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HomeMy WebLinkAboutMiscellaneous - 17 EDMANDS ROAD 4/30/2018 17 EDMANDS ROAD 210/020.0-0050-0000.0 Date........ ... ... ................... * ��►OR7�y 7h . TOWN OF NORTH ANDOVER x PERMIT FOR GAS INSTALLATION �$a�cHug� This certifies that ..........Q ......6&.10-64c ....... ............................ has permission for gas installation ............^...... .�.�..(..... ........... in the buildin s of......... 5�'.. i ;. . ................................................................................ at.......-.I...U."5......... .......�.�..,.................... North Andover, Mass. ..-Fee ..... Lic. No. .ST1.. M ?....................................................... GASINSPECTOR Check# 9252 !C--\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY __ MA DATE 2t 20 "fERMIT# T/�� JOBSITE ADDRESS _ OWNER'S NAME Lll S col q GOWNER ADDRESS TEL — FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL [j RESIDENTIAL PRINT CLEARLY NEW:[ RENOVATION: REPLACEMENT:® PLANS SUBMITTED: YES NOX APPLIANCES'l FLOORS- BN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER J _ FIREPLACE FRYOLATOR _ FURNACE GENERATOR GRILLE ---_._.. -.- ---- -- - T�� INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN - _- POOL HEATER ROOM/SPACE HEATER ( _ ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATERLL— OTHER � _l - —�I--- — a — — E- -� L- -V -- INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES >4NO [� I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY)a OTHER TYPE INDEMNITY [j 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 Q AGENT O 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 all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME _ LICENSE# ' _� SIGNATURE MP X MGF[j JP JGF E] LPGI 0 CORPORATION# PARTNERSHIP®#=LLC®#= COMPANY NAME: l�, _ ADDRESS CITY iQA� P STATE ZIP TEL Q , FAX� - u i ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTO R USE ONLY FINAL INSPECTI&NOTES Yes No Ana WV/,/Ay/ THIS APPLICATION SERVES AS THE PEI MIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NO rES r The Commonwealth ofMassachuse tis. Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Uf www mass gov/dia Workers Compensation Insurance Affidavit: Builders/Coniractors/Electr'cians/ lum er s Applicant Information Please Print Legibly Name(Business/Organization/Individual): t"r� �1a�2., a 64y 14!;L4 tN6 4 Address: D $OQZ- ?,, City/State/Zip: N o. t0yyQay_&L. DA, Phone#: • q 2D , 17 I Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I ` _z.� 6. ❑New construction employees(full and/or part-time).* have Hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. �• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. EJ Building addition [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3111 am a homeowner doing all work right of exemption per MGL 11. lumbing repairs or additions myself. o workers'comp. c. 152,§1(4),and we have no 12. Roof re airs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they ace 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name:. 6;NAu ItJ%Q4 W C f, d/Levo Policy#or Self-ins.Lic.#: wG yZ(p'3(p3 Expiration Date: Job Site Address: 17 f-,WAAX6 2m&L City/State/Zip: /QMpOtXe2WL4, 0Ity� Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: &La "I,�. Date: ���L �. Zb� Phone#: 57 r . g{S, 2y)O 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.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: Information and Instructions Yi 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 ofhire,- 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-contractors)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 workerccompensation insurance T f an T T r,� os,4aya 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 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 permittlicense 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: The Commonwoaltla.of Massachusetts Department of Industrial Accidents Office of Investigations 6.00 Washington Street Boston,MA 02111 Tel,4 617-72.7-4900 ext 406 or 1-877r ASS.AFB Revised 5-26-05 Fax#617-727-7749 www-mass,govfdia e Csr COMMONWEALTH OF MASSACHUSETTS PLUMBERS' GASF ITTERS ISSUES THE FOLLOWING" LICENSE �, L I CE1SE0 AS A MASTER P�LU �t.: IR E:kt B BLANCHE TE jf I Lu .f' U Po Box r� . Y J 4:•., P10RTH A N D 0 V E R MA 01845-072$ i 857 05/0l/:]6 = 209923 �� � V-,�q6 � � ........... I U- 52 OF NORTH, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ............................................................................................................... has permission to perform.W. k 4ply,<JA ..... ................................................... plumbing int4e buildings of..... ... ............................................................... at...... ............e)................... North Andover, Mass. ti Fee.................Lic. No. .... .. ........................................................... PLUMBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK o CITY D � MA DATE wC-? 2p PERMIT# IF JOBSITE ADDRESS `7 F OWNER'S NAME �C.' �}• POWNER ADDRESS TEL (ii►7 FAX _ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIALK PRINT CLEARLY NEW: Q RENOVATION:D REPLACEMENT: PLANS SUBMITTED: YES® N0KV FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB <Z- CROSS CONNECTION DEVICE _I _�' I { _.�._� _._.6 _..._. _I J - I _ _! _.. . P DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM ! -,__._ __�( .___ .J - __ 1 ( __ __r .- _E __ _f ____.1 I' _ ► 4 DEDICATED GREASE SYSTEM m J -_.._I __-! _-_J _`. 4 � _._.__J ___._t -___f DEDICATED GRAY WATER SYSTEM I ...-_. ( __I I - _ 1=== J --.-__f DEDICATED WATER RECYCLE SYSTEM I J .._._.._J J --A DISHWASHER DRINKING FOUNTAIN _-1 ..____J ..__-- ._-___-_► __._f - __( __...__J ______ ._-____J ._____J .___..-_ ---_.__t .__..__I _ I _..__. FOOD DISPOSER I .___._.I ___.WI __.__( ..----._.I' I .-._..._....I ..-_.-_._I ._. __.f .. .--j -_..___I FLOOR/AREA DRAIN _� ___.__J ______I __._� _-__ _J _------ INTERCEPTOR(INTERIOR) KITCHEN SINK —I _ ------l ---I _-__—I --..._J --_( -____J __._.J .__. G . ___i _._- -_I _- ------ Q LAVATORY ( _ _I _....__..� _- 1 I __.._.___I .--___..J f _.__.._.1 _I I ROOF DRAIN ( I I (F 11 1 F SHOWER STALL f _.-_-J -___.-J __j ..__._ _f _ __ __._.j -._.-_I ____) --__.1 —J _..___) .--j _--._,I SERVICE/MOP SINK _-I _l ( _._! l f _. ( I ! _...__� _-.I I ._- _f -.-._ TOILET - URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I I ..--J= i WATER PIPING OTHER ! - - ---f C INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES% NO �I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Q BOND D 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 I0 SIGNATURE OF OWNER OR AGENT j 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 bejA compliance with all Pertinent provision of the , r h4assachusetts State Plumbing Code and Chapter 142 of the General Laws. I—P J C { PLUMBER'S NAME _ "�', AaC1E _ I LICENSE# 2-1 SIGNATURE MPX JPD CORPORATION# PARTNERSHIP P# LLC COMPANY NAME ADDRESS 2 C 2 7$ i5 o2d!O CITYS ��_,�j___ ------_ TATE ZIP TEL FAX ]CELL — EMAIL ROUGH PLUMBING INSPECTYaN NOTES BELOW FOR OFFICE USF ONLY FINAL INSPECTION NOTES y Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT it PLAN REVIEW NOT S .r 4 The Commonwealth ofMassachusetts - Department of IndustrialAccidints Office of Invesfigations 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Pock, P.1 Address: PO PRCY)4 722, City/State/Zip: rq d hone#: q 71�81 S 12010 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction X. (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7• El Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. g E]Building addition [No workers' comp.insurance 5. F1 We are a corporation and its required.] officers have exercised their 10.ElElectrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1glumbing repairs or additions myself o wor ers comp. oo repa insurance ]ired.re q ut employees.[No workers' 13.[J Other 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 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. /"` Insurance Company Name: C�tm� Policy#or Self-ins.Lic.#: u raa_,�,403 Expiration Date: Job Site Address: 1- k4 M Ate& City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 d that a co of this statement may be forwarded to the Office of of up to$250.00 a day against the violator. Be advise copy y Investigations of the DIA for insurance coverage verification. I _ I do hereby cerVf. under thepains andpenalties ofperjury that the information provided above is true and correct. Signature: Date: Phone#• 9713.81s 1201'0 Of 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.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 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 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 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(ifnecessary)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 bum 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: The Commonwealth of Massachusetts Department of Industrial Accidents, Office of Investigations 600 Washington Street Boston,M.A,02111 Tel,#617-727-4900 ext 406 or 1-877,MASS.A.FI Revised 5-26-05 Fax#617-727-7749 __WWW-mass,govldxa i COMMONWEALTH OI-MASSACHUSETTSPLUMBERS . I ND GSFITTERS II LICENSED AS A MASTER PLUMBER ISSUES THE ABOVE LICENSE r(?: ROBERT B BLANCHETTE � O BOX 728 NORTH ANDOVER MA 01845-0728 8597 05/01/14 .147813 LICENSE • EXPIRATIONDATE SERIAL NO.