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Home My WebLink AboutMiscellaneous - Fountain Drive (2)10276 Date ........... TOWN OF NORTH ANDOVER Thi c i-Ar6flpe that A-e-A— PERMIT FOR PLUMBING (2 eA C- w ll ... ........................................................................................................... has permission to perf6rm4a.—k).,.)..,P ... �>� ... 49--s-�ox.,j pe -Lo o'(S ........ .......... . . .. ..... .... .. ..... ... plumbing in the buildings 4 ............................. .............. at........ ....... D. ... . ....... INot Andover, Mass. Fee.... Lic. No. ..... ...... .............................................................. PLUMBING INSPECTOR Check # 4 4 o �" I�� 9 MASSACHUSETTS IF RM APPLICATION FO A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE PERMIT # ��Z7 JOBSITE ADDRESS WNER'S NAME Sly^ POWNER ADDRESS TEL JJFAx 1 TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: Q REPLACEMENT: D PLANS SUBMITTED: YES ® NOF FIXTURES Z 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/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM 1 DISHWASHER _._fes DRINKING FOUNTAIN (.. f - - I - I .-_._!_ - —f - - - --- -! _ -1 .- - --.-.... E - -. FOOD DISPOSER -_.f -.-_.___((_.-- I -.- _ __1 FLOOR/AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK__ -- LAVATORY ROOF DRAIN SHOWER STALL _._i _._.._._1 _ -i - SERVICE I MOP SINK __....___.�_._._.._._..( 1==== TOILE,' f URINAL __—I' WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING i ( f ._.. I ! I ..__...__ 1 ... - ._� _ _E P _ _ _. 1 J OTHER ...._ I ( .-----�---f —( INSURANCE COVERAGE: dNO ! 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 OF INDEMNITY DI BOND 0 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 —( AGENT 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 proywon of th Massachusetts State Plumbing Code and Chapter 142 of th General Laws. -- PLUMBER'S NAME IJMei>�IILICENSE # SIGNATURE e MR0, JP EI CORPORATION �PARTNERSHIPLLC COMPANY NAME !ADDRESS CITYt -_— cY� - .._...._._..._i STATE ZIP �? Z—� TEL ftr f FAX i CELL - — ..__ I EMAIL . ^. - __._ -.- _ _ -4 i�_ __n r . — f,.i I — 0 ❑ Z N ❑ LLI CL ;:64 �y .1 • The Commonwealth of Massachusetts Department of IndustriqlAccidints 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: j �-- City/Stat lal,,wc,t,. We- Phone #: 7,Y/ —&qO Are you an employer? Check the appropriate bog: L ❑ I am a employer with 4. ❑ I am a general contractor and I em loyees (full and/or part-time).* have hired the sub -contractors 2. 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. FJ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other A -t u-- TO— ( t - !Any *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 aie 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. I am an employer that is providing workers'.' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:, 7—Vovi L!<l Policy # or Self -ins. Lie. #: / Expiration Date: Job Site Address: t,�(�.n,� / �y"'l�t�"^ ��``�) City/State/Zip: n 84, 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 cerfiffy under the pains and persalt' ofperjury tlia )te information provided above is true and correct. Sianattire.1j, 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. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone H,uj, ajag--L u (;�q 7z, (a23l9 11 V"m Vp- VVI �J vy\ q, - �r Enter construction cost for fee cal - North Andover Fee Cakulaflon Construction Cost $ 25,750.00 m $ - $ 309.00 Plumbing Fee $ 38.63 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 38.63 Total fees collected $ 486.25 192 Stonecleave Road 333-14 on 10/8/13 Kitchen Remodel