The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 266 BLUE RIDGE ROAD 4/30/2018N oQ W CJS Q _O N b 0 0 0 b ,7 Date. . ........ 0 4 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 1z This certifies that 9x/?, /v, o e- L K6LP1 r"Ps, c,/ has permission for ga�nstallation ............................ in the buildings of .4 U. . .......................... at . . Nort ver, Mass. .............. Fee.,- Lic. No.7/:7j .... 17A0. . . GASINrSPETOR Check#45-75V 8307 0 AA411� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r. N --- -- - 1 CITY I MA DATE' PERMIT # 2 JOBSITE ADDRESS.�,?, OWNER'S NAME GOWNER ADDRESS TEQ,?07 �1,71,� FAX TYPE OR PRINT OCCUPANCYTYPE COMMERCIAL EDUCATIONAL. RESIDENTIALK. CLEARLY NEW: RENOVATION: REPLACEMENT: 1 PLANS SUBMITTED: YESF NO! 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 UNIT 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 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 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 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 Perti ision of the p Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME � MICHAEL H HOUSE LICENSE# 7173 kTUR9 MP.V MGF v JP 1 JGF LPGI; CORPORATION',, #:'3377C PARTNERSHIP k LLC: COMPANY NAME:' MERRIMACK VALLEY CORPORATION ADDRESS 15 AEGEAN DRIVE, UNIT #3 CITY METHUEN STATE MA ZIPi'01844 TEL. 978-689-0224 FAX 978-689-2 206 CELL 978-884-3427 i EMAILI Iliftle@mvalleycorp.com or sruffer@mvalleycorp.com AA411� 0 z z u z zi 00 z z t= 9 LLI CL u LLJ cn U) z z LLJ LLJ U) rz z 0 I-- cn < S2 cn U. z z u z cn The Commonwealih ofMassachuselts DePartinent OfIndustrial Accidents Office of Investigations 600 Washington Stred Boston, Mas& 02111 wwmass.govldia Workers' Compensation Insurance Affidavit: Buffders/Contractors/Electricians/Plumbers Applicant Information - 1, — Please Me eObly Name (Business/Orgoization/Individual): ----------- Address:ZCZ city/State/zip: Phone#:– Av_f Ar:e,you 20 employer? Check the riate box: I am an employer with !�EMrop 4.0 1 employees (full and/or part time).* am a general contractor and I have hired the sub -contractors 2.0 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees working for me in any capacity. These sub -contractors have (No workers' comp. insurance employees and have workers, comp. insurance. : required] 3.9 1 am a homeowner doing all work 5.0 We are a corporation and its officers have exercised their myself [No workers, comp. right of exemption perm MGL insurance required] t c. 152, § 10), and we have no employees. (no workers' comp. insurance required.] Type of Pivj�(req�ulred).- 6. 11 New construction 7. 0 Remodeling 8. 11 Demolition 9. C Building addition 10. 0 Electrical repairs or additions I I - 0 Plumbing repairs or additions 12. 0 Roof remirs , 13.kOthel *Any applicant I i I 1� i�! i ticii!i millmilicl 1Uhc11MA1111i!! cilli'llialle g their workers, compensation poficy '0a tHomeowners who submit this affid" indicating they are doing an work and then hire outside contraCtOrs mug submit a new affidavit indicating sueL ttContactors that dwk this box Mut 2ttad an additional sheet showing the name of the sub -contractors have g@*yeM the sub"COntrSictors and state whether or not those entities have employeeL if man Provide their workers, coam . n am an enrloyer that is provi&ng workm 9 'Conrensadon Lwurancefir nW MPIOYem Below is the polky andjob site informadom __'$ Insurance Company Name: 1111A </_ K�,V�d /A T�A_ 1,d / A Policy 4 or Self -ins. Lic. �fz 0; Expiration Date: Job Site Address: Attach a copy of the City/State/Zip:"i workers' compensation Policy declaration Page (Showing the policy number and expiration (date). Failure to secure coverage as required under Section 25a of MGL 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 $250-00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coveme verification. I do herby Print OPIckd use only ffiepains o perjur y giat the ��Dale: im �Vkll Provided above is true and correct. I no, w,*e in Ms area to be conWkied by C&Y or town offi-cial City or Town: se #: Issuing Authority (circle one): I -Board of Heath 2. Building Department 3. City/Town Clerk 4* ElectricaI Inspector 5. Plumbing Inspector 6. Other Contact person: —hone #: ,7401 Date... A 0 - - 6 6 � r9t,, TOWN OF NORTH ANDOVER 0 PERMIT FOR GAS INSTALLATION This certifies that ... ........ has permission for gas installation .... ow in the buildings of ..... ...................... at ... &Zeeewl- ... ... /,,No ndovjr ass. Fee. .3.0:T. Lic. No..3VP ... ............ GASINSPEC 0 Check # 4,(114 j? 9 FIXTURES MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING Lu W Cityrrown:A" MA. Date: Permit# Building Location*96i!�? 3—/G xv Owners Name:7-�?2�� Type of Occupancy: Commercial Educational E] Industrial E] Institutional Residentialk New: F� Alteration: F] Renovation: E] Replacement: �r Plans Submitted: Yes E] No K FIXTURES INSURANCE COVERAGE: r I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes)( No E] If you have checked Yes, please indi te the type of coverage by checking the appropriate box below. A liability insurance policy E7 Other type of indemnityE] Bond E] 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 F-1 Agent Signature of Owner or Owner's Agent By checking this box E]; I hereby certify that all of the details and infc accurate to the best of my Knowledge and that all plumbing work and compliance with all Pertinent provision of the Massachusetts State PI By Title of License: umber 3s Fitter ,e sub ift d I tered) regarding this application are true and rme upo" e ml 'e perfo d a e-Ith rmit issued for this application will be in anA.Chaptof 142 of ZGenerai Laws. Eliourneyman Cityrrown f-1 LID Installer License Number: APPROVED (OFFICE USE ONLY) Fitter Lu W Z I.- < W U) (4 W it 0 L) 0 z 16- W W Q -j>. z U U) W Lu 0 W W U)02ww at 6: 0 1-- 0 z U) W > LU Z U) 0 1-- < UJ U) (L 0 uj 0 < UJ X W LL lz U) W Ir > UJ 0 Lu LU Lu Z (D z P 0 U) I z W U) X LU W I.- UJ LLJ z LU 5. 0 W Ir 4 Lu Lu R M W 0 > 0 z 0 0 > z = W z Lu I.- 0 a 0 0 X X b a. W 5 5 > 0 SUB BSMT. BASEMENT FLOOR FLOOR FLOOR 4"' FLOOR �FLOO�R CR FLOOR 7'm FLOOR 8'm FLOOR Check One Only Certificate # Installing Com any Name: IV"rrl rk a "om a Corporation Address -6 ct hr City/Town: am/40d State:M4 -A Partnership B u s 1 n e s s T e 1: Fax: El Firm/Company Name of Licensed Plumber/Gas Fitter: &-,, J -j INSURANCE COVERAGE: r I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes)( No E] If you have checked Yes, please indi te the type of coverage by checking the appropriate box below. A liability insurance policy E7 Other type of indemnityE] Bond E] 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 F-1 Agent Signature of Owner or Owner's Agent By checking this box E]; I hereby certify that all of the details and infc accurate to the best of my Knowledge and that all plumbing work and compliance with all Pertinent provision of the Massachusetts State PI By Title of License: umber 3s Fitter ,e sub ift d I tered) regarding this application are true and rme upo" e ml 'e perfo d a e-Ith rmit issued for this application will be in anA.Chaptof 142 of ZGenerai Laws. Eliourneyman Cityrrown f-1 LID Installer License Number: APPROVED (OFFICE USE ONLY) Fitter Date..?—. /-� . '. . ! ....... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...... I ......................... has permission for gas installation � .............. in the buildings of ...................................... at ........... ! ........ North Andover, Mass. Fee.. Lic. No ............ .................. ........ GASINSPECTOR Check # 3 I MASSACHUSETTS UNI,FORM-APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NAWI/rMass. Date'- �ermit 1 -3 Building Locationi�-?26 6 yx A'dit w n I r's t� a m e i F-LtCit V-"�tU7- (�4 f, de tv Type of Occupgh y New El Renovation E Replacement �-� FIXTURES Plans Submitted: Yes 11 No El Installing Company Name GLIMATE DESIGN Address 7 stal 'A ' lart strapt Haverhill, MA 01830 (978) 3/2-9999 Business Telephone Lic. Plumber: Michael H. House Name of Licensed Plumber or Gas Fitter Check one: Certificate �E--Corporation I �'Ll 3 C - Partnership .- Firm/Co INSURANCE COVERAGE: I have a current liabiliry insurance policy or its substantial equivalent which meets the requirements of 1AGL Ch. 142. Yes E— No 17 if you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy i.-- Other type of indemnity F-- Bond 0 ' 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 walves 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 the above application are true and accurate to the best of mv knowledge and that all plumbing work and installations penormed under the permit issued for this application will be in compliance with all pertinent provisions ot the Massachusetts Sij(eGds Code and Chapter 142 of theCeneral Laws. I Licenw: By T�V, he, 'turn Gastine Sig-nalyr, Licensed Pluikber'd. - Fit, Title �Aaste, Journeyman License 1i her CityfTown APPROVED (OFFICE USE ONLY] Z Cd D cc (A Uj W (,n Ln Ln ce z 0 Cd Uj < X. Z D 0 Z U.1 < cc Cal 'A < 0 0 < W Uj (A U Z < 6.1 od uri 6 2 > Q Cie Z I— < z W < z (2 Uj >- 0 Z 0 z 'A , < > tz W < 0 c) cc 0 Uj 3rd FLOOR 01111111 We I NEW Me, EMN We 01111 Mon Installing Company Name GLIMATE DESIGN Address 7 stal 'A ' lart strapt Haverhill, MA 01830 (978) 3/2-9999 Business Telephone Lic. Plumber: Michael H. House Name of Licensed Plumber or Gas Fitter Check one: Certificate �E--Corporation I �'Ll 3 C - Partnership .- Firm/Co INSURANCE COVERAGE: I have a current liabiliry insurance policy or its substantial equivalent which meets the requirements of 1AGL Ch. 142. Yes E— No 17 if you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy i.-- Other type of indemnity F-- Bond 0 ' 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 walves 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 the above application are true and accurate to the best of mv knowledge and that all plumbing work and installations penormed under the permit issued for this application will be in compliance with all pertinent provisions ot the Massachusetts Sij(eGds Code and Chapter 142 of theCeneral Laws. I Licenw: By T�V, he, 'turn Gastine Sig-nalyr, Licensed Pluikber'd. - Fit, Title �Aaste, Journeyman License 1i her CityfTown APPROVED (OFFICE USE ONLY] z 0 uj u 6L. 0 0 66 �3 66. Lf) z 0 u z 66 0 : 1 661 z 9L r 4 M 'Zi 6L. Lw 6W < < u I z 0 : 1 661 z 9L r 4 M