HomeMy WebLinkAboutMiscellaneous - 49 HAROLD STREET 4/30/2018 j
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DelleChiaie, Pamela
From: Grant, Michele
Sent: Thursday, February 17, 20112:51 PM
To: DelleChiaie, Pamela
Subject: 49 Harold st
Hi Pam,
Shirley Sullivan and Gilbert Sullivan own 49 Harold St. 978-994-0458. They have 2 tenants,Scott and Erica Cunningham,
that owe$4100.00 in back rent. They were served on January 27 with a notice to quit, and then were served with a
summons to appear in court on Feb 14, 2011 for failure of payment on March 3`d. Tenants are threatening to call the
HOD. They say they have mold in a bedroom,the landlords did a mold test, it said there wasn't any mold. However,
Mrs.Sullivan was calling to find out the procedures in the HOD when something like this happens. I also told her of the
possibility of a "Housing Program" in the future. She would like to be involved in that.
Michele E. Grant
Eu6CuWealtkAgent
NortfiAndoverNealtFi Department
NorthAndover, W. 01845
978-688-9540
978-688-8476-Tax
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1
North Andover Board of Assessors Public Access Page 1 of 1
NORTH Forth Andover Board of Assessors
,jilmilijkk
A
41
'SSACMUs�t roperty Record Card
Click Seal To Return Parcel ID :210/066.0-0043-0000.0 FY:2011 Community :North Andover
SKETCH PHOTO
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Summary
Available
Residence
Detached Structure
Condo
Commercial
Location: 203 HIGH STREET
Owner Name: ROCK,MOSHE
C/O RICHARD N.MAZZARESE
Owner Address: 203 HIGH STREET
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 5-5 Land Area: 0.34 acres
Use Code: 104-TWO-FAM-RES Total Finished Area: 3291 sgft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 368,600 376,500
Building Value: 192,700 200,600
Land Value: 175,900 175,900
gCh
rket Land Value: 175,900
apter Land Value:
LATEST SALE
Sale Price: 155,000 Sale Date: 03/17/1985
Arms Length Sale Code: Y-YES-VALID Grantor: D'ANGELO JAMES
Cert Doc: Book: 01940 Page: 0314
�lela eAlzlrm,
http://csc-ma.us/PROPAPP/display.do?linkld=1704856&town=NandoverPubAcc 1/14/2011
Location Il eQ 1 I
No. J Date
NORT1TOWN OF NORTH ANDOVER
� 9
Certificate of Occupancy $
swCNBuilding/Frame Permit Fee $
r Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
Building Inspector
r TOWN OF NORTH ANDOVER
BUILDI1o1G DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE pOR TWO FAMILY DWELLING
.., ,>_ a,, ._ ._ ...r . ..i. ..,. ,. " i•■
BUILDING PERMIT NUMBER: DATE ISSUED:
^`S
SIGNATURE:
Building Commissioner/1for oMuildings Date z
SECTION 1-SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: V '�
Zoning Dis—ft d Proposed Use Lot Area(so Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide Required2rovided. Required Provided
_+__ _
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public 0 Private ❑ Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System 0
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT i
2.1 Owner of Record
Name(Print) Address for Service: I"
U'
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
z
M
Signature Telephone
SECTION 3-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor:
C y�S 6T/7r, Fp��.f���/�/ LicenseNumyber
Address y /7 J �/ b /
Expiration Date ic
Signature Telephone
3.2 Registered ome Improvement Contractor Not Applicable ❑
Company Name
Registration Number M
Address
Expiration Date
Signature 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.......❑ No.......❑
SECTION 5 Description of Pro osed Work check au a ticable
New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other.) ❑ Specify
Brief Description of Proposed Work:
, //L�:yy
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be OFFICIAL
Completed b permit applicant
,Y
1. Building (a)»Building Permit Fee
Multiplier
2 Electrical (b) Estimated Total Cost of
Construction
3 Plumbing Building Permit fee(a)x (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5 Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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/AUTHORIZ/E�D AGENT DECLARAATION
/�//1`7? 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 ent Date
00211 iimlm
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TFABERS i ST 2ND 3 RDt
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHEVLNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL,GAS LINE
J�e f5aVI'MOM
- BOARD OF BUILDING REGULATIONS.
License: CONSTRUCTION SUPERVISOR
' - Number: CS 000718
I
It Birthdate: 1211011829
Expires:
12110/2001 Tr.no: 10084
1 Restricted To: 00
t ERNEST PICCIRiLLO •!/ �� �'"T
14 HAMPTON ST Administrator
METHUEN, MA 01944
�--� . HOME IHPROVEKEt�. CONIRACTOR
Reqstraltl6lVIDUAL�i
IYPg "
F Expiration 05/01/01
^ Ernest Piecirillo
14 HamptOn St
uen KA 01844
ADMIN{3iRa�OR
Town of North Andover of µORTH
a 0.
Building Department o
27 Charles Street * _
North Andover, Massachusetts 01845
978 688-9545 Fax 978 688-9542
�•9 Q�4ATto rP¢�,t5
SsACHUs�
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 s 54, and a condition of
Building permit.# the debris resulting from the work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a.
The debris will be disposed of in/at:
Facility location
Signature of Applicant
Date
7
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
F NoRTIy
Town 0 4 over
S
4- MV
No. #_
o =_ �A o dover, Mass., •
COCMICKEWICK
ADRA TE D p`P�` t�
BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT......�� ��
.................................................. ...... . ................................. ...... . ................ Foundation
has permission to ebet..�2...O r buildings on 0 �� .9........... Rough
.................... 4 . ..... ......................................... gh
GI�A11 W �ti�I� s �� rto �,r/� IC A
t0 be Occupied as........................ ..... ................................................................................... ney
.......... . .. . . .. . . .
provided that the person accepting this permit shall in eve respect conform to the terms of the application on file in #'E'ina
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
ELECTRICAL INSPECTOR
UNLESS CONSTRU N S S
Rough
.. ............ Service
.. ........... . ... ..............................
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal
No Lathing or Dry Wall To Be Done
Until Inspected and Approved by the Building Inspector. Burner
FlRE DEPARTMENT
Street No.
SEE REVERSE SIDE Smoke Det.
Date.2:x 9! : k?.
MORTM TOWN OF NORTH ANDOVER
O��"•°
PERMIT FOR PLUMBING
♦ i „ r
qI �°�.nO^r�•�q9
,SSACON4
This certifies that .��.1�l. `!-'!. !. . . . . . . . . . . . . . . . . . . . . . . . .
has permission to perform . . . .Ps: <� k t--<.a. .. . `
plumbing in the buildings of . . ..`.. <.".�. .f. . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . ., North Andover, Mass.
Fee. . 'W--.Lic. No.. .b-:,.,A ). . . . . . . . . . .. . . . . . .
IUMBING INSPECTOR
Check # I� `� � t
5141
MASSACHUSETTS UNIFORM APPLl.:ATION FOR EAtNIT TO DO PLUMBING
fF'rfnt or Type)
_ . ��-f�D0U61Z Mass. Date �- y�r 49 D401 Permit #
Building Location 7` y�1 ��,rli?oL�) Owner's Name S�SLI LJ/,-/l/
h Tyke of Occupancy Rr_S//7-Px /�L
New ❑ Renovation Replacement ❑ Plans Subm ed: Yes ❑ No ❑
B .P .rt SEWER? FIXTURES SSTI CC#
F- Vf
W J fn U N Z D 4J O
? w Q
F
O - W
N H U W N Y 6 y � � - � � •r(
V ct m v7 ° } a H N Z ° a ° a Ci
Z O ° d W Q < W - ° Q (n Z ° a °
W F F- W $ 0 ° $ -+ v7 c �- Q °UJ LL
U 0
< p > }- O H N N W O U b
O Q J J Q K Ct rfC Q
= nc m o v7 m o O
SUB—BS MT.
BASEMENT r
1ST FLOOR ` f
2ND FLOOR f 1
1
3RD FLOOR
4TH FLOOR 01 A
5TH FLOOR
STH FLOOR
7TH FLOOR
STH FLOOR
Installing.Company Name_ALL djP kill coND ;4- 4L Check one: Certificate m
Address/ 13cl,Mop7" sr Z-Corporation D- C-
�' AY) Partnership
Business Telephone 0J9�-3 3 ❑ Firm/Co.
Name of Licensed Plumber TJ tl (ziA/2 f)
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes [Zl— No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box..
A liability Insurance policy ZJ--- Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and informatio I have sub rtted (or ente in ab ap ' t' n are tru urate to the best of my
knowledge and that ail plumbing work and install ons perfo ed under the a ed r is ion II be ' compliance with all
Pertinent provisions of the Massachusetts State PI mbin "I e Tid 2o a ral- ws.
TitleSignature of Licensed umber
Type of License: st r❑/ Journeyman
APPFOVED ❑
City/Town � 3 a�
OFF! US ONLY) Ucense Number
35 '- 5 Date..... .. .
r
NOR711
°`��``°;•'"° TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
41
,SSACMU5�
This certifies that ....�4'.u..l.....A�.F..l.!l........��...z.......................................
e has permission to perform .... �X?vc/.....
c
wiring in the building of .... ..«... ().9-Al
at........C.. ...........
�T G. r� 57.
.......... ,North Ando er,M
'. ,,// �,�t
...... Lic.No.!t././.�- 3.... ......... .y� ...
ELECTRICAL INSPECTOR
t
Check # 3��7
Official Use Only
Permit No. 3
��Gd'n�l2d?2Zf/C�l'�d�nl�3.S�fG�ZtS�7?S
Occupancy&Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00
(Please Print in ink or type all information) Date )- L ; a
To the Inspector of Wires:
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location(Street&Number 4 7
Owner or Tenant L L S 6e L f V)g✓7
Owner's Address I4�g j91— H.,Ff},0 sT
Is this permit in conjunction with a building permit Yes 91--' No ❑ (Check Appropriate Box) /')
Purpose of Building _Utility Authorization No. o,6 -3
Existing Service Amps Voits Overhead ❑ Undgmd ❑ No.of Meters
New Service 0 00 Amps R0 3 Volts Overhead f�! Undgmd ❑ No.of Meters _
Number of Feeders and Ampacity
i
L�.ation and Nature of Proposed Electrical Work
I Total
No.of Lighting Outlets No.of Hot fuse No.of Transformers KVA
Above ❑ In ❑
No.of Lighting Fixtures Swimming Pool gmd ❑ grnd ❑ Generators KVA
No.of Emergency Lighting
No.of Receptacles Outlets No.of Oil Bumers Battery Units
No.of Switch Outlets No of Gas Burners FIRE ALARMS No.of Zone
J Total No.of Detection and
�} No.of Ranges / No of Air Cond Tons Initiating Devices
Heat Total Total
No.of Di sal No. Pumps Tons KW No.of Sounding Devices
t No./of Self Contained
No.of DishwashersSpace/Area Heating KW Detection/Sounding Devices
❑ Municipal ❑ Other
No.of Dryers Heating Devices KW Local Connection
No.of No.of Low Voltage
No.of Water Heaters KW Si ns Bailases Wiring
No.Hydro Massage Tuds No.of Motors Total HP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES= NO =
have submitted valid proof of same to the Office YES= NO = If you have checked YES please indicate the type of coverage by checking the appropriate box
INSURANCE = BOND = OTHER = (Please Specify)
Estimated Valu of Electrical Work$
F 0 (Expiration Date)
4-O
Work to Start !O—;ILOA ?— Inspection Date Resquested Rough Final
Signed under the Penalties of rJury:
FIRM NAME LIC.NO. iJd3�Q
Licensee p ,L �'X JE h n)7,j k 'Tl� Signature 4 / LIC.NO, Jla`y3/T
(�6� m��y L Ln m7Tr Bus.Tel No._J 7�3 Lee Sf ✓
Address� 3 aZ Alt Tel.No. 73? Sal
OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not havethe insurance o erage or its substantial eequivalent as required by Massachusetts
General Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
Telephone No. PERMITTEE $
(Signature of Owner or Agent)
Date:. X.
4 HORTM
.'40 TOWN F N TH D
OL
PER IT FOR PLU BI G
SA US
This certifies that .L' /-�I �1�1-LGI. . . '`� �. . . . . . . . . . . .
has permission to perform . .,. C/i-. . :. ... . . . . . . . . . . . . . . .
plumbing in the buildings of . . L.".':-. . . . . . . . . . . . . . . . .
at. . . . . . . . . . . . . . . .. North Andover, Mass.
Fee.M ,. Lic. No../L . . . . . . . .
PLUMBING INSPECTOR
Check #
5137
MASSACHUSETTS UNIFORM'APPLICATION FOR PERMIT TO DO PLUMBING
!print or Type)
Mass. Date #& Permit # 3
_ 'JJ
Building Location_ - �C/ N.(IZr)t D Owner's Name S'ULLI (1f+i4-)
h Type of Occupancy Rr)Np k,-rl L
New , Ren vation 9�-� epiacement Or Planp Submitted: Y ❑ No ❑
B .P . F RES SEPTI /a
,r SEWER CTr
Z
CM V)
N rn O Z > 3-i
W _= .jN a s v W v
O W F- W x = s N - W n ?C
U s m 'A rs
Z S W t O < N Z Q �- O
O 2 a 2 d W j y
< 2 3 Z S Y a O Z d Y O a
O 2 d. N H = O O N = _ W E' O b r
~ a' a S H H a d O a J a 2 s . .r a n a ..
x J m 0 o O J 3 x F. N LL C7 2 O d $ ¢ In p O
SUB—BSMT.
BASEMENT rI
IST FLOOR 1
2ND FLOOR
2RD FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
Installing.Company Name C1jLL/1/il/R- /4/A C�ftp/) Check one: Certificate
Address I LL/`QP S7 [�-torporation C YIFC
4'1)0 U E P - ❑ Partnership
Business Telephone Of 5 u /o W�C/�-3� ❑ Firm/Co.
Name of Licensed Plumber =/4
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 Vis, please Indicate the type coverage by checking the appropriate box.
A liability insurance policy S1_ 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:
S+gnature of Owner or Owner's Agent Owner El Agent C3
I hereby certify that all of the details and information I h�;p>erfounder
dflor entered)in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State PlumbiChapt 42o a General Laws.
Signiature of Lice ed tuber
r►�e
Type of License: Master Journeyman ❑
AU C_V
�APQf0VED OFF! USE ONLY) License Number
Date.. . ......
Of.NORTH 1'b
0 '` °p TOWN OF NORTH ANDOVER
' PERMIT FOR GAS INSTALLATION
A �,SSACMUSE�
This certifies that . . . . . . . . . . . . . . . . . . . .
has permission for gas installation . .L. .!
in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . .
at . . ./!�. , North Andover, Mass.
Fee. . . . . . . Lic. No.. . . . . ... . . . . . . . . . . ... `. . .. . . . . . . .
GAS INSPECTOR
Check# '
3 - 0 G�'T
t
MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS 7,o(Type or print) Date g
NORTH ANDOVER,MASSACHUSETTS
Building Locations �7- Permit# L
Amount$ �J
Owner's Name SU�LI U1I A/
New I Renovation ❑ Replacement ❑ Plans Submitted
U
04
a W O 00 x x n
z a N F z z o H W
W fT, W
G7 F z F Z x w W C5 O � O F U a x
z W z a O O W O W F"
O k4' W U A C7 .a U 9 > A A. F O
SUB -BA SEM ENT
BA SEM ENT
1ST. FLOOR
2ND . FLOOR
3RD . FLOOR
4TH . FLOOR
5TH . FLOOR
6TH . FLOOR
7 T H . F L O O R
l' 8TH . FLOOR
1
(Print or type) Check one: Certificate Installing Company
Name __ CSI Lt,4//,& 4 a cin )L ` -)47-6
+4i G rp, #14 C
Address Pl rJ�l-1�/)1� f7-
/ Partner.
Business Te ep one 7 I* /Q 9 91)_ Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 0/ No
If you have checked Les,please indicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity 1:1 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
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 installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Code a hapter 142 of the General Laws.
BY: ignature of Licensed Plumber Or Gas Fitter
Title Plumber 3 L IJ A
City/Town as Fitter License Number
Iaster
APPROVED(OFFICE USE ONLY) Journeyman
Date. ..l..f. . .�. . . . ..
OF 40RTH 1�
'F� °p TOWN OF NORTH ANDOVER
" PERMIT FOR GAS INSTALLATION
HISS" —us
This certifies that
has permission for gas installation . . . . .
in the buildings of . . . ... . . !. �.� . , �. . . . . . . . . . . . . . . . . . . . . . . . . . .
at . .. . . . .�/ .�1.�. . . �. . . r North Andover, Mass.
Fee. . . . .'. . Lic. No..):'. .! . . . . . . . . . . . .. . . . . . . . . .
GAS INSPECTOR
I Check# I
LI J J
MASSACHUSETTS UNIl�ORM APPLICATON FOR PFIZNU TO DO GAS
(Type or print) Date
NORTH ANDOVER,MASSACHUSETTS
� /
Building Locations /7��R U LA s-T Permit# L/ Gj^�
Amount$ Q�^
Owner's Name S U L L/ L)-+k)
New❑ Renovation 0 Replacement Plans Submitted ❑
o
• Fz EM
d x N W H
zd �
f� o w 3 A cd7 V a 144 A a 1H 0
SUB-BASEM ENT
BASEM ENT
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
8TH. FLOOR
(Print or CALLA�IJAA,- Al2 �a4,io x- 14 C one: Certificpt�In�tallu�gCompany
rp• I��.1 (o
Address l L l0 , ' ' ❑ Partner.
Business Telephone ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter CA/
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes [a— No❑
If you have checked yes,please indicate the type coverage by checking the appropriate box.
Liability insurance policy 0— 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 ❑
I hereby certify that all of the details and informatio I have submitted(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Ma s chusetts S to Ga Code and ap er 142 of the General Laws.
By: S ature of Licensed Plumber Or Gas Fitter
Title ❑ lumber
City/Town [3—Gas Fitter License Number
❑—Master
APPROVED(OFFICE USE ONLY) ❑ Journeyman