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Home My WebLink AboutMiscellaneous - 234 BLUE RIDGE ROAD 4/30/2018 234 BLUE RIDGE ROAD 210/065.0-01840000.0 Date...3..:.1!`.'(I. ........... TOWN OF NORTH ANDOVER � 9 PERMIT FOR GAS INSTALLATION SSACHUs�t c)G!V I Cl , This certifies that ... .Q................................ .... .......................................................... has permission for ga installation ....... . � c�cS..- .. ........................................................ in the buildings of...... ................................... . .. .............................................................. at..... .?- ...... �.... ... ............. North Andover, Mass. 3 Fee .. ......... Lic. No.�.-.,�... ......... ............................................................. Check# 120,5 GAS INSPECTOR o 1 MAS/SS,A.,C�H-�U�SETTS_ UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY /VD(Ll T7 /4 X EC MA. DATE: "�3_Z-06�PERMIT#iC__ JOBSITE ADDRESS: OWNER'S NAME:_Ku2T 6/r'� �/�G GOWNER ADDRESS:2zlq 12LO E VIO TEL: FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:[R" RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES[]' N0[►� APPLIANCES-. FLOOR-4 Bsmt 1 2 3 4 5 6 7 8 ' 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER. ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL,Ch.142 YES 5?"—NO ❑ If ydu have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY [[2"' 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT ❑ hereby certify that all of the details and information I have submitted(or entered)regarding this application ar a and accura4witheM Knowledge and that all plumbing work and installations performed under the permit issued for this application .JI(be in compliaprovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME:S'�(J6N �`tW✓L LICENSE#��y9SIGNA COMPANY NAME:J, /f�y� f CZ A LS" ADDRESS: Z- G LOV A V1J,A CITY: f^JI[(.lin lkJ�sWly STATE: m a ZIP: 113 �7� FAX: L TEL: CELL: !1✓�3 I EMAIL: MASTER +U/ JOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑# PARTNERSHIP 0# LLC ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL IN PECTION N ES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ RECtIPT# W PLAN REVIEW NOTES i ✓ The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LeLyibly Name (Business/Organization/Individual): Address: PO 901' ZS4 City/State/Zip: �`� �' �ti� m7' „v� Phone#: ��(F ✓� Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. F-1 New construction 2.�am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.r-1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F1 Roof repairs These sub-contractors have employees and have workers'comp.insurance.x 'G 1 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[jr06ther �/ 152,§1(4),and we have no 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 submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new 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 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 thepolicy and job site information. Insurance Company Name: � NSWA N Gtf Policy#or Self-ins.Lic.#: Expiration Date: S_-2,016 Job Site Address: Z'S q' g L U/Z /z/ City/State/Zip: NQAT?V 4/400VAe 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,§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 ve ' i tion. I do hereby ify under th' ns d penalties of perjury that the information provided above is true and correct Signature: t Date: Phone#: 7�-' �Zd 73 Ll 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#: Information and Instructions s y 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 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=contractor(s)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 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. 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 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia r ..,, ...._a�t.rr •rV rqr �, hus I o: PLUMGA$F�IuaF�RS�S` ISS �4 ,THE FOLLOWINGw 1 ICE z w�Qr AS1 M1A$r' R GASP > IN E TAYLOR f .. 2 GLOR f � AY rr4• �x. .; ,# {�",�� ..,. �•y..K Fps '�• �t'rc 13 _ I �. P s •�MI�G j rr{"AA 01887 1 00 rAv.r: ag.fA {i<: t 7 _ L Date.....✓../ .� d.. i t TM'1 or;•'r`":'_�.."°a� TOWN OF NORTH ANDOVER PERMIT FOR WIRING 40 .4 usEt This certifies that .... : S ....5� has permission to perform ....... F'C....... .................. a � wiring in the building of..........kJ ' ....... ............ ........................................... at......�........ .:... 1.. . ... ..:.....v.r....... ....... .,North Andover,Mass. Fee....35 ........ Lic.No. . ....... ... .......;�ELE ... .. . .............. . ......... . - � � CTR[CALINSPE Check # �.�L—1 r ' Commonwealth of Massachusetts Official Use Only �� 3 Department of Fire Services Permit No. i O� BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/991 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC,527 CMR 12.00 (PLEASE PRINT IN INK ORTYP A L IN ORMATION) Date: r City or Town of: To the Insp ctor f Wires: By this application the undersigned 'ves not' a his or he inte tion to pe o the electrical work described below. Location(Street&Number) ° Owner or Tenant e. Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead❑ Und d T gr ❑ 1\0.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters y Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Installation of Security system 1 Completion of the ollowin table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above ❑ In- ❑ o.o mergency ig ing rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.o Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alertin Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW SecurityNo. Devices or Equivalent Heaters KW Dat No.o Water No.o No.o a Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) Estimated Value of lectrical Work: (When required by municipal policy.) (Expiration Date) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify, under th pains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: John S. Bassett Signature LIC.NO.: 1533C (Ifapplicable, enter"exempt"in the license number line) Bus.Tel.No.• 603 594 5928 Address: Alt.Tel.No.: OWNER'S INSURANCE WAIVER: I am aware that the Lid, see does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ,