HomeMy WebLinkAboutMiscellaneous - 3 WILSON ROAD 4/30/2018&M
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type) Q
/�k0101i tJ` , Mass. Date V_q 19� Permit#—
Building Location l ISQ"� C/� - Owner's Name C kA 11,4M'/
Map: Lot: Zone: Type of Occupancy
New ❑ Renovation ❑ Replacement Plans Submitted: Yes ❑ No ❑
FIXTURES
Installing Company Name
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Address Z('j &k
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Estimate Value of Work:
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Installing Company Name
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Estimate Value of Work:
Business Telephone /-roe,
Name of Licensed Plumber or Gas Fitter
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Check one:
❑ Corporation
❑ Partnership
❑ Firm / Co.
Certificate
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes V_ No L1If you have the ked �, please indicate the type coverage by checking the appropriate box.
A liability insurance policy V Other type of indemnity ❑
Bond ❑
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:
Owner ❑ Agent ❑
of Owner or Owner's Agent
I hereby -certify that all of the details and information I have submitted(or ente d) in above applic tion are true and accurate to the best of
my knowledge and that all plumbing work and installations pertormed under a permit i f is application will be in compliance with
all pertinent provisions of the Massachusetts State Plumbing Co d pter 14 the neral Laws.
By
Signatur o 'tensed P tuber
Title AFn
Type of License: Master ❑ Journeyman lk
City / Town
APPROVED OFFICE USE ONLY License Number
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Date. V...`!'. 5rK'
23To
o`.Nc°T:'�c TOWN OF NORTH ANDOVER 2
PERMIT FOR PLUMBING
8
'SSACHUS�
This certifies that ..4 . �''.. �/vs? S .... Po'. f� .. _ .... .
has permission to perform .. .V. T ......................... c
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plumbing in the buildings of .r��..C� �. ti............
at . .. (..t.. ?J ........... h Andover, Mass.
�'f� �� ......Fee a 0..... Lic. No...�
LUMBING INSPE TOR
WHITE: Applicant CANARY: Buildinq Dept. PINK: Treasurer GOLD: File
Location
No. -3 � % Date �F�-j/ `1 S
NORTH
A
TOWN OF NORTH ANDOVER
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Certificate of Occupancy $
41,
Building/Frame Permit Fee $
sACHUSEt�
Foundation Permit Fee $ _
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $ '�
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TOTAL $ S a
Building Inspector
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Div. Public Works
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FORM U - LOT RELEASE FORM - - -- - - - - - - =
INSTF�UCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having.jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION****************
APPLICANT PHONE~
T � -
LOCATION: Assessor's Map Number C;2 C/ PARCELS_
SUBDIVISION LOT (S)
STREE- o A-Itf-P-t-VtSo" ST. NUMBER
**********************************OFFICIAL USE ONLY***************************
RECOMMENDATIONS OF TOWN AGENTS: - -
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS ��.5 ('1 I. 6n/ _
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
COMMENTS
PUBLIC WORKS - SEWERIWATER CONNECTIONS
. DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR
Revised 9197 jm
DATE
l
North'Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
The debris will be disposed of in:
wAoaD 57 l6 Vi ? I� �� ��►1- i~t t ftp l�Go3�8�8= 08'�
(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
4
he Commonwealth of Massachusetts
Department of Industrial Accidents .
Office of Investigations
-Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Na
City Phone #
❑ I am a homeowner performing all work myself.
aI am a sole proprietor and have no one working in any c paci y
aI am an employer providing workers' compensation for my employees working on this job.
Comoanv name:
Citv Phcne #:
Insurance Co. Policy #
Comoanv name:
Address
CN: Phone #:
Insurance Co. Policv #
Failure to secure coverace as required under Section 25A or MGL 152 can lead to the impcsifion cf cnminal penalties of a fine up to 51,500.00
and/or one years' imprisonment as we!I as cavil penalties in the form cf a STOP `NCRK ORDER and a rine cf (5100.00) a day against me. I
understand that a copy cf this staement may be forwarded to the Office of Investigations of the DIA fcr coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true anc =nec
Sianature
Print name
Date
Phone
Offic!al use only do not write in this area to be completed by city cr town cnida(
City or Town 4 PermitlUcensinc
❑C`eck if immediate response is required
Contact person:
Budding Dept
❑
Licensing Board
Selectman's Orrice
Health Department
17
Other
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
` JRV
7Mass. Date 19—q& Per it #
Building Location l/ sv�—�, Owner's Name
, 9.
Type of Occupancy
New Ay Renovation ❑ Replacements' Plans Submitted: Yes❑
Installing Company Name E p. s t e r n P r o o a. n e t=?. s T n c Check one: Certificate
Address 131 W2. t e r Street X Corporation
Danvers, T IA 01923 ❑ Partnership
Business Telephone (5 0 E) 774-1930 ❑ Firm/Co.
Name of licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
I have a currn lability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.'
Yes IN No ❑
If you have checked res, please Indicate the type coverage by checking the appropriate box.
A liability insurance policy A Other type of indemnity 0 Bond ❑
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:
Owner❑ Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) i above applica ion are true nd accurate to the best of my
knowledge and that all plumbing work and installations performed under the per ed for i ppli tion II be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of th al s
By T e of License:
Plumber gnature o Licensed lur r r Gas Fitter
Title asfitter
Master License Number
City/Town Journeyman
APPROVED (OFFICE USE ONLY
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BASEMENT
kid
1STFLOOR
2NDFLOOR
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3ROFLOOR
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4TH FLOOR
STNFLOOR
6TH FLOOR
7TH FLOOR
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STN FLOOR
Installing Company Name E p. s t e r n P r o o a. n e t=?. s T n c Check one: Certificate
Address 131 W2. t e r Street X Corporation
Danvers, T IA 01923 ❑ Partnership
Business Telephone (5 0 E) 774-1930 ❑ Firm/Co.
Name of licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
I have a currn lability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.'
Yes IN No ❑
If you have checked res, please Indicate the type coverage by checking the appropriate box.
A liability insurance policy A Other type of indemnity 0 Bond ❑
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:
Owner❑ Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) i above applica ion are true nd accurate to the best of my
knowledge and that all plumbing work and installations performed under the per ed for i ppli tion II be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of th al s
By T e of License:
Plumber gnature o Licensed lur r r Gas Fitter
Title asfitter
Master License Number
City/Town Journeyman
APPROVED (OFFICE USE ONLY
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Date..!? /.`�.......
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATIONS
2
This certifies that &'Q2244—..l�
has permission for g ins++talla,, do
in the buildings of . :. � �,/. i5dla , xf , , , , , , , , , , , ,
at .. �((�!YJ. ,{� , .. , North Andover, Mass.
Fee.. Lic. No. ..........................
�/� � �� GAS INSPECTOR
WHITE: App cantt :• CCAANJAR Building Dept. PINK: Treasurer GOLD: File