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HomeMy WebLinkAboutMiscellaneous - 71 BONNY LANE 4/30/2018N J �_ V ;.. N Q Q ', O z C�7� Z { :; 2 O .................. Date �.........�....�� TOWN OF NORTH ANDOVER PERMIT FOR WIRING — This certifies that............\......�....�.G....S.......I"IG.n ................................................... . . . has permission to perform �M„C, 1r� ....................... ........... .................. wiring in the building of,....'1�J.. �.. 1/i cl 5 ................................................... ................... s �— e-- , North Andover, Mass. at.....:.................................N.^................. .................. . �_ Fee _ �—, �..... ......... Lic. No ��� .......... .... . • ECTRICAL INSPECTOR Check # .- - / � r- u Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORAMTIOA9 Date: .2 • a B' ° i 3 WORK C u 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) 7/ 6#,7ny Owner or Tenant t iwy /vrCAOfs Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes 5 No ❑ (Check Appropriate Box) Purpose of Building 13 A T, Rcmo Ac C 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: Ad /,-t4 A i S 41d /- !r,. ejauolzr ilauss�d 0 Odd tQA Ur 6r a n.ru, auT/els p " 6 I,- v Awl 4. Completion of the following table may be waived by the Inspector of Wires. No. of Recessed LuminairesNf 3 o. oCell: 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- Elo. rnd. rnd. o mergency Lighting Battery Units No. of Receptacle Outlets 3 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons ......................... I KW I ....................... No. of Self -Contained Detection/Ale ting 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 i o. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of 97res. Estimated Value of Electrical Work: 12-00— (When required by municipal policy.) Work to Start: a - a$ - 13 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [� BOND ❑ OTHER ❑ (Specify:) I certify, under thepainnss and penalties ofperjury, that the information on this application is true and complete. FIRM NAME:. / �1 meu r7 •a s el /;v n. / CA A 91e e k/Z % L LIC. NO.: 0,3841,L Licenseejnr., M,,, ,WI eA n Signature T LTC. NO.: (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.; 7141 c/53 ° Zff Address: „3 ff,c,L6,1, L.rj• SAulUs M4 O%g hl Alt. Tel. No.: TitZ3 -d 0 *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 PERMIT FEE: $ Signature Telephone No. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Uf www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): yA f— Cz u1,C Address: L ­ City/State/Zip: 9 41, I's M40 1204 Phone #: Al re you an employer? Check the appropriate box: Amo1 I ❑ Type of project (required): 1. L`_am a employer with / I 4. I am a general contractor and 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors 7. ❑Remodeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have 8. ❑ Demolition workingfor me in an capacity. y p ty • workers' comp. insurance. 5. ❑ We are a corporation and its 9 ❑Building addition [No workers' comp. insurance required.] officers have exercised their 10. El Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions ' myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other 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. #Contractors that checkthis 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: C Policy # or Self -ins. Lic. #: Expiration Date: Job Bite 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 requiredunder 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 7 - 2-,k - f 2 Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone �t r '� i� ,� ;� r� 1� Ii, I f This certifies that has permission to perform .. . /.P..M (t.c�z plumbing in the buildings of ..,!V ! .......................... at ... L��.�!�.� , North Andover, Mass. Fee ?� .. Lic. No. iU7°? l.. M!�!................... .. . PLUMBING INSPECTOR Check 4 ZC5 Z 5 'A0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK POWNER TYPE OR PRINT CLEARLY CITY'7T/ /Ct_MA DATE 3-�3 PERMIT# JOBSITE ADDRESS 7[ \LYW n-1 ;� G' /�C OWNER'S NAME % to') /s ADDRESS TEL FAX OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL ©� NEW: ❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES [] NO FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liabilitv insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ❑ NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY 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 Massachusetts d that my signature on this permit application waives this requirement CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR 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 work and installations performed under the permit issued for this application will be inco fiance all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �� PL,,UM_-BEER'S NAME LICENSE # �(�/],� �1/ SIGNATURE MS,G JP ❑ (' CORPORATION [1� p1 �35 PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME 1 j r ADDRESS CITY] ►c�-lt'k STATE ZIP S �U TEL 0 FAXr%0 `7�b ��D� CELL L D fI ��J 6 y EMAIL F/2% 'A0 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): ► �J Address: A x -e W e-, Phone #: qi�k Are you an employer? Check the appropriate box: �a I . employer with ,2Nart 4. [:]I am a general contractor and I employees (full and/or p -time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance; required.) 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance reauired.l lld& Type of project (required): 6. ❑ New construction 7. M.R t leling 8. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions I 1.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. [1 Other *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. Contractors that check this 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 provld/ng workers' compensation insurance for my employees. Below is thepollcy and job -site information. ____r- , I Insurance Company Policy # or Self -ins. Lic. #:1� % n l y� Expiration Job Site Address: City/State/Zip: Attach a copy of the workers' com ensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGI, 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 certify under the pains a{d penalties of perjury that the information provided above is true and correct, Phone #: Oficial use only. Do not write in this area, to be completed by city or town ofciaL City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: s COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS f LICENSED AS A MASTER PLUMBER ISSUES THE ABOVE LICENSE TO: FRANCIS J WALSH JR ;d I� - 7 ROSE LANE IN 44f- - STONEHAM MA 02180-213 � 10729 05/01/14 '157960LICENSE NO. EXPIRATION DATE SERIAL NO. i �-.---EOMMONWEALTH OF MASSACHUSETTS 'LM' AND GASFITTERS• 7T' REGfSTERED AS A PLUMBING CORP ISSUES THE ABOVE LICENSE Ta".., FRANCIS J tqALSF, F':'J-ll'=WALSH PLUM6.IN6 8r' HEA TTN _> 7 ''ROSE -LANE' -' `STON9itAM MA 02i8:Q`==2 G5/01/14 - :t .7.9.6 Stap e eldels A TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building KOne family 0 Addition 0 Two or more family 0 Industrial 19 Alteration No. of units: 0 Commercial X Repair, replacement 0 Assessory Bldg 0 Others: 0 Demolition 0 Other o Septic 0 We# 0 Floodplain 0 Wetlands 0 Watershed District 0 Water/Sewer S779Z-1- n nb 70e `fit 1l�¢r�ll Identification Please Type or Print Clearly) Name: X A Z!- - 6ww P, C'L--4ot-> Phone: v q " - (083-' 102-3 n CONTRACTOR Name: Address: .p a &; Supervisor's Construction license: Home Improvement license: N 4-N c)fi*-4,- , IMA- © /0 LE �- `tc Exp. Date: ARCHITECT/ENGINEER 41 11 Et Phone: Address: Reg. No. FEE SCHEDULE: BULONQ PMW- 022 PER =100 M OF THE TOTAL MS MATED COST BASED ON S MO PER S F. Total Project Cost: $ LI / ra--Li FEE: $ /,-? 0�— Check No.: IOInZ©�� Receipt No (o /57 7TE: Persons contracting with unregistered contractors do not have access to the guaranty fund, Signature of Agent/Owner•� Signature of contractor TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page .x I MAP,aNO PARCEL:: Z®NING1DIST�RICaT _ w Pnnt. Io ly,6 ,O.ld Structure; yes} no;� I _. _.: HistoncDstnct yesi nod Machihpj$hop;Village; y_es� no) TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ISeptic; Well1 ' ` D FI`oodpla h; ©;Wetlands, F F1 Vl/atershedipi§trict � -- ❑ Water/S.ewer; _ ; DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Adriracc- t - ' CONTRACTOR Name: Rhone:. t I Ad'd`ress:: i Supervisor s)Constructign License: Exp', Date:° { i Home:Lmprovement,License� ,Exp: Date— ARCH ITECT/ENG I NEER ate. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owner Signature of contractor.. Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Location -1' &)ta LAr,'"e— No. Y' I — 125 Date 2 Check # 26152 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ y� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Buil ing Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comm Comm Water & Sewer Connection/Signature & Date Driveway Permit DPW Tiowr -- ]Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster onsite yes no Located at 124_Main'Street .., . Fire Depa—ament signature/date COMMENTS Enter construction cost for fee cal - North Andover Fee Cakulatlon Construction Cost $ 10,000.00 m $ - $ 120.00 Plumbing Fee $ 15.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 15.00 Total fees collected $ 250.00 71 Bonny Lane 561-13 on 2/14/2013 Bath Remodel Feb•1313 M:19p Nichols 5617445332 p.1 f haft ._•' TOWIN OF NORTH ANMO«R OFFICE OF BUMDING DEPARTMENT 49 r 1600 Osgood Street Buiking 20, Suite 2.36 �rSKwW'4{ North Andover, Massachssetts 01845 Gerald A. Brown Inspector of Buildings HOMEONWI M LICENSE EXEMPTION BtiZDLNO PERMIT APPLICA.TTON please 0631 DATE: Telephone (978) 688-9545 Fax (978)6SE-9543 JOB LOCATION: 2 / 6 2r{ L.,,'Le . /J,- -,V-4h-'f ej 'j el-, rn/-;� e-, l S�S� Number fStseet Address A4apS of I301.2EOVi?NTER����� r---- f ) 711, d k -,.A �1� �F-9 0�6� Name ROM Phone work Phone PRESENTKAILING ADDRESS/ C ,t3 Tovm c,^�� zi ,r Code The current exemption for "homeouvers" was extended to include owner -occupied dwellings to two units oor less and to allow sucb homeowners to engage an individual for Etre who does not possess z license., provided that the owner acts as supervisor). State Building (Code Section 108.3.5, 1) DEQ nol< ol: HoumowNT-R Person(s) who OVLms a parcel of land on which he -'she resides or intends to reside. on vrnich there is, or is intended to be, a one o,- rnro farm]}• structures. A person Nvho consructs more that one home in a two .year period shall no: be considered a bomeoumer. The undersi_ened "homeowner" assumes responsibility for compliances with the State Building Code and other Applicable codes; b.N-la\vs; rules and regulations. Tne undersigned "homeonmer" certifies that hvshe understands the :'ouT,, of North Andover Building Department minimur,n inspection procedures and raouircmatts and tha: he/she will comply with said procedures and requirements. /• // HOMEOWNERS SIGNATURE� � 11 ���•C1i7 ��1 � -4-4 7 APPROVAL OF BUILDLNG OFF7CL4-L Rrrised 7 2oeQ Faro Honwzrmers Hxemplim BOARD OF A.aPF- LS 69J =9543 cOxsEFA .kno,, 6r4 -458o KEA:-TH 6rf-R540F 4`�'.�-[�G OSE -952f < 0 0 =r _ (D-0CO) cCD CD � �D m v, Q n Q• C) V� z o � -o -� W'r1 C - p o C" o m mmh m W 0 m (n c N c• C° � p n to r -L to CD O p�p rt CA p p 0 z � opo �� � .\ .� F J p O-0 � z-0 E oU3 r- mj3 .� torp.CL 5LA C � 0 Qom= c� �� __ p ZNCD cam. C7 s' � o 0m cc m p �� -: Ov0 CL 0 <CD o O ti. �N � rn �< IL Q C Cn Q. CDcr � T CD ID -CD 0 -�•xy CD CD z CL CD It ir Cl) Ax CD Er cn CD CD 0 CD z ` a CD S s CD O ry o : o 3t -- VOL OX c : cD v -� `D C cn z ��tt� r < 0: o � CL VI O rD � .+ N ry 7 •* O W T m D m Z T AT O pOq S D O W N CD (D A MmmQ S m m m m 0 T -- A S VS W m 0 T n S 7 < 7,7 S T O d p' C V 0 N fD n 3 T O \ n rD 3 W D :0 o T m 2 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, roast or service drop requires approval of Electrical Inspector Yes No DANCER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G m1n.$100-$1000 fine NOTES and DATA — (For department use El Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products 40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Building Permit Revised 2012 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFtTTCNG% t (Print or Type) NORTH ANDOVER Mass. Date 7 ` building Location G/ Permit # Owners Namow, , k� 11,E-,4 • New Renovation D Replacement Plans Submitted .. ✓`�FlyT1 j C G G (Print or Type) Check one: Certificate Installing Company Nameyn-,,4,4,�"t';,Corp. Address /yo �al,�,� ST !�1%�,(�(¢»✓! A411,A411,195'5S� Partner. Vg LI Firm/Co. Business Telephone: %%—d -72y0 Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance polic Other type of indemnity � Bond Insurance Waiver: I, the under igned, 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 Ej I hereby certify that all of the devils and information I have submitted (or entered) in above appli.t. n are true and accurate to the best of my knowledge and that all plumbing work and Installations perfornud under -Permit issued to: this application will -be in compliance with aL tinent provisions of tho hiassachusetts Slate Cas Code and (Isapter 14I of the General Laws. By TYPE LICENSE: Plumber Title asfitter Sig ature of Licensed City/Town: Master Plumb, o Gasfitter Journeyman APPROVED cot Frce use ONLY) License Num er • • • Y • • 0 SENSE 0 BASEMENT ■tt�■/�O���t�s���»et»SE■ ® • • MENEM • • • • ■N■■■■■■■■■.■MI■ME■NME■■MIKE .. - ■ENOMONEE mommommommo»mm■ 0 son ONE MOMMEMINE ",Emmons (Print or Type) Check one: Certificate Installing Company Nameyn-,,4,4,�"t';,Corp. Address /yo �al,�,� ST !�1%�,(�(¢»✓! A411,A411,195'5S� Partner. Vg LI Firm/Co. Business Telephone: %%—d -72y0 Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance polic Other type of indemnity � Bond Insurance Waiver: I, the under igned, 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 Ej I hereby certify that all of the devils and information I have submitted (or entered) in above appli.t. n are true and accurate to the best of my knowledge and that all plumbing work and Installations perfornud under -Permit issued to: this application will -be in compliance with aL tinent provisions of tho hiassachusetts Slate Cas Code and (Isapter 14I of the General Laws. By TYPE LICENSE: Plumber Title asfitter Sig ature of Licensed City/Town: Master Plumb, o Gasfitter Journeyman APPROVED cot Frce use ONLY) License Num er w Date ....................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .......................................... . has permission for gas installation ......... 6 .................. in the buildings of.r:......................................... at ... ! ............................... . North Andover, Mass. Fee. ::..r... Lic. No.,l......... .......................... 06/02/94 11:34 ?t.S_tNSPQ R WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File