HomeMy WebLinkAboutMiscellaneous - 50 ROCK ROAD 4/30/2018 50 ROCK ROAD
210/047.0-0095-0000.0
I
7- e2
Date...... ...................
TOWN OF NORTH ANDOVER
0
"Haim.
PERMIT FOR WIRING
,SSACHU
This certifies that ..........)...
has permission to perform .................. C!.4 TY........ >..............
wiring in the building of............
............. .....................................
at.............SAD,
.........................�e
.. .............................. .North Andover,Mass.
Fee..................... Lic.No.. ...............
'ELECTRICAL"INSPECTOR*
Check 'I
8418
r .
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.p.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 beerl,a_oepted 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 o£ongoing construction activity,and may be.deemed-by the,ifnspector_of_Wires abandoned-and-invalidif 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-temp 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 15,20)08 and extending-through August 15,2012.
Vule 8—Permit/Date Closed: / �` ***Note:Reapply for new per '
0 Permit Extension Act—Permit/Date Closed:
l,ommonwea&o f Mamachadettd Official Use Only
2epartment of Jim Serviced Permit No.
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(ME ),527 -MR 12.00
(PLEASE PRINT 'OR TYPE AL INFORMATION) Date: 5
City o Town f: N6 ��(�Uejr To the Inspect r of ices:
By this applicati ndersigned gives notice ofhis or her intention to perform the electrical work described below.
Location(Street&Number) O /9d&K
Owner or Tenant 'ut A PA.(&,r)'P,4, 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.
I
Existing Service Amps / Volts Overhead ❑ Undgrd❑ No. of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of•Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Com lesion of thefiollowing table may be waived by the Inspector of 1,11ires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans TransTotal
Trsformers KVA
No.of Luminaire Outlets No.of not Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency Lighting
rnd. rnd. 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 No.of Alerting Devices
Tons
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
.. . .........................................................
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Loc onnection er
No.of Dryers. Heating Appliances A Dances KW Security Systems:
No.of Devices or E uivale
No.of Water No.of No.of
Heaters KW
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 rf desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: 5. (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 cove moffice.
age is in force,and has exhibited proof of sae to the permit issuing oce.
CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains mid penalties of perjury,that the information on this application is true and complete.f�]
FIRM NAME:_( rj X,, 5 0126 6,6C110LIC. NO.: 7 4 4 G
Licensee: 71bhn 1401mej Signature 2", LIC. NO.:1 c,, tt43
(Ifopplicable, enter •ex n pt"in 117e icense number li i. (r In J �G✓7 Bus.Tel.No.: " 171-
' Address: /5 7 (4 6 V o / Alt.Tel.No.:
*Per M.G.L.c. 147,s.57-6.57-6—�ity work requires Depa ent of ublic Safety"S"License: Lic.No. v t 1 6
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,l hereby waive this requirement. I am the(check one)❑owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $
F�N MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING I jD
(Print or Type)
07 Mass. Date_AP t!0 19Permit # 3 3 L f'y
Building Location Owner's Nam1 tit
of Occupancy 6e51de;41,-J
New ❑ Renovation ❑ Replacement p,' Plans Submitted: Yes❑ No ❑
N
Z Q Vf
N N V
N a N Q O N = Z
W J N W 0 U m Z •A
Z O u ~ Q CC O O tu
Z r
Q ¢ O
N O W Q = Z t- y� C � > W
W
W a7 W Z Q = H W Q W ►- O r =
WCC
W W d 0 > LL f- W J W
W Z O Z Q O Z
N
D: W Z, Q Q
'= O d Y W 3 G d J V y o a Mme- O
SUB-8SMT.
BASEMENT l
IST FLOOR t i
2ND FLOOR ` f :.
3RD FLOOR { t
4TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
STH FLOOR
Installing Company Name pT.TTmmr2 HEATING Check one: Certificate
Address 30 COACHMAN LANE ❑ Corporation
METHUEN, MA 0 ❑ Partnership
Business Telephone ii 7- 9 4.? f' Firm/Co.
Name of Licensed Plumber or Gas Fitter r1'. 5a,.,.,m d 6✓r-)
INSURANCE COVERAGE:
I have a current liaNifty 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
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 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 perm' ' edLa this application '11 be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of era]Laws.
BY T of License:
Plumber ture o 'censedOW—Mir or Gas Fitter
Titre atter p 3
City/Town Joume License Number
Journeyman
APPROVED(OFFICEUSE !!!I
i.
t
{ BELOW FOR OFFICE USE ONLY
FINAL INSPECTION SKETCHES z PROGRESS INSPECTION
FEE y
NO. :
APPLICATION FOR PERMIT TO DO GASFITTING
e
NAME & TYPE OF BUILDING
r
LOCATION OF BUILDING'
PLUMBER OR GASFITTER_
z
LIG. NO.
r
PERMIT GRANTED
s .
DATE
OAS INSPECTOR
J Date. . ,r �. . .
p10RTM
` TOWN OF NORTH ANDOVER
OF tt�eO �e qNO -
a2 yt O PERMIT FOR GAS INSTALLATION
9
♦ 09q .... en i
SACHUSE�
This certifies that . . . .
has permission for gas installation. d; .0.':
in the buildings of . t t. {/f'� r`.�'�'t ` .;-
� rr d'
at .7.r.�. I. a, / . . . . . . .. . i ., North Andover, Mass.
Fee. . !! �•Lic. No.. . .. . , . . . .
r 5 3Y4
I GAS INSPECTOR
WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File
Location110
No. - Date Y-f y3
Of °�T" TOWN OF NORTH ANDOVER
.ao �O
10
p Certificate of Occupancy $
} ; Building/Frame Permit Fee $
-�CKV. ._ , FoundatioA�Per it Fee $rermr `� $ /Sl)
Sew6r Connection Fee $
Water Connection Fee $
NOTAL $ /S';4
37) 3 Building Inspector
'-���
6341 Div. Public Works
P XMIT 0. rJ APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. ��h,W yI 3 rf- &��(A GE 1
MAP 4-40. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK .'PAGE
ZYNE p c( I SUB DIV. LOT NO. I �325_ �a
r
LOCATIONp�rn / PURPOSE OF BUILDING fc
OWNER'S NAME NO. OF STORIES SIZE \_.213 / /x��7
OWNER'S ADDRESSL-C) /J t� BASEMENT OR SLAB AV-5r
i l�
J �e�X."l /=Ply .Jrs spm a n
ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME �,., SPAN
DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS
DISTANCE FROM STREET t POSTS
DISTANCE FROM LOT LINES-SIDES �S/ REAR �o GIRDERS
AREA OF LOT 13. 29Y s. / FRONTAGE //o2/ HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW 77 7` SIZE OF FOOTING X
IS BUILDING ADDITION Y&s ff L MATERIAL OF CHIMNEY
IS BUILDING ALTERATION/ �Q IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE 1i 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 q..9
� INSTRUCTIONS
3 PROPERTY INFORMATION
I^ LAND COST
SEE BOTH SIDES EBT. BLDG. COST
i J
PAGE 1 FILL OUT SECTIONS t - 3
EST. BLDG. COST PER SQ. FT.
PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLAMS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
i Q
DATE FILED 9
$��d� 3
BOARD OF HEALTH
SIGNAT RE OF OWNER AR AUTHORIZED AGENT
FEE
PLANNING BOARD
PERMIT GRANTED OWNER TEL.
CONTR. TEL# �
19 — CONTR. LIC. d
I_p I ( E � � 4 BOARD OF SELECTMEN
4^ 1
f F i AUG 91993 i =e
BUILDING INSPECTOR
All,
BUILDING RECORD
1 OCCUPANCY
12
SINGLE FAMILY S-ORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA-
APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
CONSTRUCTION
2 FOUNDATION 6 INTERIOR FINISH
CONCRETE a l 2 13
CONCRETE BL'K. PINE
BRICK OR STONE HARDW D
PIERS PLASTER _
_ DRY VJALL _
UNFIN.
3 BASEMENT
AREA FULL FIN. B M AREA _
1/1 1/7 1/1 FIN. ATTIC AREA _
NO BMT FIRE PLACES _
HEAD ROOM MODERN KITCHEN
4 WALLS I 9 FLOORS
CLAPBOARDS B l 2 3
DROP SIDING CONCRETE �_
WOOD SHINGLES EARTH _
ASPHALT SIDING HARDW'D _
ASBESTOS SIDING _ COMIACN
VERT. SIDING ASPH. TILE _
STUCCO ON MASONRY +�
STUCCO ON FRAME
BRI K NMASONRY ATTIC STRS. 8 FLOOR _
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 (3 FIX.) _
GAMBRELMANSARD TOILET RM. (2 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 i l 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
1st 13rd I11 NO HEATING
Town of North Andover
BUILDING DEPARTMENT
Homeowner License Exemption
(Please print)
DATE
JOB LOCATION 50
Number Street Address Section of town
"HOMEOWNER" 6111a.n S'aIhyaa 5-0�s-,662- 76y0 6/ 7 - 73d' 2-2-60
Name Home Phone Work Phone
PRESENT MAILING ADDRESS 5_0 Roc_/e g-cl-
/� Aida✓P r
City Town State Zip code
The current exemption for "homeowners" was extended to include owner
-occupied dwellings of six units or less and to allow such homeowners to
engage an individual for hire who does not possess a license , provided
that the owner acts as supervisor . (State Building Code, Section 109 . 1 . 1)
DEFINITION OF HOMEOWNER:
Person(s) who owns a parcel of land on which he/she resides or intends to
reside , on which there is , or is intended to be, a one to six family dwell-
ing , attached or detached structures accessory to such use aid/or farm
structures . A person who constructs more than one home in a two-year
period shall not be considered a homeowner. Such "homeowner" shall submit
. to the Building Official, on a form acceptable to the Bulding Official ,
that he/she shall be responsible for all such work performed under the
building permit . (Section 109 . 1 . 1)
The undersigned "homeowner" assumes responsibility for compliance with the
State Building Code and other .applicable codes , by-laws , rules and
regulations .
The undersigned "homeowner" certifies that he/she understands the Town of
North Andover Building Department minimum inspection procedures and
requirements and that he/she will comply with said procedures and
requirements .
HOMEOWNER' S SIGNATURE 6i,Ca, �-
APPROVAL OF BUILDING OFFICIAL
Note : Three family dwellings 35 ,000 cubic feet , or larger , will be
required to comply with State Building Code Section 127 .0 , Construction
Control .
1
!� MORTGAGE PLOT PLAN �
50 ROCK ROAD
NORTH ANDOVER, MASSACHUSETTS
JUNE 15, 1984 OW14ER: BRIAN F. AND ANNA M. SULLIVAN
S ALE:
W
/D/•l4
Ii
W
7-
/A
� Airl,
P
o �
/G2 40' —
5 G9° •�`�' C7CehE
NOTE: 1-11iS IS ivOT A SCINV V AND 1S TO BL OSLO t01\ MC'RI*GAGE PURPOSES
ONLY.
N.Li. DO NOT its'E OFFSETS FOR ESTABLISHING LOT LINLS FOR Tilt: ERL.('TI(?N
OF FENCLS, WALLS, HE ETC.
T HLRLBV CERTIFY H.-AT TH : BUIIDIN:::: G.: ";,I`;; PROPERTY IS LOCATED
k' SHOWN ON PLAN AND C0111-PLIES WITH THE L( CAL ::('NTNG S)-T BACK Rt(
MI:NTS.
f.t
CYR ENGINEERING SERVICES, INC. I FtaJ?IFI? R CERTIFY THAT THL AL)OVI DW[LL1NG IS NOT
340 CANAL STREET LOCATEV IN A FLOOD HAZARD ZONE".
LAWRENCE, MASSACHUSETTS
FORM U - LOT RFJZASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: n m✓'l a Phone
LOCATION: Assessor's Map Number j 7J5 Parcel
Subdivision
/ ,rg41;,7T Lot(s) ?J
Street _%y lqock- St. Number
50
************************Official Use Only************************
RECOMMEN T OOF TOWN G S:
c� _?
Date Approved !
Consery a Ion Administrator Date Rejected
Comments
(/ Date Approved
To n Planner Date Rejected
Comments
Date Approved
Food Inspector-Health Date Rejected
Date Approved
Septic Inspector-Health Date Rejected
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector Date
e
�` AUG 91993 a
NORTH
)� L E D
o of 4 over
0 .* el , -10
No. 3 -
roc ,C4 dover, Mass.,Ayoc xf /0 19 Xf
ORATED P"0L
H ' BOARD.OF HEALTH
Food/Kitchen
PERM IT T Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT..JAUM!&....X/.L. ../ / /. ..............................................................................
' Foundation
has permission to erect..4Q..1.9..0 .......... buildingson .. Q.... .Q. ...4....................................... Rough
...................................................
to be occupied as..St!.I�.�!�W�.�?..ed..J�.e.�'1..../1�.�.���� 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
UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR
Rough
Service... .
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Dis lad/ in a Conspicuous Place on the Premises — Do Not Remove Rough
P 7 Final
No Lathing or Dry Wall To Be Done
Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT
Burner
PLANNINGFINAL , /?i CONSERVATION FINAL Street No.
Smoke Det.
gFIA/FR /UUATFR FINAL j ? �V/ DRIVEWAY ENTRY PERMIT
i3l ` �'
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NORTH
Town of RAndover
0VIA
";,i,� x` '.FYI••°`+���,; :y.
o� n CoCH Arprt dower, Mass., env cvfO 19 %r
ADRATED
'9S H E�
BOARD OF HEALTH
Food/Kitchen
P-ERMIT T D Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT M).14.".........4.....#4 A.�r�.�...........................................................................
••• •• Foundation
has permission to erect.,P.f..O.Ir............... buildings on ...Al..... �.a.I�...1T.�.!!.............••....••••••••••••••••••••••• Rough
to be occupied as.�. .I � j'�fi.. ! �'i K..1!� .... 1.....410.0.0.x�................... Chimney
provided that the person accepting this permit shall in every res pec 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
UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR
• Rough
�..... .............. ......................... Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove Rough
P p Final
No Lathing or Dry Wall To Be Done
Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT
Burner
PLANNING FINAL CONSERVATION FINAL street No.
QMAIPR /IAIATFR FINAI I? Smoke Det.
y DRIVEWAY ENTRY PERMIT
302 i
Date,� � .......
of HD oT a�a TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION g i
M ;
i
This certifies that . .. . . . .5. ?<.l: :% .m.o. . . . . . . . . . . ^'
has permission for gas installation . . . . . . . . . . . . . • • • • •t,
in the buildings of . . .� . . . . . . . . . . . . . . . . . . . . w. .
at . . . . . . . . . rth Andover, Mass.
Lic. No.�i 3 3 3. . . . . . . . . . . . . . .
GAS INSP
WHITE:Applicant CANARY: Buildl Dept. PINK:Treasurer
I
i
j MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
Mass. Date-ALJJ—" 19 '5?ep Permit # 3 o 2'L
Building Location so Owner's Name 4 J8 P-tyA t,.) 5 U f-L- ,AA)
Type of Occupancy__ R I5I i7L: N T! P
New Q Renovation Q Replacement Plans Submitted: YesE] No p
N
N Wan
Y Z ¢ Vf
N N V
to ¢ N ¢ O N = 5
W W to ¢ O V m ►' _ 'A
Z p V f' < Z O T.4 ¢ O O
m H r- y W o a ¢
¢ W 6 1- N 4
W y¢j 0 W = < S ¢ N W < ¢ �' W t✓ S
J H Z r.. W W O O � W I- W J h ¢
z a W < C Z >- of m Z O 2 ¢ O N z
W > Cr W Z. < ¢ < t O O W O
SUB—BSMT.
BASEMENT '
1ST FLOOR
2ND FLOOR
3RD FLOOR _
4TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
STH FLOOR
Installing Company Name Check one: Certificate
Address apt;'C H ih f4ry i-NI, ❑ Corporation
r. 7 H UE fJ M rl • C i k q ❑ Partnership
Business Telephone -17 9"7 1 2-Firm/Co.
Name of Licensed Plumber or Gas Fitter_ -Ro j,E P T A 5 A M m►9 i rel c�
INSURANCE COVERAGE:
I have a curre�nt pI' bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes Gd' No ❑
If you have checked res, please Indicate the type coverage by checking the appropriate box
M1
liability insurance policy Other type of Indemnity❑ Bond ❑
dWNER'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 OwnerD Agent O
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 pe for this application ' be in compliance with all
pertinent provisions of th
pe p e Massachusetts State Gas Code and Chapter 142 of "-CrneLaws.
BY T of license: C�
Plumber n ure of cen Plu or Gas itter
Title tter q33�
er License Number
City/Town Journeyman
APPROVED O IC NL
BELOW FOR OFFICE USE ONLY
FINAL INSPECTION SKETCHES PROGRESS INSPECTION
FEE
NO.
APPLICATION FOR PERMIT TO DO GASFITTING
NAME S TYPE OF BUILDING
LOCATION OF BUILDING
PLUMBER OR GASFITTER
LIC. NO.
PERMIT GRANTED
DATE.__.1 9._-
OAS INSPECTOR