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HomeMy WebLinkAboutMiscellaneous - 855 SALEM STREET 4/30/2018i N 9,195 Date. All ?X� . . TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING This certifies that....!,,,,,,,,,,,,,,,,,,,, has permission to perform..f?�'�!!�..T.k........ plumbing in the buildings of ............... at ..az-.s-� k ........ ,)North Andover, Mass. Fee.,V'.-��.p. Lic. No.86.Z/.......... PLUMBING INSPECTOR Check # Z3Jr3 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town _ MA. Date: %� f' Permit# V _ Building Location: 'y ptezst n� c Owners Name: (� Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional . ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: [ Plans Submitted: Yes ❑ FIXTURES 0 DEDICATED z SYSTEMS 3I' W H z Wz VJ Ln U Z a W z 'Q En -I U ~ W O ❑ a p m tn y ~ w z y h p z ¢ ¢ a Q LL F � O w W O 0 a w Z w —!32 u d LL LU Q Q H v4i O } u j Q O a z 2 w w w di 1 W m m❑ o LLIn 5 5 n° 3 3 0 aLn W <== 3 -SUB BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4T" FLOOR 5T" FLOOR 5T" FLOOR FLOOR FLOOR ins'caiiir,g \t €;,„ C+�lii(pe,ry iwame. � ` ti�� d C'.�1C Ursa Only Address: ill �`� ` P LJ c:orpa•ation V Ciiy/Tow State. OK'd Business Tel: ' ��❑ Partnership Fax: �. ❑ Firm/Company Name of Licensed Number:— INS U RA—N—C—Fz lumber: INSURANCE i--n—A Cenn�. I have a current liabilitxinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YesNo If you have checked Yes, please indicate the type of coverage by checkin th❑ / g e appropriate box below. A liability insurance policy' (�/ Other type of indemnity ❑. Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does_ n�ve 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 �i nature of Owner or Owner's A ent Owner ❑ Agent ❑ hereby certify that ail of the details and informati�haVesubmitted (or entered) reKnowledge andthatap!!�mrkand i nstallrformd under the permit Perovision of th Massachusetts Siate Plode and Chapter 142 ofGenerai r Type of License: le=— ROyE—D— Si na C� umber 9 Lure of Licensed Plumber Yy/Master 'P❑.lourneymanLicense Number: a 1 The Commonwealth ofMassachusetts Department of Industrial Accidents Office oflnvestigations' 600 Washington Street Boston, MM 0211.1 yY www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plunnbers wlicant Tnformnfin„ Namt; (Business/Organization&dividual): Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 2. Uel(full and/or part-time).* have hired the sub -contractors I am a sole proprietor or partner- listed on the attached sheaet. I ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.]officers 3. ❑ I am a homeowner doing all work have exercised their 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 i Type of project (required): 6. ❑ New construction 7. [] Remodeling 8. ❑ Demolition 9. ❑ Building addition 10 -El repairs or additions 11. VZ:Pling repairs or additions 12.0 Roof repairs 13.[] Other !Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I T Homeowners who submit this affidavit indicating they are 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. lam an employer that is providing workers' compensation insurance for my employees. Below is file policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. 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 Blue 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. Ido Itereb5. er ' uncle the ainsnaltje perjury that the information pt ovided above is true and correct. 1 1. 1 ll . il1M Offrcfal 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 Department 3. City/Town Clerk 6. Other 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone #: Date. ��� % �� ........ TOWN OF NORTH ANDOVER *00 79 PERMIT FOR GAS INSTALLATION This certifies that .. .. !�kv:,.5A .0 has permission for gas installation►,+ ..+ ...... sS' w, in the buildings of . � ''� �. .. ........ at ...-S-.�r...-� �!"^.. ��........... . , No�rth/�ndover, jM/Jass. Fee � d Lic. No.. £a.� � � ... l71. � .. ! . GASINSPECTOR Check # �S3 7907 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: l\6-1� (i V C.i , MA. Date: Permit# Building Location: bU/ SUp, yy\ e" -k- Owners Name: �:t V1 01 Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: � Plans Submitted: Yes ❑ No [ FIXTURES �p ui z C6 D W 0 MX 0O W W V to H XWWW w fAH W Q I— N 0 Z W W 0 O W fn O <W _ LL � 0 W Z 0 J W z 0 z= W W W 2 Z W W W Z W >- W to '� Q Q m W 0 Z O~ H W H FW- W W Z 2 0 o 0 w o O z Z 5 O Oa W IW- >>>� 0 IFLOOR T. T R R R R R j— I I I 1 11 11 R `' Check One Only Certificate # Installing Company Nam � Vl � t'� � ,�,� t o DR1 orporation Address\, �`,\ l�� � ��i City/Tow l \ State: ��. r� afg� � El Partnership Business Tel: % ��' �3 �% ��3� Fax: q f �'�O 3 `a t� &u -b ❑ Firm/Company Name of Licensed Plumber/Gas FitterA� Y1'C'i INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes eNo ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy a? -.I 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 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 rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. T��� of License: By L I/d Plumber ❑ Gas Fitter Title Sig ature of Licensed Plumber/ s Fitter [B�Vlaster City/Town ❑Journeyman License Number: APPROVED (OFFICE USE ONLYI ❑ LP Installer The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations, 600 Washington Street Boston, M4 02111 yY www.massgov/dia Workers' Compensation. Insurance Affidavit: Builders/Contractors/Electricians/Plumbers lican>L Information _ PIPs C'P Arin4- T Name (Business/Organization&dividual): Address: City/State/Zi.� ,a Phone Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I ployees (full and/or part-time).* 2. have hired the sub -contractors I am a sole proprietor or partner- listed on the attached she9et. t ship and have no employees These sub -contractors have working for mein any capacity. [No workers' comp, insurance workers' comp, insurance. 5. ❑ We are a corporation and its required.] L ❑ I am a homeowner doing all officers have exercised their 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 reuired ] Type of project (required): 6. El New construction 7. ❑ Rem.odeling 8. El Demolition 9. El Building addition 10. ❑ Electrical repairs or additions 11.lumbing repairs or additions 12.❑ Roof repairs U 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 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. lam an employer that is proydding workers' compensation insurance for information. my employees Below is the policy and job site Insurance Company Policy # or Self -ins. Lic. P 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 maybe forwarded'to the Office of Investigations of the DIA for insurance coverage verification. Ido Isere cerci y un a to p mrqndpenaftles ofperjury that the inforanation provided above is true and correct. Si afore: Date: 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 Department 3. City/Town CIerk 6. Other 4. Electrical Inspector 5. PIumbing Inspector 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 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 nny 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 -contractors) 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 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 Iicense 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 referencd 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 (ifnecessary) 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 iu 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: xa e C01-mormea;tl-ii of Al ssachusetts Depadment of Industrial Accidents Office of ]investigations 600 Washington Street Boston; MA. 0211 X Tot. # 617.727,4900 ext 406 or X -877 -M -A SS.AFE Revised 5-26-'05 Fax # 617-727-7749 www.mass.g.w/dia. COMMONWEALCOMMONWEALT H 0 - MASSACHRUSLT;1.S e • e -• • ce••e IN PLUMBERS AND GASFITTERS LICENI�zSAf6#ITf,]�OPLUMBE FRANCIS J DECHR.ISTOFORO 11 VALERIE AVE BILLERICA MA 01821.-5535 a DatZ X07 HOORMI TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING 40 CHU$ This certifies that ..... has permission to perform �.l.YfV .......... plumbing in the buildings of at orth AAover, Mass. Fee. Lic. No.. /lr'/ ................. PLUMBING INSPECTOR Check # �` 60 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date /�J ZV/. Xo- 7 Building Location �� / aOwners Name Permit 1#--7,_'- L �^ Amount Type of Occupancy �,� �/7�� New M Renovation [a Replacement 0 Plans Submitted Yes 13 No F1 wy Ito' (Print or type) - Check one: Certificate Installing Company Name ❑ Corp. Address Partner. Name of Licensed Plumber: M j1" Jilh IZy 4:2z _ Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Ll Other type of indemnity ❑ 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 Signature Owner n Agent ❑ I hereby certify that all of the details and information I have submitte e a ap Axion are true and accurate to the best of my knowledge and that all plumbing work and installations t for this application will be in compliance with all pertinent provisions of the Massachusetts S e of the General Laws.--- By: aws. ._ BY igna ure or Zrensecium er e of Plu bing,License Title � y City/Town ri-cense INIUMSer Master Journeyman ❑ APPROVED (OFFICE USE ONLY Date.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .............. M,# e- 7 - has permission to perform ........ ................................................. wiring in the building of N�E ............R . L) ..... M ... ��-VL:> ................................. at ............ ...... . North Andover, Mass. Lic. No... ......................... ICAL-i ELECT /i? -Ar NSPECrOR (Y �Gheck # -2--7 (0 1- 7842 1A �-� Official Use Only Commonwealth of Massachusetts Department of Fire Services Permit No. 7cf Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]/07] (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: I J ;L 2 -© -7 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) BSS 15;1+. Owner or Tenant X11 d< e..1 � O ' e (ZJ k l u O a Telephone No. R7 -°a5 - sq Owner's Address -�a M Is this permit in conjunction with a building permit? Yes ©' No ❑ (Check Appropriate Box) Purpose of Building k 4 c [, e ,n (e m o 4 -p- Utility Authorization No. Existing Service') 00 Amps J'N� KL Volts Overhead ❑✓ Undgrd ❑ No. of Meters 1 New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ,k,k 4 C(„ et, (e kA ,. j ,_ t Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires S No. of Ceil.-Susp. (.Paddle) Fans o. of Tota Transformers KVA No. of Luminaire Outlets b No. of Hot Tubs Generators KVA No. of Luminaires Above In Swimming Pool rnd. 1:1rnd. ❑ o. o Emergency Lighting Battea Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches `% No. of Gas Burners No. oT Detection and Initiating Devices No. of Ranges ct �.; �� e oJ�� ( No. of Air Cond. Total Tons No. Alerting Devices g o. o No. of Waste Disposers 1 Heat Pump Totals: um er ,' Tons ............................................... KW No. of Self- ontained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Mun'c'pal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW Heaters No. of No. of 'Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: /)—)t --u-7 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 insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Ef BOND ❑ OTHER ❑ (Specify:) I certify, under tl:e pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Alar4 .,\ Wck4lei,�, (-/ec4 ,c LIC.NO.:t✓ S1S31j Licensee: i`ll G C 4 % g Li C, 4,.e f 5 Signature A" (,Dda, ,.a LIC. NO.: (If applicable, enter"exempt" in the license number line.) Bus. Tel. No. • 9 7 e --3 8 7'013 7 Address: 1155 v i Ile 2 c �[1 11 < <� 544vk . I� cA G 13 31 Alt. Tel. No.: —' *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. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 0k�0 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): IIIc, r4 ty1 w _4 f. r c (- I e c-+ ' Q Address: 1" S o - d w; ►A v i I I t 4. City/State/Zip: P6, ,1 i p�40VN , o i 33 I Phone #: 1'1 i3 -3 :1—cI 3 7 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 2. © I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have 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.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 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. :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 job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: I 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: Al w —,L„n Date: i I" a B-O Phone #: 9.2 3- 367- %- O 13-2 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 Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: