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HomeMy WebLinkAboutMiscellaneous - 84 MOODY STREET 4/30/2018m 313 Date. ,% ••••.• TOWN OF NORTH ANDOVER PERMIT FOR MECHANICAL INSTALLATION This certifies that ... l a: r.' .......... . has permission for mechanical installation %; .�..✓�, : , f,�G. /f�!. in the buildings of /.7 ! y <? �'��... �..? .t:�! at . aEV..,f o.4 . 4.F ........... North Andover, Mass. Fee.! J..... Lic. ` .............. . GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 1 Commonwealth of Massachusetts Sheet Metal Permit Date: /0 Estimated Job Cost: tso V Plans Submitted: YES NO ✓ Business License # Business Information: I Name: � (� �I 40 q& n) Street: (Z!Z" TAA� City/Town: t C,J_ Telephone: '�36 o-)'10'7 Photo I.D. required / Copy of Photo I.D. attached: Building Type: / Residential: 1-2 family -/ Multi -family Commercial: Office Retail Industrial Permit # Permit Fee: $ Plans Reviewed: YES NO Applicant License # O e 7q Property Owner / Job Location Information: Name: V= 'T�,�) �` Street: �)C( 0�-Jloao City/Town: A) D ZI-C _ Telephone: Y1�_'o ac_� _'? Fr7�(,0 YES NO Condo / Townhouses Educational Institutional Building Cubic Footage: under 35,000 cu. ft. V over 35,000 cu. ft. Sheet metal work to be completed: New Work: ✓ Renovation: HVAC ✓ Metal Roofing Kitchen -Exhaust System Chimney / Vents Provide brief description of work to be done: INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes ❑ No)g If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ O ER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Mt.shusettsAe eral Laws, and that my signature on this permit application waives this requirement. Check One Only Owner Agent ❑ Sitnature of Owner or Owner's Agent By checking this box❑, 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 sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Date Date Progress Inspections Comments Final Inspection Inspector Signature of Permit Approval Comments Signature of Licensee License Number: Check at www.mass.gov/dpi Type of License: By ❑ Master Title ❑ Master -Restricted City/Town ❑Journeyperson Permit # ❑Journeyperson-Restricted Fee $ ❑ Inspector Signature of Permit Approval Comments Signature of Licensee License Number: Check at www.mass.gov/dpi ra Sheet Metal Commercial Guidelines / Life Safety / Critical Systems Inspection Checklist Yes No N/A, Set of stamped engineering documents and detailed description of mechanical system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper joumeyperson-to-apprentice ratios Fire dampers with access door properly installed and checked for operation Smoke and combination fire / smoke dampers with access doors properly installed - actuator checked for proper operation (May also be verified by fire department during fire alarm testing) Duct smoke detectors with access doors properly located (May also be verified by fire department during fire alarm testing) Smoke / atrium exhaust systems installed and operation verified (May also be verified by fire department during fire alarm testing) Stair pressurization systems installed (where required) and operation verified (May also be verified by fire department during fire alarm testing) Grease / kitchen hood exhaust system installed with all seams and connections welded airtight with properly located cleanouts. Proper clea;`ances, fire rated enclosures and pressure testing required: 4 Srilmints installr.Z Wh6m required 'oft equipment and Duct penetrations in fire'rdQ— wall:3 and fl0'6rs sealed Metal roofing systems installed watertight using proper materials and fasteners Flexible duct nuns installed 6'-0" maximum length Ductwork installed using proper hanger spacing, hanger stock, threaded rod and angle iron Ductwork / plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining Volume dampers installed for each supply air branch duct New/clean - properly sized filters installed (final inspection) Testing and Balancing report complete (final sign -off) Sheet Metal Residential Guidelines / Inspection Checklist Yes No N/A Detailed description and sketch of sheet metal system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper joumeyperson-to- apprentice ratios Equipment sized per heating / cooling load calculations Duct work sized per manual "D" calculations Bath / shower rooms contain mechanical exhaust fan vented outdoors Electric dryer exhaust properly installed maximum total run 35'-0", maximum flexible run 8'-0" Flexible duct runs installed 14'-0" maximum length Volume dampers installed for each supply air branch duct Ductwork installed using proper gauges and hangers Ductwork / plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining New/clean - properly sized filter installed (final inspection) Testing and Balancing report complete (final sign -off) it P_ Proiect Summary Job Name: Tramgas Tenbroek Address: 84 Moody St. North Andover Job description: Heat and Air Conditioning System for Addition Design Information Winter design conditions: Outside DB 12*F Inside DB 66*F Design TD 56*F Heating Summary Structure 45803 BTU/H Ducts 3766 BTU/H Central Vent (0 CFM) 0 BTU/H Humidification 0 BTU/H Piping 0 BTU/H Summer Design Conditions: Outside DB 87*F Inside DB 75*DB Design TD 12*F Daily Range L Relative Humidity 50% Moisture Difference 26 gr/Ib_ Sensible Cooling Equipment load Sizing Structure 18415 BTU/H Ducts 3199 BTU/H Central Vent (Ocfm) 0 BTU/H Blower 0 BTU/H Use Manufactures Data N/A Rate /Swing Multiplier 0.92 Equipment Sensible Load 19927 BTU/H Infiltration Latent Cooling Equipment Load Sizing Method Simplified Structure 607 BTU/H Construction Quality Tight Ducts 441 BTU/H Fireplaces No Central Vent (0 CFM) 0 BTU/H Heating cooling Equipment Latent Load 1048 BTU/H Area 810 810 Equipment Total Load 20976 BTU/H Volume 6480 6480 Reg. Total Capacity @ 0.85 SHR 2.0 ton Air change/hour 0.21 0.11 Equiv. AVF (CFM) 23 12 Heating Equipment Summary Cooling Equipment Summary Make: American Standard Make: American Standard Trade: Freedom 90 Trade: Allegiance 13 Model: AL1C1B06OA9361A Model: 4A7A3024A1000AA AHRI Ref Coil 4TXCB025BC3HCB Efficiency 92.1 AHRI Ref Heating input 60,000 Efficiency 13 SEER/ Heating output • 56,000 Latent cooling 3210Btuh Temperature rise 30-60 Sensible cooling 18190Btuh Actual Air flow 713 CFM Total cooling 21400 Air flow factor 0.28 Actual air flow 713 CFM Static pressure 0 in H2o Air flow factor 0.033 CFM/ BTU Static pressure 0 in H2o Load sensible heat ratio 0.95 ��-COMIVIt3NV;'EALTH OF lVlASSACFIi.1SE'tTS , ASA MASTER -UNRESTRICTED ISSUES THE. ABOVE LICENSE TO: Y MICHAEL D HORGAN 508 MIDDLESEX TURNPIKE m BILLERICA MA 01821-3514 8679 .09/28/14 274391 Fold, Then Detach Along All Pettorations TOWN OF NORTH ANDOVER 1600 OSGOOD STREET Building 20 Suite 2-36 NORTH ANDOVER MA 01845 FURNACES, BOILERS, ROOF TOP UNITS, AIR CONDITIONERS, EMERGENCY GENEREATORS Date: October 15, 2013 The undersigned applies for a permit to install the following at: Location 84 Moody Street, N. Andover, MA 01845 Owner of premises Trampas M. Tenbroek Name of mechanic Michael D. Horgan Building occupied for Single Family Material of buildi Kind of fuel Gas Chimney Thickn Address 84 Moody Street, N. Andover 508 Middlesex Turnpike, Billerica, MA 01821 Wood Frame Chimney n/a No. Of flues Size_ Lining If steel stack location Diameter Height DESCRIPTION OF HEATING APPARATUS Kind of heater gas hot air direct vent furnace how many make American Standard BTU Input 60,000 Location in buildino Garage Closet Protected against fire as required sheet rocked closet How protected sheet rock See the State Code (Pertaining to Chimneys, Smokestacks and Heating Apparatus) ROOF TOP UNITS OR EMERGENCY GENERATORS Make Weight Dimension Length Width Height Location of building how supported Size of roof timbers Material of roof timbers Span of roof timbers Distance on center Protected against fire as required How protected AIR CONDITIONS Kind of apparatus Central Air Conditioner makeAmerican Standard HVAC FORM REVISED 11.04 Datel.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING J� ,OY VNj This certifies that .......................................................... has permission to perform... . ........................................ wiring in the building of ......... J.� L.PI . .......................................................... ....... OiJ..j —.r4.. ..................................... . North Andover, Mass., e ... jl� .. ............ Lic. No. .......... ELECTRICAL INSPECTOR Checkit —1114J 4 r' Commonwealth of Massachusetts Department of Fire Services ,M BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 1 1/6 Occupancy and Fee Checked [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)„, 27 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: /�, {� //-3 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) fa 41 /yoocl/ 4") _ Owner or Tenant :7 $— ,r a Telephone No. Owner's Address 5i�ni Is this permit in conjunction with a building permit? Yes ,9 No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overheadsr t❑ Unnd��grd ❑ No. of Meters Number of Feeders and Ampacity �) SeGo� 7��Dr iFle'x.+ 'rel ,&m r3 -p- Location and Nature of Proposed Electrical Work: 401/1 C,, Pte. Completion ofthe followine table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans l No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Q Generators KVA No. of Luminaires Above In- Swimming Pool rnd. ❑ rnd. El o. o Emergency Lighting No. 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 Q No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers o Heat Pump Totals: I.NpMb.er I Tons " "" 1KW ' "'"""""".."' 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 WaterKW 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: pEstimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) 1 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 workifiay issue unless the licensee provides proof of liability insurance including "completed operation" coverage dr its substantiMi ' quivalent. The undersigned certifies that such cov rage is . force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSU INCE BOND ❑ OTHER ❑ (Specify:) Icertify, under the a. s andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME:. pr „ , C- LIC. NO.:g i lag —A Licensee: 4jrj c,-- SignatureC. NO.: (Ifapplicable,4nter "exempt" in license nu erline.) Bus. Tel. No.• --1� � 1#1 Address: ?- 4&bO44 * t!c Alt. Tel. No.• *Per M.G.L c. 147, s. 57-61, security work requiresrDepartment 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 j I Signature Telephone No. PER HT FEE. $I �7� ❑ 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 w 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 n Failed Re- Inspection Required ($.) ❑ Inspectors Comments: . i Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comm Inspectors Signature: Date: FINAL INSPE ON: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Com ts: [Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustriglAccidte is Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov1dia Workers' Compensation Insurance .Affidavit: Builders/Contractors/Electricians/Plumbers City/State/Zip: Phone #: 7-z; -;z-- 1 I & Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I `�emn loyees (full and/or part-time).* have hired the sub -contractors 2 a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 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.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. FJ Remodeling 8. ❑ Demolition 9. ❑ Building addition 1 . ?lectrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roofrepairs 13. ❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. P( Homeowners who submit this affidavit indicating they tie 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 anal job site information. Insurance Company N 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 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 Inlestigations of the DIA for insurance coverage verification. I rho hereby cert!fV under the pains and penalties ofperjury that the information providedab ve is true and correct. Signature• . /,, Date: r� �/ L Of 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 IV 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. Howevert e 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' r 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 (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth ofMmssachvsetts Department ofJndustrial Accidents Office of Investigations 600 Wasbtngion Street Boston, MA 02111 TeX, # 617-727-4900 ext 406 or 1-877:MASSAFE Revised 5-26-05 Fax # 617"727-7749 wwMass,gov/dia ,s Op 1 Fold, Then Detach Along All Perforations Fold, Then Detach Along All Perforations Date .... i ... b.. - - .................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ,T� W-0 4 � This certifies that ................................. . .............. ......................................... has permission for gas installation ...... . .................................... inthe building Of. T. ............................................................... at ..... ....... 0 ...... oo., ... .... 5.k .... ................. North Andover, Mass. Fee... Lic. M . ................................................... GASINSPECTOR Check# 2 F, bo to -7I- N M -Ijlojr� J/ ` gASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ` CITY MA DATE L PER # U V JOBSITE ADDRESS �YLd� .tOWNER'S NAME lj fLx2 GOWNER ADDRESS TEL FAX TYPE OR PMT OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL RESIDENTIAL CLEARLY , NEW- RENOVATION: D REPLACEMENT: ® PLANS SUBMITTED: YES D NOQ APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 — - BOOSTER — -- = CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE __1 L---D�_ FRYOLATOR FURNACE..�- GENERATOR GRILLE�— INFRARED HEATER_— TI LABORATORY COCKS MAKEUP AIR UNITryC._- --._. OVEN POOL HEATER ROOM / SPACE HEATER �_.. . LTJ _ -- . _ _._ _ __. l -. ROOF TOP UNIT ........ __ _ TEST UNIT HEATER�— UNVENTED ROOM HEATER WATER HEATER OTHER -. y INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 1[,NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Wi OTHER TYPE INDEMNITY [] BOND 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 E] 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 compliance with all Pe inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAMES silk LICENSE # tIGNAURE MP MGF JP—JGF LPGI © CORPORATION Ej# =PARTNERSHIP [J# LLC E]# COMPANY NAME: �p� _ ADDRESS CITY STATE ZIP ! tp TEL FAX CELL EMAIL r1. o z M ❑ } w M w w LL �4 E� 21 1 �, This certifies that�.q.n ....... has permission to perform ...... ................. i. ...Y.Y% . ........ ......................................................... plumbing in the lbuildings-f—T!�A..6±-,)4z].L.� ......................................... at ........... N ....... n 0 .............. ..... . .................. . North Andover, Mass. W�0�t.. Lic. No . ....... � C,. . - ........ ....k .... I -m Fee..b........ ........................................................ Date ..... ...... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING PLUMBING INSPECTOR Check# N 4� rr� IJIL)113 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _ { MA DATE PERMIT# ln JOBSITE ADDRESS S OWNER'S NAME POWNER ADDRESS TEL [:�:�Y FAX w TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL UQ CLEARLY NEW: & RENOVATION:E11 REPLACEMENT: Q PLANS SUBMITTED: YES ® NO [:11 FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM JI € DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _..__.._...___ N-7-7i, _,.-J_.lf( DEDICATED WATER RECYCLE SYSTEM —__—_._ -_.__-_.___.._—_._,___Jf► DISHWASHER � ____.._._.- _{II _ DRINKING FOUNTAIN .__-..__I ..__...-.J — FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY l !...... ---.—. _—J — _--J -- t ----J --- ( ROOF DRAIN.__._ ._.__.) __._i SHOWER STALL _I I _. - � i { i _.__.1 1 i 1 _ ) SERVICE / MOP SINK TOILET URINAL1..._.___i —_ _-._._►. ----._J .._._.___) ..--____-1 _._...._ (____.) ___._.._.__ .._—__� _— . B ...__...._i ...___._; __ .A WASHING MACHINE CONNECTION WATER HEATER ALL TYPES --J ---i __J WATER PIPING _! ' ; . _._ ._ f ! - ----------- -! ---.._i II _F-11 INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY N OTHER TYPE OF INDEMNITY © BOND D.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 D 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 'ompliance with Pertinent provision of the d Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Dir s i(Vk LICENSE # - i ATURE MP Q JP 2-- CORPORATION 0#PARTNERSHI _i # a LLC � I COMPANY NAME tA_ iADDRESS CITY �(Gj STATE _j ZIP \� `� TELFAX ; CELL EMAIL o z (0)F W a W w U- 1 • The Commonwealth of Massachusetts Department ofIndustrial 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): lam` t C/ Address: `f,,F 0 Y- City/State/ZipPhone #: b' "`t� cl •= ��� 7 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. &.1 am a sole proprietor or partner- listed on the attached sheet. t ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical 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 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. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company 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 requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. X do hereby t fy under the ains and penalties ofperjury that the information provided above is true and correct. Si afore: Date: 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. PIumbing Inspector 6. Other - - - Contact Person: Phone #: r � r 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. AIso 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 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 ofMossachu.setts Department of Industrial .Accidents Office of Investigations 600 Washington Street Boston., MA 42111 TeX, # 617-727-4900 ext 406 or 1-8777MASSAFF, Revised 5-26-05 Fax # 617-727-7749 27-'7749 wWw-mass,govaa r4 "COMMONWEALTH OF MASSACHUSETTS` lie LICENSED AS A JOURNEYMAN PLUMBER i.. 1 ISSUES THE ABOVE LICENSE TO: 1 JAMES- J HIGSON IV 255 PASSACONAWAY DRQ' DRAGUT MA 01826-2128: 4 31199 05/01/14 142563 Date ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... q25.,4% ...... .......e . ..................... has permission to perform ............ RA7-Al ............................................... wiring in the building of .................M Fh.. 1 .. 14 ......................................... at ....... V...... .........................NoIt Andover, Mass. Fee ... 45'.—".. Lic. No.,57,y:?-3A ................. . ELE ICAL INSPECTOR Check# 7218 Jim t1ulmyluiv 11rdlL i n yr tntLa ftL1nvaa,A 1 L3 DEPAMNTOFPDBU CSAFEIY BOARD OF FIRE PREVE MON REGULATIONS 527 aMlZ-oo Permit No. / P9 Occupancy & Fees Checked APPUCA77ONFOR PE&Vff TO PERFORM ELECMC,AL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat Town of North Andover To the In pecto of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address Is this permit in conjunction with a Purpose of Building permit: Yes [ZTNo 0 (Check Appropriate Box) i - - Existing Service Amps I Volts Overhead M Underground New Service Amps/Volts Overhead r"I Underground Utility Authorization No. No. of Meters No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work ..' w o AA .Q T -h e ta: No. of Lighting Outlets No. of Ha Tubs No. of Transformers Total KVA No. of Lighting Fixtures / Swimming Pooh Aborti Below Generators KVA grouv ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switchl@oft f . No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tots No. of Detection and No. of Disposals No. of Heat Total Total Pumps . Tons KW Initiating Devices No. of dingDevices ��gt No. of Dishwasher Space Area Heating KW No. of Self tained Detection/Sounding Devices Local Municipal r7Oth_ i No. of Dryers Heating Devices KW 0 Connections No. of Water Heater KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motor Total HP _ 0 PaM=ID Ihmesubn-advafiilptocfof=retotte00kr-- YiE+,9 LO LJ dmckig NSC)RAIM�E LjA BCND WakIDSlat kq D*Reglr.*d Rough 1 sgied unLierTz Pbnkisofpajiry.T ,� ^ Q % ��E / tJ AA r//ec,7�lCC 67 Lioertsae 5�, b,4 %nao n owl�NtSt4SURXC'EWAM3I Ianmmsh lattheIjoaeedDmmthm std dv t my sig vin cn ibis pmrlt ffkatim waim ltia rogililanat (Please check one) Owner 1:3 Agent Signature Owner 7 Lic wNa A1tT�.Na subs�rial egirivala* as laded by M Galeal Laws Telephone No. PERS FEE S Date.,...G...7 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .....-. .............................. has permission to perform plumbing in the buildings of .^..? +�............................ . at . ............ North Andover, Mass. Fee . E/...i .... Lic. No.. ............ f r' PLUMBING INSPECTOR Check # � •� —'!� 7299' MASSACHUSETTS UNIFORM APPLICA tPrtnt or T416) Mass. Date nstalling. kddre?s 3usiness T Building FOR PERMIT -TO DO PLUMBING New 0 Renovatiol,-P Replacement ❑ n p - Twf R-4 FIXTURES 4 11_1) Permit # Owner's Name 'kq Type of Occupancy iJ Plans Submitted: Yes No C1 SEPTIC# iJ • f •Jame of Licensed Plumber k one: corporation ❑ Partnership Cl Flrm/Co I ficate o 139 NSURANCE CO RAGE: have a curt ept IjIfiblilty Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ t you have checked yes, please ndicate the type coverage by checking the appropriate box k stability Insuranceclic Other e of Indemnity El Bond ❑ P Y type )WNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by ;hapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ hereby certity that all at the details and information I have submitted for entered) In above nowledge and that all plumbing warts and Installations performed under thepermit ued ertinent provisions of the Massachusetts Slate Plumbing Code and Chapter 142 Y itle Ignature at censembe u`i� itylTown Type of Ucense: Maste? Journeyman (] • p r • license Number IJC -S �l true and accurate to the best of my on will be in compliance with all o U '. N © > W W la H Z o < V! cC Q �<. V3 y a aJ .0 cc in LL 0 cc d Q Vr Z C yl W W =< 2 W 3 O Y r Y a C:Y 0 z Z a W ur U. k Q1 1- .rC v 1r- y 1. o = :9 V7 Vt < r- o Z o J o W < - Q - CL W rC d o n U < 'b C1' U 2. Y < J < t0 _ VJ C a 4 J 3 a H N _1 U. U ' Q d 3 C W 0 s ua—Bs MT. BASEMENT IST FLOOR ' 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR eTH FLOOR TTH FLOOR STH FLOOR iJ • f •Jame of Licensed Plumber k one: corporation ❑ Partnership Cl Flrm/Co I ficate o 139 NSURANCE CO RAGE: have a curt ept IjIfiblilty Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ t you have checked yes, please ndicate the type coverage by checking the appropriate box k stability Insuranceclic Other e of Indemnity El Bond ❑ P Y type )WNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by ;hapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ hereby certity that all at the details and information I have submitted for entered) In above nowledge and that all plumbing warts and Installations performed under thepermit ued ertinent provisions of the Massachusetts Slate Plumbing Code and Chapter 142 Y itle Ignature at censembe u`i� itylTown Type of Ucense: Maste? Journeyman (] • p r • license Number IJC -S �l true and accurate to the best of my on will be in compliance with all 1W UUl1'llYLULY rrr.FuAn Ur Ir ri�,cltJ.u.� u DE PARMENT OFPUBLESAFM BOAROOFFIREPREVEMONRDGULA770NS527C.11M n-00 Permit No. 'S -Al . y Occupancy & Fees Checked APPLICATTONFOR PERMTFTO PERFORMELECMCAL WO r- ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 CC -r -LEASE PRINT IN INK OR TYPE ALL INFORMATION) Date c Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) To the Inspector of Wires: Purpose of Building Utility Authorization No. Existing Service �" Amps 1 -?l')/ Volts Overhead 0 Underground No. of Meters New Service Amp -,Volts Overhead r --J Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming PoolAbove Below Generators KVA ground M around No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets . No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and of Disposals No. of Heat Total Total �No. Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP lna =Covw,V- AnA>A iDfto4uffr ocfNi%m at CmtialLaws I have arbrr & d valid proof cf same lothe Old INSURANCE � WM WodclD%ft OUM M tPm **) kweciimDateRec}retd ala:t . YES " NO lfyouhavecha JWYES,pleasirni *theN acfomeby EstirftdVaWof&ctricalWodc$ 40�� Rath FxW IioettseNo. cKey f _ LiomseNo Bt>Si =Tel Na A1tTdNO. NEM'SPWRANCEWAIVER IanawarethattheISoewdoesmthavethemsxm ewAr*orisabsuntWegivWmtasnjgtlWbyNi%md>tlsellsC,enaalLaws "dthatmysgnatinemdispewitappliratiQlwanestli5regt�ernmt (Please c ne) J%er Agent Telephone No. PERMIT FEE signature or Owner Or AgenT Rb y rtllz� C, Location No. _ w Date ko*Th TOWN OF NORTH ANDOVER Certificate of Occupancy $ i�► ► , Building/FramePermit Fee $ b' °'' Foundation Permit Fee $ �Ss�CHU-Et C��ther Permit Fee $ adjittnnection Fee $ Water Connection Fee $ 0G0 � 4PTAL $ Building Inspector Div. 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C 3 tl mcxmmm D Z 0 y N Z 2 Z 0 m 3N7 ONON UIOj SZo� O m n aoo ti n o p p Ohm mo m Z voz 4.4 0 CA000 Nps o S x: ♦ m :0 z O -4 3 3 OZ n r003 NO D •+ m DOz r.+c� •p m yc 1 N z O m 003 N am -oz .p m 3v,a a .� m< ]r S mW rC 0 0 7D m = oro 0 Z o0 V1 Z N m N 0 w v, o mN ° t!f N m 3 o z� a m m 9 m x K 3Nn ONOT/0103 N U. (VI \J T �co Z L AMM �5> co2:q-u CD �D .Db° o z Ozc° a 0 G) ° —' CO r -CI �- 1–i D "'T mp=Z Z �D z��D I� V IJ,I mOp mMCD 0 a pccn mK� CO --j �W� n 7 CL I O IT CL L � OR GIq m K 3 C lm� A 7 o S "j to CM. r _ fq,^,r.t •p � Iis H O b ft MA M m?1 m -1 (i)m T m T o m >y C o > C y� C rn y C pj v A n n c O Z T n _� O Z T n �o m m NORT►, O�t«ao .a'�tiC °: Date.... 1:.. ............ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..{.� �'11'....f...( /.......................... has permission to perform Wit i wiring in the building of��..... � � . l .SGA.. �. ..... /l71 at ................................:...... .. � f . ,North Andover, Mass. ' Fee . :.:.11f . Lic. No.! ... ELECTRICAL INSPECTOR Check # 53& TBE COMMOA' EALTHOFMASSWRUSMS Office Use only DF.PARrA1 VTOFPUXJCSAMY Permit No. '3--_3 v se3 BOARDOFFIREPREVENHONREGULAHONS527C.MR12.QO � � Occupancy &Fees Checked APPLICATION FOR PERMIT TO PIMORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSS?S ELECTRICAL CODE, 527 CMR 12:00 / (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) t Date 21,26 oj Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical wofk descri a below. Location (Street &Number) Q Owner or Tenant / f- y f � nD — P >1 �(, LV r Owner's Address _ _ 6 r+0 w� __ M4 •� Is this permit in conjunction with a building permit: Yes M No Ea— (Check Appropriate Box) Purpose of Building F41 fl e- I Utility Authorization No. Existing Service AmpsW/ 'I'CbVolts Overhead ® Underground No. of Meters New Service a0X2— Amps /-,7UVolts Overhead =Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs 7 No. of Transformers �r Total l � KVA No. of Lighting Fixtures Swimming Pool Above 1:1round Below Generators KVA round No. of Receptacle Outlets No.* of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER- kmra =Qmr, . Frau oDthetegt =iai1sdM%sxhBe1lsG=2WLaws Ihave&hAWdv;Mptoofofsmw1D eOlfioe YES VIN Got,, 'to 111111111 � iiii a : • It - M - WbikOStat h�spectimDa1eRec�d Sigledunder 1$taldesafpetw. h /� FIRMNAME r G �/G 0 Qtf • 11=351 aluYES " NO If)mhavedred®dYES,pleasein&*thetypeof try u : r. . .0 ..i , . I W M. I "ff,• , a Bu4=Td . Alt'Ii'7.No OWNER'SINSURANCEWANELZ,IamawaethattheLio wdoesnothawthein%rj=oDrerageoritsaksb tdegrAntaslec}IrtadbyMassactnsetlsGeneralLaws r and thatirysigirknon thispetrri tVpficatim wanes this Mquitemai Please check one) • Owner Agent Telephone No. PERMIT FEE $ signature of Owner or Agent'� 7 �r l � Telephone No. PERMIT FEE $ signature of Owner or Agent'� Dat%.�'` �'."....... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACHUS� ,- This certifies that .. has permission to perform......... ...... .. 11 plumbing in the buildings of ..... . . ................... at �qy�. -�/ ,.North Andover, Mass. e .l Fe.�1..... Lic. No./,._ '.-i.,'S. F. .......... PLUMBING INSPECTOR Check # 61 '19 �, In 2.1 MASSACHUSETTS (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location 8 y P)o a\ j J)` New NIFORM APPLICATION FOR PERMIT TO DO PLUMBIN .r ;� p 1 Date Q� )caner, Name vll Y� "\`T� Permit # ` Amount of O cupancy \ ��,�' Renovation El Replacement 0 FIXTURES Plans Submitted Yes 0 No (Print or type) Cec one: Certificate Installing Company Name Jb6�� �"1 Corp. Address Fo - D'X ` L' I1 0 Partner. 41897 Business Te ep one 4'I g . qS4 _3 3- Firm/Co. Name of Licensed Plumber: ✓1 Lb Insurance Coverage: Indicate th type of insurance coverage by checking the appropriate box: Liability insurance policyto Other type of indemnity 0 Bond ❑ Insurance Waiver: I, the undersigne a en 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 Massachusetts State Plumbing Code and,,Eh_apt�ji6f the General Laws. By Signature of Licenseca number Type of Plumbing License Title City/Towncense NumDer Master Journeyman E3APPROVED (OFFICE USE ONLY