HomeMy WebLinkAboutMiscellaneous - 72 FERNVIEW AVENUE 4/30/20184264 TRAVELERSJ'
The Travelers Indemnity Company
P.O. Box 1450
Middleboro, MA 02344-1450
10/19/2015
Town of North Andover Building Inspector
120 Main Street
North Andover MA 01845
Insured:
Teon Edwards
Claim Number:
HXV5707
Policy Number:
OF0828-948965648-636 -1
Date of Loss:
02/13/2015
Loss Location:
72 Fernview Ave 3 Heritag North Andover MA
To: Board of Selectmen
Building Commissioner
Inspector of Buildings
Board of Health
A claim has been made involving loss, damage or destruction of the above captioned property
which may either exceed $1,000 or cause Massachusetts General Laws Chapter 143, Section 6
to be applicable. If any notice under Massachusetts General Laws Chapter 139, Section 313 is
appropriate, please direct it to my attention and include a reference to our insured, the policy
number, the claim/file number, the date of loss, and the location.
If you have any questions, please feel free to contact me at (508)946-6317 or email me at
NVI LAN DR@travelers.com.
Sincerely,
Nicholas Vilandre
Claim Professional
(508)946-6317 Ext. 9466317
Fax: (877)786-5584
Email: NVILANDR@travelers.com
On this date, I caused copies of this notice to be sent to the persons named above at the
addresses indicated above by first class mail.
Signature
Date
P0062 F3162C1515293004264 00001 N
3'19 Date. .
-:'� TOWN OF NORTH ANDOVER
o
' PERMIT FOR PLUMBING
Sri �
This certifies that .. �?�✓t..eCJr1.Gr.... /.......... .
has permission to perform. 11P.�1�i! ?�,Pe?! . �? ... .
plumbing in the buildings of ....:y'!7 ...............
at ....1.�..,/rPc!? (J�C'/•J. %�U�... , ... , N rt AndMass.
Fee4q!'. Lic. No..4- 40. .. :...... .
PLUMBING i SPECTOR
Check # /0-5-z-
rE
HUSETTS UNIFORM APPLICATION FOR A PE
_ _ RMIT TO DO PLU�IBING
or �j,, ��„ P - — -`-_`-—APPLICATION DATE:L� ���� v l�W %� � � t� � iiPLANS SUBMITTED: YESN0�'PE: COMMERCIAL RESIDENTIALERAT10NO REPLACEMENT' REMOVAL/DEMOLITION
r PLUMBING: PIPING — FIXTURES - FIXED APPLIANCES —APPURTENANCES 1
_TERNATIVE TECHNliI 11"V ENTER TOTAL AMOUNT FOR EACH SELECTION _MITED TO FIVE 151 Im MCDAR
NAME:
ADDRESS•
I
CITY: _�9�t _� p rs� _ _.. __ _ _ _..._._.......,. .
--- JSTATE ZIP:
TEL: FAX: Lµ._.. _..• i �Z • .., ..
EMAIL.
X ONE ONLY
Business #
Business ]
Businesses--I�
/ Unincorporated
INSURANCE COVERAGE
I have a current Ilabhi insurance policy or, its substantial equivalent, which meets the requirements of MGL. Ch. 142 YES N
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. OEj
A liability insurance policy �'
Other type of indemnity
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 4 f
2 otheeMMassachusetts General Laws,
Signature of Owner or Owner's AgentOWNERCHECK ONE ONLY
_ a AGENT
OWNER'S NAME: , _ _ _ `'� _.. __.- _ ._ .---
—� - --J TEL: FAX:._ __- _----�
I hereby certify that all of the details and information I have submitted (or entered) regarding this permit application is true an
the best of my knowledge. I certify that all plumbing work and Installations performed under the permit issued, will be in compliance with
all pertinent provisions of the Massachusetts Uniform State Plumbing Code, and Chapter 142 of the General Laws. p d accurate to
(OFFICE USE ONLY)
TYPE OF LICENSE:
Permit #
❑ Plumber
Inspector L aster ure of License umber
Fee: Journeyman LIc Number: "—I _ -•r
f�
Date. .......
NORTH
Of ,4'O
° TOWN OF NOTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ... .......... lf....` ......................... .
�
has permission for gas installation . .............. .
in the buildings of.............. .
at v, t ........... ,)) North Andover, Mass.
Fee. .... Lic. No.. .`..... ... �l_.. ................. .
6ASINSPECTOR
Check # S " e3 -7/
7066
f
MASSACHUSETTS UNIFORM s.PPLICATION FC7r. PERMIT TO DO GA5 i 1 i i IlVta
MA. Date: �� `"� �� _ Permit# a�-
City(rown:\ +''1h c�1 .�
Building Location 2 e'rY1 V 0,W J- Owners Name�QI t N55 L v 'C0MYN
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
New: ❑ Alteration: ❑ Renovation: ❑ Replacement: ®' Plans Submitted: Yes ❑ No[ .
FIXTURES
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BASEMENT
1 FLOOR
2 FLOOR
3 FLOOR
4 FLOOR
5 FLOOR
6 FLOOR
7 FLOOR
8 FLOOR I I I I I
Check One Only Certificate #
Installing Company Name.?' t+�Corporation
Address �v�rh@'1ae � City/Townc.S�� �^ State
❑ Partnership
Business Tel: %o! COVE 'Acts"%% Fax: ❑ Firm/Company
Name of Licensed Plumber/Gas Fitter: ttlL-
INSURANCE COVERAGE:
I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ! No 171
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 9 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 thisCheck One Only
Owner ❑ Agent ❑
Si nature of Owner or Owner's A ent
By checking this box ❑; I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and
accurate to tfie 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 Genesi laws.
Type of License:
By ® Plumber
❑ Gas Fitter Signature of LI ensed Plumber/Gas Fitter
Title [A Master Z-%
❑Journeyman License Number:
City/Town
K11VI El LP Installer
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that F ..............
has permission to perform ..... il. .....................
plumbing in the buildings of ...
at .... .............. North Andover, Mass.
t�
Fee.-?.'�.—. Lic. ...... Y. . . ............
PLUMBING INSPECTOR
Check #
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS Date
, ld l le57
Building Location AeAA/ / tE� U/ Owners Name PDQ / 1"��C e J permit #
T e of Occupancy Amount
New Renovation E] Replacement—` Plans Submitted YesElNo ❑
(Print or type) / Check one: Certificate
Installin
_L,ompany Name
❑Corp.
Address a gey &d
Partner.
Cu�77-
33T37-
Business I e ephone trm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond ❑
Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner ❑ A ent
I hereby certify that all of the details and informatp-trf
best of my knowledge and that all plumbing wor and i
compliance with all pertinent provisions of the M ssacl
ITitle
O VED (OFFICE USE ONLY
g Li
submitted (or entered) in above applic
ations perfop d der Permit Issued
s State PlAbinn a,- ,.
Type of Plumbing License
i nse IN u,xuer Master
P true and accurate to the
application will be in
General Laws.
Journeyman ❑
Ky
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(Print or type) / Check one: Certificate
Installin
_L,ompany Name
❑Corp.
Address a gey &d
Partner.
Cu�77-
33T37-
Business I e ephone trm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond ❑
Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner ❑ A ent
I hereby certify that all of the details and informatp-trf
best of my knowledge and that all plumbing wor and i
compliance with all pertinent provisions of the M ssacl
ITitle
O VED (OFFICE USE ONLY
g Li
submitted (or entered) in above applic
ations perfop d der Permit Issued
s State PlAbinn a,- ,.
Type of Plumbing License
i nse IN u,xuer Master
P true and accurate to the
application will be in
General Laws.
Journeyman ❑
The Comnionwea&k of Massachusetts
l Department of ,industrial Accidents
Office of Invesd ations
600 Nrashinvion Street
�.6 q B b
aston, M4 0.2111
c www m=sgov/dia .
Workers' Compensation iusurance Affidavit-. Builders/Contractors/Eiectricians/pi am
Applicant IafurMation bers
Please Print Leeiblv
Name (Business/orgenization/individual):
Address:
City/State/Zip: Phone A. .
F2.M
you an employer? Check.the appropriate box:
I am a employer with 4. T7�jfq
project (requires:
❑ I am a general contractor and I
employees (full and/or part-time).* have i�red the sub-aontracxors 6ew construction .
I am .$.sole proprietor or partner- listed on the attached sheet x 7. ❑Remodeling
ship and have no employees These su}�-eontractors have
working for me in any capacity. workers' comp. insurance. g' Q Demolition
eq workers' comp, insurance 5. ❑ Weare a corporation and its 9' ❑ Building addition
required_] officers have exercised their 10•Q Electrical repairs or additions
3 • ❑ 1 sin s homeowner doing all work right of exemption per MOL 1 !.❑ Plumbirl
myself (No•workers' co g repairs or additions
mp• C. 152, § ! (4), and we have no 12 ❑ Roof repairs
insurance rt t
] .employees. [No workers'
%Y applicerrt that
t comp. insurance required.] 1317 Other
`checks bort# I must also f111 out the section below showing their workers' compensation policy information
Homeowners who submit this d isvit indicating they ars iioing an work and then hrts oasido con
1Cotrtractors dw aheok this box mustettaehcd an additions! shaetsk.o mon must submit a new affidavit indicans such.
ar arc the
nems of
the sulrcomrectors and,their workers' mr.q. poti� . neon.
entpivj,er that is provri&nrworkers' compensation insurance or
infonnadom .f m3' �Y Below is the policy and job site .
Insurance Company Name:
Policy # or Self-ins. Lie. #:
Expiration Date:
Job Site Address:
CitylState/Zip:
Atfach a copy of the workers' compensation policy declaration page (showing the policy number and expiration da*e
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal �
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WO. ORDER lp=a acus of a
Of up to 5250.00 a day against the violator. Be advised that a copy of this statement may f forwarded to the Office of a fine
investigations of the DIA for insurance coverage verification.
! do hereby certify under the pains and penaL6`s ofPerjwy that the information provided above is true and co
Si titre: .
rrect
Date:
Phone #:
of
ficial use only. 1)o not write in this area m be completed by citl, or town. o rzaL
Town:
Permit/License #
Aafirorify (circle ooe):
I. of Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector 5. Plumbing Inspector
Person•
Phone #:
Information a and Instructions
Massachusetts General Laws chapter 152 requires all emp 3oyers to provide workers' compensation for their employers.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, -
express or implied, oral or written." `.
An employer is defined as "an individual, pamership, association, corporation or other legal entity, or any two Or MOM
of the'foregoing engaged in a joint enterprise, and including the legal representatives of a dccxased employer, or the
receiver ortrustee -of an individual, partnership, association or other legal entity, employing ernpioye-.s. 'However the
owner -of a dwelling house having not more than three apa;-tmentt and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall nat because of sucb employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of license or permit to operate a business or t:o construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence.of compliance with the insurance' coverage required"
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract far the performance of public work until acceptable evidence of compliance with the insurance
requiremerts of this chapter have been presented to the contracting authority." .
Applicants
Please fill out the workers' compensation. affidavit complertely, by checking the boxes that appiy.to your situation and, if
necessary, supply sub -contractors) name(s), addresses) wind phone number(s) along with their certificate(s) of •
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, arc not requiredito carry workers' compensation insurance. If -an LLC or LLP does have
empioyees, a policy is required. Be advised.that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage.. Also be sure to sign and -date the affidavit The affidavit should
be returned to the city or town that the .application for the permit or license is being requested, nofthe Department of
Industrial Accidents. Should you have any .questions reprr-ding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the nurnber, listed below. Solt +�+sured o^rrrpar:i �ho�ld en+� +�*
self insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Departme=nt him provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Invest p ions has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which %%,ilI be used as a reference number. In addition, an applicant
that must submit multiple pormit/iicense applications in any given year, need only submit one affidavit indicating current
policy'information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of -the affidavit that has been .officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future re permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any bu=siness or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit
Tire Office of investigations would It to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Depamnent's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of lmdust W Accidents
Office of Investigations
600 Washington Street
Boston, A!SA 02111
TeL 9 617-727-4900 ext 406 or 1-977-MASSAFE
Revised 5-26-05 Fax x 617-727-7744
www.mass.gov/dia
Date. i:...... .
i
°` TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ......................
has permission for gas installation .. ..1-/, .................
in the buildings of .*P!, (eat �.�.G .i) ...................
at ...-7.? .. F r.Rm- L: *.:-.............k'x.��
North Andover, Mass.
Fee. 3°: Lic. No..7�s.%... ..... .'qS INSPECTOR
Check # //;,,/
69u7
Iq
MASACHUSEMUNWORMAPPUCAkIONFORPMUrTOWW
(Type orprmt) IG
NORTH ANDOVER, MASSACHUSETTS Date .7
Building Logations
Signature of
Plumber
Gas Fitter
®
Master
Journeyman
72tR�� f
Cta/
Permit
6•✓��;
Owner's Name
Amount
G _
New Renovation
Replacement
V
plus Submitted
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IBASEM ENT.
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ItST. FLOOR
2ND, FLOOR
3RD. FLOOR
4TH. FLOOR
STH. FLOOR
6TH. FLOOR
7TH. FLOOR.
LTH. FLOOR.
(Pr int or type)
Name >cl, C'neci one: Certificate Installing Com an
Address the5- —
Corp, p Y
sl /LJ Partr�er.
usmess 'e ep one �6'
Name ofLicensed Plumber'or Gas Fitter
INSURANCE COVERAGE
! have a current !lability insumnce•.policy or it's substantial equivalent Check one:
if you have checked ves, please indicate the type coverage by checkin Yes ❑ No❑
Liability insurance policy Oth g the appropriate box,
er type of indemnity ❑ ❑
Owner's Insurance Waiver. lam aware that the licensee does not have the Insu Bond
Mass. General Laws, and that my signature on this.permit appl�ic uve ti es Insurance
comae required b
g q y Chapter 142 of the
Signature of Owner or Owner's Agent Check one:
1 hereby certify that all of the details and information Owner ❑ Agent ❑
best of my knowledge and that all plumbing wo and installation itted (or entered) in above a
compliance with all pertinent provisions of th assach efts S e G�ormed under Permit Issu id for thane true and accurate to the
Ch 42 application will be in
l , e neral Laws.
By:
Title
City/'!
_ PPP1
own;
-------------
,0VED (OFFICE USE ONLY)
sed Plumber Or Gas Fitter
c9ens
um er
Signature of
Plumber
Gas Fitter
®
Master
Journeyman
sed Plumber Or Gas Fitter
c9ens
um er
ryn
De artment o �Qcra of MQssachuseuy
P f Indtcstriat Accidents.
D, fftce of Iavesti%atiom
600 Washin ton Street
., Bastoan, M4 0.2111
r;
Workers' Compensation Insurance •AfEidavit. $uijders/Contractors/E
A Ulica.nt Inforiaafion lectridians/P}umbers
Name (Business/Or1'p}ease Print Leaibb
anizati on/indivi dual):
Address:
City/State/Zip:
Phone #:
Are yon an empioyer? Check the appropriate box:
I . [ an. a employer
with
---
4. ❑ I azn a 'eneml
employees (full and/or part-time).*
2, ❑ I am a sole or
contractor and I
have hired the sub -contactors
proprietor partner-
ship and have no employees
listed M the attached sheet #
working for me in any apacitj
exeon�
ub-ctors have
workers,
No workers' comp. insurance
comp. insurance.
S. ❑ We are a corporation
required.]
3. ❑ I an a homeowner doing
and it
cers have exercised. their
all work
Myself . No workers ' pomp.
insurance
rig of exemption Per MGL
c• 152, § 1. (4), and wt. have
required.] t
no
mployees, [No workers'
CIDm
Type of project (required):
•6•. ❑ New construction
7• ❑ Remodeling .
8• ❑ Demolition
9. ❑ Building addition
'.'-0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.0 Roof repairs
p• insurance required.] LJ LJ Other
�An}' appii�nt that checks box #1 .must also fiil our tote section below showirtg their -
workers' coin
' 7'lomnowuets who submit this al idavii indicatin46 alkY ars doing ED tisk,.
2Cana$ctots Ihai chcci; this box must <Ir a.;;LI pensation policy inmmtatron.
attached an additional sheet showing the 'hire outside cuntraciurs rnus( su'om" a new
n�f`
e sub- .1. ctors and their wo ' a P. avirPoli indnfam lion.
t [i►rt an. emola3,er that isPr6vidirae won e.T, co„ 'comp• Policy imormation.
41forrnadorL YserEca ..P=atio. rigs employ •-x
e�
Below is the pofic3' and job site
Insurance Company Name: /n7—zk7
Policy # or Self .ins. Lid. #:
Expirmion Date:
Sob -Sit--Address: •
Attach a copy of the workers' compensation nn;;,.. A. -t__ City�Statr/ZiP
.Failure to sectu'e coverage as required under Section 2SA o fi pace (showiQ. the policy number and expiration date).
fine up to SI,500.00 and/or one-year imprisonment as well MGL c. 152 can lead to the imposition of criminal penalties of a
Of up to .5250.00 a day against the violator. Be advised that a ropy penalties in the form of a STOP WORK ORDER and a fine
Investigations of the DIA for insurance coverage ver•ificati.on, of this staterttent may
be 'forwarded >p the 'Office of
I do here 1, cerfz , ander th
c andpenalti .lP .urj' that the in or
f oration provided above rs t e an
Signature: correct
Date:
D�ciaL use nn1p. Dn not write in this area to be cornpleted.b ,
3 ��, ar to wn o�cral
City or Town:
IssuiQe Authority (circle one): PerMit/License #
1. Board of Health 2. Building Department 3. City/Town Clark 4. Electrical
G. Other Inspector S. Piumbino
• b inspector
Contact Person:
Phone#:
juitut LuaLIVU iC .jt(j jjjStj'ualOjis.
Massachusetts General
.Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined. as ".. ever -y pion in the service of another under any contract of h ire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and includ7ing the legal representatives of a deceased employer, orthe
receiver or trustee of an individual, partnership, associate on or other legal entity, employing employees. However the
owner of a dwelling house having not more than .iivee aptartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do ma int,-nance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be d. -timed to be an employer."
MGL chapter 152, §25C(6) also states that "every state o►r local licensing agenc} shall withhoid the issuance or
renewal of a license or permit.to operate a basiness or- to construct bubdinags in the commonwealth for Roy
appiicant who has not produced acceptable evidence ob-T compiiance with the insurance coverage required!
Additionally, MGL chapter 152, §25C(7) states "Neither -the commonwealth nor any of its political subdivisions shall
.enter into any cunt -act for the perfomtance of public wor7Ec urrtil acceptable evidence_ of compliance with the insurance
requciremenu of this chapter have been presented to the coritra.etimg authority.",
Applicants
Please fill out the workers' compensation affidavit comPkVetely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) --am. d phone numbers) along with their cerdficate(s) of
msurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the `
members or. partners, are not required to carry, workers' compensation insurance. if an LLCor LLP does have -.
employees, a policy is required_ Be advised that this afficlavit may .be submitted to &e Department of. Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The,affidavitshould
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should ,vou.have any questions reCr`tia rciin- the lata, or. if you are rcque�ed to obtain a workm'
.compensation policy, please call the Departme:nt at the nt nber.Iisfwd below. Self irrsL�-cd co,,;�.aties should enter their
self-insurance license number on the appropriat line.
City or Town Officials
Please be sure that the kf5davit :is complete and printed Ie bey. The Department
m has provided a space at the botom
of the affidavit foryou to fill but the. event the Office o f Investigations has to contact you regarding the appii=L
Please be sure to fill in the permifAicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/hcense applications in arty given Year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been offs ceally stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or Iicenses, A new affidavit must be filled out each
year. VWh= a home owner or citizen is obtaining a Iiceas;_ or permit not related to any business or commercial venture
(i.e. a. dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like t6 -thank you. in advance for your cooperation and should you have any questions, .
please do not hesitate to give us a call.
The Department's address, telephone and fay, number.
The CommonweaL-1tb of M=achusetts
Department OfLmdustrial Accidents.
Office of Lavestigations
600 wast gton Street
BQsrton; MA 02111
Tel. # 617-727-4900 art 406 der 1 -gam 1vIASSAFE
Revised 5-2645 Pay, 4 61 7-727-7749
wwutr.mass.Dov/dia
Date./ ... U .
TOWN OF
.N6RTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ... 5,101".e!"-XY .......................
has permission to perform .....D. kr- " .. ...................... .
plumbing in the buildings of ..��t.41", .......................
at .. V. !.'.. L......... , North Andover, Mass.
Fee ......... Lic. No..9.33.7... ......
/ PLUMBING INSPECTOR
Check #
7525
0
MASSACHLISETtS UNIFORM APPLICATION FOR -PERMIT TO DO PLUMBING rr��
Z:Q-�Xmass.
} Dat 20 Pe t#
Building LgVation ' Owner's ame
ype of Occupancy
i
New ❑ Renovation ❑ Replacementie-1, Plans Submitted: Yes ❑ No ❑
FIXTURES
B.P. #t I`CMAICM U
kddr
3usiness Telephone
,j� / LL
dame of Licensed Plumber or Gas Fitter (pl ,1 P "T < �e
Check ong: Certificate
❑ Corporation
❑ Partnership
��farm/Co. `
n�ur'AM,= vtKAGE:
IvGUhave a current liability insurance policy or its substantial equivalent, which meets the requirements of MGI -Ch. 142.
Yes No . ❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy P--**,- Other type of•indemnity ❑ Bond ❑
OWNER'S INSURNACE 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.
Signature of Owner or Owner's Agent
Check one:
Owner ❑ Agent p
hereby certify that all of the details and information 1 have submitted entered) In above application are true and accurate to the best of
y knowledge and that all plumbing work and installations performe nd r the permit lss for this application will 6e in compliance with
I pertinent provisions of the Massachusetts State Plumbing code a t 142 of the eras Laws.
A
BY
Titles ! Si nes ure of Licen ed lumber
Cityflown �
APPROVED (OFFICE USE ONLY) Type of License. bol aster
License Number
❑Journeyman
•
.®...
..
•
E
W
MW
kddr
3usiness Telephone
,j� / LL
dame of Licensed Plumber or Gas Fitter (pl ,1 P "T < �e
Check ong: Certificate
❑ Corporation
❑ Partnership
��farm/Co. `
n�ur'AM,= vtKAGE:
IvGUhave a current liability insurance policy or its substantial equivalent, which meets the requirements of MGI -Ch. 142.
Yes No . ❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy P--**,- Other type of•indemnity ❑ Bond ❑
OWNER'S INSURNACE 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.
Signature of Owner or Owner's Agent
Check one:
Owner ❑ Agent p
hereby certify that all of the details and information 1 have submitted entered) In above application are true and accurate to the best of
y knowledge and that all plumbing work and installations performe nd r the permit lss for this application will 6e in compliance with
I pertinent provisions of the Massachusetts State Plumbing code a t 142 of the eras Laws.
A
BY
Titles ! Si nes ure of Licen ed lumber
Cityflown �
APPROVED (OFFICE USE ONLY) Type of License. bol aster
License Number
❑Journeyman
Date . . . ......
ORTk
0 TOWN OF NORTH AND VER
A�
PERMIT FOR GAS INSTALLATION
This certifies that .... ...", & A. C .....................
...... .. .4 . A.
has permission for gas installation P.e!-v :,7 .................
in the buildings of ... 7 f .............................
at ........... No
Andover, Mass,
Fee. ? Lic. No. .... .... ;>L .............
GAS INSPECTOR
Check # 97 6 a)
6177
C-
V v
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 GASFITTING'
(Print or T el G,
0
{ ass. Date 20 Permit
Building do %� ers Name 0
Type of ocqupancy
New❑ Renovation ❑ Replacement Pians Submitted: Yes ❑ No ❑
installing Company Name b, 16
Address
Business telephone
P 93
Name of Licensed Plumber. or Gas Fitter
V—check one: certificate
a Corporation
❑ Partnership
INSURANCE COVERAGE:
1 have a cnnrent li blllty insuratiCe 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.
A liabllity insurance pollcy+a__"� Other type of indemnity ❑ Bond ❑
OWNER'S INSURNACE WAIYEIt: 1 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 tTils permit agp- llcatlon waives this requirement
Check one:
signature o Owner or Owners Agent Owner ❑ Agent ❑
I hereby certiff that all of the details and Information 1 have submitted for entered) Ina application are true and accurate to the best of
nay knowledge and that all plumbing work and Installations performed under the pe t b ued for ails a ation will be in compliance watt
all pertinent provisions of the Massachusetts State Gas code and Chapter 142 of the VAS.
Type ofLlcense:
BY ❑ Plumber S I At u4rm:9:5 o L ed Piumber or Cas F tier
Title ❑ Gasfltter �-
Wrownfer License Number 9
APPROVED (OFFTM USC ONLY) ❑ Journeyman
s
installing Company Name b, 16
Address
Business telephone
P 93
Name of Licensed Plumber. or Gas Fitter
V—check one: certificate
a Corporation
❑ Partnership
INSURANCE COVERAGE:
1 have a cnnrent li blllty insuratiCe 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.
A liabllity insurance pollcy+a__"� Other type of indemnity ❑ Bond ❑
OWNER'S INSURNACE WAIYEIt: 1 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 tTils permit agp- llcatlon waives this requirement
Check one:
signature o Owner or Owners Agent Owner ❑ Agent ❑
I hereby certiff that all of the details and Information 1 have submitted for entered) Ina application are true and accurate to the best of
nay knowledge and that all plumbing work and Installations performed under the pe t b ued for ails a ation will be in compliance watt
all pertinent provisions of the Massachusetts State Gas code and Chapter 142 of the VAS.
Type ofLlcense:
BY ❑ Plumber S I At u4rm:9:5 o L ed Piumber or Cas F tier
Title ❑ Gasfltter �-
Wrownfer License Number 9
APPROVED (OFFTM USC ONLY) ❑ Journeyman
` w Location 70 — '7Q oa
No. 6 Date
,.ORTp TOWN OF NORTH ANDOVER
9
_��_..' •
Certificate of Occupancy $
Building/Frame /Frame Permit Fee $ —�—
cNust 9
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
19 �
Building Inspector
i
TOWN OF NORTH ANDOVER BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHRR THAN A nNR nR TWn FA1ldrr.V nWFT i TNn
•:; y,- �: '+. f: ?F\.'1rsk't3.±.'.dvsxw-sem.. �p�¢. tt _Y-�_�('.��_ 1___-7—�E—p_
n'v .s 16115 •J'�.4�3ion for ofrici� ZJ J�. ®� .'ham- •F v-a�%`�-'$ f .1'£J -K 'E-� Z3 SsY g'�"'' S
BUILDING PERMIT NUMBER: /
DATE ISSUED: 3
G
C
SIGNATURE:
Buildin& Conunissioner/Inspectord Buildings Date
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
r ✓
lQ " /Z. ��c
N. AIf`(J wVe- - MP(
Map Number Parcel Number
1.3 Zoning Inf om�ation:
1.4 Property Dimensions:
-Zoning District Proposed Use
Lot Area Frontage ft
1.6 BUILDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide R
Provided
R red
Provided
1.7 Water Su"ly M.C.1-C.40. 54) 1.5. Flood Zone Information:
1.8 Sewerage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone ❑
Municipal On Site Disposal System ❑
2.1 Owner of Record
eCA0,e. Give,\ CIM, u�
AV, !�. Ar{d()F-c-
Name (Print)
Address for Service
Signature
Telephone
2.2 Authorized Agent
Name Print
Address for Service:
Signature Telephone
3.1 Licensed Construction Supervisor
&41tv
Not Appli ble ❑
A dress
-Ac�061�e 0, AW. IUA-
License N ber
g
ei9
f
Licensed Construction 9 sor. 1 Z11 1
7911 63 _3 3Sz
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date y
Signature Telephone
��roa�ls��a►t® fix-
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the
issuance of the building permit.
Signed affidavit Attached Yea No 0
yAR PR R I II 111 # !• R
L� S ROWN
5.1 Registered Architect:
Name:
Address
Signature Telephone
I Name:
Address:
Signature Total
Name:
Address
Signature Telephone
t
Name
Address
Signature
Name
Address
Signature
t
company Name:
Responsible in Charge of Construction
Telephone
Telephone
Area of Responsibility
Registration Number
Expiration Date
Not applicable 0
Registration Number
Expiration Date
Area of Responsibility
Registration Number
Expiration Date
Area of Responsibility
Registration Number
Expiration Date
Not Applicable ❑
Total
I Independent Structural Engineering Structural Peer Review Required Iles ❑ No ❑
SECTION 10a Owner Authorization - TO BE COMPLETED WHEN -
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Owner of the subject property
Hereby authorize
My behalf, in all matters relative two work authorized by this building permit application
Signature of Owner
Date
to act on
New Construction 0
Existing Building V
Repair(s) X
Alterations(s) ❑
Addition ❑
Accessory Bldg. 0
Demolition
0
Other 0 Specify
Brief Description of Proposed Work:
'r �>�►
�G e� o� � �
foQ rvL�J i S t
nC�led u ��
fee ` wac+el-
a149krr
sh► n les
USE GROUP Check as applicable)
CONSTRUCTION TYPE
A Assembly 0 AA 0
A4 ❑
A-2 ❑ A-3 0
A-5 0
IA
1 B
0
❑
B Business ❑
2A
2B
2C
0
0
0
C Educational 0
F Factory 0 F-1 ❑ F-2 0
H High Hazard ❑
3A
313
0
0
IInstitutional ❑ I-1 0 1-2 ❑ I-3 ❑
M Mercantile ❑
4
0
R residential ❑ R-1 ❑
R-2 ❑ R-3 ❑
5A
513
0
❑
S Storage 0 S-1 ❑ S-2 0
U Utility ❑ Specify:
M Mixed Use 0 Specify:
S Special Use 0 Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND OR CHANGE IN USE
Existing Use Group:
Existing Hazard Index 780 CMR 34:
Proposed Use Group:
Proposed Hazard Index 780 CMR 34:
BUILDING AREA
EXISTING if applicable) PROPOSED
Number of Floors or Stories Include
Basement levels
Floor Area per Floor s
Total Area s
Total
I Independent Structural Engineering Structural Peer Review Required Iles ❑ No ❑
SECTION 10a Owner Authorization - TO BE COMPLETED WHEN -
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Owner of the subject property
Hereby authorize
My behalf, in all matters relative two work authorized by this building permit application
Signature of Owner
Date
to act on
1' ti����l-c `'� �' ��� as Owner/Authorized
Agent
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed un r tl}e paid a penalti�fs of perjury
N�e�lc
Print Name
Agent
Item
I . Building
i
2 Electrical
3 Plumbing
4 Mechanical (HVAC)
5 Fire Protection
6 Total (1+2+3+4+5)
Estimated Cost (Dollars) to be
t&140
Date
(a) Building Permit Fee
Multi Iier
(b) Estimated Total Cost of
Construction from (6)
Building Permit fee t,l z (b) /910
0
7
Check Number I /
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TNIBERS 1 2 ND
SPAN
DEMENSIONS OF SILLS
DEMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIl1rINEy
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
f � � ,.� e ' �Uanvtizn�uved��. o�'✓�l'�rklc�r�u�e�J !
t
ABOARD Oi= BUiLDiNG.kGULATIONS" '
License: CONSTRUCTION SUPERVISOR a
,.4Number: CS. ., 075259!'
girthdate:'12/14%1,965
Expires 12114/2004 Yr. no: 5852 '
Restricted", 00' 3"
BRADLEY J SONTZ
7 MckINLEY RD;
MgRBIEHEAD„ MA 0194.5 `Administrator. ,
01!'11!1994 06:28 0000000000
MS. KAREN SORKIN, PROPERTY
MANAGER
DIVERSWM,D FUNDING CORP.
HERITAGE GREEN CONDOMINIUM
391;ARRWOW AVENUE
NORTH ANDOVER, MA 01845
DIVERSIFIED PAGE 01
S Mir
OFJTA� Contract
Roofing Services, Inc.
$2 Sanderson Avenue, Lynn, MA 01902-1937
Phone 781 593-9300 Fax 781 593-9399
6/23i2003
Max Sonta Rooting Services, Inc. proposes to furnish all labor, materials, equipment and supervision to remove
existing roofing system and install new "GAF" (30) Thirty Year three tab shingle roofing system complete with
all (lashings over building #'s 45-47 (2 bed); 0-70 (2 bed); 88-90 (2 bed); 99-101 (3 bed) Edgelown; 39-41
Farwood (2 bed) and 70-72 (3 bed) Feraview, all as per the following specifications;
1. Furnish owner with TEN (I0) year Max Soutx Roofing Semites, Inc. guarantee upon completion.
2. Furnish owner with (30) Thirty Year manufacturers guarantee forms upon completion.
3. Protect all surrounding bushes, trees, shrubs and flower gardens prior to commencement of work.
4. Strip existing shingles, nails, fasteners and felt down to structural roof deck on ENTIRE rear roof areas.
5- Remove existing aluminum air vents and cover with plywood
6. Broom all existing loose debris and remove from roof and premises and dispose in proper EPA landfill site.
7. Install new 6" "WHITE" finish aluminum drip edge flashing on all leading edge sides roof areas as needed.
S. Install proper base flashing around all roof projections (i.e. plumbing vents pipes, chimney areas, etc.) as per
maoafacturers recommendations.
9, install new bftuthane ice and Vater Shield to first (3) three feet of roofs edge and around .all roof projections
as per m&08faetnres recommendations.
10. Apply new 15# nonperforated felt over remainder of exposed roof deck area.
I I. Furnish and install new (25) Twenty Fi a Year three tab roofing shingles.
Color to be: SILVER LINING. Initial:
Should this contract mes with your approval, please sign, date and
return to above eadm%s. TOTAL BASE PRICE
Masspohusetts Sates rax hifte d
All.ratr.ial it k br at V,r1M. All mr* m be, completed in a wo,Fnanlikr manner arrordbrg to indusrun practins..fn, aitrnrlian Cr del iadon from the ahmr ;,perifrratias im-oh inR rtrvr, roar u i l! be r.wrutp
uppn nril'" order" and x1116"W an orgy rk" r 01 W and eba,Y rA[$ ajrFvrwnt• Al! agrerxteut r0,..r[ngen,1 x rHle . a 7 >r r r t
rrdyranrN. Are yprkrly A7Y jW(), rasrrM by Na brtrn's Conlse Pa 3 S CC dP r, a Qi aV3 QMWrd or ow,91 U�ar•' r4 ferN/lre. eJmeOu OnAV,krr nr;`MFrry
1.'3 pgvnlra[a. Thr abaw �^ssaj I'rmr. ., and L' �rxf by arrep, d� Irrd a5osr. Hr arsumr no liabtig,for Aabs(nr wntlr. o.ntr.M agwr all pr maj and Ixrvmm.y.,p Are to he. waai, in
prh n, sprt#lltalaxts cad rontllg0u ars satlrjartor and ars hrrahv arrrprfd. ,tlry .,ont: Ra,)fl ..Sm fres. Iru. L+ Arrehr aulhali_ed m pytf.�rn rkr :lllr,,r mvk .rs tperq?rf ll c, agrerd rhat all
drrpalrr arlttag cut 4JMtapn+a,ouLcnNrrXr allr ntoApd by a IhW party arpilratar ana',,yhp a7.11an n1J! (,ep+#rc
MAX S€)911 kCK*ING SPRVIC ES. INC.
CUSTOMER ACCT PTANC,E,__...._._ r( �:!
Page 1
__. -- . amu-. --1. ca
UUUUUUUUUU
MS. KAREN SORKIN, PROPERTY
MANAGER
DIVERSIFIED FUNDING CORP.
HERITAGE OREEN CONDOMINIUM
39 FARRWOOD AVENUE
NORTH ANDOVER, MA 01845
DIVERSIFIED
PAGE 02
Contract
6/23/2003
12. Install new lineal "ridge" ventilation syste(m� ver top of all gable areas.
13. Clean All txbtiag gutters and PSEWar all support brackets and downspouts. NO new gutters or downspouts
will be installed and all existing will remain.
14. Remove all roofing debris from grounds daily, clean ground premises at completioll of job,
TOTAL BASE COST:
MNM ME THOUSAND FINrE HUNDRED DOLLARS. $98,500.00
PAYMENT 'PERMS:
532,800.00 Upon acceptance of contract, 2 -,progress payments of $25,000.00, balance of $15,700.00 due upon
complethm of roofing work.
AADIT)EONAL WORK:
A. Remove and replace any rotted roof decking as necessary and/or re -secure existing decking for proper
installataaa of ehiogles @ $5.75/ft 1Wtinl_�
B. Re -lead esiatiag chimney areas as necessary. $525.00/ea. Initial
�a a3a.goo..� 3be�-'It9,Nso.
000.
Should this cmrm meet with your approval, Please sign, date and
mum to above mss. TOTAL BASE PENCE $98,500.00
1Ni M MUSMS Safes Tax Included
til ororexalla p E! 6t tpnryhd Ail wont q bt c v eplrrtd 9t a �wlsMtmrlikr naarrrr
acrording ro (sduuu
*"Kit 04ft. 0W widbwmc as vuya C Eisen, tr )t Aur a QL ?-hon nr rrrt�ie(lpr. own o r orYapMlfiratiov iarolt irtF rstrn rr,.ete will hp fxp•urp(,r oil;
w-ra;wM 0- R e overan emag lAld umm . All atiferrau rontoutlined a olF. s(HkPt. a-ridrr„f or dilvvt bruond our rant+pl. pwwrr;p Cirrtpr. tomado and othrr nrrruan
Jklly cbvt raHbp Worbnen's Coxq�cmat An /rattrt,r(re, Unlria o(hrrwiar outlined abor F. xr auunfe ro ta&i1Y jar Asbaoi waitr. owner to aquirr oil pprnrt!.t ar t pnFn r (al c,r to !x .�!adr nr
rl./rp ri rartnxg bo R�n, 9w*atlonr mM EVIA w are solixjxlory aad ara Atrybp ecreAw.. Alai: Soar Ra+firtg Srn kr:.: ar. s hnPhy autharYrrd sa ppKOrm !hr rbo:r work as svrrr�r?. h 1.c ag.0 I) rMe: e.
O L4at&wt will be mminrd by a tktrd Prry WNParor and hiorr diaian wt11 br f(xaL
M.AX SONCZ ROOFING SE"CkS, JNC,
CUSTOMER ACCEPTANCE, !t fl/ t p DATE;
Page 2
Name
Name:
The Commonwealth of Massachusetts
Department of Industrial Accidents .
Office of Investigations
Boston, Mass. 0211.1
Workers' Compensation Insurance Affidavit
- Please Print
Location:
City Phone #
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer providing worke compensation for my employees working on this job.
NI� S���mC�
9co�mlpgnvname.& X �n+n � S I C
Address 211L sc �'V\ C56, Aiz
Z
insurance co. C Policv # W C 17 i I562rq,
Company name:
AddnS.. .
r✓ ty ` Phone*
Failure to secure coverage as requiredunder Section 25A or MIL 152 can lead t&the iri pwitbn of crimina{ '
p of a fkwe up to. $1,
and/or one yeeats' imprisorur,ent w�eLLas it p aftles�lhe�amn ��7DF afirre-ct4sfi=)_ajdWA9ai st,.
understand that a.copy of this statement may be forwarded to the Office of Investigations of the DIA for
coverage verification.
Official use only do not write in this area to be completed by city or town officiar
I
City or Town -- PermuifLicensina
Building tle
❑check Af immediate response is ►egukea ❑ E.iceRsirlQ
Contactperson_ ❑ Selftbmn's
Phone # ElHeakh Depa
❑ father
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-0
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be disposed of in pro,
licensed solid waste disposal facility as defined by MGL Chapter 111, S. 150 A.
The debris will be disposed of in:
Di S OScd
(Location of Facility)
." j 0 A .., Pre ikk A
SigiatuW of 1)814t Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for this p.
through the Office of the Building Inspector
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TOWN OF NORTH ANDOVER
p PERMIT FOR PLUMBING
This certifies that ,.....° . _. . .f`.`
hT permission to perform .` .................................
plumbing in the buildings of :. s' -` :! -' ................
C� J
at .. .?`.. ` .......... `... ......... �. , North Andover, Mass.
Fee *.>..e. ... Lic.�.......... .
PLUMBING INSPECTOR
Check #
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
P
MASSACHUSETTS UNIFORM APPLICATION FOR
(Print or T) pe)
L0 . Mass. Date --,,
Building Location- C
f
T,
New ❑ Renovation ❑ Replac"
PERMIT TO O PLUMBING
_ Permit #
of Occupancy_ �t S 17 E ti ti r� L_
Plans Submitted: Yes ❑ No ❑
Installing Company Name "AQz1E,2T Q - SAirma tAe n Check one: Certirmate
Addr A r C 0 Ar ti mars) I. A J ❑ Corporation
m E k L ' F -AJ -,*1f4- 01T ❑ Partnership
Business Telephone (L - ci
C97 1 2<rm/Co.
Name of Ucensed Plumber *Aar-3r,e 1r k 5An Agiq fr4.e
INSURANCE COVERAGE:
1 have a cuffent_pNky Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes a No ❑ I
If you have checked ya please indicate the type coverage by dkddng the appropriate box
..
A liability Insurance policy Other type of indemnity ❑ Bond ❑
OWNIR'S INSURANCE WAIVER, I am aware that the licensee d0 s 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 ( have submitted (w entered) in above application are true and accurate to the gest of my
knowledge and that all plumbing work and installations urMr the pwam ' for this application will be in compliance with all
peAi Wd provisions of the Massachusetts State Plum and Of the of taws.
BY
7�7 :A7lMumbw
Title
Type of Liown: Master Joumeymal► d
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Installing Company Name "AQz1E,2T Q - SAirma tAe n Check one: Certirmate
Addr A r C 0 Ar ti mars) I. A J ❑ Corporation
m E k L ' F -AJ -,*1f4- 01T ❑ Partnership
Business Telephone (L - ci
C97 1 2<rm/Co.
Name of Ucensed Plumber *Aar-3r,e 1r k 5An Agiq fr4.e
INSURANCE COVERAGE:
1 have a cuffent_pNky Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes a No ❑ I
If you have checked ya please indicate the type coverage by dkddng the appropriate box
..
A liability Insurance policy Other type of indemnity ❑ Bond ❑
OWNIR'S INSURANCE WAIVER, I am aware that the licensee d0 s 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 ( have submitted (w entered) in above application are true and accurate to the gest of my
knowledge and that all plumbing work and installations urMr the pwam ' for this application will be in compliance with all
peAi Wd provisions of the Massachusetts State Plum and Of the of taws.
BY
7�7 :A7lMumbw
Title
Type of Liown: Master Joumeymal► d
City/Town
License Number q3 v�
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Date.././../,?... � 1.... .
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TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ....���:. �.� ?. ..... .�'� . r ...........
has permission for gas installation
in the buildings of ...
at ..% ... .................... . North Andover, Mass.
r
Fee. ? ..' .. Lic. No........... ..: �.-.... 7� ..... .
,GAS INSPECTOR
Check #
4201
MASSACH SEATS UNiI+ORM APFUCATONFOR PERNRTT'O DO GAS F Tl' NG
Type or print)Date 1,41A
�..
NORTH ANDOVER, MASSACHUSETTS
Building Locations /i7 7`�K✓�1�%L�l /�/J Permit #
Amount $ t-1,
Owner's Name
New Renovation Replacement [a Plans Submitted
(Print or type)
Address
Name of Licensed Plumber or Gas Fitter
e: Certificate Installing Company
Grp. 11: z" -Al;
0 Partner.
El firmlCo.
INSURANCE COVER -AGE Check on
I have a current liability Insurance policy or it's substantial equivalent. Yes IM No[:]
If you have checked des, please ijmflcate the type coverage by checking the appropriate box.
Liability insurance policy Other We of indemnity 1 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.
Signature of Owner or Owner's
Check one:
Owner
I hereby certify that all of the details and information t have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations perform under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas de and Chgptel2 owe General Laws.
(OFFICE USE ONLY)
_Signature of Li erised Plumber Or Gas Fitter
ML 1tlmber
MGas Fitter License Num
fMber
aster
Journeyman
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1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
8TH. FLOOR
(Print or type)
Address
Name of Licensed Plumber or Gas Fitter
e: Certificate Installing Company
Grp. 11: z" -Al;
0 Partner.
El firmlCo.
INSURANCE COVER -AGE Check on
I have a current liability Insurance policy or it's substantial equivalent. Yes IM No[:]
If you have checked des, please ijmflcate the type coverage by checking the appropriate box.
Liability insurance policy Other We of indemnity 1 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.
Signature of Owner or Owner's
Check one:
Owner
I hereby certify that all of the details and information t have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations perform under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas de and Chgptel2 owe General Laws.
(OFFICE USE ONLY)
_Signature of Li erised Plumber Or Gas Fitter
ML 1tlmber
MGas Fitter License Num
fMber
aster
Journeyman