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HomeMy WebLinkAboutMiscellaneous - 163 LACONIA CIRCLE 4/30/2018 (2) 163 LACONIA CIRCLE 210/105.D-0132-0000.0 Date,� 7// 2'. . A � TOWN OF NORTH ANDOVER < PERMIT FOR GAS INSTALLATION Y This certifies that . . Q�.x rT44 /.j' has permission for gas installation . .e.m in the buildings of. . . . / t at . ! �?. "�?? ! e -c_ ,North Andover, Mass. tt lee . Lic. No. . .F Y.3 7 . . . . . . . . . . . . . . s d . GASINSPECTOR Check# 23 97 8464 :\ _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING VVOR'rC n CITY ; ; OT-T 1,1',-Ardov 8,-r . ... ... MA DATE I..1,.�L�U,I„.G�� PERMIT# ,Y /� {{/� OWN NAME ' {{'��//��[[,�-��//��(� JOBSITE ADDRESS �Q I 1,.�.�Cia..l� J'.1tJh JIJ , OWNER ADDRESS C. O, L�1l+VIIYCI.:. .. - .,._ TEL`1Ul.' LJAX w. TOR PRI PROCCUPANCY TYPE COC.1ERCLAL EDUCATIONAL RESIDENTIAL> Ii\''F T CL1'sARLl' NEW 3, 4 RENOVATION: REPLACEMENT PLANS SUBMITTED: YES =-` NO APPLIANCES-1 FLOORS BSM 1 2 3 4 5 G 7 8 9 10 11 12 13 14 BOILER _.” BOOSTER CONVERSION BURNER COOK STOVE _.. ._ DIRECT VENT HEATER DRYER FIREPLACE — FRYOLATOR - FURNACE C GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS : MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST _ — — { UNIT HEATER UNVENTED ROOM HEATER — - NATER HEATER — .. ...:,.w.,...._.. .... .. S OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YESO I I IF YOU CHECKED YES,PLEASE INDICATE THE TYP:_OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER: I am aware that i:he licensee does not have the insurance coverage required by Chapter 142 df the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER .,t_: AGENT OF OWNER OR 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 theermit issued for this application P will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 14'?of the General Laws. PLUM BER-GASFITTER NAME LTJ Elf.,. LICENSE#gY3� SIGNATURE MP MGF . JP JGF LPGI, CORPORATION : 3 p 83.,. PARTNERSHIP _# A „w ST LLC _# COMPANY NAME i �,E ADDRESS CITY .D Fo,�?u' STATE Moo ;ZIP. 03 s� TEL' 9 71� 37Z �,T �. . ._ _ra =.h. FAX U..'.2q—j .. E�'AIL rL� ! e � i '----_, ' ., � f I �C, .^-- N2 9684 Date// !. 7/.�Z.. H°R,M TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING � sSACMUs� { This certifies that �./.�/. . l?Q. . . �0�. �. �. . . . . . . . . . . . . . p p tt! /� . 4 :has permission to perform.. . . . . . . . .::: . . i plumjb.ing.in the buildings of 'at. , North And ver, Mass. F Lic. No.9s.4/37. . /. . . . . . . rrl . PLUMBING INSPEC,OR Check # -7,397 WHITE: Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY N Of— MA DATE12012D I I PERMIT# �e ' JOBSITE ADDRESS 1.� Aobffl OWNER'S NAMEn l-" OWNER ADDRESS jtkL L►_it v TEL . L FAX �L TYPE OR OCCUPANCY TYPE COIJMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL / PRINT CLEARLY NEW: ❑ RENOVATION:[_I REPLACEMENT:v; PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 FLOOR- BSMj 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK _ TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its s:.lbstantial equivalent which meets the requirements of MGL Ch.142. YES[']'NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY EL}� 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 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 performe:cl under the permit issued for this application will be in compliance with all Pertinent provisi n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME'/-a�'' E-F-//C:--) LICENSE#8t/3 SIGNAT — MP 9-, JP❑ CORPORATION P'�1-7° e-T PARTNERSHIP❑# LLC❑# COMPANY NAME . < < � .�' f G ADDRESS CITY Vii;'. P ,Pn STATE/7-�'1�- ZIP D 3:3`-- TEL?79 Yl/ r FAQ� _ CELL _ EMAIL m4hl d- I QW-1a). (al 1l V' �rll�z9 Division of Professional Licensure: License Search Page 1 of 1 The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES—'– ............... ...................................... .............................. ........... ............................................................................................... ERVICES.....................................:.................................................................................................................................................................................................................................... Check a License Check A Professional License Locate a Licensed c Professional By the Division of Professional Licensure Online Address Change Contact the Agency SEARCH CRITERIA More... Profession:Plumber REFERENCES& License Number:8437 RELATED INFO Disclaimer Regarding LIC. BOARD LL LIC. TYPE LIC. NUMBER NAME � WCITY/STATE -LIC. STATUS Website License Searches Plumbers ti Gasfitters Master Plumber 8437 I THOMAS E.WEEKS MERRIMAC,MA Current Enforcement Process II L—.___.__._ -_. J_.___ _�_.__ __.l Your search has resulted in 1 licenses Glossary Glossary of License Status Codes More... The page above has been generated by the Division of Professional Licensure web server on Monday,November 26,2012 at 10:50:07 AM. ©2007-2011 Commonwealth of Massachusetts Site Policies Contact Us n�onninn=111nm1�or,P.�innnnoT�Tn—Q � 1 /7 /7/117 Date./. l ... .. .... . ...... . pORTk 3? "` TOWN OF NORTH ANDOVER O D { t � PERMIT FOR GAS INSTALLATION �,SSACMUSEt 14 This certifies that . ,©. .. . . .�. !!. .. . . . has permission for gas installation . Y .'.A 4er". . . . . . . . . . . . . . in the buildings of . . �6. . . . . . . . . . . . . . . . . . . . . . . . . . at �?ql��Q . . �? ' . . . . , Northnd�over/Mass. � Fee. .410P cw Lic. No. � � . . l . GAS INSPECTOR Check#��G�G 7874 - No.: Date f H°RTIy TOWN OF NORTH ANDOVER p BUILDING DEPARTMENT °�,r.o� ar �: SSACMUS� J $ $ h s: i Building Inspector MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING ` i City/Town:*V _/U�r>cf ,�s7�•,�s7 , MA. Date: Permit# Building Location: / / l�tiZ� �nl Owners Name:_& G , Type of Occupancy: Commercial❑ Educational❑ Industrial ❑ Institutional❑ Residential New: Alteration:❑ Renovation: ❑ Replacement:❑ Plans Submitted: Yes❑ No❑ FIXTURES coco uj Lu Z Q w w v _ 0 W 0 ~ m m x O w w L) cn H O = W w 1-' O J O z m Z O W O > W Z m � a a H o O w x w o a x W U W a wU' J W Z x W F_ W z Z W Z H F- O z J O W 2 W Lu O LX W � co w ul M > 00 Z 00 N ~ LU> z F_ _ 0 o 0 w (7 C9 x x O a w Z z w a 0 SUB BSMT. BASEMENT 1 FLOOR 2 Nu FLOOR 1 3 FLOOR MFLOOR Installing Company Name: Check One Only Certificate# // ty Lti"�orporation ��� Address:_ sy� State:_ ����� � El Partnership Business Tel: �� 3� Z T-z�! Fax: — Name of Licensed Plumber/Gas Fitter: El Firm/Company INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes C NN o El If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner ❑ Agent ❑ By checking this box❑;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. [APPROVED Type of License: ❑Plumber le ❑Gas Fitter Signature of Licensed Plumber/Gas Fitter ❑Master yrrown ❑.journeyman License Number: OFFICE USE ONLY ❑LP Installer 10/21/2011 11:03 978--521-5127 COSTELLO INS. PAGE 01/01 ACORD CERTIFICATE OF LIIA;BILITY INSURANCEDATE(MMIODNYYY) TM 10/21/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTH A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT: If the certificate holder is an ADDITIONAL,INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: COSTELLO INSURANCE AGENCY PHONE878,374.6352 978.521.5127 A1C No. e Ext: AIC,No 2 South Kimball St. ADDRESS: PO Box 5248 INSURER(S)AFFORDING COVERAGE NAIC 8 Bradford, MA 01835 INSURER A: Merchants Ins. Co, INsUReo Foseph A Dipietro Heating & Cooling, Inc. INSURER 8: Peerless Insurance 24198 5 South Sumner Street INSURER C: Bradford, MA 01835 INSURER D: INSURER 9: INSURER F: COVERAGES CERTIFICATE NUMBER: Master 2011-2012 REVISION NUMBER; THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITIO14 OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDI:p BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HlNE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE I D POLICY NUMBI R MMIDDIYYYY MM/DDIYYYY LIMITS GENERAL LIABILITY BOF'9097243 07/25/2011 0712512012 EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL UABILITY PREMISES Ea occurrence S 100,000 CLAIMS-MADE D OCCUR MED EXP(Any one person) S S'000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 r GEN'L AGGREGATE LIMIT APPLIES PER; PRODUCTS•COMPIOP AGC S 2,000,000 I POLICY jEpT LOC $ AUTOMOBILE LIABILITY 6)1.4077043 07/25/2011 07125/2012 (Ea acclderm $ 1,000,00 0 _ ANY AUTO BODILY INJURY(Per person) S ALL Ow SCHEDULED B AUTOS X AUTOS BODILY INJURY(Paraccldsnt) S X HIRED AUTOS X AUTOS NEO Per accldent S S UMBRELLA UABOCCUR CL 8798106 07125/2011 07125/2012 EACH OCCURRENCE $ 2,000,000 6 EXCESS LIAS HCLAIMS-MADC AGGREGATE S DED I X LRETFENTION s 10,000 S 2,000,000 WORKERS COMPENSATION t1C407704 07/25/2011 07125/2012 X AND EMPLOYERS'LIABILITY YIN TORY LIMITS I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE.L.EACH ACCIDENT S r 500,000 B OFFICERIMEMBER EXCLUDED? I N ) N I A (Mandatory In NH) l—�J EL.DISEASE•EA EMPLOYEE S 500,000 Mdc:cdbc undor DESCRIPTION OF OPERATIONS below E,L,DISEASE.POLICY LIMIT S 500,000 I DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES (Attach ACORD 101,Additional Relearks Schedule.If more space Is required) CERTIFICATE HOLDER CANCELLATION FAX: 978.688.9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of No. Andover Attn.• Mary AUTHORIZED REPRESENT E 1600Osgood St. No., Andover, MA 01845 Ben o 0 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD ff: Commonwealth of Mas \tts Division of Registrati/ •. 1 Board of Plcirirbi l L DAVJD I cGl' 1.SOUTHr • - SALEM, N ,q / Journeyman P,u �Q PL32193-J -05/01/2012 162 004 77 Expiration Date.• Serial No. -� License No. rf Date/Y�y. ��... . .. . HORT" Of of TOWN OF NORTH ANDOVER ` PERMIT FOR GAS INSTALLATION ,SSACHUSEt This certifies that . .*%w . .� has permission for gas installation l y?�. . . . . . . . . . in the buildings of . A vl)�. . . . . . . . . . . . . . . . . . . at �., /North ndovef, Mass. Fee.s k Lic. No.. ./ .,&!G. . . !1!4hc�!zr . . . . . . . . . . . GASINSPECTOR Check# &,1Z,,0 7880 1110, MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING j �► . (Print or Type) �— NORTH ANDOVER ,Mass. Date NOV. 2, 2011 permit# r� = Building Location 163 LACONIA CIRCLE Owner's Name ROBERT DAVIS Owner Tel# 978-688-5273 Type of Occupancy RESIDENTIAL New a Renovation❑ Replacement Plan Submitted: Ye[]No[] FIXTURES a � x hJ U) w a o a x H 5 c, d Fg F. x a ¢� m w ¢ w o p � a w x r W W cn w z ¢ x a a W o A v x � a � j s z FQQ z Q HQ a E > O > w u�E�j]] a F W a 2 0 0 = w A 0 ..4 U a > A a H O w SUB-BSMT BASEMENT 1ST FLOOR ' 2"D FLOOR 3RD FLOOR 4T"FLOOR 5T"FLOOR 6T"FLOOR 7T"FLOOR 8T"FLOOR Installing Company Name Eastern Propane & Oil, Inc Check one: Certificate Address 131 Water Street Corporation Danvers, MA 01923 FjPartnership Business Telephone# 800-322-6628 Firm/Co. Name of Licensed Plumber or Gas Fitter JOHN MARSHALL INSURANCE COVERAGE: I have a cur liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. Yes ✓ No ❑ If you have c ecked y s,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 13 Agent 13 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 a d that all pl bing work and installations performed under the permit issued for this application e i mpliance with all ertinent a isio oft ch tts State Gas Code and Chapter 142 of t G ral Laws. By Type f License: ••9fumber ign ture of Licensed Plumber or Gas Fitter Title Gas fitter •-Master License Number 778 City/Town •-Journeyman APPROVED(OFFICE USE ONLY) i Aug. 12. 2010 9: 36AM No. 3096 E'. 2 The Commonwealth o Massachusetts Department of Indusolal Accidents Office of Investigations 600 Washington Street Boston_li_ 02111 Workers' Compensation:insurance_Affidavit: Builders/ContractorsMe--tncians/Plumber Aipplicant Information Please Print LeObly Name (BminssalC?rganizai mgndivi&4 �a'�'�r`r/� /���o�� �• / - Addiess: ,� City/State/Zip; ���/ J S f Phone..#; Are you an employer:' Check lbt appropriate.box: Type of project.(required): 1-fll am.a employer vdth -I s 4. L] lam a general contractor andI 6. M New construction employees(fill]and/orpartAime)• have hired the sub-contractors I 2. 1 am a sole proprietor or partner- listed on the attached sheer, $ 7 T7 Remodeling Ship and have no employees 'mese sub-contractors have 8. []Detmohtion working for me in any capacity. ' workers'.comp.insurance. 9, []Building addition [No workers' comp.insuranceinsurance5. rP We are a: co oration and its � required.} officers have e.xercised their 10.0 Electrical repairs cr additions 3.0 1 am a homeowner doing all work right of exemption per MGL 11Plumbing repairs or additions . myself. [No workers'comp-. c.152;§1(4j,.and we have�0 12.[1 Roof repairs insuraaoe reuired. 1 employees. [No workers' � 4 ) 13.11 Other GasTr�iiic,� comp.innu ,ce required_] �R.t tzcpHcaatthat cLeda bas#1 mast alto tai imz the ae:eem boiow shotriesg thcc wv3�'comp�ation porky tnfonnatton 1 Hameawn=who submit this affidavit indicating theyare dui4 alt work end tiicahuc aural&:=MURntou most sebmtr a=w afdarit indi=ems saz u'onaactars that this b=mast ataohed%zn additional do=t showrog the rffimt of the sub-eon===wd thea:woriQss'COEV Policy iFve I'm I am an employer that is providing workers'rompeiasafion irrsraranceJor my:employees Below is tha policy and job site illfOrpJa?Jl)2 is � / / � Insurance Commny Name: L- -'/l_,L Policy##.or Self us,..Uc:#: iiVC_ f e-5 Expiration Date_ ?//.'5- Job Site Address: 161 L.S ca.,.:A &C icA e - . City/5tatelLip;�o��, �MeJtw,�✓� MS , QI?NS Attach.a copy of the workers'compewatiort polic;y4eclamfion page(showk g..the policy Dumber and,ezpkmOon dicta),: I Failure to secure coverage as requited under Section 25A of MGL.c.152 can lead 20 the irunosi 0n'of aminal.penalties.of:a + . fine up to S 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 sgainst.the.violator. .Be advised that a.copy of this statement may be forwarded to the O Fi of ; Investigations of the DIA for insurance coverage verification I&hem-bycerci e under.the aims and u e-ire ormadort provided above.Ls, and correct. 13' P p p�j_ f Datz Phone#: i Offcclause only. Do not write in this area,to be completed by city or lown.offkIal A , 9 City or Town: PerraltlLlcense..# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Clty/ ow r Clerk a.Electrical inspector 5.Plumbing Inspe.ctor 6. Other I Contact Person: Phone#: I