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HomeMy WebLinkAboutMiscellaneous - 110 MILLPOND 4/30/2018 110 MILLPOND 210/095.A-0110-0000.0 Date. 50� q. HORTp 3?0;<� •°„•.1�ooL TOWN OF NORTH ANDOVER .r” PERMIT FOR P,LUMBIN;O �SSwl USES ID This certifies that . . . t .P .S . . . .1.y. . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . at . . . . . J . . . . . . . . . . . . . . . . . . . .Nort h Andover, Mass. Fee. 3 Lic. No.I.Q.` ' y 7 . . . . . . . LJ LU WING INSPIrCTOR Check # i 8664 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Building Location /V Permit# P G 1 y / � Amount Owner �iN j Gi 4Zal L- ' New Renovation Replacement ® Plans Submitted Yes No FIXTURES rr S[B•>hNIC ]ST IIOfR 2%F OCR X i 3t EWW 4IH EWM 6MROM 7IH ELOOR SIH mm 7H— I I I (Print or type) Check one: Certificate Installing Company Name , 0.Corp Address Partner. Business Telephone /00S :2-31-/ 00 r? 9 Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond a Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance iSignature Owner Age ❑ I 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 knowledge and that all plumbing work and insta performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus=Pl in ode and 2 of the General Laws. i By. rgna o rcens Title Type of Plumbing License - City/Town rcense umoer Master Journeyman ❑ APPROVED toFcs um oN,y 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 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. Howevef 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)mame(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 lie 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 j 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 homeowner 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. 1 The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investibafions 600 Washington Street Boston,MA 02111 + Tel. # 617-72.7-4900 ext 406 or 1-877-MASSA-FE 1Fax#617-727-7749 Revised 5-26-05 ur rv,.mass..aovfdia Date. . '. . .... . fR f ,aOttTM 1 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION . y �9SSACMUSE�t This certifies that . . .P.T>_.S . . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . .P.Al . . . . . . . . . ... . . . in the buildings of . . .# 69./�N!.f . . . . . . at . . . . : .t. . . . . `t. . . . . . . . .tt, North Andover, Mass. Fee. Lic. No.. ?. . . . . !�. . �?. . . . . . . 'GAS INSPECTOR Check# 647 MASSACHUSETTS UNH ORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date �� Q NORTH AND,/ { OVER,MASSACHUSETTS Building Legations //0/0 / , r Z/ Oit)Al_l Permit# 73 7.ri — Owner's Name Amount$ g e New 0 Renovation D Replacement D Plans Submitted ❑ Ed ' vizw a ai w w � O a C z U w x Z E. a C C > w w v, x a a w r1 w N O F• z d a F ; o > k. F u w 0 >o x (A z 3 0 a ° m > c SU B-BASEM ENT BASEMENT IST. FLOOR 2ND. FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type)A0Check one: Certificate Installing Company Name 1JS / 0 Corp. Address L 13 Partner. Businessa ep one p Firm/Co. Name of Licensed Plumber'or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance,policy or it's substantial equivalent. Yes �� No If you have checked Les,please indicate the type coverage by checking the appropriate box. Liability insurance policy © Other type of ind emni ty D Bond ❑ Owner's Insurance Waiver: 1 am aware that the licensee does not have e Insurance i Mass. General Laws,and that my signature on this permit application waives es this requirement.e required by Chapter 142 of the Check one: Signature of Owner or Owner's Agent Owner Agent 13i 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 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 Massachuse to Gas Code Chapt!y 42 of the General Laws. By: Signature of Licensed Plumber Or Gas Fitter Title �Plumber City/Town, ❑ Gas Fitter Licehse Number ' M b ster _ APPROVED(OFF)CE USE ONLY) ❑ Journeyman MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) �t�J NO.ANDOVER ,MA Mass. Date �y7 : ig Permit # 20 92 a Building Location ��MILLPOND Owner's Name em:�gz NO.ANDOVER, MA Type of Occupancy ' RES New ® Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑ V2 Q11 N V. Q N {/f 0 U H ¢ v1 = O O N } W LU a: O U N J G a LU1-' .( >- 2 L .O t"" W `t m N F' y w o O a. c .f �.. w < . F- w > W ... � -j 2 � = x v '< w U y ¢ W W p > U. P J G W O WC < W > S W = 2 1 -K O O W a' 0 ' o v U_ 3 0 0 -j U c > a a F- o SUB—BSMT. BASEMENT J I 1ST FLOOR 2ND FLOOR . I 3RD FLOOR 4TH FLOOR I I I STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name CALLAHAN AIR CONDITIONING Check one: Certificate u Address 91 BELMONT STREET C3 Corporation NO.ANDOVER,MA. 01845 ❑ Partnership Business Telephone 508-689-9233 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter JOSEPH KEVIN CALLAHAN INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142- Yes 42Yes ? No ❑ If you have checked Les, please Indicate the type coverage by checking the appropriate box. A Ilablltty Insurance policy JD 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent C3Signature of Owner or Owner's Agent I hereby certlfy that all of the details and information I have submitted (or entered) In ove appricallon are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the permit sued for this appllcaU will b In pflance with all pertinent provisions of the Massachusetts Stale Gas Code and Chapter 142 of the neral law lay T e of Ucense: Plumber gnatur o c nse um a —or—G-537, ter I Title sriller aster Ucense Number M-3440 City/Town Journeyman APPfX)W-..D (OF FICp . ,w t • T � 2492 Date..l31� ofT40RT#q ,ti TOWN OF NORTH ANDOVER 00_ ' �;, PERMIT FOR GAS INSTALLATION • S • g SL �9SSACHUSESt 1 7 This certifies that . . . . . . . . . . CU. -has permission for gas installation . . . ... . . .. . . . . . . in the buildings of . . b .? . . . . . . . : . . . . . . . . . . . . . . . . . . . . .. . at . . . . . . . . . .. North Andover, Mass. Fee.zq: :`: . . Lic. No:3:5'. !! . . . GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD:File 1 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITCIN' G 1 (Print or Type) NORTH ANDOVER Mass. Date Building Location //'(, ( � f �j 6�✓ 4� Permit # 2 (j O 3 A Owners NameC-,&AZ 0—Ox New '—? Renovation II Replacement Plans Submitted D '� S FTx--�►�__c Uj LU s QV u1 N 14G1c of 0 UA Cl of C .Q Q to t— i tL Muyi ` -C Uj Ul t] Q d w 4 t— N � o! W C ut w 1 < e x w f. w w a U- t-- a- w a m e e _ r }- N to — o UA Q us % C O t 3 o f V c4 y G Qa� hW-� O I stl$—as7.1T. BASEMEXT I -IST FLOOR 2*40 FLOOR j 3RII FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR TTI{ FLOOR aTK FLOOR (Print or Type) Check one: Certificate Installing Company Name ,�¢ Q OCI�'l6!f/� Q Corp. Address / /� �4-D ��ii�� t�-- Partner. �y !-�/ � /4 °° 1-1 Firm/Co. Business Telephone: 3 Name of Licensed Plumber or Gas Fitter Insurance Coverace: Indicate .he type o: insurance coverage by checking the appropriate box: Liability insurance policyOuter type o; indemnity = Bond Insurance Waiver: I , the ur.dersicned, have been made aware that the licensee of this application does not have any one of thle above three insurance coverages. Signature of owner/agent of property Owner = Agent Q f hcteby certify that all of the details and informadon 14ave submitted (or catered)in al•ove appGeation ate trite and accurate to the best of my &aowtcdse and that *U phurtbin; work and LnswuLions 7=.orned under P-..rt-it i=zd rot this appiiation will be in eomplimce with all pertinent provisions of the WAssachuietts State Cas Cade and(Lapter Ia.of tie Ccac:F Ltwa. 3v LICIENS�. )� Tiumber Ti Si ature of License Title ,��slitter g C-ty/Tcwns I Master Plumbex or Gasfitter urzevman �/ APPROVED (OFFtcE USE ONLY) License Number TpDate:.. 2150 CP cF 40 DT e 'HO TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 5 ghis certifies that . .#,�?/.qA V �� !. f .n. . . .. . . . . . . kas permission for gas installation . . F(�.Rj z.A . . . . . . . ii$the buildings of . . .4.7C. . . . . . . . . . . . . . . . . . . . at. ./�/�`? ,�!ti.! .f. .��o!-�. . . . . , North'Andover,'_Mass. '. Fee. .;.-S, Lic. . . . . . . . . GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK;.Treasurer GOLD:File