The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 137 BRENTWOOD CIRCLE 4/30/2018 (2) 137 gREN1�M00D CIRCLE 21010640000.0` TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation .lil'"�- zx . . . . . . . . . . . . . . . . . . . . in the buildings of. . . . r . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , North Andover Mass. Fee... . . . . . . Lie.No �97 �. . GASINSPECTO Check#.?�"-r 8691 �p z,, , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY / ,Q.J_ a MA DATE i` 11 PERMIT# - JOBSITE ADDRESS /�� ,e- TIMI k�A� r'' WNER'S NAME 'n GOWNER ADDRESS r e n n r TE T 3.1 A_k_?_- 7� JJFAX TYPE OR OCCUPANCY TYPE COMMERCIAL.II EDUCATIONAL D RESIDENTIAL PRINT CLEARLY NEW:[ RENOVATION:® REPLACEMENT: PLANS SUBMITTED: YES 0 NO[]_I APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14 BOILER - BOOSTER CONVERSION BURNER COOK STOVEM . _ i DIRECT VENT HEATERI DRYER FIREPLACE FRYOLATOR FURNACE ( I�. I t. I� r—EZ -- GENERATOR „1I III NVIRARED HEATER J _ I _ =j -_- ---1 LABORATORY COCKS _-- J-- -1 I- . J I MAKEUP AIR UNIT J L.J J_._. . OVEN POOL HEATER ROOM/SPACE HEATER L - ROOF TOP UNIT TEST _._j I_ UNIT HEATER _ UNVENTED ROOM HEATERI _ _ . WATER HEATER _ !-_ _11`-J OTHER � �( L ( I -- - -- - � _-_ --- -- I 4 _-- INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES jalro-11 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY El 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 _-JI AGENT 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 ofmy knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance ith all Pertinent pr . ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER GASFITTER NAMEFA6,,,,, LICENSE# IGNATURE -- MP El MGF JP JGF LPGI[I] CORPORATION 0# -- !1 PARTNERSHIP D# LLC #�e � _�1 COMPANY NAME: � /� !ADDRESS 2 CITY STATE ..rJ/ ZIP�CTEL , FAX CELL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ n FEE: $ PERMIT# PLAN REVIEW NOTES 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): 6�or 060 09 it/ Y �/� Address: V1-6- PI-If 1A10 X City/State/Zip: /-/+�/Oc1^��rr rf '`V Phone#: � rS' ,�..?a d 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 1 6. ❑New construction e 2.Val=a soleoyees (full and/or part-time).* have hired the sub-contractors proprietor or partner- listed on the attached sheet.# 7. El Remodeling ship and'have no employees These sub-contractors have 8. EJDemolition working for me in any capacity. workers'comp.insurance. g, E]Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑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 t required.] employees.[No workers' ME]'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 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 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 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 for insurance coverage verification. I do hereby certify u r the pains a e hies of perjury that the information provided above is true and correct. 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#: 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 threeapartments 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 r 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 Mossochvsetts i Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston,MA.02111 Tel#617-72.7-4900 ext 406 or 1-8777MASSAFB Revised 5-26-05 Fax##617-727-7749 www.zvass.gov/dia Date. . . . . . . . HOR7: o TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING • o �• a SA US This certifies that (d' .I, � .�1 ! ., :t�. . . . . . has permission to perform : x- .1. � ,f 1i!�- . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . at. North Andover, Mass. Fee�S `. .Lic. No.S .Y77. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR ' Check 46059 'MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING fPri - - nt or Type) NO ,i , / q _.NO.A- ADDUkke Mass. Date �V#U f �Zofiy Permit Bulding Location8f.*il7r1V000 6fZfrjlr owneCs`Name 1 CIE. n . Type of Occupancy Rist 041uGf-- New Q Renovation O Replacement. 9 'Planss Submitted: Yes❑ No .V FIXTURES z rA • W Y J to < V �. N z Dgo ¢ h S ¢ h V W M Y < XL d1 W z d ` � W N ¢ J pa -6 v. _ < i 3 3 ° z _ eL o t- < < m U. Y � Y J m es o n J 3 = F• �. y, v .a < 3 ¢ m o SUR—B S MT. BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name If DIunBa TA'y[ Check one:. Certificate Address__-- Y'/�►0. 661. 72-8Corporation .160 • 14t&oVC:K- IMA . 01 ,9S `Q'Partnershlp Business Telephone_ t8 -97S- ZQ� O Funt/Co. Name of Licensed Plumber INSURANCE COVERAGE: 1 have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142: Yes No ❑ + If you Have checked yes, please indicate the type coverage by checking the appropriate box A liability Insurance policy �9- Other type of Indemnity O Bond O 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: Owner Q Agent❑ Signature of Owner w Owner's 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 the permit L=ed for this application will be in compliance with.all pertinent provisions of the Massachusetts Stale Plumbing Code and Chapter 142 of the General Laws. Signature of licensed Plumber Tail Type of License:MastertJ Journeyman Q City/Town fl USE ONLY) License Number 8547 Date.. .. ... .... ..... ,,ORTPI ° TOWN OF NORTH ANDOVER O P PERMIT FOR GAS INSTALLATION SSAC HUSEt This certifies that .%t.- has permission for gas installation . � in the buildings of L= ' . . . . . . . . . . . . . . . . . . . . . . . . . . . at �. �� llJJ� . ., North Andover, Mass. Fee. Lic. No.. �. . . . . . . . . . . . . . . . . . . . . . .. .. . GAS INSPECTOR Check# 4767 MASSACHUSETTS UNIFORM APPLICATION, FOR PERMIT TO DO GASFITTING (Print or Type) W Ijo (�PVIDOVi Mass. Date' 7vov*- 14 - -a Permit # + Building Location 117 6460M.'066.'066 CiCdC Owner's Name eve f Type of Occupancy i(&St IDfcNGk New O Renovation ❑ Replacement L ' Plans Submitted: Yes ❑ No U) W vi W X U cc � cr Lu W � W o8mZ � = O W Q Z O z fnIr CO fn 0 co W = fn w ° cn Occ > W Ir t] _ 0 F- Z J H Z t.., W W 0 p Z QLL FW- W QJ 0 W Q W > Q W j Z Q x Q r� 0 V W � V W t cc x O cry = LL n 3 c� it •> a a. P O SUB-BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR LL— Installing Company Name WiTt Pock, Plt.,do,jtj6 144*r N& Check one: Certificate # Address PD 9!% 92.» D' Corporation I(oo9 N "aue,� - moi , 0104 ❑ Partnership Business Telephone 175 g2S' f.-Z49• ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter 146&71- 13(.WC-Aee'YiG j INSURANCE COVERAGE: 4 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 5 No ❑ If you have checked Lies, please indicate the type coverage by checking the appropriate box. A liability insurance policy.*4;;� Other 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 1:1 Agent 11 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 installation performed under the permit issued for this application will be in compliance with all pertinent*.provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. i„ By Type of License: f2rl, �r7 Plumber Title f7 Gasfitter Signature of Licensed Plumber or Gas Fitter Cftyffown Master License Number ! t APPROVED(OFFICE USE ONLY) Journeyman MG RTM TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING cHUS This certifies that 4,L/, has permission to perform-,..,, ��'. �. . . .(;P,). . . . . . . . 1 plumbing int buildings of . . . . . . . . . . . . . . . . . . . . . . . . . § } at. . 7. . . .. . . . .. North Andover, Mass. a Fe ,. . .Lic. No.. . . . . . . . . . . . // . . . . . . . . PLUMBING IN Pif?TOR i 08/14/99 15:06 29.04 PAID WHITE:Applicant CANARY: Building Dept. PINK:Treasurer MAP D MASSACH JSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING PARCEL 06 or.prm N - SETTS. R / Date g— q Building Location 137 13rV4WOC4 Clrdg Owners Name OIC-A and �/P e Permit# g110 -I Amount ';?7 °z7 U n d a vel Type of Occupancy . S f Q� P/1 C New Renovation ❑ Replacement Plans Submitted Yes ® No FIXTURES An Cr x x r4 - - t_ V 5od F� vi A_. a A —0. - _ '. pC A dna TA- E� Zn ,O MROW 3)M HIM 4IH I+IDQt 6M FLOM 7M FLOW M (Print or type) 1 Check one: Certificate. Installing Company Name ��j i/e ago c k P S f/ Ca rp Corp.. /6 0 4 G Address (5' 0)( 7 Z R tt��t Partner. Business Telephone. lej7r, (j y 5 4:Z 9 ® Finn/Co. - Name of Licensed Plumber: Insurance Cove rage: hidicate th of insurance_coverage by checking.the'appwpnate box Liability insurance policy Other type of mdeinmty .® 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 andthat.all.plumbing work and installations performeduTi4We it is ed.for.this apphcat on•.will.be in _ . compliance with all pertinent provisions of the Ma hu tts Sta .Plum ing d Ch f the Gcneral.Laws.. By: Signature-ot LicenseaP7177777 - Typ�of Plumbing License Title 1 City/Town cense um e ':Master' Jrnn APPR-&VEDVWFCE USE ONLY ' 323 1 Date..�J:. . L��!•••••• ` HpRTM TOWN OF NORTH ANDOVER pF „•o ,e,hp O r PERMIT FOR GAS INSTALLATION 9- 4L' o S SAC14U5Et This certifies that . . . ... "` . . . . . .. .S has permission for gas installation o� in the buildings f . ?.-c. .. . . . . . . . . . . . . . . . . .. . . .. ... . .. at .w. .7 . • •, North Andover, Mass. Fee?n .°=. . . Lic. No.A I/.. . . ?' . . . GAS INSPECTORZ?"� * * WHITE:Applicant CANARY:Building Dept. PINK:Treasurer I LAd MASSA -� UCATON FOR PERMIT TO DO GAS FITTING f �ITYPe or print) Date 6- 9 19 NORTH ANDOVER, MASSACHUSETTS — Building Locations 137 , _LLA Permit# `-3a 1 Amount S 30>1 dry � erg �y a Owner's Name New❑ Renovation ❑ Replacement Plans Submitted ❑ Cr aUj C — �+ ! r z z w w a cn SUB-BASE •NI ENT — m BASEM E N T ,ST. FLOOR 2ND . FLOOR .R D . F L 0 0 R 4T N . F L O O R 5"r ii . F L 0 0 R 6 T 11 . F L O O R 7T 11 . F L O G R 3TH Ft, 00 R (Print or type) Check one: Certificate Installing Company Name / e C f / Carp Corp. /60 o'C Address pOX 7216 ❑ Partner. Business Telephone 975 424 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitterohr 11 P 7!'� INSURANCE COVERAGE Check one: 1 have a current liability Insurance policy or it's substantial equivalent. Yes ❑ NOM If you have checked ves,please indicate the type coverage by checking the appropriate box. Liability insurance policy � Other tvpe of indemnity ❑ Bond ❑ Owners 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 0 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[ss d for this application will be in compliance with all pertinent provisions of the Ma=ssss State Gas Code a Chapter 1 f th coccal Laws. By: Signature of Licensed Plumber Or Gas Fitter Title ❑ Plumber 6 597 City/Town ❑ Gas Fitter LlCenSe Number Master APPROVED(OFFICE USE ONLY) rl Journeyman 3224 Date. IT g....... A "0NTTOWN OF NORTH ANDOVER a 02 0� PERMIT FOR GAS INSTALLATION ,SS�CMuSEt _ L This certifies that . . . c.>. .C1�. . .. . .�U.�1.U. . . . . . . . . . . ..g has permission for gas installation . . . . . .. . . . . .. . . . . . ..., in the buildings of . . . . . . . . . .. . .. ... .. . at kc/?X! .<.� . Sri. . . . , Nsarth Andover, Mass. Fee./af .f". . Lic. No.,1.� �. .. .'- .. . .. . .. /�GAS INSPECT R WHITE:Applicant CANARY:Building Dept. PINK:Treasurer V J MASSACHUSETTS UNJIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) I U— �U7fl�l Mass. Date—l— ,7, tg Permit # Building Location p U�x�R/ �51'Owner's Name(f94Qo�//(J�Cj �Jf�tJL) Type t Occupancy S /A�l 2 New ienov2t;on ReplaCernent Plans Submitted. Yesl No n N F— j5 x v, IN 0 V, = ti�, w o tl= I � �' a r z z 0 1- 7 ¢ U � F w p O a r Q 0 a w 0 cw wLU = a: a w a ¢ O p > w U r Z r z F w w O > w F' U .�. N w Z 4 w' d c _ r } 0 9 z o z W c rn r C ¢ Q0 = O U X t7i. O r" Y o a F 0 --F+I Uj SU8—BSMT, .. H BASEMENT ---rH, � x U 'IST FLOOR — .� Z 2N0 FLOOR W 3RD FLOOR q E 4TH FLOOR. q 5TH FLOOR + •6TH FLOOR 7TH FLOOR O H STH FLOOR H q � .f�f j�j� S dl� Installing Company Name �� ---�� Check one: Certificate O Address 1! f o f ggp 15-r ❑ Corporation ! C1 1 9 q 6 ❑ Pa rship D O Business Telephone Firm/Co. � O + O Name of Licensed Plumber or Gas Fitter a H INSURANCE COV AGE: ' q I have a current bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. z Yes No ❑ 1 + ¢ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy tdseOther type of indemnity❑ Bond C1 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 0.vnar's Agent Owner❑ Agent ❑ I hereby certify that all of the details and informilion I have submittod(or entered)in above 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 applicatior)-wif a in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Law By TFe of License: Plumber Sgnature of Licensed Plumber or Gas Fitter Title I asli �( o� I Masterr License Number `� 4 City/Town I urneyman APPP VEp 0 1 NCY-F---- I