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HomeMy WebLinkAboutMiscellaneous - 12 Lincoln Street 12 LINCOLN STREET 210/070.0-0036-0000.0 Date.. .81�X z-.. . ... J pF „ao ,°,tip '6 6TOWN OF NORTH ANDOVER ? PERMIT FOR GAS INSTALLATION s a � y9SSACMUSES '3 This certifies that . . ./.!tea ? Arz '! !.firhas permission for gas installation . . . r y,� 1 in the buil2lgs of( . . . .t-!�iC . . .�'! ? . . . . . . . . . . . . . . . . . . . . } at . . Z .. .. .jam. . ± North Ando er, Mass. Fee.` �o�' Lic. No../!? ©�. 4 �! £ GAS INSPECTOR Check# rG J`'Z 8289 IL �LX MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town:Q _ GUe MA. Date: � Permit# Building Location: 111 L l N e 40 1'N S 1 Owners Name: Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residentialz New:X Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES Lu Lu Cd F— co U Z W W Q W 0 1- m = 0 w W U rn Fm- 0 = co w ZO Z ~ z p � w � W IX O F— w Ww m O a a Iw— Cl u� X > 0 v w 0 a 0 w Co 0 w LL, o x u. > v W z (9 � � O Z � O LL rn = w w W W Z Lu >- W m J Q Q . m w O Z 0 co t > Z F- _ 0 W D Q R w w Q > O 0 w z z w a F— C) G 0 U. C7 C9 x x J 0 a tY F— > > > O SUB BSMT. BASEMENT j 1 FLOOR 2 Nu FLOOR I 3 FLOOR 4 TH FLOOR j 51H FLOOR I 6 FLOOR 7 FLOOR F-FLOOR { / Check One Only Certificate# Installing Company Name:- I �— _� rtg- o` H' 1"1JC- Corporation q3 AddressA e>w-- `I't c)L City/Town: bJ State: C ❑Partnership Business Tel: 1 p 7,+ 7 &33 Se— Fax: ❑Firm/Company Name of Licensed Plumber/Gas Fitter: i INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes❑ No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:1 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. i Check One Only i Signature of Owner or Owners Agent Owner El Agent ❑ By checking this box❑;I hereby certify that all of the details an information I have bmi (or entered gar ing this application are true and accurate to the best of my Knowledge and that all plumbing w k and installations pe or under he rmit 1 su his application will be in compliance with all Pertinent provision of the Massachusetts tate Plumbing Code a d to f e Ge Laws TyT��of License: By ff Plumber Title Ll Gas Fitter Signa useof censed Plumber/Gas Fitter - aster M / City/Town ❑Journeyman License Nu ber: ( � APPROVED OFFICE USE ONLY / El LP Installer �� 1- The Commonwealth of Massachusetts Department of Industrial Accidents Office ofInvestigations 600 Washington Street .Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors Applicant Information /Electricians/Plumbers Please Pri Legibly Name(Business/Organization/Individual JL Address: p Q. L City/State/Zip:_b, A tx-,(A Phone r2. e you an employer?Check the appropriate box: am a employer with 4, Type of project(required): If— __ _ ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).*' have hired the sub-contractors I am a sole proprietor or partner- listed on the attached sheet* �• ❑Remodeling ship and have no employees These sub=contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. [No workers'comp.insurance 5. 9 ❑Biding addition p ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no insurance required.]t employees. [No workers' 12•❑Roof repairs comp.insurance required.] 13.[]Other *Any applicant that checks box,=1 must also ill cut the section below w _ .seir�. - -; fi Homeowner who submit this affidavit indicatin theyare showing i^.b T o:i:c;��"�'salon policy info.-�:'aon doin and hire outside contractors must submit a icating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp policyw affidavit oinformation. lam 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: Q(}r r L 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 ofMGL 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 u 0 P rm of a STOP WORK ORDER and P ay against the violator. Bea .!that a copy of this statement may be forwarded to the Office of a fine Inv e Ligations of the IA foi' ante covera erification. I do reby certify un r th n Pena ' sof e ury that the information provided above is true and correct Sinnatur 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.PIumbing Inspector 6. Other Contact Person: Phone#: i c ' a 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, 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 cis or town that the app ication for th� ar t Y is n e i e+ ' t e o e 'S' � P �. O.1= ens s b mg requestea,no to D�pa_rr^: nt 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-inured 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. j 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 Office of Investibations 600 Washing-ton Street Boston,MA 02111 Tel. # 617-72.7-4900 ext 406 or 1-8.77 MASSAFE Revised 5-26-05 Fax#617-727-7749 'www.mass.gov/dia M COMMONWEALTH OF MASSA:CH_USE,TTS \ -PL MBERS AND GASFITTERS• • LICENSED AS A,MASTER PLU `ISSUES THE ABOVE LICENSE To: B" T:IMi7FHY A GIARD - . 6;0 SA-UNDERS ST 0" ANDOVER MA 0184 " 2 4 I=4 T.030'1 05/01/14 -- — _------------- 1 7— 17- d7 �. Date.................................. f, ° ,�`'° '• "° TOWN OF NORTH ANDOVER PERMIT FOR WIRING ACMUsf f `7d�l�t/ �V This certifies that ....................................................... has permission to perform ........L44!m4..S'e?Pk..le;it. .......................... a wiring in the building of............moc.e/.w.�4!e:e................................ at..........t.. ..L/ Co[ / !� .....- jNorth Andover,Mass., Fee.�� �.... Lic.No� ID . ..... .......... ELECTRCAIApiR Check # r 7524 i Commonwealth of Massachusetts orllcial u«o�l�y ^'-�------ Pcrmit No :l Department of*Fire Services --�_-- BOARD OF FIRE PREVENTION REGULATIONS Oc�.uli.ttu ''"`i I cc e'heckc(1 Itc�. 9/05 -_ APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK 111 cork to be hciiirrnred in accordancc crith the Massaehusctts [:1cCu-ica1 Code WFC),527 CNII, 12. (xi II'l. -,A,ti'l. l'RI!\'/'IAV INK l)h 7')'l'l:A/J, IN ORA19770N) Date: 7//� / ( 'its. or I own of: ,(� ,j') n `-oZ f� d2 __ l rt thelir.tihr clur n/ 11�irr.�. Ii tlu, :il l li ;ui ni ihr un.lc-isil,nccl, l-n•cs nc)lirr (if his()Iher uucn n n to perfurnt IIIc cicClrr(;'I wmk dcsiiihc(1 Lor,tlion (Sire(-( R Number ()\Nncr or fcnan� ..._....�_/-'!'Y-LP.+C._.___F'LIACC�If�r-�J-�•f�,--------- frlcl,hut \o. �• Is (Itis perniil in.conjuncliun with a huildinj pernrit' Yes - ❑ (Check Appropriate BOX) Purpose of liuildinf; No l.11ilih� Aulhoriralion No. �C' ------ 5- p 1;zisting Service -/OD Amps /,2d / .1s,0,ir Volts Overhead Undgrd ❑ No. of Meters / New Service 2_A2:o Amps lAo / ,(o\rolts Overhead Undgrd ❑ No. of Meters / - Number of Feeders and Anipacity 7 - Location and Nature of Proposed Electrical Work: Com pleiion ofthe followin table may be waived by the Ins ecro of 11'1r,c r No. of Recessed Luminaires No. of Ceil.-Susp.(Paddle)Fans No. of Total Transformers KVA _ No. of Luminaire Outlets No. of Hot"Tubs Generators KVA No. of Luminaires Swimming I'001 Above ❑ In- ❑ o.o mergeI Y Ig ung — rnd. .rnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No.of Zones No. of Switches No. of Gas Burners o. of Detection and Initiating Devices No. of Ranges No.of Air Cond. TonsTota( No.of Alerting Devices No. of Waste Disposers Heat Pump um er Tons KW o.of e - ontarne Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KWLocal❑ unicipal Connection ❑ Other No. of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent 0 o Heaters Kater W o.o o•OF— Data Wiring: Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Te ecommunications Wiring: No.of Devices or uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with q MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no pdrinit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The q Ic undersigned certifies t}izt such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE .[�r BOND ❑ OTHER ❑ (specify:) I certify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: 0 58/tJ &4e it^ LIC. Licensee: f,ft/ Signature #,,,��,t f7 LIC.NO.: (/fapplicable, enter "e�rempt"in the license number line.) ��` Bus.Tel.No.: Address: 17� S G�-�; /n19r+� �l A, Akdo/C A4 al�r� Alt.Tel.No.: *Security System Contractor License required for this work; if applicable,enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ _ t i a Y