HomeMy WebLinkAboutMiscellaneous - 71 CANDLESTICK ROAD 4/30/2018 (2)N_
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TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
Thiscertifies that ....................................................................................................................
has permission for gas installation ............ rlzl..�� .... ... C ...............
in the buildings of :,�.......- /A'/
........................... .. . ...........................................................
at .......7.1..... ......................... . North Andover, Mass.
Fee Lic. No. 1779,P.7 ..... AM .........................................................
GAS INSPECTOR
Check # /42
8970
`
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY t'iz _j MA DATE I �� PERMIT #
-
I
JOBSITE ADDRESS CA OWNER'S NAME
GOWNER
ADDRESS 7aA An 49,TEI,�„,��� FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL 13 EDUCATIONAL ® RESIDENTIAL
PRINT
CLEARLY
NEW: RENOVATION: E] REPLACEMENT: PLANS SUBMITTED: YES rl NY�
APPLIANCES 7 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 [ r J -��_I .._ . _I —A . . .
DRYER
FIREPLACE 1_ _ --I --�--
—
FRYOLATOR
FURNACE
GENERATOR-- 1 _--1,__ .� L . __I
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT-
OVEN_
POOL HEATERI
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER—
UNVENTED ROOM HEATER
WATER HEATER
OTHER F
.... _.......... ............... .
L— Ill =�
- - --
-_ i-- ��FFF - = -
+ INSURANCE COVERAGE
gave a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO
f YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY E] BOND F
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
SIGNATURE OF OWNER OR AGENT
1 hereby certify that all of the details and information I have submitted or entered regarding this application are true an urate tot best of knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comp' e t I e rov' ' n of the
;Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME >3M I LICENSE # _ IGNATURE
,.
MPI MGF Ej JP 0 JGF [I LPGI E CORPORATION Ej# PARTNERSHIP ®# ( LLC #
COMPANY NAME: ���. (i�/U�j[��hC> ADDRESS'
CITY _ _ _ _ _—� STATE ZIP TEL
FAX � ELU���56AIL — - — - - --
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The Commonwealth of MassachusettsGZ -
Department of Industrial Accidents
Office of Investigations
600 Washington. Street
Boston, .NIA. 02111
www.mass gov/dia
Workers' Compensation insurance Affidavit: Builders/Contractors/ElectricianslPlumbers
Name
City/State/Zip: 4
Phone #: lleO.3� � [®
Are you anemployer? Check the appropriate box: -
L ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hiredthe sub -contractors
listed on the attached sheet. t
I am a sole proprietor or partner-
4ship and'have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
5. ❑ We are a corporation and its
[No workers' comp. insurance
required.]
officers have exercised their
3. ❑ I am a homeowner, doing allwork
right of exemption per MGL
myself. [No workers' comp.
c.152, § 1(4), and we have no
insurance required.] i
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New c6nstruction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roofrepairs
13.❑ Other
*Any applicant that checks box#f must also fill outthe section below showingtheir workers' compensation policy information.
p Homeowners who submit this affidavit indicating they Die doing all work and then hire outside contractors must submit anew 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 joh site
information.
Insurance Company N
Policy 0 or Self -ins. Lic.
Job Site Address:
Expiration Date:
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 o. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one=year imprisonment, as welt 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 laereby certi r l ' salt' of perjury that tlae information provided ab ve m rue and correct.
nate
Phone #
Official use only. Do not write in this area, to he completed by city or town official.
City or Town: Permit[License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
contnetpercon: - Phone
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Date.
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TOWN OF NORTH ANDOVER
• 41 PERMIT FOR GAS 114STALLATION
This certifies / ..........................
has permission for gas installation .... A/ A ..................
in the buildings of .. . - * . r /?!� ....................
//%IC *'
at ..7 ........... North Andover, Mass.
Fee.34 Lic. No.. �� C 11 ) .. I -
......... .......
qAS INSPECTOW
Check#
6563
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CIYTI IDCQ
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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City/Town: Ato OcpV62 , MA.. Date:, -6"1 (g _ Permit# �>
Building Location: Cid•? 7�tAC.1-- (-j Owners Name:,'\c����� .
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential ❑
New: ❑ Alteration: ❑ Renovation: ❑ Replacement: R Plans Submitted: Yes ❑ No ❑
CIYTI IDCQ
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 have checked Yes, please In cats the type of coverage by checking the appropriate box below.
A liability insurance policy 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
Massachusetts General Laws, and that my signature on this, permit application waives this requirement.
Check One Only
❑
Signature of Owner or Owner's Agent Owner ❑ Agent
By checking this box ❑, I hereby certify that all of the details and information 1 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.
Type of License:
By ['Plumber
Title ❑ Gas Fitter Signature of License 1 ber/G s Fitter
9"Master " AA
Cityrrown ❑Journeyman License Number:
APPROVED OFFICE USE ONLY ❑ LP Installer
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SUB BSMT.
BASEMENT
1 FLOOR
2 FLOOR
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4 FLOOR
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7 FLOOR
8 FLOOR
Installing Company Name: �� �'`'I YY=' ci-
Check One Only Certificate #
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Address: City/To
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State: M
❑ Partnership
Business Tei: @ �Yr,("'(—— f"J:I✓`� Fax:
❑ Fimt/Company
Name of Licensed Plumber/Gas-Fitter:aL
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 have checked Yes, please In cats the type of coverage by checking the appropriate box below.
A liability insurance policy 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
Massachusetts General Laws, and that my signature on this, permit application waives this requirement.
Check One Only
❑
Signature of Owner or Owner's Agent Owner ❑ Agent
By checking this box ❑, I hereby certify that all of the details and information 1 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.
Type of License:
By ['Plumber
Title ❑ Gas Fitter Signature of License 1 ber/G s Fitter
9"Master " AA
Cityrrown ❑Journeyman License Number:
APPROVED OFFICE USE ONLY ❑ LP Installer
cation__��
No. Date �-�
�ORTM TOWN OF NORTH ANDOVER
„ Certificate of Occupancy $
` y Building/Frame Permit Fee $
cMU � Fou4d)aio)nPerm® it F $
hex P_er It Fee $ yy�
`.-^gewer Connection Fee $
Water Connpection Fee $
10 IN
Building Inspector
e
61 -98 Div. Public Wo
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OFFICES OF:
APPEALS
BUILDING
CONSERVATION
HEALTH
PLANNING
j
Town of
MOPD
NORTH ANDOVER
DIVISION OF
PLANNING & COMMUNITY DEVELOPMENT
KAREN H.P. NELSON, DIRECTOR
120 Main Street
North Andover. -
Massachusetts O 1845
(617) 685.4775
In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit
Number A y� is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111, S
150A.
The debris will be disposed of in:
Iv,
Signature of Permit Applicant
Date
(' NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector.
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary ••
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: /(rV,yngzf eve ji",, E7A](--, Phone 26 --26 6
LOCATION: Assessor's Map Number Parcel
Subdivision
Street 1.c:--� _/�
Lots)
St. Number
************************Official Use Only************************
/RECO!EN�NDATIOY,S OF TOWN AGENTS:
v Date Approved 2
Conservation Administrator Date Rejected
Comments
Town Planner
Comments
/Food Inspect r -Health
Septic Inspector -Health
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Date Approved
Date Rejected
I ;
Date Approved
Date Rejected
Date Approved
Date Rejected
Received by Building Inspector Date
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