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HomeMy WebLinkAboutMiscellaneous - 10 CIDERPRESS WAY 4/30/2018' I - Date. a/C,100- - TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .... 4Ao-1 ..... /�L.# ............ has permission to perform ... !t/ ....... �,P.42 ................. plumbing in the buildings of �` 55 at...,. ................. North Andover, Mass. Fee". P;00 ... Lic. No.. .. ........ PLUMBING INSPECTOR Check # 0 1,.. �, �.) q MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Date _ Permit # Amount 1 ype of Uccupancy New ri Renovation Replacement 1:3 Plans Submitted Yes No ❑ (Print or type) Installing Company Name Address Name of Licensed Plumber: Insurance Coverage: Indic, Liability insurance policy •ance coverage by checking the Other type of indemnity n Check one: Certificate F1 Corp. FlPartner. FIFirm/Co. box: Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner ❑ Agent ❑ I hereby certify that all of the details and information I have 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts tate P bi Code a h 42 of the General Laws. v By: Siguacuiei License um er Type of Plumbing License Title ��City/Town is nsum er Master Journeyman ❑ APPROVED (OFFICE USE ONLY .r `# I ":N15 I MMMMMMMM M M MOO� M. -Tv D I MMMMOMOMMO.M---.-MMMMOO--ON ----M-MO------E �-��----�-�----M---------N , I 1 - 1:' -------------------------� 1 --INIM------MEM--------MMWINOWIMMMM ==I MONO _ MMMMMMMaM1WWMMMWWWMWNWWW�� (Print or type) Installing Company Name Address Name of Licensed Plumber: Insurance Coverage: Indic, Liability insurance policy •ance coverage by checking the Other type of indemnity n Check one: Certificate F1 Corp. FlPartner. FIFirm/Co. box: Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner ❑ Agent ❑ I hereby certify that all of the details and information I have 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts tate P bi Code a h 42 of the General Laws. v By: Siguacuiei License um er Type of Plumbing License Title ��City/Town is nsum er Master Journeyman ❑ APPROVED (OFFICE USE ONLY The Commonwealth of Massachusetts Department of Industrial Accidents Off'ce of lnipesVgatdons 600 Washington Street Boston, MA 0ZI11 ` www mass.gov1&a IRA= Ittfornratinn . Workers' Compensation Insurance Affidavit. Builders/ContractorsMieatricians/Plumbers Name (Business/orguization/[ndividual): Address: City/State/Zip: Phone #. . Are you an employer? Check.the appropriate box: 1. ❑ I am a employer with _ 4, ❑ 1 am a general contractor and I ject (required): employees (fun andlor part-tim )e .* 2. ❑ I am.a.sole proprietor. or have hired the sub -contractors listed construcdon partner- ship and have no employees on the attached sheet = These suircontractors have F7rn odeling olition workingfor me .in an y capacity, worers' comp. insurance workers comp. insurance.[No 5. ❑ We are a corporation and its ing addition required) I am a homeowner doing officers have dxercised their ical repairs oradditions all work myself. [No -workers' comp. right of exemption per MGL c 152, § 1(4), and we have no ing repairs or additions insurance. required.].T �]. .employees. [No workers' 12.[] Roof repairs come• insurance required.] ;Any applicant that checks hoz!/ l must also fill out the section below showing their workers' compensation Homeowners who sabmit this affidavit indicating they doing 13.7 _Other policy information ars all work and then his outside contractors tnust'submit a new affidavit indiaatiag succi - =Conttactots that check this hoz mustattaabed an additions: shear showing the name of the sub -connectors and their workers' corap, Policy information. t an, an employer feat is pro>+&fing:workers' information. compensation insurance for my. employees: Below is the policy and job site . Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/StatelZip: Attach a copy of the workers' compensation policy declaration page (showing the policy Failure to sHurn--- and expiration date). . ecure 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 5250.00 a day against the violator. Be advised that a copy of this statement b Investigations of the DIA for insurance coverage verification. may forwarded to the Office of I do hereby certify under thepains andpenaida ofpcgury that the information provided obore is true andeorreat: Otj'"d ase only. Do not write in this area, to be convigred by city or town offuzat City or Town: PermWLicense # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Cierk 4. Electrical Inspector S. Plumbing Inspector b. Other Contact Person: Phone #: Information a nd Instructions Massachusetts General Laws chapter 152 requins all emp 3oyers 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 ofhire, express or implied, oral or written." An employer is defined as "an individual, partnership, assodiation, corporation or other legal entity, or any two or more of the'fomping engaged in a joint enterprise, and includirzg the legal representatives of a deceased employer, or the receiver ortrvstee of an individual, partnership, association or other legal entity, employing employees. 'however the owner of a dwelling house having not more than three apax-tme= and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work as 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 Eicensing agency shall withhold the issuance or renewal of license or permit to operate a business or *o construct buildings in the commonwealth for any applicant who has not produced acceptable evidence.oV compliance with the insarance'coverage required." Additionally, MOL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract far the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the cordracting authority." Applicants Please fill out the workers' compensation• affidavit compiertely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) Fund phone number(s) along with their certificates) of ° insumance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not requ red to carry workers' ccrTnpensation 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 arc required to obtain a workers' compensation policy, please call the Department at the nru�rtber listed below. Self +►+sired CaMr Rni should a^.*P* *E!e:r self insumnce 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 NvilI be used as a reference number. In addition, an applicant that must submit multiple peumit/iicerm 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 futrae 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 litre 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 Lnvestigstioas 600 Washington Street Boston, MA 02111 TeL # 617-7274900 dxt 406 or 1-977-MASSAFE Fax # 617-727-7749 Revised 5-26-(15 www-mass.gov/dia Date ... F/C� TOWN OF NORTH ANDOVER 0 PERMIT FOR GAS INSTALLATION This certifies that .... 11f. ......... has permission for gas installation .... � 4 �/�' -Z - e. ......... in the buildings of 1x,)g11.'11 "2." X41 V.U? ... �(Z� � I'Vry 4 ....... 1� j" * 7 - at .... .......... I North Andover, Mass. Fee.'�PO( ....... .... Lic. No./.. S6 . ................... G49 INSPECTOR Check # N SSACHUSE M LNWORM APPUCATON FOR PERMIT TO DO GAS FMING (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations d r 1 Owner's Name New /novation Replacement ❑ Plans Submitted 0 Permit # Amount (Print or type Name_ :Mame of Licensed Plumber or Gas Fitter .r Check one: Certificate Installing Company f E] Corp. Partner. Firm/Co. INSURANCE COVERAGE Check on I have a current liability Insurance policy or it's substantial equivalent. Yes91 No If you have checked yes, please in •ate the type coverage by checking the appropriate box. Liability insurance policy13 Other type of indemnity 11 Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 112 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 Owner 0 Agent uui vy —y uiaL uiI US uic uu,1ua lLIIU uuvuuauun nave suonutreu (or entereu) in above ;application are true and accurate to the hc�t of niN knowledge and that all plumbing work and installation perfon icxl nndur Permit Issued for this application will be in compliance with all pertinent provisions of the Nlassachusctj�Statc Cis Cocje anel CJaptyr142 of the General Laws. By: Title C i tyiTow n JAPPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter `2 'as Fitter License Number �V[aster Journeyman w � 9 c a o ] C :r2l H '. a > >Gz GT, n G' o o O w 3 A W o w C7 .a U a > q a F C SUB -BASEM ENT BA SEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4T II. FLOOR 5TH. FLOOR 6TH. FLOOR 7 T H. F L O O R 8TH. FLOOR (Print or type Name_ :Mame of Licensed Plumber or Gas Fitter .r Check one: Certificate Installing Company f E] Corp. Partner. Firm/Co. INSURANCE COVERAGE Check on I have a current liability Insurance policy or it's substantial equivalent. Yes91 No If you have checked yes, please in •ate the type coverage by checking the appropriate box. Liability insurance policy13 Other type of indemnity 11 Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 112 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 Owner 0 Agent uui vy —y uiaL uiI US uic uu,1ua lLIIU uuvuuauun nave suonutreu (or entereu) in above ;application are true and accurate to the hc�t of niN knowledge and that all plumbing work and installation perfon icxl nndur Permit Issued for this application will be in compliance with all pertinent provisions of the Nlassachusctj�Statc Cis Cocje anel CJaptyr142 of the General Laws. By: Title C i tyiTow n JAPPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter `2 'as Fitter License Number �V[aster Journeyman r Date ...... ?— /2- /0 ............................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .............. ..... 4�x ............... has permission to perform ........... TN�� .... P.QeSg ................................ wiring in the building of .... ml�� ........... /D 60 -d --'e px� at ........................................... ........ North Andover, Mass. Fee,3(?!�� Lic. No3-92Z%sy—"`� ............. 2LECT ICI� i'�NSPECTOP/ Check# -��7 I-— '�'�•� VV/////IU/1WCQIIII V/ /'IOJDQ�.IILIDCLLD-------q--- ----' Department of Fire services Permit No. / �© Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 C 12.90 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of ires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) /0 t % 4--i-,0,' T = S Owner or Tenant e P 6-,? rC a, --s CG C Telephone No. Owner's Address J ./ Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Xl 74/ ^/- dz C/S 30 Utility Authorization No. Existing Service Amps f, Volts Overhead ❑ Undgrd ❑ No. of Meters New Service JM Amps �i J 1)r Volts Overhead ❑ Undgrd P�[_ No. of Meters Number of Feeders and Ampacity ifl�,ii/f� t.✓ �/ �(A�iQiLI,� �J� A,7 e -1-S Location and Nature of Proposed Electrical Work:/'n , 9 /T j� y�N ` n,'��/ _Ao Ci Comnletion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Sus p• (Paddle) TransTFans r Total sformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In ❑ g rnd. grnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Detection andInitiating No. of Switches No. of Gas Burners Devices No. of Ranges Tot No. of Air Cond. Tons No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained No. of Waste Disposers p Totals: . . .. ....... .. ..I ....................... Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal E] Other Connection No. of Dryers Y Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail y desired, or as required by the lnspecror of wires. Estimated Value of Electrical Work: y/ _ �— (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 unless 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 andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: c/%✓J l dt . e -C LIC. NO.: Licensee:L,� /1-1-e"? Signature LIC. NO.: 316 (If applicably "�exempt" in the"license num Per line.) Bus. Tel. No.: Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires epartm nt of Public Safety " "License: Lie. 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 Owner/Agent PERMIT FEE: $ M Signature Telephone No. CJ R"� 0/-Z- 9- 12-� - le) /14 L9,of- 'Id Ar - to A / ?—' - 2- - ll:f� AZ7 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 sy www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers nnlicant Tnfnrmntinn Please Print Leizibl, Name (Business/Organization/Individual): Address: 6v -os City/State/Zip: / Yr 1e),11t1X— Phone #: Are you an employer? Check the appropriate box: 1. I am a employer with 1 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 3. ❑ 1 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.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box 41 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 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: ✓ /,wn Policy # or Self -ins. Lic. #: ���/ Expiration Date: �d Job Site Address: 4LZ4 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 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, und�er�th ains and penalties ofperjury that the information provided above is/jtrue and correct. �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 one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: