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Home My WebLink AboutMiscellaneous - 31 PATRIOT STREET 4/30/2018 -31 PATRIOT STREET 210/018.0-0066-0000.0 ti � l Date....... .1 .�. ............. OF NORTh,� •• TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION � °• °r•�tag r i , I This certifies that .........eddit?rt�A�1.U.V.. .. ...... ................................. has permission for gas installation . .... . . Gam..................... inthe buildings of .. e..ea.t..f... .. .. A............................................................... ............�. .......... ................... North Andover, Mass. I[AFee.. ........... Lic. No. ...\7..1\. .... ..................................................................... L4-1 `_ GAS INSPECTOR Check# 10177 M � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK >� CITY D/f'4 l c+e%3C ✓ MA DATE ZZ /T— PERMIT# JOBSITE ADDRESS OWNER'S NAME,[/tT/co 14�-gae GOWNER ADDRESS sA w! FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL E PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO APPLIANCES-1 FLOORS— BSM 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 FURNACE GZ 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 OTHER INSURANCE COVERAGE I Mve a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YESX❑ NO ❑ hi'�YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW Q LIABILITY INSURANCE POLICYX❑ OTHER TYPE INDEMNITY ❑ BOND ❑ V 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. CHECK ONE ONLY: OWNER ❑ 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 an ccurate to the best f y knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliawith all Pertin pro 'si n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASF ITTER NAME Peter G.Viens LICENSE# 12116 SIGNATURE MP® MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATION ®#3631C PARTNERSHIP❑# LLC❑# COMPANY NAME Merrimack Valley Corp ADDRESS 15 Aegean Drive Unit#3 CITY Methuen STATE MA ZIP 01844 TEL (978)689-0224 FAX CELL EMAIL viens mvalle co .com 'lb� v ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES i Yes No 3'Z o — 6 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 4 t /The Commonwealth of Massachusetts -- `` Department of Industrial Accidents Office of Investigations ., .f 600 Washington Street Boston, M4 02111 www.natass.gov/ilia `porkers, Compensation: I nsu rai nce affidavit: Build ers/Co>;tracilors/Electricians/lP➢umbe>rs Ap>pHeant Information Please PritnQ LLe�ibl Name (Business/Organization/individual): Z7.,�'Lct, Address:_. •� City/State/Zip: Phone #: 'e%J_911 Are you an employer?Check the appropriate box: Type of project(required): 1. l am a employer with 4. ❑ I am a general contractor and ] r employees (fit]] and/or part-time). ` have hired the sub contractors 6. ❑New construction 2 ❑ 1 am a sole proprietor of partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.{ 9. ❑Buildin- addition required.) 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ l am a homeowner doing all wort: officers have exercised their 11.❑Plumbing repan-s or additions myself. o workers' com right of exemption per MGL Y � P� 12.n Roof repairs insurance required.) i c. 152, §1(4),and we have no employees. [No workers' 13. Other6,Qj� comp. insurance required.] 'Any applicant that checks box t'1 must also fill out the section below showing their workers'compensation policy information. ]7omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicatidg such. l'ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees if the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation instarance for try employees. Below is the policy 2nd job site information. Insurance Company Name: �;,`�'Jfif Policy 9 or Self-ins. LicExpiration Date: -, « ry Job Site Address:3-3 fSL��✓ City/State/Zip:-/V. W"I A fes /g4 a/-%1— Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of tip to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do het ceriif y tender the pains and penalties of perjury that the information provided above is true and correct. Sip-nature: 14 I, of d e14 44//,s Date: 2 L Phone 4: official tese only. Do not write in this area, to be completer)by city or town official. City or Town: Perm it/License#1 Issuing Authority (circle one): 1. Board of Health 2. Building Department ?. City/Toivri Clerk 4. Electrical Inspector, S. Plumbing Inspector 6. Other - - - Contact Person: Phone h: i :. dMMt NWEkLTH OF Ma S,l�iCHt1SETTSr..: COMMONWEALTH OF NPHUSETTS: r • • • • , r • • • • , BOAtRn OF BOARD OF PLUMBERS AN.O GASF ITTI?R PLUMBE=RS A0 OASFITTERS, ISSUES THE FOLLOWIRG LGOENS ISSUES THE FOLLOWtN:G' LICENSE L1 1 S ftl AS A MA=STER PLUM ER L I GEN5..E13 XS A JOURNEYMAN PLUMBS PETER G VIENS PETER G VIENS 9 BLUEl31RU LANE 9 BLUEBIRD LANE :: .W a ATKINSON ,FSH 03811-2302 �►. T1(I NSON' . k( 031311�23t?2 121:1_6 015/Q 1./16 213585 UBERM 2�& 5 a5/�a6 21.356 ''. a Commonwealth of Massachusetts I Department of Public Safety ' } Hoisting Engineer x License:HE-11,0323 ,x. �t a t ti - PETER O.VIENS` ` Refer Viens 9 SLi3EBTt2IILNi Cert# 1023121001-12 ATKINSONNII 03 1. Expires: 10/23/2015 Certification �-' Expiration: N.F.P.A.99-2012 ed. commissioner 11113/2015 ASSE 6010 Installer&ASME M Brazer Ne . Hampshire State of New Hampshire State ofMECHANICAL IDENTIFICATION GAS FITTERS LICENSE NAME: PETER NAl= C i NAME: PETER VIENS ENDORSEMENTS ST,N- STP �f L::; . LICENSE/REGISTRATION#: DATE ISSUED: 10/1,5/2013 SERVICE GFE0700587 � DATE EXPIRES: 11/30/2015 MASTER 3249 LICENSE#:GFE0700587 XPIi2F,TIC.tda: GF: 11130 PL'. 11/30/2046 Commonwealth of Massachusetts if Department of Public Safety OSHA 600316337 License: PMU-001068, Pipefitter Unrestric't'ed Master U.S.Department of Labor Occ:upanonal Safety and Health Administration Peter G Viens 3 9 BLUEBIRD LANE Peter ViensAtkinson NH 03$11 has successfully completed a 30•houf Occupational Safety and Health Training Course in construction Safety&Health t`, Expiration: 11113/2016 Commissioner (Ta •,e ce /2