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HomeMy WebLinkAboutMiscellaneous - 15 KINGSTON STREET 4/30/2018 (2) OD �t u u Date. . . . . NORTry TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ;,SSACMUS� This certifies that . .�'. . . 1� .. .. . S +. . . (. . has permission to perform . . . .A.C.An . . . . . . . . . . . . . . . . .- plumbing in the buildings of . . . . . . . . . . . . . . . . . . . at 5.f . `. . . . . . . . . . . . . . . . . . . .IN rth-Andover, Mass. . . Fee. . . . . . .Lic. No�. ?. ... . . . . . . . . .�. .,.C�?. -�'��. . . . . . . . PLUMBING INSPECTOR Check 'I � 8170 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: KI /1'�►Q�'`�� MA. Date: Permit# 1 Building Location: Is ST- Owners Name: LOZM f\L E-10 � Type of Occupancy: Commercial❑ Educational ❑ Industrial ❑ Institutional❑ Residential�] New: ❑ Alteration: ❑ Renovation: ❑ Replacement:[X Plans Submitted: Yes❑ NO)p FIXTURES z z W 0 Y N N V rn W z OIL z H Y Q�Q rn Q Q N 2 3 a z Q Q tW Q a w O 0 W z W W z V 4 LL Y = +?. 0 0 r '� x Z Q rL 3 a Y a 2 W W W a s X IL ° a 0 0 = ° a a a a a M M o t] W x Y g g M rn to ,- n 3 3 3 0 r SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR F0 FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR (�, _ \ C \ n, q , I L Check One Only Certificate# Installing Company Name: },.J �,,�'i� Ju+v L�I� ll. SI ❑Corporation Address: 1V CitylTown: o State: artnership Business Tel: \�oU� 1 Fax: ►" �1 li ❑Firm/Company Name of Licensed Plumber: ✓'_�� INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy4 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's 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 pemrR 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. By Type of License: 24—"� 1 �' Title ❑Plumber Signal o icensed lumber City/rows ❑Master License Number: 0-2L APPROVED OFFICE USE ONLY ❑Journeyman Co,,,V n nwealeh of Massachusefis 1 Delpartme"I of Industrial Accident ir Vice Of investigations tic., 6d0 Washington Street ell Boston, M4 6r2111 workers' Campensaiion Iasittranee WWW_trUssgrry/dna . A Mdavit: Suildets/Contrartors/Eiectt iciaQs/Pinmbers iicaat Ir3fi7r�ation Please Print Leeibl N8.II1E (Busi�uss/Or�aoi�ation/fndividual); �� � .w.\ 144 1 / Address: ►1'�1� � - Phone#: .FA�yonm*Yerl Cheek.the aPProP�te bo= mployer with 4. �] I am a TYPe of pro}ed(�toi�: generalcontractor and I es(fun and/or earl time.* have 6. ❑New construction ole ) hired the t -contractors proprietor.or partner. Iisted ori the attached sheet:, 7. 0.Remodeling ship and have no employees' These soli-contractors have working for me in any capacity. workers' comp.insurance. 8' Demolition [No work=,comp, iasrusnce. S. Q we rare a corporation and its 9• I]Building addition • required.] ofnc= have exercised their 10-El.Electrical 3.❑ I am a homeowner do' a}I work ri ' repairs or additions � of' m exemption per MCIL I I. PI myself �Plumbing Y [No-workers'co mg alta or ad.. . rap. 2, §I(4),'and-we have no anions insurance-required.],t .eanployams.[No work=! 12.M Roof repairs `mayappiicerttthat comp• huurancerequire&] I3.M.0ther S boz#1 must also fm omthe seehon below ahoW.intg&CirV;D Ce$'cnmpebeatian policy infornteEiot4 r Fiomeowntira who submit this awdavit Wimtin th me tl ' all _ 3Cautracmts that check this box must 6 o work nthen hire outside conoactota most submit a nein affidavit indi aaaoEed sa adcF.iottst shecsho K'iarg•the ttetttc of the cols-cortttactort nth h • �6 au cit,' I an:.an a fo er&V it wor1=,ccr;a•p�tiis fnm,e,uc � ,� is{►san*r�dirrg:rosrr�.ers'cr;�e,�so�rre nsuranre f'or --�— ir fanndio2 rnr employ , &mow it tF.e Poly a djon site Insurance Company Name: Policy#or Self-ins.Lie.#: ExPirafion Date: Job Site Address Attach a copy of the workers' cora CitylSt�/�;p' peQsataots policy dtxEaration page Failure t4 (showing the policy nd somber ae:epiratloa date). secure coverage as rexlvised under Section 25A of . fine up to$1,5D0.00 and/or one-year im MC3L e. 152 can lead to the imposition of criminal penalties of a• Of up to$250.00 a Y prisonment,as wo1I as civil penalties in the form of a STflp wpm ORD£R and a fine �3 against the vio}ator. Be advised that a copy of t his statement may be forwarded to the Office of Investigations of the DL4 for insurance coverago verin"-Milion. I do hereby cwlti under the a�u and en . / °rPP1lWy that the infnrrnation pmrnded above tr true an/d�correct Date: Phone#: Official use only. Do not write in this•snit,m he ro i rnP etedbY Mt or town officio( City or Towne Pertnit/License# Issuing Authority(circle one): oard I. then of Iiesit6 L Snilefiatg Da[mrfinent 3.City/Town Cierlc 4 Electrical Inspector 5. Plumbing Inspector b.Otber Conta ] . ct Persaa• Phone#: Information a nd 111'structions- Mas=busetts General Laws chapter 152 requires all emp Ioyers to provide workers' comrpemsation for their employees. Pursuant to this statute,an m playee is defined as"..:every person in the service of another under any contract Aire, express or implied,oral or written." An employer is defined as"an individual partnership,association, mrpomtion or other legal entity,or airy two ormare. of the'foreping engaged in a joint enterprise,and includiirtg the legal represcrrtatives of a dec mcd employer,arthe rzttiver ortrustee•of an individual,partnership,associatiam or other legal entity,employing ampioyees.'l-ioweverthe owner-of a dwelling house having not more thah froze apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maice,construction orrepair work on such dwellinghouse or on the grounds or building appurtenant thereto shall not because of such employment be d--med to be an empicyer." MGL chaptm 152,§25C(6)also states that"every state or local licensing agency steal withhold the iss ianceor renewal of a license or permit to operate a baseness or *e construct buildings in the commonwealth for any applicaut who bas not producedacceptable evidence•o'F compliance witfr the insurance coverage required." Additionally, MOL•chaptar 152,§25C(7)states`Neither t3ic commonwealth nor any of its political subdivisions shall enter into any contract for the perfomrffieco of public worie twiffl•acceptsble cMdence of complii6=with the insum= requirements.of this chapter have been pre=tcd to the c RTTft citing authority." Applicants Please fill out the work='compensation•affidavit completely,by checking the boxes that apply to your situation and,if 1 necessary,supply,sub-contractnr(s)name(s),ad&WKes):ard phone numbers)along with their ca:n ific ate(s)of insurance. Limitzd Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no-employees otherthan the members orpartners,are not rrquircd1_to carry workers'c�z°npensation insurance. ifan LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of lndust W 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.thepermit or Bcemse 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' oampensation policy,please-tail the Department at fire number fisted below. Self-insured companies should enter their self-insuramceliccnsc aumisw on dre•approoste ice. 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 tht event the.Office of Investigations has to contact you regarding the applicant. Please be sure to rill in the pwroit/license.n=ber which vt-stl be used as a reference number. in addition, an appikent that must submit multiple permit/iicensc applications in any given year,need only submit one affidavit indicesiang-current policy'infonnstion(if necessary)and under"Job Site Adds-airs"the applicant should write"all locations in city or A copy of-the affidavit that has been.officially stamped or marked by the city or town may be provided to the applicorit as proof that a valid afRdavit is on file for f tore permits or licenses. A new affidavit must be filled out each Year. Where a home owner or citizen is obtaining a lic-nse or permit not related to any business or commercial vat= (i.e. a dog license or permit to bum leaves atz.)said pars6n is NOT.required to complete this affidavit The Office of investiLations would bice to thank you in advance for your cooperation and should you have any qualions, please do not hesitate to give us a call Thu Depamnent's address,telephone and fax number. The Commonwe:clth of M=ac huse= Department of l.mdustrW Accidtmts Office-of Envestiigafions 600 Washington Stied Boston, MA 02111 TeL#617-7274900 est 406 or 1-977-"SAFE Fax#617-727-774 1L vised 5-?ti-Q5 wwwmasa.gov/dia A- Date. IZ3 2 CZ....................... NORTH TOWN OF NORTH ANDOVER 0 Aimm. 0 PERMIT FOR WIRING SS US This certifies that .......(f2o .......................................... ......................... has permission to perform ......... .................. wiring in the building of....... V. at........... .... ..... ...... . 5,--.. ........................................... North Andover,Mass. / 7 MY�9 ........... ............... Fee...... No... ........... ....� ELECTRICAL INSPECTOR Check # 7684 Office Use Only - The Commonwealth of Massachusetts Permit No. Gl Department of Public Safety Occupancy& Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 (leave blank) 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 INFORMATION) Date September 19, 2007 N. Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) 15 Kingston Street OwnerorTenant Village Green Association Owner's Address PMA - (9 7 8) 683-4101 Is this permit in conjunction with a building permit: Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Residential Utility Authorization No. Existing Service Amps 1 Volts Overhead ❑ Undgrd ❑ No.of Meters New Service Amps 1 Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Emergency call to repair damage 1 underground Total No.of Lighting Outlets No.of Hot Tubs No.of Transformers KVA Above in- No.of Lighting Fixtures Swimming Pool grnd. ❑ gmd. ❑ Generators KVA No.Receptacle Outlets No.of Oil Burners Bat of Emergency Lighting No.of Rece p Battery Units No.of Switch Outlets No.of Gas burners FIRE ALARMS No.of Zones Total No.of Detection and No.of Ranges No.of Air Cond. tons Initiating Devices Heat Total Total No.of Disposals No.of Pumps Tons KW No.of Sounding Devices No.of Self Contained No.of Dishwashers Space/Area Heating KW Detection/Sounding Devices Municipal No.of Dryers Heating Devices KW Local❑ Connection❑Other No.of No.of Low Voltage No.of Water Heaters KW ;Signs Ballasts Wiring No.Hydro Massage Tubs No.of Motors Total HP OTHER: t { INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws - 1 I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES ® NO ❑ I have submitted valid proof of same to this office. YES © NO ❑. If you have checked YES,please indicate the type of coverage by checking the appropriate box. INSURANCE IR BOND❑ OTHER❑ (Please Specify) (Expiration Date) Estimated Value of Electrical Work$ Work to Start Inspection Date Required: Rough Final Signed under the penalties of perjury: FIRM NAME CROWE & SONS ELECTRICAL CORP,, LIC.NO.1716 8A Licensee JAMES B. CROLM Signature LIC. NO.17168A Bus.Tel.No. 978 ) 453-66— Address 576 MIDDLESEX STREET, LOWEL , MA 01851 AIt.TeI.No. 978 — OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws,and that my signature on this permit application waives this requirement. Owner ❑ Agent ❑ (Please check one) 55 .00 Telephone No. PERMIT FEE$ /Cinnnt,,ra of nwnar nr Ananfl J-""�