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HomeMy WebLinkAboutMiscellaneous - 17 SUMMIT STREET 4/30/2018 i � -h' JUL-UI-GUW 1 Ut U.4;6C t'1"1 uhxlb i 1N1VbrN 6 btKul 1 u ICS 6le 6ubU V, U1 �VAk --� � 6o9CA � z- o3 Y EYJSnNG FNO. 16.2' rs.a' 46.1' 46.l1' r SUMMIT STREET FOUNDATION LOCATION PLAN w&wb=wma i° - �°WN WT ""w�,cam°` �WN A# �. CLIENT: JIM CARROLL aw a,,,mw,u wr w�ar erre am far tuff mw omimmaWNRE m cmrimwti a IW" ANA umm ;mw,� wat cor"mmm W. 119 TME AWVrE MEW. W ,,,,A.MW A.Nff MUDO a MW u Aawmu0 "WOK" L.00ATlON: Lor 2 SUMMIT ST.,No.ANDOVER mw ��of Wm� mmr dr ON 4W - uar $CALE:1"-30' vA rE:s/3%s �► CHRISTIANSENSERGI " S UrADW NO SA/N ar. liIWN94ML�aille RL em-.1u-�wo pp 3J ® ar AM OL atM1mlM�f�At t .:9800 007 09800 Date A�! /,� . . . SAF°, . �� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . . .P�� . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . . . . . . . . .. . . . . . . . . . . . plumbing in the buildings of. TWek,Ute. . .. . . . . . . . . . . . . . . . . . . at . /,7l, . . . . . . . . . . .*�. . . . . . . . . . . . ,North ndcaver, Mass. Fee q4 OP. . . Lic. No. . . . . . . . . ... . . . . . . . . . �6 PLUMBING INSP TOR Check# 4 I IL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE -� PERMIT# JOBSITE ADDRESS J7 err: j-" OWNER'S NAME vl.Cr, aC'G POWNER ADDRESS ( TEL[ �- FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EI EDUCATIONAL © RESIDENTIAL 0 PRINT CLEARLY NEW: � RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 0 NOD FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM _ _ I _ _ , ► I J �_ ___ f _ 1 _ _I ,__.J ( { DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _ _I ___J ___J FOOD DISPOSER —1 1 __—I -( _J _ I _I J _. i ..___I _._.J ---_ FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK ► _-_ k _T—I ___I __.J —__J _____I _ _._k ! ___J __ J ._J _—I TOILET 1 I J _TJ J J __.J __j URINAL i J 1 __.---I J ......... ..._...__- _.-__I WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING ( i ! ..._.._._I l _J I OTHER _ _ ._ : . —_I INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ONO J IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW eJ LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 01 BOND 0 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 �] 1 SIGNATURE OF OWNER OR AGENT F 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 com 'ance wit I ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ .- _ LICENSE# 3R I SIGNATURE , S MP EJ JP R CORPORATION 0# _ ;PARTNERSHIP 0# j LLC J COMPANY NAME Co„ t / � ADDRESS r _i CITY , j STATE ZIP USG TEL >�! /S'� 7op FAX _ ; CELLI EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# -241, PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of IndustrialAccidinis Office of Investigations 600 Washington Street Boston,MA 02111 U1 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): " Address: City/State/ZiPhone#: 's 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 _ p ployees(full and/or part-time)." have hired the sub-contractors ' 2.[V'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. E]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.[]Roof repairs 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. T 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 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:. Policy#or Self-ins.Lic.#: Expiration Date: Job 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 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 aMify under flee pat and penalties perjury that the information provided above is true and correct Signatare: Date: Phone#: �7_ � 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.PIumbing 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 j 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 cavy 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(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 bum leaves etc.)said person is NOT required to complete this affidavit. i 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 Mossochvsetts Department of Industrial Accidents offiee of Investigations 600 Washington Street Boston,MA,02111 Tel,#617727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.Mass,gov/C a u YAK - 5,4 • ' RS A' 6,,dii R� BE r� It it►:,EV 5.,A,-.J OtJRNF1'M1a I��U1111f3 . t • Y T.O.THEABOVE LICENSE F'L TE6T 11`. LACONTP LC N1- TlLD MA Otnc+() l'841 Q 5�i01/I ck 11,.4.6! MGM 1Y . I r ' A Date . . . . . .,yX,K'fUTiDl TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . A1.0— has CC has permission for gas installation .�ti�'�e-!. . .�a' --V- in the buildings of. J.&)) 0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . .�� . . tl�tlY1 ,,�r , , . . . . . ,North Andover, Mass. FeeC�.(). . . . . . Lic. No V. . . . .(1.8. . . . . . . . . . . . . . . . . . . . . . C GASINSPECTOR Check# I Ro 8589 s d'bo -va tf '?( MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I NORTH ANDOVER MA DATE FEBRUARY 5 2013 PERMIT# JOBSITE ADDRESSI 17 SUMMIT ST. OWNER'S NAME I MAURICO TRABUCO GOWNER ADDRESS I MAURICO TRABUCO TEq 978-682-1128 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL® RESIDENTIAL PRINT CLEARLY NEW:® RENOVATION:® REPLACEMENT: PLANS SUBMITTED: YES[j NO® APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER _ COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS ' MAKEUP AIR UNIT OVEN 7 POOL HEATER _ ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER �J OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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 ® 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 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 JOHN MARSHALL LICENSE# 778 SIGNATURE MP® MGF® JP® JGF® LPGI[D CORPORATION[D# PARTNERSHIP®# LLC®# COMPANY NAME: EASTERN PROPANE GAS ADDRESS 131 WATER ST. CITY DANVERS STATE mA—Izipi 01923 TEL 800-322-6628 FAXI CELLI EMAIL l ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES r Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES L 21L ZZ2 The Commonwealth of MassachusettsPrrnt Forrn Department of Industrial Accidents Office of Investigations ' I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information - - — Please Print Legibly Name (Business/Organization/Individual): EASTERN PROPANE&OIL _ Address: 131 WATER STREET City/State/Zip: DANVERS, MA 01923 Phone#: 978-750-6500 Are you an employer? Check the appropriate box: general contractor and I Type of project(required): 1.2 1 am a employer with 45 4. ❑ I am a g employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8• ❑ Demolition workingfor me in an capacity. employees and have workers' Y P ty . + 9. ❑ Building addition [No workers' comp. insurance comp. insurance.} required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.E] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no GAS FITTING 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. 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: LIBERTY MUTUAL INSURANCE COMPANY • Policy#or Self-ins. Lie.#: WC7-641-435806-052 Expiration Date: 03/ 15/2013 Job Site Address:11 Sk vv%+`^: 4. S+, Vlv)Q,,, ,; L o ! fC-b K c o City/State/Zip:J\og iA% a v-,Ld 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 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 ns andpenalties o erjury that the information provided above is true and correct Si nature: - - --- Date: 03/13/2013 Phone#: 8- -6500 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#: c. t P ' I _ d COMMONWEALTH OF MASSACHUSETTS � ■ ■ ■ •o - ■ = ■ 4• m PLUMBERS AND GASFITTIEREi LICENSED AS AN LP GAS INSTALLER ISSUES THE ABOVE LICENSE TO: ,101.-IIA F hIARSI-IALL � i 47 I-10BART STREET I, DAVIVERS MA 01923- 19�i3 778 05/0.1/14 1E14150 - i I i a i ' i r ., l _ I r F c� I � h D �TH ...a........... A � SACMW'.01 CERTIFICATE OF USE & OCCUPANCY 'OWN OF NORTH ANDOVER Building Permit Number Date 3 -a-3 0700 T)IS CERTIFIES THAT .THE BUILDING LOCATED ON /0 ,7-a A�-- 1 17 S MAYBE OCCUPIED AS lP Rom m S, CP 8 S, cS�a•// ,,� .Q���c1 IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO Y S CA I?jZ O /O4 �o Li ivn.yc.� lee_ �. Building Inspector t NORTH Town ofE over 0 No. Pdover, Mass., — � ADRATED <PPa��S S H E BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System i�os+e BUILDING INSPECTOR THIS CERTIFIES THAT...... .. .. &..................�. .. ............ .. .................................. ............ Foundation - —C � � i 3 has permission to erect............. ........................ buildings on .... ...... .. co 0 .��.............. Rough 1d �— .� 3 to be occupied as...... + � L / &V� ((V Q l *eh . chicon v...... ...... ..............�:..�.'.......d'. provided that the person accepting this permit shall in every resect conform to the terms of the application on file in Final �,c ` 3-213 o this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR t Stall ^ jt � /` 33So VIOLATION of the Zoning or Building Regulations Voids this Permit. aggh. I i I_1A Ole PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECT UNLESS CONSTRUCTION STARTS q� PR a Rough .. ............................................................................................. Service BUILDING INSPECTOR Occupancy Permit Required to Occupy Building GAS INSPE TOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final AU(6,,,_, No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street N0 VZtirZ,/.L(.G,,�--' SEE REVERSE SIDE smoke Detf- i� ,