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Home My WebLink AboutMiscellaneous - 632 CHICKERING ROAD 4/30/2018 __._.. 632 CHICKERING ROAD 210/083.0-00240000.0 Date..,2.. of NORrN,h TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,83�C U This certifies that..P�........ ................................................... has permission to perform ............ ............................................................... plumbing in the buildings of-.-.7.--+S �:�............................................................... at.... .. .. ......U!............ North Andover, Mass. Fee3o .....Lic. No. ..... ...........................PLUM.BI.N.G..IN................S P E C T 0.R..................... Check# 2 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERF PLUMBING WORK M C. (P CITY [�•�'1 / /.�r��a` MA DATE PERMIT# JOBSITE ADDRESS � �c,Co�•� ��►> OWNER'S NAMEy POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL(I PRINT PLANS SUBMITTED: YES❑ NO❑ CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Q FIXTURES 1 FLOOR-- BSM 1 2 3 4 S 6 7 b 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASJOtUSAND SYSTEM DEDICATED GREASE SYSTEMA DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER f DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY —R—DRAIN SHOWER STALL SERVICE!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- YES4 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 von are true and acanale to the best of my knowtec 1 hereby certify put an of the details and information 1 have submitted or entered regarding t aPOliCat in pce,,,,;Ih a4 Pen-v*N pr or and that all plurnbag work and installations perfomred under the permit issued for this apptica� Massachusells State Pkmt*g Code and Chaplet 142 of the General Laws. PLUMBER'S NAMED` LICENSE N3� SIGNATU MPO JP❑ CORPORATION—MN :�'3 YS PARTNERSHIP❑# q LLC❑ / 1� COMPANY NAME '47^ -� �� ADDRESS F a 1�oX �/ 1 CITY J�Sn�� '-� STATE � ZIP Z7) c�. TEL FAX CELL SJ �—`� 3.SG EMAIL t'.-) f The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/dia Yorkers'Compensation Insurance Affidavit:Bn$ders/Contractors/Ekctrkians/P%mbers. ` TO BE FILED WTTH THE PERMITTING AUTHORITY. AppKcant Information Please Print Letibh Name(Business/or�rt/Individtwy Address: City/State/Zip: Phone An yse m emplorm?CTed the app..Dri.1e ton: Type of project(required): I.D I am a®ploys*rub awiaytts(full and/or W14ime).• 7. ❑New construction 21—]l am a sok propiela a pormasbip and home no empioyees wonting for me in g. Remodelin any capacity.(No-antra'comp-inArrana-qui-d.) ❑ g 301 am s bowwwaer doing all Wort myself(No workers'con q.insurance regtnired.)t 9. ❑Demolition <.❑I am a bntroowaer and will be hiring oonasetor:to contra all wort on my propoty. 1 will 10❑Building addition ansae that all coovacton either have Wooten compenarion insurance or are sok 11.❑Electrical repairs or additions pnvricwm wtm no czzopbyom 12.[]Plumbing repairs or additions s I am a geoQa)contractor and 1 have bircd the sub-contractors listed on tote snacbed sbccL Tbac sub-eoonwims have employees and have workers'comp.itmraoce_t 13.❑Roofrepairs 6.❑We area corporation sod its ofriccn have ommised their right of mempmm per MGL c. 14.[]Other l 152,§1(41 and we have no employom(No workeri comp.ins,aance rogrwod.) •Any applicant that chocks box 01 awst also fill out the section below,showing tbeir workers'comperuation policy information i Nomoowners wbo submit this alUbvi indicating tory we doing an wort and then hit om><side contractors must submt a new affidavit indicating such. k.o ntracton dw ebcck this boot aouo,trached m additiowl sheet sbowal the name of the MAP-eootractors and store wbetber or not tbow entities have empioyoes. If the sub-000tractors bare empbyon.thry must provide their Wooten COMP.policy number. Ian an ersployer drat is proriding workers'cooWwasadon insurance for wry employees Bdow is the porky and job site information. Insurance Company Name: Policy f/or Self-ins.Lim tt: Expiration Date: Job Site Address: City/Statdzip_ Attu►a copy of the workers'compensation policy declaration page(showing the policy number and expiration date. Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to S 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 5250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for inawance coverage verification. I do hereby certify under dot[pains sad pe naldes ofpajwy that floe information provided abort h tree an/ear, Signature: Date: Phone I►: OffwW hese o*. Do not write in dds area,fns be complded by city or fi"m official City or Town: PermibUcense tt Issuing Authority(circle one): 1.Board of Health L Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Piton M