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HomeMy WebLinkAboutMiscellaneous - 75 CHESTNUT STREET 4/30/2018I OO V n o rx C7 o z 9 o C/) O -I o M CD M o -r^i Date ..... bw..-O// -?-I ................ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ....... ................. ft40,41 �rw• ......................................................................... has permission forn as installatio........... 9 ............................ in the buildirIgs of ........................... at............. Fee..,, r�O .... Lic. No�:?Sn.. Check # 9051 ...................................................................... ..... . . .' Norfh Andover, Mass. ....................... r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATEPERMIT # JOBSITE ADDRESS %S� C S OWNER'S NAME GOWNER ADDRESS i TE /- `i7�r,$ TZ/sem JFAX TYPE OR PST OCCUPANCY TYPE COMMERCIAL I ® EDUCATIONAL ® RESIDENTIAL CLEARLY NEW�ENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES Q NO APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE_1 FRYOLATOR [ _ FURNACE� -- -- T.z -� ---- -- - GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ` ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER_ UNVENTED ROOM HEATER WATER HEATER OTHER........_._......_............................................ - - - - - INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES _ NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAG CHECKING THE APPROPRIATE BOX BELOW I LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND F 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 Q AGENT �[ SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER- SFITTER NAME ���,� LICENSE _ SIGNATURE MP MGF �I JP © JGF © LPGI © CORPORATION EJj# =1 PARTNERSHIP D#L: LLC [3#= COMPANY NAME: CITY . �'► STATE ZIP ®1TEL FAX Sof'-/soe) _ CELL 7 �r -�2<DEMAIL - - — --- - - 77 {f Zt 3 Wn F O Z U W P-4 w � o a z O Nrl W � � W OF a z U w �* W 3 a w W a LLI a O > w w w Cf) a o a U J ' F °- a Q � w w z w F- LL F °z 0 H U W P-4 c I The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le0bly Name (Business/Organization/Individual):���i�% Address:_ City/State/Zip: jjnD �n �� (�., Phone #: i7 �'�'- 2� 1s Are you an employer? Check the appropriate box: 1. am a employer with 3 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3.01 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. VJkemodeflug 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1111 Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. , , . n _ Insurance Company Policy # or Self -ins. Lic. #: CS400N- CSG, 5- 3 7 n Expiration Date: 3 a? y Job Site Address: o2, City/State/Zip: J, Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required -under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. Ido hereby certify under the pains and ppeennaalties ooffperjury that the information pro videed�above is true and correct. Signature: Date fl/Cc�_:, Phone #: �-4� 7 fi­ - 1�—? 3 G' Z- I S _f, Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #• 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 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, §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 -contractors) name(s), address(es) and phone numbers) 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 Department 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 permit/license applications in any given year, need only submit one affidavit indicating current PORGY 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 out each year. Where a home owner or citizen is obtaining a license 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 to 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 fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office ofIavestigations 600 Washington Street Boston, MA 02111 Tei, # 617-727-4900 ext 406 or 1-877,7MASSAFF, Revised 5-26-05 Fax # 617-727-7244 �vww.znass,govfd�a Division of Professional Licensure: License Search I The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass -Gov Home State Agencies A -Z Topics © 2007-2011 Commonwealth of Massachusetts ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATED INFO Disclaimer Regarding Website License Searches Enforcement Process Glossary Glossary of License Status Codes More... Home ) Division of Professional Licensure > .............................................................................................................................. Check A Professional License By the Division of Professional Licensure NEW SEARCH LICENSING BOARD TYPE Page 1 of 1 Mass.Gov LIC. # LICENSEE'S NAME CITY/STATE STATUS Sheet Metal Workers Master/ unrestricted 13848 MARK B MAGNIFICO MIDDLETON, MA Current i Plumbers Et Gasfitters Journeyman Plumber 25002 MARK B MAGNIFICO MIDDLETON, MA Current Plumbers Et Gasfitters Master Plumber 13559 MARK B MAGNIFICO MIDDLETON, MA Current Plumbers Et Gasfitters Plumbing Corporation 3266 MARK MAGNIFICO MIDDLETON, MA Current Plumbers Et Gasfittersj Apprentice Plumber 1ZO301 I MARK B MAGNIFICO I MIDDLETON, MA Expired The page above has been generated by the Division of Professional Licensure web server on Thursday, September 12, 2013 at 8:59:28 AM. http://license.reg.state.ma.us/publiclpubILicsn.asp?board_code=PL&type_class= M&license number=000013559&color=red Site Policies Contact Us 9/12/20)3 IS DEC -13-13 10:43AM FROM -E-A STEVENS CO 1781-397-7672 T-704 P.002/002 yMFc7251 CERTIFICATE OF LIABILITY INSURANCE 12/12/2013 THIS CERTIFICATE 13 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the Certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and Conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not Confer rights to the certificate holder in lieu of such endorsement(! . CONTACT )3e3 adette M- Dav>,S, CPCV PRODUCER EA Stevens company, Inc. 369 Main St. P. O. Bos 188 Malden MA. 02148 INSURED MagrLi.fico Brothers pl=bit7,g Heating & Gas ]Fitting LLC 31 Forest Street MA 01949 NAME: PHONE(j� j) jQ .'x'14 FA (781) 397-7672 .. _,,. com es eewnelr%u ,.o IR11000. COVERA3ES CERTIFICATtNUIIIMI;5t;Kw+x+swi -2 LISTED MOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED- NOTWITHSTANDING INSURANCE AFFORDED BY THE POLICIES DESCRISED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE BY PAID CLAIMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES- LIMITS SHOWN MAY HAVE BEEN REDUCED AUTHORIZED REPRESENTATIVE POUCY EFF POLICY EAP OMITS PE OF INSURANCE POLICY NUMBER $ 1r000,000 LITY EACH OCCURRENCE ENTED 300,000 N1120tERALLIA1019 CIAL GENERAL LIABIDTY000 BSEL&%i5370 !2412013 !24/201 a PREMISES-fE86tcu�«$ MEb E]cP An one erean & wi9-MADE X] OCCUR PERSONAL&ADV INJURY S 00, 000 1,000,400 AGGREGATE $ 2,000,000 �GENERAL pAODUCTS-COMPIDPAGG $ 2,000,000 GENL AGGREGATE LIMrf APPLIES PER. $ C POLICY 7 PRO• LOC COMBINacc,ED SINGLELIMET 1 b00 (700 AUTOMOBILE LIABILITY a dont BODILY INJURY (Per persan) $ $ ANY AUTO LLOv M + SCHEDULED 053635 /24/2013 /2412014 BODILYINJURY(Peraeoldenl) $ AA NON -OWNED NED PROPER DAMA E $ X HIRED AUTOS X AUTOS $ X UMgRELIA LIAR OCCUR EACH OCCURRENCE $ 1,000,000 AGGREGATE � 1,000,004 A EACEssL1Aa CLAIMS -MADE 124/2013 124/2014 $ DED RETENTIONS 'a oar 85A=5370 INC STATU 0TH C WORKERS COMPENSATION X E,L,EACH ACCIDENT $ 500 000 AND EMPLOYERS' LIABILITYY! N ANY PROPRIETOMPARTNERIE%ECUTIVE OFFICERIMEMBEREACLUDED7 0 NIA BPJECRT9050 /24/2013 /24/2014 &L.DISEASE -EAEMPLOYE $ 500 000 (Mandatory In NH) , dew7kQ undor II 26' DESCRIPTION OF OPERATIONS bnlc S.L. DISEASE - POLICY LIMIT $ 500 000 DESCRIPTION of OPERATIONS! LOCATIONS I VEHICLES IAttach ACORD 101, Additional Remarks $cheduta, If Mara space is requirod} CERTIFIGATE HOL UILK ( 976) 4 65-30 64 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES THE EXPIRATION DATE THEREOF, NOTICE ACCORDANCE WITH THE POLICY PROVISIONS. BE CANCELLED 13EFORE WILL BE DELIVERED IN Town of Newbury 25 High; Road Newbury, MA 01.953 AUTHORIZED REPRESENTATIVE Thomas Cares, ,7r/WV+-�'�'�� ..�.r.— All -,�,..... _ A ACORD 25 (2010/05) W .--v .........,.-..._....... ..I.....__- --- INS025(2olom),01 The ACORD name and logo are registered marks of ACORD Date ......Z'3—...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... 4nit��&.7....:� z,,-' .......................... has permission to perform.....//:J/.-1.................................................................... wiring in the building of.......1`7`..C...........�y<e !....................................... at .,......��.V. C ............. .5.i...- ........ , North Andover, Mass. Fe iB e........ �' . Lic. No.. !. .................. ... �!. ! ..��� ...... E�TRICAL INSPECTO Check # V 12074 C�otnmonweafth o� %i%rdsactzu�¢ Official Use Only allePartmenl o�. tire Jervicel Permit No. _ fi 2, 7 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked -[Rev. 1107] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL I FORMATION) Date: _�Q _ J City or Town of: / To the Inspector of Wires: By this application the unde signed gives notice of his or her intention to perform the electrical work described below Location (Street & Number) 7 �-- 6FS;j/ Owner'or Tenant �� f� r Telephone No �y� , j7A wrier s Address Is this permit in conjunction with a building permit? Yes ❑ Purpose of Building Res -- Existing Service Amps / Volts New Service Amps / volts Number of Feeders and Ampacity No JN (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ Location and Nature of Proposed Electrical Work: ZZ �� �- No. of Meters No. of Meters No. of Recessed Luminaires -,v„ v +r+c uit ing No. of Ceil: Susp. (Paddle) Fans came may be waived by the Inspector of Wires. TO. of Total Transformers KVA No, of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ o. o mergency tg mg rid. rnd. Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection aEd-- and -Devices No. of Ranges No. of Air Cond. / To—Initiating Tons No. of Alerting Devices No. of Waste Disposers Neat Pump Number Tons__ KW_ No. of Self -Contained Totals: Detection/Alertme Devices No, of Dishwashers Space/Area Heating KW l Municipal Loca❑ ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Water Heaters KW No. of No. of No. of Devices or Equivalent Data Wiring: Signs Ballasts No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: uuaruunar aerau y aesrrea, oras required by the Inspector of Wires. Estimated Value of Electrical Work: �j SQ (When required by municipal policy.) Work to Start: o/� Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent, The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND E] OTHER E] (Specify:) I certify, under the pains and !ties ofpetjury, that the information on this application is true and complete. FIRMNAME: Aries Electrical Service and Controls LIC.N015650a Licensee: Nor and Michaud Signa n _ AC. NO..34594e (If applicable, enter "exempt" in the license number line.) K� Bus. Tel. No.: �'6 R h R 7 0544 Address: 290 Broadway suite 117 Methuen ma 01844 Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER. I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check ons ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. j PERMIT FEE: $ a =� The Comawnwetrhh ofMas adwsetts D92MU9W ofIMhM ial Acdden& Offlee afInvadgafions 4 `= Boston, Mas& 02111 Workers' Ww=��govldia Compensation Insurance Affidavit: &Mders/Co tin t t k tricians/Plnmbers Applicant Information Name(B,sine�lOrg uoMn�ividua>);— AE S L T tICAL SER4ICE AND CONTROyS Ad ' dress: Z90 _aRnADWAF sMTTF 11Z_ s u - a t i u. t I�� I I aB employer? Checkthespproprmte bo= 'rs am an employer with . 4 0 1 am ageneral orad l emPl%ves(fiilland/orpmt - 9)-* haw hired the sobco�s 2 _z Tam asole proprieDar orpartner- listed on the attaehed sIftt slip and have no evpleeyees 11te�4e wod[ing for me in any apagty_ [No wodceas, comp insmum - 3. 0 I homeownerdoinganwdrlc mysw•[N0W0*W ComP ksaranee t _ have employees and halve wodowe comp havaRm I . 5.0 Weare aeon and its officers have enwised #heir rwd ofmagdonPamMGL c.152, f 1(41 and we have no employem [no wadme CGUIP. hmmanceregarr,ed.I - Type of project ( : 6.0 New const ruction 7- 0 Remodeling 9.0 Demolition 9 0 Building addition - IAPectrcal repairs or additions I I.O-Plumbing repairs or additions 12.0 Roofrepairs 13.0 Other nsurance CampanyNar - . . Travekers- -:Ins . Policy # or Self -ins. Lic. Job Site Address:. SH3 � — _ _ Expiration Datr, f-- . Attach a copy oft ie workers: eo®bion Pommy dropie P(s / howOg the PoNCY. number and expiration (date). Failure to secure as requtred ung Section 25a ofM(3L 152 can lead to the up to $1,500.00 an&or oue year went as well as civil imposition of criminal penalties of a fine $250.00 a day against viohrtor. Be advised VW a Peres in the form ofa STOP WORK ORDER and a fine of DIA for co a vedfic agaL SPY ofthis sttnentmaybe forwarded to the Office of Investigations ofthe I do herby mRderthep&W andpenaWa 000*7 thWthe ii jinn Jded above is true and correct Normand Michaud 978 687 0544 O, ff eW use only Do not wFite in this area to he coJWlded by d& or town ntfici..r City or Toa: Permitdiceese#: ISSnmg Anthorky (eine one)- 1-RoardofHeath 2 BuildingDVwhR $t 3, ,n• i 6. Other - hapeetar 5+ I'Inmhing inspector Contact person- Ph one #_ t •lA T Date ....�z...:00-1 TOWN OF NORTH ANDOVER Vow PERMIT FOR WIRING This certifies that �� ........................................................................................... has permission to perform .......� 6dJ� S�,e le Com"'^ ............................................................. wiring in the building of ............ 044. k' ....I.........._.............................................. at ........................ d. ...................... . ,North Andover, Mass. Fee -5 5 .7......... Lic. No. .....r� 44666� ........ .................. ........ ............... ,...... ELECMCALINSPECMR Check # (� t ,I 0546 t_ccalrltJ)mnwaa[Ui o�ae3ac%�caoffi Offlciol Usa my e(JoparEnwnf a��ira �aruicae PermitNo. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked[Rev.l/071 Ocaveblank-) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with tate Massachusetts Electrical Code (MEC) S37 CPIR 12.00 (PLEr4SE.PRWBVB MORYTPB.�LLLINp'O ,L47I0N9 Date: 1,271, City or Tawn of: To the Inspector ffrires. By this application the undersigned gi es 3/o a ofhi or her i tentian to�perform the electrical work described below. Loention (Street & Number Owner or Tenant Telephone No.� Owner's Address Is this permit in conjunction with a building permit? Yes No El (ChecicApproprintc Purpose of Building Utility Authorization No.t 4a f�J cf !(p Mxisting Servicel,Z- — Amps Volts Overhead [� Undgrd ❑ No. of Meters New Service Amps V1 volts Overhead Undgrd ❑ No. of Meters Numberof t ceders And Ampncity C7 r Location and Nature of Proposed Electrical W rlc: No. of Recessed Luminaires --... ._.._.. _, ..._ ,-.._..... No. of Ceil.-Susp. (Puddle) I� ans ........... r ..� ..un•cu u ■nc Jna Cour -w it ireS. °• °f Total Transformers ICVA No. ofLuminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- rnd. grnd. o. a mergency Lighting i Battery Units No. of Receptncle Outlets No. of Oil Burners - ALARMSNo. of Zones No. of Switches No. of Gas Burners o. of Detection an InitiatingDevices No. of Ranges No. of Air Cond. Total Tons No. of Devices g No. of Waste Disposers HentPump Totals: umber Tons JKW N-0.of S elf- C ontucn Detection/Alerting Devices No. of Dishwashers Space/Area Beating ICW Local ❑ Municipal❑ Other Connection No. of Dryers No. of Water Iay Heaters Heating Appliances lav No. —of o. of Si ns Ballasts Security Systems: Na. of Devices or Equivalent Data Wiring: Na. of Devices or 1V nivaIcnt No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: fivaai aaautotmi aeratt 1t aestred, or as required by the Inspector of TI Tres. Estimated Value of E ectri a[ Worl_ (When required by municipal policy.) Work to Start: J0)—/Jt j j Inspections to be requested in accordance with MEC Rule 10, and upon completion_ INSURANCE=CO.. E:-Unless-waived-by.tbe=owner; no=permit-fdr tlte-performance ufeleetTical worlc=rimy=issue uriless the Iicensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is In force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I cerlffy, rutder the pahis andpenalties oJperjttrp, that the information an this applicailon Is trite and complete. FIRM NAME= LTC. NO.: Licensee: Signatur LIC. NO.• �p (Ijapplicable, enter "exempt " in die license n niber ftne.Y Bus. TeL No.: Address: Alt. Tel. No: *Per M.O.L, c. 147, s. 57-6I, security work requires Departure t of Public Safety "S" License: Lie, No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. 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O V a c' a1 cc cv ° x� �= co G M o o y `+� ° 7 3 o a a cn °v ° `° v C U � y x O as .c s v � c� a~i o ` a. c a 3 > H F b b b >~" y as CO a� v >~ % ,o Co ani a = �n ko c 11,)i V a rm >y � p a`q } n NaEn rn no c >°` Q°� H v 4 ca A° a, U Uta°� O0. U A Q � .-- N M et �1 �O t� ^- N r1 c} Vl -- N Cn U1 - N m 7 to W O O V1 N 69 Co. O C O O 0 0 0 O 0 0 L/'1 N N- N ell Os 64 6A 0 0 0C, O O O O O O_ V N 69 69 b9 O v1 64 0 O h N 69 0 0 0 0 O O O O 0 0 0 0 N N N N � se 60% 69 O O O O V1 O N Vl 6+3 69 0 Co 0 0 Co 0 Co 0 0 Co 0 0 0 0 0 0 0 0 0 0 0 0 0 0 O O O V1 O O N W1 vi 0 6 0 "t 64 N N Cl en N N 69 ss b9 69 69 b9 69 69 69 69 69 0 0 --• 69 Co 0 --� 69 O O O 0 0 1=1 v1 v1 64 N c1l 64 69 O O •-� 64 :1 w N L:. 0 o O G° C R d m 0 wca 4 c c c oEr, cc r7 ^' 0 � � '� CIL C b � � , o C. C3. co G= fRn' R coU y V 1,+1 cc V �E z p LI)O 11. Ln 0 o... ...." 9 `O�' .................. rpyCaO N> ..... ........ . y °' o 0 a � �+ .. 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O M M M W 00 01 O W Qw H O cnC4 0 o O o M F w o0 Cl 8 C �Qo,w U ` a� ►7C,'+J � t1 F W F U Wz � A' O O O V1 6N19 a r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 " www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. El am a employer with 4. ElI am a general contractor and I employees (full and/or pa -time).* 2I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5• ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction T,Remodeling 8. r Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other -Any appucant mar cnecKs Dox;; t must also tut out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: ,&ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do here ce ' y under the p ' s and pen es of perjury that the information provided above is true and correct. Si natur Date: l2/0.7,0 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone #: Date .....3�Z ...... . TOWN OF NORTH ANDOVER PERMIT FOR- GAS INSTALLATION t This certifies that ... ..!�4 ....... . . has permission for gas installation.. P4?!,PA �. in the buildings, of ... at ...1, 56741, -S! - ........ . , North ver, "ass. Fee. T"�' .. Lic. No.. �?��Z2. ......... ........ GAS INSPECTOR Check # Z131? • - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTIMG WORK J y` CITY �, (�� ~� MA DATE 1" PERMIT# JOB SITE ADDRESS OWNER'S NAME' OWNER ADDRESS IT L� _.... _ .. _.._.__...y._._..._._..._� __.__._....,-...,___ _..._ ._ .,. ti-� _._.......,._.._......... _�� _ TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONALRESIDENTIAL C� 1 CLEARLY NEW. j RENOVATION: lil" REPLACEMENT, ( 3 PLANS SUBMITTED: YES ( NO LJ APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER , CONVERSION BURNER COOK STOVE :.... - DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR �.: .-- ...... a . .. ._. , FURNACE - - -- GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT i OVEN I _ POOL HEATER --- - - - - ,- - - — ,-- - --- - - - - t'.. ROOM / SPACE HEATER ROOFTOP UNIT TEST- I i UNIT HEATEP. I I_ F y UN\.EDITED ROOM HEATEP. � � - WA I ER HEATER � � �' I � A � _ _ ..OTHER_ 1._ .. - .... __ ....-__. _ __ ..__..... .... ..: . . p ....... .. _ _ ..... ... .... , i 1 INSURANCE COVERAGE I have a current liabilu- insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES „ANO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY f _. ; BOND OWNER'S INSURANCE WAIVER: I am aviare that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts.Generat. Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER (._ ._� AGENT„i SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information 1 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 vAl be in complian vvit all Pertinen rovi ion of Ote Massachusetts State Plumbing Code and Chapter 142 of the General taws. PLUMBER-GASFITTER NAME:r� iLICENSE� (7' SIGNATURE MP MGF ( _, JP �. JGF LPGI „1 CORPORATION ;_ PARTNERSHIP;, :iiLLC .. T COMPANY NAMEa.._... _.._- . _.._.... _ ......- ..l _... - - _........ _.. .._. ADDRESS 'I ... .. _. CITY - ......:.. .:.. ._ ..._v:. .. _ ... � S_ TATE ZIP; fiEL �Sielell FAX - 'CELL e r'� Iii ui LL mAt 02 Utz Axe jWIMIUMP� b!TAlMieCTCtfM tIflprjAjLj)G%- &ER 2.El)Fw W, W. sDff-- pmpn, -etbr- o r, 1) a aqc� fistem, trttqdtwl Aug- I 9n led 'RIO, W,cfRrcwmpqmftfffdlits; {l I ll:tlitittgYdtlitmm t' 3.El MAIM"Mitt-WORmo ITO 1r lasurdme tw1uked.)T comp,. Insitrancen4tomu i tin I'[ litud"OSG rig- -- Porm, War Job Silo A4111m . . . . . . . Adtherta piqk th rl Bb acrilsedtfliamco mb cliE rw1ronvuldb( tAM - no Offfbet-of . . . . . .. . . . . . COliw Y h yetis fere i nuO chaptor 152 req# es erup,% ?pY ad it s? oFi tleeie can «seat ib+tHtast Qit arre�tp�oi clhf as,� yftq" :-,Way, —0 vffte se e;.ef'anottii r in ratty Com;Ctof , espies oariearpliecis.urnfof,mo'tttar _ A*&VIbiwils-deffineclas"an indiv et , ilaorZ � e eroe est oEact+uiclEERizI{al»pata�er-sTii S -- - *"vua,u�► azru:c�lijlt(!}!CF.or'.me p„nssogibtirnnorotllenttt};coernplt�Yees; Hbutevetife OiR°.fler ®f �ud4�ellnig;iioiise:TixvSn�notnmo�e �ainiFSa�eyapai�menfs;aud3��l�o3rn�i[�,t1[er�ia�,ortl�;pant�ai•'fin: t etis�g�to��s olaeioilter' oe�nglo3�p Ys'fcr�daniauzrena owl c+rnepayc��xi on s�ts�d3i�ei��tius� mrtmn:ttee;gxoeueds on:[aetr�dfi�appnrienanttFieret"a°rshai[Ing#+Iizeause'of;`s�tciiaeinpt��rrartsl3�:cie-e�ue�[i� Wan esnpio}mer.�, PV, SL: cTtaputer i5%- 25C{6Jtg s�rsta6es tlaai'"ei�ci s#: fe ar loe��Tlli rtsii rg;'eg�Fei! stiatli%tv.�fff"eoYff[fhe is,aerce or^ repe�.�{;tai'a,]iceiase der pee:nri>= 'aoperafe n Trusaires�orrtb3co�tsti-urf: btr�tlu�gs�irifieco�no�xeaf�nfbi-•nn3, piicaerf �vho leas dot pra�tuce�l �ccepfafsFe:ec%noi coinpatzee �a"ifhte t'ns�iatincs:eos!csgrequiixd:— e d.cxdafibnal�,`,°1,�1GI, ch�ptc�15�>§,�5��7}�s��es `�lfeiifes-foie;com�ru�nty$aliii,n���'t'}�p��•�psalci�nrisionsfsl�" otcr'intir:ar}«contract far tie pwrforpsa af��[iiiicrl-ar3riaccepFali%ectanslasnirthe irrgnr re ins nertts oftf>i cliapYsi-liatse l eirpre��utL�cl fo me cro�ant antg rsr�},,;�> Pbase fiil cult140 ii o&ers' end, if i mrar cm, mpeaisariou t ine _ Miami of %IST°ct®es lr :e e loib3;ees;;a polt yE.require& B6 eftfse(ftTtat'tlris aff fiilar�tf n�a} Ii suhmc'hect €a tFie I7epartnicnt 06 In{lustnal E£ccidea�ts for conlunrataon.o£n1surance.coverage. �f5t►: tae°spit,:e. to slget rand"date the atf ila oil . the affect, vFt slsou k-'reiilmeo to the cifY or town that the applicatien foie the pewit or J;tense laotifteDbM. riment of Frac}eastrib E1Accieleats. Sleottict }�oa have ony cgpesuns°regar i►�g.tlte t �� of if }�- 'wrcc�d tan'olStaiff a workers bc4 mpeiesattore po�icy ,pl'ease call the Dejia�imetitat<fd nuccrUer,bste tbel'ox :$eff-insured' tries sGiotr enter fTien- seffrllF�iF�an'Ce; IzcensesraremFierrxatfx,�-�n„y,,.M.,�s,..t..... Oky or Toivil Officiafk- Pose be acre fliaft3re affidavit is coiitptefa a�icl pri+et lilegibly . .eDepartmentltaspra d o,-si ace at th6 bottonra .ol"r Ike,afitcTkt�e%forxou+:fa.fe�l,ou i .tlee euenf tlS$:a£fi o€ Iuvestigatfons tias fo>cagthef yom Please;besier�;t'afdCm:tfiepenera't�licerrse.nimtiieeu�"rieTa.ur,�I:f�usecC'a�a�reference°uianrbar:.. £€r.auanIanappTicant fl#aGrttusEserifrro"lotuidgilepergrir fcceuseappii at arsfi ate gr n, eaey.uee eni su if' r iudi ingcnt cn►t. pa'li�iirfomra�epn(te1�"ieeyceyssarTaralf�narcer"o11rShsdlslticss'teappitsant'sfiaueld:us�ie"aliiFCafianan (Ee nor fl'�. �t�,�p��l"u.1.t11�%d'6lii!'d.��1U`tll$t. ldikS liPi'Fl�i!n'cPae�sr..e.�".... r.�s•.is_-.s,. a.. _ _. k _ --_•--r .�.vc .mv�,uoc-sr. Y9+17G{1 alFf[aF[AGfrYIIeI$�+;t)P�t1It�':IO��E'iaC'�ll! �1�fer�:a; tioxne+©�eer-oa-citi�ar tx otitaenurea•:Itcense:cu,perau� ngt' e�lafed-fc�an�lir�sness..ora�nranee-cealyeni'ai�.� a:�itC�1SrP®xnarnn f'rni5i,n..l va ,ec.N.: rr------- 'lifie ikB"ec�©fItvvexfegations avaafil ,leke.to tilati�;3�?trimsd�e¢e fds.�,�6�per�t�ie�*erl d���.� �ynq_ttestioase„ PN dcs nox fiCSitai..to<gire ens a Gaff mete b�rtiahnee�,'s;adctie��,t'eZe�ItArre-anc� fx �it��x:. M-Padmcnt oi`IO&WIMPA'coMents Mike of T5tvesf"igl� n#i 60OVaslifilgfolf Shy:, -BOSWM& QU1''F11 Tel. f- 617-72W49Wext:4 or Date . ///;Z 3�i/ ......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION .. G. I This certifies that ...1. .. U ...`N..... / .. . has permission for gas installation .,�rQrA5 qeq ? .1�1�'�{-� in the buildings of .. � a.. f?�!.'.! ................ . at .. -? �! . Sr ....... . , North Andov r, ass. Fee. 4, d(7 Lic. No. Z?* R" * * * �� !►�!� -rV401.1r.�.. . GAS INSPECTOR Check # /05�7 7925 MASSACHUSEM UNARM APP11CATON FDR FERMFT TO DO GAS FTI TIItiG (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Locations 2r L ll,!!� V,_(Ian'' Sr Permit i# Owner's Name Amount $ New Renovation Replacement PIans Submitted (Print or we) one: Certificate Installing Company Name T .�4 G L O n' n! joy .�� Corp. Address n d' i OX S7 aZ Partner. 6.9 c Aeat/cP &2!1 le VZ Business Telephone 7 -7 Y 6 Name of Licensed Plumber or Gas Fitter nloo t As J14 Ik eig rl INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes P1 No Ifyou have checked Yes, please indicate the type coverage by checking the appropriate box Liability insurance policy -0 ` Other type ofindemnity M - Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 ofthe Mass. General Laws, and that my signature on this permit application waives this requirement. - of Owner or Owner's Check one. Owner I hereby cerhiy that all ofthe details and intormation 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 ofthe Massachusetts State Gas Code anti Chapter 142 ofthe General Laws- City/Town (OFFICE USE ONLY) Signature ofLicensed Plumber Or Gras Fitter Plumber �t Yf 33 Gas Fitterick ensee Number D Master Journeyman z z t.. z Q - w ti a C > c rD °a y ° x o 3 c U N> a° o SUB-BASEM ENT BASEMENT IST. FLUOR 2ND. FLOOR 3RD. FLOOR 4TH_ FLOOR r 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or we) one: Certificate Installing Company Name T .�4 G L O n' n! joy .�� Corp. Address n d' i OX S7 aZ Partner. 6.9 c Aeat/cP &2!1 le VZ Business Telephone 7 -7 Y 6 Name of Licensed Plumber or Gas Fitter nloo t As J14 Ik eig rl INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes P1 No Ifyou have checked Yes, please indicate the type coverage by checking the appropriate box Liability insurance policy -0 ` Other type ofindemnity M - Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 ofthe Mass. General Laws, and that my signature on this permit application waives this requirement. - of Owner or Owner's Check one. Owner I hereby cerhiy that all ofthe details and intormation 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 ofthe Massachusetts State Gas Code anti Chapter 142 ofthe General Laws- City/Town (OFFICE USE ONLY) Signature ofLicensed Plumber Or Gras Fitter Plumber �t Yf 33 Gas Fitterick ensee Number D Master Journeyman Date. f I AM3 9207 TOWN OF NORTH ANDOVER slow PERMIT FOR PLUMBING This certifies that !:"*.n .... .. . has permission to perform plumbing in th bu' g dinof ... ?...����? S. ..... . tN� s at . l.S. �' S hv.. ... S%r........ , N h Andover, Mass. Fee .3 ,' . Lic. No...? y ./llC. i. 3�r .... . PLUMBING INSPECTOR Check # /057 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETIS g %3— ��/G�%,t/u 7 — S% 3� fes' f-1f�Ll1e�/ .� nate Building Location Owners Name �f Permit # Amount Typeofocupancy l�iv�L�i/l� t New Renovation Replacement M ` Plans Submitted Yes No FIXTURES (Print or type)n Check one: Certificate Installing CompanyName 'A'L L,6.9 'i A) !" �-) ❑ Corp. Address I` 0 ` , !J 1z9 ❑ ,�-Partner.- - 1 - �C,���i�C e= �.�' - � ' :yL._ Business Telephone .= j��"!� ❑ Fian/Co. Name ofLicensed Plumber. ,/D%% 11WLCtr/�'��W Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate boat Liability insurance policyis] 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 r� Owner ❑ Agent ❑ I hereby certify that all of the details and iniimmation I have submitted (or entered) in above application ars true and accurate to the best of my knowledge and that, all plumbing work and installations perfi med under Permit Issued for this application will be in compliance with all per tinent.provisions ofthe Massachusetts State Plumbing and Chapter k42 ofthe GeneualrLaws. B3'' 'Tignawre 01 1,1=0caum er Title Type of Phunbing License lCity/TownJourn cense urn er Master eyman APPROVED (OFFICE USE ONLY � �' Date. .11.t?/?!� ?.--.... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... P q. f. !� !� ... . °:............ has permission for gas Iinstallation . 11.13 .................... in the buildings fof .. .� ( C `............................ . at .. �i . 3...('.� �. :.. 1.......... �l, North Andover, Mass. Fee.. �° . Lic. No........... ... � ..... �1 .... . GAS INSPECTOR Check#1366 G 5343 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) JOIM' Mass. Date II\li��i, i g, i1��.S Permit #_,�_ Building Location 7'_,GSI ES i t�(T I Owner's Name J0 -\/CF I IOLLI N S' 014, Type of Occupancy.�:ES7 New ❑ Renovation ❑ Replacement Plans Submitted: Yes❑p'\."0,No[3 Installing Company Name BAY STATE GAS COMPANY Check one: Certificate # Address 55 MARSTON STREET SCJ Corporation 1862 LAWRENCE, MA 01840 ❑ Partnership Business Telephone 9 7 b — 6 8,7 -110 5 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery �. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked ye, please indicate the type coverage by checking the appropriate box. A liability insurance policy P( Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent O I hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and accu�te to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S. (j Tvne of License: . Plumber Signature of 'cense Plumber or Gas Title Gasfitter City/Town Master License Number _374"5 APPROVED O FIC SE ON Journeyman ■�MEN 1 tNON 0��t ��� ■■ now] .. MEN OVENEENNEENISM onONE■ ■NDN■ . .. ■NNEEMONNOaNIKENONSON No ■���SEES son • • ■NNOMENE00000000 Oxon ONE 0 NEON, Installing Company Name BAY STATE GAS COMPANY Check one: Certificate # Address 55 MARSTON STREET SCJ Corporation 1862 LAWRENCE, MA 01840 ❑ Partnership Business Telephone 9 7 b — 6 8,7 -110 5 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery �. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked ye, please indicate the type coverage by checking the appropriate box. A liability insurance policy P( Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent O I hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and accu�te to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S. (j Tvne of License: . Plumber Signature of 'cense Plumber or Gas Title Gasfitter City/Town Master License Number _374"5 APPROVED O FIC SE ON Journeyman n z• f• - LL N y. a J d 2 O O w O N � W. U � • ¢ 0 z O J O O c f LL LL � C3 J LL ° o a o 03 v a a o m lu IL a z ~cc O w .tl N O a w a z U d W a LL z .+ z O H U w CL co z_ J a z_ LL r, Q w F - Z a ¢ t� r cr w a Location-/ No. /'1 Date 117 h7 NORTH ANDOVER :cupancy $ Permit Fee $ nit Fee $ e $ on Fee $ m Fee $ L --Building Inspector Div. 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