Loading...
HomeMy WebLinkAboutMiscellaneous - 127 MASSACHUSETTS AVENUE 4/30/2018 �, SSACHUSETfSWvct.•=-' 127 MA 0.0022_0000.0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY � y MA DATEJIPERMIT# JOBSITE ADDRESSGI OWNER'S NAME _ l� c� G OWNER ADDRESS00 TE FAX TYPE OR OCCUPANCY TYPE COMMERCIAL®-. I EDUCATIONAL PRINT RESIDENTIAL CLEARLY NEW:[_ RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES Q NO APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 S 9 10 11 12 13 14 BOILER I I I BOOSTER CONVERSION BURNER ._ _.�1 ti _ _�I _---_� --J= COOK STOVE (-_._I l _F - _._- T I. ._ .___ ��J ._.._v I ! - DIRECT VENT HEATER -I ..._. . . _. T1_ DRYER FIREPLACE FRYOLATOR I FURNACE -- - _3 .T J I-, 1 GENERATOR GRILLE r= _--- -�_ INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER I TEST TOP UNIT n _..� .�. _.,..--, � _ ., .1 __ _._ f - 1 oil UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ONO _�__I I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY - OTHER TYPE INDEMNITY EA 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: ER E-11 AGENT 0 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are t and accu a to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in p,lance all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASATTER NAME � ���•e_S __. •- LICENSE# SIGNATURE 1\45 MGF[ 1 JP n JGF 0 LPG]D CORPORATION Q#L� J PARTNERSHIP[3#=LLC[_]I# .=ll COMPANY NAME: G/ dADDRESS CITY STATE�ZIP "�X02 TEL FAX CELL EMAIL[:—:, ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ � /j � I FEE: $ PERMIT# PLAN REVIEW NOTES s t' The Commonwealth of Massachusetts y Department De artof IndustriglAccidents .a r p Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov1dia Workers' Compensation Insurance,Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legib Name(Business/Organization/fndividual): �— - / �`�✓ Address: City/State/Zip: ��414 gL1f D)93 Phone#:: 7�G� Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction mployees(full and/or part-time).* have hired the sub-contractors ?. m a sole proprietor or partner- listed on the attached sheet.t 7. E]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 area 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' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 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 the#lre 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. X am an employer that is 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 require'dunder Section 25A of MGL o.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 fo ' surance coverage verification. X do hereby cJrunder a pains andpenalties of perjury that the information provided above is true and correct. Si ature• Date: Phone#: ?% 6 l 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#: I Date�U b TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 4 This certifies that . . . . 14 . . ti has permission for gas installation . . . .r).�. .{,� . . . . . . . . . . . . . . . . . in the buildings of. . . Pswo f-X . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . .... . . . � /�5 .�./r?�?.•.1 . . . , ort*Adover, Mass. Fee�. ASINSOR Check# � 9 8355 _X N° 960 Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACHUS� This certifies that 4-? .�.l ^.. . . dto-y—re-Q. .,.).C.�R I/ /'c �� has permission to perform . .,1be.j a4 . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings o >5ft,-G0.� . . . . . . . . . . . . . . . . . . at. . . .`��. . . ! S. �.,. . . . . . . . ., North Ando er, Mass. Fee ._". . .Lic. No�.`1. . . PLUMBING INSPECTOR Check # �I WHITE:'Applicant CANARY: Building Dept. PINK:Treasurer ' r _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY I _ -11 MA DATE ( PERMIT# JOBSITE ADDRESS OWNER'S NAME Vlee 6 P OWNER ADDRESS _ �; TEL L __]FAX FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:® REPLACEMENTS PLANS SUBMITTED: YES 0 NODI FIXTURES 7 FLOOR- BSM 1 2 3 4 5 ' 6 7 S 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEMi DEDICATED GRAY WATER SYSTEM i _- i I . i _._.....J R . i DEDICATED WATER RECYCLE SYSTEM ! _. i __...._._i _..__� ....__.._J ..._._.-( i ._..._.. ( i ._..___..i .__....._i DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) i l _! -_--__ ___-._J KITCHEN SINK LAVATORY _I __.._..I __.__—_1 ...__.__J _____! ---------I --_..__J ROOF DRAIN _ _._...._J SHOWER STALL SERVICE/MOP SINK TOILET URINAL ._......... ......_....._i WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER .-..-..---__I I__._._--_j I _ i ---____I _.---..! INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLI OTHER TYPE OF INDEMNITY Q BOND M 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 Q AGENT JEI SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application a rue an ccurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be omplia a with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME . ` LICENSE# "/ ( SIGNATURE M5A---JPQ CORPORATION 0# (PARTNERSHIPP#r LLC Ek COMPANY NAME ; ADDRESS ' ' CITY —-.._.....__._...._. i STATE ZIP �/ _ TEL FAX - CELL EMAIL C Q(T��,�I_ ._ -dhnC-mss .. ,.r" .. 'V ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# L J/ PLAN REVIEW NOTES wIN The Commonwealth of Massachusetts ,. Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Uf www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): �`�✓ Address: C S City/State/Zip:�4�(41 , � UJ�� Phone Are you an employer?Check the appropriate box: Type 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 ?` ma sole proprietor or partner- listed on the attached sheet. 7. ❑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 area corporation and its 10.F1 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 insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] !Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. - 7 Homeowners who submit this affidavit indicating they are doing all work and thei hire outside contractors must submit anew affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. .I am an employer that isproviding workers'compensation insuranceformy employees Below is thepolicy and job site information. Insurance Company Name:. Policy#or Self-ins.Lie.#: 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 requireclunder 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 fo surance coverage verification. X do Hereby cer ' under a pains and penalties of perjury that the information provided aahove iisstry e and correct. Si ature• Date: Phone#: 7 b 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.EIectrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: i Y 1 i i i r� i y' ETTS COMMONWEALTH OF MAS S AC HUS _ . • ..• PLUMB RS AN5 GASFITTEI LICENSED AS-A MASTER PLUMBER ISSUES THE ABOVE LICENSE TO: DEAN-„C PETERSON X58 CRYSTAL COURT IR MA, 01.832 `1026 f'HAVERHILL 172483 .. . ` N- 9612 Date.l phk 0'<"O°':'ho TOWN OF NORTH ANDOVER F PERMIT FOR PLUMBING ,SSACMUS� This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform C.y:47)45. OhN.A?.a?I. . . . . . . . . . . . . . . 4 plumbing in the buildings of . ' �. . . . . . . . . . . . . . . . . . . at. . . ./il?. . . , . . . ., North Andover, Mass. Fee. . . . .. . .Lic. No. /Q7.. . . . . . . . . PLUMBING INSPECTOR Check # Lio3 WHITE: Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY o _ _ _ MA DATE FT, F-72 ( PERMIT# JOBSITE ADDRESS OWNER'S NAME G/�G efi-c?cw POWNER ADDRESS 1 s TEL 7� � �U72FAX�� TYPE OR OCCUPANCY TYPE COMMERCIAL�]{ EDUCATIONAL © RESIDENTIALL PRINT CLEARLY NEW: Q RENOVATION:® REPLACEMENTS PLANS SUBMITTED: YES®I NO�I 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/OILISAND SYSTEM I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) ! i __._.._.I } I I 1 --------- KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK _ _I _ TOILET. IF_._ I _ URINAL ---------- ............ .._......_.� ._....._.._. WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER ___._._.} i II __-._.-..a ._ ...._! I _---___i INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESEO NO D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICJ OTHER TYPE OF INDEMNITY © BOND MI 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 ON L : OWNER 01 AGENT 10SIGNATURE OF OWNER OR AGENT E hereby certify that all of the details and information I have submitted or entered regarding this application are)(u?and a�`curate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in c anc ith all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ PLUMBER'S NAME IILICENSE# �/ >'. a SIGNATURE Mpg-- JP CORPORATION 0# PARTNERSHIP®# 'LLC COMPANY NAME , ADDRESS — - ------ - - CITY / — ;ISTATE ZIP _��� TEL FAX —- CELL 10 4 ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No �/�� (r 4-// THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# 6 2� / PLAN REVIEW NOTES 3 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): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1111 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction r---employees(full and/or part-time).* have hired the sub-contractors ? �T am a sole proprietor orpartner- listed on the attached sheet.l E]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.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 L❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]i employees. [No workers' comp.insurance required.] 1311 Other *Any applicant that checks box#1 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 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. 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 theA f r insurance coverage verification. l do hereby cert'y unde the pains and penalties of perjury that the information provided above is true and correct. Si nature: 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 U. Contact Person: Phone#: I I w1 1 � I 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"...eve person"...every p o 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-contractor(s)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 Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1--877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www,mass.gov/dia r i f r ff iyk COMMONWEALTH OF MASS.A.CHUSETTS . • ' • • PLUMBER�A MASTERI PLUMBER. LICEN ... ISSUES THE ABOVE LICENSE T0: y UEAM G .FETERSON 5g CRYSTAL COURT ' AVERHILL MA 01.85 K 2 1026 � :.: X141 05/Ol/?�t 172483 . . 0 Date '4V*`Z-. . . •• j TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . .Ca 4 . .atl c a . . • . . , . has permission for gas installation .(1 ✓�� $ . .r?�..��,� �,.a/.. . . . . . . . . / r in the buildings of. .�j�.F'� ? n. c . . . . . . . . . . . . . . . . . . . . . . . at . . . ./P�.7 . . ''�`'/ p.; . . . . . . . ,North Andover;Mass. Fee :aq. . . Lic. No./.`�� �. . . . . . . . . . . . . . . . . . . . . . . . . GASINSPECTOR Check# q,039 8356 c I (- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATEZ. PERMIT# JOBSITE ADDRESS OWNER'S NAMEf�oc V OWNER ADDRESS ,� � Sf „-T- TE FAX TYPE OPRINT OCCUPANCY TYPE COMMERCIALF,-] EDUCATIONAL RESIDENTIAL CLEARLY NEW:[3 RENOVATION:E] REPLACEMENT____ PLANS SUBMITTED: YES _(_I N00 APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER - I - BOOSTER CONVERSION BURNER __- COOK STOVE DIRECT VENT HEATER —.t(I-- r T J 1:::::i DRYERS FIREPLACE _1(:_ FRYOLATOR FURNACE ::_-f1 GENERATOR GRILLE INFRARED HEATER -[�. LABORATORY COCKS --a( -�C= =1.,.�sl - ,-f __ L-_-.T I----a I_: 1 Lt MAKEUP AIR UNIT :,E1=. .--.f�.- LL-- I1 - - -_ OVEN - POOL HEATER ROOM/SPACE HEATER ..��-_. -_�� .� �_ .,_ -=-- ROOF TOP U NIT ..........-( - T=--- _-L--j 1 --- TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER i _ 'w I- - OTHER INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ILI NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY [ f BOND [--�I 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: NE 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true andp6cV6tejtdthe best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliancdvKh allPertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME - LICENSE# S7y�( SIGNATURE Mom PARTNERSHIP 0-- IJP n JGF LPGII] CORPORATION[]# PARTNERSHIP 0(#�_��LLCI# COMPANY NAME: J GG � c%Sf ADDRESS - CITYSTATE� s -- - - FAX E-I CELL �W��I EMAIL s _ 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 The Commonwealth of Massachusetts Department of IndustriqlAccidints Office of Investigations 600 Washington Street .Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Organization/Individual): / f Address: City/State/Zip:����?�'(, Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction mployees(full and/or part-time).* have hired the sub-contractors 12-lain a sole proprietor or partner- listed on the attached sheet.t 7. ❑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.❑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.]f employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they aie 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. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy 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 ofup to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIAL ' surance coverage verification. I do hereby cer under epains andpenalties ofperjury 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.EIectrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone M. 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 mumber(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 cavy 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 Commoixwoalth.of Massachusetts Depaztinent of Industrial Accidents Office of 1"estigations 604 Washington Street Boston,SIA.02111 Tel,#617-7274900 ext 406 or 1.-877_MA.SSAFE Revised 5-26-05 Fax#617-727-7749 WWW_Mass,govfdia Location No. Date ©� NORTh TOWN OF NORTH ANDOVER • ,' Certificate of Occupancy $ �'�S'^•° �<�' Building/Frame Permit Fee $ s�cwus _ Foundation Permit Fee $ Other Permit Fee $ _ TOTAL $ Check # A C`l 5 1r. 6 8j Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING a- .S x `�.��£... ,.. . ,. ;*a.. $� 'i fix, r u' � `�.<p r•%� .%' z�`�. °' ° `:'"��Y BUILDING PERMIT NUMBER: DATE ISSUED: 0 . SIGNATURE: 1114 It Building Commissioner/Inspector f Buildings Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: W Zoning District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide red Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑> Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record J4F-t.EN R a M E-LI- NAS-5 14Ua o Name(Print) Address for Service: NO , 41VI)OVF— k � Signature Telephone r A 2.2 Owner of Record: \ Name Print Address for Service: z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number A ss icExpiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number �• .aZ() b � L P Z> S E A s -- o Expiration Date Signature Telephone SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Si ned affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check all applicable New Construction 0 Existing Building e Repairs) Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SrR_1ie f QF-R0aF SECTION 6-ESTIMATED CONSTRUCTION COSTS • Item Estimated Cost(Dollar)to be s �OCA .IISE NTY ' .& : sr r `� zst� as tri t Completed by pemtit applicant x ,y,_ �, � •.t� >, _ 1. Building Ar (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(s) x (n) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN �., OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT er ,' I, as Owner/Authorized Agent of subject property e Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION DAVID CARI —hA EI, as Owner uthorized Agen of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief C Print e b Si ahue of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST 2 ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Town of North Andover & tt ORT Building Department 0 s w 27 Charles Street North Andover Massachusetts 01845 h^ (978) 688-9545 Fax(978) 688-9542 ,°AoR;,ro �Ssace�u��� DEBRIS DISPOSAL FORM i In accordance with the provisions of MGL c 40 s 54, and a condition of. Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, sl 50a. The debris will be disposed of in/at: Facility location Signature of Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. PAGE kt 1 DATE(UNWOONY) A!GOB-D. CERTIFICATE OF LIABILITY INSURANCE 06/04/2001 PROiDUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE INTERNET INSURANCE A=NCY HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 52.2 CHICRZAING ROAD NORTH ANDOVER, H& 01645 INSURERS AFFORDING COVERAGE INSURED INSURER A: ARBEIJ A DAVID CASTRICONE INSURER E: AMWA A MTECTION ROOFING AND SIDING INC. INSURER C; IMTERN CASVALTY 200 SUTTON STREET, SUITE 226 INSURER D: NORTH ANDOVER tom► 01845- INSURER E: COVERAGES TME POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TMI$CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRtrR TYpE OF INSURANCE POLICY NUMBER gAM POLICY PfFECTIVE POLICY EXPIRATI LIMITS GENERAL LWBIUTY EACH OCCURRENCE 1 1,000,000 A COMMERCIALGENERALUABII-ITY 8500012710 06/06/2000 06/06/2001 FIRE DAMAGE on*fire) 9 50,000 CLAIMS MME M OCCUR MED EXP Anone person) .S 5 000 Ob/06/2001 06/06/2002 PERSONAL BADV INJURY S 1,000 000 GENERAL AGGREGATE j 1 _,000,000 OP-NIL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP A00 5 14000,000 In POLICY Ini P O. FM LOC AUTOMOBILE LIAIIUTY COMBINED SINOLE LIMIT E ANY AUTO (Es■ocideM) e ALL OWNED AUTOS 44506400001 08/01/2000 08/01/2001 BODILY INJURY sCMEOULEDAUTOS (Per person) j 250,000 HIRED AUTOS I (sDldRYNON-OWNED AUTOS Pawem) s 500,000 I PROPERTY OAM44E S 100,000 1 (For 800dM) GARAGE UAUIUTY AUTO ONLY-EA ACCIDENT j ❑ ANY AUTO OTHER THAN EAACC $ AUTO ONLY: AOG IS EXCESS LIABILITY EACH OCCURRENCE S OCCUR CLAIMS MADE AGGREGATE 1 OEOUCTIBLE S RETENTION S is WORKERS COMPENSATION ANOWIC STATU.- _ S EMPLOYERS'LIABILITY 1 C 99 A24009 09/29/2000 09/29/2001 E.L.EACH ACCIDENT s 100,004 I E.L.DISEABE-EAEMPLOYE S 500,000 OmER E.L.DISEASE-POLICYLIMIT is 100,000 DESCRIPTION OP OPERATIONSILOCATIONBIVEHICLES/EXCLUSIONS ADDED BY ENDO RSEMENT/$PECIAL PROVISIONS ADDITIONAL INSURED: LSM REALTY TRUST CERTIFICATE HOLDER ADDITIONAL INSURED•INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIpID POLICIES 8E CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 010 DAYS WRITTEN NOTICE TO TWE CERTIFICATE MOLDER NAMED TO THE LEFT,BUT FAILURE TO DO$0 SHALL IMPOSE NO OSUOATION OR LLASIUTY OF ANY KIND UPON THE INSURER,ITS A06NTB OR nn Ba ve AMPEARY D CORPORATION 1988 NORT►-� ED / ® ® ®ver 0 - o ,6� cor".0 y dower, Mass., ADRATED PPS` �y BOARD OF HEALTH PERMIT T . D Food/Kitchen Septic System / BUILDING INSPECTOR /I THIS CERTIFIES THAT............jj ..�.f!e V.......... .U.1'�.v.: ..1<..................................................................... Foundation has permission to ong-.....�54Rl. ........ buildings on ...... 4pl?.9"Aa../......... 1¢S 5...../`�u� Rough to be occupied as 'F- ..r`..�'...o /��S .,w�la / cs /R��� Chimney ............ . 0 .......................................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. 6/"?, �� PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTI N T'S ELECTRICAL INSPECTOR Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE smoke Det. _ Date. . ..'.. . 2326 . A - "OR, TOWN OFNORTH ANDOVER PERMIT FOR GAS INSTALLATIONcu$ SACNU`� - . � f w This certi ies that '.'5r cc has permission,for gas installation . . . . : f in the buildings of at ,7. (. .�G`.�::. , North Andover, Mass. Fee d Lic.:No. . . . . . . .. . . . . . . . . . . . GAS INSPECTOR i WHITE Applicant . tCANARY Building Dept PINK Treasurer GOLD File at+�.M-•i�ar�s1%i-..`�.epw�-[.�.it$..uwJ-+-�w1(. �.e`=., uw.-�sS3..1..da u...... �k�.�Lry_. '���._. _...—'1.�._ _ .__ � I • „ I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTINO (Print or Type) NORTH ANDOVER Mass. Date 1'7 Permit # 3 IS kuilding Location �c Ow ers Name . . New '-1 Renovation j] Replacement Plans Submitted r] S FIX U'Dalz N � W N z ts: of • w a m oc .o � � = I�— m v en r s ar 0 cc W Z m m r w w o O 4 W 4 st w t — .. H as Y w w W ox. V aC 'vs m = a °, G tjN cc W < tc .• 4 ,ttty W O '� c 4 < O O W '— O W F- Q Z O t.� u. G O .1 V rt > G o. t- O S U i�—t3 S 1dT. BASEMENT I IST FLOOR 2140 FLOOR i 3110 FLOOR 4TH FLOOR 11 1E STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR (Print or Type) Check one: Certificate Installing Company Name ANDOVER PLG. & HEATING CO. , fA . Corp. 2122 Address 573 1 /2 SO UNION SI-..-- Partner. LAWRENCE, MA. 01843 Firm/Co. Business Telephone: 508 685-8383 Name of Licensed Plumber or Gas Fitter_ GFORrF l AROSE 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 coverages. Signature of owner/agent of property Owner Agent El I hereby certify that all of the deuds and Infotmation 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 petfomted under Permit iueed for this application ww-be in compliance with all Fatinenl provisions of the Mauachusetts State Cas Code and CbApta 14:of the Central LtwL By YPE LICENSE: Title P�sfitter' si ature of Licensed Master City/Town: Plumber or Gasfitter Journeyman APPROVED (OFFICE USE ONLY) L License IJumber