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HomeMy WebLinkAboutMiscellaneous - Exception (237)Date A�..�.-.-).H ............... TOWN OF NORTH ANDOVER PERMIT FOR WIRING 011�� This certifies that.\j... has permission to perform .....'®OD� .... .. .. .... ........ .. wiringin the building of ..........................� . ..................................................... ............. at ...... . th Andover, Mass. . ................................... � ......................................... Fie Lic. No.. . . . ..... M. it .. ........ I ......... ...... . Check # Pr),Z� 12 Oe P A ELEclilCAL INSPECTOR j- �56j-IP5 rr- 2erf&W4 0/-7w services BOARD OF FIRE PREVENTION REGULATIONS Permit No. Occupancy and Fee Checked [Rev. 1/07] eave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK AU work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATI01) Date: i V L, , q City or Town of: N, gn(AQV,� To the Inspector of Wires By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes [� Purpose of Building 1,�:,k� C.Q _ �Ctm n C ,1 f -Ty -n`2 No U (Check Appropriate Boz) Utility Authorization No. Existing Service Amps f?O / 840 Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: "10 -1 >r-1ro 09 Completion of the ollawin table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans o: of Transformers Total KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above Ei in grnd. d. No. of Emergency ❑ Bane Units g No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection an Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices Heat Yum Number I Tons I KW of - ontained •ofvfmte Disposews Totals:e o e ces No. of Dishwashers Space/Area Heating KW Local ❑ Connection F-1Other No. of Dryers i'Y Heating Appliances KW Security Systems: * No. of Devices or Equivalent No. of WaterNo. Heaters o o. of Si Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Te ecoNo. of Devi es or Equivalent OTHER Attach additional detail if desired; or as required by the Inspector of Wires. ' Estimated Value of Electrical Work: I Zqb (When requited by municipal policy.) Work to Start: C ; ' a' �y Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, than the information on this application is rd complete. FIlt1VI NAME: \ lrit S�Ckr � LIC. NO,: M LI1,' Licensee: . Z am o( Signatur LIC. NO.: I y I A - (If cg�plicabl enter " empt" in the licen a msmber line.) Bus. Tel. No.: 1Ss1 D, Address: S_ Alt Tel. '511012 *Per M.G.L. c. 147,. s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally No. Pt Cu y7B (?e3`4173 The Commonwealth of Massachusetts Department of IndustritalAccidents ice of Investigations I Congress Street, Suite 100 -i. (-� Boston, RA 02114-2017 wwty m ass.gov/diar Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print llezibly LLC Name (Business/Organization/Individual): Yivint Solar Developer, _ Address: 3301 North Thanksgiving Way, Suite 500 : Lehi, UT 84043 Phone #: 801-377-9111 Are you an employer? Check the appropriate box: 1. 0 I am a employer with 10 4. ❑ I am a general contractor and I employees (full and/or part-time).* have. hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.# required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' coma. insurance reauired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10_❑ Electrical repairs or additions 11. [1 Plumbing repairs or additions 12.❑ Roof repairs 13.© Other Solar Installation *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -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 is providing workers' compensation insurance for any employees. Below is the policy and job site information. Insurance Company Name: Zurich American Insurance Company Policy # or Self -ins. Lic. #: WC 509601300 Expiration Date: 11/1/2015 Job Site Address: City/State/Zip:_ o,��� 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 certify under lite pains and penalties ofperjury that the information provided above is truet: (and correct Signature: ��r --�- —�� Dat e: �), m -it `�1, Phone #: 801-2296459 Official 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): fl. Board of Health 2. Building Department 3. City/Towey Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: VIVINT SOLAR DEVELOPER LLC PHILIP F ZA14P ITELLA JR (EL) 4931 K 300 K PROVO UT 84604 Fold. Then Detach sing M Pukka iom ELI`M i C i AN fi �.!,;; V► ISSUES TIE FOLLOWING LAMRSE AS RM- 'SME -0 MASTM �,BL E CTR I C I AN VIVf*t SOLAR DEVELOPER LLC PHILIP 1,:MMlXLLA JR 4931 N_ 300 w r vo ° w 84604 13 Y41 .A 0713•Ll16 101584 4` 167 High St, North Andover MA 01845 F ------ ------ - — ------- I — — —I m N- f3' < �Cn Cn -uI �I D I C1 r � m I U) W ui Nmp`c N I m ��A I II 7 nNz Z W IO V% ZmOX C3 CO) � m ' ox ' mom Tom D OX Z I "� I o �— — — — — — — — — — — —� Cx >m INSTALLER: o McCarth�r Residence Km ^ SITE m m INSTALLER NUMBER: 1.877.404.4129 ��yV]�'� �,Vry/ V O V 1 7 High St PV 1.0 m MA LICENSE: MAHIC 170848 O ??North Andover, MA 01845 PLAN DRAWN BY: BRG AR 4025345 Last Modified: 10/8/2014 UTILITY ACCOUNT NUMBER: 0401603003 • 1 OO o O a OO �0 VNC CD � n a0 m� W m w- rnZ op m m m 'off 90 O 0 C S r C m -i W:� D C r cn m -< c W U)r m � m II O_ /; O O n r D Z c = m K m ROOF m m INSTALLER: J� (] MCCa lhy Residence NUMBIVINTER INSTALLER NUMBER: 1.877.404.4129 1.87 m ' U � � 1 7v 9 h St MA LICENSE: MAHIC 170848 PLAN North Andover, MA 01845 ,M DRAWN BY: BRG JAR4025345 Last Modified: 10/8/2014 UTILITY ACCOUNT NUMBER: 0401603003 o� rnn DO< O O z K O Z Z+ n moo 01 0 cnr C �Cnm m __ m W �° -0nX Oz �z "� Ov -n m Z o W (nO z�� O O O D00 D 2-0 D c0 z O z A z mTl� D W D Z 0 Knm 0 r n o°0o Ko m :D tin� O m m n n m n 0 D n z < �i Z G'�D v00 y3 �� Cn D� —1 Z D� m —.1z = + n r W G7 m m z m I / �Z \ 0 m z m i < D O --I -{ - cn Ch O D --qZ r m OT C _� O- Z C m Z ;am —� prE to p r D 0 -0O lnD r m� 4 z Xm mz Z 11 G) cn r G) Z7 X G) �. G) µ 0 -IV N ;uZ mm m z C-) y D I— -0 n n nrcnr n O -1 O �m�X AM %D ZK m r D r- —i --I 0 o G) moc(n� < D F nD �m0 m n t7 ODnn ;0 A _ r x0D O fn C Ong N ?; rl m D U)N A ;, 0 W r m z zi Km MOUNT. z= mm INSTALLER: VIVINT SOLAR J� ..} p G MCCaI lhY RCSId�inCG INSTALLER NUMBER: PV 3.0 1� *./ U U u �_ 7 High St MA LICENSE: MAHIC 170848 DETAILS North And over, MA 01845 DRAWN BY: BRG JAR4025345 Last Modified: 10/8/2014 UTILITY ACCOUNT NUMBER: 0401603003 Z ,n1 3 � O � a C n p m 3 m n 0 O< 1nn� Z Z == A a 5 'I IOW GA 'mK2 0 oD >- oOz� C_ zm mz xCcm; N< O D r A n 0 3 O An Am - Q) rro 1>0m> • • L �p nn Ore O Ip0 mm 'N' C • • 3v mz o N m� r 0 0 m N Q itQ m 5 m y O � a I a r --, o=Z Q m II c_- I zA- I r 0 � Z I m �<W rm0 I o En I m_ m m � r , m , z�vn > Amw NN N' z m Fzg;s Z �- O t D D �- 0 :.- I z D z(n Amur mxm mom m z o> v 0' m= N Z m m N / 3 0 o_ 50 ON N mL) NnC N n n m n pNn� m m O m ,gym x 3m n_ K= < oAdm?d o I d/��/O9Oj j(OO�i " Dn ro -=v _zm �ma zm� A 0AmD O(n O -(A z -4 `^y '0) 'mpn<O =0 2m m o v m N j D(mn+ N �aA _ O zC r Xmz Xm� A n a 1�r 2 m < (n O Z DCO mAD zA3 2A,�1 m DOA DON A G C m (D � Om0 = N <xrm m A m c .? 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" m9 Cor- I -IAD (n O 30 3r^ o m c^A2` i 3 A 33 3 m w p a ° d m m m° m N d O r -� 3 °-' 3 °f n °= n ro' m o m F i* m o. O c� O O c� O m r =� =. o �y °� " W y z0_ =m Dv H-0 3 �o ca "omm a M a ~.o y I z <T 1pQ fDQ oyd o mo 3� rt `a _ o I m Oc DZl o au� m_� d D < a > =. I a rI� -10 Z o ro (Dn $A_ crNi,c (D cO ' �m I N D g XG o o c tOE =3 mc c I C r CD ��3 Or f gig o S m o O D Z m � S-8 3 n �o od D O A X_ t7 O Oy ° N O ri 7 7 j o p A D 6 N Z f1I rp C° S v \ r x N to N Oo V N -0O Z Z z C D w 3 r°m O n m m D ') m N D D 2 Z m 9 3 0 0 3 z D ;? D � m i z (n Km m D (n 3 -LINE INSTALLER: VI INT SOLAR - McCarthy Residence INSTALLER NUMBER: 1.877.404.4129 E 1.0 rn � !9m-- -4 �.:/ Do u � 11� 1157 High St MA LICENSE: MAHIC 170848 z DIAGRAM North Andover, MA 01845 DRAWN BY: BRG I AR 4025345 Last Modified: 10/8/2014 UTILITY ACCOUNT NUMBER: 0401603003 N Vivint Solar - PV Solar Rooftop System Permit Submittal 1. Project Information Project Name: Claire Mccarthy Project Address: 167 High St, North Andover MA A. System Description: The array consists of a 2.55 kW DC roof -mounted Photovoltaic power system operating in parallel with the utility grid. There are (10) 255 -watt modules and (10) 215 -watt micro -inverters, mounted on the back of each PV module. The array includes (1) PV circuit(s). The array is mounted to the roof using the engineered racking solution from Ecolibrium Solar. B. Site Design Temperature: (From Lawrence MUNI weather station) Average low temperature: -24.3 °C (-11.74 °F) Average high temperature: 37.6 °C (99.68 °F) C. Minimum Design Loads: Ground Snow Load: 50 psf (State Board BR&S) Design Wind Speed: 100 mph (State Board BR&S) 2. Structural Review of PV Array Mounting System: A. System Description: 1. Roof type: Comp. Shingle 2. Method and type of weatherproofing roof penetrations: Flashing B. Mounting System Information: 1. Mounting system is an engineered product designed to mount PV modules 2. For manufactured mounting systems, following information applies: a. Mounting System Manufacturer: b. Product Name: c. Total Weight of PV Modules and mounting hardware: d. Total number of attachment points: e. Weight per attachment point: f. Maximum spacing between attachment points: g. Total surface area of PV array: h. Array pounds per square foot: i. Distributed weight of PV array on roof sections: -Roof section 1: (10) modules, (26) attachments Ecolibrium Solar Ecorail 421 Ibs 26 16.19 Ibs * See attached engineering calcs 175.84 square feet 2.39 Ibs/square foot 16.19 pounds 3. Electrical Components: A. Module (UL 1703 Listed) Qty Yingli Energy YL255P-29b 10 modules Module Specs Pmax - nominal maximum power at STC - 255 watts Vmp - rated voltage at maximum power - 30 volts Voc - rated open -circuit voltage - 37.7 volts Imp - rated current at maximum power - 8.49 amps Isc - rate short circuit current - 9.01 amps B. Inverter (UL 1741 listed) Qty Enphase M215 -60 -2]J, -S22 10 inverters Inverter Specs 1. Input Data (DC in) Recommended input power (DC) - 260 watts Max. input DC Voltage - 45 volts Peak power tracking voltage - 22V - 36V Min./Max. start voltage - 22V/45V Max. DC short circuit current - 15 amps Max. input current - 10.5 amps 2. Output Data (AC Out) Max. output power - 215 watts Nominal output current - 0.9 amps Nominal voltage - 240 volts Max. units per PV circuit - 17 micro -inverters Max. OCPD rating - 20 amp circuit breaker C. System Configuration Number of PV circuits 1 PV circuit 1 - 10 modules/inverters (15) amp breaker 2011 NEC Article 705.60(6) D. Electrical Calculations 1. PV Circuit current PV circuit nominal current 9 amps Continuous current adjustment factor 125% 2011 NEC Article 705.60(B) PV circuit continuous current rating 11.25 amps 2. Overcurrent protection device rating PV circuit continuous current rating 11.25 amps Next standard size fuse/breaker to protect conductors 15 amp breaker Use 15 amp AC rated fuse or breaker 3. Conductor conditions of use adjustment (conductor ampacity derate) a. Temperature adder Average high temperature 37.6 °C (99.68 °F) Conduit is installed 1" above the roof surface Add 22 °C to ambient Adjusted maximum ambient temperature 59.6 °C (139.28°F) b. PV Circuit current adjustment for new ambient temperature Derate factor for 59.6 °C (139.28°F) 71% Adjusted PV circuit continuous current 15.8 amps c. PV Circuit current adjustment for conduit fill Number of current -carrying conductors 3 conductors Conduit fill derate factor 100% Final Adjusted PV circuit continuous current 15.8 amps Total derated ampacity for PV circuit 15.8 amps Conductors (tag2 on Z-line) must be rated for a minimum of 15.8 amps THWN-2 (90 °C) #16AWG conductor is rated for 18 amps (Use #16AWG or larger) 4. Voltage drop (keep below 3% total) 2 arts: 1. Voltage drop across longest PV circuit micro -inverters (from modules to j -box) 2. Voltage drop across AC conductors (from j -box to point of interconnection) 1. Mirco-inverter voltage drop: The largest number of micro -inverters in a row in the entire array is 6 inCircuit 1. According to manufacturer's specifications this equals a voltage drop of 0.18 %. 2. AC conductor voltage drop: = I x R x D (= 240 x 100 to convert to percent) _ (Nominal current of largest circuit) x (Resistance of #16AWG copper) x (Total wire run) _ (Circuit 1 nominal current is 9 amps) x (0.0050852) x (230 _ (240 volts) x (100) 2011 NEC Article 705.60(B) 2011 NEC Article 705.60(B) 2011 NEC Article 705.60(B) 2011 NEC Article 705.60(B) 0.18% 4.38% Total system voltage drop: 4.56% i. n ' Customer Info Name: Email: Phone: Project Info Identifier: 13019 Street Address Line 1: 167 High St Street Address Line 2: City: North Andover State: MA Zip: 01845 Country: United States System Info Module Manufacturer: Yingli Solar Module Model: YL255P-29b Module Quantity: 10 Array Size (DC watts): 2550.0 Mounting System Manufacturer: Ecolibrium Solar Mounting System Product: EcoX Inverter Manufacturer: Enphase Energy Inverter Model: M215 Project Design Variables Module Weight: 40.8 lbs Module Length: 65.0 in Module Width: 39.0 in Basic Wind Speed: 110.0 mph Ground Snow Load: 50.0 psf Seismic: 0.0 Exposure Category: B Importance Factor: II Exposure on Roof: Partially Exposed Topographic Factor: 1.0 Thermal Factor for Snow Load: 1.2 Lag Bolt Design Load - Upward: 820 Ibf Lag Bolt Design Load - Lateral: 300 Ibf EcoX Design Load - Downward: 493 Ibf EcoX Design Load - Upward: 568 Ibf EcoX Design Load - Downslope: 353 Ibf EcoX Design Load - Lateral: 233 Ibf Module Design Moment — Upward: 3655 in -Ib Module Design Moment — Downward: 3655 in -Ib Effective Wind Area: 20 ft2 Min Nominal Framing Depth: 2.5 in Min Top Chord Specific Gravity: 0.42 EcolibriumSolar Plaihe Calculations (ASCE 7-10): R1 Roof Type: Composition Shingle Average Roof Height: 20.0 ft Least Horizontal Dimension: 44.0 ft Roof Slope: 25.0 deg Truss Spacing: 16.0 in Edge and Corner Dimension: 4.4 ft Snow Load Calculations EcolibriumSolar Description Interior Edge Corner Unit Flat Roof Snow Load 42.0 42.0 42.0 psf Slope Factor 0.82 0.82 0.82 psf Roof Snow Load 34.4 34.4 34.4 psf Wind Pressure Calculations Description Interior Edge Corner Unit Net Design Wind Pressure Uplift -19.4 -31.9 -47.9 psf Net Design Wind Pressure Downforce 11.4 11.4 11.4 psf Adjustment Factor for Height and Exposure Category 1.0 1.0 1.0 psf Design Wind Pressure Uplift -19.4 -31.9 -47.9 psf Design Wind Pressure Downforce 11.4 11.4 11.4 psf ASD Load Combinations Description Interior Edge Corner Unit Dead Load 2.3 2.3 2.3 psf Snow Load 34.4 34.4 34.4 psf Downslope: Load Combination 3 14.2 14.2 14.2 psf Down: Load Combination 3 30.4 30.4 30.4 psf Down: Load Combination 5 8.9 8.9 8.9 psf Down: Load Combination 6a 28.4 28.4 28.4 psf Up: Load Combination 7 -10.4 -17.9 -27.5 psf Down Max 30.4 30.4 30.4 psf Spacing Results (Landscape) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 59.6 59.6 59.6 in Max Spacing Between Attachments With Rafter/Truss Spacing of 16.0 in 48.0 48.0 48.0 in Max Cantilever from Attachment to Perimeter of PV Array 19.9 19.9 19.9 in Spacing Results (Portrait) Description Interior Edge Corner Unit Max Allowable Spacing Between Attachments 35.9 35.9 35.9 in Max Spacing Between Attachments With Rafter/Truss Spacing of 16.0 in 32.0 32.0 32.0 in Max Cantilever from Attachment to Perimeter of PV Array 12.0 12.0 12.0 in R. s Layout EcolibriumSolar � Skirt E3 Coupling O Clamp 0 Bonding Jumper Warning: PV Modules may need to be shifted with respect to roof trusses to comply with maximum allowable overhang. Distributed Weight (All Planes) EcolibriumSolar In Conformance with Solar ABC's Expedited Permit Process for PV System (EPP) Weight of Modules: 408 lbs Weight of Mounting System: 52 lbs Total System Weight: 460 lbs Total Array Area: 176 ft2 Distributed Weight: 2.61 psf Number of Attachments: 26 Weight per Attachment Point: 18 lbs Bill Of Materials Part Name Quantity ECO -001_101 EcoX Clamp Assembly 26 ECO -001_102 EcoX Coupling Assembly 12 ECO -001_105B EcoX Landscape Skirt Kit 6 ECO -001_105A EcoX Portrait Skirt Kit 0 ECO -001_103 EcoX Composition Attachment Kit 26 ECO -001_109 EcoX Electrical Assembly 1 ECO -001_106 EcoX Bonding Jumper Assembly 3 ECO -001_104 EcoX Inverter Bracket Assembly 10 ECO -001338 EcoX Connector Bracket 10 Date ..27F - L& 7 -F - L& f NpRTN 1 oro,<��•�;..+ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING CHUS This certifies that ..... ... ....... ................. . has permission to perform .-'�"::r ". ,- ................. plumbing in the buildings of ............. at.. 11-7 -- .............. . NoxAndover, Mass. n Fee' ..... LiUc. No. .12,c�l . /�... f�+�r �. ............ . PLUM8�11JG INSPECTOR Check # 5535 tki AC- G` APMUC (Print .�orType) .,'. � l` rUf.-fiE till L U, an� Mass. Date 31(0/ -7A/') a � Building l..ocati New 0 Renovation ❑ permit Owner's Mame Type of Occupancy, -IZC4 P➢� /vim �, 13 Plans Submitted: Yes W No ❑ .installing Co Address o Business Telephone( i` 3`U'�pl ;. Name of Licensed plumber ❑ Corporation ❑ Partnership ❑ Firm/Co. INSURANCE COVERAGE: i have a current liability insurance policy or its substantial equivalent which meets the requirements o Yes ❑ No > f MGL Ch. X42. If you have checked des, please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: l am aware that the licensee does not have the insurance c Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. - overage required by Check one: q nt. Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have ubmitted (or entered) in above application are true and accurate knowledge and that all plumbing work and installations a rmh ed and r the permit issued for this application will compliance with hail be in com pertinent provisions of the Massachusetts State Plumb" de and Cer 142 of the General Laws, to the best of my By Title C Signature f License Plumber City/Town Type of License: Master ourneyman C 1 ,4PPPSfi�`�� <<JFt=iC� �S� tC(y �"� A Date... .... . / ION TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that - R. . ....... .................. ........... has permission for gas installation-. - .......... .............. ....... . in the buildings of .... ................... at ........ orth Andover, Mass, 1 3 Fee./.-.) ....... Lic. No.. . . . GAS INSPEC Check 4 4666 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) G 1 V 0 P-1 H UNLU ' /Z -Mass. Date Permit # q6' 4 Building Location 1 V7H 1 � N � � Ow ?r's Name a /� vpe of Occupancy CS I z AITIM L AV New 21 Renovation ❑ Plans Submitted: YesAQ No ❑ Installing Company Nam Address Business Tel Kr-ixa, P� Ov Name of Licensed Plumber or Gas Fitter �Q N t"-,�'^ Check one: ❑ Corporation ❑ Partnership ❑ Firm/Co. Certificate INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ❑ No 99 If you have checked ves, 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 waives this requirement. p Check one: Signature of Owner or Owners dent Owner❑ Agent [I I hereby certify that all of the details and information 1 have submitted (or entered) in ve appii. i n are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permi s ed for this plication will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the al Laws. TjMastere of License:PlumbrSig at a of Licensed PI ber orGas Fitter Title Gasfitter License Number l ��.Z...1 City/Town Journeyman APPROVED (OFFICE US ONLY) N w rn H [� z cc t- n 5 W W N a o o cl r =~ J C w F, � a Z 4 = O W au co Uf 3- C G W O O a O � — � }- C U) w N O z W a W= s¢ z E- 'A w O 1-- w > t- w x �, W w W W= O > W - W H W z a W a c I- < �- rn m z o z O till a W> W z• CC a Q O O w a O u� }- ¢ ' z O c� Y� 3 G t9 .� U Y G a F- O SUB—aSMT. BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4THFLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Nam Address Business Tel Kr-ixa, P� Ov Name of Licensed Plumber or Gas Fitter �Q N t"-,�'^ Check one: ❑ Corporation ❑ Partnership ❑ Firm/Co. Certificate INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ❑ No 99 If you have checked ves, 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 waives this requirement. p Check one: Signature of Owner or Owners dent Owner❑ Agent [I I hereby certify that all of the details and information 1 have submitted (or entered) in ve appii. i n are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permi s ed for this plication will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the al Laws. TjMastere of License:PlumbrSig at a of Licensed PI ber orGas Fitter Title Gasfitter License Number l ��.Z...1 City/Town Journeyman APPROVED (OFFICE US ONLY)