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Home My WebLink AboutMiscellaneous - 1 MILLPOND 4/30/20180 ,Date ...... �rhtlo .................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION P This certifies that-�.J&e . ........ A.'a r�' %A0 has permission for gas installation S in the buildings of . ............................................................. at ..... �If .. .............................. / ............... 1,Ngrfh Apdover, Mass. Fee Lic. No -62 . ...... .... .. .......................... SINSPECT014 Check # 0 09976 G TYPE OR PRINT CLEARLY APPLIANCES Z BOILER MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WUrcrn 7- — r n /U Q CIT�� MA DATE `�6 l i� PERMIT # �� Y / JOBSITE ADDRESS r D OWNER ADDRESS L � — OCCUPANCY TYPE COMMERCIAL ❑ NEW: ❑ RENOVATION: ❑ REPLACEMENT: nnnRc.� BSM 1 2 3 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 HEATS TEST UNIT HEATER UNVENTED ROO t4 WATER HEATER e nruFR TER OWNERSNAMf� TEL �?%e<39%'6i4 FAX 00-4 EDUCATIONAL ❑ RESIDENTIAL PLANS SUBMITTED: YES ❑ NO 4 5 6 7 8 9 10 11 12 13 INSURANCE COVERAGE I have a current liabilb nsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO [ 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 ❑ AGENT 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 urate to the best of my knov and that all plumbing work and installations performed under the permit issued for this application will be in compliance with inert -provision of th Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAM LICENSE # S E MP ❑ MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORA ON L # PARTNERSHIP ❑ # LLC # / v COMPANY ME MGA �.� t° ��`� L ADDRESS D' � X CITY ice` ct�U�2i.�-G� STATE /44 ZIP i91��_ FAX CELL EMAIL �� r! 4"o The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.govMa Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lealy Name (B, Address: City/Stat Are you an employer? Check the appropriate box: 1. I am a employer with __L 4. El am a general contractor and I ^ employees (frill and/or part-time).* have hired the sub r-- n-_ actors. 2. U I am a sole proprietor or partner- listed on the attached sheet t 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 3. ❑ I 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. msurance IType of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. [ Electricalrepairs or additions 11. 2tPhunbizig 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. t Homeowners who submit this affidavit indicating they are doing all work and Then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their work=' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. d Insurance Company Name: Policy # or Self -ins. Lic. #:—L 14 L18_Q M J134 —q — it Expiration Date: /9 Igo Job Site Address: RA V -d City/State/Zip: V Aolg4Aq- Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).0 fs/ j— 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 imprsonraent, as well as "iv'.l p *imsin the form of a STOP WORK ORDER and a rine 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 the pause, ndpenalties ofpedury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/Ucense 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 DatO,1�11.< .................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ............................................................................. has permission for gas installation. ..................... inthe buildings of ... VAA�— -� .............................................. at .......... X ...... 1�-!A .......................................... . North Andover, Mass. Fee..3-.6 . . ...... Lic. No. n.w ...... .................................................................... GASINSPECTOR Check 1010 24 H r4y ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK u A t\P oy MA DATE It PERMIT # 2 CITY I ,4k JOBSITE ADDRESS 1 I z OWNER'S NAME 1,4 GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL �/ PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: NOPLANS SUBMITTED: YES ❑ NO ❑ APPLIANCES Z 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 OTI.,--.R INSURANCE COVERAGE I have a current liabilily 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 V 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 ❑ AGENT ❑ 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 complian with gia®a ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASATTER NAME r VVI CcT V1421, LICENSE #l r� j � d SIGNATURE MPJK MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC # 11 1 ��A1 -- ADDRESS a4 �- • L t>VJGl'� �� COMPANY NAME � Ic eia.� � I� r05 . �� t� n,b+ D CITY ' " 1� `�� STATE ZIP /ice- t �-7 TEL - 12 ` 9 FAX CELL EMAIL i2.e---c---J V1 mak- 011;111 ,r, .n- 1 1) 1 � .y b'fb ;.i{(�„L". Y�-.F.� - �A� �y.'.•:J� .LF .F YiC"� 1. 3Ytn� ..+��` � � '..1 ... 4 r..^Mii e The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, ALL 02114-2017 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNUMNG AUTHORITY. Name (Business/Organization/Individual): S r L22, Address: lti . W ood C r< S City/State/Zip: CQ!><Z &A Phone #: % ? Are you an employer? Check the appropriate box: Type of project (required): 1 RI I am a employer with _employees (full and/or part-time).* 7. 0 New construction 2. ❑ I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers' comp. insurance required] 9. ❑Demolition 3.Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ 1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contractors either have workers' compensation insurance or are sole i l.❑ Electrical repairs or additions proprietors with no employees. 12. 0 Plumbing repairs or additions 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13. ❑ Roof repairs These sub -contractors have employees and have workers' comp. insurance.* 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 14. ❑ Other 152, §1(4), and we have no employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation 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. 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 and job site information. n Insurance Company y � c S Expiration Policy # or Self -ins. Lic. #: ./ '", � ,� Job Site Address:y-nd City/State/Zip: ® l Attach -a copy of the workers' co pensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under the ains and penalties of perjury that the information provided abgve is true and correct 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 #• .�y i :.t �.. � .. r , i _ .. .. • - .#�'�� ... r ff � .. ,. ! Date....--�--,,z 4 - /= ......................................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that M, K. 0--,-) P,- , -, - o / --- - --- e��l has permission to perform .... P4 0. 40", e r� r 7, /�— ou wiring in the building of .................. ............................................ at ............................ ,--,Vorth Andover, Mass. Fee Lic. No. -59-7,W ...................... P i � � V�R I&, N �OR Check # 13 3 19 9 C.�La on.weahk o f Vai6ac"eltj a1JeParfinetef o� �ir¢ �ervic¢s BOARD OF FIRE PREVENTION REGULATIONS Official Use Onk ---- ;1107] it No. cJ pancy and Fee Checked Gave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (1fdE� 527� R 12.00 PLEASE PRINTLL IN INK OR TYPE AINFO TION) Date: .5(l<t -� f City or Town of: ''nn 1k CLO Veti To the Inspector of Wires: �lt t �t By this application the undersigned gives notice of his or her tntenuon to perform the electrical work described below. Location (Street & Number) 1 / A 1! L L/9ni% K Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes Lk. No U (Check Appropriate Box) Na Purpose of Building \ TltdiiAtttliotdtion Overhead U. Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Arnpacity Location and Nature of A Work: Overhead ❑ Undgrd ❑ No. of Meters Undgrd ❑ No. of Meters C 1e t"t n _r,;- ollowi Coble may be waived by the Inspector of Wire 1 om o. nal No. of Recessed Luminaires No: of Ceil: Susp. (Paddle) Fans rransformers KVA T No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires 4 Swimmin Fool Above ❑ In- g rnd. rod. a. o meits. Lighting Battery Units. No. of Receptacle Outlets No. of Oil Burners - FIRE ALARMS No. of Zones NW of Detection an No. of Switches. No. of Gas Burners Initiatin Devices No. of Ranges No. of Air Cond. owl Tans o. of Alerting Devices i Pum P Number Tons K No of SeIPContained No. of Waste Disposers Totals: _._ . _ .__ __-.._.-- •--•_••_•••- Detection/Alertina Devices No. of Dishwashers Space/Area Heating KW untcipa Local ❑ Connection Other No. of Dryers / Heating Appliances KW Security tins'* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiriag: Heaters Signs Ballasts I No. of Dices or Equivalent Total HP T ecommttnicatioas Bring No. Hydromassage Bathtubs No. of Motors No. of Devices or E uivalent OTHER: ,4ttach additional detail if desired a as requ d by Inspector of Wi: Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unl the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. Thr undersigned certifies that such coverage is in :force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE P BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penaltieZ14 perjury that the inform�ation on this application is true and complete.FIRM NAME: Cj C Y� LG —r Lee LIC. NO. -_3 Licensee: L� Signature LIC• NO.: (If applicable, enter "erempr" i» the licen num toe.) us. Tel. No.:q EY�,l Address a 0 t U7KI—LZ �Q Alt. Tel. No.: `Per M.G.L_ c. 147; s. 57-61. security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normall required by law. By my signature below. I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's ag Owner/Agent PERMIT' FEE= S Signature Telephone No. pazle 6-k dtK -?- �- /a l3ate............... ................. Of tORTst -1 !6 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................................................. // ......... ................................ has permission to perform ........... ........................... wiring in the building of ........ L loal-1- * -0-4 *--, ............ at ..... ...... ............. , North Andover, Mass. Fee..�.—... Lic.No..16.6.7Z ................ .......... ........... ......... .... ... ... ... 2:� .............. ELECMCAL INSPECfOR Check# -�-7410-> 9281 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, th 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 Wire& -appoffiteJ'pursuant to M. G.L c. 166 § 32, an electrical permit shall be issued to tht person, firm or corporation stated on the permit application. Such entity shall be responsi�le for the notification of completion of the work as requi"realn M.G.L. c. 143, § 3L. Permits shall -be limited a * s 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 20 10 and extended by Sections 74 and 75 of Chapter 23 8 of th , e Acts of 2012. 'Ibe 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 concerning 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. 0 Rule 8 — PermitA[)ate Closed: / El Permit Extension Act — Permit/Date Closed: -A — Note: Reapply for new permit 4W 1 I `i Clmmonurea& o f MamacLmeffj eUeParfinerzt o� ire �ervice9 BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Z Occupancy and Fee Checked [Rev. 1107] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT INIIVK OR TYPE ALL INFORMATION) Date: City or Town of. '� or*n ANh t� oV %yo To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 1 `Tn t1\ Q W, \� y\% h \ ph R p�`t• W Ayk Parcel tb: Owner or Tenant Telephone Noqs7% Z o"e %4r Owner's Address \ Is this permit in conjunction with a building permit? Yes Purpose of Building �Q$ Existing Service Amps / Volts New Service Amps 1 Volts Number of Feeders and Ampacity No lig (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ U, g,d ❑ Location and Nature of Proposed Electrical Work: %%`Ae� No. of Meters No. of Meters Completion of the 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 Biot Tubs Generators KVA No. of Luminaires Swimming Pool Above El In- ❑ rnd. rnd. o. o Emergency Lighting Battea 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 Rau es g No. of Air Cand. Total Tons No. of Alerting Devices No. of Waste Disposers p Beat Pump Totals: Nffip�r Togs K - No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area heating KW Local ❑ Munfcipal ❑ Other Connection No. of Dryers ry 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 Mi otors Total III' Telecommunications Wiring: No. of Devices or ,E uivAent OTHER: Attach additional detail if desired, or as required by the Inspector of Fires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion - INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue carless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRMNAME: GIFICek,Ukt-nvtn%S4LV Q is%S rs c LIC. NO.! /66% Licensee: IbM Signature LIC. NO.: (Ifapplicable, enter "exempt" in the license number line.) Bus. Tel. isjo.-'yet �s31 7 �� Address: a 4A i\ \ hw�ra n '�4 4 L omc- \ n %,A- O Z—V Alt. Tel. No.:4Ak 6 3*, "Li l *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally zquired by law. By my signature below, I hereby waive this F?-im_iren ,r . r the ^h�^t ^e) ❑ owner P— owner's agent. Owner/Agent Signature i___. Telephone, No= � _ PEP-11—IIT FEE: , 11157 Date ... s� ...... 7c'.7.1 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ....... ...... e .......... . .......... has permission to perform ...... 41441—. X. P. fx'.* ............. plumbingin the buildings of ...................................................................................... ........ at ........ I ..... ;/ e /North Andover, Mass. ....................... 6 ..... ................ Fee.%,,'5'bc .... Lic. No. ... ... �. .4 ........................................ Check # q1 ? PLUMBING INSPECTOR i- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK POWNER TYPE OR PRINT CLEARLY CITY A DATE PERMIT # JOBSITE ADDRESS % r �Lot OWNER'S NAME�Ci S AGiO ADDRESS 90e TEL 7b -.J9'— % FAX OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL( JJ NEW: ❑ RENOVATION: ❑ REPLACEMENT, PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES Z FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I arraware 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 F1AGENT ❑ 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 with ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME fl �- L ` MR LICENSE # 2W IGN MP ❑ JP ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLCX# COMPANY AME )a I o4A t / L ,{ /V � G � (�XC�/t�C�� ADDRESS aU .t�O)C � JI— CITY STATE _ ZIP TEL 979 r q 15 -/'Q S 7 FAX CELL EMAIL I V I •cl. s.(Y)MMONWEALTH OF MASSI�CHUSETTS ��-Jw Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ........... ......................... has permission to perform ...... ...................... plumbing in the buildings of . .................. at. ................ North Andover, Mass. Fee. .... Lic. No..<�;)�,( . ......... C ........ PLU'I�BING INSPEdOR 7 c — Check # 5 X 1- ) 8524 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town. .ar �`-A44 9-r' , MA. Date: "a -?- o Permit# `_ Building Location: fir, ,Ato,n Sc�tD.rrlcW Fy Owners NameQ41Wk Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential [ New: ❑ Alteration: ❑ Renovation: ❑ Replacement: 5C Plans Submitted: Yes ❑ No (g INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes JZ No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ® Other type of 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 ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted for 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 all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title ® Plumber Sign�icensedmber ®Master City/7own APPROVED OFFICE USE ONLY)[]Journeyman License Number: FIXTURES z z j LU Yc z �- O U _ w E f V) r z z j� W Y l z a to i U) Z I Q U W 0 C a z I I cn a v; _ o_ W ai 0 l 0 x Q 0 n Y == Q N O �, Q� = W S O0 z oI Lu 'S ? w z Q W U F- O 0 0 !- W�_j U>> Q W O O( n. 0- Y �Z Q = w W W z_ N tY Q Q Q 0 F Q j Q i 0 =� :J . Q Q 4 4 F- SUB BSMT. BASEMENT I I 1 FLOOR I 2 FLOOR 3mu FLOOR E :4-L 4 ' FLOOR _5"" FLOOR I I 6 FLOOR I I 7 FLOOR 8 FLOOR �� ' Check One Only Certificate # L1 Installing CompanyName: W- 1 h! fes, _ t Corporation C l Address:�'nd \ N-<%nR �`�� City/Town�h �G'T�an State: n ❑ Partnership Business Tel:L-kt�\ q jc� 4`S y I Fax: ❑ Firm/Company _ Name of Licensed Plumber: �'(4��` tC`CvX,11g1M4 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes JZ No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ® Other type of 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 ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted for 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 all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title ® Plumber Sign�icensedmber ®Master City/7own APPROVED OFFICE USE ONLY)[]Journeyman License Number: =z tzd ac F.im im LU od w Im z LL) LLJ LT. Date ... d ....... N 0 X TOWN OF NORTH ANDOVER PE�MIT FOR GAS INSTALLATION \6 'Iss U This certifies that A'� jT has permission for gas installation ... ................ in the buildings of ......................... at ..... orth Andover, Mass. Lic ;;.10 6Fee.-?-<) No.. 4�� - - YA AS INSPEeCT�O�R7) Check 4 C -,,�7 4 2 MASSACHUSETTS UNIFORM APPLICATON FOR PERMrr TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Locations `C /( U- ,i S -ye 2q L-^ ` Permit # Amount $ Owner's Name 1,4- PL ` New11Renovation Replacement c� Plans Submitted (Print or type) Name_ Name of Licensed Plumber or Gas Fitter 6 & </4- Check one: Certificate Installing Company ❑ Corp. E] Partner. [aFirm/Co. INSURANCE COVERAGE Check ones ❑ I have a current liability Insurance policy or it's substantial equivalent. Yes Q No If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy �� Other type of indemnity Bond11 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: Signature of Owner or Owner's Agent _--3 Owner �. Agent 0 7 hrrrhv rP,+;fi,+1, o+.,11-.r+l.e A --:l.. _–r--- -- . - - -- -- - - -- au -111 -cu wr emerea/ In above application are true and accurate to the best of my knowledge and that all plumbing work and install tions p ormed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac sett Stat as Code d Chapt 42 of theneral Laws. City/Town 1 (OFFICE USE ONLY) Signature of LicenWd Plumber Or Gas Fitter Plumber e� 0 Gas Fitter icense um er O—Master " Journeyman aa z z F tq vl F W C p O O p Z FW. x c�7 H d z W H d m F wa Fy Z U x W O x 3 c a ° a > O x! SUB -BASEM ENT o a c B A S E M E N T IST. FLO O R 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8.TH. FLOOR (Print or type) Name_ Name of Licensed Plumber or Gas Fitter 6 & </4- Check one: Certificate Installing Company ❑ Corp. E] Partner. [aFirm/Co. INSURANCE COVERAGE Check ones ❑ I have a current liability Insurance policy or it's substantial equivalent. Yes Q No If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy �� Other type of indemnity Bond11 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: Signature of Owner or Owner's Agent _--3 Owner �. Agent 0 7 hrrrhv rP,+;fi,+1, o+.,11-.r+l.e A --:l.. _–r--- -- . - - -- -- - - -- au -111 -cu wr emerea/ In above application are true and accurate to the best of my knowledge and that all plumbing work and install tions p ormed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac sett Stat as Code d Chapt 42 of theneral Laws. City/Town 1 (OFFICE USE ONLY) Signature of LicenWd Plumber Or Gas Fitter Plumber e� 0 Gas Fitter icense um er O—Master " Journeyman The Commonwealth of Massachusetts Department of fiadustrial Accidents Office of Ircvestrgations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeQ><blV Name (Business/organization/Individual):- Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheet t 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.] 3. ❑ I am a homeowner doing all work officers have exercised their 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. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I I - Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other ve:ow snoe;.yb th= wcr; ems' compensation policy infbrmation. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affida $Contractors that check this box must attached an additional sheet showing thevit indicating such. . 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: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: 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 Iead 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 the pains and penalties of perjury that the information provided above is true and correct Si ature: Date.: Phone #: F ial 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 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 joint 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 apartmients 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 produced acceptable 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-contractor(s) 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 perruit or license is being r-oue"ftd., not the =a=--nt 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 Please 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 permit/license 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 bum 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 .Coammonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www-mass-gov/dia