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Home My WebLink AboutMiscellaneous - 115 COACHMANS LANE 4/30/2018 115 COACHMAN'S LANE 210/037.A-0027-0000.0 Date..l U17&..................... CF NORT#f o , TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION BSACHus� This certifies that / r�o� I ��">�- ...................................................................................:................................ has permission for gas installation ..�� -................................................ in the buildings o ....... .................. at........../��.. .. a dam. . �....../--/-.....,North Andover, Mass. Fee,+, ...=. Lic. No. ./ ......... ...........:........................................ GASINSPECTOR Check# 9571 -` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK C ' CITY r MO. �Q.41-1* 6z, �� MA DATE d / PERMIT# ii9J G JOBSITEADDRESS /� &.40 4A ,Qr� OWNER'S NAME OWNER ADDRESS TELLpr791 : FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL F] RESIDENTIAL PRINT CLEARLY NEW:El RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES E—Al NOQ APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ( _�--: . _ . .. ._. 1 l I__ BOOSTER � CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER ^ FIREPLACE —J h ._- . ._ � _ ! .. �� _�l .—� I FRYOLATOR FURNACE GENERATORS - ___ GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT { _ TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY4 OTHER TYPE INDEMNITY E] 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. CHECK ONE ONLY: OWNER 0 AGENT Df SIGNATURE OF OWNER OR AGENT I 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 compli n h all, e i rovi ' n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME erl�1 J�'l_ {�� LICENSE# SIGNATURE MP MGF EI JP 0 JGF LPGI 0 ^CORPORATION D#E=PARTNERSHIP®#=LLC M# �6c COMPANY NAMEIZM/ Iv.KB,nG >`'/+�et�i�ADDRESS e"fe j'i4e-,(--!_e__ CITY _ _ _ _. I STATE ZIP TEL �d3 TS GSd�' FAX CELL EMAIL - - _ --— �- ROUGH GAS INSPECTION NOTES TRIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION AOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ ~ FEE: $ PERMIT# PLAN REVIEW NOTES r I � a The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/ContractorslElectricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/fndividual): Address:/ f 49Wle / &I't � City/State/Zip: AL, Phone#: /e S19 Are you an employer?Check the appropriate box: Typo of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors I am a sole proprietor or partner- listed on the attached sheet. 7• E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in.any capacity. workers'comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3111 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 r insurance �ired.re q ui employees.[No workers' 13.❑Other comp.insurance required.] !Any applicant that checks box Of must also fill out the section below showing their workers'compensation policy information. 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. .1 am an employer that 1s providing workers'compensation 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 requiredunder 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 sof Investigations of the DTA for insurance coverage verification. Y do hereby cert' e2rMepa'ms �en alties of perjury Aat the information provided above is true Ynd correct. - Date: Si ature: Phone#: 1_V3 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License 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 0: K� Information and Instruction*8 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 g the legal representatives of a deceased employer,ployer,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), es address(es)and phone numb er(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 R 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 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 maybe provided to the applicant as proof that a valid affidavit is on file for fature 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 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: The Goanmmwealth of Massachusetts Depa ent of adustrial Accidents Qfte off1westigatiolm 6.00 Washingtoa Street Boston MA 02111 Tei,#QM27,4900 ext 406 ox 1-877,MASSAk'E Revised 5-26-05 Fax#617-727-7749 '(AFSSFf2F YYf9nn/rnTs°r�:i.. f COMMONWEALTH OF MASSACHUSETTS. e e o • e BOARD'Of PLUMBERS AND GASFITTE�tS ; 1 IS$UE;S THE FOLLOWING LfCENSE L I SE:D A,S AI:ASTERtP.LUNIB ' GLENh1 M MCCABE „ 1 POORFARM ROAD . DERRY' tJH 03038-4209 { i ��7 nG/ni li:A 9r,r,Q 4 v Date. . . �.`.. .. t / Of NORTH ,� r O TOWN OF NORTH ANDOVER 1• �� P ' PERMIT FOR GAS INSTALLATION �9SS^CHO . This certifies that . . . S T -. . . .S .h►'�'H 'rte has permission for gas installation . . . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . .-�:--:. . . . . . . . . . . . .. North Andover, Mass. { � Fee. 7.f.'. . . Lic. No..�>77. . . . . . . .Q ''�•'^ . . . . . . . GAS INSPECTOR Check# 3 MASSACHUSETTS UNIFORM APPLICAT (Print or Type) ION FOR•PERMITTO DO GASFITTINGG� �'.- I XL'4 ' Mass. ate -- j �d zta Pe it S L eulidV.ing L anon wners Type of occupancy New❑ Renovation 0 Replacement Plans Submitted: Yes❑ No p z� I w 1+ o cr o2 t > $ > 2 tz 0 O - /j SUB-BSMT 0 o. • BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR ; ' 4TH FLOOR . 5TH FLOOR 6TH FLOOR 7TN FLOOR 8TH FLOOR Installing Company Name 4ddress Check one: Certificate ❑ Corporation ;usiness Telephone _-U ❑ Partnership (arse of Licensed Plumber.or Cas Fitter irmiC0. j INSURANCE COVERAGE: '1 have a current IIability Insurance policy or its substantial equivalent; Which meets the requirements of MCL Ch. 142. Yes No ❑ If you have checked yes,please indicate the type of coverage by checking the appropriate box. I'I A liability Insurance policy�/ Other type of Indemnity ❑ Bond ❑ OWNER'S INSURNACE WAIVER 1 am aware that the licensee does not have the 142 of the Mass.General Laws, and that my signature on s er insurance coverage required by Chapter P application waives this requirement Signature o 0 caner or.0 wner's Agen Check one: Owner ❑ Agent ❑ ,ereby certify that all of the details and Information I have submitted for entered)in above application are true and accurate to the best of /knowledge and that all plumbing work and Installations performed under the pertnit Is e r this application be incompliance with Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of theca L By Type of License: Title ❑Plumber S gn re of L tensed Plu ber or Cas Fetter CiVrown ❑Casfitter APPROVED(OFFICE USE ONLy) D4Mter Lkense Number �� ❑Journeyman t BELOW FON OFFICE USE ONLY KCTCHES ►R0011ESS INSPECTIONS FINAL INSPECTIONS & FEE NO. APPLICATION FOR PEIIMIT TO 00 PLUMBING NAME A TYPB OF BUILDING LOCATION OF BUILDING PLUMBER _ PERMIT GRANTED DATE '1 B _ P -"ImG INSPECTOR N2 2 J L Date.... . o....��.... ... NORTOI °f+«`° '•4"o TOWN OF NORTH ANDOVER PERMIT FOR WIRING � a ,SSAcMUSEt This certifies that ........ ............... .4.............. .... ......... has permission to perform : ' .... ......... ..............:........ wiring in the building of.: '...... p..................................................... at �� , .�`�............... .North Andover,Mass. ..................................... ... Feet ...... Lic.No ltSA............................... ............................. &EcrntcAL INSPEMR 08/18/9814:18 25.00 PAID WHITE:Applicant CANARY: Building Dept. PINK:Treasurer .� Office Use only-, tl�jP �IIIItIIiIIIIIUPc�lffj D� c�55c�I�11I5P Permit No. tarpmtimIrut of Public r.".IIfety Occupancy A Fee Checked v� BOARD OF FIRE PREVENTION REGULATIONS 321 CMR 12:00 3W (leave blank) APPLICATION FOR PERMIT TO PERFORM! ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TyPELL INF RM�`TION Date City or Town of NO 2l UIU e-k To'the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) ,/a�1� Owner or Tenant �"� /r- "` " Owner's Address r- is this permit in conjunction with a building permit: Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building ��, Utility Authorization No. - Ro S "94 3 Existing Service d Amps l� Zell Volts Overhead ❑ Undgrnd �No. of Meters New Service Amps _I Volts Overhead ❑ Undgrnd ❑ No, of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets I No. of Hot Tubs I No. of Transformers Total KVA No. of Lighting Fixtures I Swimming Pool Above 17 Ir- r grnd. grnd. J Generators KVA N =m r n i No. c _ e ge cy Lighting No. c' Recectacle Outlets I No. of CI; 3urners I Battery Units No. of Switch Outlets No. of Gas Burners I FIR= ALARMS No. of Zones No. of Ranges I No. of Air Cond. Total No. of Detection and tons Initiating Devices No. of Dircosals I No.of Heat Tctal Total Pumps Tons K`N No. c`. Sounding Devices No. of Self Con:::,ned No. of D!shwashers Space/Area Heating KW Detection/Soundinc Devices No. of Dryers Heating Devices KW LocalMunicipal ❑ Other Connection ❑ No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs I No. of Motors Total HP ^` n n THER: L+ /4,iQ5 Zao A U V1 d e�6-k0 -V`l: u 'Tl0-'A Cr , INSURANCE COVERAGE: Pursuant to the requirer-ents of Massachusetts general Laws � 1 have a current :iability Insurance Policy includir Comoiete perations Coverage or its substa-tial equivalent. YES 2--'NO O 1 have submitted valid proof of same to the Office. YES 30 NO O If you have checked YES, please indicate the type of coverage by checking the apprcwate box. INSURANCE BOND O OTHER O (Please Specify) (Expiratio Date) Estimated Value of Electrical oWork 3 Work to Start '9-17 — `&- inspection Date Requested: Rough Final r fr Signed under the Penalties of perjury:, FIRM NAME.W l I,` �`r� �'�i P4%&~-`Z'L., yet a LIC. NO. Licensee 4"f1 Signature LIC. NO. /3J _ Z.7 �1 �5 S� Q�I N � � Bus.Tel. No. 97&- �&(r=— 73� Address Alt.Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does ne? have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE 5 (Signature of Owner or Agent) x8565