HomeMy WebLinkAboutMiscellaneous - 295 MASSACHUSETTS AVENUE 4/30/2018Cf)
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
T Is t
hi certfies hat ...... / .......
has permission to perform .... .........
plumbing in the buildings of ..................
a t Jr. .......... ... NorthAndom, Mass.
Fee. ;/2 .... Lic. Not). 0. .. ..... PLum ......
BING INSPECTOR
Check#
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date
Building Location J- T::� kh- Owners Name Permit# -
Type of Occupancy Amount
New Renovation Replacement E] Plans Submitted Yes No
F1YTjTV1RQ
(Print or type)
Installing Company Name A�7,6;
Address bg,40V
Check one: Certificate
11 Corp.
Partner.
Firm/Co.
Name of Licensed Plumber:
Insurance Covera&e
.� Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy E� Other ty pe of indemnity 11 . Bond
Insurance Waive : 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner El Agent El
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By:
SigndLUIC 01 Ocenseu FlumueFf
Title Type of Plumbing License
City/Town / 5.,10:2
APPROVED (OFFICE USE ONLY I-IC011SC 1'4urnoer - Master Journeyman
40
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(Print or type)
Installing Company Name A�7,6;
Address bg,40V
Check one: Certificate
11 Corp.
Partner.
Firm/Co.
Name of Licensed Plumber:
Insurance Covera&e
.� Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy E� Other ty pe of indemnity 11 . Bond
Insurance Waive : 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner El Agent El
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By:
SigndLUIC 01 Ocenseu FlumueFf
Title Type of Plumbing License
City/Town / 5.,10:2
APPROVED (OFFICE USE ONLY I-IC011SC 1'4urnoer - Master Journeyman
�14
U4
Th -P Cominonwealik Of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Rrayhinoton Street
Boston, MA 02111
www-mms.govIdia
Workers' Compensation I.Witrance Affidavit: Builders/COntractors/Electririans/Plumbers
Aicant info Lgtion
NaM'e (Business/organizadcn/individual):
Address: 'ez�
0 �/ 6o�ao
City/State/Zip: Phone #.
Are you an employer? Check the appropriate box:
f Eim a employer with 4. am general contractor Simi T
2. ernPloYees (fun and/or part-time).11%,
P_f`a� a3ole proprietor or partner-
ship and have no employees
working for me in any capacity,
[No workers, comp, insurance
required.]
r am a homeowner doing all work
myself, [No-wo '
rkers' comp.
insurance -required.] t
have hired the sub -contractors
listed on the attached sheeL
These sub -contractors have
workers' comp. insurance.
5. El We are a corporation and its
officers , have e . Xercised their
right of exemption per MOL
c. 152, § 1 (4), and we have no
.employee& [No workers'
comn insilra"^. — ""';
Type Of PrOject (required):
6. New construction
7. Remodeling
8. Demol ition.
9. ED Building addition
I G.C.Electrical repairs or additions
I 1 -0 Plumbing repair, addition,
12.F� Roof repairs
13 - M Other
*Any applicant that checks bcrZ# I must also fill ou
HomeownM who submit this affidavit indi t the section below showing their vvorkers' aomperisajoyi policy Informahom
�C' cuting, they am doing 0 work and then him outside contract ida
on must submitanew1fr vit indicating such.
onftctors that check this box must attitched an additional shwL showing. ittle muft of the sub-contractivs an,
0 theirworken;'mr-
I am an emPlOYer that is Providingworkers f compensation iftsurancefor mr ====
information. z"Floyem
Insurance Company Name:
Below is the poficy andjok site
Policy # Or Self -ins. Lic. 9:
Expiration Date:
Job Site Address: --------------
Attach a copy of the workerst. compens�a city/stateizip ------- -------
Failure to s tiot policy declaration page (showing the policy [lumber and expiration date�
ecure coverage as required under Section 25A of MGL c. 152 can lead to the 'mPOsiti I OP Of enminal 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 DlA for insurance coverage verification.
I do . hereby cvgfy under the pains and . penaUia Offiedwy that the informadoff provi&d above is &me
androrreeL
Official use ofiiy. Do not write in this area� to be conpleted by city or own
official
City or Town:
Permit/License #
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing I . mpector
6. Other
Contact Person:
Phone #.
Information and In'structions.
Massachusetts General Laws chapter 152 requires all emp I oy= to provide worken' compensation for their employees.
Pursuant to this statute, an mployee 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, assc)diation, corporation or other lop] entity, or any two or more
of the'foreping engaged in ajoint enterprise, and includir-ig the legal reprLtentatives of a dd=ased employer, or the
r=iver artrustee-of an individual, partnership, associatioin or other legal entity, employing employees. *Howeverthe
ownm of a dwelling house having not more than th= apaxtments and who resides therein, or th ' e occupant of the
dwelling house of another who employs persons to do mai-ntenance, construction or repwr work on such dwelling house
or on the grounds or building appurtunant thereto shall not b=use of such employment be deemed to be an employer."
MOL chapter I s2, §25C(6) also states dW "every i state or- local fic6using agency sball withhold the issuance or
renewal of a license or permit to operate a business or.ito construct buildings in the commonwealth for any
applicant I who W n . ot produced acceptable evidence of' compliance with the insurance I coverage requim(L".
Additionally, MGL chapter 152, §25C(7) states "Neither t3he commonwealth nor any of its political subdivisions shall
enter into any contract for the pmforrmance of public woriL until acceptable evidence of complia6ce with the insurance
requirements of this chapter have been presented to the cointractirig authority."
Applicants
Please fill oat the workers' compensation. affidavit oomplen-tely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es). zind phone number(s) along with their certificate(s) of
inmrarice. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
memb= or partners, are not mquired; to carry workers' co-rnpensation insurmce. If -an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Departmernt of Industrial
Accidents for confmnafion of insurance coverage.. Also'be sure to sign and date the affidavit. 7be affidavit should
be returmed to the city. or town fluat the application forthe permit or license is being requested, notithe Department of
Industrial Accidents. Should you have any questions regarding the law or if you am required to obtain a workers!
coMpensation policy,
pleaser call the Department at the number. listed below, Self-insured companies should enter their
self-insurancie license number on tfiz'appropriate� line.
City or Town Officials
Please be sue that the affidavit is complete and printed legibly. The Department his provided a space at the bottom
of the affidavit for you to fill out in the, event the Office of' lnves�iptiorts has to contact you regarding the applicant
Please be sure to fill in the permit/license number which Aill be used as a mf�rence number. In addition, an applicant
that must submit multiple perrnit/lic== applications in any given year, need only submit one affidavit indicating -current
policy information (if necessary) and under"Job Sit- Address" the applimt should write "all locations in city or
town)." A Copy oft . he 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 fin:= permits or licerises. A new affidavit must be filled out each
year. When a home owner or citizen i� obtaining a lic=.e or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said pars6ri is NOTrequired to complete this affidavit.
Tbe Office of Investi0ions would like to thank you in advance for your coopbration and should you have any questions,
please; do not hesitate to give us a call.
ne Department's address, telephone and fax number
The CornmonweaLlth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Roston, MA 02111
TeL # 617-727-4900 6xt 406 or 1-9-77-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/&a
1�
Date ...... 3.7.1.9-0..?.
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............... b. —M).q � � zy�,� . ........
has permission to perform �-4:n.o ....... . .......
.......... ...
wiring in the building of .............. :;�4. ...... . ................................
at .. .... M!�&5 ..... /4`—/-)l=-7 .................. In., North Andover, Mass.
FedYQ-:70�0. Lic.No.�93:�4 .............
Check # kiinkALbiiPE R
8646
or Plassacnuserrs
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Perinit No�
Occupancy and I-ee Checked
I Rcv� 9/05 1'
(Ica,, c
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL
\11 kwrk io he pci-1'0rjl)ckI ill accordance N%itll 111c klaNsachus'lls Ficcil-ical 0xic (NIF.C), 527 (.'Njj� 12.00
WORK
1.U`PR/�VT/A,'/AfK OR TYPEALL LWORALI /10A) Date: 3 - If - C., IQ
City orl'own of: To the In.vpeclor of [Vire.v:
BN Ill aPPlIcallon the undersi ned gives notice ()['his or tier intention to lierforn, (lie electrical ":'ork described belim.
Location (Street & Number)
Owner ou Tenant If
Owner's Address
Tv _;1C —
Is this permit in conjunction with a building permit?
5 e -
Telephone No.
Yes F4---N-on (Check Annro riate 11-1
Purpose of Building v
Utilitv Authorization No.,6 3—lep 3 2
F % isting Net-% ice
Amps 12 C1. 6 volls Overhead Undgrd No. of
Meters
New Service 1/0 Atups
_Z.ze,, / ?_t/& Volts Overhead In Undgrd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work-
'-- 5 -e , c�'
4
Ctullph-lioll ill fill, I'di-, I'll, I'd1j" . .. .....
No. ofRece%sed Luminaires
No. of Ccil.-Susp. (paddle) Fans
0. 0 'rot a-1
Transformers KVA
No. ofLuniinaire Outlets 2—
No. of "ot Tubs
Generators KVA
No. of T7-m—ergenev Ill—gFf —1"—g
No. ofLuminaires
AM e [I In-
Swimming Pool )v
grud. Lprnd.
BatterN Units
No. of Receptacle outlets Ll
No. of Oil Burners
FIRE ALA
Zones
No. of Switches
No. of Cas Burners
No. of Detection and
Initiatine Devices
No. of Ranoes
Total
No. of Air Cond. Tons
No. of Alerting DCViCeS
No. of Waste 0isposers
540. M ',Self-C.ontained
-Detection/Alerfing De% ices
No. of Dish%ashcrs
Space/Area Heating KW
Local[] Municip�l El Other
Connection
Nit. of Dryers
Heating Appliances KW
Securih SNstems:,
No.
" " "
No.'o f bevices or Equi,.alent
of ater
licatcrs KW
N--o—.oT— i 1
! ''I I I of
__
Data Wiring:
signs Ballasts
No. of Devices or Eqjjj�ralent
No. 11.,,dronjassage tiatiltubs No. of Motors Total tip TeTe—com in u nicat ions Wiring:
No. of De� ices or Equiva letit
OTIFIER:
r ax r"(11mcd /"1 1/1" hlspt J,w it 11
linalAi VAUC 0I* FICCIrlCill Work: (When required hv tillinicipal policN.)
Work to st�lrr_ 3 Inspections to be requested in accordance \kiih NIFC Rule'lo. and tipon conipIcI1011.
INSCRANCE COVERACE: Unless vvaived by the omier, no permit 601- tile Perf-orniance ot'clectrical �vtwk maN i!,',1LIC UllIc,-)-,
thc lit-:01scc Pr,idcs proof'ol'I lability insurance includill.,; "completed operation" coverage or its stibstjintial eqLli%aICnt, I'lle
kxf-lifies that such in Iorcc� and has e,\hibiled prool'of'saiiie to th-e Pennit kstlin._, office.
C
('I IfJ. K ()Nf.� INS(:RANC11 El 0 H 11: ' R E_j (Spccii-\:j)
I cerlift. under the pains and peitaltie�v ofperjtjq, thut the infi)rtnathw 011 1hiv application A trite and complefe.
F 114 M N A jv1 E: h7 /iF L I C N 0.: 919 �33
'ig"aitu
r Signaturc I. IC. N; 0.
41,11'rilt(o cil V 'Cwolpf ill flit, lit vtl %:(, P —MWhhI) P 3S
Address: Z
"y'Vit. Tel. No.:
Confractor License required for this %%ork: iif� pit - hle� enter tile license number here:
j.�xihje. enter the jcen, e
OWNER'S INSURAN( E WAIVER. I arn aware that the 1,1cciisce (lot.,\ )W/ I](lI*/, file liabilit\, insurance Co\rel�,_e
Junattire below. I herch" \%a've this requirement. I ani tile (check one) Ej 0WICI El WIN licl*"s �tl_lellt,
OwnerJAgent W
Signattire Pr_RN11T FF.E: S_
2- -ar �a--e
0
Date ........ I..
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
SACHUS
This certifies that ...
............ ...........
has permission to performIZ—VI. . ..............
I
plumbing in the buildings of ........... .........
at
................
..... z ........... North Andover, Mass.
a -
Fee ......... L i c. N o. //R- / . . �.
.................
PLUM W(G INSPECTOR
Check #
7699
0
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETIS
Building
Xcers Name
16>w
Date.
Permit;
of Occuppey
Amount
New Renovation Replacement ' Ea Plans Submitted Yes No
7`1
FIXTITUFN
(Print or type) Check one: Certificate
Installing Company N5e bj ly)'000 P/
Corp.
Address 01 RD0b-7/1-A I Kb L -j
Partner.
Business felephone 7— 5 Z3 Firm/Co.
Name of Licensed Plumber:
Insurance Coverage
� Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ri Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this applicatio'n does not have any one of the above
three insurance
Signature I Owner 1:1 Agent F1
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and irvea Ilons perfo er e i sued for this application will be in
compliance with all pertinent provisions of the Massatse��Stat�e PI*m ing Code and Cha ter 1,42 of the General Laws.
y:
Title �
City/Town
APPROVED (OFFICE USE ONLY
License
Master(90
Journeyman ID
Date. . ��_ A i- 69 P .....
r
41
V,ORTH
0 01 TOWN OF NORTHI ANDOVER
PERMIT FOR OASJNSTALLATION
This certifies that—',
has permission for gas instAllation_,_IAIIZ_I/ _11�711
4____ ...... ................
in the buildings of .....
at
........................ ... NorthAndover, Mass.
Lic. No..��..
...........
Check#,3,/c:2,s
6398
MASSACHUSEM UNHORMAPPUCATONPORPERNUTO DO GAS ffrnNG
(Type or print) Date 4")
NORTH ANDOVER, MASSACHUSETTS
Building Locations 9A --AW;
Permit
Amount $ -i!�p �S7
Owner's Name
New Renovation Replacement Plans Submitted
SU B-BASEM ENT
BASEM ENT
IST.
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F L 0 0 R
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SU B-BASEM ENT
BASEM ENT
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F L 0 0 R
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(Print or type)
Name_
Address
Name of Licensed Plumber'or Gas Fitter
Check one: Certificate Installing Company
Corp.
ElPartner.
-7 P Firm/Co.
— 176,Y,4,& -
INSURANCE COVERAGE Check o e:
I have a current liability Insurance, policy or it's substantial equivalent. Y : , 0 N o
If you have checked ves, please indicate the type coverage by checking the appropriate o 0, 1:1
Liability insurance policy (P Other type of indemnity 1:1 Bond 1:1
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 Agent 0
that all of the details and information I have su mitted (or entered) in above application are true and accurate to the
I hereby certi 1:1
best of my knowledge and that all plumbing work and installations erformed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachus�e�iateas Code and Chapte�,��eneral Laws.
By:
Title
City/Town,,
APPRO ED (OFFICE USE ONLY)
--j
.*rgnature of I
Plumber
Gas Fitter
Master
Journeyman
sed Plumber Or Gas Fittff
License Number
Location
No. Date
40WTh TOWN OF NORTH ANDOVER
0 -
Certificate of Occupancy $
-g Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee s -,�30
Sewer Connection Fee $
Water Connection Fee $
TOTAL
Building 11�� or
09/02/% 1 :01 P9-00 PAID
12769 Div. Public W-o-rks
Location
0
No.,*
PA -
Date
TOWN OF NORTH ANDOVER
0
Certificate of Occupancy $
Building/Frame Permit Fee $
ArSD &
CHU
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL $
Building Inspector
Div. Public Wo rks
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