Loading...
HomeMy WebLinkAboutMiscellaneous - 598 SALEM STREET 4/30/2018 598 SALEM STREET 210/038.0-0099-0000.0 r \ . f Date........�...2G ................. OF pr/,,4 TOWN OF NORTH ANDOVER * * PERMIT FOR GAS INSTALLATION ...el"'°tte 88ACHU This certifies that -10-5 �0'5.rar- . ................................................................. has permission for gas i;n/stallation ...( ....................................... in the buildings of...........1`\C....SV1.!! .t:...........................:. ,, ........................................... at.......� .. .��..:✓....... .-! :�:�?..... ....... North Andover, Mass. Fee2`�........ Lic. No:. ..... 1 .......................................................... GAS INSPECMR Check#7 * 908 f MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING W RK CITY MA DATE l / PERMIT# V JOBSITE ADDRESS __ 5 cS'r OWNER'S NAMEi1/ G.- OWNER ADDRESS L. TE _3-q D// FAX_ TYPE OR OCCUPANCY TYPE COMMERCIAL _ ( EDUCATIONAL RESIDENTIAL Id PRINT CLEARLY NEW:01 RENOVATION:E] REPLACEMENT: PLANS SUBMITTED: YES E] NO E APPLIANCES 1 FLOORS-► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I ! I I ! BOOSTER (r- _ ; = _ _ CONVERSION BURNER I �J _ � I _ —i -_ _ I---a COOK STOVE DIRECT VENT HEATER DRYER . -- FIREPLACE FRYOLATOR FURNACE GENERATOR _ _(.� -_{ _ ( ._ T. ._ i 1 ( -___f —AE-71 11 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER —1 �J —1 T-- _ I . __ (ED ROOM/SPACE HEATER _- l_. ROOF TOP UNIT TEST 1 I_.-J �- UNIT HEATER _-:I---I ._ - J L_- _ ._ - F7 I =- UNVENTED ROOM HEATER _-- WATER H EATER ! I J _-.. f �I. OTHER _..... _- JILI ar- -- --- - - INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES JHNOD( IJ IF"YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY LJ OTHER TYPE INDEMNITY Q BOND FIJI OWNER'SINSURANCE 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 F---11 AGENT F-1 - 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 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 lance with all Pertinent ovisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ �. PLUMBER-GASFITTER NAMEDom__ LICENSE# _3 SIGNATURE MP 51 MGF EJ JP E] JGF© LPGI 0I CORPORATION a J PARTNERSHIP©# LLC 0# ! COMPANY NAME: _d �`f�J1 %N�/ N %' DDRESS CITY J1__— - -- -�� STATE M ZIP J��TEL FAX -5-:bCELL �EMAIL Q/9__OI�eN � �i Q _ r 'Co — -- ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECT14NOTES Yes No 'i THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of 1Mlassachusetts ,. Department o f rndustriat Accidents Office ofLravestigations 600 Washington Street Boston, ALI 02111 www.m assgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le21b1y Name(Business/organizabon/lndividual): z Address: City/State/Zip: /��� ��� _ Phone#T�%�� AVon an employer?Check the appropriate boa: Type of project(required):' 1. 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 constriction I.❑ I am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. F (Demolition working for me in an capacity. workers' comp.insurance. 3' � �'• 9. ❑Building addition ENG workers' comp insurance 5. 0 We-area corpm im and its required.] officers have exercised their 10.[JElectricalrepairs or additions 3.F-1I am a homeowner doing all work right of exemption per MGL 11.[�Plumbing repairs or additions myself. o workers' co c. 152,§1(4 and we have no Ys � mp• )� 12.0 Roof repairs in required.]t employees. [No workers' 13.]Other comp.inns ce required-] `L g am•licsnt�t ch ys box-41 mart also$3i o•_E'ice serii^a eP••••, shmng r•,••L«y'M tun s�sti z:c inform--tion. po.. T Homeowners who submit this aindavit indicating they are doing all wort:and then hire outside contractors must submit a new affidavit indicating sucn. 4Conttactors that check this box must attached an adifitional sheet showing the name oftbe sub-conhactors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. I.nsurauce Company Name: (/// Y Z?l 1�C '/��/C (� Policy#or Self-ins.Lic.# ? D / �y�� Expiration Date: A� o; / Job Site Address: ��L/ L( City/State/Zip: i - At:,.ach 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 luvestigations of the DIA for insurance coverage verification. I do hereby certify unor the pains ands of erjury that the information provided above is true and correct, Signature: Date / Phone#: 4�� OJ ffw-idruse only. Do notwrite art this area,ta-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#: Information as d Instructions Massachusetts General Laws chapter 152 requires all.employers to provide workers'compensation for their employees., Pursuant to this statute,an emplayeels 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 includmg tie 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 oft dwelling house having not more than.4izree apartments and who resides therein,or.the occupant of the dwelling house of another who employs persons to do mainteooance,construction or repair work on such dwelling house or on the grounds or budding appmir*m*+ thereto shall not because of such employment be deemed to be an employer." MGL chapter.152,-MC(6)also states that"every state or local licensing bgency shall withhold the issuance or renewal:of a license-or permit to operate a business or to c onsfruct buildings is the commonwealth for any - applicant who has not produced acceptable evidence of coanpliance 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." A►ppiimats Please fila out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-co�xaci?or(s)name(s),address(es)and phone numbers)along with their certifiicate(s)of insurance. I i mibed Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees-other than the members or partners,are not required to carry workers°compcnsation 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 Siwe to sign and date the affidavit. The affidavit should be.reft-aned t D the city or town tUh-C—L the application ti}r the pmmuit of license is being requested,not Sze De_r;artznent of .Industrial Accid.-zits. Should you,have any questions regardiga 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 Bre appropriate line. (qty or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a spare at the bottom of the affidavit fur 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 pezmill�e mzmber which will be-used as a reference mimber. 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 venae (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.. The Office ofImestigatians would Ince to thank you in advance for your cooperation and should you have any questions, please do nothesitair to give us a call. The Department's address,telephone and fax number. .The Commonwealth cafMassarhusetts Department oflndnsftW Accidents Oce Of isvesigatie�s' 6M Wadljngtm Street Boston,MA X2111 Tel#617 727 49Q4.ext4Q6 or 1-877 MASSAFE Revised 5-26-05 Fax#617-727-7749 www mass_govAha =COMMONW LTH OP AiCHUSETTS --"2 - PLUMBERS AND GASFITTERS REGISTERED ASA PLUMBING CORP = := ISSUESTHEABOVE UCE(agETO: ._GEORGE. R LAROSE =ANDOVER PLUMBING & HEAT3.NG-:GO. '• 2.0 -AEGEAN DR -NIT: ID ihETHUEN . : 15.80 = -2T22 05/01/14 Y7254mg 5 Q � l� �:1CS'i ' COMIIIl06dWEALTH OF Me48SA9Q;DSE'I"I' _ OMMOWWEAL'�'H OF MASSACI$QBS o .� 17do.IkA[o1��,�1L°I���1►1���-°A= o:o'0' ___ _—� _ ���r_ E� _ .'- - --o O ✓O~ 3 O� ^Coli•LI C ,Z'-yl PLUMBERS AND GASFITTERS = PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMBER =:LICENSED AS A JOURNEYMAN PLUMBER ISSUES THE ABOVE UCENSE TO:= _ _ - ISSUES.THEABOVE UCENSETO.. GEORGE R LAROSE - `f -GEORGE' R LAROSE - N_ _ ._44 ODILE ST ?44 OD.ILE ST o _ - 'METHUEN MA 01844-423.3 =` ETHUEN MA 01844-4233 9983 05/01/14 172563 = 18725 05/01/14 - +0 iiiaCJ_ -7 7. R;a`Tifiit`ny'( c x; _ - 172562.:' �._.tl"u3.. 09H W-0 ° _ _. n\t:o'�t� n'fi = :11rY�►�o �^�.^ s.%.wl. ��ry—+;3.erR�+.sV°ci.-"•.,so...��,���„--.i �r-. ...vy�,..:,:,r+... .`�-.' »....`r yitt�'ww`•'ve.c-", Date..... ......... ......... ppRTh TOWN OF NORTH ANDOVER ' pF it Sao ,e 14, 0 � pp PERMIT FOR GAS INSTALLATION SAC MUSES p -:y C1 tt] This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a has permission for gas installation . . . . . . : . . . . . :. . . . . . . . . . . . . . . in the buildings of . ."" . . . a. ..� . . . . . : . : . . . . . . . . . . . . . . . . . . w i at .`. . . . . . . :. . . : . . . . . . . . . . . . . . . . . . . . . .}, North Andover, Masr CU Fee. .f: . . . . . Lic. No.. .: : . . . t.. . . . . . . . . . . . . t. . -' iGAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD:File 3038 Date.*......... 1-0 TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING SSACMUS This certifies that ........ 5.......... ........S.�..c„ .............. has permission to perform ...... ./7./*:��................. ...................... wiring in the building of.... . ................ ................................................ 7- k - �AxkST rhnd Andover— ass.... ...... . ............................................ F=3,,�--v,... Lic.No..U -�* /................ ...�&�. LECMICALINSPECT(R Check # WHITE: Applicant CANARY: Building Dept. PINK:Treasurer Commonwealth of Massachusetts Official Use Only �i Permit No. Department of Fire Services o3 ('/Occupancy and Fee Checked bvw.F BOARD OF FIRE PREVENTION REGULATIONS [Rev-11/99](leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR I2.00 (PLEASE PRINT OR TYPE ALL INFORMATION) Date: April 17,2001 City or Town of: North Andover To the .f o Inspector Wires: P By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&-Number) 598 Salem Street Owner or Tenant Tracie Desandis Telephone No. 688-5887 Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑E (Check Appropriate Box) Purpose of Building. Residential Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps Volts Overhead ❑ Undgrd ❑ No. of.Meters Number-of Feeders and Ampacity A Location and Nature of Proposed Electrical Work: Completion of the following table may be waved by the Inspector of Wires. No. of Total No. of Recessed Fixtures No. of CEIL. - SUSP. (Paddle)Fans Transformers KVA No. of Lighting Outlets No. of Hot TubsGenerators KVA No. of Lighting Fixtures Swinunin Poofbove In- No.of Emergency Lighting g d. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initializing Devices No. of Ranges No. of Air Cond. Tom No. of Altering Devices eat ump Number To KW No. oSelf-Contained No. of Waste Disposers Totals: Detection/Alerting Devices _I No. of Dishwashers Space/Area Heating KW Local Con icipti l Other No. of Dryers Heating Appliances KW Security Systems 13 No. of Devices or Equivalent No. of WaterKW o 0 o. o Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hvdromassage Bathtubs No. of Motors Total HP Telecommunications ming: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector oJ Wires. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent.The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑■ BOND❑ OTHER❑ (Specify:) Estimated Value of Electrical Work: (When required by municipal policy.) (Expiration Date) Work to Start:April 17,2001 Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify under the pains and penalties of perjury, that the information on this application is true and complete. FIRMNAME: Brink's Home Security LIC. NO. C1514 Licensee: Mark J.Sylvester Signature J.Lk_ (If applicable, enter"exempt"in the license number line.) DPS LIC. NO. SSCO-000595 Address:155 West Street,Suite 5,Wilmington, MA 01887 Bus.Tel.N o. 978-657-0443 Alt. Tel.No.617-212-7590 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law.By my signature below,I hereby waive this requirement. I am the(check one) owner owner's agent Owner/Agent Telephone No. signature PERMIT FEE: $ 35.00 I 7 eo ` MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFIT UG (Print or Type) NORTH ANDOVER Mass. Date W/o` Building Location .J / �SWL�� S7 Permit ���_ u Owners Nameef/&1-7146 11V/j rf _ New 77 Renovation Q Replacement a/Plans Submitted Q 01 6 N erf U C F.• t: W us G O U p ta t— ,e trs c. o UA � l a c = o F d to N F' < t. O O O lL }' ul 6 W ul F- C7 0. �. us c ul o V c us ul ¢ uci f' w o e UJ W .1 ... d �- '� Q U 0 F- 2 J r :� �.. 'u W O ? U- t.. .t p.. to ¢ u y BASEMENT I I{ I I II I I L I I I I I I I Z S T FLOOR 2MD FLOOR ( I I I I I I I I I I I I I I I ( I f I ( I 3RD FLOOR I I I I ( I I I I `� I I I I ( I I 4TH FLOOR I ( I ( I I I( I I I I I I I (( I I STH FLOOR 6TH FLOOR f I I I I I I 7TK FLOOR I I Itt I I I I I BTHFLOOR ( ( I t I (Print or Type) Check one: Certificate Installingompany Name v �a �� / Q Corp. Address 1Q kk 7/� - Q Partner. �/T / /� =--fFirm/Co. Business Telephone: "/E �ys 7y- Name of Licensed Plumber or Gas Fitter A/ Insurance Coverage: Indicate t:-:e type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Q Bond Q Insurance Waiver: I , the undersiened, have been made aware that the licensee of this appiication does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner Q Agent Q 1 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 chit all plumbing work and installations performed under 'ermit iuced for this application will be la comUa oa with ahs perltaeat provisions of the Massachusetts State Cas Cade sad Casptet 14'-of Lho Gcacai L ws. By ,PE LIC*'NSE* Plumber Title asfitter. Signature of Licensed City/Town- Master Plumber or Gasfitter journeyman /i�2 �1 ,-3 APPROVED (oFFIcF- USE ONLY] License i-4umber ,{ ,f���, �- ��w j�i'? ,�. �r7ca� , - i I