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HomeMy WebLinkAboutMiscellaneous - 14 BROWNS COURT 4/30/2018 J —14 BROWNS COURT fff 2101041.0-003-0000.0 =�— I I I i I ' r, i II kf s Date......... ...... 10069 '40"T TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that.--- .,, ... .............................. ..................................................................................... . has permission to perform............. ..a-:--\ P — .... . ....... ............................................................... plumbingin the buildings of.............................................................................................. �k - N) CH - at......... . . ............. ... ............................. ..................... North Andover, Mass. Fee.. ...........Lic. No. k7.................................................................... PLUMBING INSPECTOR Check# IMASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY 0 -11 MA DATE PERMIT# JOBSITE ADDRESS /"(fir✓ OWNER'S NAME ; POWNER ADDRESS TEL dFAX j TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL M RESIDENTIAL M PRINT CLEARLY NEW: RENOVATION:© REPLACEMENT: ® PLANS SUBMITTED: YES M NOM FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE j DEDICATED SPECIAL WASTE SYSTEM I DEDICATED GAS/OILISAND SYSTEM _ J DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM { _ - l _..I ( I ( f f DEDICATED WATER RECYCLE SYSTEM 1 _-,___-J _.___{ _j _ ____ ( _J __.._► .^__1 I_.__---I E_J1[ —_.k --I _ f DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER i I ._..-- I f I FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK I _J 1 ._—f 1 1 { ._..I ------I LAVATORY ( --( - - { _J ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET [ -__-. I € URINAL WASHING MACHINE CONNECT N ( ( s I _..._..f ___- ...,_J ___3 __._J WATER HEATER ALL TYPES V WATER PIPING Oi*ER _� f —! __.--.1 __i ___J U—] __--4 INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES� NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW (�t LIABILITY INSURANCE POLICY Mi' OTHER TYPE OF INDEMNITY M BOND Q 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 �Q 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 permit issued for this application will be in compliance with all Pertine t provision of the IMlassachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME e O v✓ LICENSE# _ SIGNATURE MP© JP� CORPORATION n# PARTNERSHIP # ?LLC COMPANY NAME ,re r� ADDRESS pd�_ _4 --1::Vr CITY1 STATE _ ZIP (9 _ TEL FAX CELL ._._. EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTLONNOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ 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,--- A licant Information A PIease Print Legibly Name(Business/Organization/fndividual): �' O'G/ �' e Address: cJ City/StatL P Phone Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. El am a general contractor and I 6. E]Now construction ployees(full and/or part-time).* have]fired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. [J Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.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#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 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.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 for insurance coverage verification. I do hereby certtfy under the pains and pen •lies ofperjury Aat the information provided above is true and correct. Si ature: Date: Phone#: /� � � 3 a�j�+/ Y 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#: Ilk 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 employeiis 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 maybe 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 bum 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 CoMAORW.0althofMassachusetts Department of%dustrial.Accidents Office ofwestigations 600 Washington Street Boston}MA 02111 Tel.#G17-727-4900 ext 406 or 1-877:MASSAFE Revised 5-26-05 Fax#617-7277749 www.mass,govaa Date... .................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Thiscertifies that ................................................................................................ has permission for gas installation ............................................................ 0-Te inthe buildings of............................ ............................................ at.......!.L�.............. .............4......................................... North Andover, Mass. Fee... Lic. No 2W513 ...... No:2W513..:. .................................................. GASINSPECTOR Check# 9658 l( -CN- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK {x I CITY _ _ MA DATE�� PERMIT# lT -- JOBSITEADDRESS / / ��1yej _ �II OWNER'S NAME I� _ Tye II OWNER ADDRESS T4L ��FAX ^ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL2k--1*' PRINT CLEARLY NEW:[ RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES F--J1 NO APPLIANCES Z FLOORS- BSM' 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACEI — FRYOLATOR FURNACE GENERATOR GRILLEImo- -- INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN � x.�_. . :z 1L - _--► _ - __ IT. � I I- l. .. - . _1 POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT —� �— _. ��— -.. _I --I, -- I -- TEST �— UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER .. ....... _._....._.. . ....................__............ INSURANCE COVERAGE 1 have_a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY � OTHER TYPE INDEMNITY © BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 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 permit issued for this application will be in compliance w th rtinent pro 'sion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME U✓ LICENSE# SIGNATURE MP 0__I MGF Oi JP JGF 0 LPGI© CORPORATION Q# PARTNERSHIP®#�_�LLC[E# _,_ . _1 COMPANY NAME /'P_ ADDRESS CITY _ STATE=ZIP _ TEL _ FAX CELL _-EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION OTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES C" Division of Professional Licensure: License Search Page 1 of 1 The Chi Website of the Office of C mrAm er Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov dome State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES ....................................................................................................................................................................................................................................................... Check a License Check A Professional License Lutea licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency LICENSEE More... Name: DANIEL J. DOORE REFERENCES& LAWRENCE,MA RELATED INFO NEW SEARCHJ Disclaimer Regarding "This Licensee has additional Licenses,click here to view them." website License Searches Glossary of License Status Codes Licensing Board: PLUMBERS ft GASFITTERS License Type: JOURNEYMAN PLUMBER More... License Number: 24393 Status: CURRENT Expiration Date: 5/1/2016 Issue Date: 10/17/1995 Exam Date: 9/9/1995 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Thursday,November 13,2014 at 9:18:00 AM. 2007 2011 Cominonweafth of Massachusetts Site Policies Contact Us http://license.reg.state.ma.us/public/pubLicenseQ.asp?board_code=PL&type_class=_J&li... 11/13/2014 , " : s� . t�a;,. t ! ;.3 It i)r; r�� L.�t✓,i�G�d FOR PERM11 iU UU uLL311r3tr11r4U (Print or Type( NORTH ANDOVER, Mass. Cats � � � ff'� W Bugding /// PWrnK *- O �`s Location 7 Owner'aS P/!,,,- ? 74W4- Name New Q Renovation Replacement ff' Ptffins Submitted: Yes❑ No.❑ FIXTURES sr �. A 8St t • A A O; • 1- A t•- A d >e A A } u M M S M t ti 44 '' A 2 O A e, O z 19 U s • 1e s ►. 4 R a s ae t s s O O y < r s 7 .e ail •• A < fa = et ; 19 r `` o 16 Xyy sua—esirT. 111A49MCNIT IST 1111.00111 SAID FLOOR 3AO FLOOR 4 H TLOOR sTH FLOOR 411r11 FLOOR. 7TH FLOOR ( !! f aTH FLOOR .-.- . � � Mack OM: Carl.�icaia Installing Company Name _ l�rl�+y Corp. Address le 11) LN a(lAt1 L� ;'tn ❑Partnership ofirm/Co. BuslnessTelephone_(�c'�� _Named licensed Plumber. ujt�; 1044 INSURANCE COVERAGE: Checx one I have a current liability Insurance policy or Rs substantial equivalent. Yes 0 No 5K It you have checked yam, please Indicate the type coverage by checking the appropriate box A liability Insurance policy C Cther type d in lamndy E3 Bond O OWNER'S tNSURANCE WAIVER: 1 am aware that the licensee does not have the Insuranca coverage required by Chapter JA2 d the Mass. eneml Laws, rid t my signature on Ihla permit application waives this requirement., Check one:Ngn Owner 0 Agent C slur•of e1 « / I hereby csrtity that a8 of the Walls and Information i hays suubmittrd kx entered)in above appkatlon are true and accurate to the bast of my knowledge and that al plumbing work and InsWalbns Worn-ed uruier the permit issued for Ws appkation will be in compliance with aA pertinent provisions of the Massachusetts Slate Plumbing Code and Glaptar 142 of the Gum IDY 7"'NM�L 541n4tuire of Licensed Pkmnbw Title License"=bw Cttyff own Type of Plunbang Uanse: Master APPflOWD(OFF)CE USE ONLY) Journeyman 0 t Date. 683 ftNORTM 1 O TOWN OF NORTH ANDOVER O •No �° ti PERMIT FOR PLUMBING ,SSAcmus6� This certifies that . . . . . . . . . . . . . . . has permission to perform . ,i.1 '.!(l >. . . . . . plumbing in the b ildings of . . �... . . . L I.y. .l. .�4...• at. . . . j . . . . .. . . . . . ., North Andover, Mass. Fee.2S." .Lic. NY �l .9 7 . . . . . . . . . . . . . . . . . . . . . . . . . : . . j PLUMBING INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File I~ , MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING t (Print or Type) NORTH ANDOVER Mass. Date -M 70 3, `" Building Location � L B k4DQ KJ C t Permit # Owners Name sFt.-4, ' New 7-7 Renovation 10 Replacement Q Plans Submitted D G� F:1 X'-Ll C> � trt N y Q Cf t. p (A = w W G O V Q 1" of s W W I�.t- O •Fd:� % d w W t1 c W Ul W .l r Z J ? U- W O ZcwF- wti w.O1 CtFto OUC a wy O BASEMENT ( I I I ( I I I I I -IST FLOOR i 2ND FLOOR I I ! I I I I I I I I I I I I I ( t 3RD FLOOR I I I I I I I I I I I I ( I I I ) 4TH FLOOR I ( ( I I I I I I ( I I I ( I 5TH FLOOR 7TK FLOOR STH FLQOR I f I (Print or Type) / Check one: Certificate Installing Company Name �G,,✓ 9. SnIze/Z/ Q Corp. Address111-2 .rq/tlGImcly E4ti/G�adr'%''L Q Partner. r Q Q Firm/Co. Business Telephone: Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Q Other type of indemnity Q Bond Q Insurance Waiver: I , the undersigned, have been made aware that the licensee of this ap icatio s t .a a one of the above three insurance coverages. ignature of r ag of propert,,• Owner Q Agent I hereby certify that all of the deuds and information I have autmitted (or entered)in above appliration are true and acc=zte to the best of my knowledge and (Stat aLL plumbing worst and InuALLations perfamed unser Ptr•rit i cued for this appLicatioo will be In compliance with all peilincat ptovisions of the A4aasachusetts State Cat Cade and Cbaptez la:of rho Geancr l Lws. B TYPE LICENSE: �� Y ("'� Plumber Title 374 Gasfitter Signature of Licensed City/Town: Master Plumber or Gasfitter l Journeyman M Sf APPROVED (OFFICE USE ONLY) License brumber 3 A' AUTHORIZATION CARD A I � FALL 1995 • Offer Valid September 1, 1995 to October 31, 1995Y J Equtment must be installed by November 30, 1995 y) Check one: 0'5250 Heat O'f50 Hot Water 0 3 Years Guardian Care y Installer J!jrchaAa _ I certify that have installed the followinggas heating or NAME ��✓lc� - - water heating equi meet at the ad cess below. ' g` ADDRESSIfil ADDRESS CITY/rOWN CITY/TOWN STATE n ZIP DATE INSTALLED TELEPHONE 79 O GAS HEATING O GAS WATER HEATER I heard about this offer by: BRAND O Direct Maieating� i frac MODEL# BTU 04ther EQUIPMENT AFUE Bay State Gas will confirm that the installation has been HEATING FUEL REPLACED: 0 OIL 0 ELECTRICITY completed. 0 OTHER Confirmed by Date SIGNED Cust.Aoct.No. ` COMPANY FIF/CCS No. ��a �✓� COMPANY USE ONLY SPC 63 NO POSTAGE NECESSARY IF MAILED IN THE UNITED STATES BUSINESS REPLY MAIL FIRST-CLASS MAIL PERMIT NO.721 LAWRENCE,MA POSTAGE WILL BE PAID BY ADDRESSEE BAY STATE GAS ATTN: MARTY POULIN 55 MARSTON STREET LAWRENCE, MA 01841-9986 ������6 Say State Gas Company GAS INSTALLATION AUTHORIZATION Date lPra�"Q�`✓ Issued to AJ r ` &kQ6_b A/C Address d w&S L� &II A�- For Installation of: ��S4aG d wew BTU Input Restrictions BSG Representative PERMIT ISSUED _ BY INSPECTOR This Portion of Authorization To Be Returned to BSG. Inspection Has Been Made of the Following Gas Equipment: ❑ Heating System (BTU Input ) ❑ Range ❑ Water Heater ❑ Clothes Dryer ❑ Room Heater Location All Work Has Been Done In Accordance With The Massachusetts State Gas Code And Is Ready For Use. INSPECTOR NO POSTAGE NECESSARY IF MAILED IN THE UNITED STATES BUSINESS REPLY CARD FIRST CLASS PERMIT NO.721 LAWRENCE,MA POSTAGE WILL BE PAID BY ADDRESSEE BAY STATE GAS COMPANY ATTN: SALES DEPT. 55 Marston Street Lawrence, MA 01840 GG / Date. ..` ........ t � 1970 f pORTry , TOWN OF NORTH ANDOVER ,q ti0 A 3r M PERMIT FOR GAS INSTALLATION s s A 3 �9SSACHUSE� C This certifies that . �. . . . . . . has permission for gas `installation . . . . . . . - . . in the buildi gs of . �.? .1 . .t. . . . . . . . . ._. at /. y ... . . . . . . . . . . . . .. North Andover, Mas ;a; hFele.-�/� �Lic. No%/.am�,. ... . . . . . . . . . . . . . . . . . . . . . l k St7�SU J Su GAS INSPECTOR WHITE:Applicant CANARY:Building pt. PINK:Treasurer GOLD: File