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HomeMy WebLinkAboutMiscellaneous - 680 FOSTER STREET 4/30/2018 (2) �_ --�-� 680 FOSTER STREET 210/104._ g_�053-0000.0 -� _---_-- , /� R Date. ./�'! 9487 f NORTH - 3:�, TOWN OF NORTH ANDOVER PERMIT .FOR PLUMBING 00 SSAcMUS `VIII �i�re a This certifies that . . . ( . �e�. . . . . . . , t� 'i has permission to perform . . �. . ' '!h plumbing in the buildings of . . . . . . . . . . . . . . . at . . i�it1. . !'. . --� . . . . . rth And9vler, Mass. Fee�©.S'0 Lic. No. P�!-3 PLUMBING INSPECTOR s, Check # r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _-11 MA DATE I PERMIT# 0 JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS I TEL[-- IFAX� TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL D RESIDENTIAL PRINT CLEARLY NEW: ; RENOVATION.- REPLACEMENT: { PLANS SUBMITTED: YES NOD FIXTURES 7 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/OIL/SAND SYSTEM i ._,_....._I _ { ( ... _.._.) ! __....... ._ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I I ._._..__{ f ..___J ( 1 _ ( __...._J __ ._._..._.f ._.___.. I ._.} —_} _______€ DISHWASHER DRINKING FOUNTAIN } ___......_{ I ! 1 1 .___....__E ------ FOOD -_._FOOD DISPOSER FLOOR/AREA DRAINI INTERCEPTOR(INTERIOR) KITCHEN SINK —! 1 ----...__1 f __ __,1 _.___} ..______..I .-----_..__1 LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL f __....__-� .-.--_.._f ..__j -► ------._._---( .__._....( 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. YES D_! NO 0f 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 0 AGENT JEJ 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 t/ „ .1`7L YJ�i (LICENSE# 0 SIGNATURE MP& JP[31 CORPORATION D# PARTNERSHIP Pi COMPANY NAME ; ADDRESS Lz CITY I1/PU17'U/1/ _ - _ .......I STATE �'Y I ZIP �5�— j� TEL FAX ! CELL ) EMAIL I 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 I ' i w ' r The Commonwealth of Massachusetts Department of IndustriqlAccidints Office of Investigations 600 Washington Street Boston,MA 02111 Ut www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name(Business/Organizationgndividual): Address: City/State/Zip: 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. ❑New construction employees(full and/or part-time).* have}fired the sub-contractors 2.El 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. E]Building addition { [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 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 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. 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 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. I do hereby cert!�under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: Offccial 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 _ � I Information and Instruction's 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 ofhire,• 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 roduced.acce table evidence " i P p ce of compliance with the insurance coverage overa ere wired g 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-contractors)name(s), es address hone number (s)and P (s)alo ng with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited LiabilityPartnerships ps(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 multiplepermit/license applications in angiven ear,need y g y only submit one affidavit indicating current « g policy information if necessary)and under Job °� « ( �3') Site Address the applicant should r pp 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,ofMassachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston.,MA 02111 Tel,#617-727-4900 Qxt 406 or 1-877,!MASS.AFB Revised 5-26-OS Fax#617-727-7749 www.m.ass,govldia Date..... y NORT►i TOWN OF NORTH ANDOVER PERMIT FOR WIRING J' �i�ss^cNus� S'. This certifies that .........e..........I... j�am2,.... ..p..... has permission to perform ........... i:..d .c-........u .l....................... wiring in the building of........ . '' ... Ip2nSA .......................... ,T 4 at.lae ...&OW .................................... .North Andover,Mass. PAa- Fee....4 .. Lic.No...... .. t .............. . . .. . . . . . ELECTRicAL MpEcm ° Check # 10859 commonwealth of Massachusetts Official Use only - Department of Fire Services PemntNo— BOARD OF FIRE PREVENTION REGULATIONS kOccupancy and Fee Checked (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(ME )1527C 12.00 (PLEASE PRI NTW INK OR TYPE ALL INFORMATION) Date: Z /� City or Town of NORTH ANDOVER To the Insp ctor of, Wires: By this application the undersigned gives notice of his or her intention to pbrform the electrical work described below. Location(Street&Number) Owner or Tenant �( f G j� Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) 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: 6 Co-letion o the ollowin table may be waived by the Inspector pf Wires. FNo.of Receised Luminaires No.of Cel Susp.(Paddle)FansNo.of Total Transformers KVA f Luminaire Outlets No.of Hot Tubs Generators KVA .of Luminaires Swimming Pool AN ❑ In- ❑ o.of Emergency Lighting rnd. rnd. Battery Units No.o€Receptacle Outlets No.of Oil Burners FIRE ALARMS, No,of Zones No.of Switches No.of Gas Burners No.ofDetection and InitiatingDevices No.of Ranges No.of Air Cond. Toonsl 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 KW Local❑ Municipal ❑ Other Connection No,of Dryers Heating Appliances KW Security Systems.*. No.of Water No.of Devices orEquivalent Heaters KW No.of No.of Data Wiring: signs Ballasts No.ofDevices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No,of Devices ox E uivalent OTHER: C� fitach dditional detail if desired,or as required by the Inspector of Wires. Estimated Value ofElectrical Work: (When required by municipal policy.) Work to Start: 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' surance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cov9F69e is in force,and has exhibited proof of same to the permit issuing office. 3 CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) Icertify,under thepains and penalties ofperjary,that the information on this application is true and corplieie. FIRM NAME: LIC.NO.: / Licensee: Signature IJ4 LIC.NO.: 6 2?- (Ifapplicable,ep�ter,,"�xemP�"in the license number line.) Bus.Tel.No.; Address: _/"I /7��1�,nJ 4'V', �4' IVfi' C�7 3 *Per M.G.L c. 147, -61,security work requires Department ofPublic Safety"S"License: Alt. 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 Signature Telephone No. PER WT FEE:$ r /(� • J ._ • .�'+JU1L•lel./dJ.�-w.CFJ.>;-f��J.rrtRJ.A.�.L{�� .'.;{R7i.�CJtJS�..7 J1`G-L•%L VJt.�J4� � , _ E�C7[�3lCC.�C►3�t�1.' {`C�'�Dh�.�� .. `� _ . _ � y .xao� .nor P -CAOX., '�ssetl- [ 'ailefl--[ j Re-Inspection xegnlreff($50.00)-( inspectors"co7atm.e�ufs: ' (51gp Wore signature-no Initials) Date Passe$•-[ ) paiTecl--j I te3cnspeetion equixecl($50.00)- [ InVectors"comments: Uf aijevll� yc- Z- (Ti 4ectors"hignature-)10 Iniffals) slate 3,!MAPR +oRorrND E�9PEcTZoiY:Paed-[ 1 FiazIe�--j 1 • ate-Inspectloxzaequired($60.00)�[ ] Inspectors"comments: (rtnspectors',Signature-no inifials) Pate r 4.INSPEMON— SCE: Passed--[ Walled--[ Re-Inspection required($50.00)-j � Inspectbrs'cosnm.eph: . r (fmpectors,sfgnature••no wilals) Date INS'ECTXON-•OMR: 'assecl- [ j IafIed--[ 'ate-InspMUM reyuire0($50.00)•-[ � asp ectore comments: • S 04811ectors"signature••no initials) Date 0 OOR TAGS.AR-"TO EE ESE T O'UT.AND IEFT WRITE IF THE APXA TO 3E INSPECTED is ivoT .A.CCESSBEE,AND.A.RE WSPECTZON OP`550,0 019 TO$E CHARGED. . Date.... 40RTN TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING 49 -alomw CH This certifies that ...... ........��2.. ......................................... has permission to perform .................................. wiring in the building of................................................................................... irir at...... ................ ............. ,North Andover,Mass. F —45) ee..................... Lic.No. ............. ................... R v Check # Alle '� 7320 rOfficial Use Only Commonwealth of Massachusetts Y mom Department of Fire Services Permit No. Occupancy and Fee Checked 04kv � BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(M EC),527 CM R 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: / —/�-- / -7 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) Owner or Tenant TeIA/bile7NO. k7,7 - Z9y, Owner's Address 7 Is this permit in conjunction with a building permit? YesNo ❑ (Check Appropriate Box) Purpose of Building_ „ � /A d,�r, /1Z Utility Authorization No. Existing Service �'w Amps 12�/ 2�`volts Overhead �Undgrd❑ No.of Meters New Service Amps 1 Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: � r Completion of the otlowin table may be waived by the lns ector of Wires No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of ota Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ No.ot Emergency Lighting rnd, grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.oDetection and Initiating Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump I Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑.ConnecctioMumetio n ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No,o No.of Devices or Equivalent Water No.of Noof Heaters KW . Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP ITellecommunications Wiring: No.of Devices or Equivalent OTHER: 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: Y 7 Inspections to be requested in accordance with MEC Rule 10,and upon completion. r 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 covers in force,and has exhibited proof of same to the permit issuing office. ' CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) !certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: l .NO.: 3 Licensee: o y Signature IC.NO.: y (If applicable, en 5r "exempt' in the license number line.) us.Tel. NO. Address: Alt.Tel.No.: *Per M.G.L e. 147,s. 57-61,security work requires Depatim nt 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 ars the(check oneowner owner's agent, Owner/Agent Signature Telephone No. PERMIT EEE. $ 42LD) �� P117 r I r I Date. . ... _ . NORTh pF �,ao ,°1ti0 o� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 9 + �9SSACNUSEt AIM1144-6f. . This certifies that . . . .� . . . . . . .1A ., has permission for gas installa�ti '� in the buildings of . . . . . . . . . . . . at � !. . . . . . . . , North Andover, Mass. Fee! . ,6v. LIC. No..J�7 . . . . . . . . . . . . . . . . . . . . . . . . GASINSPECTOR tiCheck# � 4691 aS C MASS APPROVAL # MASSACHUSETTS UNIFORM APPLICATION FO PERMIT GASFITTtNG (Print or Type) N3• ,As' . Mass. Date a Permit it !f i i- Building Location F' des' o%m's Name d Occupancy New p Renovation Rjfcemient p Puns Submitted: Yesp No a n c #A W a Y = C n H O r1 c F- S y c N z O O z f t7 J W H } mz C _ O F a z o u < Q c O o a v bZ s z < s W W J = c C W ~ ti V = q c z p• W J 114 S p W„ � W m 2 0 ~ W 0 M S Q w 7 =. < c < < .o o c o e+ cc 'x O C Z c d J u c > c f.IL ►- O SUB—BSMT. BASEMENT IST FLOOR I I1 Y4 IND FLOOR I I 3RD FLOOR I 4TH FLOOR STH FLOOR I - 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name YANKEE GAS Click one: Certificate Address 140 SOUTH MAIN STREET [X Corporation 103C MIDDLETON, MA 01949 [. Partnership Business Telephone 978-774 ' 2760 [ Firm/Co_ Licensed Plumber or.Gas Fitter WILLIAM Name of Li - . INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which rneael.s the requirements of MGL Ch. 142. Yes IR No O a If you have.checkedy&s, piease Indicate the type coverage by checking the zWopriate box A liability Insurance policy 3 Other type of indemnity❑ Bond 0 OWNER'S INSURANCE WAIVER: l am aware that the licensee does nct 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: Owrw.rj, Agent❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information 1 have submitted(or entered)in above an;caticn are and accurate to the best of my knowledge and that all plumbing work and installations performed under the permi for this Will be ra with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the�� ral Lams gy T of License: Plumber gna mDer or mer Title Gasfitter Master License Nurntwe 3785 Qty/Town Journeyman d ( NL a ` I JQt.l. NCYCLVrmcwI %,VnrvnA1ww 10395 Town of North Andover t - 01/30/12 50.00 i Haverhill Bank 9613 Fee f r title 5, 680 Foster St No. Andover, M 50.00 J and S Development r' $0.449 dba/Stewart's Septic Service US POSTAGE FIRST-CLASS 58 South Kimball St 0620077301833311 Bradford,Ma 01835 deVe p � �� Q ea��h o� 6 �9� iU r3 e.r... t •f0'as a a 111111,411011111llll ILIIit 'Ili-l1111 11,111