HomeMy WebLinkAboutMiscellaneous - 64 MARTIN AVENUE 4/30/2018 64 MARTIN AVENUE 210/045.=0027.0000.0 10718 Date ............ 3� TjORr tiaoL TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING CHU This certifies that ...................................................... .......1�h .............. has permission to perform...... &A- e a—6�� p.,IP....*.......................... - plumbing A- in the buildings of at..... ........ 'VIn, Feed — .) ................Lic. No.q�n....... North. . .Andover,. . . . . Mass . . ............................. ............ PLUMBING.INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -40 CITY 114 Ve �. _ j MA DATE 11'�] !1[ [ PERMIT# JOBSITE ADDRESS OWNER'S NAME r-mac y�►4�.►, POWNER ADDRESS vee' .� f�'�e I TEL =FAX j TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:El! REPLACEMENT: Q PLANS SUBMITTED: YES® NO FIXTURES-1 FLOOR-4 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/OIL/SAND SYSTEM I v„ I 1 ._.__._ r ._. J -__..w.� _ 1 _ _} _ ._( ( I 1 1 DEDICATED GREASE SYSTEM � f I ! f _I DEDICATED GRAY WATER SYSTEM ( ._ t { i � _ I _.__.._1 _._ I I I _ -. t DEDICATED WATER RECYCLE SYSTEM ____t ____t -_ ► __.� DISHWASHER DRINKING FOUNTAIN I FOOD DISPOSER FLOOR/AREA DRAIN _w _1 ..__.-...._.I _._ _ ( i � ._...__I I ..._�i I INTERCEPTOR(INTERIOR) KI CHEN SINK t 1 t f. ______j _._____1 ____.-i. _._t __-__j LAVATORY F' OF DRAIN 1 allOWER STALL �_I J ..._I __.__( SERVICE/MOP SINK .l l _ I I _ I TOILET I �._f I ! _._._. f I __f _- E URINAL WASHING MACHINE CONNECTION _ I ! .- — .€ --_ _f ....___..J _.. { _! _._J __...__! .._... _.._._. f WATER HEATER ALL TYPES WATER PIPING _` ! . i I I OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ! NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY _! BOND �I 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 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Z� �J PLUMBER'S NAME _ nAsLICENSE# O7•-r,S•IGNATURE MP01 JP W CORPORATION 0#PARTNERSHIP Q# _ s LLC E= COMPANY NAME ,��G/ � vim,�,`,� _ «�; ADDRESS 36w/C C;,z le CITY �^�1c��i;c.y ___.._.._...._1STATE �y_� ZIP ®'�(e0 TEL �-9?8-375^` J7 FAX T _ CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPE TI N NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES i kJ, The Commonwealth of lt4°assachusetts , - - Department of fndifstrigl Accidents Office offnvestigations 600 Washington Street .Boston,.MA 02111 E:r vmmass:gov/dia Workers'Compensation Imurance Affidavit:Builders/Cont°actors/ElectriciansfPlumbers Applicant Information Please Print Legibly 'Name(Rusinessiorgmizationlludividual): '�J�G F�� !Uv►ln Address: J U q IC C irr, lc-- City/State/Zip: mt //- im rte m►�y14�6a Phone#: �J7� Are y9 an employer?Check the appropriate box: Type of project(required): 1.Wf am a employer with^D 4. ElI am a general contractor and I 6. F1 New construction e�P.ployees(RM and/or parttime)* have nodthe sub-contractors 2.�am a sole proprietor or partner- listed on the attached sheet 7• ❑Remodeling ship and'haveno employees These sub-contractors have S. ❑Demolition working fox me in any capacity. workers'comp.insurance. 9. ❑wilding addition [No work-Drs' comp.insurance 5. ❑ We are a corporation and its 10.[]Electrical repairs or additions required.] officers have exercised.their 3111 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.❑Roofxcp*s insurancere edemployees.(No workers' �' .a� 1311Other comp.insurance required.] xAny applicautthat checks box41 must also fill out the section below showing their vtorkers'compensation policy information. i Homeowners who submit this affidavit indicating they go doing all work and then hire outside contractors must submit anew 0davit 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. X am an employer that is providing workers'compensation insurance for my eYnployees Belaw is the policy and jolt site infomadon. Insurance Company Name:_ c)Vin e- ✓�„. Policy#or Self ins.UG.#: Expiration Date: Job Site Address: ro 6-4'ki S-frQc f' pity/State/zip: mp✓)i, b9� Attach a copy o#the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as toh dander Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a fne 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. I do laereby certz .yy under Me pains and penalties ofperjury that the information Provided above is true and correct. - e, od -J� AU44- Date: j' 71 o l Phone#• j 9 7 `37 5` 17 Official use only. Vo,not write N this area,to be completed by city or town official City or Town: PermitlLicense## 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 and instrnction� 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 ofbiro,. express or implied,oral or written.." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or no of the foregoing engaged in a joint enterprise,and including the legal xepresentatives 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 apartmentsand who resides therein,or the o ce pant 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('�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 tfie boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),addresses)and phonenumber(s)along with their certifIcate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees otfier than the members or partners,are notrequired to tarty workers'compensation insurance. If au LLC or LLP does have employees,apolicyis required. Be advised thatthisaffidavit maybe submitted tothe 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 thepermit 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 obtaia 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 andprinted 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. 1h addition,an applicant thatmust submitmultiple permit/license applications in any given year,need only submit one affidavit indicating current policy infonnation(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (city or copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit-lion file for future permits or licenses. Anew 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 orpermit 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 CQM0i calth of MaSsaeh-p_ e,,ttS MTUMout ofZuduSWal Accidents Office offAvQSliga M19 60G ,I Ste,et Boston,M-A 02111 TO,9 617-7-27-49-00 eXt 406 or 1•-877-MASSAM Revised 5-26-05 Fay, 617"727-7 749 www.Mass,govIcha Date.......1,. -t �.i' ...... ' �NORTH TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �� gB�C►n15E Thiscertifies that ........... ................................:.... ........................................... has permission for gas installation ...1 �2..�...cLe /2�. "-4,e-- in the buildings of...: .�`'! , "I.CU1.6 ..� , North Andover, Mass. Fee. ...- .. Lic. No. ... mi. ........................................................ GAS INSPECTOR Check# 95112 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' CITY 0 ►3ndoy� _ MA DATE PERMIT# JOBSITE ADDRESS `j 1'3'! ,^ S see OWNER'S NAME rSeut vN,gr»►,'�u _-9 Z- OWNER ADDRESS (, TE J_97J-37FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:EI RENOVATION: REPLACEMENT:[3 PLANS SUBMITTED: YES F--J1 NO 0 APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE I n� � ! - 1 �! _ DIRECT VENT HEATER DRYER FIREPLACE �� FRYOLATOR FURNACE GENERATOR r--__ GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOFTOP UNIT U IT HEATER ( _ �� �I LIN ELATED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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 Dl AGENT 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 corypliance with all Pertinent piovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME _ {��� or►, �CILI _ LICENSE# SJ70I SIGNATURE MP 0 MGF 0 JP JGF 0 LPGI 0 CORPORATION 0#©PARTNERSHIP 0#=LLC D# COMPANY NAME: I_C ADDRESS (� CITY STATE ZIP (TEL FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No _fA&J7 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES ,L 0 ;:v CONtMO�1WEALTH'C3F MASSACHUS` 5T , ;. r o o ® o PLUMBED AN1) t;ASF:lTTE15 , 5 I SSUES T.HE FOLi OW ItJG L I SENSE L I CEN1ui3 A A JOURNEYMAN PL. ";UMBER HENRY:`THOMAS N I CKLAS � f 3 OAK CIRCLE MERR�I MAC _. MA 01860-16 25tj'o o5/o is/16 204143