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HomeMy WebLinkAboutMiscellaneous - 1160 GREAT POND ROAD 4/30/2018 (27) 8 Date..?q/ q1j.q ..... 10 '100 3 -7..... .. Of 40R Th TOWN OF NORTH ANDOVER 0 #.- p PERMIT FOR PLUMBING Wu Thiscertifies that.......................................................... ................................................... has permission to perform..7.. ............................................ �..7�6* plumbing in the buildings of... —k3.......... > .... .....Tat.. North Andovert,-Mcias at.. ...............................................t....... Fee......................Lic. No. ? ........ .......................... PLUMBING INSPECTOR Check# R. f MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK it ' CITY ,�._._ MA DATE PERMIT# I61M JOBSITE ADDRESSq OWNER'S POWNER ADDRESS TEL 11FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL'z RESIDENTIAL DI PRINT CLEARLY NEW: M RENOVATION:® REPLACEMENT:© PLANS SUBMITTED: YES® NOM-1 FIXTURES Z 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 GASIOIL/SAND SYSTEM T ( _. I .____ I ! DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I -- � ._._._._ � J I _... ..__1 i J —.-_( DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) .._,_.__i ___.__ KITCHEN SINK l __I T_1 .___._E LAVATORY ___-- ROOF DRAIN I _I _�( _ _.I _._._I -_.___I __._.._,.J ._.J SHOWER STALL I I _. I _. ( _—_ = __ __I _ SERVICE/MOP SINK I .__ _J _._.__f ___! ____J ____I __ I _._.__I _j .___i TOILET URINAL I _ _._._ __. i ....__ _( __....._J _-----J .___._-._( ....___._._I _.._.._.f WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I ( I t WATER PIPING f I _ _ _f (. -_.-- OTHER ___ _ __ 4 I ( ( .__._._._.1 .-_---- I ( ` _._j _._.._J _..._A .. _ 1 ____.__€ __.._j I ( INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO n IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICYd OTHER TYPE OF INDEMNITY DI BOND e OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the r Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT J® 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 a��ppdc to to a best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com li5nce ith I Pe a o-�visiof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMB S NAME _ JK LICENSE# I ��i I :' SIGNATURE IMP I JP�I CORPORATION Q# PARTNERSH �# LLC _{ COMPANY NAME 4,0A artsp-S ADDRESSlit ( I CITY _ _�STATE F_� ZIP (,�_% "� II TEL c FAX f CELL . .. �, EMAIL . — - - - --._. L ✓ -_.. --- ---....- 2m .. - ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTI I ONNOTES Yes No ICY' �! o�G�`T THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 1 M1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 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): ��Wr Of P Address: 64 yk V-4 1-�2 City/State/Zip: I/1�1 �/ DWPhone#: bo3 -918 (Do?- Arepu an employer?Check the appropriate box: Type of project(required): Lif I am a employer with �% 4. El am a general contractor and I 6. E]New construction l employees(full and/or part-time).* have Hired the sub-contractors 2.❑ I 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. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El 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' 13.❑Other comp.insurance required.] 'Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such. (Contractors 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. F�.V�. Insurance Company Name: V cos NA-AmOAA Policy#or Self-ins.Lic. LO L-[1�2 Expiration Date: Job Site Address: �� City/State/Zip: 41�t`7 ► -�,�% � 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 ofthe DIA for insurance coverage verification. Ido hereby cert'uncle ze pains and pe ties of perjury that the information provided/above is true and correct. Signature: Date: 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#: ti Informati®n 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 ifou are required to obtain a Y q 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 thea } affidavit for you to fill out m 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 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 ComjAonwoalth�of Massachusetts Department of lndustrial.Accidents Office of Investigations 6.00 Washington Street Boston.,MA 02111 Tel.#61.7-7.27-4900 eYt 406 or 1-877,7MASS.AF.E Revised 5-26-05 FaY,#617-727-7749 _WWW-Mass,gov/dia i t 1 MMONWEALTH OF MASSACHUSETTS €<.... 01 VA Ri rel oreltoLei al MIR Lei q 61191 a i BOARD OF P L UMB E5'; ND G A SF=,I TTE:FS<' ISSUES.::THE FOLLOW! LICENSE E1C1_NSFD AS-.A h1ASTER 1M'B= Sw> tit z I JASflN W THOMAS.... .F ` " D' 13 JACKIHAIJ RIDGE Rl fffk l�ter/ U fINDHAM 1VH 03087-1670 �� 10�lir •� 05!01 f 15 <' 250085 � RTH EAST ABLE ETW®RKS Matt Trotter •Voice •Data •Fiber Optics � •Splicing •Underground •Aerial P.O.Box 1204 (�03) Phone:424-2147 Merrimack,NH 03054 Fax: 429-1619 N° 14 J L Date... �,�4,,/.Z A TOWN OF NORTH ANDOVER p PERMIT FOR WIRING 8 eo AC US This certifies that ..... .(� ..# (�..�.a.Ms` ..... t�. ................... has permission to perform ......w�.!�p....... �!� 1...................... � \ wiring in the building of.....t�/.2....F.W aJ),k �T k...1. b � .................. .North Andover,Mass. Fee!V. 41M. Lic.No. CO.:......................................................... ELECTRICAL INSPECTOR WHITE: Applicant CAARY: Building Dept. PINK:Treasurer Ude �ommunwe�lih of �6Z1r4ug1 PSM*NQ"°'"`�°"" � /9��) flepartnttat trf Public £�aft:ig OCMPLncy`Fie CMdyd BOARD OF FIRE PREVENTION REGULATIONS 521 CSIR 12:00 Laim on"W" APPLICATION FOR PERMIT TO PERFORM ELECTRIC All work to be performed in accordance with the Massacnusetts Electrical Code, 527 CMR 12:00�OR� (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Oats D T& or Town of NORTH ANQOYER To the In p or of Wlres'. The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) 12An7-14pd/l) IM Owner or Tenant Owner's Addresslv! Is this permit.in conjunction with a building permit: Yes _ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps _._./ volts Overhead Undgrnd CI No. of Meters New Service Amps _/ Vohs Overhead C Una tree r 9 No. of Meters Number of Feeders ana Ampackty Location and Nature of Proposed Electrical tNoric /AUG j /Y 7e6Q �vSScZL No. of Ligntknq Outlets I No. of riot '_cs No. of Transformers Total KVA No. of Lignong Fixturesi Swimming PCat Aocve.— ,n. r. Srro — grno _ I Generators KVA No. of Recsotacle Outlets I No. of Oil Ekrners I No. of Emergency Lignung Sanery Units , No. of Switcn Outlets I No. of Gas =urrers FIRE ALARMS No.of Zones No. of Ranges I No. Cf Air C„r.c. 'Old' No. of Detection and chs initiating Devices No. of Oisoosais I No.ol Meat "o:ai -oiai Pur-::s 'ons ;tv No. of Sounding Devices No. of Sed Contained No. of Oianwasners SoacerArea +eatirq K`.v Oe[eettoruSoundkng Devices No. of Dryers I Healing Cev.ces KW L•ocai '— Municioal ^Otfter Connection , NO. of Vu )t Low voilago i No. of Water Heaters KW I Signs °ailas:s Wiring No. Hyaro Massage Tuos I No. of Motcrs ;otai NP OTHER. INSURANCE COVERAGE. Pursuant ;o the requirements Zr '.tassacnLssrs ;eneral Laws I have a current Liao[lity Insurance Policy inc[uaing C;,r-,c etec Ccerauons Coverage or its substantial equivaNnt. yC3 = NO t have suontinea valid proof of same to the Office. YES = v0 = It you nave cnecxea YES, p{sue indica checking the approlet 1M type of Coverage Illy, oriate cox. INSURANCE = aONO = OTHER = (Please Scec.`�) Estimated Value of E!sctncai Worn S (EKWaion Gawk . wont to Start Insoecnon ,Cate XacLes:ec: Rougn Final Signed under*Re Penalties of arlury: FIRM NAME ��� G /�/L � ��5 UC. NO. Licensee UC.NO. ..�� Bus. Tel. No. Address All. Tet. No. i OWNER'S INSURANCE WAIVER: I am aware inat the licensee ^.ees not nave ins insurance coverage or its suostanual equwamnl as to. dumea by Masaacnusatts General Laws, ano [hal my signature on :nis permit aopucation waives this regWremem. Age (Ptee" cnwx oner E (S.gnattue at Owner or Agsnti iieonone No. PERMIT F ■iaaa