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HomeMy WebLinkAboutMiscellaneous - 183 MASSACHUSETTS AVENUE 4/30/2018N_ w O � O � O D Q 0 O = O C CT1 N Q m o CO o CO o b m z C- m t � � �� � °� �*� V � ~� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING N MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK MA DATE -_ PERMIT 4 JOBSITEADDRESS7 S 1e� OWNER'S NAME POWNER ADDRESS"'�— -- TEL a �IFAXL TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL' PRINT CLEARLY NEW: RENOVATION: © REPLACEMENT: PLANS SUBMITTED: YES Ell NOD FIXTURES 7 FLOOR--> BSM 1 1 2 3 4 1 5 6 7 8 9 10 11 12 13 14 BATHTUB.,.._ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I _._...__1 ._.-.___I DISHWASHER DRINKING FOUNTAIN_f ..____j _._-_-) FOOD DISPOSER .._____.j _.___. FLOOR/AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK _..... LAVATORY -_-__i ._____J --L-1 __..-___1 ...... ROOF DRAIN SHOWER STALL I -_.__._I _-----_ SERVICE / MOP SINK ?OILET URINAL _...-- ASHING MACHINE CONNECTION V ATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER: lam aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachuset ene I L ws, and that my signature on this permit application waives this requirement. P111k CHECK ONE ONLY: OWNER GENT 10 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 bwl • ge and that all plumbing work and installations performed under the permit issued for this application will be in complia c all Pertine isio f t Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE # SIGNATURE �1 MP [1i JP � CORPORATION MJ #=PARTNERSHIP D# =LLC Df#! COMPANY NAME ,,,2,�.✓l w?,.��-- ADDRESS CITY I� �� STATE ZIP I Q / TEL FAX CELL I EMAIL o z N ❑ 6i iu LU Date.... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �This certifies that J , has permission for gas installation ............................................................... in the buildings of .............. . .5 . ..................................... ........ ... .. at ............ ZI ... .......... nss / ....... ........................................... . North Andover, Mass. Fee... Lic. No. .`?.6T ..................................................................... GAS INSPECTOR Check# 103 69 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK VCITY �/1+��`"� MA DATE PERMIT #2 e— JOBSITE ADDRESS_5 -- OWNER'S NAME .j II GOWNER ADDRESS i� TEL�� FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL _; EDUCATIONAL RESIDENTIAL/ CLEARLY NEW: [ RENOVATION: REPLACEMENT: tko"" PLANS SUBMITTED: YES F--Jj NO E] APPLIANCES 7 FLOORS- BSM' 1 2 3 4 5 6 7 8 9 10 11 12 13 1 14 BOILER BOOSTER -- CONVERSION BURNER COOK STOVE =A= DIRECT VENT HEATER+ DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER .._�f L--- -- - _ LABORATORY COCKS MAKEUP AIR UNIT- OVEN -I. POOL HEATER ROOM/ SPACE HEATER _( ROOF TOP UNIT ( _ TEST UNIT HEATER UNVENTED ROOM HEATER WATTR HEATER OTHE._T I I, ........-.- ......................... - - - -.:.. . - INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES [] NO [� I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E3 OTHER TYPE INDEMNITY ] BONDI OWNER'S INSU CE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts eral La s, an hat my s' nature on this permit application waives this requirement. CHECK ONE ONLY: OWNER _ AGENT Eji �'A 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 pr ion of the Massachusetts State Plumbing Code.and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME _-� `/� J LICENSE # Z SIGNATURE t : 0 MP El MGF 0 JPf6rJGF ._ f LPGI 0 CORPORATION Q# = PARTNERSHIP ©#= LLC Ej]# COMPANY NAME: - - ADDRESS ...____CL� CITY STATEi"IZIP 1�TEL51 FAX CELL EMAIL _ O z 0 U W W a z� Oz y❑ W cc � W EO+ a Z U w �* W X a w N o w C a 0 Pa a a J E. a CL � w x w F- LL H oz z 0 H U W Pi 0 The Commonwealth of Massachusetts Department of IndustrialAeeldents 1 Congress Street, Suite 100 Boston, MA. 02114-2017 ar www mass.gov/dia a�M Sy'V Wa> kers' Compensation Insurance Affidavit: Builders/Contractor s/Electricians/1'lunnbers. TO BE FILED WITH THE PERYffrM0 AUTHORIx i'. Name (Business/Oiganization/Individual):. Address: City/State/Zip:_ Are you an employer? the appropriate box: Phone #: 1.❑ i am a employer with employees (frill and/or part-time).' 2. n as -ole proprietor or partnership and have no employees working forme in any capacity. [No workers' comp. insurance required.] 3.[] lam a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no, employees. 5. ❑I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. Q We area corporation and its, officers have exercised their right of exemption per MGL c. 152 §1(4) and' ve /rave no employdes` [No workers' comp. insurance required.] Type orproject 0e4uired),.` 7. ❑ N6*'do`nstr6dti0n 8. [] Remodeling 9. ❑ Demolition 10 [] Building addition 11.[j Electrical repairs or additions 12. " 'Plumbing repairs or additions 11 [] Roof repairs 14.n Other *Any applicant that checks bbx#1 wrist also fill out the section below showing their workers' compensation policy information. i 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 cheek" Box must attached'an additional sheet showing the name of the sub -contractors and state whether or not (hose entities have employees. If the sub -contractors have employees, They must provide their workers' comp. policy number- employees. am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. Expiration Date: f Sl 2 4nnea- i i ®i tk lob Site AddressCity/State/Zip:/_/ l ' �� �y 4�� : Attach a copy of the woxkers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL e. 152, §25A is a criminal violation punishable by a fnie up to $1,500.00 ell as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a and/or one-year imprisonment, as w ay be forwarded to the Office of Invesiigaiions of the DIA for insurance day against the violator. A copy of this statement m coverage verification. X do hereby cerci zepains a���Mat the information provided above is true and. correct: Phone #: 2 G 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 o)V/3 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employ. es. 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 enferpri'se, and including the legal representatives of a deceased employer, or the receiver'di trustde 6f an individual, partnership, association or other legal entity, employing employpes. -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 applicantwho has' not produced -acceptable evidence of compliance with the insurance coverage xequired." 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 certificates) 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 PORGY information (if necessary) and under "fob 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 proofthat 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Accela Citizen Access Page 1 of 1 Need Help? For technical assistance in using this web application, please call the Announcements Register for an Account I Lopin ePLACE Help Desk Team at (844) 733-7522 or (844) 73-ePLAC between the hours of 7:30 AM -5:00 PM Monday -Friday, with the exception of all Commonwealth and �tt • Federal observed holidays. If you prefer, you can also e-mail us at t ePLACE helpdesk .state.ma.us. For assistance with non-technical, please contact the issuing Agency directly using the links below. Translation Information - Click Here Alcoholic Beverages Control Commission Division of Professional Licensure Browser Compatibility: • For Application/Renewal:lf your application requires a file upload, Microsoft Silverlight is required to do so. Please see the link below for instructions to download Microsoft Silverlight. Silverlight Download • File a Complaint: Instructions above apply for filing a complaint if you are uploading a file/picture. jj Home Manage Licenses & Permits File & Track Complaints l } I Please refer to the Licensing Entity's website for additional information regarding the status and discipline information shown below. For DPL information, please visit the DPL website. For ABCC information, please visit the ABCC website. Information Pertaining To: Journeyman Plumber 24523 Licensew Detail License Number: 24523 Licensing Entity: Board of State Examiners of Plumbers and Gas Fitters License Type: Journeyman Plumber Type Class: J License Issue Date: 04/19/1996 —L-icense Expiration Date 05/01/20166 Status: Current Current Discipline: Other Discipliner Name: ERIK F SAVOY Business Name: DBA Name: https:Helicensing. state.ma.us/CiiizenAccess/GeneralProperty/LicenseeDetail.aspx?Licens... 12/17/2015 Accela Citizen Access Page 1 of 1 Need Help? For technical assistance in using this web application, please call the Announcements I Register for an Account Login ePLACE Help Desk Team at (844) 733-7522 or (844) 73-ePLAC between the hours of 7:30 AM -5:00 PM Monday -Friday, with the exception of all Commonwealth and t Federal observed holidays. If you refer, you can also e-mail us at Y Y p ePLACE helpdesk(Dstate.ma.us. For assistance with non-technical, please contact the issuing Agency directly using the links below. Translation Information - Click Here Alcoholic Beverages Control Commission Division of Professional Licensure Browser Compatibility: • For Application/Renewaldf your application requires a file upload, Microsoft Silverlight is required to do so. Please see the link below for instructions to download Microsoft Silverlight. Silverlight Download • File a Complaint:lnstructions above apply for filing a complaint if you are uploading a file/picture. Home Manage Licenses & Permits File & Track Complaints Please refer to the Licensing Entity's website for additional information regarding the status and discipline information shown below. For DPL information, please visit the DPL website. For ABCC information, please visit the ABCC website. Information Pertaining To: Apprentice Plumber 15373 Licensee Detail License Number: 15373 Licensing Entity: Board of State Examiners of Plumbers and Gas Fitters :License Type: Apprentice Plumber Type Class: A License Issue Dater 09/03/1986 License Expiration Date: 05/01/2002 Status: Expired Current Discipline Other Discipline: Name: ERIK F SAVOY Business Name: DBA Name: https:H.elicensing.state.ma.us/CitizenAccess/Gener.alPropprty/LicenseeDetail.aspx?Licens... 12/17/2015 Date.... ................ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ......... 16 . ............................ . ..... has permission for gas in§�pllation ........ ...... A ..... 7:6-1< ........................................ .5s" in the buildings of .................... 11� ...... F .................................................................................... at ........... /YJ ....... I .... . . , North Andover, Mass. ..................................... No Feed.. 2 ...... Lic. No. ...... ................... ..................................................................... GASINSPECTOR Check # 6610 099166 G TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY _ MA DATE PERMIT# JOBSITE ADDRESS �i .� — jYl fYss c/e— iIOWNER'S NAME OWNER ADDRESS ]11 TEO FAX OCCUPANCY TYPE COMMERCIAL r4-"4EDUCATIONAL F RESIDENTIAL NEW: RENOVATION: E] REPLACEMENT: El APPLIANCES 7 FLOORS- BSM BOILER BOOSTER CONVERSION BURNER [� COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR j GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER _ ROOF TOP UNIT I� UMIT HEATER U,NVENTED ROOM HEATER PLANS SUBMITTED: YES 0 NOD 10 1 11 1 12 1 13 1 14 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 1 _NO [� IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY n--' 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�ral aws, and that my signature on this permit application waives this requirement. .I� CHECK ONE ONLY: OWNER � 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 ail plumbing work and installations performed under the permit issued for this application will be in compliance w II Pertinent of the Massachusetts State Plumbing Code. and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME ,�/�✓`� S,�✓ LICENSE # SIGNATURE MP El MGF 0 JP [JGF LPGI CORPORATION PARTNERSHIP ®#= LLC ®#= COMPANY NAME:L� CITY IF(/✓ e -e_ ___ _ `� STATE MZIP ���TEL FAX E —�_-- —•= 11 CELL EMAIL V) W H z 0 H U a � W O u) El W o a z W � � 4 Cl) w N a W �i O w w N a o a a �y J F n - a Q � w z w LL W H z 0 H U a Oa, C.- The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 _= '< Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lee blv Name (Business/Organization/Individual): Address: City/State/Zip: /621U VW0- �o L N hone Are you an employer? Check the appropriate box: 1. ❑ I am a employer with i employees (full and/or part-time).* �2. (I am a sole proprietor or partnership and have no employees working for me in �" any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub-contractors'have employees and have workers' comp. insurance.* 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no, employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. 0 Remodeling 9. ❑ Demolition 10 E] Building addition 11.❑ Electrical repairs or additions 12.F] Plumbing repairs or additions 13.E] Roof repairs 14.Fl Other *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 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-cori6ciors 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 Policy # or Self -ins. Lic. #: Job Site Expiration Date: 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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u hepaiyv!q�Vpenaldes ofperjury that the information provided above is true and correct Phone #: Official use only. Do not write in this area, to be completed by city or town official, City or Town: Permit/License # 5 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 lure, 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 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 burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia { ` » KX- 2� �»� �.�I<>�• w'\ : L : @ @ * m.m. IV Date. 7.!6 ...... 0 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... A 2 /�' ... a4.. . . has permission for gas installation . A,v�%�' in the buildings of ..1........... �-��-� tl.,./........................ . at ...�. ...1/... ��!" . , North Andover, Mass'. Fee.. � Lic. No. ./� -.` /rJ2 C � GAS INSPECTOR Check # o 06 5003 MASSACHUSLITS (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations _/ ld. �"eP19�tJ Ross ( w er's Name New ❑ Renovation f Replaceme FORM Plans Submitted Permit # ✓ t/ ✓ Amount $ (Print or type Check one:. Certificate Installing Company Name / /i�Zi 2 /�/� ' //C.i�'3 Corp. Address G(/; n�v9 �C�C Partner. Business Telephone 1'Firm/Co. A Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 0--^ No 13 If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy �� Other type of indemnity 13 Bond D 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 1:3 Agent 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 and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Poe 4nd Chapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) S nature of Plumber Gas Fitter Master l rneyman L.; sedisl&ber Or Gas Fitter License Number i R ;4TH. FLOOR (Print or type Check one:. Certificate Installing Company Name / /i�Zi 2 /�/� ' //C.i�'3 Corp. Address G(/; n�v9 �C�C Partner. Business Telephone 1'Firm/Co. A Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 0--^ No 13 If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy �� Other type of indemnity 13 Bond D 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 1:3 Agent 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 and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Poe 4nd Chapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) S nature of Plumber Gas Fitter Master l rneyman L.; sedisl&ber Or Gas Fitter License Number 1 Location / 83 �' {j� 4 /Q C F: No. Date NORTH TOWN OF NORTH ANDOVER A Certificate Occupancy of $ It�cH' t. �uss Building/Frame /Frame Permit Fee 9 $ Foundation Permit Fee $ Other Permit Fee $ C) TOTAL $ '3 i Check # e '?V u X7636 Building Inspector Y u„ TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATF, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 77=�k x owoywm hi:>' t A` °fY i"'.^: F Y: x.D..> ,, r 1�4.x..• BUELDING PERMIT NUMBER: DATE ISSUED: _- AN � SIGNATURE: " Building Commissioneor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: -Frontage Zonin District Pr used Use Lot Areas ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: 1.7 Water Supply M.G.L.C.40. 54) Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ Public ❑ Private ❑ SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT ,': r.t;r.c; l' iiStrict: S _,NJ O 2.1 Owner of Rei rd /93 lvi� ss Avg Name (Print) Address for Service o ature Telephone 2.2 Owner of Record: Name Print Address for Service: `. Signa e Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor. License Number Address Expiration Date Signature " Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Compa�y Name Registration Number Address Expiration Date Signature Telephone Wo M z M w f Ir— r SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......0 No ....... ❑ SECTION 5 Description of Proposed Work check aII applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: I SRMON 6 - FSTTMATF'n rnN4zT1DTirT3nN rncirc Item Estimated Cost (Dollar) to be CoWpleted bpermit applicant O'FICIA_1Cr USE CINL1� � . ^ � 1. Building(a) Q U © Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 —Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 GST !'ITiA1T �I Check Number .,...,.-1 ,w 1JCLl 1LU WHIN OWNERS O CONTRACTOR APPLIES FOR BUILDING PERMIT I as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION e I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/Rent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS I' 2' 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS a_ SIZE OF FOOTING X MATERIAL OF CHIMNEY — IS BUU DING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE V North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54; a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: Um J6cation of Facility) Signature Permit Applicant 113 /, 4/ D to NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print. DATE l3 a JOBLOCATION /�� / /1*S • Number Street Address Map / lot "HOMEOWNER 'oe"OVI'S Name PRESENT MAILING ADDRESS, State = -'%%57 Work Phone The current exemption for "homedwners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than onehome in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. — HOMEOWNER'S SIGNATU APPROVAL OF BUILDING OFFICIAL Zip Code The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print / I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees ,i orking on this job. Failure to secure coverage as required under Section 25A or MGL can lead to the imposition of criminal penalties of.a fine up to $1,500.00 and/or one years' imprisonment.as Well.as _civil.penalties�nthe i0f a..STOP WORK_ORDER..and_a. fine . of.($100.00)�day.against.me. I understand that a copy of this statement may be forwarded to th Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury th the information provided above is true and correct. Print name Official use only City or Town— []Check if immediate response is Contact person: do r�6t write in this area to be completed by city or town official' ❑ Building Dept ❑ Licensing Board ❑ Selectman's Office #: ❑ Health Department ❑ Other m m m m m y m 7-J CA d CA CM) 10 0 CD 2Z y CD C3. O C2 C � ? C CL y a� �o Ov CD CCD O CL cr d CD CD o CD C. 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