HomeMy WebLinkAboutMiscellaneous - 417 JOHNSON STREET 4/30/2018 417 JOHNSON STREET
210/098-A-0002-
Date. . . .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
ssACMUS
1
This certifies that . . . . . .. Win! < .. . . . . . . . . . . . . . . . . . . . . . . .
has permission to perform . . . / `.. ... . . . . . . . . . . . . . . . . .
plumbing in the buildings of .
at. Aq .. . . . . . . . . . . ,North Andover, Mass.
Fee. V.Lic. No. 1 ! ". . . . . . . . .. . . . . .
PLUMBING INSPECTOR
Check # �T3
r �
�f
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or Pmt)
NORTH ANDOVER,MASSACHUSETTS
Date J
Building Location ! / G i� n �� Permit# �7
Amount I (1
Owner
New .-Renovation Replacement 0 Plans Submitted Yes No
FIXTURES
W.
SUNBM
1ESNf
Vr
]ST IIDQt �
rM EWCR
3M EUM
4IH IIDQt
6IH ELOCR
7IH Hf=
SIH RM 4471 PIF 11 1
type)(Print or
,�/ '^ / Check one: Certificate
InstallingCompany Name �`' L /l �`��` Corp.
Address Partner.
Business Telephone irm/Co.
Name of Licensed Plumber: r /'_h/;vd
Insurance Coverage: Indicate the f insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond
Insurance Waiver: 1,the undersigned,have been made aware that the licensee of this application does not have any one of the above
three insurance
mgnature Owner Agent El
I hereby certify that all of the details and information 1 have submitted(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work an " to =in
ed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Mas usetts to g an pter 42 of General Laws.
By: igna o kens um
ypeof P umbin License
Title41
City/Town incense um er Master Journeyman
APPROVED(oFncE usE oNLY
r
The Commonwealth of Massachusetts
Department of industrial Accidents
Office of investigations
600 Washington Street
Boston, MA 02111
www mass govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): 117
Address:
City/State/Zip: Phone#: 7-_ 6L3__?
>_ _
y an employer?Check the appropriate box:
Type of project(required):
am a employer with 4. ❑ I am a general contractor and I
ees(full and/or part-time).* have hired the sub-contractors 6. New construction
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. q. ❑Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.El 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.] 13.[] Other
*my aPPlicant that cheers box#1 must also illi out the section below showing:heir 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-contractors and their workers' policy comp. Iic information.
I am an employer that is providing workerscompensation insurance for my employee& Below is the policy and job site
information.
Insurance Company Name:
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
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 ce uftd the ai s dpen ' s perjury t t the information provided above/is trueandcorrect
Simature: Date.:
Phone#:
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#:
1
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
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 rcturried 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 call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Invyestigations
600 Washington Street
Boston,MA 021.11
Tel. # 617-727-4900 ext 406 or 1-8.77-NIASSAFE
Revised 5-26-05 Fax#617-72.7-7749
va-ww.rnass..gov/dia
. Date-/-.. .........
gORTM
°�,"'°;• '"° TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
IL
"CNU
This certifies that l' ..'../ ........ ..... ...............
has permission to perform? .. ti... .....:.,
wiring in the building of... u.... • ^%...............................................
..............ALECTRIC
,North Andover,Mass.
? c ���o
............ Lic.No.
�INSSPECTO
Check #
t
Commonwealth of Massachusetts Official Use Only
Department of Fire Services PermitNo. -
BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked.&
[Rev. 1/071 (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRWflV LNK OR TYPE ALL INFORA"TlON) Date: c.
City or Town of: NORTH ANDOVER b �o
By this application the undersigned gives notice of his or her intention to perform the el�electrical work described below.
Location(Street&Number) �/7 ./ S�
Owner or Tenant —.Jame–S '
Owner's Address Telephone No.
M
Is this permit in conjunction with a building permit? Yes
® NO ❑ (Check propriate Box)
Purpose of Building S----'��+4 ��'' 1`/ l.✓�11 ^1 Utility Authorization No.7
Existing Service Amps / volts —Overhead eters
Undgrd No.of M
❑ ❑
New Service Amps / Volts Overhead
Undgrd No.of Meters
❑ ❑
• Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work: ;>
Completion o the followin table may be waived by the Ins ector of Wires.
No.oEREEEE No.of Ceil.-Susp.(Paddle)Fans No.of Total
No.oTransformers KVA
No.of Hot Tubs Generators KVA
No.of Luminaires 1 2 Swimming Pool Above In- o,o mergency lg g
d• � d. Ba. Units
--, No.of Receptacle Outlets 3p FNo.of Oil Burners
FIRE ALARMS Na.of Zone.-
No.
ones
No.of Switches s No.of Gas Burners No.Of Detection and
No.of No.of Air Cond. °�1
Ranges Initiatin Devices
�
Tons No.of Alerting Devices
No.of Waste Disposers ( eat Pump Number Tons _ KW
o.of Self-Contained
Totals: "-"" � Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal
Connection El mer
No.of Dryers Heating Appliances KW Security Systems:
o.of Water No.of No.of Devices or E uivalent
Heaters KW No.of Data Wiring;
Si s Ballasts . No,of Devices or E uivalent
No.Hydromassage Bathtubs No.of Motors Total RP Telecommunications Wiring:
OTHER: No.of Devices or Equivalent
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work:
Work to Start: (When required by municipal poIicy.)
Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless 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 coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE 11 BOND E3 OTHER El (Specify.)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete
FIRM NAME: P1 cart}I > Mot,E.,:
LIC.NO.:-Z0S po A
Licensee:jZ; k P� Irl Signature
(If applicable, ent r"exempt"in the license number line.) LIC.NO.: �0 exq tr
Address: I ne �5 Bus.Tel.No.: I�1%11Z*Per M.G.L c 147,s 57 61,secunty work requrres Dty Alt.Tel.No.: 6)
OWNER'S INSURANCE WAIVER: I am aware that the Department
a does not hav1e,the liability Lic.No.
required by law. B m signature y q e)insurance coverage normally
By y gnature below,I hereby waive this requirement. I am the(check one) ❑owner ❑owner's agent
Owner/Agent
Signature Telephone No. PERMIT TEE.S �
�`�"�
1-73 6-v
-17
r
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/Electridans/Plumbers
Applicant Information
Please Print Legibiy
Name(Business/Organizafion/Individual)_p�C GrtX
�`, C
Address: 11L\ 1�z
City/State/Zip: fy\ A `CjCs phone#: 1- �3l 137 7
Are you an employer?Check the appropriate box:
1• a employer with �•� 4. g Type of project(required):
❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6 E]New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet, $ 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance.
com . insurance 5. 9 ❑Biding addition
[No workers
' p ❑ 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 11.0 Plumbing repairs or additions
myself. [No workers' comp. C. 152,§1(4),and we have no
12.❑Roof repairsinsurance required.] t employees. [No workers'
comp.insurance required.) 13.[1 Other
.A BY a:^plicaut that checks box rl must also fill out the se, below shoM *theirworikerscompens-tionpolicy=fo_
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
�Contracors 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
information. insurance for my employees. Below is the policy and job site
Insurance Company Name: CO M A'-\L P Ce—
Policy#or Self-ins.Lic.#:
Expiration Date:_rp /O
Job Site Address: -//7
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
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 under the pains and penalties of perjury that the information provided above is true and correct
Si ature: � (fes `
Date.:
Phone#: 7�{t'- 013 - i3
E
only. Do not write in this area, to be completed by city or town officiaL
n: Permit/License#
hority(circle one):
Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector
son: 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 15.2, §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. .1f 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 of 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 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
vvvvw.mass..gov/din
APR-25-2010 05 :46 PM LARRY OGDEN 978 352 2858 P. 01
LAWRENCE X OGDEN,P.E.
198 EAST MAIN STREET
GEORGETOWNt MA 01833
978-352.8318&1978—352-2858
April 25,201Q cell: 978-503-5921
Mr. Kevin,Murphy
169 Boxford Street
North Andover,Ma Q 1845
RE: Determan Residence,417 Johnson St.,North Andover,Ma. 01845
Dear Mr Murphy
As you requested I visited the site to review the installation of the Engineered
Materials consisting of L'VLs and Steel Beams utilized in the framing of the above
project. These are shown on plans prepared by Steve Foster Dated 10-3-09 with the
framing sheets certified by me 10/15/09.
Based on the above site visit and based on what I could visibly see 1 can certify
that to the best of my knowledge the of LVLs and Steel Beam members utilized in the
framing as shown on the drawings are installed properly and meet the loading conditions
of the Massachusetts State Building Code for ldt.2 Family Residences. This certification
assumes that all other framing requirements of the drawings and code, including but not
limited to materials and nailing schedules,were properly complied with by the licensed
construction supervisor responsible for the project.
Should you have any questions please do not hesitate to call.
Yours truly,
Lawrence Ll. Ogden P.E. Structural 27765
o� wRENCE s� !
rc p Ola
DEN
4-/Zs-/W 10
OL E
V '. u) .. 3 ry
IJI Date-z...........................
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
SAcmUS
This certifies that ...............................
................. ..........
....... ..............
has permission to perform ..... ..................�r
.. .....................
wiring in the building of...... ..............................................
at.... �Zl...........:n'.,..... .............. .North Andover,Mass.
. . ........ .....
/ -�'
Lic.NZ�.�ZSa ........ ............vlr�4 (-��...............
.............
It ELECTRICAL INSPECTOR
08/26/99 12:23 35-00 PAID
WHITE:Applicant CANARY: Building Dept. PINK:Treasurer
Tgre Commonwealth of�jiSetis �t,�
DqxrtracM of Pobti�c, ` 0
BOARD OF THE FIRE PREVENTION REGULATIONS 627CMR 1200 1
Ooapwxy&Fee
APPLICATION FOR PERMIT TOPERF:
ELECTRICAL �o0"W Uaro
All work to be performed In accordance with the Massachi WORK
E�echfcal Code 627 CMR 1200
�;, ;,;(A FIRE ALARM PERMIT MUST18E'bBTAl�IEO, : 'H D P TMENTy
TOWN QF ; i l7 /7f',�
TOtheIns DATE ��
The unders gl ned appUes for a rmtt to Pforof Wires: c
Pe Perform the elecfriW Work described below.
Location(Street&Numbed `
f
Owner or Tenant Owner's �-
Address
Is this permit in conJunc ion with a building permit Yes
❑ Non-- :.
on--: (Check Appropriate Box)
Putpose of Building f &,�-
UtiQtyAuthorization No.
E)dsbng Service
Amps / Votts Overhead❑ Undgrd ❑ No. Of Meters
New Service Amps / Volts
Overhead Undgrd❑ No. Of Meters
Number of Feeders and Ampacity
Nature of Proposed Electrical Work
No. Of Lighting Outlets No.Of Hot Tubs
No. Of Transformers Total
No. Of Lighting Fixtures Swimming Poo(-Above gmd. ❑ In md.
9 � Generators t(�/q
No. Of Receptacles No. Of Oil Burners
Fire Alarms Permit Required
NO-Of Switch Outlets No. Of Gas Burners FIRE ALARMS No.Of Zones
No. of Detection&Initiating Devices__
No. Of Ranges No. Of Air Cond. Total Tons No. of Sounding Devices
No. Of Self Contained Detection/Sounding
Local
No. Of Disposals No.Of Heat Pumps YOU Tons Total IM/ Denec
Municipal Connnection
No. Of Dishwashers Space/Area Heating KW Other
No_ Of Dryers Heating Oevtoes KW Low.. . low Nottage Wring
No.Of Water Heaters Nvv No. Of Signs g No.Of Ballast No. Of Hydro Massage Tubs
No. Of Motors Total HP No. Of Emergency 17'e� ncy U9hting Battery Units
OTHER:
SECURITY -SYST:EM I NSTALLATIOV
INSURANCE COVERAGE:. Pursuant to the requirements of Massachusetts General taws
I have a current LiatNli y Insurance Policy Including Completed operations
I have submitted valid proof of same to this office. Co�r�etage or substantial equivalent.YES ®NO
If You have checked YES,Please indicate the YES® NO (�
INSURANCI type of coverage by ung the appropriate box
BOND 0 OTIIER 0 (Please Specify)
Exp.Date:
Estimated Value of Electrical Work$ % Work to Start
IhiSPVCTION NOTICES/: MUST CALL
Signed under the penalties of perjury: (PRIM)Licensee NEM ENS KY ELE�R I C UC No A 1 103 7pE2 510 8 b
Address_ S9 CD6EWW,0 Ad. SOUTN130R0 MA 01772
Phone_Sad^
signature:
OWNER'S i JF Date: Tel.
WI fV I am aware that the Licensee DOES NOT HAVE ffie In raus nce coverage or its substantial equivalent as
required a s. Gen rat Lewy, and that my s(gnature on this permit app(Ication waives this requirement OWNER AGENT
(Please Check One)
(Sl9ture of Owner or Agent) Tet-
naPermtt Fees- cJ