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HomeMy WebLinkAboutMiscellaneous - 23 GIBSON COURT 4/30/2018 Gi3SCOCA?-,r i j 1 1 1 i i _ Date. tN. .V........... �NORrN, O . tia TOWN OF NORTH ANDOVER * PERMIT FOR PLUMBING • � ,t * s A 3SACHUS� This certifies that../.".. P. ................................................ has permission to perform.. , - .. .. ............................................ plumbing in the buildings ofl at.... ` So•J. North Andover, Mass. ... ........................ ............ : - Fee.'?),}........Lic. No. ................................................................................. PLUMBING INSPECTOR Check.4 ?A MASSACHMETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITYA b saV4*dm.cDATE OWNMS NAME JOBSITE ADDRESS q—vjg; Gb R'A-00 OWNER FAX ADDRESS TYPE OR OCCUPANCYT)ff COMMERCIAL Ur ONAI RESIDENTIA! PRINT CLEARLY NEW- ■ RENOVATION: ■ L! PLANS SUBMMD: YES El NO 1:1 KITCHEN SINK 14 INSURANCE COVERAGE: I have a current IM W Insurance policy or is substimW equhrJent which meets the requirements of MGL CIL 142. YES L • LIABLITYWWRANCEPOLICY OTHER TYPE OF •EBOND 0 MassachusettsOWNEWS INSURANCE WAMR-I am aware that the licensee does not have the insurance coverdge required by Chapter 142 of the General Law,and that nry skinature on Ids permit application waives this requirement CHECK ONE • OWNER ■ a ■ SIGNATUREOF OWNER OR AGENT -4 Isand ufformation I have sul-7=1 or entered regarding and accurate to t04 best of my knowledoe and that all plumbing workand sc iai.ns perkmned underthe permitor _ nce with It vision of themassachu,sitts State Plumbing Code and Chapter I Q of the General Laws. lei I i • • CORPORATION ■ . PARTNERSHIP ■ , LLC ■ COMPANYNAME 4ohes PAJ4 ••' t P\ L& CITY ■ STATEAA A7- i• �t— FAX _ iEMAIL `� Date..................... ................... r►ORTIy,� , TOWN OF NORTH ANDOVER 91= PERMIT FOR GAS INSTALLATION i�, -.'•� rl s`S'�CHUS� This certifies that ........4.......................................... ........................................................... has permission for gas installation ...�'..`.. - '-........ `..'............... in the buildings of .......... ... . ........................................... U 1 � ,�►jS�� North Andover, Mass. Fee...2.d�'.... Lic. No. .k ... ...................................................................... GASINSPECTOR Check# �� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CiTY u.._ _ w MA DATEF_91�kt M- --. PERMIT# JOBSITE ADDRESS - - OWNER'S NAME NAMEG, OWNER ADDRESS - TE STYPE DR OCCUPANCY TYPE COMMERCIAL UC ONAL _._G RESIDENTIAL PRINT CLEARLY NEW; RENOVATION;EI REPLACEMENT: PLANS SUBMITTED: YES NO -01 APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 1 12 13 14 BOILER BOOSTER ..�. CONVERSION BURNER .. ... _ __ COOK STOVE i EB DIRECT VENT HEATER w. � �,.( .�-� ...�. 1 � f�1 =UD(�J DRYEaE-3j_, _._.__. _ I �..1FIREPLACE ) [- l � 11 . FRYOLATOR FURNACE �✓ _� _l J r_ _f --- GENERATOas GRILLE INFRARED HEATER 1 LABORATORY COCKS MAKEUP AiR UNiT _ 1 L _1 S Ej OVEN -_ ...J _ _ _ _ ..I . � 1 _ i 1 �E ` 1 . _ -C .i 1 POOL HEATER ROOM I SPACE=HEATER 4 ._ _a[ �J __-- r_ _.�...._1j I_J ._f __. l ROOF TOP UNIT J ___j ( _ ._I TEST UNIT HEATER ] ! UNVENTED ROOM HEATER WATER HEATER - I I -� --j f 1 I i !r_ i -J _�i ) OTHI=R .4--1 INSURANCE COVERAGE have a current stab.ility insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES F--_fN'0 131 l K YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVER E BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY % OTHER TYPE INDEMNITY BOND OWNSWS INSURANCE WAIVER:i am aware that the licensee doestiot havethe 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 [3 AGENT r� SIGNATURE OF OWNER OR AGENT '1 hereby certify that all of the details and Information I have submitted or entered regarding this application are trile 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 In ip once with ail Partin n provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME y CENSE# SIGNATURE MP L_AF r' JP JGF J LPOI Qi CORPORATION[]# --]PARTNERSHIP[]#[—'LL �. _- LLC[JO � .J COMPANY NAME ADDRESSC - _-- -- -- - CITY - ll STATE .34 TEL FAX j CELL i The Commonwealth of Massachusetts M . Uepaxt tent of IndustrialAccidents .1 Congress Street,Suite 100 d Boston,MA.02114-2017 . www.mass.gov/dia sy Wo kere Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers- TO BE FILED`P4TTE THE PERMITTING AUTHORITY. Amilicant Information Please Print Ile ib� Name,(Bilsiness/Drganizaiion/Tndividual): Address: City/tate/Zip: ( m 61 Phone##: �' oZ Areyon an employer?Checkt&apliropriate box: Type of project(rrequired): I.❑I am a employerwith :. employees(full and/orpart time).* 7. []New construction 2.L a sole proprietor or partnership and have no employees Working forme is 8. 0 Remodeling any capacity.[No workers'comp.insurance required] 9. []Demolition I❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10❑Building addition 4.E]I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole 11.F1 Electrical repairs or additions proprietors with no employees. 12.. Plumbing repairs or additions 5.❑I am a general contractor and I have hiredthe sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp,insurance.t ' � 14.[�Other 6.Q We are a corporation and ifs officers have exercised their right of exemption perMGL c. 152,§1(4),and we have n0.employees.[No workers'comp.insurance required.] sr *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit Ws afdavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors 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-con[ractors have employees,they must provide their workers'comp.policy number. am an employer that isprdviding workers'compensation insurance for my employees'Below is the policy autd job site inormation. -- Insurance Company Name: t Policy#or S elf-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 MGL c.152,§25.A,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 maybe forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do hereby certify un r th s an en tie f erju'ry that the information provided above is ue and correct. signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or•toren 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 PersPhone#: on: y a OMMONWEgL OF MASACHUSETTS.;' ' B£3ARb:0 PLUMBERS'*:* ND GAS;F..:;I:T`T ISSUE;, THE FOLLOW4 : t:ts":EIJSED AS A MASTER PbUMii_ AL1AI! C H0LMES 6 RUTH C1R a E4 qr)t _ OP 01832-x,900 O �.:.. 74244 I\JI I\tl 11.►ri�l� �vOMMONWEaLTH OF M} 55AOHUS TT B©ARp Olr PLUt'�i3E�tS +1n1G GASE �T 1•L1�5 AI 'Al�s ' Ht�LPtS k 6 RUTH::CIRCLE xEa? I LL A o 1832- The Commonwealth ofVlassgchasetts Department of IndustrlalAccidents Z Congress Street,Suite 100 Boston,MA. 02.114--2017 , ` . . www.mass.gov1dia SJ• Workers'Compensation Insuranice Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE F1LED WITH THE PERA TTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: ( � V1. Phony#l: � 3 Are you an employer?Chec'ktlie appropriate box: Type of project(required): 1.❑I am a employer with :._employees(full and/or part-time).* 7. F1New construction 2.F,— I a sole proprietor or partnership and have no employees Working for me in 8. F1 Rernodelirig any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself,[No workers'comp.insurance required]t 10 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. NO ensure that all contractors either have workers'compensation insurance or are sole 11.F1 Electrical repairs or additions proprietors with no employees. 12..Q plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.; 6.Q We are a corporation and ifs officers have exercised their right of exemption perMGL c. 14.0 Other 152,§1(4),andwe have nu employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submitthis affidavit indicating they are doing all work andthen hire outside contractors must submit anew 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-contractors fiave employees,they must provide their workers'comp.policy number. lam an employer that is pfoviding workesss9 compensation insurance for my employees'Below is the policy and lob site information. _ Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' cbmpensation•policy declaration page(showing the policy number and expiration,date). Failure to secure coverage as required under MGL o.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 DIA.for insurance coverage verification. Y do hereby certify un th a' s an en ties f er' ry that the information provided aboveis t ue and correct. Sign 9: Date: ,-- Phone#: Official use only. Do not write in this area,to he 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 empnoyees. , 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 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 employges 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 Depaitment 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' compensatioil 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 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 burn 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 1.00 Boston,MA 02114-2017 Tel.#617-•727-4900 ext. 7406 or 1-877-NUSSAFE Fax#617•-727-7749 Revised 02-23-15 www.mass.gov/dia J IJ i. J Date.. ...?.. .:.. .. ........ w RTN TOWN OF NORTH ANDOVER 6. 0 PERMIT FOR GAS INSTALLATION . i �9SSACHUSEtty This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . . . . . . . . . . . . . . . . in the buildings of . . . . . . . . . . . at . . . . . . . . ° `. .`: . . . . . . . . . . . . . . . . .. North Andover, Mass. Fee:.<: Lic. No/". ."Z­.% . . . .. . :. : . . . . . . . . . . . . GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO FITTING ype or print) Date NORTH ANPOVER, MASSACHUSETTS WL 9-0 II' Building Locations ��Sv� v � -..Ji -e Permitme # 210 �mount S Oq5 I New❑ Renovation ❑ Replacement Plans Submitted ❑ m U Z vi n w - C — n �^ C W w — L :. n cn z C ^J t Z ? C `^ Zcl C: i v J Z '! W '' z y, n Z C 7 iJ C t w z C C: SU 13 11 tSEN1 ENT HASE .vt ENT IST. FLOGR 2ND . FLOUR 3RD . FLOOR TT5 . FLOOR 5'r N . F L O O R 6'T H . F L O G R' s 7T 11 . FLOOR y 3T Ii . FLOOR ( i ;Print e) IA � Check one: Certificate Installing Company .Name V (0 �y Corp. \ddres Y w ❑ Parmer. {j 5 { 3usiness Te�ephone :21 ❑ Firm/ , ' vame of Licensed Plumber or Gas Fitter j/l U I ( l NSURANCE COVERAGE Checktone:, i have a current liability Insurance policy or it's substantial equivalent. Yes NO f you have checked yes,please indicate the type coverage by checking the appropriate box -iability insurance policy Other type of indemnity ❑ Bond ❑ I Dwner's Insurance Waiver I am aware that the licensee does not have the Insurance coverage required by Chapter 14 of the i vlass. General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Ow er ❑ Agent ❑ hereby certify that all of the details and information I have submitt or enter in above application are true and accurate to the )est of my knowledge and that all plumbing work and installation p e rider Permit Issued for this application will be in -ompliance with all pertinent provisions of the Massachusetts St e a r '_o the E3v: Signature o icensed Plumber Or Gas Fitter Tide Plumber ityiTown Gas Fitter (cense w moor Master APPR01v'ED(oFrlcl-USE ONLY) Journeyman