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HomeMy WebLinkAboutMiscellaneous - 1160 GREAT POND ROAD 4/30/2018 (4) 1 x""4}h� taNaY,� / � �'�d �°°�5 011 Date.. -V .1....�, . ......... i L.0 C ? OF NORrot TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 88gCMU55 This certifies that.... ................. .................................................... has permission to perform...........w F l— .............'�� . ...... .r..G,................................ plumbing in the buildings of.....�rt-.�k..5.........,..�.. -?.,o .. ....,.... ..... at.............�-� 02 ..:�....�'5.:.:.: .` 1.! North Andover, ass. Fee....j �V.....Lic. No. ...�.�".1...... ...... Check# G PLUMBING INSPECTOR t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE � _� / ( PERMIT# jb�0 JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS aT TEL -- FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: QI RENOVATION:© REPLACEMENTS PLANS SUB I'ED: YES Q NO Ell FIXTURES-1 FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM I _ I I ._..__J __. _[ _ _i ( [ [ Qk) DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM [ -._[ ( _-11_—_, [ DEDICATED WATER RECYCLE SYSTEM I _.__.._.1 � _ _[ .__ ( ( [ . _ ._...___f [ [ DISHWASHER _ [ __ ._.I -------_1 —_..J DRINKING FOUNTAIN —11F---_ _,{ .._--_{ FOOD DISPOSER FLOOR/AREADRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL IyJ WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER JF INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES .Q[ NO Q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 5 LIABILITY INSURANCE POLICY ' OTHER TYPE OF INDEMNITY Q BOND Q_1 OWNER'S INSURANCE WAIVER:la 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 ENT IQ.1 SIGNATURE OF OWNER OR AGENT r I hereby certify that all of the details and information I have submitted or entered regarding this application re tru an a curate the a my knowledge and that all plumbing work and installations performed under the permit issued for this application will be n co is a ith I in vision of the Massachusetts State Plumbin Code and Ch pter 14 of the General Laws. PLUMBER'S NAME _ _ (LICENSE# 6 _ ( GNATUR M JP Q! CORPORATION I#©PARTNERSHIPQ# (LLC COM ANY NAME N DRESS �— CITY _— ]STATE ( ZIP C ��� TEL O FAX _ ( CELL �EMAIL —-------- - - - ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES r j The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations IN 600 Washington Street Boston,MA. 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information A Please Print Legibly Name,(Business/Organization/Individual): Address: City/State/Zip: _ Phone r you an employer?Check the appropriate box: Type of project(required): 1.X11 am a employer with� 4. El am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, E]Building addition [No workers'comp.insurance 5. F1 We are a corporation and its 10.El Electrical repairs or additions required.] officers have exercised their 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' 13.❑Other comp.insurance required.] *Any applicant that checks box 01 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. r Q V L� �^) Policy#or Self-ins.Lic.#: Expiration Date: d - ^l Job Site Address: '� it G C -Q- City/State/Zip: WO 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 of Investigations of the DIA for insurance coverage verificatio Ido hereby cer un rte ins dIties of er' ry tliat the information provided above is true and correct - Signature: Date: Phone#: - t 3 d 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 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),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 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(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 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 Commonwealth of Massachwetts Department ofIndustrlal Accidents Office of Invesfigations 6.00 Washington Street Boston,MA.02111 Tel,#617-727-4900 oxt 406 or 1-877rMASSAFE Revised 5-26-05 Fax#617-727-7749 __WWW-mass.govldla ONWEALTH OF MASSACHUSETTS f �t "M•'a'Ft�v k'VC? GAS-FIT TEFc F LICENSED AS A MASTER PLUM f ' 13SUES THE ABOVE LICENSE TO: ROBERT AVILA 112 CROSS ST i :LAWRENCE MA 01841-3 . r- 9065 05/0.1/14 Fold,Then Detach Along All Perforations ' y t2� 113 Date................................................... NORrH I TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �Bs+cHu This certifies that ........ ,A... � 1MIT TO PERFORM GAS FITTING WORK has permission for gas installation PERMIT# in the buildings of ' . . ................................... .. .. (5e— ;R'S NAME dO at....�.�Nv..........Q.C> ...���" 'North Andover, Mass. .......... N ,., Fee ✓. ` ......... Lic. No. ... ''?.......... . .................................................. �a- E FAX GASINSPECTOR 1 Check A91 RESIDENTIAL 0 C n PLANS SUBMITTED: YES 0 N00 7 8 9 10 11 12 13 14 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEAT R DRYER FIREPLACE FRYOLATOR z FURNACE GENERATOR - 1 �l _-�--�� - - - I 1 1i GRILLE J. INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT [ OVEN POOL HEATER ROOM/SPACE HEATER ROOFTOP UNIT _ I _ TEST UNIT HEATER UNVENTED ROOM HEATER "WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES []NO E] 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND 0-1 OWNER'S INSURANCE WAIVER:I am aware that the Icensee 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 FI AGENT SIGNATURE OF OWNER OR AGENT 1 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 pe mit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code nd Chapter 14 of t Gene al Laws. PLUMBER-GASFITTER NAME LICENSE# SIGNATURE MP MGF[j JP ® JGF LPGI CORPORA ION©# PARTNERSHIP 0#�LLC[I# COMPANY NAMEQWv-1 IT, ADDRESS CITY _ _ _ _ - I STATE�ZIP p TEL d j FAX CELL _ EMAIL _ _ _ _ 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 . f 1 I I �.�1�3 * Date.................................................. NORTH o�' TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �s�►cHU This certifies that ........ ....................� . ....-AA �-- ........................................... 7 has permission for gas installation .... m.ec' ........................................ 7 in the buildings of.� \c 5....so W. at...I ..........P.. .............. ..... .! ......... ?.. North Andover, Mass. Fee .? ....... Lic. No ........ r).. ............................................................ �,91 GAS INSPECTOR Check# iLis' -` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY li✓ MA DATE PERMIT# JOBSITE ADDRESS OWNER'S NAME 6 0 OWNER ADDRESS TEL�� FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL RESIDENTIAL CLEARLY NEW-4 RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES 0 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 HEATQR DRYER FIREPLACE FRYOLATOR _ __- [-- FURNACE1 GENERATOR (- ,I I_. ._l ._.....I —� J Com' ___I== _ GRILLE t~ TI INFRARED HEATERS _ _ [�- - - LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATERT J I ROOM/SPACE HEATER ROOFTOP UNIT _ TEST UNIT HEATER UNVENTED ROOM HEATER TVATER HEATER _OTHER � INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ]J NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER:I am aware that the I censee does not have the insurance coverage required by Chapter 142 of the SVlassachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ]! AGENT E3 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 pe mit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code nd Chapter 14 oft Gene al Laws. PLUMBER-GASFITTER NAME J LICENSE# SIGNATURE MP MGF El JP ® JGF 0 LPGI CORPORA ION[J# PARTNERSHIP®#=LLC©#� COMPANY NAME: vila - ADDRESS CITY _ _T STATE�ZIPJ O JTEL FAX I -� CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES E Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES I i C 7 / Date.. . . .-. .. . . .. . .�...... NORTIy Of ..ao ,6 1h0 3= �` TOWN OF NORTH ANDOVER f 0 70 PERMIT FOR GAS INSTALLATION SACI/USE� This certifies that . ;! .. . . . . .`:. . . �� .: . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . .. . . . . . . . . . . . in the buildings of . . .T/.. : ' 1%', :. . . . . . at . // . . . . : ''. :°.` .�.��. :. . `� . . . . . . .. North Andover, Mass. Fee. .L.-.".. . Lic. . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR Check# 7 r �- J JJ MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations Q Permit# 3 J J r ount$ �D Owner's Name 1,l t 9- New /Renovation ❑ Replacement ❑ Plans Submitted~❑ U c a z c w O p F w d a d OQ A t7 U t SUB-BASEMENT BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR one• (Print or type) ,Certificate Installing Company Name rp. Address ❑ Partner. Business Telephone ❑ Firm/CO. Name of Licensed Plumber or Gas Fitter V INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked yes,please indicate type,coverage by checking the appropriate box. Liability insurance policy ther 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. Signature of Owner or Owner's Agent Owner ❑ Agent ❑ i hereby certify that all of the details and information I havesub (or entered)in above a cation a true and accurate to the best of my knowledge and that all plumbing work and insta tions p ed er P Iss ed f application will be in compliance with all pertinent provisions ofthe Massachu Sta ode d ter o eral Laws. i By: Signature of Licensed Plumber Or s itter Title ❑ Plumber City/Town ❑ GasFi r-icense Number Master APPROVED(OFFICE USE ONLY) ❑ Journeyman