HomeMy WebLinkAboutMiscellaneous - 80 LYONS WAY 4/30/2018 (2)IN A
7755
Date..,! . 2. .. �.l........
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
�, e Ca!1 4 F z
This certifies that ... .,.�. �?k �. .. .............. .
has permission for gas installation .. e- ...'-!`... .
in the buildings of ... M... 6. `t(A !� ! -.el.. � (a ................ .
at ........... , North Andov r,
Fee..3QC9. Lic. No.. !. � . F ..... 4. ....... . .
GAS INSPECTOR
Check #
A.-'
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Typc)
• , .-- .:: o (�rf�l "ve/, ,Mass. Date 7_20 /-/ Permit #
Building Location 1S 0 !j tl _ S UV Owner's NamerT,-
0.
Owner Tel# 9� ' - i C? ;2ae9a,2 Type of Occupancy 16s
New ❑ Renovation ❑ Replacement Plan Submitted: Yes ❑ No
FIXTURES
G
Installing Company Name :3-0 �Vx `eooc c/ Check one: Certificate
Address C.11 tI C -k Lvl ❑ Corporation
J� vn h e r . � I N..�q, 02 031 ❑ Partnership
Business Telephone # & 03 ; 300 -ri 2j ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter �� to 064G%
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ❑ No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A 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 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 13
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all
ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General fawc
By Type of License:
• -Plumber ,gnature of sed Plumber or Gas Fitter
Title -as fitter > L
0olaster Licen umber
City/Town • -Journeyman
APPROVED (OFFICE USE ONLY)
Eff. MR,
MEN..................
Installing Company Name :3-0 �Vx `eooc c/ Check one: Certificate
Address C.11 tI C -k Lvl ❑ Corporation
J� vn h e r . � I N..�q, 02 031 ❑ Partnership
Business Telephone # & 03 ; 300 -ri 2j ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter �� to 064G%
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ❑ No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A 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 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 13
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all
ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General fawc
By Type of License:
• -Plumber ,gnature of sed Plumber or Gas Fitter
Title -as fitter > L
0olaster Licen umber
City/Town • -Journeyman
APPROVED (OFFICE USE ONLY)
BUTTERWORTH & O'TOOLE, INC.
P.O. BOX 8294
SALEM, MA 01971-8294
ADJUSTERS/APPRAISERS
FOR INSURANCE COMPANIES ONLY
TELEPHONE (978) 741-5731
January 14, 2004
FAX (978) 740-9109
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B
TO: Building Commissioner or
Inspector of Buildings
City/Town Hall
ADDRESSES
North Andover, MA 01845
RE: Insured
Address:
Policy No.:
TO
V SN 0 TH AIVljO !' j
BOARD OF HEALTH
G JAN 2
Board of Health or
Board of Selectmen
Citv/Town Hall
North Andover, MA 01845
Massimilano and Shelly Gabriello
80 Lyons Way
North Andover, MA 01845
HMA0147985
Loss of: 01/10/04
File or Claim No.: 041-0075
Claim has been made involving loss, damage or destruction of the above
captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws,
Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws,
Ch. 139, Sec. 3B is appropriate, please direct it to the attention of the writer
and include a reference to the captioned insured, location, policy number, date
of loss and claim or file number.
If no reply is received from your office within ten days, we will assume
you have no liens of any type against this property and we will recommend to the
insuring company that this claim is paid.
Vicki Gardner
Adjuster
BUTTERWORTH & O'TOOLE, INC.
P.O. BOX 8294
SALEM, MA 01971-8294
ADJUSTERS/APPRAISERS
FOR INSURANCE COMPANIES ONLY
TELEPHONE (978) 741-5731 FAX (978) 740-9109
OORI�
1 iO
sly
BOA ofm��
January 14, 2004
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B
TO: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectmen
City/Town Hall
ADDRESSES
North Andover, MA 01845
City/Town Hall
North Andover, MA 01845
RE: Insured: Massimilano and Shelly Gabriello
Address: 80 Lyons Way
North Andover, MA 01845
Policy No.: HMA0147985
Loss of: 01/10/04
File or Claim No.: 041-0075
Claim has been made involving loss, damage or destruction of the above
captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws,
Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws,
Ch. 139, Sec. 3B is appropriate, please direct it to the attention of the writer
and include a reference to the captioned insured, location, policy number, date
of loss and claim or file number.
If no reply is received from your office within ten days, we will assume
you have no liens of any type against this property and we will recommend to the
insuring company that this claim is paid.
Vicki Gardner
Adjuster
I
Town of North AndovertAORTH
Building Department ? y°`., »°'a o
27 Charles Street ti -=
North Andover, Massachusetts 01845 *
(978) 688-9545 Fax (978) 688-9542Abo �` o
<OC wI[ [WKR
��SSAC HUs���y
APPLICATION FOR CERTIFICATE OF OCCUPANCY / INSPECTION
ADDRESS 010 1-e Gc> a y
LOT NUMBER 3 SUBDIVISION
DATE REQUEST FILED % ?i/j 40
DATE READY FOR INSPECTION i a /,PR
FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED
ALL WORK AND SIGN-OFF'S MUST BE COMPLETED WITHIN THIS TIME
FRAME. A RE -INSPECTION FEE OF TWENTY-FIVE ($25.) DOLLARS WILL BE
CHARGED IF THE STRUC D NOT MEET ALL APPLICABLE CODES.
SIGNATURE
ROUTING
0 CONSERVATION At& DATE �Z- 111 1cb
PLANNIN
G DATE
D.P.W. - WATER METER 0e 1:tv) DATE I z - 1 I- 00
D.P.W. MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED
PRIOR TO THE INSPECTION REQUEST DATE.
l%
SIGNA / DVX AUTHORIZATION
'- Mesiti Dev Group Fax:978-5578160 Jul 17 2000 13:54 P.01
TOWN OF NORTH ANDOVER
DIVISION OF PUBLIC WORKS
384 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 01845
Telephone (978) .685-0950
Fax (978) 688-9573
July 14, 2000
Mr. Kenneth. Grandstaf� President
Mesiti Development Group
231 Sutton St. Suite 2 F
North Andover, Ma. 01845
Re: Conditional Operation of the Campbell Forest Sewer Pumping Station.
Dear Mr. Grandstaff:
The Division of Public Works has inspected the sewer collection system and
sewer pumping station, and appurtances on Campbell Road related to the construction of
the Campbell Forest and Lyons Way subdivisions. We hereby grant conditional approval
for use of the system and pumping station subject to the Ibnowing:
1. Completion of items 1 through 15 as listed on the July 10, 2000 letter to Mr
Dennis Bedrosian from Maurice Harpin of Mesiti Development Croup, a copy
of which is attached. The work will be completed within 45 days of
acknowledgement of the receipt of this letter.
2. Satisfactory completion of an as -built plan for the Campbell Road sewerage
system.
3. Submittal for our review and approval a copy of the preventive maintenance
contract for the pumping station.
4. A performance guarantee shall be provided in the amount of $25,000.00 to
insure the proper maintenance and operation of the pumping station.
5. The Division of Public Works will be allowed access to the Pumping Station
and will be allowed to reconstruct, repair, replace, add to, service, inspect and
operate the pumping station and related equipment. and facilities in the event
-----..----.-- ........... .. . _ that Mesiti Development or its agents fail to adequately. perform maintenance
of the pumping station.
w Mesiti Dev Group Fax:978-5578160 Jul 17 2000 13:54 P.02
6. Mesiti development shall reimburse the Town upon demand for the reasonable
costs of emergency repairs to the Pumping Station.
7. Mesiti Development Group and its successors or assigns
shall uidenmtfy,
defend, and save harmless the Town of North Andover and its Division of
Public Works and their respective employees, officials and agents against all
suits, claims, judgments or liability of every name and nature arising at any
time out of or in consequence of the acts of the "Town" or its agents,
employees and officials in the performance of the access purposes covered by
this grant of conditional use or the failure of the developer and its successors
or assigns to comply with the terms and conditions of this grant.
Very Tr.q Tr.ours,
of
J. William Hmurc' E.
Director of Public Works
The undersigned acknowledge the receipt of and agrees to the terms and conditions of the
above grant of nditional use.
el up
K h Crr d dsZ�nt
Date:
N2 4553
Date. .� -C-9 .. ( d
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that , , �1 .. /..!. P.�_:. U1 V .� ... .
v , .
has permission to perform, '.. ^ ................... .
plumbing in the)buildings of ......��
at. �! :�.e %!._ .. .. �CJ . North Andover, Mass.
o
Fee y0 (o. �. L c. No O..l ;:�- ...............
PL Mp"ING INSPECTOR
Check # '"?60
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER; MASSACHUSETTS
Building Location
Owners Name
of
Date _ 0 06
Permit # �fc54S3
Amount
New Renovation Replacement Pl na s Submitted Yes E] No
(Print or type)
Installing Company Name
Address
Check one:
1 Corp.
Partner.
Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy 01
Other type of indemnity ❑ Bond ❑
Certificate
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Mass usetts StlpluA and Chapter 142 of the General Laws.
By: Signature or Licensea-Plumney,
Type of Plumbing License
Title
City/Town License Numoer Master Journeyman
APPROVED (OFFICE USE ONLY
` .-I.--ZiilmmmmmmmmmmmMMMMMMMMMMMMMMM
17M--MMMM--=M..M-MM.MNMMMMSN
■.-� is o �_;
��������������������������
(Print or type)
Installing Company Name
Address
Check one:
1 Corp.
Partner.
Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy 01
Other type of indemnity ❑ Bond ❑
Certificate
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Mass usetts StlpluA and Chapter 142 of the General Laws.
By: Signature or Licensea-Plumney,
Type of Plumbing License
Title
City/Town License Numoer Master Journeyman
APPROVED (OFFICE USE ONLY
3548 Date.... k.adl. °.0.....
HORT#q TOWN OF NORTH ANDOVER
py to ,e,tipL
p PERMIT FOR GAS INSTALLATION
This certifies that % '
has permission for gas installat(on ...............
in the buildings of ....................... :` ............ .
at . r? ....... North Andover, Mass,
Fee. i ..... Lic. No.... 7?a .. �.�....
GAS INSPECTOA
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UINTORM APPLICATON FOR PERMIT TO
T
�Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations 19 L'
tJ'�3 Owner's Name
Neww,
Renovation ❑ Replacement ❑
FITTING
Permit #
Amount S :� `.ca)
Plans Submitted ❑
(Print or,� pe)
Address
Check one: Certificate Installing Company
❑ Corp.
❑ Parmer,
/ !il�12G
ness Telephone - 6 �c'% 1G/ U' 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 ❑ No❑
If you have checked ves, please indicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity F-1Bond ❑
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 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 Staters Code and Cher 142 of4he General Laws.
By:
Title
C ityiTown
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber 2 7do-
r7 Gas FitterLIC(--rise Numoer
(10Master
Master
i
1
(Print or,� pe)
Address
Check one: Certificate Installing Company
❑ Corp.
❑ Parmer,
/ !il�12G
ness Telephone - 6 �c'% 1G/ U' 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 ❑ No❑
If you have checked ves, please indicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity F-1Bond ❑
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 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 Staters Code and Cher 142 of4he General Laws.
By:
Title
C ityiTown
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber 2 7do-
r7 Gas FitterLIC(--rise Numoer
(10Master
Master
CERTIFICATE OF USE & OCCUPANCY
Town of North Andover
au,Ian9Permit Number 17-� o.t< i—R—ac�i
THIS CERTIFIES THAT ��
THE BUILDING LOCATED ON h0�' � PD A //� vx/ 6t/i
MAY BE OCCUPIED AS s,5 W W Je, A071 IN ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND
SUCH OTHER REGULATIONS AS MppAY APPLY.
rct:-en Sl J I/.} 3 qt 5 3 `jt a 1( o ".� JQ t -
NORTH , CERTIFICATE ISSUED TO U N S Al /�•
p ADDRESS a�� .5�-kln) S S�
"'!=,U" / " Building Inspector
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NT2 2 5 64 Date ..........
0 -
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............ P ... ....... . .........................
has permission to perform ..... It'le "—' //'Q
........................................................................
wiring in the building Of .... MR.5.'A! .......... ...................................
-;at-... �? q ...... ...... W3 orth Andover, M -4 -SS.
01
Fj Lic. N o. .
;XCTRICALINSPBC
IW....
Check #
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00
Official U,sq 3-6
C/nI
Permit No. p�SJ
Occupancy & Fee Checked
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00
(Please Print in ink or type all information)
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number
Date e — 7 — 60
To the Inspector of Wires:
/ �C
Owner or Tenant
No. of Transformers KVA
Owner's Address
Is this permit in conjunction with a building permit
Yes Qs
No ❑
(Check Appropriate Box)
Purpose of Building 17e,,j /I
No. of Lighting Fixtures
Utility Authorization No. O D & S ��
Existing Service Amps
Voits
Overhead ❑
Undgrnd ❑ No. of Meters
Nei/ Service Gy Amps % v
Voits p2 Yv
Overhead ❑
Undgmd �NO. of Meters
Number of Feeders and Ampacity
Battery Units
Loc?.11'1 tion and Nature of Proposed Electrical Work
No of Gas Burners
:,-2
FIRE ALARMS No. of Zone
No. of Detection and
. Initiating Devices
No. of sounding Devices
No./ of Self Contained
Detection/Sounding Devices
/Total
No. of Ranges
No of Air Cond Tons
No. of Di osal
Heat Total Total
No. Pumps . Tons KW
e G---
-�
No. of Lighting OutletsTotal
No. of Hot fuse
No. of Transformers KVA
Above ❑ In ❑
No. of Lighting Fixtures
Swimming Pool
grnd ❑ grnd ❑
Generators KVA
No. of Receptacles Outlets
No. of Oil Burners
No. of Emergency Lighting
Battery Units
No. of Switch Outlets
No of Gas Burners
:,-2
FIRE ALARMS No. of Zone
No. of Detection and
. Initiating Devices
No. of sounding Devices
No./ of Self Contained
Detection/Sounding Devices
/Total
No. of Ranges
No of Air Cond Tons
No. of Di osal
Heat Total Total
No. Pumps . Tons KW
Na of Dishwashers
S ace/Area Heating KW
No. of Dryers
Heating Devices
KW
❑ Municipal ❑ Other
Local Connection
'i,
No. of Water Heaters KW
No. of
Si
No. of
Low Voltage
ns
Bailases
Winn
No. Hydro Massage Tuds
No. of Motors
Total HP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO =
have submitted valid proof of same to the Office YES = NO = If you have checked YES please indicate the type of coverage y checking the appropriate box.
INSURANCE = BOND = OTHER = (Please Specify)
Estimated Value of Electrical Work(Expirlation Date)
Work to Start Inspection Date R�e fqueste Oj
Signed under the Penalties of perjuryr��� %S/�G L �`
FIRM NAME ` ,�C�
64 el
LIC. NO. 1O' 337.9
�y...... C� LIC. NO.
�� b6 yP�C A4 Bus. Tel No.
Address '?o c/✓li � �Alt Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
Telephone No.—PERMIT FEE &26�0
(Signature of Owner or Agent)
Location ��o 3 �SD 1 V
No. S� Date `� _ - J
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ Z6
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ ria
Check #
y<
13 7 / Build'i'ng Inspector
MAY -12-00 F R I 10:00
v
NIF HAROLD PARKER STATE FOREST
411
TWO T' Rf—�JIREO BUILDING
m SETBACK Typ.)7
1�h
M
3s,z LOT 3 r���•a�
6XI311NO FOUND 43,761 S,F.
TOP FOUNDATION 1.00 Ac.
727,j my -132.31
, 115.9' <
sz,s'
Lma4.43'
&-80.37'25"
40.1
I
l7
312.42'
-�- N388 27°W 422.53'
t, YC>NS WAY
Lo40.40' DRA►NAGS
�A®77.09'37" EASEMENT
'.T-23.93'
S38271 334.78' A-30-00'
1 2.:51 96'
THIS PLAN IS INTENDED FOR ZONING
PURPOSES ONLY. IT WAS PREPARED
FROM EXISTING PLANS AND RECORDS
WITH THE STRUCTURES SHOWN LOCATED
BY AN INSTRUMENT SURVEY. THIS PLAN
SHOULD NOT BE USED FOR PROPERTY
LINE DETERMINATION,
CERTIFIED F
LOT 3 LYONS WAY
N013TH ANDOVER, MA
PREPARED FOR
MESITI DEVELOPMENT GROUP
231 SUTTON STREET, SUITE 2F
NORTH ANDOVER, MASSACHUSETTS 01845
WE HEREBY CERTIFY THAT WE HAVE EXAMINED
THE PREMISES AND THE STRUCTURE IS LOCATED
AS SHOWN. THE STRUCTURE SHOWN CONFORMS
TO THE ZONING LAWS OF THE MUNICIPALITY
WHEN CONSTRUCTED. ALSO, ACCORDING TO THE
F.E.M.A./H.U,D, FLOOD INSURANCE RATE MAP,
COMMUNITY PANEL NO. 250098 009C
DATED 6/2/93 , THE STRUCTURE IS NOT LOCATED
IN AN ESTABLISHED 100 YR.FLOOD HAZARD ZONE.
P _ 02
/n
OUNDATION PLAN
MARCHIONDA & ASSOC.,L.P.
ENGINEERING AND PLANNING CONSULTANTS
62 MONTVALE AVE. SUITE I
STONEHAM, MA, 02180
(781) 438--6121
SCALE:1 "�60' DATE: 5/12/00
Date. ..`.f.. 3" v......
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that . dt .....`....1.' ... ............ .
has permission for gas installation . �� . G. �� ...... I........
in the buildings of ..m!4.......... �.... /t
at .... ? �?...�. h" S.. !'4. Y ... , North %/ndover, Mass.
Fee.. S.. Lic. No..��..59.� . .�.�°�?
'jp GAS INSPECTOR
Check # � 69 8
3;82
P MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT' TO DO GAS FITTING
_.7 or print)
NORTH ANDOVER, MASSACHUSETTS
Date o4 - 02• wLoo2
Building Locations 8 o L)� o n 5 laid y L�U . f4 n d o V er ,, m a. Permit #
Owner'$ Name x
New ® Renovation ❑ Replacement (❑ Plans Submitted
Amount $S
4j
(Print or t;61 k one: Certificate Installing Company
Name �I/hlfa goof- Plu h.b enq H eof Irtiq (oOQC
Corp.
Address Q O X 7 2 8 ❑ Partner.
Z
Name of Licensed Plumber or Gas Fitter 2 o b e rf 13 ► a n &h e Art, --
❑ Firm/Co
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 0 No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy a 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 above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit lsstled for this application will be in
compliance with all pertinent provisions of the Massachusetts Sta Gas Code and Chapter 14 f th eneral Laws.
c3. g
City/Town
'APPROVED (OFFICE USE ONLY) I
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber e 5 q 7
❑ Gas Fitter License Number
Master
❑ Journeyman
•
4j
(Print or t;61 k one: Certificate Installing Company
Name �I/hlfa goof- Plu h.b enq H eof Irtiq (oOQC
Corp.
Address Q O X 7 2 8 ❑ Partner.
Z
Name of Licensed Plumber or Gas Fitter 2 o b e rf 13 ► a n &h e Art, --
❑ Firm/Co
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 0 No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy a 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 above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit lsstled for this application will be in
compliance with all pertinent provisions of the Massachusetts Sta Gas Code and Chapter 14 f th eneral Laws.
c3. g
City/Town
'APPROVED (OFFICE USE ONLY) I
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber e 5 q 7
❑ Gas Fitter License Number
Master
❑ Journeyman