HomeMy WebLinkAboutMiscellaneous - 30 GLENNCREST DRIVE 4/30/2018 (2)i"
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TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that
. . ............... ........ .... ............... "K ..............................
has permission for gas installation ........ . ........ . ..............
... . ... .........
in the buildings of ... D� ,�n6 ....... .................................................
at ........ . ,.SL) ......... rlf-' 3 'T
Fee2n.,..�.4) .... Lic. No.
Check# h(CI
0070
................... , North Andover, Mass.
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.....................................................................
GASINSPECTOR
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY MA DATE PERMIT #
JOBSITE ADDRESS �OWNER'S NAMEDWn J1
GOWNER
ADDRESS L --',5A- A4&- �TE FAX
TYPE OR
PRINT
OCCUPAN COMMERCIAL EDUCATIONAL RESIDENTIAL
=VATION:E3
CLEARLY
NEW: REPLACEMENT: El PLANSSUBMITTED: YESE] NOE]
APPLIANCES I FLOORS- BSM 1 1 2 3 4 5 6 7 8 -9 10 11 12 13 14
BOILER L::] L:j —i
BOOSTER L:::]
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
rr::
DRYER
I
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR A-1 AL—i
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
LINVENTED ROOM HEATER r
VOATER HEATER
-dT —HE
RF
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES JdNO Ej
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE E BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 B 0 N D
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 requirement.
IX
CHECK ONE ONLY: OWNER F I AGENT
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 accura o the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian It P inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUM BER-GASFITTER NAME LICENSE# "91GNA-TURE
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MP 0 MGF E -JI JP 0 JGF LPGI CORPORATION Dl# IPARTNE 0#= LLC [3#=
COMPANY NAME:Iyq- � 10-1 -J ADDRESS
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CITY STATE VEIZIP1 =TEL
FAX CELL
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The Commonwealth ofMassachusetts
I Department of lndustrlqlAccldii�ts
Office of Investigations
60 0 Wash ington Street
Boston, MA 02111
www.mass.gov1d1a
Workers' Compensation Insurance Affidavit: )3uilders/ContractorsfElectricians/Plumbers
Applicant Information Please Print Legib
NaMe, (Business/Organization/Individual)'-
city/state/zip: Phone. #:,
Are you an employer? Check the appropriate box: Type of project (required):
1. D I am a employer with 4. El I am a general contractor and 1 6. F1 Now con.struction
employees (fall and/or part-time).* have hired the sub -contractors 7 . . El Remodeling
2. El I am a sole proprietor or partner- listed on the attached shoot. t
ship and'have no employees These sub -contractors have 8. El Demolition
working for me in any capacity. workers' comp. insurance. 9. El Building addition
[No workers' comp. insurance 5. El We are a corporation and its 10.[] Electrical repairs or additions
required.] officers have exercised their
3.EJ I am a hom cowner doing all work right of exemption per MGL li.DPlumblng repairs or additions
myself. [No workers' comp. c. 152, § 1(4), and we, have no 12.Fl Roof repairs
insurance required.] t employees. [No worke& nll . other
comp. insurance requiredJ
'Any applicant that checks box#1 must also fill out the section below showingtheirworkers' compensation policyinformation.
T Homeowners who submit this affidavit indicating they are doing allworkand then hire outside contractors must submit anew affidavit indicating such.
�Contractors that check this boxmustattached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
lam an employer that isproviding workers' compensation insurancefor my employees. Below is thepolley andjoh site
information.
Insurance Company Name:.
Policy or Self -ins. Lic. ExpirationDate:
lob 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 o. 152 can lead to the imposition of criminal 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. 13 a advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do h areby certify un der th e pains an dp en allies ofperjury Ih at M e inform ation pro vided ah o ve is tru e an d correct,
Signature: Date:
Ofjr-clal use only. Do not.wrile in this area, to he completed by city or town offIcial
City or Town:
Permit[License
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
------ Dh 44.
Information ajmd Instructions
Massachusetts General Laws chapter 152 requires all employers to provide, workers' compensation for their employees.
Pursuant to this statute, an employee is defined as ".. ..every person in the service of another under any contract ofhire,.
express or implied, oral or wxitten.11
An e7n er
ploy Is defined as "an individual, partnership, association, corporation or other legal entity� or any two or more
Of the foregoiag 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 consiruct buildings in the commonwealth for any
applicant who has not produced .2cceptable evidence of compliance with the insurance coverage required!'
Additionally, MGL chapter 152', §25C(7) states "Neither the commonwealth nor any of its political subdWsions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
A-
pplicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and if
11CCOSSary, supply Sub-Contraotor(s) name(s), address(es) and phone number(s) along with their C, 3
ertifeate(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 anL1LC orLLP does have
employees, a policy is required. Be advised that this affidavit maybe submitted to the, Department of Industrial
Ac cidents 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 thic application for the permit or . license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or ifyou 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 to appropriate line.
City or Town Officials
-Please be, sure that -the affidavit is -complete -and -printed legibly. --- ------ --
space at P bottom
of the affidavit for you to fill out in the, event the Office of Investigations has to contact you regarding the applicant,
Please be sure to fill in the paimit/license number which will be used as a reference number. In addition, an applicant
that 1�ust submit multiple Permit/license applications in any given year, need only submit one, affidavit indicating current
Policy information (ifnecessary) and under "Job Site Address'; the applicant should write "all lo 'ations in (citv or
town)." A co 0
py of the affidavit that has been official1y stamped or marked by the city or town maybe, provided to the
applicant as proof that a valid affidavit ii 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 oi�crmit not related to any business or commercial Yeature
(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 shQuld you have anyquestions,
please do not hesitate to give us a call.
The Department's address, telephone, and fax number:
Tho Commonwi�ajth of Mo
DDpaftmt ofladugdaj &cjdo�uts
OfAce of
600 Washingtou Strc��t
Boston,M&02111
Tel, 9 617-72,.7"4900 at 406 or 1-87WASSAFF,
Revised 5-26-05 Fay,# 617-727-7749
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Date.. .. �? i�q' ......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .... ................................................
..................
has permission to perform ................ ".'k .... ..
wiring in the building.,of ....... 4-4'-v .................................................................
z —46—,
at... .. rl ........ -,�4 .. 2(-- , North Andover, Mass.
...............................
Fee.��4 .......... Lic. No ......... .. ...................
ELEcrRICALVNSP&-rdR
Check # #
8210
-C�1\ (flmnsonweafik ol MamacLetti Official Use Only
Mwm_ Pen -nit No. yb-la
2epartment ol3ire Servicei
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS .[Rev. 1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
f , All wor"k to be performed in accordance with the Massachusetts Electrical Code (MEq), 527 PMR 12.00
(PL EA SE PRINT IN INK 0*RYPE A L L INF OR MA' TION) Date:
I
City or Town of Andover To the lnspe'c'for oj'Wires:
a e I
By this application the unders g2ned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 2,1D gj?
- C -S
Owner or Tenant
Owner's Address
Telephone No.
Is this permit in conjunction with a building permit? Yes No UZ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps Volts
New Service Amps Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Overhead [I Undgrd [I No. of Meters
OverheadEl UndgrdE] No. of Meters
16 2,-oAnd Se*LI&C L-ne9n_
ompTetion ofth, fr FF,-Ai� I, 'ed bv tAe InSDeCtOr of Wires
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above o In
grnd. grnd. LJ
. of Emergency Lighting
Battery Units
-4,
FIRE ALARMS
INo. of Zones
N . o. of Receptacle Outlets
No. of Oil Burners
o. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pu p
in
... .... ... .. ..
J.Nu.nib.er
I ToTs
KW
.............. ....
No. of Self -Contained
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
LocalEl Municippl E] Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water
KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of ElectiQaLA10"rR: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof f li�biility i rance including "completed operation" coverage or its substantial equivalent. The
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undersigned certifies that such c ver �eis in force, and has exhibited proof of sa22.�4 the p rmit issuing o e.,
CHECK ONE: INSURANCE BO�Nl) El OTHER El (Specify:) of�
I certify, under the pains qnd�genalnes erjur that the i0orinati'v4t4v thi's application is true and WcApi Ite.
(J
FIRM NAME: �� 6 '0 4--;� LIC. NO.25D
Licensee: <Tzo b -i Signature LIC. NO.:
(Jf applicable, 3iWf emp, the hqense number lin Bus. Tel. No.:
Address: eP
tclPrupic, A el. No * I
*Per M.G.L. c. 147, s. 57-6 1, security work Jrquires Department of lic Safety "S" License: Lic.No. Co—�OJL-a�f
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) 11 owner El owner's agent.
Owner/Agent
Signature Telephone No.
PE"IT FEE: S
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Date,." -4' - """ "'
N2 4k i� L 9
4, TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ............. !: ..............
..............
-1�1 - - 71L
has permission to perform ... I...
P -t"( ...............
...........
plumbing in t,he buildings of .........
at :_� -1 . . '4� - ' -I , " '-1
.: ................... North Andover, Mass.
'Z7 !:�-
Fee,6 ........ Lic. No,�(),--7-/.
... ........
PLUMBING INSPECTOR
C,/
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT To DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUS=
DateT-
Building Location �-�6 -Z),r OwnersName k 0rArLV.Sn--,) Permit# L
ount A6127
Type of Occupancy
0
New Renovation rl Replacement rl Plans Submitt es E] No
FIXTURES
(Print or type) Check one: Certificate
Inst0ing Company Name rl� , rA-�- 9 0 Corp.
A" El Partner.
U , 7Z A 04 va Firm/Co.
Business Telephone -P�3(-p
Name ofLicensed Plumber 4 -ti -4 14 C, 14,j
insurance Coverage: Indica! the type of insuronce coverage by checking the appropriate bo)c
Liability insurance policy Other type of indemnity El Bond
insurance Waiver L the undersigned, have been made aware that the licensee of this application does not have any one of the above
threeinsurance
hignature Owner Agent
I hereby certify that all of the details and infi=ation I have submitted (or entered) in above application am true and accurate to the
best of my knowledge and that all plumbing wo*-aa4 installations p under Permit Issued for this application will be in
compliance with all pertinent provisions of the ��a#=4 S
Its*Code and Chapter 142 of the General Laws.
P;4MM I
'own
ROVED (oma risE oNLY
Typp of Alumbing License
0'--�� 0 /'�) -
.5se Numoer Master
Journeyman F1
iLMASSACHUSE—ji S UNIFORM APPLICATIC14 FCR PERMIT TO 00 PLUMEING
ll\ (Ptint or Typ4i
NO.RTH ANDOVER. M&sl. Date 21?Z- ..-to
Buf1d Parma
rA
Loc.2flon
New 0 Renovation C-)
Cwneea
Name
RepiacemerA M__� Plant Submftted: Yes C1 NoIC3
FIXTURE!
installing C-ampany Na
Add r es s
Busineii Te!ephone
Name c4 Ucensed F
C�heck one:
C] Corp.
0 Partnership
C1 Frm/Co.
"'l'CX one
I have a current liability Insurance policy cr Xs sulstintL&I e-qutj-&jer;L Yes C3 No 171
It You have checked �Le_s, please IndIcita the *-pe czierage by checkkig the apprcpriate box.
A Ilabilty Insurance p<:41cy C1 C-ther t�7-a c( bclerr�ndy 0 Scnd 0
CartxIc4Id
0WNER*S INSURANCE WAIVER: I am aware that the licenses dQes not haM the Insurance c-verne required by
Chapier 142 o( the Mass. General Lxwz. and that rny sigrAtLze on tN& pernA appilc2tion watves this requirement.
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incw4dge " that &A ;�urntlnq vr"k and ImW&tlonz -+rfv.—*d w�dw ttio p*fmA 1,simpd ke t-mik Anoca"VI bo in compilanca wiLlh 0
pw1inant proviuon.j of the Mamachusetts State P%mnbiry Coo* " ajactag 142 *1 tkwe Gerw�_
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Add r es s
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I have a current liability Insurance policy cr Xs sulstintL&I e-qutj-&jer;L Yes C3 No 171
It You have checked �Le_s, please IndIcita the *-pe czierage by checkkig the apprcpriate box.
A Ilabilty Insurance p<:41cy C1 C-ther t�7-a c( bclerr�ndy 0 Scnd 0
CartxIc4Id
0WNER*S INSURANCE WAIVER: I am aware that the licenses dQes not haM the Insurance c-verne required by
Chapier 142 o( the Mass. General Lxwz. and that rny sigrAtLze on tN& pernA appilc2tion watves this requirement.
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'�Lwdffi lemuD CWnef EV A g e. -A C1
S;Qn&(tA4 Of O"ei or Owref & ACent
I hateby cwtify that &A of the detaJis sAd In(mmi0on I htys r_-t>crAj*d bt entwoo in gbe" j*Q&3L;On ug tgU4 and C=ate to tt�,s b-ast of rry
incw4dge " that &A ;�urntlnq vr"k and ImW&tlonz -+rfv.—*d w�dw ttio p*fmA 1,simpd ke t-mik Anoca"VI bo in compilanca wiLlh 0
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Type of PkNnb4ng Lkxnss: Mssfef
ATTIIU�E 0 (Cf FK E U S E 0 NLY) Joulneyrnan 0
Date.
28?,2
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that .....
has permission to perform . . /,/"
plumbing in the buildings of
at . . . -:� '? - /-.
F e e . .3 J. "—" . . L i c. N o. . 1,0)41)
WHITE: Applicant
02/22/% 12:33
CANARY: Building Dept.
.. ... .. ., North Aiidover, Mass.
...............
PLUMBING INSPECTOR
31.
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PINK: Treasu(d, GOLD: File
Date. .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that . V'-'. 'r * * -, *-*****-**-*---
has permission to perform ... t. I L"(
...............................
plumbing in the buildings of . .(—. I . o.'. �. I . - . .'. . . ................
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at ... ) ........ It .... (-. .�A. I A J ............ North Andover, Mass.
Fee. ..... Lic. No.. .. ...... ......
PLUMBING INSPECTOR
Check # ) -) '--' I (
A
MASSACHUSETTS UNIFORM APPLICA
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location
I)R
Owners Name
FOR PERMIT TO DO PLUMBING
Date ; C//C,
Permi7t# C) Tr
Amount
Type of Occupancy P us /,C)
New Renovation ri Replacement M--� Plans Submitted Yes No
FXT11RES
E r-MM75071 M-MMMOOMMMMMMMMMMOOMMMMMON
(Print or type) Check one: Certificate
Installing Company Name_ Corp.
Address 6 0 PL-�10—urd �r Partner.
Ur-TAWo-1 HASS all?vq
BusmessTelephone V 9 &.1 Firm/Co.
Name of Licensed Plumber: /-/U7-/L-/2r
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy El-`� Other type of indemnity E] Bond El
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
Signature Owner 13 Agent E]
I hereby certify that all of the details and infon-nation I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing ork and insjta *iq perf )ed under Permit Issued for this application will be in
w s
compliance with all pertinent provisions of the Massach;u e P u g C-94e-ftri&Chapter 142 of the General Laws.
By: Signaw I Ylumuer
s (
Title Ty� reoirdabieng License
City/Town I � g /
APPROVED (OFFICE USE ONLY , 4se n t ister Journeyman 0—