Loading...
HomeMy WebLinkAboutMiscellaneous - 700 Osgood Street! NORSE ENVIRONMENTAL SERVICES, INC. 92 Middlesex Road, Unit 4 Tyngsboro, MA 01879 TEL. (978) 649-9932 • FAX (978) 649-7582 Website; www.norsieenvironmei7tal.com May 14, 2014 North Andover Conservation Commission 1600 Osgood Street —Suite 2035 North Andover, MA 01845 Re: 700 Osgood Street North Andover, MA 01845 Commissioners; Norse Environmental Services and Conservation Administrator, Ms. Jennifer Hughes, performed a site visit at the above property on May 13, 2014. The existing property is approximately 1.02 acres of open grassed field with a relatively flat topography. I walked the entire perimeter of the property and saw no culverts entering onto or existing from the _property. Ms. Hughes was concerned about the possible presence of hydric soils located in a depressed area at the center of the property. Mr. Zahoruiko had a small backhoe machine on the property to dig (3) deep holes. Performing deep holes on the property provides a better view of the soil and soil profiles. The estimated seasonal high water table can be easily identified in a deep hole. The (3) deep holes confirmed our initial analyses of the soils on the property as stated in the May 7, 2014 letter. The first deep hole was performed in the depressed area at center of the property. The topsoil or Ap was thick, dark, rich layer and had a -Munsell Color Chart color of 10 yr 2/2 with no evidence of redoximorphic features to a depth of 9". Immediately below the Ap was the C -Horizon consisting of loamy sand and gravel with.a Munsell Color Chart of 2.5 y 5/2. The estimated seasonal high water table was located at 36 inches or the bottom of the hole. The soil was moist and exhibited the typical "rust" bands. The. C -Horizon located immediately below the topsoil exhibited a light gray color. This light gray color is a typical color for hydric soils. However it is evident that the soil was disturbed or altered because of the absence of a subsoil or B -Horizon. The area was excavated and the topsoil and subsoil were removed. After the excavation the topsoil was returned to the site. It may have been excavated for the house located on the adjacent lot. The single family dwelling and septic is raised and perhaps this material. was used for that purpose. Two additional deep holes were performed on the site. The second deep hole was performed on the northwesterly comer of the site. The second deep hole exhibited a 10" thick, dark, rich topsoil with a Munsell Color Chart of 10 yr 2/2 with no evidence of redoximorphic features. A subsoil or Bw was evident at 10-18" with a Munsell Color Chart of 2.5 y 5/6. Below the subsoil w N O b uq O hl n o E! c o w r3 a o 0 X X fD a. UN w N O M m C CL m S 6 O O FDQ UN w N O M O v N kn n 00 O O O i a 0 b�A as IT t1, z m d o � O v N kn n 00 O O O i a 0 b�A as IT t1, 0 N M_ c�" m � p ; d U C p E m N O o cv m rz m U N m 7 o x d �' � m - L N 0 N M_ c�" g r 0 L x w O Y n O w d o . U U m H I 4 Date.......................................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that`���' ./.M.'b....c e.q has permission to perform .............. /�. �^� c�-��-- %%.................................................................................... wiring in the building of.............T `< /- orth Andover, Mass. ................. . at ................................... (;; .r......Z....................... Fee....f-CJS-'.-""'..... Lic. No??M.! j"" ............. ...................................... .. ELEC ]CAL INSPECTOR Check # //67 0 `T .;A Commonwealth of /Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use. Only Permit No. ) _t `Q "/ Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code qpq, 5 7 CMR 12.00 (PLEASE PRINT.ININK OR TYPEALL INFORMATION) Date:' City or Town of: NORTH ANDOVER To the Inspector o Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) `�?,OC) Owner or Tenant ,��E C Telephone No. (,t:7 _ Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate ]Box) Purpose of Building _At— Utility Authorization No. 1-76,S—Y-3-72 - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service %ter) Amps ( to Volts Overhead ❑ Undgrd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: l�i �,5 140 L) Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool rnd. ❑ rnd. o. o mergency Lighting BatterV Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number ...................... Tons KW """""""".""" No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ElOther Connection No. of Dryers Heating Appliances KW Security Systems:" No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of WYres. Estimated Value of Electrical Work: ��"�W0 , " (When required by municipal policy.) Work to Start: Fd Lo I i Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C VE GE: 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 coverawis in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, antler the gins and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: _ cA-t. LIC. Licensee: i A-r3)a A nature IC. NO.: (If applicable nter "exempt" in the license narmber line.) Bus. Tel. No.: 7 -- US. Tel. Q �lil h t . Alt. Tel. No.: -- Per M.G.L c. 147, s. 57-61, security work requires apartment of Publ c Safety "S" License: Lic. No: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) [] owner ❑ owner's agent. Owner/Agent Signature Telephone No. Ruw_ FEE. $ i ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the +� permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed , on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses conceming the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection, Pass %�� Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments Y LAIJ Inspectors Signature: Date: SERVICE ECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: o� N�. y, Date: PARTIAL ROUGH INSPECT N: Pass 151 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Co ents: Inspectors Signature: Date: FINAL INSPE Pass V Failed Re- Inspection Required ($.) ❑ Inspectors Comm s: Inspectors Signature: !f�� Dat DEB WEINHOLD ... TOWN OF MER IM MA........dweinhold@townofinerrimac.corn .1 <15. The Commonwealth of Massachusetts Department of IndustrlalAcclki& Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): (C�IAA Address: Q F5 -OE> Z_ City/State/Zip: � �� c�� /V1.4 Phone #: � 7 - 3 7 Are yo n employer? Check the appropriate box: 1. lam a employer with 2 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. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3111 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ew construction 7. ❑ Remodeling 8. ❑ Demolition 'f 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. f -Homeowners who submit this affidavit indicatingthey are doing all work and then hire outside contractors must submit anew affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. A.w OJ Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: `? 0 O ©`J fe�–Z) s—,- City/State/Zip: f �IAz Lll��,� 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 civilpenalties 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. Ido hereby cert der thepains andpenalties ofperjury that the information provided above is true and correct Simature: Date: 2-7Z_l _, 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 ones: 1. Board of Health 2. Building Deparit3r@nt 3. City/Town Clerk 6. Other - - Contact Person: 4. Electrical Inspector 5. Plumbing Inspector Phone � ?t Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, • express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a j oint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who.has not producedacceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials PIease be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permithicense applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial ,Accidents Office of Investigafions 600 Washington Street Boston, MA 02111 Tel, # 617-727-4900 est 406 or 1-877-M.ASSAJFE Revised 5-26-05 Fax # 617-727-7749 www-Masa,govIdia 0 Date ..... �Z.!../..�........ 10698 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...."I 1� ...1... P.,I/P�................................................. has permission to perform.-. �{��:^-?........ �.� -- _........................................... plumbing in the buildings of ...... 1 e �,.............................................. at ...... ? ..... ���� J d .. �!. .................... . North Andover, Mass. Fee:. A.-�...... Lic. No...., ��5../....................................:.................. PLUMBING INSPECTOR Check # 2� . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _ MA DATE a/ PERMIT # apq WOBSITE ADDRESS OWNER'S NAME r POWNER ADDRESS v TEL FAX TYPE OR TYPE COMMERCIAL 0 EDUCATIONAL © RESIDENTIAL OCCU7RENOVATION: PRINT CLEARLY NEW: 0 REPLACEMENT: Q PLANS SUBMITTED: YES � NO FIXTURES Z FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 k BATHTUB CROSS CONNECTION DEVICE �I rv.r _f f _6 ..—__1 �f (} __...� I ; _.. .. f f ( < DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM ! I ' --JA ,-.. j .—,_ I -. (- -, __ _i I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM f .-. I 1 ___._.. 1 _ 1 _ _I DEDICATED WATER RECYCLE SYSTEM DISHWASHER __I _._----I DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE /MOP SINK-_f----- -,.._ TOILET AL WA.. TING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING E . '>I OTHER ------------ I INSURANCE COVERAGE: have a current liability insurance or its substantial equivalent which the MGL Ch. 142. /NO policy meets requirements of YES 0 IF YOU CHECKED YES, PLEASE INDICATE TH TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW T f \1 LIABILITY INSURANCE POLICY_'!, OTHER TYPE OF INDEMNITYE] BOND D, 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: OWNERF-11 AGENT 10 SIGNATURE OF OWNER OR 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 compliance withall P rtinent vis' of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME �.-- LICENSE # / I SIGNATURE MP B WP Q CORPORATION Q#� PARTNERSHIP Q# i LLCr �1#f 1- VIA 9 0 - - COMPANY NAME ;ADDRESS CITY�,��--- -- -- ]STATE ZIP TEL FAX CELL -- .�'/MAIL.__ W rL w W U - *l • 4 The Commonwealth of Massachusetts Department of Industrigl Accicidents Office ofInvestigations 600 Washington Street Boston, MA 021.11 www.mass gov1d1a Workers' Compensation Insurance AfrdavR: Banders/Contract Name (Business/Orgaui-zaiionlXndividual): �/ ►. Address: l 12 City/State/zip Are you an employer? Check the appropriate box: Type of project (required): 1.0 a employer with 4. ❑ I am a general contractor and I 6, [] New construction r employees (fall and/or part-time).* have liked &a sub -contractors listed the attached t 7• ❑ Remodeling 2. T am a sole proprietor or partner ship and'have no.employees on sheet: These sub -contractors have S. ❑ Demolition working forme in any capacity, workers' comp. insurance. 11 9. ❑ Building addition [No workors' comp. insurance 5. ❑ We area corporation and its 10.❑ Electrical repairs or additions required.] 3.01 am a homeowner doing all work officers have exexcised.their right of exemption per MGL 1L[] Plumbingrepairs or additions myself [Eoworkers' comp. c.152, §1(4), and we have no 12.QRoofrepairs iusurancerequired.] i employees. [No workers' 1311 Other comp. insurance required.] *Any applicantthat checks box#1 must also felt out the section below showingtheir workers' compensationpolicy information. -Homeowners who submit ihis affidavit indicating they Are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check Us box must attached an additional sheet showing the name of the sub-contracfors and their workers' comp. policy information• I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Policy 0 or Self -ins. Lic. ff: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' comp ensation P olley declaration page (showing the policy number and expiration date). Failure to secure coverage as xequiredunder Section 25A ofMGL o. 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 DTA. for ibsurance coverage verification. Ido hereby cert& under AepVns an penalties o r tliattl¢e informationprovidedabove is trupudeorrect. Official use only. Do not write in this area, to be completer) by city or toren official. City or Town: Permit/License 0 Issuing Authority (circle one): 1. Board of Health 2. Building D epartment 3. City/Town Clerk 4. Electrical lnspector S. Plumbing lnspactor 6. Other - - - Contact Person: Phone Information and Instructi on s ' Massachusetts General Laws chapter 152 requires all employers to provido workers' compensation for their employees. Pursuant to this statute, an ea`,nployee is defined as "...every person in the service of another under any contract ofhire,- express or implied, oral or written." An employer is defined as "an individual, partnership, associat[on, corporation or other legal entity, or any two or more of the foregoing engaged in a j oint enterprise, and including the legal representatives of a -deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house havingnotmore than three apartments and who resides therein, or the occupant ofthe dwelling house of another who employs persons to do maintenance, construction or repair work on such. dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonweall nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fi11 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s), address(es) and phonenumber(s) along with theirceMcate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members orpartuers, arenotrequiredto carry workers' compensation insurance. IfanLLC orLLP doeshave employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for contiam.ation of insurance coverage. Also be sure to sign and date the affidavit. the affidavit should be returned to the city or town that the application for thepermit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the Iaw or if you are xecluired to obtain a workers' compensationpolicy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance, license number on the appropriate line. ' City or Town Officials Please be sure that the affidavit is complete andprinted legibly. The Department has provided a space at the bottom Of the affidavit fox you to fill out in the event the Office of Investigations has to contact you regarding the applicant, Please be -sure to fill in the permit/Rcense number which will be used as a reference number. Ih addition, an applicant thatrnust submit multiple permit/license applications fn any given year, need only submit one affidavit indicating current policy information (ifnecessary) and under "Job Site Address" the applicant shouldwrite "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavitis on file for future Hermits or licenses. Anew affidavit must be fiffeed out each year. Where ahome owner or citizen is obtaining a license orpermitnot related to anybusiness or commercial venture (i.e. a dog license orpermit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office bf Investigations would like to thank you in advance for your cooperation and should you have any questions, please do nothesitaie to give us a call. The Department's address, telephone and fax number: `>'he 6inaonwealth of assac�hvsPtts JDepattenb Qfladus al ,Accidents Office QfjAVQSg9ftAo111% 600 WasbiVon Street Dostm, MA 02111 Tel,, # 617-7.2' -49-00 W, 496 ax 1-8,77-MASSAF`E Revised 5-26-05 Fax # 617-727'7749 • �ww.zz��ass,g¢vfclia /c� Date. .. .............................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .....l/ /� . ............ ...... .. .... ........................................ ... ... has permission for gas installation ...... .................................................. in the buildings of ...... K2 .. . .... Z -.I -..e . ................................................................. at ........... ................ . ............... . North Andover, Mass. Feel. . ..... Lic. No. ..... ........... ...... ....................................... ................. GASINSPECTOR Check #-.,,?-24-3 9479 INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES 101NO 0 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERA E BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [7 OTHER TYPE INDEMNITY ® BOND 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 _ i AGENT El SIGNATURE OF OWNER OR AGENT 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 compliance with I Pe 'nentMsithe Massachusetts State Plumbing Code and Cha ter 142 of the Ge eral Laws. PLUM BER-GASFITTER NAME v ' _ T LICENSE SIGNAT RE MP 5jj/MGF EjI JP D JGF 0 LPGI © CORPORATION [J# PARTNERSHIP ©#E:-__—. LLC [j# - COMPANY NAME: ADDRESS CITY _ — STATE ZIP `Z Q �TE FAX CELL -/ jMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .71 CITY MA DATE / PERMIT# 1lJ JOBSITEADDRESS�OWNER'S NAME G-;- OWNER ADDRESS TEI� FAX TYPE OR PRINT OCCUPANC TYPE COMMERCIAL[] EDUCATIONAL E] RESIDENTIAL CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 0 NO APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR[� _' ( _ ( ( FURNACE _ _ GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES 101NO 0 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERA E BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [7 OTHER TYPE INDEMNITY ® BOND 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 _ i AGENT El SIGNATURE OF OWNER OR AGENT 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 compliance with I Pe 'nentMsithe Massachusetts State Plumbing Code and Cha ter 142 of the Ge eral Laws. PLUM BER-GASFITTER NAME v ' _ T LICENSE SIGNAT RE MP 5jj/MGF EjI JP D JGF 0 LPGI © CORPORATION [J# PARTNERSHIP ©#E:-__—. LLC [j# - COMPANY NAME: ADDRESS CITY _ — STATE ZIP `Z Q �TE FAX CELL -/ jMAIL "o , i