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HomeMy WebLinkAboutMiscellaneous - 107 CAMPION ROAD 4/30/2018 107 CAMPION ROAD 2101062.0-0089-0000.0 it I i I Date.... / �� ................ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION `4'�CMUgg� Thiis certifies that .........................1 ! ....� 1. ........... ...................................... has permission for gas installation ..........r1. :.... -,,/�� - in the buildings of...............�...�1 v!1 at..., ' ..... ...........i b.,1...1�� ' ................. North Andover,Mass. Fee.. ..—... Lic. No. .:�;h ' ...... . ...................................................... 1��� L��( GAS INSPECTOR Check# T ce 2 5 a -` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK — 1. PERMIT# CITY - ¢ MA DATE1 JOBSITE ADDRESS Ute. OWNER'S NAME G OWNER ADDRESS �/7 X17 cf7 FAX TE TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:® REPLACEMENT:® PLANS SUBMITTED: YES D NO E APPLIANCES Z 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 � 1 DRYERS .e� __ _ _ FIREPLACE FRYOLATOR FURNACE GENERATORI_ GRILLE — INFRARED HEATER LABORATORY COCKS _ �, i _.._ _I , l _ _ r1 MAKEUP AIR UNIT [-- OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER [ UNVENTED ROOM HEATER WATER HEATER OTHER ................. ............... . .. ...... - 1 1 — — --- — - —---_-_J INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES)o NO 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW _y LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND Ej 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 6LMMPOR 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME �sr. se �a�4_ LICENSE MPV MGF Ej( JP[I JGF LPGI© CORPORATION Ej#[:=PARTNERSHIP®#L9 LLC®# COMPANY NAME: o,v��{. ti f _�f F��I iQ �ADDRESS6 CITY NP w1 _ _. `� STATE ZIP 11TEL FAX CELL _---EMAIL o ,,,� 1,� t'u _ ___ ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES � i } I r The Commonwealth of Massachusetts - Deparlment of IndustriglAccidents Office of Investigations 600 Washington Street .Boston,MA 02111 www.massgov/dia WorkeW Compensation Insurance Affidavit:Builders/Cont°actors/Electriciaans/Pliimber:s � Applicant Worm.ation Please Print Legibly Name(Businessiorganization/Individual): (�k/€ E t k Address: City/State/Zip: X)&/ . mss�e l 0?07 Q Phone#: G 0Y -,7;157 -g 1.9 7 Are you an employer?Check the appropriate box: Type of project(required): .1111 am a employer with 4. ❑ I am a general contractor and I 6. []New c6nstraction f employees(full.an.d/orpart-time)-* have hired the sub-contractors I am a sola proprietor or partner listed on the attached sheet: `7. ❑Remodeling ship and`have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. E]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its officers have exercised.therr 10.0 Electrical repairs or additions required.] ' 3.❑ I am.a homeowner doing all work right of exemption per MGL 11.❑k'lumbingxepairs or additions myself.[No workers'comp. c.152,§I(4),andwehaveno 12.❑Roofrepairs insurancerequired.)i employees.[No workers' 13.W Other ��S comp.insurance required.] IAny applicant that checks box#1 must also fill out the section beldw showing their workers'compensation policy information. i'Homeowners who submitthis affidavit indicatingthey Are doing allwork and then hire outside contractors must submit anew affidavit indicating such. rContractors that cheekthis box must attached an additional sheet showingthe name ofthe sub-contractors and their workers'comp.policy information. i ram an employer that isproviding workers'compensation insurance formy employees Bellow is the policy a�ecilob site information. Insurance Company Name% Policy#or Self ins.Lic.ff: Expiration Date: lob Site Address: City/State/Zip: Attach a copy of the workers'comp ensation.poliey declaration page(showing the policy number and expiration date). Failure to secure coverage•as xequiredunder 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 fnie of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert&under the pains and penalties o fperjury treat the information•provided above is truet. fand correct. - Sianature �� Date: —�� �'1 Phone 4: Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitJLicense 0 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 9: Information and Instructions Massachusetts General Taws chapter 152 requires an 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 oxwrittemll An employee is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a j oint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee ofau.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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have b eon 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)andphonenumber(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are notrequired to carry workers'compensation insurance. If an LLC or LLP does have employees,apolicy is.required. Be advised that this affidavit maybe submitted to the Department of hrdustrial 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 thepermit 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' compensationpolicy.,please call the Department at the number listed below. Self-insured companies should enter their selfinsurance 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 foryou 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 whichwill be used as a reference number. In addition,an applicant thatmust 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 towb)."A:copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit-ii 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 ox permit not related to any business or commercial venture (i.e.a dog license orpermit 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: Tho CQmmoa.w.ealtlh,of M ssa.,c�hvsett - Department QfJadustdal AceldontE ofte OffAvestigAti ate. 6bQ Wasllagtm Sireot Boston,MA p21,X 1. T01 617-7-2-.7-49-00-4.9-40 oxt 406 Qx 1-8,77-MASS.AF,E - Revised 5-26-05 Fax#617-727-7749 �.z�ass,gov�clia e i i • I LHU r S F I TTERS # A A PLU" ,.R TRE BL y 256 ( `, E 1 NEW,.. "66TONNH 03070 t ,. 2 60� '` ` ! � ,A JOUR R' PLUMBER R €RdLA . 25 T � RPO IN I I TOINNNOF NORTHANDOVER kORTH rice of the Building Department 0 Caffipfe&P fatunity Developmentand Services 27 Charles Street North Ando)�er. Mas±achuscfls 01845 SA USEt )7Q) D. Robert Niceit,-i, t.!1. ;'." GS5 t J -I 1311ildin-Commissioner EAX(97ti)OB'-9542 April 14, 2003 Fulcrum Inc. Architects 22 Lafayette Road, Salisbury, MA 01952 Attn-. Darlene Whitmore Intern Architect Dear Ms. Whitmore: I am in receipt of your letter of 4/10/03 in regards to the parcel of land located on lot 12A. Please be advised that the subdivision has been completed for some time and that the protection of the lot is no longer available. This department will need a certified proposed plot plan showing where the structure is to be located as well as a building permit application in order to ascertain how to proceed with this project. Please be aware that it will require Zoning Board of Appeals approval, which is approximately a 3-month process. Should you have any further questions please do not hesitate to contact me during my office hours of 830 — 10-00 AM at 978-688-9545. Respectfully, Michael McGuire Local Building Inspector April 10, 2003 RECEIVED Fulcrum, Inc. Michael McGuinn A R C H I T E C T S Building Inspector APR 1 1 2003 27 Charles Street BUILDING DEPT. No. Andover, MA 01845 Dear Mike, I've enclosed a copy of the site plan for the property our client, James Saragas, purchased last year with intentions of building a single family home on. As I mentioned in our conversation today the subdivision on this lot was recorded in 1986. Could you please review the site (Lot 12A) and provide me with suggestions as to what actions we need to take in order for Mr. Saragas to build a home on his property. If you have any questions please feel free to contact me. Thank you. Regards, foo PA Darlene R. Whitmore Z Intern Architect X60 Cc: Plan of land by: Christiansen Engineering, Inc. 22 Lafayette Road, Salisbury, MA 01952 Tel. (978) 462-5151 Fax (978) 462-5518 April 10, 2003 A, I RECEIVED Fulcrum, Inc. Michael McGuinn A R C H I T E C T S Building Inspector APR 1 1 2003 27 Charles Street BUILDING DEPT. No. Andover, MA 01845 Dear Mike, I've enclosed a copy of the site plan for the property our client, James Saragas, purchased last year with intentions of building a single family home on. As mentioned in our conversation today the subdivision on this lot was recorded in 1986. Could you please review the site (Lot 12A) and provide me with suggestions as to what actions we need to take in order for Mr. Saragas to build a home on his property. If you have any questions please feel free to contact me. Thank you. Regards, Darlene R. Whitmore Intern Architect Cc: Plan of land by: Christiansen Engineering, Inc. 22 Lafayette Road, Salisbury, MA 01952 Tel. (978) 462-5151 Fax (978) 462-5518 Darlene R. Whitmore FULCRUM, INC. Intern Architect ARCHITECTS 22 LAFAYETTE ROAD SALISBURY,MA 01952 Tel. (978)462-5151 Fax (978)462-5518