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Miscellaneous - 92 PUTNAM ROAD 4/30/2018
Date.4 �..1�I TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies tha . l�. .......0 2,�.., v/ k ( .�� Cl�rs��. ce, ........................................................ has permission for gas installation rp.a'`".`. G?--„. J .... UY�.... L� in the build' s o � 4 f...................n............................................................................................... at ...... !1.... !....!..'44 ° .:............................. North Andover, Mass. Fee -3b `....... Lic. NoJO 1.NP.......... ...................................................................... GASINSPECTOH Check -1 t0 '� I 07 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I North Andover MA DATE 5/2212014 PERMIT # JOBSITE ADDRESS 92 Putnam Rd OWNER'S NAME _X) LpLIkA GOWNER ADDRESS Same I TEL— �FAXI� TYPE OTR OCCUPANCY TYPE COMMERCIAL[]EDUCATIONAL ® RESIDENTIAL[j CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ® PLANS SUBMITTED: YES❑ NO❑ APPLIANCES Z FLOORS- BSM 1 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 I SPACE HEATER ROOF TOP UNIT TEST SNIT HEATER NVENTED ROOM HEATER NATER HEATER OTHER Replace 1 Gas Meter x INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ❑ NO ❑ 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 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 [jAGENT 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 m iance with all Pertinent provision of t Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ',AA PLUMBER-GASFITTER NAME I Joseph Marino LICENSE # 8736 7 -SIAATDRE MP EEI MGF ® JP ❑ JGF ❑ LPGI 0 CORPORATION ❑# 3285C PART SHIP[J# LLC ❑# COMPANY NAME: RH White Construction Co ADDRESS I 41 Central St CITY J,Auburn STATE=ZIPI 01501 TEL (508) 832 3295 FAX 508-926-4347 J CELL 508-832-4614 EMAILJMarino@RHWhite.com w H O z z 0 H v w a CA z z w c 0 ❑ a z o �❑ � w � ~ w O a O LLI w a F- N w CL w d W y a zz a a Q � U J F, a CL w x w LL CA H O z z O ok H w a � w � N O a aa/� ;�i:: "'itF? •�:. :�••t"�.eS• `�,U:�}n.• n4 ••";:'•1r '. t'.`'.: � ` �" .iir:,_ •��'•j' • ti;.:+:�?r';�i�?.I�r 'S�,j,`..:(nr, i_�a:i,�4T�r: r' ar r�ilm' ;:LL?�'t, 'Ii: riLiJt"arP l:c�"P;rr.'�,.I :., i;,;j r�:�.,. y;�,7� �;: • '�1� {.,., i'i .�k p °:;q :'� ii:• ,so-.;. ":'tt `Y+ •� �:1 �:.;�G', �.':� ' : i�c;.• • i�`'i rILI Ld.3, �,+i) ;"� �'}f^tj•. a�'+, li-�1.; ,C v "•`'. ':•. •' ,1i f , :'tl 0 '. G. • ��.1 �1��r,,�; , 'if•j. �.:f�:::F: %iL� iJr� rr w , =f cn w LL W � !L cn tolu c Z'. az U)fu w LL. ,-R :iu rt ,y, tiaC' u O m' ..-. ❑M> 2 ca �"' • `�� .w COW LU ul MU) LU w CD 04 •,err.• I ' '.1, 7iJ.. 'j, ... "�. ". i;{,. '.kf1• I r '(+T;: w 1�'Fy. ''1•l.�n'�j-. .(3! 'r •:1;:fes,%ri•.Sll>.'a,Cn�: i'.� tY i..,. � '`: :'��•����: p't L'•), tIt'�af`k€,},:sa+ti�a' ,� ,� i7�1 •'. •. , - ,p*t,r. i'�.; t'` •"i�'�a;tnF':�;p�ttit;'nc:'u:-;r`:�ri,:,.:,:r'.nf"-J�j• ,,t,, ' • �'�' ^v+-: rF: ":•, ,rt;, , `m1:i•?r+' r: ': .f r'd : �J "1rr1'' ' '', •i�,r•'���i i, �f �CC7 a® �l--- CERTIFICATE OF LIABILITY INSURANCE Page 1 of J 0a�29/2U31 i HIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE; AFFORDED 13Y THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED RE=PRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the Certificate holder is an ADDITIONAL INSURED, the policy(ios)murt be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not conferrights to the Certiflaate holder in lieu of such endorsement(s), willia of Nlaeadehuaette, Ine. C/o 29 cottury BIVA. P. 0. sox 305191 Nagh-ills, TN 37230-5191 R. X. White Conxtruotion Company, Inc. 41 Cantral Street P. 0. Boa 257 Auburn, MA 01501 INSURER A: The Chartor Oak Lino Ineuranp9 Company 25615-001 INSURERS: Trava:LmrD property Cdeualty COA>pany oil Am 25674-003 INSURER C:NatiOnAl Union Fire) Insuranea Company o£ 7.9445-001 INSURER D; Travelers Ind=n9.ty Company 25659-DO1 •••�••• ••,amu �crc r Irl�>� i NUfY1FStft: a02675Bo REVISION NUMBER; THIS IS TD CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ,ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF IN A GENERALUABILITY IMFRCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR APPLIES PER; B AUTOMOBILE LIABILITY X ANYAUTO ALI,OWNED SCHF.DULED AUT08 AUTOS X HIREDAUTOS X NON -OWNED AUTOS X Co Ded X Coll Ded C01300 H XUMBRELLA LIAR OCCUR EXCESS LIAB CLAIMS -MADE DED I V IRETENTIDNS 10,001 D I WORKERS COMPENSATION AND EMPLOYERS' LIABILITY D ANY PROPRIETORIPARTNE.RIEXECUTIVE� NfA OFFICERIMEMSER EXCLUDFD7 below xvidence of Inmurance VTC2000 977RD948-13 9/7./2013 I'VI/2014 MED EXP 977K95sA-13 9/1/207.3 9/1/201.4 BODILY INJURY(Perperson) $ BODILY INJURY(Peraoddont) $ BES766140 19/1/2137,3 9/1/2014 AGGREGA 8205A1a5-13 9/1/2013 9/1/207,4 9203.A71A-13 9/3,/2013 9/1/2014 Remarke more ep eco 2,000,000 IDENT $ 1,000,000 EA EMPLOYEE S 1,000,000 POLICYUMIT $ 1,000,000 SHOULD ANY OF TWE ABOVE DESCRIBED POLICIES BE CANCI ILLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE vAA;'% J40U"1 XPI:1694012 Gert:20287680 ©1988-2010ACOR-0 CORPORATION. All rights reserved. ,CORD 25 (2010105) The ACORD name and logo are registered marks of ACORD 7365 w .ro Date. .......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ,SSACNUSEt This certifies that .... ..... ..4- .. ..... . . has permission for gas s allation�/� ...... . in the buildings of . �' .�?"! �................. . I� v / n at .......... !... ? ........ , North And�ver,� jas�s. Fee 3U. !'.. Lic. No.. f V >.. .............. .... ! -......?. GAS INSPECTOR Check # ,{ . _:.-- .MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO ]DO PLTTMBING r (Type or print) NORTH ANDOVER, MASSACHUSETTS D �/�/) Date / /VA/Ti�/I�/y1 6CJ 1 ♦ C1wnPrc Name Permit #--L-1 Building Location � ���. - • -�. - Amount New Renovation 0 Replacement 'VYYTTiI?T Q G Plans Submitted Yes n No (Print or type) Chec ne: Certificate installing Company Name Andover Plumbing & Heating Co. , Inc. Corp. 2.12.2 Address 20 Aegean Dr. Unit #10 Partner. Methuen, Ma. 01844 Business Telephone ( q 7$) r A F A q 83 Finn/Co. Name of.Licensed Plumber: George L a R o s e Insurance Coverage: Indicate th type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one ofthe above three insurance Signature K, Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are.trae and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the MassachusekState Plumbin gWkpW 4& 142 of the General Laws. APPROVED (OFFICE USE ONLY Type ofPlumbing License License um er Master 9983 Joumeyman ❑ J .,I ii I KWON 0 0 OWN MIN No 0 E NONE No mom Now No mm mm 01101001 No 0 01IIIIIIIIIIII11010 No No NINON WINNIEN0000001 No (Print or type) Chec ne: Certificate installing Company Name Andover Plumbing & Heating Co. , Inc. Corp. 2.12.2 Address 20 Aegean Dr. Unit #10 Partner. Methuen, Ma. 01844 Business Telephone ( q 7$) r A F A q 83 Finn/Co. Name of.Licensed Plumber: George L a R o s e Insurance Coverage: Indicate th 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 ofthe above three insurance Signature K, Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are.trae 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 MassachusekState Plumbin gWkpW 4& 142 of the General Laws. APPROVED (OFFICE USE ONLY Type ofPlumbing License License um er Master 9983 Joumeyman ❑ Date. . . . TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING �,SSACMUSE��� This certifies that .d✓�!1 . . has permission to perform ... V4 44,/ ......... plumbing in the buildings of .. 40A ...../. -�J !' . ....... . at. 9a . lt.... ...... ��... d ........ Nort Andover° ass. Feb- 6 -00. Lic. No../ S. ? . ....... .. . / PLUMBING INSPECTOR Check # ? 8674 _ The Commonwealth of Massaclutsetts Depaitment of hidustrial Accidents Office oflitvestigations ILIr 600 Washington Street Boston, MA 02111 )wPip.mass gouldia Workers' Compensation Insurance Affidavit.- Builders/Contractors/Electricians/Plumbers', Applicant Information Please Print Legibly Q r Name (Business/Organization/Individual)-.-Ay/hog,�/%%CJJ/(/�•- jl/C j� _ Ly[ airy/Ntate/Glp:/ , AMot- Phone M Are ypu an employer? Check the appropriate box: 1. I am a employer with 6 4. ❑ 1 am a general contractor and 1 employees (full and/or part-time).* have hired the sub -contractors ?. ❑ I am 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. employees and have workers' [No workers' comp insurance comp. insurance # required.] 5. 0 We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp, right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. (No workers' comp. insurance renuired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. Building addition 10.❑ lectrical repairs or additions I I.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. 'Contractors that check this box must attached an additional sheet showing the name of the sulrcontizetors and state whether or not those entities have employees, if the sub -contractors have employees, they must provide their workers' comp. policy number. I ani an employer that is providing workers' compensation insurance for my eniplgpees Belmv is the policy and job site information. _ Insurance Company Name:-%t"4W Policy # or Self -ins. Lie.} #:the- `R -1 S f �j�/ Expiration Date: d Job Site Address: %9Ty4� d /`C>� City/State/Zip:41.4-4k,001k 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 ns 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 fonvarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify unfor thepains and penalties of perjury that the information provided above is true and correct. Oficial itse 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. EIectrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #• V, 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 mora 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 die 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." r 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 it 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 nffrdavit. 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 die Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a reference number.. In addition,. an applicant that must submit multiple permittlicense 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 find 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 1477-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia MASSACHUSETTS U SHORM APPUCATON FORPERAW TO DO GAS FUTIV (Type or print) Date /a NORTH ANDOVER, MASSACHUSETTS -A � n. -3*9 Building Locations WAUA Owner's Name New ❑ Renovation E Replacement Permit # Amount $ OF Plans Submittedri Name of Licensed Plumber or Gas Fitter Cb e& one: Certificate Company Corp. Partner. E]Firm%Co. INSURANCE COVERAGE Check on . I have a current liability Insurance policy or it's substantial equivalent. Y es V Now -" If you have checked yes, please ' dicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnityBond Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 0 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 erfornmd under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts SOF Code and Cha tere General Laws. Title City/Town IAPPROVED (OMCEUSEONLY) �1urnber of 1 Plumber as Fitter Master Journeyman sed Plumber Or Gas Fitter License Number • �SUB-B AS EM ENT ;B A SEM ENT ����FLOOR ���r�o■������������ :4TH. FLOOR ;5TH. FLO Name of Licensed Plumber or Gas Fitter Cb e& one: Certificate Company Corp. Partner. E]Firm%Co. INSURANCE COVERAGE Check on . I have a current liability Insurance policy or it's substantial equivalent. Y es V Now -" If you have checked yes, please ' dicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnityBond Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 0 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 erfornmd under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts SOF Code and Cha tere General Laws. Title City/Town IAPPROVED (OMCEUSEONLY) �1urnber of 1 Plumber as Fitter Master Journeyman sed Plumber Or Gas Fitter License Number 1 The Comnnonnvealth ofMassachusetts Department of Iiiditstrial Accidents Office. of Investigations 600 Washington Street `—` Boston, MA 02111 i'invw.mass gov/dia Workers' Compensation Insurance Affidavit:. Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Hanle (Business/Organization/individual): %�/f/��/. JOL IV /1/� ff jf/��.�j� t Address: City/State/Zip: 'Phone M Are u an employer? Check the appropriate box: '1. ✓ I am a employer with 6-_1 4• : ❑ 1 am a general contractor and 1 employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the atiached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp: insurance comp. insurance# required.] '" ' 5. [] We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. (No workers' comp. right of exemption per MGL insurance required.) t C. 152, § 1(4), and Nye have no employees. [No workers' comp. insurance required.l Type of project (required). 6. ❑ New construction 7. E] Remodeling 8—[] ] Demolition 9. C❑ Building addition 10.❑ lectricaI repairs or additions 11.5Plumbing repairs or additions 12.Q 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-contiactors and state whether or not those entities have employees. if the sub -contractors have employees, they must provide their workers• comp, policy number. ant an snip oyer drat is providing workers' conipensadon insttrancc for my eutployees. Belon► is the policy and job site information. Insurance Company Name41/1: y V Policy # or Self -ins. Lic. #: ale-- 7o?�f �� Expiration Date:—AD/A/0 /e 1-7 Job Site Address:_ /� D� � /W /1 City/State/Zip; /YD- / it/�Or,EyC� /%%�� 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 ora 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 certify it der they pains and penaltiesa erjrrry that the infornta_ tion provided above 's true and correct. Sign lure: Date: Official ttse only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): - L Board of Health 2. Building Department 3. City/Town Clerk 6. Other 4. EIectrical Inspector 5. Plumbing Inspector Contact Pers on: Phone M 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 y 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,thc 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 die 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 thenumber 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, 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 permittlicense 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 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 4-24-07 www.mass.gov/dia 10 N2 2�i Date...1./... N- °f<��`°;•�"o TOWN OF NORTH ANDOVER ,� • oc p PERMIT FOR WIRING This certifies that � has permission to perform ...... .....`...................... : �.{. �. "'.......................... wiring in the building of ...... =..!.!...... ...... tt................................................... ..z;c 4 l F lamr...I......r, North Andover, Mass .......... F.................. . _ �1 Fee... .:<.:. Lic. No .............. ............... 4 :,�.....; . ; ..�....•....... ELECTRICAL INSPECTOR G Check # � (i'i ''4 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Location 9� MA A) /�d No. 112')Date �D42 9 w HORTM TOWN OF NORTH ANDOVER O O?O°,t`•O ,•,MOn a Certificate of Occupancy $ 141 Building/Frame Permit Fee $ cHuS Foundation Permit Fee $ s.�E Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ `— TOTAL v$ a` 7, �-/ Building Inspector 'I 5 12 10/12/99 12:18 227.00 PAID Div. 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CO, cl)� fD ^� o G� H 0 c i a' r'' n-< H z a- '� Srt 'lo M a- a �1 � 7C o O O 0 tx yr r ACO�D,. CERTIFICATE OF LIABILITY DATE (MM/DD/YY) 1NSURANC,E y 08/12/1999 PRODUCER (978) 374-6352 FAX (978) 521-5127 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIO14 OSTELLO INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 2 South Kimball St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO BOX 5248 COMPANIES AFFORDING COVERAGE ' Bradford, MA 01835 .... ............._ ......... ............ .............. COMPANY Home Builders Insurance Attn: Patricia Fi l l i o Ext: A ..._. ,.... .... ......... ......_......... INSURED Paul's Remodeling _.. ... ... _.._..... _ COMPANY e 36-A Baltimore Street -- — ---- Haverhill, MA 01830 COMPANY C .. . .. ......... ......... .. ........ ......._..... COMPANY I D dOVERAGES,;... _ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ......_. ........................ ........................... ...... .................................._...... . ._.....,.... .... .............................................._.... ......... .. ..__............... ......... .......... .... ._........., ........... CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE .POLICY EXPIRATION LIMITS LTR DATE (MM/DD/YY) DATE (MM/DD/YY) GENERAL LIABILITY GENERAL AGGREGATE $ 600,000 j ;COMMERCIAL GENERAL LIABILITY j .......I. ......... ! � PRODUCTS -COMP/OP AGG t $ 600 ,000 CLAIMS MADE X OCCUR' A ITBI PERSONAL & ADV INJURY J.$ 300 , 000 08/12/1999 08/12/2000 F--- - --_..._.._....... __.__�................. ;OWNER'S &CONTRACTOR'S PROT 1EACH OCCURRENCE is 300,000 FIRE DAMAGE (Any one fire) $ 300,000 j i MED EXP (Any one person) ` $ 10,000 AUTOMOBILE ............. LIABILITY ! i COMBINED SINGLE LIMIT $ ANY AUTO I I I ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per person) $ HIRED AUTOS BODILY INJURY is -. NON -OWNED AUTOS (Per accident) ............ ......................................................................................................... I � i PROPERTY DAMAGE _ $ j GARAGE LIABILITYAUTO ONLY - EA ACCIDENT $ ANY AUTO I OTHER THAN AUTO ONLY. i EACH ACCIDENT' $ t. AGGREGATE'$ EXESS LIABILITY UMBRELLA FORM EACH OCCURRENCE $ AGGREGATE is OTHER THAN UMBRELLA FORM j ' $ I WORKERS COMPENSATION AND EMPLOYERS' LIABILITY I TORY LIMITS IER,,, •. EL EACH ACCIDENT $ THE PROPRIETOR/ _• —j INCL PARTNERS/EXECUTIVE EL DISEASE -POLICY LIMIT I $ ..... ..... ................... _.._..___. OFFICERS ARE: 1 EXCL EL DISEASE - EA EMPLOYEE is ;OTHER i i ! I ! I DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS Aerations usual to a carpenter. -CERTIFICATE CANCELLATION' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Paul's Remodeling BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 36A Baltimore St. OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. Haverhill, MA 01830 AUTHORIZED REPRESENTATIVE Patricia Fi l l ACORD^25(1195-5 ~fir .. w ,r . i _ © CORD; CORPORATION 1988 TOD �oDG do w a y Mtysq70 sip U SDUU� _ i A A� RAI r • r• I a y. ot REGULATIONS' ARD OF BUILDIN G BOi� k«� GONSTRUCTION SUPERVISOR a y Mtysq70 sip U SDUU� _ i A A� RAI r 1 �. yA�'f,Pylj� . aRf St I ot REGULATIONS' ARD OF BUILDIN G BOi� k«� GONSTRUCTION SUPERVISOR L isen5e 042063 .. �-- er Numb'„ r ateSj 1957 0 s h _ Birth , . Tr. no:7769 0@712001 Exp►res . F •,��, ResMcteolo 00 f. r PAUL M SOUCY r BALTIMORE ST - 36-A Admini$trator MA 01830 HgVERHILL, -rpt r•.,.r y'�a{ia+ N'�. r - :i K .. - r a i North Andover Building Department ' Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number YV-7 is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: <N CfG1������ (Location of Facility) s s Signature of Permit Applicant — G Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector 0 O;iice Use Onl The Commonwealth of Massachusetts6�< Per .it No: Department of Public Safety _ Occupancy 6 Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12-00 3/90 heave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance with the Massachusetts Electrical Code. 527 CMR 12:00 � (PLEASE PRINT IN INK OR TYPE INFO ION) Date �tL . �AM&4LN OC) City or Town of �a To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street 6, Numb ) Owner or Tenant Owner's Address Ck 9 Is this permit in con' ction with a Ikuildi permit: Yes ® No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization NO Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Nunber of Feeders and Ampacity Locaati�onn and Nature of Propose No. of Meters No. of Meters No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures g g Above In- Swimming Pool grnd. ❑ grnd. ❑ Generators KVA No. of Receptacle Outletsia No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets 3 No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices Local Municipal E] ❑ Other Connection No. of RangesNo. of Air Cond. Total tons No. of Disposals No. of Pumts Total Total Tons KW No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Devices KW No. of Water Heaters KW No, of No. of Si ns Ballasts Low Voltage Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YESIj& NO 0 I have submitted valid proof of same to this office. YES NO If you have checked YES,,please indicate the type of coverage by checkin the appropr ate box. r� INSURANCE b4 BOND ❑ OTHER ❑ (Please Specify) coExpiration Date Estimated Value of Electrical Work $ Work to Start Inspection Date Requested: Rough w Final Signed under the Ape'nalties of perjur, FIRM NAME I Y � � eLtILI �k ^3 LIC. NO.P91t(09_8 License Address It. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or Iis sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this it application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FE 46) Signature of Owner or Agent ACORD CERTIFICATE OF LIABILITY INSURANCkANNE-ID BR DATE(MM/DD/YY) 1 11/06/00 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Landmark Insurance Agency, Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 198 Massachusetts Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. North Andover MA 01845-4190 COMPANIES AFFORDING COVERAGE Charles S. Randone Phone No. 978-688-8829 Fax No. 978-975-3987 COMPANY A National Grange Mutual INSURED COMPANY B Canney Electric COMPANY Thomas P. Canney C P.O. BOX 118 Methuen MA 01844 COMPANY D COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO LTR TYPE OF INSURANCE POLICY NUMBER POLICY DATE (MM/DD/YY) POLICY (MM/ D/YY)N LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ 2000000 *A X COMMERCIAL GENERAL LIABILITY MPP93743 02/10/00 02/10/01 PRODUCTS - COMP/OPAGG $ 2000000 CLAIMS MADE ❑ OCCUR PERSONAL &ADV INJURY $ 1000000 EACH OCCURRENCE $ 1000000 OWNER'S& CONTRACTOR'SPROT X BOP FIRE DAMAGE (Any one fire) $ 500000 MED EXP (Any one person) $ 10000 AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per person) HIRED AUTOS NON -OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY . EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY JOTH. TORY LIMITSi ER EL EACH ACCIDENT $ THE PROPRIETOR/ INCL PARTNERS/EXECUTIVE EL DISEASE . POLICY LIMIT $ EL DISEASE - EA EMPLOYEE $ OFFICERS ARE: EXCL OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS Electrical Wiring CERTIFICATE HOLDER CANCELLATION NORTHA3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Town of North Andover Charles Street Attn: Electrical Inspector 27BUT 27 C EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY North Andover MA 01845 OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Charles S. Randone �.%�/►Z�-ti. ACORD 25-S (1/95) " ACORD CORPORATION 1988 I), N2 4691 Date /� .......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING J This certifies that ......... . 7 ..................... .......... has permission to perform ...... ........... plumbing in the buildings of .... ............................. .• ............ I North Andover, Mass. Fee./.` ...... Lic. No. . . . . . . . . . . . —PILUIAAGA4SPECTOR Check # -" I/- � WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 19 V NVIDI D313 AS S)IHVW3H O 7 m F 0 0 0 V z (� 3 N v m rt m m n. Z tin Q 7 Q 0 O 7 m F 0 0 0 V z MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location 7,�- /10 ti Owners Name of New M Renovation Replacement Date �/ 1611-0 d Permit #— Amount a( &W Yes F� No (Print or type) Installing Company Name Check one: M Corp. `Partner. , n Finn/Co. Name ofLicensed Plumber. L'���ti�r�7�✓� // �C�-L Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 0 Other type of indemnity ❑ Bond ❑ Certificate Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance " Signature Owner r-1Agent 11 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 Massach Plumbin e�yttj C 22ftLneral Laws. By Igna oi Licenseaum er / Type of Plumbing License Title �� o City/TowniceXJ2seNum5er Master C/1 Journeyman APPPROROVED (OFFICE USE ONLY •M IT. 33 Bel......................... (Print or type) Installing Company Name Check one: M Corp. `Partner. , n Finn/Co. Name ofLicensed Plumber. L'���ti�r�7�✓� // �C�-L Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 0 Other type of indemnity ❑ Bond ❑ Certificate Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance " Signature Owner r-1Agent 11 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 Massach Plumbin e�yttj C 22ftLneral Laws. By Igna oi Licenseaum er / Type of Plumbing License Title �� o City/TowniceXJ2seNum5er Master C/1 Journeyman APPPROROVED (OFFICE USE ONLY 3��5Date ,- :r ..................... N�TM TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that-h:��' 'ti ��� %� : tom.. .. . has permission for gas' installation .. .....................• .: •`•y in the buildings of'` ....... . . I .: ......................... . at .. - ' .. • . "`•' • • • • • • • • • • , North Andover, Mass. Fee? ...... Lic. No. f `y;/ .. ........ "................ . GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer r i d MASSACHUSETTS UNIFORM APPLICATON FOR %1M Sv 6 yee (Type or print) / NORTH ANDOVER, MASSACHUSETTS MAP 1 cQ- .9 PARCEL TO DO GAS FITTING Date //, -) - ��o G Building Locations / Permit # && li Amount $ Owner's Name New ❑ Renovation IT Replacement Replacement ❑ Plans Submitted ❑ (Print or type)k Corp. one: Certificate Installing Company Name /� F -IC ` I47 -( f--I��G LCL �' , A � %Gi ❑Partner. / ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURAN 4E COVERAGE Check one: I have a cur nt liability Insurance policy or it's substantial equivalent. Yes No❑ If you have cDecked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Iza— Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Cha lr nnP- Sianature of Owner or Owner's Aaent Owner ❑ Agent ❑ I nereny cenity that an of the aetarls ana lntormatron 1 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 Massachuseqs�4t4t<Gas Code aed Chanter 142 ofSlseJagneral -Laws. (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber = GZ-12— 1�' ❑ Gas Fitter License Number 0-M- aster [:]Journeyman • • (Print or type)k Corp. one: Certificate Installing Company Name /� F -IC ` I47 -( f--I��G LCL �' , A � %Gi ❑Partner. / ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURAN 4E COVERAGE Check one: I have a cur nt liability Insurance policy or it's substantial equivalent. Yes No❑ If you have cDecked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Iza— Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Cha lr nnP- Sianature of Owner or Owner's Aaent Owner ❑ Agent ❑ I nereny cenity that an of the aetarls ana lntormatron 1 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 Massachuseqs�4t4t<Gas Code aed Chanter 142 ofSlseJagneral -Laws. (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber = GZ-12— 1�' ❑ Gas Fitter License Number 0-M- aster [:]Journeyman Location R4414,1 No. Date 119-0' U v TOWN OF NORTH ANDOVER /y,?- )lIkj f Building Inspector i Certificate of Occupancy $ 'TS'"'°''<�' �ICHU Building/Frame Permit Fee $ Foundation Permit Fee $ a Other Permit Fee $ + TOTAL $ d Y Check # _� /y,?- )lIkj f Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUELDING PERMIT NUMBER: ! DATE ISSUED: C SIGNATURE: /ti Building Commissioner/IEfjwor of Buildings Date SECTION I- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 9 /"u 1�7a.,P, Stir e c t� 4pa-1-- ap Number 1.3Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water S ly M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 S e Disposal System: Public X, Private ❑ Zone Outside Flood Zone ❑ Municipal On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record _ J,oA,a //V. arC 9.2ati,� CoQ Vii° �'avP Name (Print) Address for Service: 978 30 F Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed ConstructionSupervisor: Not Applicable ❑ PA( % 6�J L ya cC Cid Licensed Construction Supervisor: 0 � S 0 M 8/ - ! %o /yly / t �C (e' j1a �� ©��%o CJT�' (r��� License Number Addres &_a 1421,211-01 cJ Expiration Date ' Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name O 67clf H Cr �r f k- Registration14um/ber ,3131%/ Address dz—�Telephone 78 70 —.788 Expiration Date Si nature 00 rn X Z O rn 0 1 CJ O Z rn 90 O Mnr v M _r Z P1 SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes ....... V No ....... 0 SECTION 5 Description of Proposed Work checkall a Ucable New Construction ❑ Existing Building Repair(s) ,t Alterations(s) �K Addition ❑ Accessory Bldg. ❑ 1 Demolition ❑ 1 Other ❑ Specify Brief Description of Proposed Work: Oft I SECTION 6 - ESTIMATED CONSTRUCTION COSTO I Item Estimated Cost (Dollar) to be Completed by permit applicant -; , " OFFICIAL USE oNLY,.-11 1. Building ¢s 000 (a) Building Permit Fee Multi lier 2 Electrical X/000 (b) Estimated Total Cost of Construction 3 Plumbin 0 Building Permit fee (a) X (b) , � q I,--- /5 4 Mechanical HVAC 0 Q 5Fire Protection O 6 Total 1+2+3+4+5 .2 5-53 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, fit. `�`J?�%r �✓ as Owner/Auftew*w*j*sat of subject property Hereby authorize Z"9 y / /S My behalf, in all matters relative to work by this building pennit application. A Signature of Owner Z� Date SECTION 7b OWNER/AUTHORIZE A E DECLARATION _to act on 1, as 6= eeAuthorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief .//41 C� Print Name i of Qvmeo el c/o C9 c./(,f-- iG/500 Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST 2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE x9e /-./ ./ 11 Town of North Andover Building Department 27 Charles Street North Andover, Massachusetts 01845 (978)688-9545 Fax(978)688-9542 DEBRIS DISPOSAL FORM f p►ORTH O �t�.mo �b'9ti 00 0 � M +�X \SACHuW In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, sl 50a. The debris will be disposed of in /at: Facility location Signature of Applicant l� Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. ' � �c �'amono-nu�eall�e n�.� iir�k;nr/+u,:riz`a � = = ;: ,= 08E I8PR4VEBEl;I CONtRACI4R Registration: 129432 - Expiration: 8/31141 .. ' Type: DBA Bevacqua Enterprises QBevacqua Gavin Circle �gpMiNiSTRATOR Andover Mp 41814 ✓lae Uan�,nanu�xr� v� u BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 08$815 Birthdate: 10121/1949 Expires: 10/21/2001 Tr. no: 8368 Restricted To: 00 PAUL D BEVACQUA 10 GAVIN CIRCLE ANDOVER, MA 01810 Administrator i a 0 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 62111 Workers' Compensation Insurance Affidavit Please Print Name: Location: City Phone am a homeowner performing all work myself. �I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. ac v Address >✓ City: /l 1/0/Ifle, Q/8/0 Phone#: 670 Y70 –38Pe' Insurance Co. &S lean Osua & POliCy # Gy!�' ✓ 300/ 1t QY Company name: Address City: Phone # — Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify und" pains and penalties of perjury that the information provided above is true and correct. Signature. Print Official use only do not write in this area to be completed by city or town official' ❑Check if immediate response is required Building Dept Contact person:_ Phone FORM WORKMAN'S COMPENSATION Phone # r-1 Building Dept E] Licensing Board F1 Selectman's Office E, Health Department 0 Other C/) m U) 0 m _v, y CD Di � O n Z CO) CCD O 'Oo d rk C ? O CL CO) a� 0 o CD CD o CLQ d CD CD O CD C CD co) d 0 y O �Q COD v CA O -o Z O O O CD CD rye• �J tx La 1•� cn cn n 0z i C c?=o°7 = O -•yoQ CA §d o m .a Ns 4Ramo ® tC n G n '� m � 0) H 17 o. o .... �omd 0 Cm/d y � O =r CD CCD m 0 p C y: n W a m C =r= -O: ce ' d �Or,dW m CD H CD n'fl C CL03 col CD dCAh ccl �"a Cr :a _a < cco CD: _ = N o CA `m CD: wy :dp co ON .•�' t0 .nr r to ® a o s z N 'v o CD =: CD C o•: oc D m m �o� c� OCA" � o C O E O � Cn W A W OTJ �y 9 ?f gi �a Cn 7d Al z r A z ::rC n� m o ✓fir ncn b - .n Co a n C) b C x z 0 O C ►s 1'... 5.-'% No ' /— Date./........... . ............... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......................................... !... ............................................. has permission to perform .................. ............................................................... wiring in the building of ............................... at ... ................... . .... ................ . North Andover, Mass. ................................. Fee//................ Lic. ................. ................... 'EE" C*'r* R**I*C* A*'L* *iN"S*P—E'C"r'0R WHITE: Applicant CANARY: Building Dept. PINK: Treasurer � COMMONWF.4LT71OFiVL4- S4L711,,SE Office Use only DF ARTA1ENTOFPUBLICSIF= Permit No. BOARD 0FFIREPREYF1V770NREGUTA770NS527CY/R11:00 Occupancy & Fees Checked APFLICA77ONFORFF,RAlTTOF,7ZFORMLLE=CAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORIVIATION) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. IAP �„� J PARCEL (Dr--> Q 9 . Location (Street & Owner or Tenant Owner's Address Is this permit in con Purpose of Building with a building permit: Yes = No (Check Appropriate Box) Utility Authorization No. Existing Service �—c= Amp && Volts Overhead Jnderground No. of Meters New Service Amps / Volts 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 No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground and No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets " No. of Gas Bu=rn FIRE ALARMS No. of Zones No. of Ranges f 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 Sims Bailasis No. Hydro Massage Tubs No. of Motors Total HP O=- In�Cot�agt+ pLastm�lflther�ana�oi�Ga�'aliaws Ihawatu a Lialaklt ' 1a)d%CCMP10le C0AMXCr&sutS=bal04ffW1a1 YES NO Ibawsu valtdtotheOfca YES IJ if whawdb2c�YES, indica(ethetypeofooe Wbyd-jEdmlgthe INSURANCE BOIZ Q UIHETL (Fuse Spcdy) Expna I)Eue Estrrn&dValxdEb±icalWc& $ W(>3ctoStart 6 Rot>gll Emal SUrdun±rTr l ofp Licrisee ,1//�/ f t� Sio=re / BL>Sa=Td.No. L --C/ !✓r%� �Z �/ �-- n'� AlTeiNi _ —�1 % OWNER'S INSURANCEWAMR Iainawaretml.-ff does notluw dm,,rar=ammwcrjtsL alequ4kriasreqmerlbylvlgsmdmseltsCkmalLaws arra that my simmbze cn this F=Tl aFph*caticn wars this to 4mt matt (Please check one) Owner Agent Telephone No. PER1vUT FEE S u_mamre ot owner or Agcm Location 9 /a, No.y Date ,40WTh TOWN OF NORTH ANDOVER o?oi...o ;•,ho�� Certificate of Occupancy $ Buildin.g/Frame Permit Fee $ (,E% S O C � Foundation Permit Fee $ I {� Other Permit Fee $ 'G' Y Sewer Connection Fee $ �— S; ��ater Connection Fee $ TQTAL $$}- 4. , SO Building Inspector 6683 Div. Public Works 1?FRJiIT 1VOr APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP KJO. "f a I " I LOT NO. f7 IV f, �_ 2 RECORD OF OWNERSHIP DATEQ BOOK PAGE ZONE SUB DIV. LOT NO. Y I 328 i S LOCATION 9a ��,` /� /V PURPOSE BUILDING �Ai2AG g 0vP.�r/✓oP OWNER'S NAME �,� NO. OF STORIES / SIZE f OWNER'S ADDRESS r/t/r9In CAA BASEMENT OR SLAB - ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME SPAN DISTANCE TO NEAREST BUILDING ti J.�.. DIMENSIONS OF SILLS POSTS DISTANCE FROM STREET ^/3o L!�gdT DISTANCE FROM LOT LINES - SIDES ? F'4.. REAR 4 7te. GIRDERS AREA OF LOT /�,cwo s�e FRONTAGE/u,Z 1C4 HEIGHT OF FOUNDATION h/ THICKNESS�i IS BUILDING NEW Y4s SIZE OF FOOTING x IS BUILDING ADDITION[ Vg.5 MATERIAL OF CHIMNEY -� IS BUILDING ALTERATION) '.'Jo IS BUILDING ON SOLID OR FILLED LAND { �p •'v. WILL BUILDING CONFORM TO REQUIREMENTS OF CODE yg^.•77 � IS BUILDING CONNECTED TO TOWN WATER Lo BOARD OF APPEALS ACTION. IF ANY PCITfi%O�/ d10. ���3 IS BUILDING CONNECTED TO TOWN SEWER 1,0 644AMD IS BUILDING CONNECTED TO NATURAL GAS LINE No INSTRUCTIONS 3 PROPERTY INFORMATION ID LAND COST SEE BOTH SIDES so 3 4p-mp EST. BLDG. COST ���� 13 of PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FI, A / '� �Q - mADn se UWAR Tu OF OWNER OR AUTHORIZED AGENT FEE tT J\Q 11U S/ PERMIT GRA N Tf 19 L� OWNER TEL CONTR. TEL. # CONTR. LIC. # OCT 2 91993 PLANNING WARD WARD OF SELECTMEN �UILDINa INSP[CTOR BUILDING RECORD 1 OCCUPANCY 12 THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA - RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. ��RR ^# i SINGLE FAMILY x STORIES 11 HEATING MULTI. FAMILY OFFICES APARTMENTS FORCED HOT AIR FURN. _ CONSTRUCTION 2 FOUNDATION STEAM 8 INTERIOR FINISH CONCRETE PINE HARDW D 3. 1 _ 2 13 CONCRETE BL K. BRICK OR STONE PIERS PLASTER DRY WALL UNIT HEATERS _ UNFIN. 3 BASEMENT I n crrOir AREA FULL FIN. BM'T' AREA '4 '/v '/. FIN. ATTIC AREA y _ N_O B M T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS CONCRETE B _ FLOOR 1 2 3 _ — DROP SIDING WOOD SHINGLES ASPHALT SIDING ASBESTOS SIDING VERT. SIDING _ EARTH HARDW D COMMCN ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME ATTIC STIRS. b BRICK ON MASONRY BRICK ON FRAME CONC. OR CINDER BLK. WIRING STONE ON MASONRY _ STONE ON FRAME SUPERIOR I� POOR _ ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP GAMBRELMANSARD FLAT I SHED w BATH 13 FIX.) TOILET RM. (2 FIX.) WATER CLOSET _ _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING je TAR & GRAVEL STALL SHOWER ROLL ROOFING MODERN FIXTURES Ist 13rd I II NO HEATING { y l �I TILE DADO I - `w 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. 3 COLS. STEAM STEEL BMS. 3 COLS. HOT W'T'R OR VAPOR WOOD RAFTERS %r AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GOAS lL I n crrOir Ist 13rd I II NO HEATING { y l FOR14 U— LOT RFLrnSF FOR11 INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and pepartme*+ts having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant APPLICANT:;elw �/l/�i I fills out this A ��2Tl�TTPhone section***************** // 49S-3©+�' .� 9Z -Ir LOCATION: Assessor's Map Number ;2f Parcel 3a Subdivision Lot (s) Street "'V7-Allfl7 /(aha St. Number - 1 ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Date Data ec Rejected wed Comments Date Approved Town Planner Data Rejected Comments Date Approved Health Agent Date Rejected Comments Public Works - sewer/water connections , /,0 Z9 - 93 V✓- driveway permit / - 0 _ 2� 7-5 ire Deaartment f% f�©��`�� Received by Building Inspector Date I Town of North Andover BUILDING DEPARTMENT Homeowner License Exemption (Please print) DATE 101,W91 JOB LOCATION 9,� Number Street A ress limy Section of town "HOMEOWNER" dOA/��/l�i /Gf�N. ��J�2il iT o�9.1%30`1i 9A5--2z15- Name Home Phone Work Phone PRESENT MAILING ADDRESS 9Z�T,i//,W j(-021,rp Al &avz5 % 018ys City own State Zip code The current exemption for "homeowners" was extended to include owner occupied dwellings of six units or less and to allow such homeowners to engage an individual for hire'who does not possess a license, provided that the owner acts as supervisor. (State Building Code, Section 109.1.1) DEFINITION OF HOMEOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one to six family dwell- ing, attached or detached structures accessory to such use acid/or farm .structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit .to the Building Official, on a form acceptable to the Bulding Official, that he/she shall be responsible for all such work,,performed udder the building permit. (Section 109.1.1) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other applicable codes, by-laws, rules and .regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/sh will o ply with said procedures and ,requirements. 'HOMEOWNER'S SIGNATURE i �7y� APPROVAL OF BUILDING 0 ICIAL Note: Three family dwellings 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127.0, Construction Control. C Any appeal shaW be filed • u1c. Dpi• } ., _:, n within (SC) :'a�,-; �f�er the. <..;,��• V. : s, Lass ; • R X93 date of f is nb,a ;:f tris jtlllotice � ;ss+'criu��U, Q� I� in the Office_ of the Town TOWN OF NORTH ANDOVER ► MASSACHUSETTS ATi'ESt A True Copy BOARD Of APPEALS NOTICE OF DECISION Town Clerk Date ..Augus.t 17, . 1993........ . Petition No.. 037-93.............. Date of Hearing. .August..1Q.. 1993. Petition of ..... John .B.. and. Nancy. N... Bartlett .......................................... Premises affected 9.2 .Putnam .Road ..................................................... . Referring to the above petition for a variation from the requirements of tix .. S?coon , Paragraph 7.3 and .......................... Table 2 of.the Zoning Bylaw...................................... so as to permit .relief. .Qf. sev.en.(7). fe.et.for.. the. side. yard. setback. and. :twenty-four .(24) . fee.t .fQr. the- .rear- setback. in..o.rder. to. .cQnstruc.t..an.addition. stall .to. an... existing garage. After a public hearing given on the above date, the Board of Appeals voted to ..GRANT ..... the variance .................... .... and hereby authorize the Building Inspector to issue a permit to ..John. B.. and.Nancy-.N.. Bartlett ........... ................................... - - - - - Signed Frank Serio, Jr., Chairman William'Sullivan, Vice-chairman Louis Rissin ......................................... Robert Ford .. .................. Board of Appeals Zk d Cj Q C - 0 a° r-- �_:- O th__-_ Zk d Cj Q C - 0 a° w �cY-01 +� a 1 , DIETZG �o FN_100„ Rag_Tracing-. VAllum .- - - - --- .:-- ------_--- -- - --=------- -- �-'— -- --- -------._-- -- -- •----- --- � _ _ .. i n y r 1 , DIETZG �o FN_100„ Rag_Tracing-. VAllum .- - - - --- .:-- ------_--- -- - --=------- -- �-'— -- --- -------._-- -- -- •----- --- � _ _ .. - -- - -- - : - i I ------------ i : 1 1 : } 3 X — - =.--5 -` - - -- - - : -- — -- �. -- ----. -- --- - -- -- i --o - -- IA , i 7-7 a i •- I I �`L '1 1 I i i : - - -- - -- - : - I ------------ : I _DIETZGEN-1oo4--Rig_.Trating Vellum___.__._._.__ __ I I �77-77'76 777 I ig �Rt.4r i%wo �54,54 'In AS ..... ..... —04 PL, Pr �—j C=:>f=— Q H qq -15 LANG SV C;. P- t -L L -<7-T- ----"X, RE CE FCR: N0 R TH DISTRICT ESSEX 0? D-"E:D" L.!%WTj,EIT(,'77' 01840 REGISTER OF DEEM &L REGISTER OF DEEM D Z Z ii C7 O z m Do D O z T z D r 0 C � CO)CD C7 0 z CO) Q O n� r � � O CL =' CO) O O CD CDCLO O cr CD CCD O CD _� C O Vii �v y O tC O CD � v yO CD CD zo o CD 0 co O -•in0c CA ao4ccD w � 0 CD Cl) o y 0 no P. m N 0 co - cL Mn co 0) CD � o CO H p OCD CD CA CD OCC] o •-► Gy' CC'! COco)411" m a""'^` f co co CA ~ U2 o 0 c co CA Im ca � Q Z {6.`l_JJi C l C3 'Wr 1 '� CA CCD y C/) H o CD CD O O ... G O co 0 � �y�� Kolb � • :rt C* -- dco M� aM- s �� • 0 z o o cn 3 (n . W a R C7 � m 0 < o91 G y w 7� c z m y c -n c 7 z cn b � O p d ON 0 0 c 4174 Date. ......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that has permission to perform .............. ......................... plumbing in the buildings of .................. at ...................................... North Andover, Mass. Fee ,.' 7. .. Lic. No f ....f ................... PLUMBING INSPECTOR" WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR P MIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date /d-Ld .7? Building Location q Z p _,...,,J Owners Name Permit #Q 4117 Y�� Amount t Type of Occupancy.—Q1'"^a' New ri Renovation Replacement [3 Plans Submitted Yes ® No FIXTURES (Print or type) Check one: Installing Company Name 0 r Ll --i A al � � �/ 0 Corp. _ Address S G '4 0. b ojE 1q, A✓ tZ Partner. S' Atrt=K-1 /V• H, 0- 6?9 Business Telephone G o -3 .3 .3 ► [ErFirm/Cc Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage bv checking the appropriate box: Certificate Liability insurance policy IJ Other type of. indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance ,Signature Owner Agent F1 I 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 Plumbiin Co and Chapter 142 of the General Laws. By: SignalA of icen'L s ,d'Ffum e- v �� Type of Plumbing License Title 715-0 7 City/Town License Number Master APPROVED (OFFICE USE ONLY Journeyman ❑