HomeMy WebLinkAboutMiscellaneous - 85 MAPLE AVENUE 4/30/2018N
09761 Date.) �....
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` TOWN OF NORTH ANDOVER
7
PERMIT FOR PLUMBING
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This certifies that ....). t �. `M a`�`� \r� \'C�� +�,� , , , , ,
has permission to perform ... \ ...!.. 1? ?4-.. �-✓ (�
plumbing in the buildings of. . .•Z. .. . ,
at ...' ............. ,North Ando ,Mass.
Fee . � -- .. Lic. No.
PLUMBING INSPEC
Check # Qqj
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TYPE OR
PRINT
CLEARLY
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY NORTH ANDOVER MA DATE%—� % PERMIT #
JOBSITE ADDRESS '
00 5- /1%f OZe: 9il� OWNERS NAME IM7-f ,V4
OWNERADDRESS o26 jvvsseff S7- �.4,V4oj1e„ TEL FAX
OCCUPANCY TYPE COMMERCIAL'___ EDUCATIONAL � RESIDENTIAL
NEW <_w RENOVATION ; REPLACEMENT fes; PLANS SUBMITTED: YES ` NOi
FIXTURES 1 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR / AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 1
ATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES.)__-, NO T
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
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: OWNER ' . AGENT
SIGNATURE OF OWNER OR AGENT
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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME THOMAS HALLORAN LICENSE # 24833 SIGNATURE
MP '= JPS; CORPORATION '# PARTNERSHIPS_;# LLC _#
COMPANY NAME HALLORAN PLUMBING ADDRESS 826 DALE ST.
CITY NORTH ANDOVER STATE MA ZIP 01845 TEL 978.685-9504 \�
FAX CELL EMAIL
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1 I rY611,11 4y, 91e J 21 2-t, I13 �4
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The Commonwealth of Massachusetts
Department of Industrial Accidents
1t5 Office of Investigations
ASF 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
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Workers' Compensation Insurance Affidavit: Build ers/Contractors/Elecctri cpaPr�t m ers
Name (Business/organization/Individual):' p �41-
Address: R,2-6 A ie S7—
:/���✓ a/'8 1/S Phone #:
Are you 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).* have hired the sub -contractors
lictPrl on the attached sheet.
�.� I am a sole proprietor or partner-
ship and have no employees
working for the in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
These sub -contractors have
employees and have workers'
comp. insurance.1
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.]
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.❑ Roof repairs
13.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
heet showing the name of die sub -contractors and state whether or not those entities have
$Contractors that check this box must attached an additional s
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
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
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 certify under thepains andpenalties ofperjury that the information provided above is true and correct.
Phone #:
Official use only. Do not write in this area, to be completed by city or town off ciaL
City or Town:
Permit/License #
Issuing Authority (circle one):
own Clerk 4. Electrical Inspector 5. Plumbing Inspector
1. Board of Health 2. Building Department 3. City/T
6. Other
Contact Person:
Phone #:
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Signawter _--
This certifies that ........ —AJ
I& permission for gas installation
in the buildings of .... Q
at ......... ....... ........ . - ..y ......... . , No Ando ve ass.
Fee ,. . Lic. No.;X.? I ! .. ... .... .
GASINSPECTOR
Check # _
8552
lb"\
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
rf
CITY NORTH ANDOVER MA DATE / PERMIT #
GOWNER
JOBSITE ADDRESS a,- 1)j4&.!t O✓ e OWNER'S NAME je7//j/,f
ADDRESS d,6, %1 uSSe Cf sr y. 1v'4aj e;,` TEL FAX
TYPE OR
PRINT, ,
OCCUPANCYTYPE COMMERCIAL EDUCATIONAL E] RESIDENTIAL
CLEARLY .
NEW: RENOVATION: [ REPLACEMENT: Vr PLANS SUBMITTED: YES NO
APPLIANCES 1 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
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER 1
OTHER
2
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO
1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY XJOTHER TYPE INDEMNITY BONDI:]
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: OWNERAGENT
L—i
SIGNATURE OF OWNER OR AGENT
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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME THOMAS HALLORAN LICENSE # dW 33 SIGNATURE
MP 0 MGF El JP L& JGF LPGI CORPORATION # PARTNERSHIP Ej# LLC['
COMPANY NAME:HALLORAN PLUMBING ADDRESS 826 DALE ST
CITY NORTH ANDOVER STATE MA ZIP 01845 TEL
FAX CELL EMAIL
978-208-0840 `1\
1��� t rI 6Y) 4;1e- 2Iz-�p V3 gip,
f"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
l Boston MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):/�
Address: ��� ,/�� jC ,S"7—
City/State/Zip:/C//)/✓4b,4,�o/t— IVJ� j'S Phone #:
Are you 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 partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.1
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.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. F1 Electrical repairs or additions
1 I.❑ Plumbing repairs or additions
12.0 Roof repairs
13. ❑ Other
*Any applicant that checks box 41 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.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that isproviding workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
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
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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature-
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 Cle k 4 El t
6. Other
r . ec rival Inspector 5. Plumbing Inspector
Contact Person- Phone #:
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Date ..... -..2.�?�.....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that.....................(......(/,//U/!%........................................
V
has permission to perform 4en5&r — ' ..644. .......
wiring in the building of .............. ?. . S S d ..........................................
E
at .........`r...........4. n1.�........ vim ............ . North Andover, Mass.
eo
Fee. S ........ -.. Lic. NdF� .6
t? .7.........Pe.
TRICAL INSPECTOR %
Check # Z'3 >'
"vk
Commonwealth of Massachusetts
- Department of Fire Services
w BOARD OF FIRE PREVENTION REGULATIONS
(leave blank)
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: Vec g / ' 7
City or Town of: NORTH ANDOVER To the Inspector o 'Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Num,,hgr) Q� A4,4791,1 -T.
Owner or Tenant ryyA! 1,11S5e /4
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑
Purpose of Buildingd- t'ltlniAy 1z;;C AC.�
Existing Service Amps /Volts Overhead 11New Service Amps
Telephone No.
No n (Check Appropriate Box)
Utility Authorization No.
Number of Feeders and Ampacity
Volts Overhead ❑
Official Use Only
Permit No. ? F 2 %
Occupancy and Fee Checked
[Rev. 1/071
Undgrd ❑
Undgrd ❑
No. of Meters
No. of Meters
_ Location and Nature of Proposed Electrical Work: e,
Pcb f ltCi
Crnnnletinn of din fnllrnvino lnhln Hutu ho v,nivod by tho hoc„n�inr
nfW?roc
No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total
Transformers KVA
No. of Luminaire Outlets No. of Hot Tubs Generators KVA
No. of Luminaires Swimming Pool Above ❑ Ln- ❑ o. o Emergency Lighting
rnd. rnd. Batter 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. Total Tons No. of Alerting Devices
No. of Waste Disposers Heat Pump Number Tons KW No. of Self -Contained
Totals: Detection/Alerting Devices
No. of Dishwashers Space/Area Heating KW Local ❑ Municipal El Other I'
Connection
No. of Dryers Heating Appliances KW Security Systems:
No. of Devices or Equivalent
No. of Water KW 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 Equivalent
Hach additional detail if desired, nr as required by the Inspector qJ 6!'rres.
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 i ranee including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such cov ge is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify, under the a rs r rd pe ralti s of perjury rat dee i tforuration nut 's appl/ rtion s true and complete.
FIRM NA r� b � �cr" l pvl�-� � LIC. NO.:
Licensee: i oN/ ry Signatur LIC. NO.:
(/J'crppliccrhle, enter "exenrPt� the license nunsGe � line.) Bus. Tel. No.:
Address: Os BB++ � • ODI/"
✓t�W�J /V 410 Alt. Tel. No.:]Gl
*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. 1 am the (check one) ❑owner [I owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE:
OTHER:
$
Date. ......
TOWN OF NORTH AND?AIER
L
PERMIT FOR GAS IN4- -, LATION
This certifies that (//v ................
has permission for gas installation /.
in the buildings of T.0.1.7/1' -x .........................
at . - 7
....... North Andover, Mass.
Fee. ..... Lic. No. JkY.).'. . .... ......
GASINSPECTOR
Check# 7C7TI1
r
6285
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING3 ����-1
(Print or Type)
- ND27 N Mass. Date Permit # t; IA-)
G
Building Location- ?5 8.7 IIA LE A yE Owner's NameA,�7NUfZ DUFeE,51)E
D 7N A N�JD� C tr'1/� Type of OccupancyES�DE►J7�
New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes[] No ❑
Installing Company Name BAY STATE GAS COMPANY
Address 55 MARSTON STREET
LAWRENCE, MA 01840
Business Telephone g 7B-68.7-1105
Name of Licensed Plumber or Gas Fitter Francis X. Corkery
Check one:
XJ Corporation
❑ Partnership
❑ Firm/Co.
Certificate #
1862
INSURANCE COVERAGE:
1 have aY usrrenntt liability insoura❑nce policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy X 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❑ Agent [I
hereby certify that all of the details and information I have submitted (or entered) in aboplication are true and accu%e to the best of my
knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of -the Gene S.
By T e of license:
Plumber Signature of cense Plumber or Gas fs
Title Gasfitter
Master License Number
City/Town Journeyman
O IC SE O
■��l�������<A�t�t
MNMI
EN]
• •
00000000000000000
Egon
on
Installing Company Name BAY STATE GAS COMPANY
Address 55 MARSTON STREET
LAWRENCE, MA 01840
Business Telephone g 7B-68.7-1105
Name of Licensed Plumber or Gas Fitter Francis X. Corkery
Check one:
XJ Corporation
❑ Partnership
❑ Firm/Co.
Certificate #
1862
INSURANCE COVERAGE:
1 have aY usrrenntt liability insoura❑nce policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy X 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❑ Agent [I
hereby certify that all of the details and information I have submitted (or entered) in aboplication are true and accu%e to the best of my
knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of -the Gene S.
By T e of license:
Plumber Signature of cense Plumber or Gas fs
Title Gasfitter
Master License Number
City/Town Journeyman
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Location �` v�� J),°.p/e
No. s Date
H°R TOWN OF NORTH ANDOVER
y
} > Certificate of Occupancy $
cNustt�' Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $ c
TOTAL $ 3 /
Check # 130
13527 ��-
Building Inspector
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The Commonwealth of Massachusetts
Department of Industrial.ACCidentS
Office of Investicyations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Name Please Print
Name:
Citi Phone #
F7
I am a homeowner perfcrming all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this job.
Comanv name: 6iy-s
Address
o f4 N,
Insurance C
Comanv name:
Address
Phone T:
Policy,- A?—U-)
Cihr' Phone #:
Insurance Co. Policy #
2-1
Failure to secure ccverage as required under Section 25A or MGL 152 can lead to the imposition a criminal penalties of a fine up to 51,500.00
and/or one years' impnscnment as'Neil as civil penalties in the form of a STOP WORK ORCER and a Fine of (5100.00) a day against me. I
understand that a copy of this statement may be for,varded to the Office of Investigations of the GIA for coverage verification.
1 do hereby certify under the pains and penalties or perjury that the information provided above is true and correct.
Sionature
Print name 077,
Date 1-2-101-9
Phone# �Z"K--67-3l
Official use only do not write in this area to be completed by cry or ,own cfridai
City or Town PermitlUcensino
❑Check d immediate response is required
Contac; person:
Phone r
❑ Building Dept
Licensing Board
Cj Selectman's Office
Health Department
Other
BUILDING DEPARTMENT
DEBRIS DISPOSAL FORM
In accordance with the -provisions of MGL . c 40 S 54, a condition of Building Permit Number
Is that the debris resulting form this work shall be disposed of in a properly -licensed solid waste disposal facility as
defined by MGL c 11, S 150A
The debris will be disposed of in:
Location of Facility
Signature oPermit Applim4V
Date
NOTE: Demolition permit from the Town of North Andover must be obtained Por this project through the Office of
the Building Inspector
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