HomeMy WebLinkAboutMiscellaneous - 353 PLEASANT STREET 4/30/20187364 Date ... �q,//d .......
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"NON TOWN OF NORTH ANDOVER
n
,z PERMIT FOR GAS INSTALLATION
r §
This certifies that ...../4 4............."' , , , , , ,
has permission for gas installation lam... / . .
in the buildings of . 7m, �� Iv .... . ......... . , ,
at ... .-� ............ G"'' .. `5 , North Andover,` _
Fee. 3G'. Lic. No.. T. ! !� :?. UJ� ........ .
GAS INSPECTOR
Check # x) 6 L
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Wdetorllmov
Inth Antlaver sass. 29 /D Penoftl
w -...Gam 353 Pleasant St. o..oftumm Toni Vento
eewo RVAMMISM8
�psalo ► Resideptiall
teme Yesg pop
-lnswung company name: Andover Plumbing & Heating Cp., Inc. checkone: certificate
Address 20 Aegeah Dr. Unit x`10 It corporation 122
Methuen. Ma_ -01844
U Pah
Business Weplfon@ { 978) f 85=8M
El FlrtelCai
Name oFt.kensed Muller ordas Fifter AgMe LaRose
Iia, 4mm cis, -142-
yes
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tF yos 1�er duad Tom, pleese%uzwk tae tRpe of m bytbecuft as awe flow
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OWMEMEMBROMMUOKMM 1a�a�aepoeiUeriGeamest�est♦utlta•aireiest:asoacneecaptlttY
ofit�sl��LIMS6apdAMILMlrs�eM _ iAWil sails
_ Orlrtt*'_O�.TS - 0�' � A191d<tt Q
t b8mbq cwdfy that alt of tiro details and Inftwm tkm 1 have submitted for entemd1 in above on are true and accurate to the best
my knowledge and that all plumbing vroM and Installations polbr and Under tiro penult r this application vdU be in compliance wt
alt PernnOft W vislons of the Massachusetts State bas Code and Chapter "142 of the cental ,
OFI.icemm
BY:['
%dc O _ o1r'tass tomer
a*+m���� l3nessla�
The Commonwealth ofMassachusetts
Department of Industriitl Accidents
Office oflnvestigations
' 600 Mashington Street
Boston, MA 02111
ww►v.nrass gov/din -
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers"
Applicant Information Please Print Legibly
yy�Q �07
Name (Business/Organization/Individual}:�1 !01 -IA -pe— /�JvX14
Phone M
Are Vu an employer? Check the appropriate box: _
i. ff I am a employer with 6
`. ❑ 1 am a general contractor and 1
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sbeet.
ship and have no employees
These sub -contractors have
worldng for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance #
required.] .
5. (] We are a corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, § 1(4), and we have no
employees. [No workers'
comm. insurance reouired.l
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Illectrical repairs or additions
1 Qj(PPlumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
•Any applicant that checks box #t must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the name of the sub -conductors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I attt mi employer teat is providing *porkers' cot)tpensudon ittsurattce for niy employees Belosp is thepolicy and job site
information.
Insurance Company
Policy # or Self -ins. Lic. #: Ll1e795/�/ -�/ Expiration Date:--��Ile
Job Site Address:_ �5J �s���%! %!� C1/ City/State/Zip:/W.-
/�/�
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 MOL c. 152- can lead to the imposition of criminal penalties of
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.
I do hereby certify ruler the pains and puna * of perjttry that the information provided above is trite and correct.
Phone M
Official ttse only. Do not sprite in this area, to be completed by city or town official.
City or Town: Perndt/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information and 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 of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint 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
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 n business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with.the insurance coverage required:"
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance .
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have.
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents 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 the application for the permit or license is being requested, not the Department of .
Industrial Accidents. Should you have any questions regarding the law or if you 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 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 fill 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
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "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 provided to 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 bum 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 should you have. any questions,
please do not hesitate to give us a calf.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department .of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1477-MASSAFE
Fax # 617-727-7749
Revised 4-24-07 www.mass.gov/dia
Date. . vl�llq .
TOWN OF NORTH ANDOVER '
' PERMIT FOR PLUMBING
. o, ......._,. 101,
;,SSACNUSi ,,,,// a
This certifies that ...Ado.xe, !.. .. .
has permission to perform ... 1 .............
plumbing in the buildings of .�-P� ." ................ .
at JJ&
S. 3..0/0 5.... ... ,North An over/„Mass. -
Lic. No.. �i `i. ... ... ...... !.
PLUMBING INSPECTOR
Check #
8 6/ 5
.w
MAOM,
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, :MASSACHUSETTS
Date
Building Location 353 Pleasant St Owners Name Toni Vento Permit #
Tv e of Occupancy Residential Amount
New Renovation Replacement [if Plans Submitted Yes ❑ No ❑
irtTRFIQ
(Print or type) Check one: Certificate
Installing Company Name Andover P l u m b i n & H t g. Co., I n 10 Corp. 2122 _
Address 20 Aegean Dr. Unit 110
Partner.
Methuen Ma. 01844
>;usrriess' Telephone ( 978) 685-8383 Firm/Co.
Name of Licensed Plumber: George LaRose
Insurance Coverage: Indicate th type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond F1
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner❑ ❑
Agent
I hereby certify that all ,f the details and information 1 have submitted (or entered) in above ;Wlicatit;n are true and accurate to the
}x+st of my knowlcd,je .uuil that al plumbing work and insGtllations p I fomred under Permit Issued Ci>r tM;; application will he in
compli;utee with ;ill ju.rrinent provisions of the 1(a:;sachusctts St.i 'lumbi ng C an J. General Law;;.
By. uf;na urc c, ucen . m cr
fype Of Plumh n
Title g
License
City,Town 9983
rcense utn er 'Master Journe,,man ❑
��PPROV ED :'ol=FiCF. USE ONLY '
MIUMV Oki ago--------.IIM-..---------I
i ,•
---.-m---�.-----------
,., IMMM
mmmmm
MM�����1
----------------------'
-.--------
--I
----------------------t
5MN
MWW=
NO
MWM���1
(Print or type) Check one: Certificate
Installing Company Name Andover P l u m b i n & H t g. Co., I n 10 Corp. 2122 _
Address 20 Aegean Dr. Unit 110
Partner.
Methuen Ma. 01844
>;usrriess' Telephone ( 978) 685-8383 Firm/Co.
Name of Licensed Plumber: George LaRose
Insurance Coverage: Indicate th type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond F1
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner❑ ❑
Agent
I hereby certify that all ,f the details and information 1 have submitted (or entered) in above ;Wlicatit;n are true and accurate to the
}x+st of my knowlcd,je .uuil that al plumbing work and insGtllations p I fomred under Permit Issued Ci>r tM;; application will he in
compli;utee with ;ill ju.rrinent provisions of the 1(a:;sachusctts St.i 'lumbi ng C an J. General Law;;.
By. uf;na urc c, ucen . m cr
fype Of Plumh n
Title g
License
City,Town 9983
rcense utn er 'Master Journe,,man ❑
��PPROV ED :'ol=FiCF. USE ONLY '
The Corrrvronwealth of Massachusetts
Department of Industrial Accidents
J'r Office of Investigations
600 Washington Street
Boston, MA 02111
Yy" rprplpmassgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers,-
Applicant Information Please Print Legibly
Name (Business!OrganizationiIndividunl): e
Address:
City/State/Zip:&M
Phone #: §Zgjr
•Are ypu an employer? Check the appropriate box:
Type of project (required):
1. 9 I am a employer with
4• ❑ 1 am a general contractor and 1
6 ❑ New construction
employees (full and/or part=time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or 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'
9. ❑ Building addition
[No workers' comp insurance
required.]
comp. insurance.1
5.0 We are a corporation and its
I0.❑ Iflecttical repairs or additions
3. ❑ I am a homeowner doing all work
officers have exercised their
11.fia/Plumbing repairs or additions
myself. [No workers' comp.
right of exemption per MGL
12.❑ Roof repairs
insurance required.] t
c. 152, § 1(4), and .we have no
13.❑ Other
employees. [No workers'
comp. insurance required.!
•Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside commctors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub -conductors and stale whether or not those entities have
employees. If the sub-contmctots have employees. they must provide their workers' comp. policy number.
I ant an employer that is providing workers' cotttpeusatiott insurance for my euiployees. Below is the policy mrd jobsite
information. _ _
Insurance Company Name:
Policy # or Self --ins. Lic. #:_ aje_ 7.96-1791 Expiration Date: D �_
Job Site Address: 3�5-9 Aul i, T C�>,/ City/State/Zip %Z,V�
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requited under Section 25A of MGL c. 152 can lead to the imposition ofcriminal 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.
I do hereby certify rt der the pains and pens ties n perjttry that the information provided above is trite and correct.
Rionnhire, ����._ llntP• /�/�D
Phone M
Official use only. Do not write in this area, to be completed by city or town offrcidL
City or Town: Permit/License #
Is -suing 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 #:
Information and 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 of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or:other legal entity, or any two or more
of the foregoing engaged in a joint 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 construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with.the insurance coverage required.—
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance .
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. if an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents 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 the application for the permit or license is being requested, not the Department•of _
Industrial Accidents. Should you have any questions regarding the law or if you 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 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 fill out in the event the Office of investigations has to contact you regarding the applicant.
Please be sure to fill in the permittlicetise number which will be used as a reference number. In addition, an applicant
that must submit multiple permittlicense applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "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 provided to 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 homeowner or citizen is obtaining a license or permit not related. to any business or commercial venture -
(i.e. a dog license or permit to bum 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 should you have -any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents. .
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1=877-MASSAFE
Fax # 617-727-7749
Revised 4-24-07 www.mass.gov/dia
Location
35 -�2 . l�z .
1 ib,5 Date 3
NORTN
TOWN OF NORTH ANDOVER
`
Certificate of Occupancy
$
4�
Building/Frame Permit Fee
$
�V ACHUstt
Foundation Permit Fee
$
Other Permit Fee
$
Sewer Connection Fee
$
Water Connection Fee
$
TOTAL
$ 59 - o(3
T�n Building Inspector
�-& 35 09:10 59. CO PAID
Div. Public Works
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Location
mss`'�sr
No. r�� Date
-2 ioMu
Building Inspector
Div. Public Works grau,
TOWN OF NORTH ANDOVER
p
Certificate of Occupancy
$
Building/Frame Permit Fee
$
,'t$4 1411sE�
Foundation Permit Fee
$
Other Permit Fee
$
Sewer Connection Fee
$
Water Connection Fee
$
TOTAL
$
-2 ioMu
Building Inspector
Div. Public Works grau,
PE%iii1T NO.
APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
PAGE 1
MAP h40.
LOT NO.
2 RECORD OF OWNERSHIP ;DATE
BOOK ;PAGE
ZONE
SUB DIV. LOT NO.
�I
LOCATION /
PURPOSE OF BUILDING ^ " � A r
�X//
_ V`� L ✓ L
OWNER'S NAME
o
NO. OF STORIES � SIZE
OWNER'S ADDRESS A"
BASEMENT OR SLAB
ARCHITECT'S NAME
-
SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME
K1�
SPAN
DISTANCE TO NEARESTT BUILDING
DIMENSIONS OF SILLS
POSTS
DISTANCE FROM STREET
DISTANCE FROM LOT LINES - SIDES REAR
GIRDERS
AREA OF LOT FRONTAGE
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
7
SIZE OF FOOTING X
IS BUILDING ADDITION
MATERIAL OF CHIMNEY
'IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS 1 - 3
APAGE 2 FILL OUT SECTIONS 1 - 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
c
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATE FILED
2
SJyO(ATU�OWN F.,R)n� IE NT
FEE n dE
PERMIT GRANTED
I/ Ila
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BUILDING INSPECTOR
OWNER TEL. #
CONTR. TEL. #
CONTR. LIC. #
H.I.C.#//� 2317
1 OCCUPANCY
SINGLE FAMILY STORIES _
MULTI. FAMILY OFFICES _
APARTMENTS
CONSTRUCTION
2 FOUNDATION 8 INTERIOR FINISH
CONCRETE 3 1 2 I=
CONCRETE BL'K. PINE _
BRICK OR STONE HARDW D — _ — —
PIERS PLASTER
_ DRY VJALL _ _ _
UNFIN.
3 BASEMENT
AREA FULL FIN. B'M'T' AREA _
'/. lb 1/. FIN. ATTIC AREA _
NO BMT FIRE PLACES _
HEAD ROOM MODERN KITCHEN
4 WALLS I 9 FLOORS
CLAPBOARDS B 1 2 3
DROP SIDING CONCRETE �_
WOOD SHINGLES EARTH _
ASPHALT SIDING HARDW D
ASBESTOS SIDING _ COM/dCN _
VERT. SIDING ASPH. TILE
I STUCCO ON FRAME
WIRING
5 ROOF
II 10 PLUMBING
GABLE I HIP
HO'
BATH 13 FIX.)
_
GAMBRELMANSARD
I
RAE
TOILET RM. 12 FIX.)
UNI
FLAT SHED
GGA
WATER CLOSET
_
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
6 FRAMING 11 HEATING
WOOD JOIST PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. 3 COLS.
STE,
STEEL BMS. 3 COLS. _
HO'
WOOD RAFTERS _
AIR
RAE
UNI
GGA
7 NO. OF ROOMS
1st 13rd 1 11 NO HEATING I I
BUILDING RECORD
12
THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA-
RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
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