Press Alt + R to read the document text or Alt + P to download or print.

No preview available

The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 51 JETWOOD STREET 4/30/2018 �l Q 0 b rb Date........ t......... OF NORT#y TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,ssACHUS�t This certifies that ........�1..... ..�.{... ......... ... ..4.......+ ......'.................................................. has permission to perform ....., ...... rt ... ................................................... wiring in the building of........ .�. ..t.S........,Q........90L . ............................................................. at .... ..�.........—x................. .� •........s...`.........................................North Andover,Mass. I�XFee..5 f..........Lic.No.l.gA.,.. ..........��.; v- --- ELECTRICAL INSPECTOR Check# LI Z� Print Form II i � C,onxmonuiealt�o�/i'/a�eachu.�e� Official Use Only Permit No. alJepart?mertt o� ire�eruiced �' Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(ME7,527 CMR 12.00 (PLEASE PRINTIN INK ORTYPE ALL INFORMATION) Date: y City or Town of: A1C/- Auiz To the Inspec or o Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) .Sl ��w�b f T Owner or Tenant _ L.DJ"5 '444j4�1 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑0 (Check Appropriate Box) Purpose of Building Utility Authorization No. 1 ` 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 Pr7osed Electrical Work: �e Z- - Z Completion ofthefollowing table may be waived by the Inspector o Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans TransTotal Trsformers KVA No.of Luminaire Outlets No.of Hot 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. TotalTons No.of Alerting Devices No.of Waste Disposers Heat Pump I Number er Tons KW No.of Self-Contained Totals: .............. ......I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection El Other No.of Dryers Heating Appliances KW Security Systems: ''Y No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent Bathtubs No.of Motors Total HP Telecommunications Wiring: No.Hydromassage No.of Devices or Equivalent OTHER: J t Attach additional detail if desired,or as required by the Inspector of Wires. S Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. Pl ` 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 pains and penalties of perjury,that the information on thispl' e and complete. FIRM NAME: DAVID ELECTRICAL CONTRACTING LLC u IC.NO.: 16� Licensee: DAVID HAGGAR Signature LIC.NO.:14963 (Ifapplicable,enter "exempt"in the license number line.) Bus.Tel.No.:978-682-6262 Address: 87 BELMONT ST, NORTH ANDOVER, MA. 01845 Alt.Tel.No.:978-375-5734 *Per M.G.L.c. 147,s.57-61,security work requires Department of Public 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. $ 55-� —�---- -----_------ F — — 01 --- ----- ---- -- - ---------------- —-------------- I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 ' www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): I DAVID ELECTRICAL CONTRACTING LLC Address: 87 BELMONT ST , .01845 City/State/Zip: NORTH ANDOVERMAPhone#: 978-682-6262 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4 4. El I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet.+ 7. E]Remodeling ship and have no employees These sub-contractors have 8. E3Demolition 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 I L[J Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.[0.Roof repairs insurance required.]t employees.[No workers' 13.1 Other comp.insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information- 1 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. Insurance Company Name: FEDERATED INSURANCE Policy#or Self-ins.Lic.#: 9353694 Expiration Date:11 3/1/16 Job Site Address: City/State/Zip: ` Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insucoverage e ven' ficatton. I do hereby certify under the ns an en f perjury that the information provided above s tru and correct. Signature: Date: �L Phone#: 978-682-6262 - Official use only. Do not write in this area,to be completed by city or town ofciaL 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#: ' I Date klCI.u?. ............ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 1sSACHU 9 r This certifies that................ has permission to perform....... ...e..4................................................ .. ...... .... ... ........ plumbing in the buildings of....N.< c> ... ................................................................... at............ .......:3 ....................... .. ........................................... North Andover, Mass. ..... . .... . Fee.,ZS........Lic. No. PLUMBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY NORTH ANDOVER MA DATE 4/8/2016 PERMIT# JOBSITE ADDRESS 51 JETWOOD ST OWNER'S NAME NAPOLI POWNER ADDRESS TEL FAX TYPE OR OCCU7RENOVATION: TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: REPLACEMENT:O PLANS SUBMITTED: YES NO FIXTURES 7 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY I ROOF DRAIN CX SERVICE SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING (/� OTHER BACKFLOW FOR BOILEF(� - 1 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 CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are truejapndfaccurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 71 PLUMBER'S NAME JEFF HUTNICK LICENSE# 15212 SIffRATURE MP , JP CORPORATION # 3532 PARTNERSHIP # LLC # COMPANY NAME CALLAHAN AC AND HTG ADDRESS 91 BELMONT ST CITY NORTH ANDOVER STATE MA ZIP 01845 TEL 978-689-9233 FAX CELL EMAIL PLUMBING@CALLAHANAC.COM `� Date. ..�. . .� ........................ F NoFRI TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION T SSACHUs� . YThis certifies that ...... ..Q...c r . . t. .. .� ... ...�- ..................................... ... ............ ............... ... ..... has permission for gas installation ...bLA ,-t-............................................... inthe buildings fof........... .:�,...aoA............................................................................. 1...... , North Andover, Mass. at.... .............. Fee..�....... Lic. No. ,.152.Q..... ..................................................................... GASINSPECTOR Check# vi- I Lj s , , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY NORTH ANDOVER MA DATE 4/8/2016 PERMIT# JOBSITE ADDRESS 51 JETWOOD ST OWNER'S NAME NAPOLI GOWNER ADDRESS TEL FAX ~TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: V RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO F YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW Y LIABILITY INSURANCE POLICY v OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT _ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tru//Mth urate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com all Pertin rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME JEFF HUTNICK LICENSE# 15212 / ATURE MP , MGF JP JGF LPGI CORPORATION , # 3532 PARTNERSHIP # LLC # COMPANY NAME: CALLAHAN AC AND HTG ADDRESS 91 BELMONT ST CITY NORTH ANDOVER STATE MA ZIP 01845 TEL 978-689-9233 FAX CELL EMAIL PLUMBING@CALLAHANAC.COM The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Stree4 Suite 100 Boston,MA 02114-2017 oRM www mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNIITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):Callahan A/C &Heafing Services, Inc Address:91 Belmont Street City/State/Zip:North Andover, MA 01845 Phone#:978-689-9233 Are you an employer?Check the appropriate box: Type of project(required): 1.Q I am a employer with 25 employees(full and/or part-time).* 7. ❑New construction 2.o I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.a I am a homeowner doing all work myself[No workers'comp.insurance required]t ❑ 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees_ 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp_insurance.* 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c_ 14.E]Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] Any applicant that checks box rl 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 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: AmGUAR© Ins Co Policy#or Self-ins.Lie.#: CAWC604073 Expiration Date: 9/25116 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 MGL c. 152,§25A is a criminal violation punishable by a fine up to S 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct Signature: "- ��i�'' Date: Phone#: 978-689-9233 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#: OP ID: PS CERTIFICATE OF LIABILITY INSURANCE DATE(MMfDUI 111116=15 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE.HOLDER. THIS,' CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. . IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Pete Sullivan Foster Sullivan Insurance NAME: 163 Main St. W1,No E :978-686-2266 Falc o):978-656-6410 North Andover,MA 01845 F=-MAIL Stephen Sullivan ADDRESS:PSUiliVan@fOstersullivangroup.com P oD CALLA-1 CUSTOMERID/• INSURER(S)AFFORDING COVERAGE NAIC# INSURED Callahan A C and Heating INSURER A:LIBERTY MUTUAL INS CO 23043 Services,Inc. INSURERB:GUARD INSURANCE COMPANY Kate Callahan 91 Belmont Street INSURERC: North Andover,MA 01845 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR kUUL= POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR INSPOLICYNUMBER MID MIDD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY X CBP4016154 09/25/2015 09125/2016 PRMAG EMISES E0 a N LU occurrence) $ 100,000 CLAIMS-MADE �OCCUR MED EXP(Any one person) $ 5,000 CONTRACTUAL UAB PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'LAGGREGATE LIMITAPPLIESPER: PRODUCTS-COMPIOPAGG $ 2,000,00 POLICY X PRO-- LOC $ AUTOMOBILE LIABILITY X COMBINED SINGLE LIMIT A ANY AUTO BA4544035 09125/2015 09/25/2016 (Ea accident) $ 1,000,00 BODILY INJURY(Per person) $ X ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULEDAUTOS X HIREDAUTOS (PERACTY ACCIDENT)GE $ X NON-OWNED AUTOS $ X UMBRELLALIAB X OCCUR EACH OCCURRENCE $ 5,000,00 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,00 A X CU8809334 09/2512015 09/25/2016 DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATIONWC STATU- X OTH- ANDEMPLOYERS'LIABILITY TORY LIMITS ER B ANY PROPRIEfORIPARTNERfEXECUFIVE Y 1 N CAWC604073 09/25/2015 09/25/2016 E.L.EACH ACCIDENT $ 500,00 OFFICERIMEMBER EXCLUDED? --I N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space Is required) **EVIDENCE** x#978 688-9542 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD STREET AUTHORIZED REPRESENTATIVE NORTH ANDOVER, MA 01845 O 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD .....--. e• .,• a ew�.�aMs �IlCdidlC117. OLQL VI 1-4Gw rlgIIIL1,1111C ® o 0 0 o MECHANICAL IDENTIFICATION BOARD:0F PLUMBER6""'.-A N:'' DGASFITTER5 �f I SSUES THE FOLLOW!NG I CENSE I NAME: JEFFREY HUTNICK LENSEp AS A JOURNEYMAN PLUMBER Q' R JEFFREY P HUTNICK LICENSEIREGISTRATION#: iW SERVICE GFE0801283 60 PLYMOUTH ST 1 �� M7HUEIV MA 'o i844 4256 ' x" 21881 o5%ot/t6; 204053 "I s' State of New Hampshire COMMONWEALTH OF MA$SACHUSETT$:.... MECHANICAL IDENTIFICATION e o o • o o SAAR OFNAME: JEFFREY HUTNICK PLUMBEF7S ANO GASF ITTllR,S ISSUES THE FOLLOWINGLI.CENSE AX. s L I CENSER A5 A MASTER PLUMBER I LICENSE/REGISTRATION#: i JEFFREY .P HUTNICK GAS SERVICE GFE0801283 PLU MASTER 4519 v 60 PLYMdUTH ST U) ;Ws 1ETHUE,N MA 01844-42 � rv%t�tf�� t5z7z 05/01/1.6 199305 • B• Q .COMMONWEALTH OF MASSACHUSIETTS BOARD'OF PLUMBERS .ANO GA'S FITTERS ISSUES THE FOLLOWING>. LtCENSEW REGI'SrtEREO AS A,.PLUMBING CORP l� JEFFREY HUTNICK, CALLAHAN A:/CANp HEATING SERVICE 60 .PLYMOUTH' ST -•._� - °METHUEN MA 01844 4256' 01. 16 204054 35-1 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the permit application form to provide no`ice of installation of wiring shall be uniform throughout the rvommcnv.*alth,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 Jnspector-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 puipose 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. ule 8—Permit/Date Closed: / ***Note:Reapply for new perm ❑Permit Extension Act—Permit/Date Closed: \ 9761 Date......... ff...'.�8'�L) } f NORTq, TOWN OF NORTH ANDOVER 0 p PERMIT FOR WIRING �Ss�c�eusf� This certifies that .��2 S has permission to perform wiring in the'b— .�:uilding of...............N. t z � .. .................................... ........... �....................... . h Andover,Mass. Lic.No..(L x`8.4.......... /RICAL'INSPECTOR BLE ` + Check 4 2-C� Q ammonmeA 4/Massa" Off[ciml Use Only 20pa� Peru*No. -273 1 UT BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked - � nave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All wu&m bepesfommd in a=rdmuee vft&e?Aasachusm Eixmimd code(MEQ,327 12.00 (PLEASE PRBff JNBVK OR TYPE AU DWORMAnOM Date: AO/oz(p T1U City or Town of<~ AG a" To the actor ofWO-W. By this application the signed Wives �o�fhis or l us /�to pednam tire electrical work dsscxc'bed below. 9 7� Location(Suva&Number) �JJ � S-L Owner orTenaut lal.11 A /JO Telephone No. Owner's Address Is this permit in conjunction w�ith� a building pin Yes ❑ No (Chei*Apprepriee Box) Purpose of Bul1d ng /Z sQ/C�D��l CSX Uh'fiEy Authorization Na Existing Service Amps !_ Volts Overhead❑ Undgrd❑ No.of Meters New Serviee Amps I Volts overhead❑ Undgrd❑ Na of mcbers Number of Feeders and Ampaeity Location and Nature of Proposed IIectFiM Worms �L —(11L? 6�-----=--e"/l't u tcompletion 0fdW tablemay 6ewabed by sloe fimmqw ofwires. No.of Recessed Lundrudrres Na of .(lie)Fans Tr of ansformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators S�— ICVA No.of Luminaires Swimming Poo! erad.Above ❑ grad- ❑ Units No of Receptacie Outlets No.of OR Burners FmALARMS Na irf ZORM Na irfGas Banners O.of Damon aad Not' fSwitches Devices TIE No.of Raages o.of AirCan& Toes Ko.of Alerting Devici ss ed Na of Waste Disposers Totem ben. ons a of-� _ -gg Devices Maoicipai No.of Dishwashers SpaedArea Hea#ing lid 1AWA❑Connedian ❑Other No.of Dryers Heating Applia� KW 5e No,of -0es or No.of of Data Wlrhw No.of Heaters KW S" or hmt i Wi No.HydromasmV Bathtubs No.ofMotors Told HP ' TeleNcomm ns o.gj Devkes or � OTHER Aaads a�iond&fagxydabed or as rearmed bydae InspeCmr of fres Estimated Value of Elearrcal Wo& (� by municipal policy.) Work to Start: Inspections to be requested in=ardance with MEC Rule 10,and upon completion INSURANCE COVERAGE: Unless waived by the owner,leo permit forthe per6orma a of elax�rit l wodc may issue unless the licensee provides proofof liability mcdudiag completed ap oe coverage or its substantial egnivalenL The undersigned cues brat such coverage is in farce,and has ednbited ptaofofsarne m the permit issuing office. CHECK ONE-- n4SURANCE ❑ Bo m ❑ oT� ❑ (sps) I xnder*epafds.and penaWks ofperlttts,*at Oe- flus 'on fs true aftd cv nplete FIRM NAME: - seas %ES 1 LIC.NO.: Licensee: (If aPPrcaw er r ormpt"lir dine Ifeow mwrber $ns.TeI. Address:. �E' i � Alt,TeL Nos sr"��Z ,351 *Pert a 147,s.57-61, Yaik regainer of M&�y"S" S� Liu No_ OWNER'S INSURANCE WAIVER: I am awercthat the does rmr hone the liabilit3►insernance coverage no=rnally retlaired by lave. By my sianatare below,i hereby waive rte. I am the ti heck one)❑owner ❑owner's eUL Signatu re ownermgefft - Telephone-Na. P BART FES' 745; /L Ob Date. TM Of.NOQ14, TOWN OF NORTH ANDOVER O 9 ERMIT FOR GAS INSTALLATION �1SSACHUSE4 This certifies that . . . .f�. �^" -'� 5. . . � LA '.`�. .-?. . . . . . has permission for gas installation� .�f' . . . . . .�� . . . . . . . . . . . . . . . in the buildings of . . . .&Yr/. //.,. at . . . e . . . . . , North over Mass. Fee:��: �.0. Lic. No.f� r . GAS INSPECTOR Check# r i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING CitylTown: /ld 19n eZv 4LA'/ Date: )d/-4 /a Permit# Building Locatic Owners Name:^� /vC9196 . A7 11 Type of Occupancy: Commercial Educational: Industrial lnsfiWUonal- Residential New:; Alteration: Renovation: Replacement-.- Plans Submitted: Yes No. FIXTURES U)W co o; W iw.. y _ B W. 0 g y rn ® _ ° Lu W " fao !— d p Ir w u O 6 N w m o a 0 w IL P o �G F N > w N CD < = W �0 B w w w Lu I- z w } 2Ix ¢ Q M I� O Z O y > z Q O W a w w Q > 0 4 o to Z w o a o try a s _j > o SUEVBSMT. 1 1 BASEMENT 1 ,Fr-FLOOR ( 1 2ffl7FLOOR 3 FLOOR ! 4 FLOOR I i 51"F OR ' :8 FLOOR 7 FLOOR 8 FLOOR 1 1 Check One Only Certificate# Installing Company Dame: ' A rri'i`.S Corporation %� % '$j �i.Pc't;% City/Town:. Address:; jV�C'. Cl Stater MA Partnership Business Tel:,_101191, V<17 -Firm/Company, . . {Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: I have a current flabilityinsurance policy or its substantial equivalentwhich meets the requirements of MGL Ch.142 Yes. , No If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement Check One Only Owner Agent = Signature,of Owner or Owner's Agent By checking this box[J;I hereby certify that all of the deti its 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 Instailatio�rs performed order the permit issued for this application wHl be in compliance with all Pertinent provision of the Massachusetts State Plumbing r6de and.0 1 the General Laws. / 1 Type of License: .. By Plumber Title. Gas Fitter Slifnalare of Licensed Plumber/Gas Fitter Master Journeyman License Number: APPROVED OFFICE AME ONLY) LP installer i I FINAL INSPECTION BELOW FOR OFFICE USE ONLY PROGRESS INSPECTION(S) FEE: $ PERMIT if APPLICATION FOR PERMITTO DO GAS FITTING L4J�tw�&TYPE-MIMIL DIM, i L'11MIJl3L�..C�,�LtL'1'L'li.131•!'I�I'�L.l�!? � �. 1AMNSE NUMBER; ITI MIT GRANTI;I)E] QA''?! CTAS ITITING INSPE TIOR -, rA PLUti�$Ef S AND GASFCTTERS LICENSED AS A JOURNEYMAN PL KEVIN M LEHANE 255 HIGH ST TAUNTON MA 02780-3-5 . 21619 ' . 05/01/12 795590 yZ7 `LIC LASED AS A�MASTER IS BE KEVIN M LEHANE 255 HIGH ST TAUNTON ON MA 02780-3525, 12868 05/01/12 795591 y �Xj 8761 Date. NORTH TOWN OF NORTH ANDOVER A PERMIT FOR PLUMBING ,SSACNUSE� This certifies that . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . PC b y . . . . . . . . . . . . . . . . plumbing in the buildings of . . . .1�.� t . . . . . . . . . . . . . . . . North Andover, Mass. Fee./; r7. Lic. No.., ) . . . . . . . .� ,. . . . . . . . . . . . . . . PLUMBING INSPECTOR ~Check # 1 j MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town:_ t w` MA. Date: —{a Permit# Building Location: ' TokAxrwy Owners Name: Type of Occupancy: Commercial�Educational❑ Industrial ❑ Institutional❑ Residential❑ New:❑ Alteration: ❑ Renovation: W Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES DEDICATED Z SYSTEMS LU Z Zz 4n Y Z a H S of a w ? F W Z ~ VI ? ~ N 4A F W Q 3 CO &n o: ¢ r N �. Q x V1 J X x J_ Q a Q D Q Q W Q: C t7 W Z W Z DC LL — W 3 a x i z a o 3 x z a LL 3 a Y z i` W o� a > W u ►- v+ vo '' > > o 0 o Z a a a x o �, W Q 'n Q m aa0 0 0 LL S X vxi in 3 3 3 o tz SUB BSMT. BASEMENT 1'FLOOR 2ND FLOOR 3RD FLOOR FLOOR 57°FLOOR 6T"FLOOR FLOOR 8T"FLOOR Check One Only Certificate# Installing Company Name:��y � / -- fErCorporation 6 Address:& � � � City/Town: 441 / State".01 -i_ - ' --- " ❑Partnership Business Tel:T�0 �� (1-17 Y3 Fax: �Id �7 �,3� ❑Firm/Company Name of Licensed Plumber: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes Q-14❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information 1 have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title Plumber Si na ure of Licensed Plumber �City[Town 2'�ster �C/ 7 APPROVED(OFFICE USE ONLY ❑ (� License Number: Journeyman �_� i FINAL INSPECTION BELOW FOR OFFICE USE ONLY PROGRESS INSPECTION(S) FEE: S PERMIT# APPLICATION FOR PERMIT TO DO PLUMBING NAME&TYPE OF BUILDING I I LOCATION OF BUILDING SKETCH PLUMBER I i LICENSE NUMBER: i I PERMIT GRANTED D DATE: I PLUMBING INSPECTIOR Date.. 0*, TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION SAcHU This certifies that . 0 V- . . . . .Z-.ITI-2-. '% . ;�'. . . . . . . . . . . . . . Aas permission for gas installation . . . . . . . . . . . . . I — 671, in the buildings of . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . North Andover, Mass. Fee Lic. No. . . . . . . . . . . . . . . f. GAS Check 9 5 2 S, MASSACHUSETTS UNIFORM APPLICATON FOR PERMrr TO DO GAS FTITING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations �� "e. �� Permit# Amount$ Owner's Name U t� S —i4 a/vQ k New Renovation ❑ Replacement ❑ Plans Submitted ❑ U �+ O U F W d F a z o F L) x a w F o SUB -BASEM ENT B A S E M ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type)pp !� C e one: Certificate Installing Company Name Y� `y ) S t- ff Corp. Address S� �`9 X ❑ Partner. Business Telephone (n -© R Z0 13-firm/Co. Name of Licensed Plumber r Gas Fitters INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes � No❑ If you have checked Yes,please indicate the type coverage by checking the appropriate box. Liability insurance policy 01- 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. e 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massae u tts Sta as Code d Chapte 42 oft eneral Laws. Signature of Licensed Plumber Or Gas Fitter By: ❑P umber Title E]ity/Town Gas Fitter License um er 0--master PROVED(oFMCE USE ONLY) ❑ Journeyman Location a cvo.d --3>1( No. Date 9,- '&a N�RTN TOWN OF NORTH ANDOVER O F A 9 s ; ; Certificate of Occupancy $ Building/Frame Permit Fee $ �cMus t Foundation Permit Fee $ Other Permit-Fee $ TOTAL $ Check # 3 y o' 15839 Building Inspector r TOWN OF NORTH ANDOVER �= BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVAT5 OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER DATE ISSUED: aG 4 SIGNATURE: ` Building Commissioner/103ecror of Buildin Date Z SECTION 1-SITE INFORMATION O 1.1 Property Ad 1.2 Assessors Map and Parcel Number: Map Number Parcel IQumber 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided v 1.7 Water SupptyM.G.L.C.40.° 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private n ? `I Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 111 2.10 er of Record 4Name(Print) Address for Service: Si re Telephone 2.2 Owner of Record: Name Print Address for Service: O Z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ ticen'sed Construction Supervisor: o J < Li nse Number Wn Address' aj/LJL� Exytmfiofi Date ic Si lure Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Registration Number r qd r ' Expiration Date ^� Si na re Telephone v' SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) i Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit wiu result--- in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction 0 Exipting Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ S ` p�irfy� Brief Description of Proposed Work: ' • SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY' Completed by permit applicant 1. Building qX (a) Building Permit Fee ✓P ��d Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(e)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 I, Z//q.+ �OAuthorized Agent of subject property Hereby authorize to act on Mv behalf,in all erselative to work authorized by this building permit application. S. of Date TION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Autrofized A 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 Pr' t e � Si nat of caner/ ent Date ti N OF STORIES SIZE - BASEMENT OR SLAB SIZE OF FLOOR TUVMERS 1 2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS S17E OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE a The Commonwealth of Massachusetts _ Department of Industrial Accidents d Office of Investigations Boston, Mass. 02111 ��+M 5�1b Workers'Compensation Insurance Affidavit Name Please Print Name: r Location: City `G / i? Phone # /� cT I am a homeowner performing all work myself. dI am a sole proprietor and have no one working in any capacity I am an employer providing workers'compensation for my employees working on this job. Company name: Address City' Phone#: Insurance Co. Policy# Company name: - Address City Phone#: Insurance Co Policy# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to$1,500.00 and/or one years'imprisonment_as well_as_civil.,penattiesin2heform-ofa STOP WORK_ORDER.and_a.fine_of1.$11]0.00.)-a day.against.me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify un the pains and penaitie f p 9 ry that the information provided above is true and correct. Signature Date — Print namz?/7� 4z�A—/� Phone# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept nCheck if immediate response is required Q Licensing Board p Selectman's Office Contact person: phone#: E] Health Department Other _ I Frank Valente BUILDING &REMODELING CONTRACTOR 7 Zachary Crossing 603-894-6162 Salem, NH 03079 MA REG#112723 THIS AGREEMENT IS MADE ON - JOB ADDRESS: (DATE) (O ER). I (ADD SS) TELEPHONE: JOB TELEPHONE: - CONTRACTING AGREEMENT - Read this agreement and make sure you understand.it before signing it. this agreement has legal force and effect and binds those who sign it. I. DETAILED DESCRIPTION OF WORK TO BE PERFORMED AND MATERIALS TO BE USED 17 d �� f z T NORTH Od E J"t Of Andover 0 4 , dover, Mass., ADaATED BOARD OF HEALTH Food/Kitchen tRM11 1 D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.......`.......D...V .5..,......, 14... a.. ../ .............. .... Foundation has permission to erect..../. .�.............. buildings on .. i . .�.. ..,. „�.,,,,,.,,,,, Rough to be occupied as.....� .. �. je e S t o�•�> �" 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. f) ` 3.3 P M PL UMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. sRough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough 1.ok 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 I.Ahing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. � L; Date.................................. NORTH TOWN OF NORTH ANDOVER Q p PERMIT FOR WIRING 9 8 wOwwn° ,SSACHUS� CU 1 This certifies that/..:. .... ..........� .....................:. .................................. M has permission to perform . ..................�........ .......................................o wiring in the building of...... ............ ............. ........................................ ; at.....:�' "-.. .......................... .North Andover,Mass.. aI,-. .,'"......(.. Lic.No�:.:�l..r;. ...........................................o ELECTRICAL INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer p- a 771e Commonwealth of Massachusetts � r.,ralt Departmenf of Public Safcty Ce. t✓ �cwpanc� I ree rheCked BOARD OF FIRE PREVENTION REGULATIONS 527 CZAR 12:00 3/90 4lea.•e blank) !APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All Work to be performed In accordance wilh the Mafsachusetu Electrical Code. S27 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL II FORHATION) Date City or Town of NDA?TN AyooeEi2 To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) .T/ ✓ErwooD S7/2EE7- Owner or Tenant LQGJ/S " 06/V/V4 A/19 PO[./ Owner's Address SAME 97S') (.&S-C4.29 Is this permit in conjunction with a building permit: Yes ❑ No ❑X (Check Appropriate Box) Purpose of Building Utility Authorization 110. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No, of Meters _ flew Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Installation Of Alarm System No. of Lighting Outlets No. of Hot Tubs ' No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above❑ In- grnd, grnd. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners , Batter Emergency Lighting Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges Total No. of Detection and 8 No. of Air Cond. tons Initiating Devices No. of Disposals No. of Heat Total Total P PumsTons 1(41 No. of Sounding Devices No. of Dishwashers Space/Area Heating KW No. of Self Contained Detection/Sounding Devices No. of Dryers Heating Devices KW Local❑ Municipal ❑Other No, of No. o Connection No. of Water Heaters KW Signs Ballasts w olta trin u 6 E .d�A No. Hydro Massage Tubs No. of Motors Total HP OTHER: C1) SMOKE 1>VTLE 0-Tpk-_ INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES❑ NO ❑ I have submitted valid proof of same to this 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 Value of Electrical Work S 33y C p (Expiration ate Work to Start S-S-98 Inspection Date Requested: Rough Final .IF- 94, Signed under the penalties of perjury: FIRM NAME A.D.T. SECURITY -SYSTEMS NORTHEAST INC. LIC. No. 1231C Licensee DONALD A BROOKS stgnat a No. 1231C Address 60 William Street, Wellesley, 8 s. Til. No. 413-732-4400 Alt. Tel. No. 617-431-5831 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts CeneralTaws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) 00 Signature of Owner or Agent Telephone No. PERMIT FEE S a ry Date 9 . . !. 1.� N2 !. t; TOWN OF NORTH ANDOVER �? ,< PERMIT FOR PLUMBING ,SSACMUS� J y / This certifies that . . . . . . . . . . . . has permission to perform . : . . : . ..:. . `. . . . . . �. plumbing in the buildings of ,_ !. . .��'. . . . . . . . . . . . . . . . . . . at . . . . . .�. -... . . . . . . . ... ,-North Andover, Mass. Ir Fee--6. . . . . . .Lic. N0d:-1 ` �. . %:� PLUMBING ^ . . . . . . PEkTOR Check # WHITE: Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS _ ( Date Building Location 5 1 J c. k, v d��/f Owners Name -/OL, /VA 10y Permit# -/f 7/777 Amount TypeofOccupanzz- New Renovation El Replacement Plans Submitted Yes Wo E] FIXTURES w x a d a �j W F W H Q .. tr, a a z Q a, Q a E., p A, F O C� Q Z S03-EM &�g1VIIVT SEHjOCIR r Z0 H,oaR 3MFLOCIR ani Hja R sMHJOM seat 7MILOM M HBM (Print or type) / Check one: Certificate Installing Company Name-5/4 J �/��1 io�cl l L zl 4 c -r Corp. Address , C ACaek,?� S <<.— Partner. Ld'tl Business Telephone '7 (-6 85—3 13 ® Firm/Co. Name of Licensed Plumber. sCfilr/��awe C�e�c'�Jo Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy M Other type of indemnity 1:1 Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner El 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts S to Plumbing C and Chapter 142 of the General Laws. By: 5ignaafiue o�Ffum er Type of Plumbing License Title a 3 6) / City/Town icense7MEET= Master ❑ Journeyman APPROVED(OFFICE USE ONLY