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HomeMy WebLinkAboutMiscellaneous - 59 HEMLOCK STREET 4/30/2018 59 HEMLOCK STREET 210/045.G-0059-0000.0 Date.... 711./........... t tIORTh TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING This certifies that ............ ... .... . .c.I............................................................. has permission to perform/ . . . .....I. .. ........ . -'�—,Aking in the building of................ ................................................................................ 1.1 North Andover Mass at ................................................................................... 2 Fe1. e'�.. ..&.........Lic. No. .77. ......6 ........ ...... ...... ... - - -ETRi D � �C Check# �I 1 Commonwealth of Massachusetts Official Use Only Per>mt No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS , [Rev.9/05] (leave blank) .APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK, All work to be performed in accordance with the Massachusetts Electrical Code(1v1EC),527 CMR 12.00 (FLE'ASEPRI 1Yfl,1K OR=EALL INFORMATION Date: City or ToWn of: t J0<1J�\ A'Y0 0.0 9'Q To the Inspector of fres: Cl�1 4�\ By this application the undersigned gives notice of his or her intention to perform the electrical work described below. l\ Location(Street&Number) q0,th 1_0C'�—' S"C2e e-C Owner or Tenant S, L. po 1y Telephone No. TW ' Ll 6Sc1 e) 1 Owner's Address .Scc-1� Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building - Utility Authorization No. Existing Service Amps'. 1 Volts Overhead❑ Undgrd❑ No. of Meters New Service Amps, / Volts Overhead❑ Undgrd❑ No,of Meters Number of Feeders andAmpacity / Location.and NatareofProposed ElectricalWork., C,InuwcaA I�lecTn�cG ( �20of1'*^n► Pc u�� C�uTlpr ' � oazTabl� � Tc�►2 Completion of the followtn-table may.be watved the Inspector of FPires. No. of Recessed Luminaires No.of Ce>1.�sp.(Paddle)Fans No. of Total Transformers KVA No, of Luminaire Outlets No. of Hot Tabs Generators ��S KVA ' 9— Above In- o. o Emergency g grnNo. of Luminaires Swimming Pool d. ❑ grnd. ❑ Battery Units " No. of Receptacle OutletsNo.of Oil Burners FIRE ALARMS No. of Zones No.of Detection and. .�..i No. of Switches No.of Gas Burners 'h tiatin Devices �- • •� No. of Ranges No, of Air Cond.. Tons No.of AlertingDevices ` Heat Pump Number Tons' KW No. of Self Contained No. ofWas#eDisposers Totals: Detection/Ale Devices ' }"{ No. of Dishwashers Space/AreaHeating�KW Local❑ Municipal ❑ Other Connection •� No. of Dryers Heating Appliances KW 5ec>sity fDev or Equivalent � No. of Water No. of No. of Data Wiring: i *: Heaters K� Signs Ballasts No.of Devices or Egutyalent $ }..j r--{ Telecommunications Wiring _ No.Hydromassage Bathtubs No. of Motors Total HP No.of Devices or Equivalent OTHER -- A tach additional detail if desired or as regtidred by the Inspector of Fires. 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 C OVERAGE: 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 g BOND ❑ OTHER ❑ (Specify.) I certify, under the sins and penalizes of perJccry,that the infanna�ion on this app&cat on is true and complete FIRM NAME. Cj, % " LIC.NO.: Q 077 Licensee: Q 1 •�Al Tdt._ Signatnxe LIC.NO.: [( a (If applicable, enter anpt' int�l license munber hhe.) Bus.TeL No.:Q���7 �O Address:(4 0 ncl&%q( te=e e-t N Qy C?ti� i t, _ M/A 0 (83Z, Alt TeL No.: *S-ecurity System CcEtractoi License requrred for this worlr,if applicable,enter the license number here: OWNER'S INSURANCE WAIVI;.R I•am aware that the Licensee does not have the liability ir.surance coverage normally required by law. By my signature below,I hereby waive this requinement. I am the(check one)❑ owner []'owner's a ent Owner/Agent Signature Telephone No. FEE: � � . .The Coxn�rtonwearih af'll2"assach.use& • . Offaee of Invesfigafeoas 600 Washkgton,Street Boston,MA 02111 wi m ass govIdia Worke]r$,compensation Ynsurance Affidavit:BuRder,,iCoyit°actorsIFIectr lcla)Llql*bBrO Appltranatxon Please.Vrxnf T--JT-xy 'Name(BusinosiorganizationJl (Rvidual): Address: VZ3 C City/Statelzip: E___� n��o21�1�, ►MA �tA� 'hang -7��3�� � �c .Are you an employer?check the appropriate box: Type of project(required): �. []X am a general contractor and T F 1.�( T am a employer with __. �. ❑Now c6nstructzon employeos(fun and(orpaxttime)T have hiredthesub-contractors 2. 1 am a soleproprietor orpartn.ex listed on the attached sheet.� 7• n�-emodeling hip and`haveno•employees Time sulr-c(ntractoxshave 8. [(I)emolition working forme in any capacity. workers'comp.insurance, g. Building addition [No workers'comp.insurance 5. ❑we are a corporation and its 101]Electricalrepairs or additions xecluired.� officers have exercised.their 3.01am a homeowner doing all work right of exemption per MGT 1l-[]Plumbing,repairs or additions mys6Y Ufoworkers'comp. c.152,§1(4)a andwehaveno UPRoofxepairs in¢nrancere ed. employees.[Nowoxkexs' 18.0 Other comp.insurance required.] =Any applicanttliat checks box#�I musEalso iill oucthese�fion beldwshowing theirwbrkers'compensation policy infbimation. Homeowners who submitthis affidavitindicating they ire doing allwork and then hire outside contractors must submit a new affidavit indicating such. ToDn-ttactors that cheAthis box must attached as additional sheet showingtheMyna of the sub-contractors andtheirworked comp.policyfnformation. am are -mofoyei thal s vroviding wOFIfi s'cornperasation ir�sr��ar2ce fog�.�y ernproyees Beiow is Aepolicy amijob 5*e infax�matior2. . Insumuce Company Name% Policy#or Saxf 7ns.f'ic.#: Expixation.Date: lbbSite Address, City/Statel p: Attach a copy of fha wo-rkers'compensation-policy ileclarallo)a page(showiug•tlie polxcp manber and expiratloa date). Failure to secure coverage as xequireduuder Section 25A ofMOL c.152 can lead to the imposition of eriminalPenalties of a fine up to$1,500.00and/or one�year imprisn�;unent�as well.as civilpenalties xn.the forn�.of`a STOP V�OR�ORDER.and a fine aimt the violator. Be advised that a copy of this statement may be forwarded to the Office of of-up to$250.OQ a day ag fnvestigations oi:ffio DIA.for insurance,coverage verification. �dolae�eby c rt�fyurider ilieliainsandpenaZtie�soj pe�jurytliattlteirefo�natior2p�ovic�ec�a�oy fraeand Preet Si afore: Date: a 4 Phone#: O ciaZ use©_Vly. ,Do r2ot write in Mis area,to be completed ry city or tO olei I- City or Town: Perminiceose# IssuingA.rxthority(circle one): 1.)3oard of Health.2.BuildinglDepartmen.t I dCitylTowaz Clerk 4.Electrical Inspector 5.Plumbingfuspector• f.Other - - Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Puxsuapt to this statute,an e�r�,ployee is defimd as"...every'person k the service ofanother under any contract o hire; • express orimplied,oral orwxitten." An,eng1loyWig defined as"an individual,partnership,association,corporation or other regal entity,or any tyro oxzLtaxe. ofthe foregoing engaged in ajoint enterprise,and includingthe legalxepxesentatives ofa deceased emplQyex,.ax the receiver ortrustee of au individual,partnership,association or other legal entity,employing employees, l ewevex o owner of a dwellinghousehavingnotmoxe thaatbree apartments andwho xesides therein,orthe occupantofthe dwelling h oum of another who employs persons to do maintenance,ConsttuctiolL ox repair work oa such.dwelling house ox onthegxounds oxbuilding appurtenantthereto shallnotbecause ofsuch employm.entbe deemedto be an employer." MQL chapter 152,§25C(6)als o states that"every state or to cal IteenM* g agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth forany applicant who has not produced"acceptable evidence of compliance with the insurance coverage repwad:' Additionally,.u'.�QLr chaptex 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contxactfor the performance ofpublic woxkuntil acceptable evidence of compliance with the insurance xequiiements of this ch.aptexhave beenpreseoted to the contracting authoilty," .Applicants Please X11 out the workers'co m* onsailon affidavit completely,by checking the boxes that apply to your sitaatioxz and,if 9iecessaty,supply sub-contractox(s)name(s),addresses)andphonenumber(s)along with their cextifzoate(s)of insurance. LimitedUabilityCompanies(LLC)or UiltedLiabilltyNiaerships(LU)Vdthno employees othexthmthe members orpattnexs,arenotrequiradto can7workers'compensationh=s nce, Han LLC orLLP does have ez�aployees,apolicyisrequired. Do advisedthattbis afddavitmay be submittedto the Department of Tndu&1al Accidents for confirmation of insurance coverage. .Also be sure to sign and date the affzdavi. 'the affidavit should b e xetumed to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Shouldyou leave any questions regarding the law or if you are required to obtain,a Workers' compensationpoEey,pleasecalltheDeparEmentatthenumbexlistedbelow. Sel-&h=edcompanies shouldentexthok ' seli~insurance license number onthe appropriate line. City or TOM Qfizcials Please be sure that the affidavit is complete andprinted legibly. TEoDopathuenthasprovidedaspacoatthobotom of the addavzt foryou to fill out in the event the Office ofTnvestzgationshastc contactYou regarding the applicant, Please be sure to fll inthe permit/lz'cense number tvhicla will be used as a reference number. Tit addition an,appi1cant that:t6st submitmuWple pexmit/license applications in any givenyear,need only submit one affidavit indicating current Policy information(if necessary)and under"lob Site Address"the applicant shouldw2a"all locations in (city or town)"A copy o£the affidavit that has been officially stainped ox marked by the city ox towu maybe provided to the a pplicantasvrooffhatavalidaffidavit.lson,:Wefoxfuturepexmitsorlicenses. Anewaffidavitmustbefilledouteach year.Where a dome owner ox citizen is obtafi a lice e ns ox ermi g tnotxelatedto p anybusiness or commercial venture (i.e.a clog license orliermit to burnt leaves eta,)saidperson is NOTxequired to complete this affidavit. The Office ofInvestigations'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 Depattment's address,telephone aitd faxnumber; 60G WasWh S xe S0. ton, 02111 TQL 617H72Z-49-00 ut 406 Q-1-877"- _ Revised 5-26-OS Faye 1 GENERATOR APPLICAT DATE: LOCATION: ,2-714 A� ► o�<( OWNERS NAME: S4 I L_t fav-r G E N E RATO R kw -7,9 k—LJ NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: PHONE NUMBER: S? aQ� ELECTRICAL GAS RESIDENTIAL COMMERCIAL MPORARY )--- LOCATION OF GENERATOR: D wTIeT *ZONING DISTRICT: mPLANNING APPROVAL (IF IN WATERSHED) *CONSERVATION APPROVAL r North Andover MIMAP August 27, 2014 F s .y, - wf 1_ 09 •' P � yrs ��{�t ~{ .. i . CHIS E� 6 E#h O S 4� '1f WEA �y ff r « , �, .w •� � old. .-� " Interstates —I SR Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, Roads Meters Data Sources:The data for this map was produced by Merrimack � M Valley Planning Commission(MVPC)using data provided by the Town of {Easements North Andover.Additional data provided by the Executive Once of C3MVPC Boundary �j. �« ��O� Environmental Affairs/MassGIS.The information depicted on this map is for planning purposes only.It may not be adequate for legal boundary (iPemels i definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING t # THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY 4 OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT o* !r ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION 1"=82ft i • ............. NORTFI TOWN OF NORTH ANDOVER O p PERMIT FOR WIRING SSACNUS� This certifies that ..kA".A.A .....ae k..I.?z. ........ ................................ has permission to perform ... 4?!. t. ...................................................... wiring in the building of sqz k.'q. ''�C- L a�'2' at...15f !2z.A?,.2.... -.................... .. . .North Andover,Mass. i Fee. .. ....... Lic.No. J,/J '��'.........4LEC'MICAL ........ . &. INSPE R nn / a` Check # "l _� 8326 1 I (f wnuweaR of)Wamachadetb r Official Use Only t_ cc-�� Permit No. 2 2epartmenf ol5ire Serviced 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 TYPE ALL INFORMATION) Date: i CJ8w0 City or Town of: pJo•zl­�_ R -,LLQ J To the Inspector of fres: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street&Number)_j Owner or Tenant. �,_ Telephone No. q-7 S A,\V!A T c� 2 cam_.__.__�,�o 4A'_ (P r Owner's Address 0,81ne Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building 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: c_u 01 P E(J quvt Q P421 Ru'b 40QTFP-\ Slor1�y p Compietion'of the folloiving table may be waived by the Inspector of Wires. of No.of Recessed Luminaires No.of Ceil.-Sus P (Paddle) Transs Total Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators- KVA Above In= mergency Lighting No.of Luminaires Swimming Pool rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners :5 Zoa,r,, FIRE ALARMS No.of Zones No.of Gas Burners �, o.of Detection and No.of Switches � 10 Q Initiating Devices No.of Air Cond. Total No.of Alerting Devices No.of Ranges Tons No.of Waste Disposers Heat Pum Num.. ons,er K o.o Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Connection Heating Appliances KW Security Systems:* No.of Dryers No.of Devices or Eq uivalent No.of WaterKM, No.of No.o Data Wiring: Heaters Sign Ballasts No.of Devices or Equivalent elecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Tota!HP No.of Devices or Equivalent OTHER: Attach additional detailrlf desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: __&ho' (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and uponcompletion. 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 4 BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: (, U �c _C-u ' LIC.NO.: E l7 0 2� Licensee: Signature W LIC.NO.: F_l7 G 7 7 a.�. ��t,,t`tr� (If applicable, enter `xempt"in the license number line.) Bus.Tel.No.: 4�f? 1?2PaG� Address: R� M� ST2C v.r � t U-C d� 3L Alt.Tel.No.: *Per M.G.L.c. 147,s.5t-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. j Owner/Agent PERMIT FEE: $ 0�6 Signature Telephone No. �T 3qa �I ' The Commonwealth of Massachusetts ,^, ! Department of Industrial Accidents Office of Investigations 600 Washington Street \ bNpI �-, Boston, MA 02111 \ www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly �j Name (Business/Organization/Individual): a l a 0�x T'1 i ea E L e GT2,c Address: ict 0 &1-1 _ � s-rq,.el City/State/Zip: ���e��..�(( 'Alp Phone#:_ {2 P' 37 9z U,0? - Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors • 2.'Jam 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. 9. ❑ Building addition [No workers'comp. insurance 5. El We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 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' 131-1 Other comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. +Homeowners who submit.this a„idavii indicating they are doing ati work and hien 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: Policy#or Self-ins. Lic.#: 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. I do hereby under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 2, SP 1- a 5 Phone#: C0 7,4 2 d 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#: ct 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,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)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 cant' 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 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 Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26-05 www.mass.gov/dia Date. . . . . . . . i �'.".O1OT�.��O TOWN OF NORTI ANDOVER ' PERMIT OR PLUMBING ,SSACMUS� F. . . . ' . . . . . . . . . . . . . . . . . . . � This certifies that `� . . . . :--�1.--Q:�-� . .,. $: has permission to perform . . . . . . .: . . . . . . . . . . . . . . plumbing in the buildings of .,. . . . � . . . . . . . . . . . . . . . . . . . . at . . . . ... . . ?. . . . . . . . . . . . . .. North Andover, Mass. Few . . . . .Lic. No.. � . .. . . . ` �PLUMINSPECTOR Check ff S Goo i' 7696 tyrantoriype) r' Al ,Ms. Date/ 20/ l � Q �Permit# OBuilding LocatioOwner shame� 'SA'11X1 ez v Q,r1fr Owner TelType of Occupancyo/ /X/y// � New �i' Renovation.o Replacement.❑ Plan Submitted: Yes ❑ No ❑ FIXTURES Z' �• d o z �" C w N y Qa U F z o z N a a O •z W E, W E. U U z Wj a H U x ! _ .a Z y 3 " a O F Z W O U Q < x y O < O SUB-BSMT IST Em Nn 3"FLOOR 4"c FLOOR 5n'FLOOR 6"H FLOOR 7°H FLOOR aR'HrionRl e Installing Company Name /-4/cC Check one: Certificate a Address�3 /J A lQ TS WC 0 ,0 D !'ll ❑Corporation h1,41 0 / 3 o ❑Partnership 4!7C Telephone# :�Ip P J, 0 91 ❑Firm/Co. Name of Licensed Plumber V/-VC ext 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 have checked Les,please indicate the type coverage by checking the appropriate box. A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:1 am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. :i:gn eral 'and that my 2Zsignature on.this permit application waives this requirement. • Check one: Owner X Agent ❑ atuie of Owner or Owner's �ent I hereby certify that all of the details and information I have submitted(or entered)in above application are true aqd accurate to the best of my knowledge and that all plumbing work and installationssp rfotmed under the permit issued for this application will be incompliance with all pertinent provisions of the Massachusetts State Plumbing,Code and Chapter 142 the General Laws. By Signature of Licensed Plumber. Title _ Type of License:Master)< Journeyman ❑ City/Town . . p APPROVED(OFFICE USE ONLY) License Number O i FOR OFFICE USE ONLgf INALINSPECTION SKETCHES PROGRESS INSPECTION I PEE No. APPLICATION AOR PERMIT TO DO GASFITTINO NAME i.TYPE OF BUILDING ILOCATIONOF >3UILD1?IO PLUMMA OA GASFBTTER - m , LIC NOS ?sRMIT GRANTED . . 'DATE GAS INSPECTOR