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HomeMy WebLinkAboutMiscellaneous - 58 LINDEN AVENUE 4/30/2018 58 LINDEN AVENUE 210/045.A-0020-0000.0 01 4 Date. '5............................................ 0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING 0 This certifies that ............................................................... has permission to perform .......................................................................................................... wiring in the building of........................& ......................................................... ....... .... ..... at ......�—.g..... ........... North Andover,Mass. ............ ......... 7— 'tee,5�5 Lic.No. .. ...4 ............................. ......... .. ELECTRICALINSPE TOR Check# 13 3 1 A Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Seririces �— Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: /t�. 41�IP aVt, 10 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) Owner or Tenant L/Z IS%1/�✓ �/�j�(//�/ Telephone No. t y Owner's Address LAAE: Is this permit in conjunction with a building permit? Yes ,g No ❑ (Check Appropriate Box) Purpose of BuildingL `r MOUS Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd--o No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:(/(/j E Std 11-6 tzf ro /V 1C_W 4 0 C/4 T t o N r-o f>– Y-�/��l2- Q G 14 T" 6 /Uo Completion of the ollowin table ma be waived by the Ins ector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans o.o Total /I✓ . Transformers KVA I No.of Luminaire Outlets 4 No.of Hot Tubs Generators KVA jove n- o. o Emergency Lighting No.of Luminaires /j/ Swimming Pool rnd. ❑ rnd. Battery Units A.of Receptacle Outlets No.of Oil Burners FIRE ALARF No.of Zones No.of Switches No.of Gas Burners o.o etection an Total Initiating Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers eat u pI. um er ons o.o e - o0ine Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KWLocal❑ Municipal EJOther Connection No.of Dryers Heating Appliances KW ecurity S y stems: No.of Devices or Equivalent No.of Water KW o.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP a ecommunicationsirmg: No.of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. 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. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless lie 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 a BOND ❑ OTHER ❑ (Specify:) I certify,under thepains and enallies ofperjury,that the information on this application is true and complete. FIRM NAME: CTNr- ONrPTNO PT.FrTgTr rART.P.' LIC. NO.;A1 1983 Licensee: LO 1T ONTTNO Signature . LIC. Na "P.28788 (If applicable, enter "exempt"in the license number line) Bus. Tel. No.:9 7 s_16 3__5 4 2 0 Address: _, nnNnvaN nuWEST--NEW-BTJR%, >�111~A 1 985 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: $ I Location r1 " '� `J e-.- No. S� Date a �� . - TOWN OF NORTH ANDOVER {{ Certificate of Occupancy $ Building/Frame Permit Fee $ 34� etc ,' Foundation Permit Fee $ r e,sOther Permit Fee $ ' ' TOTAL $ Check# � i { Building Inspector Date . 9. . .0. .3 . . A TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . . . . . . . . . . . . . . . . has permission for gas installation . 1 . . . . . . . . . . . . . . . . . . . . in the buildings of. . . . . . . . . . . . . . . . . . . at . . `�S. . . , North Andover. Mass. Fee Lic. No. .��,�.�? GAS INSPECTOR Check# 3 32 o 8545 E MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING W RK !�� _ C CITY L.- • ,�.urfn„ ,2 � MA DATE��, PERMIT# JOBSITE ADDRESS OWNER'S NAME �5� A GOWNER ADDRESS TE >,��,� FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[J] EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW-0 RENOVATION: REPLACEMENT:© PLANS SUBMITTED: YESF-11 NO Q APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER _ J CONVERSION BURNER COOK STOVE r. DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER — LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL EATER _ I ( _.J __I ROOM/SPACE HEATER I _ ROOF TOP UNIT _-, _ -- TE&I` 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 MOL.Ch.142 YES 1096- I 0 _I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I OTHER TYPE INDEMNITY 0 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-0-1 AGENT ]-I SIGNATURE OF OWNER OR AGENT hereby certify that all of the details 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 installations performed under the permit issued for this application will be in complianc ith all Pertine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTERNAME l f- a .......�M,F:._. .. z_�.�i_ T� .✓ �( LICENSE# 4�, SIGNATURE MP[J MGF E-1 JP f JGF D LPGI 0 CORPORATION F PARTNERSHIP[- # LLC D!# _ -g_� COMPANY NAME: pADDRESS CITY �, _ - - --. STATE�ZIP �.�- F (TEL o FAX _ o?9'( CELL _ - . EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ Q m-� FEE: $ PERMIT# PLAN REVIEW NOTES l Y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 UV. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 1-14i Address: yl�_ � ' 7 01 -i'Il City/State/Zip: t-`J;4e v CJ 4/2( Phone#: (jj G,-Y - C,z,1P� 7a6' Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors ❑Remodeling2. m a sole proprietor or partner- listed on the attached sheet.t ship and have no employees These sub-contractors have 8. ❑Demolition 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.F1 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' 1311 Other comp.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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. am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site !formation. isurance Company Name: olicy#or Self-ins.Lic.#: Expiration Date: ib Site Address: City/State/Zip: .ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 F up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Lvestigations of the DIA for insurance coverage verification. do hereby certify and the pains and pe 'es of perjury that the information provided above is true and correct i nature: Date: / ,lone#: 0,_i — OO r Official itse 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 M , i 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 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,b checking the boxes that apply to your situation and if necessary,supply sub-contractors name (s),address es and phone numbers along with their certificates 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 of town may be provided to the ,p 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 burn 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 �I Boston,MA 021.11 Tel.#617-7274900 ext 406 or 1-$77-MASSAFE evised 5-26-OS Fax#617-727-7749 .. - _ www,massgov/dia s • N PNSED""A SA JOUti:!`EYMAN PLUMBER LICE - -• ISSUESyTI ABOVE4l ENSE (O THDMAS S FFARHADTA.N' 415 rMAIN� ST ..w.NH, >013b41 2073 ' HAMPSTEAD 19420 05/01/.14. . Date.. . . . . .. .. .. . . ...... . , ,�ORTIy TOWN OF,NORTH ANDOVER • PERMIT FOR GAS INSTALLATION r� �9SSACHUSEt� -. This certifies tha . . .�. .�. . . . . . . . . . . . .... . . ... :�. . . has permission'for gas installatio � f . . - . . in the buildings of . ,: ./.-ja�iJ�.r� . . . . . . . . . . . . . . at . . f �!1!gx-c.. . .h. . , North Andover, Mass. Fee � & . Lic No...37 ter. . . . . . . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR Check# x4795 MASSACHUSETTS UNIFORM APPLICATION;=FOR PERMIT TO DO GASFITTING (Print or Type) Q p Mass. Date Permit # 17-7f� Building Locatlon.. F L.! tJAUC- Owner's Named P—djnP,0 UESUAMrti1 --UQLIIAW6 Type of Occupancy kt540t-Wj fl- New ❑ Renovation ❑ R "I ement�) Plans Submitted: Yes[] No ❑ N a Y W N N N U Z rz 0 � N Z O � N = FZ W W w V m H z S �A tl z o u ~ Q z o +- Cr a m y H .,a, W o ° a r ,� N a of 0 W W s z � N O. `t > W W z yr W a a cc W r o 0 f- Z ; h Z f. W W It tl O > W }- U j W 7: a W Q C y. N m Z O z a O X Q W > a W 2, Q a Q p ¢ '.S O d Z U. 3 a tl . V G > a CL - O SUB—BSMT. BASEMENT 1ST FLOOR 2N0 FLOOR 3RDFLOOR 4TH FLOOR 1-7 STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name BAY STATE GAS COMPANY Check one: Certificate # Address 55 MARSTON STREET �C] Corporation 1.862 LAWRENCE, MA 01840 ❑ Partnership Business Telephone .687-1105 ❑ Firm/Co Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have aY currentliabilityliability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. If you have checked Yes, please Indicate the type coverage by checking the appropriate box. A stability Insurance policy , � Other type of indemnity❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent El I hereby certify that all of the details and information I have submitted(or entered)in abo plication are true and accu�te to the best of my knowledge and that all plumbing work and installations performed under the permit Iss f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene BY T of license: Plumber Signature o cense Plumber or Gas Title Gasfitter 3�1 �}5 Master License Number Cit /T Journeyman APPFi01/ED(OFFICE USE ONLY �i �w BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION i FEE N0. APPLICATION FOR PERMIT TO DO GASFITTING i NAME S TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIG NO. i 1 ' PERMIT GRANTED DATE GASINSPECTOR I Location No. — �f Date e* ca N°RT" TOWN OF NORTH ANDOVER i.. A Certificate of Occupancy $ # Building/Frame Permit Fee $ �Snda n Permit Fee $ a r ermit Fee r � Sewer Connection Fee $ M Water Connection Fee $ `< TOTAL uilding Inspector J p s •' L7 Div. Public Works Pm) .A,f ' f7o. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP KJO. LOT NO. 2 RECORD OF OWNERSHIP -DATE BOOK -PAGE ZONE I SUB DIV. LOT NO. F - LOCATION PURPOSE OF BUILDING OWNER'S NAME NO. OF STORIES SIZE OWNER'S ADDRESS BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET " POSTS DISTANCE FROM LOT LINES-SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST PAGE t FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC-METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED / LJ13 1 / SUILDING INSPtCTOR SIG UR OFOWNER L���/ OR THORIZW AGENT F E E � OWNER TEL.# PERMIT GRANTED B' CONTR.TEL.# CONTR.LIC.# <9 el H.I.C.# i9 /. BUILDING RECORD 1 OIRF UPANCY 12 V &tEES. SINGLE FAMIL sr IES THIS SECTION MUSTSH�(O�QW�, XACT?�(D.P�f N�1DF�D7�' I FROM MULTI. FAMILY ) oFF CES LOT RAGESNETCASUPER M �`� uN �i GA- APARTMENTS CONSTRUCTION 2 FOUNDATION 6 INTERIOR FINISH - CONCRETE _I 3 1 2 I3 CONCRETE BL K. PINE _ BRICK OR STONE HARDW D PIERS PLASTER _ DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B M'T' AREA _ '/ 1/1 1/ FIN. ATTIC AREA _ NO B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS 8 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARD1!✓'D _ ASBESTOS SIDING _ COMMCN VERT. SIDING ASPH. TILE STUCCO ON MASONRY _ STUCCO ON FRAME BRICK N MASOTTIC STRS. & FLOOR I_ BRICK ON FRAMENR CONC. OR CINDER BILK. STONE ON MASONRY WIRING STONE ON FRAME SUPERIOR POOR ADEQUATE I-1 ONE 5 ROOF 10 PLUMBING GABLE I HIP BATH (3 FIX.) GAMBRELMANSARD TOILET RM. (2 FIX.) A FLAT SHED WATER CLOSET ASPHALT SHINGLES LAVATORY '�` WOOD SHINGES KITCHEN SINK AVVV\ \ SLATE NO PLUMBING ��..// TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES {� 5 TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD J ISNEELESS FURNACE t �' CED HOT AIR FURN. TIMBER BMS. 3 COLS. STEAM STEEL BMS. 8 EO HT W'T'R OR VAPOR QL \T \\v\ WOOD RAFTE A 3CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OFR O! S COIL B'M'T 2nd ELECTRIC 1st 13rd NO HEATING NORTH Town of � M. bAndover ro No. 4 y ori dower, Mass.,- 319,76 P COCMIC nE wICK ADRATED "q � BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.......... .... .... ... .. .. . ... ..... .. Foundation has permission to weet........ . ......... buildings on ... ... ...... ........ Rough to be occupied as...... Chimney .... ....... .... e provided that the person accepting this permit II in every respect conform to t&d6ms_o�f the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings In the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS ' Rough eo- .. ....... . ............. ....... Service BUILDING INSPE TOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in Conspicuous Place on the Premises — Do Not Remove Rough P Y a P Final No Lathing or Dry Wall To Be Done a FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner PLANNING FINAL CONSERVATION FINAL Street No. Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT &ASSACHUSETTS UNIFORM APPLICATION FOR PERMIT To DO GASFITTING ole, (Print or Type) NORTH ANDOVER Mass. Date 4uilding Location S Permit # I Owners Name @ e'41 c� f4--i (3.2,- t New Renovation Replacement 13,-' Plans Submitted FIXTUPcc a r � x 4 a m 3 O U m f" « z N ° m t•- a x a C f. a a m y t- a cc o ° ° z t— CC W 6 W W t. yt 0. CC W 4 0W z U W x W W aC CC a t, X o I-- z J z F- W d > LL. W Z d W d Cts ., f' y. N p� :. 0 2 WW ° N = d ,W > a W , 2 41M <j < 0 0 W ° W U, R O 0 u. a c7 .j V tz > ❑ d t- O SUa—BSMT. BASEMENT 1ST FLOOR 2ND FLOOR G1 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR (Print or Type) // Check one: Certificate Installing Company Name (6:1 4--i �- Q Corp. Address /'0 X lc�U a-,—a Partner. V G✓t- L.J, Firm/Co. Business Telephone: ��L� d Z Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy [ Other type of indemnity Q Bond E] 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 coverages. Signature of owner/agent of property Owner Agent i hereby certify that all of the devils and information 1 have submitted (or entered)in above application are true and accurate to the best of my knowledge and that al! plumbing work and Installations perforated under Permit iuued for this application wW-be in compliance with au perttneat provisions of the Massachusetts Slate Gas Code and Chapter 142 of the General Laws. ' TYPE LICENSE: By . lumber Title Gasfitter Signature of Licensed City/Town: Master Plumber or Gasfitter Journeyman 6 3 (� APPROVED (OFFICE USE ONLY) L1censE'_ Number C'"If-gff ��oo of N°DTs ,tio TOWN OF NORTH ANDOVER FO? PERMIT FOR GAS INSTALLATION SSACMUSEt This certifies that . . .P'. . . . . . . . . . . ... . . . . . . . . . . . . . . has permission for gas installation . . . ... . . in the buildings of . ! !: . . . PIC. �. . . . . . . . . !. . . . . . . . . . . . . . . . at . . .` r:. !... ... . . . !`qtr. . . . . . . . . . ., North Andover, Mass. Fee.f . . `. . . Lic. No. � . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( I - GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File