd �4 �4 a ¢ ¢ x ? o za N U� N 34 x ( o u' m ~n x r a rW _n # I z w m Z ¢ s m o N N N W LU W x Q x 3 O Z S Y d ~ a Y W LL X r } r o l a W z o a W r w F- o Q a ~ a a x m a o a a a x o a o a B P. yp4, 3 r m yr o o -j 3' SUB—BSMT. BASEMENT 1ST-FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5THFLOOR 6TH FLOORTT 7TH FLOOR i • 8TH FLOOR F Installing Company Name Heritage Htg. &Plg. Co. Inc. Check one: Certificate Address 35 Peasant Street EX Corporation 714 Stoneham, Ma 02180 ❑ Partnership Business Telephone 781 —438-7776 E7 Firm/Co. Name of Licensed Plumber Gordon Switzer INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 9 No ❑ If you have checked, please indicate the type coverage by checking the appropriate box. A liability insurance policy L Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent 0 I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 42 of the General Laws. By Title Signa ure o icensecl Plumber City/Town Type of License:Master[XJourneyman L]APPROVE (OFFICE USE ONLY) License Number 8322 %Z"Watts 9D bfp on water line to water boiler-- P n BELOW FOR OFFICE USE ONLY FINAL INSPECTIONS SKETCHES PROGRESS INSPECTIONS FEE NO.- APPLICATION FOR PERMIT TO DO PLUMBING i NAME&TYPE OF BUILDING LOCATION OF BUILDING PLUMBER PERMIT GRANTED 4 DATE 19 II PLUMBING INSPECTOR