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HomeMy WebLinkAboutMiscellaneous - 149 BRIDGES LANE 4/30/2018 149 BRIDGES LANE 2101104_�2"0000.0 - 1 9 32 Date. "�907:�ha TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ;S�'O++no�'•��lh .a SSACMUS� NI This certifies that . . .�1�t ?�1. !?. .. .!. . . . . . . . . . . . . . . . . . . . . 4 has permission to perform . . ./. .%r. . . rra&".7. f.a�. . . . . plumbing in the b�uiilldings of . . . .�1 eL.. . . . . . . . . . . . . . . . . . . . . . at . .,✓ '.,�C�'sr.! ' .. . . . ., North Andover, Mass. Feel-f 56.Lic. No..�`� ,� �. .�.1�! G!.1� .. . .. . . . . . 5 PLUMBING INVE� R Check # ZAS' l MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: MA. Date: permit# Building Location: ,LI4 &C, Owners Name: Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential Alteration:❑ Renovatiorl Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES DEDICATED H SYSTEMS 2 y �' U h W Z N n. 'n 'n F• Y ,Q U !�•• W ❑ ❑ QCO c=ii 1 H in F w y p Z o N < w w w ❑ cc Q h � a ¢ F- F_ LU B a y o LU C3 '' > > o o " z fw- rw W df o N w a m m o ❑ LL i g 3 w x ° a a a a FF. ❑ W W } W �, 0 3 o a -SUB BSMT. G BASEMENT 1sT FLOOR 1 2ND FLOOR 3RD FLOOR 4T"FLOOR 5T"FLOOR eH FLOOR 7T"FLOOR 8T"FLOOR (' f7SL' flirt ��I;i &r i4+8rn�: T \VL� -vli`�QI S ( S ac �i�"�cck Orly"'til �:Ggii i3�+�e _t .. Address: "A4_Af1ty/Town:_V% ElCorporation State:—Off Business Tel:-_ � ' LB?-- ❑Partnership 01�66 Fax:�3� 3-�013,6 Name of Licensed Plumber: �'j✓L 1 � rrm/Company INSURANCE COVERAGE: 1 have a current liabilit ' _Yr nsurarl policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes ElNo.❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ❑� Other t ype of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:1 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 >i nature of Owner or Owner's A ent Owner ❑ Agent ❑ I hereby certify that all of the details and information 1 have submitted(or entered)regarding Phis plication are true and accur + Knowledge and that all plumbing work k and installations performed under the permit issued for th app►ication will be in compliance with all Pertinent 4rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General ws a e tc bes`of my � O 0 Type of License: fie ❑Plumber gn a icense d Plumber `y/Town El Master L� 'PROVED(OFFICE USE ONLY) ElJourneyman icense Number: J The Commonwealth ofMassachusetts DepaYtmeut oflndustrialAccidents Office of Investigations, 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organizationllndividual): 1�{�—-ml A- lL Address: t o WVAv City/State/Zip:1/.l L ,/JA- da,0s_7 Phone Are you an employer?Check the appropriate box: _ 1.❑ I am a employer with 4. Type of project(required): ❑ I am a general contractor and I 2/employees(full'and/or part-time).* have hired the sub-contractors 6. ❑New construction I am a sole proprietor or partner- listed on the attached shSet.s 7.�emodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp,insurance. [No workers comp. 5. 9. ❑Building addition ' p ❑ We are a corporation and its required.] .officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MC-rL 11.[]plumbing repairs or additions myself. [No workers'comp. C.152,§1(4),and we have no 12.[]Roof repairs insurance required.]f employees.[No workers' COMP,insurance required.] 13.[]Other *Any applicant that checks box#I 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 showingthe name _ g me oft he sub contractors and their workers com p.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. 1 Insurance Company Name: M' Policy#or Self-ins.Lic.#: Expiration Date: • J'ob 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 a as required g q under Section 25A o • f MGL c. 152 can Lead to the' fine up to$1,500.00 and/or one- imposition of criminal penalties of a 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 Investigations of the DIA for insuraAe coverage verification. Ido hereby certify un z ai 'es o perjury that the information provided above is true and correct. Si nature: Date: 6 ?hone#: Offrcfal 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical 6.Other Inspector 5.Plumbing Inspector Contact Person: Phone M 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 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-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 conflimation 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 r 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 permithicense number which will be used as a referencd number. In addition,an applicant that must submit multiple permit/liceuse 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: Me Common WeaPih.of Massachusetts Depart ent of Industrial Accidents Office of Investigations 600 Washington Stmet B osto_n}1A.0211 1, Tel.#61.7.727-4900 ext 406 ox 1-877-MASSA FE Revised 5-26-05 Fax#61.7-727-7749 www.naass.l;av/dia -�COMMONWEALTl ®F MASSACHUSETTS PLUMBERS AND GASFITTERS LICENSED AS A MASTER:PLUMBER I ISSUES THE ABOVE LICENSE TO: S JASON W THOMAS rs iro 13 JACKMAN RIDGE RD . WINDHAM NH 03087-1670 l =10315 05/01/12 795950 . Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record FSEP 2U all Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTM NT DEP has provided this form for use by local Boards of Health. Other form , information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front of house, right front of house, left side of house, right side of house, Left rear of house, right rear of house, left side of building, right rear of building, under deck. E 7 6r L N4"J� - ` Cityrrown State Zip Code 2. System Owner: Name �J \ Address(if different from location) City/Town Statei Code ✓ � Telephone Number B. Pum„i--- 1. 2. Quantity Pumped: Gallons 3. -SepticTank ❑ Tight Tank 4. E If yes, was it cleaned? ❑ Yes ❑ No 5. C 6. Sy; Nei F5821 Nam, __ Vehicle License Number BatE - Company 7. Lo where contents were disposed: LG.L.S.D. LcAell Waste a 1-t> Signature/off/a4uer Date t5form4.doc°06/03 System Pumping Record°Page 1 of 1 Commonwealth of Massachusetts City/Town of w° System Pumping Record SEP 20 nil Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other form , information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front of house, right front of house, left side of house, right side of house, Left rear of house, right rear of house, left side of building, right rear of building, under deck. I q— Lv� 4"J� CitylTown State Zip Code 2. System Owner: Name �J \ Address(if different from location) City/Town State r �ir Code ~r l f Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons .3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes E3 No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition `f System: 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Lo where contents were disposed: G.L.S.D. LgOell WaW VVaTRr f Signature of plauter Date Illli L '�/ t5form4.doc°06/03 System Pumping Record°Page 1 of 1 A r .r Date..j..'..3G....1 .... ORT" 3? p� TOWN OF NORTH ANDOVER PERMIT FOR WIRING SS�cNUS This certifies that .........1..'... �`{ " (t ,, ' has permission to perform ......y!...!..�` ..... ... ..74W.............. wiring in the building of df.............. ............................................ ... 5..........®'� . North Andover, at..... ................ :. /....................... v yZ/ 9� ,. Fee....�..�.......... Lic.No � ...... ...............:.;' : ....................... ELECTRICAL INSPECTOR Check # J3 2 G Commonwealth of Massachusetts Official Use Ont ' Department of Fire Services Permit No. 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: 9/29/11 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) 149 BRIDGES LANE Owner or Tenant STEVE&KATHLEEN WILLIS Telephone No. 978-6894911 Owner's Address SAME Is this permit in conjunction with a building permit? Yes X No LJ BLDG PERMIT# Purpose of Building SINGLE FAMILY Utility Authorization No. N/A Existing Service 200 Amps 120/240 Volts Overhead❑ Undgrd❑X No.of Meters 1 New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters 1 Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: KITCHEN,BATH&LAUNDRY REMODEL 1 Completion of the followin table may be waived by the Inspector of Wires. No.of Recessed Luminaires 10 No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets 20 No.of Hot Tubs Generators KVA No.of Luminaires 20 Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting grnd. grnd. Battery Units No.of Receptacle Outlets 6 No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches 6 No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges 1 No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers 1 Heat Pump Number Tons KW No.of Self-Contained Totals: - Detection/Alerting Devices No.of Dishwashers 1 Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers 1 Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: � OTHER: No.of Devices or Equivalent Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: $6,000.00 (When required by municipal policy.) Work to Start: 9/29/11 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAUM UnlFs—swaived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑X BOND ❑ OTHER ❑ (Specify:) I c&kfy,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: MIKE'S ELECTRICAL SERVICE OF SOUTH HAMPTON,INC LIC.NO.: A10421 Licensee: MICHAEL KELLER Signre LIC.NO.: E25006 (If applicable,enter"exempt"in the license number line.) Bus Tel.No.: 603-394-0117 Address: 27 WOODMAN ROAD,SOUTH HAMPTON,NH 03 7 Alt.Tel.No.: 603-231-6068 *Per M.G.L.c.147,s.57-61,security work requires Department of Public Safety"S"Licen LIC.NO.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signa- ture below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$ �' �, s t� . d � � ,� � y� J ( � �t "� � � � ��� �, i The Commonwealth of Massachusetts _ Print Form Department of Industrial Accidents - Office of Investigations -- 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): MIKE'S ELECTRICAL SERVICE OF SOUTH HAMPTON, INC. Address: 27 WOODMAN ROAD City/State/Zip: SOUTH HAMPTON, NH 03827 Phone #: 603-231-6068 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 3 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. F-1 New construction listed on the attached sheet. 7. 0 Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. $ 9. E] Building addition required.] 5. ❑ We are a corporation and its 10.F1 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4), and we have no 13.❑ Other employees. [No workers' comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached 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: INTERGUARD Policy#or Self-ins.Lic.#: MIWC237599 Expiration Date: JULY 16, 2012 Job Site Address:149 Bridges Lane City/State/Zip:N.Andover, MA 01845 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 u to$250.00 a da against the violator. Be advised that taco of this statement may be forwarded to the Office i Y g PY Y Of ce of i Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains a#penalties of perjury that the information provided above is true and correct. Si atur Date:9/29/11 Phone#: 03-231-606 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.BuildingDepartment 3.Ci /Town Clerk 4.Electrical p City/Town Ins ector 5.Plumbing Inspector P g P 6.Other Contact Person: Phone#.