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Home My WebLink AboutMiscellaneous - 28 CIDERPRESS WAY 4/30/2018m I N2 9642 '40 41 i s s S This certifies that Date. N R1. A %1. ( -2.-. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING fy\. I Vc-. . VC -At " r- ... ..... .............................. has permission to perform ................ plumbing in the buildings of . \Alb"�—. '. . . . at. .............. North Andover, Mass. I Fee. 3"'.6. -.VYLic. No.A.5.6.7 ......... /&Q� PLUMBING INSPECTOR Check # 15 -73 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer DEDICATED GREASE SYSTEM MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK F M M FW -0 FM— FM— F M FM— F W-- FM— FM— W CITY I I I I - I MA DATE PERMIT# JOBSITE ADDRESS ER'S NAME j OWNER'S N POWNER ADDRESS TO FAX L —i TYPE OR OCCUPANCYTYPE COMMERCIAL Ell EDUCATIONAL El RESIDENTIAL PRINT �RENOVATION: CLEARLY NEW: 0-- REPLACEMENT: D PLANS SUBMITTED: YES Eq NOD FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB FLOOR/ AREA DRAIN CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIL/SAND SYSTEM l=—J =1 F771==iH DEDICATED GREASE SYSTEM FW— FM— FF—W— FM— F M M FW -0 FM— FM— F M FM— F W-- FM— FM— W DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM F0— W— FM— FM— WF f W— FM— F- I WN M F=— W I W— FW— FW— FW— FW— DRINKING FOUNTAIN F W-- FM— FM— F=— F W-- F W-- FM— F W-- FW— F M F M F M M FW— F=— FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR)—'Fo--MFM—FM—FM—FM—F-M—F=—[—M-FM—FM—F—M-FM—FM—FP—MFM— KITCHEN SINK FW -W FW -M 0 FM- FM- FM FM- FW- M M FM FM- F W-- W F M-- FM - 0=1 a,, YA F00-0 F W-fi- F" F=— FW— FM— FW— FW— F=— FW— F W-- F W-- FW— FW— = : -is 1112111.1-11 SHOWER STALL F M W K F M F M F=— F M F=— FW— FW— FW— F=— FW SERVICE / MOP SINK FM M I M- FW— F— FM— F=— W F=— r M FW— FW— F=— F M W W F— F -W— FWM 06 IN N W —F—F—F—F=—FM--1W--F=—FM—FM—= FM M M M 0--WF1MFWFWWWMM F—F--F--F--F=—FM—F=—F=—FM—F—M-I= RA11.11144 a I 10 [ell LTA -MFM—F=—F=—FM—F=—F=—F=—F—M-F=—F=—FM—F—M-F=—I= F �-- F �-- F M- � I �-- FM- � F�- F �-- I �-- F�- F�- F�- FM- F M -- WATER PIPING OTHER F I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 NO M-1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ej OTHER TYPE OF INDEMNITY 0 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 01 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 complianc^ith all Pertine rovjpion of the Massachusetts State Plumbing Code and Ch I Laws. '�p? '/�& of the Genera PLUMBER'S NAME LICENSE # SIGNATURE M P R"*" J P nj CORPORATION RI # PARTNERSHIP LLC -mix FAX CELL [� - L _7 o z LU CL W uj LL. - �'_V The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AM 02111 www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone 4: Are you an employer? Check the appropriate box: 1. El I am a employer with 4. El I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. 1 am a sole proprietor or partner- E] listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. El We are a corporation and its required.] officers have exercised their 3. 1 am a homeowner doing all work E] right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] employees. [No workers' comp. insurance required.] Type of project (required): 6. n New construction 7. E] Remodeling 8. 0 Demolition 9. F1 Building addition I O.n Electrical repairs or additions 11. 0 Plumbing repairs or additions 12.F] Roof repairs 13.n Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. t 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. I am an employer that is providing workers' compensation insurancefor my employees. Below is the policy andjob site information. Insurance Company Name: 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 firie 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 andpenallies ofperjury that the information provided above is trite and correct. Sip -nature: Date: 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 Person: Phone#: 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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLQ 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 retained 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 pennit/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 bum 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-MASSAFE Revised 5-26-05 Fax # 617-727-7749 WWW mnq-, onv/din 0 ejnjeu6is V) Lf) - LU LU 0) m D 1 LU D C.) - �— —j rl Cl) w C, cn ul Z, LL 'o Lu > 0 LLI z m 0 < -j tri _j < w cn V) U.J LLJ < U) ui LLJ Lil P- no z L =)z LLI LU z LLJ z < Ln CL L) L) cl LU Date. P This certifies that .... 1,0 777./,- c ............... has permission to perform ... 1).0 ................. �j q771 �� / wiring in the buildin of c ....... 9 at . . !!�' �� . . Ujyr'.y� ... . North Andover, Mass. Lic. No. Afg 5� 6 . ...... P."-'�'. . (-�C. .. . Ckck # ELECTRICAL INSPECfOR 54- Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblnk APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Cod�rQ, 527 CMR 12.00 (PLEASE PMT IN INK OR TYPE ALL INFORMATION) Date: 1 3( ' It-, City or Town of. NORTH ANDOVER To the Inspector of Wires: d below. By this application the undersigned gives notice of his or her intention to perform the electrical work describe N, - Location (Street & Number) Owner or Tenant J�A� F v L C-,- � 5 !! 5,. 7 TelephoneNo. LY7-U3 Owner's Address I L,& f--\ ZUIL r-% — (Check Appropriate Box) Is this permit in conj unction with a building permit? Yes E] No Ej Purpose of Building � -5 T'be A,7, &-f— utility Authorization No. Existing Service Amps Volts Overhead 0 Undgfd [] No. of Meters New Servic Amps Volts OverheadE] UndgrdE] No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: i-- 1�t;A" �fth, frdinwina tl7hlp may be waived by the Inspector of Wires. Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value o�Elect�cal Work: L�.OnC)-f (When required by municipal policy.) Work to Start: I ID 12,1111 , Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERXGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation7' coverage or its substantial equivalent. The undersigned certifies that such cover ermit issuing office. ,,Ke is in force, and has exhibited proof of same to the p CBECK ONE: INSURANCE W BOND 0 OTHEREI (Specify:) Icertify, underthepains andpenalties ofterjury, thatthe information on this application is true and complete. FIRM NAME: ILK, i- /�A 4 Ca 6. LIC. NO.: !4gnatunk I Licensee: L LIC.N0-: -ILI Bul-Tel. No.: (if applicable, r exemat in the license number line) 11�� I ip -1-" 7D e Address: .,r C --k A Alt. Tel. No. I ires D artment of Public Safe "S" Licensel Lic. No. 0 1:1- 1.r OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (che one) El owner El owner's aunt. Owner/Agent Telephone No. FEE.- $ Sij!nature No. of T-o-t—al No. of Recessed Luminaires No. of Ceil.-Susp- (Paddle) Fans Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above Ej S mining Pool ernil. f Emergency LigFt�ing Batte Units un;, No. of Receptacle Outlets No. of Oil Burners FM]9!AL:A: S]�,o, of Zones No. of Detection and No. of Switches No. of Gas Burners Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices w�t—pu HeatPump Ny.mber].:Eq!j� ........... No. of Self -Contained No. of Waste Disposers T 0 t am, �S:— ............... .......... I.KW ........... Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW �E] nutnicipal E] Other Local -.....ection Heating Appliances KW ��ecurit stems:� or Eguivalent No. of Dryers No!oNevices No. of No. of Sizns Ballasts Data Wiring: No. of Devices or Equivalent No. of Water Heaters KW ; ec ommunications Wiring: No. Hydromassage Bathtul 0s No, 0 otors HP---TTTel No. of Devices or Rquivn lent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value o�Elect�cal Work: L�.OnC)-f (When required by municipal policy.) Work to Start: I ID 12,1111 , Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERXGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation7' coverage or its substantial equivalent. The undersigned certifies that such cover ermit issuing office. ,,Ke is in force, and has exhibited proof of same to the p CBECK ONE: INSURANCE W BOND 0 OTHEREI (Specify:) Icertify, underthepains andpenalties ofterjury, thatthe information on this application is true and complete. FIRM NAME: ILK, i- /�A 4 Ca 6. LIC. NO.: !4gnatunk I Licensee: L LIC.N0-: -ILI Bul-Tel. No.: (if applicable, r exemat in the license number line) 11�� I ip -1-" 7D e Address: .,r C --k A Alt. Tel. No. I ires D artment of Public Safe "S" Licensel Lic. No. 0 1:1- 1.r OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (che one) El owner El owner's aunt. Owner/Agent Telephone No. FEE.- $ Sij!nature Asp actors, Co=etts; Pate MAMN, T ]?ass a a L V. Za xnlkvpecto � P -o e'ufg. tp 'S -7-2-0- Pate v MOM) -11 is .v actors, Comments: CID -Sp ecfoxs�' Signatyxe -)ao ful-CIRIS) Plate CAY LMR D WAPKTOXM� GRIM. -7 VA- A 3socl—f I P'e-Inspection required ($50.0 0) (fusp ectorig, Hlp�ture - io �dflajs) Date M)ACTXON - amp'., eff—F I ntoxs' Colilments: p Becors, minatue ..ao liduals) Pate The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLyibl Name (Business/Organization/Individual): --A A-e— Address: 3 GA -s R2 j City/State/Zip: 6%qt- Phone 4: Are yp-an employer? Check the appropriate box: 1. Y1 am a employer with 4. El I am a general contractor and I employees (fall and/or part-time).* have hired the sub -contractors E] I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. El We are a corporation and its required.] officers have exercised their 3.0 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] f employees. [No workers' comp. insurance required.] Type of roject (required): 6. Egl�ew construction 7. E] Remodeling 8. E] Demolition 9. Fj Building addition 10. El Electrical repairs or additions I I. F-1 Plumbing repairs or additions 12.Fj Roof repairs 13.n Other *Any applicant that checks box# 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 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. I am an employer that is providing workers' compensation insurancefor my employees. Below isthepolicy andjob site information. Insurance Company Name: 10 Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: ZY (�_� L-_�Ak 0', S �=� City/State/Zip: ),)0 - At��f �A &- 0 c S --e Attach a copy of the workers' compensation policy dellaration page (showing the policy nu'mber 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 fmc 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 :)f 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. F do hereby certifyunder the pains andpenalties offierjury that th e information provided above is true and correct. Official use only. Do not write in this area, to he 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 Person: Phone 9: 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 ajoint 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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLQ 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 perinit/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 bum 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-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia