HomeMy WebLinkAboutMiscellaneous - 7 WALKER ROAD 4/30/2018 (2)Date.5.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
�.�,� ��� ✓ire F��r �� f
This certifies that . :�'-k-" .. f Z 5 f I- + -k—
has permission to perform .....- . �" 7.
plumbing in the buildings of ... .. .
at 7 :� �.�' .. !. . ........... , North Andover, Mass.
Fee. J... Lic. No .......... .....................
PLUMBING INSPECTOR
Check #�
85105
�� rI
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location -2— 1 1.4,- / Kf�
Owner Sa 17 l E L
Date
Permit
Amount
New ❑ Renovation Replacement
Plans Submitted Yes 14 rl No
W,Wxrnmr�--
vrnnt or rype)
nL�/
Installing Company Name_ ��'t✓/f/�t/ j� l/SSO !�' Check one: Certificate
Corp.
Address Gy (,�j�. y ❑
Partner.
rr
rsusmess J eiephone g S 7
Firm/Co.
Name of Licensed Plumber:
Insurance Coveram Indicate the type of msurance coverage by checking thea to box:
Liability insurance policy ® Other of 7�
type indemnity ❑ Bond n
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner 1..1 Age ❑
I hereby certify that all of the details and information I have submitted entered) of m knowl ) in above application are true and accurate to the
y edge and that all plumbing work and installations performed under. permit Issued for this application will be in
compliance with all pertinent provisions of the Massa ch e State Pl C d
By:
Title
City/Town
APPROVED (OFFICE USE ONLY
Ti
i re o e and Cbe�t y142 of the General Laws.
TPe of Plumbing License
r�---���r
rcense umor- Master 41 Journeyman
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, M4 02111
ovldia
Workers' Compensation Insurance Affidavit Builders
A licant Information /Contractors/Electricians/Pinmbers
Please Print Legibl.
Name (Business/Organization/Individual): Ci
U
Address: C G� I X Y
City/State/Zip: 0Z:V )7 GY
Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with _ 4. ❑ I am a general contractor and I
2. [employees (full and/or part-time).* have hired the sub -contractors
I am a sole proprietor or partner- listed on the attached sheet I
ship and have no employees These sub -contractors have
worlang forme in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
workers' comp. insurance.
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
`:.ny aYpiicaut that checks.box ri must also fill cut tie aection beton, shoe, n
t Homeown-e s who subm't 4 a —_L workcn, co—r - il
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.7 Roof repairs
13.❑ Other
`� t ss affidavit indicating they are 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 worker' rnm .,,,t:..:_o_
.i an employer that tS providing workers' compensation
information. insurance for my employee& 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' 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 foam of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a co
Investigations of the DIA for insurance coverage verification py of this statement may be forwarded to the Office of
Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct
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
6. Other Department 3. City/Town
Contact Person:
Clerk 4. Electrical Inspector 5. Plumbing Inspector
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 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 coinpliance 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 numbers) 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. re„ turned to the city or town that the application for the pernait 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 (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 Investigaions
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-72.7-7749
Revised 5-26-05 WVrVI.mass-alov/dia.
Date 5 -%G e!' .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
i r
This certifies that ........./V .. `t. /V ...... .
has permission to perform ................
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plumbing in the buildings of-.`?...` .................:--u-e�.
at ... �-.-.. �� ......... North Andover, Mass.
Fee_. ..... Lic. No. ... .. ........... .
PLUMBING'INSPECTOR
Check #
6846
�L
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location� Owners Name
Type of Occupancy
New ri Renovation Replacementz
Date
Permit# Sy
Amount
Plans Submitted Yes ❑ No ❑
! (Print or type) (� Check on: Certificate
f Installing Company Name to ej r ❑ Corp.
Address
Partner.
Business Telephione 7 - 3 CF Firm/Co.
Name of Licensed Plum .�
Insurance Coverage: Indicate the t pe of insu nce coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity C] Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
I hereby certify that all of the details and i or
best of my knowledge and that all plumbin
compliance with all pertinent provisions of the
113y:
own
ZOVED (OFFICE USE ONLY
ner ElAgent
I have ubmitted (or ente)/d) in above
tts
�rt are true and accurate to the
r this application will be in
of the General Laws.
Type of Plumbing�License
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e um er Master Journeyman ❑
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! (Print or type) (� Check on: Certificate
f Installing Company Name to ej r ❑ Corp.
Address
Partner.
Business Telephione 7 - 3 CF Firm/Co.
Name of Licensed Plum .�
Insurance Coverage: Indicate the t pe of insu nce coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity C] Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
I hereby certify that all of the details and i or
best of my knowledge and that all plumbin
compliance with all pertinent provisions of the
113y:
own
ZOVED (OFFICE USE ONLY
ner ElAgent
I have ubmitted (or ente)/d) in above
tts
�rt are true and accurate to the
r this application will be in
of the General Laws.
Type of Plumbing�License
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e um er Master Journeyman ❑
4
Date.?.` : A : � G.
T^ 28SA
TOWN OF NORTH ANDOVER
p PERMIT FOR PLUMBING
This certifies that ...V...
has permission to perform ... D. 1. `
plumbing in the buildings of .. R-�!.L
at ... 7 .. L4-<. /%z �� / c� , N rth Andover, Mass.
..... ... \
Fee .. � � �. � . Lic. No.. 16.3P . .,. .. .
LUMBING INSPE TOR '
04/01/Sa' 16:45 2�.', 'Wl)
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
IN
MASSACHUSETTS YNIFORM APPLICATION FOR PERMIT TO DO PLUMBING w" —
Mass. Date (» Permit
PuAding Location/ W Owner's Name
Ty of Occupancy
New ❑ Renovation ❑ Replacement II�J Plans Submitted:
pl Yes O No D
FIXTURES + {URES
B.P.# SEWER#SEPTIC#
Installing Company Name_ o' w
Business Telephone
Name of Licensed Plumber
'8 PLUAIlBINO ING. Check one:
N. N.H. 03079 ❑ Corporation
❑ Partnership
Certificate #
!NSURANCE C VERAGE:
I have a cu entliability nsYesoura ce policy or its substantial equivalent which meets the requirements of MGL Ch. 142
It ; ou have [check' ed ye§, please Indicate the type coverage by checking the appropriate box
i ;:ability Insurance pocky LTJ " Other type, of Indemnity ❑ Bond ❑
4NER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
apter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner ❑ 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 permit issued for this application will be in compliance with all
pertinent provisi_ons7of the Massachusetts State Plumbin a.and .Ch U'1A4ZqfLtheG*eneraILLaws.
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Name of Licensed Plumber
'8 PLUAIlBINO ING. Check one:
N. N.H. 03079 ❑ Corporation
❑ Partnership
Certificate #
!NSURANCE C VERAGE:
I have a cu entliability nsYesoura ce policy or its substantial equivalent which meets the requirements of MGL Ch. 142
It ; ou have [check' ed ye§, please Indicate the type coverage by checking the appropriate box
i ;:ability Insurance pocky LTJ " Other type, of Indemnity ❑ Bond ❑
4NER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
apter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner ❑ 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 permit issued for this application will be in compliance with all
pertinent provisi_ons7of the Massachusetts State Plumbin a.and .Ch U'1A4ZqfLtheG*eneraILLaws.
8Y
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FI S license Number
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TOWN OF NORTH ANDOVER
wr jwqr ,p PERMIT FOR WIRING
ui
This certifies that .........:.C.. t 4 /Z-).. e
.. .t..../...........
has permission to perform 9Q. �i
ko
'0
wiring in the building of ... 1A1. C"
.............................
at.... / ...... . ........................ . Northlkndover, Mass. 4
Fee../.*>...= ..... Lic. No. ..........................................................
ELECTRICAL INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
N 014t (101milauvicaltll of MationC41100tr; t,„ , -
DPPartment of Public Safety Permit No.
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00
pccyptr+ry tv I r•e r lur kpl
U90 lka+r i+lank)
APPLICATION FOR PERMIT TO PERFORM F_I_ECTRICAL %-IORK
All work to be pedoiniol in accordance with the Massachusens f h4 oir.,l r .a ,',.-CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION)
City or Town of
The undersigned at+ldies fora permit to perform
Location (Street R Nunitirrt 9 0/9 L /1014 r3
Owner or Tenant J6/V/V / S P L /1-0
Owner's Address
Date �/ �/�/,
1+. It-(, htcl+ectnr of Wir—
Is this permit in conjunction with a building permit: Yes LJ No L'n (Check AppropriaU• Bax)
Purpose of Building Utility Awlhnriratinn No.
Et Wna Service _Anil" / Valls ovellwad [I Undgrd ❑ No. of Melert
New Service Amps / Volts Overhr.xl U Undgrd U No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
W L U Iz7,-7u
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusnes General Laws
have a current Liability Insurance Policy including Completed Operations Coverage or its suh.t.vvial .•.lnix alent. YES C1 NO l 1 -.ubmitted va!id pul, 0
of same.to this offic-P. YES U NO O
If you hive checked YES, please Indicate the type of coverage by checking the appropriate NIX.
INSURANCE BOND ❑ OTHER❑ (Please Specify) OoU F/66
(Expiration Date)
Estimated Value of Electrical Work $
Work to Start
Signed under the penalties of per
.
Philip A. �aghemfii
FIRM NAME ■__as__s n,..,+.�..�
Inspection Date Requested: Rough
Final
LIC. NO. 47 172`1C
,Licensee i, x 633 23 Mair : t. �a LIC. NO.
Address Atkinson, N.H. 03811 Bus. Tel. No.
1■W3-3 Alt. Tel. No.A23w .2 ol�s_
.OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance row,,mv nr it< <uhoantial Pquivalent ac required by Massachusr.nc
.General Laws, and that my signature on this permit application waives this requirement. Owner (Please check ones
Telephone No. PERMIT rtr s157, 06
(Signature of (caner or Agent)
TOI AL
No. of Lighting Outlets
No. of I•lot Tubs
No. of Transformers KVA
Above In- 1
❑ 0
No. of Lighting Fixtures
SwimmingPool rad. grnd.
Generators KVA _
4,1. of Emergency Lighimr,
No. of Receptacle Outlets
No. of Oil Burners
li-mt- Units
No. of Switch Outlets
No. of Gas Burners
rIPF ALARMS Nn of 7omra
No. of Detection and
10,11
No. of Ranges
No. of Air Conditioners Tons
Initiating Devices
of Sounding De: u r c
Heat orat j(11.11No.
No. of Disposals
No. of Pumps Tons K1N _ _
No of Self Contained —,
I e lectiotusnunding III %- e.
No. of Dishwashers
Space/Area I Ieatin KW
(�}�
l l_J Connection Oilier
No. of Dryers
Hearin 1• Devices K�
ex al
No. of No. of
I osv Vo tage
No. of Water Heaters KW
Signs Ballasts
Wiring
No. Hydro Massage Tubs
No, of Motors Tota) VIP
W L U Iz7,-7u
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusnes General Laws
have a current Liability Insurance Policy including Completed Operations Coverage or its suh.t.vvial .•.lnix alent. YES C1 NO l 1 -.ubmitted va!id pul, 0
of same.to this offic-P. YES U NO O
If you hive checked YES, please Indicate the type of coverage by checking the appropriate NIX.
INSURANCE BOND ❑ OTHER❑ (Please Specify) OoU F/66
(Expiration Date)
Estimated Value of Electrical Work $
Work to Start
Signed under the penalties of per
.
Philip A. �aghemfii
FIRM NAME ■__as__s n,..,+.�..�
Inspection Date Requested: Rough
Final
LIC. NO. 47 172`1C
,Licensee i, x 633 23 Mair : t. �a LIC. NO.
Address Atkinson, N.H. 03811 Bus. Tel. No.
1■W3-3 Alt. Tel. No.A23w .2 ol�s_
.OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance row,,mv nr it< <uhoantial Pquivalent ac required by Massachusr.nc
.General Laws, and that my signature on this permit application waives this requirement. Owner (Please check ones
Telephone No. PERMIT rtr s157, 06
(Signature of (caner or Agent)