HomeMy WebLinkAboutMiscellaneous - 1799 Salem StreetTOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: % D�
CVCTrn. �.
' L"' kJ rrADDRESS
SYSTEM LOCATION
(example: left front of house)
JFMtA;�- off' kcxJS�k—
DATE OF PUMPING: /—'.3 QUANTITY PUMPED/
_GALLONS
CESSPOOL; NO YES =_ SEPTIC TANK: NO
YES
MATURE OF SERVICE: ROUTINE
—2(_ EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS —'--
EXCESSIVE SOLIDS --�
SOLIDS CARRYOVER
51 STEM PUMPED BY:
OMMENTS:
O.N'TENTS TRANSFERRED TO:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED ---
OTHER (EXPLAIN) ---__
TO'vgN OF NORTH AND
BOARD OF HEAJH
�g - 4 2002
s�
MASSACHUSET T5
(Print or Type)
UN
41 n3 c,� Oy E , Mass.
Date -:5-/e cl 1GL_ Permit # 23�1 3
Building Location / °7 cl-q -'3A), E - ti, s%. . Owner's Name W h Tj L z - `z
Ny A �J OQ r/ F 2. A114- Type of Occupancy dawF/h&;
Now Renovation O Replacement p . Plans Submitted: Yesp No 9 --
Installing Company Name e o I I o Pu 4 wi� iNe. /Check one: Certificate
Address ( 5 h 2 TT (-1 C lac ST. orporation 1 O 9 2 C
_L a W i e 1\/C�r o1 14G3 Lql3 [) Partnership
Business Telephone . Co 8 8 — 17L�� O Firm/Co.
Name of Licensed Plumber or Gas Fitter _Do,A• Lf) I) FS R LI I Sc,, F A q x
INSURANCE COVERAGE:
I have a current IjAbliity insurance policy or its substantial equivalent which meets the requirements of MGL Ch, 142.
Yes 2' . No O
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability Insurance policy;M" Other type of indemnity O Bond O
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:
OwnerO Agent O
Signature of Owner or Omnert Ment
I heroby certify that all of the dotails and information 1 havo'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 will) all
pertinent provlslons of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
T Plumber se: signature
ense Plumber or Gas -itl
Title, asterIttF— --
aster Ucense Number S G
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6TH FLOOR
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@Tfit PLOOR-1
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Installing Company Name e o I I o Pu 4 wi� iNe. /Check one: Certificate
Address ( 5 h 2 TT (-1 C lac ST. orporation 1 O 9 2 C
_L a W i e 1\/C�r o1 14G3 Lql3 [) Partnership
Business Telephone . Co 8 8 — 17L�� O Firm/Co.
Name of Licensed Plumber or Gas Fitter _Do,A• Lf) I) FS R LI I Sc,, F A q x
INSURANCE COVERAGE:
I have a current IjAbliity insurance policy or its substantial equivalent which meets the requirements of MGL Ch, 142.
Yes 2' . No O
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability Insurance policy;M" Other type of indemnity O Bond O
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:
OwnerO Agent O
Signature of Owner or Omnert Ment
I heroby certify that all of the dotails and information 1 havo'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 will) all
pertinent provlslons of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
T Plumber se: signature
ense Plumber or Gas -itl
Title, asterIttF— --
aster Ucense Number S G
�y�wn Journeyman
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• " Date.., �:. ........... .
v `I
,,ORTH TOWN OF NORTH ANDOVER
0 1
T PERMIT FOR GAS INSTALLATION
y9SSAC HUSSt JJ
This certifies that%�c..f l ...... .. /................. .
�r
has permission for gas installation . ✓.. , . , ;�....................
in the buildings of .. , t,.!.
at . l -*/ ....---- / ........: ........ . North Andover, Mass.
Fee. /, ..:.. Lic. No. T�. e. ....... I ....................
GASINSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File