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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 ` o IOUs hS Address Z('j &k kG .�� �� H VC Estimate Value of Work: �nnnoonnnwnnnno �moonnnnaunnnnw �onnnnnnaonnnou �onnmm�n�un000u �nnnnnmm�nnnnm �nnnnnnnaoo�nnn� Installing Company Name ` o IOUs hS Address Z('j &k kG .�� �� H VC Estimate Value of Work: Business Telephone /-roe, Name of Licensed Plumber or Gas Fitter _3 3 r Go'c F Oy 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 Rovisrvl 5127,�2 1 T r c A m r O A D d 0 z O m 0 c F 0 z O z a m 9 m O m m c F v_ z O z 0 m m u. z D r z N T m A O z N IN m 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 d 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 p Certificate of Occupancy $ 41, Building/Frame Permit Fee $ sACHUSEt� Foundation Permit Fee $ _ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ '� a TOTAL $ S a Building Inspector ;OJJi Div. Public Works Ism 70 LP � �. C f V°z _ _ - .. fi p a v y z y LA n („ y 'V 7 N 0 "" - = c m o n ❑ z rn z M z z O � rn O a rn w r n n O a o O' O Z n •n O O O z z z z rA n z n o O cn_ ^ j b O n n n Z N in r=r e7 z m n ��;�, n n ren M o in n o o o O O N tQ ^ ^ Ln z %4Ch- G, o C3 C. � ct 1.0 N (b (n v^3 1 _ 7_ N O r� w o b a n n Ism C/) 33 C a) Cl) 0 m 'DC7. r.� CD CD a� �CD N CD o• CA o -- m C! mc�a� m � H O r, clH CL 0 CD CDC o y CO) N ?m C 2 0-40 m 00 --iocl) C R = CA CL =ro "* " //^^CD VJ m H C 0 CD nm •: r� w o :a O `Y Z a �' _. 0 W :� W a �� a y m : ;O oCD 3 N (� m CD rF � CD 0 O z CD ..: CD ED �j• �;CDo Lr: = W O: n� O �I A' 0 c o�n n lot III X 9L b7 C/)a o y n o g z d Z O z v� O a 7� A' 0 c 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 C ff r I , t JA, J.4,�IE3 /4 %A YL O2 ET UX 6'ar- , Old Wi�c ince % 1,P.f 2ZT.$3". r 231. 13 23lot }� ----- - 10 • . }{Dasa � � to 3v 24x 3o d5 Q - �l�Xa`��/¢5 . rRrrnpr,S Pcr+ck 2Zl.aa� x.2ZS,t3 U11 k2�•33 i .� ,:, is .�,. f � � �•P. 'Li1A %V D / N ®r l-.-i-,VOIC - �A' 12TWUR--lL*j.� ?E1 MON 5CA L E _ / 20 . No V /61 ,2Ac.PH r3. BRA SSEviZ� C, E. f1AyrR14Iz,i Mg ss. 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 W N N ¢ W N N N Y U 2 ¢y WW C O U p h S A J N W r- 0 O W< c¢ 0 0= ku f. < ¢ W Z U W N < C O O > W W {y N .j t- < S C IC ¢ W 0 ¢ W F W f U = J H h } N m 2 0 W O (AA Z ¢ Z O t7 Z a 3 o v j 0 C> G a 1,- O SUB-BSMT. BASEMENT kid 1STFLOOR 2NDFLOOR I 3ROFLOOR I 4TH FLOOR STNFLOOR 6TH FLOOR 7TH FLOOR I 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 W n r Iv z 0 r F ^ W LL a N N J 2 O Z N O N O W � W N n O O O f, C F 6 n r Iv F LL N J O Z O O � W N O O f, F 16 O 0 z a O O 6 W 3 2 c � J �.. W < O V J 6 6 Q W W 6 n r Iv A • 'T1 2122 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