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HomeMy WebLinkAboutMiscellaneous - 14 STACY DRIVE 4/30/2018 14 S7ACY DRIVE 210/081.0-0058-0000.0 Date-9-1.)-a-I..1-.2................. 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ss�cHU This certifies that ...M.-6U. .MAV.(..........U..Ay.4....... has permission for gas installation ...... -G-............................ in the buildings of......../Om v- r4.�-,-ell ........... Mc ( ............................................ at.......j..y..........S.4, ............ North Andover, Mass. Fee!?.O.......... Lic. No. ...... . .. .................................................................... GASINSPECTOR Check# Lm .0e MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY Vr MA DATE PERMIT# max:w L JOBSITE ADDRESS—A/ 7 1 OWNER'S NAME A& GOWNER ADDRESS TEL �,5 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[ PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:x PLANS SUBMITTED: YES❑ NOj(�— APPLIANCES-1 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 3 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS J MAKEUP AIR UNIT OVEN POOL HEATER — ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑ �, I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ z 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 ❑ AGENT E]SIGNATURE OF OWNER OR AGENT N I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli ncg with all Pert' r vi ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Michael H. House LICENSE# 7173 ��1 SIGNAT E MP D�MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATION S�# 3377C PARTNERSHIP❑# LLC❑# COMPANY NAME MERRIMACK VALLEY CORP. ADDRESS 15 AEGEAN DRIVE, UNIT #3 CITY METHUEN STATE MA ZIP 01844 TEL 978-689-0224 FAX 978-689-2206 CELL 978-815-4523 EMAIL ZIA 1011 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No � 2 ^`3 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,Mass. 02111 www mass gov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: /��°rJit>cP.� ,�,� e7jeof�� Are you an employer?Check the appropriate box: Type of project(required): 1. I am an employer with 4. 0 I am a general contractor and I 6. C New construction employees(full and/or part time).* have hired the sub-contractors 2. :1 1 am a sole proprietor or partner. listed on the attached sheet. 7. C Remodeling ship and have no employees These sub-contractors have 8. L Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.t 9• ❑Building addition required] 5.0 We are a corporation and its 10. C Electrical repairs or additions 3. 11 I am a homeowner doing all work officers have exercised their myself [No workers'comp. right of exemption perm MGL 11. C Plumbing repairs or additions insurance required]t c. 152,§ 1(4),and we have no 12. 1,Roof repairs employees.[no workers' ' comp.insurance required.] 13 Other -U )Vl *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy tuformation. ;Homeowners who submit this affidavit indicating they are doing an work and then hire outside contractors must submit a new affidavit indicating such. $Contactors that check this box must attach an additional sheet showing the name of the sub contractors and state whether or not those entities have employees If the sub-contractors have employees.-they must Provide their workers'cum ,Policy number. I am an employer that is providing workerscompensation insurance for my employees.Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#:_�Qj/��,(/Ljl( /3 Expiration Date: 3, / Job Site Address• / �� /a `tl City/State/Zip: ,4j /�,t� ,� �©�9/ 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 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 $250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. Ido herby cern nder t ns nd p ti o p jury that the infor ' n provided above is true and correct. Si nature: �J�A�'r/2� Date: Print Name: Official use only Do not write in this area to be completed by city or town official City or Town: Permit/license#• Issuing Authority(circle one): 1.Board of Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#• 001kA1Ql iVEALTH OF MASSACHUSETTS �"L�ERS AND GASF(T"�'��t�. : ' E1 D AS A VASTER PL.�ER ISSUES THE ABOVE LICENSE TO:- HiCHA .. HHOUSE :-63 RAIMH LN 'E 'l4 TWP ME 0441`4-6137 85/83/14 G Z Date!. . .. . ORT .4 O' 0 , TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SACHUS c(� This cerfWies that ff,4�em—,ej. .��".! � • has permission to perform . . 1�� p7` 4>`7 72 / plumbing in the buildings of . .Sv !u. . �?'. . . . . �� . . . . at. �� '. . .�2 vF � / North Andov�)r, Mass. PLUMBING INSPECTOR Check # 5—'5 ;7 5 '+ 23 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING f SS �L (Type or print) Cklk NORTH ANDOVER,MASSACHUSETTS ) �.- [� Date /,/2-3)0) Building Location STS'c 1911- Owners Name Tolls c ,4LH Permit#S' Amount ,�oMow Type of Occupancy Owe i/. � New Renovation Replacement ® Plans Submitted Yes ❑ No FIXTURES A SL$Bsv»c lS>C FIDCR M HBM 3M HDM 4M Hf= 5M Hf CB 6M Hi" 7M MOM 9M HAOCIR (Print or type) Check one: Certificate Installing Company Name 1,44//y 4,4- ❑ Corp. Address - 1�D" "Jn X s-J Z ❑ Partner. ems...'itN-C_ Business Te ep one l yr 93_0 T E] Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy JD Other type of indemnity El . Bond El 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 r Owner El Agent El 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 Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plu bin2 of the General Laws. By: Signa ure o Licensee rr►umoer Type of Plumbing License Title Z Yy 3 3 City/Town icense Numoer Master ❑ Journeyman APPROVED(OFFICE USE ONLY Date. ... ....�.. ..0.... .- . NORTH Of .ao ".,tip o= 0� TOWN OF NORTH ANDOVER ~ q 9 PPWAW PERMIT FOR GAS INSTALLATION SACH `'SE� This certifies that . . !:rA . �?�./ � P � �. . . . . . . . . . . . . . . . . has permission for gas installation . . /`�. .�{,!(�Y. . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . ./. /. . . . 5.�.�.C.�. . �� �. . . , North Andover, Mass. Fee. . . . . Lic. No. . 3. ��<�... . ... . . . . . . . GAS INSPECTOR Check J �: n MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO.GASFITTING tPrint or Type? Date J _qas GZ Permit # - Building Location �`/ 5-7-,1 r ti oo`t MC&A 4 v-e Z Owner's Name_�011h' /YI Type of Occupancy_ Owe/1. � New p Renovation ❑ Replacement Plans Submitted: Yes❑ No,g in U3 C to C Cl y J y U p i- C W _ v a < } x — C N Q W Q ` f t17 Q C < W W W0 W < C .� C C w. ~ W h- 2 a r 2 J f- ` W C C > LL > La C C = W o < W > C w < C < < o O us O w H C _ O t7 _ W O 3 C C J U C > G a H O _ ' Sub—a�i.iT• I ! I I I i i t i i i. I (I I I � � � BASEMENT ! ( I I ( I I I ( I I I ( I I IST FLOOR I I I I I I I I I I I I I I 2ND FLOOR I I I I I I I I I I I I ( I I I I I I I ( ( I 3RD FLOOR I- I I I I I I I I I I I I ( I I I7 47H FLOOR I I I I I I I I I I I I I f I ( I 5TH FLOOR 6TH FLOOR 7TH FLOOR I ( I I I I I I I I I I ( I I ( I I I I BTH FLOOR I I I I I I I 1 I Installing Company Name h�1164* .Ozvn i1.:� Check one: Certificate Address—/6-,0. 4o e 1.� ❑ Corporation ❑. Partnership Business Telephone 1�5�a.`' `i Firm/Co. - Name of Licensed Plumber or.Gas Fitter 20"n. A/*//e I INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ?' No EJ If you have c ecked ves. please indicate the type coverace by checking the appropriate box. A liability insurance pdicy R Other type of indemnfty❑ 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: S+gnature of Owner or Owners Agent Owner❑ Agent ❑ !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 rno++'ledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State.Gzs Code and Chapter 142 of the General Laws. i T of License: itle Plumber S+gnature of Ucensed Plumber or Gas Fitter Gasfitter Master License Number 33 atY/Town :�.ioumeyman LVED(OPTIC US ONL