Loading...
HomeMy WebLinkAboutMiscellaneous - 40 SUMMIT STREET 4/30/2018 40 SUMMIT STREET 210/081.0-0026-0000.0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK I CITY J.NORTIJ ANDOVER - 29/201PERMIT#45 I t JOBSITE ADDRESS40 SUMMIT STREET-1ST FLOOR OWNER'S NAME DARLENE ELLIS POWNER ADDRESS 1.40 SUMMIT STRET-1 ST FLOOR TEL 978 685-6584 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL El RESIDENTIAL PRINT CLEARLY NEW:F1 RENOVATION:Q REPLACEMENT:0 PLANS SUBMITTED: YES Q NDE] FIXTURES 1 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE `t__= C _ - - 4 DEDICATED SPECIAL WASTE SYSTEM s.- _ _ L - ', _ _ L: DEDICATED GASIOIUSAND SYSTEM f - DEDICATED GREASE SYSTEM - ~ i - - - - =--L - _J L. -- DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM :(.� ' - { = DISHWASHER DRINKING FOUNTAIN T 1 _ _ _. l_ l � _ FOOD DISPOSER iJ FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY , --- _ j �� - �: _ _ ROOF DRAIN L.:. AL -- - SHOWER STALL L --- , SERVICE 1 MOP SINK —� 7 -- TOILET � n �� "v----�I ._..._.� ,'r �I� I --� '1QQ .- URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 WATER PIPING -•, OTHER _•__ __- L _ 71 - - {S TE 80 GALLON EVVH INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY[:'] OTHER TYPE OF INDEMNITY 0 BOND E] 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 Q AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application arelrue and urate to th of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in liance 'h all Perti nt Dibvision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 411 PLUMBER'S NAME JTHOMA§CAREY LICENSE# 8481 SIGNATU E MPO JP Q CORPORATION Fl# 1501_C _ _ PARTNERSHIP❑# LLC[D# COMPANY NAME I WELCH BROTHERS CO., INC. ADDRESS I 148A TANNER STREET CITY I LOWELL STATE MA ZIP 01852 TEL978 453-2100 FAX CELL EMAIL wblowell@comcast.net ��� r 11127 Date..A�015...... of".aRT TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING g8�caus� This certifies that....lu.W.C1.5.. has permission to erform.�.�.�-�.�..�.... ........................................................ PP ... .. .................................................................... �. plumb'ng in the buildings of...............-.. .......... ?..................................................................... /-L at....-.......U.- !n^. �1[ — � 5i �. 00C North Andover, Mass. p ......................... Fee.N..-.......Lic. No. ........ ............:............:....................:...............................:.. PLUMBING INSPECTOR Check# 3(0 The Commonwealth of Massachusetts Department of Industrial Accidents a i d 1 Congress Street,Suite 100 Boston,MA 02114-2017 � www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information _ Please Print Lesibly Name (Business/Organization/Individual): Address: I�A 7A'v��� S'T City/State/Zip: 1.r ll MA 0%� Phone#: _r 70 "yS•3 -02loo Are you an employer?Check the appropriate box: Type of project(required): 1.W I am a employer with . a . employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition P rt3 I will 4Q am a homeowner and will be hiring contractors to conduct all work on my P roe 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12._E3 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ROOF repairs These sub-contractors have employees and have workers'comp.insurance.$ 14.Q Other, 6.Q We are a corporation and its officers have exercised their right of'exemption per MGL c. 152,§1(4),and we have no 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. I 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-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. C© �v Insurance Company Name: fZWATfD MO(OAL TA)SOZAAZ E M A C� L Policy#or Self-ins.Lic.#: (Q I q✓D Expiration Date: /gyp S MM L7 S7 1�T �fea Q City/State/Zip:Y, AVDo tt fk Job Site Address: l Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. ed above is true and correct. tion provided I do hereby certi er t pat d penalties of perjury that the znforma p Date: Y/yo /3 Signature: Pho q�o - d�jOD 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#: s 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-contractor(s)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 cant'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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Division of Professional Licensure: License Search Page 1 of 1 The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES ...........................................................................................................-.......................................................................................................................................... Check a License Check A Professional License Locate a licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency LICENSEE More... Name:THOMAS F. CAREY JR. REFERENCES& CHELMSFORD,MA RELATED INFO NEW SEARCH I Disclaimer Regarding "This Licensee has additional Licenses,click here to view them.** Website License Searches Glossary of License Status Codes Licensing Board: PLUMBERS 8:GASFITTERS License Type: MASTER PLUMBER More... License Number: 8481 Status: CURRENT Expiration Date: 5/1/2016 Issue Date: Exam Date: School: I This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Thursday,April 30,2015 at 11:17:20 AM. 2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://Iicense.reg.state.ma.us/public/PubLicenseQ.asp?board code=PL&typeclass=_M&li... 4/30/2015 PERMIT U ► 5 —1I APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. V PAGE 1 '" MA KBO LOT NO. 2 RECORD OF OWNERSHIP IDATE (BOOK `PAGE ZONE I SUB DIV. LOT NO. �— I LOCATION \,,r\ , PURPOSE OF BUILDING OWNER'S NAME RV kc\. �t� (7-o n NO. OF STORIES UJ IA SIZE OWNER'S ADDRESS 'Al)c � \xX ` ' , ��jjl BASEMENT OR SLAB l ARCHITECT'S NAME a SIZE OF FLOOR TIMBERS IST 2ND 3RD BUIL,DER'S NAME SPAN Lk DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET - POSTS DISTANCE FROM LOT LINES-SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW 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 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST ' �tiC.Gc�•...,r. ��y� PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FTr- EST. BLDG.COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 12 SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DAT ILED_ 0 IJ- J�9At;--t ti,C�Q� �i�� BOARD OF HEALTH SIGNATURE OF OWNER OR AUTHORIZED AGENT FEE O.Oa PLANNING BOARD PERMIT GRANTED 19 BOARD OF SELECTMEN BUILDING INSPECTOR WHITE: Building Dept. CREAM: Assessors CANARY: Treasurer BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES _ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE a 1 2 13 CONCRETE BL'K. PINE BRICK OR STONE HARDW D PIERS PLASTER DRY VJALL UNFIN. 3 BASEMENT il AREA FULL FIN. B'M'T' AREA _ 1/1 1/1 '/. FIN.ATTIC AREA _ NO B MJ FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B T 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ 'S ASPHALT SIDING HARDW'D ASBESTOS SIDING COMtACN VERT. SIDING ASPH.TILE —I{_ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATAIC STRS. 8 FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ 14 SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING - GABLE HIP BATH )3 FIX.) GAMBREL MANSARD TOILET RM. )2 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING II 11 HEATING WOOD JOIST PIPELESS FURNACE _ FORCED HOT AIR FURN. TIMBER BMS. &COLS. _ STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st 13rd NO HEATING - lop I Location =—j O-IA7 No. k� WS-\1'A Date \,-- k1-AA NCIlTq TOWN OF NORTH ANDOVER 10 OeMficate of Occupancy $ Building/Frame Permit Fee $ `z) -J0 b'^rya Foundation Permit Fee $ SsAcwusE< Other Permit Fee $ Sewer Connection Fee $ By ej�t eection Fee $ TOTALII►Ipp $ LCT 16 1�,q Building Inspector biv. Public Works Location No. Date ►CRTPI .TOWN OF NORTH ANDOVER 0�• •ao ,•'fit i Carfificate of Occupancy $ •. A 41 4L 1 • fBuilding/Frame Permit Fee $ �' ''',��•'"'`� Foundation Permit Fee $ ,ssAC14 Other Permit Fee $ py (y' . evronnection Fee $ Water Connection Fee $ UL ' :-NOTAL $ DIA bydove � Building Inspector Div. Public Works NOH T" 1'.. Town of OFFICES OF: o °< 120 Main Street • APPEALS : NORTH ANDOVER Nc,rtlt ►,(I�,vcr• BUILDING ;, �:; ::,° Mi1SSNCIMSC1tS(11H4> f CONSERVATION S@A`"9`s DIVISION OF ((i 1 7)(385-4775 HEALTH PLANNING PLANNING & COMMUNITY DEVELOPMENT KAREN H.P. NELSON, DIRECTOR October 19, 1989 Ms . Darlene McAloon 40 Summit Avenue North Andover, MA Re: Art . 21 , Sec. 2109 . 7 "Used Stoves" Mass . State Bldg. Code Dean Ms . McAloon: Thtiz Z6 to ceAt i 6 y that I' have inspected and appnoved the in,stattation o6 a woodbunning stove at yours kaidenee, Zoeated at the above addneh6. The iutaM t%on meets aU the neguikement,s oU the State Building Cade.; see above Section . very t.uty yowus, As s't Bui td%ng Inspectors /gb P. E D A R D 9. P1][ C'" ob R P [3 -r. t4. !3 4-::'p F" P4. 'f I C, ° � c o m -r o x s N S U R A N C E � � IE � � 'ir � iht C--, ° 151 Hampshire Street . ^ Lawrence , MA. 018,10 Telephone ( 508) 688-8829 � | / ~ October 3, 1989 | �r K ' . � _� Darlene 8 Louis M M��loon ' | � 40 Sommit St � No Andover MA 01845 Re� Policy# PM-NEN (HOMEOWNERS $138OOO) Effective October 3, 1989 to October 3 , 1.990 � � IN VIEW OF THF FACT THAT YOUR NOODBURNINC STOVE WAS NOT ` PROFESSIONALLY INSTALLED , HOWEVER, NAS INSPECTED BY THF ' ANDOVFRBUILDINC DEPARTMENT AND FIRE INSPECTOR , PREFERRED MUTUAL WOULD LIKE A COPY OF A CERTIFICATE FROM THEM STATINC . THAT THE AOODBURNINC UNIT MEETS ALL SAFETY STANDARDS , AN ENVELOPE IS ENCLOSED TO RETURN THIS . THANK YOU . ' Sincerely yours , Bedard 8 Michaud Ins Agency , Inc ^ ' � � � ~~ JOAN PELLERIN J(A)/pe � [BUILDING DEPARTMENTI 171 / � | � ' ^ ' �� " - - ]]-- �� 'mv^v v , . _