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HomeMy WebLinkAboutMiscellaneous - 396 CHESTNUT STREET 4/30/2018 396 CHESTNUTSTREEi 210/098.7-0000.0 Date. 9395 ,40 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING MUS e This certifies that . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . .. . . . . . . . . . .. . . . . . . . .. . . . . . . plumbing in the by'ldiogs of . . . . . . . . . . . . . . . . . . . . . . . . . . . . at. . . .45,40, Sr . . . . . . . . . . . . . . . . . . . . . . . . . . . . orth Andover, Mass. Lie. No. . . . . . . . Fee. . . . . . . PLUMBING IN PECTOR Check it MASSACNUSETT S UNIFORM APPLICATION FOR A prmit TO PERFORM PLUMBING WORK e OITY R car�JG!t� MA DATE 1 ZO tfZ I PERMIT# 40QSITEADDRESS 356 CAa?zx4 S q4- I!OWNER'S NAME .�cr I J OWNERODRESS+ I TEL IFAXI TYPE-Ok OCCUPANCYTYPE COMMERCIAL) EDUCATIONAL [ I RESKNTIAL PRINT CLEARLY NEWI I RENOVATION:: I REPLACEMENT-.1-T' PLANSSUUMITTED: YES] I NOf I FIXTURES T FLOOR-' 13SM 1 2 3 4 5 6 7 n 9 . 10' 11 12 13 14 BATHTUB CRASS 06NNECTION DEVICE .. .. - DEOICATEO 8PI_(21AL WASTE'SYSTEM DEDICATED GASl01USAND SYSTEM - DEDICATEO GREASE SYSTEM I l DEDICATED G ; : RAY WATER DEDICATED tNATER RECYCLE SYSTEM 4 DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREADRAIN INTERCEPTOR(INTERIOR) -- -- KITCHEN SINK LAVATORY --: - i ROOF DRAIN _ -- SHOWER STALL - SERVIOElMOP SINK TOILET URINAL WASHING MACHINE CONNECTION -- - — WATER HEATER ALL TYPES WATERPIPING _ bTHER ... INSURANCE COVERAGE: --' ..! have a current.iabilit ihsilraitce policy.br its sulistanflal equivalent which sleets the fegairenients of MGLCh.942. YES IBX 0 L I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COI/ERAGEBY CHECKING THE APPROPRIATE 13OX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY] BOND OWNER'S INSURANCE WAIVER::ant aware that the Iicetrsee.rloes nol have the fllsurallce coverage required by Chapl:6142 of time Massachusetts!General Laws,and that my sironature on tliis pertliit application L gives this regUi(etitent. — -CHECK-ONEQNLY:. OWNER I I AGENT I -I - - SIGNATURE OF OWNER OR AGENT 1 hereby cerlify lhat all of the details and information I have sbbrililled of dnlered regarding'Ois applicaliorf ate true and accurate to the best of my knoededge and tha(all plunmbfng worli and installalions performed under the permit issued for this application W11 be in compliar wminent ol'the I Massachusetts Stale'Plumbin Code and Chapter 142 of the General Laws. j PLUMBER'S NAME 1jt LICENSE fl(3/GSI I SIGNATUR I MPI I JP V-t' CORPORATION] _]fl! ;PARTNERSHIP] j fif (LLC jNI I COMPANY NAME+/ r p� 1 ADDRESS - CITY ��g�°may STATEIf'�/'� ZIP '7G0 TEL FAX CELL I i EMAIL I I I II20ucur mumugGINSPE,CTIION•NOMS. $CLOS 'OP ugr-. gNjAT tKSPECTION1V07CrS Vey 'Vo THis APPLVCATIOU SERVE-SAS THE D-rr ❑' ❑ FEE:: PLAti-R^'F7IIII,W-NOa]CS I I I i C-s--- The Commonwealth of Massachusetts - Department of IndustriqlAccidints Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/ilia Workers'Compensation Insurance Affidavit:Builders/ContractorslElectricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/lndivi Address: City/State/Zip 0,1, e 1 6.5 Phone#: j?S- ?z 7—Z �P Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 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.�am a sole proprietor or partner- listed on the attached sheet.x 7• F1 Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition wonting for mein any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I L[]Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]; employees.[No workers' comp.insurance required.] 13.[}Other_, 'Any applicant that checks box 01 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 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. I am an employer that is providing workers'compensation insurance for my employees Below is thepolicy and job site information. Insurance Company Name:. Policy#or Self-ins.Lk.#: Expiration Date: Job Site Address: Icity/State/Zip: 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 ofup 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 berely cert un er tl ai and penalties ofperjury that the information provided above is true and correct. - Signature: Date: F—a r L Phone#: z 9 P;f- Official use only. Do not write in this area,to be completed by city or fawn 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#: 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 ofhire, 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-contractor(s)name(s),address(Bs)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 notrequired 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 he. 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 Iocations 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 orpermit 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: Tho Comm. 011wealth of Massachusetts De-partment of ludustdal Accidents � Office ofIavestigatiom 600 Washiap a.Street Boston}UA,02111 Tel,#617-727-4900 at 446 or 1-877,MASSAE Revised 5-26-05 Fax#617^727;7749 www.mass,gov/dia Date././. /G/.0 5 "path TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMUSE� - This certifies that . . . .�!�.��.r .�.'. . . . . . . . has permission to perform . . . . �.,/� f'� T . plumbing in the buildings of . lc t"' ' r . . . . . . . . . . . . . . . . . . . . . at �' ... . . . .(., North Andover, Mass. Fee. . . . .r`.Lic. No..2 13.`1 1� . . . . . . . . . . . . . . . PLUMBING INS'PECTOR Check # 1 7 8284 (J~7 7 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: 1 N ��'1�-,MA. Date: ]LL�()1 U� Permit# �y Building Location: �� C�� '�i l S Owners�Name:. Type of Occupancy: Commercial❑ Educational❑ industrial❑ Institutional❑ Residential(� New:❑ Alteration:❑ Renovation:❑ Replacement: Plans Submitted: Yes❑ No FIXTURES a z O x v U! U) j � F W rn IL z a U L l 03UJwto z O a a o co p a Q �-in 4 z T W `e IL �. u iQs .te-� W 00 p O O O O g B x Y y N r ED g 9 910 SUB BSMT. BASEMENT 1 FLOOR z FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR r� Check One Only Certificate# Installing Company Name: �J(�► ORD ❑Corporation Address: ��t�-�I \�� \\t-t CltylTown• j State: [l Partnership Business Tei: � l3 � Fax: T• Q FimUCompany Name of Licensed Plumber: ✓�� INSURANCE COVERAGE: , 1 have a current fin bi ft insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes No❑ If you have-chocked Yes•please indicate the type of coverage by checking the appropriate box below. A liability Insurance policy` Other type of indemnity ❑ Bond OWNER'S INSURANCE WAIVER:I am aware that the licensee 02a not have the insurance coverage required by Chapter 142 of the Massachusetto General Laws,and that my signature on this permit application waives nmia requitement Check One Only Owner [] Agent ❑ Signature of Owner or Owner's 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General La By Type of License: " jt/-� y �— Title ❑Plumber Signature of Licensed Plumber Cityfrown ©Master License Number: APPROVED OFFICE USE ONLY Journeyman -- N2 4613 40 TOWN OF NORTH ANDOVER 3:.� ...._.,. Oc I. ,ftinkift p PERMIT FOR PLUMBING +no.O`49 i ,SSAC MuSt:� This certifies thatf !. . .t. . .- . .� has permission to perform//4�4A yam'. f� �j�• plumbing in the buildings of . - -s�-Q-�. P g �. J� -� at ti.;3.��.�. . :--.'. . : . . . . . . . . . . . . .� . . . . . . ., North Andover, Mass. Fee;�,7.:5. . . .Lic. No.dQ .?" �L BING INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK:Treasurer v1`� �zsi MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Pri t or Type) Mass. Date 1 WOO Permit# �'161,3 , — Building Location'3 C#eSTN OF S T- Own ' Name_ 11 _ cufl 153 I .y 1 ype of occupancy Residential New ❑ _ Renovation ❑ Re ent N Plans Submitted: Yes 0 No ❑ FIXTURES N �, N o z r O C7 W `f7 >- V ¢ j W td V) Z of 4 ¢ ¢ S ~ N Z O 2 a rt�wY(( nL{1I x O N '^ U. R W N Z a O 7W d N 2 W N p 2 J — a0 G w z a x 3 O x x x a o F" Q Y w u x 3U�r ~ V > F O = a N Z O O w z z W ~ o V +� +� +� •H 3 x -ai m m 'o o j 3 = li m a o D n z 3 o M rd N rd cd SUB—BSMT. BASEMENT i IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR • 7TH FLOOR STH FLOOR Installing Company Name Heritage Htg. &Pig. CO. Inc. Check one: Certificate Address _ 35 Pleasant Street IX Corporation 714 Stoneham, Ma 02180 ❑ Partnership Business Telephone 781 .—4 3B—7 7 7 6 71 Firm/Co. Name of Licensed Plumber Gordon Switzer INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ® No ❑ If you have checked,res, please indicate the type coverage by checking the appropriate box. A liability Insurance policy (H Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent❑ { Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued foWis application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code a9djChapter 142 of the G oral ws. BY Title Signature o c sed P lumber Type of License:Master[X Journeyman p City/Town APPPOVEff O IC N ) License Number 8322 BELOW FOR OFFICE USE ONLY FINAL INSPEC IONS SKETCHES PROGRESS INSPECTIONS FEE NO. APPLICATION FOR PERMIT TO DO PLUMBING NAME&TYPE OF BUILDING LOCATION OF BUILDING PLUMBER PERMIT GRANTED DATE �g PLUMBING INSPECTOR i 2 � Date. .'`. . . . . . . N1° 4358 "oRT„ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSAC04US� This certifies that . . . . . . . . . . . . . . . . . `has permission to perform .14t'. G- -- r' . . . . . . . . . . . . . . dumbing in the buildings of . . . . . . . . . . . . . . . . . . . at.,2. . . . . -- n.:• - . . . . ,North Andover, Mass. 01111 n, Fee.:` . . . . . .Lu. No../ . . . If . . . . . . . . . . . . PLUh 81NPANSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) Im -Qo Mass. Datei-3 Permit # Building Location 39 �.�,Q cowners Name/!U Uck-G //O/`.W e �1 �/ �' e v�(� Type of Occupancy 5 C ti i V New O Renovation ❑ Replacement t!d Plans Subm' ed: Yes ❑ No ❑ FIXTURES z m N O z y ¢ W Y J N >- V < N ? W W O W H W N M V N ¢ m 03 y ¢ } < NZ ¢ 6 t7 < a C X z O O ¢ < W1- 0 Q < .W - O < N z .LC a ¢ O W W < s 3 0 z S !L d i- < x < W k Y W f- o = d. N z z 2 O V1 �" O 3 Y J m N G G J 3 Y f V) 4 t7 D < S C: @ O SUB—BSMT. BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR F 4TH FLOOR STH FLOOR `) 6TH FLOOR 7TH FLOOR STH FLOOR _Ej I— E Installing Company Name AOI')Ee,T 1 ,-cjj?mm/4TAe-Q Check one: Certificate Address_ C'c;Rc H mai sPJ ❑ Corporation 171E Ki' C--A) Al A • y1 (ILL ❑ Partnership Business Telephone I?-i177 l ❑�—"Ico. r Nme of Licensed Plumberf`r3.=,P_T frl A,�►�rvlr9 �r4t?c INSURANCE COVERAGE: I have ayes currentfiabilfty insoura ce policy or its substantial equivalent which meets the requirements of MGL Ch. 142. 11 If you have checked Les, please indicate the type coverage by checking the appropriate box. A liability insurance policy ld Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner O Agent❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations ormed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum ' g e and pter of the oral Laws. ey �(.L Title Vw1re of Licensed um r Type of License: Master Joumeymah p Oty/Town APPROVED OFFIC US ONL License Number �33 5 BELOW FOR OFFICE USE ONLY II FINAL INSPECTIONS SKETCHES 1 PROGRESS INSPECTIONS FEE NO. APPLICATION FOR PERMIT TO DO PLUMBING NAME&TYPE OF BUILDING LOCATION OF BUILDING PLUMBER PERMIT GRANTED DATE 19 PLUMBING INSPECTOR