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TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
P . n) A —e
Thus certifies that &A,5 .... ........ .D' ............. ....gP... 1....CP a
has permission for gas installation . !w ..... ..... A ......� 5..... 5 '�-
in the buildings of....vU.'J..........................................................................
at........ 14 �U �� a� ....
.��-J.................. North Andover, Mass.
Fee . � -Q. Lic. No...3() Z C.��.... M `�
...............................
GAS INSPECTOR
Check #
0/4.35
r
nc�(Do-5/v�`-(
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
- — =
CITY I NORTH ANDOVER MA DATEAUGUST 25 2014 PERMIT # ILI `,
JOBSITE ADDRESS 72 CAMPION RD. OWNER'S NAME I GREG JOHNSON
GOWNER
ADDRESS GREG JOHNSON TEO 978-265-2446 IFAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL RESIDENTIALED
PRINT
CLEARLY
NEW: ® RENOVATION: ® REPLACEMENTEI PLANS SUBMITTED: YES[] NO
APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE r_ 1 -- - — - - _
DIRECT VENT HEATER
DRYER _-
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER[-.
_.
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES E] NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY E] 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 AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this applicati re true an curate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will beomplianc th all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME I BENEDICT BREITUNG LICENSE # 3o a ? 3 SIGNATURE
MP 0 MGF ® JPEJ JGF ® LPGI [Z] CORPORATION ®# PARTNERSHIP®# LLC ®#
COMPANY NAME: EASTERN PROPANE GAS ADDRESS 1131 WATER ST.
CITY I DANVERS STATE MA ZIP 01923 _ TEL 1 800 322-6628
FAXI CELL EMAIL
The Commonwealth of lyiassachusetts
Department of IndustrialAccidents
Office of Investigations
I Congress Street, Suite 100
Boston, JUA 02114-2017
', swww ntass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Eastern Propane Gas, Inc
Address: 131 Water St
City/State/Zip: Danvers, MA 01923
Phone #: 978-750-6500
Are you an employer? Check the appropriate box: Type of project (required):
1. a I am a employer with 45 4. ❑ 1 am a general contractor and I 6 ❑ New construction
employees (full and/or part-time). have hired the sub -contractors
me}.*
listed on the attached sheet. 7. ❑ Remodeling
2. LJ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' camp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
These sub -contractors have
employees and have workers'
comp. insurance.1
5, ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, §1(4), and we have no
employees. [No workers'
comp. insurance required.]
8. ❑ Demolition
9. []Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.0 Other Gas Fitting & Fuel Supply
*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.
+Contractor that check this box must attached an additional sheet showing the name of the sub -contractor and state whether or not those entities have
employees. If the sub -contractors have employees. they must provide their workers' comp. policy number.
I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Safehold Special Risk, Inc
Insurance Company Name:
Policy # or Self -ins. Lic. #: EWGCD000080614
Expiration Date: 03115 / 2015
Job Site Address: City/State/Zip:18yJ j�— A & 1�%►4. 61 �s
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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Phone. #: 979.7506500
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Issuing Authority (circle one):
1. Board of health 2. Building Department
6. Other
Contact Person:
Permit/License #
3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Phone
05/19/2014 08:11 9783886592 AMESBURY PLANT PAGE 01/01
NH477156
Q ng
C! CERTIFICATE OF LIABILITY INSURANCE
DATE (" 3/201YYYY)
3/13/2014
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
Commercial Lines - 800-990-7465 (CA DOI 9 OG13561)
Safehold Special Risk, Inc.
CONTACT
NAME: Donna Desharnais
PHONE 603 559 1361 FAx 855 -529-7684
A/C No ExtI: A/C. No
ao�RESS: don na.desharnais@safehold.com
INSURER(S) AFFORDING COVERAGE NAIC #
230 Commerce Way, Suite 230
INSURER A : HDI -Gerling America Insurance Company 41343
Portsmouth, NH 03801
INSURED
INSURER B:
Eastern Propane Gas, Inc.
INSURER C:
P.O. Box 1800
INSURER D:
INSURER E:
i GEN•LAGGREGATE LIMIT APPLIES PER:
INSURER F:
Rochester, NH 03866
COVERAGES CERTIFICATE NUMBER: 7441964 REVISION NUMBER: See below
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ACCORDANCE WITH THE POLICY PROVISIONS.
INSR IADDL SUBR: POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE POLICY NUMBER MM1DG/YYYY ,POLICY
LIMITS
A I X ;COMMERCIAL GENERAL LIABILITY EGGCD000080614 3/15/2014 3/15/2015
EACH OCCURRENCE i S
2000000
CLAIMS X s OCCUR
DAMAGE TO RENTED
250000
-MADE_
P• _MIS=S =a occurrence)$
MED EXP (Any one person) I S
5,000
j
PERSONAL &ADV INJURY i S
2000000
i GEN•LAGGREGATE LIMIT APPLIES PER:
GENE:?ALAGGREGATE S
2000000
PRO-
I POLICY —1 JECT _' LOC I
PRODUCTS-COMP;OP AGG I S
2000000
OTHER:
; S
A i AUTOMOBILE LIABILITY
_ EAGCD000092214 3/15/2014 3/15/2015.
COM3IPIED SINGLE LIMIT I S
(Ea.accident
2,000,000
X I ANY AUTO
BOCILY INJUR`! (Per person) �S
ALL OWNED SCH=DULEG
30GILY INJURY 5
_ AUTOS AUTOS
—
;Per accident)';
NON-CWNED
H,IRED.AUTOS — AUTOS
PROPERTY DAMAGE
(Peraccident` S
, S
UMBRELLA LIAB OCCUR
EACH OCCURRENCE I S
I�EXCESS LIAR CLAIMS -MADE CLAIMS -MADE
AGGREGATE I S
DED RETENTION 3
!WORKERS COMPENSATION l 03/15/2014 03/15/2015
A 'AND ENGCD000080614
"R OTH-
x STATUTE ER
EMPLOYERS' LIABILITY YIN -
!ANY
1,000,000
PROPRIETOR;PARTNERiEXEC1ITIVE
'OFFICERjTOEMBER EXCLUDED' N N I A
t. L. EACH ACCIDENT S
E.L.
:(Mandatory in NH)E.L.
DISEASE - EA EMPLOYEE/ S
1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS belcx
. POLICY LIMIT 3
1,000,000DISEASE
DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
Evidence of coverage
CERTIFICATE HOLDER CANCELLATION
Any city/town in Massachusetts
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
MA
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
MA
AUTHORIZED REPRESENTATIVE
The ACORD name and logo are registered marks of ACORD
ACORD 25 (2014/01)
(This .srnftate •=oiaces -. Mfiw a 7"1310 ss— 3n 3i1312014;
@ 1988-2014 ACORD CORPORATION. All rights reserved.
mi
0.�.. .�
... . .. .....................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
Thiscertifies that .............................................. . ...........................................
..............
has permission for gas installation k6 .......--�, 4
......
in the buildings ....-.30v-,
........................................................................
at ..... 7z ......
....................................... I North Andover, Mass.
Fee.6 . 7 ......... Lic. No. M ... ....)I/ ......................................................
GAS INSPECMR
Check# 2,1
402
FA
Pd 4 coo"-) 6-t*-- aq a
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
•
CITY I NORTH ANDOVER MA DATEI I PERMIT # l
JOBSITE ADDRESS 72 CAMPION RD. OWNER'S NAME GREG JOHNSON
GOWNER
ADDRESS GREG JOHNSON I TE978-685-2446 FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL [j RESIDENTIALE]
PRINT
CLEARLY
NEW: RENOVATION: El REPLACEMENT: ® PLANS SUBMITTED: YES® NO®
APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 1 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE _
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER I VENT FREE LOG SET 1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Q NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY F71 OTHER TYPE 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 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 o my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli wi all Pertine ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME I ROBERT WHITE LICENSE # • D SIGNATURE
MP � MGF ® JP ® JGF ® LPGI CORPORATION E]# PARTNERSHIP®# LLC ®#
COMPANY NAME: EASTRN PROPANE GAS ADDRESS 131 WATER ST.
CITY I DANVERS STATE MA ZIP 01923 TEL 1-800-322-6628
FAX CELLI JEMAILI_--
The Commonwealth of Massachusetts IF I'rinirrn
_ Department of Industrial Accidents
Office of Investigations
' 1 Congress Street, Suite 100
Boston, MA 02114-2017
www. mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant -Information -------- - -Please-Print Legibly
Name (Business/Organization/Individual):
EASTERN PROPANE & OIL
Address: 131 WATER STREET
.. City/State/Zip: DANVERS, MA. 01923
Phone #: 978-750-6500
Are you an employer? Check the appropriate bog:.
1. ❑✓ I am a employer'with 45
4.. ❑ I am a general contractor and I
employees (full and/or part-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 mein any capacity.
- employees and have workers'
[No workers' comp: insurance
comp. insurance.1
I
equired.]
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 required.]
Type of.project (required):
6. ❑ New construction
7. , ❑ Remodeling
8. ❑.Demolition
9. ' ❑ Building addition
10: ❑Electrical repairs or additions
11.❑ .Plumbing repairs or additions .
12. ❑ Roof repairs -
13.❑✓ Other GAS FITTING
*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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ENERGI
Policy # or Self -ins. Lie. #: EWGCD000080613
Expiration Date: 03/15/2014
Job Site Address: a ecv.. tM 1 eA City/State/Zip: j0o,-A
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). 0%84q
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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Phone #: 978-750-6500
Official use only. Do not write in this area, to be completed by cio? 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
G
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n M�_ O= m the !Y==nal ruer Ges Cha, L, N- 7"'3
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=min td n'a�
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int. -w ._>� NY 100 C�s
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f N2ri:=-S Dim=sions or Solid Foel B'iL'=g
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M Si OD= aL_ ht.F.L_. WiL^ ILII 1121-IIIIC
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m_SL=,-=b,=_1_.S:r"' abDve'_Tlr-n!2-==
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T—T-sranL i'T=ri3S su= h zmSi''r.L` 23C =Zable.. TR".S_ •^..`,.' Z lr
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IIe Sl ieS O Ilt c rmnirnUM p0. l j_1 LY above tht t] =aj,_c, D� c-� ^-n
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rnd 30' ianm) T_*az, i . =n �blar oDeRii _
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doorl-nocaimmeyprof-sionaliycleanedtorave FR "E 0TEIl�tG : h*-_ DKC—�'Efn
snCZ. soo[,cre;so:-- orDcnc 0.=Enic:io-*y ING COLIUSIDN, '?P.rliCTS FROM D_.CO.R
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wzI! q- a �n;zw F .3O , a zm „w eat Dilor
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30
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ire 11 and o _z[e the aoniiarce �� di�-.ed in this n=_nuzl. Chimney i
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FOR spa ~•1 p7ACF.S rii
r Z? OFE'?ry _ •J� Crrh �` D?'ER FDR fir' --T- - ,
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C QMH 1DIN' PRODUCTS ' F:R.QIVI TECDP,-_T�7_TE
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171 S_al r.ht ^'77T71�J _Ijl� ^71L7 Aai anchor hoic 15 D -my ,:d in n`- tr✓0 bD=D' "sial mt:0
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soD� �eeso�, zshs.and base .
32
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wiLi Dreven: the damper :resit
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Natonal =ue.! Gas Cod=. . her the e=s io=n re oDerLT_-O v
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I
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_ a r"Tl2,.
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Rcci NY00i SlIOULe no 7 bto.aot-' ihoar�.o.i,) �s�?�oio
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`=Colt_o -: Sys _T^ . lI1D., ADpL :atior. Of
�2T<i?S)'mmy adverselt
of J:ne htar TVZ_���I�NG �Il nreYiQisly apDuee
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Re e_ to n`u� t r - ?0 zo o,-dh- lots. malal (rozh 4v001).
-,ri ziz ba.: Sltl_ F 14!..173x-b=anr) 2S'
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of 1,n ual =i=�Md as fat 10- s L
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Dume Ilamt DHLurPS. Do no-, low
f -
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RDD11_ACt arm LeC' 4YILD CC'L7lIl 0'1_. =1fI^S
C:17 boDoi =sen �_ :nese cnemicJs are not nar;i-,iut, but
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cm SM', 'D"Dt7-Z7-__,vC1"EmaEt _-. ona L-eJIl-S' D' 105S
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LEhf l- J tjl_'4110.: lollo'v ShnE in.., -ti 0as
?,i.' F 0 R.. 1 C- LT\ CJ SM211 all 1i =6 til!-D.D n n C'.
'area for ea_;. BE S'ur! to sIn`J Ile,._ to the L007 be^.AL'S?
3aMT E. is Ile^via" trtu P.L7 anE IYiLSetfl1 on ttht EDOr
Do no:t IS i?cRI 9L� 3ppuanc=
- Do hbt touch a,ny �i_ice swiz_e;
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YJ 15 f= -oBt is . Ur .e1 t: c�
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D_ 7= ---, cm ml ), Db c�� _:1ocL-^sett
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r n
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w �� LE�= the Diio_ Lf i)i=o iphol dos not L-E±z #LP
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DLlO� £Z.:er10 s:'D %.
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n T_um cmc coiatrol imob dmkvY1St. ib. 1hf- _OZ'T
adjus—L Il esm m d�.�"ed S� �
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11. J= ibt gas loos will y-, ovoD_61.2 , fch.c+r'-!Le ins
ON/Q- - .Sikh Lo 0-m-sidon.
T'.L�li O C -2i To Apul=__E c.c. _O) y0=1 S=:
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i or 2 Si D'al eT_
l.. c, i'riinc.jea7 the 00r. 1_ vOL 5 neL STQ�i .�O!-
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At
Date.
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
... L
This certifies that .?�-G� ...........
s
has permission for gas installation1?'nG�}¢.
in the buildings of .. v��^� �..........................
at ....I Z. . 0 North Andover, Mass.
Fee .. Lic. No.�3I.... M ................... .. .
G GAS INSPECTOR
Check # I I�_
I
8627
8627
-I r-
C('*:tz (95(0
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY NORTH ANDOVER MA DATE MARCH 19 2013 PERMIT #
JOBSITE ADDRESS 72 CAMPION RD. OWNER'S NAME I GREGORY JOHNSON
GOWNER ADDRESS I GREGORY JOHNSON TE978-685-2446
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL
PRINT
CLEARLY NEW:® RENOVATION: ® REPLACEMENT: ® PLANS SUBMITTED: YESE] NO®
APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE _
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER 1JII III
WATER HEATER
INSURANCE COVERAGE
have a current liability -insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES E] NO
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q OTHER TYPE 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.
�n
a
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 in compligacq withTa1Pertinent vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUM BER-GASF ITTER NAMEROBERT WHITE LICENSE #W –l0?3 SIGNATURE
MP Q MGF ® JP ® JGF ® LPGI ® CORPORATION []# PARTNERSHIP ®# LLC ®#�
COMPANY NAME:j EASTERN PROPANE GAS ADDRESS131 WATER ST.
CITY DANVERS STATE MA ZIP 01923 TEL 1-800-322-6628 ct�
FAX CELLI IEMAILE-77-
1
-3143 r76J�A 191 AACL-1 \A11
1
R
� w
r.� Print�Form
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
ApplicanUnform-ation - Ple-ase P -lain# Le2ibl-y-
Name (Business/Organization/Individual):
EASTERN PROPANE & OIL
Address: 131 WATER STREET
itv/State/Zits: DANVERS, MA 01923
Phone #: 978-750-6500
Are you an employer? Check the appropriate box:
1. ❑✓ I am a employer with 45 • 4. ❑ I am a general contractor and I
employees (full and/or part=time).*
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp: insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.:
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. E] Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.[] Plumbing repairs or additions
12. ❑ Roof repairs
13.❑✓ Other GAS FITTING
*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.
I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: ENERGI
Policy # or Self -ins. Lie. #:
EWGCD000080613
Expiration Date: 03/15/2014
Job Site Address: 1(a Cov.. `� w. 41l , City/State/Zip: J),D o k, �v�r�Iy�.Pri �(11St o tptiS
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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Phone #: 978-750-6500
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,iLiS anntiance;�F a�n7s :.r -an .
37
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=TOIf=
9265 Date.1� .. .
TOWN OF NORTH ANDOVER
° yo
PERMIT FOR PLUMBING
11 �
This certifies that .4dl ............ ...... .
has permission to perform . QCT? .../t/2•?�t" 01
plumbing in the buildings of ..ree .or .........
at....'%Z, ..&..... .., orth Andover, Mass.
Fee. Z,�.4� Lic. No..4�J lel /� ...... ... ..............
PLUMBING INSPECTOR
Check # -LCL_
'? .
FDCFURES
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
CitylTown: NQ r1k ic v f r MA. Date: / z
ll /f Permit#
Building Location:_ i✓ c2. �Kp r0 Vl Owners 6
Name: re.!30 u S a Y1
Type of Occupancy: Commercial[ Educational[] k dustriat [] tnstihitionat ❑ Residential gl,
New: ❑ Alteration: ❑ Renovation: ❑ Replacement: Plans Submitted: Yes ❑ No ❑
FDCFURES
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1 FLOOR
2 FLOOR
3 FLOOR
4 FLOOR
5 FLOOR
6 FL40R
7 FLOOR
8 FLOOR
Installing Company Name: A&W q _ 1 (
� C' /-T
Check One Only Certificate #
/_ ,(
Address:/b I �i t, (f 5 bcL r cciiyfibwn; �K ✓Cls State: 4
[] Corporation
Business Tel:% �s' � 7 q d' S Fax:
Q Partnership
Name Licensed Plumber: S� 6A�
❑ FirmlCompany
of Q w t� ,
I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 Yes 0 No ❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy f a 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 ofthe
Massachusetts General Laws, and that my signature on this. permit application M awes this requirement
Check One Only
❑
Signature of Owner or Owner's Agent Owner 11Agent
I hereby certify that all of the details and Information 1 have submitted (or enterers) r�egardrg this application are true and accurate to the best of my
Knmdedge and ttrat ab pliimlbingwork and nstallations performed under bre permit issued for this appitcation will be In compliance with all
Pertirietit provision of the Massachusetts State Plumbing Code and Chapter 142 of the General laws.
By tihtf' /L Type of Ucense:
Title ///�/�2be
U Plumber Signature of Licensed Plumber
Cityfrown ❑ Master
APPROVED 0FRCE iisF timi vi Sjourneyman License Number 1
r It
The Commonwealth of Massachusefts
Department of Industrial Accidents
Ogee of Investigations
600 Washington Street
Boston, MA 02111
www massgov/ria
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Businessiomanizationandividua ): SkQq k UA (-+e-1/aAtb 1 k 5+ f fec ,%Vyc
4 Pj 1(54 c r,/ Ale
City/State/Zip: 1 /a ,, a E rS AQSS O%'�Z3 Phone #-J I -7t -7 77 & 4 S
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).*
2. ®. I am a sole proprietor or partner-
have hired the sub -contractors
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. ❑ We are a corporation and its
10.E] Electrical repairs or additions
required.]
3. ❑ 1 am a homeowner doing all work
officers have exercised their
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 #t must also fill out the section below showing the¢ workers' compensation policy hifozmation.
t Homeowners who submit this affidavit indicating they are doing aU 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 ofthe subcontractors and thea workers' comp. policy information.
I am an employer that isproviding workers' compensation insurance for my employee& Below is thepolicy and job site
information.
Insurance Company
Policy # or Self -ins. Lie. #: 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 certify n er the pains and penalties ofpedury that the information provided above is true and correct
Siunature-
Phone #- lq 7,? 77 7 K5 R J '
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/rown Clerk 4. Electrical Inspector 5. Plumbing. Inspector
6. Other
Contact Person: Phone
- = - Zog92 ��
Board CONT IMP 1 VOU( 50 - gton
iy d noo S11111
IL Of destroy.ensure' �d"
vise los - ,.I ur- our bo - rd
S kice �ess%O
tA 0?jj8-
or, 0A Pilo 'Im I
A -d' (10 wmg 01 1,
pi 51 Dostofll SkAoNNVI IS change Ilicense-Ifo , t.
1. -Fth1f-%Ool , gropef MOLI
ddvess ,
Of a aLdr 5 to to loll,
naLff\E yes. . refer . 01 �kbe koAed'
ki 01 name Of Awav O\j .1ljAons The uf
d Mus' "0 On
01690 , ,,pq\-%c,0On- kyie 0 an ense
eNNa sable ck to , ,I\jjlege, this Air,
.'Be c(Ila yee
\krer\sl is - apP-11' Person
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nended: �t Is oev P \a)N
as or
to any P°
ip ed by
feq
6t s ed
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0
'Pet stc,
E A LTW(59 MAR -Qi
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JOURNEYMAN PLUM
.ISSUES THE ABOVE LICENSE TO:
HAWN ,.0 WHITE
B 1186
UTON
MA 019.49=3166
25491 05/01/12
788605
Date. .z�.............
° TOWN OF NORTH ANDOVER
PERMIT FOR GAS- INSTALLATION
This certifies that .. e�.'rq .., h ..C"
has permission for gas installation ...(��f7-ice /!.A4,.. .
in the buildings
of ... acd? U! ... �'`�'�''... !I ..............
at ....�.. ,t�/O.� ..........�. , /North Andover, Mass.
Fee. .? Lic. No. ,w?o%1". !!;�0 .
GAS INSPECTOR
Check # a-476
7932
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
N ANDOVER
Building Location 72 CAMPION RD
. Date 11/29 2011 Permit #
Owner's Name GREGORY JOHNSON
Owner Tel# 979-852-2817 OR 978-685-2446 Type of Occupancy RESIDENTIAL
New Renovation❑ Replacement D Plan Submitted: Ye[] No[]
FIXTURES
Installing Company Name Eastern Propane & Oil, Inc
Address
131 Water Street
Danvers, MA 01923
Business Telephone # 800-322-6628
Name of Licensed Plumber or Gas Fitter �c��e��+e�,�.O •�,�
Check one:
ZCorporation
nPartnership
Firm/Co.
INSURANCE COVERAGE:
I have a es liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
cur ✓
curI No ❑
Yes
If you have c ecked ygs, please indicate the type coverage by checking the appropriate box.
A liability insurance policy F( Other type of indemnity ❑ Bond ❑
Certificate
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:
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of m)
knowledge and that all plumbing work and installations performed under the permifissue for this appli 'on will be in compliance with all
ertinent, provisions of )he Massac a State Gas Code and Chapter 142 of the en al Law &_
By v Type of License:
• umber Signature of Licensed Plumber or Gas Fitter
Title Gas fitter r
•
-Master License Number 1� 123
City/Town • -Journeyman
APPROVED (OFFICE USE ONLY)
•
u
'
Installing Company Name Eastern Propane & Oil, Inc
Address
131 Water Street
Danvers, MA 01923
Business Telephone # 800-322-6628
Name of Licensed Plumber or Gas Fitter �c��e��+e�,�.O •�,�
Check one:
ZCorporation
nPartnership
Firm/Co.
INSURANCE COVERAGE:
I have a es liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
cur ✓
curI No ❑
Yes
If you have c ecked ygs, please indicate the type coverage by checking the appropriate box.
A liability insurance policy F( Other type of indemnity ❑ Bond ❑
Certificate
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:
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of m)
knowledge and that all plumbing work and installations performed under the permifissue for this appli 'on will be in compliance with all
ertinent, provisions of )he Massac a State Gas Code and Chapter 142 of the en al Law &_
By v Type of License:
• umber Signature of Licensed Plumber or Gas Fitter
Title Gas fitter r
•
-Master License Number 1� 123
City/Town • -Journeyman
APPROVED (OFFICE USE ONLY)
Date... IA. 114' ....
° TOWN OF NORTH ANDOVER
P
PERMIT FOR GAS INSTALLATION
K,
This certifies that.. 2'44s rn .. `�, �'� e .. t4s . .........
has permission for gas installation .. �-- `' .. ...... .
in the buildings of .... �j. !�' q ...vc'f� Sd'// ........... .
at ... �..S.�at*?�?!o+!�.../4 r......, Nrth oAndover, 'ass,
Fee. U?�:o� Lic. No.....�.. .......
/ f GAS INSPECTOR
Check #
(Jot -&
G
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
NORTH ANDOVER ,Mass. Date JAN. 9, 2012 Permit #
Building Location 72 CAMPION RD.
Owner's Name GREGORY JOHNSON
Owner Tel# 978-685-2446 Type of Occupancy RESIDENTIAL
New W] Renovation❑ Replacement ❑ Plan Submitted: Ye[] No[]
FIXTURES
Installing Company Name Eastern Propane & Oil, Inc
Address 131 Water Street
Danvers, MA 01923
Business Telephone # 800-322-6628
Name of Licensed Plumber or Gas Fitter ERIC PELLETIER
Check one: Certificate
Corporation
Partnership
Firm/Co.
INSURANCE COVERAGE:
I have acur liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ✓ No ElIf you have c ecked yes, please indicate the type coverage by checking the appropriate box.
A 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
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
I have submitted (or entered) in above application are true and accurate to the best of m,
iowledge and that all plumbing work d installations performed under the permit issued for this application will be in compliance with all
�rtinent pyovisionso2f the Vass AEh is State Gas Code and Chapter 142 of the Gene I.L-aas.
By CIA Type License: y
•
umber Signature of Licensed um er or Gas Fitter
j� � •
Title / r as fitter -5T-
• •Master License Number
City/Town • -Journeyman
APPROVED (OFFICE USE ONLY)
7760 Date.."7....6 7.�.�.....
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .. C. ( `�� ....0 d r, ! .pa,.,e,................
has permission for gas installation .. T� a .,�...�n wC ........... .
in the buildings of .. G. I. e ..1 Q. \A ..................
at Cc, L. 49 ..0).4vi .. ....., North Andover, Mass.
1
Fee�.:�. Lic. No.
GAS INSPECTOR
Check # 2
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT
ETTO DO GAS FITTING
City/Town: `� MA. Date: i l Permit#
Building Location: i "�
Owners Name:
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional
❑ Residential [—
New: ❑ Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑
FIXTURES
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W
Z FW- Y
D W RN' V = �
M = W W U = N N
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0 y J Q Q m W O Z Q 0 !— W W W 2
v o o = 2 O 0 9 O w z z W Q I.--�
UB BSMT_ I' > > > 3 O
1" FLOOR
MUNNUUMMMMMMUMM man===
mmmm
MMUMMUMMMUMMUNUMMMMUMMUM in
nummunum
mmmmmmMMM. E-NOW-Unnomel
Installing Company Name: Check One Only Certificate #
Address: V gftrporation
ity own: "� te: �L"—
Business Tel: �� ��� Fax:—�L5 ❑ Partnership
Name of Licensed Plumber/Gas Fitter: ❑ Firm/Company
INSURANCE COVERAGE:
I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 1
If you have checked Yes, please indicate the 42 Yes [I No E]type of coverage by checking the appropriate box below.
A liability insurance policy Other
type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee doe'snot ave 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 ❑
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 a d
cin
ompliance with all Pertinent provision of the Massachusetts State plumbing Code and Chapter 142 of the General Laws.
By Type of License:
plumber
Title L�'r;as Fitter
❑ Master Si nature of Licensed u
City/Town (]Journeyman
APPROVED (OFFICE USE ONLY) ❑ LP Installer License Number:
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EDF D
OR
MA 01730
12-426 05/01/12 7588
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EDF D
OR
MA 01730
12-426 05/01/12 7588
The C ommonwed& ofMmadkoeft
Aeddaft
Offxe ly
0f
600 Washington Street
Boston, MA 02111
�� �� kers' Compensation Insurance Affidavit: Bgilder$JCo bars
ptow&eA Print IAMM
Name (Businen.%or¢alizmonrxdi,,idLm]):;
,;
City/State/Zip:
Phone#:___---
Are you an employer? Check the appropriate box:
4. rl I am a gancaal contutor and I
1. E] I am a employer with
employees (hill and/or part-time).-
have hired the �,�
lye on the attached shy
2. ❑ I am a sole proprietor or partner-
Thi sub-c�rs have
ship and have no employees
employees and have workers'
working for me in any capacity'.
t
(No workers' comp: insurance
We war cm7or
5• � We are a corporation and its
requka)
3. ❑ 1 am a homeowner doing all work
officers have exercised their
rW of exemption per MGL
myself (No workers' comp-
c. 152, §1(4N and we have no
msraance required -1 t
empbyees• [No work=`
comp. insumnce reyrrired-]
Type of project (raph ed)
6. ❑ New coram
7. ❑ Ram
8. ❑ Demolition
9. [] Buflft additim
10.❑ Electrical repans or additions
11.0 Plumbing repasts or amens
12.1—] Roofrepairs
1313 Either
•,any �pticaot that cheeks box ill ,mut siso fin oat the section below show* ibex vis' = Pd* &M8d=
t H. who snbmit this g fty an do* all cork eid then bno outside amts a new st such
the name ofthe sob-oonaa�o�s and
date whether or mit tlsose des have
:Conuaes that chock this boa tmas;at sa a�W sheet t M8 h eaicets' comp• d_
rmaiovees- If the si-oom�m; have emPiayem they inti %P
I am = anployer Utast is
Insurance COY Nag
, F employees. Below is theP*&7 MaPo she
serf Lic. 12 EM
Policy # or -los.
Job Site Address:, ft 2'
Attach a copy of the t
Failure to scene covet
fine up to Sl,5M00 at
of up to =50.00 a day
I do hereby cert }' wider
v
City or Tows
L Board ofHC20 I
6.Ober
Ito
CitY/State/Zzp= y ��
�' °M -
tio„ deuton page (showing the policy namber and contion date}
• t"s of a
s reqSection 25A of MGL a 152 can lead to the imposition of abniaal pensi
�y� imprisaa�eat, as well as civil peaabies in the form of a STOP WORK ORDER and a fine
est the violator. Be advised dint a copy of this statetne& may be forwarded to the Office Of
above is arae ani currGct
aren6 to crty or Mm effieW
Permsse 0
oyster r 5. P�bing b*eelor
�ity!
3 (!'owe Clerk 4. 1
Contact Person-
M*
7 Te J Date ... 9...a.. /. /....
` TOWN OF NORTH ANDOVER
• + PERMIT FOR GAS INSTALLATION
This certifies that ..E et. �t -k Vii... 7` q ! ....6A4...... .
has permission for gas installation
in the buildings of ..............
at ... e" (D.t.o.A. . RA ... . , North Andover, Mass.
Fee.,3Q.cti? Lic. No...........
GAS INSPECTOR
Check #
i
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
NORTH ANDOVER ,Mass. Date JUNE 30, 2011
Building Location 72 CAMPION RD.
Owner Tel# 978-685-2446
Permit #
Owner's Name GREG JOHNSON
Type of Occupancy RESIDENTIAL
New W] Renovation❑ Replacement F-1 Plan Submitted: Ye[] No[]
FIXTURES
Installing Company Name Eastern Propane & Oil, Inc Check one: Certificate
Address 131 Water Street Corporation
Danvers, MA 01923 Partnership
Business Telephone # 800-322-6628 Firm/Co.
Name of Licensed Plumber or Gas Fitter ROBERT WHITE
INSURANCE COVERAGE:
I have a cures liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yesl ✓ I No r-1If you have "'cTiTTe--"'cked y s, please indicate the type coverage by checking the appropriate box.
A liability insurance policyF—,(] Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
I hereby
I have submitted (or entered) in above application are true and accurate to the best of m
knowledge and that all plumbing work and installations performed under the permit issued for this application will 9,e in compliance witn an
ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen a s.
By Type License:
d +umber Signature of Licensed Plumber or Gas Fitter
Title
City/Town
APPROVED (OFFICE USE ONLY)
G�s fitter
d�IQfaster License Number /77 -/a:73Y
• -Journeyman
'
a
Installing Company Name Eastern Propane & Oil, Inc Check one: Certificate
Address 131 Water Street Corporation
Danvers, MA 01923 Partnership
Business Telephone # 800-322-6628 Firm/Co.
Name of Licensed Plumber or Gas Fitter ROBERT WHITE
INSURANCE COVERAGE:
I have a cures liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yesl ✓ I No r-1If you have "'cTiTTe--"'cked y s, please indicate the type coverage by checking the appropriate box.
A liability insurance policyF—,(] Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
I hereby
I have submitted (or entered) in above application are true and accurate to the best of m
knowledge and that all plumbing work and installations performed under the permit issued for this application will 9,e in compliance witn an
ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen a s.
By Type License:
d +umber Signature of Licensed Plumber or Gas Fitter
Title
City/Town
APPROVED (OFFICE USE ONLY)
G�s fitter
d�IQfaster License Number /77 -/a:73Y
• -Journeyman
Date ... el,,9
... ..........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ... . ......... ..........................................
.............
has permission to perform ... ..................................
wiring in the building of .............. ...........................................................
at .... �7
....................... ... ....... North Andover Mass.
Fee 4,5 ............. Lic. No... ...................
�INSP�ECTO
Check #
9-1 1 4
l.omnwnwealth oB kamacl of Official Use Only
MKMcc�/
�] Permit No.
2eparh d of - ire �eruiced
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code ), 727 CMR 12.00
(PLEASE PRINT IN INK OR 7-YN ALL�VFO�RMAT ION) Date: Ill ill G
City or Town of: To the Insieltol of Wires:
By this application the undersigned gives hot7ice of his or her�iTtention to perform t1W electrical work described below.
Location (Street & Number)
Z
/
No. of Luminaire Outlets
Owner or Tenant
Generators KVA
D huslmTelephone
No.
Owner's Address
r
N6. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
-Is this permit in conjunction with buil 'ng pe it?
Purpose Building S ti
Yes ❑ No (Check Appropriate Box)
of
o. of Detection and
Initiating Devices
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:
Comnletion ofthe fnllnwino tnhle mint h,, wnivoil by tho hnvn tnr nfW'ror
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 E]I ❑
nd. nd.
o. o Emergency Lighting
BatteryUnits
r
N6. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
o. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
Heat Pump
Number
. ..
J.Tons
J.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,
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
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value fectr' al Work: (When required by municipal policy.)
Work to Star�O d4 1 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE (AVE GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability ' surance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such cover ge is in force, and has exhibited proof of s to,the�it issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains a penaltii�es of p *ury, th *q nfiormation on t is pplication is true and complet��
FIRM NAME: CIV �y�eG t 'C tC ��,4 , r ,�� LIC. NOy`,,{.,/
Licensee: 'y 1 -
(If applicable,en ffi "exem in he li nse nun
Address: :N ,1 , r, &A 1h
*Per M.G.L. c. 147, s. 57-61, security work
OWNER'S INSURANCE WAIVER: I ai
of Public Safety "S" License:
_ LIC. NO.:
Bus. Tel. No.:
Alt. Tel. No.:---_—_Z�
Lic. No.
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/Ag
Signature
Telephone No. PERMIT FEE. $ �%
/1/0 '041ee�14 �
a
4
Location 17a f
No. Date o2 1a 9
NORT1y
TOWN OF NORTH ANDOVER
p
Certificate of Occupancy $
Building/Frame Permit Fee $
�'�b',••° •'<�'
ss�cwust
Foundation Permit Fee $
�
Other Permit Fee $
°
Sewer Connection Fee $
Water Connection Fee $
TOTAL $, IC231 r
Building Inspector
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Date . /) . ?. ?.: `..'
TOWN OF NORTH ANDOVER
° PERMIT FOR PLUMBING
A 40
This certifies that ..,�!.r..c �.r�.... �.t`� . j'� ..........
has permission to perform .... f .`" ... r ........ . ........... .
plumbing in the buildings of ...`.../................ .
i
at. ............. . North Andover, Mass.
Fee. . . - . Lic. No.. `^!S.,f.? . ....... \:.._... t .... ;d?�`-.... .
PLUMBING INSPECTOR
Check # 2 ( I }
5077
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type)
Mass. Date
Permit
Building Location__ 11- CG Mi2,10y), Owner's Name ! i
Tyne -of Occupancy_��r�3`
.f
New ❑ Renovation ❑ Replacement 10 Plans Submitted: Yes ❑ No ❑
B . P . # SEWER# FIXTURES SEPTIC#1
Installing. Company Name Andover Pl bg. & Utg. Co-, Tnc_ --Check one: Certificate #
Address 20 Aegean Dr. Unit -10 (2/corporation 2122
Methuen; MA 01844 ❑ Partnership
Business Telephone ( 978) 685-8383 ❑ Firm/Co.
Name of Licensed Plumber Genrgp I agnep
INSURANCE COVERAGE:
I have ayes entliability Insuran
ra ce policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy V Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner ❑ Agent ❑
I hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed and r the permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plumbing Code and apter 142 of the Ge ral Laws.
BY ix�
Title Signature of LrcenwdPlumber
City/Town Type of License: Master T____Journeyman ❑
VPPYVED OFFIC USE ONLY) License Number 9983
Y
�
•
Sol
Installing. Company Name Andover Pl bg. & Utg. Co-, Tnc_ --Check one: Certificate #
Address 20 Aegean Dr. Unit -10 (2/corporation 2122
Methuen; MA 01844 ❑ Partnership
Business Telephone ( 978) 685-8383 ❑ Firm/Co.
Name of Licensed Plumber Genrgp I agnep
INSURANCE COVERAGE:
I have ayes entliability Insuran
ra ce policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy V Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner ❑ Agent ❑
I hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed and r the permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plumbing Code and apter 142 of the Ge ral Laws.
BY ix�
Title Signature of LrcenwdPlumber
City/Town Type of License: Master T____Journeyman ❑
VPPYVED OFFIC USE ONLY) License Number 9983