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HomeMy WebLinkAboutBuilding Permit #694, Gas Permit #6671, Gas Permit # 900 - Permits - 4/23/2019 i Location_ pV@.rr a p No.�°..... Date I -.__._____.__� P TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee i Foundation Permit Fee N. Other Permit Fee $ TOTAL i Check 25378 Building Inspector E 1 } J t r f tyORTH BUILDING PERMIT TOWN OF NORTH ANDOVER a a APPLICATION FOR PLAN EXAMINATION y p.��'y �r ply Permit IVo. Date Received 7q HATED Date Issued IMPORTANT Applicant must complete all items on this page r- a N x rriFr/r .✓r x ,� ✓ r J xr v Jri < t✓ rf yt r✓- i - °;.s /r�' � r r Y/l ✓,/` / f f � I/ryr✓ rt v �' ,✓ ! r / r /� r a r/i fr/i / rr f a / r} 1 - / r r r ✓/ f r / r Y 11 it izr,.r r r o rv/ �fr' rq r !.;!v, ' r 5 1:� r M��f�i r x' do x r 7f' �/ ''�!' ' r J ✓b rye -rfi /r rf rJr/ rvr ' rr rr, r i r��y a u rr,/sv/l s :✓ �r r ! 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O1R .r Y( .✓� ,1,,, ':::l x,..ru. / � ;, ,� ,r,,;ar ,,,, /r,r-„ //Y „i- .a na+ U,r.. d ..r,. ,r".ll /'i r /...7v ./A.f -h /._ri 1 ✓ /a, --, r„ ..;,: d/ /"/ r.h /r rk/rAr., ,,1.%.Ff, ri ltl ,4r J�S.Jo r ✓ 1 / y(//r u„r r�,,. r r^ v/ .,f ,e:r :,.; v Y / r ,;Jrl,r.�lr! r ;r:ry;f l ,,v/,,. �:�, �r r//;, fo G ,t, F,� f��rl� �Jr✓v✓. f r;. ,f /ivv r r / -:v.r :v a r7I s ' ., r ^✓ ,e. 4�' :./1� of �/rt,.rl'//,.�r. rirrn 7 9 r / III ,f�� r ,N. -!/nNr r��i/ v ur/�..r / r r i. sw .,, 1 r F9'F «> r, r i /�l'�r �. �f/� 1. ✓ I� GOi! 1,,, � ^; ✓ r. /. /,'i,r~,,,�vl /r 9,�/✓ lc„.� ,,,,cc,.-„ ,a-., 7/r / rr 1� ,.d �'.�, ,, r ✓ •; „N r !✓r a r vlr� r/.;/ ,.�1 / ,r„„ „r' xr' ,,; '� �rr.� qr�U�7i ,..F' �r y//w/% C,�"� rf (� / r ,^, ,r � �u �li�,r,✓ /rh, v�r� r'�,, , ✓. , „ /sl�ps'xo�Ic Dastrle r 9f ✓/ l a/ r,,, r �i' ',., � / /l.yr:lr ,,. r�/ w r / � r 5/1/,1 v (vi/ .r!r ri:. ,✓i, :+/a�✓'/f,✓r�%'r1,°(J;N F3',,,fa::,,, / ,r,rrr��,!..!fi i ,, �! it,, ., r�I/ ".1 / y/,NN r��H/�//! .rfr r/lr '`'"/ r r ✓ r r r /ir ✓ r �r; tr rrr /. rir �r r r/ / /Gn r/l^r�. d �%' /rr r( r/ r ar✓ n�; hop�Vl[ age yes TYPE OF IMPROVEMENT PROPOSED USE Re�intf�al ��� Non- Residential ❑ New B Iding [] Ad on El Two or more family ❑ Industrial ❑ eration No. of units: ❑ Commercial Repair, replacement ❑ Assessory Bldg [I Others: ❑ Demolition ❑ Other Spt�c ,,„i Well ' ❑rFlood [a�n rrr CI etlads ❑ Watershed a�skrtct r (i i(� rm rnr ✓ di r i/ r �, e ✓ %r r `// N F ✓r r(r r r r/✓ / / d DESCRIPTION OF WORK TO BE PREFORMED: 7, Identification Please Type or Print Clearly) OWNER: Name: L Phone: Address: ' CCJNTRACTOR Narr�ef J/ r r r ! / '� ✓ r v � I l Add mess r ! ma r /i ! rr'rrN r rr✓, yrxNtiri'r lj rNl/�rf a r rrr /f /,kr�l 3r a NPR r rC//rU�rr✓ x,l / / rr �uper�ris�ar's Corastru�f�on �icens� Ex Dated �� Home [rriprcivement Licehse: ,,. x D.�fe (;,� �, ,N'' , ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE;BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ - FEE: $ c" Check No.: Receipt No.: MOTE: Persons contracting with unregistered contractors do not have access to the fund Sigr at re`of AgentlCtwn r signature of contractor � � �� rim ®RTH 1 -01" OfAndover `�:..No. 4!!: z �0- LAKE ® ®ver' Mass., COCWCHEWICK � oRATED P'VR Cl BOARD OF HEALTH P E n mMm I T T Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT................ ...................... �.�............ .......... ................. ..... .......... ......................................... Foundation i has permission to erect........................................ buildings on4 �T .......... Rough to be occupied as ��i Chimney provided that the person acceptin this permit shall in every respe onform to the terms of th application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteratiorr and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMrr EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS U TS Rough r Service BUILDING INSPECTOR I Final Occupancy Permit Required t® cmpy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final o Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. t Member Df NH Batter Business bureau Fully Licensed and Insured • Member of MA Better Business Bureau 66661 GAF Cert.ME#20212 FIIC Reg#1 y E ff EIN#26-1081508 NR CSt#104728 4728 S General Contracting, LLB 51 S. Broadway#2214 Salem, NH 03079 • (6031990.0084 1 10 Stevens Street#141 Andover, MA 01810 (978)475-0095 PHONE ';DATE - PROPOSAL SUBMITTED TO = E-MAEL STREET - CITY,STATE,AND ZIP CODE JOB LOCATION Completely protect the home with tarps to catch falling debris. Respect and protect shrubbery and flower beds. Strip offs aJayers of roofing material down to the bare roof deck. Inspect the roof deck for structural defects. Determine the condition of the underlying plywood or boards, and repair and replace as necessary'. Inspect roof ridge for proper"I 1/2" spacing on either side of.ridge for maximum exhaust ventilation. Cut in if necessary. Install new heavy gauge -.` ri c" (color) A ,. r �drip edge at roof eaves. Install 3.-24 V ice and water shield to meet manufacturer's specifications (i.e. 6 feet from roof edge, 3 feet centered in valleys, around all skylights, chlmney bases, roof penetrations and at all sidewall transitions), Install ?n' u ' `"� °'' breathable roof deck protection to remainder of the roof deck. ' z'= (color) ` :. ;4 drip edge at roof rakes. Install new heavy gauge Install " starter strip at roof eaves and rakes }� 4 desired color. (colon Install new flashings to meet manufacturers specifications. (i.e. sidewalls, chimneys, skylights and roof penetrations}. Install _{feet} of vent at roof ridge to allow maximum ventilation. Hand nail to ensure proper fastening. Install.. (feet) of v le distinctive hip and ridge cap. Hand nail to ensure proper fastening. Thoroughly clean up and dispose of all roofing debris on property. Magnetically sweep property for nails. Notes Edmunds General Contracting will: • Obtain all necessary construction-related permits to complete this project. • Perform work as efficiently as possible without sacrificing quality. • Furnish and install all necessary materials to complete the project. • Provide a thorough clean-up and disposal of all debris generated during project. -4, 0- 3 Edmunds General Contracting LLC agrees to commence work on/or about �J and described work will be completed in about �days. Product Upgrade If- Product Upgrade 2: �� ,. - -€:,e =72 � . . g a_ agreed hat this ct may be assigned by Contractor's employees are fully covered by workmen's compensation and liability that the obligations thereof shalltbind and apply to their heirs,successors aotl spates in of the parties. Upon completion of the above work,all undersigned agree to execute and deliver to the contractor,their joint note in accordance with his(their)above obligations as Edmunds General Contracting LLC guarantees all workmanship performed far requested by contractor.Upon refusal to do so,contractor may at its option declare ;.OL_ ryears. the entire contract price or so much as then remains unpaid,immediately due and - payable.It is agreed that,if permitted by law,contractor shall be paid by the We will register ' factory enhanced warranty owner(s)all reasonable costs,attorney fees,and expenses,in addition to the providing_`'��°�years of material defect coverage and ` years of amount due and unpaid,that shall be incurred in enforcing the terms and conditions workmanship defect coverage through GAF Materials additional locost of of the contract and/or any lien in connection herewith. n for: "no charge- 'Edmunds General Contracting LLC will provide the materials,later and disposal to replace up to 64 so,ft,of roof deciciing and 20 it of fascia at no additional cost. p p _-��- ...V _-.linear foot. Any additional materials including/char and disposal will tra replaced at per sheet or`'`� All materiat Is guaranteed as specifled.All work to be completed in a workmanlike manner according to standard Edmunds General Contracting, LLC agrees to furnish the material and practice.Anyalterationordevialionfromabovespecilicationslnvolvingextracostswiiibeexecutedonlyuponwritten labor complete in accordance with the abo ecifications,for the sum orders,and will become an extra charge aver and above the stated contract price.Contractor is not responsible for �., `. _� damage due to high winds,tornadoes,hurricanes,lire or other hazards.awner(s)agree to cane fire tornado and other a - "' necessary Insurance.Contractor is considerate of owner's landscaping and but due to the nature of the rooting of _ , a: ,� � �,.w -.� ' s� dollars($ � � n .� -s - ;vr installation some damage may occur.we atternpt to minimize any damage,and will not be hold responsible if any r- ^�; ,.v ;, " damage occurs, contractor is not responsible for any damage to the interior of pmperiy,including pre-existing a - conditions ti.e.water stains,crumbling plaster,Unposed nails)or canditiors resulting from application of materials as Payment Terms: specified above.Items in the attic may need to be covered dy the owner.contractor Is not responsible for damage caused by lee dam build-up.All agreements a o cePtlingent upon stdkes,,riccidents or delays beyond out control ® A deposit of_ >`_.-{not to exceed 1I3 of the total contract} is g �� due upon start of work.The balance of 1: 44 is due when work Authorized Sinature Edmunds General Contracting L�Q is completed to the satisfaction of a!I parties y ® A finance charge of 1.5o/o per month 08% per year)will be charged on Bate: This proposal may, withdrawn by us if not accepted within past due accounts over 30 days days. CIepCaitCP D rR IA��� 'The above prices,specifications,and 00 NOT SIGN TyIS CONTR X THERE ARE ANY BLANK SPACES. conditions are satisfactory and are hereby accepted.You are authorized to do �1 the work as specified Payment will be made as outlined above. Authorized Signat}tre � Date of acceptance �� �"'' ,° � Authorized Signature: � ��= All home improvement contractors shall be registered.Any inquiries about a comradar of subcontractor relagdg to a reglstratlon should be directed ta:9flice of Consumer Attairs and Business fis:gulauen,lf3 Park Plaia Sails 5176,Boston,MA 115(Fho-ne'.647-973-8700). owners who secure their own construction-relalt pound s or deaf with unregi5teied contractors shall be excluded fro-m access 1a She Guarantee Fond prr noloeri of.C;oge142A Rev.04711 The owner will receive a signed copy of this contract before work wfl1 commence.The owner has Three(3}business days to caeca€this contract and incur no penally.Carraspondance should pa directed to Edmunds General Conlraclin9 LLE al the above address. ^ _CXThe Commonwealth of Massachusetts Department oflndustruclAccidents Office of Investigations to 600 Washington Street Boston,MA 02111 www.masv.gov1dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricia-ns/Plumbers Applicant Information Please Print Legibly Naive(Business/Organizationfindividual): CL44 Cc, k Address: City/State/Zip: U' Phone#:_ Gib Are yop an employer?Check the appropriate lox: Type of project(required): 1. am a employer with '?-- 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time),* have Hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.? 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g El Building addition [No workers' comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(d),a-adwe have no 12.❑Roof7repairs insurance required.]i employees.[No workers' 13.[i Other comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they n're doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that checkthis box must attached an additional sheet showing the name ofthe sub-contractors and their workers'camp.polloy information. 11I37P an BYIZplo_J1ef that is providing workers'compensation insurance for my employees. Below is thepolicy(ndjob site infoTmadon. Insurance Company Name:. t-4 1-ty' Gb Policy#or Self ins.Lie.0: L5: ,f Gj 7. Zcp2<Zi_-- Expiration Date: -z-e, - Job Site Address: CMR� 7-K. icity/state/Zip:_ Q Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 one 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 tlrA fo ' prance coverage verification. grlo I2ereb rtify un a pa' a penalties ofperfury that the information provided above is true and correct. .r Si atur6: i Date: � 1 Phone#: Official use only. t��Jle in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): x.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other ry - Contact Person: Phone#: From:Julie Dortona FaXID: Page 2 of 2 Date:4/212012 11:55 AM Page:2 of 2 ' OP ID: JD CERTIFICATE OF LIABILITY" INSURANCE DATE 04102DlYYYY) 4102112 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONACT PRODUCER 603-890-6439 NAME: Planright Insurance-Salem 6038906521 PRONE FAX - - 224 Main Street Suite 3C AIC Na Ext: _ AJC Na_____ Salem,NH 03079 ADDRIESS: ,lames A Santo PRODUCER EDMUN-1 CUSTOMER ID M: INSURER(S)AFFORDING COVERAGE NAIC It INSURED Edmunds General INSURERA:St Paul Surplus Lines Ins CO Contractor LLC INSURERB:Riverport Insurance Company PO Box 2214 Salem, NH 03079 INSURERC: INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMlDDIYYYY MMIDDIYYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIA3€LITY CP572203 11l11l10 11111/11 PREMISES Ea occurorence $ 60,000 CLAIMSMADE OCCUR MED EXP(Any one person) $ 5,000 WS091261-(RENEWAL) 11lif111 11111l12 PERSONAL&ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO ELOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS -......—......._.---. BODILY INJURY(Per accident) $ SCHUOU LED AUTOS PROPERTY DAMAGE $ -— -- - HIRED AUTOS (Per accident) NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION S $ WORKERS COMPENSATION X I WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS I I ER $ ANY PROPRIETOWPARTNERlEXECUTIVE YIN C288300042503-NH 04/03/10 04103/11 B,L,EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? N I A (Mandatory in NH) WC288300042503 04/03/11 04/03/12 EL DISEASE-EA EMPLOYEE $ 100,000 If yes,des efi be under - DESCRIPTION OF OPERATIONS below E,L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) C: 3A:NH & MA / David Edmunds has elected to be excluded from coverage on the NH policy. CERTIFICATE HOLDER CANCELLATION TOWNNOA SHOULD ANY OF THE ABOVE DESCR[BED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. 1600 OSGOOD STREET NO ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE ©1989-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks Of ACORD ✓die -�a�rr�nza-ruue��C� o� Office of Consumer Affairs&li�sincs✓�R g tz _ — HOME,IMPROVEMENT.CONTRACTOR Type". -Registration 166661 Expiration 612112012 Corporation EDMUNDS GENE5RAL CaNTRAGTING,LLC. DAVID EDMUNOS, 1 SHAKER LN HAMPSTEAD, NH 03841` Undersecretary " s.iattlati t1a 'i'1>tatiatc}3US etis- 5;ttiaitii�a1 � LiCen e�i�tl : . o#'dui#t1it� e �E1a�t t# a ervisar �Cnsir�C�ic��S P License: CS 104725 pP,\jP. p g0X 221 4 SA�EMS ��'d3073 �;�iration: 10f3f2p13 104728 7- ' g75:�11131<1 - (55i53i Date � raoaar� i • , , . . , , . .. , j TOWN OF NORTH ANI)OVER Io PEAIWIT FOR GAS INSTAILLATION x ro This certifies that . . _,. has permis , siaar� for it stallati in the building ctf o'� � s . , at . . Fee. o . Lic o. Andover,rth t � Mass. Check# GAS 1FV TOR . . . . . . . { MAS_SACHUSE'TZ S UNIFORM APPLICATON FOR PERM TO DO GAS G (Type or print) Date �1 NORTH ANDOVER, MASSACHUSETTS CI Building Locations AD j Permit# Owner's Name LlAmount$ New❑ Renovation .❑ ReplacementElk" Plans Submitted " © U c C) �z . � U w � v, z E- p � � z w F U p > u w c z z v ea z o z w o w x � D O try SU B -BA5EM ENT 3 ❑ :? .4 U tz ^ 0 BASEMENT 1ST. FLOOR 2ND . FLOOR 3R D . FLOOR 4Tl-1 . FLOG R 4'rH . FLOOR 6TH . FLOOR 7TH . .FLOOR. STH . FLOOR (Print or type) Name , Z Z-/ A 7t Check�on�e: Certific a fngaliing Company Address l fI�JC.1(f l ✓ Partner. usiness I a ep one U Fi;7n/Co. Name of Licensed Plumber or Gas Fitter FINSURANCF COVERAGE current liability insurance,policy or it's substantial equivalent Check one: ave checked Yes please indi a the type coverage by checking the appropriate box Yes NoO y insurance policy Other type of indemrxity n ❑ Band Owner's Insurance waiver: I am aware that the licensee does not have the Insurance c Mass. General Laws,and that my signature on this permit application overage rewired by Chapter 142 of the waives this requirement. Signature of Owner or Owner's Agent Check one: wner Agent t hereby certify that all of the details and information I have submitted(or ewer d in xb�ove applicatiana a and accurate to the best of my knowledge and that all plumbing work and installations peri ed e compliance with all pertinent provisions of the Massachusetts State Cs ' Issued for this application will be in ° C. 2 of the General Laws. By: Signature Li sod Plummer Or Gas F or 1.Title ?lumber City/Tow,n; �cense umber Gas Fitter Master APPROVED(OFFICE USE ONLY) Journeyman ,. "ORTpj �a 0" MIT FOR GAS, INSTALLATION r gCHO ''ro91 irilyi rlr o This certifies t at v. t has permission for gas installation in the buildings Of . . 4 t . . 4 F'. . . . . . . . . . North Andover, Mass Fee. . . a w, . ro . Lic. No.el'. . . IAA INSPE TOR WHITE:Applicant ' CANARY: Building Dept, I"RNkf;Treasurer ta(7CD>File ASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTIN Type) (Print r�` ,,r.m r ...,,( �„ dr 1 g `°/° r d _ ,��. Mass. Date ��; �'r � `� Permit # .A .F � �ram. fr.irlciirti Location_ �..,,,, . w. Owners Name g .�d. l ,_. Type of Occupancy RESIDENTIAL New [:] Renovation Replacement ❑ Plans Submitted: Yes❑ No ❑ u: W ui z cc r r w w X ® 0 � h 0 W w -� Cr r- Q m us h d cc ® o q i! W 0 t = R 0 cc W z v W x U) z kt cc a ' W W W v' Q = = cc tW7 C W W N3: cc ca - X t= z W W 0 > _j .g W 42CC z O x W C X .t rca > a W �. ¢ sc ¢ a 0 0 a C 0 0 u. es a a a o sue--BSMT4 BASEMENT 1ST FLOOR 2NlD FLOOR 3RD FLOOR ++ 4Trt FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH r"LOOR d E011= Installing Company flame BAY STATE GAS COMPANY Check one: Certificate # Address 55 MARSTON STREET Corporation 64C LAWRENCE r MA 01840 ❑ Partnership Business "Telephone_ 5 0 8-6 8 7-110 5 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter ( i iNSURANCF COVERAGE- I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 11 No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy (Yl 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 Owner's 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 the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the G to PY _ T e of license: Plumber Signature of Licensed Plumber or Gas Fitter Title Gasfitter Master License (umber M—4 2 9 ___ _ City/Town Journeyman AF'P(iC1VCf) (c>iWf IC L USf ()t�liYl __._. MASS ACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Building Location 6-5 Owners Name Permit# Amount 1 e of Occu2ancy New Renovation Replacement 1:3 Plans Submitted Yes No FIXTURES Cn Z > SuWqmm 114SEMEW IST FLOCR ZIQ 11" 4MILCM 5M FUM 6M FL" 710R HIM (Print or type) Check one: Certificate Installing Company Name—16" / /L El Corp. Address 13 Partner. Firm/Co. R-u s me s-s TeTe-p f Fo n 6 Name of Licensed Plumber: �7, Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy El---. Other type of indemnity 1:1 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 El 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 MassachiVetts State Pinb�nZgode and Chapter 142 of the General Laws. By: 77gna tire Of Llcensearjumt)'er Type of Plumbing License Title '2 City/Town r1cenM TIMOR Master r-1 APPROVED(OFFICE USE ONLY LJ Journeyman El—