HomeMy WebLinkAboutMiscellaneous - 97 BRENTWOOD CIRCLE 4/30/2018 (2)Date ... /--7 ......
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that
has permission to perform....... .......... ................... .
plumbing in the buildings of ......................
v 4
at Ij ... & k & 7 r, M 6 ... (�e— ,.. North r &S
Lic. No.. .-3 . .......... . ....... .......
PLUMBING INSPECTOR
Check
MING
.mA.SSACRUSETTS VNIFORM APPLICATION ICOR 3PERYRT TO JD O PLU.
(Type or print)
NORTH ANDOVER, MASSACR=17S Date
Building Location �7 (�;• Owners Name �/� permit,�Amount -
Tvne of Occuvancy
New 0 Renovation Replacement
,cry mr-nD' e
Plans Submitted Yes No El
Check e: Certificate
(Priator type) ��J'
InstallingcompanyName AQ/ R ;� y6r�, 'QorP-
Partner.
FitmlCo.
t�
Name of Licensed Plumber. .—..r& ��
insurance Coverage: Indicate the a of insurance coverage by checking the appropriate bo�cBond
I iability insurance policy Other type of indemnity. 11
,Insurance Waiver. L the undersigned, have been made aware that the licensee of this application does not haire any one ofthe above
-three insurance _
•Signature Owner Agent
I hereby certify chat all ofthe details and information I have submiitpd (or entered) in above application are.tme and'accurate to the
best of mykmowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
rmmnl;a,;r.Pwith all uertinentnrovisions ofthe Massachu,soft State plum
cgde�pi4apter 142 ofthe General Laws.
CiVTown
APPROVM IOFF�CsuSR ONLY
Type ofPlumbing Ucense
censeum er Master ff'1 yman Q
7.46:
HORTI
D
x'95..... o •. G1t -° —
Date...*/j ........
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .. AJ,4VAI.....
has ermission for as installation . VO {..... ....1 /
P g •�'•�
in the buildings of......................... .
at.�.....f!?.��.�....0 �!' , North Andover, Mass.
Fee.. U. Lic. No. �S....�i
.GAS INSPECTOR
Check #
=-1
:-IA%ACHUSEM UNIFORM APPLICATON FOR PFa 'Vffr TO DO GAS FfrDNG
(Type or print) Date
NORTH ANDOVER, MASSACHUSETTS ---
Building Locations
Permit #
Amount.$
Owner's Name 9 >�
New ❑ Renovation Replacement Plans Submitted
(Print or type) y��
Name_ 090601" A�L(//lA60A -Oi&1414- A - ice.
Name of Licensed Plumber or Gas Fitter ��D� :7 -
Chea ne: Certificate Installing Company
Corp. 49411A
FlPartner..
E] Finn/Co.
INSURANCE COVERAGE Check on
I have a current liability Insurance policy or it's substantial equivalent. Yes No
If you have checked Yes, please i cate the type coverage by checking the appropriate. box.
Liability
Liability insurance policy Other type of indemnity1:1 Bond13
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 1.12 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•
beat of mti 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 StIrGas Code and Chapt�l43A the General Laws.
By:
Title
City,Town
:APPROVED (OFFICE USE ONLY)
bnature of:
Plumber
Gas Fitter
Master
Journeyman
sed Plumber Or Gas Fitter
i
ME( nse A umber '
•
•
IST. FL OR
14TEI.
FLOOR
,6TH. FLO-OR
(Print or type) y��
Name_ 090601" A�L(//lA60A -Oi&1414- A - ice.
Name of Licensed Plumber or Gas Fitter ��D� :7 -
Chea ne: Certificate Installing Company
Corp. 49411A
FlPartner..
E] Finn/Co.
INSURANCE COVERAGE Check on
I have a current liability Insurance policy or it's substantial equivalent. Yes No
If you have checked Yes, please i cate the type coverage by checking the appropriate. box.
Liability
Liability insurance policy Other type of indemnity1:1 Bond13
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 1.12 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•
beat of mti 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 StIrGas Code and Chapt�l43A the General Laws.
By:
Title
City,Town
:APPROVED (OFFICE USE ONLY)
bnature of:
Plumber
Gas Fitter
Master
Journeyman
sed Plumber Or Gas Fitter
i
ME( nse A umber '
Tlie Co�xuioiziyealtlz, qfMassqc11fqe&s
-.-,-,600iWashingtonS&eet
-,tit it
Bostoit, MA 02111
MPIP.Mass.90v1dia
Workers' CompensaflofiInsuran Afri6vii.- ttdd erdtoifitiactors/Eleefirlc' ian's/Plumbers
Applicant InformationPlease Lmiblv
e not
Name (Busine'ss/Organizadon/Individuulj:::'A oe),) Ale -
A
Address: - I'`' ,D . ' v�. � i I �" , � .. ��—� �t,.�•-�..' . • T�1 � ,
-City/State/Zip-
Are pu an employer?'Check the appropriate. box: tw 71 ,i V11", al')
Type of project (required):
inojoyii with 1.91 .0: -
4. [],1 am a general contractor. and I
6.-.E]Ne* construction
employees (full "and/or part-tinie).*
.have hired the sub-contmetprs.
listed,on the
7. [JR�Hn
2.E1 I am a sole proprietor or partner-
attached sheet,A.
ship and have no employeesThese
-
subcontractors have
8. Demolition
working for me in any capacity.
employees and have workers'
9 - M .. � -
.' Building addition
insurance,,
[Wworkers',,.comp'. J
. . I , , -1
pomp. msuranceJ
1 0.E1
required.]
OVe'6re abdrporation and its
-;; '
Flectrical,�'epairs or addifions
3.0 1 am a homeowner, doing all, work
officers
Off ers have exercised their
rl 1.gPlumbingrepairs'o:r'a'd'ditions-
myself. [No workers'.co
.MP --
right of eximptioh -pdr MOL
11F1 Roof repairs
insurance required.) t[. lf":7 T
c 152 §l(4)--'and*ehave ,no
60 qyeesJNoWorkerV
_
1313 Othir
ibmp'� instirnnce-requiretL]a,_ - -
IF,
•Any applicant that checks box #1 must also rill out die section hP'1n1'1F'shn',V'inS the irwomers compenstition policy inrarinution:
Homeowners whosubmit this affidavit Wicating they are doin, g all Vvork and then hire outside contractors must submit anew af7idavit indicating such V
'i6ichecV1hii;b6i must aum�6h6cl art sheit slid-.41hi the of the and state whether or not Contractors It thoi entities have
z)
employees. z I f the.sub-contructors have employees. they must provide their workers' comp. policy numbeL
lani aii,L,iiiployi.,rthat isproviding workers' coijipetisadoiziiistiraijc,L,'for iijyemployees
information.,
Insurance Company,
if
Expiration Date:
Policyk,?rAell Lie. M We-,
'Ps
45Z
10 Y-11
Job Site Address---
- 1. � '. 1. '[--
Attach a copy of the workers'compensatlofi policy declairation`6agi (showing the policy number and expiration date).,
Failure to secure coverage as required under Section 25A of MGLC'. 151ciri leid io'th6 imposition of criminal.penalties of a
fine up to $1,500.00 and/or one-year imprisq, ii djnent,iiiwdl as civil penalties in -the fohn of a STOP WORK ORDER and a fine
of up to $250.00 a day againk'the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for instimnce,coverege,verificafion..,-,,
IW671zereby certify 44kder thepains attdpenalfies ofperjurythat the information provided. above is true and. correct.
Signature: Date:
-IJ A.
Official use only. Do not write in this area, lobe coinpilitedbjidb; dir-tof_011 officiaL
City or Town: r Permit/lUcense #
Issuing Authority (circle one):
'_.�Eleit'in
1. Board of Health 2. Building Deliartment"10tyffowii C161C, 4cal Inspector 5. Plumbing Inspector
6. Other
Contact Person: r. Phone #:
Information and`Instructions
Massachusetts General Laws chapter 152 requires all employers to peovide4orkers' compensation for their employees.
Pursuant to this statute, an employee is defined as ":::every person iii the service of another under any contract of hire,
express or implied, oral or written." u ; t
An employer is defined as "an.individuA 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 employee"; ; 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 wlio employs persons to do maintenance, construction ortepaic 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 licensingagency shallwithholdthe issuance or
renewal or license or permit to operate a business or. to construct buildings in .the cominonivealth for any ....
applicant i� ho Lias not produced acceptable evidence of compliance with the insurance coverage required. shall
,
Additionally, MGL chapter 152, §25C(7) states{'Neitherthe commonwealth nor Any of its political subdivisions
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
n presented to the-contracting authority:
requirements of this chapter have bee
Applicants :r
Please fill out till workers' compensation affidavit completely, by checking fife boxes that apply to your situation and, if:
necessary, supply sub-contractor(s) name(s), addresses) and phone number(s) along with their certificate(s) of
Limited Liability Partnerships (LLP) with no employees other.than the
insurance. Limited Liability Companies (LLG) or
members or partners, are not required to cavy 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 confinnation 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 nuniber.listed below. Self insured companies should enter their
self-insurance license number on the appro nate line.
City or Town Officials "
Please be sure that.the nffdavit is complete and printed legibly. 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`regar`ding the applicant: !
Please be sure to fill in the permit/license number which will be used as a reference number. 'In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if•necessary) and under "Job Site Address" the applicant should write "all locations in (try
or
town)." A copy of the. affidavit that has-been officially stamped or marked by the city or town may be provided to die
applicant as proof that a valid affidavit is on file for future permits or licenses... Anew affidavit mustlie filled out each
year. Where a home owner or citizen is obtaining a license or permit.not reltited.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. i
The Office of Investigations would like to-thank you.in.advance for yourcooperntion 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 0211.1-
Tel.: # 617-727-4900 ext 406 or ;1-877-MASSAFE :'
Fax # 617-727-7749
Revised 4-24-07 www.mass-gov/dia ;
The Commonitvealtli of ltIassaclusetts ,
—Departm61t ofbidtistrial Acts
- 0jfzm,of1nve$t1gqtion ,
600 Washingtoit Street..
:..
Boston, MA 02111
i r •r
wwl.tv.massgov/dia
Workers' Compensation. Insurance Aftidavii: Builders/Contractors/Electrieians/Plumbers
Applicant Information'. Please -Print LeeibIy '
Name (Business/Organizadon/Individual): 1/ A ,% �7� Q z: / d •
y
Address:. * &?g?g!tA/
City/State/Zip:/.0V, /,WW• . I_1/834V _..;Phone #
Are ypu an employer? Check tete appropriate. box.* ; :�.r : 92 4 ar, a ,, 7 _
1. I am a employer with_;
`• ❑ l am a general contractor, and .
employees {I'1i11 and/or part-time).'"
have hired the sub -contractors
2. ❑ 1 am a sole proprietor or partner-
listed on the attached sheet,
ship and have no employees I. -
- These sub -contractors have
working for me in any capacity.
employees and have workers'
(No workers' .comp:. insurance, , r..'.
required.] , r',•
. comp. insurance.$. _
'5.-❑ Weare a corporation and its
3. ❑ I am a homeowner doing all,work
officers have'eicercised'iheir" '
myself. [No workers' comp.. , `1 ; -
,: ,�dght of exemption per"NIGI: ' `
insurance required.] t
t a:}152, §1(4), and`we have no
t i i •
employees. [No workers' la It; i-
instirance'ri ice
tali d.i
M,
a
Type of project,(required):. .
6. New construction
YJ (!
7 ❑ Remodeling' U:"
8...❑ Demolition _
9. ❑ Building addition
10.0 gleqtrical repairs or additions
111lumbing repairs or additions..,.
`12.Q Roofrepairs
13.❑ Other" - •
•Any applicant that checks box #1 must also fill out the section belowshowing their tvoikem eompensutidn policy informatioii.
t Homeowners who submit this affidavit indicating they are doing all work and then hire (iutside' contractors must submit a new affidavit indicating such.
=Contractors that check this boz must attached an addidonal sheet show the'name of the �sub�contiactors and state whether or not those entities have
employees. If the sub -contractors have empioyccs• they must provide their workers' comp. policy number. ;
I aur an employer tliat is providing [porkers' contpetisadoii insurance for my eatp/oyees Bela»► is tliepolicy and job site
information.
Insurance Company
Policy #. or Self ins. Lie. #: We- i ' Expiration Date:
Job Site Address: ` .: Q . �/� .' f t' ` } r City/State/Zip: %1/D 'OA iM /1 ,
Attach a copy of the.workers' compensation policy declar'ittiori page'(shoiving the policy dumber and expiration date).
Failure to'secure coverage as required under Section 25A of MGI; c. I52 can lead to the imposition of criminal:penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil'penaities in the forth of ti STOP WORK ORDER and a fine
of up to $350.00 a day against the violator. Be advised that a copy of this statement may be fotwarded to the Office of
Investigations of the -DIA for insurance coverage verification.
1 do /ierebp certifyu��nd��er thep�a/in%s gird penalti ufperjury that the iuformatiott provided above is trite and correct..
Cionghire _.�i�',Gl.� .�Ki�— llntr+• ` S/�/�� s _
Official use onlj. Do not write in this area, to be'"coiupleted by city or toiviroff1ciaG
City or Town: 1 Permit/LIcense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk' '9.'Electrical Inspector° 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information ad `Instructions
Massachusetts General Laws chapter 152 requires all'etnployets-to provide'workers' compensation For their employees`:
Pursuant to this statute, an employee is defined as ".Avery'person;in the service of another under any contract of hire,
express or implied, ora{ or written." .1k
An employer is defined as "an individual, partnership, association, corporation or other Iegal.entity, or any two or more
of the foregoing engaged in -'a joint enterprise, and including ihe,1egal representatives of a deceased emplOyer,.or the •) i
receiver or trustee of irNndividual, partnership, association or,other.legal entity, employing employees. However the
owner of a dwelling house hoving.not moce,tltan, three apartments and who resides. therein, or the occupant of the
dwelling house of another wNo employs persons toenance, construction or repair work on suc
' do-mainth dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed,to be an.employer."
MGL chapter 153,.§25C(6)"also states that "every state or.toeal licensing agency shall withhold the issuance or
renei.val' or a license or permit to operate u business or to construct buildings in the commonwealth for any
applicant ivho has not produced acceptable evidence of compliance with the Msurance coveragere uired." ,
Additionally. MGL chapter 152, §25C(7) states"Neifher the cornrnonwealth nor any of its political subdivisions shall `
enter into any contract for the performance of public•worl until'acceptable evidence of compliance with the insurance
requirements of this'chapter have been presented to the"contracting authority.." J i
t [ 1 4
Applicants
Please fill out fire workers''compensation affidavit completely, by. checking the boxes that apply to your situation and, if
' necessary, supply sub -contractor (§) name(s), address) and
es,plione numbers) along with their certificates) of
Limited Liability Partnerships (LLP) with no employees otherthan the
insurance. Limited Liability Companies (LLC) or '
members or partners, are not required to cavy workers'; compensation insurance. 1f 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
g1.
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.Fpgarding 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 J
self-insurance license number on the appropriate
City or
Town Officials . , ....=o`• :�� ti ri .y . , t: _ ,; : ! s ,
z Please be sure that Jhe nff davit is:compli and p6ted legibly.:17heDepartment has provided. -a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations hie to contact-you.regarding the applicant.'
Please be sure to fi.11'in the permit/license number. which will be used as a reference number tri addition, an applicant
chat must submit ,multiple permittlicense applications iiiany given year, need only submit one affidavit indicating ccrren` =
policy information (if necessary) -and under "Job Site Address" the applicant should write "all locations in __.(city o
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 tie filled out each
year. Where a.home owner or,citizen is obtaining o license or permit. not related.to business or commercial venture.,
(i.e. a dog license or permit to burn.leaves etc.) said person,is NOT required to complete this a'flidavit. -
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
all:The Department's address' telephone and fax number.
The Commonwealth of Massachusetts,�-
_ Department0Industrial Accidents-.:.. _
- _ tpffice.;of Investigations
600 Washington Street
_ Bostott;'MA 02111
�. r! T
r Tel.:#.617-727-4900 ext 406 or-1,-$77-MASSAFE ,
Fax # 617-727-7749 ........... ,
Revised -4-24-07 www.mass.gov/dia
Date.../..ft?....... .
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ... .........
Ooh C.. ....
has permission for; gas installation .... , .._S...�'
in the buildings of .. .,1 44 //? ............. ... .,!/.... .
/f . , .
at ... e��°? ?G!�a U �! ........... , North Ando er, Mass.
Feh ..... Lic. No..115-o&... .....,�! . .
( GAS INSPECTOR
�{On f✓'l Ci � dA.�t
Check #
7290
FIXTURES
itCn
W
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
=
City/Town:.�
Date: 7 %�.�i... Permit#
Y to
Building Locatic
....L/<�✓l..�riGC' Owners Name: il. j� •'./S(
Type of Occupancy:
Commercial Educational. Industrial: Institutional
Cesidential
New: Alteration:t
Renovation,, Replacement: Plans Submitted:
YesNo ,
FIXTURES
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SUB BSMT.
BASEMENT
1 FLOOR
2 Nu FLOOR
3 FLOOR
4 FLOOR
5 FLOOR
6 FLOOR
_7
'FLOOR
8 FLOOR
Installing Company Name:.
Check One Only Certificate #
.............. ... ... ..:
Corporation
Address: /
( .✓�Yi 1�% Gt7
Cit !Town:
/j/c' y
,� ^ ,�
! -/z%��
State.)
_.._
Zi Co de
P..... :
Partnership
Business Tel;Cell:
Fax:.Firm/Company
F ompany ... .
Name of Licensed Plumber/Gas Fitter:
`,ryry
:,.
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes:, �: No
if you have checked Yes, please indlcate the type of coverage by checking the appropriate box below.
A liability insurance policy: ✓ Other type of indemnity Bond
OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Owner Agent
Signature of Owner or Owner's Agent
By checking this box ❑; I hereby certify that all of the details and Information I have submitted (or entered) regarding this application are true and
accurate to the best of my Knowledge and that all 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.
.._........................ _....... . ,Type of License:
By. .. _ Plumber
......:.....:............:........ .
Titre. Gas Fitter Signature of I is used Plumber/Gas Fitter
Master
City/Town Journeyman License Number: 0/1
APPROVED OFFICE USE ONLY
LP Installer
Toivn of Andover
Massachusetts
(Office Hours 8:00 A.M" to 10:00 A.M.)
Gas & Plumbing Fees
Effective March 12, 2003
❑ NEw: New Construction and Additions ❑ RENOVATION: Plumbing within the existing system
❑ REPLACEriILNT: Removal and replacement of a fixture to the existing piping
*ALL TENANT FIT -UPS ARE CONSIDERED "NEW"
PT ,T TMRTNCr VP,*PS
New Domestic Construction — up to 3 Units
$100 Ius $5
er fixture
DNEW
New Domestic Construction — d units or more
$200 plus $S
per fixture
DNEW
Renovation (Domestic)
$50 plus $5 per
fixture
DREN
Replacement(Domestic) Existing Fixtures ONLY
$ f 0 plus $2 per
fixture
DREP
Bacicflow Preventer (for boilers)
$10 plus $2 per
fixture
DREP
Bacicflow Preventer (for irrigation systems)
$25.00
DBAK
New Commercial] Industrial
$200 plus $S
perfixture
CNEW
Commercial — Renovation
$100 plus $5
per fixture
CREN
Commercial Replacement — Existing Fixtures ONLY
.150 plus $5 per
fixture
CREP
Backflow Preventer for boilers
$50_plus $5Per
fixture
CREP
Bacicflow Preventer (for irrigation systems)
$25.00
Commercial Replacement — Existin Fixtures ONLY
CBAK
Re -inspection Fee
IS25.00
- INSP
C_ A ,R T?IV 4
New Domestic Construction — up to 3 Units
$75 plus
$5
erappliance
$50 plus $5 pera liance
DNEW
New Domestic Construction — 4 units or more
$150
plus $S
erappliance
$25.00
DNEW
Renovation (Domestic)$50
$25.00
lus $5
erappliance
DREN
Replacement (Domestic) Existing Appliances ONLY
$20
lus $2 per
appliance
DREP
Gas Boiler / Furnace / Conversion Burner Domestic
$50 plus
$5 pera
liance
DREN
New Commercial / Industrial
$150
plus $5
pera
liance
CNEW--
Commercial — Renovation
$100
plus $5
pera
liance
CREN
Commercial Replacement — Existin Fixtures ONLY
$50 plus
$5
er appliance
CREP
Gas Boiler /Furnace / Conversion Bumer (Commercial
$100
plus $5
per appliance
CREN
MTSCFr .r .A ivr.0T r.c
Gas Lo /Fire Place
$50 plus $5 pera liance
DREN
Gas Stove/Heater
$50 plus $5 pera liance
DREN
Utility/ Bar Sinks
$10 plus $2 per fixture
DREP
Capped Sewer Lines
$25.00
SCAP.
I Re -inspection Fee
$25.00
INSP
i hese ices are useo iT me peranrt is per tnis work oety. Al the permit includes other plumbing `work, the
fee charged will be the f"LYture fee which appears under renovation, replacement or new work ($2.00 or
$5.00)
r----.._ -
U6y04M0.NWqALTH OF MASSACHUSEffi-.
LICENJ
10 S A JOURNEYMATJrL�MgEp
ISSUE_r
SSUE THE ABOVE LICENSE TO:
WILLIAM DESANTIS
is:. 14OUNT VERNON DR
PEL H.AM NH 03,076 1 e-2349
�;t(L-13 E3-2010 1 ,:48 THE ANGUS7 GROUP
603 421 0052
uCSR 603.421-0021 1 THIS CERTIFICATE tS BSSUED AS A MAi
THE ANGUS GROUP INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UP(
ti 18 ROCK1IVCsNAM ROAD ALTER
THIS CERTIFICATE DOES NOT
ALTER THE COVERAGE AFFORDED BY 1
LONDONDERRY, NH 03053
Iwwii%D
WILLIAM DESANTIS
ODA DES ENTERPRISES
P,O. BOX 1
PELHAM, NH 03076
INSURERS AFFORDING COVERAGE
INSURERA: MERCHANTS INSURANCE
P.00i�r�01
mas®{iiSWIDBA'yMYj j
OF INFORMATION
THE CERTIFICATE
IIID. EXTEND OR
MAIC
THE POLICIES
ANY REOUIREMENT,
MAY PERTAIN,
POLICIES.
iKBR
6YZ-woL—
OF INSURANCE LISTED BELOW
TERM OR CONDITION
'*HE INSURANCE, AFFORDED
AGGREGATE LIMITS SH®WN MAY
MAVE BEEN ISSUED TO THE INSURED
OF ANY CONTRACT OR OTHER
BY THE POLICIES DESCRIBED HEREIN
HAVE BEEN REDUCED BY PAID
--
POLICY MYMNR
NAMED ABOVE FOR THE POLICY
DOCUMENT WITH RESPECT TO WHICH
IS SUBJECT TO ALL THE TERMS,
CLAIMS.
PleA
OLY IPSCTIV y 9MRTION
PERIOD INDICATED. NOTWITHSTANDING
THIS CERTIFICATE QQAY BE ;$SUED OR
EXCLUSIONS AND CONDITIONS OF SUCH j
�— --' LIMITS
08iF8RA6tw$i6I1Y
X IcoroMEACIALGENERALL!A31LIiY
CLAIMS MADE EXI OCCUR
BOP 9093162
A
03131121010 i 03131/201
�
£ACHCCGLRNENCE $ 1,000,000
PlFga Llff 1®0,000
�MFDEXP(AiyqptoWwn) S 16,000
IGENERALAGGREOATE
I
RY 5 1 000.000
�, S
j$ 2,000,000
PRODUCTS- COMP/OP AGG S 2,000,000
GE-N'L AGGREGATE LIMIT APP4191,; PER:
j`PRO.r-�
AUTORAOiXL®LtAAP:UTY
ANY AUTO
A" GV/NEB AUTOS
scHrDULEDAL•Tos
HIRED AUTC6
NON-ONINE.0AUTOS
i
(rEQM nt ING(.E LIMIT ;
(Porwoon) —�-
180DILY INURY z
�.... — _
IBODILY NJURV $
(Po ycCitlartt) I
j*--- •m••--.
,
PROPERTY OAMAGC
(Per acCieant)
.—
GARAGE LIAV10TY
--
li ANY AUTO
..�..�._
I
����
AUTO ONLY - EA ACCIaENT S
�_. _...._. —
OTHER THAN
AUTO ONLY' —A0GG $$
EXC9$$1UWIfAiILALU1IMUtY
'JCCU,4CLAIM$ MADE
DEDUCTIBLE
I;,—
i
1
I
EACHOCCURR6N«c'
AGGRECATE
b.....—___
RETENTION�---
i WORK048COM"N*ATION
ANOE4�LOV 'LIABiGTY YIN
ANY PAOPPt@TOkrnlUiTNER/EY.ECU'fIVE
OFFCERlMP-MBF.itf-XCLUD,D?
(Meflowmi"NN)
j Il yes, dgstAbo WMOr
1 SPECIAL PROVISIONS t.11-
--
I
I
I
Wy rATU� iQTH?`s
El EACHACCIDENT S
------}-_,•-- .------.y
G.L. DISEASE-CA,£i4PL0?`EEI S
E.L. D18EASF, - POLICY LIMB L j
OTH64
OHSCRJPTION OP OPURATiONB I LOCATION$ / VE"ICLO r EX( -USIONS ADDID IY EAIDOR31QIIiNT 1 SPACIAL PROVOIONS
RESIDENTIAL PLUMBING CONTRACTOR
FAXED TO; 635.8046
I i
CERTIRCATE HOLDER CANCELLATION
i SHOULD ANY Of ?HE ABOVE DESCRIDED POLICIES OR CANCELLED BE#OAETHE RXPiRAIION
DATE TKEREOF, TN NO IH$URFR WILL END VOR TO RAIL ,V„ DAYS WRITTEN
NOTICE TO T C'R ICATE HOLDER NAMED E LEFT, BUT FAILURE TO DO SO SHALL
TOWN OF NORTH ANDOVER WPOBE P6 OB ATION OR Lu�LITV 0F' A KIND UPON TWE IMSURER, ITS AOENTS OP,
MA,SSACHIISETTS ---sJ 1 11 /
25 (2009101)
The ACORD name and TOtw
of
rights reserved.
TOTAL P,:0
The Coit:fnonrvealt ro assachusetts
" `Deparlbnent 'vffiidustrial Accidents
Office ofInvestigadons
600 Waslungton Street
Boston, MA 02.711
wwwanassgov/dia
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A licant Information Please:Print Le 'bI
Name (Business/Organization/Individual): v�. C_ S- %^;1 A;
Address: a Az -z / 1/
City/State/Zip: P1._n_1kY,4t, Phone #:
/�- 3��
Are you an employer? Check the appropriate box:
I . ❑ I a employer with 4- El I ata a general contractor and I
Type of project.(required);
loyees (fall and/or part-time). have hired the sub -contractors 6• ❑ New construction
2. I am a sole proprietor or partner- listed on the attached sheet 7. ❑ Remodeling
ship and have no employees , , These sub -contractors have g- Demolition
working for me in any capacity- employees and have workers'
[No workers' comp. insurance comp, msurance t g- D Building addition
required.] 5. We are a,corporation and its 10.❑ Elec 'cal repairs .oradditions
3. ❑ I-am-a,homeowner doingall work officers have exercised their
1 I. umbing repairs or additions
myself- [No workers' comp, right of exemption per MGL 12-C1, Roof repairs
insurance required.] t c. 152, §I(4), and we have no
employees. [No workers13-❑ Other
comp. insurance required.l
Any applicant that checks box #] must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such,
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp, policy number.
I am an employer that isproviding worleers' compensation insurance for my em
information. ployees Below is thepolicy andjob site
'
Insurance Company Name:
Policy # or Self -ins. Lie. M Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORD ORDER and a fine
.of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certiunder the pain and pe patties o per jury that the information provided above is true and correct
Signature: /I✓ijfy/ate: % ��` d / 6
Phone #:
Ofj cial use only. Do not 3vrite in this area, to be completed by city or town official
City or Town: Permit/License #
............. . .
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
b. Other
Contact Person:�-
N2 1887
FA
Date..................................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
.-
This certifies that ...... ..'.1...`- ..1......... \_ ` P c ... �(..`:. �.`. `.4.... `'c �. 2. ``. { ...
has permission to perform
wiring in the building of t ` ` �.
at ..... ..7 ..... w.0.9 ........ C ` )4orth Andover ,iii s.
Fee./?`W .. Lic. No. ---f ..f /.
/EdfcrRICAL IN§PECfOR
A v
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
Office Use o y
THECOMMONWE4L7710FMA�I MC TS=
DEPARTMEIVT0FPUBLICS4FE7Y0 v
Permit No.
BOARD OF FIRE PREVEN7IONRECUTAT10AS 527 CMR 12.00
Occupancy &Fees Checked
FORWARD
9,4PPUCARONFOR PIIaW T'O PERFORM aECMCAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 Q
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 02, - =
Town of North Andover . MAP To the Inspecto of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number)2
PARCEL Af 14 i
Owner or Tenant 1,0
Owner's Address �'4 n P-
Is this permit in conjunction with a building permit: Yes No ® (Check Appropriate Box)
Purpose of Building We- S Utility Authorization No.
Existii1g Service Amps Volts Overhead M Underground ® No. of Meters
New S�ce� Amps / Volts Overhead rI 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
11g
and
ound
No. of Receptacle Outlets
�9\
No. of Oil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
No. of Gas Bumers
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons
No. of Detection and
No. ff Disposals /
Nd. of Heat Total Total
'
Pumps
Tons
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers r
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
Local Municipal
Other
No. of Dryers
Heating Devices KW
Connections
No. of Water Heaters KW
No. of No. of
Signs
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
OTHER �. _._..._.� .. __. _.._� ......
Icstaa =Cama Ptaqmrtb1here4�.sdMwsa&ucftsG=alLaws
Ihma=mtLnbihiyh-&==PchLym& dmCo#At(?EmOmCmawcrits mbstmlialumvalert YES- Ell--'-I�o
Iha%emhniltedvalidpocfofsa=to YES �toediedWYESpkmmdc*tctyWofm,wWbydakirglir
aWqx bcpL
NSURANCE BOI`ID OfflER ftmeSpadfy)
EVidmDaIL
ValwcfEkcftical Wc& $
WO&IDStart - - hWmlicnD*ReVesWd Ra# .... 9 -dy `� _.. Final
sal` ,/`-i ! �.,-� /5 41 (.� � - �Q
FIf2MNAME .--- � < o�-y�c.� he � Lit�eNa � �/ 7 /
L—
=
-
�d fat my s�aemthis pem� appliesion wanes the teglm�tt.
(Please check one) Owner Agent
r. M
i' .yi .:A%!., + r�.I
— AhTeLNa.
;tec�dbyRC>enoat
dpi
Telephone No. PERMIT .FEE v `� f
Location . 0r 2 6feq)lq�lo/i,
No. C9 Date
NORT1r TOWN OF NORTH ANDOVER
O?O� t�•O HMO
, Certificate of Occupancy $
4g jL Building/Frame Permit Fee $ _9�ji
Foundation Permit Fee $
.7 CHUst
Other Permit Fee $
Sewer Connection Fee $ .�
Water Connection Fee $
TOTAL cy
r,/�'� lflr'I'°
Building Inspector
'i3283
08/04/99 11:47 949.00 ppID Div. Public Works
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No: 17 Date
o<
OR ,ti_ TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $ a
. o
Other Permit Fee
Sewer Connection Fee $
Water Connection Fee $.
TOTAL $ 1�
-� uilding Inspector
0
10727
Div. Public Works
PERMIT NG. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
IF
PAGE 1
MAP d-40. �\ (,
\ /
LOT NO. ®
I
2 RECORD OF OWNERSHIP :DATE
BOOK PAGE
:
ZONE
SUB DIV. LOT NO.
PAGE 1 FILL OUT SECTIONS 1 - 3
F -I
LOCATION it r -t .L,-._ &t
�l
PURPOSE OF BUILDING
dJ
OWNER'S NAME ' �( C ^� ��`��
1_
lin
NO. OF STORIES , SIZE���
OWNER'S ADDRESS _ C
A
1 ,Nt.I-c
BASEMENT OR SLAB
ARCHITECT'S NAME n'�, -p
--
SIZE OF FLOOR TIMBERS IST 2--�2ND 3RD
�-
BUILDER'S NAME �Cv/ �\ �1,� ^
SPAN 1 (
—
DIMENSIONS OF SILLS
POSTS
DISTANCE TO NEAREST BUILDING �'�71 I
V
DISTANCE FROM STREET i 1
DISTANCE FROM LOT LINES- SIDES j_ REAR
l I
" GIRDERS
AREA OF LOT ; V`v FRONTAGE
\ V"
i I
\
HEIGHT OF FOUNDATION THICKNESS -
IS BUILDING NEW .i. )
`v�
SIZE OF FOOTING �A /t^ X
IS BUILDING ADDITION 1
1�
MATER:AL OF CHIMNEY
IS BUILDING ALTERATION f` p t'
IS BUILDING ON SOLID OR FILLED LAN��`
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE
IS BUILDING CONNECTED TO TOWN WATER D ('
BOARD OF APPEALS ACTION. IF ANY A )-)
��C/
IS BUILDING CONNECTED TO TOWN SEWER
L 3�
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS
�F�PZ.
Ell
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
a
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
FEE �—
PERMIT GRANTED
19 T
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST
EST. BLDG. COST PER SQ. FTT.IJ[/�—\
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BUILDING INSPECTOR
OWNER TEL.#y��� ! G
CONTR. TEL. M 608) "5 3 -3 5—
CONTR. LIC. N p eAi
H.I.C.#
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY
STORIES
MULTI. FAMILY
OFFICES
APARTMENTS
_
CONSTRUCTION
2 FOUNDATION
8 INTERIOR FINISH
B 1 2 13
PINE
CONCRETE
CONCRETE BL K.
BRICK OR STONE
HARDW D
PIERS
PLASTER
DRY WALL
UNFIN.
_
3 BASEMENT
AREA FULL
V, 1/2 %
NO BMT
HEAD ROOM
FIN. B'M'TAREA
FIN. ATTIC AREA
FIRE PLACES
MODERN KITCHEN
_
_
_
4 WALLS I 9 FLOORS
CLAPBOARDS
B
_
1
2
_
3
_
DROP SIDING
WOOD SHINGLES
ASPHALT SIDING
ASBESTOS SIDING
VERT. SIDING
STUCCO ON MASONRY
_
CONCRETE
EARTH
HARDVV D
COMMCN
ASPH. TILE
STUCCO ON FRAME
_
BRICK ON MASONRY
BRICK ON FRAME
CONC. OR CINDER BLK.
ATTIC STRS. 6 FLOOR _
WIRING
STONE ON MASONRY
STONE ON FRAME
SUPERIOR(� POOR
ADEQUATE NONE
5 ROOF
10 PLUMBING
GABLE I
HIP
BATH Q FIX.)
GAMBQELMANSARD
I
TOILET RM. 12 FIX.)
FLAT
SHED
WATER CLOSET
_
ASPHALT SHINGLES*
LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
_
TAR & GRAVEL
STALL SHOWER
_
ROLL ROOFING
MODERN FIXTURES
_
TILE FLOOR
TILE DADO
6 FRAMING I
11 HEATING
WOOD JOIST
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. 6 COLS.
STEAM
STEEL BMS. & COLS.
HOT W'T'R OR VAPOR
WOOD RAFTERS
AIR CONDITIONING
RADIANT H'T'G
UNIT HEATERS
i NO. Of ROOMS
GASOI
L
ELECTRIC
B'M'T 2nd _
It 13rd
NO HEATING
t
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.
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'is mortgage inspection plan is for mortgage
•rposes only, is not an instrument survey, and Mortgage
not to be used to establish property lines,
►ccs, hcdgcs etc. or to be used for any purpose Inspection
%er than, its original intent. Pion
'rcrcby. certify that the building shoran o►1 this plan is AL1µ Of
prOximatcly located on the ground as shown thereon and '14 'G
It it conformed to the zoning and building laws of the cit or cosMo
un of �f•, n -r'a; SIV DOV R Y DAMIANO
ren cotlQtruct d•tind o reatrict'o on recor � 3 enroalANco
t 7704
ISTER
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A review of the Flood Insurance Rate Map, 1
CommunityPanelNumber 250098 600$g {
dated �[JN� t5� 1483 has been conducted
and to the beet of ourinterpretalion this property
is lOCatnd 1/Ivilif. wwu!►__� __.. e
Location_ e17 ��R .. �c/ T W[��+•+ y/R
ADV,ER MA',
Scale: Iin.■4otL Date Oe -7*# 4'. 1 981
Plan Reference
MORTGAGE INSPECTIONS INC.
BUITF 811, 285 MFOFORD t1'I'., SOMFRVILLF,, MASS.
Joh H
Location �,/, rI A"40 eff:� ("//Z -
No. (2,37 Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
RECFf �� Sewer Connection Fee
g�r�rction Fee
TOTAL ``►►vv !!
R9�}R — 3—
Nv. AndQVr caElect - . a .� —
$
Building Inspector
Div. Public Works
PER11IT NO../)437 APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. �� PAGE i
i
MAP KVO.
I LOT NO.
2 RECORD OF OWNERSHIP (DATE
BOOK 'PAGE
ZONE Q nn SUB DIV. LOT NO.
LOCATION N'L�?^}-'r��
PURPOSE OF BUILDING
OWNER'S NAME
NO. OF STORIES SIZE
OWNER'S ADDRESS �.� (Z ^
\�
BASEMENT OR SLAB
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME
W ,1
SPAN
DISTANCE TO NEAREST 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 a 5 Se 1 ,
MATERIAL OF CHIMNEY
IS BUILDING ALTERATION/
IS BUILDING ON SOLID OR FILLED LAND So L-" U0
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 /�7T
v'vyIF-5
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS 1 - 3
PAGE 2 FILL OUT SECTIONS 1 - 12
lA
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
4'
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATE FILED
SIGNATURE OF
FEE c 3D, e0
PERMIT GRANTE �J�
L 19 /
J
e
FEB 2 5 iocr,
BUILDING D PAI -
OWNER TEL. q,S�''-G i qW
CONTR..
CONTR. LIC. #-X0-9
P�' 3� O'� 6'7/
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST C%0®c L c
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
H /
PLANNING BOARD
BOARD OF SELECTMEN
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J MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)Z. u f2 -j_
U� . Mass. Date a 19 -% Permit # 46" 'y
Buildinglocation? 8 ,Ll MCIOwner's Name �2r Al
rd
Type of Occupancy
G
New ❑ Renovation ❑ Replacement KK Plans Submitted: Yes ❑ No ❑
FIXTURES
Installing Company Name SIAEA i GRrnN k
Address c3® $ M n /A) 5'4
Business Telephone 6--0 rS' .3 7 a
Name of Licensed Plumber or Gas Fitter
Check one:: Certificate
EKorporation ! -3 ? �-
❑ Partnership
❑ Firm/Co.
is 3
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ®/' No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy ,-- 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 walves this requirement.
Signature of Owner or Owner's Agent .
Check one:
Owner ❑ Agent ❑
I hereby cenify that all of the details and information I Nave submitted for entered) in the above application are true and accurate to the best of my knowledge and that all plumbing work
and installations performed under the permit issued fon this application will be in compliance with all pertinent provisions of the Massachusetts Stab Gas Code and Chapter 142 of the General Laws.
By
Title
Citv/Town
APPROVED (OFFICE USE ONLYI
Type of License:
U Plumber
.4-A 1,4 z9j1--;rd-
D Gasfimn
!! 't ter Signature of L' PI mber or CaWsFitter
O Journeyman .
License Number 1/�� %
Sth FLOOR
Installing Company Name SIAEA i GRrnN k
Address c3® $ M n /A) 5'4
Business Telephone 6--0 rS' .3 7 a
Name of Licensed Plumber or Gas Fitter
Check one:: Certificate
EKorporation ! -3 ? �-
❑ Partnership
❑ Firm/Co.
is 3
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ®/' No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy ,-- 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 walves this requirement.
Signature of Owner or Owner's Agent .
Check one:
Owner ❑ Agent ❑
I hereby cenify that all of the details and information I Nave submitted for entered) in the above application are true and accurate to the best of my knowledge and that all plumbing work
and installations performed under the permit issued fon this application will be in compliance with all pertinent provisions of the Massachusetts Stab Gas Code and Chapter 142 of the General Laws.
By
Title
Citv/Town
APPROVED (OFFICE USE ONLYI
Type of License:
U Plumber
.4-A 1,4 z9j1--;rd-
D Gasfimn
!! 't ter Signature of L' PI mber or CaWsFitter
O Journeyman .
License Number 1/�� %
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y2' Date .: .:.3:
,IORTH - TOWN OF NORTH'. ANDOVER
3? �a •e pL
o p PERMIT FOR GAS INSTALLATION .$
. �Gt
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'SACH
This
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This certifies that !(.. .1� 6A?..... . lz;
has permission for gas installation J�, :x. ,'
in the buildings of. .. ��. ..... .. .
e _ ,may'
at 'Yd.`. C,-;a.. , North Andover, Mass..
Fee. t��.l, Lic. No.,!/.i`fd.. ...
y �j GAS INSPECTOR
WHITE:4�1,jan't i r3 NARY: Building Dept. PINK: Treasurer ' GOLD File t
MASSA CH IUSF-1 'p- UN1t ORM i11'I'I ICA IIUN > "
UU PLUMBING
(I'rini ur lylu`)
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2nd FLOOR
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Date ... j .. 3 ... 7
5 3 2
o';".� �r :1ti TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING $
,SSACNU,
This certifies that
has permission to perform ... .......... �... • • • • • • • •
plumbing in t -buildings of .
at . /• .%?'i ..... , North Andover, Mass. o
Feer i G..'.Lic. No... .. ................. .
PLUMBING INSPECTOR
S
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
' 4138
Date.�?
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that . r/4.f!4h! ?�o!+!!..o ... ���' !.......... �•
has permission to perform :.�. O.k�t r.4 .... ............(. $
plumbing in the buildings of . I. #./.l!!! .................. .
n
at ..9e.7. 13/.gi'`! +'��!0 0 . ... G i...... ,North Andover, Mass.
Fee. L?,� . Lic. No..%CSU?!Y . ......
PLUMBING INSPECTOR ;
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
.s^_:.y.,}.` a .-..a r. �P% ..✓_::t ,. a._u,.'S _�[w :,... ..�:._� J� _...:...': r �,T_—a.a .+. ...._,�. .... ..r.: =T.v �.�v..'�M �- v._rn... 1... -.•ba
t
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date U
Building Location �lIG�/V �{�d 4 Owners Name / /y Permit
Cite
Amount (�
Cite Type of Occupancy
;v
Plans Submitted Yes
(Print or type) 7z Check one: Certificate
Installing Company Name /� L-10 ❑ Corp.
Partner. .
Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy � Other type of indemnity 0 Bond ❑
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner 11 Agent 11
RI hereby certify that all of the details and information I have submitted (or entered) in a ve ap
-best of my knowledge and that all plumbing work and install a ' s p id t Iss
compliance with all pertinent provisions of the Massachus State Plu ' 9C
By igna oulcensryiumuer
Type of Plumbing License
Title 1.4,o 17,f
City/Town License Numoer Master
APPROVED (OFFICE USE ONLY or
are true and accurate to the
pis annlication will be in
the General Laws.
Journeyman ❑