The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 200 MIDDLESEX STREET 4/30/2018Date.:/ /V........... 3r p•♦ ��io ,♦ ♦rypL TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION no •r•• 4h fJ,/ SSAGHUSE� / This certifies that ... ° .'� A1746 has permission for gas installation .....�'` in the buildings of . A/C. /:'vyY............................. at oQ r -C :`... . ........r, North Andover, Mass. Fee—A-.�:.. Lic. No.. �i �... .... �� .`.'`'�/1 ......... LA's INSPECTbR Check # 7150 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date- NORTH ANDOVER, MASSACHUSE TS Building Locations < S 5 Permit # Amount $ Owner's Name /11, New13Renovation a Replacement' Pans Submitted (Print or type);1 /� Name �y Address �O Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company Corp. Partner. ® Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or, it's substantial equivalent. Yes ❑ No If you have checked Les, please indicate the type coverage by checking the appropriate box. 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner �. Agent 0 1 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 Code and Chapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Gas Fitter M ster Journeyman w w 0 F a w. x a Q a w z w o > w QIZ w Q F H o > w F w w> �' w z a a¢ d o 00 .xa o x SUB-BASEM ENT x o x z > o ° c B A S E M ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8-T.H. FLOOR (Print or type);1 /� Name �y Address �O Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company Corp. Partner. ® Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or, it's substantial equivalent. Yes ❑ No If you have checked Les, please indicate the type coverage by checking the appropriate box. 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner �. Agent 0 1 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 Code and Chapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Gas Signature of Licensed Plumber Gas Fitter M ster Journeyman Gas The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers DDIICant 1nfnrmafir.- Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.7 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other omeowners who submit this affidavit indicating theyare doing all work and then hire outside contractors must submit a new $Contractors that check this box must attached an additional sheet showing the name of the affidavit indicating such. sub contractors and their workers` comp. Ii P policy information. information. I an employer that is providing workers' compensation insur¢nce for my employees. Below is the policy and job site 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 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 Investigations of the DIA for insurance coverage verification. of I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Offecial 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 6. Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector Phone #: Are you an employer? Check the appropriate boa: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or have hired the sub -contractors listed partner- 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.] 3. ❑ I am a homeowner doing officers have exercised their 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.] n� applicant that checL. box 41 must also fill out Fhe section below• -6n'-, mg f g *.:e Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.7 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other omeowners who submit this affidavit indicating theyare doing all work and then hire outside contractors must submit a new $Contractors that check this box must attached an additional sheet showing the name of the affidavit indicating such. sub contractors and their workers` comp. Ii P policy information. information. I an employer that is providing workers' compensation insur¢nce for my employees. Below is the policy and job site 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 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 Investigations of the DIA for insurance coverage verification. of I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Offecial 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 6. Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector Phone #: Information ant d 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 includinCY g t1he 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 notbecause 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 applicafion 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 permittlicense 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 perznits 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 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 Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4940 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 mrvirw.mass.. gov/dia Location PV I No. Date 9 /y TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ /S Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ � Building In or e`K f�i'�4 24:31 15.00 PAID Div. Public Works PER'lfh NO. ' 1 APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 '�j MAP 4q O. LOT NO. 2 RECORD OF OWNERSHIP iDATE BOOK ;PAGE ZONE SUB DIV. LOT NO. LOCATION ,�Z a v M I p OCr' 3c �fi PURPOSE OF BUILDING r _ _ t?'/";t &I Esc f ShN¢ o �7t"T.s . OWNER'S NAME- NO. OF STORIES SIZE OWNER'S ADDRESS A,/ 1/ BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME.�7,SPAN ( . �,. DISTANCE TO NEAREST BUILDING ^� DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES - SIDES REAR GIRDERS AREA OF LOT - FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIR ENTS OF CO IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE I FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS I PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR i PERMIT GRANTED" 19 �L 3 PROPERTY INFORMATION LAND COST EST. BLDG.COST C,� EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BUILDING INSPBCTOR OWNER TEL. # CONTR. TEL. # ON F i'Lc CONTR. LIC. N H.I.C. it Cko75'8 SINGLE FAMILY STORIES MULTI. FAMILY OFFICES APARTMENTS CONSTRUCTION 2 FOUNDATION —I 8 INTERIOR FINISH CONCRETE PINE 3 2 I3 CONCRETE BL K. BRICK OR STONE HARDW PIERS PLASTER LASTER DRY WALL _ UNFIN 3 BASEMENT *AREA FULL FIN. B'M'TAREA 'L /1 '/ FIN. ATTIC AREA _ NO BMT FIRE PLACES _ HE ROOM MODERN KITCHEN _ _ 4 WALLS 9 FLOORS _ CLAPBOARDS 8 N FLOOR 1 22 f 3 I_ _ _ _ I_ DROP SIDING WOOD SHINGLES CONCRETE EARTH ASPHALT SIDING ASBESTOS SIDING HARD" D COMMON VERT. SIDING •: _ ASPH. TILE ATTIC STIRS. & STUCCO ON MASONRY STUCCO ON FRAME :Z -n BRICK ON 'MASONRY BRICK ON FRAME CONC. OR CINDER BILK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I_j POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I I HIP GAMBREL MANSARD FLAT SH ASPHALT SHINGLES WOOD BATH (3 FIX.( TOILET RM. (2 FIX.) _ _�_TTVST TORY QIIIEN SI C _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR _ TILE DADO 6 WOOD JOIST 1 HE ELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR _ WOOD RAFTERS CONDITIONING _T RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS B'M'T 2nd T., 13,d T&C SO HMtHt P_ BUILDING RECORD 12 l �3��fi2 x3Y��4 4 i M v v THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES ANd, EXACT DIMENSIONS OF -BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. N4 I tN, � 0 4, u-Nio F G�s t 5 1 ys .. a t r R 4 IN G CD 0 z O S CD O _ _ to 0 C a CD cc c d O N G 0 a N CD t cr O N y 6 a0Cl) Q � do 1 CD C= r N �� i1 Im co CD CL 0 CD a p) = T r C CD y CO) O O =CD = ® G 2>4 O z5.� O N CD G a = CLir.. • o CSD W N : a3 N � d y : CL C T�! W `C s" SCD 0 O. C � N CD CD ^^ CD 1 {i CO) CQ CO's\ 1 Iiv .� goo -L�i cc CD CO) 111 ° D a .o c -� CD" a� A<�'-z ^r N CD 10 0 CD to Co ¢r a�r�� 0 O .y+ CD c o cl) o=' = CD: �=: a) aim, cn O 0 rD I cn � 0 CO z In �= 7n M m- v Gz� n y ;t W C � n PCI OGn 7n or- o. C cn 91 a "TI 'D O ZE CD C7 Z y r CD o Q � �•w o v CD o CD ,c CL CT CD n CD o CD w w CD y� m c. v y C) cc CD z S- CA CA o 1 CD Z O CD T z O C D r CD IN G CD 0 z O S CD O _ _ to 0 C a CD cc c d O N G 0 a N CD t cr O N y 6 a0Cl) Q � do 1 CD C= r N �� i1 Im co CD CL 0 CD a p) = T r C CD y CO) O O =CD = ® G 2>4 O z5.� O N CD G a = CLir.. • o CSD W N : a3 N � d y : CL C T�! W `C s" SCD 0 O. C � N CD CD ^^ CD 1 {i CO) CQ CO's\ 1 Iiv .� goo -L�i cc CD CO) 111 ° D a .o c -� CD" a� A<�'-z ^r N CD 10 0 CD to Co ¢r a�r�� 0 O .y+ CD c o cl) o=' = CD: �=: a) aim, cn O 0 rD I cn � 0 CO PTI In �= 7n M m- cn "t w n M P^ ;t W r m Q'- n PCI OGn 7n or- o. C cn 91 a t� C) 0 c 2