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Home My WebLink AboutMiscellaneous - 224 Bradford Street i r Date. H�QTM ' F jOy ..ao ",ti0 A TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION s � a SSACMUSE� This certifies that . . . . . . . . . . . . . . . has permission for gas installation Ir�,4'.�. in the buildings of . 1!1?f9 h •r� at . . .0 . fl P.1%. A C. �_. �. . . . . , North Andover, Mass. Fee. . 4. Lic. No. P F f : . 9 — .. . . . . . . GASINSPECTO Check# O �( 694 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) W h v , Mass. Date- City, ate City, Town Permit # Building tr O 1�d Forl Owner's AT: Location �O TG S J Name Type of Occupancy: New Renovation ❑ Replacement ❑ Plans Submitted Yes ❑ No ❑ to Q) W y Y = cc N N N N cc p N F ti S t.. N WWd N W � Z C W ►' < >- _ ' O F W x 4 GC O Z m W W W F N W W W W W 1 Z < Y a C cc W F' W H Y H ¢ G W V C WLU> OC W Z 6 N at Z O z O N Z 0 Uj W x O O U. 3 o c� 10 W � a u0 o i SUB—BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR (Print or Type) Check One: Certificate Installing Company Name laumsend_nil Co�, Tnc ® Corp. Address 27 Cherry Street ❑ Partnership IlanvarG� MA 0192 ❑ Firm/Company Business Telephone 978-777-0701 Name of Licensed Plumber or Gasfitter �.Iasei h Ciirr) 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 Code and Chapter 142 of the General Laws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signature of Owner/Agent I have a current liability insurance policy to include completed operations coverage. ❑ By TYPELICENSE: 31A- Title ❑ Plumber ignature o t sed Plumber or asfitter City/Town ® Gasfitter APPROVED (OFFICE USE ONLY) ❑ Master /— ❑ Journeyman License Number �/l Date.//-TO//Z. .... ... . HOATM o? �' TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION SACNUSE�t This certifies that . . . �.� . .�`�.ec,L)M R,: has permission for gas installation . . . . . . ... . . . . .. .� . in the buildings of !r'! ��►�r� . . . . . . . . . . . . . . . . . . . . . at . . ?-7�.`-�. . . . r�. l. . . . . .. ,WNr/hX--iover,iMass. Fee.`�� Lic. No.�/? �! � {L . .. . p GASINSPECTORv Check#j263 7M1Z-,ao1 ar 8030 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING eIV®RIfC ' CITY MA DATE a�� ' IPERMIT# JOB SITE ADDRESS 14, Y �OWNER'S NAME GOWNER ADDRESS ��y TEL[q T7 7 � FAX tl TYPE OR OCCU PANTYPE PRINT COMMERCIAL[] EDUCATIONAL ® RESIDENTIAL CLEARLY NEW: REPLACEMENT- 0 PLANS SUBMITTED: YES E] NO[� APPLIANCES-1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER -- BOOSTER - - - - j CONVERSION BURNER COOK STOVE DIRECT VENT HEATER - DRYER FIREPLACE - FRYOLATOR FURNACE - - - --- -- _ -- GENERATOR - GRILLE INFRARED HEATER - - - LABORATORY COCKS l ; i MAKEUP AIR UNIT { OVEN POOL HEATER ROOM/SPACE HEATER -- - -ROOFTOP UNIT - -- TEST UNIT HEATER - UNVENTED ROOM HEATER WATER HEATER OTHER _ _ - - �� a INSURANCE COVERAGE _ I have a current liabili insurance policy or its substantial equiv lent which meets the requirements of MGL Ch.142 YES r O C ? I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE E BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [ I 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 ( 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 complia ce wiih ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE �..' �13G SIGNATURE MP { MGF�, -1 JP I -( JGF LPGI[Y� CORPORATION - PARTNERSHIP #Cv _ LLC +# ADDRESS COMPANY NAME {1 hS �� -_-- _ ..�_. (�'� i 7 CITY�--�- 4u,)t-�,�n C (`" — ----J STATE l�y zipFo_$Y]1J'TEL�Cj�g" r _'c? FAX( �. CELLI _ ��EEMAILE i ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USVONLY `' FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Cnnnnorrturuttb ofl amwkwers Depnrtn o,�"Itrrt�t�iR�'A'��sitr�¢rifs' the 0011PES119,89bus 600 Washbigfonf RPM Boston,7W 02, 111 ww1wimss gotvIrl, 'Wodue CbmjWmafibw fus,upffitce Affidilfift%II erosIODUfM.QtOMfiRCCfIfd=st)W ff jstf A�efinr�i P.tcm E'irirr Lt D1)!itttt�Q131rsn[as. zat�u+fiiaditi3dttal�, ' Adhessb GI'.Yft fflpr Phone ff, here}oua nn endo}er?`( ie ,tEtc anpro rintN Doze TyP of prCrie (raquhleq. 1:0,t.1m.a:mnplbycrrritft d.E f ama,getteralmilmcrormrtP,1. ! cr[rxaes:�CtEE andl+ocpalfi rnncit� Itam hared tlrc scife¢oeurcnctars �" ��et�enust�ctr"mt 2.Q ti aetr a sofe proprietoror partner- listed opt tftc aunfied sua t 7. slti fr tutdl Nveno emptQyms Time Sidi-coutiacrom Elim & Dentblii om Working forme>st mtyrcapacity. workers?comp:msittatrce; c 9� �liti ftrmgs�fditibn, iwor mim croup:itasurauce 5=❑we are acorporation and i[s re mrrcR]! offters haw exerrked[ifeix 10��dectricn#,t irs,or nirdi�onx 3.®IM a tomeoeriler°dbbig,a!I vverfk i ght of'cxentptiom por MGL l{l.D'P timbfn&rc Wm or a diti'ous � u:rys+eCf,[tufo worgers''comp: 0o mor'repaae inwraucerernared eutpfo5mes.[E+fmvLor els' IX(]Otltcr, comp.Ensurailmrequim f J �Fnyr{igiieaitEfbxt.ett:rfirBox&f,mus"cPsofig OutlAcleciie,h�toltistt��ingttwirttnrLen croiirpcns�tron oticyfiffoentatron Mnn�ute.�[x errms�►Bmirfliis aQnririf rirdicrtiurg,lhcy acc doatgoll�coct:aad thea Rire®utud�ceauracic�is ruSFSuUnt[n rico�cbcr•�iaidwLn�scCr�� i tEhpCtftiQiFi,UlatctttcE<tiis�l:rxnus;ta'tircLrdsmattditiomd sL^��[°.sbsnfnu.lt�r xa:nt�+�i1}45uh-¢�+uKs�Cctri;arst�dFtir v�rt�,�'a�nq'_ S;utfi*rtll�tir�ic t l riru ozvevq fltjtcvrtlt as,prorlitiag ivarkers'campenswbalt►surance for txe, ertrpf*wr B'et f�QEeprrllct�attdl�vb stfic { tta,�irrtirnttart�, lnsmmiccCompanyNhow. Polley tf or$eft=ittsl)ne_ft: Teplrntiotu Date;. ©}?Stle t fEt 55: t,,,; Idit'ff k, . . Attack acopy of(tic aorterecmupensietionpolkydecratmtibtr t;a srrottf (tree, s l �'� >� EroEi�;rim�itibct�aard�espfuairt3't@c Praftice Mseeucecow.1ge;as:regtiired underSeettoti 25h.of MGL c.V52 6a kad to dte coil osiristu oferii»ititttip itai ics ofia rote up for S f.,5#0,.Go aud!or:onc:}earunprisomargntn as tveEE as civil psuaEYies irr t1'ie fontr oU t,S7?D1"-1lOIiK ORDER slid a tiir afupto�5(1t.Q�a.da}*a;�,2nisGtfic violator. tie acTcised`1lyata',coisj:o£'t0isstatimlcaitura�;toe forir;atitexGlrnttieOf.�ee:of luveaLl�;a"Ilibasofike'DefA,for'hisuraticecoverapmifimadom. Ieq,frer }c°crrCf nrrrfetllrelrtrttEsetrdj►rrr tesa.rpafttrt;matgletil,{vrrracais�pror�ilerlati�e•�is'lnrr�citrilgcarrerG _3n3i<�t'ttre: Phone A% Uf,�rcf�Uw0ff4*Do trattrrIfu lm Ws area,fo becamj"ed fiy ciy}wfvwm aff Zr�: City:or-Town.- PevnrrVLE.ffaitsc ff, � fssuiug�iirffiorif};(cEtrfe:ouc):; t.Btraraf of Etcattli:2.E3it Cling;T3epitrtumni J.Cify f'"owte Clerk d,Cfeei'cicar`Cirspec(bI 5 1111imtMig ampectoe� &Ofrier f i Ciaeitact:Ptrsotrr, Okotrep 1 a .a� andInsf � n Mldmsett General LaIvs chapter 152 mgitires an em plbyersto,proutd6workers'soWei 'iora for their employeese I'ttvsiratrl.to this statute,an errplopee is as every person in the semiM of am&-er untierauy, contractof Mr% WqxM or inipIied,oral or writtem7 AM eUrpfrtper is defined as"an individual,padmrshkk assaciatiotg caparWon or o. eiitify on any 4vas or more Of the foregoing;engaged itt a joint enterprise,and irWjadfng,time Feedyerorfamsteeofaniudividhtal artiieasl' , melirepresentafiu of&-.deceased{enipto��er,or the sp dA,R aciat" orotherlegafentity,en�iloyiitgemplo . however,the owner of a d�veDing hoose hac+ing,not m®ire tLtan tett a agar nsmts and Who xesidcs therein;,or the occupant ofth9e d!ir�eMg,Ihouse of another who employs,petr ns tea db mefiltenance,construction or ar GM the,grioulids or building appurtenant thereto shalli no,because ofsuc11,,ern 1 m ent bead tnon Esq an employer:,dwegfng h p� AM chapter 152;§25C(6),afro states that"'every state or bent licensing;agency sli>alf wit7tFtolht the issuance or roneu l offt license ot~pprtti it to operate n bor es or to coustriret biii�ding irn the comrtron ltln for airy xgAicaairt who has not pt odured ameptabler evitfearse ofcout. enter romatly,MGL chapter 152; &25C(7)states�leitlier the crtmmenwealtlt noir a�Ftof pIt algseubrceliivtm'stio sltatt` eater mica any-contract for the Performance,ofpublic workuntr'1 acceptft bk evidence of p]imte�with the insurance requirements of th2s chapter have been.presented to the contracti ng,authority. Appli mt.ts PkM ffilout the workere compensation affidavit c,0mplctely,by eFiecking.tits.Eto�es ih�tf a tc� .oursituat on arid if ney suppil"sul�-contracnr s tram s p , () e(),ad h ess(es}.amd pltome number(&-)alomg,With thein eertificcate(s)of insurd Ilm'ited.LiabilitY Ccunpanies 91C)or edt ability Pfirtm ers&ips(LL I�)eeit ino anployees other than,the: members paffners�are not:required to cavy 1vorl ers,eompensatiorn insurance, If am LW 0 r UPr does.have etnploYess&-policy is required- Be advised.that this a�ffrd'avdf may,be submitted to the:Department of Industriat Accidents for conftmtation of insurance insurance—coverage. Atty be sure fa sign and,date Elie:affidavit The affidavit should be returned to the city or town that the application fog::the Permit or license is being requester not the Department of lndatstrW Accidents. Should you have atnY%lestions regaed'ntg tare[atis or if you are requiied for olxkaitg a workers'' compensation policy,please call the Department at fhenumber listed below.Serf-insured! s mance license number on the 80ro to fine. comPanies should enter their CftY or Totsn Officials Please be sure that the affidavit is cotupieta and printed legibly. tie.Depatfrrient has.prauided a sPce at the bottom, :ofthe affidavit for you to fill out in,the eve nf..the offtee of Investigations has to conta�.a�c►u regarding applicant.. that m st sura to f71 inn the-pen'M'"cense ttumrber which.tenlf be.used as a�reference�mmiber In addi"tion an applicant trial must submit multiple perm it/license applications in any,gWw y,Tar,need onL3r submit one&- davit indicating:current Fo"'W,infOrmation(if necessary),and under"Toth Site Addressr the:applicant should Vvdte"aft locations,in Wtv or town)-7 A,COPY ofthe affidavit that has been oflncial!fy stamped of marred fiy the city;or foto may bepro,ided to the applicant as prooftl at a valid affidavit lion file for.f rture pertmifs.or licenses. A Raw-affidavit roust.6eMexd out:each, Year..mere.a Home owner or citizen is.obtaining a.licemse or permrtted .notrela .to,any business or caommereial'.venture (i e a dog license or permit to bum leaves etc)said persmr,t„NCI7required to complete:this affi'davi-L The Office.ofTutiestigations would litre to thank you in advance for YDVF cooper and I€I you l xny questions; please:dog nothesitafe tia gine us a call. e D?ep Iment's address,telephone,and fax mimber. The CQL6 mOMMIth of Mamxhmetts Department of Industrial Aceldwts Ofl ce Of Int est gra 600 Washington Sfreet Boston AIA 02111 i Tel.#617_727-4900'ext 406.of 1:-877-MASSAk Rovised 5-26-05 Fax 617-727=.7749 WWW:Mass.gomldia } i l , Commonwealth of Massachusetts SEP '132010 .:.City/Town of NORTH ANDOVER MAS TS System Pumping RecordHl:A(.TH DEPARTMENT R Form 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. _A..Facility Information Important: When filling out 1. Sy em OCatIOn; fortes on the computer,use (- r�U P17W�0 A <E-St-1 only the tab key Addj�� to move your LE t cursor-.do not Clty/Town r State t use the return ip Code, key.. 2. SOwner: t IGS , Na e tG Address(If different from location) Cityrrown State Zip Code Telephone Number Pumping B. n Record .� P 9 1. Date of Pumping L. Quantity Pumped: Date tYGallons 3. Type of system: Cesspool(s) Yp Y ❑ YCeptic Tank ❑ Tight Tank Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System;� , 6.. System Pumped B : Mc( t me Vehicle License Number Company v 7. . wh conte were di osed: a ipn er Date http://www.mass.gov/deptwater/approvalsA5forms.htm#inspect •i'' t5form4.doa 06/03 ., System Pumping Record•Page 1 of i fr a: i _ •7"