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Miscellaneous - 83 MILLPOND 4/30/2018
Date ....... �Xy ............... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION I This certifies that ........ R ...... 4 ..... 47.i�. A .......................................................... hag, permission for gas installation ......... ............... i ........ . ......................................... inthe buildings of .................................................................................................................... at ..... i ........................................... North./Ando-ver, Mass. Fee., Lic. No. ....... ....... Check # S INSPECTOR 10411 =� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK L. vl MA ATE PERMIT # �..;,;=; CITY / 1)V JOBSITE ADDRESS �r 3 M ,1 / v 7 OWNER'S NAME IeA v OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENTA PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCES Z FLOORS- BSh1 i 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM ISPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER I OTHER 1 INSURANCE COVERAGE I I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO [I I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW - LIABILITY INSURANCE POLICY% OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that thelicenseedoes not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit Issued for this application will be in compliancqoM h 911 Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -- PLUMBER-GASFITTER NAMEI'd //,// -L4, a t'l..5 LICENSE # / /a Ll SIGNATURE MP 5r MGF E] JP E]tt JGF [ILPGI F-1 CORPORATION ❑ # PARTNERSHIP [:]# LLC E1# COMPANY NAME z—i�t� L"�� ,S J`-= - Kl&? ✓A ''ADDRESS CITY ll� �'►�yc' STATE ,�d/ ZIP /T` / "7 TEL (� % ' �"�� ~ 'Y� FAX CELL EMAIL G I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): A� AatA,-S Address: '5-`'i iAlewd rQ� City /State/Zip: S¢ Phone #: �/ 7 1 Are you an employer? Check the appropriate box: 1�I am a employer with S 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors listed on the attached sheet. } 2. ❑ I am a sole proprietor or partner- These sub -contractors have ship and have no employees working for me in any capacity. workers' comp. insurance. 5• ❑ We are a corporation and its [No workers' comp. insurance officers have exercised their required.] 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and 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. #: Job Site Expiration Date: City/State/Zip: / L/. 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 aboye is true and correct. Official use only. Do not write in this area, to be completed by city or town offtciaL City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone #: EDWARD J MATHEWS Ili (PL) 24 WEST WOODCREST DR MELROSE MA 02176-3414 IMPORTANT NOTICE PERMITS FOR PLUMBING AND GAS FITTING INSTALLATIONS ON STATE OWNED OR USED FACILITIES MUST BE FILED AT THE OFFICE OF THE STATE BOARD. f( DATEIMINOWYYYY1 CERTIFICATE OF LIABILITY INSURANCE 1'111112015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND On ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERISj. AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: IF the certificate holder is an ADDITIONAL INSURED, the Poll 1611) must be endorsed. 11 SUBROGATION Ig WAIVED, Subject to the terms and conditions of the Policy, certain Policies may require an endors nt. A statement an this certificate Goes not confer rights to the certificate holier In itou of such endorsement a I .._.. A T coetsLlravchRx.tUIID PRODUCEk!!�-^-" ___..__....._:z __._____.___-____ ___....FAX Paychex Insurance Agency, Inc. PHONE ,.1 ,t, a; ac7cs atC Na: 150 Sawgrass Drive ,AODRE99• -'- Rochester, NY 14620 It4sURJSi�SjAfFORDINccovvERacE_-----______ 877-266-6850 AmauARD nxarznc=_ 0 -:Puny azra, _ INSVIIA , .._._._....._.___...._�_—__ —___—__—___—__ NaI;JARG I,_�lan;; Carnp�x.y INSURED INSURER H ...._._.._I_....._ _._. MATHEWS BROTHERS PLUMBING HVAC LLC ER. ---------------------J— — 39 ASHMONT ST IN- ER MELROSE, MA 02176 INSUHEREI �.--.__-- ---- -- Ct 6tTIFICATF_ TtUi1R88R' IiEVl+s1t]w pttAbiBtZ ____-- - m,cn Tn TNS inL411fif0 NAMED ABOVE FOR THE POLICY PERIOD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANGE USIEu o-Lvvr na•= INDICATED. NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHS H TERM , HEREIN IS SUBJECT TO ALL THE S CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED _.____...._,......___.....__- CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ _-- - EXCLUSIONS AND -- INSRi"`__......_..._.__ _ . ._.__.r'_`--- ----------,.-..._..._ + POLICY EFF S POLiCitP T' LIfdRS i S -Wil , M --" TR ' TYPE OF INSURANCE , . POLICY NUM { cAC#iQCCM�4 GENERAL LIABILITY + AI a COS!h1ERC�!t. GENERAL LV.eILnY I i _____._��_ PR€*TIS0.ri A�.. SOCCUR--`----_-i.........._ Ik-- MABP620049-3 109115,2 t115 ' 09!15' 2016 S ; .PERSONAL &ADV INJURYS IUCIU •E,`;__ ' 1 S GENERAL AGGREGATE , ;PROD CCMPA�PAGG & ? ':c,00r vENL,WGREGATE UMIT APPLIES PER: i S H^ i POLICY.' ' : t.00' - i AUTOMOBILE UAUILITY a ecyaOTt} _ 1 I._ANYAUtO , ._..� ...._.. _ YINJURY (Per $ 6'PR+F'fY I . ,_._ __I AUTOSM"'D AUTOS ( _ __ __ __.____ ; ; DAMfiOE $ HON.OINMEG..._--- HInEDAUTC6 I�--.--� AUTOS I : ' UMBRELLA LtAO IOCCURI r EACH OCC�3RRJCE __..._ _..a ._,_. {_. §...___�--______._..__ EXCESS UAB CiAiR!SNAgE S _.._.. AGGREGATE __...... _. __..._ t OEU I I RETEHi!ON$ ! S - ; I VtCSTAIU- j OAjH- 'LY IY/OF21(ERS COMPENSATION . B I AN D EMPLOYERSLIABILITY YIN I _LIRf1Y_UMITS_i_.._ , ' 1 i E.L EACH ACCIDENT ' 1 ANY PROFRIETORMARTNERfE(ECUTIVE I ' ff6tCEriRfiEMBER EXCLUDED'/ {NIA PviAWC693231' 0 710 1 120 1 5 ; 071(11 /2076 j ----.---�- ,E.L DtSEASE-tA EM_PLOYEC7I- " 10" 20" ____-- (0.landaWrylnNH} S II 5, eOxtibo under S ,roro L`ESCRLcTION Cf OPERATIONS 4eYse .. ; . S . I E.L. DISEASE- POLICY L!Mir ' S -C') 000 I I 1 DESCRIPTION OF OPERATIONS I LOCA4nONS )VEHICLES (ARech ACORD 101, Addl4dnei RemerRe Schedule, It more space IS requ6ee} CERTIF c T E H0t_oFmp ,4r„8..R, �r.,,.,,.. ---_.__. ..................._....------- SHOo!.D ANY OF THE Ah NE OESr:R16F. , Pi Apartment Developers LLC FXPIRAI'O' DATE. TSERFi*, ti_%T!C E ri'iLL rF. O=LIVE RED INACCORDANCE P:jrH?HE Portside POL '1'P. Vi:310NS,i::1TFAIL!JR TOrytn!L.6Ui,-HN--IIICF3HALLLiAP:�:ENG 50 Lewis Street O L GATI N OR LIA611 IT l' OF ANY K!ND VPGN THE QL:PANY, ITS Afi N sn OR r] East Boston, MA 02128 RFPRP'G TAT IVES. rv7t+oRcrtnnaesEt�7a!vF: — y -"�� t98$�2QIO ACORD GOR PORA t0?1, R11)10 ht- n4S60 ;7 registered mSrkS of ACORD ACORD 25 {2010105} The.ACOt2L3 i1Ame And.togo.are Date.... 11203 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING :t464CHUiit- This certifies that ............... ............................ I ...... .......... ............................ has permission to perform .... . .4 ................... plumbing in the buildin Of.. ............................. at ............... ............................... North. A.-nd-o-ver., Mass Fee.+[7? ... Lic. No. '3P ............. Check # I U.1- .PLUMBING INSPECTOR WATER HEATER ALL TYPES WATER OTHER .._._.__( I I INSURANCE COVERAGE: ,,�., 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YF_,8'j/�J, NO -I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ��� LIABILITY INSURANCE POLICY' OTHER TYPE OF INDEMNITYE11 BOND ©_I. OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the (Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and ac cur 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 h rtinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1 PLUMBER'SNAME?.LICENSE# �4 v SIGNATURE IVDP Elf JP CORPORATION n#PARTNERSHIP-i # _ ; LLC COMPANY NAME P F i ADDRESS CITY-�1iGf�-r�1--- - --...._.._..__� STATE Ot _ ZIP ��� -- -- TEL FAX�jjCELL EMAIL ,� 4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK POWNER TYPE OR PRINT CLEARLY CITY . MA DATE PERMIT# 11YP6� JOBSITE ADDRESS :OWNER'S NAME — e Vy ADDRESS I TEL —FAX' -OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL Q RESIDENTIAL NEW: M- II RENOVATION: ® REPLACEMENT: j�J PLANS SUBMITTED: YES N � FIXTURES 'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I - _ i I I I _._ I . _ I _ __. f -i —I CROSS CONNECTION DEVICE _I _ TI I _. _I _ _) . .._.__-_I -__._I w___ .I f M. I =1 DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM _ [=j DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _-_.f .-___-{ ______ i ._______(' ._...__._I _ _[ ._..__.._ ___..__ I .-.-I ..___.....j ...__...I --Ji _1 __...I FOOD DISPOSER r _I .- 777--1 ....... ____._.I FLOOR/AREADRAIN INTERCEPTOR (INTERIOR) I J -------) _.___._1 --_—I (---.-__ _____-J KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET I ----- _I --_I _._-.j J URINAL WASHING MACHINE CONNECTION _, I I 1, 1 1_ r1l__.._._filIII WATER HEATER ALL TYPES WATER OTHER .._._.__( I I INSURANCE COVERAGE: ,,�., 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YF_,8'j/�J, NO -I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ��� LIABILITY INSURANCE POLICY' OTHER TYPE OF INDEMNITYE11 BOND ©_I. OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the (Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and ac cur 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 h rtinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1 PLUMBER'SNAME?.LICENSE# �4 v SIGNATURE IVDP Elf JP CORPORATION n#PARTNERSHIP-i # _ ; LLC COMPANY NAME P F i ADDRESS CITY-�1iGf�-r�1--- - --...._.._..__� STATE Ot _ ZIP ��� -- -- TEL FAX�jjCELL EMAIL ,� 4 I El z V1 ❑ LU Ix ui w LL The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual):� I Address: �j ft Jk1 1* City/State/Zip: L-fV1(,bRA�Jl fiY►e, 06�/ Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. I am a employer with employees (full and/or part-time).* 'a %. ❑ New construction 2I amsole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers' comp. insurance required.] 9. ❑ Demolition 3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 10 Building addition ❑ 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11. ❑ Electrical repairs or additions proprietors with no employees. 12. ❑ Plumbing repairs or additions 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13. ❑Roof repairs These sub -contractors have employees and have workers' comp. insurance.$ 6. ❑ We are a corporation and its officers. have exercised their right of exemption per MGL c. 14.F] Other 152, § 1(4), and we have no. employees. [No workers' comp. insurance required.] *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 mustattached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providiiig workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. Expiration Date: Job Site Address: � 3 1 Y11 �z`dl'1 U 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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify uisjer toe pains and penalties ofperjury that the information provided above is true and correct. 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 Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub=contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the 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 burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia A C Oi d - <:� >MA 01876 Date ... 77�--? ............................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......... ...... ............................................................. ... ...... ..... .... ... ........ ..... rm .. t(�I ........ has permission to perfo ... winng in the building of ....... V ............................................................ N h Andover, Mass. at 0 ..... ... ...... Fee . ......... .......... Lic. No. ;UT16 .......... ELF-CTRICAL**IN*SPECTOR*"*******"'**'*'*."** Check # 2, 4467� SL -N Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank 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 ININK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice Mill his or her intention to perform the electrical work described below. Location (Street & Number) ''33 M f t Pcr,-d rI Owner or Tenant Owner's Address 'r, M,,11 Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Meters No. of Meters Completion of the following table maybe waived by the Inspector of Wires. No. of Recessed Luminaires `7 No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets l No. of Oil Burners 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. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number "' Tons '' ""'" " " KW """ "........... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of 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: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE R3 BOND ❑ OTHER ❑ (Specify:) Icertify, under the. ains and e alties ofperjury, that the information on this applica `on is true and complete. FIRM NAME:. _r C LIC. NO.: Licensee: % 1/ar.� %,{J��H "Signature_ LIC. NO.: -,-2 /'7,,%�j (If applicable, enter "exempt" in the license number line) � Bus. Tel. No.- 7n god--%fvS� Address: 1% .s 411 c1:'�-- �GYUl�+.�-e_.y a l! ' Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Deparhi"fent of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. ` Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8—Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass I?] Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signatur Date: ROUGH INSP ION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: -- S FINAL INSPE ION: Pass Failed 0 Z % Re- Inspection Required ($.) ❑ Inspectors Comments: 44 oe) Inspectors Signature: Date: % DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com w - The Commonwealth of Massachusetts Department of IndustrialAceidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 .,; '` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: City/State/Zip: 6 6 4e ptc,e 11� C is y75 Phone #:__2 Are you an employer? Check the appropriate box: 1. Q I am a employer with employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. Q I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑ 1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6.FJ We are a corporation and its office rs ,have exercised their right of exemption per MGL c. 152, §1(4), and we have no. employees. [No workers' comp. insurance required.] rrSa•��` 3 Type of project (required): 7. ❑ New construction 8. 0 Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.0 Electrical repairs or additions 12. Plumbing repairs or additions 13. Roof repairs 14. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submif 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 state whether or not, those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. 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. Lie. #: 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 MGL c. 152, §25A is a criminal violation punishable by 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. 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 -4h pains and penalties 9fperjury that the information provided abpve is true and correct. .iiunai�rre Tate 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 Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, anemployee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Date .7. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that.jh!�I,/W,4.. XaL/),�, has permission to perform ... 7 06 / .......... wiring in the building of .... 774 ....................... at ...... ........ North Ando ver, Mass. Fee.j. ... Lic. No.... L L E TRICAL I.NSP/CTO Check # 10971 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued. to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the V notification of completion of the work amequired It M.G.L. c. 143, § 3L. Permits shall -be limited a ' s to the time of -ongoing construction activity, and may be.deemed-by the Jnspector-of-W.ires abandoned.and-invalid-if he— or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 23 8 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending"through August 15, 2012. 8—Permit/Date Closed: /"Szf!�z le:�I� * * * Note: Reapply for new 0 Permit Extension Act — Permit/Date Closed: Commonwealth of Massachusetts O � ial Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leaveblank 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: 7 * ! V ` % dl, City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives n tice of hiPOA/0 r her intention to perform the electrical work described below. Location (Street & Number) e,3 -74 � Owner or Tenant Owner's Address Is this permit in conjuaction with a building permit? Purpose of Building off` L) H Du s r Existing Service c�00 Amps IR6 /o-796 Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Telephone No. Yes ❑ No 9' (Check Appropriate Box) Utility Authorization No. Overhead ❑ UndgrdX—J�l No. of Meters Overhead ❑ Undgrd ❑ No. of Meters C a AJ iu L C %t `f< G.7 0,U 4 0 )� fid+' Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In Elo. rnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners 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. Total Tons No. of Alerting Devices No. of Waste Dis posers p Heat Pump Totals: Number Tons 1.1ons ........ KW ................ No. of Self -Contained Detection/Al ting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW SecuritySystems:* Devics or Equivalent No. of Water KW Heaters No. of No. of 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 regtdred by the Inspector of Wires. Estimated Value of Electrical Work: J -SO .G (When required by municipal policy.) Work to Start:, ) ?' ) P---- Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE TX- BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME:. m P S Y—o y®vrl q cJ � C •4 LIC. NO.: Licensee: t E -S O fJ `/O tJri .q a?J Signator �c Pl,, LIC. NO.: (Ifapplicable, enter "exempt" in th licensjumber lin g Bus. Tel. No.: �2' 6Q 4 /`4• Address: 6.'ihv4tc Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. �'asse�•- j } • �+`atTed--j � � ).te,�ns�Iecttoxlxec�utxec� ($50.00}-• j � . �tls�iectors' coJninextts: �. ------------------ (fils�ectors' ftnature - )ao Wilals) )late Passers - j j �+atiet�- j) �te�fns� ecizo�xe[Tuire� ($ 0.00) � j � inspectors' comments. , (Inspectors',�ignaiure•-�.o?nittaTs) nate � . WSPPICUON--19B ACEI: WAM, CM, —Tb XIUITOXM� asseci-j }ailed --j Ispeetbrs' coxnmepfs: (xuspectors',�tgnature � �.o �e-�nspectionx ysed•-[aiSer-,j litenspecttottxeluizel ($56.OD) •- j PectOrs' coIC1meffs: . • S • ]late '" ��s�, ectoxs' i9xgnaiure � uo xnzttals} date I a Off. TAGS AM TO EE FMLYD OVTAM YEFT Off' RU -9 N TM .APXA TO 3E INSPECTED Xg NOT r T F The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): (::S !h �S (�� 0ro-V M Z' JN 60 Address: t�S— 66k) Zc- lC,b City/State/Zip: IV • �6--A vqt, e, PA • 01$6 `j Phone �60 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).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have w working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. [] 1 am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required. Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition I(�. . lectrical repairs or additions 11.❑ 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 anew 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. #: a Expiration Date: Job Site Address: City/State/Zip: Attachia 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. 1 do hereby c�ertj r the p nd pe alties of perjury that the information provided above is true and correct. N � ' Date- ) V /I `>6b- "114-1 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the 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. 't 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 i town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for,future, permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www,mass.gov/dia 2967 Date./ TOWN OF NORTH AND Y N a? &10 # PERMIT FOffi"V1wiMLAT N 0 .... . OCT 9 M .. SS. C I HU Awb6VtR, MASURER-COLLECTOR This certifies that../.".. 1-.,-jf.e ........................ has permission for gas installation . . ............. in the buildings of .......................... at ............. North Andover, Mass. Fee..2 Lic. No..4V.(..!J .. .......................... GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 1 ✓IASSACHUSETTS UNIFORM APPLICATON FOR PERMTN/ODO GAS FITTING or print) rwn In ANDOVER, MASSACHUSETTS Building Locations Owner's Name Newf:] Renovation Replacement Date y 19 Permit # a - c"7 6 Amount $ �J f Plans Submitted (Print or type)Check one: Certificate Installing Company Name �2 i?/ /S Corp. Address o2 Partner. Business e ephone 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 121No� If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policyOther type of indemnity Bond I hereby certify that all of the details and information I have submitted (or entered) in above application are true ana accurate to the best of my.knowledge and that all plumbing work and inst tions performed under Permit Issued for this plicationn will be in compliance with all pertinent provisions of the Massachu de and Chapter 142 of the G pp ��� By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber /d/lo Q Gas Fitter ►cense1 umber Master Joumeyman G C m ni- n U F v3 C n C w n x w r z z C z x C C P. C x Z W z4r. w -e w ❑ Cn C > v W W L w F n Z r �, C .r7 ti w ' C z -t W w > i; .r W Z `� > C n 't m �f C C C �i Lc i L U i G F C SUB-BASEM ENT BASEM ENT IST. FLOOR 2ND. FLOOR 3RD. FLOOR JTH. FLOG R 5T Ii. FLOG R 6T H. F L O O R 7T 11. FLOG R 8T H. F L O O R (Print or type)Check one: Certificate Installing Company Name �2 i?/ /S Corp. Address o2 Partner. Business e ephone 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 121No� If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policyOther type of indemnity Bond I hereby certify that all of the details and information I have submitted (or entered) in above application are true ana accurate to the best of my.knowledge and that all plumbing work and inst tions performed under Permit Issued for this plicationn will be in compliance with all pertinent provisions of the Massachu de and Chapter 142 of the G pp ��� By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber /d/lo Q Gas Fitter ►cense1 umber Master Joumeyman