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Home My WebLink AboutMiscellaneous - 1 ALCOTT WAY 4/30/2018 (3)\� � �Y �- --- --- 310 CMR 10.99 Form 8 Commonwealth of Massachusetts TO%4 : t NOR! i, OCT 14 9 33 DEQE File No. 242– 366 (To be provided by DEQE) City Town NORTH ANDOVER, MA Applicant ALCOTT VILLAGE Certificate of Compliance Massachusetts Wetlands Protection Act, G.L. c.131. §40 AND UNDER THE TOWN OF NORTH ANDOVER BYLAW, CHAPTER 3, SECTION 3.5 From NORTH ANDOVER CONSERVATION COMMISSION Issuing Authority Shocket & Dockser, Attorneys for P.O. Box 8007 To Alcott Village Condominium Assoc. Natick, MA 01760-0050 (Name) (Address) Date of Issuance �� - 9 This Certificate is issued for work regulated by an Order of Conditions issued to�n� �_—dated 2`e!5;�3"e%nd issued by the IV A -n 1 . It is hereby certified that the work regulated by the above -referenced Order of Conditions has been satisfactorily completed. 2. C It is hereby certified that only the following portions of the work regulated by the above -refer- enced Order of Conditions have been satisfactorily completed: (If the Certificate of Compliance does not include the entire project, specify what portions are included.) 3. ❑ It is hereby certified that the work regulated by the above -referenced Order of Conditions was never commenced. The Order of Conditions has lapsed and is therefore no longer valid. No future work subject to regulation under the Act may be commenced without filing a new Notice of Intent and receiving a new Order of Conditions. .......................................................................................................... i (Leave Space Blank) 8-1 Effective 8/1/89 0 Date ..."I291 .1....! ................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .......-e 1 P..�C_ !,.�..-t?................................IP'.L. has permission for gas 'nstallation .......A,,,., ............................................................ inthe buildings of ........ � � Ze. U at ......................................... 't..... ....................... North Andover, Mass. ... Fee .�... �.... 7..._. Lic. No. f.............MA- ,........................................................... GAS INSPECTOR Check # 070! *- 17� -IA\" MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK rbl �j CITY eff%� /�.rl'�t! MA DATE//a7�� 976 1 o�D/f/ PERMIT # JOBSITE ADDRESS /t?pf% lrl%/�1y� OWNER'S NAME '&Z" / OWNER ADDRESS TEL MQ 9L�1 FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIALX CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NOK APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 tt t2 13 14 BOILER BOOSTER CONVERSION BURNER COOKSTOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM 1 SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch, 142 YES /f 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 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and rate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian Pertinent y all pr visi of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Peter G. Viens LICENSE # 12116SIGNATURE �— MP(J( MGF JP JGF LPGI CORPORATION# 3631 C PARTNERSHIP # LLC # COMPANY NAME: Merrimack Valley Corporation ADDRESS 15 Aegean Drive, Unit #3 CITY Methuen STATE MA ZIP 01844 TEL 978-689.0224 FAX 978-689-2206 CELL 978-807-2819 EMAIL pviens@mvalleycorp.com 17� -IA\" t. 1The Commonwealth wealth of Massachusetts - -- Department of industrial Accidents Office of Investigations 600 Washington Street Boston, AM 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Comteactors/Elec>tricia>ns/Plumbelrs Appplicautt Information Please Print Legibly Name (Business/organization/Individual): % J 1 `j; 7 J lL Lj,,'I��' '! Address: City/State/Zip: ,'%� ;✓v`r>�` il��'� /�� Phone #: Are you an employer? Check the appropriate box: I.' I am a employer with /J29,t7 4• ❑ I am a general contractor and I Type of project (required)- required):l. employees (fill] and/or part-time).'` have hired the sub -contractors 6. ❑New construction 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. employees ' loyees and have workers 9, ❑Building addition [No workers' comp. insurance required.] comp. insurance.+ 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all wort: officers have exercised their 1 l .❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repa' insurance required.] t c. 152, § 1(4), and we have no ] 3. Other employees. [No workers' comp. insurance requireo.I 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. iContractors that check this boN must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. if the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy mzd job site information. 1__'111 Insurance Company Name: Policy # or Self -ins. LLic. #: r� j�%/%/` c� / �j� c� Expiration Date: Job Site Address: /�pems. �5,� Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the nnposition 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 rip 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. 9 do hereby certify e der ze pa' s and nalti of jury th al the informatiozz provided above true and correct. Siena re: i Date: l/ / Phone #: 7Z�° A! -e3� r� Official use only. Do not write in this area, to be completer) by city or town official. City or 'own: Perm itUcense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/"Down Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 4 - Hoisting Engineer License: HE -110323 PETER G VIENS`�` 9 BLUEBIRD L1A ATKINSON NIT 0341 al r Commissioner Expiration: 11/13/2015 State of46W, Ham shire GAS FITTERS`° l- C --I -SE p NAME: PETER MENS—' )� j fff , , ENDORSEMENTS IS�T� ; $ P DATE ISSUED: 10/1-5/2013 DATE EXPIRES: 11/30/2015 LICENSE #:GFE0700587 i certify that I have examined in accordance with the Federa o or amer Safety ul ions (49 391.41-391.49) and with knowledge of the driving duties, I find this person is qualified; and, If applicable, only when: ❑ wearing corrective lenses ❑ driving within an exempt intracity, zone (49 CFR 391.62) ❑ wearing hearing aid ❑ accompanied by a Skill Performance Evaluation Certificate (SPE) ❑ accompanied by a ❑ qualified by operation of 49 CFR 391.64 waiver/exemption The information I have provided regarding this physical examination is true and complete. A complete examination fnrm with anv affarhment emhndies my findinns comnletely and correctiv. and is on file in my office. SIGNATURE OF MEDICAL EXAMINER T EPHO E l/ ME AL EXAMINER'S NAME (PRINT) ❑ MD ❑ Chiropractor ❑ DO UAdvanced Practice Nurse MEDICAL EXAMINER'S LICENSE OR CERTIFICATE NO. ISSUING STATE r / Y / `Y/ � ❑ Physician ❑ Other Assistant Practitioner NATIONAL REGISTRY NO. SIGNATUR OF IVER INTRASTATE CDL ONLY ❑YES NO ❑YES NO DRIVER'S LICENSE NO. STATE ADDRESS OF DRIVER MEDICAL CERTIFICATION EXPIRATION DAT PLY 1 DRIVER PLY 2 MOTOR CARRIER 26520 (5/73) Commonwealth of Massachusetts Department of Public Safety Pipefitter Journeyman License: PJ -028388 ,,Vb `x" tet. PETER G VIENS 9 BLUEBIRD Llf-0®r, o ATKINSON NH -,038 �. !.'.-- /1 10 0 Expiration: Commissioner 11/13/2015 �- STATE OF NEW HAMPSHIRE BUREAU OF BUILDING SAFETY 81 CONSTRUCTION PLUMBING SAFETY SECTION k NAME: PETER G VIENS LIC #. 3249 M EXPIRES: 11/30/2014 M[DIC 4L EQUIPMENT 4ETE1TM CfR IrIGAf10 N, a.LC Peter Viens Cert # .r- .....1._,..,..a�- 1023121001-12 Expires: 10123/2015 Certification N. F.P.A. 99-2012 ed. ASS 6010 Installer & ASME IX Brazer