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Home My WebLink AboutMiscellaneous - 401 STEVENS STREET 4/30/2018 (2) JTO� S7PJC.is �JMW 1 > 1 \ BUILDING FILE 1 Date R� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 2This certifies that . . . . . .�J. . .'S Q!",r Ile,. . . . . has permission for as ire taxation . � J /' �"'. �`� P g / .' J . . . . . . . . in the buildings o . . f '' �,`Y 'a"� ^^-fc-- . . . . . . . . . . at . . . . . . . . . . . . . . . . . . . . ,N rth And ver Mass. Fee `. �` . Lic. No.l��a . . . . . . . . . GAS IN PECTOR Check# �Zfo ' 372 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING VVORrK CITY _ MA DATE�6./.-/`,Z_ PERMIT# JOBSITEADDRESS[ OWNER'S NAME _._. OWNERADDRBSS ��- TE TYPE OR PRINT OCCUPANCY :YPE COMMERCIAL[] EDUCATIONAL RESIDENTIAL[ ' CLEARLY NEW: ✓1 RENOVATION: REPLACEMENT:El PLANS SUBMITTED: YES[ N0[:] APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILERBOOSTER _ : .. . . CONVERSION BURNER i-�yi __��_. -'E.�... 'i��. I� l-7I--�- F ---F COOK STOVE i --.�_�C DIRECT VENT HEATER - - - DRYER ==IF-7a, .. I(........_.'� �i: . .,..i( r. . i:.::..:., �� -i---^i F+_T.. FIREPLACE - - _ ._..__.__.. __...__ _. _ - FRYOLATOR i._._.w_i.~. .-[.... ..I µI-_ - l - . ... i. ... ..;C _... .l.... ... �.... . ! ..T_.L- ., FURNACE - GENERATOR 177---i —_ GRILLE INFRARED HEATER ----` �- - -- - - -- - -- : Lam....: LABORATORY COCKS 17-7 � - - MAKEUP AIR UNIT - - - --- .. !f:..__...i._.... ._ L. .. I. �, -OVEN 1,-_.-. --- �-POOL HEATER -_, -- _- ---- ROOM/SPACE HEATER [ i i-��(� E. ROOF TOP UNIT .. .-.'( TESTL .. L..._.::......,M'._..__._......Ii.T.. :...... ... .....�.~_.:....f ... ..... .,.:........... '. UNIT HEATER �.-I--i ..,._ �_ i .... I UNVENTED ROOM HEATER .......... i-.-i-_ �....,__.l h.:4_ ._ ,... C .- WATER HEATER ...:...:.:.... - l_._...._... ,:,_... _L:_....._.......L_,..._:.:.__.. ._ --i__ r OTHER - — -- - — Mnw: ....... ... _'C Com; .............. .. .__. _�-i--�___ �►�-�-�-r�-l--rte INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY-CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY � OTHER TYPE INDEMNITY 0 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER Ej AGENT El I hereby certify that all of the details andinformation 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 comp' ice with P rtinent rev' ' of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASP( ER NAME '4 !yiiGc. 0.... :..: LICENSE# t6.2 SIGNATURE MP GF[ JP[-j LPG(( ] CORPORATION # �PARTNERSHIPF LLC[ # COMPANY NAME: ADDRESS CITY �/ / jy/L`� STATE F�ZIP Q./ Z_ TEL . �$ ?.Z .2 �. _ FAX CE L `//7/ .EMAIL 25;4s� G- 4 /G _....__ DC7 R -hv ROUGH GAS INSPECTION NOTES TMS PAGE FOR INSPECTOR USE ONLY ]FINAF.,INSPECTION ION NOTES Yes No THIS APPLICATION SERVES A8 THE PERMIT ❑ ❑ C) FEE: $ PERMIT# ]PLAN REVIEW NOTES PLO i Jr ,•. ,ti ti The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly c Name (Business/Organization/Individual): 292 t//EL ,��5e--:;7w'1G L Address: Y O,CV �/,1•�!/�,�,r� �/.J. City/State/Zip: gVjW !L.c.� f Phone#: T 7 g 3 7 A Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. construction employees(full and/or part-time).* have hired the sub-contractors 2. m aa sole proprietor or partner- listed on the attached sheet. # E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in 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 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.] t employees. [No workers' comp.insurance required.] 13T1 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 a new 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: S le �. Policy#or Self-ins.Lic.#: 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 3f 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. F do hereby cert' under the ains penalties f Jury that the information provided above ' tru and correct. 3i nature: Date: 0/0 ?hone#: 97 Ir Y 7.2- .Z R IF 9 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# 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 chore thari three apahinents'and who resides th@rein,of 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 stick employment'be`deemed•to be an employer." MGL chapter 152, §25C(6)also state's that"every state'or lochl licensing agency.shall Withhold'the issuance air 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 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 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 Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia G.vrvnvtO:CV;WEA-LTH. LiCE��SED A5 .A MASTER P1 IJM ER:; ISSUES THE ABOVE LICENSE TO% s° 1 � NIEL r E_LSEMILL.E-R 6 : G.L IJ 'S A M-K E E RD HA 17RHIL,. MA. 01832- 1067 l 12..8:8 05/01/14 1477.29 _ S • J i Enter construction cost for fee cal- North Andover Fee Cakulation Construction Cost $ 388,625.00 m $ - $ 4,663.50 Plumbing Fee $ 582.94 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 582.94 Total fees collected $ 5,929.38 401 Stevens Street Permit 250-13 on 10/1/12 New Single Family Home N° 9 6'19 Date/ohta/-/Z . y# .h HORT1y °'•��•° "o TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ssACMUS This certifies ,�. . . . . . .�eha... . . . . . . . . . . . . . . . r that . . . . � has permission to perform ZL.t,1s..� plumbing in the buildings of .,1� . . . . . . at SX . . . . . . . . . . .. North Ajpdover, Mass. FeAQ?,9 .Lic. No. . . �-►. . . . . . . t PLUMBING INSPECTOR t check # YZI,,.3 WHITE: Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITYMA DATE /0 /_l PERMIT# k JOBSITE ADDRESS 1. A10 OWNER'S NAME hj, ,�.¢T� �9v r� 7 OWNER ADDRESS . __ . . TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL [ RESIDENTIAL PRINT CLEARLY NEW:RENOVATION:Ej REPLACEMENT:Q PLANS SUBMITTED: YES NO[] FIXTURES-1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 � !> I- C--' --.II--II-'(--i[---�� BATHTUB �- _-1I CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM -'F.7 DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAINIE-771r �—� I— FOOD DISPOSER _-11______:':__- -;[_:_:.—! .:_Ij FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK (— 1 F =-= == _ - 1— LAVATORY I [-.^ ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET 1 --=1- �[—_' �jl �CI ----`•I' ±�—'C �� URINAL WASHING MACHINE CONNECTION -�!--------...... ;(— ;I WATER HEATER ALL TYPESr_ [u_ 'E. II_- .. _ . _._ WATER PIPING n._..::+C i[-._.__._? [^—_L-: F--JF__ 1 - I- [--1L......._::.._i[,. OTHER [-. C._._........ I.........._..... I�-,...................:...:_...._:_: _.._.._. _ _..... 1 -!rte..C [-..T!l_.........._.. .... INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES R--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[ 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 Ej AGENT 0 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 be in pliancez Partinentp on of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME , LICENSE#F/7.729j? SIGNATURE MP JP[ CORPORATIOND# _ PARTNERSHIP[--I# LLCQ# COMPANY NAME ,oj,/ ADDRESS CITY �lL G STATE ZIP TEL 3�� FAX��ELZ �CJ9 ly/ / EMAIL fes? < L. ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES bg 2 cl; Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ -7— g— 06et FEE: $ PERMIT# PLAN REVIEW NOTES ��i7 �/✓� J'Ll P q J ' Fr Z � K � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lelzibly Name (Business/Organization/Individual): Address: ,, le e46 l•�N�.��,�.� ,Q�i City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6 construction em ees(full and/or part-time).* have hired the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet. # ? Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their ME]Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]i employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f 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 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: �C v S .� ?olicy#or Self-ins.Lic.#: <71,3 ,P U2 0 fpr 6 Expiration Date: 9 7 t Z— d lob Site Address:_ ��l .S�l'"�GE•-mss' �/ .K /Oey City ate/Zip:,, /y/4- Ql kttach 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 ne 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 ►f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. 'do hereby cer under th at d penaltie jury that the information provided above i fru and correct. +i nature: Date: (( 'hone#- I? 3 7,2,- 02.Fr 7-' 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#: ! r 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 carry workers' compensation insurance. If an LLC or LLP does have d employees,a policy is required. Be advised that this affidavit maybe 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 Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia c � rivlFU.N f Ll`H x, LICEti .SED AS A JiASTER-PsLUMS- R ISSUES THE ABOVE LICENSE TO 1i NIEL ELSEttIIL.ER i. 6' O.;LD 'a,AMKEE RD UlA 17RHIL, MA: 0183 - 1067 i . 1,288 05/01/14 147729 .r Enter construction cost for fee cal- North Andover Fee Cakulation Construction Cost $ 388,625.00 m $ - $ 4,663.50 Plumbing Fee $ 582.94 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 582.94 Total fees collected $ 5,929.38 I 401 Stevens Street Permit 250-13 on 10/1/12 New Single Family Home Location G/O/ -574KUFwS No. Date • TOWN OF NORTH ANDOVER Certificate of Occupancy $moo-'' Building/Frame Permit Fee $ .�"G Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check 25765 Burg spector