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HomeMy WebLinkAboutMiscellaneous - 1115 OSGOOD STREET 4/30/2018 BUILDING FILE r i E 1. Date. P. Z.3� 40°7:�tio TOWN OF NORTH ANDOVER 3: ++,, o� m PERMIT FOR PLUMBING SSAemus� �6� 5 /i c., �< This certifies that . . . . . . . . ./ . . . .c1 . . . . . . . . . . . . . . . . . . . has permission to perform . . . . �' �.`'. I'll , ' . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . at. . . . .l�.s. . .G , North Andover, Mass. ,c Fee. .Lic. No.. . . . . . . . . . . . . . PLUMBING INSPECTOR Check # a MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASS�A,CHUSETTS Building Location 1 I I ©` fJ /(ft �- Date Z tJ /O Permit# x&o Owner ".v ROL, Amount New rj Renovation Replacement ®/� Plans Submitted Yes No FIXTURES W. r S[B-lI� a�vnvl' M ELOCR PM EWE 3MEWM 4MIIOCR 5MROM 6IH EWM MHEM SIH IIOQt (Print or type) Check one: Certificate Installing Company Name CGS s /�/}�J { 111L�1 Ili al q ❑ Corp. Address aff�� �S o koPckVS Ifs Partner. Business Telephone 9 7X,R�T7 ,-(ed(3 � Firm/Co. Name of Licensed Plumber: C Ctp.tk k l e C skS'�t'�&j Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy �%]/ Other type of indemnity 0 Bond ❑ 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 Signature Owner Agent 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 installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By: Signature of LicensM.Plumber Type of Plumbing License Title /e a ? 7 APPROVED(OFFICE USE ONLY ` — City/ icense er Master [D,--Joumeyman [D The Commonwealth of Massachusetts Department of fndustrial Accidents Office of investigations UT 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ---{s'TS r4 Address:_ � City/State/Zip:_8e KQ,®AA 4464 C J q 2( Phone#: 17r,--FeZ• Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and I employees(full and/o5za -time).* have hired the sub-contractors 6. E]New construction 2. am a sole proprietor or partner- listed on the attached sheet. 1 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. • o workers' comp. insurance 5. 9. Building addition � p. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 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.] t employees. [No workers' comp.insurance required.] 13.0 Other "°II3'applicant that checks box.ril must also I'M out the section be,'ow shei L-g T.^A,-wOrren!comp--sat.; i-� information. rte-- y�.:..j'�- atiOII. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub contractors and their workers'comp,polity information. I am an employer that is providing workerscompensation 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: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under 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. I do hereby cerci der the pains and penalties of perjury that the information provided above is true and correct Si ature: Date: Z 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#: 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 coinpliance 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 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 mturaed to tl e.ci�—,or town that the application for the per udt 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 of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.rnass_govfdia Location 1 s Na Date NORTH , TOWN OF NORTH ANDOVER F 9 41 Certificate of Occupancy $ �sswcMustt Building/Frame Permit Fee $ r Foundation Permit Fee $ Other Permit Fee $ ' TOTAL $ Check # 41,VI �, 0 Building Inspee6 r` Location l . Date No. NORTM TOWN OF NORTH ANDOVER Of�«•o y,tip L F 9 41 Certificate of Occupancy $ --- ��ss�cMusEt� Building/Frame Permit Fee $ ' Foundation Permit Fee $ 1 Other Permit Fee $ — V TOTAL $ —�=`-- Check # 17946 Building COMMONWEALTH OF MASSACHUSETTS TOWN OF NORTHANDOVER , APPLICATION FOR CERTIFICATE OF INSPECTION Date: alOC8DH (• Fee Required(Amount) D () No Fee Required Accordance with the provisions of the Massachusetts State Building code, Section 108,15, 1 hereby apply for Certificate of Inspection for the below-named premises located at the following address: Street and Number I I I5 O S GOOD ST R-a- T r Name of Premises P C�'r-e C.T 0 S (,1�(--`- Purpose for which Premises is Used 007 S6 R-0106 Licenses (s) or Permit(s) Required for the Premises by Other Governmental Agencies: Contact Person Tel License or Permit Agency d C Y. Certificate to be issued to Address Telephone Owner of Record of Building Address Name of Present Holder of Certificate Name f Agency if any W K oz- SIGNATURE O PERSONS TO WHOM CERTIFICATE TITLE IS ISSUED OR HIS A UTHOIRIZED AGENT DATE INSTRUCTIONS: 1) Make check payable to: Town of North Andover 2) Return this application with your check to: Building Dept., _ 400 Osgood Street,North Andover MA 01845 PLEASE NOTE: Application form with accompanying FEE must be submitted for each building or structure or part thereo' bE certified. _3) Application and fee must be received before the certificate will be issued. TOWN OF NORTH ANDOVER INSPECTOR'S NAME OFFICE OF THE INSPECTOR OF BUILDINGS MICHAEL MCGUIRE INSPECTION REPORT FORM CLASSIFICATION PASSES INSPECTION yes Ono 0 DATED OWNER BUILDING NAME OR NO. STREET LOCATION TYPE OF OCCUPANCY - Day Care Center 0 Aud. 0 Caf6 0 Gym 0 Apt. 0 School 0 Common Victualer's 0 Liquor 0 Place of Assembly 0 Other OCCUPANCY NUMBER (include stories # and occupancy per floor - use reverse side EXISTINGS EXIST SIGN yes U no LIGHTED EXIT SIGNS operable yes 0 no 0 EMERGENCY LIGHTING SYSTE M operable 0 dry cell 0 wet cell 0 SPRINKLER SYSTEM operable 0 gage pressure yes 0 no 0 SMOKE DETECTOR operable 0 yes 0 no -IRE ALARM SYSTEM expiration date yes 0 no 0 kNSUL SYSTEM yes 0 no 0 FIRE ALARM SYSTEM operable 0 municipal 0 yes 0 no 0 ELECTRIC EOUiP.AENT PROPERLY PROTECTED yes 0 no D EGRESSES LAWFULLY DESIGNATE unobstructed 0 yes 0 no 0 a STAIRS PROPERLY RAILED yes 0 no 0 HALLS AND STAIRWAYS LIGHTED yes 0 no 0 RADIATOR GUARDS yes 0 no 0 COMPLIES HANDICAPPED PERSONS LAWS yes 0 no 0 FIRE RESISTANT CURTAINS OR DRAPERIES HOW HEATED NO. FIREPLACES yes D no BOILER ROOM CONDITION VENTILATION UTILITY ROOM - CLOSETS NUMBER OF GRADE FLOOR MEANS OF EGRESS DOORWAYS NUMBER OF SEPARATE STAIRWAYS ACCESSIBLE PER STORY SHOPS FOR INSPECTOR USE ONLY Revised2tgg JMc i Date..,=;) ................................ 0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING .......... 3 CHUS This certifies that ,Z�2 �qq-e-- ........... ....................... ................ . .................... has permission to perform.............- wiring in the building of......... ................................................. at..............................V....................................... North Andover,Mass. FeeZ Lic.No ............................ .......... . ........ ......... . .......... . . ........ ELEcTRICAL INSPE R Check # 4?, :�:7 9255 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked f BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WOR All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PM7flV INK OR TYPE ALL INFORIMIATION) Date: City or Town of: NORTH ANDOVER To the Ipector of W By this application the undersigned gives notice of his br her intention to perform the electrical work dires:esabed below. Location (Street&Number)_ Seo Owner or Tenant i,) L Owner's Address Ta '.r Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No Purpose of Building �—� (Check Appropriate Bog) Utility Authorization No. Existing Service Amps / 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: t`�P�� a J` o J- Completion o the ollowin table may be waived by the Inspector of wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total No.of Luminaire OutletsTransformers KVA No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above In- 1 o.o mergency ig grnd. d• 17 Batte Units' g --, No.of Receptacle Outlets No.of Oil Burnerst , FIRE ALARMS No,of Zones No.of Switches No.of Gas Burners No.of Detection and No.of N Ranges Initiatin Devices g o.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposerseat Pump Number Tons KW o.of Self-Contained Totals: ._...-•...___._ ._._._.__..._.... _._. ... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* , No.of Water No.of Devices or E uivalent KW No. Heaters No.of of Si s Ballasts . Data Wiring; No.Hydromassage Bathtubs No.of Devices or E uivalent No.of Motors Total Hp Telecommunications Wiring; No Attach of Devices or E uivalent OTHER: t Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: �a Work to Start �i (When required by municipal policy.) o -aa-i d 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 insurance including "completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER I certify ❑ (Specify:) under the pains and penalties of perjury,that the infoMation on this application is true and complete. FIRM NAME: Licensee: LIC.NO.: / 3�3 `T i�d it ('ra ij Signature (If applicable, enter `exempt 11in the license number line) � ^— LIC.NO.: Address: _ �-` .+��} O� �a ( Bus.Tel.No.: *Per M.G.L c 14 t,s S/ 61,security work requires Department of Public Safety"S"License: Alt Lici 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/Aent Signature" ___ Telephone No.���d�'/� -tj,F j PERMIT FEE. $� r-�- t The Commonwealth of Massachusetts Department of Industrial Accidents Dice of Investigations 600 Washington Street - into - Boston, ALL 02111 www massgov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeQibl Nanie (Business organization/Individual); Address: City/,StatelZip:� Pli 4 Phone i Y�aG0 Are you an employer?Check the appropriate box: 1•❑ I asn a employer with 4. Type of Pref(required): ❑ I am a general contractor and I in (full and/or part-time).* have hired the sub-contractors 6 New construction 2•!�"�I am.a.sole proprietor or partner- listed on the attached sheet.x 7• ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity. & Q Demolition workers' comp, insurance. [No workers'comp.insurance 5. ❑ We are a corporation and its 1. Q Building addition 3.❑ ImT ed-] officers have exercised their l 0 Q Electrical repairs or additions 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 insurance required.]t em I 12•❑Roof repairs p oyees. No workers' comp. instlranc a required] 13.❑Other Any applicant that checks bot:#t must also fill out the section below showing their workers'co t Homeowners who submit this afridavit indicating they are doing all wank and then hits outside c�uactom policy information ;contracwts that check this box mustattached an additional sheet showing. must submit a new affidavit indicating such mg the rt+«nc of the sub-cmit gch_nc.wea Fs~. __P. R I ant an employer that is prpWding workers'co ensatwn �#icy inibmiation. information. mp insurance for my employe= Below is the policy and job site ,( Insurance Company Name: Policy#or Self-ins.Lic. Expiration Date:_ Job Site Address: City/Stat:Zip: Attach a copy of the workers' compensation policy declar-ation page(showing the policy number and expiration date Failure to secure coverage as required-under Section 25A of MGL c.152 can lead to the imposition of criminal fine up to$4500,00 and/or one-year imprisonment;as well as civil penalties in the form of a STOP WORK ORDER and a fine >t 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct SitraatuTe: � Phone#: .�/�� Ef use only. Do not write ut this area,to be completed by ezty or town offcFaL a; Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector son: Phone#: