HomeMy WebLinkAboutMiscellaneous - 85 HIGH STREET 4/30/2018Date......../! / ................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .... S Je' 1 Cx-
... ...... I
............................. .............
has permission for g ....... ..............
in the building of ......
"�7
.....................
at ... .... ........ ( .. .. ..... ..... .................... N�Orltl Andover, Mass.
- .51 5-
Fee....................... L* No../ Y...... .....................................................................
GASINSPECTOR
Check # '3 ? (? -6 -6)
09i3b IV4--
I
G
TYPE OR
PRINT
CLEARLY
UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY T a N _ MA DATE �% 'f� PERMIT #
JOBSITE ADDRESS �ia� SiOWNERS NAME
j�'�` _
OWNER ADDRESS TE`i- � FAX
OCCUPANCY TYPE COMMERCIAL Ej EDUCATIONAL �]
NEW: Q RENOVATION: 2"" REPLACEMENT:
APPLIANCES Z FLOORS -4
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT .
OVEN e
.POOL HEATER.
ROOM/ SPACE HEATER
ROOFTOPUNIT-,
Tr'[lT .
TER
:D ROOM HEATER
WA
BSM 1 2 1 3 1 4 1 5 1 6
RESIDENTIAL a
PLANS SUBMITTED: YES D NO2'
7 8 9 10 11 12 13 14
�T ��� INSURANCE COVERAGE
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES JR11N0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY � OTHER TYPE INDEMNITY E] 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 El AGENT El
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
and that all plumbing work and installations performed under the permit issued for this application will be in compliance
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME S"D 6`` I�'� LICENSE # IS`y,S-
MP [a MGF El JP ® JGF Q LPGI ® CORPORATION Qf� PARTNERSHIP
COMPANY NAME: icae,r 'Gb'Gc'rrs S�'-���ct' ADDRESS fw3 r-cSrit'ry S�
CITY ��c�nc� cti STATE ZIP TEL
FAX==CELL( - EMAIL �11A,�er,ccf+�ca��)o�•.��sr ...,�•;"
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w� rt' nt all In�o ion of the
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The Commonwealth of
Massachusetts
Department of Industrial Accidents
a r
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers, Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers.
Worke P TO BE FILED WITH THE PERNIITTING AUTHORTTY.
Please Print Le ibl
A licant Information
Name (Business/Organization/Individual):
Address:
Phone #: ,
City/State/Zip: Type of project (required):
A
ren employer? Check the appropriate box:
7, [] New construction
employees (full and/or part-time).* 8 0 Remodeling
a employer with for mein
a sole proprietor or partnership and
required-1 ave no yees working 9 �] Demolition
capacity. [No workers' comp.
all work myself. [No workers' comp. insurance required.] t 10 ❑ Building addition
a homeowner doing roe I will
m a homeowner and will be hiring contractors.toconduct all work on my p P rh' 11,0 Electrical repairs or additionssure that all contractorseither have workers' compensation insurance or are sole 12 E]Plumbing repairs or additionsprietors withno employees.13• Roof repairsm a general contractor and I have hired the sub -contractors listed on the attached sheet. 14 ese sub -contractors}, a employees and have workers' comp. insurancet of exem tion per MGL c. insurance required.]
e are a corporation and its_ officers have exercised their ri P52, § 1(4), and we have no. employees ` [No workers' comp. ensation olicy information
davit indicating
Any pp the are doing all work and then hire the sub contractors and state whether eor no those entities have such -
also
* applicant that checks box #1 must fill out the section below showing their workers' comp P
Homeowners who sirbaf this.affidavit indicating Y
must provide their workers' comp. policy number.
#Contractors that check this box must attached-anadditional sheet showing the name o
employees. if the sub -contractors have employee's, they P compensation insurance for my employees.' Below is'the policy and job site
I am an employer that is providing workers' comp
information.
Insurance Company Name:
. _Expiration Date:
Policy # or Self -ins. Lic. #:
City/State/Zip:
Job Site Address: a showing the policy number and expiration date).
Attach a copy of the workers' compensation policy declaration pag ( punishable by a fine up to $1,500.00
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation p
rageas, as well as civil penalties in the form of a STOOP WORK ffice of In Os gations of the DIA for in uran 0 a
and/or one-year imprisonmentof this statement may be forwarded to the
�caainst the violator. A copyge verification. �juthat the information provided above is true and correct.
Ido hereby certify under thepains and penalties of
one:
Official use only. Do not write in this area, to be completed by city or town official.
Fermit/License #
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3
6. other
Contact Person:
City/Town 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 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 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 returned to the cityor 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 (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 burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
7 6�6 4 Date .... S W .......
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ...,�`'J'6y1,!/1.... fGr•►
�
has permission for gas installation . � . � ..� ... ......... .
in the buildings of ...........
at d .. h t.. S .......... North Andov/�r, Massy
Fee d �� Q(J . Lic. No.. 91 � 3... ......
! YZt1'',��.�,.t�(, . � �
GAS INSPECTOR
Check # Z(;Q
MA%ACHGSEITSUNIFUR"iV1APPUCATONFORPERffrTTODO GAS F17TIlVG
(Type or print) Date
NORTH ANDONTER, MASSACHUSETTS
Building Locations /f ,5 /Y/ L le Permit #
Owner's Name
New ❑ Renovation ❑ Replacement ❑
1
Amoun -$
Plans Submitted ❑
(Print or
Name—
Name of Licensed Plumber or Gas Fitter /rA0A0/'� 144WA1e.0
Ch ne: Certificate Installing Company
Corp.e?/0PA .
❑ Partner..
❑ Firm/Co:
INSURANCE COVERAGE Check one
I have a current liability Insurance policy or it's substantial equivalent. Yes No
If you have checked Yes, please jpd1cate the type coverage by checking the appropriate. box.
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
:Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner p Agent ❑
I actCvy e:cn,ty tnat all Of the ueaaus ana inrormauon i nave sunmitted (or entered) in above application are true and accurate to the -
best of mti knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with.all pertinent provisions of the Massachusetts State gas Code and Chaptery,42_9f4he General Laws.
ICityrTowrr ,'
IAPPROVED (OFFICE USE ONLY)
bnature of
Plumber
❑ Gas Fitter
Master
Journeyman
sed Plumber Or Gas Fitter
iq
-dense; i u Ser
FLOOR
(Print or
Name—
Name of Licensed Plumber or Gas Fitter /rA0A0/'� 144WA1e.0
Ch ne: Certificate Installing Company
Corp.e?/0PA .
❑ Partner..
❑ Firm/Co:
INSURANCE COVERAGE Check one
I have a current liability Insurance policy or it's substantial equivalent. Yes No
If you have checked Yes, please jpd1cate the type coverage by checking the appropriate. box.
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
:Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner p Agent ❑
I actCvy e:cn,ty tnat all Of the ueaaus ana inrormauon i nave sunmitted (or entered) in above application are true and accurate to the -
best of mti knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with.all pertinent provisions of the Massachusetts State gas Code and Chaptery,42_9f4he General Laws.
ICityrTowrr ,'
IAPPROVED (OFFICE USE ONLY)
bnature of
Plumber
❑ Gas Fitter
Master
Journeyman
sed Plumber Or Gas Fitter
iq
-dense; i u Ser
The Comrnouwealdr, of Mttssackuseits
'Depitrt»rrtt of bidtistrial Accider:ts
Office of Investigations
r.
I
600 Waslrin on ,Street gt i .. .
Boston, MA 02111
wlvlvurass gov/din .
Workers' Compensation. Insurance davit. Builders/Contractors/ElectricianslPlumliers
Applicant Information`.. Please Print Leizibly
Name (Business/Organizadon/Individuali:. AV)ViIAZ �X,6f%/4t- & /U D . ANd '
:City/State/Zip:/
. Plione #:'Sr'
�..�
Are y u an employer? Check the appropriate. box:.;, ,
Type of project (required): J
1. IJ 1 am a employer with
. 4• ❑ 1 tun a general contractor. and 1 ,
6. [] New construction f
employees (ftill and/or part-time).*
?. C1 I am a sole proprietor or partner-
....have hired the sub -contractors,
li sted:on the attached,sheeL . .
7..0 Remodeling
ship and have no employees =
These subcontractors have
g, Demolition
worlan for me in an capacity.
g Y p h'-
employees and have workers'
9. ❑Building addition
[No workers' comp: insurance
required.]
comp. insurance.#
5: We are u corporation and its
10.❑ plectrical repairs or additions
3. ❑ I am a bbmeowner.doing all work.
'" officers have exercised, their
.11. Plumbing repairs or additions-
myself. [No workers'. comp..
right of exemption per MOL _
12,E] Roof repairs
insurance required.] t
c. 152, § I (4) and we have no
Un Other'
C.
employees. (No workers'
. _ . _. 11
.
TAny applicant that checks box St must also fill out the section beloiv showing thcFt woikers' compensation policy information.
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 boi must Punched an'addidonal sheet showing the name of the sub -conductors and state whether or not those entities have
employees, if the sub -contractors have employees. they must provide their workers' comp. policy number.
1 aur an employer that is providing workers' compensation insurance for my employees. Below is die policy and job site
information.
Insurance Company Name:
Policy # or Self: ins. Lic. #: u& . - Fxpiration Date:110�i
Job Site Address: " City/State/Zip: zWe44 4
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. 1.52 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 statetnetit may be forwarded to the Office of
Investigations of the .DIA for insurance -coverage verification. ,
I do herebp certify un er t/te pains grid, enay/tiies of erjI at, the information provided above is trite and correct.'
nntt.
Official use only. Do trot write in this arca, to be coinpleted by citybr toivru ofciaL
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 #:
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 reptrsentatives 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-maintenhIT16, 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 compliance with the irisirrance 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 rill out the workers' compensation affidavit completely, by checking the boxes that apply to youisimation and, if
necessary, supply sub-contmctor(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 cant' 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 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 app ro nate line.
City or Town Ofllcials
Please be sure that.the'aridavit 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 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 Massachusetts
Department of Industrial Accidents _
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel.. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 4-24-07 www.mass.gov/dia
L
COMMONWEALTH OF MASSACHUSETTS
LICENSED AS A JOURNEYMAN PLUM4,
ISSUES THE ABOVE LICENSE TO:
GEORGE R LAROSE
44 ODILE ST
METHUEN MA 01844-4233
18725 05/01/12 784 282{ i
COMMONWEALTH OF MASSACHUSETTS _ I
LICENSED AS A MASTER PLUMBER
ISSUES THE ABOVE LICENSE TO:
GEORGE R LAROSE
44 ODILE STREET
METHUEN MA 01844-4233.
9983 05/01/12 78428}
`_COMM
ONWEALTH OF MASSACHUSETTS
RF
TERED AS A PLUMBING CORP;
ISSUES THE ABOVE LICENSE TO: v� }
GEORGE R LAROSEt
ANDOVER PLUMBING & HEATING C j
20 .AEGEAN DR
UNI.T. 10
METHUEN MA 01844-1.5.80.
2Y22 05/01/12 784263
N'To
0
/tib
Date . �? .................�.......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........1..�"l� �,..�//........t , f-'' ...............:.....
has permission to perform
f
....................:.:.. /... �!.................
wiring in the building of ..!..... ...!.:.. �:: - : -r-' .........................................
�_,,r
�`S'.......................... . North Andover, Mass.
GVI
l Feea%.......... Lic. No �1��1�. ...... .....................................................
ELECTRICAL INSPECTOR
05/05/99 01:33 35.(/00 PAID
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
THE09MM0NWE4L7H0F 444 4CfIUSE77S Office Use only
131 DEPARTMENTOFPUBLICS4= Permit No. / (J 1
BOARD OFFIREPREVEM70NREGMT10M 527CMR 12*
Occupancy &Fees Checked
U94PPLICATIONFOR PERAff TO PERFORM ELECTRICAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACI USSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) /
Owner or Tenant , ( 1'64'-V 144Dw
Owner's Address I 67'
Is this permit in conjunction with a building permit: Yes m No ®`(Check Appropriate Box)
Pu ose of Building �D�! (� O
rP g Utility Authorization No. ------
Existing Service 00 C1_ Amps/�/d`�D Volts Overhead �TTndergroundNo. of Meters d
New Service Amps_ / Volts Overhead Q Underground No. of Meters
Nuer of Feeders and Ampacity
Location and Nature of Proposed Electrical Work _ �� �,C' G !�I/,c.t� foe 166
Nq'ofLighting Outlets
No. of Hot Tubs
No. ofTransfotmers
Total
KVA
No. of Lighting Fixtures
Swimming Pool Above
Below
Generators
KVA
ground
1:1round
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons
No. of Detection and
No. of Disposals
No. of Heat Total Total
Pumps
Tons
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
Local Municipal
Other
No. of Dryers
Heating Devices KW
P
Connections
No. of Water Heaters KW
No. of No. of
Signs
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
OTHER -
Niii
.. •.. ...
OWNER'SWSURANCEWANFR;IdnawareihattheLx=dmio t�
aodftmysgnbaeaitmpmTitappfixdm v4aitiEstmm*Mmat
(Please check one) Owner F-1 Agent F7
BusiressTeJ.I�i •- 1'-1�f '�
AJLTeLNa(525 %l; - CPS L'
the irstra>l wmaWoritssdrtattialecgridmtasm*xedbyM=xhselsCnetalLas
Telephone No. PERMIT FEE $