Loading...
HomeMy WebLinkAboutMiscellaneous - 90 HIGH STREET 4/30/2018Date...... ................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 0 This certifies that I. ......... V ................................................................ has permission for gas install4on ... la 4 - ......................... inthe buildings of ..................... I. -...h ... ........................................................... at.......... �.Q:�ft.1.. .. . ........ 5.4,U . .................. . North Andover, Mass. Fee ....2.Q.. — Lic. No. M.0� .............................................. GASINSPECTOR Check# I —_I �� .10 L)7 Date ... .......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that..4r 44 ...... .............................................. has permission to perform r .................................................................... plumbing in the buildings of.. .. ... q ....... .. 0 .... ...... E...(.....'' .. ... r-t' Andover, M- at ...........Fee.3.� ...... ......... Lic. No. 4.4-0.7.3 M. bur . . ... ........................................................ ? PLUMBING INSPECTOR Check # I I x-- P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY No MA DATE - ( PERMIT # JOBSITE ADDRESS OWNER'S NAME OWNER ADDRESS TEL ^�—FAX OCCUPANCY TYPE COMMERCIAL © EDUCATIONAL Q NEW: � RENOVATION: ® REPLACEMENT: QR FIXTURES Z FLOOR- BSM 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 �AVATORY ROOF DRAIN f SHOWER STALL SERVICE / MOP SINK URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER I RESIDENTIAL' PLANS SUBMITTED: YES ® NO© 10 1 11 1 12 1 13 1 14 INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY UI BOND F 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: OWNERF-11 AGENT IR —I OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are ue 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 plia ce wi all Perti t provision of the Massachusetts State PASIJ" `�, l�Q.� p p lu—m-bbiiinng Code and Chapter r114-2, of the General Laws. PLUMBER'S NAME /I 6 II LICENSE # �7�_ SIGNATURE MP/0 JP 01 COMPANY NAME CORPORATION IPD# _ s LLC Ek ADDRESS 1 2-2- 7 " r,/ _i CITY C 1 ✓yam ]STATE ® ZIP FAX CELL I� j EMAIL (J am H"IN on 0 H U W a A W 0 E z O W w z u _ F- 0 a w w o a p z W F- J IL n. � w z w F- u. F z O H U a a a p O x y .The Commonwealth of Massachusetts Departmentof?'ndustriglAccidie is Office ofInvestigations 600 Washington Street Poston, MA 02111 www.massgov/dia Workers' Compensation. Xnsurance Affidavit: Builders/Contractors/EIectriciansl.L l mber•s Appllicaln Information Please prn6t Legibly Name (BusinessiOrganization&dividual): (///� MLLC Address: 2_-Z7 t 4 4h% City/State/769:_ d 1A,,f Phone #: ` 71' y%lC cbel ? Are you an employer? Check the appropriate box: Type of project (required.): III I am a er with employer Z- p y 4• ❑ I am a general contractor and I 6. []Now construction employees (fill and/or part-time).* 2. ❑ 1 am a sole proprietor or partner have Hired the sub -contractors listed on the attached sheet 7• F1 Remodeling ship and`have no.employees These sub -contractors have S. ❑ Demolition working forme in any capacity. workers' comp. insurance. 5. ❑ We area corporation audits 9. El Building addition [No workers' comp. insurance required.] officers have exercised.their 10.0 Electrical repairs or additions 3.E1 I am a homeowner doing all work right of exemption per MGL ILE] Plumbing repairs or additions myself. [No workers' comp. c.152, §1(4), and we have no 12.QRoofxepairs insurancere fired. � � i � employees. [No workers' 1311 other comp. insurance required.] f Any applicantthat checks box#I must also fill outthe section bel6w showingtheir workers' compensationpolicy information. T Homeowners who submit this affidavit indicating they Rr doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 employes' that is providing workers' compensation insurance for my erriployees atO1s ihepolicy and jolt site information. Insurance Company Policy # or Self ius. Lic. #: Expiration. Date: Job Site Address: Pity/State/Zip: Attach, a copy of the workers' compensationpolley declaration page (sb.owing the policy number and expiration date). failure to secure coverage as requiredundex Section 25A ofMGL o. 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 AIA. for insurance coverage verification. f do Hereby ee / miler the pains a/nd penalfiies oj"perjury viat time information proviaea aboovye rs true ana correct. Phone M Oficial use oily. Do not write in this area, to be completed by city or town official. City or Town: PermiffAcense Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Numbing l'nspector 6. Other ContactPerson; Phone #: u Information and Instaructions 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 cmitract ofhire,• express orimplied, 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 wdeceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. I16ever the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant ofthe 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have beenpresentedto 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, apolicyis required. Be advisedthatthis affidavit maybe submitted to the Department of Industrial. Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. 'he 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. ` City or Town Officials Please be sure that the affidavit is complete andprinted 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 "fob Site Address" the applicant should write "all locations in (city or towiz)" 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 -ii oa file for future permits or licensm..A new affidavit must be filled out each year. Where a homeowner 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 shquld you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: Tho Co oumalthofJ1_us.arhuso& - Dep aftent ofIndust W.EE4„coldouto Of Roe Qf fAVeStzga-UQ= G00 Wasbi gton sire ea Boston, MA 021. It TO. # 617-7.27-4900 Q9406 or 1-877• MMSAFE Revised 5-26-05 Fax # 617"727-7749 t�wt�'.ztitass,go�'fdja. v MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY \\"1 -x`npvwvj .� MA DATE ( �-- (%'r Ij PERMIT # r i �rsas-c.W—� JOBSITE ADDRESS S OWNER'S NAME r OWNER ADDRESS _ _ , TEL___ 71FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: © RENOVATION: REPLACEMENT: (� PLANS SUBMITTED: YES 0 NO APPLIANCES 7 FLOORS- BSM' 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _ I . _ n __. J BOOSTER _ _I CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER- FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER I . ROOM / SPACE HEATER _ _ ROOFTOP UNIT TEST— UNIT HEATER UNVENTED ROOM HEATER WATER HEATER j ... . INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ®f 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 QJ AGENT[] SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true d 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 com i ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE # SIGNATURE MP�MGF jI JP ® JGF LPGI CORPORATION P# Z� ' PARTNERSHIP ®#= LLC D# COMPANY NAME:n %�jj �t-�✓,_- ADDRESS CITY t C(�-� _ STAT Eimzlp-,J - TEL -- FAX :� CELL[=EMAIL O Z O H U W' rA O A W °❑ Z O N❑ W } H W W O H a Z LU V) a w a W P4 > O � w U) o a a a U J E, a a Q C w x w LL H z° 0 H U a The Commonwealth of Massachusetts Department of Industrial Accidents .,, Office of Invesdgations 600 Washington Street Boston, MA 02111 UV. www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeAW Name (Business/Organization/Individual): Hp" gc ✓, J C� Address:S1— City/State/Zip:_�l ( ( Phone #: ��� — �� 71 - Are you an employer? Check the appropriate box: Type of project (required): .1p I am a employer with 2_ 4. ❑ I am a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* 2. F1 am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7• E] Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. F1 Building addition [No workers' comp. insurance 5. El We are a corporation and its 10. ❑ Electrical repairs or additions required.] 3. ❑ 1 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.❑ Roofrepairs insurance required.] 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. t Homeowners who submit this affidavit indicating they tie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors 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 the policy and job site information. Insurance Company 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 o. 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. Ido hereby rt% rider thepains and enalties ofperjury that the information provided above is true and correct. Signature: Date: Date: �G 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 #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. e 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 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. 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 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 Massac-14usetts Department of Industrial Accidents Office o£Investigatiom 6.04 Washington Street Boston, MA, 02111 TQL # 617-727-4900 ext 406 or 1-877rMA.SSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass,go�fd�a Claim # 2669958 Advantao Claim Services Adjuster Assigned: Glenn Guarente 522 Chickering Road #B North Andover, MA 01845 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 3B To: Building Commissioner 4/ Board of Health or Inspector of Buildings Boar`dof Selectmen Town Hall Town Hall North Andover, MA 01845 North Andover, MA ­ Re: sured: Jo n h&n Finnimore R In at _ Property address: 90 High St. North Andover, MA 01845 Policy #: 2669958 X Loss of: 2014/07/20 F File or Claim No. AD 1529 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. _Gen. _ Laws,_ Chapter_143,_Section_6 to be applicable. If.arty �• notice under'Mass_Gen_Laws,_Ch._139_Sec._3B{is appropriate please direct. it to the attention of'the writer and include a reference to the captioned insured, location, policy number„ date of loss and claim or file number. Glenn Guarente Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. 07-30-14 Signature and date it it X10 0TN O r i CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 319(10/28/05) Date: August 4. 2006 THIS CERTIFIES THAT THE BUILDING LOCATED ON 90 High Street MAY BE OCCUPIED AS Single Family Dwelling In IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Steve Saracen r 90 14igh Street North Andover Ma 01845 f7 / Building Inspector f c � . C O O c � N O C �c. CL o ev O C o � ya� C n mysy- CD V O n h cp E � t/ m C CL -- ca E CD o o z`OLD y t ,3 m � O'O h H O O E m CLC0 ca of CD -8 .0. c I 0= m � 5Z o c n o C o, c = `mc 'c O c.="' o H H m ~ D W .E v p c°; .w O 4D ca a _cm 02 n •� O1 _ ca .0 C3 r- c CL m 0 U C/) � c cm CD p 'O y m � CD 0 CD = t F-� f=L O .p �3 CD a� 0 0 CD LM cc `O a Q C cc .C3 .300 C. O CD C Z 0 CL V y O C _cc C. y cz .a AO '� I � .� W '� •°j � � 'ao a! � � c cq co cn c � . C O O c � N O C �c. CL o ev O C o � ya� C n mysy- CD V O n h cp E � t/ m C CL -- ca E CD o o z`OLD y t ,3 m � O'O h H O O E m CLC0 ca of CD -8 .0. c I 0= m � 5Z o c n o C o, c = `mc 'c O c.="' o H H m ~ D W .E v p c°; .w O 4D ca a _cm 02 n •� O1 _ ca .0 C3 r- c CL m 0 U C/) � c cm CD p 'O y m � CD 0 CD = t F-� f=L O .p �3 CD a� 0 0 CD LM cc `O a Q C cc .C3 .300 C. O CD C Z 0 CL V y O C _cc C. y cz 4 0(1 APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION Building Permit # :3 ISI ADDRESS/LOCATION OF PROPERTY: (:�p vkti G�A S-C20A`w Parcel SUBDIVISION Lot Number DATE REQUESTED FILED/READY FOR INSPECTION CLOSING DATE ON PROPERTY: 0, FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE- INSPECTION FEE OF TWENTY DOLLARS $20.00) WILL BE CHARGFD IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. SIGNED CONSERVATION PLANNING DPW - WATER METER SEWER/WATER CONNECTION NOTE i 740 C�zOCO DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST : n S Signature File: OC form revised 2006