HomeMy WebLinkAboutMiscellaneous - 30 ANNIS STREET 4/30/2018CP
C)
E
C)
C)
p
0
7
Date..7/-C/*"*�***%—
............
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that .... � — .. ...... Q.( ... CAA..e ... 4 . .. .. .. ........
.... .... . . .. . .... . ........... .. .... A . . ..
has permission to perform ...... () .. C, 4 ...... IV .. 0 . 0 ... S ...... Ar- . I . L_ .
... . ... ..... ... .... ..... ....... . .....
plumbing in fixe buildings of VIA
............... .. ...........................................
North Andover, Mass.
r'j NA ..........
.... ..... ...........................................................
Fee��O .. . ..... Lic. No. !1(,0J.Pj ... ................................................ ................................
PLUMBING INSPECTOR
Check #
= I
AN-
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY
0 t"z1VQz_
MA DATE M L3 0, Z0.1- PERMIT#.
JOBSITE ADDRESS
INSURANCE COVERAGE:
0 WNER'S NAME
POWNER
ADDRESS
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance cove rage required by Chapter 142 of the
TEL __JIFAX
TYPE OR
OCCUPANCY TYPE
COMMERCIAL
EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY
NEW: 01 RENOVATION: REPLACEMENT: Ep PLANS SUBMITTED: YES Ell NOE&
FIXTURES'l FLOOR-
BSM
1
2
3
4 5 6 7
8 9
10
11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/01LISAND SYSTEM
I
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
OF—D
_j
DEDICATED WATER RECYCLE SYSTEM
I
DISHWASHER
=7_n __j
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREADRAIN
I _j
INTERCEPTOR (INTERIOR�
------ ------
KITCHEN SINK
LAVATORY
ROOF DRAIN
------ -ji
SHOWER STALL
SERVICE / MOP SINK
TOILET
I F
URINAL
�ALASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
"�LE�RIPING J
OiHER 'A
3'_
F__J A_____J __J
__I __j
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGIL Ch. 142. YES NO Ml
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND IjJ
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance cove rage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER M-1 AGENT If --]I
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledg
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent rovisionofthe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME [K—LICENSE # SIGNATURE
MP Ot JP CORPORATION FIJ# PARTNERSHIPD-I# LLC D�
COMPANY NAME 111'ADDRESS
CITY STATEF_Ki;�_11 zip TEL
FAX C ELL EMAIL =_ jt'
V'NIAIN
r R311
NOW
F -I
LLI 0
CL z
LLI
ux):
LLI
LU CL
LU
&0
z
0
L)
I
CL
IL
LU
LLILI
NOW
Name
The Commonwealth ofHassachusetts
Department ofindustrialAceldents
I Congress Street, Stilte 100
Boston, MA 02114-2017
www.mass.gov1dia
q
Vit: BuRders/Contriactors/FIectricians/pI wbers.
Workers', Compensation Insurance Affida
TTT-ffvPERMTT1NGAUTj10R1TY
Please Print Le.Eib--IY
Ap� v
al): Mm.� As_
(Busin,,ss/Oigauizationlfndivil,,
Address: q IT-
city/State/Zip:.. \\A _83Q> Phone
0 e tije app�oprlate box: Type otproject ()Vequired)'.
Are you an e . r? . eck
. loyees (ftill and/or part-time)."*' 7. El NdVd6nstr�dtiOn
I.E] I am a employer with -------PmP ees working for Me in 8. El kemodelihk
2gl am a sole proprietor or partnership and have no employ
any capacity. (No workers'comp. insurance required-] 9. Demolition
3. 1 am a homeowner doing all work mYselt [No workers, comp. insurance required.] 10E] Building addition
4.Fj I am a homeowner and will be Wring contractors to conduct all work on my property. I will II.E] Electrical r airs or additigAs
ensure that all contractors either have workers' compensation insurance or are sole I . I . I . pp .
12 %krumbing repairs or additions
proprietors with no employees.
s. Fj I am a general contr4etpr and I have hired the sub-colitrartors listed on the attached sheet Ro6f re&ir6
comp. insurance.t
These sub-contract�is hav6 e#loyees and have workers' 14.tj Other
6. n We are a corporatipri and its * officers.have exercised their right of 'exemption per MGL c.
152-, § 1(4), and We hav-6 ulance required.]
pldy6es. [No -workers' comp. ins
Ust 0 -workers' compensation policy information. Fa indicating such.
*Any applicant that chq�,ks bbk,91 pS -�ls' fill out the section below showing their
f . , , , . _ - icating they are doing all work �nd then hire outside contractors must submit anew af davit
i jjojneo)�ruers -who submit,this.affidavit ind sheet showing the name of the sub -contractors and statq whether cr pot thosqpntities, have
lContractors that check ihis b6z , must attached �n additional - their workers' comp. poli y b r
c num e
employees. If the sub-cont'ractors have, employees, they must Provide
lam an employer that isproviding-workers'eompensation insurancefor my emp1byees. Below is thepolicy and)ob sit�
information.
Insurance Company
Policy # or Self -ins- Lie.
ExpirationDate,
fob Site Address, City/State/Zip' iration date).
Attach a copy of the workers' compensation Policy declaration page (showing the policy number and exp
Failure to secure coverag a as required under MGL c. 152, §25A is a criminal violation punishable by a ffib up to $1,500-00
enalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a
and/or one-year imprisonment, as well as civil P ay be forwarded to the Office of Investigations Of the DIA for insurance
day against the violator. A copy of this statement m
coverage verification.
n provided above is true and correct
I do hereby certrfyad r thepains andpenalties qpur id e informatio
6L rm;����D�ate: L n 16 -
in this area, to be completed ly citY or town official.
official use only. Do not write
City or Town:
Permit/License #
Issuing Authority (circle one): i
1. Board of Health 2. B-ailding)Department 3. City/Town Clerk 4. Faectrical Inspector 5. Plumbing Inspector
6. Other
Phone#:
Contact Person:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their ''I"
. emp; oyees.
Pursuant to this statute, an employee is defmcd as "...every person in the service of another under any contract of il�e,
express or implied, oral or written."
An employer is'deffibd as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint enf6rprise, and including the legal representatives of a deceased employer, or the
receiv6for trustdd o1fan 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 ofthe
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 b6 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 op6rate a business or to construct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence of compliance -with the insurance covera I ge ieq'yijred."
Additionally, MGL chapter 152, §25C(l) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acce p*table evidence of compliance -with the insurance
requirements of thi I s chapter have been presented to the contracting authority."
Applicants
Pleasb K11 out the workers, compensation affidavit completely, by checking the boxes that apply to your situation and, if
nec6sary, supply sub 'contractor(s) name(s), address(es) and phone number(s) along with their certificate('s) of
insurance. Limited-Liab ' ility Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers, compensation insurance. lfanLLCorLLPd6eshavC
employees, a policy is required. -1�e advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmationof 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 requ�sted, not the Department of
Industrial-Accidenis. �hould you have an y* questions regarding the law or if you are reqi*ed . to obtain a workers'
comPensatiori policy, please call the Department at the number listed below. Self-insured companies shoWd enter their
self-insura*nc'e 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 0 out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
thai must submit multiple ponnit/license applications in any given year, need only submit one affidavit indicating current
Policy information (if necessary) and under "fob Site Address" the applicant should write f'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 provid e -d t ---o the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled 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 Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, M -A 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
i
COMMO-N- W-E-ALtH OF MASSACHUSETTS
Location
-�J
J0- ?-03
No.
Date
TOWN OF NORTH ANDOVER
of
0
Certificate Occupancy $
j,
of
S must
Building/Frame Permit Fee $ zo
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ C3
Check #
WA
67,07
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENO TE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUELDING PERM[IT NUMBER: DATE ISSUED: 03
SIGNATURE:
Building Commiss�tor of Buildings Date
SECTION 1- SITE INFORMATION I
1.1 PropertyA ess:
1.2 Assessors Map and Parcel
Map Nurn
Number:
Parcel Number
licensed
1.3 Zoning Information:
Zoning Distr ict Proposed Use
1.4 Property Dimensions:
Lot Area (sf)
Frontage (ft)
1.6 BUILDING SETBACKS (ft)
Lic�nsed Construction Supervisor:
Front Yard
Side Yard
k d,
Rear Yard
Required Provide
Required Provided
Required
Provided
? -2 ?
. Cf� - -7610 -3
Telephone
1.7 Water Supply M.G.L.C.40. 54)
Public 0 Private 0
1.5. Flood Zone Information:
Zone Outside Flood Zone 0
1.8
municipal
Sewerage Disposal System:
0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHILPIAUTHORIIZED AGENT Historic Dlstdct Yes _No
2 0 ner of Record
/44, 3
Name (Print) Address for Service
OL/ 2�9
2.2 Owner of Record:
Name Print Address for Service:
10
ACTION 3 - CONSTRUCTION SERVICES
Construction Supervisor:
licensed
Lic�nsed Construction Supervisor:
5� (� /� o 6-� �
k d,
Address
a j
? -2 ?
. Cf� - -7610 -3
Telephone
Home Improvement
Company Name
'I S? All
/900A in
T
/t,11q
9 -7 ? , C ?�' - —/ �o 3
Not Applicable 0
G 3,3 C —7
License Number
() I/ ((� A
Expiration DatW
Not Applicable 0
I 9!�(Q
Registration Num r
Expiration Date
M
M
X
z
0
0
z
M
90
0
Mn
M
G)
I SECTION 4 - WORKERS COMPENSATION (NLG.L C 152 § 25c(6) 1
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (check applicable)
New Construction 0
Existing Building 11
Repair(s) 11
Alterations(s) 0
Addition 0
Accessory Bldg. 0
Demolition 0
Other 0 Specify
Brief Description of Proposed Work:
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
OFFICIALUSEONLY,"
Completed y permit applicant
1. Building
00
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
Plumbing
Building Permit fee (a) x (b)
.3
4 Mechanical (HVAC)
5 Fire Protection
6 Total -(1+2+3.+4,+5)
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1
1, / I as Owner CAuthonzed A3gent of subject property
'&<- - (2 I)AI
Hereby authorize to act on
My behalf, in all tt lative to work authorized by this building permit application.
.7,11('
/5 3
Signature of 2*1- Date
SECTION 7br OWNER/A&HORIZED AGENT DECLARATION -T
Z /L//'02Z
, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
4111
Print Nam
M, ) lo
- C/
Si aturre o Own ed Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS I ST 2ND 3RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HE IGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHRvfNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
FNa�me Please Print
11
Location: 0 ki r, T-
C . itV /0 d, A 1, jo Lt ^I Phone # T7 k
I am a homeowner pefforming all work myself
I am a sole proprietor and have no one working in any capacity
F-1 I am an -employer providing workers' compensation for my employees working on this job.
Compauy name:
Address
city: Phone*,
Insurance. Co. Policv
Company name:
Address
Phone*
Failure to secure coverage as required under Section 25A or MGL 152 can lead tothe irnposition ofaiminall penalties of.afte UP to $1"!
and/or one years' iffpdsonnwnt-m-weH-w-ciWuenaMes-in ofa-ST11P YAORKDRDERArAa ftw_it_MWM)_a jJW,-mjainstjM
understand that a copy of this statement may be forwarded to the Office of investigations of the DiA for coverage verdimmon.
do hereby cerbry undar the jowns and penaftms ofjoetimy that the Munnaflon provided above is Inie and caffect
Signature Dat
Print name Pbone_#
CXNcW use only do not write in this area to be completed by city or town officiar
City or Town Lamul/licensi Lr)g
BUMM79 Del
DCheck I Immediate response is requked Lkensirig, Bc
Selechmn's
Contact Phone #. Heaffh Depaj
o Other
U
C*O*l
6
z
as
I"
om
co
=0 L3
C2
C2
CJ CJ
CL.
w
CD
CE
CD
0
'A
CCIL
E s
00
t; A�
0
E
Go
c' 2
P
ca
e
0 cm
'Col AID Cf
Q
cm
CL
Coll
C9
e : L -
4D CCDL.:
CO CD :5
MD li m
CO) CL=
c=a cm
C.3 CD 0
CL 42 0:5
ca .0 ca=
0
cc 42 L-
= *- CL:*E- 19
C/)
0
C/)
C/)
z
0;
p
u
C/)
z
0
u
C/)
C/)
u
0
I
Tzi
E
G3
CL
C) CO)
CD
cc Cc
0 CD
Q IS
w
Cc C3
a -
C*
.0-0 C cc
Li
cl CD
ca
cc
'a
co
is
w
w
U)
cr
w
w
cr
w
w
U)
0
�2
U)
CL
u
cn
0
cc
1.2
P2
rg
lew
0,
PQ
C2
C2
J)
—ca
to
g2
—cz
ZW
C6
z
(n
o
U)
I"
om
co
=0 L3
C2
C2
CJ CJ
CL.
w
CD
CE
CD
0
'A
CCIL
E s
00
t; A�
0
E
Go
c' 2
P
ca
e
0 cm
'Col AID Cf
Q
cm
CL
Coll
C9
e : L -
4D CCDL.:
CO CD :5
MD li m
CO) CL=
c=a cm
C.3 CD 0
CL 42 0:5
ca .0 ca=
0
cc 42 L-
= *- CL:*E- 19
C/)
0
C/)
C/)
z
0;
p
u
C/)
z
0
u
C/)
C/)
u
0
I
Tzi
E
G3
CL
C) CO)
CD
cc Cc
0 CD
Q IS
w
Cc C3
a -
C*
.0-0 C cc
Li
cl CD
ca
cc
'a
co
is
w
w
U)
cr
w
w
cr
w
w
U)