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HomeMy WebLinkAboutMiscellaneous - 472 MASSACHUSETTS AVENUE 4/30/2018 (2) 472 MASSACHUSETTS AVENUE 210/045.G-0049-0000.0 BUILDING" ..FILE Date. . . .�.// : A . .. . . ... . .. . Of MO oTM 141 0� 9 TOWN OF NORTH ANDOVER 41 ' PERMIT FOR GAS INSTALLATION �9SS.9CHU`�Et This certifies that .! .:) f . .S . . . . `?'. . ! . " . . . . . . .4"d- has permission for gas installation -<. . . . . . . . . . . . . . in the buildings of . .?-7 ! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . 73 .s.5. . . . . ,eNorth Andover, Mass. Fee. . . . . Lic. No.. 'a-36 . . �`. �/ . . . . GAS INSPECTOR + Check# 6 $ 0 MASSACHUSEM UNffDRMAPPLJC,kIONFORPMZ(V rTpnpGMff , ING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date ,�/% �Q Building Loqations L' Z Permit# New Owner's Name I Amount S ❑ Renovation a Replacement Plans Submitted � a w. u x . .� x e a z z o a Z Z W F W W tr] A w c d Z p w C W SUB -BAZ SEM ENT C ; a BASEM ENT p 1ST. FLOOR ZND , FLOOR 3RD . FLOOR 4TH . FLOOR TH . FLOOR 6TH , FLOOR 7TH , FLOOR STH . FLOOR. (Print or type) 4� Name d- Check one: Certificate Installing Company �- Address f- Corp. p, L5-0-64--- ❑ Partner. usmess a ep one '�'�� Name of Licensed Piumber'or Gas Fitter IaFirm/Co, INSURANCE COVERAGE I have a current liability Insurance,.policy or it's substantial equivalent Check one:, ` If you have checked v s,please indicate the type coverage b Yes ✓� No� L`jability insurance policy y checking the appropriate bo � Other type of indemnity � X' Owner's In Waiver i am aware that the licensee does not have the Insu Bond E Mass. General Laws,and that m a store on thls. ermit�— insurance coverage required b Y P application waives this requiremetrt q Y Chapter 142 of the Signature of Owner or Owner's Agent Check one: hbY certify that all of the details and information I have submitted Owner Agent best of my knowledge and that all plumbing work an 'ny l}s n (or entered)in above appii..... are compliance with all pertinent provisions in worhe M sachuse erformed under P true and accurate to the Permit Is ed for this application will be in G Code and Chapter. of the Gen Laws. By Signature of Licens Title lumber Or Gas Fitter 1 City/Town, LJ Plumber /1 �i Gas Fitter V ��,,� icense um r _ APPROVED toFF�CE USE ONLY) v Journeyman 0 i ••••..wiLWCQ(U1 of Massachusetts' ! ►Hentart De f Industrial P o ' �',� Accidents sot Df,T�ce of Investigations "N 600 N'ashinaton Street r; Dastost, 1VL4 02111 Workers' Com ensatioa Insurance H'N'�'� ssgot�/cfiQ A Iicant Information vit: guiders/Contractors/Eiectr-idians/Phtmber- s NQIIle (Business/Or , P}ease print Legibly gan'zabon/Individuai): Address: City/State/Zig: Phone#: Are you an employer?Check the appropriate box: 1.El an a employer with . 4' ❑ I am a general contractor and I . Type of project.(required); employees(full and/or part-time:).* have hired the sub-contractors •6. ❑ New c 2.7 I am a sole proprietor or partner- construction ship and have no employees I d an the attached sheet 1 7. ❑ Remodeling. wonting for me in any capacity. work=, have ❑ ' com . ins g' Demolition No workers'comp. insurance 5.. P insurance. required) ❑ We are.a corporation and its 9. ❑ Building addition 3.❑ I an a homeowner doing all work right c have exercised.th. 10. ❑Electrical repairs or additions Myself ght of exem tion Y [No.workers' comp. P P�MGL 11.❑ P}cunbing repairs or additions insurance required.] t P c. 152, § I(4) and we have no employees. 12-ElRoofrepairs [No workers comp, insurance required) 13•(]Other 4n3'aPPfi nt.that cheeks box 9 .must also fill out the section below sho t ilomrowuen who submit•t{tis awi IIdavit indicating il:ey are dOirg a,E ng their workers'compensation oft , lConinmtors that check this box.musi atmched an additional sheet showing thP c} information. Y tt �hire outside coniruciurs rnusi submit a new atntiavii rhe: -.. e of.fhe tab_:G,,,t=tota and their workers's o S'....h I ti►rt an.enrplc},e'the is providing wore '; �;pfier��eo comp.Policy i:riormation. ua0ormatiom ��Za nce_for►T,emp11V,ee& Below,is theoft Insurance Company Name: p c1 msdjob site Policy#or Self-.ins. Lic.#: Job Sriee Address: Expiration Date: Attach a copy of the workers' compensation poficy declar-ation Q CIfy/St&Zip: Failure to secure coverage as required under Section 25A of pate�showin-the poficy number and expiration date}. fine up to $1,500.00 and/or one-year irrt MGL c. 152 can lid to the imposition Dfcriminal Of up to.5250.00 a da Q ' Imprisonment a well as civil penalties in the form of a STOP WpRI,O pees of a y a=aor i the violator. Be advised that a copy of thisstatement ma, RDER and a fine Investigations of.the DIA for insurance coverage verification, be forwarded to the 'Office of Ido hereby,Certo)under the Pains , Penalties of perjur3l Zhat the in or Si--nature- f creation provided above is true and correct Phone#: Official use onLP. Do not write in this are to e c b g ompletsd bJ'esti,or town ojj—LciaL Cite or Town: Issuin•a Authority Permit/L,icense e ritJ (circle one): I. Board of fi ealtb 2. Building Department 3. C' /T fi. Other u7' °wn.Clerk 4. Electrical Inspector S. Piumbitt- e Inspector Contact Person: Phone 4: I I .Luxvi LuaLIVu exam lil5tt ucrionS . Massachusetts General.Laws chapter 152 requires all employers to provide workerscompensation for their employees. Pursuant to this statute,an employee is defined.as"..ever-y person in the service of another under any contract ofhire, express or implied ;oral or written." An employer is defined as`pan individual,partrrership,association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and incluci!-no,the legal representatives of a deceased employer,orthe receiver or trustee of an individual,partnership,associati on or other legal entity,employing employees. However the . owner of a dwelling house having not more than three ap,artments and who resides therein, or the occupant of the dwelling house of another who employs persons to do ma int.-nance,construction or repair work on such dwelling house or on the grounds or building appurtenant th=eto shall.not because of such employment be deemed to be.an =picyrr." MGL chapter 152, §25C(6)also states that"every state a r local iicensiag a°ency shau withhoid the isstuanceor renewal of a license or permitrto operate a business or- to constmat building's 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 poiitical 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 corib-acting authority.". kpPlicants Please fill out the workers'compensation affidavit comprli-etely,by checking the bores that apply to yotr situation and,if necessary,,supply sub-contractor(s)name(s),address(es) and phone numbers)along with their c.-riificate(s)of insurance. Limited Liability Companies (LLC)or Limitr-c Liability Partnerships(LLP)with no employees other than the members or,partners,are not required to carry workers'compensation insurance. rf an LLC or LLP does have-. employees, a policy is required_ Be advised that this affidavit maybe submitted to fine Department of Industrial Accidents for confirmation of insurance coverage. Aliso ]be sure to sign and date the.affidavit. Theaffidavitshould be returned to the city or town that the application for the permit or license is being requested,trot the Department of Industrial Accidents. Should you.have any gieestions re='girding the-iaw or.if you are required to obtain a workers' compensation policy,please call the Depariinent at the n a mber.Iisted below. Self-insured Companies should enter their self-insurance license number on the atinropriate-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 foryou to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permitflicense number which will be used as a reference number. In addition, an applicant that must submit multiple permi0icense applications in arty given year,need only submit one affidavit indicating current poiicy information(if necessary)and under"3ob Site Address"the applicantshould write"all locations in a(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 futuae permits or Iicenses. A new affidavit must be filled out each year. VA= a home owner or citizen is obtaining a licensi� or permit not related to any business or commercial venture (i.e. a dog license o-permit to burn-leaves etc.) said person is NOT required to complete this affidavit. The Officeofinvestigations would like to.thank you in ativa.nce for your cooperation and should you have any questions, . please do not hesitate to give us a call. The Department's address,telephone and fay, number. The Commonwealth Df Vl=achusetts I3cpartment of Lmdustrisl Accidents office of lE avm ieat-ions 600 Wash an Street Boston; MA G21 11 TeI. # 637-727-4900e�-t 406 or 1-8�-MikESA.FE Revised 5-26=05 Fax#61 '7-r-7-7749 Ww.422SS.gov/diff MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING F (Print or Type) Alle1w�_. Mass. Date/f�t�'!_ 19� Permit * D f Z. Building Location - Lp /" Owner's Nam l Type of Occupancy_ e-51 7t✓N T, New ❑ Renovation ❑ Replacement Plans Submitted: Yes❑ No ❑ N H W z N Y cc y 0: N Q p N = W J N W V o ¢ ►- a } z Z a r °C 2 p W a a: CC 0 0 O a m rn f- y W O a ¢ fa � Q N D N t7 V W = N Z O O W W yr N J = a W Q S 4: O = W ~ W V = (7 f- 2 J !- Z �.. i-, YW- N m 2 O 2 W O H S W a > oC W 2. Q Q Q Q: pc '= O c7 S U. O 3 o 0 V C > o a Fes- O SUB—BSMT. BASEMENT I ISTFLOOR 2NDFLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name :,rjAegT A ;elm hiA TyVO Check one: Certificate Address 3 120A C W m i4 ry i-of, ❑ Corporation flyE 7N U E 0 ill rA U t key ❑ Partnership Business Telephone 1,992--17 5-7 ( R-'Fi rrn/Co. Name of Licensed Plumber or Gas Fitter 't' Q 13 F-k T A -5 A m m i T A LD INSURANCE COVERAGE: I have a current 1' bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checkedrtes, please Indicate the type coverage by checking the appropriate box. A liability insurance policy 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent , Owner❑ Agent C3 I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the pe ' i ued for this application ' be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of th 'GdheralLaws. BY T of License: C� Plumber 4Khature of Gobrised Plu _ or Gas itter Title Gaslitter aster License Number I q33L�) APPROVED O FIC S ONL Journeyman BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE N0. APPLICATION FOR PERMIT TO DO GASFITTING NAME& TYPE OF BUILDING LOCATION OF BUILDING - PLUMBER OR GASFITTER v ' LIC. NO. v PERMIT GRANTED R DATE- 19 I GASINSPECTOR I I , ' 2 Date. .. ....... . 2062 A Npa*M TOWN OF NORTH ANDOVER 0: op PERMIT FOR GAS INSTALLATIONO 9SSACHUSEt G! CT This certifies that . ,S'� if??!'? ?.�. . . . . . . . . . . . . . . . • • . , o has permission for gas installation . . . . . . . . . . . . : 0 in the buildings of f'.°.!t ! . . . . . . . . . . . . . ... . . . k at ..... . , North Andover, Mass. 3 Fee—b—,.'. . Lic. No..`2;3? . . . . , , !Y:. . . . . . . . . GAS INSPECTOR WHITE:Applicant CANARY:Building.Dept. PINK:Treasurer GOLD`.File i. ,j Date. ! � ? .. .. .. NpRT1 3� TOWN OF NORTH OVER 41 - PERMIT FOR GA . STALLATION •� 4�°+o+ a +.�"qh E= 9SSACMUSES r This certifies that . s J. . .F'1k7/.:<. . . . —. n . . . . . . . . . . . . . . . . . . has permission for gas installation . . /4! f-:.f. :!. . . . . . . . . . . . . . . in the buildings of ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at S . . . . . . . . . .. North Andover, Mass. F Fee. :. . . Lic. No—S-,,.) .c. . . . . . •_u ,.�. . . . . Gk;INSPECTOR Check# /7�f S ,, 5980 MASSACHUSETTS UNIFORM APFUCATON FOR PERMTf TO DO GAS FITTING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations 7 14Ky1-5-5 /2-4/170 . � Permit# Amount$ Owner's Name i' pa 1 New Renovation Replacement Plans Submitted D W Fe 0 a H T pf, W F 11 1z >0 SUB-BASEM ENT 92 C7 OV > N O B A S E M ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH . FLOOR STH . FLOOR 6TH . FLOOR f 7TH . FLOOR STH . FLOOR (Print or type) / % C Name-. k one: Certificate Installin Com an --1 �f�vz t It-e /' Lf g P y Corp. Address � adc A0 A--1 •-�? � � Partner. I BusinessTelephone �r — � 2-0 �� L.1 "rm/Co. Name of Licensed Plumber or Gas Fitter L INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ©- NoC3 If you have checked ves.please indicate the type coverage by checking the appropriate box. Liability insurance policy 13-- Other type of indemnity 13 Bond 13 Owner's Insurance Waiver: 1 am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. q ent. Signature of Owner or Owner's Agent Check one:Owner Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work a,pd installations performed under Permit Issued fort is application compliance with all pertinent pp ation will be in P p t provisions of the Massachusetts Gas and hap t 142 of thener taws. By: .� Si nature of Licensed Plumber Or Gas Fitter Title Igumber City/Town Gas Fitter (cense um � . aster APPROVED(OFFICE USE ONLY) Journeyman