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Home My WebLink AboutMiscellaneous - 36 CIDERPRESS WAY 4/30/2018, aw E - C2 Date... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .. �?`�' ..... .'� �... P.f ................. has permission for gas installation .. �^-� . � ....... . in the buildings of ............. c �` : ZSS ............... at ................ North l A di er, Miss. 4 Fee.��.. Lic. Nod v3 `f g.../i .' ... . GAS INSPECTOR 6 � Check # -% 5 -� 8270 5, 9 Date .7.:31 -i.. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... ` p C'. has permission to perform . M!=`-� -\ (NAC- ........................... ., r plumbing in the buildings of ............ at. 34 Nroh Andover, Mass. Fee &5;e ""I . Lic. N o..1 3 y S . ' �a :!!%............. . PLUMBIN INSPECTOR Check p ?� 3 6 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 e i com liance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER/GAS FITTER NAME: STEPNEN C. GALINSKY LICENSE# 10341' SIGNATURE COMPANYNAME: QAL4S3k%1 PLOrA6i G t }4cKj-jt & ADDRESS: P.O- WX 1701 CITY: HAV;=RHILL STATE: h1,A- ZIP: 0183) FAX: 978- 6a1-4131 TEL: 978 - 3714- 17g3 CELL: 5_04 - 6'�- 5gOy EMAIL: W'W W. enrol unbeff "v,,\ MASTER V JOURNEYMAN ❑ LP INSTALLER ❑ CORPORATION /# 31 q(, PARTNERSHIP ❑ # LLC ❑ # GOWNER TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: VSO fl�8_k 000 19,_T MA. DATE: 77-3O—Q_ PERMIT # JOBSITE ADDRESS:9,_�>6 OWNER'S NAME: t 0ey'k-p(&1 U.0 ADDRESS: TEL: FAX: OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL)R R NEW: [ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCESZ FLOOR—Bsmt 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 j GENERATOR GRILLE INFRARED HEATER t LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM NEATER WATER HEATER INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY [�f' 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 EDAGENT ❑ SIGNATURE OF OWNER OR AGENT 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 e i com liance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER/GAS FITTER NAME: STEPNEN C. GALINSKY LICENSE# 10341' SIGNATURE COMPANYNAME: QAL4S3k%1 PLOrA6i G t }4cKj-jt & ADDRESS: P.O- WX 1701 CITY: HAV;=RHILL STATE: h1,A- ZIP: 0183) FAX: 978- 6a1-4131 TEL: 978 - 3714- 17g3 CELL: 5_04 - 6'�- 5gOy EMAIL: W'W W. enrol unbeff "v,,\ MASTER V JOURNEYMAN ❑ LP INSTALLER ❑ CORPORATION /# 31 q(, PARTNERSHIP ❑ # LLC ❑ # i 0 ro t� n 0 z z 0 m = m Lor) -o y r i' Iq D Gn 0 a o b C r V, h a m z X o m r� .-. { m > z X En W r� It C) z � m o � � z UD Gn c� CD N o Z ❑o . a r � r b r� n y O Z N z ° J�, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK F ROMM PSND VeMA. DATE ` 3 0 Z PERMIT # E ADDRESS �3 6 0CAP M,&& OWNER'S NAME CS OIr,�IL WSS. LLC POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL [9) PRINT CLEARLY NEW: RENOVATION: ElREPLACEMENT: ❑ PLANS SUBMITTED: YES E]NO E] FIXTURES Z FLOOR-- BSMT 1 2 3 4 5 6 7 B 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIL/SAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER FOOD DISPOSER FLOOR / AREA DRAIN y INTERCEPTOR (INTERIOR) KITCHEN SINK I LAVATORY 3 ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET L URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liabili insurance policy or its substantial equivalent which, meets the requirements of MGL Ch. 142. Yes &,No ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Z OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: 1 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 BOX ONLY: OWNER ❑ AGENT ❑ Signature of Owner Dr Owner's Agent I hereby certify that all of the details and information 1 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER NAME STEP4150 C_ GAL.I10SKY SIGNATURE LIC # 10311 S MP [?' JP ❑ CORPORATION [f# 31910 PARTNERSHIP ❑ # LLC ❑ # COMPANYNAME &AWOSKY PLVM0iA1b ¢' !I1'171OG ADDRESS: P.D. Gcx r7ol CITY STATE r11.A• ZIP 01131 EMAIL Www. rnr•pl0mbegw1. coves TEL g'7Y` 37y- l7N 3 CELL SOB- 50ci 5q OH FAX C176 -5,11-4413i ElCD CD m This certifies that ... �-!�'�'{ ......0 ................. . has permission to perform ...... x .b C7 . wiring in the building of ... r` .' f ..�d at .. C/)t>l /-/C� r.5 U _ °.. h Andover,, mass. Fee ......... Lic. No..N .. ? .....r,-� . ELECTRICAL INSPE6TOR Check # 1 Commonwealth of Massachusettts Official Use Only a Department of Fire Services PemutNo. ,rte BOARD OF FIRE PREVENTION REGULATIONS [ROccupancy leav b14) ed . (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code �G , 527 CMR 12.00 (PLEASE PRINT IN INK OR YTPEALL INFORMATION) Date: ( Z -- City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street& Number) -31, C-A--rU,At tnSS a jA-J Owner or Tenant Owner's Address Is this permit in cc Purpose of Building �/ cS t ,Gti� �,� Gp�� n Utility Authorization No. a Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:(fi(,4- � VN 1- -- No. of Meters No. of Meters 5 c� Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value o I-G—E:Unless cal Work: (When required by municipal policy.) Work to Start:�_ Inspecfions to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cover a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ff BOND ❑ OTHER ❑ (Specify.) I certify, underthe pains and penalties ofpedury, thn_t the information on this application is true and cor p"Ete. FIRM NAME: h I LIC. NO.: m ASI Licensee: Mj 6VA &l., M 4, ,,) A Signature LIC. NO.: —Z7 p (Ifapplicab a er "exempt" in the lice?rA�e number line.) Bus. Tel. No. L� 2-C77`l Address: vil . til. N (s� o N Alt. Tel. No.: 7 L S -C*1r _• 'Per M.G.L c. 147, s. 57-6I, sec ity work requires Department ofPublic Safety "S" License: Lice No. 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) ❑ owner Owner/Agent El owner's agent. Signature Telephone No. PERMIT FEE: Com letion o the ollowin table m be waived b the Inspector of Wires No. of Recessed Luminaires No. of Cell.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No, of Luminaires Swimming Pool Above ❑ In- ❑ o. o mergency ig ng rnd. rad. Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of hones No. of Switches No. of Gas Burners No. of Detection and Initiatin Devices No. of Ranges No. of Air Cond. Tons Total No. of Alerting Devices No. of Waste Disposers Heat Pump Number """"""'� Tons ' KW """""" No. of Self -Contained Totals: """-"""""""" Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of WaterNo. No. of Devices or E uivalent Heaters KW as Si s BBallasalts signs Data Wiring: No. ofDevices orEquivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: 5 c� Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value o I-G—E:Unless cal Work: (When required by municipal policy.) Work to Start:�_ Inspecfions to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cover a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ff BOND ❑ OTHER ❑ (Specify.) I certify, underthe pains and penalties ofpedury, thn_t the information on this application is true and cor p"Ete. FIRM NAME: h I LIC. NO.: m ASI Licensee: Mj 6VA &l., M 4, ,,) A Signature LIC. NO.: —Z7 p (Ifapplicab a er "exempt" in the lice?rA�e number line.) Bus. Tel. No. L� 2-C77`l Address: vil . til. N (s� o N Alt. Tel. No.: 7 L S -C*1r _• 'Per M.G.L c. 147, s. 57-6I, sec ity work requires Department ofPublic Safety "S" License: Lice No. 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) ❑ owner Owner/Agent El owner's agent. Signature Telephone No. PERMIT FEE: r' ^ ._.L'/JtJJL•lll../.LJ.VI.'V.CJ.1l Jl �.•-�-4rM J. �®�.'•••lI3�Jl:U'1.i.1{,�®�.tio.+:+JC r.i�T� � • ELECMCAT, INSPECTOR Re-impection xequizecr($50.00)- [ I Inspectors' cotte�af . + tr r 00app ectors7 Signature -A kiivals) Pate rad ROTJND ]WR CTION. omments. ('inspectors}Signature- nokifials) Date r fir'. INSPECTION --SERVICE: Passed.--[ ) p'aited—[ Inspeetbrs' colo moils: ectors' Signature •• uo NAM: . te-inspection r 'assed--[+ailed--[_ Ite znspeetionrecluixecl ($50.00) •-[ uspectoxs' calhm.eats: bate (t spectors'Signature-noinitials) abate [)GOR TA GO .ARE TO BE EMLED 017T.AND BEF3! ON ITB )` TM .A.I,EA. TO BE INRECTED IS NOT .A.CCENSI IE AND .A. RE INSPECTION OF SAO IN TO BY, CHARGED. Passed Failed--[ ] � �te^3�nspeetioxtxec�uixeci ($0.00)-• [ � ' :inspect S' o7m7mienfs: . (ffispec ors', igna e -no ' 'als) Jute rad ROTJND ]WR CTION. omments. ('inspectors}Signature- nokifials) Date r fir'. INSPECTION --SERVICE: Passed.--[ ) p'aited—[ Inspeetbrs' colo moils: ectors' Signature •• uo NAM: . te-inspection r 'assed--[+ailed--[_ Ite znspeetionrecluixecl ($50.00) •-[ uspectoxs' calhm.eats: bate (t spectors'Signature-noinitials) abate [)GOR TA GO .ARE TO BE EMLED 017T.AND BEF3! ON ITB )` TM .A.I,EA. TO BE INRECTED IS NOT .A.CCENSI IE AND .A. RE INSPECTION OF SAO IN TO BY, CHARGED. a The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information (� Please Print Legibly Name (Business/OrganizatiorAndividual): Address - o City/State/Zip:Ir��t951U� .v D c6 q Y Phone #: ? Are you an employer? Check the appropriate box: 1. Rfam 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. ew construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_ �_4 A-) D\l 1 �J S Policy # or Self -ins. Lic. #: Expiration Date: .lob Site Address: cr f 5 City/State/Zip: A- `u 5A _Z,1 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 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. I do hereby cert4o under the pains and penalties of perjury that the information provided above is true and correct. Phone #: 7 g- 3) S —0 �i-% Z Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # ;? t 3_A _( _t -- 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 #: 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 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 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 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 Investigatitons 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877rMASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass,gov1dia