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HomeMy WebLinkAboutMiscellaneous - 508 MAIN STREET 4/30/2018 - - --- - - - 508 MAIN STREET 210/071.0-0030-0000.0 Date................................................... TOWN OF NORTH ANDOVER F � � PERMIT FOR GAS INSTALLATION $8'�CHug� This certifies that -1.49.1.1"'...... u �' .............................................................................. has permission for gas installation ..............u`....:................................................... inthe buildii of................................................................................................................... at, Of ..1 /A.,... ............................................ N�rth Andover,Mass. Fee '. ... Lic. No. ....... ................................. ASINSPEG40R Check# 97672 pcwg -i����� 4 �T MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TOP RFORhlI GAS FITT114G WORK r; CITY 1V D r" /9-1,V b oueft MA DATE l PERMIT# JOBSITE ADDRESS 4'0 44f .* OWNER'S NAME OWNER ADDRESS 0 TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL(g] PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:09 PLANS SUBMITTED: YES❑ NO❑ APPLIANCES I FLOORS 8SM 1 2 3 4 5 6 1 7 8 9 10 11 i2 13 14 BOILER _ , BOOSTER CONVERSION BURNER , COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER. <� UNVENTED ROOM HEATER. WATER HEATER OTHER INSURANCE COVERAGE I have a current liability 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 COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:t 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 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 Slate Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Dj+v�A g , LICENSE# QQ � SIGNATURE MPF MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC LM# COMPANY NAME SABINE. ftu,w A/��. — ADDRESS ,TO p�LG�`1� Alb®r40 :kD CITY 6r1& STATE Lip TEL979 --7�9"'S&I-1 FAX _ CELL EMAIL—S Th e f o;y 81iolt Pt12Ld/i`itI Of jt'tisSCeCi?fd�e�d`F Department of IndustrialAccideids t*= �_J. ``� f Lce of II€TteSti GTtI0i1S 600 Iflaskington Street t L r Boston, JVAA 02111 L , TV-VIV.17€[i'FS. OvlCitl1 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PleaseTrint Legibly Name(Business/Organization/Individual):_ /'L Address:- 30 City/State/Zip: Phone#: �'2 ^�"�o�9--SVJ.11 ire you an employer?Check the appropriate box: Type of project(required): ❑ I am a employer with 4. Q I am a general contractor and I 6 New constniction employees(full and/orpart-lime).* have hired the sub-contractors he attached sheet_ 7. Remodeling I am a sole proprietor or partner listed on t ❑ P P P ship and have no employees These sub-contractors have g. E] Demolition employees and have workers' working for me in any capacity. 9. 0 Building addition [Noworkers' comp insurance comp. insurance.1 l Electrical repairs or additions required.]red.] . 5. We are a corporation and its 0 ❑ P ❑ 1 am a homeowner doing all work officers have exercised their I1.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]+ C. l 5?, k( },and we have no 13.❑ Other employees. [No workers' comp. insurance required.] ny applicant that checks box 111 must also fill out the section below showing their workers'compensation policy information. orneowners who submit this affidavit indicating they are doing all 1work and then hire outside contractors must submit a new affidavit indicating such. mtractors that check this box must attached an additional sheet shoxving the name of the sub-comractors'and state whether or not those entities have ployees. If the sub-contractors have employees,they must provide their workers'comp.policy number. � I rerr an employer that isproviding workers'compensation insurancefor mi,emplavees. Below is the policy acrd job site P a Formation_ ! mrance Company Name: r- -� t L7 j ]icy# or Self-ins.Lic. M Expiration Date: b Site Address: '12M hinT -CIL- /YD /�t✓1�e /i��Ll1, City/State/Zip: .tach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ilure to secure coverage as required under Section 25A oFMGL c. 152 can lead to the imposition ofcriminal penalties of a ie 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of the DIA for insurance coverage verification. to hereby certify tinder the pains andpenalties of perjury tient the.inforrnertion provided above is true and correct- �.©1't� • _ �., Bate t?nature• i--� Date- tone it Cl'7 '2 9 Qfji'chd rise only. Do not write in this arerr,to be Campleted by tiff:Or town. off cML City or Town: Permit/Lic£r,tse# Issuing Authority(circle one): 1.Board of Health 2.B€rildiria Department 3. City/Town Clerk; 4. Electrical I nspecior 5. Plumbing Inspector 6.Other ,Contact-Person: Phone th Date...1, 1..L..`7.............. 0 RTIy - pF o, TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION s+cHU This certifies that A. ... ...................................................................... has permission for gas installation ...... .. ........................................... inthe buildings of................................................................................................................... N Andover, Mass. Fee.—6,�...... Lic. No.1.�..�v.......... ` � .r, •••................................. GASINSPECTOR Check# .0726 I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GA FITTING VIfOR{< �_ r•G x ,�-' MA DATE _ leiPERMIT-# 5'\„E_,�, CITY JOBSITE ADDRESS Q1ta��_ OWNER'S NAME lM 41y/4C C' � OWNER ADDRESS TEL FAX 2n-4�a2�L 1 TPR �tR OCCUPANCY TYPE COMMERCIAL❑ EQUCATIONAL ❑ RESIDENT►AL CLEARLY NEW_❑ RENOVATION:❑ REPLACEMENT: (' PLANS SUBMITTED: YES❑ Np❑ APPLIANCES Z FLOORS 85M 1 2 3 4 5 6 7 8 9 10 t1 t2 13 t4 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER, WATER HEATER OTHER 0 Co INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES rt;' NO ❑ 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY �]I OTHER TYPE INDEMNITY E] BOND F]the OWNER'S INSURANCE WAIVER: I am aware that (� licensee ee does not have the insurance coverage Massachusetts General Laws,and that my signature on this permit application waives this requ remenqu[red by Chapter i42 of the SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT ❑ I hereby certify that all of the details and information I have submitted or entered regarding[his application are true and accurate to thebest 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 Stale Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME LICENSE# `'� l� 910 SIGNATURE MP V MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION[:]I, PARTNERSHIP❑# LLC(W# COMPANY NAME fAIJE RILLA-_ '1'V ADDRESS ;6 41p-ed �itbl�a4/ AZ CITY N_C_m STATE Zip ®/ TEL FAX — CELL 1,1 229^—,4'111 0t /d C' o:P"Bt`1io:FFtleld/"h ofc vlassachn-eats Depart.4{2E'w sof Industa€fl_Accideflts =:� - Qf ice of Investig aborts GOD RMaslibi tort Streei $`L__7 'Zv Boston, 1'a' 4 02111 jvlviv.niass.goi?1dda Workers' Compensation Insurance Affidavit: Budde;i-s/Con4tg-acto>i-s/Electricians/Plumbei-s Applicant Information Please Print Legibly ]Tame (Business/Organization/Individual): Address: .10. Alht.4 IMAUbdAZ AD City/State/Zip: Al9. thlb- a/&0 _ Phone#: 4f— rare you an employer?Check the appropriate box: Type of project (required): .❑ I am a employer with 4. 1 am a general contractor and 1 6. ❑ New construction employees(full and/or part-lime).* have hired the sub-contractors Fin I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. E] Demolition workingfor me in an capacity. employees and have workers' o y P h'- p f 9. ❑ Buitdino addition +� ; [No workers' comp. insurance com insurance. required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions ❑ I am a homeowner doing all work officers have exercised their I 1 X Plumbing repairs or additions myself. [No workers' comp- right of exemption per MGI 12.❑ Roof repairs insurance required.] l c. ]52, 1(4); and have no employees. [14o workers' 13.❑ Other comp_ insurance required.] uty applicant that checks box III must also fill out the section below showing their morhers'compensation policy information. iomeowners who submit this affidavit indicating they are doing all%work and then hire outside contractors must submit a new affidavit indicating such. bntractors that check this box must attached an additional sheet shoe.-ing the name of the sub-cornractors'and state whether or not those entities have i tployees. If the sub-contractors have employees,they must provide their xvorkers`comp.policy number_ .arre an employer that is provcrling t-vorhers'conttpentsation insurence for mY employees. Below is the polirp and job site formation. surance Company Name: �l / N alicy# or Self-ins-Lic. b: Expiration Date: tb Site Address: 0(903 how lyryk a City/State/Zip: ya A104600A 03- ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne up to$1,500.00 and/or one-year imprisonment, as we]) as civil penalties in the form of a STOP WORK ORDER and a fine up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify under the pairs and p/e�nalties of perjury that the informatio,-i provided above is true and correct. mature: Date:.. 1A���® hone t/• 7419 SCO A- _ Qfjici.d use only. Do ntoi write-in !Iris area,!o be campleted by cite%or tottrn. offci?L City or Town: Permit[Liemse 9 Issuing Authority (circle one): 1. Board of Health 2. Building Depari-anent 3. City/Toon Clerl€ 4. Electrical inspector S. Plunibing, Inspector 6. Other Contact Pte_son:r Phone #: 756Date../. 2.`!, 11• ...... .. NpRTM 3? �` TOWN OF NORTH ZAN ER ' PERMIT FOR GAS'INLATION Ja, �-Iss CMUSEI This certifies that . . ./--,-./. has permission for gas installation . . , � �� r.<y.. :6. . . . . . . . . . . . . in the buildings of . .A17 ... . . . . . . . . . . . . . . . . . . . . . . . at n l. .R z,.4 North Andover, Mass. Fee.3!a .`. . . Lic. . . . . . . .. .� GA'SINSPECTOR / Check# Y MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING i City/Town /� � � Date: / M�1� . Permit#',. � r Building Locati . i9,�n , , _7._-� .��,. % Owners Name:. 3 Type of Occupancy: Commercial; Educationalrc IndustrialL ] Institutional, Residential New Alteration:"' Replacement:V Plans Submitted: Yes; ? NoKCA ,? FIXTURES U) Z H Y Q N V uj m = J Ir Ir 0 ~ W 2 W W0 I �' Z .0 z Z O a n w 0 Q O a I=— fL > N v Z N L9 w 0 ~ x v a u_ w u� o Z W >. � W _jQ QQ~ m w O z O ~ � Z F IW- ~ W 0 W a W w W > O O w Z w Q Q Q I v c 0 ur 0 0 x x g O a � I— > > 3 33: 0 SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3mu FLOOR 4 FLOOR 15 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR Check One Only Certificate# Installing Company Name Climate Design Systems div Merrimack Valley Corporation 111 Corporation 3210 Address:!15 Aegean Drive Unit#3 City/Town:'MethuenState FMA - G .. t Partnership ,, Business Tel '978 689 8312 Fax 978-689-2206 r ...._..... . . .,>„ .._ ,.rI lFirm/Companyl—"., Name of Licensed Plumber/Gas Fitter: Stephen R.Landry INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes Nd,, If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy / Other type of indemnity L] Bond L 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 Owner's Agent By checking this box❑;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 Cod d Chapter 142 of the eras Laws. i- — - Type of License: By ° Plumber E" Gas Fitter Titled ;m Signatur f icense mberl as er µ Master City/Town; Journeyman License Number: 10704 APPROVED OFFICE USE ONLY) LP Installer FINAL INSPECTION BELOW FOR OFFICE USE ONLY PROGRESS INSPECTION(S) FEE: $ PERMIT# APPLICATION FOR PERMIT TO DO GAS FITTING NAME&TYPE OF BUILDING LOCATION OF BUILDING SKETCH PLUMBER GASFITTER,LP INSTALLER LICENSE NUMBER: PERMIT GRANTED❑ DATE: GAS FITTING INSPECTIOR !ne C ommonweatirt uj lvtuvaucituYcttN Department of Industrial Accidents , Once of Investigations -� 600 Washington Street Boston, MA 02111 ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information // /Please Print Legibly Name(Business]Organization/individual): (�//FYI (�9>'� �l�s �A7 S bn/, Address: rva 2V/'W_ City/State/Zip: L, C Phone#: (?7e- 68 Are you an employer. Check the appropriate box: Type of project(required): 1. ®I am a employer with _56) 1�_ - 4.❑I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors attached sheet. 7• ❑Remodeling 2. I am a sole proprietor or partner- listed on the attac ❑ P P ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'compo insurance compo insurance.t 10.❑ Electrical repairs or additions required.] 5.F1We are a corporation and its 3. ❑ I am a homeowner doing all work - officers have exercised their 11.❑ Plumbing repairs or additions V myself. [No workers'compo right of exemption per MGL c. 12.❑Roofrepairs insurance required.] or I have hired 152,§1(4),and we have no 13.❑Other the contractor listed on the attached employees.[No workers' sheet compo insurance required.] " Any applicant that checks box#1 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. iContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'compo policy number. I am an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site information. / p Insurance Company Name: Policy#or Self-ins.Lie: WX2t ��3 ®/� Expiration Date: � /5�, Job Site Address:1,; ►4,e/ L1�� �� C _City/State/Zip: �� '( AA 1:0 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$250.00 a day against the violator.Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penaltie f perjury that the information provided above is true and correct. Signature: Date: . Phone: i OMM NWEALTH OF MASSACHUSETTS', S\::ITT I� �LSUEM�B/E�R�S/�A(�NA$TEAR�{�L,U.�f��R SUES:THE ASQ.�t LICENSE TQ ST pHEN R 'I.AN. RY ' .I 9 �ENV�ORTH BELL CI.RC�._E • BRADF© 2D MA loyal t'