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HomeMy WebLinkAboutMiscellaneous - 250 MIDDLESEX STREET 4/30/2018N_ O Cil O O (OD I Q v O mp O mv Cl)CP Y' X O N O O ;a m O m 10735 Datellk?44 .............. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ........ . K .. C .... j .............. —4 ................... ...................................................................... has permission to perform ... ........................................ Plumbing in the buildings of.->V.-J..P— ........................................................................ ICK, - at ... . ......................... North Andover, Mass. Fee ..31)......... ** le PLUMBING INSPECTOR Check# r fAP JP ❑ CORPORATION PARTNERSHIP ❑ ;! LLC ❑ it COMPANY NAME ����� `"� -- ADDRESS CITY 1 `� iE� STATE ��` ZIP e> 415 TEL _ Fast _ �'Z CELL— Ef:�a.ilt'e'vt� '{A-�F MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �N Z CITY MA DATE ` PERMIT ,f JOBSITE ADDRESS Zr-50 �l�f�O«i�,� Q4NER'S NAME OWNER ADDRESS TEL Com' _S'01_)°z FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT. PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES Z FLOOR—BSM 1 2 3 4 5 � 5 7 B 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE I DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM I DEDICATED GREASE SYSTEM 1 DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR 1 AREA DRAIN INTERCEPTOR. (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL f SERVICE / MOP SINK f o TOILET URINAL i =WASHING MACHINE CONNECTION WATER HEATER ALL TYPES " WATER PIPING OTHER I INSURANCE COVERAGE: I have a current liability insurance its the MGL Ch.142. policy or substantial equivalent which meets requirements of YES �0 ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYP COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 1 LIABILITY INSURANCE POLICY OTHER TYPE OF INDEI:1NITY ❑ 6OND ❑ 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 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true acid -accurate to a �l)P st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in pliance wit tri a rovision of the Massachusetls State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE" SIGNA R fAP JP ❑ CORPORATION PARTNERSHIP ❑ ;! LLC ❑ it COMPANY NAME ����� `"� -- ADDRESS CITY 1 `� iE� STATE ��` ZIP e> 415 TEL _ Fast _ �'Z CELL— Ef:�a.ilt'e'vt� '{A-�F LIR Date .... ...11..!; .k .... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Z`lns certifies that ........,�:i...`.....�C, ........................................................................... has permission for gas installation ...............................................:.... inthe buildings of............?..................................................................................... at...."�:. ?....r.."1!.tQ....... f' ,, '{{ r ................. North Andover, Mass. . Fee....'. Lic. No.19W.....I.......... V !. GASINSPECTOR Check # 9526 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO EI IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGEECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 _Q 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 accurat to a best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in.comR ianee A tFe�ail e " ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i PLUMBER-GASFITTER NAME _�., LICENSE#�51G(V TURE M,P�F �� JP( JGF © LPGI 0 ' CORPORATIONPARTNERSHIP©# LLC ®# COMPANY NAME: - 4 1 c c,t ADDRESS F-257T� oT I _Y_ CITY _i-�i _� STATEZIP ! TEL FAX Q� 3 .15 CELL _W EMAIL ►t>� �r" V MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE 12 iiPERMIT# JOBSITE ADDRESS Almyng4 NER'S NAME ,,G OWNER ADDRESS TELF--15-77 Z FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL ®� CLEARLY NEW: Q RENOVATION: El REPLACEMENT: �/ PLANS SUBMITTED: YES D NOQ APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I -- - ' BOOSTER - - . _ - - - ED __I=1 CONVERSION BURNER COOK STOVE DIRECT VENT HEATER [-- DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO EI IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGEECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 _Q 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 accurat to a best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in.comR ianee A tFe�ail e " ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i PLUMBER-GASFITTER NAME _�., LICENSE#�51G(V TURE M,P�F �� JP( JGF © LPGI 0 ' CORPORATIONPARTNERSHIP©# LLC ®# COMPANY NAME: - 4 1 c c,t ADDRESS F-257T� oT I _Y_ CITY _i-�i _� STATEZIP ! TEL FAX Q� 3 .15 CELL _W EMAIL ►t>� �r" V The Commonwealth afffassaehusem , _ - . * U1 Offlee offAMS119afeons 6`00 Washington Street -Hoston., HA 02111 vmrmsy.govld a WQrckexo' Compengationbsuxa ace Affidavit:UP ,&; giant orznaffon PX ase, xzn Y,M111Y Nam° cBusitiessiorganizationik(Rvidiial): Ad&ess: k Phone:_ C��ep� �Ut5 Are yo an eXgIoyer? Cfee-tho appropxiatebom Type of project (required): t t 4, U X am a general c onracor and I 1. S am. a exnployex with 4, 0 New c6nsitucti011 eznpXoyees ( and(or z time) T have hiredtho sub -contractors 2. [l T a -M a soleprolrrietor Orpartnex listed on the attached sheet. T I EI�' emodeling BMP and`ltavena•employees These sub-contxactoxshave 8. � Demolitioaz wormug forme in. any capacity. workers' comp. insurance, 9,E] Building addition. !N o workers' comp. insurance 5. ❑ �l e axe a corporaiioxi and its 10.r]Electricalxepairs ox additions xegahed.] officers have exercised. their 3.01 am a homeowner cjoing all work right of exemption perMGL 11-�bingxepairs or additions myseL. !° workers' comp. c.152, §1(4), andwehavano 1 .Q Roo£xepairs insurarza�xe ed. employees. PTOWOrkers' � comp. insurance xecluixed.] 1311 Other Auyapplicantthat cbecksbox imusEalso ilontthenectionbeldwshowingtl kWorkerecompensWonpolicyInformation. i Homeowners wha wtma6fiis affidavitMoati gi iey dee doing auworkandthen Me outside contractors must, submit a new affidavit indicati$g such, TContactorsthat chedct h bgmust attached an. additional sheetshowingthename ofthe s4 -contractors audthei8workers' comp. policy information. I a nr2 empi`oyez't�iaii p a�ic % g woke s' cornpe�asat�on znsr��a�tce,�o r y er %gees; Bet ow ist�iepalicy r r jo ,�it'e in, farmation Insurance Company Nam Policy # or 8elc ins.1zc. ExpiraiionDate: • Sob Bite. floss; City/state/Zip: Aitacb a copy of t ewoxkers' coxnpen9atton-poiZcy'cleclaxationpage (shpwing•thepoUcynurrmber and expiration. cl 9. Nailute. to somra covexage as xecluircdmder Section 25A of1V. OL c.152 can, lead to the imposition of eximina113enaiiies Of a trine up to $1,500.00 andlor ones ear Npxiso�mextt,. as well.as chApenalties in. the foam of a S'H'OP WORK ORDI R and a fine ofup to $250.00 a dap against the vi ator. Be advised that a copy ofthis statement -may be forwarded to to Office of• investigations of ffio DI& fox e coverage vexification. xdo iter'eby cep ` r�c%r<tr `���� IVena7tieso� ver Vi1iattligin ornationpr�ovir�ec�a�i�ye%situlan�ieort°eet, OjfIeial use ggy. Do not write ht tram area, torte cora ued by city or tonin offieiaf. Cite' or Town: BeMPUICense # SssWng A -.thorny (ekele ono): i. Board of 7ffealtb. 2. BuildiugDepartmed. I CRYMown Clerk 4. Electxical inspector 5. Blimbing fuspector f. Other Information a�.d Insiructions Massachusetts Greneral Laws chapter 152 requires all employers to provide workers' compensation for their employees. ` + Pursuanttothis st,%Mo, an. emierayeeis defined as"•..everyperson iiithe service ofano�herundex any contract OX g. express or Jmplied, oxal oxwxitten:' Au evT1gfe;s dei7ned as "an ladkidual,patinersbip, assor ,jaf1o4, assoc001poratzon or other legal entity, or anytwo oxxaore of the f6xego7ng engaged in a joint enterprise, and 1cludingthe legalzepxesentatives ofa•deceased em. to yon. the receiver or-ircistee oaxr inctivzdua� pazership, association ox otbexXegaX entity, em to ' em to ee sowevexthe p Ymg p y owner of a dwelhghousehavingnotmoxe thmthree apartments andwha resides'ihexeiu, oxfhe occupantofihe dwelling house of another who em'Ploys persons to do maintenance, constmetion oxrepair work on such, dwelling house OT on, orbuilding appurtenant thereto Shall not because ofsucb employmentbe deemed to be an employer" MGL chapter 152, §25C(6) also states that "every state or local Ile-enslag agency shall withhold the issuaztce or -renewal of a Ifcells a or permR to op erate a business or to construet buildings in. the comutonwealth for any applfcaxtt who has not produced•acceptable evidence Of compliance with the insurance coverage x��uixed:' Additionally; MCL chapter 152, §25C(7)slates ` 7ezihexthe commonwealthnox any of its political sub6isions shall Outer into any contractfor the performance ofpublie workuntil acceptable evidence of compliance with the insurance requirements ofthis chaptexhave boanpresentedta the egatracting authority," Appucaitts Please frll out the workers' comp ensaiion affidavit completely, by checlflng the boxes that apply to your siivaon and, jr necessary, supply sub-contractor(s) name(s), addresses) andphononumber(s) along with their certificates) of insurance. LimitedLiabik Companies (LLC) orUmitedUabftrpartnexships (f fj)withno employees other than. the members oxpariners, arenotrequiredto canyworkers' compensaiioniuswr me. Tf anLLC OrLLP doeshave employees,aPolicyisxequired. Be, advised thattbisafdavitmaybesubmittodtothe Department of rndusiriai A ccidOnts for confirmation of insurance cOverage. Also be sure to sign and date the arfzdavz : ate affidavit should b e xettubedto the city or town that the application fox thepermit or license is being requested, xto� the De�ariment of Industr al.Acoldents. Shouldyou have any questions regarding the law or ii you axe:r0quixed to obtain a y�orkexS, compensafftonpolroy, please call the, Department atftmunberlisted below: Selfinsttxecicompaniessboutdentertbe3x Balt insurance license number on the appropriate line. I city or Town MOOS i'leasebesurOthatt$eai�xdavztiscompletOandpxinfecllegibly: The Departmenthasprovidedaspace atthebottom of the affidavit for you to fill Out k the event the Office offavestigailons has to contactyouxegarding the applicant Please bO-sure to till irt'� e pem f/cense number wh7eb will be used as a xezexenco number, l'n, addition, art applicant thatznust submitmultiple permit/license applications la any given year, need only submit one a fx• davit indicating current 1'ORGY uifoxmation (i<fneeessaxy) and under "Tob Site Address" tiro applicant shouldwxitO "all locations in (city or town)" ,A- copy Quite affidavit thathas been, of ficially staff apod ox marked by the city or Lown may bO pxo-dded to the applxcantaspxflofthat a.valid afrtdavitrsan le ox iUxepexmitsorlicamag.Anew affidavit �nustiaOMedouteach YOM Where ahome owner orcl zenh obtaining a license oxpennitnot related to anybusin.ess or commercialventure (x,e.adog licenseorpexmittobum loaves etc)saidpexsoars TOTxeclniredtocompletethisaffidavtt. The Offzco ofInvesiigationd would like to thank you in advance for youx cooperation and should you have aay guest'tons, please do not hesitate to give us a call. The Deputwent's address, telephone a-hd fax number. - The CQ onwtalth o 600 i aqW-A&j Bodon, M -A 02X 11 Revised 5 26 -OS Fax # 617H72MM vv'�w•�2,a��,g���c.�ia No 4594 f Date . �U. j�. -� o TOWN OF NORTH ANDOVER .` °oma p PERMIT FOR PLUMBING °SACNUst This certifies that ...... ...... ...................... has permission to perform!" ..` � ................... • • • • • • plumbing in the buildings o ............................. . at. �?39.. ? .. • . • • • • • • •; North Andover, Mass. /i5. . Fee '``s....... Lic. No. .� ............ �� ' ............ PLUMBv G INSPECTOR Check # �� WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS � �� �7t1 Date fU Building Location ��Ia s C Owners Name (�(f u`j40l� Permit Amount 7"' Tvoe of OCCUoancv / New Renovation Replacement Plans Submitte es No (Print or type) Check one: Installing Company Name r' -1v �� Corp. Address Business Telephone Name of Licensed Plumber. /l`Q,�-j /� Insurance Coverage: Indicate the type of insurance coverage Liability insurance policy n Other type of LiPartner. . 11 Firm/Co. the appropriate box: ❑ Bond ❑ Certificate Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above Ih"urance ignature Owner � 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 der Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus tate P in ' Code and Cha ter 142 of the General Laws. By: SignaMe oi 17censeaum er Type ofPlumbing License Title 31,9 City/Town Dice-ns=eTNumoer Master Journeyman ❑ APPROVED (OFFICE USE ONLY • (Print or type) Check one: Installing Company Name r' -1v �� Corp. Address Business Telephone Name of Licensed Plumber. /l`Q,�-j /� Insurance Coverage: Indicate the type of insurance coverage Liability insurance policy n Other type of LiPartner. . 11 Firm/Co. the appropriate box: ❑ Bond ❑ Certificate Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above Ih"urance ignature Owner � 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 der Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus tate P in ' Code and Cha ter 142 of the General Laws. By: SignaMe oi 17censeaum er Type ofPlumbing License Title 31,9 City/Town Dice-ns=eTNumoer Master Journeyman ❑ APPROVED (OFFICE USE ONLY G Date. ............. . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ................ ................ has permission for gas installation ...M ............. in the buildings of ... ...... ' �� �f ' f ............. . . , North Andover, Mass. Fee: ! ....... Lic. No!....1 ... ...... fes ............. GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 1ASSACHUSETTS UINTFORM APPLICATON FOR PERMIT TO DO GAS FITTING or print) INUK1H ANDOVER, MASSACHUSETTS Building Locations P - '(3 GJ.]L5 oLj Owner's Name New Renovation ❑ Replacement ❑ Plans Submitted ❑ 1.9 ©c Permit # 71U/ Amount S A a (Print orCheck one: Certificate Installing Company Name ,Y"-�tA MQ A R Uj, n Corp. Addrx's:s ��� �tdd�e„4e�1 -f ® Partner. t� -e Business Telephone ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No If you have checked ves, please indicate the type coverage by checking the appropriate box. 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 M ss. eneral 1,aws, and that my synature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent El I herebv 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 pertormed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 14" of the General Laws. By: Title CityiTown 1 APPROVED (OFFICi: USE ONLY) Signature of Licensed Plumber Or Gas Fiffer Plumber / a,-� 1 9 ❑ Gas Fitter License i umoer P. Master ❑ Journeyman r' a■�� ����������������� (Print orCheck one: Certificate Installing Company Name ,Y"-�tA MQ A R Uj, n Corp. Addrx's:s ��� �tdd�e„4e�1 -f ® Partner. t� -e Business Telephone ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No If you have checked ves, please indicate the type coverage by checking the appropriate box. 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 M ss. eneral 1,aws, and that my synature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent El I herebv 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 pertormed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 14" of the General Laws. By: Title CityiTown 1 APPROVED (OFFICi: USE ONLY) Signature of Licensed Plumber Or Gas Fiffer Plumber / a,-� 1 9 ❑ Gas Fitter License i umoer P. Master ❑ Journeyman