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HomeMy WebLinkAboutMiscellaneous - 85 FLAGSHIP DRIVE 4/30/2018 (4)7 Date. Mz:�/w .......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . /*T� . 1' Z4 r/P ......... has permission for gas installation . A.;A Al. .j. in the buildings of .......................................... at .. � %?. i. , North Andover, Mass. Fee Lic. No. /. a 70 4 GAS INSPECTOR Check # -T472— .. MASSACHUSET'T'S UNIFORM APPLICATION FOR A PERMITTO DO GAS FITTING CITY/TOWN: _ STATE: MA APPLICATION DATE: JOB ADDRESS: J a���� 11-0 Q� G OCCUPANCY TYPE: COMMERCIAL 9 RESIDENTIAL PLANS SUBMITTED: YES NO NEW ALTERATIOMfo REPLACEMENT REMOVALIDEMOLITION l ! NATURAL & LIQUEFIED PETROLEUM GAS: PIPING - EQUIPMENT - APPLIANCES - ENTER TOTAL AMOUNT FOR EACH SELECTION LIMITED TO FIVE 5 NUMERALS SYS'T'EMS Z, AIR ROTATION UNIT �"-'— FURNACE: ALL TYPES BOILER: ALL TYPES GAS PIPING : �_ TEMP HEATING EQUIPMENT BOOSTER GENERATOR STATIONARY ENGINE ` 1. `- THERMAL OXIDIZER - BROILER - ILLUMINATING APPLIANCE TURBINE BURNER: ALL TYPES INCINERATOR UNIT HEATER --- CO-GENERATION UNIT - "? INDUSTRIAL AIR HANDLER -- WATER HEATER: ALL TYPES - COFFEE ROASTER - INFRARED HEATER _ -_- EQUIPMENT OVER 12,500MBH --�- COOK APPLIANCE HOUSEHOLD f KILN /GLORY HOLE / CRUCIBLE -- =_ 7OTHER NOT LISTEDI _ -- COOK APPLIANCE COMMERCIAL LABORATORY COCKS _ DECORATIVE APPLIANCE EUP AIR UNIT EQUIPMENT -_'- DIRECT VENT I MAK APPLIANCE - _ ... MECHANICAL EXHAUST _ I DRYER: ALL TYPES _ _ _� OVEN: ALL TYPES FIREPLACE: VENTED / UNVENTED �-'� FRYOLATOR _ POOL HEATER ROOF FUEL CELL ROOM HEATER-VFNTFnlvruri ... PLUMBING /GAS FITTING FIRM INFORMATION NAME: Merrimack Valley Corporation ADDRESS: Aegean Dr., Unit #3 --- — ----- 15 0 CITY: Methuen STATE: MA EZIp: 01844 TEL:. 978,688-0224 FAX: 689-2206 Ilittle mvalle cor .com EMAIL: @ y p OF / GAS FITTER: CHECK ONE ONLY ©✓ Corporation Business # L--L2-.P. - Partnership Business#i—__.--.--..._ LLC�: --__ ----- =- Business # EIDBA l Unincorporated INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YE S ✓ NO If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnityFl OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 1842 of thMassachusetts Laws, and that my signature on this permit application waives this requirement. General Signature of Owner or Owner's Agent I OWNER'S NAME: CHECK ONE ONLY OWNERE] AGENT TEL: FAX I hereby certify that all of the details and information I have submitted (or entered) regarding this permit application is true an the best of my knowledge. I certify that all plumbing work and installations performed under the permit issued, will be in compliance with all pertinent provisions of the Massachusetts Uniform State Plumbing Code, and Chapter 142 of the®General Laws, d accurate to (OFFICE USE ONLY) Permit )Spect:r Fee: E Type of License: ❑✓ Plumber RV Gasfitter ❑✓ Master E]Journeyman ❑Undiluted LP Installer Limited LP Installer of License Number: 10704 1 Gas Fitter The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street -Boston, MA. 02111 'www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers �plicant Information u);,_.. Y ___w, -V Name (Business/Organization4ndividual): ��,�?,M19 e d,4 I/� Address. • 45-Z—&�e,,u City/State/Zip: 461�" Zrl V VI - � >� .W Are on an employer? Check the appropriate box: 1.I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time),* 2. ❑ I am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheget t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing .officers have exercised their all work right of exemption per MGL myself. [No workers' comp. C. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp, insurance required ] 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. E] Roof repairs , 13. *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. S Homeowners who submit this 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 workers' comp. policy information. I am an employer that isproviding workers' compensation insurance for my employees Below is the policy and job site information. J Insurance Company Name: !% Policy # or Self --ins: Lic. #: /✓y f}'jl�j/� c��f� ` I Expiration Date: Job Site Address:__ � �A i1 �Q)�— e _ City/State/Zip: gel 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 ofMGL 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 cer f un er / e/p ins an nal 'es ofperjuryAtl�JQ�t�tlzpehin�o�rrnfi on provided ab v7— WIcIaluseon,tv. ' true and correct. Signature: Q / , City or Town: Do not write in this area, to be completed by city or town official. 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 M. I North Andover Board of Assessors Public Access f µORiq 1 p Click Seal To Retum Search for Parcels Search' for Sales Summary Residence Detached Structure Condo Commercial Page 1 of 1 North Andover Board of Assessors roperty Record Card Parcel ID :210/107.C-0113-OOOO.F FY:2013 Community: North Andover Location: 85 FLAGSHIP DRIVE Owner Name: FLAGSHIP, NA, LLC Owner Address: 21 PARTRIDGE LANE City: WAKEFIELD State: MA Zip: 01880 Neighborhood: 0 Land Area: 0.00 acres Use Code: 405 Total Finished Area: 6453 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 534,000 523,900 Building Value: 534,000 523,900 Land Value: 0 0 Market Land Value: 0 Chapter Land Value: http://csc-ma.us/PROPAPP/display.do?linkId=2258993&town=NandoverPubAcc 4/1/2013 M 0 N LL W a V/ c� J LL Ln 00 U NWN 1.1. p ap ca Q U J o W 8(-) Of < 0- a) LL a 2 o ao 0 L0 r O J co r r O Y U O J m U ti 0 r Q LL 9 0 co LL O 0 0 M U ri 0 0 N N 2 a y co co!0 U N Nj! 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