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HomeMy WebLinkAboutMiscellaneous - 87 KARA DRIVE 4/30/2018N J O D�'' o � i Y' � '' o � o <' o m a 0 0 Date ..� ............ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that A'.,'.. (., �'� ....................................................................... has permission to perform ..(.......... G..... !. r�.. ..... / e . ....................... wiring in the building of...1/�?� d . ............................................................................................. at ....... (Crn.. G.— �.� Q - .... , North Andover, Mass. .............................................................. Fee. ��....... Lic. No. .J...lf _r ��.r� .................................................................... ELECTRICAL INSPECTOR Check 11 / Commonwealth of MassachusettsMEN Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked �P BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank �M APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), f27 CMA 12.00 (PLEASE PRINT WINK OR TYPEALL INFORMATION) Date: off- % �✓ 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. n Location (Street & Number) 8 ' 1 (250 or � Tenant 0V/ E)n- s Je. Telephone No. Owner's Address k - Is this permit in conj unction with a building permit? Yes R No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead ❑ Undgrd [j Overhead ❑ Undgrd ❑ No. of Meters No. of Meters I Completion ofthe 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- E] rnd. grnd. o. of 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 . .. KW .............. No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal El Other Connection No. of Dryers Heating Appliances KW Security Devi es or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts 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: 190<C� (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 [j� BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: M cGAg-C_ 12/Ly Signature (If applicable, enter "exem t" 'n the it ense a er limine) Bus. Tel. No.. 1 (O Address: f C -'e5 /+�C� cilSsY Alt. Tel. No.: -- *Per M.G.L c. 147, 9.57-61, security work requires Department 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: $ �s =- 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 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed (] Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass F?1 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Da FINAL INSPECTION: Pass M ed ❑' S Re- Inspect)n Required ($.) ❑ Inspectors Comments: d'L &e.AC,(./ i' etc '' /w, S Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts { Department of indiustrialAeeldefits 1 Congress Sheet, Suite 100 a. ::� • is � �='. d --: F Boston, MA 02114-2017 www mass.gov/dia • �a�M Sy' V� Workers' Compensation Insurance Affidavit: Builder/Contractors/Eleciricians/Pinxnbers. TO BE FILED WITH THE PERMTTT'NG .A.UTHORITY. - -- ,. , Name (Business/Oiganization4ndividual): Address: City/State/Zip: Are you an employer? Check the appropriate box: phone #: 1. ❑ I am a employer with employees (full and/or part-time).: 2.❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 1 am a homeowner doing all work myself~ [No workers' comp. insurance required.] t 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 14 proprietors with no employees. 5. ❑I am a general contractor and 1 have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6.Q We are a corporatioii and its, officers have exercised their right of exemption per MGL c. 152 § 1(4) and we have no employees. [No workers' comp. insurance required.] Type of project (required); 7. ❑ NeVd6nstr66tion 8. [] Remodeliing 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 1Z:[].Plumbing repairs or additions 11 Ro6f repairs 14. El Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. rs I Homeowners whosukb� s a8a alta � additional o e sheegshowing the nall work and thame of theen hire contractotside rs and state whether or pot fhoseow affidavit indicating n it e ��e h. $Contractors that ch 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. Lic. Expiration Date:. City/State/Zip: Job Site Address: Attach a copy of the vvoxkers' compensation policy declaration page (showing the policy number and expiration date). olation punishable by a fifie up to 0-00 Failure to secure coverage as required under civil25A is enalties inthe form ofra STOPal rWORK ORDER and a fne of lip to $250.00 a and/or one-year imprisonment, as w P day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. coverage certify under the pains and penalties of perjury that the information provided above is true and correct: Date: Signature: offzcial 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 S. Plumbing Inspector 6. Other Phone Contact 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 de£uied as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enferpri'se, and including the legal representatives of 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 bd 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 r'equi red" 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 Pleasb 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 certificates) 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 maybe 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' compensatio.6 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 thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "fob 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 This certifies that ........ .. �.............I...��Z-F ...............................................has ermission to erf rm ,��^ (e' � 0 j e Pperform �j*........................................................t...... plumbing in the buildings of................J -r-�. ps'7�?? J' ................................... at .......... ..7. ...... kG..../,2av ¢- ............................. North Andover, Mass. 677/ Fee. LV ...... Lic. No....................................................................................................... Date......��.1.� . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING PLUMBING INSPECTOR Check #�— P)p 25)-kp vn S�?Sjll-1 URINAL ' WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER ..._.._...___I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES' -'NO [11 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND Dj 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-11 AGENT 10 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 Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME [7 (- - �LICENSE # , SIGNATURE FM P Elf ip CORPORATION FJI# PARTNERSHIP DI # LLC COMPANY NAME RESS W CITY =STATE ZIP TEL I FAX CELL I ------ _ .. ......... JJEMAIL V� 10 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE PERMIT# JOBSITE ADDRESSOWNER'S NAME POWNER ADDRESS I TEL TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL D RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: EI REPLACEMENT: PLANS SUBMITTED: YES NO F-1 FIXTURES 7. 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 __j —JI --J DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM I DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) _.____I __..._i KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/ MOP SINK --i --j _.._...5 ---i F -Al -j TOILET —i URINAL ' WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER ..._.._...___I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES' -'NO [11 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND Dj 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-11 AGENT 10 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 Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME [7 (- - �LICENSE # , SIGNATURE FM P Elf ip CORPORATION FJI# PARTNERSHIP DI # LLC COMPANY NAME RESS W CITY =STATE ZIP TEL I FAX CELL I ------ _ .. ......... JJEMAIL V� 10 y r �W z 0 H w + oo z - I❑ ID o � w 0. z u LLI o a w W co aLU W a O zo W F- U I a a a CO s w �- LL. H °z 0 H U W a �7 a a O a The Commonwealth of Massachusetts Department of IndustrialAceldents M }� I Congress Sheet, Suite 100 Boston, MA 02114 2017 7 v`9�C www mass.gov/dia ��M 5J1 Workers, Compensation Insurance Affidavit: Buildexs/Contractors/Electricians/Plum ers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: Phone 7--77-7-- City/State/Zip: Ase you an employer? Check the appropriate box: Type of project (required): em to ees full and/or part-time).* employer with P y for in 1.[riamin 7. ❑ NdV dons"6tion 8. [] Remodeling 2. sole proprietor or partnership and have no employees working me any capacity. [No workers' comp. insurance required.] 9. Demolition 3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required] t 10E] Building addition <1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will compensation insurance or are sole 11.❑ Electrical repays or additions ensure that all contractors either have workers' with no employees. 4 12 Wliunbiug repairs or additions proprietors s. ❑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 13,, 0 Rb6f repair§ 14.0 Other 6. ❑ We are a corporation and its, officers have exercised their right of exemption per MGL c. 152 § 1(4) and we have no employees. [No workers' comp. insurance required.] *Any applicant that check's box #1 must also sill out the section below showing their workers' compensa On policy information: i Homeowners who submit•. , addax. indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors that check This I1 4 must attached an additional sheet showing the name of the sub -contractors and state whether or not (hose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. X am an employer that is providingworkers' compensation insurance for my employees. Below is the policy and)oh site information. insurance Company Name:. Expiration Date: Policy # or Self -ins. Lic. #: ^J � City/State/Zip: �/� � doveji� Job Site Address: 07 ers' cored mpensation policy declaration page (showing the policy number and expiration date). Attach a copy of the yvorkunder MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 Failure to secure coverage as sl co and/or one-year imprisonment, as f flus statement mas civil ay be forwarded to the Officies in the form of a STOP e WORK ORDER and of the DIA for insurance200 a day against the violator. A copy o coverage verification. X do hereby certify under the pains andpenalties of perjury that the information provided shove is true and correct. ..� Official use only..Do not write in this area, to he completed by city or town official City or Town: Permit/License # / I — Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone Contact 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 receivef6r, trusted 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 bd 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 O£fiicials 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 Iuvestigations 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 thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "fob 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 Ictidress, 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.................................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .............. ...................... �....V a.�!.....,../.......................................... n j u -i � �e, M Cc�P\ has permission for gas installation ............................................ ..................... in the buildings of ....�!.rhI-0- VI'S� s ......................................................................................... at .........7......... /��`n ��+✓e....................... North Andover, Mass. ...................................... . Fee .22--`` if............. Lic. No. 5.0 .7/....................................................................... GASINSPECTOR Check # 101-2- - O1-2- ' - GRILLE INFRARED HEATER_( LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER, -- - - - - E . --:._INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES jdNO El IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE E BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY U OTHER TYPE INDEMNITY Ej 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 Ell AGENT ] SIGNATURE OF OWNER OR AGENT 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 Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASATTER NAME LICENSE # SIGNATURE MP 0 MGF JP _ JGFJ LPGI CORPORATION ©# PARTNERSHIP 0#= LLC [J# COMPANY NAME:1 AgIZIESS CITY' _ Q _ � S EZMIZIP]TEL FAX .W .— .II CELL - ------ ! EMAIL - -- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,G' TYPE OR PRINT CLEARLY CITY -- dT� `II MA DATE — PERMIT # JOBSITE ADDRESS niT�G :OWNER'S NAME rCr VC7�Td17/� __II OWNER ADDRESS L TE 01_ OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL NEW: D. RENOVATION: REPLACEMENT: Eir"" PLANS SUBMITTED: YES NOQ APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _..--.I. - E:, . _ . _ m n I L:::] [:::i BOOSTER E:j =1 -- _ CONVERSION BURNER COOK STOVE DIRECT VENT HEATER I- E DRYER FIREPLACE FRYOLATOR FURNACEGENERATOR ._: I _.-._....111-1 GRILLE INFRARED HEATER_( LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER, -- - - - - E . --:._INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES jdNO El IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE E BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY U OTHER TYPE INDEMNITY Ej 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 Ell AGENT ] SIGNATURE OF OWNER OR AGENT 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 Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASATTER NAME LICENSE # SIGNATURE MP 0 MGF JP _ JGFJ LPGI CORPORATION ©# PARTNERSHIP 0#= LLC [J# COMPANY NAME:1 AgIZIESS CITY' _ Q _ � S EZMIZIP]TEL FAX .W .— .II CELL - ------ ! EMAIL - -- A 49.11 MMONWEALTH OF MASSACHI SETTS B©ARD Oi` PLUMBERS I. AND�GASF:>ITTERS ISSUES THE FOLLOWING LICENSE <: LICENSED 0:A JOURNEYMAN PU..UMBER' z 8 WORDSWpRTH_ ST Z y RANOOL1'H MA o2368-2116 . >05%0i:/:1::6;<:<;; °207849 _ ..._. Date. ?. ........ . aOFTM TOWN OF NORTH ANDOVER Of<«ao ,a1ti0 PERMIT FOR GAS INSTALLATION This certifies that .......................... has permission for gas installation ............... in the buildings of ...:...' ................................... at ......... ........... , North Andover, Mass. Fee. !....... Lic. No..:..'.. ?... .......................... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 GASFITTIN (Print or Type) NORTH ANDOVER Mass. Date _ wilding Locationzza r ,z //r , Permit Owners Name `�.��-/-� Y • New Renovation D Replacement Plans Submitted �] FIXTUP=c (Print or Type) Chec one: Certificate Installing Company Name c:Cw�-r ✓¢ �o Kc Corp. Address Partner. e- y Firm/Co- Business Telephone: Name of Licensed Plumber or Gas Fitter Insurance' Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity = Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner ❑ Agent D 1 hereby certify ttut ail of the dcuils and information 1 have submitted (or entered) in afore 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 wi all pertin=t provisions of the lrtassachusetts State Cas Cade and Chapter 141 of rho General Laws. V. Ll r By TYPE LICENSE: f Z 1 Plumber Title 7 Q 1^n Gasfitter Signature of License' Master City/Town: Plumber or Gasfitterl Journevman APPROVED (OFFICE USE oNt_YJ — License Number YW N Z W tz of N 2 F tyle a m j O V m f' _ N O W d MW m 0 w .� w O a y 4 LU 0-1 O Z< U W` a 2 Q C a Q w 0 F" G W U w x full Q a t- Z J t- Z t.. � � O? O W -4F to 2 Q d u W >z W OC O r 2 4 G � d G1 Q O O W O O N W S N rs O O U. = a O .1 U > Q a F- O sua–i3s7.1T. t BASEMENT IST FLOOR 2N0 FLOOR 3R0 FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR HIE STH FLOOR I I d 11 (Print or Type) Chec one: Certificate Installing Company Name c:Cw�-r ✓¢ �o Kc Corp. Address Partner. e- y Firm/Co- Business Telephone: Name of Licensed Plumber or Gas Fitter Insurance' Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity = Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner ❑ Agent D 1 hereby certify ttut ail of the dcuils and information 1 have submitted (or entered) in afore 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 wi all pertin=t provisions of the lrtassachusetts State Cas Cade and Chapter 141 of rho General Laws. V. Ll r By TYPE LICENSE: f Z 1 Plumber Title 7 Q 1^n Gasfitter Signature of License' Master City/Town: Plumber or Gasfitterl Journevman APPROVED (OFFICE USE oNt_YJ — License Number