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HomeMy WebLinkAboutMiscellaneous - 67 EMPIRE DRIVE 4/30/2018 �` 1\ � 7 ��o� �� ��P��� i i �� 900, Date.`7- 15.`,�. . �Tol 1�o TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING ,SSACMUS� ff h This certifies that . . . . . ` . . . .`.'r""?. . . . .l �.�° .... . . . . . . . . has permission to perform . . . �r. .1. .. . . . . . . . . . . . . . . plumbing in the buildings of . . .V Nin ?. . .M11C-- 6 t`.1\1".�?. . . . . . . . at . . G.7. . . . . . . . . . . , North Andover, Mass. Feed`{ ' ' . .Lic. No.. . . . . . . . . PLUMBING INSPECTO Check # vr1`1 r�I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town:/ �r�,ric?�e MA. Date: l� Permit# Building Location: Owners Name: Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential jo L. New:M Alteration:❑ Renovation:❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES f DEDICATED Z SYSTEMS z z > Y V LU> z H �n Ln d Ln ? x in Li 0 LU Q w C7 l Z o ¢ W o Ln a z o N o ° s J ¢ ¢ L.LH D o w Z w Z u ° LL LU u Fx- x a o F- u Z ¢ a s ¢ Z w w oif O w w c a ¢ 0 Ln o o > > o 0 o z z = o i s �- d m m o o LL x Y g g m y = d ¢ ¢ �. N 3 3 0 ¢ ¢ -SUB BSMT. 3 BASEMENT 1'FLOOR 2ND FLOOR 3RD FLOOR 4T"FLOOR ST"FLOOR 6T"FLOOR 7T"FLOOR 8T"FLOOR Installing Company Name: e Check One Only Certificate11 # El corporation Address: City/Town:/ State:zg (� El Partnership Business Tel: /�r���3 Fax: 1❑/ Firm/Company Name of Licensed Plumber: ( YG�v✓LLl) 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 Yes,please indicate the.type of coverage by checking the appropriate box below. `A liability insuranceolic ' p Y 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Si nature of Owner or Owner's A ent Owner ❑ Agent ❑ , 1 here by certify that al!of the details an d information I have submitted(or entered)regardin this a li Knowledge and that ail plumbing work and installations erf g Pp cation are true and accurate tc p the best of ormed under the my Pertine ermitissued nt provision of tfi P for this a lication e Massachusetts State Plumbin C PP wrll be In coin liance with all g ode and Chapter 142 of the Ge P neral Laws. By Type of License: Title [7f Plumber Signatur f icens Plumber City/TownElMaster APPROVED( OFFICE USE ONLY) JZJourneyman License Number- COMA10j ELT H OF MASSAC IN.: '• , _ ;jUSEYS LICENSEpMASRS AND • ' ISSUES THE Bo NFYMAIU 1 r LICENSE Tp. L UA4 , COREY . Eli CATALFAMO 945 RLVERSIDE ME.1'H�EN DR 5 2. 0 29 MA.. 1 .4 4 4 r 4 i CONTROL# i.a 0 O - 320 If this license is lost or d PORTANT Division of professional destroyed 7th Floor Licensor notify your Board at the: ' Boston,MA 021 m e, 1000 Washington St. It Your name or address Of correct arae or address Renew changed, Latif This license Always to proper Mailing board as a se is subject to Ys refer to your lice g°f next mended.It is the provisions nse number. or assigned to a Personal priy oth vire of the General laws person or Posted req u red by law. e P hnd is license On'Jsf not be Your WARNING THIS DOCU..-,,., ENHANCED RCUArry F' 1r�,gE� + 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 ofongoing construction activity,and may be.deemed.by the Inspector-of-Wires abandoned-and.invalidaflre—_. 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. Mule 8—Permit/Date Closed: 2—Z, — L�'* *Note:Reapply for new permi� 0 Permit Extension Act—.Permit/Date Closed: 976 /- Date.... NORTH ' TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING CHU This certifies that .......................... .... ..... ...................... 12ohas permission to perform ................ ...... ..... wiring in the building of........... .................................. at.....6.7....... ........to..X�............... North Andover,Mass. Fee... Lic.No....L>>..Iff:tM....... CTMRICAL IrrsPEClORf Check # 67 Z Viq Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 62, BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [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 WINK OR TYPE ALL INFO TION) Date:-- =Z62- City or Town of: To the Inspector of Wires: By this application the undersi es ed givnoti e of hisser her intention to perform the electrical work described below. Location(Street&Number) ,6 7 Z:�o.,-77 Owner or Tenant ' lfw'� G �LJI.Z`nC Telephone No. Owner's Address •.5'/}�j Is this permit in conjunction with a building permit? Yes Q�- No ❑ BLDG PERMIT# Purpose of Building�jo / �,2 G Utility Authorization No. Existing Service. Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / VoIts OverheadEl Undgrd ❑ No.of Meters Number of Feeders and Ampacity ' Location and Nature of Proposed Electrical Work: _ J��►e ��o� ®� Completion.ofthe following table maybe waived by the Ins ector 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 Swimming Pool Above ❑ In- o. mergency Lighting rnd. rnd. Batteo Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection anif- Initiatin2 Devices No. of RangesNo.of Air Cond. Tonsl [Detection/Afert o.of Alerting Devices No.of Waste Disposers Heat Pum Number Tons o.of Self-Contained KW Totals Ain Devices No.of Dishwashers Space/Area Heating KWLocal❑ Municipal ❑ Other Connection ' No. of Dryers Heating Appliances KW Security Systems:* ,r No.of Devices or E uivalent No. of Water No.of No.of Heaters KW Data Wiring: j Si s Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: 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: t'l`'�.— 16;1 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 is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I cern under the airs an fy, p andpenalties of perju ,that the this information on r1' .f rs application is true and complete- FIRM ompfete.FIRM NAT G LIC.NO.: f 3� Licensee: �os,.� _ -e Signature LIC.NO.: g (If applicable, ent exempt"in t e licensetuber ing.) Bus.Tel.No.: -� -7 Address: 16 ~SA� l Alt.Tel.No.. *Per M.G.L.c.147,s.57-61,security work requires epartment of Public Safety"S"Licen 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: $ The Commonwealth of Massachusetts UVDepartment ofindustrial'.Accidents Office of Invesfigations 600 Washington Street Boston,MA 02111 www.mass.gov1dia Worker' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly; NaMe(B.usiness/OrganizationAndividual): Address: City/State/Zip: Phone#: 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 2.❑ I am a sole proprietor or partner- listed on the attached sheet.? 7. ❑Remodeling . y ship and have no employees These sub-contractors have 8. n Demolition working for me in any capacity. workers'comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 1011 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs insurance required.]i employees.[No workers' 13.❑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. tContractors 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.Lie.#: Expiration Date: Job Site Address: City/State/Zip.- Attach ity/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 d $ a a against the violator. Be advised that a co o this statement p f m nt ma be forwarded to the Office of Y g PY Y Investigations of the DIA for insurance coverage verification. X do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: PermitUcense# Issuing Authority(circle one): X.Board of$ealth 2.Building Department 3.CitylTown CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: '4974(, Date... ........................ TOWN OF NORTH ANDOVER �0 0 0% PERMIT FOR WIRING AcwU This certifies that .......10.14C...... ........................................ has permission to perform ... ........./f�........ wiring in the building of..... .4. ...................... ,0 atXv -,- z 2- e /Z�-, ...................... ............ ............... ...... .....ANo h Andover,Mass.. 71 Lic.Noll. .. ... .. ..................... ...4...... j. ............... ELECTRICAL INSPECTOR Check # commonweartlr of Massachusetts Official Use Only Department of Fire Services Peet No. ----UV 7� BOARD OF FIRE PREVENTION REGULATIONS Rev. i/07)Occupancy 1/071 and Pee Checked l cave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be Perfontied in accordance with the Mas, chu. is Electrical Ct (MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: //- 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) Owner or Tenant Telephone No. Owner's Address c X7 di Is this permit In conjunction with a building permit? Yes NoCh Purpose of Building ❑No (Check Appropriate Box Utility Authorization No._ /"9-0 Existing Service _ Amps / $ Overhead ❑ Und rd ,. OltOg ❑ No.of Meters New Service :2 vy Amps /7 v lZ yo Volts Overhead❑ Und d t ❑''�No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Com fetion of rhe olfo4-in table ma be waived by the Ins eetor o Wire, No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle) Fans °•° Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool OVe ❑ n" o.o mergency rg ng rnd. rud. ❑ Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.a etecdon an Initiating,Devices No.of Ranges No.of Air Cond. ota Tons No.of Alerting Devices No.of Waste Disposers eat mp um er ans o.oSelf-Contained Totals: DetectioNAiertin Devices No.of Dishwashers Space/Area Heating tKW Local❑ municipal e Connection ❑ Othw No.of Dryers Heating AppliancesKir urttysystems:* No.Of ater ; o o No.of Devices or Equivalent Heaters !K W Signs Ballasts Data Wiring: No. Hydromassage Bathtubs No.of Motors Total HP a No.of Devices or Equivalent ecommumcatwnswiring: OTHER: No.of Devices or Equivalent Attach additional detail if desired,or as required by the Inspector of Wires Estimated Value of Electrical Work: (When required by municipal Work to Start: policy.) inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit far t� the performance of electrical the licensee provides cal work may issue unless p a ides proof of liability insurance incl y e's h' udtn "c g ompleted operation"Covera undersigned certifies that such coverage is in force and h e er Its substantial equivalent. The as exhibited proof p o0 of same to the Permit is CHECK ONE: INSURANCE pNp P Suing office. ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. s FIRM NAME: /l Licensee: LIC. NO.: fqy 3 3 Signature LIC.NO.: d Q 9 3 3 r lJ rq p/iceh/r. 1 •r "c xrm/jt"in the license number line l yy-- Address: 5 .% Bus.�ef * . *Per M.G.I.c. 147,s. 5 -61,security work requires lie artm „ Alt.Tet. No,. , P of Public Safet S License: OWNER'S INSURANCE y e- Lic. No. I St RANCE WAIVER. 1 am aware that the Licensee clues nv have the liability insurance coverage normally required by law. fly my signature below, I hereby waive this requirement. I am the(check onQ-0 owner owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ , . Y� �� ��� i � ORTFy Town of And -- Sa3- 20i� _�_ LAKE O y dover, Mass., a 17) COCHICMEwICK.44 RATED PPp��S S BOARD OF HEALTH Food/Kitchen -PERM IT T.. D Septic System I BUILDING INSPECTOR THIS CERTIFIES THAT.........p2c. r^ r lJ.�.�.'.�9- U..4n ........... ........ ............................................................. Foundation w has permission to erect... ........ buildings on .....�� . .�.� ....... � ou d Chimney to be occupied as.........5AIS-P,.........&.qn . .��...........j!q. .............�L...... .......... . . . . .... . . .. . . . .... ..... . . . provided that the person accepting this permit shall in every respect conform to the terms of the application on file in ina �j 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 _ UNLESS CONSTRUCTI TARTS ELECTRICAL INECTOR O oiL- HCl-/U'�� u ,,� .:. Service JJ��� fi✓1� �t1-1-" � ................................................... ......................... fG � BUILDING INSPECTOR �� `� OccupancyPermit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the- Premises — Do Not Remove Final No Lathing or Dry (Nall To Be Done FIREDEPARTMENV Until Inspected and Approved by the Building Inspector. Burner, Street No. SEE REVERSE SIDE smoke Det. LAWRENCE H. OGDEN, P.E. 198 EAST MAIN STREET GEORGETOWN,MA 01833 978-352-8318 fax 978—352-2858 cell: 978-502-5921 November 6, 2010 Mr. Robert Messina Orchard Village LLC. Empire Drive North Andover, Ma 01845 RE: THE FRANLLIN GB# 9301 Lot 22 Empire Drive,North Andover, Ma. 01845 7 p5- Dear Mr. Messina As you requested I visited the site 11/4/10 to review the installation of the Engineered Materials consisting of LVLs and Steel Beam utilized in the framing of the above project. These are shown on plans prepared by G.J. Bruno and Associates A-1 to A-5 Dated 8/8/09 with the framing sheets certified by me 6/15/10 and revised 8/25/10.. The following items require additional work. 1. Insure that the 3-16d nails from ±1e plate to bctivPen the studs as shown on the Braced Wall Additional Connection Detail are in place. As I discussed with Jeff Horne this nailing should be from thelate to the rim p board. 2. Add additional studs under the LVLs at the Breakfast Area to insure the number of studs required match the plan. Review post at all other locations. Based on the above site visit and based on what I could visibly see provided the above additional work is completed I can certify that to the best of my knowledge the LVLs members and Steel Beam utilized in the framing as shown on the drawings are installed properly and meet the loading conditions of the Massachusetts State Building Code for 1&2 Family Residences. This certification assumes that all other framing requirements of the drawings and code, including but not limited to materials nailing schedules, blocking, connections and other details were properly complied with by the licensed construction supervisor responsible for the project. Should you have any questions please do not hesitate to call. \PITH Of Yours truly, ops+ �s A WREN �y D Cn cN m H `-1 27765 O �' awrence H. Ogden P.E. Structural 27765 GYAI Cc: Mr. Gerry Bruno t�f61 Copy mailed to Mr. Robert Messina, 44 Great Pond Road,Boxford,Ma. 01921 8 2 Date. lC� G�NORTM•�.4, TOWN OF NORTH ANDOVER , CL PERMIT FOR PLUMBING �SSACHUS This certifies that . .(O`/.,. . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . ���.+JQ- . . . . . . .`. . . plumbing in the buildings of . �. a _ . � . . et �� !t'.�.(.,�. .t`�. . . . ......�. North ndI r, Mas . 4xic. No/o.�1.�. . . . . . .� Check It 73� � PLUMBING INSPECTOR 311 a� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: -df C4 MA. Date: 1 .9— to Permit# Building Location:—6 7 Etnpc4,t. Owners Name: Orekcn V tl Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential New: Alteration:❑ Renovation:❑ Replacement:❑ Plans Submitted: Yes❑ No❑ FIXTURES DEDICATED SYSTEMS W z W Y U > Z G Y Q in 'J Q W l7 OC z D: ? W 0: Z Vf Z Q c of Z Q Q = W Q 3 V1 x V1 Q W f' WFd- 41 L O t- N fA W �.. N Q of Y Q H Q W 0 Q Z = � X W Z #AC3 -j h U a X LL F- 'S' 0 3 W 0 o W in W --A ? a• 0l1 O W W IL 0 he Z Ln W Q Q Q m m o c LL x Y J J ° #A N 3 3 3 ' SUB BSMT. BASEMENT In FLOOR I 2ND FLOOR T. FLOOR 4"'FLOOR 5'FLOOR FLOOR FLOOR FLOOR Check One Only Certificate# Installing Company Name: G 4 l i n y�u ��V Yrs�wl.r � ��v - / v Corporation 6 Address: i3 a 1-7y I Ci own: L5q �- ty/r � �1-c1 V-t • State: Business Tel:�7�' 37 Fax: .5-7 Cr- '--1 L/Q/ ❑Firm/Company Name of Licensed Plumber: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes fR No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Othera of indemnity ty ❑ Bond ❑ OWNER'S INSURANCE WAIVER:1 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 ❑ ❑ Signature of Owner or Owner's Agent Owner Agent I 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 workand installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: A A— C. — Title Qg Plumber Signature of L censed Plumber City/Town 19 Master 1 O APPROVED OFFICE USE ONLY ❑Journeyman License Number: 7424 Date..,l ,HORTh 3? y TOWN OF NORTH ANDOVE p 41 ' PERMIT FOR GAS INSTALLATION .: SSACNUS*' �-- This certifies that . . .clwle.�?S!`' ' il�� . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . V . . . .� in the//buildings of . . . . . a. �t .�. . . . ./. . . at t.V-e-. . .6 . . . . . .. North Andover Mas Fee 100.t).C1Lic. No.. /D3 V . . . . . . . . . . . . . . . . . . GAS INSPECTOR Check# 5 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: HL-�d R 1 '' , MA. Date: -1 ` l Permit# �1 G-, LCC Building Location:�j 1N^ n i,�Q„� Owners Name: ©cctw K. 0.� Type of Occupancy: Commercial ❑ Educational❑ Industrial❑ Institutional❑ Residentiarg New: Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES �� �• z Q U) Y 2 D w a' O U) = rn to m 2 0O a J } W uj U) ~ y O M w R w W UJ m O 1-- a W W X uj fA U W Z Q 2 N - W H 13 = LL > v w z (9 P p O z -jO u- = w � W w O W W :) Q rrw w m w O z O y L- > z Q U o O U. C7 t9 = _ -j o 11 H > > > 3 O SUB BSMT. BASEMENT 1 -i'FLOOR 1 2 FLOOR 3HO FLOOR 4 FLOOR 5 FLOOR 61m FLOOR -i'FLOOR FF-FLOOR //��4.� `` • n c 1 Check One Only Certificate# Installing Company Name: Vf SIM., 1"(uy1-,6 4, Vt-ea�► Q h � t Corporation L Address.-Pt V '10 City/Town: �J'&-r--&M LL State: N -- - - -------- ..... - ---- - -------.------------------ ----- --__'._ . ._- G c ❑Partnership Business Tel: -( 7 a ` 3)�(-1 Z�� Fax: n 7z-- 671 "(11 ❑Firm/Company Name of Licensed Plumber/Gas Fitter: Tt G�L�w INSURANCE COVERAGE: I have a current flabilitv insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 Yes[JD No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy (P 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑;1 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Ty of License: By umberAzK;X Gas Fitter f ' t�4A Title Signature of�L tensed Plum r Gas Fitter Master City/Town Cliourneyman License Number: 03�� APPROVED OFFICE USE ONLY) ❑ LP Installer