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HomeMy WebLinkAboutMiscellaneous - 141 DALE STREET 4/30/2018 (2) q1 UiLDI ILE Date..1?ZG/1!.. . .... .. . NORTIy 0 TOWN OF NORTH ANDOVER ti _i A • PERMIT FOR GAS INSTALLATION o, SACMUSEt 1 l nn This certifies that . .err.L4.A. ..!! . . . . . . . . . . . . . . ... has permission for gas installation . . s!�'S it P/S'G e . . . . . . in the buildings of/ . .If?el�7 . .&glir4l?. . . . . . . . . . . . . . . . . . at . . . .1. . . .�1 . . . . . -5 . . . . . . . . . . . . . . North/Andover; Mass. . . . cfr �.. .r . . . GAS INSPECTOR Check# 7941 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) Mass. Date1 vim- of 20_"Permit#/ r� ii''tt Building Location I y� 5yyT-,eOwner's Name Owner Tel## Type of Occupancy2 New ❑ Renovation ❑ Replacement ❑ Plan Submitted: Yes ❑ No ❑ FIXTURES W UU) 0 w V) U a W [aJ7 x O UU U x 2 z w ¢ 0z z o W m v) E- W W O a a W Q w w ¢ z LU ¢ � o A > w z F- w w H Z F W tW7 > F U a F W x r ( p z o z W Q W > o cn x m it W z a a Q o o w = o o = w 3 Q 0 a U x > o a �- o w SUB-BSMT s BASEMENT 1sT FLOOR ✓ 2"D FLOOR 3RD FLOOR 4T"FLOOR 5T"FLOOR 6T"FLOOR 7T"FLOOR 8T"FLOOR Installing Company Name Eric C. Foster Plumbing & Heating LLC Check one: Certificate Address 145 Stedman Street Corporation 3092C Chelmsford, MA 01824 ❑ Partnership Business Telephone# 978-256-5976 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Eric C. Foster INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes V No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy 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 ❑ Agent ❑ 1 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 plumbi 9work and installations performed under the permit issued for this application will be in c iance with all ertine t rovision of the Mas acP usetts State Gas Code and Chapter 142 of the Ge ws-_-- BYOC AkLeType of License: • Plumber Signature of Licensed Plu s Fitter Title :las fitter aster License Number City/Town ••Journeyman APPROVED(OFFICE USE ONLY) F I I\Al. IVSI'IJ I IUB ISI.I.(M I OR ()I I K I. l!SI. ONI.1' PRO(IRLti` I\`I'I.0 IIU\(S) FI-:1::: SPLRIIMI1 u APPLICATION FOR PFRIMI I T.O I)O GAS F1-I TING Y NAME R I YPI Of BUILDING LOCATION OF BUILDING SKETCH PLUMBER.GASF IT-1 ER.LP INSTALLER I L1(7ENSE NU.-MBFR: PERMIT GRANTED I i GAS PITTING; INSPECI-IOR I Date....... .���n...`...9...... NORTN °ft"�°:•�"� TOWN OF NORTH ANDOVER p p PERMIT FOR WIRING Z K �,SSACMUS� This certifies that .....:....::.. ?.... �.:.............................................................�--•- .. . ......., � ., . � , , 1 has permission to perform ...•._... .... ' . .. ............................................................... wiring in the building of........................'"� at �y... •...�..'..' --� ... ,North Andover,Mass. F ............... Lic.No..4-.:....... ...............�..: ELEcmcALIN E R Check # 8 5 '! 6 0"7 4 U J Date...��' A. NORTH 1 pf o? °� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION SA US This certifies that . . . -! �/. . .� '�� . . . . . . . . . . . . . . . . . . has permission for gas installation . . . .e,0 ALI1v in the buildings of . . .. . . . . �Lf . " at .1.1//. . .'. . . .. . . .� . . . . . . . . . . . . . . .. North Andover ass. Fee. .2-0-:"" Lic. No.. . . . . . . . . `. GAS INSPECTOR Check# NMSSACHLiSETI5 UNII+D&M APPLICATON FOR PERIM TO DO GAS FITTING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations !411 ,bR L F_ r Permit# Amount$ Ke V l N CB A/ k 4 % N Owner's Name New❑ Renovation ❑ Replacement M Plans Submitted F1 U a ° M a. ox z ° H W q En O M4 a te] W W rn � � a CC 4 �, H A j U3 n' �i O A C7 a U x A 2 H SUB -BASEM ENT BASEMENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR . 4T II . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR ('Print or type) Check one: Certificate Installing Company Name 1 N u 1 N 942° �/N� Corp. Address b D f rC U e A bA ki FlPartner.. 131.1siness Te ephone Firm/Co.- Name irm/Co:Mame of Licensed Plumber or Gas Fitter Ay ) j7 J3, .,8 I IV fi `• INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 1" No If you have checked yes,please indicate the type coverage by checking the appropriate.box. Liability insurance policy Other type of indemnityEl Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 1.12 of the :Plass.General Laws..and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 0 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 nn knowledge and that all plumbing work and installations perrorintA under Permit Issued For this application will be in compliance with all pertinent provisions or the,V1asSachuSettS State Gas Code and Chapter 143 of the General Laws. By: Signature;of Licensed Plumber Or Gas Fitter Title Pltunbcr a CityrTow.n Gas Fitter License i um er Master APPROVED(OFFICE USE ONLY) Journeyman C.ommorttuealth o�///a�aac�iueel Official Use Only r� cc�� rr77 Permit No. eUe�vartinent o�.lire�eruiceb Occupancy and Fee Checked ; BOARD OF FIRE PREVENTION REGULATIONS [Rev- 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 113,-Xyl City or Town of: MY)Ifo✓Cc , M o,, To the Inspec or of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) N I Dale S { Owner or Tenant (/, C V a h c G"O"I Telephone No. 2q-?-3S-7-,7 P� Owner's Address I e V n COA Y A Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building S,,, 1Zuo✓✓1 Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: &,i 2 o c yam►, '7 Qu�)e f s 1,4 A f S Completion o the ollowin table mg be waived by the Inspector of Wires. r No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans r o Total Transformers KVA No.of Luminaire Outlets -- No.of Hot Tubs Generators KVA No.of Luminaires _ Swimming Pool Above - El o.o Units Emergency g a g d. nd. Battery Units No.of Receptacle Outlets — 7 No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches-- No.of Gas Burners No.o Detection an 3 Initiating Devices Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump umber ons KW No.of Self-Contained p Totals: _.... ._........_......---....._.................. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ unicipal ElOther Connection No.of Dryers Heating Appliances KW �No Suriof Devicmes or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts I No.of Devices or E uivalent No.H dromassa a Bathtubs No.of Motors Total HP a ecommumcations inng I I'Y g No.of Devices or E uivalent i OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: / 3 e d 9 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE OVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The, undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) 1 certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: n o✓Ol, LIC.NO.: ,$-13 Licensee:�.. c, r., M c✓l LIC cin tv aN Signature LIC.NO.:/a (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.: 9'18-k 09-I 13- Y Address: o r d)er S L(s r Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCF,WAIVER: I am aware that the Licensee does not have the liability insur coverage normally required by law. afore o ,1 hereby waive this requirement. I am the(check one owner El owner's agent. Owner/Agent Signature Telephone No. �� 7a PERMIT FEE. $-1,f - Date.... -.2©:.: f HORTh� 3:;.<;�``°:•.�."�a� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,SSAcMus This certifies that ........:..i-=2- ....... F,7 r.F.--....,:`................... ...................... has permission to perform .... Sof Ui G" ............ ............................................. wiring in the building of ��1v k I- ................................................................................... at...............................................................................-r North Andover,Mass. ori... Lic.No.t Z Z o 3 Fee.5' ................... • ELECTRICAL INSPECroR� Check # .27--32 8002 Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No. Z. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: �. f R-a$ City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) l t(1 Dole SdTet+ Owner or Tenant ko-v" , Cony141 Telephone No. q7 D9Ef_G%7 Owner's Address I4 I pC-te S¢-reet Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service loo Amps Jdv /3-�c Volts Overhead R Undgrd❑ No.of Meters � New Service Amps Iii / Volts Overhead M Undgrd ❑ No.of Meters r Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: S� ;� je Completion of the followingetable mg be waived by the Ins ector of Wires. No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool ove ❑ - E] No.Ot Emergency Lighting d. grnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones o Detection and_ No.of Switches No.of Gas Burners No. InitiatingDevices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pum Number Tons KW No.o eI ontained Totals ..-.. ........... ........................ Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection. No.of Dryers Heating Appliances KW ecuntySystems:* No.of Devices or E uivalent No.of Water , No.o o.o Data Wiring• a Heaters Sims Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Te ecommunicationsu1ng: No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: oo.oa (When required by municipal policy.) Work to Start: d-`J"z--oY Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE a BOND ❑ OTHER ❑ (Specify:) I certify,under thepains andpenalties ofperjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: (jt?r-old AAcr56,11 Signature .kemitnmAtLIC.NO.: iad03'15 (If applicable, enter "exempt"in the license number line.) Bus.TeL No.• q7 -90.33 yy Address: � (Choll"ul rok 7ey-y,54.a,^4 Alt.Tel.No.: `17Sr- S 791 *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety "S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner 0 owner's agent. Qwner/Agent PF.RuFr FFF- S The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations " d 600 Washington Street ` Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricans/Plumbers Applicant Information Please Print Legibly Narne(Business/Organization/Individual): GerGlcl A4c+rshG lI Address: 4 K►v11woa4 4 ` City/State/Zip: re-c56ry MA 0l�'�6 Phone.#: Q78Roy-33y y. Are you an employer?Cheek the appropriate box: 4. am a Type of project(required):, 1.El am a employer with ❑ I general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.0�I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g• ❑Demolition working forme in any capacity. employees and have workers' 9• ❑Building.addition [No workers' comp.insurance comp.• insurance.$ required.] 5. ❑ We are a corporation and its 10.[r'Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL insurance required.]t c. 152, §1(4), and we have no 12.0 Roof repairs employees. [No workers' 13.7 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Hameow^ers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new athdavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. 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 maybe forwarded to the Office of Investieations of the DIA for insurance coverage verification. I do hereby certify under the pains�and penalties ofperjury that the information provided above is true and correct Sienatur`e: �I_6U A Date: �( OSS Phone 1#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuin*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 employ6rs 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." i 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"ever state or local licensing agency shalt withhold the issuance or renewal of a license or permit to,bpera`te>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, §25CO) 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 burn leaves etc.) said person is 1-I0T 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 02.111 Tel.#617-7274900 ext 40-6 or 1-877-MASSAFE Fax# 617-727-7749 Revised 11-X22-06 + www-mas&govldia