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HomeMy WebLinkAboutMiscellaneous - 59 MILLPOND 4/30/2018 59 MILLPOND 2101095.A-0059-0000.0 111k1IIMMIN V%{1RYli gt.rm rb�fr •OR.T)Ii ANDOVER,BUELDING DEPAR.'�MENT lCr Nal1F51600 00 Jsgood Street . . No tll Andover Tel: 978-688-9545 Fax: 978-688-9542 B USMESS FO"FOR TO WN CLERK DATP- v NAME: S7 ADDRESS: Z®NMGMST.I T: TYPE OF13USINESS-1. C-0/u SOZ- 7 1A) /0m, B• ILDING JGAYOUT P:B OVIDED:, YES `� NO .AVAMARL-F,PARK GSPAM: ZONI1 G EY LA's USAGE:_ 'YES NO BUIIC D&Gr Il�S�EG GR BIGN'.A.T PX EUSINESS FORM FORMWN CLERX � -' .. �•? # '! t i T.� � 'SRL�'� ' 2. 0 Horne Occupation(1989132) An accessory use conducted within a dwelling by a resident who resides in the dwelling as his principal address, which is clearly secondary to the use•of the building for luring pluposes. Home occupations shalt 'iiiclizde,"but not 7imi-ted to the following uses; personal services such as fwnished 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 nm ufacturing o£goods,which.impacts Ilio residential nature of the neighborhood; 4. For use of a dwelling in any residential district or multi-fanify district for a home occupation,the following conditions shall apply. a. Not more than a total of;three (3)'people may be employeq�in the iiaine occupation, ono of whom shall be the owner ofthe homo cicdupatioh anal residing ire i9d"&,ening; b. no use is carried on strictly Within the,principal building; c. There shall be no exterior alterations, accessory buildings, or display which are not customary with residential buildings; d. Not more than twenty-five (25) percent of ffic existing gross floor area of fho dwelling unit. so used, not to exceed one thousand (1.000) square feet, is devoted to"such use. In connection with such use,there,is to be kept no stock in trade, commodities or products which occup3r space beyond these aimits; e. There will be no display of goods or wares visible from 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 m any other way become objectionable or detrimental to any residential use within the neighborhood; g. Any such building shalt include no features of design_not custtimary in buildings for residential Signature Date i - I Date.........(....................................... .HORTIt . K, TOWN OF NORTH ANDOVER h � 9 PERMIT FOR GAS INSTALLATION gB�CHUS� IAW This certifies that ........................ . .... .. .. �`.�! has permission for gas installation ��1 ... .��.����.�:-............ in the buildings of.....`.." .a..1.......'.................. at..............�.......4......H.t.'..1....C�.�. ............. North Andover, Mass. . Fee.—....4.."....... Lic. No.2...''L..543..... ................................................. . GASINSPECTOR Check# co 9432 -` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,1 CITY MA DATE[ 7- 3 PERMIT# `I JOBSITE ADDRESS S`l GOWNER ADDRESS TE LL $ ^p j$' FAX TYPE OR OCCUPANCY TYPE COMMERCIAL F-] EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:[Q RENOVATION:[& REPLACEMENT:® PLANS SUBMITTED: YES 0 NO APPLIANCES 7 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 --= _! r�1 _._fl._ - -- 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 1"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 INDEMNITY BOND E 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 AGENT E3 SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc to to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in pi ce w all Pertinen ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. .4 - .PLUMBER-GASFITTER NAME �4_ w-�Ce-l� LICENSE# �SYf3 SIGNATURE MP© MGF 0 JP M JGF[j LPGI© CORPORATION©# PARTNERSHIP©# LLC®# COMPANY NAME:L�._-F'N1jI-%V44 � ADDRESS ---n—���.�.��- vim•-` CITY _Pln, , --kj _ I STATE�ZIP TEL FAX "!�I CELL �- I(.[ EMAIL vim-• . ,� .. eu ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No Z& , //C/ THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES y i R i The Commonwealth of Massachusetts Department oflndustriglAccidents 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 Legibly Name(Business/Organization/Individual): Address: 1°? City/State/Zip: Q�v}:�hcsw NW 0396 Phone#: 6 6 3 Are you an employer?Check the appropriate box: Typo of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(fulland/or part-time).` have hired the sub-contractors 2.Pq I am a sole proprietor or partner- listed on the attached sheet. 'l• ❑Remodeling ship andhave no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g ❑Bg addition [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.F1 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.E]Plumbing repairs or additions myself [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance employees.required.] loyees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they Lire 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. lam an employer that is providing workers'compensation insurance for my employees. Below is thepolicy 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 requiredunder Section 25A of MGL o.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 c u der ze pains a enalties of perjury that the information provided above is true and correct. - Si ature: 4,,� Date: u Phone#• (01) 15'7 3 3 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.PIumbing Inspector 6.Other - - Contact Person: Phone#: w' Information and Instructions . Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for they 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 ofits political subdivisions shall enter into any contract for the performance ofpublic 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 maybe submitted to the Department of Industrial Accidents for confirmationof 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(ifnecessary)and under"Job Site Address"thea « applicant should uld 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 Iicenses. 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: Tho GomMonwealth ofMlassarhusotfs Dep.a tmeut of Industrnal.Accidents Mice ofInvestigatious 600 Washiugtoxi.SfxQet Boston?MA.02111 TQL#617-727-4900 ext 406 or 1.-87TMASSAFB Revised 5-26-05 Fax#617-727-7749 vVur.mace an-t-rhl;a I O MONWEALT MASS 4CHUS�TTS .: s BOAR.D F PLUMBERS AND' GASFITTER8 ISSUES THE FOLLOWING' LICENSE '` L I GENSEI7 A$ AJOURNFYMAN;`O, UM It �.JOSEPH M PAGEAU J 17 T I MBERLANE RD. �'x ,/ W!, pL I S SOW NH 03865-25..* 22 4 0 0 1'61 237718