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HomeMy WebLinkAboutMiscellaneous - 62 CIDERPRESS WAY 4/30/2018 i (p2 r ,4 a Date....... .....Z'�...... .. . ,&OATH TOWN OF NORTH ANDOVER qtr•'� �'` ' °°� p PERMIT FOR WIRING 8'B�ICMUSE This certifies that ................... .... GLy� G� .W ....................................................... has permission to perform .......... 'w �.&.1).0 ...................... ........................................ wiring in the building of....... F ', f V �� ,North Andover,Mass. at ..�b.2:.....( �b... ..P/lc .. r� Od Fee, . "".r...Lic.No. rz- � ................... 4.42. ..� /1 ��!.......... iLEMUCAL INSPECT6R Check# 13 b 7 V Commonwealth of Massachusetts Official Use Only Permit No. l `-t(p7_ Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C,527 CMR 12.00 (PLEASE PRINT IN)NK OR TYPE ALL INFORMATION) Date: l City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) &Z PtAt S S �=c/ Owner or Tenant Telephone No. -2-63 Owner's Address /is- Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building X�t ()4 ti-'I\ d"t-- 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 Location and Nature of Proposed Electrical Work: Q/LJ A- (-j&:1,)0 Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires 17,— No.of Cell:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.omergency ig ting rnd. rnd. Battery Units No.of Receptacle Outlets O No.of Oil Burners FIRE ALARMS No.of Zones No. of Switches No.of Gas Burners No.of Detection and 3'� Initiating Devices No.of Ranges Total g No.of Air Cond. Tons 3 No.of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: ""...... ""'""""'"" '" """............. Detection/Alerting Devices No,,of Dishwashers Space/Area Heating KWLocal❑ Municipal ElOther Connection No.of Dryers l Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as regidred by the Inspector of Wtres. Estimated Value o Elfti 'cal Work: ( O 0 v v' (When required by municipal policy.) Work to Start: 3 � Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VERAGE: 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 coveW is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) I certify,itnder the gins and penalties of perjury,that the information on this application is true and complete. FI RM NAME: . vL4 M Bus.Tel.No.: 0 LIC.NO.: Licensee: l ({"t -&-L— Nl fi-�/��c t 4 gnature LIC.NO.: 0 Z`7 k� (If applicable,ent "exempt"in the lice n a number line.) 3 �0--2..ca`3 Address: �(11 Quo �t4 ��� �> �[ g;7j�vE , Alt.Tel.No.: d17A- �7 *Per M.G.L c. 147,s.57-61,sec rity work requires Department of Public Safety"S"License: Lic.No. 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 PERMIT FEE:$ Signature Telephone No. 3RS—dso— ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the ' notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8–Permit/Date Closed: ***Note:Reapply for new permit❑ ❑ Permit Extension Act–Permit/Date Closed: Trench Inspection Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: f. Inspectors Signature: Date: b SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: — —Pass 0 Failed[N Re-Inspection Required($.)❑ Inspectors Comments: s Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 i Failed Re-Inspection Required($.) ❑ Inspectors Co ents Inspectors Signature: V 1) Date: FINAL INSPECTION: Pass 177 �( Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): b1A -T 6�C - NA t r Address: City/State/Zip: `�c c t,t �i c)N� - D�S-W Phone#: q 7k 3 )s--0 AL� Are yoSAn employer?Check the appropriate box: Type of project(required): 1. am a employer with b 4. ❑ I am a general contractor and I 6. [1Tew construction employees(full and/or part-time).* have hired the sub-contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet.# 7. [J Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I 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.]t employees.[No workers' 13.[i Other 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 ace 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site informgtion. Insurance Company Name:. tA-Ac-,o,J Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 6 L C t ct S w City/State/Zip: Q D c�✓�1��,,,(-� Attach a copy of the workers compensation-policy leclaratn page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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. Ido hereby cert' under thepains andpenalties ofperjury that the information provid77-1 Bove is true and correct. Si ature: r Date: Phone#: 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##: i 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 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 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." r 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 may be 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 r 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(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 Coroxwnwealth.of Massachusetts Department of Industrial Accidents Office of Investigations 600Washington Street Boston,MA 02111 Tel,#617-727_4900 ext 406 or 1-877rMASS.AFB Revised 5-26-05 Fax#617-727-7749 vvwW.mass.8ov1dxa 0451 Date . 'Z:9V:t>. . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING w This certifies that . . 4-Ch : e. l. . c Q.�,Q_-r", , , , , , , , , , , , , , , , has permission to perform . .�,� Q. . . , (Nn&'t.e , , , , , , , , , , , , , , , plumbing in the buildings of. Q. ✓�.Q .t. ,w� �n�,, 5. . at . . . . . . . 0,.;.(.Ua--K D. ,. , , . . , , , ,North Andover, Mass. t .... . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check# ► 4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK IMP CITY MA DATE PERMIT#---�"F JOBSITE ADDRESS /7Sj OWNER'S NAME 77C POWNER ADDRESS I TELL_ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL E9 EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:® REPLACEMENT:Q PLANS SUBMITTED: YES E] NO.D! FIXTURES Z 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/OIUSAND SYSTEM ! ...... A DEDICATED GREASE SYSTEM L__€ _..__.__.f. DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM € IF-7i _.____ { ._.___1 __.._.._! ( _.___.__i __..-_1 _.__.__I ._.___._{ ._.-_-...__€ _.—....! _[ ..__ __i DISHWASHER _I .__..._.f DRINKING FOUNTAIN I E FOOD DISPOSER ( _ .__j FLOOR/AREA DRAIN 1 1 ___...__i INTERCEPTOR INTERIOR I E- ____ _...___..) _._.___..1 _----__E KITCHEN SINK L—A_. ___.t _____-€ _.-- € _---._._€ _.__( -.-_._I ------ LAVATORY ROOF DRAIN SHOWER STALL J= J-- SERVICE SERVICE I MOP SINK _. -..I _.-.-- _ _€ € I € _ € .._.__.! P -_....._._� .._--€ -- I ..._.__.f TOILET i _. .._- ( .. ( E � _.� I .._..__.� E ( � . . -_.I _._.__I ._______I URINAL U.—_i --___- WASHING MACHINE CONNECTION NATER HEATER ALL TYPES € _ J _.._ -__ _ ...-_, ..__ a _.___-.J�_f . . __! ------ i m 'VATER PIPING J - __J===== d --__..€ _ _' ...___I _ € 7= -__ I `THER 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 Q BOND 0 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 F 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 _ , -I LICENSE# IS7 SIGNATURE ] MPJP 0 CORPORATION[]f# PARTNERSHIP D#� LLC COMPANY NAME _ �� / -// ADDRESS h _i CITY ---- - -. - -._......-._._.-)STATE 1 ZIP � Q7 G TEL FAX i CELL i ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ — FEE: $ PERMIT# PLAN REVIEW NOTES r � K y � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Y www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le6bly Name (Business/Organization/Individual): yL�J Address: C) City/State/Zip: f f .�2 G367 C Phone#: 6_3 Are you an employer?Check the appropriate box: 1.ElI am a employer with 4. ElI am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6 El New construction 2.❑ 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. ❑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 required.] officers have exercised their 10-ElElectricalrepairs or additions 3.E] 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 12,0 Roof repairs insurance required.]t employees. [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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. t am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ?olicy#or Self-ins.Lic.#: Expiration Date: lob Site Address: City/State/Zip: kttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 if up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certyyunder the p 'ns a penalties of erju t the information provided above is true an correct. i nature: ✓f �J7 Date: hone i 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#: a 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 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 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-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 may be 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,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 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia Division of Professional Licensure: License Search Page 1 of 1 4 The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> I ONLINE SERVICES Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency LICENSEE More... Name:MICHAEL W. KELLER j REFERENCES& PELHAM, NH RELATED INFO Nays 5i t�P.Ct Disclaimer Regarding **This Licensee has additional Licenses,ctick here to view them.** Website License Searches Enforcement Process Glossary Licensing Board: PLUMBERS It GASFITTERS License Type: MASTER PLUMBER 1 Glossary of License StatusCodes License Number: 15157 More... Status: CURRENT j Expiration Date: 5/1/2014 Issue Date: 10/2/2006 Exam Date: 10/2/2006 1 School' i i This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. I t i The page above has been generated by the Division of Professional Licensure web server on Wednesday,March 20,2013 at 10:18:21 AM. ©2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg.state.ma.us/pubLic/PubLicenseQ.asp?board code=PL&type class=_M&1... 3/20/2013 Date . IA7PI �. . . 5£�Ler,Tia TOWN OF NORTH ANDOVER r PERMIT FOR GAS INSTALLATION This certifies that . .! , 1 : has permission for gas i stallation . .N Q -�. . !�.���!"�- --. , , . , . . . . , . in the buildings of. . .P. . . \Vi c e. An-v,n at . . .�Z-. . 1. 2�,p�RP55 . . . , , , , , . . . ,North Andover, Mass. �. t"�. . . . . . . . . . . . . . . . . . . . . Fee 11.0):7 Lic. No.1�.� GASINSPECTOR Check# 12,071-1 8629 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE PERMIT#_ JOBSITE ADDRESS OWNER'S OWNER'S NAME GOWNER ADDRESS TE FAX _. . TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PST ® RESIDENTIAL d CLEARLY NEW:[RENOVATION:[I REPLACEMENT:0 PLANS SUBMITTED: YES Q NO E] APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER =====I BOOSTERS _I _ I ._. I CONVERSION BURNER COOK STOVE DIRECT VENT HEATER I —�1 I _ _ DRYER _. J FIREPLACE FRYOLATOR �_._J _r�a1 ___ .- _ ._ . ry • I FURNACE _ r_ J l - -_ I __ z _. .:. _�J__ _ I- ------- GENERATOR GRILLED INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN _J POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER _= ! J ___.. 3 UNVENTED ROOM HEATER �--Y WATER HEATER J INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES JVO [ 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY _ OTHER TYPE INDEMNITY Ej 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 E 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 compliance with all Perlin pt provis, n o t Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME _ � wW � LICENSE#l.5/� SIGNATU E MP __ MGF[� JP [JJ JGF�_' LPGI n CORPORATIONF-11# _ PARTNERSHIP 0# - J1 LLC[]# __ COMPANYNAME: �--�ADDRESS CITY STATE ZIPTEL _ . .-_ ... FAX CELL[ Yt�'�. t.� �1 EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES r i - The Commonwealth of Massachusetts I DZ Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Organization/Individual): Address: City/State/Zip:g lvry � �� 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 6. F1 New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. �• F1 Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3111 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.]t employees.[No workers' 1311Other 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 their workers'comp.policy information. 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.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 requirectunder 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 of perjury that the information provided above is true and correct. Signature: / Date: l Phone#: ro G.3 " S fY _I S Ix/ 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 employeiis 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 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-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 may be 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,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 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 Commonwealth of Mossachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston.,MA,0211 t TO,#617-7274900 ewt 406 or 1-877,7MASSAF& Revised 5-26-05 Fax#617-727-7749 _ wwvu.nciass,govfd�a. Division of Professional Licensure: License Search Page 1 of 1 E ' The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES ........................................................................_....._................................................................................................................_............_.................................................. ......_......... Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency LICENSEE More... Name:MICHAEL W. KELLER REFERENCES& PELHAM, NH RELATED INFO NLW SEARCH Disclaimer Regarding **This Licensee has additional Licenses,click here to view them.** Website License Searches Enforcement Process Glossary Licensing Board: PLUMBERS 8 GASFITTERS Glossary of License Status License Type: MASTER PLUMBER Codes License Number: 15157 More... Status: CURRENT Expiration Date: 5/1/2014 Issue Date: 10/2/2006 Exam Date: 10/2/2006 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Wednesday,March 20,2013 at 10:18:21 AM. ©2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg.state.ma.us/pubLic/pubLicenseQ.asp?board_code=PL&type class=_M&1... 3/20/2013 Enter construction cost for fee cal- North Andover Fee Cakulation Construction Cost $ 257,625.00 m $ - $ 3,091.50 Plumbing Fee $ 386.44 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 386.44 Total fees collected $ 3,964.38 62 Ciderpress Way 494-13 on 1/4/2013 New Townhouse NH ORT Town of � : _ bAndover No. ,� b27 h ver, Mass, / / �d 04Are S U BOARD OF HEALTH PERMIT T Food/Kitchen LD Septic System (� ^'ISI BUILDING INSPECTOR THIS CERTIFIES THAT ....��'.�%�l�1`t /rl.�!'���........:.....................�a:i'`.'r.......................................... �� �l, .5 Foundation has permission to erect ......... buildings on ` C m Rough to be occupied as ...... U.` r/� T/G�USf ......... Chimney provided that the person accepting this permit shall in every respect conform to the terms of he application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ARTS Rough Service .. .................... ............. .........�..`............................... Final BUILDING INSPECTOR �! GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. .P ' �'� SEE REVERSE SIDE 7 tans S bu mi d Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL blic r Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF- U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT -' COMMENTS 19 -9 CONSERVATION Reviewed on Si nature COMMENTS ,A DSP Zq2-I I I j n 0,,r(:6rArAj)g wf OOC av�Q �•rta�4� HEALTH — Reviewed on_ Signature COMMENTS rlit AA) Zoning Board of Appeals:Variance, Petition No: "—" Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: 2 q?-- 1) Comments Water& Sewer Connection/Signature&Date Drivewa Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRS.DEPARTMENT: _Temp Du ter on site. . es no . Located at-1 2 4 Main Street 7-7 Fire f Department signature/date COMMENTS' = 1 . �., NOTES: 1) THE BOUNDARY INFORMATION SHOWN HEREON WAS TAKEN FROM A �•` r PLAN ENTITLED "PLAN OF LAND, MEETINGHOUSE COMMONS AT SMOLAK FARMS, SOUTH BRADFORD STREET, NORTH ANDOVER, MASSACHUSETTS"; SCALE: 1" = 80'; DATE JULY 20, 2001 BY THIS �eD+?B % i �•� `, MAP 104C LOT 29 OFFICE. RECORDED AS PLAN #14828 IN THE ESSEX COUNTY N/F ESSEX COUNTY NORTH DISTRICT REGISTRY OF DEEDS. y�d F tt I 13.12' GREENBELT ASSOC., INC. 2) THE INTENT OF THIS PIAN IS TO SHOW THE AS—BUILT LOCATION 1121' OF THE FOUNDATION ONLY. 11.09' 3) THE FOUNDATION SHOWN HEREON IS NOT WITHIN THE 100 YEAR FLOOD ZONE AS TAKEN FROM THE FLOOD INSURANCE RATE MAP FOR THE TOWN OF NORTH ANDOVER MASSACHUSETTS COMMUNITY 11.09' PANEL NUMBER 250098 0007 C, MAP REVISED: 6/2/83. � � ��S / O,l• S R j p78 (rN 4) THE CONCRETE FOUNDATION SHOWN HEREON HAVE BEEN INSTALLED 1 �� VSsvij SUBSTANTIALLY IN ACCORDANCE WITH THE 40B SITE PLAN AS 46, "6, APPROVED BY THE TOWN OF NORTH ANDOVER PLANNING BOARD. I HEREBY CERTIFY THAT THE LOCATION OF THE TOWNHOUSE UNIT NUMBERS 16-19 FOUNDATION SHOWN HEREON IS THE RESULT OF A FIELD SURVEY BY THIS OFFICE MADE ON NOVEMBER 8, 2012. N o7 / OF AL SL MAP I0p4C ` —NZ- 25' NO a CHNSTOPHER AL LOT 2S I mo DISTURBANCE FRANCHER s �Llc ZONE Na 36116 V ti lip-11'2- c /A\ i -. —''- LICENSED LAND SURVEYOR DATE CERTIFIED FOUNDATION PLAN i MEETINGHOUSE COMMONS TOWNHOUSE UNITS 16-19 GRAPHIC SCALE CIDERPRESS LANE o z6 5o loo NORTH ANDOVER, MASSACHUSETTS _- -� PREPARED FOR MEETINGHOUSE COMMONS, LLC (W FEET) 121 CARTER FIELD ROAD 1 inch = 50 ft. NORTH ANDOVER, MASSACHUSETTS 44 Stile,Road,Suite Ona Salm,N,w Hamp,hir,03079 —_ (603)893-0720 MHF Design Consultants,Inc. ENGINEERS•PLANNERS•SURVEYORS _ SCALE: 1" = 50' DATE: NOVEMBER 12, 2012 DRAWING NO. DESCRIPTION BY DATE DRAWN BY: CHECKED BY: PROJECT NO. 11 NAME REVISIONS CMF 250508 1 2505CFP.DWG Massachusetts -Department of Public Safety Board of Building Regulations and Standards Z Construction Super0sor License:C"55417 IHOMAS D ZAH%UIICO 115 CARTERFIELD ., N ANDOVER M* 01" 'f J xpiration Commissioner 04/05/2014 The commomveaf "eP�- rlt°-ff al Accdeius Offim afhcvea ,.tions y -600 Arashing"S&P�et Bostor� 4 OZIIZ Workers'Cosaov/tea �c� mon 'oo Tcusnrance Affidavit:g�ders/Coirtrac lorsMect6d=sMnmbers Maw Name � mizatioou/fndiv; Addnmss: l Cilym a� of� ,A/1 d? �_ Pbone 8' Are you an am PhWa?Check ffie appropriate be= I-❑ I am acmpioyerma 4. ❑I am a T�aprolect(requ ire4.-- . GOMbackr�Ployees{fu11=&0rpazE-taac).* have lined gm � 6- i4(N ; cammmation 2.® I am a sole pivpdetts arparb= listed on$ e "' � �P and bmno employe= Th�sc wed sit t 7. Woddn f+or me auy a R,adMM, ccmp.jMW=M,[soodc8- ❑man q �m&j - S ❑We area audits 9- 0 Btu moa 3-❑ I am a�lmeowm=doing an vo* Off==hake c2mviseed 20-11 Ebctdcw rVaim orwakm mysex[soIW of M pes MGL I L(]Plumbing r�m'additions ms�e ]t P aLit,¢I(41andwehmno I20Roofxqeim - I3.Q od= `s-sYffiecarr. baz !ma�rl�►�om ' >�:ebmaals at5denrit• 8� hcivw aimUML adffibowd amq - mnct'Mmhc°Ta" dtm- 14e:�-a��- Iasi an employertlh&ispravidorgwarlrem,aO aa0doas-°0g'p0fiqy a efor . - m3'enrloyam Below is S►eprzry M,,W aft, - Poficy#or Seam&Inc.#.- ' Job Site Address: cm Attach it oogry of the wm aCify/StatelT. Faih=to secu¢e comPaumfiDn Pa�9 Paid( the po$ey and a date fins UP to SI,500 zeqwed un&w Sefton 25A°as wa as M can lead m fbe dam P'�altns ofa of Up to MM.00 a day apiw the viohim Be ' ed that ar 9 is fbc fWM of a STOP W01M ORDER affil a fine 6oms ofdw DIA� may be ceded m 6e Office of - Ido uadPrLPpsisP+VTmT Slat - SionAn..,r- A--if, is true m�corm - �$uial erne onrl�c Do"W turtle fa A&MT&,to be cono City or Tow= Issanng A.athu*(cb-de am); 6 OBoard of Hem Z Btnlamg Dvartment 3-cx-Wrown I 5.Plupmbitm.Iuspectur Contact rm—sum Phone