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HomeMy WebLinkAboutMiscellaneous - 46 SHANNON LANE 4/30/2018 46 SHANNON LANE 21011070229-0000.0 I I I I I Date �(�. . . . to TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING L This certifies that . . d. �v. . . . . . . . . . . . . . . . . has permission to perform . . J,?.( . . . . . . . . . . . plumbing in the buildings of. .. . . . . . . . . . . . . . . . . . . . . . at . . . 4(e rte:cje� . .L N ,North Andover, Mass. '�r• . Fee . . .'J Lic. No. 71 j.cq . . .{�. . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check# - Date . �. . . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . . .r `'`� - P4, �C has permission to perform . .v ! plumbing in the buildings of. . :C. �f �' ( ,,. , , , . . , . . . at . . . `�.�'. . 5 j'1 S.v�c�n �►--2�. NortAn ver, Mass. Pt�. UMBING.INSPE Oji Check# i Z 17 1 � r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _P01-4 ltiw d v e MA DATE 9-S i 3 PERMIT# X0111 " JOBSITE ADDRESS 4(o �A1XV1-pyl ( jj _---= OWN ER'S NAME O vv) e POWNER ADDRESS S ,�.� - __. _ _ TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:' PLANS SUBMITTED: YESE] NOD FIXTURES Z FLOOR— BSM 1 1 1 2 3 4 5 6 7 1 8 1 9 10 11 12 13 14 BATHTUB -! CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM -- - j _ _.. I- _ DEDICATED GAS/OIL/SAND SYSTEM _ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AR ADRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY -- - - ROOF DRAIN SHOWER STALL - c= SERVICE/MOP SINK TOILET — URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER 1 --s 4A d i INSURANCE COVERAGE: 1� I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES® NO V IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE:APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY d 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ® AGENT SIGNATURE OF OWNER OR AGENT C 1 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 Laws. __ 4%�?,�''✓C/ cL `� PLUMBER'S NAME vi LICENSE# y �!(o SIGNATURE MP® JP0, CORPORATION®#PARTNERSHIP❑#O LLC®#� COMPANY NAME (� �` Lu �` ADDRESS Z-/ CITYec'y 1:5(04)y`7 I STATE® ZIP D( 2)6 TEL S6�- ')S2-// �,4 FAX I I CELL Fy,50-s2 EMAIL_ VY— �I �`� 1 ` s Ell S C.� kik i 1 COMMONWEALTH OF MASSACHUSETTS,. PLUMBERS AND GASFITTERS LiCE.NS.ED AS A JOURNEY WAN PLUMBER ISSUES THE ABOVE LICENSE TO: ANTHONY M PALDINO IIto , 43 WAMESIT ROAD TEWKSBURY MA 01876•-2155 `'. , 24516 05/01/14 1it,621`. Date.. .. . .`. . NORT/� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION g$Acaug� PAIS This certifies that .... ...... ..............j. .............................�..r. ......................... has permission for gas ' sta11 tion .......�.(,�. ..... .. n ... in the buildings of................ II .. ......41�" .N). ....LrJ................... North Andover, Mass. at...........4 Fee..�.O —.. Lic. No. . .�.�P.... ... .t....................................................... GASINSPECTOR Check# Date..........A...........1 . ��....... NORT#,, /^ oa°�'"•`� ..•coos TOWN OF NORTH ANDOVER ' "PERMIT FOR GAS INSTALLATION HU This certifies that .........0 . �" �cX ~ ..............�1............. �.cJ........................ has permission for gas installation ...C.f-o k - in the buildings Q f ��- V tNt C_= .......................................................................... r[d� HP Q'C G t.-Cr, at.......q.6.............................................................................. North Andover, Mass. Fee; 0.... Lic. No. o�?.4(r GAS INSPECTOR Check# 1857 �(2-k jj� � t � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY w. G7`�d 6 �o`�„ MA DATE —. -Y ��,,,,__j PERMIT# y� L I OWNER'S NAME J-F F P L U!J t JOBSITE ADDRESSvL,o G $WNER ADDRESS --C4 vtl i TEC_ FAX j TYPE & OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:(" PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER - BOOSTER CONVERSION BURNER [ _ COOK STOVE I _ DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATERi LABORATORY COCKSI— MAKEUP AIR UNIT OVEN POOL HEATER _ I ROOM/SPACE HEATERrr7=7 I I- I§— I I 1 ROOF TOP UNIT �� 1 k E TEST �UNIT HEATER E,-�DD— UNVENTED ROOM HEATER WATER HEATER I� w OTHERI GoD Td k �— s INSURANCE COVERAGE I have a current Ii,abilily nsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY © BOND 4 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the tt Massachusetts General Laws,and that my signature on this permit application waives this requirement. i. CHECK ONE ONLY: OWNER ® AGENT ,❑ SIGNATURE OF OWNER OR AGENT Y 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 P ' nt provisi of the ., Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 1d `h LICENSE#,ZySJ SIGNATURE MP❑ MGF❑ JP9 JGF❑ LPGI❑ CORPORATION❑# ^�PARTNERSHIP EI# LLC❑# M - COMPANY NAME: l/VT t V {>° 0L uv ki ,ADDRESS 1 1J 3 W 6t rn es i� I CITY ,'-("c w t-S o o v. STATE=ZIP d! ?G. TEL( ,S'n g I _ FAXI I CELL ysb-s- (v EMAIL so b Ok 1� T Date. 89 : 5 TOWN OF NORTH ANDOVER 3? �e • OL a PERMIT FOR PLUMBING ,SSACHUSf 1. This certifies that . . . . .A 1) . :• . . . .� !. . . . . . . . . . . . . . . . . . . . . . 3r has permission to perform . . . /`A. .74.�!f: . �ry1�1. . . . . . . . . . . . . . . . . . plumbing in the buildings of . . S at . North Andover, Mass. Fee., . . . . . ./�,�� PLUMBING INSPECTOR Check ." MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING Cit y/ yrs-1� Town• MA. Date: Permit# Building Location:—' `�--� Owners Name: N3C FFlt�' Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential New:❑ Alteration:❑ Renovation:❑ Replacement: Plans Submitted: Yes❑ No Kj/ FIXTURES DEDICATED LU z SYSTEMS f- Z Z h O <n YU O LU Z of O H a it Z v LU 'y acc Z e Q ? m H SNC K W to H _W Q H H 0 2Z. (_., N H W FW.. C O Q W 0 Q Z oG Z Vel U d X S Q Q O LL F" ?� 0: 3 W O 0 D W in j ? cc LL LU 3 Uj LU U H h N O ~ U > > O O a Z Z N F F-LU LU W o21 I Q } H Q m Co o S LL °x r g g �° N IQ- 3 3 3 0 a a SUB BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4T"FLOOR 5T"FLOOR 6T"FLOOR 7T"FLOOR 8T"FLOOR / � �h�� I-IV y I Check One Only Certificate# Installing Company Name: / 7Z�` Address: Ai KIWA.,O El Corporation City/Town: 2 State: ?"�T ❑Part ship BusinessTel: � � Fax: irm/Company Name of Licensed Plumber: 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 Yes,please indic the.type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity emnity ❑ 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. Check One Only Signature of Owner or Owner's Agent Owner El 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 Laws. By Type of License: Title ❑Plumber S' iature"ofUicensei Plumber Cityrrown ❑M er AP ROVED(OFFICE USE ONLY urneyman License Number:_ 4N, The Commonwealth of Massachusetts Department of Industrial Accidents I Office of Investigations �t'-n 600 Washington Street Boston MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print'Lej4ibly Name (Business/Organization/Individual): Address: _� �Q r City/State/Zip: J,14 6126— Phone#: -7f-/- 'Z:e (141V Are y aln employer?Check the appropriate box: Type of project(required): ! 1. I am a employer with 4. ❑ I ain a general contractor and I 6. ❑Newconstruction employees(full and/or part-time).* have hired the sub-contractors 2.F1 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 10.0 Elec, ical repairs or additions 3.ElI am a homeowner doing all work right of exemption per MGL 11.' lumbing 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 *Any applicant that checks box#I must also fill out the section below showing their 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'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: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: �`ifa�v� �� d� 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. Ido hereby certify under yZa' andpenalties ofpeijury that the information provided above is true and correct. Si nature. Date: " Phone#: -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#: 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 numbers)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 pen-nit or license is being requested,not the Department of y 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 pen-nit/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 pen-nits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or pen-nit 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 42111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFB Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia 9/LL/"LU11 TiMe: 9:00 AM TO: anclover, of north H 9,19786889542 Page: 001 CORD, CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDDIYYYY) 04/22/2011 HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS t:ERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certiflicate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CLINIACI NAME: Kathleen Munyon Tarpey Insurance Group Inc PHO(AIIC,No,Ex : 781.246.2677 (FALX No): 781.224.0973 442 Water St I= AIL ADDRESS: PO BOX 567 CUSTOMER ID A: Wakefield, MA 01880-4667 INSURER(S)AFFORDING COVERAGE NAICA INSURED INSURERA: Travelers Insurance Co 36161 John DiPietro dba JD Plumbing & Heating INSURER B: 69 Chase Street INSURER C: I Apt 1 ' INSURER D: BEVERLY, MA 01915-0002 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 11-12 Full REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSR WVD POLICY NUMBERLIMITS (MMIDDlYYYY) MMlDD/YYYY) GENERAL LIABILITY I6808753P954ACJ1 03/31/2011 03/31/2012 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE IORLN I E15 PREMISES Ea occurrence) $ 300,000 CLAIMS-MADE [X] OCCUR MED EXP(Anyone person) $ S'000 A PERSONAL&ADV INJURY $ 1'-000'000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 rX POLICY PE 0. LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ �. HIRED AUTOS (Per accident) NON-OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ AND WORKERLOYERS COMS LIABILITY YIN NSATION IHUB8704PISAll 03/31/2011 03/31/2012 X TORYLIMITS ER A OANY FF CER/MEMBER EXCLUD ECUTIVE a N 1 A E.L.EACH ACCIDENT $ 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Evidence of Insurance - Residential Plumbing CERTIFICATE HOLDER CANCELLATION FAX: 978.688.9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of North Andover AUTHORIZED REPRESENTATIVE 120 Main Street North Andover, MA 01845 Kathleen Mun on O 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD " � ✓lie -t�ammzomtiuea/�/� 'Business of Consumer Affairs&Business Regulation HOME'IMPROVEMENT CONTRACTOR Registration` 124536 Expiration,` 7/15/2011 Tr# 287041 Type: { IridiJidual''n, Christopher J. Melillo' ' Christopher Melillo 179A Lakeshore Boxford,MA 01931 Undersecretary XIMMILmassachusctts - Department of Public Safct� Board of Building Rc� ulutions and Standards Construction Supervisor License License: CS 68105 CHRISTOPHER J MELILLO 179 A LAKESHORE RD BOXFORD, MA 01921 ` Expiration: 5/19/2012 ('ununissiuner Tr#: 2965 i