HomeMy WebLinkAboutMiscellaneous - 10 ICEHOUSE ROAD 4/30/20187/6/2016
20839
This is an e -permit. To learn more, scan this barcode or visit northandoverma.viewpointcloud.com/#/records/20839
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PERMIT FOR GAS INSTALLATION
This certifies that David R Carleton
has permission for gas installation Cap Gas Line and Test Line
in the buildings of FOURNIER, JOANNE D.
at 10 ICEHOUSE ROAD 10.0, North Andover, Mass.
Lic. No. 20731
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Date: July 06, 2016
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%-` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'" CITY d i Cl�� MA DATE PERMIT #
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JOBSITE ADDRESS Gs�.�_ OWNER'S NAME
GOWNER ADDRESS L6)1'— TEL ^ _ FAX
TYPE OR OCCUPANCYTYPE COMMERCIAL_I EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: E3 RENOVATION: ® REPLACEMENT: El PLANS SUBMITTED: YES 0 NO
APPLIANCES 1 FLOORS- BSM*l 1 1 2 1 3 1 4 1 3 1 6 1 7 1 8 1 9 1 10 1 11 12 13 14
BOILER 11 111 11 111 111 111 11 111 111 111 111 1 I i^7 i—
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
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES 10NO Ej
1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY L!J OTHER TYPE INDEMNITY BOND F
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 0 AGENT El
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 co ian a wit e ' t prov' n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASATTER NAME �i �� iA r' ��� LICENSE # E _ bleNATURE
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COMPANYNAME:r�� / -> ADDRESS 1
CITY w STATE � ZIP d TEL Q
FAX CELL EMAIL
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SNThe Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street, Suite 100
t
Boston, MA 02114-2017
www.mass.gov/dia
'Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Name (Business/Organization/lndividual): OA V )O /',alt" t/ F/u-vy6!�n -4 //moi 7✓✓
Address:
City/State/Zip:/Ct,A6Q IV H 537 d Phone #: 6 Q 15' YE y4
Are you an employer? Check the appropriate box:
L Vam
a employer with ..: employees (full and/or part-time).*
2. a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. ❑ lain a general contractor and I have hired the sub -contractors listed on the attached sheet.
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.
152, § 1(4), and we have no. employees. [No workers' comp. insurance required.]
Type of project (required):
7. ❑ New construction
8. E] Remodeling
9. ❑ Demolition
10 ❑ Building addition
11. ❑ Electrical repairs or additions
12. [dumbing repairs or additions
13. ❑ Roof repairs
14. ❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who submif 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 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 tliat 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 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.
I do hereby c c under th ins enalt' ofpeijury that the information provided abov is true nd/correct.
iiunattire- ��_ / i��r///i /J./ Date:
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 #:
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 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 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 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
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 burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
Q COMMONWEALTH OF MASLACHUSETTS.
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BOARD OF
PLUMBERS AND GASFITTERS
ISSUES THE FOLLOWING LICENSE
,
LICENSED AS A JOURNEYMEN PLUMBER
DAVID R CARLETON '
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142S MAIN ST.:
NEWTON,. Ni 03858-3709
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20731 05/01/2018 32598
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Date. IF/// e....
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ... /7/
has permission to perform ..... /u x :Ir ..........
plumbing in the buildings of .... 1-/-? ?� 4��
at ...
................ North Andover, Mass.
Fee Lic. N o.,2 ----N ......
PLUMBING INSPECTOR
Check vo
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TOPO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building
� Date if 0 C,
vame 4"Lan'P�•l /Pennit # 7a6 y
Amount Zrrp
Type of Occupancy
New Renovation 0 Replacement 0 Plans Submitted Yes Q No ❑
F1YTf IQFQ
(Print or type)
Installing Company Name
Address
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Check one: Certificate
11 Corp.
Partner.
Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the,4pe of insurance coverage 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 Owner ❑ Agent ❑
I hereby certify that ;ill of the details and information 1 have submitted (or entered) in above application are true and accurate to the
hcst of my knowled'-e and that :ill plumbing work and installations pert,. n -lied unilcr Permit issued for thus application will he in
compliance with all pertinent provisions of the Y1assachL1 •tts St e I'll b',n ind Ch.upter 142 of the c;encral Law's.
By:
1."FlanlrC GIf"F'I ISca ['
Title
Type ,:)F Plumhing License
City,Town_ r-Fcensse, urn �r
Luster 11Iourne man c�
APPROVED : cC>; F r;�ONLY J L.J
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MUNOW
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(Print or type)
Installing Company Name
Address
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Check one: Certificate
11 Corp.
Partner.
Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the,4pe of insurance coverage 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 Owner ❑ Agent ❑
I hereby certify that ;ill of the details and information 1 have submitted (or entered) in above application are true and accurate to the
hcst of my knowled'-e and that :ill plumbing work and installations pert,. n -lied unilcr Permit issued for thus application will he in
compliance with all pertinent provisions of the Y1assachL1 •tts St e I'll b',n ind Ch.upter 142 of the c;encral Law's.
By:
1."FlanlrC GIf"F'I ISca ['
Title
Type ,:)F Plumhing License
City,Town_ r-Fcensse, urn �r
Luster 11Iourne man c�
APPROVED : cC>; F r;�ONLY J L.J
Date. . ......
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0
TOWN OF NORTH ANDOVER
0
PERMIT FOR GAS INSTALLATION
This certifies that . .1;71 �. A -.� ..... /f n ...............
has permission for gas installation . . .).t. k/,. .. . . ........
in the buildings of .... efe."�. Af� . . ................
at ............. I North Andover, Mass.
Fee. 5 0. Lic. No..?, .. ....
L I N�St �PE C -T-- O -:'R'
Check #
3684
INIASSACHUSEITS UNIFORM APPUCATON FOR PERMIT TO DO GAS FfITNG
(Type or print) Date
NORTH ANDOVER, MASSACHUSETTS
Building Locations "I) /' /zOdS-c �G y
Permit # S O Y
Amount $ �-
Owner's Name
New Er Renovation ❑ Replacement ❑ Plans Submitted ❑
(Print or type)
Name__
Address
Check one: Certificate Installing Company
Corp.
Partner.
Firm/Co.
INSURANCE COVERAGE Check o
I have a current liability Insurance policy or it's substantial equivalent. Yes No
If you have checked Yes, please jrACate the type coverage by checking theappropriate box. 13Liability insurance policy z 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
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner IT 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 MassachL tts Slatas Co e and Cha er 142 of the General Laws.
r3 y:
Title
City/Town
[APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber -Zr, 514 ;z
0 Gas Fitter License iNumber
Master
ourneyman
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SUB -BASEMENT
A
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B A S E M ENT
1ST. FLOOR
2ND. FLOOR
3RD. F L O O R
4T 1I. FLOOR
5 T H. F L O O R
6TH. FLOOR
7 T H. F L O O R
8TH. FLOOR
(Print or type)
Name__
Address
Check one: Certificate Installing Company
Corp.
Partner.
Firm/Co.
INSURANCE COVERAGE Check o
I have a current liability Insurance policy or it's substantial equivalent. Yes No
If you have checked Yes, please jrACate the type coverage by checking theappropriate box. 13Liability insurance policy z 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
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner IT 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 MassachL tts Slatas Co e and Cha er 142 of the General Laws.
r3 y:
Title
City/Town
[APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber -Zr, 514 ;z
0 Gas Fitter License iNumber
Master
ourneyman
Date... ... ........ ..... .....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............... 13.,0 /. z��
..... ....... ..
... . . . ......
has Permission to perform ..........
wiring in the building of ....... ?;n�
. ............
Nort, I. 'Am d o v e r, M a s S.
�=Lic. No. .......... '14,
Fee ... C/ 7-!: ... OR .......
L�ic �Ma� i�.,;Pw
Check # /eq 3 /</
ir
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 68 7
Occupancy and Fee Checked
[Rev. 9/051 leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code ( EC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: & � b L O "
City or Town of: 00 _ To the Inspector ofWires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 1_n L t^ �— vj a,) -, p� v� .
Owner or Tenant
Owner's Address
Is this permit in cc
Purpose of Building V `- —� Utility Authorization No.
Existing Service Amps / Volts
New Service )_aa_ Amps
Number of Feeders and Ampacity
Overhead ❑ Undgrd ❑ No. of Meters
Overhead ❑ Undgrd E�' No. of Meters
Location and Nature of Proposed Electrical Work: LA.,,1 _„, { (-e-Oy 56—
Completion
6
C'omnletion ofthv inllnwinv tnhly mn) 110 1—i—d 1111 thD 1— —f— of 1/11;v
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
_ _ __
No. of otal
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- ❑
rnd. grnd.
o. of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection an
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
eat Pump
Totals:
Number
Tons
I
I KW
lVo-75TS—eIT-Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:
No. of Devices or Equivalent
No. o Water Kit
Heaters
No. o No. o
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications firing:
No. of Devices or Equivalent
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: �' p 6 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 cover 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.
FIRM NAME: h l�--%C_ ? ' LIC. NO.:
Licensee: l�� r,/1��,L,� Signatur LIC. NO.:
(If applicable, enter "exempt" inthe licen a number line.) Bus. Tel. NO.� 3gZ-Z���i
Address: 7 ��S._.>.
_.> (tom .✓:::�4 Alt. Tel. No.:�i7fs 37S c am'
*Security System Contractor Lic nse required for this work; if applicable, enter the license n tuber here:
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 a ent.
Owner/Agent
Signature Telephone No. PERMIT FEE. $
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