The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 180 GRAY STREET 4/30/2018 (2)e Commonwealth.. of Massachusetts City/Town of System Pumping Record Form 4 l Gly 'r'``te DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of -Health or other approving authority. . A Facility Information Important: When filling out 1. Syste forms on the computer, use only the tab key Address to move your cursor - do not i use the,retum City/Town State Zip Code key. 2. System Owner. Name Address (if different from location) CityrrownState iZi "od Telephone Number B. Pumping Record A. bate of Pumping 2. Quantity Pumped: Date Gallons 13. Type of system: ❑ Cesspool(s) eptic Tank_ ❑ Tight.Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No Ifes y , was It cleaned? ❑ Yes ❑ No Condition of System: Vehicle License Number http://www.mass. t5form4.doc• 06/03 System'Pumping Record • Page 1 of 1 Date.. f,/./.�/�2 ......... p`tao -,Volt pL TOWN OF NORTH ANDOVER -.abate I got. 'PERMIT FOR GAS INSTALLATION VSs^`" SES , / �. This certifies that ... Ale/'! �%129�+�... vgZ_. 4 1 has permission for gas installation in the buildings of ... Ar 4.. 47� Mq .................... at .. 1l. ..� .. ............ . . North dover,, ass. Fee. !'fr Lic. No.. GAS INSPECTOR Check # -5-0/ W_ C wloffii -0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I /f� �✓ /r , t�'�%�r!�Z/�� ' MA DATE PERMIT PERMIT# JOBSITE ADDRESS; 10'7C) �r OWNER'S NAME c[09r�Cj�/lC� GOWNERADDRESS _..- TELJ�'-�a- �$�� FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL; EDUCATIONAL I RESIDENTIAL CLEARLY NEW: RENOVATION: REPLACEMENT: `/`- PLANS SUBMITTED: YES -., NO i_ ti APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE .. ... ... _...:..µ.. , . _ .:.... _..,... _... _...., _ DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE r GENERATOR . GRILLE INFRARED HEATER - LABORATORY COCKS MAKEUP AIR UNIT _._. _...:.. OVEN _.._ POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT; I TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER t , s r z Ri € i INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES j NO `. I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY 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 _._ 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 Penine t ro ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. J I PLUMBER-GASATTER NAME [MICHAEL H HOUSE J LICENSE #' 7173 SI AT RE MPI MGF' JP I - JGF LPGI CORPORATION ; 1# 3377 C PARTNERSHIP # `LLC , # COMPANY NAME:1 MERRIMACK VALLEY CORPORATION ADDRESS 15 AEGEAN DRIVE, UNIT #3 CITY METHUEN STATE MA ZIP! 01844 TEL 978-689-0224 r FAX 1978-689-2206 CELL( 978-884-3427 EMAIL Ilittle@mvalleycorp.com or srutter@mvalleycorp.com � n wloffii -0 w F O z z 0 U W a z a z 00 z O N w } � ~ w O W O E^ a it Z W (A U) w Z N a W a W a W d w N a C7 zz a Q F a a � U C[ J F a a a U) Lii FE W U- W F O z z 0 U W 0. z Q c� x t� 0 �J b N TYPE OR PRINT CLEARLY FIXUTRES Z BATHTUB CROSS CONN DEDICATED S' DEDICATED C MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY , MA. DATE / /O PERMIT # JOBSITE ADDRESS _ _ _ OWNER'S NAME !l r OWNER ADDRESS: TEL: FAX: i OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL NEW: ❑ RENOVATION: ❑ FLOORS I Bsmt I1► WASTE SYS 'SAND SYS DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYS DEDICATED WATER REUSE SYS DISHWASHER DRINKING FOUNTAIN FOOD WASTE GRINDER UNIT FLOOR /AREA DRAIN INTERCEPTOR INTERIOR LAVATORY URINAL WASHING MACHINE WATER HEATER ALL WATER PIPING I have a current liability insurance policy or its REPLACEMENT: 9259 PLANS SUBMITTED: YES ❑ N0)K Date..��J/�/Z.. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that has permission to perform plumbing in the buildings of .. t�%�..-?fe?�14............ . . . at ...MO. 4147W..IV,...S'%.. ...........Porth Andover, Mass. Fee .R'. -P . Lic. No.. Y17.3 . PLUMBING INSPECTOR Check # SGlel equivalent which meets the requirements of MGL. Ch. 142 YES IN1 NO If you have checked YES please indicate the type of coverage by 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT F-1 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 applicatiq� will be in compliance 'th all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER NAME: I MICHAEL HOUSE LICENSE # 7173 SIGNATURE ?MPANY NAME: MERRIMACK VALLEY CORPORATION ADDRESS: 15 AEGEAN DRIVE, UNIT 3 CITY: METHUEN STATE: MA ZIP: 01844 FAX: 97&689-2206 ,TEL: 978-689-0224 CELL: 978 884-34277-1 EMAIL: LLITTLE@MVALLEYCORP.COM MASTER_ JOURNEYMAN CORPORATION ❑■ # [� PARTNERSHIP ❑ # LLC ❑ # `1 . The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Busiriess/Organization/Individual): 1J1e�1 n19c Address: /S A,,,, City/State/Zip: , `jy Phone #: 9,2 an employer? Check the appropriate box: A�11,1,oarn 1. a employer with rl 4. ❑ 1 am a general contractor and I - employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working ' for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1 l.❑ Plumbing repairs or additions 12. ❑ Roof repa' s 13 g Other *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 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:��j ?1i�/iFI q 1041A 11 / /C� 1AA I,,, , Policy # or Self -ins. Lic. #: 102�114eglAl f�P 43 j,15211 Expiration Date: Job Site Address: /�� l��c/'� City/State/Zip:J v , 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 cert' y un e7th,,,,pains��andies of per' y that theinformationprovided abov is true and correct. /Si nature:M U10' Date: /r'� r 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 #: