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Home My WebLink AboutMiscellaneous - 203 DALE STREET 4/30/2018 (2)74 Date,/� G�.... TQWN OF NORTH ANDOVER PERMIT FOR PLUMBING {i ,-s4cmuSE� This certifies that .T)144�-. f'. l`�. (t¢l.�✓..`- ............ . has permission to perform..................... plumbing in the buildings of .................... at ...�.2.. n�?.� * .. `.......... , North Andover, Mass. Fee, .16P:�U.. Lic. No.? , 7.— �� . ....... . PLUMBING INSPECTOR Check # ? l 6737 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS nn Date Building Location Z63 ST Owners Name, ,FS Permit # 3 Type of Occupancy Amount New Ey Renovation 1:1 Replacement 1:1 Plans Submitted Yes No ❑ (Print or type) Check one: Certificate Installing Company Name �j41! /� �{�}�C�i a ❑ Corp. Address rU'&)X 'S Partner. (,�J �-►2-`� lei 1 /. /y1,� b 18 3 � Business Te ep one T7 '7 — 53 a3 Firm/Co. Name of Licensed Plumber: ,1)/Q,/ / —1) OALR'{,K"-f Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 11 Other type of indemnity ❑ Bond n Insurance Waive , and rsigned, have been made aware that the licensee of this application does not have any one of the above th e s ra ce V/ t e Owner Er Agent El 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 MassachuwqState 5Fn de d Chapter 142 of the General Laws. By:'signatuic 31 Ocerisecium er Type of Plumbing License Title Z 3 L 7 L, City/Town Icense lNumDer Master ❑ Journeyman 11 I APPROVED (OFFICE USE ONLY 1' • i J .r • .J .r i il --------------------- .=.-t%-DLVID�IMMMMMMMMMMMMMMMMMMMMOmm MM-- MMMM----MM--------------- MMWMMWWMMMMMMMNMWMMMMM MM /, "/. - .-M.--.-M---------------- . ----�®------------------- mii:lorce.!RNMMMMMMMMMMNNMNNMMMNmmmmm MWMMWWMMMMMWW�MMM MM MMM . MMWMMM------------------- - - mmmmmM------------------- (Print or type) Check one: Certificate Installing Company Name �j41! /� �{�}�C�i a ❑ Corp. Address rU'&)X 'S Partner. (,�J �-►2-`� lei 1 /. /y1,� b 18 3 � Business Te ep one T7 '7 — 53 a3 Firm/Co. Name of Licensed Plumber: ,1)/Q,/ / —1) OALR'{,K"-f Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 11 Other type of indemnity ❑ Bond n Insurance Waive , and rsigned, have been made aware that the licensee of this application does not have any one of the above th e s ra ce V/ t e Owner Er Agent El 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 MassachuwqState 5Fn de d Chapter 142 of the General Laws. By:'signatuic 31 Ocerisecium er Type of Plumbing License Title Z 3 L 7 L, City/Town Icense lNumDer Master ❑ Journeyman 11 I APPROVED (OFFICE USE ONLY Location (D03 1811 No. 3 S o^1 Date 03 MORTM TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ Building/Frame Permit Fee $ �d wcMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $� Check # ' 3, '� J Building Inspector 1.1 Property Address: ..o 3 fl 9 Si; Historic District: Yes No 1.2 Assessors Map and Parcel y. Number Num"01 Parcel Number V b IV • , Do jrNTap c.6 3 Ste; 1.3 Zoning Zoning Information: Zoning Dia6ct Proposed Use Address for Service: 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft 2.2 Owner of Record: Front Yard Side Yard Rear Yard Required Provide R red Provided ReqWred Provided SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: 1.7 Water. Supply M.GL.C.40. 54) Public ❑ Private ❑ 1.5. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSIiIP/AUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record ,S" D Y % � 1gA4 b AIS -7 c.6 3 Ste; Name (Print) Address for Service: 6 2?"� A�A/6(l�le Signature Telephone 2.2 Owner of Record: C7 -Name Print Address for Service: .Y Signature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address L . Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ DAVID CA -s T -k[ c.WE RFC-, t s PG, / / < d LIJ-G Company Name Registration Number 1L /Z//O L-9-0 a S L= AI 9Y; S �> T� �� A ess �— C) Expiration Date Si nature Telephone T rn �o z 0 v rn G W 0 z rn 90 0 aan ic anm� r v rn laaaa _r ^z Y/ 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 ....... 11 No ....... ❑ SECTION 5 Descri tion of Proposed Work check applicable) New Construction ❑ Existing Building V Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: sn 1 P SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Co leted by permit applicant OICIA> ITSE UNLY .. ` I . Building 4S d (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee tel X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, 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 I, J) kV l D ('.A ST'Al c D N F— 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 DlqViD s c,F_ Prin ame i /.J lz1 Z b 3 Si attre of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 sr2 ND3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 7-3 `E d A a Board of Building Regulations and Standards_ `4 i HOME IMPROVEMENT CONTRACTOR Registration: _;_104569 Expiration 7/14/2004 a Type Private Corporation i DAVID CASTRICONE ROOFING;. S i Y1d astricone 7 Hillside Road ' Boxford, MA 01921 h i Administrator '1& Commonweakh of Wassachusetts 'Department of IndustrialAccidents Office of Investigations 600 Washington ,Street (Boston, 5M 02111 Workers' Compensation Insurance Affidavit APPLICANT INFORMATION Please PRINT Legibly Name: SA -AI 7781 A d %1i S Location: City: hJ b , Atl DQ it -F—R Telephone C:_2 JG ❑ I am a homeowner performing all work myself, 0 I am sole proprietor and have no one working in my capacity I am an employer providing workers' compensation for my employees working on this job Company Name: j ,!/J� h {/ I n LAST?,, l C -_6)A IE RbpEM6, `� �l� /A 7 Address: ! s� Lk%T-(} lU L S , City: AI M T`� /-t / 1f' 00 'V F_k k Telephone*: Insurance Company: Ab yAlm S SIV A1 -Li AJV C)JF- Policy #: J x Q % 9L4 b I am (circle one) sole proprietor, general contractor or homeowner and have hired the contractors listed below who have the following workers' compensation policies: Company Name: Address: City:, Insurance Company: Telephone #: Policy #: Company Name: Address: City: Telephone #: Insurance Company: Policy #: Attach additional sheet if necessary Failure to secure coverage as required under Section 25A of MGL 15B can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S 100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certi unde e pains dd penalties of perjury that the information above is true and correct. / Signature:,, �.,� Date: r Official Use ONLY -Do not write in this area City or Town: Permit/License #: o Check if immediate response is required Phone # '- 9,a ^- _-Z q..Z, C) _ o Building Department o Licensing Board ❑ Selectmen's Office o Health Department 11 Other INFORMATION & INSTRUCTIONS Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law" 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 be deemed to be an employer. MGL chapter 152 section 25 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, 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 in the workers' compensation affidavit completely, by checking the.box that applies to your situation and supplying company names, address and phone numbers as all affidavits 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. City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. 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 Fax # (617) 727-7749 Telephone # (617) 727-4900 ext. 406, 409, or 375 Ir M AI W w ® A � L w° cn U Cl) 0 � a4 GO z U z ad b u; � U -co w a W C7 as '� tw w F W U �" U -C r2 v cn w O U w w W w A w 9Q ° cn co O c L O O cs co O CO) ® C co c! CO) O co MA O O E cco cm co m CL CD �> D O CDL O O d CL cmcr y C O= r=-+ ccC C.2 CD C L.± co O C C _c CL I O o ® L C H O C V V •dam CL. C R W m C Z O O � CDc N t' dl on COD � E c a Y �= =� = E 3y� m CD CL -- :mcm N com= DO C% C42 . m O:mo A � : ym CC t = O Cf O .0 O _ O p m N O t0.1 Z O cm C a0 c U : N m C C _ ® :COL. 3 � 0 w E v�vH O C.3 CM FE _y Q m� O: C N C . lHp O CL *- y co O c L O O cs co O CO) ® C co c! CO) O co MA O O E cco cm co m CL CD �> D O CDL O O d CL cmcr y C O= r=-+ ccC C.2 CD C L.± co O C C _c CL I