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HomeMy WebLinkAboutMiscellaneous - 34 MILK STREET 4/30/2018Im Date...'/ ......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that.. ( ......................................... ............. / ..... :� ............ . ...... `.C�f has permission to perform.... )/1 .......... I ................ : .......... . ..... 6 t ........... ...................... plumbing in the buildings of ........... �J�i .......................................................... 0) at ...... ...... ....... I-V . ....... .................................... I North Andover, Mass. Fee ... �� r — 1.-- ..1, , [�— ................... Lic. No. ....... 2 ................................................................................ -r- 2 b PLUMBING INSPECTOR Check # 4 •- • �- • •-14TITL91- R OWNER ADDRESS '� - OCCUPANCYTYPE COMMERCIALD1 ' • ' - 1 ' RENOVATION:REPLACEMENT:SUBMITTED: NO CROSS CONNECTION DEVICE •' I�il�l11!dill�dlll'i1�11�1��II�II�Jf�J 1 , 1 , , I!1II-JI��tIMJl�llllW��I�il�ll(� 11���--� 1 1 1 • ' / IL! tM--t� FN-Ml�FM-FM—-FM�11111111111FM—FO- 9[M -M / 1 / .SE SYSTEM lI��JI!1111!!�II(I�tli��l��tl�ll-1 / 1 ' 1 '' I!IN !�t1I11�!!�11!!!J11!9IW1!!!lllI!!�11!!111 DEDICATED WATER RECYCLE SYSMAEN— W—[W IPISHWASHER i ,'DRINKING FOUNTAIN FOOD DISPOSER �ll-MFM-Fl-MFMFM-FP-WrM-FM-FM-MMMFM-FM-FM-[M-K Fe—W(�1FW—W FM W(WFN—KWFW— M FN—W FO—MFW W LAVATORY ---jFM-MFM-Fm-WFM-MFM-KFM-FM-FM-FM-FM-MFM-lM-[M-FM-FM- • • DRAIN WWWWWMWWWMWWWWW fA STALLSERVICE / F�MMS!,IIWWW1WMWWWWWWW •' 5FSWWWMMWWWWWWM TOILET !W�—tW�lW�lM1W1M1�FMFM-1MF�IWN�FM� URINAL ILIMFMFF[NMFM-F tM—�FFfM-l-MM-1m {�-�(M�� WATER HEATER ALL TYPES �IFP-MF-MrMFM-Fm--MFN---M[M--MFN-MFM-F=-FM-FM-MFM-F-MFM- O. -.- ---_FONIOIIOIMM�I0t��IR�ttlJll�t I�� �rI� F�— �F�—�F�— F�— F�—�F� INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES �q NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICYV OTHER TYPE OF INDEMNITY © 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 General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT J® 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 knowledge and that all plumbing work and installations performed under the permit issued for this application will be in pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME CfiC LICENSE # SIGNATURE CORPORATION # PARTNERSHIP Eb _ ; LLC U ; COMPANY NAMEC�..(.-t1Ii2S f. ADDRESS Z— `�1�� CITY �� _ tJ STATE ZIP f/ �� fl TEL FAXCELL I EMAIL _ P W F O O F U W FloW on z N ❑ ti.i w LL : -. on z N ❑ ti.i w LL : -. Date ...... ..... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 7 . I r Tris certifies that...:..+..1.:...................................................................:.....:..:................... has permission for gas installation ........... 4:=..2 ........................................... lJ in the buildings of..........................:'L .:......................................................................................... at ..... :..'.:......!�!.�..1..��- ��''t rI.. .. .............................North Andover, Mass. Fee 0......... Lic. No. `1.........I-IL— .......!.............................................................. Z q 7 � GAS INSPECTOR Check # 1� ' DRYER FIREPLACE-- FRYOLATOR FURNACE f GENERATOR GRILLE. INFRARED HEATER LABORATORY COCKS _z I _ %— =1 _... I _,r( _. -I _ _ L - MAKEUP AIR UNIT.._. _. _ �._ -- OVEN — --J -IL POOL HEATER (� J _ , - ` .�,.,�,�. .. _ _ -_ I - L -J ROOM / SPACE HEATER ROOF TOP UNIT _J TEST UNIT HEATER_ UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ONO a IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND 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 0E 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 accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co lianc with ertine rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMES�C,ft;, LICENSE # SIGNATURE MP E4MGF El JP ® JGF LPGI CORPORATION P# Z k PARTNERSHIP ®#= LLC 0#= COMPANY NAME: A?=I ADDRESS CITY J r1�e1 _ _--_ 11 STATE ZIP FAX : CELL _ EMAIL ^ I- _ ro MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY oto MA DATE U— PERMIT# �I'�c t2 JOBSITE ADDRESSOWNER'S NAME _ G'` OWNER ADDRESS TE FAX L� TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL I PRINT CLEARLY NEW: E] RENOVATION: El REPLACEMENT: fA PLANS SUBMITTED: YES 0 NO APPLIANCES Z 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 f GENERATOR GRILLE. INFRARED HEATER LABORATORY COCKS _z I _ %— =1 _... I _,r( _. -I _ _ L - MAKEUP AIR UNIT.._. _. _ �._ -- OVEN — --J -IL POOL HEATER (� J _ , - ` .�,.,�,�. .. _ _ -_ I - L -J ROOM / SPACE HEATER ROOF TOP UNIT _J TEST UNIT HEATER_ UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ONO a IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND 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 0E 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 accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co lianc with ertine rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMES�C,ft;, LICENSE # SIGNATURE MP E4MGF El JP ® JGF LPGI CORPORATION P# Z k PARTNERSHIP ®#= LLC 0#= COMPANY NAME: A?=I ADDRESS CITY J r1�e1 _ _--_ 11 STATE ZIP FAX : CELL _ EMAIL ^ I- _ ro O H H U W a O F] Z � N W ❑ F- W � W O H a Z W = Q w Q. O w w w w o a a a i J E.., a CL < s w LL H °z 0 H U W a �7 C�7 O y 1 The Commonwealth of Massachusetts Department of Industrigl Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Naive (Business/Organization/Individual):. Address: 2z, '] ill/A t tlJ ST / City/State/Zip:�Jua kjJ)q_{ 1&,&bMi Phone Are you an employer? Check the appropriate box: 1. 91 am a employer with ­ )' 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- Listed on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. A;j�Remodeling 8. ❑ Demolition 9. ❑ Building addition 10..-Electricalrepairs or additions 11,JgPlumbing repairs or additions 12.❑ Roofrepairs 13. ❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name; Policy # or S elf -ins. Lie. #: Expiration Date: Job 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 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 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby art undep the pains andpenalties ofperjury that the information provided above is true and correct. — " / cl Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone