HomeMy WebLinkAboutMiscellaneous - 48 WINDSOR LANE 4/30/20187 4.6/ Date ...✓��. .
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TOWN OF NORTH ANDOVER
• PERMIT FOR GAS INSTALLATION
This certifies that .,�yh.. �!!!- ..................
has permission for gas
--i installatiio-n'... �................
a!•
in the buildings of . ��lfd!1 .. {!��?��....................
at .lf; .%�.�1.�7 � &-e/...... North A o er ass.
Fee..b.'.. Lic. No.{�...7. !GY... .
GAS INSPECTOR
Check # ��
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
�I 2W 1A1AQt1G"72._ , Mass. Date C% - Z7 Ifc'10 Permit*
Building Location_ YS 411116'as 4L- lt/L` Owner's Name i
Type of Occupancy,
Im
New ❑ Renovation ❑ Replacements Plans Submitted: Yes[] No pr
Installing Company Name
Address
Check one:
❑ Corporation
❑ Partnership
Business Telephone ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter/IA�cII/Z i//I'• ��/� -2'
Certificate
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 have checked yes, please indicate the type coverage by checking the appropriate box.
A 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
hapter 142 of the Mass. Gene5al Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner Agent ❑
Sign ture of er or Owner's Kaeht
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 Gas Code and Chapter 142 of ft General Laws.
4
By T of license: % G
Plumberture of Licensed Plumber o Fitter
Title Gasfitter
Master License Number /W/f y�j6
Ciry/Town Journeyman
APPRdVF.D OFFICE USE ONLYI
NJ
Installing Company Name
Address
Check one:
❑ Corporation
❑ Partnership
Business Telephone ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter/IA�cII/Z i//I'• ��/� -2'
Certificate
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 have checked yes, please indicate the type coverage by checking the appropriate box.
A 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
hapter 142 of the Mass. Gene5al Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner Agent ❑
Sign ture of er or Owner's Kaeht
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 Gas Code and Chapter 142 of ft General Laws.
4
By T of license: % G
Plumberture of Licensed Plumber o Fitter
Title Gasfitter
Master License Number /W/f y�j6
Ciry/Town Journeyman
APPRdVF.D OFFICE USE ONLYI
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............ K .......Y. ..............................
has permission to perform ...............6.2
.............. 6.24.s ..... ....................
wiring in the building of .... . ..............................................
at ........... '/.ff .. r as
...... .......... North Andover, Mass.
Fee ...%.-d ......... Lic. No. 3P. 4............... .
TRICA
ELEC L INSPE R U /
Check #
4
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. q 7 L10
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 5 7 CM 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: j�Q 7
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives noti e f his o her intentio to perform the electrical work described below.
Location (Street & Number w7®
Owner or Tenant Telephone No.
Owner's Address &--
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building /. Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
r Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:6 Low
Completion ofthe following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑In- ❑
o. o . mergency Lighting
rnd. grnd.
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
Heat Pump
Number
Tons
KW
......
No. of Self -Contained
Totals:
Detection/AlertingDevices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of WaterKms,
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of E ctri al Work: Z60,00 (When required by municipal policy.)
Work to Start: 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 cover a is in force, and has exhibited proof of same to the permit issuing office.
CIIECK ONE: INSURANCE Pr BOND ❑ OTHER ❑ (Specify:)
1 certify, under the pains d penalties o perjury that th i formation on this applic n is true and complete.
FIRM NAME: p�/j,�l d ,� LIC. NO.: o'�
Licensee: `' Signatu a C. NO.:
(If applicable: enter " e pt"' the li numb line.) us. Tel. No.:1�1'
Address: Alt. Tel. No.: !—
*Per M.G.L c. 147, s. 57-61, security work uireepartment of Pub is Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's a ent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $
•t 2710 06:57p
The Commonwealth ofMassachuseus
Department of Indust W Accidents
Off -we of Investigations
600 Washington Street
Boston, MA 02111
Print Form
www massgov/d1a
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (&sines/Organization/Individual): _JrEdi.'6
Address:
Are you an employer? Ch6k the appr
1. ❑ I am a employer with
loyees (frill and/or part-time)."
2. IZI am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
1� required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
Phone #:
Hate box:
4. ❑ I am a general contractor and I
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance-:
5. ❑ We area -corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required./
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.�1ectrical repairs or additions
11.❑ Plumbing repairs or additions
I2.0 Roof repairs
13. ❑ Other
*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 hue outside contractors mast submit a new affidavit indicating such.
4DOntractors that check this box must attached as 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 mast provide their workers' oomp. policy number.
I ma an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy it or Self -ins. Lie.
Expiration Date:
Job Site Address: City/Statetzip:.
Attach a copy of the workers' compensation policy declaration page (showing the policy numher 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
1 fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties is 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.
Phone #: 7X-1 7 7f — Z&9' `-%
feral 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 #-
C
THECOMMONWEUTHOFMASSACHUSEnS Office Use only
DEPARTAfflW0FPUBL1CS4FM Permit No. ` -!5� i+ `� - i
BOARDOFFSEPREVEMONREGUL4HONS527CMR12 00
/ Occupancy & Fees Checked
/J I
APPLICATTONFOR PE Aff TO PERFORM ELECTRICAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSST f ELECTRICAL CODE, S2% CMR 12:00 /� 1
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) 7 , Date /G p `r
Town of North Andover / To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work di
Location (Street & Number) 4191 Wwr) SO /2? 1-4y
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit: Yes � No a (Check Appropriate Box)
Purpose of Building,/L�.S j/J�,d� �= Utility Authorization No.
Existing Service Amps�Volts Overhead a Underground No. of Meters
New Service AmpsVolts Overhead r-1 Underground No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
.J No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Total
KVA
No. of Lighting Fixtures
Swimming Pool Above
Below
Generators
KVA
round
ground El
No. of Emergency Lighting Battery Units
No. of Receptacle Outlets
No. of Oil Burners
Hitch Outlets
No. of Gas Burners
.anges
FIRE ALARMS
No. of Zones
No. of Air Cond. Total) r�
+r
)isposals
Tons /. 5
No. of Detection and
Initiating Devices
—�
No. of Heat Total Total
Pumps Tons... .
Space Area Heating
_KW
KW
Dishwashers
No. of Sounding Devices
No. of Self Contained
Detection/Sounding Devices
Local Municipal
_
Othe
'Dryers
Heating Devices KW
a Connections
Water Heaters KW
No. of No. of
Signs
Bailasis
lydro Massage Tubs
No. of Motors
Total HP
ER'
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rysigna mondispemritappbcationwaivtsdlisregtmunut.
check on ) / Owner Agent _ _
lt,� �," -- Telephone No. 7y1. %S y i3% rE12MTT FEE $ I
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Locationry►��Ai LGV1 �-
No. Date �2-6&
Check # SPS
TOWN OF NORTH ANDOVER
Certificate of Occupancy
$
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL $ -79010D
174 3j 1 . L.* r- 10rCN4 re
Building Inspector POO—
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVyA�yTEj,� OR DEMOLISH A ONE ORTWOFAMILY DWELLING
�' £ � !y�'T $ Hf=a•'+4iV��.�� V8l µ'�w } °PF w^y`� F{y�� �
BUILDING PERMIT NUMBER: O O / DATE ISSUED:
SIGNATURE: /Vc
Building Commissioner/I for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
elVJ1 iU S 6 f L- �/4��
1.2 Assessors Map and Parcel Number: {�
" Q —
Map Number Parcel Number
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Areas Frontage ft
1.6 BUELDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide R red Provided
Rapired Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public ❑ Private ❑ Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
Historic District: Yes No
2.1 Owner of Record / .
)C ! Aw-w-z M - fit CE jE-5 z T& • Ya �<Nb$61Z �9Ale- /{/�V&—;'Z,
'Name (Print) Address for Service
179' GFie- 2424L
na a Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
-1.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature Telephone
Not Applicable 1"4/0
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable
v
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
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SECTION 4 - WORKERS COMPENSATION (M G.L. C 152 6 25,(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 .......❑ No ....... ❑
SECTION 5 Description of Proosed Work check all applicable)
New Construction ❑
Existing Building ❑
Repair(s) ❑
['Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
2e.V.-Z_
oZ Q P�P7 GV1.S 1- �f. lT• �1�p +N" S (Ji✓
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
1. Building
(a) Building Permit Fee
2 Electrical
4-
-Multiplier
(b) Estimated Total Cost of
Construction
3 Plumbing
/ oop
Building Permit fee tat x (b)
�Q
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
? O�
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,�� 11^�l� �' W-- �2` —as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED 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
Signature of Owner/A Ient Date
NO. OF STORIES SIZE
BASEMENT 6
SIZE OF FLOOR TIMBERS -((p 1 ST2ND 3
SPAN I bZ
DIMENSIONS OF SILLS o? � 6 P f -
DIMENSIONS OF POSTS I, (3
DIMENSIONS OF GIRDERS t d
HEIGHT OF FOUNDATION THICKNESS 1,6 "
SIZE OF FOOTING 0 X L c�
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND .tea (
IS BUILDING CONNECTED TO NATURAL GAS LINE X) 0
,Qadt4a�'
FORM U -LOT RELEASE FORM b -Cf''
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.
*****************************APPLICANT FILLS OUT THIS SECTION*********************** ` J
APPLICANT AANl&z X4 --T1z
LOCATION: Assessor's Map Number.
PHONE !78 4��
PARCEL
SUBDIVISION LOT (S)
STREETAI AibSO& L�it/� ST. NUMBER
USE
ATION ADMINIST
COMMENTS
TOWN PLANNER
COMMENTS
FOOD
COMMENT
EALTH
OR4fEALTH
AGENTS:
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9197 jm
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:
(Location of Facility)
Signature of Peit licant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
TOWN OF NORTH ANDOVER
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c. 142 A requires that the "reconstruction, alteration, renovation, repair, modernization,
conversion, improvement, removal, demolition, or construction of an addition to any pre-existing
owner occupied building containing at least one but not more than four dwelling units ... or to
structures which are adjacent to such residence or building" be done by registered contractors,
with certain exception, along with other requirements.
Type of Work: A 4d, � (-J—A-1 Est. Cost 79 /<
Address of Work Y9 VIILI Olz
✓Owner Name: �9.r.//�Z /fit- �J2
Date of Permit Application: 7✓NE /Y 2o"y
I hereby certify that:
Registration is not required for the following reason(s): For office Use Only
Work excluded by law Pemit No.
Job under $1,000 Date
Building not owner -occupied
pulling own permit
Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS
FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION
PROGRAM OR GUARANTY FIND LINER MGL c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
Date
Contractor Name
Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date Owner Name
Name
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass 02111
Workers` Compensation.Insurance Affidavit
`% '
Please Print
Location:�i/�1' k1l S
.(/��
Citv IV �%Na'iye—_-?Z Phone # 6 ff6 Z4. Z j�,
Q1 am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity' .
I am an employer providing vANkers' compensation for my employees working on this job.
Comyany name.
Address
QW,
Insurance Co. Poffigg #
Address: .
Fawro'to seeureeoverage as required undo Section 25A or MGL tS2 cmks tit&ftwiiip� of ;p is
and[or ane years' unpriaonrrsanl p�eoalties�nsheSom�a�7DR 1ioe�pE:(
understand that a copy of this statement may be forwarded to the CMroeof hrrestigabom oithe biA for vnenage,
A
r doherebycert%y'mcbr Mo paW s and penmWes olpegwythat Me'Mmmadmprovkbdabovo isb m a7d correct
Signature
Print name P1Ee4
Official use only do not write in this area'to be completed by dtyr or town drx:kf
CAY q# Towwri _ . nrr:.
Bdffc sig
OCheck O'wwwbiate respanse is required
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Date..................................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Thiscertifies that ......................................... .... ................................
has permission to perform ....... r...11...1�4
..... ........................................
wiring in the building of ....... Ze� ............................................
at ....... . .-.d.. . .. ........-—
.. , Nor/h n
)dover, Mass.
I(x
Fee... Lic. No .............. v.... . ................. ...............
C—ELEcrRICAL INSPECPO—
Check # U
54.6
TBECOLYIMONWE4LIHOFM4S,S4CHUSE77S Office Use
/only /
DEPARTA1ENT0FPUBL[CS4FEIY Permit No.
BOARDOFFIREPREVE%MONREGUL4HONS52l CW]2.00
Occupancy &Fees Checked
APPLICA71ONFOR PERMIT TO PERFO ` ELECTRICAL WORK
( ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSST ELECTRICAL CODE, 527 CMR 12:00 /Q `
PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date
Town of North Andover
The undersigned applies for a permit to perform the electrical work df
Location (Street & Number) �eg' WIAO S61?
Owner or Tenant
Owner's Address
To the Inspector of Wires:
Is this permit in conjunction with a building permit: Yes E No F] (Check Appropriate Box)
Purpose of Building / // Z::5V665'" Utility Authorization No.
Existing Service AmpsVolts Overhead Underground M No. of Meters
New Service Amps / Volts Overhead Underground r --J No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
O No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Total
KVA
No. of Lighting Fixtures
Swimming Pool Above
Below
Generators
KVA
round 1:3round
No. of Receptacle Outlets
AA
No. of Oil Burners
No. of Emergency Lighting Battery Units
.No. of Switch Outlets
No. of Gas Burners
ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. TotalFIRE
Tons
s
No. of Detection and
No. of Disposals
No. of Heat Total Total
Pumps
Tons '
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
Local Municipal
Other
No. of Dryers
Heating Devices KW
a Connections
No. of Water Heaters KW
No. of No. of
Si ns
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
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Telephone No. 9 PERMIT FEE $
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Date . 2..j....� , .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ..QlI..,.'.'.. U c .CI,r .`.`................ .
has permission to perform .... .................
plumbing in the buildings of ...�..... `. �..`..` �..................
at ...�'b' ... . �'..`� �..` .1.t............... , North Andover, Mass.
Fee ...l . Lic. ....... vk .1 .- :.,� ..... .
/PLUMBING INSPeCTOR
Check # '
MASSACHUSETTS UNIFORM
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location Z/9
L4/t-- Owners
FOR PERMIT TO DO PLUMBIN
Date '-1 Y 6-�l
6Z Permit #
1 Amount
Type of Occupancy/
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New Renovation Replacement ® Plans Submitted Yes No ❑
FIXTURES
(Print or type) Check one: Certificate
Installing Company Name El Corp.
Address
Partner.
Business Tele phone 0 Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy F1 Other type of indemnity 0 Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
reeinsuranc
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i ature Owner Agent D
I hereby certify that all of the Uils 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 ssachusettts tai Piu bi g Co5e an hapter 142 of the General .Laws.
By: ig a re o icense um er
Title+
Type of Plumbing License
�3G y 19145—
City/Town 1cense NumDer Master Journeyman
11 1 L�
APPROVED (OFFICE uss ONLY
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Date �-. lA 'Jul
....................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
9
This certifies that ...........................................
.........................
has permission for gas installation ..'* ............
in the buildings of ... `... . ......................
at North Andover, Mass.
Fee : `�� Lic. No. 41/tl-Q ... r 1h1/.`........ .
CGAS INS P CTLgR
Check # //(o
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MASSACHUSErIS
(Type or print)
NORTH ANDOVER, MASSA
FORPIUMHTTODO GAS FrITNG
Date 12-161e K
Building Locations If VV�
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�/� Amount $
Owner's Name D/9/U'lL~L
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INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 13No
If you have checked yes, please indicate the type coverage by checking the appropriate box. 13Liability insurance policy ❑ . Other type of indemnity C]13
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
General Laws,and that m si ature on this permit application waives this requirement.
i' Check one:
gnature of Owner or Owner's nt Owner ElAgent 1:1
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
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compliance with all pertinent provisions of the chusetts State Ga de and Chapter 142rf the General Laws.
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Plumber AIA' l -S- p
Gas Fitter License Number
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