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Home My WebLink AboutMiscellaneous - 5 BRIARWOOD COURT 4/30/2018 Ut A �� d C �� i 11110 F NOR T#1 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING gB�CHU This certifies that.... has permission to perform..... VA.,,.............r.............................. plumbing in the buildings of... .. . .............. at.......5...... .. ................................ North Andover, Mass. Fee....4�.k),...L i c. No. PLUMBING INSPECTOR Check 4t i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY_' `b T, � MA DATE PERMIT# I o JOBSITE ADDRESS('` ('( OWNER'S NAME POWNERADDRESS TEL FAX TYPE OR OCCUPANCYTYPE COMMERCIAL❑ EDU TIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:F1 RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 FLOOR— BSM1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR NTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current Habil' insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142- YES WIVO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E/ 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 L]SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and infomration 1 have submitted or entered regarding this application are a 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 coin lea with all Pertinent 'o f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Yf\ I fYr- LICENSE#1'5� M SIGNATURE MP JP[2 CORPORATION❑# PARTNERSHIP[I# LLC❑# \—V COMPANY NAME—40� ADDRESS I` 0 CIN_ �>,U�. L STATE A ZIP--.,.( TEL FAX CELL -' = } EMAIL �► Magi v � �. .� r --. - r �� Date......"...1.... .............. OF NORTN,� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION .......... CHU This certifies that ...... ...................................................... has permission for gas installation .... ..... .............................. in the buildipgs of............... .......... ..................................... at ......... ................................. North Andover, Mass. Fee... Lic. No.1'341...... ..................................................................... GAS INSPECTOR Check# 05954 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK --- — _ - _ PERMIT# CITY ��STC 1 iK{ l( -:. �---- MA PATE � �c -J JOBSITE ADDRESS _ w_ OWNERSNAME OWNER ADDRESS ._ TELF FAX TPIR><NT YPE OR OCCUPANCYTYPE COMMERCIAL EDUCATfdNAL RESIDENTIAL CLEARLY NEW:C RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES[:,]-# NO APPLIANCES 7 FLOORS-+ BSM 1 2 3 45 8 7 8 9 10 11 12 13 14 BOILERI .w1� . ;I . 11- - H BOOSTER I 1� [ 11 # LL_ _ CONVERSION BURNER _J-# .._.__1 ..._ _I — COOK STOVE 1 _1I DIRECT VENT HEATER ::_# DRYER FIREPLACE FRYOLATOR FURNACE (`-fI . _.1 - GENERATOR =( — ._ GRILLE INFRARED HEATER 1 ! C #[-.- # C;. .� _.# ! LABORATORY COCKS r [_ #i I�,....! ._ -_J _ __ #._._ I(� ji 1I # -l1 - .- -# .__I MAKEUP AIR UNIT ( ! _1 i Jmay;i OVEN =_ _j �..J POOL HEATER ED 1 . <�.:...:.,.. ROOM]SPACE HEATER ROOF TOP uN1r # n IT<J I -I i �.z TEST __.#f M .J 1�:_._.I .. _.I[--I(- { _.#I ._ I I .^I ,J _.�z__,i -_�J( #L j UNIT HEATER 177-1 UNVENTEO ROOM HEATER ( iJ . WATER HEATERF. -`j OTHER L JII INSURANCE COVERAGE /' I have a current Iiabilit insurance 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 COVERAG Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY[-A 13OND OWNER'S INSURANCE WAIVER:I ain aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Latins,and that my signature on this permit application k1alves tills requirement. CHECK ONE ONLY: OWNER F.A AGENT F I SIGNATURE OF OWNER OR AGENT _Fhereby 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 complian with all Pertinent pr fon f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFI7TER NAME - _ ?_l.=_6ES L#CENSE# M SIGNATURE NIP GF r JP JGF __; LPGI Q CORPORATION E]# W ` PARTNERSHIP E-]#[ . LLC COMPANY NAME: LA -SLL R ..._. CITY STATE iP TEL i � The Commonwealth o Massachusetts Department of IndustrialAceldents X Congress Street,Suite 100 •; Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE PILED WITH THE PERMITTING AUTHORITY. AyMicant Information Please Print Le 'bl Name(Business/Organizatioblfndividual): Address:- � ` -� r-ed.-c— City/State/Zip-&fib.ec �_ A Phone Are you an employer?Check, c appropriate box: Type of project(required): l.❑T am a employer with employees(full and/or part-time). 7. E]New construction 2, sole proprietor or partnership and have no employees working£or me in $. Remodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition �] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. 12: Plumbing repairs or additions 5.❑I am a general contractor and T have hired the sub-contractors listed on the attached sheet.. 13Roof Te These sub-contractors have employees and have workers'comp.insurance.# .❑ pairs 6.,0 We Are a corporation and its Officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have na.employees.[No workers'comp,insurance required.] . *Any applicant that checks hoz Rinust also fill out the section below showing their workers'eom�ensation,policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub cori]ractors fiave employees,'ttiey must provide their workers'comp.policy number.' X am an employer that is piovidiizg workers'compensation insurance for my employees.' Beloiv is the policy and job site information. Insurance Company Name: l , ice— 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify and - lie and penalties ofperjury that the information provided above' true and correct: Signature: 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#: