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HomeMy WebLinkAboutMiscellaneous - 20 LEXINGTON STREET 4/30/20180 0 w 0 0 0 0 0 0 0 Date........ ....................................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 't,,, - This certifies that ........(�?................©2.........O....�'....... has permission for gas i 1 ation ........................................ in the buildings of O� 4—co ..................................................... atPX.......... .... ...............t................................., North Andover, Mass. Fee ........... Lic. No Z�1.T........ GASINSPECTOR Check #�_ VIA OF NOR7{q 1ti ; ', r;•• ��c 3•r Date........ ....................................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 't,,, - This certifies that ........(�?................©2.........O....�'....... has permission for gas i 1 ation ........................................ in the buildings of O� 4—co ..................................................... atPX.......... .... ...............t................................., North Andover, Mass. Fee ........... Lic. No Z�1.T........ GASINSPECTOR Check #�_ VIA MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA. DATE I:U PERMIT #I �Ztp . ,iOBSITEADDRESS aO Loi R of OWNER'S NAME I Q.)., Ccs POWNER ADDRESS TEL FAX TYPE OR PRINT CLEARLY OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL-- NEW: ❑ RENOVATION: ❑ REPLACEMENT: �� PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES 1 FLOOR- BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIUSAND SYS DEDICATED GREASE SYS )EDICATD GRAY WATER SYS )EDICATED WATER RECYCLE SYS )RINKING FOUNTAIN ASHWASHER =00D DISPOSER =LOOR / AREA DRAIN NTERCEPTOR (INTERIOR) (ITCHEN SINK AVA TORY 0OF DRAIN IHO ER STALL ;ERVICE / MOP SINK _T _ IRI AL DASHING MACHINE CONNECTION /ATER HEATER ALL TYPES /ATER PIPING iTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which, meets the requirements of MGL Ch.142. YesQ- Ncf$— YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY �— OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the lassachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE BOX ONLY: OWNER ❑ AGENT ❑ i nature of Owner or Owner's Agent iereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the !st of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in )mpliance with all Pertinent provision of the Massachusetts State Plumbing Code ander 142of the General Laws. .UMBER NAME SIGNATURE 1 # MP ❑ JP ❑f.N��i'- W # PARTNERSHIP ❑ # LLC ❑ # )MPANY NAME Raul Ortega ADDRESS: TY 105 CIO St EMAIL :L =w1afte. 01 M3 FAX `•: �_ ti �, �:: �; ,r t a� , >".. . t 1( < I"14.6Lt. Date ...�.v. ��.�. �. %, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...............Gu ..�......y..'. P ............ has permission to erform y, t�- -� s p p..It.-�.......................................... plumbing in the buildin sof....o....A..e..o,,,, ,�. ................................. . at ........C?.... .L ............. ......................................... North Andover, Mass. le - Fee... ..... Lic. No. �1.1�p................................................................................. PLUMBING INSPECTOR Check #— MIY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE L0 -�,q—` 5' PERMIT # t 14 JOBSITE ADDRESS �O {-�.E. xl I)g �w ►✓ St- 1 O1NNER'S NAME ;_ P© Vj C. O 1 ,,T . OWNERADDRESS f. _ TELF - JFAXI 1 TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL! ] EDUCATIONAL I RESIDENTIAL,��,— CLEARLY NEW: I RENOVATION:! ) REPLACEMENT: ` PLANS SUBMITTED: YES (- ] NO ] APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER- BOOSTER i CONVERSION BURNER COOK STOVE DIRECT VENT HEATER — - ,'; DRYER FIREPLACE - -- FRYOLATOR FURNACE - GENERATOR GRILLE-- INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT - - - OVEN POOL HEATER l ROOM / SPACE HEATER ROOF TOP UNITr'- TEST - --- --- - I 1> - -- j _. :.-... - UNIT HEATER , UNVENTED ROOM HEATER WATER HEATER. OTHERI V r 4 - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY , � OTHER TYPE INDEMNITY r I 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' I LICENSE #J SIGNATURE MP ( MGF I ] JP JGF I LP' TION J# ( J PARTNERSHIP ;#j 'LL- LLCCOMPANY NAME: 105 Coolidge StrESSI COMPANY Lawrence, MA 01 CITY ( JZIPj 375-4407 1 I (978) FAX j CELL, Liceni * 25016 v pAlW,C0MM0NwEALfH OF MASSACHUSETTS B..OARD OF PLUMBERS AND='GASFI.TTERS ISSUES THE FOLLOWING LtGENSE . LICENSED AS::'A JOURNEYMAN PL,_UMBER' ` RAUL E ORTEGA k fl!" 105 COOLIt?GE STREET { J LAWRENCE MA 01843 1 153 25016 5/01 16 2o4ot6 The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 t 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 Ledbly Name (Business/Organization/Individual): C, k -t' Address: [0,S C ©� Z �Arr City/State/Zip: \J'A0–Phone #: Z�! �'� C-1 Are you an employer? Check the appropriate box: L ❑ I am a em loyer with i employees (full and/or part-time).*-,_ 2, a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.FJ 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.FJ 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 Building addition 11.0 Electrical repairs or additions 12.0 Plumbing repairs or additions 13. F1 Roof repairs 14. [] 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 state whether or not those entities have employees. If the sub-contraciors have employees,'tliey 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: Policy # or Self -ins. Lic. #: Job Site Address: 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 DTA for insurance coverage verification. I do hereby certi under the pains and penalties of perjury that the information provided above is true and correct. 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 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 b6 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 foi• 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-iiisur6d 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. 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-NIASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ..................`................. ^ S ............................................... has permission to perform .... .(...&-4.....h� plumbing. in the buildings of.. `..:.. ............................. at ......... zv..... � ? X .................................... North Andover Mass. , Fee ... I- Lic. No.A ---- O k----- f4� PLUMBING INSPECTOR Check # CITY NORTH ANDOVER MA DATE I�`�°5` PERMIT # d . r. JOBSITE ADDRESS -2Q L t=,1(l V670AZ ST OWNER'S NAME/J� t3�PA COO OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL' ,.: EDUCATIONAL . „ RESIDENTIAL PRINT CLEARLY NEW: ", _ RENOVATION: , ^ : REPLACEMENT: _X PLANS SUBMITTED: YES NO`S FIXTURES Z 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/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN s ` SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING ATHER INSURANCE COVERAGE: 1 have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. YES. NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF 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, Q and that my signature on this permit application waives this requirement, cj CHECK ONE ONLY: OWNER ; AGENT .,._ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information 1 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. : �� .%fit.-- f�y��'�'r"_...... PLUMBER'S NAME THOMAS HALLORAN LICENSE # 24833 SIGNATURE MP' _ JPS CORPORATION; # PARTNERSHIP', LLC:.;_. # COMPANY NAME HAL.LORAN PLUMBING ADDRESS 826 DALE ST. CITY NORTH ANDOVER STATE MA ZIP 0180 TEL 978-685-9504 FAX CELL EMAIL Date ............. ...Z.... }.``.. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...... !. `G..S ..... ..................... ......... . .................. has permission for gas installation .... ....... in the buildings of ....... n........... . at .........2-C�...... �:-Q'� North Andover, Mass. ....................................... Fee . Z: 0-...... Lic. No. .. ......... ,tt,, -- GAS INSPECTOR Check # `T� A&... MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FrMNG WORK - CITY MA DATE oZ - PERMIT# �'w NORTH ANDOVER JOBSITE ADDRESS 0-0 Sr OWNER'S NAME �•�rQ'P`'4 e0o&: " C OWNER ADDRESS S'A M TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL: = EDUCATIONAL , RESIDENTIAL X PPJNT . . CLEARLY NEW:'—_ RENOVATION: _ .: REPLACEMENT:: PLANS SUBMITTED: YES :'.­ '.; NO k APPLIANCES 1 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 POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER INSURANCE COVERAGE I 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 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 7AGENT . . SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and kftmration 1 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 vAl be to compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE # 24833 SIGNATURE MP : ^ MGF - _ ; JP jC JGF LPGI CORPORATION _ . _ .# PARTNERSHIP ; . , _ # LLC .. _ # COMPANY NAME:T.HALLORAN PLUMBING ADDRESS 826 DALE ST. CITY NORTH ANDOVER STATE MA ZIP 01843 TEL 978-685-9504 FAX CEL1__i2k'&24 EMAIL r� a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 " v www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information _ Please Print Legibly Name.(Business/Organization/Individual): ' 7Wz7,* ✓.4..1 i7j•¢Lt 1�.t3 �� Address: Ya & ye City/State/Zip:, I/L N4 -- Are you an employer? Check the apps 1.0 I am a employer with ' employees (full and/or part time):* 2.19 I am a 'sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t Phone.#: ^ 6 ` 95-a Y date box: 4. [] 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.# 5. 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.l Type of project (required):, 6. 0 New construction 7. ❑ Remodeling 8. ❑ Demolition 9. 0 Building addition , 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.[] Roof repairs `Y.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation ptoicy 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. lContractors 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 isproviding workers' compensation insurance for my employees, Below is thepolicy 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). Failuie 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 the pains and penalties of perjury that the information provided above is true and correct. Signattue: Date• Phone #: ��- �s ` % S� y City or Town:' area, to be completed by city or town official Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 6.. Other 4. EIectrical Inspector 5. Plumbing Inspector ContactPerson: Phone #: COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASNAFM LICENSED AS A JOURNEYMAN PLUMBER ISSUES THE ABOVE LICENSE TO: j THOMAS M HALLORAN s :826 DALE ST NORTH ANDOVER MA 01845-1422 R 24833 05/01/14 142701