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HomeMy WebLinkAboutMiscellaneous - 16 ALCOTT WAY 4/30/2018 (2) �TT WAY 2101025�0016.D Date..... OF NonrH, TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ....i�jlhll 41f .......... .. .... ......5................................................. has permission for gas installation ............... : ,p Ac ............................... inthe buildings of................................................................................................................... at ... v,(Q /................ North'Anlover,Mass. Fee.:-�.��.. Lic. No. , . ...................(............................ GLINSPECTOR Check# 10223 t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY /-1— r—Jf/ /t MA DATE u/ PERMIT#-- --- --� JOBSITE ADDRESS OWNER'S NAME G OWNER ADDRESS w, TEL _ _ AX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Ej RESIDENTIAL PRINT CLEARLYNEW:[ RENOVATION: REPLACEMENT:® PLANS SUBMITTED: YES Q NO APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER . .. I __ . BOOSTER -- CONVERSION BURNER - COOK STOVE n __ __ DIRECT VENT HEATER DRYER FIREPLACE —1 .._ _ _-z,_1_� FRYOLATOR FURNACE = 11 r..l _ — GENERATOR _� i GRILLE INFRARED HEATER ( I ! – LABORATORY COCKS MAKEUP AIR UNIT OVEN APOOL HEATER � ROOM/SPACE HEATER ROOF TOP UNIT UNIT HEATER I-- --- UNVENTED ROOM HEATER f WATER HEATER I r I OTHER - !__ INSURANCE COVERAGE have a current liability insurance policy or its substantial equivale t which meets the requirements of MGL.Ch.142 YES ._ NO D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT rA SIGNATURE OF OWNER OR AGENT 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 A Perti rovision o the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBS ASFITTER NAME t-, 7l�LICENSE#I'�,x -- SIGNATURE MP " - MGF 0 JP® JGF[ LPGI Q CORPORATION Q#��PARTNERSHIP E19=LLC D# COMPANY NAME: f � l7�/S'C ADDRESS CITYL-A---/ 1a STATE hi/ ZIP 41 TEL FAX I CELL __,=EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECT101Y NMES Yes No d ?j 6 /Sr THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES i I The Commonwealth of Massachusetts Department of Industrial Accidents X Congress Street,Suite 100 - Boston,MA 02114-2017 www mass.gov/dia WPorkers,Compensation Insurance Affidavit:Builder/Contractors/Electricians/klumbers. TO BE FILE,D WITH THE PERMUTING AUTHORI',Y. ' -,Please Print Le 'bl A ••licant Information I Name(Business/Orgatization/Individual): .__�� T Address: Phone#: City/State/Zip: N- Are you an employer?Check the appropriate box: Type of project(required); em to ees full and/or part-time). ']. �New�COriStrll•Ct10ri l.n I�n aemployerwith • • P Y ( 2. am am a sole proprietor or partnership and have no employees working for me in 8. E]Remodelitig any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.D I am a homeowner doing all work myself(No workers'comp.insurance required.]t 10❑Building addition 4-0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additiops proprietors withno euiployees. 12 ;,fl.Plumbing repairs or additions 5.❑I am a general contractor and I;have hired the sub-contractors listed on the attached sheet. 13%El R06f repairs These sub-contractors have employees and have workers'comp.insurance.$ 14J0 Other 6.n We are a corporation and its.officers have exercised their right of exemption per MGL c. 152,§1(4),and We have no empldyees.[No workers'comp.insurance required-] *Any applicant that checks box*1,must also fill out the section below showing their workers'compensation policy information Homeowners who submit•tbis aff davit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such :. i llomeown that check this Box must attached an additional sheet showing tae name of the sub contractors and state whether or not those,entities ave 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 emplbyees. .Below is the policy and job site information. Insurance Company Name- Policy#or Self-ins.LIC.#-. Expiration Date' City/StatelZip: fob Site Address- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requixed under MGI',c.152,§25A is a criminal violation punishable by a foie 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.A copy of this statement may be forwarded to the Office of Tuvestigations of the DIA for insurance coverage verification. X do hereby certify uncle' t pains and aloes perjury that fie information provided above is true and correct. Date: Si ature: Phone#: 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): L6.'Other rd of Health 2.Building pepartment 3.City/Tovvnt Clerk A.Electrical Inspector 5.plumbing Inspector ct Person: Phone#: V ,J 1 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 We, 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 enferprise,and including the legal representatives of a deceased employer,or the receiv6t'or,trustdd 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 occupani 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 Pleasb 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 certificates)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 listedbelow. 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 NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia Rule 8. stn -acccerdance with the provisi6ns o1 M.G.L. c. 143 § 3L, the permit applica- tion form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. 4fte P" e vt1applicatiBIF as bees WMc j'ed an Inspector Wjresuapp OILdtf,&Wg u ant to M G?Lac 1G5�§32� an electric 4wr�� rorP v aa'�r c a ,rt' vy* x permrtshailbe issued,to the pet; t o corporaiionKst 'ted^i�nthe pertruta licatronSuch entity shall be`respons ble�forjthefnotification.of cor tetigz. l ee wotic as equi eii iV". 143§3L Permrtstslialllbe�lirnitedas tothe tim .. ."tSq"�e. . ,� — ..�. ,ur� 0f oongoing� constrtrc�t�©tx I T-1 t,Q maybe deemedby� thlnspcor�o ir,slab`ndo� d a d �and h o haslldeterminedithat the1- tthorzzed�0 ikv r* liasnat cornrnencedor hsaopra essed�dOfingRthe p ecedrng atfi orit AI eriod Upanrilten apwphcatt N47, wy arc +m & 6 ai k}a d al tensionxGofatime�for�eornpletion,ot`�.�wor �r rwrtr .m �a@arl^k. tw�°�',* shallbe�permittedfor reasonablocatxse� A ,pen hall the tterm ha�dK t p'q=� e vritten,reggeest of either the owner or tli rnstalhngaentity,statedI'd rr+.the pmzta �"�licaticiu' X11 r+w X" i nn - Date...... ...........-7 Np Pr TOWN OF NORTH ANDOVER I" Oil PERMIT FOR WIRING A NU This certifies that ...... ............................ ..................... ....... .. ....... .. . ...... )*kAb0Q'-E- Am 15�T/022k has pennission to perform ............................................................................... f (:::� FFKA v wiring in the building o ....../I.............;..7..................................... at.............. ;,!(MY........... North Andover,Mass. Fee..................... Lic.No. ............... EXAL� "Y4 NSPCTOR Check #. 7997 Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No. '7 7 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked ev. 11/991 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: 1/23/08 City or Town oh 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) 16 Alcott Way Owner or Tenant Sophia Caffray Telephone No. 978.685.8247 Owner's Address same Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building dwelling 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: furnace rm 1"floor Completion ol thefollowing table may be waived by the Inspector o Wires. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA Above In- o.o Emergency Lighting No.of Lighting Fixtures Swimming Pool rnd. rad. E] Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners 1 o.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heatum mber Tons KW No.o Self-Contained Totals: u - Detection/Alerting Devices No.of Dishwashers Space/Arca Heating KW Local ❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.o Water KW No.o No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent f OTHER: _Iltach additional detail if desired or as required by the Inspector of Wires. 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 ❑ BOND ❑ OTHER ❑ (Specify:) 3/08 (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 1/23/08 Inspections to be requested in accordance with NEC Rule 10,and upon completion. I certify,under the pains and penalties of perjury,that the information on this application ' true and complete. FIRM NAME: Andrew F.Sheehan Electrical Service LIC.NO.: A11498 Licensee:Andrew F.Sheehan Signature LIC.NO.: A11498 (Ifapplicable,enter "exempt"in the license number line) Bus.Tel.No.• 978.375.4016 Address: 249 Pine Hill Road*Chelmsford Ma.01824-1965 Alt.Tel.No.: 978.622.5852 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 ❑owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE.Q 0 "��� �- �..: F - ,/ ,� .. , .. � J. � ' - '. � ,. ! t rf a, '7 __ — t . — r. . . .. i � �., t r , ,. � � � � r 7 i ' ''1;... ,�r w r �� ,.. i The Commonwealth of Massachusetts Department of IndastrialAcddeau Office of Investigations 600 Washington Street Boston,MA 02111 ' www.massgov/dia ' Workers' Compensation Insurance davit:Builders/Contractorsmlectricians/Plumbers A "t Information Please Print 1&dblyr .. Name(lzusict�ss/0rganiza6oMadividual): l�J��-•� +� �' � . -Address: _ City/State!Zip �te�uc Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4. [] I am a genual contractor and I Type of pi olect(required): =Vloym(full and/or part-time).' have hired the sub-contractors 6. ❑New construction - 2.❑ I am a"sole proprietor orpa�rtaer- .: _----.....__Iistead..on-the_ .sL�. . - -._ ..7;..Q")te_mode- _ ship and have no employees These sub-Contractors have working for we in any capacity, employees and have wogs' & ❑Demolition [No workers'Comp.insurance comp.insurance.#- 9. []Building addition required.] 5. We area corporation and its 10.i31eetarioal repairs or additions 3.❑ I am a homeowm doing all work off cern have exercisedtheir - 11.0 P umbing repairs or additions myself Wo workers'comp- right mif exemption per MGL insurance required.]t c.152,§1(4),and we have no I2.0 Roof repairs employ.[No workers' 1.3 JM Offici_Lc t" t?somp.insurance required.] filly appiicaot 6ntdax�bbx#1=m also fig out the SeC ionbdowshowing their WO&M,ft as policy h6tu afion. lioenwwnas�vho atbodt flus affidavit"sting t cy am doing all work and dm hies outside ooahacfoes must submit anew afedavit indicating axh. $Contractees Ifia ck&this box meat attached m additiond deed sbowing ae name o fdic su� andsine adder ornot those atities ban seaptoyees. [f the subconuactoes have empioyeex•they must p�their vwbNe OOmP-poEryauneber. . I am an mxnpioyer that is providing workupcompeiasdon in #mime for my employees. Below is the policy acrd job site information. Insurance Company Nanhe: Policy#or Self-ins.Lie M. A_, e-i 1' 9 , --? c c I✓! Expiration xpuatron Date: Job Site Address: Attach a Dopy of the workers'compensation 'cy declarationa e sho P ( wing the policy number and expiration date): ' PoAm-to secure coverage as required under Section 25A of MGL e.152 can lead to the imposition t - tine tip to 51,50000=&Or one-year imprisonment,as well as civil ofaSP of oriminalpenalfies of a of to$250.00 a da Penalties to the form of a STOP WORK ORDER and a fine j UP Y age�violator. Be advised that a copy ofthis-statement-may be forwarded to the Office of Investi tions of the ins cov a verification Ido hereby . e paums of.Pe&ry that the inform on prot�veand mwrreet SrDate. OffWW we only. Do not write in this area,to be completed by,city or town offieiaL City or Town. PerndUUcense# Issuing Authority(circle one): 1.Board of Health 2.Badding Department 3.City(Pown Clerk 4,Electrical Inspector S.Plumbing Inspector-6--Other ..-__ .-_. Contact Person: Phone#• Date.. .� Q a ..... . „ORTp 3? °` TOWN OF NORTH DOVER . O � F PERMIT FOR GAS'INSTALLATION � Sy �9SS^CMUSES This certifies that . .�.�?x,!r. f�!� . .r. . . / G f. . . . . . . . . . . . . . has permission for gas installation .. L . �?.�.5. . . . . . . . . . . . in the buildings of C Xf//.-.�.7. . . . . . . . . . . . . . . . . . . . . . .. . . . . . at .f .,til �?� t-t �a`,� . . . . . . . . North Andover, Mass. . �\ ,�. . Fee. 7P. Lic. No./.r/d� . . . . . . � J� . . . . �. 6AS INSPECTOR .Check# 6319 MASSACHUSET S UNI ORM APPLICATION<i0PERMIT TO DO GASFITTING / G � 600' Mass. Date 1 � J 20 ff Permit# (m Building Location Owner's Name Type of Occupancy New ❑ Renovation C3 Replacement a.• Plans Submitted: Yes❑ No d a tri V a0 O U m aH E- �. � � � j Z d 0 f4 a! � vwax w � � o0', d zawdQ ¢ � Q ° O 0z0 d 04 < 4 � x° � 0 a SUB-BASEMENT BASEMENT FIRST(I ST)FLOOR c SECOND(2ND)FLOOR THIRD 3RD FLOOR FOURTH(4TH)FLOOR FIFTH(5TH)FLOOR SIXTH OTH FLOOR . SEVENTH(TPH)FLOOR EIGHTH 8TH FLOOR Installing Company Name I 4,17 Address � C eck one: Certificate cp MA Corporation Business Telephone j`j— r — 57 p p Name of Licensed Plumber or Gasfitter ❑ Firm/Co— INSURANCE COVERAGE: I have a current Iia I Wnsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes No 0 If you have check please' icate the type of coverage by checking the appropriate box. A liability insurance policy W Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE A ER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the MGL,and that my signature on this permit application waives this requirement. [Signature of Owner or Owner's Agent Owner ❑ 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 my knowledge 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 Gas Code and Chapter I42 of the General Laws. By Type of Li _ Title ❑ PlumberMaster SiVmftue of Licens Plu bedGasfitter City/Town ❑ coritter Ioumey M License Number I _ APPROVED(OFFICE USE ONLY)