HomeMy WebLinkAboutMiscellaneous - 255 HAY MEADOW ROAD 4/30/201810944 Date ... 1213.41, 1 ........ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING KKA , Y9 (�4-, 6� This certifies that ................ *1*1**,**,***Im ............................. ...... has permission to perform .... V,� e.on " Z- .................. ..... plumbing in the buildings of......r A 0 r) Crj �� ............................ .................................................. at . . . V -\X c ................. North Andover, Mass. .............. Fee�n ....... Lic. No. .2 . .......... !1.�................................................................. Check# I q ` I PLUMBING INSPECTOR e MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY i�V. -e rz _ MA DATEI ( PERMIT# b�1 JOBSITE ADDRESS tYl (Z �� OWNER'S NAME POWNER ADDRESS TEL —FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: Q PLANS SUBMITTED: YES ® NO F1 FIXTURES -1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM _ _ DEDICATED GAS/OIL/SAND SYSTEM f 6 _. --.J (. _ 1 A DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER _-I .-%____.f J --j L=3 __._I -_,–j DRINKING FOUNTAIN f .._._-� _--__I f _ 1 _ f ____._! —J. FOOD DISPOSER ._____1 FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) __ KITCHEN SINK -- LAVATORY I _l _v.___ ...... __(�__1 —J ROOF DRAIN SHOWER STALL f .. ._1 SERVICE/MOP SINK TOILET— URINAL WASHNG MACHINE CONNECTION { f _- ! _ 4 _ 1 _. l WATER HEATER ALL TYPES UIHLK INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES E] NO Ell IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0]I BOND 0 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 10 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 accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp,liAnce with all Pe 'nent provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMELICENSE # ( SIGNATURE MP of JP 0 CORPORATION �].1 # PARTNERSHIP 0# i LLC D� �� -- -- I ai- .:_._. _- Com_ f,M FAX CELL �� EMAIL Mo H z° 0 U W ,a w 0 E z ❑ O W COD w O IL Z u LU _ a W a w 5 W � aco co a 0 z w �a 0 J IL a- < x w f— LL F z 0 H v w a a a 46 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 qu www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizatiorandividual): I ?Ly m Address: onklv C1. 5rt %. City/Stat e/Zip:2r C4> "C d Phone #: R�? 2 Are you an employer? Check the appropriate box: Type of project (required): '1111 am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction ,, ployees (full and/or part-time).* have ]fired the sub -contractors listed the sheet. t 7• ❑ Remodeling 2.01 am a sole proprietor or partner- ship and'have no employees on attached These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g, ❑Building addition [No workers' comp. insurance 5. El We are a corporation and its 10.❑ Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] i employees. [No workers' 13. ❑ Other comp. insurance required.] *Any applicant that checks box41 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit 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 their workers' comp. policy information. X am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -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 requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby under the pains and penalties ofperjury that the information provided above is true and correct. 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 Pers Phone M Information and Instructions 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 -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 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 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 call. The Department's address, telephone and fax number: 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 AMSSAFE Revised 5-26-05 Fax # 617-727-7749 www-mass.gov/dia Date ..... ...... . . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... ............. I ......... ......... has permission for gas installation in the build' ings,of ............................ .......................................... G at ........................................ ......... North Andover, Mass. Fee ..... Lic. No. 2- 41w .........................."....... .....k.... . ..................................................... 60, 4W GAS INSPECTOR Check # 9769 P -P v�, �2-17-H MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK , CITY j.8Z-- A 1V ` /Z _ MA DATE MIT# JOBSITE ADDRESS h��PCc 6 ul(11 OWNER'S NAME r�pl/Q AQ OWNER ADDRESS _- SR r✓L�--� T TEL- FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: Ej REPLACEMENT: ® PLANS SUBMITTED: YES NO APPLIANCES 7 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 �_i- E _ ROOM / SPACE HEATER _ ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATERS _ OT—HE RImo. - INSURANCE COVERAGE--- haveka liability its the MGL. Ch.142 YES JE!rNO 0 current insurance policy or substantial equivalent which meets requirements of 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [ef' OTHER TYPE INDEMNITY E] BOND Fil 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 0 AGENT Eil 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 and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMESLICENSE # S E MP El MGF ED JP ✓ JGF LPGI ® CORPORATION ©# PARTNERSHIP [J#= LLC E]#= COMPANY NAME: 11ADDRESS CITY _) STATE W ZIP TEL - FAX Iw CELL EMAIL a W z 0-1H w lam, O ❑ � Z o ❑ w � � w ° a °z U w �* t w t 7 co w cn w w o a a a �hji J IL a a U) w s w F w H zz 0 U W C7 �, C�7 � 410 �Iocation No. / Date N°STM TOWN OF NORTH ANDOVER 3? �� • oL p Certificate of Occupancy $ V Building/Frame Permit Fee $ //20 / • U U Foundation Permit Fee $ sAC14 Other Permit Fee $ Sewer Connection Fee $ Wate"nnection Fee $ '�. %TAL 0C) Building Inspector = (jrli 6 u 6 9�,--�rt� d -� f Div. Public Works Locatior2!5-5 %✓In Date 5 119" " ?.3 1►C•7 °RTS TOWN OF NORTH ANDOVER p Ott�°c °�h0 p Certificate of Occupancy $ # y Building/Frame Permit Fee $ C s 4 MU us ��� Foundation Permit Fee $ sc Other Permit Fee $ Sewer Connection Fee $ ----'- 2F Water Connection Fee $ p � ' 1117 �6 TOTAL $ /� - " Build`Inspect ��ta.= f Ye� 6410 DIV. Public Works 2 0 0 Z W IL 0 m A. M x d g } m J I 0 0 0 LL I u Z LL 0 0 F �S 1 W j ((� W N N > ? n Z g N m a < LL W _ pI J O p © F W z Z 0 O u Z Z o 0 (n wJ Z 0 f 0 LL ZO < U U N N W W K < F UI 0 J 3 F O F V N < N N F F p < Z< Z 0 0 Z<< O Z a W 0 0 O < N Z F N 0 F m LL m 4 F 0 J Z Z_ Z_ p J d < _p J_ J_ N C W C F W U Z U Z U- Z LL 0 p J p J p J j m LL O p ►_- LL LL 0 - N W 3 = p < N_ < N_ in < N < w 7 m 7 m m ,� J rc O m W W W < < 0 C p < m p p < N tll N 3 m N d d +r r J I 0 0 0 m .:E 0 3: , 0 0 ��D m.p, Nm DOvD DD ;+0 Cr) 3 1 N N ooznnmmv00> n m m N c N m D D ZyA mOV D m m OOO n n n ZN D 3 NZ MC= 0 p p, M— 7nnNxp� n D m � Ann pmm A0mmm-: i ^ r OOpO ppO ZoZZZON 7. NO A3 0, OOC) m O D -N`N " �'.+` . 0 " o• O � Z Z Z A Z2.. 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This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. **************�*%*Applicantfills out this section***************** APPLICANT:h��f� //�.r �I �Y Phone a'e- 7) .-/ LOCATION: Assessor's Map Number Parcel _60�- 0 000. 6 Subdivision Lot (s) /*9�1� Street /6 / Rog St. Number ************************Official Use Only************************ RECONNENDATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments Comments Health Agent Comments Date Approved' Date Rejected Public Works - /water connection, 1"11i Lzlr�lad�&. - driveway permit QA.A� (10A11AA & 4._�q..Q,�,c,n,,,.nd f1 i . ' I Fire Departmentt4 �i��e�vei Eby BuilthiFUILDING DEPARTAfiENT1 97 g r--nspector _ Date u.1 �}}F��.,aL yy G E a N E" VICES Building Inspector Town of North Andover Town Hall 120 Main Street North Andover, MA 01845 Dear Sir: � r 12 PLEASANT STREET .t NEWBURYPORT, MA. 01950 TEL. 508-465-2216 ' September 25, 1992 This is to advise that I have inspected the existing house foundation located at Lot #64A, #255 Hay Meadow Road, North Andover. The only problem that I observed was a vertical crack along the center of the front frost wall. This crack should be sealed with epoxy on both sides for its entire length. If the above repair is accomplished, I consider that this foundation is suitable for use in completed construction of the house, within the requirements of the Massachusetts Building Code and good construction practice. Please feel free to call if you have any questions. cc: Ken Daher -D G® C:i��s, STRUCTURAL INVESTIGATIONS Ec DESIGN Very truly yours, Woh�n S. O'Connell, P. 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P-3 , O.or amm z m m i t -!9 a N -� m O Z i�w 0 r y C i C �� 3_ O m m O N m m •+it7 m r. en �.� m c m D O c ;K O o p1 A z Mn• D r- O y n D C ao mO T z z 'Dr^ .� t7 r m opo m ? co m .p y D O r N m y -n m O -� m Z 0 9m, WRINIMEM iLl l, CONSTRUCTION NGINEEF31iiIG SERVICES Building Inspector Town of North Andover Town Hall 120 Main Street North Andover, MA 01845 Dear Sir: 12 PLEASANT STREET NEWBURYPORT, MA. 01950 TEL. 508-465-2216 September 25, 1992 This is to advise that I have inspected the existing house foundation located at Lot #64A, #255 Hay Meadow Road, North Andover. The only problem that I observed was a vertical crack along the center of the front frost wall. This crack should be sealed with epoxy on both sides for its entire length. If the above repair is accomplished, I consider that this foundation is suitable for use in completed construction of the house, within the requirements of the Massachusetts Building Code and good construction practice. 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