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HomeMy WebLinkAboutMiscellaneous - 251 PLEASANT STREET 4/30/2018Date .... 4/ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . ............................................... .... ..... ................. in the buildings of ................. . . ................. .... ..... i has permission for gas install tion ........ ... .............. ... at .2 -,0 ......... ...... ��/ .................. North Andover, Mass. F6 . .................. ee— ........ . ..... Lic. No. ...... .................................................................... GAS INSPECTOR Check #(o 7 � ok Or I 9.11 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK GOWNER TYPE OR PRINT CLEARLY CITYue-✓ MA DATElcl/9�PERMIT#'v JOBSITE ADDRESS S/ ��ta.s a r+t ST— OWNER'S NAME Id» we}ht In f AA Ir - ADDRESS 5*A .M,? TEL 9766 -IJU —49&e FAX OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL 0� NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ NO Fe APPLIANCES -1 FLOORS— BSM 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 COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST U14IT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YESX❑ NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY X❑ 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 a d ccurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli c with all P rti nt pro n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Peter G. Viens LICENSE # 12116 SIGNATURE MP ® MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION © # 3631C PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME Merrimack Valley Corp ADDRESS 15 Aegean Drive Unit # 3 CITY Methuen STATE MA ZIP 01844 TEL 978 689-0224 FAX CELL EMAIL viens mvalle co .com Or I 9.11 W F O O F o. z z w a Z❑ z o y❑ � ~ W O W O z F" n- 4LU V) cn w a CC w � w Q (� O fS. 0. Q r r�i J F � d Q � N_ 111 S W F U- W F'n O z z 0 F U W a z Q c� x 0 �'J 1The Common wealth of Massachusetts, -- Dep artment of Industrial Accialerts i 1, Office of Investigations 600 Washington Street BOVOn, AM 02111 ' www. n'a(ass.gov1dia Workers, Compensation Insurance Affidavit: Build ers/Con>traeifdrs/Electrieians/PI><lrl hers aunt Inlormatlon ?FameBusiness/Or anization/Indiv: 1idual ." c g ) e LC Address: x�� City/State/Zip: 11 ,.� L%'I Y/ Phone #.. Are you an employer? Check the appropriate box: I am a employer with 4. ❑ I am a general contractor and l employees (fill] and/or part-time)." have hired the sub contractors ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees working for me in any capacity - [No workers' comp. insurance I equired.] 3. El am a homeowner doing all wort: myself. [No workers' comp. insurance required.] These sub -contractors have employees and have workers' comp. insurance.! 5. ❑ We are a corporation and its officers have exercised their Tight of exemption per MGL e. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Please Print Legib 'type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs of additions 11.0 Plumbing repan-s or additions 12.❑ Roof repairs 13. they 690 .ome r- Pfq 'Any applicant that checks box i' 1 must also fill out the section below showing their workers' compensation policy information. ' Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicatir`g 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 thepo/icy ante job site information. Insurance Company Name:�r Policy # or Self -ins. Lic. #: r ��I�� ��� / , � Expiration Date:d � AI e15 Job Site Address: a4rl 'R tMAd-, -r Sr City/State/Zip: X/di'.43'l 41.10uLY mq") 61&11J� Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of STOP WORK ORDER and a fine- of ineof tip to 5250.00 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 (Io her , certify unrler the pains and penalties ofperjuiy that the information provi(led above is true and correct. 46 Official use only. Do not write in this area, to be completed ly city or town official. City or Tien: ---- -- — Perm it/License #— — --- - -- Issiting Authority (circle one): 1. Board of Health 2. Building Department ?. City/Town Clerk 4. Electrical Inspector- 5. Plumbing Inspector 6. Other - Contact Person: Phone #: OMMONWEALTH OF KASSAC USETTS :. BOAM OF PLUMBERS A*D GASF I'TTE<R:S ISSUES THE FOLLOWVI+G' LfCENSE . LICENSE# AS A JOURNEYMAN PLUMB - PETER G VIENS in 9 BLUE01,A9 LANE i? ATRfNSON Mi 03811-2302' 2163_ O'�/4 if i 6 2) 3586 MERl41t EOUtpMEN7 TR4lNtM0. AMO ` . ER1YF'IC ATeOM.'ll.0 Peter Viens Cert # 102312100'1-12 Expires: / 1 Certification. N.F. P.A. 99-2012 ed. ASSE 6010 Installer & pSME IX Brazer State of Mew -',,Hampshire GAS FITTERS L>1GI=NSE NAME: PETER AENS ENDORSEMENTS. STN, STP DATE ISSUED: 10/1512013 DATE EXPIRES: 11130/2015 LICENSE #:GFE0700587 OSHA 600316337 U.S. Deaanmerrt of labor 0mopatmnai Safety and Hearth Administration Peter Viens has sucr_esstuity completed a 30 -hour Occupational Safety and Heafth Training Course in Consb-u Safety & Health , r ace �-----71T6/2Q ) — 9,,iC MMONWEALTH_OF MASSACHUSETTS 01 TI • i 101 a if • • I = 161 Z s en BOARD PLUMBERS AND GASF ITTEAS, ISSUES THE FOLLOWING LICENS IV lip Lti€(S D AS A MASTER PLUMBER PETER G VIENS 9 BLUEBIRDLANE ATK:INSON It" 03811-2302 12f r O�/01/I. 2 3585 -- . t� Commonwealth of Massachusetts Department of Public Safety Hoisting Engineer License: HE -110323 PETER G VIEN$�- 9 BIUEBIRDLNA w = ATKINSON NVf 03>�X # r I L —J -+ Expiration: Commissioner 11/1312015 Mate of New Hamwshire MECHANICAL IDENTIFICATION NAME: PETER VIENS LICENSE REGISTRATION #: SERVICE GFE0700587 MASTER 3249 Commonwealth of Massachusetts Department of Public Safety License: PMU-001068, Pipefitter Unrestricted Master t' Peter G Viens 9 BLUEBIR[? LANE Atkinson NH 03811 pp �iyExpiration: 11/13/2015 Commissioner