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Home My WebLink AboutMiscellaneous - 176 CHESTNUT STREET 4/30/2018Date ....!......... ........ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING I v >0 / This certifies that . i.. � ! lx- ..1�.'.'V!�.O e hasp rmis�sion to perform....r4 I..! ..�.. .. 7n..j`1.. j...�.`�:..�?..�1............ plumbing in the buildin sof Pe.r�..�.............................................. ............ at ............ ....................:'S'...............�..�........................... North Andover, Mass. Fee ...... .'�... Lic. No. i�.tol .... ........................................................................... PLUMBING INSPECTOR Check WATEP MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE PERMIT # JOBSITE ADDRESS i -7 6 Crew Nur Swr4 OWNER'S NAME=,_?__y POWNER ADDRESS -------- TEL Ecn S FAX TYPE OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL F-1 RESIDENTIAL PRINT CLEARLY NEW.Ell RENOVATION:0 REPLACEMENT:0 I PLANS SUBMITTED: YESE] N05§ — FIXTURES I FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ------ I CROSS CONNECTION DEVICE J DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASfOlUSAND SYSTEM ....... DEDICATED GREASE SYSTEM li DEDICATED GRAY WATER SYSTEM E - DEDICATED WATER RECYCLE SYSTEM ---J DISHWASHER DRINKING FOUNTAIN j FOOD DISPOSER 7V F - FLOOR/AREA DRAIN E INTERCEPTOR (INTERIOR) - - - .- __==F ... .... ... KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL ---------- SERVICE i MOP SINK TOILET . ........ URINAL MASHING MACHINF r WATER HEATr' WATEP T10 ►have a curr,,,, Ifi Y I J S o CHECKED ycS, uranceP,,,,y or its Substantial UABIl PLEASE 'NDICArE TWE TYPE OF 04101 tvhi,, mDov I --_c: ip ,4 OWNER NCEPOLICyo --VERAGEBy 8ets the requireme,, Massachusetts WRIVER: I are OTHER TYPE OC"'CK"VGTIiEAIPRlp,,A,�, 'SofMGLCh.142. YESte Usetts Gel7eral Laws, and am aware F/ND8MAl nd that that the 1- OX SEL OW NO not hatille, the Insurance BOND cy 8 My Signature 1cenS08 doe, 1 h8Teby On this permit s cerf* ;Zit a �po�,�a��? and that -1-pliVatton all "alloffI CV -W-a-iv CovOra ge r, Mass, bin 'iD Usetts no "I$ requlp,.m 0111red by State tu and Installations''!' ent. ChaPter 142 Of the and h .g cod e have sub PLUMBER'S and ed undLnmated or 'S NAME aPter 142 rtheperr,11I ii'lidregard- CIIECK I OINE ONLY; Y" OWNER AGENT Of ti General L.'s 'for this Ued 9 this application JP wiU be in LICENSE COMP11a CID all p accuratethe best to COMPANY COP? # e ent F Iny Ome IF, PORATION dqe CITY I a f E::PAF?TA1ERSHp0# S/ T PAX ADDRESS 6 - �-- - �-- / E.SSL, -i�— STA - : . �,e� '] LLCO� CELL ?7 ZIP EMAIL --_O I �..3-�.___�-i ., _1Y1 � -_... --._._ ,___ TEL q.- ------ q.- Date ... �..�....��. ~ ................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that - . ' has permission for gas installation -.^U`:.�.... �. ..`..'.......'2 �' inthe buildings of ......e .. 2cr�............................................................. at ....n.�.. ...: !L'r S.. `'"",........... �...................... North Andover, Mass. Fee.ti �....... Lic. No..�i .... �'�i 17 ................................................................... GAS INSPECTOR Check # .3' " UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK FMASSACHUSETTS ,\_ti?✓EIL_..___. MA DATE S2ol_ PERMIT#y 1f' JOBSITE ADDRESS __iZ Co C H E y- 3•t� OWNER'S NAME r "?��y t p.--- OWNER ADDRESS -� y"Zz� Ctt� µC____ TE _i 1-SS`I�F-:-.�J TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL( RESIDENTIAL CLEARLY NEW, RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES NOD APPLIANCES Z FLOORS- BSM F—F 2 3 4 5 F 6-1 7 8 3 10 1 11 12 13 14 BOILER r ��,1~i T ==--J—_JBOOSTER CONVERSION BURNER 4. KO;�._._! .__.rJ _-_-1 . _1 ._.__-_. - _..------! ---�_i _,..�_i __�._J �......,.1 �.._.-..- •_--=--�-1 ----I COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR J .__ GRILLE ------- L777' ....._: INFRARED ........).€ ___.._.... HEATER LABORATORY COCKS MAKEUP AIR UNIT i.__: 1 1 -. _€ _ :«._1 _, _ . __.. OVEN POOL HEATER _I ..:.._I . ROOM I SPACE HEATER ROOF TOP UNIT TESTIC--. JF---- UNIT HEATER UNVENTED ROOM HEATER WATER HEATER_ M., OTHER - T J �� _ _i J= INSURANCE COVERAGE I Pave a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL. Ch.142 YES a NO D I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY W OTHER TYPE INDEMNITY U 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 F] AGENT 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 Massachusetts State Plumbing Code and Chapter 142 of the General Laws. , , n PLUMBER-GASFITTERNAME Rs4.K: =A.=`��1_iu -: LICENSE#[ii(:. SIGNATURE MP 9- MGF F..-- JP D JGF D LPGI ® CORPORATION [J# PARTNERSHIPS#� - LLC [--jl#[: COMPANY NAME:Pr2l_.i _..`�'t ADDRESS — `I O._-LOC10E CITY �l} 624{ 1. t_� ---_---- - - --- � STATE MA ZIP FAX _-- CELL ��£r771- 6 ySl EMAIL i .../11_--__c�-' -- The Commonwealth of.Massachusetts - Department of . dgstriglAecidents Office of Investigations 600 Washington. Street Boston, .MA 02111 Vww.mass gov/dia 'workers' Compensation Insurance Affidavit: Builders/Cont°actors/ElectxiciangfPlumbers pplieanfCormaiion Please Print Legibly Name (Businessiorganization/individual): Address: y() L...oc1<6 S� ,, 0015 'L3`"S City/State/Zip. 1�pJtjzAA 1 Lj_ I M A. Phone #: 9 X19--77 71- (PY 5-1 Are you an employer? Check the appropriate box: 1. Q I am a employer with - 4. ❑ I am a general, contractor and I employees (fall and/or partlime)* have hired the sub -contractors listed on the attached sheet. 2 Lam. a sole proprietor or partner- ship and'have no employees These sub -contractors have working forms m any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its [No Workers, comp. insurance officers have exercised their required.] 3.0 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c.152, § 1(4), and we have, no employees. Wo workers' insurance required.] ? comp. insurance required_] Type of project (required): 6. [] New construction f 7. ❑ Remodeling 8. [( Demolition 9. ❑ Building addition 10.[] Electrical repairs or additions 11. g2lumbing repairs or additions 12.[] Roofrepairs 13.❑ Other *Any applicant that checks box#1 must also fill outthe section bel6w showing their workers' compensationpolicy information. •Homeowners who submit this affidavit indicating they 2•re doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that checkthis box mast attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. X am are employerthat ispr'oviding workers' compensation insurance for•my employees. Below is thepolicy and job site information. Insurance Company Name: Policy i# or Self -ins. Lie. #: 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 required.under Section 25A of MGL o. 152 can lead to the imposition of criminal penalties of a fine up to $1,500A0 and/or one-year imprisonment, as well as civil penalties in the form. of a STOP WORD ORDER and a frm of up to $250.00 a day against the, violator. Be advised that a copy of this statement maybe forwarded to the Office- of Investigations of the DIA for insurance coverage verification. X do liereby Certo under• the pains and penalties perjury Mat the rig formation provided above is trite and correct. SiLynature: 4�w L , Date• 11c�.G.- �^ , Z�I y ��.o Official use only. Do not write in this area, to he completed by city or tower official. City or Town: PermitlLicense 0 Issuing Authority (circle (ine): 1. Board of Health 2. Building Department 3. CityiTowa Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - Contact Person: Phone 9: 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 bire,- 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 indiiidual, 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 shallnot 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 cgntracting 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 phonenumber(s) along with their certiftcate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are notrequired to carry workers' compensation insurance. If an LLC or LLP does have employees, apolicyis required. Be advised that this affidavit may be submitted to the Department of ludustrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. rhe 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 andprinted legibly. The Departmenthas provided a space atthe 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 cuarent 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. Anew affidavit must be filled out each year. 'Where a home owner or citizen is obtaining a license oz permit not related to any business or commercial venture (i.e. a dog license orpermit to burn leaves etc.) saidperson is NOTrequired 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 ai.d fax number: `rho CQmm.on oalth of ME Dopatdaont Qf fadwWal .A acidoita Off Ne ofTAVe'stigatxo)" (bo Wa"gQ-11 St oa Boston,1 A 021.11 Tel, # 61.`x -7.2x_4900 est 406 ox- 1-877-MA:MAFF, Revised 5-26-05 Fax # 617-727-7749 www.�ass,ga��clia. P. Date.........Iz � .-�V ................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .........,V.IO l L -C-,/ ............. .!.................................................................................. .... ....... has permission to perfuni, .........' ., W .r ---1,w.... ' r �...�' wiring in the building of.............`Z ............................................................................. rr 6 �'�;inT v�.( ........ ..7- ....................: ...,North Andover, Mass. at....l...7...:............................. Fee Z �' Lic. No, .. ............ � ELECTRICAL INSPEC�R / Check ,4 1 N Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 12- Occupancy and Fee Checked r BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 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;) , � - 1 iA City or Town of: 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) j *� (t Owner or Tenant 1)exv�� J ?err\,( Telephone No. I7L5$-55'18 Owner's Address Is this permit in conjunction with a building permit? Yes W No ❑ (Check A iateBex�'- Purpose of Building 5.N- Fa N.I l ��v�e Utility Authorization o. �� j Existing Service 1()0 Amps lad / ;)I() Volts Overhead� Undgrd ❑ No. of Meters -L— New Service a. Vu Amps I -.�o l '� LW Volts Overhead n gr No. of Meters Number of Feeders and Ampacity 1 (>AV -TQ ) Z,.—K. .- JLC � Location and Nature of Proposed Electrical Work: I(- F .r -A C Completion o the ollowin table may a waived by the Inspector of Wires No. of Recessed Luminaires t) No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires 3 Above In- Swimming Pool rnd. El In ❑ o. o mergency Lighting Batte Units No. of Receptacle Outlets i, p No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners of Detection and No. initiating Devices No. of Ranges l No. of Air Cond. Tons Tot No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number I Tons I KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters KW 1 No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Eq uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: , n (When required by municipal policy.) Work to Start: 3 - w, Inspections to be requested in accordance with MEC Rule 10, and upon completion. 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 0- BOND ❑ OTHER ❑ (Specify:) I certify, tinder the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Val - c d C. • LIC. NO.: Q Licensee: \,.Jr,� Signature U L� ` LTC. NO.: , (If applicable, enter "exempt " in the li nse number lingg.) 1 Bus. Tel. No.' qT9 D I' / 13` Address: '� \ �ti" � Av-e �3r��r1v-cc `V� pc O t�i3� Alt. Tel. No.: u(19 - D& - I I *Per M.G.L c. 147, S. 57261, security work requires Department of Public Safety "S" License: Lic. No. 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 PERMIT FEE: $ Signature Telephone No. P,"x-k- 1241-1y"Pl�' I%