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HomeMy WebLinkAboutMiscellaneous - 58 PINE RIDGE ROAD 4/30/2018 ROAD 210106 �g pINE RIDS E�000.0 5 Date.1.....1...........` ..... I TOWN OF NORTH ANDOVER ° a PERMIT FOR PLUMBING a oma::°• t 8`4gCMU5E k / 00 x0-1 ' 'his certifies that........:...:'......`.^:. . .u-C`w� e n - . ... : has permission to performY. ".:..... .:r�..:...... ........: plumbing in the buildings of............................. L.................................. :. ................... .."« � �°f North Andover Mass. Fee.k.......Lic. No..-3>...!.X76.. _..� ...........................................:. PLUMBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY Or l.- MA DATE !O [ PERMIT# JOBSITE ADDRESS C_ �F- c OWNER'S NAME �tJ G��G' ( POWNER ADDRESS eye TEL 1,C-j 1/ ;may/ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW: ] RENOVATION: REPLACEMENT: Q PLANS SUBMITTED: YES NOE]( FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 4 1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM =======_J========1 DEDICATED GAS/OIL/SAND SYSTEM f ( F ^j .,___( -._l DEDICATED GREASE SYSTEM _..__.1 _._l � @ I DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM 1 __l ____I _...___ ._._____I -,--.J=== DISHWASHER __.___4 __j _-.____I _._..1 -._...__._1 DRINKING FOUNTAIN _..___f I __.__1 __.__-__I ._.___-. .._._.-__.1 .___..1 .__.__f .__..._.J _j _._..._` FOOD DISPOSER i -. -. ___.__-I _--_.__j ___-.__i L—I I _..__._1 __._ _! ._.___1 __._._._f .--_.__ = ( _._.__I FLOOR/AREA DRAIN ! Y._.-_.� -___-- � f 1 _ _f _._._.1 .. 1 _.__.__._ _--.-__- INTERCEPTOR(INTERIOR) ( _[ -_T. __._.( .. I f � . ___.....__I __. _1 . .._J I I I KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK - TOILET URINAL 1 ...._....--I -_--.__S ..__1 .._ __._... _I WASHING MACHINE CONNECTION 1 _ ! ___._._ WATER HEATER ALL TYPES WATER PIPING OTHER _. _ _ .__� I ! 1 __1 ....._. ...( _-_.__( ___..__- ._ _i __.____I ......._. _ I i _-____I ._.____IF _J _--_! .__ ___I. __j __,f _I —- INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES _ .I NO Ell 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 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 Q AGENT ID 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 the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co fiance with all Pertinent provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME S e1r/-f^ [LICENSE# GNATURE MPQf- JP Q CORPORATION Jf# PARTNERSHIP O# LLC�1# COMPANY NAME ADDRESS mclN X(vj ' CITY �,��E;LI, _ �STATE ( ZIP �_ TEL I_ AW FAX L _J CELL EMAIL - - �I ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No f n. THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES i, AV : r P - The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations IN 600 Washington Street Boston,MA 02111 www.massgov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print �Lre 'bl Name(Business/Orgg1tion4ndividual): �[� 660Address:(Business/O: City/State/Zip: b� Phone#: u � Ar you an employer?Check the appropriate bog: Type of project(required): 1. a employer with 4. El am a general contractor and I 6. E]New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers comp.insurance. 9. E]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its officers have exercised their 10. Electrical repairs or additions required.] 3.❑ 1 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.] employees.[No workers' 137KOMer comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i 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 their workers'comp.policy information. X am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:- `2v WZ4 - `� E Policy#or Self-ins.Lic.#: L Z3 Expiration Date:� xp Job Site Address: ,!O? ( — t- 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. X do hereby cer. ' under the pains and penalties o er' at the information provided ab ve is true and correct. - Signature: Date: 6l/ Phone#: -7,5,4— 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#: 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 dee ed " m 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-contractors)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 maybe 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,anapplicant 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 bum 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 CoMJA0RWeajtjjofMassacl,usPtts Department of Industrial Accidents Office ofInVestigatxons 600 Washita on Street Boston,,MA 02111 Tei,#617-727-4900 opt 406 on 1-877rMASSAFB Revised 5-26-05 Fax#617-727-7749 www.naass,govfdia Date ................... 0-0 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION sgCMU3E This certifiesthat ....... ................................... has permission for gas installation .................................................... inthe buildings of................................................................................................................... at..........6 ...... A�.........Id., North Andover, Mass. Fee.. ..... Lic. J.. ....... .................................................. GASINSPECTOR Check# 9615 li MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY /{� Yi1�pl?�i� ��—I MA DATE ot,3 PERMIT# JOBSITE ADDRESS OWNER'S NAME 4G OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[jjEDUCATIONAL �( RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT:® PLANS SUBMITTED: YES NO F APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNERJ ,-. JI Y._ -J======= COOK STOVE DIRECT VENT HEATER _I DRYER .. FIREPLACE FRYOLATOR FURNACE1 GENERATOR GRILLE !... INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN f �► T I I ( - 1 (- POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER _ ► _ j j ��I, UNVENTED ROOM HEATER WATER HEATER OTH—ERF _ INSURANCE COVERAGE - 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES)&0 FA IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OFCOV RAGE 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 0 AGENT D 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 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-GASFITTERNAME LICENSE# SI RE NIP GF Fj JP ® JGF �( LPGI© CORPORATION�# PARTNERSHIP®# LLC 0#= COMPANY NAME:CGR PN'Tl✓G __ ADDRESS _3< _d��✓ a _ _ _ _ CITY v, h STATE TEL 7e!— g y-- _ FAX CELL EMAIL SStc &I�.bG%� C-QI'Yl ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No 3--r. ZOARe//V THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES t r t w h �OOMMONWEi LTH OF MASSACHUSETTS:. `, • PLUMBEO.— ASFITTERS ISSUES TH'E FOLLOWING LFCENSE LI :EN;SEO AS A MASTER PLUMBER ANTHONY R0SENSTfNE I"' ' 31 MOUNTALN.tRD #3'URII N:GTON MA 01803 4739 1600$ 05/01/16 223185 i 1 =E� COMMONW r • • EALTH OF MASSACHUSETTS : • • • - PLUMBERS '�WSF ITT E,RS, : ISSUES TFfE' FOLLOWING. LICENSE Ll C.ENSED: AS; A JOURNEYhfAN PLUMBER ANTHONY ROSENST:m- 31 MOUoi NTq 1 N `Rp BURS I NITON MA 0.1$03 413J 31795 05/01/16 223 186 >: i C COMMONWEALTH OF Maj46Hl3SETT.. I PLUM 6 � j BE1� / ASF I TTERS ; I SSUES THE= F0LLOW[At':1 L VCE NSE ! REGESTEREO AS A PLUMBING CORP II ANTHONY ROSENSTfNE tii 1 r Z ..::.CLASS I C — CONSTR; REMODELING PLBf'� x " 31 MOON ISI :RD l `! � I f!a z Lu BI1RL INGTON MA 01803 4739 .:... J 35605/01/16 223184 1