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HomeMy WebLinkAboutMiscellaneous - 67 CRANBERRY LANE 4/30/2018 r 67 CRANBERRY LANE /�/ — csr / 210/059.0-0073-0000.0 Date.kk .. .. . Noa�M °f11.0 or TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION �'ISS AC HUSE'k ` This certifies that . :5V.kir�4rx -. . . .174-5:�5:. . . . . . . . . . . has permission for gas installation . . C. .�. . in the buildings of . .6R{.5;A,4 !u!. . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . .�I. . .C/A .n A.Ae.4i . . 4GAS ort And er, Mass. Fee,,,g0 . . . . Lic. No.. . . V . . . . L6. . INSPE OR Check# 7985 .R t ' .v� s MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING l' City/Town:�a MA. Date:/.,,Z-,? / /f/ Permit# Building Location: Owners Name: Type of Occupancy: Commercial Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES IY co N W Lu 0 ~ co c� 0 x Q O I.- Z ~ °a 0 W } W z rn 00 2 W W O Z z o W z W W 0 1- W Cl) W m 00 Q n. H 0 0 W X > W Z U) O Q W Cn 0 Q W W x u. WI a > V W Z J W I— O Z O LL (n x Z W LL uj Z Wa, } N Q Q . m w O z 0 t > Z x V o o 0 0 z _ O a FW- > > > O 1 SUB BSMT. BASEMENT 1ST FLOOR 2 Nu FLOOR 3 FLOOR 4 FLOOR 61H FLOOR 6 FLOOR 7TH FLOOR 8 FLOOR Check One Only Certificate# Installing Company Namej �s" Corporation Address:-& �Y &Cityffown:/ � State: ❑Partnership Business Tel: � '2if4 Fax: ❑Firm/Company Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 Yes ❑ If you have checked Yes,please indic to the type of coverage by checking the appropriate box below. A 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 Signature of Owner or Owner's A ent Owner E] Agent ❑ By checking this box❑;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. Typ f License: �rte Bylumber Title ❑G fitter Sig ature of Lsed . ber/Gas Fitter aster Cityrrown ❑Journeyman License Number: APPROVED OFFICE USE ONLY El LP Installer p i i - The Commonwealth of Massachusetts Department of Industrial Accidents Office ofInvestigations ..600 Washington Street Boston, MA 02111 Www massgov/dia Workers' Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers APPlicant Information Please Print Legibiv . Name (Business/Organizafion/Individual): Address: Gy J rIamnCity/State/Zip���! 1 ,� Phone#: ���, j J � 1 la ployer?Check the appropriate boa: loyer with /� 4. ❑ I am a general contractor and IType of project(required); (full and/orpart-time).* have hired the sub-contractors 6. ❑New construction proprietor or partner- listed on the attached sheet 1 7. ❑Remodeling ship and have no employees These sub-:contractors have working for me in any capacity. workers' comp,insurance. g' Demolition [No workers'comp. insurance 5. El We are a corporation and its 9. ❑Building addition required.) officers have exercised their 10.❑Electrical repairs or additions 3.❑ 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 insurance required.]t employees. [No workers' 12-❑Roof repairs comp.insurance required.] 13.0 Other *Any applicant That checks box#1 must also fill out the section below sho„n. = e T Homeowners who submit this affidavit indicating they are _e doing all work and then hire outside contractors must submiusrdOn Policy t 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 information. for my employees Below is the policy and job site Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: • Attach a copy of the workers'com ensatio en City/State/Zip:_ P 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 Investigations of the DIA for insurance coverage verification. I do hereby ce under the pains and penalties of perjury that the information provided above is true and correct. Sienaturn- 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5tor.Plumbing Inspec 6.Other Contact Person: Phone#: 7 ! /v • 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-eontractor(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 th r app"cation for the pal-ltof license is being requested,not the Depas'tment 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 permitllicense 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 Massachusetts Department of Industrial Accidents Office of Investitbations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-72.7-7749 vnw, ,.ma&s..gov/dia ` --. itT ' F A' �• y LtCE�SED A'S'q MASTER'PL NFBER _ ISSUES THIS LICENSE TO I DANIELT CLUF`F 77 EME-R.Y RD q i NSEND MA 01469 1.274 116.60 05101112 762248 i ' y • �j t I II y ' G. Location ' /26~fN Zo No. ! Date Z C NORTH TOWN OF NORTH ANDOVER ? �� • O o Z. Certificate of Occupancy $ !fJ Building/Frame Permit Fee $ Foundation Permit Fee $ s�cNus Other Permit Fee $ tg N Sewer Connection Fee $ ER Water Connection Fee $ TOTAL $ L,/G7/p Building Inspector 9313 Div. Public Works C� V PERMIT NO. oAPPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE I MAP KJO. LOT NO. QQ� 2 RECORD OF OWNERSHIP DATE BOOK ;PA ZONE O�q SUB DIV. LOT NO. I LOCATION �(� �� PURPOSE OF BUILDING ASI le Ce _/� G AO- OWNER'S NAME ,`,' G NO. OF STORIES G Q SIZE R - ^f ` OWNER'S ADDRESS 627 BASEMENT OR SLAB ARCHITECT'S NAME ! SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME J ,` ` I SPAN -- DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES -SIDES REAR ' GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X 19 BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST . SEE BOTH BIDES EBT. BLDG. COST , dcx.;, PAGE 1 FILL OUT SECTIONS 1 - 3 EST: BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS - PLANS MUST BE FILED AN APPROVED BY BUILDING INSPECTOR E' DATE FILED 2 L7 BOARD OF HEALTH SIGNATURE OF OW R OR AUTH IZED A NT 1 FEE a PLANNING BOARD PERMIT GRANTED s� 19 9 � 1 7Z BOARD OF SELECTMEN S IJ�YJLS 61-, 14 BUILDING INSPECTOP WHITE: Building Dept. CREAM: Assessors CANARY: Treasurer NORTH F Town of dover No. o dover, Mass., - Z � 199� COCH C�EWICK AO'QATEO 5 BOARD OF HEALTH Food/Kitchen PERMIT T Septic System / BUILDING INSPECTOR THIS CERTIFIES THAT...........................M c C h ol-�../..............Cd�.Ac..ZT. ............................................ Foundation has permission to erect...... YI.A. .A(k...... buildings on ...... ........C.k4..Lv..�..rEJQR..y.....41-eJ4_7 Rough t0 be OCCUpled as.....................................:............................... z �.F-.>.............1...��.I.l y.............................. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final 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 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STAR ELECTRICAL INSPECTOR START Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove F naih No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. 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