HomeMy WebLinkAboutMiscellaneous - 28 SOUTH BRADFORD STREET 4/30/201800
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TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that 9�4
,�.,
..............................
has permission for gas installation . .... 12d.y:-!�':�7 ....
in the buildings of - -Lu/A. ............................
at 4�, Andov
,&Mass.
Fee.D-.S7.VA Lic. No...V'A3.6..
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YAA, or, P4E
Check #
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town: /-/Z- MA. Date: Permit#
Building Location: S-4) 11:1AI �OX� et-5wf ners Name: -(A -/k. -el,
Type of Occupancy: Commercial El Educational E] Industrial El
New: El Alteration: El Renovation: El Replacement: E5"' -
Institutional El Residential kj�-
Plans Submitted: Yes ED No F1
SUB BSMT.
BASEMENT
15' FLOOR
FLOO
5'" FLOOR
6 1H FLOOR
FLO—OR
FLO—OR
Installing Company Name:. Ic A-174-
- I City/Town: &ko
Address:'S � 431)k F( ) A�'
Business Tel: "0 Fax: 444 -
Name of Licensed Plumber/Gas Fitter:
Check One Only Certificate #
[]—corporation
El Partnership
El Firm/Company
INSURANCE COVE
I have a current liability insurance policy or 1 . ts substantial equivalent which meets the requirements of MGL. Ch. 142 Yes 9/No El
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy B---- Other type of indemnity [:1 Bond n
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the lns�urance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Signature of Owner or Owner's Agent Owner 0 AgentE]
By checking this box E]; 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 Plum5p Codeppd Chapter 142 of the Ofeneral Iaws.
By
Title
City/Town
APPROVED (OFFICE USE
Type of License:
Erplumber
El Gas Fitter Si n;aure of Licens d PlumberlGas Fitter
9 -Master
Diourneyman
0 LP Installer License Number:
/A. -
FIXTURES—
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SUB BSMT.
BASEMENT
15' FLOOR
FLOO
5'" FLOOR
6 1H FLOOR
FLO—OR
FLO—OR
Installing Company Name:. Ic A-174-
- I City/Town: &ko
Address:'S � 431)k F( ) A�'
Business Tel: "0 Fax: 444 -
Name of Licensed Plumber/Gas Fitter:
Check One Only Certificate #
[]—corporation
El Partnership
El Firm/Company
INSURANCE COVE
I have a current liability insurance policy or 1 . ts substantial equivalent which meets the requirements of MGL. Ch. 142 Yes 9/No El
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy B---- Other type of indemnity [:1 Bond n
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the lns�urance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Signature of Owner or Owner's Agent Owner 0 AgentE]
By checking this box E]; 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 Plum5p Codeppd Chapter 142 of the Ofeneral Iaws.
By
Title
City/Town
APPROVED (OFFICE USE
Type of License:
Erplumber
El Gas Fitter Si n;aure of Licens d PlumberlGas Fitter
9 -Master
Diourneyman
0 LP Installer License Number:
/A. -
MASSACHUSETTS U-NIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
2
1 1)
7=
1h
9(t 6AZDO , mass.
City, Town
Building
AT: Locationd% � o L4 -A A L AJ F' 'A
Date 19 �0
Permit *0",- f *
owner's -Ep—
Name
51/ �jxk
Type of Occupar, y:
New 11 Renovation 0 Replacement [Z
Plans Submitted Yes [] No []
(Print or Type)
Installing Company Name W, /4. a x,.c—
Address A�E /�!
(1,621 fA 60
Check One: Certificate
f9 Corp. I�MC—
C] Partnership
C1 Firm/Company
Business Telephone Name of Licensed Plumber or Gasfitter
I hcfeby certify that zU of the details and information I have submitted (or entered) in above application ate true and accurate to the best o(my
knowledge and that all plumbing,.wotk.and-ini(&Uations-petfon;cd under Permit issued for this applicat PLAnclawiLhapettAnent
ion W"T K
provisions of the Massar-hitisett; Stite GisC&de Ad Chapr. 142 the General LAws.
By e TYPE LICENSE: ;K14nature 6f Licensed
JLF f- lc,-�P,19 P I u m b e r
Title Gasfitter tyuMber or Gasfitter
Master
City/Town:
0 P�� Journeyman
APPROVED (oF.F�CE—USE-Oft--f) License Number
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0
33
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(A
It 0) a
Locationr---'O -.24
No. Date
TOWN OF NORTH ANDOVER
jCertificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check# lz�-4 V
r 4
Z Building Inspe_Q
a
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
WELDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE: ly WSW
Building_ CommisSioner/IlIgIfector 6f Buildings Date -L/ 1�4- 0—s—
QVIrTM19 I-QTTIV I
I . I Property Address.
1-2 Map and Parcel Number:
-ST'
/0-3
6601
Map Number
Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning District Proposed Use
Lot Area Fsf)
Frontage (ft)
1.6 BUIELDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required PrOvide ReqWred _... I Provided
Required Provided
I -Mater Supply M.G.L.C.40.154) 1.5. Flood Zone Information:
1.9 Sewerage Disposal System:
Publi 0 private 0 Zone Outside Flood Zone 0
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIPJAUTHORIZED AGENT
2.1 Ownerof Record
R LkTH wbLlTriEt� .2,9
So, Ro�j?DRkD
Name (Print) Address for Service :
-4.7-6
A00, fiAd)o VE AQ,
Signat�re Telephone
2.2 0wher of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable 0
License Number
Ad�aress
Signature Telephone
Expiration Date
3.2 Registered Home Improvement Contractor.
Not Applicable El
DAVIP CASIF�&je-DA-2rz RFr,, SO4'.�&Qc
Company Name
Suc=b/i 97: SU
Registration Number
Xodzd�eoO
ss
jExpiration
�S.g�nature
Telephone
Date
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I SECTION 4 - WORKERS COMPENSATION (MG.L. C 152 8 2566) 1
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
—Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (check_ applIcable)
New Construction 0
Existing Building
Repair(s)
Alterations(s) 0
Addition 0
Accessory Bldg. 0
Demolition 0
.0
Other 0 Specify
Brief Description of Proposed Work:
e -p- Eko. (3
SECTION 6 - ESTE14ATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE
I Building
17 00 0 0
(a) Building Permit Fee
multiph
2 Electrical
(b) Estimated Total Cost of
Construction
3 PlumbinE
Building Permit fee (a) x (b)
—4 Mechanical (HVAC)
5 Fire Protection
—6 Total (1+2+3+4+5)
(DID
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
11 DA I Z C_ A 6 7"R, t cp V E as Owner/Authorized Agent of subject.
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
DAVIE)
Prull_�' e I -%
J -'_ 9 r_
Sij=ture ofoZer/Ajent Date
NO. OF STORIES SIZE
BASEI�ENT OR SLAB
SIZE OF FLOOR TUvIBERS I ST 2ND 3M
SPAN
DINIENSIONS OF SILLS
DIIVENSlONS OF POSTS
DINIENSIONS OF GIRDERS'
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHNMY
IS BUIR1,13 ON SOLID OR FILLED LAND
IS BUUDING CONNECTED TO NATURAL GAS LINE
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CIL
APPLICANT INFORMATTON
The Commonwealth of Wassachusetts
Departv=t of Indwtrialqccidents
Q6ice of lnvest�yatiolu
.600 Washi" Street
� Oostoi451(A 02111
Workers' Compensation Insurance Affidavit
Please PRINT Legibly
Name: [A T -,q W 9 1 T -7-t F— P,
Location: .1-2 So. 134,42F09J) 97)
City: 0 , &v L9 0 () F- P- -Telephone 0
13 1 am a homeowner performing all work myself.
0 1 am sole proprietor and have no one working'in my capacity
13 lam an employer providing workers' compensation for my employees working on this job
Company Name:_Dhym (,.AsT?Q)c,t)J0F= Rot)FM(�- 4-- ��IPIJVg�z. -r&,
Address: U 7-7-0 Al
City:_ AlokTIJ 141VOOVF—k k- Telephone'#:
Insurance Company: A 57 LUO Ak4ZAA�CJF- Policy M kf!�94 6 J
1 am (circle one) sole proprietor, general contractor or homeowner and have hired the contractors listed below who have the following
workers' compensation policies: I
Company Name:
Address:
City: - Telephone #:
Insurance Company:
11
Company Name:
Address:
City:
Policy #:
Telephone#: -
Insurahce. Company: Policy #:
Attach additional sheet if necessary
Failure to secure coverage as required under Section 25A of MGL 15B can lead to the imposition of criminal penalties of a fine up to S1,500.00
and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby er epainsan penalties ofperjury thatthe information above is true and correct,
Signature: Date:
I
.MMI M, MAM
Official Use ONLY - Do not write in this area
City or Town: Permit/License #:
9 Check If Immediate response is required
Phone # L-1 — :z 4,Z D
• Building Department
• Licensing Board
• Selectmen's Office
• Health Department
13 Other
INFORMATION & INSTRUCTIONS
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation
for their employees. As quoted from the "law" 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 adeceased
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 section 25 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, 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 in the workers' compensation affidavit completely, by checking the.box that applies to your situation
and supplying company names, address and phone numbers as all affidavits may be submitted to the
Department of Industrial Accidents for confirmation of insurance coVerage. Also be sure to sian and date the
affidavit. The affidavit should be. retumed to the city or town that the application for the permit or.Ecense 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.
City or Towns
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 permi't/license number which will be used as a reference number. The
affidavits may be returned to the Department by mail or FAX unless other arrangements have been made.
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 andfax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investicrations
600 Washington Street
Boston, Kk 02111
Fax # (617) 727-7749
Telephone # (617) 727-4900 ext. 406, 409, or 375
1'.
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
in accordance with the provision of IVIGL c 40 S 54, a condition of Building Permit
Number is . that the debris resulting from this work shall be
dispose of in a properly licensed solid waste disposal facility as defined by MGL
c 11, S 150 A.
The debris will be disposed of in: L -f S .1 Kc,, 9 /J 9
*I A e 12 - 9 ;�- 4�+ IV , 44, .0�, , ", -P
(Location of Facility)
Signature of Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
Date ...................
7q
,40RTH 'TOWN OF NORTH ANDOVER
0 q PERMIT FOR GAS INSTALLATION
I , V
A
This certifies that . . . .,. )'. . !� ..............................
has permission for gas installation .... f ............ I ..............
in the buildings of ................................................
at ..... ......... I North Andover, Mass.
Fee.� ... Lic. No..
.............. �o ............
GASINSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File