HomeMy WebLinkAboutMiscellaneous - 427 WOOD LANE 4/30/20184
10311
Date... .........�Z�/��/3
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that .... ....(..........hl�,�... / 1 ......:!`�......
has permission to perform .............�...1?...........
plumbing in the buildin s of.. .r..��..:.:.......................
at...................L:•,!................................... North Andover, Mass.
FeeC� Lic. No.�d.......:..............................................................
......................
PLUMBING INSPECTOR
Check #
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITYlr_ . �&r,. _.; MA DATE Id ff _ PERMIT #
JOBSITE ADDRESS � �J� � OWNER'S NAME
POWNERADDRESS TELA w� FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL bk, RESIDENTIAL I
PRINT
CLEARLY NEW:l RENOVATION:REPLACEMENT: PLANS SUBMITTED: YESD NO, 5
FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 1 12 13 14
BATHTUB
k
CROSS CONNECTION DEVICE p i
DEDICATED SPECIAL WASTE SYSTEM ` -
s(
DEDICATED GAS/OIL/SAND SYSTEM # "'
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM M
DEDICATED WATER RECYCLE SYSTEM
w
i
DISHWASHER
W
DRINKING FOUNTAIN r
f �
FOOD DISPOSER 7 $
FLOOR 1 AREA DRAIN
INTERCEPTOR (INTERIOR) _. , w
w,.....
r.
KITCHEN SINK E
F _
LAVATORY I i
ROOF DRAIN
SHOWER STALL
{
SERVICE / MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION F 1I
WATER HEATER ALL TYPES _, tit
_.•
„
} { v
WATER PIPING _
OTHER.,. ,:. a _.a.... _.
I ,�wwn,wn �{ ..,w...�..:: r. ,.. F�
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It
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4 INSURANCE COVERAGE:
I havb a current liability 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 LJj OTHER TYPE OF INDEMNITY L BOND L—j
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: OWI
SIGNATURE OF OWNER OR AGENT 11
I hereby certify that all of the details and information I have submitted or entered regarding this applica n ar tr d accurat o 1
and that all plumbing work and installations performed under the permit issued for this application will b in co anc w h rti
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Ste phenHogan ' LICENSE # 10808 SIGNA
�. , ,W ., n:. �..
ER AGENT :8
:st of my knowledge
provision of the
MPD JPS, ; CORPORATIONS #i 340 _PARTNERSHIPF# LLC #InI
COMPANY NAME i Atlas/Glenmor
ADDRESSL295 295 Eastern Ave
CITYi Chelsea STATE MA ZIP 102150 a TEL 617-687-7300
I_ ~
FAX CELL i 6 6059u EMAIL
tph.............
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
�This certifies that f '... ...........................................
If
has permission for gas installation
in the buildings of ..... �.........................
at ....... Z.. ................. Z .....Z....-.......... North Andover, Mass.
Fee... Lic. No. Z� .................................................
GAS INSPECTOR
Check #
9029
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
- •
CITY MA DATE PERMIT # / v
JOBSITE ADDRESS OWNER'S NAME
GOWNER
_ M
ADDRESS Z r r (.� TEL�QJ7' T5FAX
TYPE OR
PRINT
OCCUPANCY TYPE COMMERCIAL .,_w EDUCATIONAL �.. RESIDENTIAL AA
CLEARLY
NEW: ! RENOVATION:..... REPLACEMENTA.,! PLANS SUBMITTED: YES .._.. J, NO
APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
.... ..... .t I _.... t _ f _ .._
CONVERSION BURNER _ __
COOK STOVE f
DIRECT VENT HEATER _ ........ _._.._,._�._ ._._ z _...._j ___.__.J —J _»__. I
DRYER i � f
i
FIREPLACE
FRYOLATOR __
FURNACE
GENERATOR f
GRILLE ;
INFRARED HEATER _._. _. _...m_ i __. _..� _:..._.__
LABORATORY COCKS I
a _ - - -- __
-.
MAKEUP AIR UNIT i €
...... _. ..... .. ..... .. A _... ....._ z .......... i . .
OVEN '
.._ _.. ..... ... €
._.......... ..J
POOL HEATER _ _
ROOM / SPACE HEATER!
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER if
4
�!
_._......_�..,..._......�..,.._....._..,._...»»._�._»....._................. - £ I __ ,»J � ..._..»,..� .,.. �{ ... t ... J{
- - - - - - - - - - J . . .
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES j% NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
e LIABILITY INSURANCE POLICY _�_ OTHER TYPE INDEMNITY BOND j._.....
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 _.. AGENT ---i
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application accurate tot best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be inmplianc ith all P rti nt provision of the
\retrueand
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME St hen Hogan _ »_ LICENSE # 10808 _ G
MP _�, MGF ____# JP _.._; JGF f LPG[ CORPORATION ,# 3403 PARTNERSHIP_4 # LL
COMPANY NAME: Atlas/Glenmor ADDRESS 295 Eastern Ave
CITY Chelsea STATE MA ZIP 01250 'TEL 617-887-7300 i
t
FAX CELL 617-721-6059 EMAIL
_..
.TH OF MASSACM
OF MASSAGHUSI
The Commonwealth of Massachusetts
Department of Industrial Accidents
'
Of of Investigations
1 Congress Street, Suite 100
Boston, M4 02114-2017.
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders%Contractors/Electricians/PIumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ATLAS GLEN -MOR
Address: 295 EASTERN AVE
City/State/Zip: CHELSEA, MA 02150 Phone #: 800-433-1616
Are you an employer? Check the appropriate box:
1. Q 1 am a employer with 120
4. E] 1 am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2.0 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.
employees and have workers'
[No workers' comp. insurance
comp. insurance I
required.]
5. F1 We are a corporation and its
3 A=2m---a=homeowner:aoing-�ll�-wnrlc
"'�=r_s_hay,"xer4sedjhek
myself [No workers' comp.
insurance required.] t
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp -insurance required.] "
Type of project (required):
6. ❑ New construction
7. 0 Remodeling
8. 0 Demolition
9. 0 Building addition
10.0 Electrical repairs or additions
12.0 Roof repairs
13.0 Other
'Any applicant thatchecks box 41 must also fill out the section below showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicatingsuch.
(Contractors that check this box must attached an additional sheet showing the name of thesub-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.
Insurance Company Name: NEW HAMPSHIRE INSURANCE COMPANY
Policy # or Self -ins. Lic. #: 258-89-049 Expiration Date. 10/1/14
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 certify dto pains and ertalties f perjury that the information provided abov is tr a and correct
Si ature: Date:. �v t 1,3
Phone#: It
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 S. Plumbing Inspector
6. Other
Contact Person- Phone #: