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Home My WebLink AboutMiscellaneous - 26 DANA STREET 4/30/2018Date. i� ��%... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that70A Lf Y . `.�".... ...... . has permission for gas installation . U-(aA o R ....... in the buildings of ........................... .at .... ��P. ^.,-��..� ........... ,North Andover, Mass. Feed .6 - ... Lic. No a455 .. Mb ...................... . 1, Check 02199 3658 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY NORTH ANDOVER MA DATE �%/0 1.� PERMIT # JOBSITE ADDRESS :2& 0,A/JA S7' OWNER'S NAMEAI,1C/Mee— OFIOOW04/t/ GOWNER ADDRESS SAM e- TEL FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL L-1EDUCATIONAL RESIDENTIAL CLEARLY NEW: [] � RENOVATION: El REPLACEMENT. !>C PLANS SUBMITTED: YES �' N0 APPLIANCES Z 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 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY - OTHER TYPE INDEMNITY E] 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. •0 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 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 of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ PLUMBER-GASFITTER NAME LICENSE # 24833 SIGNATURE MP MGF,} JP 71 JGFLPGI CORPORATION PARTNERSHIP # LLC j �# COMPANY NAME:T.HALLORAN PLUMBING ADDRESS 826 DALE ST. CITY NORTH ANDOVER STATE MA ZIP 01843 TEL 978-685-9504 FAX CELL EMAIL This certifies that !ate � � � �j j has permission to perform .. ............. .............. plumbing in the buildings of. .� !%--.d�.................... -at ....- .. !,. C �. �} .jl✓ P �`' ... , North Andover, Mass. Fee --3Q �' .. Lic. No?'A'S ?>.3 '..I.p ................ ... PLUMBING INSPECTOR Check 417-19q MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK v_wi,CITY NORTH ANDOVER MA DATE y—%� /.S PERMIT# JOBSITE ADDRESS DQA)A Sy- OWNER'S NAME /y. �*AGl_ GPS �i�OAit/ OWNER ADDRESS S'/-� /tq TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ' ..:' EDUCATIONAL, RESIDENTIAL XPRINT . CLEARLY NEW: ,>_: RENOVATION: REPLACEMENT: ; PLANS SUBMITTED: YES ; . NO" FIXTURES Z FLOOR— SSM 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 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL 'WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 WATER P1PiSdG OTHER INSURANCE COVERAGE: I have a current liablifty nsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESNO -IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY .: BONA :. 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 .,.. AGE%TT 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. j v PLUMBER'S NAME THOMAS HALLORAN LICENSE # 24833 SIGNATURE MP, , JP CORPORATION , ' # PARTNERSHIP _ # LLC . .# COMPANY NAME HALLORAN PLUMBING ADDRESS 826 DALE ST. CITY NORTH ANDOVER STATE MA ZIP 01845 TEL 978-685-9504 M� FAX CELL EMAIL v �\ 1 p 1- 11111 vx rel VI ^0,h, e• r Date ............. OE NORTH °p TOWN OF NORTH ANDOVER " 6PERMIT FOR GAS INSTALLATION This certifies that .�:�'..S.74�.!s?. ,l�, , , , , , has permission for gas installation ..K� n .`� �° n ............. . in the buildings of. .U�..l..?..,,,,,,,,,,,,,,,,,,,,,,,, at ...... ., North Andover, Mass. Fee.. Lic. No. GASINSPECToV Check # ' /5/ 72`6 ve le MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FMI NG (Type or print) Date d NORTH ANDOVER, MASSACHUSETTS -- Building Locations Permit # Amount $ Owner's Name jz-` New ❑ Renovation Replacement Plans Submitted ❑ (Print or type) Name_ Address l7 (J il�d K(�— Y1 V yl'l) V -flit.. I,/,. ,/ , "T7, Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company 0 Corp. UPartner. M_F�m/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 13--- No If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy EF 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: Signature of Owner or Owner's Agent Owner n A uPnr n 1 hereby certify that all of the details and information I have best of my knowledge and that all plumbing work and mV compliance with all pertinent provisions of the Massachy(set Title City/Town VED (OFFICE USE ONLY) (or entered) in above application are true and accurate to the ed under Permit Is ed for this application will be in Code ankChapter l4of the neral Laws. ,Rgnature of LicensediE Timber Or Gas Fitter Plumber C�. as Fitter , 2=' i►c,ense 1Number—P Journeyman V U W CG v� a a o x z w o° F w Q w z H a w U a a z o z a o x o xz 3 U C > SUB -BASEMEN T A C7 O a F O BASEM ENT 1ST. FLOOR 2N'D. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR STH.FLOOR (Print or type) Name_ Address l7 (J il�d K(�— Y1 V yl'l) V -flit.. I,/,. ,/ , "T7, Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company 0 Corp. UPartner. M_F�m/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 13--- No If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy EF 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: Signature of Owner or Owner's Agent Owner n A uPnr n 1 hereby certify that all of the details and information I have best of my knowledge and that all plumbing work and mV compliance with all pertinent provisions of the Massachy(set Title City/Town VED (OFFICE USE ONLY) (or entered) in above application are true and accurate to the ed under Permit Is ed for this application will be in Code ankChapter l4of the neral Laws. ,Rgnature of LicensediE Timber Or Gas Fitter Plumber C�. as Fitter , 2=' i►c,ense 1Number—P Journeyman The Commonwealth of Massachusetts Department o f Industrial Accidents Office of Investigations 600 Washington Street Boston, M14 02111 �-�`" w►+�►v.mas�gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers oniirant Tnfnv-m m"__ Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employee& 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 required under 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. I do hereby certify under the pains and penalties of perjury 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): I. Board of Health 2. Building Department 3. City/Town Clerk 6. Other I� Contact Person: 4. Electrical Inspector 5. Plumbing Inspector Phone #: Are you an employer? Check the appropriate boa: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/orpart-time).* 2. ❑ I am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. ince,-ance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] t;nY applicant that checks box #1 ruust also fill out the section- below shcwi^r* :heir . -A- Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employee& 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 required under 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. I do hereby certify under the pains and penalties of perjury 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): I. Board of Health 2. Building Department 3. City/Town Clerk 6. Other I� Contact Person: 4. Electrical Inspector 5. Plumbing Inspector Phone #: Information an d 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 coxnpliance 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 appficafion for• the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regardin'_g 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_than _k 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-NikSSAFE Revised 5-26-05 Fax # 617-72.7-7749 vrww.mass-gov/dia Date -:/ii. ,/ii , /,1 , . o .:.... 41 °� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... /.:y''l .�.l'. ........................ . has permission for gas installation ..F` . :' . r in the buildings of .. '?! .41: ! ?� . ! ............................ at ..........North Andover, Mass. Fee.... Lic. No..... .7.. ..... �L..1..�!-`,�'?........ GASINSPECTOR Check # + f 3 7 L nu MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or T ) _ V �- . Mass. Date_ d '� �. -42 oo l Per itl A Building Location1 Y1 e.n Ow er's Name Q �~ Type Occupancy reS ICQAA,�tetl New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes[] No ❑ Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Business Telephone -68,7-1105 Check one: Certificate # X7 Corporation 1862 ❑ Partnership ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability insurance policy K 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: Signature of Owner or Owners Agent Owner❑ Agent I hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and accu�te to the best of my knowledge and that all plumbing work and installations performed under the permit issu f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. � T of License: Title Plumber Signature of Licensed Plumber or Gas Gasritter City/Town Master License Number 8697 APPROVE O FIC SE ONLY Journeyman • y • ■■■■■w■■■ ■■■■■ ■■■■■■■■■■' • • ■■■■■r■■■■■■■■■■■■■■■■.■■NEI .. ■■■■■■■■■■■■■■■n■■■■■■■■■ ... ■■■■■■■■■■■■■r■■■■■■■■■■■■■ .. ■■■■■■■■■■■■■■■■■■■■■■■■■01 ... ■■MEMO■■■■■■■■■■■■■■■■■■■■ Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Business Telephone -68,7-1105 Check one: Certificate # X7 Corporation 1862 ❑ Partnership ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability insurance policy K 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: Signature of Owner or Owners Agent Owner❑ Agent I hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and accu�te to the best of my knowledge and that all plumbing work and installations performed under the permit issu f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. � T of License: Title Plumber Signature of Licensed Plumber or Gas Gasritter City/Town Master License Number 8697 APPROVE O FIC SE ONLY Journeyman rail mm JI Q Z LL CC 0 a w m a I n U z• N Z , N N W n O cc J a rail mm JI Q Z LL CC 0 a w m a I n z• LL N J p � o O . W N o r v � ' LL W O z a a ac 0 0 LL LL 3 Z G O w W Q � U J CL CL a W w LL rail mm JI Q Z LL CC 0 a w m a I