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HomeMy WebLinkAboutMiscellaneous - 11 PUTNAM ROAD 4/30/2018 11 PUTNAM ROAD 210/016.0-0027-0000.0 1 Date. . ././zS .... . ... NORTH Of � °.,4, or M TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION • o� i SAC14U5ES h This certifies that . . l'�'l. �'!1. .Ac /7�;F>�h _ ,r has permission for gas i stall t, . . . . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at Fee�,9:OC?. Lic. No./�7Z/Z: . GAS INSPECTOR Check# 00 8261 b MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY NORTH ANDOVER a MA DATE 7/25/2012 PERMIT# N Y JOBSITE ADDRESS PUTNAM OWNER'SNAME ROSSETT . TOWNER ADDRESS _ TEI�a _ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL ! PRINT CLEARLY NEW:E11 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 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 } f DRYER ,,,,r.� 'i ..,., r FIREPLACE FRYOLATOR I _ _FURNACE GENERATOR wj GRILLE 1a � _.. INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT ._..nn.... OVEN POOL HEATER ' ROOM I SPACE HEATER I „ . ._ � iw _ ROOF TOP UNIT :_ J I t 1 I TEST _ _ 3 :. w UNIT HEATER I UNVENTED ROOM HEATER _ i I WATER HEATER Wi $ 'i: I __�. .. i OTHER 1 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 Dv 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER [,—_] AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and pate to the best of my knowledge and that all plumbing work and installations perforated under the permit issued for this application will be in complianc all Pejdnent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME JEFF HUTNICK yiz LICENSE# 15212 SIGN RE MP[:11 MGF 0 JP 7 JGF -] LPGI Ej CORPORATION[.,]# 2840 PARTNERSHIPEI#= LLC 0#= COMPANY NAME: CAL�LAHANAC&HTG ADDRESS[19j BELMONT ST CITY NORTH ANDOVER STATEMA ZIP 01845 STEL978 986 9233 FAX CELL[,,. EMAILi PLUMBING@CALLAHANAC COM _ ��/,z Y Z_\= 2lie COinrnonweahh o Massach .�� artmerit o r De a,�;==— ,-•ice--•=,� P flrZd"strialAeciclents Office oflrrvesti ations •60.19Washington Street 460st0n,MA 0211.1 Wuri:t:z-s' �oxupens A } Jlicant lnforniatiarafiozInsuraaceAffidavit: Bu;fde s/Conlr;c$yz�slElcctz.icia ,s/ls luirbcrs i;, �'►eas:�1't•ltlt �,c Jil,ly, 1\.;I11E' (I3usinessiUr�,tu�ization/Individual): '� //All i A,idress: -7t cf� Cit)'/State./L --------- _ -- ��`� fr 'hone Are you au employer'? Check, flat appropriate box:Lrtq a employer with ,,?5- 4. ❑ I am a general contractor and 1 l ype of1"odeci('e4it'i''eci): loyees (full and/or pari-tune).* have hired the sub-contractors 6. ❑ NCW corrstiui tropa sole proprietor or partner- listed on the attached sheet. 7. ❑and have no employeesThese sub-contractors have ing for rue irl any capacity. employees and have workers' b' ❑Demolitionorkers' comp, insurance comp. insurance,$ 9. ❑ Building additioned j 5. ❑ We are a corporation and its10.[] Electrical repau's in'addiuous a homeowner doing all workofficers have exercised their'f. [No workers' corp, ght of exemption perIv1GL 11. 1 lumbin,i e airs or additions ri b' ' P'rice required.] tc. 152, §1(4),and we have no 12.❑ Roofrepaiis employees. [No workers' 13.❑ Other ._ comp. insurance required.] --- -------- rNli�attt that checks boa#1 must also fill out tlae section below showing their workers'compensation policy iuiormaliun. T i Coraco Hers who submit this affidavit indicath19 they are doing all work and then hire outside contractors must submit anew z�onnactors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those jidic li It the sub-contractors have employees,the must Provide their workers'co affidavit indicating such. Y P hdvc i araC an errTployer that isproviding workers'compensation insurance for my errtplayees. l;elow is fire it fOrrnauolz policy urttljub site ln,uralce Company'Name: ��^c. _ C. t Gz:_r^Q� Polic)• ;'r or Self-ills. Lic. #: / ------- Expiration Date: Job Site Address: — Aitach a copy of the workers, counPensation policy declaration page City/State/Zip:_ Failure to sectn-e coverave P g {showing the policy nuniber and expiration date). ttrie u to 0 as required under Section 25A of MGL c. 152 can lead to the imposition of erinni.na.l penalries of a 1� $1,500.00 and/or One-year if u to ,2" y mlprisonnnen i as well as civil penalties in the form of a STOE WORK ORDER grid a fine P 00.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office o nvestigations of the DIA for insurance coverage verification. f :lo hereby certify under the pains and penalties o er ur that the in ormatio fp y f n provided above is-true and correct. i«rtarure- Y:• i �, r2 7—�G' trot Dat, /~. Uificia!use only. Do,lot r�,rite in this urea, to be completed by city or town o iciaL City or Towit: Issuing Authori Permit/Li�ense tk 1• Eoard ofrlea 4(2.Build ng p 6. Other lle ai tnzent 3. City/Towu Clerk 4.Electrical inspector 5. i'luraabinr liispector Co.utact Yersou: Phone#: Date.. . .!. . �.�.? MORTM 3� TOWN OF NORTH ANDOVER • - PERMIT FOR GAS INSTALLATION s • SACMUSE�� This certifies that . .!``. . . . .E. . . . . . . . ....e. . . :. . . . . . . . . . j has permission for gas installation . . �! :7� . . k.e t4; " in the buildings of . ! 0,5 .?. .irk. . . . . . . . . . . . . . . . . . . . . . . . ' f f�T V11 v► ✓+�- at . . . . . . . . . . . . . . . . . . . . . . . . . ., North Andover, Mass. Fee. .a.5�!4!4 Lic. No.. . 7-0 . . . . . . . . . . . . . . . . . . . . . . . . . . GASINSPECTOR Check# / 67 / 6036 MASSACHUSETTS UNIFORM APPUCATON ICORPERwrToDoGAsffrnNG (Type or print) Date (y /���'� NORTH ANDOVER,MASSACHUSETTS Building Locations t111U ru U PL4- Permit# Owner's ount$ Na-me!��� � �.. 1 t New D Renovation D Replacement Plans Submitted D R � z �" H Z w w U W Z > d C7 F Z F d x W a W a w F x x 0 Z 0 Z F W C� O �a x o x 3 0 U a > SUB-BASEMENT BASEM ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type) p Che k one: Certificate Installing Com an Name 5. le i -e f g P Y _ ^� � Corp. Address �7� �J L) K f~` Partner. Business Telephone Firm/Co. .Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: 1 have a current liability Insurance policy or it's substantial equivalent. YesIZ_ NoO If you have checked Yes,please indic to the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 1:1 Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. ,. Check one: Signature of Owner or Owner's Agent Owner 13 Agent I hereby certify that all of the details and information I have submitted(or entered)in above application 13 are true and accurate to the best of my knowledge and that all plumbing work and i ations p ormed under Permit Issued for this application will be in compliance with all pertinent provisions of the Mass huse State as Code and Chapter 142 of the General Laws. By: Signature of License Plumber Or Gas Fitter Title 0-11-lumber City/Town Gas Fitter �� t...�,' � ' ���� �C ��umoer ©Paster APPROVED(OFFICE USE ONLY) Journeyman