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HomeMy WebLinkAboutMiscellaneous - 58 MAPLE AVENUE 4/30/2018 58 MAPLE AVENUE 210/019.0-0010-0058.0 I i i 09710 D ate TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . 4-1.all U.1�1x . . . . . . . . . . has permission to perform . Q,/11.. , , , , , , , , , , plumbing in the buildings of. �.1,.; . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . � . . . . . . . . , North Andover, Mass. PLUMBING INSPECTOR Check# I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK x " CITY NORTH ANDOVER MA DATE 2- PERMIT# JOBSITE ADDRESS ^1G" I;a_ OWNER'S NAME�j,�;// P OWNER ADDRESS SAME TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL( EDUCATIONAL RESIDENTIAL Fj PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES E] NO FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 1 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR 1 AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET j URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 WATER PIPING tOTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 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 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 State Plumbing Code and Chapter 142 of the General Laws. < PLUMBER'S NAME THOMAS HALLORAN LICENSE# 24833 SIGNATURE MP EI JP D CORPORATION # PARTNERSHIPE]# LLC[]# COMPANY NAME HALLORAN PLUMBING ADDRESS 826 DALE ST. CITY NORTH ANDOVER STATE ZIP TEL 978 �v MA 01845 -685-9504 FAX 08 08 0_ _ CELL EMAIL 7 2 4 9 8 1 I t, The Commonwealth ofMassachusetts Department o Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: PBu><lders/Contractors/Plectricians/Plumbers Applicant Information Please Print Lesribly Name (Business/Organization/Individual): Address: 8026 City/State/Zip: /V��W/L �l8l � phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ 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. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp, insurance comp.insurance.t 9• E] Building addition 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. ❑ 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.E] 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 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 ani an employer that is providiisg workers'compensation insurance for niy enzplovees. 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). 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is trite and correct. Si nature: �-- Date: 122— Phone Official rise only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: COMMONWEALTH OF MASSACHUSETTS.. 0 ® ® ® • 0 D 0 ` PLUMBERS AND GASFITT S' ;LICENSED AS A JOURNEYMAN;PLUMBER IS$UES THE ABOVE LICENSE TO: I THOMAS. .M HALLORAN 82'6 DALE ST .� NORTHs'_ ANDOVER MA 01845 .- 14-22 . 24`8.33 05/01/14 1.427.01—.11I Fold,Then Detach Along All Perforations J I Date.12— I 0 J Z.. . • �y1 CT7sp'"� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION _. 7 `This certifies that . .( . . � U �r ! 6 • rJ�/ . . . V . . . . . . . . . . . . . . . has permission for gas installation • • • • • • • in the buildings of. . Dle -JQ . . . . . . . . . . • • • • • • • • • • • • • • • • • • • • • at . . . . . . . .t5-b. . .H� �•�• /�. . . . . . . ,North Andover, Mass. Fee . . Lie. � GAS INSPECTOR Check# 8487 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK S b r CITY NORTH ANDOVER MA DATE ?/-2f/2- PERMIT# v JOBSITE ADDRESS J � f0 ��� OWNER'S NAME�P Gce,4� OWNER ADDRESS SAME TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL E] PRINT CLEARLY NEW:® RENOVATION:® REPLACEMENT:El PLANS SUBMITTED: YESE] N0[] APPLIANCES Z FLOORS-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER OS R 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 r 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: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 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. PLUMBER-GASFITTER NAME THOMAS HALLORAN LICENSE#24833 SIGNATURE MPEI MGF® JP[j JGF® LPGI® CORPORATION®# PARTNERSHIP®# LLC®#n- COMPANY NAME:HALLORAN PLUMBING ADDRESS 826 DALE ST. \ CITY NORTH ANDOVER STATE MA ZIP 01845 TEL uu \V FAX 978-208-0840 CELL EMAIL Date. . 9566 1 D tio TOWN OF NORTH ANDOVER s PERMIT FOR PLUMBING rF s i, • �. �,SSACMUS��h This certifies that . . . . . . . . . . . . . . . ' has permission to perform ik. plumbing i4thn buildings of . . . . �/GI. . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . .?Z� . . . . . .. . . . . . . . . . . . . . , No Andover, Mass. 5 . . . ., Fee� -r' . .Lic. No.. .z ... . . . . . . . , . . . . . . . . . . . . . . . . PLUMBING INSPECTOR l Check # f��/ . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY NORTH ANDOVER MA DATE $'12-1/1.2_ PERMIT# JOBSITEADDRESS 58' /'JA0P4& epCG OWNER'S NAME ®c-//"Of POWNER ADDRESS S,4w" &'-'g TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:® RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES® N0[3 FIXTURES 7 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/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR 1 AREA DRAIN INTERCEPTOR INTERIOR E KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY[3 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 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. PLUMBER'S NAME THOMAS HALLORAN LICENSE# 24833 SIGNATURE MP® JP E) CORPORATION®# PARTNERSHIP®# LLC®# COMPANY NAME HALLORAN PLUMBING ADDRESS 826 DALE ST. CITY NORTH ANDOVER STATE MA ZIP 01845 TEL 978-685-9504 FAX CELL EMAIL ail i D . . . . ate.. . ...... !/. .. . . NORTH pF4��ao ,s,ti0 o= °` ° p� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION f _� �9SSACHUSEt s This certifies that . . .7f1alv�'.5. ./,416c..gkI . has permission for gas installation . ! rr in the buildings of . . . . . . .[. . .1` . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . �.,I71R . .,,A�. . . . . . . . . No 7Andover, Mass. Fee. lac 'v Lic. No.. . . . . . . GA INSPECTOR Check# c� z 8314 1 � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITYNORTH ANDOVER NSA DATES %.'L P � � ERMIT# JOBSITE ADDRESS 53k r3,�� /��� OWNER'S NAME,0Vw`(iij,►P,0 OWNER ADDRESS 6- TEL FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL._.`,_; EDUCATIONAL RESIDENTIAL _ CLEARLY NEW:F-, RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES W,.` APPLIANCES 1 FLOORS— BSM 1 2 3 1 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 COCKSr 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 liabili 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 ;. a OTHER TYPE INDEMNITY `_ 1 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 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. PLUMBER-GASFITTER NAME THOMAS HALLORAN LICENSE# SIGNATURE MP MGF JP JGF LPGI CORPORATION 4 PARTNERSHIP # LLC ..: COMPANY NAME:HALLORAN PLUMBING ADDRESS 826 DALE ST. CITY NORTH ANDOVER STATE MA ZIP 018 TEL FAX 978-208-0840 CELL EMAIL The Commonwealth of Massachusetts Department of Industrial Accidents m Office of Investigations a 600 Washington Street Boston,MM 02111 t: s www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name.(Business/Organization/Individual): fY1/4f..1_Qd AA-1 P/_ 4 JX, Address: S1.2-6. Q,g L if `S'7— City/State/Zip:/V49✓?T�1 Phone.#: Areyou an employer?Check the appropriate box: Type ofreect ro aired ' 4. I am a general contractor and I p I ( q )'t ❑ g 1.El I am a employer with , 6. New c employees(full and/or part-time):* have hired the sub-contractors ❑ 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 g. Demolition working for me in any capacity. employees and have workers' insurance.# 9. E]Building addition [No workers'comp.insurance comp. 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.El Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t e. 152, §1(4),and we have no - employees. [No workers' 13.0 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 is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#:' 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 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 coveragre verification. I I do hereby certify under the pains•-a�ame�nd penalties of perjury that the information provided above is true and correct Si attire: Date: Phone I Offlcialwse only. Do not write in this area,to be completed by city or town officiaL Ci r 'Town• t3'oPerinitlLicense# 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#: