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HomeMy WebLinkAboutMiscellaneous - 1011 OSGOOD STREET 4/30/2018`' :AO Date" ? ! n 9359 TOWN OF NORTH ANDOVER ' PERMIT FOR PLUMBING `14�sAtMUss- t This certifies that.': `.. C) .. . has permission to perform T. !�� �- f..."L�4................ . plumbing in the buildingsof�^�........ . ............ . Sk at ... + O ... �....�., ... North Andover,Mass. Fee �j1. . Lic. No- Olt .,. .... PLUMBI d INSPECTOR Check # r_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK. - = CITY MA DATE ] PERMIT# JOB81TE ADDRESS !. I m 1 t C`� S�j Oo c� 1 OWNER'S NAME p OWNERAI)DRESS Ss TEL .F.... ! TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ~ RESIDENTIAL I J PRINT CLEARLY NEIN:(„.,. RENOVATION:(,. ' .REPLACEMENT:[., J PIANS SUBMITTED: YES(J NO]"'I FIXE UREB I FLOOR— BSM 1 2 3 7 8 9. 10 It 92 13 14 BATHTUB CROSS CONNECTION DEVICEDEDICATED SPECIALWASTE SYSTEM'DEDICATED GASIOIUSAND SYSTEMOEDICATEO GREASE SYSTEM j ff46 I _-DEDICATED GRAY WATER SYSTEFd DEDICATED WATER RECYCLE SYSTEM DISHWASHERIDRINKING FOUNTAINFOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY I I i _ I ,"�_ ROOF DRAIN_$ ..1 .. I I I SHOWER STALL I ... SERVICEIMOPSINK _ ,. TOILET • I URINAL I I'- ... ,: x- .. :. _ I I I i I WASHING MACHINE CONNECTION �- + I ., WATER HEATER ALL TYPES EI l i -.-- WATER PIPING OTHER INSURANCE COVERAGE: I have a current liabilit. iiisuratice policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY AOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the'insurance coverage required by Chapter142 of the Massachusetts General Laws, and that my signature on this pennit application waives this requiretitent. CHECK ONE ONLY: OWNER I J AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding Misapplication are true and accurate to the best of my knowledge and that all plumbing work and lnstaflations performed under the permit issued for this application,60 be i='vAlli all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME j' A 1 G A-6 LICENSE 11 / 36 j SIGNATURE MPOI JP I' I CORPORATION( }#! JPARTNERSHIPJ 4#j LLC( COMPANY NAME KAI &*&Ar., Q1. ADDRESS CITY STATEAl IA ZIP Oft; Ll... f TEL - _. ...... I I � _ I [ .Sri 2 FAX I CELLI I EMAIL , * - ' � J- - - - - - 00 04 Ls- tw ,Y YOC-0iilrnItof `h�ak""Ursa! XI�*Odljleritoflitthish- alAccideks �tt�nitEl�tfouunfidit 3'le s1�-�:L'� i�F:L -' T. 1: ! iiyylttl��[3tE$uta�OigAiii2�tionrludividual}:, 4�lyFl�t�ifgfZjit . • • 1'h0ilt lle • _ • .. 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Y.Z.:7.1.2. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......... ....... has permission to perform ......... Z�: nv'00 ......................................... wiring in the building of T.7R. 1.. J.i M-:!. a ......../11.0..--/.....6/.e......... ...../oz.1 ... LI, lf'ao ...... S.:7 ....................... North Andover, Mass. Fee ./14.—=�'.�'..'. Lic. No..iPIL:�k&l ...... ...... Check 4t ) 6 c2— 10751 it commonwealth of Massachusettts a Department of Fire Servlces BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. ) �O -7,-S—/ c Occupancy and Fee Checked [Rev. 1/071(leave blank APPLICATION FOR'PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEA SEPRINT) N NK OR TYPEALL INFORMATION) Date: �J Z - /a City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her into tion to perform the electrical work described below. Location (Street & Number), Owner or Tenant (� (i( 10 a e— (� G Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service _Amps 12-0 /29 Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 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: 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 ' surance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ° BOND ❑ OTHER ❑ (Specify:) Icertify, under the gins an enaldes o perjjury, that the informati�r: on this application is true and corpl'eie. FIIt1Y[N L°6�% e� -�;q. / dervl 496 LTC. NO.:Z�? Ar Licensee: Signature r fapplicabe, enter `exemZ LIC. NO.: p ) No: c—'Address: 42: 49117 y%- Bus. Tel. .0 6 'Per M.G.L c. 147, s. 57-61, security work requires Department ofPublic Safety "S" License: Alt. 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 Signature Telephone No. PERMIT FEE: $ Com letion o the ollowin table ?nay be walvedby the fns ector o Wires. d Luminaires No. of Cell: Susp. (Paddle) Fans No. of Total Transformers RVA ire Outlets FefLuminaires No. of Hot Tubs Generators KVA Swimming Pool Above ❑ In- rnd. rnd. ❑ o. o Emergency Lighting Bane Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No, of Zones No. of Switches No. of Gas Burners No. ofD nti Devices No. of Ranges No. of Air Cond. Total Toms No. of Alerting Devices g No. of Waste Disposers Heat Pump Number Totals: Tons _ KW _ No. of Self -Contained "" Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers No. of Waterof eaters KW Heating Appliances Xy No. Signs Ballasts NO- of Security Systems:X• No. of Devices or E uivalent Data Wiring: No. of Devices orEquivalent No. Hydromassage Bathtubs No. of Motors Total HP "Telecommunications i Telecommunications Wiring: 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: 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 ' surance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ° BOND ❑ OTHER ❑ (Specify:) Icertify, under the gins an enaldes o perjjury, that the informati�r: on this application is true and corpl'eie. FIIt1Y[N L°6�% e� -�;q. / dervl 496 LTC. NO.:Z�? Ar Licensee: Signature r fapplicabe, enter `exemZ LIC. NO.: p ) No: c—'Address: 42: 49117 y%- Bus. Tel. .0 6 'Per M.G.L c. 147, s. 57-61, security work requires Department ofPublic Safety "S" License: Alt. 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 Signature Telephone No. PERMIT FEE: $ pka:ssed --ectors' comments: . (luspectors'signaiuxe-.uo initials) Data 4. )NSpECTxoN—SEBWCE: -Vassed-- [ x +'ailed— j I-ae-inspectiottxequired ($50.00) •• ( ) Inspectbrscornmeph: {.iuspectors' Signature .. Bio initials) Date 'assed �- [) �'silecl-- [ )_ ' Ite inspection required ($50.00) � [ � lspectoxs' coazm.enfs: ' f1Lspeeioxs' ignaiare uoxni a7s) Date DOOR TAGS ARE TO BEFILLED MIJ AM LEFT OST RU E IF TM AMA. TO BE INSPEOWD IS.WOT AiC'rt1-sVOMMY. . AWD A '010rnw orn nn roW-1I ew fT"AT)r-lV" . The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/ContractorsAElectricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individal):( � r// (c ,p -pr Address: `- o u City/State/ZipJ-1# © 6 � I Phone #: Are ou an employer? Check the appropriate box: Type of project (required): 1. M I am a employer with _� 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors 7• ❑ Remodeling 2. ❑ I_ am a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10. ❑Electrical repairs or additions required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] f employees. [No workers' 13. [i Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: F Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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. Ido hereby ceribli under thepains andpenalties ofperjury that the information provided above is true and correct. L Signature: �g Date: Z � ` � l Phone #: L '7 _ /7 Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitUcense # 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 bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth o(Massachusetts Department of Industrial Accidents Office of IavestigatIM' s 600 Washington Street Boston., MA 02111 TO, # 617-727-4900 ext 406 or 1-877rMASSAFE Revised 5-26-05 Fax # 617-727-7749 www mass,govfdia Date ORr#1 TOWN OF NORTH ANDOVER .10 PERMIT FOR PLUMBING This certifies that ....�z'9. . '/ has permission to perform ... ............................. plumbing in thebuildingsof . ................... . at. ....... � .............. North Andover, Mass. Fee. .... Lic. No.. ... ........ PLIU*MBING INSPECTOR Check # 864 4 FIXTI IRFC MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: MA. Date:_1®'�'-Ug Permit# 7e Y Building Location: /d61 OSgeocl S4 Owners Name:—3.141y I Type of Occupancy: Commercial X Educational ❑ Industrial ❑ Institutional ❑ Residential ❑ New: ❑ Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTI IRFC INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy W Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only ❑ Signature of Owner or Owner's Agent Owner ❑ 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 n1jumeuye anu mat au pwmomg worK ana installations pertormed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title ❑ Plumber Sigg ature of Licensed Plumber City/Town ® Master / ? / c� APPROVED OFFICE USE ONLY ❑Journeyman License Number: ✓(0 6 Q Z CO Z O C N Y Q �' J J U U W (' CL to z W ~ W H N Q N Q 0 � �� = N w Q a o W Q N 0 Q.� Y to z W� D_ X O wUi-=4° = W U Z Q U. Jto YO Z WWW Q Q D U) Q O a s°=°aZNc� O Q Hv H Q Q Q m m o LL 0 2 Y J J Q' fq fn E- O SUB BSMT. BASEMENT ! l 1 FLOOR --i 'FLOOR 3HuFLOOR 4 1 H FLOOR 5 FLOOR 6 1 H FLOOR 7TF FLOOR 8 FLOOR Installing Company Name: l � Qt< VAA,IA 2- Check One Only Certificate # Address: &d &Y doo City/Town:- State: A ❑ Corporation Zip Code:® E] Partnership Business Tel: 3 3 Cell: Fax: Firm/Company Name of Licensed Plumber: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy W Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only ❑ Signature of Owner or Owner's Agent Owner ❑ 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 n1jumeuye anu mat au pwmomg worK ana installations pertormed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title ❑ Plumber Sigg ature of Licensed Plumber City/Town ® Master / ? / c� APPROVED OFFICE USE ONLY ❑Journeyman License Number: ✓(0 6 Q This certifies that. ...- u `,�k✓..... . has permission for gas installation.:!`-............... in the buildings of ..................... . at G�� ,North Andover, Mass. Fee.... Lic. No/A --G''-=r'........ GA�S'1NSPLECT Check # e1a f/ 6187 el /�.-�a ... Date. .- . . TOWN OF NOMA ANDOVER PERMIT FOR GAS INSTALLATION This certifies that. ...- u `,�k✓..... . has permission for gas installation.:!`-............... in the buildings of ..................... . at G�� ,North Andover, Mass. Fee.... Lic. No/A --G''-=r'........ GA�S'1NSPLECT Check # e1a f/ 6187 MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date / Q -- t"8" —p `,;2 Building Locations /0/,,- Permit # f , rn m ,P 2 e k� Owner's Name Amount $ � 110 4"1 . �'/z ►mss o New Renovation ❑ Replacement ❑ Plans Submitted ❑ (Print or type) � / C Name may_' C Address Check one: Certificate Installing Company D Corp. ❑ Partner. ® Firm/Co. INSURANCE COVERAGE Check one: 1 have a current liability Insurance' policy or it's substantial equivalent. Yes M No❑ If you have checked Yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy ® Other type of indemnity ❑ Bond ❑ 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. Check ;one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I herehv certifv thnt all —A kv, c„�c,oup ,n aoove appucation 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 tas e and �apter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber ❑ Gas Fitter License Number ❑ Master 13 Journeyman x w a & c a Gq E, OC O O O p zCLI E, w rAG OF z x W w U x C7F F Z oC F" W �- Cw7 y a07 Z O w Z w 14 O � CYr T. � O > o a vFi F O SU B-BASEM ENT BASEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type) � / C Name may_' C Address Check one: Certificate Installing Company D Corp. ❑ Partner. ® Firm/Co. INSURANCE COVERAGE Check one: 1 have a current liability Insurance' policy or it's substantial equivalent. Yes M No❑ If you have checked Yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy ® Other type of indemnity ❑ Bond ❑ 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. Check ;one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I herehv certifv thnt all —A kv, c„�c,oup ,n aoove appucation 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 tas e and �apter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber ❑ Gas Fitter License Number ❑ Master 13 Journeyman