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HomeMy WebLinkAboutMiscellaneous - 693 JOHNSON STREET 4/30/2018 (2) 1v93 S h � S�� M1!"�f1!."�ate,;,"� a"o'?:'TT�?`ti.$ Date............... ........ ................... OF &ORT/ 1ti TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 8`QACHU`3� r' ` This certifies that ........................................... ............... !.:....!"`...... C I J4�... ��.`�..�.........�..� �2 11. �. has permission for gas inst llation ..........e.`1 P..................................................... �, � yin the buildings of...:............................................. .......... . ..................................... at........W. �t�kN S,C4 61� , North Andover, Mass. ... .................. ............ ... . . . . . Fee.�-5v`�...."...... Lic. No. . r..H7. ........ M ...................................................... �i GAS INSPECTOR Check# �2 a ;��A MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY ./�. l� �ti_ MA DATEPERMIT# JOBSITE ADDRESS 6 �,T l OWNER'S NAME GOWNER ADDRESS ,),�r,-„ TEL g� ,�> . ar y g FAX TYPE OR OCCUPANCY TYPE COMMERCIAL( EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:El RENOVATION:E] REPLACEMENT: PLANS SUBMITTED: YES 0 NOD APPLIANCES'l FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER . BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER I _. .. .. . _ . _ FIREPLACE FRYOLATOR FURNACE GENERATORx� GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER ,UNVENTED ROOM HEATER f I I WATER HEATER BOTHER �� i .........._.............. — - -- - -J - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES JOINO Ej 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 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 0 AGENT 0 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 compliance with all Pertiont provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAMEi eti, /_ a�/ -gamLICENSE# Sl SIGNATURE MP EJ MGF Ej JP [ GF[:1 LPGI El CORPORATION©# PARTNERSHIP©# LLC E]# COMPANY NAME:Fa N ADDRESS S' 1 CITY /�� �+,°.ftjo�„ aC _ , _ I STATE ZIP Od li Y/ JTEL FAX II CML` == -O/ EMAIL _ — — — 1 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department oflndustriglAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electriciians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): /`f Address: C{r,S" �� /,�, �s 7— City/State/Zip: City/State/Zip: � ,� F C-,/ ,e) /-.I- Phone#:_6o — 9 c- 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 gmployees(full and/or part-time).* have hired the sub-contractors 2. g 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. g El Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.F1 Electrical repairs or additions 3.❑ I 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 wehave no 12.❑Roofrepairs insurance required.]i employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they tie doing all work and then hire outside contractors must submit 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 1s 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. X do laereby certi der the pains penalties ofperjury that the information provided above is true and correct. - Signature Date: /X,,, Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/I,icense# 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 F 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 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 j oint 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 employes." 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-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 required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe 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 multiple permit/license applications in any given year,need only submit one affidavit indicating current Policy information(ifnecessary)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 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 of Ma ssa chu setts Department ofladustrial.Accidents Office ofInvestigatious 600 Washington Street Bostw MA 42111 Tel,#617-727-4900 ext 406 oar-1-87T:11/1'ASS.AFF, Revised 5-26-05 Fax 4 617"727-7749 XVWW_mace ornsrfri;a w �P.COMMONWIt LTH OF MASSACHUSETTS. PLUMBER?W15ASF ITTERS ISSUES THE FOLLOWING LICENSE . . LICENSED AS A JOURNEYMAN PLUMBER cca THOMAS S F ARHAD 1 SAN 415 MA t N iLu F}AMP`SEAD N:H 03841-20]:3 Location ` �7 No. V /�cl l/ Date .�v i 40RTIy of�•` ° ,..,h TOWN OF NORTH ANDOVER + ; , Certificate of Occupancy $ Building/Frame Permit Fee $ JACHUS Foundation Permit Fee $ `� cv Other Permit Fee $ '7 TOTAL $ yz Check # 1 C 5 Building-Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI.E,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. DATE ISSUED. rn SIGNATURE: Oil' L Building Commissioner/I r of Buildings Date Z SECTION 1-SITE INFORMATION 0 1.1 Property Address: 1.2 Assessors Map and Parcel Number: tv93 / Map Number Parcel NumberNorM 1N U,1'� A UyJ 1.3 ZoningInformation: Property1.4 Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReqWred Provided Required Provided v 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT rn 2.1 Owner of Record /K Lt`V G n �NV r v � G S74. Name(Print) A r ss for Service O Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z rn Signature Telephone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number mn Address Expiration Date Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ 0 Company Name � l/ ` /0 C Registration Number Address 7 `i� e 7-(a r/V Expiration Date rnr Y St nat re Tele hone SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......13 No.......❑ SECTION 5 Description of Proposed Work check au a Iicable New Construction ❑ Existing Building ❑ Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify a Brief Description of Proposed Work: U SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be ,OFFICIAL..USE:ONLY -_ Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT °t 1> 1zze�X" �o/sa.gy as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all n er� ork alloiedNd by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION ` 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Signature of Owner/A ent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DfMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: y r, Board of Building Regulations and Standards Registration 129167 One Ashburton Place Rm 1301 Expiration &11;9/2003 Boston,Ma.02108 Typ61 Individual Michael J.Phelan , r Michael Phelan 30 Canobieola Road -X- _ �- --- Methuen,MA 01844 Administrator Not lid wit out signature Y PATRONS MUTUAL INSURANCE COMPANY OFCONNECTICUT ��,�yArceovs`goGA GLASTONBURY, CONNECTICUT — ARTISAN CONTRACTORS POLICY DECLARATIONS ALM« Policy Number: CTR0000920 RENEWAL OF BOP9003736 Effective date: 10/04/0' NAMED ........S - ItED AGENT':; 8640; MECHAEL PHELAN T A SULLIVAN INSURANCE AGCY, INC 30 CANOBIEOLA ROAD 369 MERRIMACK ST METHUEN, MA 01844 METHUEN, MA 01844 (978)681-8200 Policy Period: from 10/04/01 to 10/04/02 12:01 a.m. Standard Time at your mailing address shown above. Insured is: INDIVIDUAL Business Classification: ROOFERS Coder 10240 LLBILITY CERAE COVERAGES LIMITS OF INSURANCE L. Bodily Injury and Property Damage Liability $300,000 Per Occurrence $600,000 Aggregate M. Medical Payments $5,000 Per Person N. Products/Completed Work $300,000 Per Occurrence $600,000 Aggregate 0. Fire Legal Liability $50,000 Per Occurrence P. Personal and Advertising Injury Liability $300,000 Per Occurrence PRCI�'EI COVERAGE DESCRIPTION AND LOCATION OF PROPERTY Loc. 1: 30 CANOBIEOLA ROAD METHUEN, MA 01844 COVERAGES LIMITS OF INSURANCE Loc. # Building# Limit ACV Ai Building B„ Business Personal Property 1 1 $2,500 C. Loss of Income ACTUAL LOSS SUSTAINED, NOT TO EXCEED 12 MONTHS. WAITING PERIOD: 72 HOURS Increased Property Off Premises: Automatic Increase—Coverages A&B: 0% ANNUALLY PROPERTY DEDUCTIBLE: $250 SUBJECT TO THE FOLLOWING FORMS AND ENDOR5EIVIENTS .....,,....... AP-100 Ed. 2.0 AP 0611 01 99 AP 0643 12 99 AP-432 Ed. 2.0 GL-895 Ed. 2.0 ... PREMIUl1'I AND BILLING INFORMATI®lY . .... ...... ANNUAL POLICY PREMIUM: $1,188 BILL TO: DIRECT BILL TO THE INSURED ENDORSEMENT PREMIUM: MORTGAGEES PRINTED: 08/22/01 INSURED COPY THIS IS NOT A BILI Nv"" " ED 0 o over No. ceo - -_ �o' C �, dover, Mass., �o-2OOZ DRATED O' co S H E BOARD OF HEALTH T T Food/Kitchen Septic System PERMI M � BUILDING INSPECTOR THIS CERTIFIES THAT............... ...1�........... ................................................... Foundation g 93 has permission to erect................ ...................... buildings on . ........................... . .... .... ......... ...... ... ..... ...... Rough to be occupied a . ..... ....................................... Chimney ...... .................................................................................................... provided that t e person acce mg this permit shall in every respect,conform to the terms of the application on file in Final this office, and to the provisi s 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 CONSTRUCTIONT S ELECTRICAL INSPECTOR �t�� � Rough ......................................:.............. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. North Andover Building Department r- Tel: 978-688_954; DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid.waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant ' Date NOTE: Demolition permit from tt�ie Town of North Andover must be obtained for this project through the Office of the Building Inspector