HomeMy WebLinkAboutMiscellaneous - 96 OLD VILLAGE LANE 4/30/20189877
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Date......!...-.. 3......l...�
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ................ :. J.. ge...... z `••G `L
has permission to perform ........,..................................::�...............
wiring in the building of ....................... Sv [. L!..!!li.............'.................
at ........j. i.. .(���.�..�,1.�..... /r. v ................... orth Andover, Mass.
Fee ..................... Lic. No. �� 3 .................
Eu cwt, itvse x � j
Check #
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,\,El< 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. p. 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 corpormition 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 theinspector_of _Wires abandoned.and-invalidsflie—.._ .
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 entitystated 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
puipose 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 an xtending"through August 15, 2012.
Rule 8—Permit/Date Closed:Pate
fL *** Note• Reapply for new perm
0 Permit Extension Act — Permiosed:
r
C.oinnsonwea&o/7 Vda."tb
Aparimed o1.}ire Servicee
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. gZ77
Occupancy and Fee Checked
[Rev. 1/071 leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code C), 27 CMR 12.00
(PLEASE PRINT IN INK OR TYPE AT,L INFO TION) Date: ` f t/ /
City or Town of: (� To the Inspecto of Wires:
By this application the undersigned gives notice of his or her tention to erf rin the electrical work described below.
Location (Street & Number) _ f `�j�r�
Owner or Tenant
Owner's Address
M
ppj
Telephone No.
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service
New Service
Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: 2 K k) KA /
rmi:..., fit t r1 .., LI- —' L---` 11 .1 1
No. of Recessed Luminaires
-- -
No. of Ceil.-Susp. (Paddle) Fans
— rvut veu Uy tete inspector o Yvires.
o. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators -4- KvA
No. of Luminaires
Swimming Pool Above ❑ n- ❑o.
nd. grnd.
of Emerge-n—cy-Eignting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
o. of Detection an
Devices
No. of Ranges
TotInitiatin
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Number
•"
ons
-'
'"`-'""
o. of Self -Contained
Detection/AlertingDevices
No. of Dishwashers
Space/Area Heating KW
Local ❑municipal ❑ Other
Connection
No. of Dryers
No. of Water KW
Heaters
Heating Appliances KW
No. of o. of
Signs Ballasts
Security Systems:*
No. of Devices or E uivalent
Data Wiring:
No. of Devices or E uivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications
No, of Devices or E uivalent
OTHER:
arracn aaattionai detatt y desired, or as required by the Inspector of Wires.
Estimated Value of le -hical Work: (When required by municipal policy.)
Work to Start: / 0 Inspections to be requested in accordance with NEC Rule 10, and upon completion.
INSURANCE C GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability in urance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such cove e is in force, and has exhibited proof of s e t� tnhef rmit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) /�Ki/ �tO
I certify, under the pains a aloes ofperyinformatiu, l this application is true and complet �c
FIRM NAME: ALIC. NO.: � V 7
Licensee: 5-A-;0,J0kt4-A `J -y b>4 Signature LIC. NO.-
(If applicable, enter "exempt" int a lice �/,�se number lino1 J Bus. Tel. No.'
Address: CF//(3r�i�i a/ 0
Alt. Tel. No.:
*Per M.G.L. c. 147, s. 57-61, security work refuires Department o Public Safety "S" License: Lic. No. V6 0
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
Signature Telephone No. PERMIT FEE. $
TOWN OF ANDOVER
ELECTRICAL PERMIT FEES
(Effective March 12, 2003)
NO SE CABLE ON
OUTSIDE OF BUILDING
Air Conditioners: $40.00 each
Alarm Systems Security: (for fire
systems see smoke/heat detectors)
Residential: $40.00
Commercial: up to 10 Devices
$60.00 additional devices over 10-
$1.00 each
Carnival Equipment: $50.00 each
Ceiling Fans: $1.00 each
Commercial New Construction or
Alterations:
$100.00 per 1,000 Sq. Ft. of
Construction Space
Commercial Service Change/
Repair:
Must have Utility Authorization Number
$100 (first 100 amperes or fraction, one
meter)
a) each additional 100 amperes
capacity or fraction. $30.00
b) each additional meter $25.00
Commercial Temporary Service:
$100.00
Must have Utility Authorization Number
Commercial Repair and/or
Maintenance Permit: (Blanket
Permit) up to 2 Electricians $150.00
per pair of Electricians over 2 $50.00
Data/Telecommunication:
Residential: $1.00 per port
Commercial: $30.00 up to 10
devices over 10 - $1.00 each
Dishwashers & Disposals:
$5.00 Each
Dryers: $15.00 Each
Emergency Lighting (Battery Units)
$ 1.00 each unit
Feeders or Sub -feeders:
each 100 amp capacity of fraction
thereof
Residential: $5.00 each
Commercial: $15.00 each
Gas/Oil Burners:
Residential: $20.00 each
Commercial $20.00 each
Generators Residential &
Commercial:
a) including photovoltaic &
generating Equip Per KVA $1.00
b) un -interruptible power systems,
per KVA $1.00
c) batteries over 100 amp. hours, per
cell $1.00
Heat Devices: $1.00 each
Heat Pumps: $40.00 each
Hydro -Massage Bathtubs/ Hot
Tubs: $20.00 each
-Lighting Fixtures $1.00 each
Lighting Outlets: $1.00 each
Major Appliances: (not listed)
$20 each
Motors: (per hp or fractional part
thereof) $2.00
Oil /Gas Burners:
Residential $20.00 each
Commercial $20.00 each
Office Furnishings: per circuit $10
(Relocatable Partitions/Cubicles
Outlets & Fixture: $1.00 each
Ovens Built in/Counter Top Units:
$10.00 each
Panel Change/Circuit Breaker:
Residential: $20.00
Commercial: $25.00
Phone Jacks: See
data/telecommunications
Ranges $15.00 each
Receptacle Outlets: $1.00 each
Recessed Fixtures: $1.00 each
Re -inspection Fee: $25.00
Repair to Service Residential:
$20.00
Residential New Construction
(Dwelling): $220.00
(with service up to 200 amps)
Must have Utility Authorization Number
for services over 200 amps see below
a) for each 100 amps capacity or
fraction add $20.00
b) each additional meter $10.00
c) each additional panel/sub panel
$25.00
Residential Additions/Alterations:
$220.00 maximum
Residential Service Change or
Underground Service:
$40.00
]dust have Utility Authorization Number
a) one meter, up to 100 amp capacity
$40.00
b) each additional 100 amp capacity
or fraction $20.00
i
c) each additional meter ..$10.00
Sewer Ejection Pump: $25.00
Signs: $25.00 each ballast
Smoke & Heat Detectors &
Initiating Devices:
Residential: $1.00 each
Commercial: $60.00 up to 10
devices over 10 - $1.00 each
Space Heaters:
area heating $1.00 each
Sub -Panel: $25.00
Swimming Pools:
Residential:
Above Ground: $25.00
Inground: $50.00
Commercial Pool: $100.00
Switches: $1.00 each
Temporary Service:
Nfust have Utility Authorization Number
Residential $25.00
Commercial $100.00 "
Transformers:
a) capacitors, Per KVA $ LOV
b) ducts, conduit & conductors
(Associated w/ Padmount Transformers) $:
c) each manhole $10.00
d) each handhold $5.00
e) per KVA $1.00
f) primary feeders, $25.00 each (ove
600 volts, non-utility owned)
vaults and equip. $25.00 each
Washers: $15.00 each
Waste Disposals: $5.00 each
Water Heaters: $30.00 each
For Multi -Family & .
Large Commercial P� ojec
see Wiring Inspecl®0or
pricing:
Paul Kennedy (978) 623-8306
(Office Hours 8 ani to 1.0 ani)
:Inspection Schedule:
I ROUGH
I FINAL
I TRENCH (if applicable
ADDITIONAL
INSPECTIONS *$25.00 (if
applicable)
(revised 07/05)
Date...
" 37'72
NORTq
<�•° •1"o TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
�o A
SSACHUS�
This certifies that ........... ..................
has permission to perform ... ..................
plumbing in the buildingo ........................ g
at ...... �. �P.... .. ..... ... , North Andover, Mass.
co
Fee�7... Lic. No .......... ..............................
l PLUMBING INSPECTOR ti
0
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
Sa..\
MASSACHUSETTS UNIFORM APPUCATION FOR PERMIT TO DO P MBING
(Print or Type)
NORTH ANDOVER, ,Maas. Osie _19 %
Buildln0/ ,� PermK
Locallon ZG� U/��i�9b�
Owner's
Name ��/a�ii�
F�
7
New M-' Renovation ❑ Replacement ❑ Pians Submitted: Yes ❑ No. ❑
FIXTURES __.....
C1'
Insialllnp Company Name
Address
®ualnr•.�� �-
Y
Check one: Certificate
❑ Corp.
0 Partnership
(RFlrm/Co.
Name of Licensed Plumber
INSURANCE COVERAGE: UnecK one
I have a current Ilabilty Insurance policy or Its substantial equhWenL Yes ❑ No ❑
It,you have checked Y". please Indicate the'tVpe coverage by checking the appropriate box
A fiLbllly Insurance policy 9 Other type of Indemnity 11 Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the Ilcensee does not have the Insurance coverage required by
Chapter 112 of the Maas. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner ❑ Agent ❑
a ure of Nvnef a Owners AGent
I hereby certify that al of the details and Informatlon I have submitted lot entered) In above appflcation are true and socwat• to the best of my
It and that 11 plumbing wak and Installations performed under the permM t two ap will be compliance with an
pertlnent provisions of •Massachusetts State Pkembbg Code and Chapter 1 Laws.
SIChafixii of Licensed
``//
ucense Nurnlet Ale--f-
Type of Plumbing License: Master ❑
Journeyman
0
MiiiiOii101010101■�nNMI
■
...........MUNI
....
C1'
Insialllnp Company Name
Address
®ualnr•.�� �-
Y
Check one: Certificate
❑ Corp.
0 Partnership
(RFlrm/Co.
Name of Licensed Plumber
INSURANCE COVERAGE: UnecK one
I have a current Ilabilty Insurance policy or Its substantial equhWenL Yes ❑ No ❑
It,you have checked Y". please Indicate the'tVpe coverage by checking the appropriate box
A fiLbllly Insurance policy 9 Other type of Indemnity 11 Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the Ilcensee does not have the Insurance coverage required by
Chapter 112 of the Maas. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner ❑ Agent ❑
a ure of Nvnef a Owners AGent
I hereby certify that al of the details and Informatlon I have submitted lot entered) In above appflcation are true and socwat• to the best of my
It and that 11 plumbing wak and Installations performed under the permM t two ap will be compliance with an
pertlnent provisions of •Massachusetts State Pkembbg Code and Chapter 1 Laws.
SIChafixii of Licensed
``//
ucense Nurnlet Ale--f-
Type of Plumbing License: Master ❑
Journeyman
0
:location_
Yo.
N
5
Date 9 — - '- /"L
TOWN OF NORTH ANDOVER
F, A-aaWdiftp
Certificate of Occupancy
r�ilding/Frame
$
Permit Fee
$
Foundation Permit Fee
$
.� Other
Other Permit Fee '
$ -
,�;1+
OIL
c��,Q Connection Fee
$
G®r
Water Connection Fee
$
TOTAL
$
Building Inspector
Div. Public Works
APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
W
PAGE 1
MAP 4-40.
LOT NO.
I
2 RECORD OF OWNERSHIP DATE
BOOK 'PAGE
ZONE
SUB DIV. LOT NO.
-I
LOCATION
PURPOSE OF BUILDING .Z%GSL
OWNER'S NAME ry t
NO. OF STORIES U SIZE
OWNER'S ADDREVS
v
BASEMENT OR SLAB
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME
SPAN
DISTANCE TO NEARS T BUILDING
DIMENSIONS OF SILLS
DISTANCE FROM STREET
POSTS
DISTANCE FROM LOT LINES — SIDES REAR
" " GIRDERS
AREA OF LOT FRONTAGE
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE OF FOOTING X
IS BUILDING ADDITION
MATERIAL OF CHIMNEY
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION, IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
-
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS
SEE BOTH SIDES
PAGE 1 FILL OUT SECTIONS 1 - 3
PAGE 2 FILL OUT SECTIONS 1 - 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
YPLANS MUST BE FILED AND APPPROVED BY BUILDING INSPECTOR
DATE FILED 41�,//
E OFz OWN OR AUTHORIZED AGENT
h 11)FYI J74 97-f42
FEE 5z;z V V
PERMIT GRAN ED
J -4Al� 19
�a %413
5-1
y
OWNER TEL, #-
CONTR. T E, ff 25 am6
CONTR. LIC. N12,igDTf _
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST O
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
BUILDING RECORD
1 OCCUPANCY 12 ,
SINGLE FAMILY
SiOR1ES
MULTI. FAMILY
OFFICES
APARTMENTS
CONSTRUCTION
2 FOUNDATION
8 INTERIOR FINISH
CONCRETE
B
1
2
13
CONCRETE BL'K.
PINE
BRICK OR STONE
HARDWLASTERD
PIERS
PLASTER
DRY VJALL
_
UNFIN.
3 BASEMENT
AREA FULL
FIN. B'M'TAREA
_
'/. 1/2 1/1
FIN. ATTIC AREA
_
NO 8 M
FIRE PLACES
_
HEAD ROOM
MODERN KITCHEN
4 WALLS I
9 FLOORS
CLAPBOARDS
CONCRETE
EARTH
8
_
1
2
�_
—{I_
�—
3
_
DROP SIDING
WOOD SHINGLES
ASPHALT SIDING
ASBESTOS SIDING
HARDVJ'D
COMMCN
ASPH. TILE
VERT. SIDING
_
STUCCO ON MASONRY
STUCCO ON FRAME
_
BRICK ON MASONRY
ATTIC STRS. & FLOOR _
BRICK ON FRAME
CONC. OR CINDER BLK.
WIRING
STONE ON MASONRY
STONE ON FRAME
SUPERIOR(� POOR
ADEQUATE NONE
5 ROOF
10 PLUMBING
GABLE
I
HIP
BATH Q FIX.)
GAMBRELMANSARD
TOILET RM. (2 FIX.)
FLAT
11
SHED
WATER CLOSET
_
ASPHALT SHINGLES
LAVATORY
_
WOOD SHINGES
KITCHEN SINK
_
SLATE
NO PLUMBING
_
TAR & GRAVEL
STALL SHOWER
ROLL ROOFING
MODERN FIXTURES
_
_
TILE FLOOR
_N
TILE DADO
6 FRAMING
I 11 HEATING
WOOD JOIST
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. & COLS.
STEAM
STEEL BMS. & COLS.
HOT W'T'R OR VAPOR
WOOD RAFTERS
_
AIR CONDITIONING
_
RADIANT H'T'G
UNIT HEATERS
7 NO. OF ROOMS
GAS
OIL
B'M'T 2nd _
to 13rd
ELECTRIC
NO HEATING
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.
Castricode Roofing & Siding
REPAIRS FREE ESTIMATES
Telephone: (508) 682-4266
MARIO CASTRICONE
61 Water Street, No. Andover, Massachusetts 01845
i
I/we, the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish
all necessary mat ials, labor and workmanship, to install, construct and place the improvements according to the following
specifications, to s and conditions, premises bglow described:
Owner's Name. G.%y�i v(�
.... .. .. . ......................
....... .. ..
......... ....
Job Address .............. L v
City . ... ..... . .. ....... State . .........................
SPECIFICATIONS
.'��-.. .G.?..�t k
r........ ................. %`'`'T L..... � .r��.� ,�,.... ........... .....
c.. ...rl..............(/.................................... .
.......... 4
'� ...:........G...'.,,............................................................................................................................... ................
..........................................................................................................................................................................................................................
................................................................................................................................................................................... ...............................
I ,
::.........................................:....... :. �Pz4....................
1
............... . .
.......................... .. a ....
Materials and labor to cost $(.���n .. �............ Payable �..... �......... on �................... and balance in ................
monthly installments of $ .................... each, payable on ........................ day of each and every month thereafter until paid
in full ( ............ % charge per year is to be added to above cost of labor and materials and is included in monthly payments.)
Contractor will do all of said work in a good workmanlike manner.
Upon completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accord-
ance with his (their) above obligation and a completion as requested by the contractor. Upon refusal to do so, contractor
may at its option declare the entire contract price or so much as then remains unpaid immediately due and payable. It is
agreed that if permitted by law contractor shall be paid by the owner(s), all reasonable costs, attorney fees and expenses,
in addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of this contract
and/or any lien in connection therewith.
It is further agreed that this contract may be assigned by contractor; and also that the obligations hereof shall bind
and apply to their heirs, successors or estates of the parties.
The undersigned warrant (s) that he is ( they are) the owner(s) of the above mentioned premises and that legal title
thereto stands of record in his ( their) name (s) .
PROVISO: This contract shall be void and of no effort if credit approved of owner(s) is refused.
There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any
agreements collateral hereto, nor is this contract dependent upon or subject to any conditions not herein stated. Any sub-
sequent agreement in reference hereto shall be binding only if in writing and signed by all parties.
J
Receipt of a copy of this contract is hereby acknowledged, and it is further acknowledged by the undersigned that the
foregoing provisions have been read and the contents thereof understood and that no representation or agreement not here-
in contained shall be binding upon the parties and that all of the agreements and understandings of said parties are con-
tained herein.
Owner or Owners are not responsible for Property Damage or Liability while job is in oper�tt y
IN WITNESS WHEREOF, the parties have hereunto signed their names this .. . da of . 19.. ....
Accepted:
(OWNER HAS 3 DAYS IN WHICH TO CANCEL CONTRACT) Signe .. ............. ........ .... ........��...'J....... �.... /
caner
Per ........ZNII.. 1�............................
epresentative
Signed...............................................................................
Owner
Signed......................................................................................
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Date.
NORTH TOWN OF NORTH ANDOVER
4,00L O
p PERMIT FOR GAS INSTALLATIONZ
'oACMU�'
hl"
This certifies that .............. .
has permission for gas
in the buildings ofi
at . v�;... ...
�o
Fee .57Lic. No...........
. ........ .
...4 ............ .
`^
7 .... , North Andover, Mass.
.
GAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT T DO GASFITTING t
(Print or Type) -
NORTH ANDOVER ,Mass. Date /
s ` !}iuilding Location Permit # `�-
,� Owners Name
New renovation Replacement Plans Submitted
• . FIXTURES
(Print or Type) Check one: Certificate
Installing Company Namez�440-0 �/G t� Corp.
Address 9/ //�/� Partner.
Firm/Co.
Business Telephone:�`��J
lame 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 Q Bond
• InsuraAce Waiver: 1, 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 17 Agent F1
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 petformcd under' Permit issued for this application will -be In compliance with all pertinent
provisions of the Massachusetts State Cas Code and Chapter 142 of tho General Laws,
-TYPE LICENSE:
Plumber
Gasfitter
/Si nature of Licensed
aster Plumber or Gasfitter
Journeyman
License Number,
V
•
. ...
■■■■■bio■m■■■■■■
■nm■■
■■■
.. .. -
■■■■■■■■■s■E
■■■■■
■■
�1 ...
monsoon
■■soon
■■
■■■moss■■■
A
Ross
Monsoon
(Print or Type) Check one: Certificate
Installing Company Namez�440-0 �/G t� Corp.
Address 9/ //�/� Partner.
Firm/Co.
Business Telephone:�`��J
lame 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 Q Bond
• InsuraAce Waiver: 1, 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 17 Agent F1
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 petformcd under' Permit issued for this application will -be In compliance with all pertinent
provisions of the Massachusetts State Cas Code and Chapter 142 of tho General Laws,
-TYPE LICENSE:
Plumber
Gasfitter
/Si nature of Licensed
aster Plumber or Gasfitter
Journeyman
License Number,