HomeMy WebLinkAboutMiscellaneous - 60 RUSSELL STREET 4/30/2018 l
-60-60 RUSSELL STREET
210107 000-0
5/31/2016
Date: May 31, 2016
20329
This is an e-permit.To learn more,scan this barcode or visit northandoverma.viewpointcloud.com/#/records/20329
❑.� .❑
TOWN OF NORTH ANDOVER
fry. PERMIT FOR WIRING
��Rarev s�"� ■
This certifies that Anthony D Perelli
has permission to perform remove ungrounded wiring and add 6 new curcuit to replace
wiring in the buildings of Nicholas Bordeianu
at 60 RUSSELL STREET , North Andover, Mass.
Lic. No. 53382
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Date.......... .....
TOWN OF NORTH ANDOVER
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PERMIT FOR WIRING
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This certifies that 7....B........4.... Aih—C-Lr
.........................................
....................................................
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has permission to perform ................................................................:,:�....................................
wiring in the building of....... �,..Nv.........................................................
at 2-
.................................................. ............North Andover,Mass.
Fee..95��.............Lic.No.zl.v��....................................................................................
ELECTRICAL INSPECTOR
Check#
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Commonwealth of Massachusetts OfficialUse 1y
Department t of Fire Services Permit No. 1 l
p Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank
M
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 NK OR TYPE ALL)NFORMATION) Date: 3 A b
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) 6,:9. S7—
Owner or Tenant Telephone No.
Owner's Address SaY-4
Is this permit in conjunction with a building permit? Yes E2'--No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
4 - 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: a`rZ` �oocv. inoQ
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans ;' No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires SwimmingPool Above ❑ In- 1:1 o.o mergency Lighting
rnd. rnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones
No.of Switches -3 No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
g Tons
No.of Waste Disposers Heat Pump N_ umber Tons KW No.of Self-Contained
.. . .......................................................
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
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 Telecommunications Wiring:
No.of Devices or Equivalent
r
OTHER: j(�
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
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such covera ism force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties ofperjury,that the information on this application is true and complete.
FIRM NAME: . c 160 c, LIC.NO.: 3
Licensee: Signature LIC.NO.: cZ/(o y34
(If applicable,enter "exempt"in the license number line.) - Bus.Tel.No.• 329'— (1,23-3/a7
Address: 02 Tz?!,,.,ar u L-4 /2rfl /a i s-76;,r- 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 PaMITFEE.$
Signature _, Telephone No.
'f
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the v
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 may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
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 applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012.
❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑
❑Permit Extension Act—Permit/Date Closed:
Trench Inspection
Pass M Failed IN Re-Inspection Required($.) ❑ �.
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass M Failed Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass[a Failed Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
ROUGH INSP TION: "r't
Pass V Failed Re-Inspection Required($.) ❑ }
Inspectors Comments: '
Inspectors Signature: Date:
FINAL INSPECT ON:
Pass Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date: —A �,
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
M Department oflndustrialAccidents
t 1 Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le0bly
Name(Business/Organization/Individual): !�,rtaz;_A
Address: c 0.V►-�0.V`Q C� rQ
City/State/Zip: WffaS Phone#:
Are you an employer?Check the appropriate box: Type Of project(required):
1.❑I am.a employer with employees(full and/or part-time).* 7, ❑New construction
2.F1 I am a sole proprietor or partnership and have no employees working for me in g. E]Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
S. I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
❑ 13. Roof repairs
• These sub-contractors have employees and have workers'comp.insurance.$
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no.employees.[No workers'comp.insurance required.]
*Any applicant that checks box#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.
tContractors that check thisbox must-attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site
information.
Insurance Company Name:
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 MGL c. 152,§25A is a criminal violation punishable by 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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature s Date: /6
Phone#: 99$"— `f P3
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 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)naine(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-iii'sured 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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel.# 617-727-4900 ext.7406 or 1-877-NIASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
:COMMONWEALTH OF MASSACHUSETTS
• • •
E.LEtTRO'C 1 ANS.
ISSUES THE FOLLOWING LICENSE AS A .: i
REGISTERED MASTER ELECTRICIAN Ic
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,Z
BRIAN M BOUCHER SR
� W
2' TAMARACK RD ui
z
PLAISTOW NH 03865-2774
?1643 A ' 07/31/16 77997
i
The Commonwealth of Massachusetts
.0 Department of industrial Aceldents
M ' ^ 1 Congress Sheet,Suite 100
_ Boston,MA.02114-2017
�t www mass.gov/dia
Worke&,Compensation Insurance Affidavit:Builder/Contractors/Electricians/Plnxnbers.
TO BE FILED WITH THE PERMITTING AUTHORIZ '. Please Print Lt bl
A ''licant Information `
Name(Businsss/Oxganizat on/indiVidual):
Address: `�
e
City/State/Zip: cue
,✓
C
ro riatebox: Type of rojecf(required);
Axe you an employer.Chec
1.[�I am a employer withefnk the app p
(full and/or part-time).* 7. New doristriiollon
P to yees
2.❑I am a sole proprietor or partnership and have no employees working forme in 8. E]Remo de&g
any capacity.[No workers'comp.insurance required.] � 9, Demolition
3.❑I am a homeowner doing all work myself Fo workers'comp.insurance required.]t 10❑Building addition
4.[j I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11[]Electricaor aclditibns
l repairs or additions
ensure that all contrac&s ether have workers'compensation insurance or are sole 4 A
�.. 12.�,;'PlO nbing repairs'
pro rietors with no•employees.
S. "am a general contraefo'and I have hired the sub-contractors listed onthe attached sheet. 13; Roof repairs
These sub-contractors have employees and have workers'comp.insurance.T 14 Other
6.F1 We are a corpoza-— and ifs,officers have exercised their right of exemption per MGL c.
152,§1(4),and We Havo�do employees:[No workers'comp.insurance required.]
*Any applicant that chgcls bqX ]:must also fill out the section below showing their workers'compensation policy information:
i Homeowners who subdk§,'b is affidavit indicating they are doing all work andthen hire outside contractors must submit anew affidavit indicating such.
$Contractors that checkthis box must attached'an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
lam an employer that is providing-workefs'compensation insurance for my employees. Below is the policy and j ob site
information.
Insurance Company Name: v!J
' � � Expiration Dater/� -�G
Policy#or Self ins. ic.#: /�tJe %,fib l, D� � / /,
Job Site Address:
�• .�C/ City/State/Zip:A- �/U/
Attach a copy o 'Lw' kers'compensation policAdec
ration page(showing the policy number and expiration date).
a foie up to$1,500.00
Failure to secure coverage as required under MGL e.152,§25A is a criminal violation punishable by
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DTA for Insurance
coverage verification.
' tliepains andpenalties ofperjury that the information provided alcove is true and correct
X do hereby cer and
Date• � ��
Si ature:
Phone#: 7
Official use only. Do not write in this area,to be completed by city or town OfficiaL
City or'To-wn• 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
Phone#•
Contact Person:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their emlloyes:
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract o:�lii e,
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 enferprise,and including the legal representatives of a deceased employer,or the
receiver'&-trusted oi'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 df 1d
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-whd�has'not,produced-acceptable evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 152,§25C('1)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=contractox(s)name(s),address(es)and phone number(s)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 aff Avit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidenis. Should you have any questions regarding the law or if you are required to obtains a v's&kers'
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 orpermit 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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext:.7406 or 1877-AIASSAFE
Fax#617.727-7749
Revised 02-23-15 wwwmass.gov/dia
ABSOLUTE ROOFING 9
BERUBE PLUMBING & HEATING
BRIMAC ELECTRIC
RICHARD ROONEY
MORGADO CONSTRUCTION
A CONTE )r�otvq Gla f-" C)ti
DON QUINTAL /40�
CSI C"(, o
Y
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µoRry
1
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NORTH ANDOVER BUILDING DEPARTMENT
1600 Osgood Street
�sSACHU
North Andover
Tel: 978-688-9545
Fax: 978-688-9542
BUSINESS FORM FOR TOWN CLERK
DATE:
NAME:
ADDRESS: 6c
ZONING DISTRICT: I`- Ll
TYPE OF BUSINESS:
BUILDING LAYOUT PROVIDED: YES NO
AVAILABLE PARKING SPACES: DJJNzz
ZONING BYLAW USAGE: YES NO
BUILDING INSPECTOR SIGNATURE
BUSINESS FORM FORTOWN CLERK
2.40 Home Occupation 1989132
An accessory use conducted within a dwelling by a resident who resides in the dwelling as his principal
address, which is clearly secondary to the use.of the-building.for hiving ptuposcs. Home occupations shall
' include,"but not•limited to the following uses; personal services such as famished by an artist or instructor,
b
• ut not occupation involved -with motor vehicle repairs, beauty parlors, animal kennels, or the conduct of
retail business,or the manufacturing of goods,which impacts the residential nature of the neighborhood.
4. For use of a dwelling in any residential district or multi family district for a home occupation, the
following conditions shall apply:
a. Not more than a total of three (3) people may be employed in the home occupation, one of
whom shall be theT owner of the home occupation and residing in said dwelling,
b. The use is carried on strictly within the principal building;
c. There shall be no exterior alterations, accessory buildings, or display which are not customary
with residential buildings;
d. Not more than twenty-five (25) percent of the existing gross floor area of the dwelling unit.
so used, not to exceed one thousand (1000) square feet, is devoted to'such use. In
connection with
such use,.there is to be kept no stock in trade, commodities or products which occupy space
beyond these limits;
e. There will be no display of goods or wares visible from the street;
f. The building or premises occupied shall not be rendered objectionable or detrimental to the
residential character of the neighborhood due to the exterior appearance, emission of odor,
gas, smoke, dust, noise, disturbance, or in any other way become objectionable or
detrimental to any residential use within the neighborhood,
g.' Any such building shall include no fe res of design not customary in buildings for residential
use.
Signature Date-
I
i
November 4, 2011
Building Department
Brian Leathe
Building Inspector
And Commissioner
Town of North Andover
Dear Mr. Leathe
I as the property owner at 60 Russell St.,Albert Taylor, respectfully request that you allow my
son James Taylor to use my address for his DBA—JET ELECTRIC. He uses% of my garage to store
electrical stock and as somewhat of a workshop. He does not have customers come to this
address nor is his truck parked here overnight. As an Electrical Contractor, he basically works
out of his truck, in which he conducts most of his business, including calls on his cell phone and
some computer work on his lap top.
My son James holds a Master Electrician license in MA, registered under his name,James E.
Taylor and in order to change the name on his License and become registered with the State of
MA., and be issued a new license under the name-JET ELECTRIC, he needs to set up this DBA.
Thank you for your consideration in this matter.
Sincerely
Albert H.Taylor
F •--
60 Russell St
No Andover, MA 01845
(978) 686-5345
Date./ .l.4,/6• . .... . .
I
NORTh
o? °` TOWN OF NORTH ANDOVER.
• PERMIT FOR GAS INSTAL ION
•` CMUSE4�y
This certifies that . . . c.. . . .!r . . . . . . . . . . . . . . . . . . . . . . . . . .
has permission for gas installation . . . �. .t:�:. . . . . . . . . . . . . . . . .
in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I at . . .3.-. .�:. �. . . . . . . . . . . .t , North Andover, Mass.
Fee. r . . Lic. No..P O.16. . . l -� ��. . . . . .
GAS INSPECTOR
Check# 3 7
r
5394
4nspec on of Gasfitting
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
�1 � 3�1
-- Mass. Date Permit #
Building Location s-�(-1�V5�61 Owner's Name/
Type of Occupancy 1VI
New ❑ Renovation ❑ Replacement ] Plans Submitted: Yesp No❑
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SUB-SSMT.
BASEMENT
r 1ST FLOORIA
2ND FLOOR l '-
3RD FLOOR
-----
4TH FLOOA '—
STH FLOOR
6TH FLOOR
7TH FLOOR
BT'HFLOOR
Installing Company Name�(���«Y iC�`S ��_m� Cheek one: Certlticate
Address C( py0 r0 S ypnf
Corporation o
Q Partnership
Business Telephon ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter po r�
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes R No, ❑
If you have checked yM, please indicate the type coverage by checking the appropriate box.
e A liability Insurance
policy P6 Other type of Indemnity O 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 ❑
I hereby certify that all of the details and information I have submitted(or entered)in above
knowledge and that all plumbing work and Installations performed under the permit iss f p isaa�on a tr wiandll be I ur to lthe best of my
pertinent provisions of the Massachusetts State Gas Code and Chaplet 142 of the Ge aws. piance with all
=Title
T e of License.
Plumberignature of License um er or s itterGasfitler
Master License 1VumberLMast�Jovtneyman
I
- �i.Nk�4`IN�PEC`hONs aK1ETOME! •
FEE
. - . . RR0�.01!`,33.INfPtCt'tONa
N0.
APPLICATION-FOR PERMIT TO 00 PL
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