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HomeMy WebLinkAboutMiscellaneous - 530 MAIN STREET 4/30/2018 (2) _ � — � 530 MAIN STREET _ 210/071_0-0035-0000.0 ��e Date...... Z.....a......... NORTH TOWN OF NORTH ANDOVER PERMIT FOR WIRING 'IS CHUS This certifies that ...................... . ..../.................... ............................ '004 .. has permission to perform ............ ...... ........ ...... ... wiring in the building of.................... ...... .... ............................................ ...... 53a M#"4/ 5'r— at............................................................................... .Nrth Andover,Mass. Fee............. Lic.No..Cif r...................... Check # 341732-05 ELECTRICAL INSPECTOR 7 ii N, 10511 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 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 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 maybe-deemed by-the-Inspector_of_Wires abandoned-and_invalid-ifhe—.. ._ or she has detemrined 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. 1 ❑ 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 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 ap licable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 anwexte ding through August 15,2012. ❑ Rule 8—Permit/Date Closed: **Note:Reapply for new per ZG M it ❑Permit Extension Act—Permit/Date Closed: 2 i �/ X /! ,'7 �� ! l Qficizl use Only V—Cn.rnc:wee al Ja-6sdz r c;a_ Pe.;nit No. Occupancy and Fee Checked Or^�=�0 OF FIRE ?RE� E!"I T ION REGUL4 T IONS [Rev. 1/071 (leave blank) � AP P ;CA TION� FOR PERMIT 10 PERFORM CL EC T R(CAL WORK AH wo- k- be Dir on-i ed in accordancewitri Che Mmsachusetts Electrical Code(AVEC),527 CMP.12.00 (PLEASEPP, N LRfL%�KaR _7PEALL1L1-,'iF'O.lt--fAlL J Date: City ofI-TovirIl of: -N Oc [ 'eki—o-theTaspector of Wires: $y this appLcation.the undersid.-ed gives notice oz ills o:her intention to per orm the electrical work described below. Loca=.ion(Street&Numb edirf IT . Omer-orTeaant- • A – FA-M Telephone No72-kl rof Owner's Address elki, fT• / N 0' & G/ ?- Is this permit-in conjp_nc en Yrith a buildingpermit? Yes No- (Check Appropriate Box) Purpose of Building Utility Authorizaaor.No. _ Ex sting Service Amps i Volts Overhead Undgrd,� No.of Yleters - New Service ._mas / Volts Overhead Fj Undgrd No.of iWeters Number of headers and Ahead y Location and Nature ai broposed Electrical Work: 1 t Completion of the following table may be Y'atV2d by the inspector of Is'iras. t (I\o.of Tot?I No.o=Recessed L=.iniaaires" ;Ne.of Cel.-Buse.{!'addle)Fans _" z r _—� 1 ransformers KSIA INo.of Luminaire Outlets ;No.of HotTubs f Generators I'VE. – ! aboveFj in- neo.of Tmergency Lig?nrig No.of Luriiinaires iSv:i„In:ingPool 2rnd- _ end. IE �BatterY Units 11 �iNo.of Receptacle Outlet No* of of Oil Burners . FIRE ALARIVS -INo.of Ganes Ii4o.of Detection and �No: 1`O.off Gas Burners } Initiatira Deyices ai f- No.o;RaNnges ' a.ofA-ir Cord. R°` (No.of Alerting Devices Tons Y�pa�Pump!riutnber_ Kim No.of Self-Can�.ained. No.of Waste Disposers _ ` -I'£tals: 1(Tcns tDetection/Alertina Devices .. l��Ylunlcinal No.of Dishwashers [Space/Area Iieadn� K-W Local onnection- C1 her. ! ecurity.Systems:': No.n:`Dr;�ers ;Iie,:lna Appliances . Kl'v I? i^ No.of Devices or Equi alent li1o.or Water `No.of ivo.o; (D2t2 Wiring: Beaters bi'/ j Suns Ballasts I No.efDevices or EguivaIent I ITAlecommunications 1✓irma: — No.Hy rolrassage Bathtwos �1t`c: 0 mE:i; otors Total HP ; No.of Devices or uivalent IOTHER: 197` •1�7" r itCCh ddittonal detail 1 desired.oras rzquir ed by t,:e lnsp.CfCl Gf i'.'tr2S. - Estimated Value of Elec-mccl t^?b.r:: 33,5" (-1�+'aen requited by municipal policy.) Work to SCx_ insnechors to be egLestFa is accordance with NELC Rule 10,and upon corn:leticn. IhISUR.4NCF.COVE kGE: Unless waived by the ov.�ier,no per,�it for the pe ornlance o`electr ical perk miiy±slue ur_les's the licensee provides.proof of liability insurance including"coripieted operation coverage or-its substantial equivalent. i h� undersigned certifies that such coverage is in force,and has exhibited proof of same to the pr— t issuing 0,lee. CHECK ONE; INSURANCE f—Al BOND ❑ OirIER " (Speciy:)" f Cert2�y, Z!i!dt?Y fke 17atY°S aF?d penalties of perjllr}r,�Fet the to or,afior__on r is applicafion is true and complete. ^� FIRM NAME; ^• 5�!� -.c t W� �a t� I�IC.1`TO._ L � Licensee- 1C�a f ' �Z'Cu7 � SianaP3 (,, LIC.NO.:_ (If Qgglicabfe,enter Axel.': i :Zi 41he 11c2nse rritTjJer­br-e.5 t r Bus.Tet.No.: /C' J �— ddress e` Gt= r,—,crn f l Iro 1 ST ©30 4\ Alt.Tel.Tvo.:—_------ `Per M.G.L.c. 1-i,s �7-ul,seceri ,von r;cuires Depa,_:,:ert o Public Sal ty`'S"License: L;c.No. �Q 953 OWNER'S 1N1St1RANC E W RIVER: I ar e aware that the Licensee fle�rot r,Gve i'.he liability insurance coverLge"nolriaily required bylaw_ y my signa �le belr,N ^Hereby dive�ll is regtiirement. I am-ihe(check one)❑owner L!ovme;'s went. Owner/Agent SiQnzture SEE: TelephoneNo. PRrYIT ) .n'1��t•i;a.l i.r�v•l,l(•f ;f.ac'.i -- - EGIs i��ED s ,s i Ftp co�i.� Ac'�off. 'issuEsTHE-i ovEuCENS'cTO. — _ DT., =SECUFI i Y. SER% ICES :-i APr:.fA _BP+UP1-iY=:.S_F c--v n V E 1�iQOD 07/31/1-3 old-'elan DvfsCl:.t-=_Ar,PnGerCcrs - . Keep top for receipt and chanae of address no55ca5o;,. � Des-Ck9 u a'N Sfl�•7tl762003tACJ<S��r+Fr7 _ I ffic a�rw.rscoo uclzl.c ✓Ic�cuaclit :s I DEi'ARTWENT OF PUBLICS:iI iY S.Licanse g—EVa Numb>c'SS CO 1100953 � . - Expir_s:•QyQ7l2DS3 - Tr.na; 195.0 5-11tense: ADT 1 ARK A BROPHY--SR ./ 41 O UNIVER51TY AVE L I /J�— DIG SAFE CALL CENTER: (665)3�7233 WESiiN00D. NIA 0209Q Comnissioner t i - � 1 •Date/4'). d...... � ..... ,aORTq 'We °f�•``°:�'"o TOWN OF NORTH ANDOVER p PERMIT FOR WIRING Ss�cHUS I E This certifies that .. o /�".�'� ..... .... .................................................... has permission to perform ..... .............. wiring in the building of......... �!. � '�..`. G. ..... at...........!J ......!. t//7...�T........................... .North Andover,Mass. Fee ....... Lic.No.............. ........................................................�. ELECTRICAL INSPECTOR Check # 9088 C,ornmonurealth o� ad�achude Official Use Only Permit No. aL.J¢partmen�o�..tire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] 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 7TPEALFO�RM—ATION) Date: City or Town of: E2 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_3::> 1\44iw Sfi Owner or Tenant Telephone No. - 10- Owner's Address Is this permit in conjunction wit a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building lJ�� lL u Utility Authorization No. 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: -Ao,,/gce-- -/c-0 `-rL 7:.r Sw /T h GJ Com letion o the ollowin table maybe waived by the Ins ctor of Wires. No,of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans o.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ n- El Battery o Emergency ng d. d. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners IVo-.-oT Detection and Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pum Number Tons KW No.o Self-Contained Total . . ........ ........... ...................... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Omer Connection No.of Dryers Heating Appliances KW SecuritySystems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP elecommumcations Wuting• No.of Devices or Equivalent OTHER: Attach additional detail if desireg or as required by the Inspector of Wires. Estimated Value of Electrical Wor � a, — (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 coverage i i force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) I certify,under the pains andpenalties ofperjury,that the information on this application Is true and complete. FIRM NAME: LIC.NO.: Licensee: Q��7- �/`X Signature LIC.NO.: �;V/u (If applicable enter"exempt"in the license,number line.) Bus.Tel.No.:,T�l?yG1�7� Address: �F/�✓��e 1¢� f!�/�s1�.�> Alt.Tel.No.• *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 agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ AC RDF CERTIFICATE OF LIABILITY INSURANCEFDA`E (MMIDDIYYYY) `� 10/20/2009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Salisbury Insurance Agency,Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 10A Elm Street Salisbury MA 01952 INSURERS AFFORDING COVERAGE MAIC B INSURED INSURER A: Hartford Fire Insurance Company Ron Kirk&Bowman Electric INSURER e. INSURER C: 5 Florence Avenue INSURER D: Salisbury MA 01952 INSURER E COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR Dim TYPE OF INSURANCE POLICY NUMBER LIMITS A GENERALLIAMLITY 08SBMVY9380 10/21/2009 10/21/2010 EACH OCCURRENCE_ s 1,000,000IYAMAGe TO RENTED . ❑ COMMERCIAL GENERAL LIABILITY PREMISES Me 0=Men0e $ 300,000 CLAIMS MADE a OCCUR MED EXP(Any one ) y 10,000 PERSONAL&ADV INJURY $ 1,000500 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY PROJECT f 1 LOC ❑ AUTOMOBILE LIABBJTY COMBINED SINGLE LIMIT i ANY AUTO (Ea acciderd) ALL OWNED AUTOS DDILY IN JURY $ SCHEDULED AUTOS HIRED AUTOS BODILY INJURY f NON-OWNED AUTOS (Per aodderd) PROPERTY DAMAGE $ (PeraedAenl) ❑ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S EA ACC $ ANY AUTO AUTO ON�L�YN AGG E EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ ❑ OCCUR CLAIMS MADE AGGREGATE $ S DEDUCTIBLE $ RETENTION $ $ WORKER$COMPENSATION AND TORY LIMITS ER EMPLOYERS'LIAMLITY Y I N ANY PROPRIETORIPARTNERIEXECUTIVE EL EACH ACCIDENT $ OFFICER(MEMBER EXCLUDED? (Mandatory In NH) F1 DISEASE-FA81PLOIff i ff .yes describe under E. DISEASE-POLICY UM $ SPECIAL PROVISIONS below OTHER Electrical Wiring-Commercial and Residential CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS IIYRITIEN Town Of North Andover NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE 70 DO SO SHALL IMPOSE NO OBLIGATION OR LIABRM OF ANY RIND UPON THE INSURER,ITS AGENTS OR 120 Main Street A North Andover MA 01845 =:4= ACORD 25(2008101) Page 1 of 2 O 1988-2 ORD CORPORATION.All rights reserved. The ACORD name and logo are reg' red marks of ACORD 1 COMMONWEALTH OF MASSACHUSETTS OF ELECTRICIANS AS A REG JOURNEYMAN ELECTRICIA ISSUES THIS LICENSE TO } RONALD J KIRK 'a FLORENCE AVE APT 4 SALISBURY NA 01952-2113 .29813 E 07/31/10 314834 i o�iJ Win? i 'f�cIGL Ck r , Date.& /4.1;21 NORM TOWN OF NORTH ANDOVER O �° I �O p PERMIT FOR PLUMBING ,SSACNUSE� G f_ This certifies that . .1 �:.^^ .: . . . : :*`_" . . . . . . . .^.. has permission to perform ' ,r ?. . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . v� D .. Y.Y` `" `'. . . . . . . . . . . . , North. Andover, Mass. Fee�O. . . . . . . .Lic. No. a--. . . . . . . . . . Y PLUM 1NG>NSPECTOR Check # �. 1) v 8297 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date � Building Location �j J�b �l a%yf ��(°(� Permit oZ 17 Owner (OJ r C f Amount L ✓ New 0 Renovation � Replacement ® Plans Submitted Yes � No FIXTURES W. ed WA BMW ]S)HD(R 3m ELOCR �>aDOR sM 8DM 6M ERM 7M FUM s�>HiOOR i (Print or type) ` 1 heck one: Certificate Installing Company Name l 00q �- H `T' Corp. Address 1 f d'u V� f I El Partner. ' vi 5 0 0 3 Business Telephone Firm/Co. Name of Licensed Plumber: Ti�A 1 O Insurance Coverage: Inde the type of insurance coverage by checking the appropriate box: Indicate Liability insurance policy q Other type of indemnity E] 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 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 bing Co and er 142 of the General Laws. By: Signature g i of i wd er Title Type of Plumbing License 1 / City/ own icense INUMM •L Master Journeyman ❑ APPROVED wmF,usE oNLY � � � s y The Commonwealth of Massachusetts Ln f Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): via Le �l AddressA C r0 W (� 1\ ��d � 1�5_ n l(� City/State/Zip: Phone#: (Q Q ?6 27— 6, q 17' Are you an employer? Check the appropriate bog: Type of project(required): 1.❑ I am a employer with Z. 4. ❑ 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.t 7• [ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. q. ❑ 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 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑.,Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] * �'r!'Ylieant that checks box 41 liu;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 their workers'comp.policy information. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: l� f O I V 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 fife 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 certify u der the airs nd penalties ofperjury that the information provided above is true and correct Signafore: 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#: 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 Iocal 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 bas not produced acceptable evidence of 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 certificate(s)of 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 workers' 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 Officials 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, 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 4.06 or 1-877-MAS.SARE Revised 5-26-05 Fax# 617-72.7-7749 vmrw.mass.gov/dia �. . a e. y y h a f aP A I L Da15 te N I -C OT �E�­'V, rtiG�h � actio `P ance 3 AS,YIC�t.ATi "NS-'OF Art1cle' ,Sec ca'n pf the B ►[Idl—Co-de k Piave bs n'#ourjd can ,Aticte sectlo�n ca 'the =Gods �ses. .1fBY L it? ' cz `ice ➢#h the:abav a`° de'fia , tje a ns .e e d. # 4M _ r t 1._� 1 fi s ��Wn,.r y fiS •fi ,� tz `�" /fa+.��.. � Orr tfi R11Qr1� Qi si,Lio 1 _m, alma#. rl r'rpa. � � ��.'g.w t P���.�lerJ'��o�� s+Ek� �+✓�" � �..^. *, �1 i �;,y� .���tr`k+�r wa. �"�� .a+ � �t � c,E � `^�+. � 4.;,� �s' ,H A °Atl i ns°a t!r�g orlfr'ly tot WVr0o►`�4 r,r.0Rlotring,or rr�t t� t9n'; th :i + tl arsAlia,'lo td�arrest'u'nlQss,su� s�4 +�Obk d byri e P partttner�t . . w W n ,. .- � . J ' x,e �,j%,do c--./ ce- ae-A-e- cl�- Z,), �dt 4- i T a F1 f` �2- s `'f T - -� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) _ NORTH ANDOVER , Maas. Date ig—� I-V BuAding1 Permit # o O Y I Z�/ Location Owner's Name ) New ❑ Renovation ❑ Replacement ar-0, Plans Submitted:. Yea ❑ No ❑ 0 0 s R 4 0k h 00 K M K „ h K z o pap s O h W d M 1' sc z O o O ht w 0 K 0 dc d u r z s p K > < W p a1 K K K d a I 2 h K i } Z de hhr J h M O 1� � 0low O O Sue—esMT. • IIAI RMENT IST FLOOR IND,FLOOR I SAD FLOOR 4TH FLOOR STH FLOOR i STH FLOOR 7TH FLOOR t LSTH on-171 �. Check one: Certificate Installing Company Name Corp. Address lj Partnership ❑ Firm/Co. Business Telephone_ Name of Licensed Plumber or teas Fitter INSURANCE COVERAGE: Check one have a current liability Insurance policy or its substantial equivalent. ' Yes ❑ No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance pdicy td 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: nature of towner or Owner'sent 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 perfprn*d under the permit Issued for this application will be M compliance with all pertinent provisions of the Massachusetts Stale Gas Code and Chapter 142 of the General laws T of License: Plumber Tule na ur o nae um of or of Oasfiller CRY/Tgwn Master License Number . C�Journeyman APIT)0NED(OFFICE USE ONLY) Date. . . . !�,;?. . ./., . . . NORTH TOWN OF NORTH ANDOVER OF qti 3r y�tt`Eo PERMIT FOR GAS INSTALLATION SSACHUSE This certifies that . . . . . has permission for gas installation. in the buildings of . f'��t`. !?t. ,.�... . . . . . . . . . . . . . . at . . :-,. .. .! .l• (. /i. .', //, . . , , . . . , North Andover, Mass. Fee,16?. --Lic. No. �./.<^. . . . . . . . . . . . . . . . . . . . . . . . . . . . / Z' 4. GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File