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HomeMy WebLinkAboutMiscellaneous - 557 SHARPNERS POND ROAD 4/30/2018 557 SHARPNERS POND ROAD 210/090.B-0043-0000.0 --- r d NORTH ANDOVER BUR-DING DEPARTMENT 1600 Osgood Street North.A ndover Tel: 978-688-954 _ . Fax: 978.-688-9542 BUMWS&FORM FOR T0WNCLERK D.A.TP,, NMAE: ADDRESS: oMxT: �- EULDIL GLAYOUTPROVIDED: YES NO - A LAELE PA MG SPA CM: ZO NING BY LAA USAGE: YES NO BUMD)NG INSPECT&SIG-NA.1'M .BUSINESS FORMFOR7OWNCLERK 2,AO Rome Occupation(1939132) 4 An accessory use conducted wiffi a dwelling by a resident who resides in the dwelling as his principal address, which is clearly Reconduy to the use-of the-bwlding for hi ni piuposes. Home occupations shall 'iiiclizde,"bi t iiot'Iinvted to the following uses; personal services such as fiunished by an artist or instructor, but not occupation involved with motor vehicle repairs, beauty,parlors, animal kennels, or the conduct of retail business,or the manufactud6g of goods,which impacts the residential nature of the neighborhood;' 4. For use of a dwelling in, any residential district or multi-family district for a home occupation,the following conditions shall appIy: a. Not more than a total of three (3) people 47 "may,be eniployet xa i�i bzne occupation, one of +_ whom shall bethoowner ofthe1to�ne oabupatioa and wsidnsg i6i lid diC,elling; b. The use is carried on strictly withinthe principal building; c. Thexe shall be no exterior alterations, accessory buildings, or display which are not custowW with residential buildings; - d. Not more than twmly five (25) percent of the existing gross floor area of the dwelling unit. so used, not to exceed one thousand (1000) square feet, is devoted to'such use. 7n connectionwith such use,there is to be kept no stock in trade, commodities or products which occupy space beyond these;[units; e. There will be no display of goads or wares visible Ecom the street; f The building or premises occupied shall not be rendered objectionable or detrimental to the residential character of the neighborhood due to-the exterior appearance, emission of odor, gas, smoke, dust, noise, disturbance, or in any o4her way become objectionable or detrimental to any residential use within the neighborhood; g. Any such building shall include no features of design.not cust0mary in buildings for residential Use. `S- signature Date Date , 2`.1llz-- M TOWN OF NORTH ANDOVER ,.. PERMIT FOR GAS INSTALLATION a b�. This certifies that . c�i,-.P. :.j�.J . . :�-.,. .�.�-- . . . . . . . . , . . has permission for gas installation Rf N-6e.. . . . . . . . . . . . . . . . . . in the buildings of . } pcJr?<e . . . . . . . . . . . . . . . . . at . . . . . d� �. .cL,..) � aA �P-A.'S. t.✓!^� ,North Andover ass. � M Fee2��:. . . Lic. No.3.t`�}. . . . !. ! . . . . . . . -%'. GAS INSPECTOR Check# 350 8475 w MASSACHUSETTS UNIFORMAPPHCATON FORPERNffr TO DO GAS FMING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS/� J Building Locations 5,71- SY�Q��Dh P Pend PC! Permit# Amount$ Owner's Namer New Renovation ❑ Replacement ❑ Plans Submitted ❑ ��• � w a v z 94 .a FF z H o OM p. O w d � w � � z `w 3 A ch a � U E.z Go a a a HE o 1 a S.UB -BASEM ENT BASEMENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type) ,, Check one: Certificate Installing Company Namet"1 en ©I n�• Corp. Address Q 1 i U n rlf i—c J d MA 0 I C16O b ❑ Partner. , l Business Telephone q'K— Si /— aR q ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter u,-e,aJ A IC I/1 a,( v INSURANCE COVERAGE Check on I have a current liability Insurance policy or it's substantial equivalent. Yes No❑ If you have checked yes,please dicate the type coverage by checking the appropriate box. Liability insurance policy f 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 ❑ 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Coded Cha 42of th General Laws. Signature of Licensed Plumber Or Gas Fitter ❑ Plumber Title City/Town Gas Fitter License Number ❑ Master APPROVED(OFFICE USE ONLY) ❑ Journeyman I40 CI-7( The Commonwealth of Massachusetts =r j Pnnt Form Department of Industrial'Accidents �� Office of Investigations l;- ,qI 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Inc. Name (Business/Organization/Individual):Holden Oil, — Address:91 Lynnfield Street City/State/Zip:Peabody, MA 01960 Phone#:978-531-2984 Are you an employer? Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 45 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have g• ❑ Demolition working for me in any capacity. employees and have workers' 9• ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. F-1Weare a corporation and its 10.0 Electrical repairs or additions re 3.❑ i qu a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions rn myself. [No workers' comp. right of exemption per MGL c. Roof repairs insurance required.] t c. 152, §1(4), and we have no Gas Fitting employees. [No workers' 11 Other comp. insurance required.] Any applicant that checks box#1 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 a new affidavit indicating such. Contractors 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. 1 f the sub-contractors have employees,they must provide their workers'comp.policy number. I ann an employer that is providing workers'compensation insurance for my employees Below is the policy and job site i`i formation. Insurance Company Name:HDI-Gerling America Ins.Co. EWGCD000014511 12/31/2012 Policy # or Self-ins. Lic. #: Expiration Date: .lob Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Fai I ure 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 tip to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify tio der the-PaW and enalties o er'u that the information provided above is true and correct. Si rnatUre: _ ___._ ... _ _._. _.._._... _ _. . . _ Dater Phone#• 9:ZL— �3 I' :Pq eY Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6, Other Contact Person: Phone#: {Y Lk Comm l�llE�IETM ®F M1�►SSAiGHU v t_G,ASFITEt � L A C. hid€a 9� , { N:I �,GlgS'INST LL°E = SUES fiHE�{`BOEaI -NSETO 4EVEN' t' r ttx,x, ;1' N By,P ,L N �3AV 9 _ � f J r i � r r �Rp4# � i+lT J atY e SON �MP�dyed ;ptlry You aB ngtoh St, W loft Of desl) sure, S en. _t is e la s 1, en n. - � lir s, t1�U:• rd 1 this oies 1�- , 1, r boa 1 r pivision of ostori,MA021 .1 d�fi�UN�u,of.next �i� cess sMg`N���5 b e pePP�r cense nu b N 1 a or add ri Cs r lien ws t e s 4° ou ,1,a Vol,,dam or addres ; re let Y 1-e- � It_Y orrect name Always sot the e loaned c, tion• v�s�on notb , of lira , the Pro d must ,sS out gg wal'APP. ert to e.asr nse o Y Rene e ys subl nil�ovile9 the lige e } livens erso l�ee`r" This ed It is:a.P ®r Peon* ovI E ams geed to any teIred kt`! r as as 1 r . s' Person or }i o- / r y 1 _ gip$ CC�IVIM� W�q'LT OpMASSACI U E1`ts � . e a PLcn' F1 TEF�S. CJ i �� fDfi3 ; Ni.� GAS`Ifu � f �SSUES t r e 7' M -r oc• 1 L TFi iAB0�1 Li EN ,14S' ✓ku {ST UVE1 ' ���i��."-.�:t� .< �` I\:' '�f� A'�` '�$ •r fir;= T.ik J •a"s�-�'� .:: t _,MA's;0`1 ,o �5�1793f'E. y: ~ { 4.*". 1 {#�•5v .M.i�J?O� y. �'�/01h/.14X. ' rati ORNBoard cc aryo ton St., f .' destroyed f�d�,Wasl� � i,3 t .t s'r+ s`s '' IOSt,or, 1•nca{][®e .\ rte' t se Lice r If this Ince f pro our board ' t. fon,o M� e h�itiN� bi. xt -05 pwis 710;Boston,_ chin d r m��1in9 ne Suite sho`Nn , roper. numbs\ n r address �i�sure'p r license, aws or ss�t? ou f 1 If your name e or addre refer to of the Gene� oane�.<,. n� t{OIl. P�VNry r Vf510t1S �flt_b0 U r _ of 4 tica, the P nd must on Y0 r at PPS ct to a rise 15"'ll �tenetfe9 th1cJ,.fICenSd.ttlSrends ether fx-' Tw as am to any rf ; 21 ,or ass19hed tedestetasted 'a 1� f BB "< perso of P°5•yA� LG 4�+ t {+*+` 'r f N° Date. .ka ZY.J. - NOR7M ?�1", on co TOWN OF NORTH ANDOVER L PERMIT FOR PLUMBING sSAcmUS� ' This certifies that i 1 l�. '`: t✓ . . . J . . . . . . . . %M 4 has permission to perform . . . . . . . plumbing in the buildings of . . . orf at . .56 � .�.4�r�n�1�s � .q-�. ., North Andover, Mass. � { Fee..�.%�4 . .Lic. No.. . .7��3 . . . . . fl,, ti _ PLUMBING INSPECTOR Check # 6 WHITE: Applicant CANARY: Building Dept. PINK:Treasurer u MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK z n CITY MA. DATE _..__._..---.--__...___........_...___ PERMIT# JOBSITE ADDRESS �' _ OWNER'S NAME + OWNER ADDRESS: ' TEL: FAX:�� 1? . __.................. TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXUTRES 7 FLOORS— Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONN DEVICE DEDICATED SPECIAL WASTE SYS -DEDICATED GAS/OIUSAND SYS DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYS DEDICATED WATER REUSE SYS DISHWASHER DRINKING FOUNTAIN FOOD WASTE GRINDER UNIT 'FLOOR/A REA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING r n A:C U INSURANCE COVERAGE have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES X NO ❑ If you have checked YES please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY [� OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S iNSur^cAiNCE VJAIVER:t nrii 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 Ihereby ce rtify that all of the details and information I have submitted(or entered)regarding this application are true and accurate 10 the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in omp'a ce w'th all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER NAME: -. ........ .......... ...._ ....C2_..._S. LICENSE# SS SIGNATURE COMPANY NAME: .... . ......... ... ..`. . .... '......-........:. .-.....-..... _.... - ..........._....... DTRESS: CITY: ........... STATE: ZIP: --._-- CELL:� �EMAIL: MASTER JOURNEYMAN❑ CORPORATION LK# PARTNERSHIP❑# LLC❑# 1 \ ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES D' <, Roo i The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations lug, I Congress Street,Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Complete Comfort Systems, Inc . Name (Business/( .DBA CLIMATE ZONE Address: 230 Essex Street, Haverhill MA 018.32 (866)891-7203 fax: (978) 372-2273 i C ty/State/Zip: Are�u an employer?Check the appropriate box: a vi Type of project(required): 1.[9 I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. E] Demolition working for me in any capacity. employees and have workers' insurance.: 9. ❑Building addition coin [No workers'comp.insurance P• required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.7 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12❑ oof repairs insurance required.]t c. 152, §1(4),and we have no ; ' l n 8 employees. [No workers' 13. OtherJ V comp.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. lContractors 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-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. _Lr7S�.2 i'K�r-rl- S r'OC-r #<0Insurance Company Name: m�(''_ Y" �-1 Policy#or Self-ins.Lic.#: U. 199thy' ) 7 aT Expiration Dater Ll C/ I 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of j Investigations of the DIA for insurance coverage verification. I I do hereb certifyunder the ains and enalties ofPerjury that the inormadon provided above is true and correct Si afore: _ ti ; Date Phone#: R6c,v RC-? t ' 7 ao Official use only. Do not write in this area,to be completed by city or town official, City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• je . _ FORL Then OetaCn Along All PertomwS Q� COMMONWEALTH OF MASSACHUSETTS -' • a PLUMBERS AND GASFITTERS REGISTERED AS A PLUMBING CORP ISSUES THE ABOVE LICENSE TO: MICHAEL HOUSE COMPLETE COMFORT SYSTEMS INC 63 MARSH LN E BEEMEE TWP ME 04414-6137 3316 05/01/14 146742 J 7 -e j Department of Public Safety One Ashburton Place, Rm 1301 Boston, Ma-02108-1618 j License: OR Bumer Technic a Certificate Number. BU 025.143 5,xplrss:1012112013 Restdated To: 1617 (MICHAEL H HOUSE 63 MARSH LN EHEEMBE TWP, ME 04414 Una: 1130.0 . Keep top for receipt and ahsrive of address notiilostlon. �f'&Gil Q iuM.UWID•PC4)BSACC,4593PAPOW-Yl1 .. .. ...._ ... .1 Date •, a�,aiLra3�z TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. has permission for gas installation . .. '. . ... . . .. w�.. 1. in the buildings of. . �.'. . �v✓4-- A-C . . . . . . . . . . . . .at . . . . . . . . . . . . North Andover, Mass. GASINSPECTOR Check# a S 76 8393 (, so MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY .......11i� Y._......... ..._................ MA. DATE ._..__............ PERMIT# JOBSITE ADDRESS �$_S" OWNER'S NAME risen G OWNER ADDRESS: _.� 7...._._....__... _.. ... ...... .__._........_ TEL: FAX: / .. . .. TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXUTRES 1 FLOOR— Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 . BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE- GENERATOR URNACE GENERATOR GRILLE LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER j UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES M NO ❑ If you have checked YES,please indicate the type of cove rag by checking the appropriate box below. LIABILITY INSURANCE POLICY OTHER TYPE 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 hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to th best of my Knowledge and that all plumbing work and installations performed under the permit issued for this applicap9n will be in complall Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General La-'ws� ' PLUMBERlGASFITTER NAME: LICEN E# L 23 SIGNA RE COMPANY NAME: J ADDRESS: CITY; STATE: ZIP: — ...' ELL: EMAIL: MASTER JOURNEYMAN❑ LP INSTALLER❑ CORPORATION ff# PARTNERSHIP❑#=LLC❑# ) N It)�� e e t NJ til CA �� �0-4� tv1 ROUGE GAS INSPECTION NOTES BELOW FOR OFFICE USE ONLY FWAL INSPECTION NOTES j Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES O- } S N2 9601 + TOWN OF NORTH ANDOVER ' PERMIT FOR PLUMBING ,SSACMUSE� (..tt.- This certifies that . . . V"A. . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . plumbing in the buildings of . . L.t1 °�'.`�.�^-'d ' .. . at. . . . . . .St . . . .l . �'". . . . . . . . . . . . . . . North Andover, Mass. Fee.3: %9F .Lic. No.. !0 3.a.1. . . . PLUMBING INSPECTOR Check # l� 6 WHITE: Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _ _ MA DATE _�0 PERMIT# JOBSITE ADDRESS OW ER'SNAME POWNERADDRESS ;B TEL FAX TYPE OR OCCUPANCYTYPE COMMERCIAL 0 EDUCATIONAL © RESIDENTIALO` PRINT CLEARLY NEW: 011 RENOVATION: REPLACEMENT:Q PLANS SUBMITTED: YES NO FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _( � —J1 .____...1 _.-.f _._...-_1 ___.___J -____� FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK .--...__._._i LAVATORY _ _I J I _---_11 __._....._a _.-__..I __.. 1 _.___-.( .___..__J _: ......I _._.... ROOF DRAIN F=j SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING i !.__f OTHER ( _.__... I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 141 NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D1 BOND 0 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 require nt. CHECK ONE 0 LY: NE R 1 AGE SIGNATURE OF OWNER OR AGENT B hereby certify that all of the details and information I have submitted or entered regarding this application ue an ac r t e b to y no edge and that all plumbing work and installations performed under the permit issued for this application will be in com 1' ent pr Sion of e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NA _f (2o ( LICENSE# _ O . ? SIG URE IVIPid JP Q CORPORATION 0#=PARTNERSHIP 0#._ ___ I LLC COMPANY N I r.-o J'-J?�f-�- ADDRESS CITY — ----- - -- 3 STATE ®ZIP TEL CELq� -7_! ._I EMAIL - - - - - -- - - - ry ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES C9 f� L O 1 � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individ'ual): ~�t Address: o 6(,> City/State/Zip-Y vG- ,- Phone#: ���F-M Are ou an employer?Check appropriate box: Type of project(required): 1 Jain a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. F1 New construction 2.El employees am a sole proprietor or partner- listed on the attached sheet.t ��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.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing 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.] 1311 Other *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. 1Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. tam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Vel ?olicy#or Self-ins.Lic.#: Expiration Date: rob Site Address:—kb E* rt '' City/State/Zip: N,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 25A0 f MGL 52 can lead to the imposition of criminal penalties of a .Inc up to$1,500 -an e-year imprisonment,as well a ivil nalties in the form of a STOP WORK ORDER and a fine if up to$ 00 a day against iolator. B advised t a copy is statement may be forwarded to the Office of nvestig tions of the DIA for insuran a cov ge ver' ation. do hereby cer er the pa' enalt'es o rju that t e information provided lbove is t ue and correct. >i nature: Date: W28-12612- 'hone 282a12'hone Official use only. Do not w ite 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#: r 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 number(s)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 permit or license is being requested,not the Department of 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 permit/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 permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit 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 02111 Tel. 4 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia �� COMMONWEALTH OF MASSACHUSETTS,77 PLUMBERS AN:D GASFITTE_RS . • t10ENSED AS A-MASTER PLU 8. ISSUES THE-ABOVE LICENSE TO: TIMb7HY ,A- GIARD SAUN,DERs ST NO ANDOVER M,A 0184 2414 �. 1031 05/01/14 g34gy ii## Date ,J0-L z - j y,'S'dL`Ab Ij�y TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . . .c�. has permission for gas installation . in the buildings of. . . .1.�.�t�+.� e.�. . . . . . . . . . . . . . . . . . . :. . . . . at . . .5. 5 .7 . :-'� North Andover, Mass. Fee 3:6-..cap. . Lic. No. .ko.79. . . . . . . . GASINSPECTOR Check 8385 MA%ACHUSHITS UNNORMAPPUCATON FOR PERMIT TO DO GAS FITIITG (Type or print) Date lo �(,� ZQ NORTH ANDOVER,MASSACHUSETT S Building Locations 5,C5-q-5,C5-q- 5hcu®n�J A-4- Permit# Amount$ Owner's Name E I stn berg New Renovation ❑ Replacement ❑ Plans Submitted ❑ x w U H a w w o � x a o w a z z ° z w w o a z Gww x a w w F w C7 F z F z E. �� w O O z O z U O w O z c4 O U Oa F a O o x w o a a SUB -BASEM ENT BASEM ENT 1ST. FLOOR 640- 2ND . F L O O R 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type) / Check one: Certificate soling Company Name i+Id -oil 1 rC • Corp. � Address Q1 1U 0j/41d �' &b044 YW6 M&® E] Partner. 41 Business Telephone ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter �`�/!��/Ut//� INSURANCE COVERAGE Check o I have a current liability Insurance policy or it's substantial equivalent. Yes 0 No❑ If you have checked yes,please iuAicate the type coverage by checking the appropriate box. 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 ❑ 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code nd„Sha ter of the General Laws. Signature of Licensed Plumber Or Gas Fitter Title ❑ Plumber 2 l City/Town Gas FitterIcL� um er Master APPROVED(OFFICE USE ONLY) ® Journeyman P 11-ow Z. TOO