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HomeMy WebLinkAboutMiscellaneous - 915 JOHNSON STREET 4/30/2018 (2)O a? o` bz V 0 Z O Cl) O --1 O X O rM 6 -1 NORTH G QATOWN OF NORTH ANDOVER O G PERWi FOR GAS INSTALLATION �SSqCHUsP� v, This certifies that .... ............... ..................... . has permission for gas installation in the buildings of ...*:-:: !! ..... yr ............... . at .... f.....`.... , North Andover, Mass. Lic. No. .......................... GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File LIM ;•ii MASSACHUSETTS UVIFORM APPLICATOV FOR PERMIT TO DCS} Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations 915 J6ny\--pyi c'S-z✓-Pt A Owner's Name Key, �Iuq � CS dew Renovation ❑ Replacement Plans Submitted ❑'F� k'" J k% Prim ur rype) hec ne: Cenifi* Installing Company �:ame Andover Plba. & Ht4. Co.. Inc. , Corp90. -address 20 Agean Dr., Unit -10 ❑ Parmer. ;< Methuen. Ma. 01844 «;' Business Telephone (978) 685-8383 ❑ Firm/Co 'game of Licensed Plumber or Gas Fitter Manrna I aRncra I NS U R A INCE COVERAGE Checkon ! have a current liability Insurance policy or it's substantial equivalent. Yes No E3 ! you have checked ves, please ird in-icate the type coverage by checking the appropriate box. _iabiGn• 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: Sienature of Owner or Owner's Agent Owner ❑ Agent.';-' 011�"._ hereby certify that all of the details and information I have submitted (or entered) in above applicatn, ;end accurate to the. Dcst or my knowledge and that all plumbing work and installations performed under Permit Issued for ihia�iccition will be in _ompiiance with all pertinent provisions ofthe Massachusetts State Code and Ch ter 43 oft.i 1 Goner; �,Gaws. By: Tide C;IY/Tow n APPROVED ioi,n F. USE ONLY) 34ignature o Licensed Plumber Or Gas Fitter,` 1umber 9983 Tvl as Fitter icense I umoeraster ❑ Joumeyman C 86 a � rn _ G: F vJ a' v z > iii 5.t; C ii1 % •• z �I V :•��^f' lj r — — — �(: 8-U.%5ENI ENT BA-iE.M ENT ► i:�ri- ' is F. FLUUR NU FLOUR w; 7R U. FLUUR 71- r T If F L U O R Tr 11 FLUUR -6T —11F L 0 0 RI I F I I I I I I - 7T 11 F L U U R "' 8 T II F L O U R Prim ur rype) hec ne: Cenifi* Installing Company �:ame Andover Plba. & Ht4. Co.. Inc. , Corp90. -address 20 Agean Dr., Unit -10 ❑ Parmer. ;< Methuen. Ma. 01844 «;' Business Telephone (978) 685-8383 ❑ Firm/Co 'game of Licensed Plumber or Gas Fitter Manrna I aRncra I NS U R A INCE COVERAGE Checkon ! have a current liability Insurance policy or it's substantial equivalent. Yes No E3 ! you have checked ves, please ird in-icate the type coverage by checking the appropriate box. _iabiGn• 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: Sienature of Owner or Owner's Agent Owner ❑ Agent.';-' 011�"._ hereby certify that all of the details and information I have submitted (or entered) in above applicatn, ;end accurate to the. Dcst or my knowledge and that all plumbing work and installations performed under Permit Issued for ihia�iccition will be in _ompiiance with all pertinent provisions ofthe Massachusetts State Code and Ch ter 43 oft.i 1 Goner; �,Gaws. By: Tide C;IY/Tow n APPROVED ioi,n F. USE ONLY) 34ignature o Licensed Plumber Or Gas Fitter,` 1umber 9983 Tvl as Fitter icense I umoeraster ❑ Joumeyman 10 Date........`..!........ ,to 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �~ h This certifies that .. ��% `� ' ,f .................... has permission for gas installation .. _72 !' ..! ................. . in the buildings of ...P. . ............................... . at ...`.;: ! ::. < <.....:. f ...... North Andover, Mass. Fee..t. Lic. No.. ... ..... �._... �.*:�-z ..... . dAS INSPECTOR Check # r (Print or Type) '" musir�hm Ar'I'LIUATION FOR PERMIT TO DO GASFITTING NORTH ANDOVER , Maas, Date ' 19 a Building Permit Location 9f )r C) .PQ /Y J?z) # � Owner's Name New ❑ i SUR—semT. 1111ASEMEHT EFLOOR TH FLOOR ITH FLOOR Renovation O Replacement ff"' Plans Submitted:. Yes O No ❑ S u, b uIC 0 J h W O 0 tl H X M o a: r >• s s 0h ac as M F- ac M O a a s w y s U 1�i1 i M X lO+ 110 F d 06 0 i!, O 3 U C i p d O Install) Com n Check one: � Company Name �� � , S� �,L C/ l"iQ�%� Corp. Address a� �-- �Q�11 U Partnership Certificate Business Telephone 3 3 q 7 5 `-" firm/Co. Name of Ucensed plumber or Gas Fitter INSURANCE COVERAGE: Check o qw I have a current Ilablllty Insurance poilcy or its substantial equivalent. Yes It You have checked Yes, please indicate the the appropriate box. �type coverage by checking A liability Insurance policy Other type of Indemnity O gond O OWNER'S INSURANCE WAIVER: I am aware that the licensee does nd 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 Aguilt Owner O AgentEl I hereby certify that an of the details and Information I have submitted (or entered) M above 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 appikailon will be M pertinent provisions of the Massachusetts State rias Code and Chapter 142 of jha r pllance with all Tr(Gla cense: Tnle ber na ure o cense um er o as er er Cftpwn ,�er License Number Joumeyman u'r'rWED (OFFICE USE ONLY This certifies that has permission to perform. �)a Ir �......, , , , , 1. plumbing in the buildings of. . `- .I U.? .S.../ ............... . at .....�.r) ..nh,��..�...� . . . ,North Andover, Mass. Fee 41 :D . Lie. No.. 3 Z. 7 6 ) ` S . � �................. .. . PLUMBING INSPECTOR ti Check # Z.. (3to � (0 � - (-� ... MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE ?-1 - / j PERMIT # t I JOBSITEADDRESS OWNER'SNAMEjj ,l�p��� S _ POWNER ADDRESS k cy� Ste. TEL FAX L - TYPE OR OCCUPANCY TYPE COMMERCIAL © EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: El RENOVATION:JT REPLACEMENT: ® PLANS SUBMITTED: YES EQ NO©I FIXTURES 7 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/OIUSAND SYSTEM i _r. ! ( __. _I _I __ _i —"-JI i J I DEDICATED GREASE SYSTEM_.__J DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM i __.. _ 1 ...._..___I DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN i ___....1 I i 1 I � ______! .__...__ _._._ i ..._._.._ i _....-._.JJ __..._J 1 _.._._-( INTERCEPTOR (INTERIOR) f I { _ I _..,._.__l i I-_.-_.J KITCHEN SINK _—{ _....—__I== ....___.--1 _ __._.1 _______I .---___..J ...._.... ___iMEALAVATORY I J .. _ .._! ..-.._.__.1 _..-_-_J---_-•-_J _...__ (..___J __..._.__f-_..._J EROOF DRAINJSHOWER STALL--.__J ___J ___- __f _—__..._i ..___J----___I_._I .^_J __._J _SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION _ S _ l __...._1 ._...1 __..._+ _ ... ! ___... -i WATER HEATER ALL TYPES I i i _ - _. i 1===—== WATER PIPING OTHER __ _ N__._ _. _._-_ — ___I ___I 1 .-__-._J i _(_ __..i ._._ - I ..._.._f __-_. ► ..___I i INSURANCE COVERAGE: C have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO �1 t `J IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY kr OTHER TYPE OF INDEMNITY © BOND P, OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the L() Massachusetts General Laws, and that my signature on this permit application waives this requirement. r. 6) CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT 1 her by 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 chat and all plumbing work and installations performed under the permit issued for this application will be in compliance with all P inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Lam. v PLUMBER'S NAME �I. , _ r%�_�.( LICENSE # �� _ I SIGNATURE MPn JP I CORPORATION E]#r-- PARTNERSHIPO# i LLC i cc, 'ADDRESS COMPANY NAME T ,��� ��e CITY _ --- �..__..._......... ....._..t STATE ZIP d (_ S II TEL FAX (CELL EMAIL G,L.,�FS_-.- ... W H z 0 H U a � G V► . o❑ z U) F, O � W p w O CL z U =ft o Q W 55 a W O > L W 3 p o w w� as a U J IL a- < U) w x w LL W H z° N z o w a ca a c�7 O a i� The Commonwealth of Massachusetts Department of Industrigl Accidents Office of Investigations 600 Washington Street 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: 8 QST S T. City/State/Zip: /VO, Q„ ,JgLA,- M1¢ 006 Phone #: 9;` 9� 9 - 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 ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all 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 required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. El 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. Al 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. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. I� Insurance Company Name:. 7-he/fce—% , W 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 requiredunder 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 5` 2 Sienature• Date: 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 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 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. 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 Massachusetts Department of Industrial Accidents Qfiice of Investigations 600 Washington Sheet Boston, MA 02111 TO, # 617-727-4900 ext 406 or 1-877rMASSAFE Revised 5-26-05 Fax # 617-727;7749 wwwanass.gov1dxa W Commonwealth 0 a usetts. • Division of Registrati Board of Plumb THOMA EN 429 WA APT 1 ? NORTH A Journeyman 'GSM :PL32-701-j 05/04/2014 004905 ..�..License No. ExOration Date. Serial No. Date... W.o......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION c11rv�rd .AV 1" �C� �1 o ' This certifies that..................................................................n ............... has permission for gas installation .... ...... .s,..{,1.1.., .............................. in the buildings,*......1.?� �\_.......................................................................... at !�10�1NSo�) ... ........::.-...'!':...., North Andover, Mass. Fee.. ?........ Lic. No. .A�.��.�....... M.�.�.................................................... GAS INSPECTOR Check #2— �J C 7 f MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY/l%i P/' _ MA DATE l PERMIT # `112A JOBSITE ADDRESS SaGh —� OWNER'S NAME GOWNER ADDRESS 7V1-. - . TE _ IFAX � TYPE OR OCCUPANCY TYPE COMMERCIAL [ EDUCATIONAL F1 RESIDENTIAL'' PRINT CLEARLY NEW: Rf RENOVATION: 0 REPLACEMENT: PLANS SUBMITTED: YES F NOF APPLIANCES 7 FLOORS- BSM' 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER -� % . �... _ L BOOSTER CONVERSION BURNER J _ — --- ---� COOK STOVE. . DIRECT VENT HEATER DRYER- FIREPLACE FRYOLATOR FURNACE GENERATOR) GRILLE INFRARED HEATER_, LABORATORY COCKS MAKEUP AIR UNIT _ OVEN - POOL HEATER _. 1 ROOM / SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER t LINVENTED ROOM HEATER I OTHER r - - ........_.........................................._.................... INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES P190 D IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Zl OTHER TYPE 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 0 AGENT [71 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 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 T�p,� LICENSE # /S l l SIGNATURE MP Z MGF Ej JP E] JGF [I LPGI 0 CORPORATION ©# PARTNERSHIP©#LLC D# COMPANYNAMEI�/b1�(� ADDRESS gT�-fir✓ CITY STATE ZIP / TEL FAX CELL `Ili'-%a'�GY� EMAIL 0 z 4k�l� F W w o F1 a z W }El � ~ w O 0 a U w f z w m � a W a a LU O LU w L LU w CO) a o a a a U J F a 0. ' Q et? � LLI S w f— LL O z 0 H U W W L�7 .U' O ♦ 11 The Commonwealth of Massachusetts - - Department of Industrial Accidents Office of Investigations qu 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lep-ibly Name (Business/Organization/Individual): �'. d i0i ez L,, - ced Address: 7- City/State/Zip: 4*2 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 # 2. [ I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all 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 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 13.40ther 6;r -,f *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 2ie 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. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. �r Insurance Company Name:. Policy # or Self -ins. Lie. #: Sp a e� % Expiration Date: ?�� . Job Site Address: 115 City/State/Zip:dVL%�, 0 %til S 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 rine 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 of perjury that the information provided above is true and corgect. , i Signature: d�� ``� Date: Phone#• � 72 -Z -2-91-j y� 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. 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 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: Tho Commonwealth, ofMossachwoutts Department ofIndustrial .Accidents Qfmce of Investigation's 600 Washington. Street Boston., MA, 02111 `Fel, # 617-727-4900 ext 406 or 1-877rMASS.AF.E Revised 5-26-05 Fax # 617-727-7749 wwwanass,gov/din. Commonwealth of Division of Registry Board of Plumbil THOMA 876 Fore 3 North Ado Master Plu PL16151-M 05/01/2016 License No. Expiration Date. 1�11ulletts , N 005498 Serial No. Location T011VSOA) S� No. —3 6 Date 13./S°� ` NaRTh TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ 3O� Building/Frame Permit Fee $ ? cHUNust <� 4'? s Foundation Permit Fee $ Other Permit Fee $ s Sewer Connection Fee $ v Water Connection Fee $ TOTAL $ 3a Building Inspector >/# :? J 06/16/99 14:47 32.00 RAID Div. Public Works x M I IN a w � � u w U t• .� Q! Y 7 w I � � O G z U I L-. O - O I_ W a A u Ln z p < 7, w ^' A O O I~ ] t 41� U W G C O W z � O U cc x x x k X x a z a X � a a N U W ^ I C q C rn v) v v a ,� ;Wj W^ nj G Z C V) � ❑ a � L � 1 O O H U w 0 h V �h 2 � v z o �p a � p v; b z a w w z w z w? o d d d IN a w w � � u w U t• .� Z 7 Z U I � � O G I L-. O I_ W a o u Ln z p < 7, w ^' W O O I~ ] t 4 U W G C O W O U cc w � � w U t• .� Z 7 Z U i O O RM ■ I C- ON FORM U -SLOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *************APPLICANT FILLS OUT THIS SECTION APPLICANT `J�/!/LLT� ✓ �U ��'i (PHONE13E!:P'I LOCATION: Assessor's Map Number PARCEL SUBDIVISION I LOT (S) %y STREET ���ti"�� `}� x ST. NUMBERF/5' USE ONLY********************************* RECOMMENDATIONS OF TOWN AGENTS: ����'PICK Ale ERVATION ADMINISTRATOR COMMENTS IBJ D U"`1 n2k) TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH �JC l��ti SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED_ r , 16 A" DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm as p wo a cn w° U 7 °aD v U m uc". O Hu U w a m ii O w u w W 7 rL cx cz a. 04 O � cG w w w z cn cn V :.y o x :U :w O O.&C O S` "c :rts 0 CL o0 0 0 cm �i a :cmc U Lo :CD J : U, O�: �y N cm Cf) M-ir Zy C C O mac: y M o w U CO qmo ar d CD Crn^� y lei m v cmw � P-4 o � m x:�yo o Ct U CL c CM lamb H c •c /h L, c N F•- ov� F— m W C Oro 0 Z " T C . C �.. r. ~ •y +=+ '!.s Ccc Z O c JL C.)_ a g 2 A 0 y�O O 9 Co co 0 co O Z O 0 y CD CD L C O V �7 y O O C3 .Q COO) C O V ev d CA LU C) Cn LLI Cn W W Ccw Qz a. l F-' Z v 46 7 ? h J z o � 2 ? � 4 � Qz a. l F-' T 1 a North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance w Jh the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: / lWaCT-. (Location of Facility) Si atur of Permit -Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Nam Location: q!5— AJ-S©1J City Nmlq 1fQAJAX L =- Phone I am a homeowner performing all work myself. 0 I am a sole proprietor and have no one working in any capacity F7I am an employer providing workers' compensation for my employees working on this job. Comoanv name: Address Citv Phone # Insurance Co. Policv # COmDanv name: Address Citv: Phone #: Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a Tine of (5100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature Print name Date one # Official use only do not write in this area to be completed by city or town offciai City or Town Permit/Licensing ❑Check if immediate response is required Contact person: ❑ Building Dept ❑ Licensing Board ❑ Selectman's Office ❑ Health Department 7 Other