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Home My WebLink AboutMiscellaneous - 53 Marblehead Street J { Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACHUS This certifies that ............. ...77/L.................................. has permission to perf ormj�e /....................... wiring in the building of......................... . ....�2............................................... at.... AIAW .......5,7.............. .North Andover,Mass. Fee... Lic.No ............ .........dQ?AL INSPECTOR Check # 7994 Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No. 1O ` BOARD OF FIRE PREVENTION REGULATIONS [Rev 1//07]y and Fee Checked (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 13 —y$ City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 5'—? fVJ0,,101 f\r,@,J 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 2t4�cl- C_:,/,`n S p �( Utili uthorization No. Existing Service Q v O Amps /al 0 Volts Overhead Undgrd❑ No.of Meters 6- New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity I • Location and Nature of Proposed Electrical Work: Completion o the ollou i table maybe waived by the Inspector of Wires: No.of Recessed Luminaires /3 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- El .o mergency ig g _ rnd. rnd. Battery Units No.of Receptacle Outlets C�S No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and InitiatingDevices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers .Heat Pump Number ,Tons KW No.of Self-Contained Totals: - """"" Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ unicipal El other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Waterrs KW No.of No.of Data Wiring: HeatSigns Ballasts . No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP TelecommunicationsWiring: OTHER: No.of Devices or Equivalent tAttach additional detail if desired,or as required by the Inspector of Wires. I Estimated Value of Electrical Work: SC7 (When required by municipal policy.) Work to Start:c2—/3-y 9 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: C f.'c LIC.NO.: 0 az-Tz Licensee: Z-�iijf3 2,r a v;l,a,r-J Signature LIC.NO.: (If applicable, enter"exempt"in the license number line.) Bus.Tel.No.•f J3 .31& `;773 y Address: Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$ i ooil� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street i Boston, MA 02111 www.nzass.gov/dia . Workers' Compensation Insitrance Affidavit: Builders/Contractors/Electricians/Plumbers At Plicant Information Please Print Legibly � ,n t Nannie(Business/Organization/individual): G� ��Uvi v\ �d Address: 02 ter., S-1)A City/State/Zip: L7' 1+C 7 sYhone P 9 (n 's 7 7 3 Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction ployees(full and/or part-time).* have hired the subcontractors 2. I am.a.sole proprietor or partner- listed on the attached sheet.2 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for me.in any capacity, workers' comp.insurance. [No workers'comp. insurance 5. ❑ We are a corporation and its 9. Building addition required.] officers have exercised their 10•❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself.[No-workers'comp. c. 1.52, §1(4),and we have no 12,Q Roof repairs insurance required.]t employees. [No workers' 13.M Other comp, insurance required..] 'Any applicant that checks bort#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 hire outside contractors must submit a new affidavit indicating such. ;Contractors that check this box mustattaehed an additional sheetshowing the name of the sub-contractors and their workers'comp.policy in1rination. I ant an employer that.is providing workers'compensation insuranceformy employees: Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cerci under the pains and penalties of perjury that the information provided above is true and correct Si auris: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: 4 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the'foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence at compliance with the insurance'coverage required." Additionally, MGL chapter 152,§25C(7)states'Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out. the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractors)name(s),address(es)and phone number(s)along with their cenificate(s)of r insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of industrial Accidents for confirmation of insurance coverage.. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not`the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a_zarkers' compensation policy,please call the Department at the number listed below. Self.-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officiais Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the Bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating•current policy information(if necessary)and under,"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any.questions, z please do not hesitate to give us a call.. The Department's address,telephone and.fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel.# 617-7274900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-77451 www.mass.gov/dia TRIPI ENGINEERING SERVICES,LLC ® 110 Winn Street, Suite 207 Woburn,Massachusetts 01801 www.tripiengineering.com Memo - 01 15 April 2008 To: Mr. Peter Marino Showcase Construction 53 Marblehead Street North Andover, MA 01845 Project: 060063.00 53 Marblehead Street, North Andover, MA 01845 Subject: Post 4/4/08 Site Visit Follow-Up This Memo documents our review of the follow-up work that you performed pursuant to our recent site visit. The Building Official will need this documentation to close out the project; this Memorandum should be submitted with the "Construction Control Affidavit at Project Completion." Based upon our field visit on 4-4-08 and review of subsequently completed structural punchlist items, we find that the completed work that we observed meets our design intent. The scope of work that defines our design intent is as indicated in the drawings and sketches that we stamped on 9-1-06 (Drawing S-1, and Sketches S-2 through S-10, inclusive). By: J. Matthew Tripi 0.lva•,Ss� � r No.45212 FSS �Ca J Q L rC NA Telephone/Facsimile ■ 781-287-0077 r ENGINEER—STRUCTURAL CONSTRUCTION CONTROL AFFIDAVIT AT PROJECT COMPLETION Project Number: Project Name: 9ARU30 2,50604770J Project Title: tZ ) Project Location: 53MiQ2p� F_u�'di, �',_ �cT-` K-)QM ALIWZIE HA Scope of Project: f;Ti-e,=2AL tltt,) r OF:' 2Wr �.Q►J��lyi GiK�GT��`s �'�i 'T'fl�QAu/rl„# !"��n. STI�I.f�F In accordance with paragraph 116.0 of 780 CMR,the Massachusetts State Building Code, I, J. HAMEtilEA I PF Massachusetts Registration Number 45A? being a registered professiondl Engineer hereby certify that all plans,computations and specifications,and changes thereto, involving the structural systems of subject project have been prepared by or under the direct supervision of a Massachusetts registered architect or Massachusetts registered professional engineer and bear his or her original signature and seal or by the legally recognized professional performing the work, as defined by Massachusetts General Law(M.G.L.)c. 112, §81R. For the above named project-1, or a registered professional architect/engineer under my cognizance, have reviewed the design concept, and other submittals which are submitted by the contractor in accordance with th requirements of the construction documents. NOT'9 WWI V. I have reviewed and approved the quality control procedures for all code-required controlled materials. I further certify that 1 was present on the construction site at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine, in general, if the work was being preformed in a manner_consistent with the construction documents. Pursuant to 780 CMR 116.2.31 have provided the results of st�_urat tests and inspections to the building official and owner. ooT REatulabB Fop 7 4J s geoP5 Pic ~91C. I have submitted, periodically, a progress report with all pertinent comments of the site visits and compliance of all pertinent items to the building official. I have submitted a reDort as to the satisfactory completion and the readiness of the project for occupancy. A7rAc*El.Tit's mEqQ-01 9 i5 08 E n r Dat Subscribed and sworn to before me this /�—L—day of A � 200 ARIAL W.GEORGE NOTARY WIBUC MWOWEALIH OF Wamims MINOR otary P lic Date ry dMaw R1 09/27/00 Location `` No. Date pRT TOWN OF NORTH ANDOVER • _ ; , Certificate of Occupancy $ Building/Frame Permit Fee $ sACHUS !w Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 13 7 7 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. DATE ISSUED: c SIGNATURE: 1041 Building Commisdbner/IEEeEtor of Buildings Datej z SECTION 1-SITE INFORMATION I O 1.1 opeRy Address: 1.2 Assessors Map and Parcel Number: n Map Number Parcel Number \xv\ 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 Re red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSIIIP/AUTHORIZED AGENT M 2.1 Owner of Record Name(Print) Address for Service Signature r Telephone •c g� gaosc 2.2 Owner of Rec d: Name Print Address for Service: O z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: O License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date ^z 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 Proposed Work check ail a lIcabie New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: L/ w SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be Z#>F I+'ICIl USE�f1�TLY r Completed by permit applicant n �, 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) 41 3 Check Number SECTION 7a OWNER AUTHORIZATIOS TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property H eby authorize to act on Mv behalf 'n all matters relative to work authorized by this building permit application.,--, G� W9 160 t nahue of(fu/mer 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 Si ahue of Owner/A ent Date r NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TRABERS 1ST2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE gORTN Town of North Andover Building Department 0 . p 27 Charles Street t r North Andover, MA. 01845 s D. Robert Nicetta Building Commissioner (978) 688-9545 -- - ,:(978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print DATE G i 9 100 JOB LOCATIONS Number StreetAddress Map/lot "HOMEOWNER9�J tXL$ G% ao,15, ' 79g G 5950 33 ®ham I �a � Name Home Phone Work Phone PRESENT MAILING ADDRESS �3 0 t$4 S City Town Sl@te Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings of two 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 108.3.5.1) DEFINITION OF HOMEWOWNER: 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 or two family dwelling,attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other Applicable codes b aws rules pp y-1 les and regulations, e9 , The undersigned"homeowner'certifies that he/she understands the Town of No.Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'SSIGNATURE n- / �C• APPROVAL OF BUILDING OFFICIAL Town of North Andover t1ORTH O Building Department o 27 Charles Street North Andover, Massachusetts 01845 ?, (978) 688-9545 Fax (978) 688-9542 �i4SSACNUs�� 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 NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. NORTH ovm oEAndover O .� 0 = - rK1 No. Z63 Y -- fA. �- �Ad�- o � dower, Mass., COCMiCKEwICK A0RA7ED S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT......�......v............. 5.. .OW..%........................... ...... Foundation �• has permission to erect.../..v............................. buildings on .......��.....��.��.��.�....�. Rough t0 be OCCUpled as �: r him � �'i :...... .oO................................ ............ ............................................. 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. MA? #4 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION ST S ELECTRICAL INSPECTOR Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE smoke Det. Date . . . . . .... ... . NORTH pft„ao ,°1ti0 �= y` TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION 9 h �9SSACHUSES< This certifies that . y. .. . . . ?. . . . . . . . . . . . . . . . . . . . has permission for gas installation. . . . . . . . . . . . .. in the buildingsof ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at�5 . . .7��l. :�orth-Andover, Mass. 3o Li . N . . . Fee. . . c o.. . . . . . . . . . . . GAS INSPECTOR Check# 6309 MASSACHUSETTS UNIFORM APPUCATON FOR PERVIlT TO DO GAS FITTING (Type or print) Data �— G NORTH ANDOVER, MASSACHUSETTS Building Loqations c UJ )'d Permit# �o�o Amount$ Owner's Name �- New Renovation Replacement Plans Submitted U V1 W W z ' , O cc O O Z W 4 C7 U W x F C C C > W C7 F Z d x w a W cs] [•, w x a Z, Q W C F' F >' W Z O W > W SUB-BASEM ENT a U BASEMENT 1ST. FLOOR 2ND . FLOGR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type) Check one: Certificate Installing Company YName .r`'c� 7Corp. I� Address ' L L/2. S , t"_(,t r—d rd 0 Partner. Business a ep one _ SQ F1 Firm/Co. Name of Licensed Plumber'or Gas Fitter INSURANCE COVERAGE Check one: r I have a current liability insurance,policy or it's substantial equivalent. Yes If you have checked es lease indicate the No Y.,P type coverage by checking the appropriate box. .y Liability insurance policy ®� Other type of indemnity 13 Bond 1 Owner's Insurance Waiver: [,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. Signature of Owner or Owner's Agent Check one: Owner 13 Agent 13 I hereby certify that all of the details and information 1 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 Co and Chapter 142 of the General Laws. By: SignatuQ7of Licensed Plumber Or Gas Fitter Title Plumber - .b 7 City/Town, D Gas Fitter License Num6er Master _ APPROVED(OFFICE USE ONLY) E3 Journeyman t}, Date /...Ar g is t row<AO RT:.',tion TOWN OF NO�,T- ANDOVER 0 9 PERMIT FOR PLUMBING F '" S3 S.4CHUS � a This certifies that • • • . • . • . . . . . . . . . . . . . . . . . . . • • • • -�-! . . c '� r' � has permission to perform . . . . . . . . . . ..�. . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ats.."5..3. . . A<-Cs.- old:t—�. . . ., North Andover, Mass. Fe`e3 . . '�' .Lic. No �, �. . . . . . . . . . . . . PLUMBIN INSPECTOR r Check # r 7642 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS ( n Date Building Location �� e t'�i� �-r/` Owners Name Peter Permit# (v y Amount Type of Occupancy New ri Renovation Replacement Plans Submitted Yes r No FIXTURES w a rA o " o WW U BA41YM M ROM M ROM 3n)FI" ) ) 41H)HIDM 5M H10CR 6MF10CR J M H-0CR MHHM (Print or type) �� Check one: Certificate Installing Company Name t��c-c� ('torp Address __�� pJ /L—Celt ❑ Partner. C 1n e1•�.-t ryVt v9 0/��. � uusiness Telephone 4 7 Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond El F1 Insurance Waiver: I,the undersigned,have been made aware that the licensee of this a lication does not have PP any one of the above three insurance Signature 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 Massachusetts S Plu ing C d Chapter 142 of the General Laws. By' igna ureo se um er Title Type of Minbing License City/Town ^ /JOuicen um er Master rneyman APPROVED(OFFICE USE ONLY ❑ i