HomeMy WebLinkAboutMiscellaneous - 81 MAYFLOWER DRIVE 4/30/201800
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CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER r
Permit # 148 ,8/24/071 Date: June 25, 2008
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 81 Mayflower Drive
MAY BE OCCUPIED AS Single Family Dwelline IN
ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING
CODE AND SUCH OTHER REGULATIONS AS MAY APPLY.
Certificate Issued to:
Key Lime Inc
10 Hepatica Drive
North Andover MA 01845
Build ng Inspector
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APPLICATION FOR CERTIFICATE OF OCCUPANCYIINSPECTION
Building Permit # /019
ADDRESS/LOCATION OF PROPERTY: YY1 A�� I' �ow ere,
Map 187.-,d Parcel /(o jo 7 j Lot Number A '-
SUBDIVISION
DATE REQUESTED FILED/READY FOR INSPECTION
CLOSING DATE ON PROPERTY:
FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED
ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE-
INSPECTION FEE OF TWENTY DOLLARS $20.00) WILL BE CHARGED IF THE STRUCTURE
UUtS NU 1 Mtt I ALL AVVL1UAt3Lt UUUtU.
Permit Issued to: _/- �i`� �?. �%'1 G
Address b 690, 110 l�i¢p 4#1404 417A B/XOC
J V ROUTING
�I CONSERVATION 5
PLANNING
DPW - WATER METER P-71 N/� �� v
SEWER/WATER CONNECTION
NOTE
DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO
SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST
Signature
File: Application for OC form revised Jan 2007
June 23, 2008
603 Salem Street Nantucket, MA 02554
Wakefield, MA 01880 Tel: (508) 228-7909
Tel: (781) 246-2800 NOA-0064
Fax: (781) 246-7596 Refer to File #
Town Planner
Town of North Andover
Office of the Planning Department
Community Development and Services Division
400 Osgood Street
North Andover, MA 01845
RE: Occupancy of Unit #15 Old Salem Village, Rte #114, North Andover
Dear Planner:
Unit #15 and the foundation, walks and drives shown on "'Old Salem Village of North Andover
Condominium' Condominium Site Plan in No. Andover, Mass.", dated May 7, 2008 by Hayes
Engineering, Inc., have been completed substantially in accordance with the Old Salem Village Site
Plan titled "Site Plan in No. Andover, Mass", dated October 4, 2004, revised through March 1, 2006,
as amended by the plan titled "Plan of Land in No. Andover, Mass, Showing Proposed Foundation
Unit 15 & Unit 18", dated July 26, 2007, revised through August 20, 2007.
Very truly yours,
Peter J. Ogren, P.E., P.L.S.
President
PJO/mas
cc: Key -Lime, Inc.
ARCHITECTURE I DESIGN I PLANNING
0 ' S U L L I V A N
A R C H ITECTS I N C
June 12, 2008
Mr. Lincoln J. Daley
Town Planner
Town of North Andover
1600 Osgood Street
North Andover, MA 01845
Re: Old Salem Village, Unit # 15
Dear Lincoln,
We are the architects for the Old Salem Village project off route 114. Per paragraph 6A
of the Site Plan Review we have reviewed the buildings, site layout, signs and lighting
concerning unit # 15 and feel they are in substantial compliance with the approved plans
referenced in the decision.
Please call if you have any, questions or need any additional information.
Si ely,
s�'"S��,ftEQ Af
e �Q - S4
David H. O'Sullivan, AIA
President, O'Sullivan Architects, Inc �o No. 6010
READING,
MA
OF 01
KA0sgood\RTE1 WCorrespondenceUun 11-08 lanning memo#15.doc
20 1 EDGEWATER" DRIVE, SUITE 2 1 5 WAKEFIELD MA O 1 880
e78 1 .246.1 667 1078 1 .246.1 683 ® WWW.OSULLIVANARCHITECTS.COM
W4
603 Salem Street
Wakefield, MA 01880
Tel: (781) 246-2800
Hayes Engineering, Inc. Fax: (781) 246-7596
June 23, 2008
Town Planner
Town of North Andover
Office of the Planning Department
Community Development and Services Division
400 Osgood Street
North Andover, MA 01845
Nantucket, MA 02554
Tel: (508) 228-7909
Refer to File #
RE: Occupancy of Unit #15 Old Salem Village, Rte #114, North Andover
Dear Planner:
NOA-0064
Unit #15 and the foundation, walks and drives shown on "'Old Salem Village of North Andover
Condominium' Condominium Site Plan in No. Andover, Mass.", dated May 7, 2008 by Hayes
Engineering, Inc., have been completed substantially in accordance with the Old Salem Village Site
Plan titled "Site Plan in No. Andover, Mass", dated October 4, 2004, revised through March 1, 2006,
as amended by the plan titled "Plan of Land in No. Andover, Mass, Showing Proposed Foundation
Unit 15 & Unit 18", dated July 26, 2007, revised through August 20, 2007.
Very truly yours,
Peter J. Ogren, P. E., P.L.S.
President
PJO/mas
cc: Key -Lime, Inc.
Date .... & ... . ......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............................... ......................................
has permission to perform ............. J .....................................................
wiring in the building of...
at
P. ..... ......
........................................ . N&rth Andover, Mass.
Fee .&�"- ... L i cL'N oe zT). 3 ............
'��
LRICA INSPECli�
Check #
7785
Commonwealth of Massachusetts Official Use Only
�—
t Department of Fire Services Permit No. oV
Occupancy and Fee Checked Aejfi
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (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 INFORMATION) Date: // - y - - T
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) ZY a,,.. C_,�
Owner or Tenant /, ,,, x�� C_ - Tel&d.- e No.,,"
Owner's Addressi6, ZZ A 4 c �/�
Is this permit in conjunction with a building permit? Yes K4 ---No ❑ (Check Appropriate Box)
Purpose of Building d = /_ Utility Authorization No.
Existing Service Amps / is Overhead ❑ Undgrd ❑ No. of Meters
New Service � Amps /Zo' / a yc, Volts Overhead ❑ Undgrd E]-- No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
o. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above EJ In-
rnd. rnd. ❑
o. o Emergency Lighting
Units
No. of Receptacle Outlets
No. of Oil Burners
-Battery
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Tonal
No. of Alerting Devices
No. of Waste Disposers /
Heat Pump
Totals:
Number
Tons
o. oSelf-Con.,tained
Detection/Alerting Devices
No. of Dishwashers /
Space/Area Heating KWLocal
❑ un'cipal ElOther
Connection
No. of Dryers
Heating Appliances KW
Security Systems:
No. of Devices or Equivalent
No. o Water Kms,
Heaters
No. o No. o
,
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: //— % G 7 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 i brce, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, drat the information on this application is true and complete.
FIRM NAME: �' �, �/ "'� f"' LIC. NO.:
Licensee: /h . / s ,;,r sem, y LJ Signature LIC. NO.:
(If applicable, enter exempt" in the license number line.) Busf' el. No. !S___7 —
Address: _ r S� ' ti�`, Alt. Tel. No.
*Per M.G. c. 147, s. 57-61, security work requires Department of ublic 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 one) ❑ owner ❑ owner's agent.
Owner/Agent FPERMIT FEE. $ o� .
SignatureturaTelephone No.
S /L CJ
m1T =9-d la,
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 LeEibly
Name (Business/Organization/Individual):
Address:
City/State/Zip:
Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
workers' comp. insurance.
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
l0.❑ Electrical repairs or additions
1 l.❑ 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.
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:
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 DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
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 #:
November 3, 2007
Mr. Benjamin Osgood
Key Lime Inc.
1538 Turnpike Street
North Andover, MA. 01845
LAWRENCE H. OGDEN, P.E.
198 EAST MAIN STREET
GEORGETOWN, MA 01833
978-352-8318 fax 978 —352-2858
pager 978-502-5921
fax to 978-685-1099
RE: Unit "G" Alt. of 15 Old_Sale illage, North Andover
Dear Mr. Osgood
As you requested I visited the above project to review the Engineered Lumber
used in the framing as shown on plans prepared by G.J. Bruno Associates 5-8-02. and
certified by me January 2007.
The Engineered lumber is installed as shown on the drawings and field
modification sketches as prepared by me. I therefore certify that the use and installation
is acceptable and will support the loads as required by the Massachusetts State Building
Code 6t' Edition.
Should you have any questions please call.
Yours truly
V,1 ce J
awrenH. Ogden P. E,
GF
oma. sc\�
LfD
BICE
D
1765 O
o � NAL FW j
il/3 f 07
Date. ,/f �i .7.......
to ,e.'ryO
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TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .. %l! s � V. '�Ar .....................
has permission for gas installation l..........
in the buildings of ... r/'). r. s�. s X ..........................
at ...... , North Andover, Mass.
Fee. )4..... Lic. No.. ?r, :� ... �:- �. ..._.�_........ .
I GAS INSPE&OR
Check # /cii � -
6231
A
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
JY 1 jti/>Q1/e,,n,' , Mass. Date //- / y - 20 D -7 Permit # 1'o'I J
Building Location $/ /y1/�y�/o„�,,�,,,y2, Owner's Name 13e,,l
Telephone 937 3// 3 Type of Occupancy 12eS,�,
New � Renovation Replacement Plans Submitted: Yes El No❑
Installing Company Name EnergyUSA Propane, Inc. Check one: Certificate
Address 100 Myles Standish Blvd., Suite 101 X❑ Corporation 132 C
Taunton, MA 02780 Partnership
Business Telephone (800) 822-1300 X8055 Rick Rousseau C (603) 231-2702 Firm/Co.
Name of Licensed Plumber or Gasfitter William Kent Corson (800) 822-1300 X8051 Cell (508) 294-6660
INSURANCE COVERAGE: EnergyUSA Propane, Inc.
has a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch. 142.
Yes XD No ❑
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy X❑ Other type of indemnity 1:1 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
Signature of Owner or Owner's Agent
1 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 pertinent provisions of the Massachusetts State Code
and Chapter 142 of the General Laws.
By
Title
City/Town
APPROVED (OFFICE USE ONLY)
Type of License:
Plumber ,x/4111--
X❑Gasfitter Signature of Licensed Plumber or Gasfitter
X❑Master
Journeyman License Number 3707
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Date ..... .- `..4.-.��.
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........................... wz........ c/ .
..............................
has permission to perform............................................. ... 'r /�/�
..................................
wiring in the building of ............... t... 41.. G ......................
at .......,....%....' ............... . North Andover, Mass.
Fee.:$:,.`" "-'. Lic. No...ft�30......................C%R
ELECTRICAL INSPECTOR
r 'Check #
f
76'j 1
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
/
Permit No.
Occupancy and Fee Checked
[Rev. 9/051 (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 INFORMATION) Date: y _ -7
City or Town of: IV- A 1 G,,z To the Inspector of Wires:
By this application the undersigned gives notice of his orher intention to perform the electrical work described below.
Location (Street & Number) Ji/ /-j 4-1, �/� ,
Owner or Tenant
Owner's Address
U
w
TeIe6tione No.eIJ4 — /7( i
Is this permit in conjunction with a building permit? Yes U No E:J-� (Check Appropriate Box)
Purpose of Building /7----/l -e /,- r-- Z- Utility Authorization No. 3 z y Flo ' Z—
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service G d Amps 12ol/ Z YyVolts Overhead ❑ Undgrd �— No. of Meters T
Number of Feeders and Ampacity V — A _
Location and Nature of Proposed Electrical Work:
Comnletion nf/he (nllnwina inhio mm> ho ,anh, l ,, tb— „hilt
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
o. o Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No, of Luminaires
Swimming Pool Above ❑ n- ❑
o. o Emergency Lighting
rnd. rnd.
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
o. of Detection an
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
eat Pump
Number
TonsKW
No. of Self -Contained
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KWLocal
❑ Municipal El Other
Connection
No. of Dryers
Heating Appliances Kms,
Security Systems:
No. of Devices or Equivalent
No. of Water
Heaters KW
o. of No. o
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HIP
Telecommunications firing:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired. or as required by the Inspector of Vires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: —S'—rj 7 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 cE��
_force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ OTHER ❑ (Specify:)
1 certify, under Me pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: S.�ZZ LIC. NO.:���
Licensee: — W Signature LICA. NO.: /�9y33
(/I'applicable, en r "exempt" in the license number line.) RIIsrf & No.• 6d:
Address:�'` m Alt. Tel. No.:
*Security System Contractor License required for this work; if applicabl , enter t e license number here:
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 one) ❑ owner ❑ owner's agent.
Owner/Agent PERMIT FEE: $
Signature Telephone No.
Date. .7 .......
o? �` TOWN OF NORTH ANDOVER
• PERMIT FOR GAS INSTALLATION
. 9
SACMUSE4t ,
This certifies that.. f .� s�..�................
has permission for gas installation .......
in the buildings of .. t . . - Il!.t--- ........................
at .. kl ...I??.I,: -. 4r ... . , North Andover, Mass.
Fee,(/. �-7 Lic. No A?. Y. t..
/GAS INSPECTOR
Check # 7 U
6179
Z do" iS—
MASSACHUSETTS UNIFORM APPUCATiON FOR PERMIT TO DO GASFITTiNG
--� (Print or Type)
�l Mass. Date j0 -1t Permit # % �
i=
0
Building Location is .Lf— Owner's Name %�K •i ✓ �L C
i'
Type of Occupancy �� i` .�7
--
New Renovation ❑ Replacement ❑ Plans SubmtUed: Yes❑ No ❑
Installing Company Name Vit,, n 6 vii j
Check one: Certificate
O Corporation
❑ . Partnership
Business Telephone 1�) 11 - 6 1 L( —k 1 '--fi ---" fl Firm/Co.
Name of Licensed Piumber or. Gas Fitter f vCr &a L i dA 6 �^v
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 inability insurance policy [P---- Other type of indemnity ❑ Bond D
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:
OwnerD Agent 0
Signature of owner or owner's Agent
I hereby certify that all of the details and information I have submitted for entered) in above application are true and accurate to the best of my
knowiedge and that all plumbing work and installations performed under the permit issued f r this , pli e in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General w.
$y T �fmi�cense:
Title !'lumber Signator o censed Plu Gas Fitter
Cya�sfitter t �
ster license Number
City! raven.--umeyman
Af'PF�NED i i U NL
SOMEONE
�HENERNMENEENEEN
Elmo
MEN
0
MEN�
IMMEMEREEMENS
onnammussins
Installing Company Name Vit,, n 6 vii j
Check one: Certificate
O Corporation
❑ . Partnership
Business Telephone 1�) 11 - 6 1 L( —k 1 '--fi ---" fl Firm/Co.
Name of Licensed Piumber or. Gas Fitter f vCr &a L i dA 6 �^v
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 inability insurance policy [P---- Other type of indemnity ❑ Bond D
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:
OwnerD Agent 0
Signature of owner or owner's Agent
I hereby certify that all of the details and information I have submitted for entered) in above application are true and accurate to the best of my
knowiedge and that all plumbing work and installations performed under the permit issued f r this , pli e in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General w.
$y T �fmi�cense:
Title !'lumber Signator o censed Plu Gas Fitter
Cya�sfitter t �
ster license Number
City! raven.--umeyman
Af'PF�NED i i U NL
Date AV- 1�le - 7
MORTM
+ TOWN OF NO1THZDOVER
PERMIT FOR PLUMBING
This certifies that . *,. r. ..................
has permission to perform k ............
plumbing in the buildings of .................
at. . ... /11,1 eV. . u -T ...... North Andover, Mass.
Fee ... Lic. No./
PLUMBING INSPECTOR
Check
Check# 7,0
7528
r,
v
I-0,1— >.5-
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
),pe or print) WAT6 P41436141-
MASSACHUSETTS
4143614 -
MASSACHUSETTS
tsunding Locations
r
Date >� ' 11 -6
Permit , EL
Amount
- - - Owner's Name Le i Uo" L. L C -
New O Renovation 13 Replacement
FTXTTTR VQ
Plans Submitted
(Print or type) Check one: Certificate
Installing Company Name G a l i n s k v P l u m b i n g & H g a t,�n e� XM Corp. 1 9 0 6
Address P . O .Box 1701 ❑ Partner.
Jlavarhi 11 MA (11 R41 �-
Busmess Telephone 978-374-1743 Firm/Co.
Name of Licensed Plumber: Stephen C. G a l i n s k y
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 licensee of this application does not have any one of the above
three insurance
Signature Owner ❑ Agent rl
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 pe rm u P it Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State ing o - d Chapter 142 of the General Laws.
By:
signature o LICMW Plumner
Type of Plumbing License
Title
City/Town �cen um er Master�x Journeyman11
APPROVED (OFFICE USE ONLY
OWN
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(Print or type) Check one: Certificate
Installing Company Name G a l i n s k v P l u m b i n g & H g a t,�n e� XM Corp. 1 9 0 6
Address P . O .Box 1701 ❑ Partner.
Jlavarhi 11 MA (11 R41 �-
Busmess Telephone 978-374-1743 Firm/Co.
Name of Licensed Plumber: Stephen C. G a l i n s k y
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 licensee of this application does not have any one of the above
three insurance
Signature Owner ❑ Agent rl
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 pe rm u P it Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State ing o - d Chapter 142 of the General Laws.
By:
signature o LICMW Plumner
Type of Plumbing License
Title
City/Town �cen um er Master�x Journeyman11
APPROVED (OFFICE USE ONLY