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Miscellaneous - 767 JOHNSON STREET 4/30/2018 (2)
O -4 PD 2 0 Z O U) Zo Z O cn, O 0 I O m-4 1 Td� Date.......... .. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that CJa .................... ��.v....- 4 r............ has permission to perform .... :............................. wiring in the building of ........j% ..!E 6 (/q.. ........................:.................... at ........ 76...x........ J o� f'i/ S �''L....... 5. j- .) , North Andover, Mass. Fee... ?...".� Lic. No. /"!'.h'.�..........., . �...................?f: , ELECTRICAL INSPECTOR.. . . Check # ZO � 93b8 "I Commonwealth of Massachusetts official Use Only Department of Fire Services Permit No.� BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07j APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASEPMTININK 0)? TYPEALL INF0RM4TI0N) Date: City or Town of: NORTH ANDOVER -L-- / G By this application the undersi ed To the Inspector of Wires: gn gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) -767 Owner or Tenant i ) o� Ai Owner's Address Telephone No. Is this permit in conjunctio7 with a building permit? Yes/ Purpose of Building �, @�,, � NO u (Check Ap ropriate Box) — ! IA -4— Utility Authorization No. Existing Service 2oy Ams G / P Volts Overhead ❑ . Undgrd ❑ No. of Meters New Service Amps ----L—Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: --i /en _ . —. C Sec k P T ' No. of Recessed Luminaires Com lesion of the ollowin No. of Ceil.-Sus p. (Paddle) Fans table may be waived by the Inspector of Wires. No. of Total No. of Luminaire Outlets No. of Hot Tubs Transformers ��' Generators KVA No. of Luminaires Swimming Pool Above In -o. d. ❑ o mergletg g - No. of Receptacle Outlets d. No, of Oil Burners Batte Units No, of Switches FIRE ALARMS lvo. of Zones No. of Gas Burners No.. of Detection and No. of RangesN . o. of Air Cond. Total Initiatin Devices No. of Waste Disposers Tons eat Pump Number ons KW No. of Alerting Devices Totals: No. of Self -Contained Detection/Ale No. of Dishwashers Space/Area Heating KW Devices Local ❑ Municipal No. of Dryers g�� A Heating Appliances KW Connection ❑ �� Security Systems: o. of Water Heaters KW N o• of No. of No. of Devices or Equivalent Si s Ballasts Data Wiring: No. Hydromassage Bathtubs g No. of Devices or E uivalent No. of Motors Total gp Telecommunications Wiring: OTHER! No. of Devices or Eauiv9lent Anach additional detail if desired, or as required by the Inspector of Wires Estimated Value of Electrical Works. ZZ5� " ` (When required by municipal policy Work to Start: 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 covers in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER I certify, under the pains and ens 'es o � (Specify:) P fP�9ury, th the information on this application is true and complete. FIRM NAME: � a �✓ Licensee: (� c�Y� ' LIC. NO.: Signator „ (If applicable, enter 'exe t " in the license number line.) LIC. NO.: Address: Bus. Tel. No.: I--%6 01 Y� *Per M.G.L c. 147, s. 57-61, security work re uiresc d„ „ Alt. Tel. No.: �pq f yZ OWNER'S INSURANCE WAIVER; I am aware that ptl a Lnt icensee does not have theliability Lic. No. required by law. By my signature below, I hereby waive this requirement. I am the (c Owner/Agent heck one) ❑owner Signature Telephone cover owner'sna ent No. PERMIT FEE: $ —7] a 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 Name (Business/Organization/Individual): Address: City/State/Zip: s Phone #: W( S_� C 0l %-7 Are an employer? Ch k the appropriate box: 1. I am a employer with 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 x 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.] *Any applicant that checks box #i must also 1111 out the sedion blow S1 --L.. r Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 1 L ❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other •• b .....L w0:'ers compensation IYJ:.'CY :nfarmatlon. Homeowners who submit this affidavit indicating They are doing all work and then hue outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policyin formation. I am an employer that is providing workers' compensation insurance for my employees. Below, is the policy and job site information. Insurance Company Name: /Ud lL. a(,k QIP Lf iq �( Policy # or Self -ins. Lic. #: E �P Expiration Date: Job Site Address: Ila 7 T6 14^j S U) S �— City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day st the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the 1A for ins ance coverage verification. I do hereby cerci under a pai and penalties of perjury that the information provided above is true and correct Sij ature: 6 Date.: S Phone #: 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 #: a 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-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 i 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 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 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 bum 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 of Investigations 600 Washington Street Boston, AZA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-72.7-7749 Revised 5-26-05 www.mass..gov/dia Date ....I.. �... ....... . NORTq °ft 4,. TOWN TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �-Icll V1 z 4.. This certifies that ................� ..... V .. � ecv. j............................. has permission to perform . ��.�. ...�. �. L ............................... ' wiring in the building of ...�.. S ....... , North Andover, Mass. at .......... w. A!.►1............. :.w? -Fee.... %--a .. ............... Lic. No.............. ........... rt. ....... ELECTRIC AL INSPECTOR / Check # 3 657 t t 1 -_ Commonwealth of Massachusetts ' )I Ise ,tl t - I 77- Department of Fire Services i T. Occupanc} and Fce Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9 051 , I� blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK \II %. Airk to he hertormed in Iccordallce %%Ith the \la,saChuSetts Hcdl•ical Code t\W('). 52" (AIR I' Qo tPLE. ISE PRLAT IN I KOR TYPE. ILL I F1)R.ILITION) Date: y—/Y-66 Citi' or Town of: •144 . _ '9-�hi aueL_ TO the h7N/?eL•10P 11/ lFil 's: By this application the undersigned gives nutice of his or her intention to perform the electrical \kork descrihed helow. Location (Street & Number) �j[+,)�b J ST— Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Purpose of Building Existing Service ?sY! Amps olts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Telephone No. Yes ©V No ❑ (Check Appropriate Boz) PI�ndgrdFl horization No. Overhead No. of Meters _ Overhead ❑ Undgrd ❑ No. of Meters 14 No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets T No. of Hot'Tubs Generators KVA Vo. of Luminaires Swimmine Pool ,above ❑ In- ❑ �rnd. o. of -Emergency Lighting— ,irnd. Batter Units No. of Receptacle Outlets r, No. of Oil BurnersFIRE _ ALARMS �No. of Zones No. of Switches 2. No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers P HeatlP ams, Number Tons KW 1 No, of Self -Contained Detection/A lerting Devices No. of Dishwashers / Space/Area Heating KW gLocal ❑ Munlclpal ❑ Other Connection No. of Dryersht p y, Heating Appliances KW Security Systems:* No. No. of Water KW No. of No. of of Devices or Equivalent Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Nil otors Tntal FIP _ Telecommunications Wiring: No. of Devices or Eq uivalent ll I h EK: cy�7 .INrr.,4.n1,./utuilu� Jr;ul r/.h^;rrr/. :r'arsrr/urrrJ/;t. itr• L,�,/,c�lr,rII,. F.',timatcd b•alue of Electrical Work: • • 0 (Gk hen reLluired by municipal policy. j \b ork to Start: Inspections to be requested in accordance �0h \IEC Rule 10, and upon cumplotion. INSLRANCE C'ONERACE: t.,nless�' tivcd by the okrncr. nu Permit for the perlormttnCC Ofclect•ical �rurk uta} i.:�ue unlet. the licensee pra�icles grout of liuhilit�'in.sur;tncu includin'' "t omplctcd operation" coverage or its ."ub:,tantial cquiealent. t tr. uu!er i :,ne:.l cerritie: that .uch c �� .1"We i:, in I tree. ,m (l;n; c .hihih:cl prtwt r:t ;anx ro the permit i ,tato : uEticC. IIFCK0"'E': li�til R.\�:l'I f3t1\.I) �.� )I1;1 -R ❑ I:ih:i.cil'y:) d . r't'fll►, lIN1C'f :111' U: /!.S •i1N� )Ct1l.lilV!c 1 JPS m:),, ;lml the ;v fi ''uY; lr111 '51101 NAME: 1 Licensee, .ecx —_ "at:,rulez— 1,` Wk. •cit 1. il.r i. t,: ..anti`,. ,,!c, ---- — Address: _—-. �1,� 441 wlt, TCA.Securit S ,tem Conh;tJor I,icuw;c rcquircd for this r tf �pPlic,tble. enter the license number here:Y•Y0NVNFR'S INSt_'RA CE NNAIVER: I ;nn mv:ll thatl.i ;cn ec ,lr:,. rr,l hr.rnr. the li;.tbilit insw;utcc : �'.. _TT e n,. rm;ill� teiluired by law. fay my :.icn Uure bclo�r. I hcrcb} '.rairc this rcquircmcnt. 1 ;1111 the (_heck one) ❑ a.>��ncr ❑ u�� net':, ,u,crt� Owner,'Acrent .'sgitatilt't; ' !oF'R.L-JiT t•'F'I� 6 Commonwealth of Massachusetts - Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS t )I6t.i,il I .c ( )Ilk 11crmit No. lam- Occupanc\ and Fee Checked [Rev. 9 051 (lease plank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK SII •.turk to he pertorntcd in acau•d:utce Keith the \Lusachusetts I:Iccu•icaI Code I\11:0. 52" CMR 12. 00 ii'LE.ISEl'RI,NTI.N INK ORTYPE.ILLINFI)R.11.ITIO ;7 Date: -Y— ly-eb City or Town of: &m"mTo 11le 11I.Speclor of 16`ires: fay this application the undersigned gi�es notice of his or her intention to pertitrm the clectrical \Mork descrihed below. Location (Street & Number) Owner or Tenant I Vii- Telephone No. Owner's Address Is this permit in conjunction with a building permit? Purpose of Building Existing Service 24r- Amps %2f7 / f4'olts New Service Amps / Volts Yes Mz No ❑ (Check Appropriate Box) LtiIity ttorization No. Overhead t;ndgrd ❑ No. of Meters _ Overhead ❑ Undgrd ❑ No. of Meters _ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:f�� CM o/I /it ;rdfrntiris, luhle / lIaI he wati,d i'v the 1:ra)-e,.l,a' o/ )V,, No. of Recessed Luminaires No. of Cell.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of HotTubs Generators KVA No. of Luminaires '%bove In Swimming Pool „t.nd. ❑ rnd. o. o Emergency Lighting t;artery ! nits FIRE ALAR V1S �No. of Zones No. of Receptacle Outlets S No. of Oil Burners 'I No. of Switches Z No. of Gas Burners No, of Detection and Initiating Devices No. of Ranges Tl No. of Air Cond. Tons ;No. of Alerting Devices No of Waste Dis oscrs P 1 Heat Pump umber Tuns _ ......... KW INo. of Self -Contained .. __ Totals: [Detection/Alerting Devices No. of Dishwashers Space/.Area Heating KW [Local ❑ Municipa❑Other Connection No. of Drycrs� . ,� i^ L Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. o No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage B;tthtu . No, of Motors Total HP 'clecommunications Wiring: No. of Devices or Equivalent OTHER: Illuril rJ,.l;nuilu Jcioll rl •lrs,rcd, a ,l.crrlurrr,ll':1 ,i1c Il,�.ptL,/,,I' 11 F, timatcd �•;rluc of Electrical bV ,rk: Yy' ' 7 `' 1 \k hen required by municipal policy.) \b ock to Start: Inspections to be requested in accordance N01i \IEC Rule 10, and upon completion. INSLRANCE C'O� ERA(:E: t.,i less v-aivcd by the oerncr. no permit tar the performance 4clectrical �s,ork may i ::,ue rhe licensee pr,:vides proof otli;thili v�itt.surancv includinr�" ompleted operation" c ��era e,)r its .,ub,luntial cyui�alcnt. Ill,. ,ndersi,.Ilcd ccrrilic: that °uch c ,k .ra;;c i:. in Ir:rcc.:nt.l h:rs r .hihih.d I;roof c.F:,cunc totlte perm:(: .:uin : ultict`. III: t:'K C)�I : liv,`il �•\�:t.'i i3(i'� I) �� i (FI I.R �_� I tir,:cily:; ,'I fl t , • �1)Ider Ill F1U ls .oid )Cie,i ur , 'N! vhe !H.1l•'N l fr-,NV, M!lrul/i,ill:,;7! !l l,v•�y).!,; 9IZiti1 N.VVI w : tala'r'• C. i0.: = _ : l,`,r' /:1(� .N>li I,l• ! ...N ii., is r:, !,. , ..r:n1i, . ,:'roc. ; i � Sus. TO.. �o. Address:C J r ! . %— I L�— --- Alt. f cl. Nn.:W-2LJJ ;eeurity Sys WITI Contractor License raluirtd tirr [Iris 11,'�4r , itapplic,tble. Lntcr the: license number litre: OWNER'S INSURANCE'NNAIVER: I ,.im ,twin that Ch1: I.i,:en:ee Jr.,. n,;t have the liabiht} insurrnce ::...r l.c ni. IMIlk, Icquired by law. fay my :.i, nahtre bcloGr. I IlVI%A y '.raiVC this rcquirtntent.I am the (Jhcek unc) ❑ owner':, :uzeOt. Owner/Agent R f�6,4- d,k d h-- y - ter - o (, P/1-1-( Date. 3? .G. l ......: . o o ,40 o� ` TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �9SSwru1lSESS This certifies that .... has permission for gas installation X ...... . in the buildings of ... .�.`. ........ `."-`- ................ . at .. _:�..s� ... J z G ..:................. North Andover, Mass. Fee..'. °. Lic. ... ...� �L �,.'..... /GAS INSPECTOR Check # / 3 I 5485 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFiTTING (Print or Type) N N Ai �%i��jEr�- .Mass. Date Permit #�� y p s- �� Building Location '� Jr ��SON ST Owner's Name' �I '. STO�?� MM( AOLEVUL PIA Type of Occupancy CLEC F,CA,?TC New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑ 7 • ■��f�t�������■ ■���� Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Business Telephone 9 7 b- 6 87-"l 10 5 Name of Licensed Plumber or Gas Fitter Francis X. Corkery Check one: Certificate # X7 Corporation 1862 ❑ Partnership ❑ Firm/Co. INSURANCE COVERAGE: I have a current liability insoura❑nce policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy X 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 ❑ I hereby certify that all of the details and information I have submitted (or entered) in abo pplication are true and accurpte to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application willU , n compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. By T e of License: Plumber Signature of Licensed Plumber or Gas Title WGasfitter City/Town Master License Number _374'5 APPROVED O FICE SF ONLY) Journeyman MEN Mono OMEN son • • • • ........... ■. ■..■■ s.. no mom mom Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Business Telephone 9 7 b- 6 87-"l 10 5 Name of Licensed Plumber or Gas Fitter Francis X. Corkery Check one: Certificate # X7 Corporation 1862 ❑ Partnership ❑ Firm/Co. INSURANCE COVERAGE: I have a current liability insoura❑nce policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy X 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 ❑ I hereby certify that all of the details and information I have submitted (or entered) in abo pplication are true and accurpte to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application willU , n compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. By T e of License: Plumber Signature of Licensed Plumber or Gas Title WGasfitter City/Town Master License Number _374'5 APPROVED O FICE SF ONLY) Journeyman J Z O w N w, U k U. 0 a O U. 3 0 J w m w w 0. N w z U F - w X N 0 z� LL H H IN d O a O 1- o a w z 0. a ' 0 u. z 0 F Q U_ J CL CL a 0 I oI u. N a 0 a 0 a w m 2 M J CL Date - �1-4� � ... TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING SACHUS This certifies that ................... has permission to perform 77. ....................... plumbing in the buildings of .. S. t> ....................... at. . 31Z .. J.0.4 ...... .. North Andover, Mass. Fee. Lic. No. ? .. ......... ....... PLUMBING WING INSPE&OR Check # 69,04 .4 IN MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING . ftnt or Type))/� 100 H70n lle -- Mass. Date Permit # 0 .� r Building Location .3/6Owner's Narrx Type of OccupancyC1-1— New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES 3 308 MAIN STREET, GROVELAND MA. Business Telephon 978 372-6981 Name of Licensed Plumber Check one:. Certificate Corporation 2486 C ❑ Partnership ❑ Firm/Co. INSURANCE COVERAGE: 1 have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 14Z Yes 181, No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box A liability insurance policy 1� Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: i am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and information t have ed (or ent in above application are true and accurate to the best of my knowledge and that all plumbing work and installations under the it issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbi a and Chap of the General taws. By rile tore umber own Type of License: Master Journeyman ❑ APPRC7VED, (0 IC US ONLI�License Number 11027 z Z Y J ca O _¢ Y< a H v a a W= < 2� C F- < x < W 9LY W ~ < G1 > t• O = IL V D t. 0 = 0 0 vj _ _ W t- < o U S > } < < S a < < z < J J< a� ¢ ¢ ¢ 3 O < r x j m 02 a J 3 r �. v.. a< c m o SUS—BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR . 6TH FLOOR 7TH FLOOR STH FLOOR STARK & CRONK PLUMBING & HEATING 308 MAIN STREET, GROVELAND MA. Business Telephon 978 372-6981 Name of Licensed Plumber Check one:. Certificate Corporation 2486 C ❑ Partnership ❑ Firm/Co. INSURANCE COVERAGE: 1 have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 14Z Yes 181, No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box A liability insurance policy 1� Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: i am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and information t have ed (or ent in above application are true and accurate to the best of my knowledge and that all plumbing work and installations under the it issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbi a and Chap of the General taws. By rile tore umber own Type of License: Master Journeyman ❑ APPRC7VED, (0 IC US ONLI�License Number 11027 a r N A O . Z fA I Ac Q O m A ; � O � • � f Y O. . Q - N. Date.e, f ...... O' TOWN OF NORTH ANDOVER -' O D • PERMIT FOR GAS INSTALLATION �9SSACHUSEI� This certifies that.. /�.. ................ has permission for gas installation .....1q wV.j? 7 .-........... in the buildings of ......................... at y � ............. North Andover, Mass. Fee d.. Lic. No. 2.1.Z. L . .... ... .'� .- . . AS INSPECTOR Check # 551 NIASSACHL SIJTCS Ulf-IFORNI APPUCATON FOR PERNIlT TO DO GAS F nTING (Type or print) Date tr0 _ } _ 0 L ;NORTH ANDOVER, MASSACHUSETTS Building Locations °� V7 -40NJsom ST Permit # J ^� Amount S 1 .�� Owner's Name New Renovation Replacement Plans Submitted e e e e (Print or type) C e one: Certificate Installing Company Name W i12 ,A 4 PLUMISIQ6. t tj e Prrjh0L-Corp. Address Z'oI �j A'l4 /Jr' 2i7 11 Partner. fel LL4sp�tr;_ _ iM_1�_ et Rl."z Business Telephone c} 'I Pt �h 1 -0"t --v 0 Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE • Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes [M No If you have checked Vis, plea e Indicate the type coverage by checking the appropriate box. Liability insurance policy & Other type of indemnity 13 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 t 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 aII plumbing %. ork and installations performed under Permit Issued for this application will be in cc.mpliance with all pertinent provisions of the Massachusetts State Gas Cote and Chapter 142 of the General Laws. t le ity/Town i\PPROVED,OFFICE (SE ONLY) Signature of I ® Plumber Gas Fitter Master Journeyman ensed Plumber Or/Gas Fitter z zt g tcense 1 um er t Date. . ,.ORT1y TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 41 SACMUs�ty+ This certifies that ................ ,T x has permission to perform ... ...... . . . .. . . ; plumbing in the buildings of .... rt t`/�f��!�................ at .... North Andover Mass. Fee ..J�. 7.. Lic. No.. Z. Z ? . ...... V.... ..... PLUMBING INSPECTOR Check # l i `V 2 6926 , MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Ll - i R -6(. Building Location ' 7 G 7 Sb W tV3otJ ST Permit # Amount � Owner ti U Lr p I r 1Z A l k New Renovation Replacement 1:1 Plans Submitted Yes No FIXTURES .: - • OUR, 7" ...-®-------------------- ------------------------- �7, a ��.;sM0MMMnMMMMMMMMMMMMMMMMMMM 147 M®MMMMMMMMMMMMMMMMMMMMMMM W.11-11211-17 MMMMMMMMMMMMMMMMMMMMMMMMM (Print or type) Check one: Certificate Installing Company Name t41)�Z>2PF[]Corp. Address Z `'I T NAS r4 u A ;?'17 . Partner. tRiG M14, Business Telephone q 7& h 1- 0:412 � Firm/Co. Name of Licensed Plumber: TLO ii" D . 4 Ur?- LA-;� Insurance Coverage: Indicate the type of insurance coverage by checkiing the appropriate box: Liability insurance policy 0 Other type of indemnity D Bond D 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 D Agent D 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 Massachusetts St to Plumbing Code and Chapter 142 of the General Laws. By igna ure M pcenseu r1umq Type of Plumbing Lic se Title Z7.Z 13 h City/Town icense NumDer Master D Journeyman n APPROVED �oFFlce use ONLYL� Check # 41 1$930 Building Inspector yf,� Location2 / 'coy?�XLp- 21 No A Date j ,. TOWN OF NORTH ANDOVER F t Certificate Occupancy $ • i „ ; of �' b''•'°''�� ,Ss4C Hush Building/Frame Permit Fee $ Foundation Permit Fee $ { Other Permit Fee $ TOTAL $ _� Check # 41 1$930 Building Inspector yf,� TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT RENOVAT4 OR DEMOLISH A ONE OR TWO FAMILY DWELLING 1M DATE ISSUED: BUII.DING PERMIT NUMBER: 47 71 SIGNATURE: Buflaing 6mmissionerfl r of Buildings Date SECTION 1 -SITE INFORMATION 1.1 Property Address: 7 1.2 Assessors Map and Paroel Number: .11� - V Map Number Parcel Number -,fv�L 1.3 Zoning Information: Zoning Distrid Proposed Use 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided ReqWred Provided 1.7 Water Supply M G L C.40. 54) 1.5. Flood Zone Information: Public ❑ , Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes _ No _ 2.1 Owner* of Record ` �-7 De ric e4 7(a C ,J ev6 yZ:5 ( "T1 me (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 LicensedConstructionSu f r/ Licensed Construction Su sor:r -`� -51j—License Address Si lure V Telephone Not Applicable ❑ 0 Number Expiration Date 3.2 Registered Home Improvement Contractor J �(1 Not Applicable 0 Company Name d. Registration Number Expiration Date Address Si atu Telephone Z M 0 an M r e>aas z 0 SECTION 4 - WORKERS COMPENSATION (M:G.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 all applicable) New Construction El 'EvdGfing Belding ❑ Repair(s) ❑ Alteratibns(s)t vFil`U Addition ❑ Accessory Bldg. D, Demolition ❑ Other ❑ Specify Brief Description of PrVdW I SECTION 6 - F.STIMATF.D CONSTRUCTION COSTS 1 Item Estimated Cost (Dollar) to be Completed by permit applicautapplicant s� ii?FI£IAL--IISVONLY� � _�- a � 1. Building cd 00 (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) 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 r ece,l 'TI 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, As Owner/Authorized Agent of subject property 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 -1 Si ture f O r/Agerit Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST 2 ND 3 RD SPAN DIMENSIONS 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 r IS BUILDING CONNECTED TO NATURAL GAS LINE CA m v. y d O � ■ W Cos 10 l CD O CCD O 'C CL y ncm o co 0 v CD CCD O CL Q..T CD CD O ee -J O y 0 O O1 C y = O p a y _d O A Z C9 O. �dm ca nod m = CD m ,q p O y .+ H NO p ? m CO o 2 > > G �• O 0 O imp+ ZRE `4 1 p y =r O C to _ CL .b ^• : w C =r O ,m y m ,cc d CD �d y ; C.0 d d ;LIQ O W N N ` •�O ca 7h m m O fu y � D F ~r� . .� C9 CD CD . CD yCD I d -ft: O C: O d d d ,c I C -J c i O d O c O = ' y 0 The Commonwealth of Massachusetts Department of Fire Services Office of the Mate Fire Marshal P. 0. Box 1025 State Road, Stow, MA 01775 PERMIT Date: North Andover permit No ( City of Town ) (If Applicable) Dig Safe Number In accordance with the provisions of M.G.L.l 4 $ CChapter_1Q_ as provided in section S 2 7 CMR 34 Start Date This Permit is granted to: . /I Z-4, T` /Full name of person, Firm or Corporation Permissionto locate dumpster for construction/renovation/demolition of building. Comments: dumpster must be 25' from structure if unable to place with required Restrictions: clearance dumpster must be covered with plywood or tarp end of work day at •1. J ( Give location by street and no., or describe in such m�ngrar as t� 111 ied adequate identification of location ) Fee Paid$ 50.00 �//�,. Y fL.Y Fire Chief This Permit will expire ' 3' U 6 ( Signature of offical granting permit) Offical granting permit ( Title ) �♦ TW1C PERMIT MI ICT RF r_r)MCPlrl Ir11 IC1 V Pr1CTF1l 11PrW TNF PRFMICFC ��� 01/17/2006 09:01 9787443575 GERALD MCCARTHY INS PAGE 01 Gerald T. McCarthy Insurance Agency, Inc. P.O. Box 839 91 North Street, Salem, MA 01970 978-744-6433 - Fax 978-744-3575 January 17, 2006 Town of North ,Andover 400 Osgood Street No. Andover, MA Re: Lawrence Leblanc, Liberty Mutual Pol# WC231S352562014 Dear Sir: Enclosed,please find a certiftcatc of insurance as evidence of liability coverage for the above mentioned. By law, certificates for workers' compensation insurance must be issued by the assigned insurance carrier; therefore, we have faxed a request to the above mentioned company to issue a worker's compensation certificate of insurance which they will mail directly to you. In the meantime, please be advised by us that this coverage is, in fact, presently active for the period of 9/28/05-06. 1 hope you will find everything in order; and if you have any questions, please feel free to call. Sincerely, Deborah Tournas dt Tl,. �'anvrz.uea rr�'✓i�Craaczc�uu�elta -( Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 135829 < �' Expiration: 5)14!2006 Type: Individual i' LARRY LEBLANC, LARRY LEBLANC`, r } 21 WINGATE ST #704` .� { HAVERHILL, MA'01831 Administrator ,-` E, �%ze �omvrca�uuea�iz o�'✓�/iaaoaclzuaelta q i BOARD OF BUILDING REGULATIONS License CONSTRUCTION SUPERVISOR i Number:„CS 090414 Birthdate 01728/1959 Expires. 01/28/2008 Tr. no: 90414 � Restricted Q0�' Y$ i ' LARRY J LEBLANC: 21 WINGATE ST 004 . j HAVERHILL, MA, 01832: Commissioner Location''` v % `'-,-, � No a r Date / N�RTM TOWN OF NORTH ANDOVER Certificate of Occupancy $ *Arao tt�Building/Frame Permit Fee $ 34CH Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ,- Check # 7 a r .r 16845 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REWJ RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING eN i r � .✓ v.,. as , r :..� ori ..� . �..., - ... +2� � z..� +ka Wyy�M,. S � BUILDING PERMIT NUMBER:� � � DATE ISSUED: � 0 SIGNATURE: AW.C l Building Commissioner/I for of Buildings Date SECTION 1- SITE INFORMATION Property Address: 1.116 �J 1 O�✓�- o, ` S4-gL��F- 1.2 Assessors Map and Parcel Number: 30 I Map Number Parcel Number Name Print) Addressss7 for Service: 1.3 Zoning Information: Zoning Dis-&ic—t Proposed Use Signature Telephone 1.4 Property Dimensions: Lot Area Frontage ft 2.2 Owner of Record: 3 ti= co 1.6 BUILDING SETBACKS ft Si ' ture Telephone Front Yard Side Yard .t Rear Yard Reqtiired Provide Required Provided ReqWuired Provided Licensed Construction Supervisor: 7 / Information: s' 1.5. Flood Zone Informat 1.7 Water Supply M.GL.C:40.' S4�) ��, Public ❑ Private 0'' Zone Outside Flood Zone 0 1.ew S 8 Se � Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2.- PROPERTY OWNERSHMIAUTHORIZED AGENT Historic District: 2.1 Owner of Record Name Print) Addressss7 for Service: Signature Telephone 2.2 Owner of Record: 3 ti= co a V Name Print Address for Service: V- Si ' ture Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable OF Licensed Construction Supervisor: 7 / 1 L , 1 C Q- �..� l V License Number Ad . Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ii o 1\ 2-zo �o J Company Name Registration Number xx Add Expiration Date -Signature Telephone W J� M O r z�qq M go 0 ic M z a e SECTION 4 - WORKERS COMPENSATION (M.G.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 rmit. -Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Pro osed Work check ad applicabte New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Tddition 0 Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: y I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be iiiFIiC�USE�flNY 3 Completed by permit applicant 1. Building 0 (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (e) X (b) 3 0 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SEUTIOIN 7a OWNER AUTHORIZATION TO BE. COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES. FOR BUILDING PERMIT h , 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, as Owner/Authorized Agent of subject property 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 Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS PT 2 ND 3 RD SPAN DIMENSIONS 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 f North Andover Building Department Tel: 978-688-9545 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 a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of_in: (Location of Facility) SIgnature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for .this project through the Office of the Building Inspector` t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # 3� ` U 7 I am a homeowner performing all work myself. I am a sole proprietor and have no one worldng in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name. Address City: Phone Insurance. Co. Policy# Companv name: Address Faikwe to secure cowmage as required under Section 25A or MGL 152 can lead to•tl* xiiposi Won 6F cxtnWral:penaltie3of a -fine upr fo $1'.50 andlor one yew imprisonmenLas welLas_tb&Jam_oFASTDP ��f�4I[1aflDj�liagFagetn�m� understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for cove -rage verification. n . do hereby catfy under are pains and pennies of perjury that ere ivrlcrmabba provkbd above is true and correct Signature \ Da#e /0 .V Print name 777Ze. c y=, 4�- 2Z� PhcnQ # Official use only do not write in this area to be completed by city or town officiar of Town - .... Perir�lLicer�sirxr- (ChedcifirrrmedJate Bulldtnt�f Dept` response it requved [ Lkensfng &Do j Cj sefechnaft d Contact person: Picone # E] Health Departs E] Other 14 M4 14 a u u w2 cn o U 'd w2 xpp a�' U w � W a w a o W U W dD cn u. a0 ER . O C w z W w G 0 cn Q 0 cn L� 0 0 W w CCW w Cn m c o . O C V :.3 :•dam : C. C O A C =OO m ` •gm o = v m c VJ �o a.� _ E IS :—: C CD E O � y y 4 CO m r y y O O -wc 0: m o ID :... 0 cm y v�y O G : W M.: C C O d C CD C •O Q � � m $ y 0� o ua g s LL.•N ... W C �... .O dZ �= m•y z p UJ V O m C d COD Cos m�o0 (A CD p.. t - dw-m 5 L� 0 0 W w CCW w Cn 'I Date.// : 64, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that r has permission to perform ...._._. :..�-c!�...... ( plumbing in the buildings of .... ............................ at .... /t.��../.... .............. . North Andover, Mass. Fee? .115 `. Lic. No" Il!- ............ PLUMfB,NSPECTOR Check # 5785 MASSACHUSETTS UNIFORM APPLICATION (please type or pant) /tea✓ O a V e2 Mass. �T is Owne5s Mame: • DO PLUMBING e Date: �� y Permit: Renovation ❑ Replacement ❑ Plans Submitted ❑ FIXTURES Installing Company Name: Address: Please Check One: Certificate Corp. ❑ Partner. _ Business Telephone: ❑ Firm/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 license of this application does not have any one of the above three insurance coverages. Signature of Owner/Agent of Property Owner ❑ Agent ❑ I hereby cartify that all of the data8s and information 6 have submitted (or entered) In above application are true and accurate to the best of my knowledge and that all plumbing work and hestaftfions performed under Permit issued for deka application will be in compliance with alt pertinent provisions of the Massachusetts State Plumbing Code Chapter 142 of the General Laws. (OFFICE USE ONLY) By: Title: City/Town: a PPRnvpn 6� of Licensed Type of Plumbing License: Master IQ--- Journeyman [a -- 7TH FLOOR Installing Company Name: Address: Please Check One: Certificate Corp. ❑ Partner. _ Business Telephone: ❑ Firm/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 license of this application does not have any one of the above three insurance coverages. Signature of Owner/Agent of Property Owner ❑ Agent ❑ I hereby cartify that all of the data8s and information 6 have submitted (or entered) In above application are true and accurate to the best of my knowledge and that all plumbing work and hestaftfions performed under Permit issued for deka application will be in compliance with alt pertinent provisions of the Massachusetts State Plumbing Code Chapter 142 of the General Laws. (OFFICE USE ONLY) By: Title: City/Town: a PPRnvpn 6� of Licensed Type of Plumbing License: Master IQ--- Journeyman [a -- T� NORTH Date.. //-. 2-'n ..... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ........................................... rN. has permission for gas installation ............... in the buildings of . ..._. ....`................ . at ..7l..North Andover, Mass. . ° L �� �n Fee' ..:...'Lic. No.. ° .... _............. . G '--GAS IN' 4ECTOR Check # / 76--3 4497 ,.b MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) Date _r�! 3 NORTH ANDOVER, MASSACHUSETTS Building Locations (� / /;%C1 d�/�ovrl cs7� Permit #9/ Owner's Name New Renovation 0 Replacement ❑ / Amountj. C3,;,.,.5 ♦ /�� Y�6ir Plans Submitted ❑ (Print or type)heck one: Certificate Installing Company �,/ Name �D //,z �' Corp. Address 1'0 , Z52 oe 1-Y-4e/14i1/Cu/ Ar" ❑ Partner. Business Telephone 7 7 —/—,? 72 aZo2 T 7 ❑ Finn/Co. Name of Licensed Plumber or Gas Fitter _ lJd,�%�9 (d INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ Ifyou have checked M please ind�ioate the type coverage by checking the appropriate box Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 ofthe 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 ❑ i nerevy ceruty mat an or the aetaus ano mrormanon t nave suvminea for enterea) in above appocation 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 Massachuseps-�tate Gas Codeapd Chapter W ofthe General Laws. APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber 2 rj Gas Fitter (cense Number Master journeyman FLOOR4TH. FLOOR (Print or type)heck one: Certificate Installing Company �,/ Name �D //,z �' Corp. Address 1'0 , Z52 oe 1-Y-4e/14i1/Cu/ Ar" ❑ Partner. Business Telephone 7 7 —/—,? 72 aZo2 T 7 ❑ Finn/Co. Name of Licensed Plumber or Gas Fitter _ lJd,�%�9 (d INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ Ifyou have checked M please ind�ioate the type coverage by checking the appropriate box Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 ofthe 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 ❑ i nerevy ceruty mat an or the aetaus ano mrormanon t nave suvminea for enterea) in above appocation 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 Massachuseps-�tate Gas Codeapd Chapter W ofthe General Laws. APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber 2 rj Gas Fitter (cense Number Master journeyman r &imam.. Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Mu - This certifies that ..... ........................................ ................... has permission to perform- .............. wiri ng in the building/sof ......... 16 as at ........ ............ . North Andover, Mass. 00-/ Bm3 ........... Lic. NoAm .... ... . ............................................................... //w 5 9� - ELECTRICAL INSPECTOR Check # 4907 APPLICATION FOR PERMIT" TO PERFORM ELEGFRICAL WORK All wofk to be performed In aecofdance with the A4assachusettu Eketrkal Code. 527 CMR 12:04 (PLEASE PRINT IN INK OR TYPE ALL INFORHMON) / Nate 1p G City or 'Totem of Nri. To the Inspector of 'Hires: The undersigned applies for a permit to performthe electrical work described below. O I �f9 lgcastion (Street & Number) kl 1M, Owner or owner"a Address ")la rvU l I Is this permit in conjunction with a building permit: Yes E] No Jh (Check Appropriate Box) Purpose of BuildinG cxd l•Ar�Li1 JWk1'rije Utility Authorization 00. Existing Service Amps 0 'i Volts Overhead Undgrd ® No. of deters New Se�ce, Amps / Volts Overhead ® Undgrd ® No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work 1 AI -C-11 S11i9Sr AH �ir�0�►/i� Nk%.Vl A- Itta'1YX Rti: mt1A No. of lighting Outlets No. of Bot ubs No. of Transformers x°yt� No. of lighting Fixtures Swimin Above In- g Pool rttd. � grnd. ® Generators 1LilA No. of Receptacle outlets No. of Oil Burners No. of ency Lighting Battery UniRi�s No. of Switch Outlets No. of Gas Burners FIRE ALUM No. of Zones No. of Detection and .�.® Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices Local MunicipalOther ® Connection No. of Ranges No. of Air Cond. Total No. of Disposals No. of BPMts12ns T°tial No. of Dishwashers Space/Area Beating KW . Dr. ,�:, No* of,yere,, zeatin Devices gW g No. of mater Beaters Kir _:. Si a Ballasta Wir nolta k' Wiring Hydro Nas�ge'Tubs No. of'@4sstors Tcital BP , INSURANC£ COV£RAC is - :Pursuant to the requirements of Nassachusetts General Laws I have a current iabilit Insurance Policy including Completed Operati°ns Coverage o, its substantial equivalent. YES NO (J I have submitted valid proof of same to this office. YES NO If you hav checked'YES, please indicate the type of coverage by checking the appropriate box. INSURANCE) BONED O gnlIE o (Please Specify) ( YJ IQ (Expiration ate Estimated Value of Electrical Work S � ^ Work'io Star.t� � Inspection irate Requested: Rough t1LFinal LIt_ QAJI "•y Signed under the penalties of perjury: FIRM'NAME. LIC. NO.fi l_ Licensee i7 Signature LIC. No. ' �!✓ Address L ,L yyrt)„��•l��J ( pjC _A Bus. Tel. No. Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or is sub- sCantial.equivalent as requiredrby Massachusetts Genera l_.aws,-and-that my signature on -this permit” application'i+afvisi=