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HomeMy WebLinkAboutMiscellaneous - 56 Perley Road I I I i i I 0995 Date . ���� . . . . • TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .41.Ailb!. ('."-j. . .0 .t. has permission to perform . ':If. . . . . . . . . . r plumbing in the buildings of. . . L..).0. . . . . . . . . . . . . . . . . . '. at . . 15� I.P.. .0 , . . . . . . . . . . ,North Andover, Mass. Fee Lic. No. �. N b. . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check# 4 7 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 93EREM�3— - .00 C11 C� CITY NORTH ANDOVER MA DATE (0 PERMIT# JOBSITE ADDRESS 5-g OWNERS NAME Z,,'rl OWNER ADDRESS. TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL X PRINT CLEARLY NEW: RENOVATION:,' REPLACEMENT: PLANS SUBMITTED: YES NO FIXTURES 1 FLOOR— l3SM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB GROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES ATERPIPMG OTHER INSURANCE COVERAGE: I have a current Ilabilbinsurance policy or its substantial equivalent which meats the requirements of MGL Ch.142. YES ek: NO N11 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY X- OTHER TYPE OF INDEMNITY BOND OWNER'S INSURANCE WAIVER:I am aware that the licenses 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 Paw 1 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 State Plumbing Code and Chapter 142 of the General Laws. 4- PLUMBER!S NAME THOMAS HALLORAN LICENSE#24833 SIGNATURE -7 MP. ip. CORPORATION'-, # PARTNERSHIP.. # LLC .0 COMPANY NAME HALLORAN PLUMBING ADDRESS 826 DALE ST CITY NORTH ANDOVER STATE MA Zip 01845 TEL 978-685-9504 FAX CELL EMAIL V4 `f � � I f I ti( J I II 1 C j/,2 ay 69 o� I I The Commonwealth of Massachusetts r ` Department of Industrial Accidents Office of Investigations a ' 600 Washington Street Boston,MA 02111 r' www.mass gov/dia ' Workors' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name.(Business/Organization/Individual): /� c� ar9 l✓ .r1, j Address: e S7— City/State/Zip:/Ve,';j y/ Phone.#: Areou an employer?Check the appropriate box: Type of project(required): 1.F1 am a employer with ; 4. E] I am a general contractor and I , x 6. New construction • em to ees full and/or have hired the sub-contractors p ,y r art time . � P ) 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. ❑Demolition working for me in any capacity. employees and have workers' co msurance.T' 9• ❑Building addition [No workers'comp.insurance comp. . required.] 5. [] We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.[]Roof repairs insurance required.]t c. 152,§1(4),and we have no . employees. [No workers' 13.❑Other 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. :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. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding 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: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failuie 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains•and penalties ofperjury that the information provided above is true and correct. Sign Date: Date• f _ hone#: -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.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact.Person: Phone#: 0 i COMMONWEALTH OF MASSA:C.I-1lJSE.TTS e e e � e PLUMBERS A D GAS LICENSED AS A JOURNEYMAN PLUMBER ISSUES THE'ABOVE LICENSE TO: THOMAS `M HALLORAN -:W826 DALE ST _ fi ORTH .ANDOVER 'I MA0184!5-1.4-22 : . 24,63;1 05/01/14 1427D1 �' Date . �.�.� . . . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION l , This certifies that ! N �� has permission for gas installation . .�:��� -. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . in the buildings of - Le + 1. .� t�. . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . '`� . :!�. �.E'. `'-9 . , , . ,North Andover, Mass. Fee GASINSPECTOR Check# ` 3 Zl� 8737 -� MA55ACHU5ETT5 UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTINrG�WORK MA DATE �l3! �3 PERMIT# F, CITY NORTH ANDOVER m R Y � JOBSITE ADDRESS � %'L �► ,�p OWNER'S NAME OWNER ADDRESS TEL FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL; EDUCATIONAL _: RESIDENTIALiX CLEARLY NEW. RENOVATION REPLACEMENT 3C PLANS SUBMITTED: YES 4_ NO 'G APPLIANCES Z FLOORS— BSM 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 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 1 OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ISG;NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY !4N 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 i_v� AGENT , SIGNATURE OF OWNER OR AGENT i 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 v 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. ` PLUMBER-GASFITTER NAME LICENSE# 24833 SIGNATURE MP;_-,_ MGF f JP X; JGF > LPGI CORPORATION _^# PARTNERSHIP; -,# LLC .M # COMPANY NAME:T.HALLORAN PLUMBING ADDRESS 826 DALE ST. CITY NORTH ANDOVER STATE MA ZIP 01843 TEL 978-685-9504 FAX CELLJZ�'— � EMAIL :. �� � g � I I ��l�'��� �±7 � r ���� '�� ��� � �( _ i r III • The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations s 600 Washington Street Boston,MA 02111 www.massgov/dia ' Warkors' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print Le, ibly Name,(Business/Organization/Individual): /�f &.cel d✓ ,� .r1,�j O,,r Address: . L)/4 L e S i City/Mate/Zip: eMi i// �✓��C1� Phone.#: �t`% Areou an employer?Check the appropriate box: = 1.ElI am a employer with ' r, 4. E] I am a general contractoi and I Type of project(required)s, employees(full and/or part time):" have hired the sub-contractors 6 ❑New construction 2. I am a sole proprietor or partner- listed oil 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' [No workers'comp.insurance comp.insurance.t 9• ❑Building addition 5. We are a corporation and its 10. Electrical repairs or additions required.] - ❑ rp ❑ p ' 3.❑ I am a homeowner doingall work officers have exercised their 11.❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL insurance required.]t c. 152, §1(4),and we have no 12.[]Roof repairs employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeoti;niers x rho 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. 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. Insurance Company nip y Name: _ Policy#or Self-ins.Lie.#:' Expiration Date: Joh Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failuie to secure coverage as required under Section 25A ofMGL 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 the pains•and penalties of perjury that the information provided above is true and correct Signature: .� Date Phone#: Offu:ial,vse only. Do not write in this area,to be completed by city or town offcciaL City or Town:' Perinit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6,Other Contact.Person: Phone#: 4 1 COMMONWEALTH OF MASSAC.I.IUSIE.TTS � )i P E3ERS A D G S T R LICENSED'AS AJ OURNEYMk LUM=BER ISSUES THEABOVE LICENSE TO '` ! THOMAS M •HALLORAN I 826 'DALE ST �! -NORTH - ANDOVER MA 01845-1422 24833 05/01/14 I�r2701 • • ,__..- T 1 f lo Date . . ./. .7 �. HpRT" TOWN OF NORTH ANDOVER 3? ��w -'•..'• pL o PERMIT FOR PLUMBING ,SSACMUSE� ► This certifies that Vis-- �. . . . . . . . . . ..4- has permission to perform ?_ . _ �lr._. . . . . . . . . . . . . ti plumbing in-the buildings of . . .� . . . . . . . . . . . . . . . . at . . �. . . . . . . . . . . :- . . . North Andover, Mass.. . . �.' Feed. 0 . . . . . .Lic. No.c?/#/. . !. . . . . . . . . . . . . . . . . . PLUS JN INSPECTOR Check # v 6224 .f MASSACHUSETTS IFORM APPLICATION FOR PERMIT TO DO PLUMIRP (Type or print) NORTH ANDOVER,MASSACHUS TTS r Date Building Location J(e::2 ��=1ZL� Owners Name 4C' �Z Q Permit# Amount art Type of Occupancy P&s New Renovation Replacement 13— Plans Submitted Yes No ❑ FIXTURES S1(BRiVIC B4MY0If ]S1C FIDCR �FIDCii 4M HOR 5M FUM M Hi" A 7M FLCXR gm FInm (Print or type) Check one: Certificate Installing Company Name P, / Corp. Y/ - yav711 Address P) � Partner. r'� 5 Business Telephone 13-2 Fire/Co. Name of Licensed Plumber: `_ Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature 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 installation performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus P m 'ng Code and Chapter 142 of the General Laws. By: igna ur o ense um er T e o lumbing License Title City/Town MEMO NumDer Master Journeyman APPROVED(OFFICE USE ONLY. Dat .. . . . .. . ... .. 0* 0 T 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �9SSAGHUSEt Thissertifies that(:4-�� . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas ingAllation . . . . . . . . . . . . . . . k--i the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ort 0.. . . . . . . . . . . . . . . . . . . . . North Andover, Mass. Fee. . . . . . . . . Lic. No.. - . . . . . . . . . GAS C !R Check# IS'41 4904 3 `MASSACHL�SE�"S UNIFt}�t�t ��'P1.�CA�" Ci+# F R�P�RMOTr'�'C3 gC,} �ASF�TTi�fi lPdnt or Type) � - _ i ! -- -Own Name � ata 1 TYPe °f p -- — ;New [p � Renovation _ Ae i cement_�""- Plans �ubrnitted Yes( o w t-- cs -? 15 x Q e ; O �► cc tl lr N L7 3Rlf y} L� .� NO O: � �►! tsr z { uy v FAyr. 14, A SUt TS'fFLflO;R - � _ I 2t�O F10{jA s STtILOQR s FS r- _ 7 t TTt3 FtOQA ' eTi� ELodR - Installing Company #dame ' t. .> s Check one Certil3cate Address Business TelephoneY - z D 1"irmlCo Name of Licensed Ffurrtber or=Gas Fitter ` t ��-i.,G�:� 4 Y y ) 2 f INSURANCE C{)VERAGE ' � � _ f have a current 1i Itty insurance policy of its substaniial�equlvaient which meets the tegttitetnents of MGt.Ch 142 time checked es #ease indicate #fie ecoJera e b 'checktte_a to mate tiox. - A tl�nity insurance-pollcyF ' Qtt�er#ype�or lnc#emnity D `'� Bond z CI S - OYIftIB#t'S INSLIftANCEI yAi1l=R #acct arare #hof the iicensee does"not fiave tine insl�raace coverage required by Chapter 142 of the Mass Gt:nerat LaHrs, and that nny signature=an this permft appNca#ion vtiralvesthis fiequlrement = �' - Cttezk ohe' - - � O�r�erp Agent D 7&gnalure of O�rmer of Ureter s l�gent #treceby eerily that aq of Zhe detabs and tnfocmaiton 4 fiave submitted tot enleredf in_above appiicailni�are the and accttrate_Eo the best o[ ' knowledge and that all ptunibing wo k ar,d lnstatl R!` sd6e 1n�o lat►ce7y lth er pertinent Provlsronso[the Massach'useiis Stale Gas-Co��and-q�apte�742 of the�etseral La�+vs ' �P � = r BY T 'e-o[License � Idle i' bet nature o sense um er:or Gas.; rtter Y s5rl(f Cdj+r[own stet YJcense tJwnber 1U'f'1K31T�1`i�: ,Journeyman - I Q I 11 .t .1 :, .. r, % f 4 ti �,; t: , , t �t;: ,. a. 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