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HomeMy WebLinkAboutMiscellaneous - 95 SANDRA LANE 4/30/2018N �f `,gyp RTH 1 N 3r ,W 0 r Date..�..�G: TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION i This certifies that has permission for gas installation ............. in the buildingss,,of . u a .................... at * ...... ��- ��........ North Andover, Mass. Fe& --7..... Lic. No. ✓:........ GAS W EC 0 Check #,--;)L) % 29 TI 24 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations rA Owner's Name Permit # Amount $ d-' New Renovation❑ Replacement ❑ Plans Submitted ❑ w � w w C U x p p W F z ZF CG x° F z H a w w w w > w U U x. x a Q p w po F., .a p W x s o' x 3 G U C1 o w a W O SU -BASEM EN .a U C > D BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR Ell 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8.TH. FLOOR (Print or type) Name - ` Name of Licensed Plumber or Gas Fitter . % ^ Check e: Certificate Installing Company p. ElPartner. Firm/Co. INSURANCE COVERAGE Check one I have a current liability Insurance p licy or it's substantial equivalent. Yes No If you have checked roes_, please Liability insurance policy cate the type coverage by checking the appropriate box. Other type of indemnity Bond Owier's Insurance Waiver: I am aware that the.licensee does_ not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts AStfe Gas CM aid Chapter 142 of the General Laws. City/Town IAPPROVED (OFFICE USE ONLY) Signayare of Licensed Plumber Or Gas Fitter Pler Gas Fitter License Number Master Journeyman s .- The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Uf 600 Washington Street Boston, MA 02111 www.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers [mlirnnt Infnrma*i^m Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: 5' Are you an employer? Check the appropriate box- ox:1.❑ 1.0I am a employer with 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheet $ 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.] 3. ❑ I am a homeowner doing officers have exercised their 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.] * ° n�' appiic2at that checks t.Vv i must alsv iil uut the section b .,. 1, shon,i t rho,.. works Type .of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other Homeowners who submit this affidavit indicating they are doing all work and thea hire outside contracompensctors 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 IpIicy 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: 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 Sinature: Date.: Phone #: LOther only. Do not write in this area, to be completed by city or town official n• Permit/License # hority (circle one): health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing b Inspector son: Phone #: I Information an d 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 notbecause 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 coxnpliance with the insurance coverage required." Additionally, MGL chapter 152, §25CM 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 pernaitor license is being reaaested, not the Depa=ent 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 Ime. 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 Of re of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4300 ext 406 or 1-877-MASSAFE Fax # 617-72.7-7749 Revised 5 -26 -OS www mass.-gov/dia „ .✓"'^"+N`^S�.�r+•-7-r�»f-. r::�-•'Zr'Y""��"'Y� -aa �:` �^ti�.a.«.�'—Y R--..�a•+.,,..r.-.v.+c`-:i^.^ - 00, Ko.: 1 '� '�- Date NORTH �S% . • `. j . 1�O0. T6;IV - OF- NO tTk ANDOVER ° , A 5O" FILDING DiF,',,A TMENT '�,9 pD'�ATiD �PP•�'l' Building/Fran ermit Fee $ D SSACHUS� 3 Foundation'Perr it Fee$ ` Other Permit Fee 0/0 f $ & Building Inspector VI � 0 tai z 0 F- IL z W L 0 m IL n N z 0 H u 7 H Z L z 8 0 z f a W L U t W G W 0 m L L < S 0 g 0 z z z N z 0 a 0 < u J W V � d u z W z IXZ Z W O g Z J < O 7 w m 0 N m ' 6\ �-k o m a13 w III W N ` �7 ?0 O K lnJ 1 0 z d x OZ O < u fir- �---- Z m F n I O Z 0 < rA \ L 1 U 7 y�j W V I � Or 4 S 1 0 W < m O I O w I J i N Ix 4 u W i J W N N F U m 4 W F I u' W F < W W Ix L W < O ro 4 d L] 1. 7 z ^ • az W < It 4 i L 0 Z zf 0 o P wz 0 < F Wo J 0 u W W O J o Z < < z 4 < 0 Z Z Z LL 0 0 0 ro O O O W m m m J < t N W N 3 m z 0 F- IL z W L 0 m IL n N z 0 H u 7 H Z L z 8 0 z f a W L U t W G W 0 m L L < S 0 g 0 z z z N z 0 a 0 < u J W V � d u z W z IXZ Z W O g Z J < O 7 w m 0 N m ' 6\ �-k o m a13 w III W N ` �7 ?0 O K lnJ 1 0 z d x OZ O < u fir- �---- Z m F n I O Z 0 < rA \ L 1 U 7 y�j W V I � Or 4 S 1 0 W < m O I O w I J i N Ix 4 u W i J W N N F U m 4 W F I u' W F < W W Ix L W < O ro 4 d L] 1. 2MO%>D 01 IO OIm IO I�Iti l�lml A O O T n m m y N< D D v n m Z D v m nn D; N znn�nymv00D A rl0' m GJ pn00 N '>clz n7c 7cnn yD Op ow om D Nuc r) A=0 00000 p N O n;- p ,° m A Z > Z O O O N x 2 m O, C p m m Z D m n A 3 Z Z Z `^ N o Z Z O 0 ZD "340_ Gl N O c m30D> ZGZI Z <{ Amz30 > m m z M Z y { ~ Z ^ DDnx n ,,TT c0� xv M pN N S m A y Z` m< m •� 1^ Z N azo zrn; rAo i NN l7 n y 0 { a n^AD A Z OI I I IL O Z D D II II II II w �o IIIIIIIW IIII IIIIIG'rill ;ar-i SON N NrN Zm Irq • DO NZZ CC)C �kN 1 D n 010 mo* mim • mx xN_n 1AOo �z_ U) "D vOZ �m� c M 0 NDN r v X00 -4G)r Z (n 0 rr 70 ?�Z A xo O o- v mD �z x� mm Nm 00 D� 3 t r . ' aVF FORM U - IAT 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 local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: Cen+�r • co ,y N C. Phone .SOS - as o ri.%) 3 LOCATION: Assessor's Map Number 216 109-1.0 Parcel ©o `) 3 Subdivision Lot s)c3►01 Street 5 e!),nr:>2A St. Number 51�— ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: C./ Date Approved Conservation Administrat Date Rejected Comments Date Approved N Town Planner Date Rejected Comments Food Ins ector-Health (/ Septic Inspector -Health Comments Public Works —sewer/water connections Date Approved Date Rejected Date Approved ��- Date Rejected - driveway permit J,XFire Department '{��^ c e'eiv d,,),by Building Inspector L� V� ,� l� 1S I3 ' +, APR ? 1 Date �t. + CI�C:,tM FOPrj cF:F`(_CTR_ IU 5082561$ �i 3 Wt r WOOD STFIFE-r CM UvISFORD, MA 01824 ORI Tit :At- SUBMITTED TO poui & N"'If,1y BratIley APR 09'93 PROPOSAL PHONE (506)),57-1967 STM I I JOB NAME • B Act�Ry C11 Y, STAT[ AND ZlP CODE J09 LOCATION N MA. 01645 ARC.HIfiI-C'T DATE OF PLAN DATE 0410APe?, JOB PHONY YVF- propo�b ick fumiah materiatE alit labor necc,�rnry for tho cornplolwn of: for a 8'x13`6" addition to the exweting otfice spnto' t! c� installation of a 8'xl2')(S' foundation, 10" wide on a 10'•x24" fooling, Back fill to grc.,:r, ttival, poly- a ooncrela sirb 4" thick with a gravel base. Owt)il's will bA respone'!Oe for the �',i,;' �;.,► sy srem rl:'oxjval Of thu 0XIDI ting office window with the irrtOnt to f6 usa M In thA. now room, Mr•vs.. v -V bath- r:'C!?} Windc1w enough 10 AC-CO;nmodate the nee room. FlopinSt?r lt)e bathroom WM aroly'::t 11:n, rjow pl, rtornont of the wtndow does not incki&4 w aupaper. PoIDI a 13'x13'6" r cwA According to tha dinwing filed with t n building ev�pA? mant. R,rY,;,ve the wooer hurning 9lcwe, And the brick work ajo0 lntf it, Ri )move the Axslsting carl-i 41 t►w I,,mily roan Hod the the In the hack hell and battuuom, fl -!-Ove the OX81rtln; eniertalnmr,nt c -A -mer and prepAtg the ar(,a for a now cabin(+t whist, w. Ii r•g inSlalled by Another contractor, not In•^_•!uded 1st this mrib w -l. ocint on pg. 2 K+E PROPOSE hereby to itgnic) rnwwlals And Tabor-cooiplete in accoldancru Wlth aheve gpr,0i,:r!Ii+ns, for 1ho etkii i of, N,' r �'.: rV ..Tikksks.�+n' �... C+r� a (L�.�ry h i_+ �_ ----dollar s-j`{��t., ;.1+•�Ct��F . `c Fa.lrnr_NY----�-�--...�'.�.-- �+�� -------�nL�.:..«l�lX� " _.._�S_� _�+�.V�! -ILix�----`y'+l.��etr`�-..._s:!�T.�R�+.G.4. 3ap_�r,�..��.Yr•• _ All is guaranteed to be As spec;fied. All to .b9 Cc0nlpMed in the SUbstantiAl Wolkn+Ar'�%� I rr,arr;:,r �C.r..ording to zp9cH{cAtlonS strhmiftQd, pyr slAnda?'d practice, Any All&atiOn Or Cls,vinti,,n tIorn 0(—v cI,l,C.i+iCW*ns involving extl'a 00 t6 Will t3Q g)(9CUlPd 011ty upon wrdliAn Ordc:-i o. And ww h.creie Lr, F:• 1' A OvIrgo Door And Above the estimate. Ah Conting9nt Upon Stlik,eR, aCCiC44''4 . CGl t,i�yc,nd our coraiN. Owner'lo carry fico. Vm"fkdo and olt,gr:n6ePSt#Ary inetwanc+e. Authtl6iAid signalklie Th;; liyopoeal may be withdt awn �y oti i1 not Accepted witNn ----days ArCFPI-ANCE OP PROPOSAL The above prices, ar�oc•ifications end c-ond�ions are and ks holc.tly au*Pted, You are'Aulh01ized to do the work Ar spocifiad. 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Ma OU2l CERTIFICATE OF USE &OCCUPANCY Town of North Andover Building Permit Number 111 Date SEPTEMBER 3, 1993 THIS CERTIFIES THAT THE BUILDING LOCATED ON 95 SANDRA LANE MAY BE OCCUPIED AS ADDITION TO BASEMENT OFFICE IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. �NORT� 1 CERTIFICATE ISSUED TO Paul Bradley °� 95 Sandra Lane ADDRESS ZIA d Amy Building Inspector • 0 z • f OR v-� S-! 0 z 0 �a+ c O i CO) O La O c • N r.+ Ea r ts C3a in o m o� Qc C=)N m m• i• L L c c3N m cm:1. c ' OJ w c mo. _ � = c N M N m E .o act N ® O `C CM) �Z Y_ O N c S o m CLO - cc .' O 4=0 W p ��•yt u1i C** tL m U C 'r N dt O C Lu E. col zIII C-3 C2 �' C4 a.(t m 1 o ��foi 6� N_ Z co 7 N c O cm CD s cm m 0 rn c N t 0 Z O g O_ i . y H O V co Q. 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