HomeMy WebLinkAboutMiscellaneous - 99 MEADOWVIEW ROAD 4/30/2018 (2)N O O w Q 0 cin 0 0 0 0 0 .� [O m D v 0 m 0 v Date ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................... .............................................. has permission to perform wiring in the building of .... K ....... 'V ................................ at ....... 9.1 .... ........ .. North Andover, Mass. Fee..U.-S.40P.. Lic. No.dA9 ........ . . ELECTRICAL INSPECTOR Check 7798 Official Use Only Commonwealth of Massachusetts Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINTININK OR TYPE ALL INFORMATION) Date: / / /-3 '-w% City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his for her intention to per onn the electrical work described below. Location (Street & Number) / �Cf cio t 7 �/ 2 i�l C)Q a Owner or Tenant MCLr- i Owner's Address Is this permit in conjunctio,)�with a building permit? Yes Purpose of Building ZCC S) Aa/ � ra L Existing Service Amps ! Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: L �J� ,'n Telephone No. `l7 F 75F � No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters A a- IV VV V 1'o 1 lljoyliJ cvp Cuniplelion of the ul"?ing table may he waived by the Inspector of Wires No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators K -VA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o mergency Lighting Ra-ttery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches tJ No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: umber ........ .. ............................. Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal Connection ❑ Other No. of Dryers Heating Appliances KW Security stems: No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP a ecommunications rang: No. of Devices or E uivalent OTHER: Attach ad&tiunal detail if desired ur as required by the Inspectur of Wires. Estimated Value of 1 trical Work: �% (When required by municipal policy.) Work to Start: r Inspect ons to be requested in accordance with NEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no pennit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specit}y:) I certify, under the ainsnd p nahies of perju , that the information on this application is true and complete. FIRM NAME: j/r LIC. NO.:1 6 Z)sa L— Licensee: Signature. LIC. NO.: (If applicaN me pJin he lic ymherI.�— Bus. Address: ,1Xe�)q o ( Alt. Tel. No.. *Per M.G.L c. 147, s. 57-61, security work requires Depahment of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee sloes not have the liability- insurance coverage normally required by law. my signature below, I eby give this requirement. I am the (check one ❑ owner ❑ o-vvner's agent Owner/Agee G PERMIT FEE: $ Signature l� Telephone No. 7'i -.iS Date ..... �.1" Z�! -,C.7 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that.........PR I v�— /4 ........................................................................ has permission to perform ..aR'.�...!�T�! .............................................. wiring in the building of ............... .!,!ttt................................. at ..............%L?!!.!irty North Andover Mass. Fee.33Da- Lic. No'.G10SZ. .. p ...... ELECTRICALINSPECT6R 'y Check # SOta� 7826 C-9 Commonwealth of Massachusetts Official Use Only - Permit No. -752_6 USPIM Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEY,), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date:/ Lh City or Town of: NORTH ANDOVER To the Inspector ojWir"es.- By this application the undersign ves notice of his or her intention to perform the electrical work described below. Location (Street & Number) ,%�A Ch b1 r/I,-, t R,0 Owner or Tenant j�rj� r- �'� V V M Owner's Address S Q . n --e ---- Telephone No. 97<,,`7 J `l- 35--> Is this permit in conjunction with a building permit? Yes [A --'No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd Number of Feeders and Ampacity No. of Meters No. of Meters No. of Recessed LuminairesNo. <� of Ceil: Susp. (Paddle) Fans v o. of ota Transformers 'KVA No. of Luminaire Outlets No. of Hot Tubs Generators ICDA No. of Luminaires Above In- Swimming Pool rnd. E]rnd. E]Batte o. o Emergency Lig ing Units No. of Receptacle Outlets a No. of Oil Burners FIRE ALARMS No. of Zones No. of SwitchesCL No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number .."' ITons ........ KWNo. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ unictio El Other Conneection No. of Dryers Heating Appliances KW Security stems:*No. No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsWiring: No. of Devices or Equivalent OTHER: c. ,Gw Attach additional detail if d'esirea( or as required by the Inspector of Wires. Estimated Value of lectr'cal. Work: (When required by municipal policy.) _ Work to Start: 2 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation'' coverage or its substantial equivalent. The undersigned certifies that such coverage is in tierce, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE J�J BOND ❑ OTHER ❑ (Spec4 :) I certify, under the ains nil peualties of perjury, that the fnfonnadon on the application is true and complete. FIRM NAME: Rlch /Q C t° _ f 11 v e LIC. NO.: Licensee: ! J)I,-?C ( Iq pyj Signatu < LIC. NO.: `" (I.f applicable, nt ex� rpt" int a license number line. Bus. Tel. No.. ` - p Address: cl r/fa, Il n;/d ''A�f�S'� /1'/q�.16121 Alt Tel. No. a.1rS1 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Saf ' S" License: Lie. No OWNER'S INSURANCE WAIVER: I am aware that the Licensee sloes not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one)❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature _ Telephone No. Date. r%�.''. e -. ...... TOWN OF NORTH ANDOVER +; PERMIT FOR GAS INSTALLATION 9 - This certifies that . !f < (/P `-'.1 ............................. has permission for gas installation .... %.13 ................... in the buildings of ...� ! : �'<.a� .�..................... . at ... . , North Andover, Mass. Fee. ,l,� :.:.. Lic. No..�'. �/ :.... .... �L� .--.-..... . GAS INSPECTOR Check # /) � /I 4453 C A lj--- M 1. ASSACIAUSETTS MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type)�J Date U f T C 3 Permit # q J J Building Location��A t1i�.� IJI�I h Owner's Name Type of Occupancy New ❑ Renovation ❑ Replacement B--- Plans Submitted: Yes❑ No ❑ Installing Company Name CSI LLA/4AA- A ZZ rorv-) j- 17tl Check one: Certificate # Address_ / _L. /),177 e-, G --Corporation /,-AGC ❑ Partnership Business Telephone '12 C ❑ Firm/Co. Name of Licensed Plumber or Gas Filterf c� C i1 L( A,4(j+A,) 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 Ilablilty insurance policy p-- 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. Check one: Owner❑ Agent ❑ Signature of Owner or Owners Agent 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 Ilia Permit Issued for this application will be In compliance with all pertinent provisions of the Massachusetts Stale Gas Code and Chapter 142 of the General laws. T a of License:t, r, k 4 Plumber SXnature ocense Plumber or Ga alter Title - Gastillar � 4 Master Ucense Number City/Town Journeyman Al't i1C7Vf ()O TFC _ O EMMENFAMENINS NE No NONE mom ������������■�STH Ft 0 NNNENSMENSINERMENSION momIN E SEEMS ME MINN NNN noNONE 0 No 0.10001000,0010 mom Sol Installing Company Name CSI LLA/4AA- A ZZ rorv-) j- 17tl Check one: Certificate # Address_ / _L. /),177 e-, G --Corporation /,-AGC ❑ Partnership Business Telephone '12 C ❑ Firm/Co. Name of Licensed Plumber or Gas Filterf c� C i1 L( A,4(j+A,) 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 Ilablilty insurance policy p-- 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. Check one: Owner❑ Agent ❑ Signature of Owner or Owners Agent 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 Ilia Permit Issued for this application will be In compliance with all pertinent provisions of the Massachusetts Stale Gas Code and Chapter 142 of the General laws. T a of License:t, r, k 4 Plumber SXnature ocense Plumber or Ga alter Title - Gastillar � 4 Master Ucense Number City/Town Journeyman Al't i1C7Vf ()O TFC _ O A r 0 Co a Y T m M N A M -1 n Y m N w M r 0 -n 0 O -r1 m 0 in C: w m O x r -t Date.... 7:77...�.�." TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that ............. M.............. m .................................... Z�f� ..... lc� Sug P�r�.Q /iq G has permission to perform....................r�.1.�..................................................... wiring in the building of ........ iM....... /..'. t. ..n! Y at........n7I...............4-.,..�!....W ................ North Andover, Mass. S -S'''0.. Li Fee...................c. No.....��........ ........ ...... � � � ELECTRICAL INSPECTOR Check # 'S 30 7 ti 7627 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 76 d Occupancy and Fee Checked :ev. 1/07] (jeavP hlankl APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical CodeEC , 527 MR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned fuhres notice of his or her intet}tion to perform the electrical work described below. Location (Street & Number) % �'�iC %l lir la Owner or Tenant Owner's Address Z,/ 6tI Telephone No. Is this permit in conjuncti with a buil ' q permit? Yes Purpose of Building Xf , t )-J0 Existing Service / CO Amps k /dc0 Volts Overhead No ❑ (Check Appropriate Box) Utility Authorization No. _0 / / 70 ❑ UndgrdO No of Meters New Service c-,4-0�;Amps �o / U Volts Overhead ❑ Undgrd Number of Feeders and Ampacity AN a I/ ?d C- Location and Nature of Proposed Electrical Work: J1#iW mrd C[/ r„m„1�,; L. r ,1 No. of Meters No. of Recessed Luminaires v«uwxrix No. of Ceil: Susp. (Paddle) Fans uute muy ae waivea oy me inspector of Wires. No. ' Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- El o. o mergency Lighting rnd. rnd. Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS TNo. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond.Total �� Tons No. of Alerting Devices No. of Waste Disposers Heat Pump- - ' Number "" Tons KW No. of Self -Contained Totals: ""' Detection/Alertin Devices No. of Dishwashers S ace/Area Heating KW p g Municipal Loci ❑ ❑Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Water Heaters KW No. of No. of N o. of Devices or Equivalent Data Signs Ballasts No. ofitinDevices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Alta cn additional detail tJ desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 0 Q r7 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Z BOND ❑ OTHER ❑ (Specify:) I certify, under the at and perialites o perjury, that the information on this applicati is true and complete. FIRM NAME: A 1j lle LIC. NO.: Licensee: P216419<7 h? Signator LIC. NO.:b (� a (If applicable me , " m t " in t e license number line. Bus. Tel No. lf' Address: t / .f Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Drepartment of Public Safety "S" License: Lic. No. id 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. $ SE -PV ©f( q - z -,!97 Pl*�I* �r JJ)F1 f '1st i i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 f 3 www.mass.gov1dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/individual): 11 b"CL %N pr% jl c Address: % rijXrf.X, �l 1 /ill City/State/Zip: Ysy �!l i� l?`��� Phone #:. 9�4 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑New construction employees (full and/or part-time).* 2 I am.a.sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. i 7.12 Remodeling "[�Is- ship and have no employees These sub -contractors have 8. Demoliti.on working for me .in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its g, ❑ Building addition required.] officers have exercised their 10.Q Electrical repairs or additions 3. Q I am a homeowner doing all work right of exemption per MGL i 1.Q Plumbing repairs or additions myself. [No -workers' comp. c. 1.52, § 1(4),' and we have no 12.E] Roof repairs insurance required.] t employees. [No workers' 13.[] Other comp. insurance required.] -Any applicant that checks bort # I must also fill out the section below showing their workers' compensation poi icy information. t Homeowner; who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractor; that check this box must attached an additional sheet showing the name of the sub -contractors and their wortcers' comp. policy information. 1 ant an employer that is providing workers' compensation insurance for my employees: Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date Failure to secure coverage as required. under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby of perjury that the information provided above is)true and correct Of xiat use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other V) Contact Person: Phone # 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 shat) 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 license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence.of compliance with the insurance' coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) 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 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 confirmation of insurance coverage.. Also be sure to sign and date the affidavit. The affidavit should be returned to the city, or town that the application for the permit or license is being requested, not'the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance- license number on the appropriate tine. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (.if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum 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 42111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia Date. 3= O TOWN OF TH ANDOVER � 9 PERMIT FOR GAS INSTALLATION This certifies that ..... ... Q..... .............. U has permission for gas installation ............. in the rbuildings of.-�.�............ at ... 1.7. North Andover, Mass. Feed..'.. Lic. No,:?,�. / ......... 'j GAS INSPECT©R Check # D V s kd MA,SSACHUSEITS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations `97 New Renovation ❑ v Owner's Name 0� d Date „y Replacement ❑ Plans Submitted ❑ Permit # 4, /e yp Amount $ <..?o &d (Print Name Addre or type) / Che k one: Certificate Installing Company b e�� ssCi �+�0��/ �.^/> // p D�� ❑ Partner. ,ss Telephone - --� s- r ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter 1 INSURANCE COVERAGE Check one: I have a current liability Insurance, policy or it's substantial equivalent. Yes ❑ No❑ If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy 0---- 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I IlArahv —t;A. t6.,* .JI C♦6 A a : ,,,,,,,,, —Vil , „ayp ,p1/1111"CU wr emereu) In aoove app►ication 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 Gas Code and Chapter 142 of the General Laws. By: Signature of Licensed Plumber Or Fitter Title Q umber a�3.s—/ City/Town ❑ Gas Fitter 7cenSe Number ❑ Master APPROVED (OFFICE USE ONLY) �rneyman � a � w � � o0a W c O c z F �, w w w U a w F a q w F w l x O z ¢ w ¢ a F F m > z w O z w p x a x o x 3 a.da ° > o a F o SU B-BASEM ENT a° BASEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print Name Addre or type) / Che k one: Certificate Installing Company b e�� ssCi �+�0��/ �.^/> // p D�� ❑ Partner. ,ss Telephone - --� s- r ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter 1 INSURANCE COVERAGE Check one: I have a current liability Insurance, policy or it's substantial equivalent. Yes ❑ No❑ If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy 0---- 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I IlArahv —t;A. t6.,* .JI C♦6 A a : ,,,,,,,,, —Vil , „ayp ,p1/1111"CU wr emereu) In aoove app►ication 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 Gas Code and Chapter 142 of the General Laws. By: Signature of Licensed Plumber Or Fitter Title Q umber a�3.s—/ City/Town ❑ Gas Fitter 7cenSe Number ❑ Master APPROVED (OFFICE USE ONLY) �rneyman Date. J.; .-?j-�!9 �'.��•� :�ti TOWN OPNORTH ANDOVER ... o p PERMIT FOR PLUMBING SSS �C HU All This certifies that .......... �`:. ...................... has permission to perform ........... ........................ plumbing in the buildings of �.. ...................... at . 1.......:.. ....... .":. . ....... , North Andover, Mass. Fee !W- `S . Lic. Nox�J. .3.V ...l ..... :. ...... . PLU�SPECTOR /w Check # 7549 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print),, NORTH ANDOVER, MASSACHUSETTS L"" -eV Date Building Location �Ce 4 L" / eV Owners Name / P Ile 4/ i%7 Permit I Amount Type of Occupancy — –/ T ,��5, �cph /� New ❑ Renovation [3' Replacement 0 FIXTURES Plans Submitted Yes No El (Print or type) - / Check one: Certificate Installing Company Name Partner.' Firm/Co. Name of Licensed Plumber. ' Insurance Coverage: Indicate the type ' urance coverage by checking the appropriate box Liability insurance policy Other type of indemnity ❑ Bond ❑ LLLL���1111 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 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Cha 142 of the General Laws. BY Igna o i Title Type of Plumbing License City/Town TIME Numoer Master Journeyman EAP PROVED (OFFICE USE oNLY