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HomeMy WebLinkAboutMiscellaneous - 89 PLEASANT STREET 4/30/2018N O � O � C Q D C, cn 2z qo --4 o� C:) m o rm Date2.��.- 10818 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that.�Ar",A ..................................................... .................... 17 '`has permission to perform ..... ....... ........... plumbing in thebuildings of......ZZ .5.s.e.z� ....... .................................. . ...... rr at .... ................ North Andover, Mass. Fee.!:*. ..... Lic. No. ........... Check # 13 PLUMBING INSPECTOR f ' -_'fir WATER OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES E] NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY n OTHER TYPE OF INDEMNITY © BOND M OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusett.5.peneral Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT 101 1 '0- / 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 pro sion of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �",� z--7 6P�Ct GeY 1L -e— 4:g:: —C PLUMBS NAME ` I LICENSE # �v 0 D i SIGNATURE MP1 JP 0 CORPORATION F#PARTNERSHIPQ# _ LLC E E COMPANY NAME ADDRESS �— CITY =_— STATE ( ZIP TEL FAX L....__T-,_. —lj CELL -s 1; IL Fri MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY 3 MA DATE' Z C ( PERMIT# JOBSITE ADDRESS OWNER'S NAME (1� __._. ✓Sf@ �� POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE _ COMMS AL Q EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: 0 PLANS SUBMITTED: YES ® NO FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE _ �f _ DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM 4 f _ f __�-f-____,! �_ I ____,1 DEDICATED GREASE SYSTEM DEDICATED GRAYWATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN f---- _.. INTERCEPTOR (INTERIOR) _ f ___.. _.__f _ _ ! (____.__I _.__� �_f _.__ f _._ _ -...._ f ► .__— r KITCHEN SINK LAVATORY ROOF DRAIN _..._._.____ SHOWER STALL 4--1 SERVICE / MOP SINK TOILET A URINAL WASHING MACHINE CONNECTION _i ! (_. _.__I -j WATER HEATER ALL TYPES _f _—I I _. _f i = WATER OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES E] NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY n OTHER TYPE OF INDEMNITY © BOND M OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusett.5.peneral Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT 101 1 '0- / 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 pro sion of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �",� z--7 6P�Ct GeY 1L -e— 4:g:: —C PLUMBS NAME ` I LICENSE # �v 0 D i SIGNATURE MP1 JP 0 CORPORATION F#PARTNERSHIPQ# _ LLC E E COMPANY NAME ADDRESS �— CITY =_— STATE ( ZIP TEL FAX L....__T-,_. —lj CELL -s 1; IL Fri OF ui W LL a P The Commonwealth of Massachusetts . Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA. 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print Legibly Name (Business/Organization/Individual):. Address: City/State/Zip: Phone #:_ Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (fall and/or part-time).* 2. El am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. �• El Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition workingfor me in an capacity. y p ty workers' comp. insurance. 9 ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' 13. ❑ Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. "Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis 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 the policy and job site information. Insurance Company N 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 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 certo under the pains and penalties ofperjury that the information provided above is true and correct. Signature: 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical inspector 5. Plumbing Inspector 6. Other - - - Contact Phone Informati®n 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 -contractors) 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 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 appropriate line. I- 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 bum 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 Ma ssachu setts Department of Industrial .Accidents Office of Iuvestigations 600 Washington Street Boston, MA. 02111 Tel # 617-727-4900 at 406 or 1-877 MASSAFE Revised 5-26-05 Fax # 617-727-7749 ww�v.�ass,go�fdia. 1,' Date.... ' ...... 3� TOWOF RTH ANDOVER O P r PERMIT FOR GAS INSTALLATION �9 �,SSACMUSEtt This certifies that ...�t-a! ........ ......... . . has permission for gas installation ......... �7 r in the buildings of .. Wit-.....-........... . at . (� .'-r-r-�``.. C, North Andover, Mass. Fee .. Lic._.f .... . i� GAS INSPEG-T Check # (J' 622 I (Print or Tom) F per, Mass: Date 19 Permit # Building Lc aiiori ! � c� �i� pWnStr's Ner'nek4j UW Type of Occupancy S New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes ❑ No ❑ Installing Company Name Addressit.:a' ❑ !,J. U I 84R❑ Check one: Car;ifica'e # Ccrperavor, Partnership Business Telephone - n,�co > a) r , --4407 , Name of Licensed Plumber or Gas i=itteri, 2M11 A INSURANCE COVERAGE: have a current li bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked es, please indicate the type coverage by checking the appropriate box. A liability insurance policy. p�� 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 ❑ ,�. a -Y IV -MY 11 [Ilk ail o1 ine aeraus ana information I have submitted (or entered) in above application'are true and accurate to the best of my knowledge and that all plumbing work and installation performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By Type of License: 1 Title O Plumber t O Gasfitter Signature of Licensed Plumber or Gas Fitter Gty/Town O Master Al C APPROVED (OFFICE USE cm Yl O Journeyman L�canaz Number ,fes r SEE 0 ONE No No ME ON mom 0 .. a M�s���� Installing Company Name Addressit.:a' ❑ !,J. U I 84R❑ Check one: Car;ifica'e # Ccrperavor, Partnership Business Telephone - n,�co > a) r , --4407 , Name of Licensed Plumber or Gas i=itteri, 2M11 A INSURANCE COVERAGE: have a current li bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked es, please indicate the type coverage by checking the appropriate box. A liability insurance policy. p�� 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 ❑ ,�. a -Y IV -MY 11 [Ilk ail o1 ine aeraus ana information I have submitted (or entered) in above application'are true and accurate to the best of my knowledge and that all plumbing work and installation performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By Type of License: 1 Title O Plumber t O Gasfitter Signature of Licensed Plumber or Gas Fitter Gty/Town O Master Al C APPROVED (OFFICE USE cm Yl O Journeyman L�canaz Number ,fes z m 0 z Z m Q � � D m z � m m .a 0 C ' 0 m I 9 2 n .Z > r m a. � i a fa o 0 - m z v m n a o • z Date .c'.;'. - . . ..... 0, TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...................................................... ...... ;2 has permission to perform, ... �" k wiring in the building of ............. Xr�A ... ................................................ . at.ZF .... Q� ....................... ............ . North Andover, Mass. Fee/V77', Lic. .......... ........... ELECTRICAL INSPEGfOR Check # 2,-�eflp 5601 Official Use Only Permit No. ? S G lo72lrrag.L'? of Sr��.S577s aye S� occupancy & Fee checked BOARD OF FIRE PREVENTION REGU TIONS 527 CMR 12:00 APPLICATION FOR PERMIT T PERFORM ELECTRICAL WORK Ali work to be performed in accorda ce with Massachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all information) Date To the Inspector of Wires: Town of The undersigned applies for a permit to perform the electrical lwwork �described below. Location (Street & Number f�l Owner or f.(� _ ` ^ �,( Vi, s Address 9 Wil J .�- P® 1 o 7t' 1 �2 G`I c A, L IN Oi his permit in conjunction with a building permit Yes ❑ No t� (Check Appropriate Box) 2 0 b . Purpose of Building Existing Service Amps! New Service Amps 2G�-ZLrj Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Utility Authorization No. V64S Overhead B--' Undgmd ❑ No. of Meters Overhead M-` Undgmd ❑ No. of Meters OTHER —21 da f> 5 &T� va.y "iU7iZ1��7 INSURANCE COVERAGE. Pursuant to the requi►emen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO = have submitted valid proof of same to the Office YES = NO = ff you have checked YEAS �� indicate the type of coverage by checidng the appropriate box INSURANCE= BOND = OTHER = (Please Specify) —Z='Z t-2. d ��G� (Expiration Date) Estimated Value of Electrical Wo Rough Final, Work to Start� '� 1 / ' Inspection Date Resquested Signed under the Penalties of perjury: 159&-:0A FIRM NAME1 t7VZ �i I�1 d �'� \✓Lri'f G� LIC. NO.,n Lk�ensee d4 ' % CAisL-: Signature, � �' ` LIC. NO. .1 d i t?�'ry- �%` / A a 7� q3 Bus. Tel No. I d7� Address �' v �ty Alt Tel. No. ev 60 3 _ . YYY OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have,the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMITTEE 5 1 � S Total No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA Above ❑ In ❑ No. of Lighting Fixtures srAmming Pool gmd ❑ gmd ❑ Generators KVA No. of Emergency Lighting j No. of R es Outlets No. of Oil Burners BatteryUnits No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No. of Diposal No. Pumps Tons KW No. of Sounding Devices NOJ of Sett Contained No. of Dishwashers SpacefArea Heating KW DeiectioNSwnding Devices ❑ Municipal ❑ Other No. of Dryers Heatino Devices KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW Signs mlases Wiring No. Hvdro Massage Tuds No. of Motors Total HP OTHER —21 da f> 5 &T� va.y "iU7iZ1��7 INSURANCE COVERAGE. Pursuant to the requi►emen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO = have submitted valid proof of same to the Office YES = NO = ff you have checked YEAS �� indicate the type of coverage by checidng the appropriate box INSURANCE= BOND = OTHER = (Please Specify) —Z='Z t-2. d ��G� (Expiration Date) Estimated Value of Electrical Wo Rough Final, Work to Start� '� 1 / ' Inspection Date Resquested Signed under the Penalties of perjury: 159&-:0A FIRM NAME1 t7VZ �i I�1 d �'� \✓Lri'f G� LIC. NO.,n Lk�ensee d4 ' % CAisL-: Signature, � �' ` LIC. NO. .1 d i t?�'ry- �%` / A a 7� q3 Bus. Tel No. I d7� Address �' v �ty Alt Tel. No. ev 60 3 _ . YYY OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have,the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMITTEE 5 1 � S