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Home My WebLink AboutMiscellaneous - 334 WAVERLY ROAD 4/30/2018I \1 10209 Date .................................. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...... e .. . ............ &.9 has',perfiii-s-sion to perform .... ��i ...... ........................................................................... ......................................... plumbing in the buildings ojfL . ............ ..... .............. at ....... ah- ........................................ Nbrth Andover, Mass. FeeW,I,.,i!2 ....... Lic. No. .......... . .......................... SPECTOR Check # Av�ff MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY h. !iF MA DATE Ap / 1 PERMIT # b Z JOBSITE ADDRESS 33, y �v�i�,/ �4_ OWNER'S NAME 5& POWNER ADDRESS 3.3 y Ah9-� / __ TEL '77 ._ 5 3G FAX TYPE OR OCCUPANCY TYPE COMMERCIAL [ EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: E:1 RENOVATION: ( REPLACEMENT: E] PLANS SUBMITTED: YES 0 NOD FIXTURES Z FLOOR— BSM I 1 1 2 1 3 1 4 1 5 1 6 7 8 9 1 10 1 11 1 12 1 13 1 14 DEDICATED GRE DEDICATED GRJ DEDICATED WAl DISHWASHER DRINKING FOUN FOOD DISPOSE FLOOR / AREA D INTERCEPTOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP TOILET URINAL WASHING MACE WATER HEATED WATER PIPING OTHER WASTE SYSTEM WATER SYSTEM R RECYCLE SYSTEM ALLTYPES I have a current liabilb insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES [j] NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY P] OTHER TYPE OF INDEMNITY 0 BOND Q OWNER'S INSURANCE WAIVER: i am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts Genual Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER El 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 anjf qwurate to the best of my knowli and that all plumbing work and installations performed under the permit issued for this application will be in compi m all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. l - PLUMBER'S NAME I Steven Carr LICENSE # 15366 ! SIGNATURE MP 0 JP E CORPORATION 0 #F=PARTNERSHIPEI#O LLCEI#SOLEPROP COMPANY NAME SPC Pluml>irtg &Heating ADDRESS 12 Concord St. CITY Methuen STATE ®ZIP 01844 TEL 978-8153936 FAX 978-208-1081 CELL 978-8153936 EMAIL h@verizon.net ?'he Connnonwealth ofMnssachrisetts Department of Industrial Accidents = Office of Investigations 600 Washington Street Boston, .IIIA 02111 wlv)v.ntass:gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name (Business/organization/Wividuai): 3AG 1?1 h i3 tr11, Address: 12 Cert con:rJ Sr City/State/Zip: art wk rV. OA 01144 Phone #: q 7-5L_G• -3Q 32 Are you an employer? Check the appropriate box: Type of project (required): I am demployer with 3 4. ❑ I am a general contractor and 1 employees (full and/or part-time).* have hired the sub -contractors 6. ❑New construction 2. ❑ 1 am a sole proprietor or partner- listed on the attachcd sheet. t 7. [M Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its - 10.❑ Electrical repairs or additions required.] o fCcers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself (No workers' comp. c. 152, § 1(4), and we have no 12.[] Roof repairs insurance required.] t employees. (No workers' comp, insurance required.] 13.Q Other *Any applicant that checks box # t must also 511 out the section below showing their workers' co►npensation policy inromution: t 1lorrreowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew atrdavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers' comp, policy information. lam an employer that is providing workers' eonrpe►tsatiort insurance for my employees. Below is the policy and job site heferneation. Insurance Company Name: ly0 40I L Policy # or Self -ins. Lie. #: U )F. Expiration Date:_12-11q12-013 Job Site Address: Z3`1 G.� /�/Z>T �/� Al 47ypcl�►cAf City/State/Zip: / /fP/)b;/�/t� Attach a copy of the workers' compensation policy declaration page (showing the policy number and explration 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 $1,500.00 and/or one-year itnprisomnent, as well as civil penalties in the four of a STOP WORK ORDER and a fine of up to $250.00 a day fgainst the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the IiA for insurance coverage verification. 1 do hereby certify t�djr the pains and penalties of perjtrr), that the Information provided above is true and corn-ect- Oficial use only. Do not wrM in this area, to be completed by city ortowit official, City or Town: Perrnit/Llcense # Issuing Authority (circle one): 1. Board of health 2. Building Department 3. Cityrrown Clerk 4. Electrical Inspector 5.. Plumbing Inspector 6. Other Contact Person: Phone #: s rz. rttkt15i.1� a T Ne CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS 140 RIGHTS UPON THE CERTIFICATE HOLDER. THIS CI!'KnFICATE DOHS NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED RY THE POLICIES BELOW. IMS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BBTI EEN THE ISSWNG INGURERft AUTHORMED REPRESENTATIVE OR PRODUCER, AND THE CEMVICATE HOLDER. IMPORTANT: If the cottfloate holder is an ADDRIONAL INSURED, Ute Poltcy(igs) must be endorsed If 108ROUTION ISWANED, "#a to the temp area conditions of Ow policy, COMIn PoWes maV require an andwseMent A statement on this carWom does net confer rights to the OerdtiCAts holder M lieu of such endp s aaoclCaR Erik Hap Heys Insurance Apncy. Inc. DAM,t37$ 3182 35 Mawltrome Ave. #" Ma 01844vmfti�A! Norfolk A Dedhism h iAtBYeEO Swim Carr . �{{ �R B �L�R�ilf•� .�IDW�YI,SK 1P nq and Heat •,• �' , "\ r�� .V�V D 12 Conewd SL Ateowenhila 01844 COVERAGES CERTIFICATE NUMem. THIS IS TO CERTIFY THAT THE POLICIES Oi INSURANCE LISTED BELOW K-AVF- SEEN MUM TO THE MR WDICATM, NOTWITHSTANOM ANY RMUMEMENT, TERM OR CONDnION OF ANY CONTRACT OR OTHER CERTIFICAT! MAY BE ISSUED OR MAY PWAIN, THE INSURANCE WORDED BY TNN POUCIEB DESCRI51 &XCLUSIONB AND CONDITION$ OF SUCH POLICIES. tJMfTS "OWN MAY hAVH BEEN REDUCED BY PND CLAIMS TYPa cw m9uwm -.1 • IOENERALLmum WCOMM0Oft WNER CLM> A l R0508298A 0312t112013 0N&J01 t "i �ENt Ao i mg, Te LtMrr APPLIEe Pine LOC AUToMOM L IAGIM AWAM evv►nlo acstl�tk0 1 HIRW AUTOS Auras UMBULLA Luc OCCUR —1 Otcasa Lux CLAMASMAMi • .Mi0lbtaRrDCOM/[NfAtteN 'ANO tA1P'W�"�6p1.Rl�pL�4R11ttlfY A �r RAN�Me�R! up= �N NIA WE1DS W 1$i1B1$012 12/+$J2813 �eaCaoTbN oC oaeRAttpus t tAGATiONf i eH11CLia tAwon AooRo tOt, Atldtttontl eamtAs sat�arub. N scan, spat b nivuwwl Instailown and waif of piumbing and heaft eationem !A NAMED ABOVE FOR THE POLICY PERIOD XOCUM@NT WITH RESPECT TO WMICH THIS D HEREIN IS SUBJECT TO ALL THE TERM$, UMR1E AqQVwww OCt>!lRRENCE 1,000,000. Cm5,000. ±080KALtAQYW&W 2,000,000. SRMAGORMU s 2.000XD. Aoa x,000.000. a $ OOD LY Kuty pw mmol S BOMLY MYURY (Pu OWWW4 f s S aA0K UPA2WM e R ATE A El. 1,000,000 E 1,000,0. E.L-POLiCYLJM(r = 1.000,0. Town of North Andover BItOULD ANY OF THS ABOVE VASCmW pCLI tis SB 0AANCMLW WWCRE Building Dept TM tl MATION DATE THt.REOF, NOTICe WLL SE URNERED 0 169'6 Osgocid 3t :. - ACCORDANCF WffH THS PoWy pm0VWUM& Building 20, suit q 2-36 a mp ams North.Andover, Ma 01845 to 1W 010 ACORD COVORATION. AI! lights ►emVed. ACORD 2S (2010105) The ACORD name and logo are registered marks of ACORD Commonwealth of Mas achusett Ci /Town of f L'h ron6v e System Pumping Record RECEIVED JUN - 8 2009 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Facility Information: System Location: Address �jo City/Town State Zip Code System Owner: 1 4 ZC1,U Name: Adress (if different from location of pump) City/Town State Zip Code q:7s,- w - (p64,)- Telephone p6`-CTelephone Number Pumping Record Date of Pumping j� (d- 11. Oq Quantity Pumped �JUgallons Type of System-$— Septic Tank Grease Trap Other (what) System Pumped by: () eq Company: ROOTER -MAN 12 East Dracut Rd., Methuen, MA 01844 Location where contents were disposed:41"'Afo_ Signature of Hauler Date a