HomeMy WebLinkAboutMiscellaneous - 24-26 Fernwood Streetl
Date. 7J..- 9.K. -
TOWN OF NORTH ANDOVER
PERMIT FOR, GAS INSTALLATH
1-11
This certifies that ..... A..01..��+ i.... r
has permission for gas installation.ftf l 6
in the buildings of ...................
at ..................................... North Andover, M!ss. �,
Fee.,,, . . . Lic . No. .........................
�Q�/�3 GAS INSPECTOR
Check
6628
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO U® GASFITTING
jf (Print or Type)
W4 UE ,Mass. Date rtl-
20 F(Pennit # --
Building location FEap L)oo o S T Owner's Name
Owner Tel#i
Type of Occupancy_ A l/
New ❑ Renovation ❑ Replacement ❑ Plan Submitted: Yes ❑ No n
FIXTURES
Installing Company Narne��,,� - -� --. ��` �� Check orae:, Certificate
Address ' s dk �= % - fir._.. atorporatiion
---4k
❑ Partnership
Business Telephone # .... Firm/Co.
Name of Licensed Plumber or Gas Fitterj 1 J" l4U%/V f e-
1 -7 -
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes [7 No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A 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
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner F1 Agent 11Signature of Owner or Owner's Agent
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 the permit issue o fR is ap lication will be in compliance with all
ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen 1 S.
BY Type of License: s
• lumbe „ Sign ur Licensed Plumber or Gas Fitter
Title • Gas fitter1T_.`
�as e3 License Number_ _ A
City/Town ^ -Journeyman
APPROVE® (OFFICE USE ONLY)
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SUB-BSMT
BASEMENT
1ST FLOOR
2"D FLOOR
3RD FLOOR
4T" FLOOR
5T" FLOOR
En" FLOOF
7T" FLOOR
8T" FLOOR
Installing Company Narne��,,� - -� --. ��` �� Check orae:, Certificate
Address ' s dk �= % - fir._.. atorporatiion
---4k
❑ Partnership
Business Telephone # .... Firm/Co.
Name of Licensed Plumber or Gas Fitterj 1 J" l4U%/V f e-
1 -7 -
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes [7 No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A 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
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner F1 Agent 11Signature of Owner or Owner's Agent
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 the permit issue o fR is ap lication will be in compliance with all
ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen 1 S.
BY Type of License: s
• lumbe „ Sign ur Licensed Plumber or Gas Fitter
Title • Gas fitter1T_.`
�as e3 License Number_ _ A
City/Town ^ -Journeyman
APPROVE® (OFFICE USE ONLY)
Date. .1. ?'....l. c.,. {. , ; .
of °� TOWN OF NORTH ANDOVER
F P
PERMIT FOR GAS INSTALLATION
♦ O .
,SSACNUSEt
1 L"/x- .
This certifies that a . 5.G . .. .:'�`� .......... .
has permission for gas installation . ..--.1 %:-. .. .
in the buildings of.C:..!"{/!�!t^�?,�'�................. .
at ..... ........ ,North Andover, Mass.
Fee. Lic. No.
,.�
1 / GAS INSPECTOR
Check
6629
W
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
/? f Uw V ,Mass. Date –7:5/— 20_at Permit /i __
Building Location r -e -]at, ,, ooD 51 Owner's Name
Owner Tel#I
Type of Occupancy_
New ❑ Renovation ❑ Replacement ❑ flan Submitted: Yes o No ❑
FIXTURES
Installing Company Name C-1fL4Ad&i-11 A- C. L 6-6 Check one: Certificate
Address 2/ dC� / torporation
juL ❑ Partnership
Business Telephone # t"-) C/C/'13 t❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter . J t;l% /' OT)W d�-
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ET-- No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy 'f3 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
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) in ab
knowledge and that all plumbing work and installations performed under the permit issu
ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen)
BY Type of License:
• lumbe "4�1
Title •^Gas fitter
• as ef. License
City/Town • -Journeyman
APPROVED (OFFICE USE ONLY)
are true and accurate to the best of my
ration will be in compliance with all
Plumber or Gas Fitter
IR
11,
10
Location c�Y Felip wood 2
No. ! Date
i
TOWN OF NORTH ANDOVER
` Certificate of Occupancy $
s�cHus Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ ci
Check # CA f#
8462 j _A
sBuilding Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
k,,
BUILDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE:
Building Commissioner/1 for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Pr erty Address: //
lit/OO(J
1.2 Assessors Map and Parcel Number: �f
Map Number Parcel Number,
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Areas Frontage 11
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Required Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public 0 Private ❑ Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
lstoric District: Yes No
2.1 Owner of Record
Na—me (Print) Address for Service
,
Signature Telephone
2.2 Owner of Record:
dame Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature Telephone
Not Applicable ❑
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Co1'hpany Name
Registration Number
Adores
` �
Expiration Date
nature Tel:phone'
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SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 6 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 .......❑ No ....... ❑
SECTION 5 Description of Proposed Work check a!I
applicable)
New Construction 11Existing
Building ❑
Repair(s) ❑
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
` OFFICIAL_ Ute" QTY
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) X (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZAIION TO BE COMPLETED WHEN
OWNERS A T 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.
i
Si ature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, 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
i
Print Name
SiNature of Owner/A ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 - 2 3
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
jO�e eovaq1—&r6oac,4,4e,,�a4
Board of Building Regulations and Standards
i HOME IMPROVEMENT CONTRACTOR
Registration: 146622
2. Expiration:v5/g/2007
Type:- t)Bi4
ACCURATE RENOVATIONS
,..?�
PHILIP CUCINOTTI;, if;
Accurate Renovations
11 Suring Street
Stoneham, -MA. 02180
(978)943-2567
Client Name l%y A
Address - cjGai
Ci State M4A , Zi code
Home Phone 6 2,K ) -� S -1,� d Cell #(_
Work Phone
Descri tion Of Work:
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Materials Included Yes
PXC�-Jatrov &
No
Labor
Estimate
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X�-00,
Proposal Accepted
�- Date
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Department of InduftWd Accidents
Office of invesd9adons
600 Washingtton Strut
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridanw?lumbers
Aoolicant Information Please Print Lerdbly
Name (Business/orpnizatimgndividuai):41e—(? K,±% e:vd l/ f C4y�/
Address: &
City/State/Zip:
5 72Jh (�f
Are yowam employer? Check t e• 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-contraclors
2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet 1
ship and have no cmployeea These sub -contractors have
working for me in any capacity. workers' comp. insurance.
[No workers' comp. insurance 5. ❑ Weare a corporation and its
required.] officers have exercised their
3. ❑ 1 am a homeowner doing all work right of exemption per MGL
myself. [No workers' comp. C. 152, § 1(41 and we have no
insurance required.] t employees. [No workers'
cwv. insurance roauire&1
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
s. ❑ Demolition
9. ❑ Building addition
100 Electrical repairs or additions
11 •❑Phunhing repairs or additions
124118 of repairs
13.❑ Odler
;Any applicant tint chedd box 91 mut 0190 811 out the section below rhowing M wrortats' ,
r Homeowners who submit this at8davd ' common po Y mionna8od
ndicatlma they are doioa an wort and then hire outside soman mtut submit a new Wn&vit "c� such
tconuOcm that duct this box must 0whed m addWawl sheat ahowioa the =MR of the mb-coofteton and *1* WO&WI' GoaP• policy inbrntrttion.
I an an employer that is providing woriera' com, pmedon insurance for my employees, Below Is dose p.Jky andjob do
informadow.
Insurance Company Name: KAA#V 7i�-
Policy # or Self -ins. Lic #: �2 7 Expiration Date: • / Q
Job Site Address: .2 C -'6100 C/E'-
_ Clty/Statcaip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failum to secure coverage as reqwcf under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up m $1,500.00 and/or one-year t, 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 ce der the prams and penekin of penury that the information provlled about Is trate and eorreeti
SUMture:
Date
0fflcial use only. Do not write in tha area, to be cord pkted by C4 or
to" o,Q?clal
City or Town:
Permwuceose 6
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. Cky/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: Phone 0:
1.111V1 1nativa> UAJ1%g ii LOI&A M%►ravALM%V
Massachusetts General Lag's 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 hira, ..
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 ab individual, partnership, association or other legal entity, employing employers. However the
owner of a dwelling house having not more than three aparvrrents 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 badness or to coostrnct buildings in the commonwealth for any
appilcut who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGI- chapter 152, §25C() 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 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 any be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sore to sign and date the amdavtL The affidavit should
be resumed 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 mmaber listed below. Self-insured companies should enter their
self-insurance license unmber on the appropriate line.
City or Town O(Aciais
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 511 out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fin in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple pernuVhcense 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 �qt has been officially stamped or marked by the city or town may be provided to the
applicant 0 proof that a valid a i vi is on file for future permits or licenses. A new affidavit most 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 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 caR
The Department's address, telephone and fax numbs.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mm.gov/dies