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HomeMy WebLinkAboutMiscellaneous - 68 PROSPECT STREET 4/30/2018 68 PROSPECT STREET 210/080.0-0021-0000.0 V Y s Date. .f?!.� � .... .. .. NORTH 6,6 6 TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION 9 � •`t �9SSACMUSEt ,ter This certifies that . . ./.7•%CJ�'f,e&45 Xl... `? . .r.! . . . . . T has permission for gas installati n in the buildings of . . . . . .�7d ! . �! ' -? f . . . . . . . . . . . at . . . . . . . . . . . . , N h A dover, ass. Fee.,. Lic. No.s. .�C?l�J. . . . . . ry 'f GAS INSPECTOR t Check# 7946 z i NIA%ACHGSEi'I'S UNIFORM APPLICATON FOR PERtNIlT TO DO GAS FMING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations __ fin --&o S/'rr l ST, Permit,# Amount Owner's Name — �d( E ��L C 96 J New❑ Renovation ❑ Replacement ® Plans Submitted ` n O a F w z O U ] H .Fy x z Z F o w O x U x z e A 0 H Z z F, 4 W W7 p > z c z .r z c c c w O° w - G O 3 A Cti a U z > A a F C SUB -BASEiM ENT B A S E M ENT 1ST. FLOOR 2ND . FLOOR 3RD. F L O O R 4T H . FLOOR 5TH . FLOOR — 6TH . FLOOR 7 T H . F L O O R 8TH . FLOOR , (Print or type) L Check one: Certificate Installing Company Name (er S I t?E L G,5 K I rR, ® Corp. Address !/.0 s 'AAIp6 — O Partner. V 151? y M ® Business Te ephone 579 — 3go 0 Firm/Co. :Mame of Licensed Plumber or Gas Fitter &/C HA E INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 13 No If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner' In,urance i r: I am awa that the licensee does not have the Insurance coverage required by Chapter 112 of the y s'an• ur&on this permit application waives this requirement. Check Signature of Owner or Owner' Agent Owner hereby certify that all of the 'ails an information I have Submitted(•or c in above application are true and accurate to the, best of m% knowledge and that ail p ibing work and installations perfo mcd under Perrnit Issued for this application will be in cinnpliance with all pertinent provisions of the Nlassachusctts St: ;a\Co c nd Lhnp 'r 12 the General Laws. By: Signature of Licensed Plumber Or Gas Fitter 1� Title Plumber City/Town Gas Fitter 11cense t um er 13 Master APPROVED(OFFICE USE ONLY) � Journeyman _) _. The Commonwealth of Massachusetts JD .fo Department Industrial Accidents P Office of Investigations 600 Washington Street Boston, MA 02111 s. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): IG H19 6- L .S 1676 L 65 K I Address: City/State/Zip: M?6Y, //A Phone 4: 79- 31 o 626D 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 1 6. ❑ New construction employees(full.and/or part-time).* have hired the sub-contractors 2 I am a sole proprietor or partner- listed on the attached sheet. + E] 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 officers have exercised their ]0.❑ Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL 1 l jPlumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑`Roof repairs insurance required.] t employees. [No workers' 13.50 Other 1�6PI aCMC-jtij comp. insurance required.] *Any applicant that checks box#11 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 rubmit 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 jot 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 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 certify under the pains an penalties of perjury that the information provided above is true and correct. Sign ure: e P Date: 2 — Phone#: 'l75 - 3 / 0 — 9 2 71 D Official use only. Do not write in this area,to be completed by city or town offlciaL 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#: o COMMONWEALTH OF-MASSACHUSETTS. LICENSED AS A JOURNEYMAN PLUMBER ISSUES THE ABOVE LICENSE TO: MICHAEL E SIBELESKI JR 5 DES s MARAIS AVE ro � DERRY NH 03038-2508 31018 '05/01/12 789617 i I I I I I Date a(.. ....... /........ TOWN OF NORTH ANDOVER F p PERMIT FOR WIRING SACHU`�� rThis certifies that ................................. ........................................ has permission to perform l"71/l iv�d wiring in the building of..... ......................................... at.................. ............ d J .............................................. North Andov r,Mass. a /ca�S 7 . Fee. ............... Lic.No.............. .................... . .... ...... .. ........,...... E crrticnc INSP cro Check # 10543 Commonwealth of Massachusettsofficial Use e Only Department of Fire Services FPermitNO- I BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev. 1/07] (leave blank ' APPLICATION FOR PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 00w0RK (PLEASE PRINTININK OR TYPE ALL INFORMATION) Date: 1 1 City or Town of: NORTH ANDOVER —n— —'-L— By this application the undersi ed To.the Inspector of Wires: gn gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) ro Owner or Tenant Owner's AddressTelephone No.278'-6f,2-3YG� Is this permit in conjunction with a building permit? Yes ❑ NO (Check Appropriate Boa) Purpose of Building 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: // -(�/a✓��v1q' 6� (dI�W NOV r�r eterHLS ;rl bas( Completion of the followin table may be waived b the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Sus No.of p.(Paddle)Fans Transformers Total No.of Luminaire Outlets TI1A No.of Hot Tubs Generators KVA ! No.of Luminaires Swimming Pool Above in_ d• rad. o.o mergency Ig g Units Batte ---., No.of Receptacle Outlets No.of Oil Burners FMF ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detec .on and e IWtiatin No.of Ran Devices g s No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: . n Devices Detection/Alerti No.of Dishwashers Space/Area Heating KW Local❑ 1Alerti pal Connection Other r No.of Dryers Heating Appliances KW Security Systems: No.of Water No.of No.of Devices or E uivalent Heaters �' No.of Data Whin Si s Ballasts . No.Hydromassage Bathtubs No.of Devices or E uivalent g No.of Motors Total gp Telecommunications Wiring: OTHER: No.of Devices or E uivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 0-0-0 t( Inspections to be requested in accordance with MEC Rule 10,and upon completion. 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 I certify,under the pains andpenalties o � (Specify:) P I f perjury, that the information on this application is true and completes FIRM NAME: Licensee: LIC.NO.: I,Z,S*r3 Signature (If applicable, enter"exempt"in the license number line.) LIC.NO.:/o2S8'8'j? Address: rt[vtwt&vt f— 1 L4 Pr�2 - � ©ttti'a C Bus.Tel.No.: *Per M.G. c 147,s 57 61,security work requires Dty Alt.Tel..No.: OWNER'S INSURANCE WAIVER: I am aware that e Licensee does noSaft have liability ins Lic.No. required b law. B m signature ty urance coverage normally I' q Y y y gnature below,I hereby waive this requirement. I am the(check one) ❑owner Owner/Agent iEl owner's agent. Signature Telephone No. PERMIT FEE: $ &x 7 � i :r The Commonwealth of Massachusetts k Department of Industrial Accidents • Office of Investigatiotrs g,t��� 600 Kl t slii ashin n Street `•'�� Boston, MA 02111 { ' www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Ele Actricians/pi�bers licant Information Please Print LeQibl Name(Business/orgsnizadon/fndividual): J"I, b-L Address: (�( Gec&4 City/State/Zip: (�/�,. ��- ✓ D(t of 6 Phone #: . I N—$0 `( 'q6 Aou an employer?Check the appropriate box: 1C am a employer with 4, Type of project(required): ❑'I am a general contractor and I ployees(full and/or part-time).* have hired the sub-contractors 6. 0 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 for mein an g Q Demolition working y capacity. workers' comp.insurance. [No workers'comp,insurance 5. ❑ We are a corporation and its 9. Q Building addition ,r required.] officers have exercised their 10.Q Electrical repairs or additions 3.❑ i am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No-workers'comp. . c. 1.52, §1(4),'and we have no insurance required.)t employees, (No workers' 12.[] Roof repairs comp. insurance required.) 13•❑Other t'Any applicant that checks bob#l must also flit out the section below showing their workers'compensation policy information Homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit anew affidavit indicating such. their work'comavit in ;Connectors that check this box mustanached an additional sheet showing the name of the sub-contractors and p,avit in infa ration Jam an employer that is providing workersco►npensation insurance for my employees; Below is the policy andjob site . information. � Insurance Company Name: Policy 4 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 required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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. 1 do hereby c �411yund the pains and penalties ofperjury that the information provided above is true and coria Sct i tune: Phone#: e' fSo,( - �G 7eD useonly. Do not write in this area,to be completed by city or town ofciaC n: Permit/License# ority(circle one):Health 2. Buildin De rtment 3.Ci /Town Clerk 4.Electrical Ins for 5. Pinmbin fnsg pecg pector son: Phone#: 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 tnsstee 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 shalt 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 comm-onwealth 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 mquiredAo 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,nofthe 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 numberlisted 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 t 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 4' 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 Investigations 600 Washington Street Boston, MA 42111 Tel. #617-72.7-4900 ext 406 or 1-8.77-MASSAFE Fax#617-727-774 Revised 5-26-05 www.mass.gov/dia ' MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) l�d lke� , Mass. Date i 19 ly' Permit # 17 �Yb V-4- Building Location dA� c 674 Owner's Nam � y Type of Occupancy 1�E51 T)CN T1 0 New p Renovation p Replacement 21-11 Plans Submitted: Yesp No p N ' N C SC W N 2 S y N N UCC N C N C O zN = x W W N C O V rp r = .� Z p �Cj r < Z C j �. W m N r y W IrW 0 6 r N C y�j 2 V W N W < C H r S OCC W > WW r V J Z < W < C M r < S < i O O W C p W r SUB-8SMT: BASEMENT ISTFLOOR 2ND FLOOR I 3RD FLOOR _ 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name �l i r'Ai��(z T A . `AM M A T rl X20 Check one: Certificate Address 0-0A H�n(4 ry � E. ❑ Corporation 01' 7,H Ue tj M to 0 ( k p Partnership Business Telephone /o.?22 — 7 9-7 f 2- Firm/Co. Name of Licensed Plumber or Gas Fitter "'R 0(A E P--r A- '5 A m m ig-TA Pn l INSURANCE COVERAGE: I have a current II-ability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes G�' No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box A liability insurance policy yid 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owner's Agent I 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 that all plumbing work and installations performed under the i ed for this I Pe Pe app kation be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ner Laws. BY T of license: �� Plumber n ure of, oen u or atter Title tter er License Number sJ q3 City/Town Journeyman BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING NAME 11 TYPE OF BUILDING LOCATION OF BUILDING - --- PLUMBER OR GASFITTER LIC. NO. PERMIT GRANTED DATE GASINSPECTOR -•,ter:`a`S�'`�v`s-"Tro�`� *a.+-u--�,...,. — . . '"+.�cr-;v+�'�'s+��x-�.-.,��+,.iE.'�'i-,.r+siy,���:-, ,w � - .. . ... ... . T 2179 D . o MORTh TOWN OF NORTH ANDOVER Of t,.ao $O 3? • oL PERMIT FOR GAS;1Nt*ALLATION?. �9SSAC HUSES ' .y This certifies that has permission for gas installati � in the buildings of at�. . . . . . . . . . . . . . . , North Andover, Mass. Fee /-), Lic. No.;, . r GAS INSPECTOR �o?- WHITE:AppllcantANRY: Building Dept PINK:'Treasurer GOLD.File..