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Home My WebLink AboutMiscellaneous - 7 COCHICHEWICK DRIVE 4/30/2018 BUILDING SUerTab® Oversized-Tab Folders 90%Larger Label Area CpItlMdFlb�r8aue6�9 NpRTN TOWN OF NORTH ANDOVER 0 PERMIT FOR MECHANICAL INSTALLATION # o � '17 9Opn°err'4h 9SSACHUSEt This certifies that . nGll.? . . . . . . . . . . . . . . . . . . . . . . . . . . has permission for mechanical installation . ., J� --. . . . . . . . . . . in the buildings of . . . C.- c. �. . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . .. . . . . . . �. . .r.:. �� :.�. , North Andover, Mass. Fee./A Lic. No.. . . . . . . . . . . . . . . . . . . . . . J GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. IPINK:Treasurer Commonwealth of Massachusetts Sheet Metal Permit Date: q ( l, Permit# Estimated Job Cost: $ ' Permit Fee: $ Plans Submitted: YES o NO Plans Reviewed: YES NO a Business License# 0 Applicant License# M 3 t Business Information: Property Owner//Job Location Information: Name: 4,�6 �� l ask St a Name: Street: S s 5 w 0�kt St Street: City/Town: L City/Town: k�, f Telephone: C� 1`a� �s�`�{� 3 Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES NO Staff Initial ff/Z unrestricted licens J-2/M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. /2-stories or less Residential: 1-2 family V� Multi-family Condo/Townhouses Other Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft. ✓ over 10,000 sq. ft. Number of Stories: �J Sheet metal work to be completed: New Work: Renovation: HVAC ✓ Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: t / .Yw s'��( or-L w c.t►� �-,�( \`"-/�c.e ��`� �f� t h �u-bc r�r� w i't- w M k D A so w N� 4-y 6- WR w l-1- \ Js o U«-tti-Cy r i I I I � I I II _ � � Rue�➢�7l?w�nq�,vy�s+�� i I I I � 11 • 1 I 0 . � I ISI .� z��zt, cwt I -.--.• t+r ""°°��''''''''""''''''FF "'R�� nrwrrm"'gm�o��n�avruac�r�raeuFxanax�xurranKywwn/\aet � �.�� i r ` aroawrocasq�,;�o�Rmausexwuw�y� I r t lam` I a �" 'w�..w..�.w'°'01"�'�awmwarww �arrraan�.,w �,nn,lnteWtrmr�„y i " a'+itm�aeumwnn�,,t.+om sm.4""Wstv� f Vi— E .f �l 1 _ 1 f 1 � NA A .. I f s i I I I 1 1 T . I Y I �--«..,.«...., .+....�.....,..«..................��,.....:.....—mni+nw.e...._«..- ..n.«...-..�..,-.. -.....n n..r..... ��..:��,..\�.�� .�...................��n��.n....s..e...w v.,..,« � r • gni I / u> C` �s i \ p tp I 1 1 i. t V _ a 1 3 a ,A�.,, .w.�«.�."'..e"^".`"•'"„�"""w'+v+ ,.�sr;w.ruawcuewwYe+u.,. c � i i n Sheet Metal Residential Guidelines/Inspection Checklist Yes No N/A Detailed description and sketch of sheet metal system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper journeyperson-to- apprentice ratios Equipment sized per heating/cooling load calculations Duct work sized per manual "D"calculations Bath/shower rooms contain mechanical exhaust fan vented outdoors �— Electric dryer exhaust properly installed maximum total run 35'-0", maximum flexible run 8'-0" Flexible duct runs installed 14'-0"maximum length Volume dampers installed for each supply air branch duct Ductwork installed using proper gauges and hangers Ductwork/plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining New/clean -properly sized filter installed(final inspection) Testing and Balancing report complete(final sign-off) � 1 v r COMMONWEALTH OF MASSACHUSETTS. f { SHEET METAL WORKERS !jAS A JOURNEYPERSON-UNRESTRICTE r}� ISSUES THE ABOVE`-LICENSE TO: T1,MOTHY R PA- L.MER 112 LOWELL AVE HAVER-HILL MA- 01832.373-0 k 3731 09/28/12 929164 i►.ry � ti , i /i 1 i - /r t I i • I V Load Short Form Job: Date: July 25,2012 Entire ,House By: HEATING SERVICE f=rank's Heating Service 055 Woburn 51,Tewksbury,MA 01876 Phone;970-061-4403 Fax:978.051-0398 Em�ll:mlkohgfranksheating,com Web:http:/Miww.rronk^hn�ling roml For Jeffco 7 Cochichewick Dr, North Andover, MA, MA 01845 Design • • Htg Cig Infiltration Outside db("F) 1 88 Method Simplified Inside db(°F) 70 75 Construction quality Tight Design TD(°F) 69 13 Fireplaces 0 Daily range - M Inside humidity(%) 50 50 Moisture difference(gr/ib) 50 28 HEATING EQUIPMENT COOLING EQUIPMENT Make Make Carrier Trade Trade BASE 16 PURON AC Model Cond 24ABC648A**31 AHRI ref Coil CNPV*4821A**+59*N*A100V21**20 AHRI ref 4744963 Efficiency 80 AFUE Efficiency 12.7 EER, 15.5 SEER Heating input 0 Btuh . Sensible cooling 29400 Btuh Heating output 0 Btuh Latent cooling 12600 Btuh Temperature rise 0 OF Total cooling 42000 Btuh Actual air flow 1400 cfm Actual air flow 1400 cfm Air flow factor 0.028 cfm/Btuh Air flow factor 0,042 cfm/Stuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat Load sensible heat ratio 0,93 ROOM NAME Area Htg load Clg load Htg AVF Clg AVF I' M2) (Btuh) (Btuh) (cfm) (cfm) dln 162 3578 2238 102 94 kit 263 2112 705 60 30 bathl 70 1542 607 44 26 liv 189 2984 1385 85 58 foy 138 2069 1394 59 59 fam back ent 189 3632 2126 103 90 25 973 853 28 36, wlc 54 1050 240 30 10 m bath 77 1236 872 35 371 bath2 99 1388 924 40 39, bed1 225 3438 2290 98 96' bed2 189 1813 1976 52 831 up foy 171 1959 1451 56 61 ' mas 283 9570 9826 272 414, bed3 413 5444 2854 155 120 bath 63 1005 702 29 301 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. - wrightsoft° RI 2012-Aug-101D:37i:64 nt s alto®universal 2012 14Er 9 12.0,09 RSU1oo67. Fape 1 C^A ...oft HVAC2tproMclljerrco-7 cochlcnewlck north nndover ma.rup Calc-MJB Front Door feces: I ,9 Load Short Form Job: Date: July 26,2012 MSMW Entire House By: HEATING SERVICE Frank's Heating Service 555 Wobum$1,Tewksbury,MA 01876 Phono;970-051-4403 Fax:978.051-0398 Emall:mlkeh@frallkshodling.com Web:hrtp:llwanv,twmkshnating,00m/ Project • For: Jeffco 7 Cochichewick Dr, North Andover, MA, MA 01845 Desigiii Information Htg Cig Infiltration Outside db(°F) 1 88 Method Simplified Inside db(°F) 70 75 Construction quality Tight Design TD (°F) 69 13 Fireplaces 0 Daily range - M Inside humidity(%) 50 50 1 Moisture difference(gr/Ib) 50 28 HEATING EQUIPMENT COOLING EQUIPMENT Make Make Carrier Trade Trade BASE 16 PURON AC Model Cond 24ABC648A**31 AHRI ref Coil CNPV"4821 A"**59'N*A100V21"20 AHRI ref 4744963 Efficiency 80 AFUE Efficiency 12.7 EER, 15,5 SEER Heating input 0 Btuh Sensible cooling 29400 Btuh Heating output 0 Btuh latent cooling 12600 Btuh Temperature rise 0 OF Total cooling 42000 Btuh Actual air flow 1400 cfm Actual air flow 1400 cfm Air flow factor 0.028 cfm/Stuh Air flow factor 0.042 cfm/Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat Load sensible heat ratio 0,93 i ROOM NAME Area Htg load Clg load Htg AVF Clg AVF (ft2) (Btuh) (Stuh) (cfm) (cfm) i din 162 3578 2238 102 94 kit 263 2112 705 60 30 bath 70 1542 607 44 26 liv 189 2984 1385 85 58 foy 138 2069 1394 59 59 fam 189 3632 2126 103 90 back ent 25 973 853 28 36 wic 54 1050 240 30 10 m bath 77 1236 872 35 37 bath2 99 1388 924 40 39 bedl 225 3438 2290 98 95 bed2 189 1813 1976 52 83 up foy 171 1959 1451 56 61 mas 283 9570 9826 272 414 bed3 413 5444 2854 155 120 bath 63 1005 702 29 30 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. i wlri htsoft° 2012-Aug-1e 10:37:54� Rlpht-Salle®Universal 2012 12.0.09 RsU10pr,2 /fi+vA ofl HVAC2lProf ectllefrce-7 cnchlchc+wlcic north andover m:i,rtip Cele-M-18 Front Door faces: Page 1 J bed4 384 5378 2807 153 118 Entire House d 2992 49170 33251 1400 1400 Other equip loads 0 0 Equip. @ 0.93 RSM 30923 Latent cooling ?680 TOTALS 2992 49170 33603 1400 1400 I i Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. • wri htsoffi- 20121-Aug-1A 10:37'.54 9 RI!fhl-Butte®Unlvereal 2012 12.0,09 R&U10082 ACCN ...oft HVAC2%ProJntlfJeNco•7 cochicht. Irk north andovcr mo.rup CeIG=MJB Front Door faces: Page 2 j Date .%. 7- t TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . . . . has permission to perform . . . . . . . . . . . . . . . . . { wiring in the building of 'Q. . < —. . . . . . . . . . . . at . . . .7 -6tfxv'!. b.�L!J/C:fc. . . . ., !�. . , orth Andover, Mass. ' Fee .1/0O --. Lic. No.4 q&54. . . . . . ^a ELCTRICAL INSPECTOR Check# 1 '1000 1 Commonwealth of Massachusetts Official f / Use Only Permit No. Department of Fire services 1 ` t Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: q 2 — 1.2. 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) 1 c—h e c-i Owner or Tenant 3-Pi 'C,® 1 vL, Ci Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No F1 (Check Appropriate Box) Purpose of Building Utility Authorization No.,U3 0 S 7 � - Existing Service Amps v� / u Volts Overhead❑ Undgrd❑ o.of Meters New Service 0 Ams l Gu /z`Ovolts Overhead❑ Undgrd No.of Meters L P Number of Feeders and Ampacity s, Location and Nature of Proposed Electrical Work: LQ1 re rjv�(� Completion ofthefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of .(Paddle)Fans Ceil:Sus No.of Total P Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.of EmergencyTi-gE—ting 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.of Detection and Initiating Devices � No.of Ranges No.of Air Cond. TotalTonsNo.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other P g Connection SystemNo.of Dryers Heating Appliances KW Security Devices Y No.of Devices or Equivalent No.of WaterKW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring. No.of Devices or E uivalent 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: 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 ceBOND is in force,and has exhibited proof of same to the permit issuing office. CECHECK ONE: INSURAN ❑ OTHER ❑ (Specify:) I certify,under the p ins an nalties o.perju ,hat 11 information on this application is true and complete. FIRM NAME: /LPG / � E'N/CPi LIC.NO.: rL l w Licensee: p �—' e-, Signature "2- LIC.NO.: 6 (If applicable, ter "exe t"in the license number line ,, l' �/�fj b �d�g Bus.Tel.No.: / *Per M.G.L c. 147,s.57-61,security work requires Department 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 am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. ti The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia I Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers I Applicant Information Please Print Legibly Name (Business/Organization/Individual): damher Address: Al-11 [�� Phone � City/State/Zip: Ar(°ty4 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with � 4. ❑ I am a general contractor and I * have hired the sub-contractors 6. El New construction employees(full and/or part-time). '7, Remodeling � 2,f] I am a sole proprietor or partner- listed on the attached sheet.# ❑ g i 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 required.] officers have exercised their 10.❑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 we have no 12.❑Roof repairs insurance required.]f employees. [No workers' comp.insurance required.] 1311 Other *At.iy 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. $C4ntractors 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: v 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 Pune 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 Df 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 and penalties of perjury that the information provided above is true and correct. Signature: Date: 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Date. .810elli .... .... NORTN 0f 4�... ...4, o� °` TOWN OF NORTH ANDOVER M 9 44 • PERMIT FOR GAS INSTALLATION h SSAC HUSEtt LCr re�f/ This certifies that . . . . . � //.'. . . . . . . . . . . . . . . . has permission for gas installation . .44--e. . . . . . . . . . . . . . in the buildings o . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . .491�1 . . .. . ..�.�! . . . . ., North Andover, Ma s. Fee.14?,.a:' /k . Lic. No.I ,�! . . ir ! �? . GAS INSPECTOR Check# S^ ICU 8306 T,• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r CITY _ MA DATE- -e 5RMIT# JOBSITE ADDRESS = WOWNER'S NAME GOWNER ADDRESS TE FAX PST OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW:.rk" RENOVATION:0 REPLACEMENT:r� PLANS SUBMITTED: YES NO APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER j L�1, _( .__- _Lj I CONVERSION BURNER �! _�_1 COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR --.I .-r _ ... __. FURNACE .._ILI�ll�._ 11.- -TSL___. �. 0 GENERATOR ,-� -1 GRILLE 1=�- (--A L--1[`��_ N�f�=f�-�['T [✓ � __ E C��_- T INFRARED HEATER I— ��(—J.(--I LABORATORY COCKS ( -( - I - -!r-i 1---_�!f _ 1 ,. __I!�__1�2_ . J L--- I - �rT MAKEUP AIR UNIT -lI . -,.--:I l_.._ G ±I�,f Ir-= I_.,, f -1I _ - ,., OVEN POOL HEATER ( 1 1 7---a E-._.11.�-.J ROOM/SPACE HEATER ROOF TOP UNIT ED= i__ UNIT HEATER -� - � _t- �I ��-I---1��fr-_�__-(�.-._.� � '.:-._. ---_-_-iY UNVENTED ROOM HEATER L- I_,._..,... WATER HEATER OTHER ------- -- ---- - J!__1�_-,I 1--1 SI — 1I J INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YESC*, 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 02 OTHER TYPE INDEMNITY EA 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 I0 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 'h allfPsaiLvi.prit p vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME ~~ - _- LICENSE#E SIGNATU MP W_I MGF El JP R-j JGF 0 LPGI ( CORPORATION PARTNERSHIP rte_f#=LLC D.-j#= COMPANY NAME: Qom' I ADDRESSp�j� ----'--� CITY STATE ZIP TEL O_ _ FAX CELL l EMAIL v F• The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA.02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/ContractorsfElectricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Organization/Individual): {� Address: VGJoM City/State/Zip: Phone#: v Are you an employer?Check the appropriate box: Type of project(required): 1.T I am a employer with� 4. El am a general contractor and I 6• [�New construction c employees(full and/or part-time).* have hired the sub-contractors 2J:17.am a sole proprietor or partner- listed on the attached sheet. �• Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for mein any capacity. workers'comp.insurance. 9. F1 Building addition [No workers'comp.insurance 5. El 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 we have no 12.❑Roofrepairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other :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 aie 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 is providing workers'coin F do insurance for my employees Below is the policy and job site information. /�� Insurance Company Name% (J � J 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 certio under the vqAisVdpenalties ofperjury that the information provided above is true and correct. Si -z Signature Date: 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical Inspector 5.Plumbing Inspector i 6.Other - - i Contact Person: Phone#: Date. iFIM , z ./J6 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING �SSCHUS This certifies that . . .l././yl. .�. . / ' '`�. . . . . . . . . . . . . . . . .. has permission to perform . . . 4! • . • . . . . . . . . . . . . • • • . plumbing in the buildin s of . . . 7R . . . . . . . . . . . . . . . . . . . . . . . . at . . . . .7-6. . • • • • • • ., North Andover, Mass. Fee.-�1.T.��. .Lic. No.. . . PLUMBING INSPECTOR Check " P MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY V, MA DATE _ _�-7( MIT# JOBSITE ADDRESS Ll lid /- 1'11/CJ II OWNER'S NAME P 09 (J OWNER ADDRESS p { TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL RESIDENTIALV PRINT CLEARLY NEW: !] RENOVATION: . REPLACEMENT:D PLANS SUBMITTED: YES D NOD FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 � 14 BATHTUB 1 — ( ° _I ._._ � ( i CROSS CONNECTION DEVICE I DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/O(LISANDSYSTEM DEDICATED GREASE SYSTEM f ..__._._.1 DEDICATED GRAY WATER SYSTEM ( ( ( .___-{ I _I ( ' _ J 1 f f DEDICATED WATER RECYCLE SYSTEM (Of { ( 1 ._! ____JDISHWASHER ( 1 � 6 ____ I -_.____(DRINKING FOUNTAIN _-..�( ._ 1 E J 1 J 1FOOD DISPOSER 1FLOOR/AREADRAIN INTERCEPTO R(INTERIOR) 1 _ 1 ._ ( I ..... I ( ..__MJ KITCHEN SINK f -- __I LAVATORY ___-----( -_.___1 _._.___.I ._____1 __.____I ____._J .1 _._......._1 ROOF DRAIN ( -._..__._� _.-_._ SHOWER STALL SERVICE/M �PSINK TOILET URINAL WASHING MACHINE CONNECTION _-_-__. __ ! _ _ WATER HEATER ALL TYPES WATER PIPING _i ► _—_1 __._._-_( f _ _. .__ ___._._1 .__._ f ( —_-- 1 OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICYV OTHER TYPE OF INDEMNITY D 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER D AGENT DI 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 com with all Pe ' rovision of the i Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME / ^—IILICENSE# SIGNATURE MP—W JP DI CORPORATION 0# PARTNERSHIPD# LLCD� j COMPANY NAME ( 04 1ADDRESS G CITY ^ _ ---_._._...._I STATE ; ZIP d TEL ! FAX L CELL �!I The Commonwealth of Massachusetts Department of IndustrialAcci6nts Office of Investigations U1 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Le ibl Name(Business/OrganizatiorAndividual): - 1 _0Z ,/J0 cy. Address: / City/State/Zip: � 1411 d �� Phone#:j(a_a :3 -/ y z1-660 I Are yqn an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 7-77 4. 111 am a general contractor and I ' 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.t 7. ❑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.El trical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.VfPlumbing 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.❑Other comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they hire 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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. le I 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 certjqyn&r the pains altdes ofperjury that the information provided above is true and correct. Si ature: Date: — –' 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 66 Other - - - Contact Person: Phone#: Date • bVK'tLRD 7�4. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 0 �045V l ( a This certifies that . . . .'. . . . . . . . . . . . . . ./ has permission for gas installation , in the buildings of. 1 e, ?c`C . , . . . . . at . . . ! . l. .[? ! QQ. �,,N �!c.r fly , , , , , , , ,North And er, Mass. Fee�0� . . Lie. No . . ! . . . . M . . . y. GASINSPECTOR Check# 8452 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I NORTH ANDOVER MA DATE NOV.23 2012 JPERMIT# JOBSITE ADDRESS 17 COCHICHEWICK DR. OWNER'S NAME JEFFCO INC. GOWNER ADDRESS I JEFFCO INC. TE 978-609-3762 DFAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIALEDUCATIONAL ® RESIDENTIAL CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES Z 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 FIREPLACE FRYOLATOR FURNACE GENERATOR _ GRILLE i INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN ! POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST. UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER CONNECT TO A PLUMBERS INSPECTED LINE f INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q 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 ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT - i I hereby certify that all of the details and information I have submitted or entered regarding this application are trueAnd 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 can a with all Pe in t p i 'o � t Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I JOHN MARSHALL LICENSE# 778 SIGNATURE MP® MGF❑ JP❑ JGF❑ LPGI 0 CORPORATION Q# PARTNERSHIP[j# LLC❑# COMPANY NAME: EASTERN PROPANE GAS ADDRESS 1131 WATER ST. CITY I DANVERS STATE=ZIPI 01923TEL 800-322-6628 FAXI CELL EMAIL II 2r, ►2 1 V ' ��\v , � c- L lam/-/zA&44� The Commonwealth 0 D2Da7-L-menz of-TnLiz1-sz-,-LaI 7 Cop Suite 7 00 3O-Ston, 02'14-2017 1 , www.mf.,o,,s.go vl'dia r�M TI fm 10L-I Ida a 12-1...... EP-S-FERN PROPAN- -DIL N='- (Busin,2ss/C)rL,2n]721]OII,�n6lvidual): " kdditss: DI W/-.- I j -,i -. ,, STFEET CIY/STaL-/ZiDL,NVERS MA 01923 T97B-75D-65DD Are You an =Djoyey" Che,ch the appropriate box: I Type of project (required):. 45 4. cOn-r:U7,T.0-; and I I I a=1 a. employer with- 6. --jf,�eV? COrL-[rUCD0TJ " * have hired the sub-contactors tuiploytts (lull and/oT-part-=5). 7. Remodeung listed on the attached sheet. 2-71 1 a= a sole proprietor or partner- These sub-contractorshave01,- ❑ D-amolitiOD ship and have no employees hese and have workers' 9. Building addition wOrl-iii!z forme ID any capacity comp. ir-suranct., Gin insurance �aj -5 or additiot, PNO workers' --OM-P. insuz 5. We are a corporation and its 0.[] El -pair officers have r-- sed the' 1 l.❑ Plumbing T-P=5 or addhion'S 3.711 am a homeowner doing all worl, eT T-Igb7L Of 5x--Mp'nC)D P PO 0 f repairs Inyself. FNo workers' comp. C. 152, §1(4}, and We have no AS F 1-1 1 N G ia=azo-,required.] I13.D Ufh employs- [No worhers, in=ane required.] thLt�r wary 'secton -1()V"shcmd� aamp--iis onj)Dh--,'jIIf0IM2Ii=- ,jL=y appii=r thz cbLe-cL-s box ill mist also a out the D. b=it ffadavit indica=g such- Is =ng ttL--, u,-dom.,;all wore:arid then him outsidecaittra=lrs mus'su L Hormowz=.-,who submit ibis affidavit mdic whets=: C,7:Lcr S= (hose=utits have �Con=acmr,that Ch=L fni-box M12,-, addidonal sh---t showing the n=-of tll-slih-0-01ta- - s and=ployt:es. Y the sit-r6nzactcrn have=P10 -�: the MmssDroviciz thewc)-.k=' comp.PC)h-)'nU3:6b=- Ye— ncef07-my frr�pjo-pe_,�_ �CLow is fhfpoR�, and lob sit- T am- anfMpLoyer that iSV7-OVidjn,(7 Wo,-j-7rS' C.0NIPMSafi0K L-ZSLLra ?Zf07w=±io?L LIBER Ty KALT-11JAL INSURANCE COMPANY =Urancc Company Name. 03 / 15 / 2013 D WC7-641-433 5806-052 -052 Dale: clicy or Self-iiis.LIC. #-. -- III .-7 cc)ct"( C C /Statt/Zip:1)0 JAL I 01W- Job Sim f,ddrt.cs- -IA PL" S, CI � ,-ttach a copy of file workers' compensation policy declaration page (shoving the policy'iminberand expiration date)- SeCtiDn 25A ol'l\/j'GL c. 152 can lead to the imPOSIUDD Of criminal Pelaalt'tS of- ,ailUrf TO StCUrt CovtTaclt as T--qUiT5d under -WORK ORDER and a fine '7. - I the fD,-D, of a STOP-me lip to S1,300.00 and/or OnE-YEal'InID-Isonment, as wet as civil penalties in - )f UP to 5250-00 a day against the violator. Be advised that a copy of this statement may be foT-%;mTded to the OITICE Of -verificat�on. insurance C'Overage - DVe,sTa.-atioiLs of the DIA for tie and correct That race information provided above is t, do herebyr-e7tfi; under the Pains and penalties af LL L an ar�g 03 13 2013 "hong ;=, , 978-750-6500 Lq area: to be ConZyIE'ed kj; _i7); 07- town0/��2ciaL 0fjLCjaj ZSe Onjj,, DO nOi' WTZ�- th 0 FCity or Tom n: -------- T s Loi 'Pi lti.sPtC� -al _D_ST)5CLOT 1, Bo2rd ofHealth -T 6. Other F COZLT-aCt Per SOIL: COMMONWEALTH OF MASSACHUSETTS G PLUMBERS AND GASFITTERS LICENSED AS AN LP GAS INSTALLER ISSUES THE ABOVE LICENSE TO: JOHN F MARSFIALL 47 HMBART STREET thy DANVERS MA 019223- 1965 I 778 05/01/14 1Ei4150 � " i i r f