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Home My WebLink AboutMiscellaneous - 3 BELMONT STREET 4/30/2018IQ 12 03 cl) m m Date... TOWN OF NORTH ANDOVER PERMIT FOR.GAS INSTALLATION A� This certifies that ........ ................................ .......................................................... I . ............. has permission for gas XjnItallation ....... .................................... in the buildings of ................... R.C4 . .......................................................................... at ....... a ......... 6e—� North Andover, Mass. Fee ...... Lic. No. ........ GASINSPECTOR Check# 90.14 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 INSURANCE COVERAGE I have a current liability nsurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YESONO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE Box BELOW LIABILITY INSURANCE POLICY Pff" OTHER TYPE INDEMNITY [] 13OND 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 requirem_ent.-----,, SIGNATURE OF OWNER OR AGENT CH7CK ONE ONLY: I hereby certify that all of the details and information I have submitted or entered regarding this applicatilk are true and acci and that all plumbing work and installations performed under the permit issued for this application Will be 11<ioie�7` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMEJ2_/ LICENSE #J& IVIP O'MGF 0 JP El JGF LPGI CORPORATION PARTNERSHIP [3# COMPANY NAM& ADDRESS CITY J-Ax� �Iq STATE ZIP TEL FAX�� CELLJ-Y?�&- /6r]JEMAIL �7 LLC E]# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK low CITY . ..... MA DATE Q R 11PE MIT# G JOBSITE ADDRESS 'iOWNER'SNAME ff OWNER ADDRESS TEI]__=FAXI TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENT150 CLEARLY NEW:Ej RENOVATION: El REPLACEMENT: PLANS SUBMITTED: YES D NO APPLIANCES -1 FLOORS, 13SM 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 r -i 1MK I A n� 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 INSURANCE COVERAGE I have a current liability nsurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YESONO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE Box BELOW LIABILITY INSURANCE POLICY Pff" OTHER TYPE INDEMNITY [] 13OND 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 requirem_ent.-----,, SIGNATURE OF OWNER OR AGENT CH7CK ONE ONLY: I hereby certify that all of the details and information I have submitted or entered regarding this applicatilk are true and acci and that all plumbing work and installations performed under the permit issued for this application Will be 11<ioie�7` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMEJ2_/ LICENSE #J& IVIP O'MGF 0 JP El JGF LPGI CORPORATION PARTNERSHIP [3# COMPANY NAM& ADDRESS CITY J-Ax� �Iq STATE ZIP TEL FAX�� CELLJ-Y?�&- /6r]JEMAIL �7 LLC E]# ml F-1 LLI M LLJ LL The Commonwealth ofMassachusetts Department ofIndustrialAccldi�ts Office of Investigations 600 Washington Street Boston, MA 02111 Uf www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ON M.— M, Address: City/State/Zil): Phone r 0"�an employer? Check he appropriate box: I anm a employer with _ IWr 4. 0 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2.0 1 am a sole proprietor or partner- listed on the attached sheet. I 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. F1 New con.struction 7. Remodeling 8. Demolition 9. FJ Building addition 10. El Electrical repairs or additions 11. E] Plumbing repairs or additions 12. E] Roof repairs 13.d Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they tLie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name ofthesub-contractors and their workers' comp. policy information. lam an employer that isproviding workers'compensation insuranceformy employees. Below is thepolicy andjob site information. n_ A Insurance Company N Policy # or Self -ins. Lic. 6— 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 requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1500 00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine of ulj�5 �$;;G��a ainst tbAolator. Be advised that a copy of this statement may be forwarded to the Office of ; of the I do Nm_by certify coverage th at the information provided aboV6 is true and correct. Official use only. Do not write in this area, to be completed by c4 or town offIcIaL City or Town: PermitUcense 0 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 defiried as "....every person in the service of another under any contract of hire, express or implied, oral or written." An employerlis 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 subdivi r. sions 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. Pleas ' e be sure to fill in the permittlicense 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 00 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 burn 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 oflovestigations 600 Washington StrQet Boston, MA 02111 Tel, # 617-727-4900 oxt 406 or 1-877,MASSAFE Revised 5-26-05 Fax # 617-727-7749 __WWW.mass,8oV/dia NWEALTH OF MASSACHUSETTS SHEET METAL WORKERS A& A-MASTER�UNRESTRICTE- ISSUES THE 'ABOVE LICENSE TO: - A GIARD Y - � �1, -',-T-; I M� 0 T. H tt - ! I,.. -, �l s, �:g 0 �SAUNDERS -ST LNORTH '�-ANDOVER--MA"tO 1845 -':*2414*; A7611, 07/28/12 �9.75499 nmrfr- ravra rA7nrwv.vv,.T.rd.Y.m W Date/,:,? -,'2,f 6)/ . ...... ... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING "'- �IIUI' � G� 4� This certifies that ........................................... has permission to perform ........... plumbing in the buildings of ........................... at .... North Andover, Mass. Fee /Q ...... Lic. No .......... y ��CT . 0 . R ........ Check # &.? =0 MAS:�ACHUSETTS UNIFORM APPLICATION FOR PERMIT (Print or Type) NORTH ANDOVER kuilding Location I - New '7 Renovation E3 Replacemen Mass. k-� F I XTURES rDO GASFITTING Date Permit # 1%52�"79 ers Name Plans Submitted 401/5- (Print or Type) Check one: Certificate ?I �'C. - i R-tq- ct>- T-V)r- [&'�'&rp. 2 iz2- Installing Company Name AnAc>�, Address Zo AeAeon �p.r-, L�- - j Partner. "j . in, I- 4tlo /Y -L-. Firm/Co. Business Telephone: (97f-�,) Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ff Other type of indemnity = Bond ED Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner 17 Agent El I hcscby certiry tl�at &U or th dc(ails and Wonnation I haire submitted (or cntcfcd) In above application wo true and accusate to the best of my knowtcdge and that aU plumbing Work and Lnitattations Vctfamlcd undcr,reftnit iuLcd fo: this application will-bc In compUance wjUx LLI pertlucut pecyWons or Lho MissachuscUs State Cas Code and CbAptcr 142 cC the Cencral LAw&. 2 By YPE LICENSE: P - rriber Title asfitter- Signa<ure of Licensed City/Town: e.M,4aster Plumber or Gasfitter 0 jq%3 Journeyman APPROVED (OFFICE USE ONLY) License Number us U! V, .0 0 Z Lis 0 0 Z us Cr. 02 oull 0 CL W uj ta 07 (A us a a. ii Q 41C 'U 07 Cr. a &X US W Z -A I- z Ld 1-- L" a ;X* W 0 ui -4 $- W LLI .4 a: -4 :0- 0 0 5 0 W > ul = C < 0 0 W 0 us Ir - 0 W .41 (j Q C6 0 13ASIEMERT I ST FLOOR 2NO FLOOR 3130 FL06R 4TH FLOOR STKFLOOR 6TKFLOOR 7TK FLOOR STHFLOOR (Print or Type) Check one: Certificate ?I �'C. - i R-tq- ct>- T-V)r- [&'�'&rp. 2 iz2- Installing Company Name AnAc>�, Address Zo AeAeon �p.r-, L�- - j Partner. "j . in, I- 4tlo /Y -L-. Firm/Co. Business Telephone: (97f-�,) Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ff Other type of indemnity = Bond ED Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner 17 Agent El I hcscby certiry tl�at &U or th dc(ails and Wonnation I haire submitted (or cntcfcd) In above application wo true and accusate to the best of my knowtcdge and that aU plumbing Work and Lnitattations Vctfamlcd undcr,reftnit iuLcd fo: this application will-bc In compUance wjUx LLI pertlucut pecyWons or Lho MissachuscUs State Cas Code and CbAptcr 142 cC the Cencral LAw&. 2 By YPE LICENSE: P - rriber Title asfitter- Signa<ure of Licensed City/Town: e.M,4aster Plumber or Gasfitter 0 jq%3 Journeyman APPROVED (OFFICE USE ONLY) License Number 3344 Date ...................... 0 n'40'RT#Nj TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATiON 7�- This certifies that ..... ( ................. has permission for gas installation .............. in the buildings of ............................ at 7.2. North Andover, Mass. Lic. No. G A Si I 1`� �C��"k* e� R WHITE: Applicant CANARY: Building Dept. PINK: Treasurer lzo I— MAS SAC K U S ETTS,-,U.V1F'ARm APPLI.C.-ATION FORVIP!;�# 1 �Q-�q4sf:ITTIHG (Print or Type NORTH ANDOVER Mass. Date '�u en) �uilding 'Locat1qq Pernift # 13 L/�/ 02 Own A er., �4: %T, New `1 'p 'FIXTURES as V us 0 UJ ca 0 G1 7TK FLOOR 8TH FLOOR (Print or Type) Check one:, Certificate Installing Company Name ANDOVER PLBG. & -HTG. CO-.:::jN CO ep-. 91 ?2 Address 20 XEGEAW.:�.DR. UNIT IQ -,.=,,Partner. METHUEN, MA. 01844 Firm/Co.-- Business Telephone: 978-685-8383 Name of Licensed Plumber or Gas Fitter- rFngr.F I AgoqF Insurance Coveraq Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy To Other type of indemnity.:�._,,�,9nd Insurance Waiver: 1. the undersigned, have been that the l.icensee. of this application does not have any one of the above 'three: Ansurance.. coverages. Signature of owner/agent of property Owner :01.-�'gent I hcscby ccrtify that aH *17the dcub and Ldonnation I have tubmitted (of C and accucatc to the beft,of enY knowicdge and that Q plumbin,% wait and Inscallatious vcsfbsmc�l 4adefrecadt UsLed roz thu W4M In go us"With au, Pet ;-ns oC tho fKassachuscUs State Cas code " Chaptes 142 of ths"PeactaJ LAws. By Title City/Town: APPROVED (OFFICE USE 014�y)' YPE LICEilsti. 'T Plumber Gasfitter- of. Licensed Master Gasf itter jJourneyman 9983" Liqense Number NEESE EWEN ME 7TK FLOOR 8TH FLOOR (Print or Type) Check one:, Certificate Installing Company Name ANDOVER PLBG. & -HTG. CO-.:::jN CO ep-. 91 ?2 Address 20 XEGEAW.:�.DR. UNIT IQ -,.=,,Partner. METHUEN, MA. 01844 Firm/Co.-- Business Telephone: 978-685-8383 Name of Licensed Plumber or Gas Fitter- rFngr.F I AgoqF Insurance Coveraq Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy To Other type of indemnity.:�._,,�,9nd Insurance Waiver: 1. the undersigned, have been that the l.icensee. of this application does not have any one of the above 'three: Ansurance.. coverages. Signature of owner/agent of property Owner :01.-�'gent I hcscby ccrtify that aH *17the dcub and Ldonnation I have tubmitted (of C and accucatc to the beft,of enY knowicdge and that Q plumbin,% wait and Inscallatious vcsfbsmc�l 4adefrecadt UsLed roz thu W4M In go us"With au, Pet ;-ns oC tho fKassachuscUs State Cas code " Chaptes 142 of ths"PeactaJ LAws. By Title City/Town: APPROVED (OFFICE USE 014�y)' YPE LICEilsti. 'T Plumber Gasfitter- of. Licensed Master Gasf itter jJourneyman 9983" Liqense Number Date. la I:Pf -0/ . . . . . . . . . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING. "Ir- �IIUSI � (21 #-, This certifies that ........................................... has permission to perform ... ............... ............. plumbing in the buildings of .... �2� .............................. at . . ........... North Andover, Mass. Fee 5��. Lic. No..,��ePJ. . Check # CT 0 R $080 IN e MASSACHUSETTS 61NIF'ORMAPPLICATION FOR PERMIT TO DO PLUMBING ftnt or Type) ALt.h- alo&,i I'D Mass. Date �Pz / �Sv fo dV Permit # *7ZIM Building Locatio �--.Ownei's Name La r rLA New C] B. P. r4 Renovation 0 SEWER# � Typ f Occupancy. Replacement Plans Subrn FIXTURES i SEPTIC# : Yes 0 No C3 Installing. Company Name Andover Plb4. & ljt�i, Tnc. C eck one: Certificate # elc-lorporation 2122 Methuen, MA 01844 El Partnership Business Telephone — (978) 685-8383 hrm/Co. Name of Licensed Plumber George It a R . 6 -,p INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes iF No C3 'f you have checked ves. please Indicate the type coverage by checking the appropriate box P k liability Insurance policy 12/ Other type of Indemnity 0 Bond 13 AVNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by :�hapter 142 of the Mass. General Laws, and' that my signature on this permit application waives this requirement. Check one: �onatum Mf r)umar A --4 owner 0 Agent E3 hereby cer* that all of the details and Information 1,,have submitted (or entered) in above application are true and accurate to the best of rrfy nowledge and that all plumbing work and installationsperformed un r the permft-issued for this application will be in compliance with all u P! de and aper M, ertinent provisions of the Massachusetts State Plumbing Code and apter 142 of th G erall y S1 �ture 0 s Juml gna e of n lum6er itle fty/Town Typ el ' of Ucense: Master Journeyman E) PPROVED—FOFFRIC-E E ON —LY) Ucense Number 9983 2E 0 (n > Cn UJ 0 W -cc i, - 0 2 W Z 0 i W Cr 9) = = U V, U) . " — .4 (n U. = Z E a :z :�: a) X: UJ to W W < 0 = = -< 0 < W z = M 0 4-) Lu IU 0 -j Nd IL 16- OC be -j U. U W > 0 w 0 o 0 LLI rz 0 4 0 0 Q 0 j Z run) U. a W CM 0 SUEL—SS MT. BASEMENT IST FLOOR f 2NO FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLO�OR 8TH FLOOR )o Installing. Company Name Andover Plb4. & ljt�i, Tnc. C eck one: Certificate # elc-lorporation 2122 Methuen, MA 01844 El Partnership Business Telephone — (978) 685-8383 hrm/Co. Name of Licensed Plumber George It a R . 6 -,p INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes iF No C3 'f you have checked ves. please Indicate the type coverage by checking the appropriate box P k liability Insurance policy 12/ Other type of Indemnity 0 Bond 13 AVNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by :�hapter 142 of the Mass. General Laws, and' that my signature on this permit application waives this requirement. Check one: �onatum Mf r)umar A --4 owner 0 Agent E3 hereby cer* that all of the details and Information 1,,have submitted (or entered) in above application are true and accurate to the best of rrfy nowledge and that all plumbing work and installationsperformed un r the permft-issued for this application will be in compliance with all u P! de and aper M, ertinent provisions of the Massachusetts State Plumbing Code and apter 142 of th G erall y S1 �ture 0 s Juml gna e of n lum6er itle fty/Town Typ el ' of Ucense: Master Journeyman E) PPROVED—FOFFRIC-E E ON —LY) Ucense Number 9983