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HomeMy WebLinkAboutMiscellaneous - 74 RUSSELL STREET 4/30/2018-11 CA y Date ... `-?��1,(..T.Z TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION . r" - 4 -- This certifies that. has permission for gas installation ... ............................................. in the buildings ........................... ........... at ............... �t 4 Fee .n�.a-,..... Lic. No. ............. Check # _�-/ 4111 9127 ..... . North Andover, Mass. ......................................................... GASINSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK > CITY ._ND.(?Z1a _ n,.Nt�.?�R, -...._. , MA DATE; j�� PERMIT# JOBSITEADDRESS ._. �( Y OWNER'S NAME GOWNER ADDRESS amu,,, . ` LAS -TE G17� 3�% FAX - - ...- _ PSTOCCUPANCY TYPE COMMERCIALQ EDUCATIONALF-] RESIDENTIAL(±% CLEARLY NEW: RENOVATION: Q REPLACEMENT:(t� PLANS SUBMITTED: YES El N0� APPLIANCES 7 FLOORS- BSM 1 2 i 3 4 1 5 6 7 8 9 10 11 12 13 14 BOILER -- -- - - --- -- -- _ ,-•-- -. _..._...--- ..._.� .... _ - I. _ - - . •,_� - ....,- :.. _. _. �-j' -- I � BOOSTER-- - _.� .. --_ - -_. CONVERSION BURNER r --I _..._ - COOK STOVE DIRECT VENT HEATER:-- DRYER - - - ��I-__..--I_�I-� _ - FRYOLATOR _ ... _. FURNACE - I GENERATOR - GRILLE __- _. -- ..I __. _ _...___ _._._ !__--- INFRARED HEATER .-- - _ _ - - i , LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM .SPACE HEATER - ROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER TER HEATER ._.. I_..._. OTHER Al . .. --- - - - — -- - - - INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 2NO 0 I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [7 OTHER TYPE INDEMNITYF-] BOND O 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 F--1AGENT0 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 compliance with all P 'ne rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Q V_(J�._iJ-G.�.2� LICENSE# 1.5� 5 NATURE -.. MP ( MGF E--1 JPF-1 JGF 0 LPG10 CORPORATION #�� PARTNERSHIP F]#LLC [2# 3 fo J COMPANY NAME: DD �e.e,�e_ DRO'C(��R�...SetiU(C�e ADDRESS CITY �cwc (aalJ _ STATE�ZIP Da30 / TEL !/7-4g_:/ad FAX EMAIL dr�P� O z 0 F U P. rA Q a on z O yo W W o o W a # W W PLO F- z a a > `� W U LU F4 > OW w w y a z a 2 a a H U x F a < Ess x w W F O z z 0 H U P, Cx7 O a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' a 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders[Contractors[Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 1125- 6Uyr--6W S> City/State/Zip:�S�p,-J �{� Phone.#: 41,17— a�'7—lyo4/ Are you an employer? Check the appropriate box: 1: ff I am a employer with � 1-16 4. ❑ I am a general contractor and 1 employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I ama sole. proprietor or partner-'. fisted on the -attached sheet ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. (No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required):. 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other 6 .5 600AZK 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. tContractors 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 providb their workers' comp. policy number. L I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Ql h- XSFU +,t 1,4- 4-S M4A %_ ��rasv¢ 7ci� C -P• Policy # or Self -ins. Lic. #: /i 2C. VJ 0 -4 SO 140D Expiration Date: Cah>f 12 -215 - Job Site Address: City/State/Zip: 00krlA AYoO d/1 (>7A. _ 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 rip 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 maybe forwarded to the Office of I do hereby ce er th in • d penalties of perjury that the information provided above is true and correct Si ature. Date: 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): L Board of health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information .and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every persori_m 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, §25C(6) 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, MGL chapter 152, §25C(7) states "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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and 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, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, 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, 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.Deparhnent at the number listed below. Self-insured companies should.enter their self-insurance license number on the appropriate line. City or Town Officials 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. In addition, an applicant that must submit multiple pertr t/license 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 permits or licenses. -A -new affidavit must be filled oiif tach year. Where a home owner or citizen is obtaining a license or permit not related fo any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would like to thankyou 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 fax number: Te t 0MMonwealth of Massachusetts D.epartrawt of 1ndustdal Accidants Office of layest gatIORS, 6W Washin&Wn Street Boston, MA 02.111 Tet. ## 617-727-49-00 ext 406 or 1-$77-MASSAFE Fax ## 617-727-7749 Revised 11-22-06 wmass_govldia FEENBRO-01 CLEDDUKE CERTIFICATE OF LIABILITY INSURANCE (MMDD/YYYY) 721251'2014 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 enddrsement(s). PRODUCER Rogers 8r Gray Insurance Agency, Inc. 434 Rte 134 South Dennis, MA 02660 CONTACT NAME: April Skala PHONE FAX A/c No Ext): A/c N.I: (877) 816-2156 E-MAIL SS: askala@rogersgray.com INSURER(S) AFFORDING COVERAGE NAIC # A2CG07501400 INSURERA:OId Republic General Insurance Corp. 02/01/2015 INSURED INSURER B: Feeney Brothers Services LLC 103 Clayton St PO Box 220801 INSURER C: INSURER D INSURER E: Dorchester, MA 02122 INSURER F: - CUVERAGES CERTIFICATE Nl1MRFR- RFVIAInAI IUI IMR=D- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE 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. INSR LTR TYPE OF INSURANCE ADD INSR SUBR WVD POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MMIDD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F_x1 OCCUR A2CG07501400 02/01/2014 02/01/2015 EACH OCCURRENCE $ 1,000,00 PREMISES Ea occurrence $ 1,000,00 MED EXP (Any one person) $ 10,000 PERSONAL &ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X PRO- LOC PRODUCTS- COMP/OP AGG $ 2,000,00 EBL AGGREGATE $ 2,000,00 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS EOMaBINEDSINGLELIMIT $ BODILY INJURY (Per person) $ BODILY INJURY Per accident $ ( ) PROPERTY DAMAGE PERACCIDENT $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLO ERS'LIABILIITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) IfySCRIPTION OF OPERATIONS below describe under DESCRIP N / A A2CW07501400 02/01/2014 02/01/2015 X TORS IMITS ER E.L. EACH ACCIDENT $ 1,000,00 E.L. DISEASE - EA EMPLOYEE $ 1,000,00 E.L. DISEASE -POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) GEK 1 IFIGA I EHOLUEK f A AIC M I ATIl%LI ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD HE FOLLOWI`fVd"i I CEN_S D AS;-:A>;<>Rt-UMB I NG COR rs� COMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE - BOARD O 'PLUMBLPS AND GASFITTERS LICENSED 6-S A IAASTER PLUMBER ISSUES THE ABOVE LICENSE TO: f DAVID W'. GARFIELD ` zD ` :21 WILLOW S'! BROCKTON MA 023U1'=1451 15645 L5/01/114 166583 ' LICENSE NO. EXPIRATION DATE SERIAL NO. COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASF 11"ja 2 LICENSED AS A JOURNEYI'IAN PLU BER ISSUES THE ABOVE LICENSE TO: DAVID W.GARFIELD 21 -WILL.OW ST \ BROCKTON . MA 02301-1`45.1 23645 05/01/14 161594LICENSE . =! . EXPIRATION DATE SERIAL NO. WkkoHLIZ3L I I b UVI /\E I I..ILA] ION FO11 PERMIT I O DO GASFITTINV � (Print or Type) -ridavtrMass. Ualc �D 19 ?--/ Permit # �1 Building Location 7 _`fps Owner's Name New ❑ Renovation Ll I Type of Occupancys Replacement Plans Submitted: Yes❑ ' No ❑ Installing Company Name__ A N p 0 V L R P_L_U_. f.x tI T G. LO, INC.l one: CertKicate # Address , 7 S n I1 n i o n S T r p P t L`l Corporation 1051. Lawrence, M a . ❑ Partnership k Dusiness Telephone 685-8383 _ ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter ' INSURANCE COV RAGE: I have a currentj6bllity Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No 0 s, If you have checked Vis, please ' dicate the type coverage by checking the appropriate box. f A liability Insurance policy L6 Other type of indemnfty ❑ pond O 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: Signature o1 Owner or Owner's Agent Owner❑ 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 my knowledge and that all plumbing work and Installations performed under the permit Issued for this application II beIn mpli ce with all pertinent provisions of the Ma&;=: -setts Slats Gas Code and Chanter te? cf ,;; tier Lawy. Typo of License: Plumber Signature of Ucensed'Plum er or GasFitter,..; Title_ Gasfitter —y r Master license Number / City/Town - Journeyman /U'PFtO'VEU O IC str OFILY► ' rn N W N N N X U Z pC 2 F- N Z rn W a J W W a O O U M N S 0 Cy a a a0 Z Z O F- oC w 4 a m a w O a f- `t N a w Z ul U W z N W E- a +n a O h = 0 H x ►- x H a w o o> W H w_j N m z a a W> '= W a a� w n z. r a 3 r W w Q d o, x U o Q o o a �n �u x O ¢ O O x w o Y F^ SUB—BSMT. BASEMENT I ST FLOOR 2NbrLOOR 3RD FLOOR 4TH FLOOR STH FLOOR i 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name__ A N p 0 V L R P_L_U_. f.x tI T G. LO, INC.l one: CertKicate # Address , 7 S n I1 n i o n S T r p P t L`l Corporation 1051. Lawrence, M a . ❑ Partnership k Dusiness Telephone 685-8383 _ ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter ' INSURANCE COV RAGE: I have a currentj6bllity Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No 0 s, If you have checked Vis, please ' dicate the type coverage by checking the appropriate box. f A liability Insurance policy L6 Other type of indemnfty ❑ pond O 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: Signature o1 Owner or Owner's Agent Owner❑ 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 my knowledge and that all plumbing work and Installations performed under the permit Issued for this application II beIn mpli ce with all pertinent provisions of the Ma&;=: -setts Slats Gas Code and Chanter te? cf ,;; tier Lawy. Typo of License: Plumber Signature of Ucensed'Plum er or GasFitter,..; Title_ Gasfitter —y r Master license Number / City/Town - Journeyman /U'PFtO'VEU O IC str OFILY► ' -w Date ............. G�.NO °T �,A'p TOWN OF NORTH ANDOVER o A PERMIT FOR PLUMBING 441 TwIl"Ir SSACNUS� This certifies that .......................................... . has permission to perform .................................... plumbing in the buildings of .................................. at ...................................... North Andover, Mass. Fee......... Lic. No .......... .............................. PLUMBING INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File Date ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING I /16E. 'F/rc �Ptc Thiscertifies that ...... .. ..................................................................... ........ ha�permission to perform ......... 4 ) ... .......... ... ........................... II wiring in the building of ..... ........ ............................ at ........................................... ,North Andover, Mass. Fee ..... P ..... Lic. No. -- ELECTRICAL 14PECTOR Check# 30-111 / The Commonwealth of Massachusetts office Use Onll Permit No. Department of Public Safety Occupancy 6 Fee Checked BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 12-00 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance with the Massachusetts Electrical Code. 527 CMR 12:00 (PLEASE PRINT IN INK OR's E ALL INFORHA.TION) Date 14 1 lo 0Z City or Town of- A%too �� To the Inspector of Wires: The undersigned applies for a permit to perform the electrical cork described below. Location (Street & Number) /c=am — Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes 11No ❑ (Check Appropriate Box) Purpose of Building oc },�A* Utility Authorization NO. Existing Service I� Amps k>��yVolts Overhead D-Indgrd ❑ No. of Meters New Service Amps ! Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Location and Nature of Proposed Electrical Work LUI ALP / C— v V No. of Lighting Outlets No. of Hot Tubs No. of Transformers TRoVtAl No. of Lighting Fixtures Swimming Pool Above In- grnd. 1:1 grnd. ® CVA1 Generators No. of Receptacle Outlets g No. of Oil Burners No. of Emergency LightingBattery Units No. of Switch Outlets No. of Gas Bur nars FIRE ALARMS No. of Zones No. of Detection and Initiating Devices _ No. of Sounding Devices No. of Self Contained Detection/Sounding Devices Local ❑ Municipal ❑ Other Connection No. of Ranges g Total No. of Air Cond. tons No. of Disposals No. of Heats TotalTons Total KW No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Devices KW No. of Water Heaters KW No, of No. o Signs Ballasts Low Voltage Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current L lity Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES [n ❑ I have submitted valid proof of same to this office. YES ❑ NO If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE BOND ❑ OTHER ❑ (Please Specify) Estimated Value of El e trical Work S %�0�? Work to Start Inspection Date Requested: Signed under the Denalties of perlury: FIRM NAM Licensee Expiration Date Rough Final LIC. NO LIC. NO.� Address ��� XSir/C'. �J r Y' /�� ��^�-fJ� Bus. Tel. No. Alt. Tel. No. , � - 3 P V3Ify OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its ub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this pe it application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE Signature of Owner or Agent Date.... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... ......... .................. has permission for gas installation ................. in the buildings of ..... ........................ at K ............ North Andover, Mass. -41t Fee.?-. (3.. Lic. No..'f:.'&... ... ........ GAS INS E -CO Check # 2 3 4%-4#33, 1aj MASSACHUSETTS UNIFORM APPUCATON FOR PERNIlT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations/ yI ( L, Owner's Name New ❑ Renovation ❑ Replacement Date t-//-7 /0 3 Permit # 433 0 0 Amount X7 & �► f 1--- ,,;l C, Plans Submitted ❑ (Print or type) /� -; ` A ?o � R" a )o hec one: Certificate Installing Company Name 1" C- Corp. Address P. & (LC57" ❑ Partner. Business Telephone C 6 s FiFkm'1Co. Name of Licensed Plumber or Gas Fitter TCS V" �,C, INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑ If you have checked M, please indioat a type coverage by checking the appropriate box. Liability insurance policy 19 th 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. Signature of Owner or Owner's Aizent Owner ❑ i numoy cermy mat an or the aetaus ana mrormation 1 nave submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Codea d Chapter 142 of the General Laws. n 0 I _ D_ (OFFICE USE ONLY) Sit PI tubere of Licensed Plumber Or Gas Fitter /❑ r 'FO.7 C` ❑ Gas Fitter icenseum ear ' s� Master ❑+ Journeyman Date. /./..... . "I.. :+ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ♦ i, + a SSACMUS This certifies that. ...... ..(._J`�`:.Il �................ �� has permission to perform .......-� ................ Plumbing in the buildings of . f ""``'�� '`................... . at ... 7 / . , ..�t� ��--�� ... ....... North-�kndover, Mass. (� Fee. /, .Lic. No.. 94 . .... f'..-'. :- . ......... PLUMBING INSPECTOR Check # " MASSACHUSETTS UNIFORM APPLICATION FOR PERMIIT TO DO PLUMBING (Type or print) / NORTH ANDOVER, MASSACHUSETTS eZ/�j/ (0 3 j I Date Building Location %�� �y S, <:.-, ► G \ �S� Owners Name 1 C' L Y) C� Permit # L Amount��� Type of Occupancy o2 %`�c h, i• I ih New 1:1 Renovation 1:1 Replacement Er Plans Submitted Yes O No FIXT4RES 1.-' F • •. � �• � (Pent in type) A A Q Uv\ 0, � i (� b Installing Company Name Address 0 ` �G �d 2 S 0 Check one: Certificate 11 Corp. Partner. Firm/C0. Name of Licensed Plumber: d 6 V,Y1 SC;L ki-tj Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity El Bond a 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 Agent F1 l 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 my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Mass usetts tate Plbin Code and Chapter 142 of the General Laws. By: Mpyure oi 17censeaum er ype of Plumbing License Title . ':�70-7Y ,�/ City/Town icense um er (�Master ' ' Journeyman 0- APPROVED (OFFICE USE ONLY �—+