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HomeMy WebLinkAboutMiscellaneous - 74 ROCK ROAD 4/30/20181 N Op\ �4 A :17 O0 0 9 A O D C) v 0 0 Location No. % J Date Check # l!3 �P 7 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ c Other Permit Fee $ TOTAL $ 14 1 6 8 Building Iq ector A— : -i6 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING DATE ISSUED: BUILDING PERK E •Jl77 SIGNATURE: Building Commissioner/122eector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: L\ \\ y 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frortta e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Infomation: Public ❑ Private ❑ Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2. ner of Record71 _ %Ls Name (Print) Address for Service Signal4e Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address r7 � C Expiration Date signature Telephone Ma M M Z O 0 M C� W 1. O z M go O r sv M ror z G) SECTION 4 - WORKERS COMPENSATION (AG.L. C 152 § 25c(6) 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 Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check atl applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) :l Addition ❑ k Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify .,•..� , 1%14 ' .�e Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit a licant (iFFICIAL USE+ ONLY =' I . Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (e) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT -T I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I,�z.,,�, as Owner/Authorized Agent of subject prolferfy Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name ignature of Owner/Aent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS 1ST2 ND3RD SPAN DIN ENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE The Com monlvealth of Massachusetts Department of Industrial Accidents Office Of1fl esUgallnfls 600 Washington Street Boston, Mass 02111 Workers' Compensation Insurance Affidavit city Z1• 4YNA6"i-e\ ❑ 1 am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one working in ❑ I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation polices: comostty name ..i e Failure to secure coverage as required under Section 25A of MCL 152 can lend to the Imposition of criminal penalties of a fine up to 51,500.00 and/or one years' Imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and peer lies of perjury drat the information provided above is true and correc j Signature Date / Print name �_C, i`Z1 (a ( C-0 I E Phone # ofllcial use only do not write in this area to be completed by city or town official city or town: ermitAicense # P nBuilding Department ❑Licensing Board check if immediate response is required oSelectmen's Office 011calth Department contact person phone # nOther %,--- j-3 r/A) Mario Castricone, Prop. Tel, 682-4266 1 CASTRICONE ROOFING & SIDING CO. 31 Court St., No. Andover, Mass. 01845 nQI f f., A jo 0 /e CA N --,j 1\ w r w"� Town of North AndoverF tkoRTH o O Building Department o W 27 Charles Street - North Andover Massachusetts 01845 Z .^ (978) 688-9545 Fax (978) 688-9542 04 "`""" �• "� �` DEBRIS DISPOSAL FORM In accordance with the provisions. of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in /at: Signature of Applicant Date r NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. m m M C/) 0 m y .p CO2 CO) 10 O CD MZ y CLO C7� O D. = y Im CD CD CD p CD o CLQ % d CD CD o CD w w Po C CD y CD d O H CD CA O 1 Z CD a O CD C CD O C C �� O d �• fA C cr y o RJ »m o m n CS m C7 C., o ..e 3 07 d co CAA CP ..a CL �.1 Ca n g. CD O y O m O m O tv -p O CO's O y� C7 •C . ? y 7d C W y ,oC CL -1 H Im y C. y c �:• O. �c. Dr. m . O N y ; Q g o� —c CD moo: 0 C �C T N C*C: d m CLOP-: �(-Dyy A W ►�y o RJ /q w ;� ° V ?i - qo �.1 �'r1 n g. CD tz Eg eY '7 tv 7d 0 c Location' .f t C�('1T/iCr fC_,IJ No. Date �C/,/ f NortTh TOWN OF NORTH ANDOVER r..' Of�t�ao a1ti ' - a Certificate of Occupancy $ g Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee Sewer Connection Fee Water Connection Fee TOTAL X0994 Building Inspector Div. Public Works r > > 10 A A Q Q M 0 _ 7 r r 0 0 rl+ c c a m i i e i n Ian m -nl n - i m Z z A a a Z 0 w � � C i Z to rn iin z + 0 ' n m c i r i O z n i 0 p M i► a A A 1 A 1 0 u n 2 z z > 0 O r N C r m m n m m > � n A p G p 0 O Q O 4 � ! $ Z > i 0 0 0 C C > > 0 < z0 = i M O m r r r O z Z p Z M A m O C O p O n n n A A a a tI r Z Z � r A A A � � � O >Q Q Q-4 m Z 2 M F m m a > 0 0 0 m > 0 O r N a+ 1 Z z Z > A r C C C > > `> -mi r > = O m r r r O z Z p Z M A m O C O p O n n n A A a a tI r Z Z � r A A A � � � O >Q Q Q-4 m Z 2 a z 0 z O> Q r o m z z A ti A 3 a > b n O -+ f O A; A a Z D -m+ M a >r y O i a z r 1 0 a Z z - m R Lq i t Z i a o © C 0 _ L b yl z ^a W -i M Q z. 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O C CO) d OCD v CD o CLV CD CD O Cp CD CO)• dv y CD I C2 CO) O CD .O•t O CD C CD E•� z r m c c?�p 0 = H O Q H FLOSS y t0 CisCLC2 m cs Z H, O ty d -C y �' �a •a. c T ? sa ..► m H y „�� m OE Pf N; O b_ =ro 2 O 7 O ' O 2-4 t0 p C N C N n .to m CO n � CL..-«: so p m m H C-� On O O of H vv H n06 H C COEQ'�1 t0 m ,J H H� O y t0 oh O 1 ' H 'C O co O p � O H m Z m: n � ca c O Cn of Cn ° byx 'Jd ro �t7 F � ro z r !7-- y �r) ro x rZ N Irl H 0 0 c -------------- 207 871 7646 PortlandGlass VW 004 'D Fdj M.afri Portland INK, A HOM5 IMPROAM.ENT`�;-.' T SALEAGREEMENT ,.i -`:WINDOW 1W FAPTOR "c( ti;.. '! xj-pc , C0NNE&16&6 01 ... u2A;j,. Tax.. r!j; 5561.� M-43-iJunur u l, m. 161 1800 34 t 'Minijacr. KH KV MY' I.':, Wi 4 r o a k. M E 0 4 0 9 i "I V, -F; IAJ4'-4'%'0 1-900-477-00 ftVII009I.. Taw ID 014 A7669 Ccjrirjcuc of Reg 0545-924 .HIS ma q7. 'W""W4A, opt IMPrqvcn*n ONTIRAOT. 7ft4e-' between IdAt _:.!j" 2_4r, o oh .­.. F.— (a—) ar pinafter-&[gd th�;Own�r and AND GLASS. bara�naljer ;g9d Mp. Contractor. WITNESSET)I. . ..... Said ConliPgpr hereby .p1haj iivwifl fo4tfie'6oi0deratio­n*hSrj8­ !n *qarl;".Mqferrel necessary the 100 daperb workc T** " ` .hp words.�J, A.. meLand.*!py'jefer to oath PUS= whq tigAs iM Owner. The words "you'm 0, "your refer to the Sailor of holder of this gra.amaliulfmft thaxon6pokof�slons Wow person* 1s)olnfly and 5­@V6'rWiI'y,.'II&We for the promises made in alis gree . m I Llt�:i I J., .. I ,a EM so scribed below arthe Total Cash Me of V{ F A-- -mot :z oq9W;WQdz '0;� I a FIZL_b-4ZVL_LL_nZ_,0E Ad p imise and agree asfollowe,''i irftiwkbil MIM Insidal6d (IMa'Aiplaceh�int. WIMKys­il -:6 '"Mu •;j I TOTAL WINDOWS PURCHASED 01,A,: ")!IT-cv_ y - 7-, OV W, 31 E k I -A so TqTAO:�48K -VAARANTY' N -W.PRICE TURF IN OR OUT STOPS Additional, D000211 MPLETION .777 M, 7"T7 STORM REMOVEF IF -1016N INGLE.- DEL, -TRIPLEB­. _71 Lrry _77.4 . a Sbatantial C;emplqu0M,- Ix. 1l.'.1.:Nj work on' or about work will be completed wo (dam). 7he W by,' CAPPING- ou IN LATE Wr4'f CITES AI. W1111 order 71�v 4'a r f V;q WEPRr;FUR1 I J Joe SIGN WNER SHALL AY OR THE WORK (62 8, over) l(enibr citfwn discount eligibility IN CASH LESS DEPOSrr UPON COMPLETION -• * By E3 , ANKMODERNIZATION LOAN'. J. -L 0 $a 7 Pdcq of Oero qd It CON?iirAt~TOR REPlLESET�TS THAT II CARRIES WORKMEN'S COMPENSATION AND PUNUC U It MY INS (MMCP INAMOUNT EQUAL TO OR GREATER THAN S%0.00o, . IN OR OUT STOPS Additional, D000211 MPLETION MULJJON REMOVED -7 STORM REMOVEF • Pe Does ilei do a;4 "nA • Do Is rM mapprowo IV W40grce or &bA_W*"6 0yand 'm cormw W ng US a Sbatantial C;emplqu0M,- Ix. JJ work on' or about work will be completed wo (dam). 7he W by,' L 4'a r f V;q WEPRr;FUR1 I J Joe SIGN WNER SHALL AY OR THE WORK (62 8, over) l(enibr citfwn discount eligibility IN CASH LESS DEPOSrr UPON COMPLETION -• * By E3 , ANKMODERNIZATION LOAN'. J. -L 0 $a 7 Pdcq of Oero qd It CON?iirAt~TOR REPlLESET�TS THAT II CARRIES WORKMEN'S COMPENSATION AND PUNUC U It MY INS (MMCP INAMOUNT EQUAL TO OR GREATER THAN S%0.00o, . PROMISE TO, PO.I.PPOMIMTO PAY. YOU: ['HE PURCHASE PRICE LESS ANY DEPOSITS ON THE ATE OF MPLETION 0 OVERNING LAW; THE -MENT SHALL BE GOVERNED BYTHE 7 THIS AGREC LAWS OF THE STATE IN :rg` WHICH THEWORK IS BEING PERFORMED. ;'Notice T, 0Owner..; .,y ID4 r! be work on' or about work will be completed wo (dam). 7he W by,' rdinipl. and agrees that the scheduling dates __r hereby acknowlcd appioxhuato and that delays that W not avoidable by the Contractor shall not be considdrld 4.,' -vioIadons of this Agieemcntl zn, you do not fu rill your obligadeirki under this contract your pruptmy may be subjCCE W i mechanics lien, --yau a tit!0 A SIAM" F -Y-2 I ON@ -, W. 5 geu!ll -M t..1.5 MYER'S RIGHT TO ANd V CELTHIS iiiNiACTIOITAT ANYTIME PRIOR TO MEDNIGHT OF THE THIRD Busrim DAY.AFT Eg.THE DATE OF THIS TRANSACTION. '1`7SEE THE XnACHED NOTICE OF CANCELLATION FOR AN WLANA17ON OF is RIGHT, IN WrrNSSS NWHEREOF, thIe pjr�c�ia'vefhcreinto dills - / * day o T .ff"111111- 51. CONTRACT F. R.E E L_N SIGNED 17 j�.Qnllinb Glass Re ta4ve 7 - -5, NW Owner X -ACL Portland 61456 LO o o LO tX O:• '� 1 •6. rJ P` 7� 1 N m o h� W rw-- G G x� to M W 3 O w ill 'G iC3, M tm w U V d d x (m •...• O W I I Z� Fri (if Q (` 0� co W O OD LL1 G c i O� (0 o O O O 0 0 0 F- i 1 N 1-4 Q cu 4) U3 m N :j co z r+ 0 0 'C- cG � � •� u Elf 1--0 I— W O CL F- 0) O (b U i -s U v Z :✓ •W Q i— CO U7 4` J LUlr + -0 f= Z O 3 - fA � O :3 U1 +J U O X to N C� fX m CC U3 N Q Z co 00 W Q� O N U H Ltd r WO W14W Z i O 1- • J x O LW W G< >--0 0O zS- >O> ZS.m�. oro 1-4 �+ n m a00. Uocn cj -4 a; H +> I a C. 3 W O 4 ( h r f— J. r T00%TtiO�j 110HUd LM 9LL LOZ,$ 6S'ZT L6"til- Cti i� T00%TtiO�j 110HUd LM 9LL LOZ,$ 6S'ZT L6"til- Cti The Commonwealth of Massachusetts Department of Industrial,Accidents tT. — Office oi/nDestigations 600 Washington Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit name: i 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 workers' compensation for my employees working on this job. F� I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the following workers' compensation polices: contractors listed below who have Failure to secure coverage as re:aEs_! a tion 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as wellena intheform of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a copy of this statement maybe fo to Office of Investigations of the DIA for coverage verification. I do hereby cert y e t penalties of perjury that the information provided above is true d�j rrect. Signature Date �P / Print name _,.�:._ _ _ _.,_,..Phone # ' AW - rrQD ^s 115�� official use only do not write in this area to be completed by city or town official city or town: permittlicense # MBuilding Department pLicerisingBoard check if immediate response is required pSelectmen's Office pHealth Department contact person: phone #; 0Other (revaea JIVE wn) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written: An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address. and phone numbers as. all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth Of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 Maine Service Office of Assurgx Ir#WP Insuraacs. Corporatlon with over 80 offices Worldwide. e i,L xS d� {t yzj S�Sda� ' i I�NZC7•P}"- "F cp 'S t fix - - - - - -_ _ -_ _ _ y�j 01/02/1997 12:3't (207) 775-0339 `a gra -- - - - - Horse, Pagso, anFB Hoyes, Inc, _ P2 a. PRODUCER Morse, Payson & Noyes 100 Middle Street Plaza Portland, ME 04101 HAC INSURED. PG Vinyl Windows and PG Proglass Construction Attn: Diane 525 D.W. Highway North Manchester, NH 03104 1/02/97 NL AND OONFER0" NO41IGHTS UPON THE CERnRCATE HOLDER. THIS CERTIFICATE DpES� NOTAMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE '= Offl'IM�Qnvi nw. - COMPANIES AFFORDING COVERAGE COMPANY A Royal Insurance COMPANY B U • S. Fire Insurance Company LETTER Y C - COMPANY D - - LlrTOR .E THIS IS TO CERTIFY THAT THE POLICIES OP INSURANCE LI$�E� p E'BEEN' ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT„TfRMrOR`COf�(ION P`ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY'PERTAIN THC INSUFjpNCE./ARDED' BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. UMIT8'SHO,YVN'•M9Y, FIAVE;BEEN REDUCED BY PAID CLAIMS. Co TYPE OF INSURANCE pOUCYlPFECTIV! I poucv ru�iBEg' ', noucY ExplwLnoN . 1! (M DA MND t NOmI /YY) DAT! MM LIMITS GENERAL LIABILITY A X COMMERCLALGENEIkLLIABILITY 000067869 1/04/97 CLAIMS MADE FTI OCCUR. OWNER'S 6 CONTRACTOR'S PROT. j AUTOMOBILE LIABILrIY X ANYAUTO — ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS GARAGE LIABILITY 00067869 1/04/97 I � EXCESS LIABILITY B� x IUMBRELLAFORM 000067868 • 1/04/97 OTHER THANUMBRELLAFORM WORKERSCOMPENSATION AI AND 060067865 1/01/97 I EMPLOYERS' LIABIUTY I OTHER I r. DESCRIPTION OF OPMATIONSAjDCATIONqNswirsispemn nwe L 1/01/98 1/01/98 GENERAL AGGREGATE 42,000,000 PRODUCTS-COMP/OP AGO. 02,000,000 PERSONAL 6 ADV. INJURY >f1 Q Q Q Q 00 EACH OCCURRENCE 4'000, 000 PIRE DAMAGE IAny am firm 0 300, 0 0 0 MED EXPENSE wry em paw COMBINED SINGLE LIMIT $ 5, 060 41, 000, 000 BODILY INJURY (PW Paeonl �— BODILY INJURY IPa Aooldonq PROPERTY DAMAGE 1/01/98 EACN OCCUMENC!, 0 0, 0 0 0 AOORlpATE s1, 000, 000 X I SrATUTORYUMITB 1/01/98 EACH ACCIDENT �5 Q 0, 000 DISIASE•POUCY LIMIT $500,000 DISEASE•EACH EMPLOYEE 15 0 0.00, 0 SAMPLE BHouLo''ANY OP` THE-A80VE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION nATP Tld000ne rue ,��,.•.... 3190 Date.-,/...... 1 G H F TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION SACMUSEt M This certifies that ... tt l 3.� J1. l • • • • • ...... • • • � has permission for gas installation .. ........ in the buildings of 7 ............... 7 ° �z• �• �• ', North Andover, Mass. at .. .`!.. ,c, • • • • • • • • • • • • • Lic. ... .k ": :.. j^ -• /%GAS INSPECTOR Applicant CANARY: Building Dept. PINK: Treasurer WHITE: .21 )^, MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTNNG (Print or Type) l NORTH ANDOVER (Muss- Date .� tuilding Location NN Permit # 3 1 d Owners Name o2j l�L" " Y ) ng • New .7 Renovation D Replacement Plans Submitted D FIXTUP_c �r (Print or Type) nn pp Check one: Certificate Installing Company Name ,Corp. Address an Partner. Partner. N,64k �nA��a�'� Firm/Co. Business Telephone: Name of Licensed Plumber or Gas Fitter "�'_ Insurance Covera e: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Q 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 coverages. Signature of owner/agent of property Owner I I Agent F7 1 hereby certify that all of the details and infocmation t have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and Insatlations paformod under Permit isseed fo: this application will -be in compliance with all pact cnt provisions of the Massachusetts state Cas Code and Qnaptes 1S: of ow General L awa. _ By Title City/Town: APPROVED (OFFICE USE ONLY) TYPE LICENSE: C_. o!S Plumber Gasfitter- Signature of Licensed Master Plumber or Gasfitter Journeyman )a zozo o License Number H � W N W � tz- 4 O W < Q o _ Q z W d cc lta H i` G W W 0. Cr W 4 O z< W — tff .. 1- 4 to Q O r- p > p. W z W o W I- a� Z_jW j FG- z I. W 0: W a Q O? sat a W r C? .t c3 I- Q W Z d M N y- H m `'- O z Uj O m S d ,m y a W z< c a d o o u, Q W N a z O 0 = W O 0 C7 1 �A U c y Q a f- Q SUat-8SNIT. BASEMENT IST FLOOR 2ND FLOOR ` 3RII FLOOR I 4TH FLOOR 5TH FLOOR 6TH FLOOR TTK FLOOR 8TH FLOOR (Print or Type) nn pp Check one: Certificate Installing Company Name ,Corp. Address an Partner. Partner. N,64k �nA��a�'� Firm/Co. Business Telephone: Name of Licensed Plumber or Gas Fitter "�'_ Insurance Covera e: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Q 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 coverages. Signature of owner/agent of property Owner I I Agent F7 1 hereby certify that all of the details and infocmation t have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and Insatlations paformod under Permit isseed fo: this application will -be in compliance with all pact cnt provisions of the Massachusetts state Cas Code and Qnaptes 1S: of ow General L awa. _ By Title City/Town: APPROVED (OFFICE USE ONLY) TYPE LICENSE: C_. o!S Plumber Gasfitter- Signature of Licensed Master Plumber or Gasfitter Journeyman )a zozo o License Number