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Home My WebLink AboutMiscellaneous - 22 GARDEN STREET 4/30/2018112 7 1',,, D a t e it�.. I �..s ..... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING K 02-9-42�t I-ItA -7-1 r f - Thiscertifies that ........................... .......................................................................................... -n ...... has permission to perfon blt-\ plumbing in the buildings of ...... ..... C—c ..... –�.* .. ................... at .... .. ? . .... (�; ....................... North Andover, Mass. �-Z)- . ...... - Fee'T�.�. ..... Lic. No.20 .. ................................................................................. Che . ck # (a Ik-' Vl�� PLUMBING INSPECTOR M N-11 (-�)p 4 � k 4s-- ('s vk 9 1 �-' � 11-%-" POWNERADDRESS TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY North Andover MA DATE 30 July 2015 PERMIT # 1 �� JOBSITEADDRESS 22 Garden St OWNER'SNAME Belford Constructio 130 Marbleridge Rd TEL 508-509-9430 FAX OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL NEW: ❑ RENOVATION: ® REPLACEMENT: ❑ PLANS SUBMITTED: YES ® l ❑ 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 1- DRINKING FOUNTAIN DRINKING FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK 1 LAVATORY 1 1 ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET 1 1 URINAL WASHING MACHINE CONNECTION 1 WATER HEATER ALL TYPES WFii ER PIPING 1 OTHER S,illcock a INSURANCE COVERAGE: I have a current liabili 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, 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 djaccateMthe of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co i ceasion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Robert J. Frazier LICENSE # 13425 S16NOW MP ® JP ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME Bomar Plumbing & Heating ADDRESS PO Box 694 CITY Derry STATE NH ZIP 03038 TEL 603-325-895 FAX CELL EMAIL Bob@BomarPH.com �. ro-11 Ak' .N i r &d The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600. Washington Street Boston, MA 02111 `` Nov www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Bomar Plumbing & Heating Address: PO Box 694 City/State/Zip: Derry, NH 03038 Phone #: 603-325-8958 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time). * have hired the sub -contractors 2. Q Iam a sole proprietor or partner- listed on the attached sheet. ship 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 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 Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. Z Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ 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. 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 is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Liberty Mutual Fire Insurance Company _ Policy # or Self -ins. Lic. #: WC2-31 S366059-022 Expiration Date: 22 -Apr -16 Job Site Address: 22 Garden St City/State/Zip: N. Andover, MA 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;,(` u er e p s d penalliiies of perjury that the information provided above is true and correct Signalme: ��/ Date: 30 Julv 2015 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 #• �4 Cunningham Lindsey U.S., Inc. P.O. Box 703689 Dallas, TX 75370-3689 Telephone (888) 738-8714 CLCAT@CL-NA.COM k ! Facsimile (214) 488-6766 ***********************AUTO**3-DIGIT 018' 767 T3 P1 95000058957 Building Commissioner or Inspector of Buildings 120 MAIN STREET N ANDOVER, MA 01845 Claim Number: Policy Number: Company Name: L 0) Cause of Loss: co C) Date of Loss: 0 Insured: Property Location: Cunninfiham va t�Lindsey Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS Ch. 139, Sec 3B 1014786 1014786 28 CAMBRIDGE MUTUAL FIRE INS ICE DAM 2/10/2015 GERTRUDE PARADIS 22 GARDEN ST F_ Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 313 is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Section,36.-No insurer shall pay any claims (1) covering the loss, damage, or destructions fto.a,building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss, damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code, to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to the payment the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a' lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall extend to and may be enforced by the city or town against any casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were initiated. No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed to a city or town under the provisions of this section, or for amounts not disbursed to a city or town under the provisions of this section. On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Cunningham Lindsey Catastrophe Department cicat@cl-na.com 800-867-3885