HomeMy WebLinkAboutGLSD - Organics to Energy Project - Application - 240 CHARLES STREET 1/30/2017 Commonwealth of ia a eft
Division of Professional Licensure
Board of State Board of Examiners of Plumbers and Gas Fitters
1000 Washington Street a Boston • Massachusetts a 1 -6100
VARIANCE FROM STATE PLUMBING CODE
PREmINSTALLATION
$86.00 application fee able to "Commonwealth of Massachusetts,
DO NOT USE THIS APPLICATION IF PLUMBING WORK HAS BEEN COMPLETED
PLEASE PRINT CLEARLY
( ectionl)APPLICANT II F RMATI I :
Applicant Name: Firm Name(if applicable): date:
Daniel Flaherty C M Smith 1 3 1
Title or Position with Firm(if applicable): Type of Work:
Mechanical deer New Construction: Renovation: 0
Street Address: City Town: State: Zip Code;
240 Charles St, North Andover, MA 01845 North Andover MA 01845
Cell Phone: worm Phone: Emall:
(857) 505-1608 (617) 452-6312 flahertydm@cdmsmith.com
ALL of THE FOLLOWING ITEMS MUST BE INITIALED,
IF LEFT BLANIO THE FORM WILL BE DEEMED INCOMPLETE AND WILL NOT BE ACCEPTED.
..l have included with this application wr$tten documentation that the local Board of Health has been petitioned INITIAL BELOW
regarding this variance request.*(Variance requests for City of Boston must Include petition to Irnspectional Service s)
Note:No Board of Health petition Is required for buildings owned,used or leased by the State of Massachusetts,
,1 have included all necessary supporting documentation regarding this variance request. INITIAL BELOW
DF
3.I have included a non refundable check for$86.00 parable to the Commonwealth of Massachusetts, INITIAL BELOW
Note;No payment is required for bulldings owned,used or leased by the State of Massachusetts.
DF
I NITIALBELOW
.The unusual or extraordinary circumstance or established hardship that warrants special terms or conditions Is
clearly stated in(section )on the second page of this applicationDF
5.I understand that this variance€ quest is for one instance at the location Information stated in(Section ) of this INITIAL BELOW
application. DF
INITIAL BELOW
.1 certify that the plumbing work relevant to the Information stated In(section 5)has not yet been performed.
DF
* "Additionally,any response by the Board of Health or Health Department must be provided,however,the Board may waive this
requirement so form as the petition was made In a timely manner."
TEL: 17y 7- 9 FAX: 617-727-6096 TT 1TD . 617.727.2099 http://www,rnass. ovid pilboa dsipI