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Date. .
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that -77molhll
has permission for gas installation ...... ...... ve
in the buildings of .... /I
h -e pdover,, M.ass.
at ... North A
Fee. ik Lic. No.,—?4!�Fl. 4A��,aA �..
GASINSPECTOR
Check # Z3-;7
8165
4""i� 4
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY MA PERMIT #
— ----------
---]OWNER'S NAME
JOBSITE ADDRESS
on- ca--�fl
G
OWNERADDRESS TELF _.=FAX[
TYPE OR
PRINT
OCCUPANCY TYPE COMMERCIALE EDUCATIONAL RESIDENTIA
CLEARLY
NEW:0 RENOVATION: L-1 REPLACEMENT�� PLANS SUBMITTED: YES [j NO),-ej'
APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 71 =L
BOOSTER
CONVERSION BU�NER
COOK STOVE -J11 F -
DIRECT VENT HEATER 7 -
DRYER LLmj
FIREPLACE
FRYOLATOR
r- 7 -F—
FURNACE 1 7
1 7- F
GENERATOR L=
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN 1= F -A
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER 771F 11 ------- 11
UNVENTED ROOM HEATER I=
L -AL -=1
WATER HEATER
OTH
..........
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND F -
_j
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT
SIGNATURE OF OWNEROR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this 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 compli provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASATTER NAME FTimo � i �e itt LICENSE #E��391i SIGNATURE
-]#[DBA
MP E -j MGF E JGFO LPGIEJ C6RPORATION 0# PARTNERSHIP D#L-- LLCL
JP E:
COMPANY NAME] WJ Plumbing ADDRESS rL,72 Adin-gto—n&
STATE MA:JZIP
CITY I Franklin -]TEL F978-67-2156
FAX CELL[-- WJ717-5-@c—o-m-cast.net
EMAIL
The Commonwealth ofMassachusetts Print Form_...]
Department ofIndustrial Accidents
Office of Investigations
I Congress Stree4 Suite 100
-2017
Boston, MA 02114
wwwmass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/individual): U_ � -�>
Address: -
Phone #:
Are you an employer? Check the appropriate box:
1. El I am a employer with
4. E] lam a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2 1 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.1
required.]
5. n We are a corporation and its
3 -El I am a homeowner doing all work
officers have exercised their
myself [No workers' comp.
right of exemption per MGL
insurance required.] f
c. 152, § 1 (4), and we have no
employees. [No workers'
comv. insurance required.]
Type of project (required):
6. E] New construction
7. 0 Remodeling
8. E] Demolition
9. 0 Building addition
10.0 Electrical repairs or additions
11. E] Plumbing repairs or additions
12.0 Roof repairs
13.0 Other
*Any applicant that checks box #1 must also fill out the section below showing their workcrs'compensadon 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.
tContractors 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. Ifthe sub -contractors have employees, they must provide their workas'comp. policy number.
Iam an employer that isproviding workers' compensation insurancefor my employees. Below is the policy andjob site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:-- Expiration Date:-,
Job Site AddrMes Cily/State/Zip-v
,Av
Attach a copy of the worke�rsl compensation policy declaration page (showing the policy number and expiration date)bl V-t�-
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 diepaim—AndWellaides o
fper*
ju
,y that the information provided above is true and correct
Phone M
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):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#: