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HomeMy WebLinkAboutMiscellaneous - 105 BERKELEY ROAD 4/30/2018Idd Date ... .-�.�.�%�� .l ................. OQ p►ORTH,�� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION A/�..J L`" /.�D-s 5���� gyp. Thiscertifies that......................:...�,-'�............................................................................. has permission for gas ins _ llation��!.. j....�........ in the buildings of ....... . v% �� ...................................................................................... at .............1G ..� 2 /gel P .North Andover, Mass. ...................................................... ,�I Fee .<...:`... Lic. No..7..3..............!�-' .................................................................... -1O^I l GAS INSPECTOR Check # 92g, 11 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �I V MA DATE PERMIT #� CITY I \�*. \�1N`�' JOBSITE ADDRESS OWNER'S NAME �- 1•� c+� C'� II _ ^� GOWNER ADDRESS TELC40S FAX[ ---- TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL'] CLEARLY NEW: ©. RENOVATION: [� REPLACEMENT: PLANS SUBMITTED: YES 0 NO _ APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER I+ . DRYER_-�- FIREPLACE - J Lam_ —� . FRYOLATOR- FURNACE 11� -_1 - _ T_z C— GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS I .. I MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER! ROOF TOP UNIT.- TEST UNIT HEATER UNVENTED ROOM HEATER�.a WATER HEATER OTHER �.r r INSURANCE COVERAGE r have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES _ NO �] IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF kvERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 801 OTHER TYPE INDEMNITY BOND E 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 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 accurat to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application wi compli c ' all PSIVnent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GAFITTER NAME _` ' `S L+ '��'* V`II LICENSE #`37.3, ,-.-� NATURE - - - MP [j MGJP Ej JGF 0 LPGI CORPORATION# PARTNERSHIP [3# LLC 0#_:_ COMPANY NAME. �����ADDRESS CITY STATE ZIP (©�01 _-TEL �'�`� �1a� L'�� 1 _ .. - F *;6 ` CEL _ $-yg MAIL 11 O z 0 H w a, w a z W } � W H a O c� w z r re Q w co a. o L w LU CO a a J H °- Q � U) S w H LL 00 H z O U W d` C7 D r The Commonwealth of Massachusetts - Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information c� Please Print Leuibly Name (Business/Organization/Individual): Address: City c -NS C) `lila-3 Phone #: re you an employer? Check the appropriate box: am a employer wish 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] f employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11. Ll Plumbing repairs or additions 2. El repair .%-- 13' ] Other *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. v 7 Homeowners who submit this affidavit indicating they are doing all work and then.hire outside contractors must submit a new affidavit indicating such. tContractors 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' co enation insurance for my employees. Below is thepolicy and job site information. �� `" GC t Insurance Company Name: _ Policy # or Self -ins. Lic. # `- G'Q LF7�s Expiration Dater l% v� Job Site Address:lis GCC ( `� City/State/Zi _1�"Mw lz�N 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 o. 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 liereb certi under the p . s�anen�al&sofperjury that the information provided above is true and correct Si ature: 1 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/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone r Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract ofhire,- express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two 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, numbers) 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. AIso 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 (ifnecessary) 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 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 ofMossachusetts Depattmiat of Industrial ,Accidents Office of Investigations 600 Washington, Street Boston, MA 02111 Tel. # 617-727-4900 mt 406 or 1-877rMASSAli'B Revised 5-26-05 Fax ## 617"727-7749 www.MQss.8oV/ is 01923-2 Date ....... r.. .. . r" .13 0'."DrM 1� TON O W;F NORTH ANDOVER p 'PERMIT FOR PLUMBING . _ • SS'qcHusE� This certifies that.c ...-r-•^.�'.►'�- rye �•v1�-u•�' ....... has permission to perform .............. .. � plumbing in the buildings of .......... ......... . at fes. ...... - ��-`-........ , North Andover, Mass. Feer00 ..... Lic. No..1`�tf ........... p -- PLUNBI UNSPECTOR Check # �- 7218 Mass. Date �`�i G 20 Permit # Building Location LiC r � Owner's Name A Type of Occupancy 1 / r . New ❑ Renovation 0 Replacemenm4— Plans Submitted: Yes 0 No 0 B.P. # SF=1i1/FR A FIXTURES R Installing Company Name Address_ Business Telephone ( �'jQ t{—jc Name of Licensed Plumber or Gas Fitter Check one: Certificate IJ--rporation Z- (vU(n ❑ Partnership 0 Firm/Co. I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch. 142. Yes 0 No 0 If you have checked Yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy 0 Other type of indemnity 0 Bond O OWNER'S INSURNACE 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. Signature of Owner or Owner's Agent Check one: Owner 0 Agent 0 hereby certify that all of the details and information I have submitted (or enter n abo application are true and accurate to the best of ny knowledge and that all plumbing work and installations performed under the per It ' ed for this application will c in compliance with ill pertinent provisions of the Massachusetts State Plumbing Code and Chapter 1�r eras Laws. By Title city'?own aPPROVC FFICE USE ONLY1 Signature O-Lie-erised Umber of License: O Master License Number =(G L.} ❑Journeyman • MM����� �a • ` i��� ��■��s�������M����r .. • i�Mi�s���■1�+� MMM ������� MM M M MM Installing Company Name Address_ Business Telephone ( �'jQ t{—jc Name of Licensed Plumber or Gas Fitter Check one: Certificate IJ--rporation Z- (vU(n ❑ Partnership 0 Firm/Co. I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch. 142. Yes 0 No 0 If you have checked Yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy 0 Other type of indemnity 0 Bond O OWNER'S INSURNACE 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. Signature of Owner or Owner's Agent Check one: Owner 0 Agent 0 hereby certify that all of the details and information I have submitted (or enter n abo application are true and accurate to the best of ny knowledge and that all plumbing work and installations performed under the per It ' ed for this application will c in compliance with ill pertinent provisions of the Massachusetts State Plumbing Code and Chapter 1�r eras Laws. By Title city'?own aPPROVC FFICE USE ONLY1 Signature O-Lie-erised Umber of License: O Master License Number =(G L.} ❑Journeyman No 4636 Of HORT,y 1M F P • oma+ _ , � 4 '4 n, n •�'�.t9 SSS SEc Date/:' ... ).... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ACH. This certifies that E .. .. G ...... ... • • • • S............ • • has permission to perform .. `. . plumbing in the buildings of .... . .. �.-. .............. at ...e.f? a .. !�.f� ! .� �` .7........... , North -Andover, Mass. Fee..? .... Li c. No. ..S .3 ........ ` . ......... . . PE"UMBING INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer I& - MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) Mass. Permit * 6 ✓ Building Location 1b-1) $erKl2u, -4 A- O er's Name Ayjt New ❑ Renovation ❑ —/Type of Occupancy �d Plans Submitted: Yes ❑ No ❑ B.F. 7 SEWER# FIXTURES SFPTTC; Installing. Company Name d I)e PI bn£ Z Check one: Address i 20 rn I tr - (D R Corporation P k� a -Y\ N►rti - c`� ISt 1-1 Ll ❑ Partnership - Business Telephone L9 75) 10% 's - !zv15 r5 3 ❑ Firm/Co. Name of Licensed Plumber C:2eOrg2 Certificate 17177 INSURANCE COV d I have aY usrrent bility Insurance No policy or its substantial equivalent which meets the requirements of MGL Ch. 142. If you have checked Les; p.1ease f tate the type coverage by checking the appropriate box. A liability Insurance policy Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by :hapter 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 AgentOwner El Agent El 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 nowtedge and that ail plumbing work and installations performed u der the permit issued for this application will be in compliance with all ,ertinent provisions of the Massachusetts State Plumbing Code apter 142 th enerai Laws. y itle Signature o sed Plumber " ity/Town Type of License: Master Journeyman C3 PPF?OYEp OFFI USE ONLY) License Number J Jr 9 Date ..................... HONTN TOWN OF NORTH ANDOVER .ao ,ti0 3� PERMIT FOR GAS INSTALLATION P iS 1 i • s SS/IC MUsE�IC`' This certifies that has permission for gas installation �: `...�.{.................. in the buildings of ....f .! ........:.......................... at North Andover, Mass. Fee... !..... Lic. No.... 1 ::.:. .......:............. -.. . GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MIN 4ASSACHUS= Wi IFORM APPUCATON FOR PERMIT TO DO or print) Date lvvK I H ANDOVER, MASSACHUSETTS j Building Locations ew Renovation ❑ Owner's Name Replacement © - �,dd1e-tom Plans Submitted �rinr or type) Check one: Ccrtifirtiue;lnstalling Company sm Andover Plbd. & Ht -g. Co. ■ Inc.Corp. ��I I ■ irYY.r address 20 Agean Dr.; Unit -10 ❑ Partner. Methuen. Ma. 01844 Business Telephone (978) 685-8383 ❑'Firm/Co ame of Licensed Plumber or Gas Fitter ; orge LaROce �,.��■. 4SL; R. -\NCE COVERAGE Check one - have a current liability Insurance policy or it's substantial equivalent. Yes No ! r you have checked yes, please I dicate the type coverage by checking the appropriate box. _i oiliry insurance policy Other type ❑ Bond `# p typ ❑ ,<> Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required. by Chi `9 ass. General Laws, and that my tignature on this permit application waives this requirement. Check one: Sienarure of Owner or Owner's Agent Owner ❑ Agent herebv cerzifv that all of the details and information 1 have submitted (or entered) in above application -0 rsr ui' my knowledge and that all plumbing work and installations performed under Permit Issued for tbtS;ap _ornpliance with all pertinent provisions of the Massachusetts State Gas Codd Chapter 143 of the GtnerW'l �a Title Ci wTjwn .-kPPR0 VE IoFFICF. USE ONLY) peer 1.42 of the . Dqd 3Ccumte to the �ition.will be in Iws. lgnature of Licens d Plumber Or Gas Fitter Plumber 9983" ❑ as Fitter License Number Taster ❑ Journeyman j z F z C w � . C ,n z it ti y n Z C R C C a aS z - — — - — — — U 0 •ElSE rt ENT t3:� SE.M ENT ,,^. .- . Is r. FLo0R 2NU. F L 0 0 R acr. 3,4. D- F L O U R .4 ?II. FL00R its .t S r 11 F L o o R t . 6T"11 FLU 0 R %T 11 FLo0R Y T I I F L 0 o R 777 7:, i �rinr or type) Check one: Ccrtifirtiue;lnstalling Company sm Andover Plbd. & Ht -g. Co. ■ Inc.Corp. ��I I ■ irYY.r address 20 Agean Dr.; Unit -10 ❑ Partner. Methuen. Ma. 01844 Business Telephone (978) 685-8383 ❑'Firm/Co ame of Licensed Plumber or Gas Fitter ; orge LaROce �,.��■. 4SL; R. -\NCE COVERAGE Check one - have a current liability Insurance policy or it's substantial equivalent. Yes No ! r you have checked yes, please I dicate the type coverage by checking the appropriate box. _i oiliry insurance policy Other type ❑ Bond `# p typ ❑ ,<> Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required. by Chi `9 ass. General Laws, and that my tignature on this permit application waives this requirement. Check one: Sienarure of Owner or Owner's Agent Owner ❑ Agent herebv cerzifv that all of the details and information 1 have submitted (or entered) in above application -0 rsr ui' my knowledge and that all plumbing work and installations performed under Permit Issued for tbtS;ap _ornpliance with all pertinent provisions of the Massachusetts State Gas Codd Chapter 143 of the GtnerW'l �a Title Ci wTjwn .-kPPR0 VE IoFFICF. USE ONLY) peer 1.42 of the . Dqd 3Ccumte to the �ition.will be in Iws. lgnature of Licens d Plumber Or Gas Fitter Plumber 9983" ❑ as Fitter License Number Taster ❑ Journeyman i'�v w> Date. ,%G� . �? % : G.4 ..... ,ORTIy TOWN OF NORTH ANDOVER • - , PERMIT FOR GAS INSTALLATION h 'tl,9SSAC NUSEtA This certifies that .. �//q t�. �! �. ...G .................. has permission for gas installation ...(� ,��,r... r.. f ........... in the buildings of ....................... at . �n.� �...�.!a l P �. <<......... „ orth Andover, Mass. Fee..?C>...... Lic. No.. '.:.. ��1 t �, ....... GAS INSPECTORY Check # 16L 3 4259 MCA SS OUP P MASSACHUSETTS UN In r jai 4 3-0 ..:F. IFORM APPLICATION FOR PERMIT TO DO GASFITTING New l-- Renovation ❑ Replacement ❑ Z Pe'rmit' # net's Napn e► Type of Occupancy ? �_ Plans Submitted: Yes❑ No ❑ Installing Company Name YANKEE GAS Check one: Certificate Address 140 SOUTH MAIN STREET ® Corporation 1 0 3 C MIDDLETON , MA 01949 ❑ Partnership Business Telephone 978-774-2760 O Firm/Co. Name of Ucensed Plumber or Gas Fitter WILLIAM R. HARRIS INSURANCE COVERAGE: 1 have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes X3 No O If you have checked Yes. please Indicate the type coverage by checking the appropriate box. A liability Insurance policy EX . Other type of Indemnity O Bond O 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: C+wnerO Agent O Signature of Owner or Owner's Agent 1 hereby certify that all of the details and information I have submitted (or entered) in above apprication are a and accurate to best o! my knowledge and that all plumbing work and installations performed under the permit Issu�Wrls his appli ' tl ' in li a with sit pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen. G/ / By - T of Ucense: Plumber Signature o um r or as Fitter Title Gasfitter 3785 Uc aster ense Number o City/Townc Jurneyman o u�RIY)-- ■��l��t�������■ MEN ■E■ you.. ■��������������������■ new Installing Company Name YANKEE GAS Check one: Certificate Address 140 SOUTH MAIN STREET ® Corporation 1 0 3 C MIDDLETON , MA 01949 ❑ Partnership Business Telephone 978-774-2760 O Firm/Co. Name of Ucensed Plumber or Gas Fitter WILLIAM R. HARRIS INSURANCE COVERAGE: 1 have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes X3 No O If you have checked Yes. please Indicate the type coverage by checking the appropriate box. A liability Insurance policy EX . Other type of Indemnity O Bond O 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: C+wnerO Agent O Signature of Owner or Owner's Agent 1 hereby certify that all of the details and information I have submitted (or entered) in above apprication are a and accurate to best o! my knowledge and that all plumbing work and installations performed under the permit Issu�Wrls his appli ' tl ' in li a with sit pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen. G/ / By - T of Ucense: Plumber Signature o um r or as Fitter Title Gasfitter 3785 Uc aster ense Number o City/Townc Jurneyman o u�RIY)--