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Home My WebLink AboutMiscellaneous - 10 CONCORD STREET 4/30/2018 (2)0 n 0 A O �t a Date.. TOWN OF NORT OVER PERMIT FO=1NG This certifies that ...... ) ........................... has permission to perform ...... ...... ......... ......... plumbing in the buildings of .... at ...... ...... .......... North Andover,,Mass. Fee Lie. No. .................. PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location r1 Caro f ,f Owners Name lG� Date % �!J` Permit# 7?b° T e of Occu anc /� Amount _ /_ N I -'w LJ/ Renovation Lj Replacement ' 1:3 Plans Submitted Yes1:1No rl ' TiTPTTT7ltrnr� kr1711l or Lype) Installing Company Name /�1 Zir ��,, f'�UGCheck one: Certificate Li — r crp. Address U 130 / %'� Ca, 0 Partner. usmess Telephone _ Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance covers e by checking theappropriate box: Liability insurance policy R — Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have anyone of the above three insurance Signature Owner ❑ ID 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 MassachusettsShe lumbing C and Chapter 142 of the General Laws. City/Town APPROVED (OFFICE USE ONLY Type of Plumbing License ice se um er Master I]--- / Journeyman ❑ Date.,,:.,Y, '/" 0 / ............ 0 f '0 TOWN OF NORTH ANDOVER .. , 49 0 PERMIT FOR GAS INSTALLATION This certifies that ...... ;—." ............... .................. has permission for gas installation �J ................ in the buildings of .......... f .................. at .... tz ................. North Andover, Mass. Fee. Lic. No,e��'!(.- ,,GAS INSPECTOR �>k - I Check# 4e MASSACHUSETTS LMORM APPUCATON FOR PERVIIT TO DO GAS FrrnNG (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Legations �0 r�0 v. ri,.�� 1 Permit # 19460 Amount $ O'O Owner's Name New Renovation ❑ Replacement ❑ Plans Submitted ❑ U B-BASEM ENT ASEM ENT ST. FLOOR ND. FLOOR RD. TH. FLOOR FLOOR TH. FLOOR TH. FLOOR -FL TH TH. OOR FLOOR — � i, WW W Q W w y w w w. � � � � m a w C tra.7 F A F w Q W > F Z O z wuW Ey, W U B-BASEM ENT ASEM ENT ST. FLOOR ND. FLOOR RD. TH. FLOOR FLOOR TH. FLOOR TH. FLOOR -FL TH TH. OOR FLOOR (Print or type) I ' n Name__ %rhly Check one: Certificate Installing Company L..1 _orp. ❑ Partner. ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter 6-- INSURANCE COVERAGE Check one: I have a current liability Insurance, policy or it's substantial equivalent. Yes If you have checked yes, please indicate the type coverage by checking the appropriate box. 13No 13Liability insurance policy Other type of indemnity appropriate ❑ Owner's Insurance Waiver: 1 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. Signature of Owner or Owner's Agent Check one: I hereby ceOwner ❑ 13rtify that all of the details and information I have submitted (or entered) in above appl cation 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 State Gas Ck anhapter 142 of the General Laws. By: Title City/Town,. (APPROVED (OFFICE USE ONLY) Signature of Licensed Plumte-r—Or Gas Fitter ❑ Plumber /'[y --,? ❑ Gas Fitter License Number Taster ❑ Journeyman `i To MAS,SACHUSE'I'IS UNN ORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) Date , '%/// NORTH ANDOVER, MASSACHUSETTS Building Locations Permit # 4 4�/,/ Owner's Name�/, %C 17tmount $ 1/ u1yr1 New Renovation Replacement P 0 Plans Submitted SU B-BASEM ENT BASEMENT 1ST. FLOOR 2ND. 3RD. FLOOR FLOOR 4TH. FLOOR 5TH. FLOOR 5TH. FLOOR 7TH. 3TH. FLOOR FLOOR (Print or Nam,- Chone: Certificate Installing Company ElPartner. 11 Firm/Co. Name of Licensed Plumber'or Gas Fitter %7TH j INSURANCE COVERAGE Check one: I have a current liability Insurance, policy or it's substantial equivalent. Yes 12- NoO If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 13 Bond 13 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 Owner 13 Agent 13 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 State Gas Cpdend Chapter 142 of the General Lawc By: Title City/Town, APPROVED (OFFICE USE ONLY) Signature of LicenseJr d Plumber Or Gas Fitter Plumber 64 3 Gas Fitter License Number 13 --Master Journeyman W vi y Ci O W F fY' y � v� F• w 0: p O � p Z F V w d S w E. ?, 4 y w C 1 e d C x z w E' C > w a m w Z O w F F+ w x F w NilE s 3 0 y z o s .da > a W o Chone: Certificate Installing Company ElPartner. 11 Firm/Co. Name of Licensed Plumber'or Gas Fitter %7TH j INSURANCE COVERAGE Check one: I have a current liability Insurance, policy or it's substantial equivalent. Yes 12- NoO If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 13 Bond 13 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 Owner 13 Agent 13 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 State Gas Cpdend Chapter 142 of the General Lawc By: Title City/Town, APPROVED (OFFICE USE ONLY) Signature of LicenseJr d Plumber Or Gas Fitter Plumber 64 3 Gas Fitter License Number 13 --Master Journeyman Date. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ��-*t D 5 This certifies that �-O. . -I, . . . . I ................ has permission to perform ............ plumbing in the buildings of ............ at ... I �. 11!� .......... North Andover, Mass. Fee -N'- Lic. No.. ... ...... I ........ ...... PLUMBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS /G Date 7�//d Building Location /U (Gvt(u.� f� Owners Name T�crs`� Pernut # = Amount Type of Occupancy /4(f i New 0/ Renovation rj Replacement 'o Plans Submitted Yes No FWTT T12 T` c (Print or type) r Installing Company Name _%.11:! p /),fid ^�.LcJ I& A,, 4.5� I AAArPee e V ^ 6v ) "0, Check o Certificate Corp. Partner. Firm/CO. Name of Licensed Plumber: P74tv— 7;i a a Insurance Coverane• Indicate the type of insurance coveratiF by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ 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 State P in ing Code and Chapter 142 of the General Laws. By. Signa ��rr n irrn u a /„ aunAm Tide Type of Plumbing License /a-oG 3 City/Town Jcense um er Master n( /Journeyman ❑ APPROVED (OFFICE USE ONLY 1._! ?, I( - e-, ..................... Date ....... 7. lop TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING US 1-1�v .... —z- e. /'? ........................ This certifies that .................. ....... 4--s .... /"/V.T has permission to perform ........... AA ... k.J 4,�� , -- ( , '�"' ) .... .. ...................................... wiring in the building of ................ We- L -e /-/ .................................................................. at ........... ...... !� 1;71- ......................... . North Andover, Mass. ree "? - ---7" '07!� 3 111f 0"' ................... Lic. No . ............. ... —, ............... Check # ELEMICAL INSPECTOR Date ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .............. .......................... has permission to perform ........... �oFlk/ ..... ....... wiring in the building of ............... ............................................ at ...... ........ �2 . 7 ................... . North Andover, Mass. -7 ic. No.. Fee ............... ....... L Z .. ................ z It .-65.... —'PI&I INSPECMR Check r A' wmmonweairn of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. I/07 1 n__ 1, 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 W INK OR TYPE ALL B&ORM14TION) Date: City or Town of NORTH ANDOVER r ..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) IA 0 Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes Purpose of Building C'pn 6 14<NO ❑ (Check Appropriate Boa) Utility Authorization No. Existing Service tAmps / Volts Overhead ❑ Undgrd Na; of Meters New Service '-'"��- Am.,s / Molts Overhead �� Undgrd ❑ No. of Meters 2� Number of Feeders and Ampacity Location and Nature of Proposed Elec 'cal Work: rlec� 0ondoC A No. of Recessed Luminaires • No. of Luminaire Outlets No, of Luminaires o NHy&omassage eceptacle Outlets Q witches Q anges .2�5 aste Disposers ishwashers �ryers 2atereaters �" KW romassage Bathtubs s Com letion o the followin 'table may be waived by the Inspector o Wires. No. of Ceil.,Sus p. (Paddle) Fags No. of Total Transformers KVA No. of Hot Tubs Generators KVA Swimming PO Above In_ arnd. o. o mergency lg a d. Batte Units No. of Oil Burners FIRE ALARMS INo. of Zones No. of Gas Burners .2— No. of etecuon and No. of Air Cond. Toe ns Initiating Devices No, of Alerting Devices Heat Pump Number Tons Totals: " No. of Self: Contained Detection/Alertina Devices Space/Area Heating KW Local ❑ Municipal ❑ Other Heating Appliances K, Connection Security System:* . o. of No. of No. of Devices or E uivalent Si s Ballasts . Data Wiring: . No. of Devices or E uivaleat vn. of Motors Total HP Telecommunications No. of Devices or EnurvA Prt Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required 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 cove a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE (BOND ❑ OTHER I certify ❑'(Specify:) under ihns and penalties erjury, that the information on this application is true and complete. FIRM NAME: Licensee: aVYl¢LIC. ND : i Signature (If applicable, enter " t" in the license nu ber, /, �/ LIC. NO. Address: Q �, Bus. Tel. No.: 7 7�3 *Per M.G.L c. 147, s. 57-61, security work requires Department o ublic Safety "S" License: Alt Tel. Noo .:�9E?�_� ¢meq OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liabili Lic. No. required by law. By my signature below, I hereby waive this re tY insurance coverage normally Owner/Agent gt�ement. I am the (check one) ❑ owner ❑ owner's agen` Signature Telephone No. [PjRMIT�FEE_- Y/3` (07 tga-e-� 0 4c % - 2 s -cD4a 90--r- 'jo� 0 I �l LOMmonwealth of Massachusetts Official Use Only '+ Department of Fire Services Permit No. L 4" BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked ' [Rev. 1/07 /lPovo 61.,..1.1 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 IN NK 01? TYPE ALL NFO RMA Date: _ �°— � y! _ O '? City or Town of: NORTH ANDOVER By this application the undersigned To the Inspector of Wires; gn gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant r Owner's Address Telephone No. Is this permit in conjunction with a building permit? yes Purpose of Building C'p/1 6 V n NO (Check Appropriate Box) - Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ . No. of Meters New Service ;3dAmps / Z dVolts Overhead Undgrd ❑ No. of Meters 2— Number of Feeders and Ampacity Location and Nature of Proposed Electical Work: v� r? LoCo n, e n No. of Recessed Luminaires of Luminaire Outlets No, of Luminaires Completion ofthe No. of CeiL-Susp- (Paddle) Fans No. of Hot Tubs Swimming Pool Abbot/ e ❑ No. of Receptacle Outlets Q lNo. of Oil Burners No. of Switches No. of Gas Burners No, of Ranges ,2 G' R -S' No. of Air Cond. No. of Waste Disposers No. of Dishwashers 2, No. of Dryers 112- 0. o. of Water KW Heaters' No. Hydromassage Bathtubs vin table may be waived by the Ins ectoi No. of Total Transformers KVA KVA o o- ergency rg = JGenerators attnits IRIt1S No. of Zones No. of etecfinn A�� Of Alerting Devices Totals:. "---- `�"' -� E'40- of Sett --Contain Detection/Alertin I pace/Area Heating KW ❑Municipal .eating Appliances KW Connectim 7SecuritySystems:* o. of Nn. of o, of Devices or Si s Ballasts Wiring: . No. of Devices or o. of Motors Total HP Telecommunications No. of Devices or ❑ Other Attach additional detail if desired, or as required by the Inspector of Wires, Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: '7 -- a A -0 9 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 cove a is in force, and has exhibited proof of same to the permit issuing office. I SCK ONE: INSURANCE (BOND ❑ OTHER [] (Specify:) fy, under th 'ns and penalties of perjury, that the information on this application is true and complete. FIRM NAME: '}� Licensee: d-ry%,Q LIC. NO.: (f Iapplicable, enter ., m et " in the license nu t:ber SrguatSignatureLIC. NO.: Address: �/ O Bus. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department o ublic Safety S License: Alt TeL No.: !F2 if q QRg767 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the L Iiabil: Lic. No. co required by law. By my signature below, I hereby waive this requirement I am the (check one) 11owner❑ owner's a ent Owner/Agent Signature Telephone No. PERMIT FEE: $ 1 156 r t i I 0 4t Y 4f 4k. Alk 4., i ..C,, tis a f, The Common wealth of Massachasew, Department of ,industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Workers' Compensation www.rnass.gov/dia 1witrance davit: Builders/Contra.ctors/Mectricia�tslPiccmbers splicaat Information Name (Business/Cnwizafion/individuul)' Mt9 Address: :2 2 tt_ t^I City/,State/Zig: b I phone #. 9 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).* . have hired the sub-contractors2. I am -a -80le proprietor or partner. ship and have no employees listed on the attached sheet = 7bese sub -contractors have working for me .in any capacity, [No workers' comp, insurance workers, comp. insurance. 5. ❑ We are a corporation and its required.] 3. [] I am a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No•warkers' comp, c..152, § I(4), and we have no insurance required.:] t .employees. [No workers' comp, insurance re uired ] Type of project (required): 6. r7 New construction 7. ❑ Remodeling 8. Q Demolition 9. El Building addition 10. F7 Electrical repairs or additions Plumbing repairs or additions 12.[ Roof repairs q 13-n Other 'Any applicant that ehec ks bob #1 must also fitl out the section below showing their workers"com 1 t Homeowners who submit this affidavit indicating they are daring all work and then hire outside contractors must submit an1 ICY ew affidavit indicating such. 4contractors that check this box nuistattached an additional sheer showing the tram of the sub-contractms and their worker coma. Policy in%tnration. I am an employer that.is providing:workerscompensation inuaefor �infornadonamptoYeesBelow is.he olic Y and job site Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/Stlite/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 here ertify under the�{ ns and penpl&_s of perjury that the information provided alcove is true and costed �r 141"14X. C25( Ofj9chd use only. Do not write in .this area, to be completed by city or sown aids( City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health L Building Department 3. City/Towu Clerk 4. Electrical inspector 5. plumbing Inspector fi. 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 ofhire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two ormore of the'foregoing engaged in a.joint enterprise, and includirlkg the legal representatives of a deecased employer, or the receiver or trustee0f 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 er 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 mquimd." Additionally, MOL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any eontmact far the performance of public work tmtil 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 complotely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) Emd 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.we required to obtain a workers' compensation policy, please -call the Department at the numberlisted below. Self-insured companies should entertheir self-insurance'.lieense number on ffie•appropriateline. 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/iicense 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 provided town may be to theof ' applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out Mach 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 parson is NOT required to complete this affidavit The Office of Investiaptions 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 Investigations 600 Washington Street Boston, MA 42111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7744 www.mass.gov/dia # 313aqD U0103dSNISVE) . . ..'. . , * !. *;'* , ... .,. . . .... - -ON - 31-1 ....... �- aad 'SSEW 'IQAOPUV qjlON .................. X/ -VII .......... Ir .................. jo sSuipl!nq aip ut ............... ........ uoilL,111olsui wS ioj uoissiwiad suq ............................. IUM SQUI1133 slqJ NOliV'11VISNI SVS U0:1 IIWU3d 7 U3AOCINV HIUON :10 NMOI