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HomeMy WebLinkAboutMiscellaneous - 12 MATHEWS WAY 4/30/2018 BUILDING FILE _f Date.. .! . .�.................. ��. OF NORTN,h TOWN OF NORTH ANDOVER o * PERMIT FOR WIRING + CHUS�t� s This certifies that ......... has permission to perform ..........' 2 � �.±Jk� .............. ............................................ . ... wiring in the building of............. . �'4!�'r ...... . . .�?. ............................................. ate .:..12- 1 �`� y` North Andover,Mass. ... .............................. .................. Fee...... ' ....Lic.No. .... ................................ ...... .. ...:.. .. ..........:........... ELECT..RICA..LINSPECTOR...... .. .. Check# fA, { 2-1 1 .3' 252 ' �� „. Commonwealth of Massachusetts Official Use Only p Permit No. Department t of Fire Services ' Occupancy and Fee Checked a 6y BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical CodeCj,527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL)NFORMATION) Date: � (o (��p City or Town of: NORTH.ANDOVER To the Inspector of Wires: By this application the undersigned gives notic.0 of his or her intention to perform the lectr'ci work described below. Location(Street&Number) W Owner or Tenant y�C6- S0 TD A) Telephone No. Owner's Address 6 Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Ne6 3 Utility Authorization No. 24 �9 �J7 •& - Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service 200 Amps 11 / 1--iNolts Overhead❑ Undgrd 0/ No.of Meters Z� Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: l.4-�t,,�,C Completion of thefollowing 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 Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- E3 o.oEmergency �g ting rnd. rnd. 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 and Initiating Devices No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other P g Connection No.of Dryers Heating Appliances KW Security Systems:* 3' 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 E uivalent . OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Elctrical Work:ooC�%00 (When required by municipal policy.) Work to Start: `� 1.� t 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 in urance including"completed operation”coverage or its substantial equivalent. The undersigned certifies that such cover 'i is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under ili pains and penalties of perjury,that the information on this application is true and complete. FHMNAME: " h,�M A-L --t Ac-- LTC.NO.-- Sal Licensee: Signature LTC.NO.: Z7 kOv---J (If applicabl enter "exempt"in the license number h e.) Bus.Tel.No.: Address: ee o. A oly k b6?_ w W (- - --, � a'1' t a�`(� Alt.Tel.No.: 'Ok6 2 *Per M.G.L c. 147,s.57-61,security work requires Deparhnent 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 required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. 1 ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the r' 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 Wires appointed pursuant to M.G.L c. 166,§32,an ` electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as 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 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The 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. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Ins ction Pass Failed Ed Re-Inspection Required($.)❑ Inspectors Comments: —0/Inspectors Signature: Date: r SERVICE INSPECTION: ' Pass Failed 0 Re-Inspection Required($.)❑ Y Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Com ents: r Inspectors Signature: Date: ]FINAL INSP CTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: .4 Date: — Z DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Z F Department oflndustrialAccidents a 1 Congress Street,Suite 100 `= Boston,MA 02114-2017 \ www mass.gov/dia yy Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNIITTING AUTHORITY. . Applicant Information . Please Print Legibly Name(Business/Organization/Individual): — tk Address: PIUO , Ob City/State/Zip: WLR©t Phone Are71a,,,rnployerwith_�.Y, mployer?Check the appropriate box: Type of ject(required): 1. employees(full and/orpart-time). 7. 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 10 Building addition 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 11.[]Electrical repairs or additions proprietors with no employees. ` 12. 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.Q We are a corporation and ifs officers have exercised their right of exemption per MGL c. 14.0 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. I Homeowners who submit#his 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'camp.policy number. I arrt an employer that is providing workers'compensation insurance for my employees.'Below is the policy acid job site information. Insurance Company Name: L A--,c Policy#or Self-ins.Lic.#: Expiration Date: 16- 11_�� 1 k-6t f �2,)(7 Ci /State/Zi 'JA-'JA- 1 I MWS Job Site Address: tS' p� Attach a copy of the workers' compensation policy declaration jage(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'10$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. Y do herebycerti nder thepains and penalties of perjury that the information provided above is true and correct fY P _ t e• Date• �A ral 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#: I Information an ~' • d 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 ail 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 a licant who has not• r d e " o uc d acceptable evidence PP p p 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-contractors)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 maybe 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-insure_d 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 V )' 'COMMONALT OF M., ' SSACHUSETTS BOAAD-of . E LECTFt MANS I ANS 1'.SSUES THE FOLLOWING LICENSE AS .q REG L:.STERE'D MASTER ELEC1 R°I C I`AN `. BRI:MAC ELECTRICAL SERVICES- r z MI CHAEL F :MAC'DONALD PO BOX '8062 H.AERHILL ; MA o1835-056i >� .., X 16M2 f 0 f 0 +� 20MA6NwE irOF M, SA�I�I) BOARD-Of Et s f`CTk'I C I ANS ISSUES—THE FOLLOWING LICENSE AS A .REG JOUR:NUMANi ;ELECTR'I.0 I AN 1 MICHAEL F MACDONALD. Y •' ,PQ .BOX ;8062 I 01835-0562, .H'AVl RH`I LL :M1 7805 <E 9/ 1/16.: ;`75208 . Ot Mo eTM, c. ••,'gyp O • CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 904-2016 on 2/22/2016 Date: September 12, 2016 THIS CERTIFIES THAT THE BUILDING LOCATED at 12 Mathews Way MAY BE OCCUPIED AS IN a single family home ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Steve Smolak 12 Mathews Way North Andover,MA 01845 Building Inspector Fee: Prepaid$100.00 Receipt: 30032 Check : 263 r ,.� +' F NORTH' _ - ver 0 : .. : _ . h ver, Mass , cocHUNe.c. � ATIED ` U BOARD OF HEALTH ? a r Food/Kitchen PERM ' :.. ,,. Septid+ temTHIS CERTIFIES THAT ..... ,�� I► •. ..... ,,,, ,,, ,,,,,,,,,,,,,,, BUILDING INSPEC70.R7 i ® Q� � ,� r Foundation MN OO�•�s ,.. has permission to erect ... buildings on . ` .. ® y • ....... ....... ...........................�.... .. to be occupied as .....W� . . ..................................... ... chi; provided that the person accepting this permlt sha .�in every respect conform to the terms of the Iicatlorr on file in this office, and to the provisions of the Codes arid By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of`Oorth Andover. ,CLIMBING INSPE T Rough I► 4 /®'� N VIOLATION of the Zoningor Building Regulations Voids this Permit. is g g :_' • Final 7 112* i PERMIT EXPIRES IN 6MONTHS ELECTRIC INCEjYb UNLESS CONSTRUCTIO START Rou ��L> = F,, Servic 4 Fin I BUILDING INSPECTOR \\\ GAS INSPECT ..; . Occupancy Permit Required to Occupy Building w RougnP'° z y Final Display in a Conspicuous Placon the Premises Do Not ( move No Lathing or Dry Wall .To Be Done FIRE DEPARTMENT w Until Inspected and Approved by the Building Inspector. ^i° «,, Burner ' .. Streett No. �Z Smoke Det tit � giORTy q O �teo re s O O 0 � APPLICATION FOR CERTIFICATE OF OCCUPANCYANSPECTION T �+� oyb � • X1,95 RArmc BUILDING PERMIT# SACH 01 ADDRESS/LOCATION OF PROPERTY: xx 14j, Map-'r,2— Parcel Lot Number SUBDIVISION: DATE REQUESTED FILED/READY FOR INSPECTION: CLOSING DATE ON PROPERTY: FIVE(5)DAYS NOTICE PRIOR TO CLOSING DATE IS REOUIRED ALL WORK AND SIGN-OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLLARS ($20.00)WILL BE CHARGED IF THE-STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. APPLICANT SIGNATURE Permit Issued to: 70-, 1 '.5 L C Address: 7(, ,f_ 41a.Xe J l 6 ROUTING TOWN ENGINEER, SITE PLAN—DRIVE-WAY REVIEW 9M/6 CONSERVATION (� PLANNING DPW-WATER METER L�1 SEWER CONNECTION DPW MUST INDIC TE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF OCCUP CYANSP TION REQUEST DPW SI TUBE File:Application for OC form revised Jan 2007/2011 PERFORMANCE AIR LEAK TESTING, LLC 100 MCINTOSH LANE HAMPSTEAD, NH,03841 978-852-7207 Building Air-Tightness Test Form Customer Information: Building &Test Conditions: Name: 'Mz Address: O CS f` Date: City: b State/Zip: Phone: I� Time: Email: Billing Address:(if different from above) Street: �� l� Floor Area(ft2): � w City/State: Comments: ()5� -- ku 91,1116 Test#1 Depress: Press: Test#2 Depress: Press: Pre-test Baseline Pressure: ` Pa Pre-test Baseline Pressure: Pa Bldg Press. Flow Ring Fan Press Flow Bldg Press. Flow Ring Fan Press Flow (Pa) Installed (Pa) (cfm) (Pa) Installed (Pa) (cfm) K1 O. 010 Post-test Baseline Pressure:" (Pa) Post-test Baseline Pressure: (Pa) Fan Model/SN: Fan Model/SN: Results: r Results: CFM50; I. CFM50: ACH50: �'� ACH50: PERFORMANCE AIR LEAK TESTING, LLC 100 MCINTOSH LANE • HAMPSTEAD, NH,03841 978-852-7207 Duct Leakage Test Form Client Information Building Information Name: ut Address: Address: / _bo City/State/Zip: � ��Ver" / City/State/Zip: , Test Date: LIZ- Phone: Test Time: Email: Point of Construction: 0 Rough Final System #1 System #2 Location: 14N1 Location: Type of Test. Total/Oto Outside Type of Test: O Total/Oto Outside Approx. Floor Area Served: 1025Approx. Floor Area Served: CFM Leakage at 25pa: CFM Leakage at 25pa: Approx. Leakage for Single System*: Approx. Leakage for Single System*: System #3 Combined Results Location: Total Conditioned Floor Area: sq.ft. Type of Test: 0 Total/0 to Outside Leakage Limit:N6% Y�' �8% 12% Approx. Floor Area Served: Leakage Limit: °7 cfm@25 CFM Leakage at 25pa: Combined Leakage**: � cfm@25 Approx. Leakage for Single System*: 12009 IECC Compliance: Pass 0 Fail *Approximations for single systems are for diagnostic use only. **Total combined duct leakage is required for 2009 IECC Compliance. certi that this test was pref d in compliance with applicable standards. es er's Signatur Date w A*Plumbing Permit 1720281-' X Apps ffl ViewPoint I Own o-Nora Andover, NIA 20- 200111 'Plumbing Permit-In Conjunction with a Building Permit(Commercial or Residentiall TIMELINE Add New- x�' May 12,2016 at 8:21 am 4- Go nS, ; In ProEress t 978-374-1743 STEVE SMOLAK Attachments Primary Contractor Change... Search for your contractor using the search bar below.Either the Firm's Name or licensee#is required. Galinsky Plumbing&Heating Inc Stephen C Galinsky 319f, Plurnhine Cornnratinn f� 1FC- "b .O .. 7�v{;i 8:37 AM 5)12)2016 Thursday,May 12,2016 08:37 AM VO �+��4�`,�Y� *Gas Perm*x20283-Vi Apps Ea ViewPoint k 21288, *Gas Fern,ir_-in rc'm4vn1f-n amih a&MKI[g Fefr&HC mmndA or RE§dentiiali Thl'"ELI if A ., F ,,,r:-F'. Go - c — _ t a �fa a7£ )s 3 Pl8mry 1_Orivi#or rda a�w snrT�tr rasing-,1e search.i;Z&-Juw.i:ieher the Fun's Harm or licensee 4 is requirexl. Gainsky Flu r hirg&-He Inc 9.-aen C cabnsl'y S14:�J� 8:99 ATI _. 511:212015 Thursday,May 12,2016 08:49 AM Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ -424,000.00 m $ - $ 5,088.00 Plumbing Fee $ 636.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 636.00 Total fees collected $ 6,460.00 10-12 Mathews Way 904-2016 on 2/22/16 Two family Condex BUMBING FILE Date.ftl...i.. ....11'�.... 11736 -FloNonrHTOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies lt-haNlc-)v Of ........ ................................................ ............................................................... has permission to perform....t�xq—.'j....�v'�................................................. . ........ ....................... plumbing in the buildings of..61MA.!�A�....................................................... at..... ........... North Andover, Mass. Fee Lic. No. PLUMBING INSPECTOR Check 4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK :v. CITY 6 MA DATE �}y3 _ PERMIT# 1 l _ JOBSITE ADDRESS I-44q OWNER'S NAME S 7-c=►/-L;�, ..'A! ,r v POWNER ADDRESS TEL a I FAX _ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL 2- PRINT CLEARLY NEW: RENOVATION:® REPLACEMENT:Q PLANS SUBMITTED: YES NO Q 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 GASIOIL/SAND SYSTEM DEDICATED GREASE SYSTEM _ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER _._ I ._/._._.l 1: -._., ._.._ 1 ( i ..__._.__1 ._...._�[ � ....__._1 ..__._._.� 1 ( -__A FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) e-- KITCHEN SINK LAVATORY ! _/.J _33_._( ___..1 ___I ROOF DRAIN SHOWER STALL SERVICE/MOP SINK T%6, ) _ E �.3_ __[ URINAL WA9TNG MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY d OTHER TYPE OF INDEMNITY 0 BOND Q 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 0 AGENT IR 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 co fiance wi II Pertinent rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAM LICENSE# >���' ( SIGNATURE IMP JP Q CORPORATION Q# t PARTNERSHIP PA _ I LLC COMPANY NAME ADDRESS es a I CITY '8 AJ1 STATE ZIP ��8 -� TEL & 3 3 P--2 FAX I � __.___...__.__� CE ,37��d EMAIL�� � ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES 0,4 S - 2 4!� Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES v r } a' DateA.... -A R 0 , TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �sgCHU This certifies that ......... has permission for gas installation in the buildings of... V ............................................................................................................ at.....AA......"�Ay\IP 01-� w&A -1 North Andover, Mass. ......................................................... .................... --S40 Fee....AJ .. 0,6.. ...Lic. No. .2.................. .............................. GAS INSPECTOR Check# 'U "21 ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �a CITY 4,-0d��V�c. - MA DATEPERMIT# JOBSITE ADDRESS �lT - OWNER'S NAME 4e j/� l2�avC���G_ II ;OWNER ADDRESS TE��3�d 0 a�.,�"�FAX TYP&OR OCCUPANCY TYPE COMMERCIAL( EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:a' RENOVATION:D REPLACEMENT: PLANS SUBMITTED: YES F1 NO0 APPLIANCES'l FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER �— �J �I 1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER 1 DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE 'r`+ INFRARED HEATER LABORATORY COCKS �- MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER _ ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER l WATER HEATER OTHER F .............. - INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES JE]NO D I IF 4 CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY LZ 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 0 AGENT SIGNATURE OF OWNER OR AGENT 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 comp'ance with all 73L� Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME d)eJ'*I pf P �e�� ENSE# SIGNATURE MP[dMGF 0I JP ® JGF© LPGI© CORPORATION©# PARTNERSHIP[j#=LLC E]# COMPANY NAME: C)2.(,b ADDRESS /d _Y G i��dL ti d2 CITY /✓P t,c1 -6 _ � 11 STATE�ZIP Q�� ]TEL FAX CELLEMAIL __ ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY AAL INSPECTJ.ONAOTES Yes No GC THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES w . The Commonwealth of Massachusetts , Department oflndustrialAccidents 1 Congress Street,Suite 100 '< Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/ludividual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am.a employer with employees(full and/or part-time).* 7. ❑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. F1 Demolition 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. Twill 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑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.] i; • *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit#his 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 that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 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/'I'own 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. t 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 f The Commonwealth o!fMassachusetts t Department of dndustrialAccidents X Congress Street,Suite 100 Boston,AM 02114-2017 �- wt www mass.goh/dia ,y1 Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE,FILED WITH THE PEPMTTING AUTHORITY. Applicant Information Please Print Le 'bl Name(Business/Organization/Individual): �UC� �t'!�'!/f r e ✓� Address: ®JtJ L k_11 CL City/State/Zip:A1eLJ7_?A/� A.?11, a`3F'gPhone#: 6e 3 v d a 7 9OZ 9 Areyon an employer?Checkthe appropriate box: Type of project(required): ,-Ella a employer with :,, : employees(full and/or part-time).* 7. New construction 2. a sole proprietor or partnership and have no employees working for me in $, 0 Remodeling any capacity.[No workers'comp.insurance required] 9. ❑Demolition I Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 []Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.b�P umbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.Q We are a corporation and its off,rcers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *x *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit!his affidavit indicating they are doing all work and then hire outside contractors must submit anew 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 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:1 Job Site Address: I 1 ala, ' City/State/Zip: Attach a copy of the workers'compensation policy de laration 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. X do hereby certi&under tlrep sand enalties ofperjuiy that the information provided above is true and correct. Signafore: Date: Phone#: Official use only. Do not write in this area,to be completed by cit 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#: h " Of4WEALTH..OF.MASSACHl3'SET'TS xr : 'rGASF ITT1=R pi t�NIBERS AND 1 NO �� ENS . = `r F b LL OW . £ �Or SSU�tS THE {{ AS A JO1JRlJEYi+IAN pj U?ABE'R.' r £ t P .. a §Sp � D QX S7ERU15 Cot G. a t .i i q, k y .• � r BROAD k nr :a :`COMMONWEALTH OF MAS1�CMl3SETTS �(3ARE3,Ol z p1UMBERS AND GASF 1:TTERSz 1SUES THE FOLLOWING LICENSE d w s ,} LIEENSE]3 AS ANIASTER,fpCUMBERr; a sF E NORMA.ND P B.ERUB , X13 L I NEDLW,:� RD,:� j > ,} 03858 3.10 � •1 f M°ItTy 0 o ► x i i �ds�cxuzet CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 965-16 on 3/9/2016 Date: September 1, 2016 THIS CERTIFIES THAT THE BUILDING LOCATED at 9 Mathews Way MAY BE OCCUPIED AS a single family home IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Steve Smolak 9 Mathews Way North Andover, MA 01845 Building Inspector Fee: Prepaid$100.00 Receipt: 30115 Check : 288 r No STN c=,•.r. ` obi M oo 1 CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Pen-nit Number 965-16 on 3/9/2016 Date: September 1, 2016 THIS CERTIFIES THAT THE BUILDING LOCATED at 9 Mathews Way MAY BE OCCUPIED AS a single family home IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Steve Smolak 9 Mathews Way North Andover,MA 01845 *Building Inspector Fee: Prepaid$100.00 Receipt: 30115 Check : 288 r 1 NORT#1 O 9(ps -Z61 iii 4: mh ver Mass p % I 9 COC mc"IW1[u y1 �,9Sp4A TE o U BOARD OF HEALTH Food/Kitchen PERMIT T L D Septic System � xy S G�l`d iv% �'� �� BUILDING INSPECTOR..--`-. THIS CERTIFIES THAT .................................................... ........ ........................................................ �> has permission to erect ............... .. ....... buildings on . —., �� :�::%�. .. �y.. ,..,.,..,.,,, Found ion f R ,Cagh�O '6_': ro -4_' to be occupied as ............ .. ...... `.� .....t.:..... .. ............................................!................. ac rfe�c �`�` provided that the person accepting this permit shall In every res ect conform to the terms of the application Fin I on file in this office, and to the provisions of the Codes and B Laws relating to the Inspection, Alteration and 1 � Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this PermitRoug . / / Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INs CTOR UNLESS CONSTRUCTIONS ARTS Rou ��-�` �� �f. .............:.........t.yrfl: ......................................... �� � "'�.'`� BUILDING INSPECTOR Fina ' GAS INSPECTOR Occupancy Permit Required to Occupy Building RouL)" o Display in a Conspicuous Place on the Premises - Do Not Remove Fina ," . No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner moo _ Street No.� Smoke Det. —®` � �oRry i�� yE'r a, rt6 0 APPLICATION FOR CERTIFICATE OF OCCUPANCYANSPECTION BUIPING PERMIT# SsacHuse ADDRESS/LOCATION OF PROPERTY: 4" Map Parcel b, Lot Number SUBDIVISION DATE REQUESTED FILED/READY FOR INSPECTION: CLOSING DATE ON PROPERTY: Ii'IVE(5)DAYS NOTICE PRIOR TO CLOSING DATE IS REOUIRED ALL WORK AND SIGN-OFFS MUST BE COMPLETED WITHIN THIS TANTE FRAME. A REINSPECTION FEE OF TWENTY DOLLARS ($20.00)WILL BE CHARGED IF THE-STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. APPLICANT SIGNATURE Permit Issued to:_���,� S/4 OZ-1-1 Address: _76. ROUTING �--� TOWN ENGINEER, SITE PLAN—DRIVE-WAY REVIEW CONSERVATION PLANNING DPW-WATERMETER 1 SEWER CONNECTION DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCYANSPECTION REQUEST .DPW ��� 1�. <.� C 11 �p SIGNATURE File:Application for OC form revised Jan 2007/2011 PERFORMANCE AIR LEAK TESTING, LLC 100 MCINTOSH LANE HAMPSTEAD, NH,03841 978-852-7207 Building Air-Tightness Test Form Customer Information: Building &Test Conditions: Name:.. Address: 1[ CGfCia r Date: City: �i 111 State/Zip: ,�* ( Cj�f Phone: �" /1 `��Y� Time: 1 1 Email: Billing.Address: (if different from above) Floor Area(ft2): Streef City/State: Comments: n,, / ;!) P� 141 j3 P l y V S Test#1 Depress: Press: Test#2 Depress: Press: Pre-test Baseline Pressure: ®" Pa Pre-test Baseline Pressure: Pa Bldg Press. Flow Ring Fan Press Flow Bldg Press. Flow Ring Fan Press Flow (Pa) Installed (Pa) (cfm) (Pa) Installed (Pa) (cfm) Post-test Basel' a Pressure:_(Pa) Post-test Baseline Pressure: (Pa) Fan Model/SN: 0_19,0 I C'� 106CY Fan Model/SN: Results: 1 Results: CFM50: 1 CFM50: ACH50: °�� ACH50: PERFORMANCE AIR LEAK TESTING, LLC 100 MCINTOSH LANE HAMPSTEAD, NH, 03841 978-852-7207 Duct Leakage Test Form Client Information Building Information Name: Re Address: Address: g City/State/Zip: City/State/Zip: � ° , 1 �U Cain ' Test Date: Phone: Test Time: l e Email: Point of Construction: O Rough Final System #1 System #2 Location: Location: �.� Type of Test:"�NwTotal/O to Outside Type of Test: O Total/O to Outside Approx. Floor Area Served: �� Approx. Floor Area Served: CFM Leakage at 25pa: CFM Leakage at 25pa: Approx. Leakage for Single System*: Approx. Leakage for Single System`: System #3 Combined Results Location: Total Conditioned Floor Area: sq.ft. Type of Test: O Total/O to Outside Leakage Limit: � 6% 6% 1 12% Approx. Floor Area Served: Leakage Limit: 9 cfm@25 CFM Leakage at 25pa: Combined Leakage**: 7S cfm@25 Approx. Leakage for Single System*: 12009 IECC Compliance: Pass O Fail *Approximations for single systems are for diagnostic use only. **Total combined duct leakage is required for 2009 IECC Compliance. cerA that this test was preformed in com lance with applicable standa ds. r Y Tester's Signat re - Date Fjigi eeringl,& Sp.pvi�yjing Servjices Date: AUGUST 1, 2016 To: North Andover Planning Board RE: #9-11 Mathews Way (Lot 5) Map 52 Lot 72 Board members, The existing dwelling location and topography layout substantially comply with the approved plans. If you have any questions regarding this matter, please feel free to contact me. Regards, .Patrick ower, P.E. 70 Bailey Court * Haverhill, MA 01832 978.556.0284 jVk, H4eU,-"3 a - y nmeto 41& 01 q Above-Grade Wall 21.00 Below-Grade Wall 0.00 Floor 30.00 Ceiling/Roof 49.00 Ductwork(unconditioned spaces): 'Window Door 0.30 Heating System: Cooling System.-JLL— 13 ftee— Wat.er Heater:&S YO Name: Date: Comments Date. ......... 11737 0' TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING CH This certifies that..................." .............................................................................. has permission to perform.... •a..............1...................................................................... plumbing in the buildings of,.... .......... .. .... ...±4'.f!............................................................ at......... ......0A.-T6,11 .. . North Andover, Mass. . ......................... ................................................................................. ............... Fee. .Af.........�ic. PLUMBING INSPECTOR Check# rozo< * MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK fit/ b✓e . CITY MA DATE -13-,//- [ PERMIT# JOBSITE ADDRESS r4 CtO-S cJ14 OWNER'S NAME / ✓� S�/rs P OWNER ADDRESS TEL s FAX TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: Or RENOVATION:® REPLACEMENT: ® PLANS SUBMITTED: YES Q NO[--][ FIXTURES'l 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/OILISAND SYSTEM ! r_. ! , _i ._ ( --,l — DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN -- { ---.._ ._..._..� ...___-._! _._._{ _[ I _....._� ._..___ .._._.._j .__.._...i 1 .__-.._I _____.3 _......._. r- FOOD DISPOSER __ i ._.o_1 ! E I FLOOR/AREADRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ( _ —1 -al- __.._._1 ___t ___.1 ( 1 -__ ROOF DRAIN SHOWER STALL SERVICE/MOP SINK __.I _____t' _.____I __! __.._ _{ _..__.M{ ..__J ..___..__i __► _-.._ _! ___! __- ! { `v TOILET ! f.._ _� —_I URINAL 1 ...._.__ t _ I ---_. { ..._._---t { 1 � ...._ F-7— ..-_. 1 .._..._.-1 W.' G MACHINE CONNECTION VFRI rr'HEATER ALL TYPES WATE,..PIPING OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO Q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY[2r OTHER TYPE OF INDEMNITY © BOND --I 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 �1 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 cyripliance wi II Pert'n t provision of the IMlassachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME A- Jb g-LICENSE# ./`S-yyI SIGNATURE mpI JP 0 CORPORATION RI PARTNERSHIPO# LLC D� & COMPANY NAME ��y¢," Fc. f ADDRESS - CITY ��t.cJ� — STATE ti� e ZIP d � � T FAX ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY p FINAL INSPECTION NOTES 1 Yes No .v e<11 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ r FEE: $ PERMIT# PLAN REVIEW NOTES r ' Date..............13�`. °................... r►ONTH OF .ao r�,tiQ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Ss�CHUS� This certifies that ...........M..................... 2v .......................... has permission for gas installation ....0 .......................................................r�-►�- in the buildings of..Jf .d1r��� .�cr at........ . .... .... . ...... . ..... ..a................, North Andover,Mass. Fee. .PLic. No. 2734 GASINSPECTOR Check# ,G U U62 a K, Ni - .A. '151-1 11t. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 4AJdtIr ►/ - __ MA DATE f 3 PERMIT# I U"J aoZ.ls JOBSITE ADDRESSTI� 9� '4TI�i�u�c ��,_ OWNER'S NAME ���'✓� �S�'Ia C��G � GOWNER ADDRESS _ _ TEL LSUFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:[Ef/'RENOVATION: REPLACEMENT:® PLANS SUBMITTED: YES 0 NO APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 1.3- 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 OTHER _ INSURANCE COVERAGE I have a current liability 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 0 OTHER TYPE INDEMNITY 0 BOND E 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 0 AGENT D SIGNATURE OF OWNER OR AGENT 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 nce with Pertinent pr ' ion of th Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME iii¢ Ycv LICENSE SIGNATURE MP 2MGF EjI JP D JGF LPGI© CORPORATION©# PARTNERSHIP[J#=LLC D#= COMPANY NAME: erL�L G8 9�-� ADDRESS �.✓���Gam. CITY �c.v�""ait/ - STATE,MZIP a�3 ��]TEL FAX C ,376� EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No iL THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES I The Commonwealth of Massa.chusetts Department of IndustrialAceldents r d 1 Congress Street,Suite 100 Boston,MA 021142017 SV,yWt www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERAUTTING AUTHORITY. Applicant Information // Please Print Legib Name(Business/Organization/Individual): Address:_/ i�c) L yv t�cL - City/State/Zip:,41e 77'Z A/ W '13"7 Phone#: d 3 Are you an employer?Check the appropriate box: r Type of project(required): 1.❑I a a employer with :.. : employees(full and/or part-time).* 7. El New construction [Zam a sole proprietor or partnership and have no employees working for me in $, E]Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10❑Building addition 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 11.❑Electrical repairs or additions proprietors with no employees. 12. 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.F1 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. i 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 state whether or not those entities have employees. If the sub-c6ri6ctors have employee's,'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. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: rA 0✓ �'e-,7 0 City/State/Zip: Attach a copy of the workers'compensation policy d claration 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 certi underChep s andPena res ofperjury that the information provided above is true and correct. Si nature: Date: Phone#: (ao 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#: r� i 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-contractors)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 M�1lONWEALTHOF MASSACHI#SETTS � • FOLLOWCNIG L10ER r ' A;:10URN 'fMANyPLtlMBER ,x BERUBE !N'¢ • xhd � ��,FS till/� AI] V ;— � Z � ° .COMMONWEALTH OFTr M`ASSAHl1SETT HOARA f) At ER ikN � CAS I tTS n ISSUES 'TNE F',bt _�0Wj1VG .V I dE,NSE 1 I CI<iVSn AS A MASTER C-6 M, l2rj 2e I LtNC{ LN Rp 3 � q Ew>oN$ k r mHaZ03858 3 03