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HomeMy WebLinkAboutMiscellaneous - 295 MASSACHUSETTS AVENUE 4/30/2018Cf) Ell N3 m 6 -4 0 cn 6 m I Date. FAA, - - - 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 ME ;To 4 z M I =*� 0 ON, MMMWMMMMMMM M MMMI WRIFFIF MM M FA M MM NMI W)ekya I MIMIIIIIIIMMMMMM MMMM MMMMMMMMMMM MMMMMMM MM IN MN11MMMMMM M NMI ON M M MMMM M1MM1MMMMMNWMMMMMMMMMMMMMM1 (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. F L 0 0 R 2 N D . F L 0 0 R 3 R D . 4 f H . i T H F L 0 0 R -FL 0 0 R F L 0 0 R 6 T H F L 0 0 R 7 T H 8 T H F L 0 0 R F L 0 0 R Z Z W U t > Z > 2 z U SU B-BASEM ENT BASEM ENT IST. F L 0 0 R 2 N D . F L 0 0 R 3 R D . 4 f H . i T H F L 0 0 R -FL 0 0 R F L 0 0 R 6 T H F L 0 0 R 7 T H 8 T H F L 0 0 R F L 0 0 R (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 1 1>6 I ; z I �' > :.j z rn Ln ry" 4t :IL m 'A- 6,j z m z m > > > > > r, rr r- Lh > z n > 74 C) L) m 'A- z m z m > > > > > r, rr r- Lh > z n z -, t.j ;o rn v� v� Z > r) rn z m > z Z LA i "n x x m LI) ffi V, z m T 4 p 74 C) L) > 'A- z m z m > > > > r, rr z n z -, z F, M4 ;o rn v� v� Z > r) rn z m > z Z LA i "n x x m LI) ffi V, p > > > > z n z -, z F, M4 ;o rn v� v� r) rn z m > z Z LA i "n x x m LI) ffi V, z m T 4 m m LI) m m z z > m rr, > ==M > ;.=;Zzz z C) 14 Ln rr, Z- LA rz-, m Z m > 7, m x Pm rr, M x T DEPARTMENT OF PUBLIC SAF ETY CONSTRUCIJON S.UPERVISbfjIcENS' E, 1 7-� Ex 'Pi r f =izi -�; , j. . thdate,- _j '298 #21 e5fil,7260 05/21/1945 t Res.. - 00 -4 j I S H PO 8004,819 MOULTON OR ------- E HAMPSTEAD, NH 03826 "N HOME �.MpROVEM ENT co Regii�ration NTRACTOR 102097 TYpe INDIVIDUAL Expiration -.06/3 - 0/00 JOSEPH p. 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