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HomeMy WebLinkAboutMiscellaneous - 148 MAIN STREET 4/30/2018 (20) -r I C t i 9236 Date. �'.."•�'R°T:�� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 49 ,SSACHUS� This certifies that . . /&rel M' 'qeK- . . St,<�I' . . '•'' . has permission to perform . .41?1QCsbv"l plumbing in the buildings of . .M* at. . . . . . . . . . .. . . . . . ., No h Andover., Mass. Fee. . . :.. . . . . PLUMBING. . INS TOR Check # SS^ 4 i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITYLU MA. DATE 149/,-)K// PERMIT# JOBSITE ADDRESS C ..• -.5..., OWNER'S NAME l S POWNER ADDRESS: TEL: $ Fp,X;� TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:[ PLANS SUBMITTED: YES❑ NOV FIXUTRES 1 FLOORS Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONN DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIL/SAND SYS DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYS DEDICATED WATER REUSE SYS DISHWASHER DRINKING FOUNTAIN FOOD WASTE GRINDER UNIT FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY 1 ROOF DRAIN SHOWER STALL ERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES no NO ❑ If you have checked YES please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY N 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 Massachsetts G a nd that my signature on this permit application waives this requirement. SIGNAT E OF WNER OR AGENT CHECK ONE ONLY: OWNER [I 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 of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 6 LUMBER NAME: MICHAEL HOUSE LICENSE# 7173 IGN T R OMPANY NAME: MERRIMACK VALLEY CORPORATION ADDRESS: 15 PLUMBER DRIVE,UNIT 3 CITY:I MET HUEN STATE: MA ZIP: 01844,._ FAX: 978-689-2206 TEL: 978-689-0224 CELL: 978 884-3427 EMAIL:I LLITTLE@MVALLEYCORP.COM MASTER ■ JOURNEYMAN❑■ CORPORATION ■❑# PARTNERSHIP❑# LLC # The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organization/Individual): Idwr?J) /z a4 Address: /� 'PA�J , ,�i -,08 City/State/Zip: t/e A5P e5l4g � Phone#: Are ou an employer?Check the a propriate box: Type of project(required): 1.W. 1 am an employer with_ 4. 1-- I am a general contractor and I 6. D New construction employees(full and/or part time).* have hired the sub-contractors 2. D I am a sole proprietor or partner- listed on the attached sheet. �• ❑ Remodeling ship and have no employees These sub-contractors have 8. D Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance. 9. D Building addition required] 5.0 We are a corporation and its 10. E Electrical repairs or additions 3. `l I am a homeowner doing all work officers have exercised their myself [No workers' comp. right of exemption perm MGL 11. I_I Plumbing repairs or additions insurance required]t c. 152,§ ](4),and we have no 12. D Roof repairs employees. [no workers' comp.insurance required.) 13. D Other *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. tHomeowners who submit this affidavit indicating they are doing all 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'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: 4/p /3 Job Site Address: City/State/Zip: /t') 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. 1 do herby ce under t pat a�n7d alti s of erjury that the information pr vided above is true and correct. Si nature: .. � J �,�< < /Ic"r fiAt Date: j / Print Name: �G tJ �, ;51 J Phone 9: 97S 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#• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statue,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 defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the forgoing 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 that 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 section §25(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 section §25(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 in the workers' compensation affidavit completely, by checking the box that applies to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificates(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 Towns 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 homeowner 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, lease 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 phone#: (617)727-4900 ext. 406 or 1-877-MASSAFE fax#: (617)727-7749 Revised 11-22-06 www.mass.gov/dia i I r COMMONWEALTH OF MASSACHUSETTS LICENSED AS A MASTER PLUMBER ISSUES THIS LICENSE TO MICHAEL H HOUSE 63 MARSH LM J2 TS T5 R 9 TWP 'n EBEEMEt: TWP., ME 04414rt613, � 7173 05/01/12 763715 J L,d 6LL9996LOZ esn0H 8VN dgL:£0 LL £L deS a 4 Fold,Then Detach Along All Perforations COMMONWEALTH OF MASSACHUSETTS DIVISION OP PPOPESSIONAL BOARD IMPORTANT NOTICE PL REGISTERED AS A PLUMBING CORP PERMITS FOR PLUMBING AND GAS FITTING INSTALLATIONS ON STATE OWNED OR USED ISSUES THE ABOVE LICENSE TO: FACILITIES MUST BE FILED AT THE OFFICE OF THE STATE BOARD. TYPE MICHAEL H HOUSE MERRIMACK . VALLEY CORP -C 63 MARSH LANE 4Z EBEEMEE. TWP ME 04414-6137 82903 3377 05/01/12 82903 LICENSE NO. EXPIRATION DATE SERIAL NO. F Fold,Then Detach Along All Perforations e r Office Use On Permit No. 0144 &mwnwM4 of Anottr4natts Occuparicy&Fee Checked 11leprtutent of-public E�Hff:tg 3/90 (leave blank) lug BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Ward Area n a APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR,, ``TYPE ALL INFO MATII�ON Date -; City or Town of N0RTW iM2DVE To the Inspector of Wires: m n The undersigned applies for a permit to perform thq electrical work escribe�d/ below Location (Street & Number) �) t Owner or Tenant �f" z- <S�M E Owner's Address Z Is this permit in conjunction with a building permit: Yes ❑ No ❑ (Check Appropriate Box) I z Purpose of Building Utility Authorization No. m Existing Service Amps—1 Volts Overhead ❑ Undgrnd El No.of Meters o New Service Amps Volts Overhead ❑ Undgmd ❑ No.of Meters M C-> 0 Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Installation Ofalarm system No. of Lighting Outlets No.of Hot Tubs No.of Transformers Total m 4 KNA I Above In- No.of Lighting Fixtures Swimming Pool gmd. ❑ grnd- ❑ Generators KVA tD No.of Emergency Lighting Oz No.of Receptacle Outlets No.of Oil Burners Battery Units n O v No.of Switch Outlets No.of Gas Burners FIRE ALARMS No.of Zones -� No. of Ranges No_of Air Cond. Total No.of Detection and tons Initiating Devices O Heat Total Total No. of Disposals No_orpumps Tons KW No.of Sounding Devices I No.of Self Contained z No.of Dishwashers Space/Area Heating KW Detection/Sounding Devices CO M MunicipalC_> No.of Dryers Heating Devices KW Local ❑Other 0 ❑ Connection Da No.of No.of Low Voltage � No-of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs No.of Motors Total HPSIAM I�yt) 0 OTHER: DD M m Z: I INSURANCE COVERAGE:Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy includ- m Ing Completed Operations Coverage or its substantial equivalent.YES O NO 0 1 have submitted valid proof of same to the Office. n YES O NO 0 If you have checked YES,please indicate the type of coverage by checking the appropriate box. __4 INSURANCE= BOND 0 OTHER 0 (Please Specify) (i ©� (Expiration Date) z Estimated Value of Electrical Work S ` 2 n Work to Start Inspection Date Requested: RoughFinal V { �( Signed under the Penalties of Perjury: FIRM NAME LIC. NO. 1 2 31 C Licensee Signature LIC.NO. Bus.Tel.No.617-431-5800 Address 60 William St /We11eG1ey, MA 02181 AM TeL No.6 17-43 1—9 8 3 7 t. C OWNER'S tNSUEtANCE,WA1VEFt:'t arri"aware that the Licensee does rat have the'msuranoe coverage tX its substar►ttal equivalent as re- ,s, 4u1<ed dY..Massgdwsetb'Cierierat tawa:•`and thatYmy signature,on this permd appGcatiori waives•this tequirernertt.Owner' _ Agent '�� rzt \•.'o y�vCtteCtC Ofle h'%ai�ti. •F�h+r: f :'. ��My, �ro`f .�{:fi�-' -"�'.t h,:;�, riy..�.F i rw i���4f .}'i�t"?sa'"'f-""r; . ;'� t7'•`�Fs��i' :.mss.?': ^r• isyr•.r�,�p.��A tl5 �-'�4t a'.�+% S� ,Td'1'+nC'i.5r1'.ix fis'�`..-�%^2�?cY;Si�:Si:;�j1 ;�.�. $;".,f��.f�fwr'�.fi•.+ .,� :+�':.d ':"{ o.�•.i i� C:P� r..:�.i.� •"�� .•,,,y. ..• •.,, � s.u' v .t T•a x�:E`.'�:.,.. .. :,�-5�Q O ' `'�`- `+:.x{.. �,.ax<«�s �ky��t-�•f•��.zf *� �i7 szr:� Teteahone No.'s PERMIT FEE 3 2 9 A N°RTM TOWN OF NORTH ANDOVER o . % PERMIT FOR WIRING i ��SSACMUSEt I. This certifies that ......1.. .....O..T........ ...............S. .S............................... has permission to perform ...../ .l.q...?f'!... ... ..SY.S.. °�L- ............................... wiring in the building of G ........ ... .............................. at......1... ..jt�.R, ?......S.f................................. .North Andover,Mass. Fee... . ..:Q.. Lic.No. ELECTRICAL INSPECTOR 'i 04/01l9611i�8� PAID WHITE: Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File f