Loading...
HomeMy WebLinkAboutMiscellaneous - 22 Carlton Laneti 4 F -A � �,� C'.1 I - Dat( . ..... ...... ....... .... .................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ........... . . ...... P& has permission for gas !in�tallation inthe buildings of ................................................................... ........... at ... 22L� V6--� ......... I .......................................................................... North Andover, Mass. Fee:3�0� Lic. No. 035 ...... dD ......................................................... GASINSPECTOR Check 00f __.� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY A10o'+f-1 /EA/'P0V r– - MA DATE 10-q-13 PERMIT # 40 JOBSITE ADDRESS2 2 �{ L' cvr l 'b Cs,N `'� OWNER'S NAME / G OWNER ADDRESS TEL FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL E I ENTIA CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 1C� APPLIANCES 7 FLOORS--- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE C INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER ° OTHER INSURANCE COVERAGE I have a current liabilft nsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND OWNER'S INSURAN : 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 1 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. p PLUMBER-GASFITTER ��lc«n�J`j NAME LICENSE # 10035— SIGNA MP MGF JP JGF LPGI CORPORATION # PARTNERSHIP # LLC # COMPANY NAME: EX ECv`M✓r- P -r4 ADDRESS PO 6oY a o8D- CITY pec�lo t),A— `` STATE f* ZIP 0 lei (0O TEL q /Y 06 � FAX CELL EMAIL W O z 0 H U W 0. W z z ow Fag r a O Won� � ~ w a � H W z ok W U) W a U) a a N zz a a a CL F, a a us H z 0 z Q c� O a The Commonwealth ofMassaehusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual):�DA [ �- Low &I;Cun VC t4 /i Address: U a 6 ox a © ocoa City/State/Zip: �l` �PJ l 4/4 Dl a Phone #: Are you an employer? Check the appropriate box: 04 I am a employer with 7/ 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& Other &5 Lln tP *My 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 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. I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance CompanyName:C/% lt-E7� G Policy # or Self -ins. Lic. #: / A�1� %% Expiration Date: Job Site Address: ( 01 City/State/Zip: No o AA , 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 andpenalties ofperjury that the information provided above is true and correct Signature: K`�� Date: /o —. _ 13 9 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 F GOWNER TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK a CITY: MA. DATE: PERMIT # JOBSITE ADDRESS: OWNER'S NAME: ADDRESS: TEL: FAX: OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL ❑ NEW: ❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCESZ FLOOR— Bsmt 1 2 3- 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalentwhich 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. LIABILITY INSURANCE POLICY ❑ 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 ❑ 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 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 COMPANY NAME: CITY TEL: LICENSE # SIGNATURE ADDRESS: STATE: ZIP: CELL: EMAIL: MASTER ❑ JOURNEYMAN ❑ LP INSTALLER ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # M� COMMONWEALTH OF MASSACHUSETTS LICENSE EAS A M STERIPLUMBER ISSUES THE ABOVE LICENSE TO: DALE A LANDRY PO BOX 2082 n `PEABODY MA 01960-7082 .J 10035 05/01/14 161.174 {� ' loaa Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record form 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authori . A.. Facility Information Important: JUL., 7 '� o When filling out 1, System Location, U U 10 forms on theffid�af'�i computer, use l TOWN OF NORTH ANDOVER only the tab key Address to move your cursor - do not Cf /row I )cnn use the return ty State Zip Code key. 2. System Owner: Name Address (if different from location) Cityrrown State Telephone Number B. Pumping Record 1. Date of Pumping co/ ho - 2. Quantity Pumped Date Y P 3.: Type of system: ❑ Cesspool(s) Vseptic Tank Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. System P ed By: TIName Company Zip Code : — - / 5-C 6 Gallons ❑ Tight Tank If yes, Was it cleaned? ❑ Yes ❑ No vehicle License Number http://www.mass t5form4.doc- 06/03 " System Pumping Record • Page 1 of 1