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F i W -7 ....................... Date ...... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ...................... . This certifies that ........................................... /.Ita ati .... ........................................... $ permission for ha S4 15 in the buildings of .......................... 290 ;q . I ... ........................................................................ at............ ..................................................................................... . North Andover, Mass. Fee....................... Lic. No. ................... ..................................................................... GASINSPECTOR 11 0 1, 0 2 4/j, U >< MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK "r ' CITY _ _ MA DATED( : PERM. IT#- JOBSITEADDRESSI •, 5 -I OWNER'S NAME GOWNER ADDRESSI v ti G TEFAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW: [3 RENOVATION: I REPLACEMENT: P�r PLANS SUBMITTED: YES F1 NO ED APPLIANCES Z FLOORS- BSM 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 _ I-- L—� ---- _._ ___ __ GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVE,NTED ROOM HEATER WATER HEATER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES &10 El IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE Y 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: SIGNATURE OF OWNER OR AGENT i hereby certify that all of the details and information I have submitted or entered regarding this application re true < and that all plumbing work and installations performed under the permit issued for this application will be in ompliai Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �= PLUMBER-GASFITTER NA /�r v _ _ f _ LICENSE # 6 ) o f TI— MP tfMGF El JP 0 JGF 0 LPGI © CORPORATION [ ` Y--3 ]1PARTNERSHIP] COMPANY NAM . % G4 ADDRESS CITY _ �.— STATE ZIP] {� TEL _a FAX CELL G_ .� lGd' EMAIL ( )=zua6w 'NER [ E T 6'to beXq/m,/knowledc rtinr is' n of the NATURE = LLC [# N All �d y s_ ,L e Coynyno� :..c . Depart Weal th yyte o Co>? �t Oflndus a a�sachuse&,v b' ess lice A V[�°piers' Co pens BOston Street, Suite tdeht� Name antXuf02 ortu TOBnXnsurance�wwIMUS. 1�2p17 Business/prg ation EP D �,1 f,d' . B� v/dla Address. ati0dividual). TPET ntractors/E C1 'Stat 0 ! G AUTBo TYctrtctatts/Plutub e/Zip: ers, I Qre you an employer? r Please Pri check t . nt Le ibl 2•Dj� a emPloyerWith he app'roprrate box: Phone 3 any capaci� roPrietoror p enPloyeeg full 4 DI am 4 horneo. o W orkers aeluer hip d have no Band/or part time)— Dzamahorneo rd0mgallWork mance requiredloyeesworkrn. ensure Wneran myself, j g for Type of prOPrietorstWil contracto s will be hiring contract(No Workers' com . me rn 7, D N PrOJect (re e 9uir 50 haee sgener Contractployee erhave tvorkrs?conip nsato all Wo ko cerequ ledl t 8. DRemo Cons j struction d). 6.0 We re a co ntiactors haveruplovehired the su n insurance Or so em' I tvi71 9 0Demojitio g 152 rPorati Yees b-co 10o$ n *�Y a §1(4) and We haand Its off, ice and have WorkeIs �t0rs listed on 11.013, /� itildinb' #t Xorne Whecan t fat heck e.no.einPlo rssave exero' d the comp instue #the ttached beet. V EjeC jca j addition o c Yee rse an s tr ern °ntract°rs that hO submi • 0�� ees, sold employ satin any contact;°f hrre, list en at• 11 ad workers' convex Index 10 rovlde ofan°th i��p��l. lovers to p the sex�'ice o or more ter 15� re(V all every person em entity oz any ox the seas GeneralL emP °yeE xs a,Nsdefined Other legal ed employ ever the tion ox a deceas 11091 assachu statute, hen" ociation, c°rpoxSesentatives ing empl0y��upant °f the house -VOrsuant to thx lied, oral Ox ` �ership� ailing the legal ee al entity, C09101.yexenl °x theon such dwe e Plover:, xess Or lmp "an indi`�idual' . and 313.0 tion Ox other le who xeslde or repair W ore jjjed t° be an exp as ointenteIT ss ents an 'auctiOn the de loyeY is defirrag d in a J al' pa nershipan three ap� tenance' consch emplOymen th trance oT stye fore%°mg eng f � lndxv�du not woxe s to do n'am use of su thlrold a tt fox anY of vex or tmstee O househavm%TIO s pexsex to shallnotbeca ency shall ommon+'ealt e nixed., recei a dwelling who ant th licensing d ngs in the c ce coverage x divisions sha1L lu OWV of ouse °f anb lding appuxten «every state °xto°�opstxuctb tli the insu a lts political w tithe insuxanpe owell NVI h Bounds °r states that buses ox compliance nor any Bance on e §25C(6) also to Operate a evidence °f e comm°n`Nealt bleevidence °1, omp Gl, chapter 1 sense ox pex°x ped acceptablees "Neitheo kunfil aoceputhOrity M a1 Of I li not pxOd 2510) stat ublic W cting a and, if renew it has a ter 152' §2510)' Ince Of p to the contra "Jour situation Lica GL ch p the perform ented that apply to of app al1y,M fact fox ve been pres en c e fl ees)o her thanthe Addition ha theboxeS thth enteuij3to n s of flys °hapten checking along wx e letely by un1bex(s) S alp) with n° l,P dpes d Sial reg affidavit comp and.phone n ership LLC °r l' In da Ould ensation addxessi d �,iability Y urance if va went of vi en of Applicants ewOxkeXs' comp e(s), ite edtotheDep t The e th actoi(s) nam LC) ox L , compensatiO e submitt the affidavi of a aexs' lease fill out ly sub;cOntr es Workers to nested, n the work Supp Companx is affide su ae to s cgnse be ng red to obtain a n cessary, l,iabilitytxeguhed to ed hat th so Ti are req'pred anies should e ter then l; ited comp insurance ox p taexs, a SegUis Be nvl coverage. fO the Permit e law ox if y self�insuxed .. members a policy is on of insur e application S regarding edbelow COP confirmati thatth gaestion e number list dents for city ox to ouhave any ent atth Acci ed to the - Should y e Degas, line e bottom be return ccidents • se er ll th e apprOpate s ace Ott cant. Industrial Ao - 61101 plea b onth ided a p e apphcaut e Depa neat hata t y°u regia agl n' a. app" ting current compensafi 'ce license n an s has to cO e number. In dica se>fimsur rinteal4bll- gat- Tn efer afftdaA . (city ox ti en submit one cials ce Of In used as a x ite "all locations in Offl and p dto the ox'f°� avitis COmpletentthe Offr 'h-VIllbe need only ldwr a be provide Out each City sure thatthe to Out int ens number w Slin anY gl ene apPliO�t shoe city °r tOwnmt W3%tbe $lied enture be ou tllic licatiOv ess th edbytl' ofgidavr conoerclaly please affidavit fox yl in the per►license app«3ob Site Addr ed or mark ses. A new business or of th be s"Ise u ml multiple perm and under O ffrc. 113 staiap or lice related to any e tivs affidavit. Blease cess been tuxe p it not cornplet thatmust s ation TI( nec itthathas file for en e or perm xegunedto o inform t1�e affidav davit is Ort s N oli y „ copy of valid aff1 Obtaining I li ersOn xs OT town) A s xOOf that a 'VIlex Or citizen i leayes said p apearcauta home pexynittobX11a etc wxere y dOgllcen nunrbex: sachuseIM eandfa N OTMealth °trial las ccldents agent's address,telephon The CoTom n of Ynd'�s Sut 1p4 The Dep Dept Con�eSs sa 0211`l 20�� BostOn'� 406 o t Xr 1 # 611'7�7-ao 61�r�2 ova a Te �ass.g gevised02y23�15 U A - Date..M ...... 10244 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING . ........ (\ ... This certifies that ........ I.... has permission to perform .... ............................................... .. .................... plumbing in th� buildings of ..a.: ........ CA, . ......... '7 ............ ..M ...... ...... ........ ............... .. at.- ... ..... A, .. ......................... North Andover, Mass. mo............................................................... Fee. p . . ....... Lic. No. PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY NORTH ANDOVER MA DATE PERMITIt JOBSITEADDRESS `3' /j'l a¢r�r/ S7— OWNER'S NAME .$T ReVZ S 0`IV261`% OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL _' EDUCATIONAL ` ~ RESIDENTIAL K PRINT CLEARLY _ NEW. '-.: RENOVATION:' REPLACEMENT; PLANS SUBMITTED YES.-....*' NO"K: FIXTURES 1 FLOOR IF 2 3 4 5 6 7 8 9 10 11 12 U 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATERPIPING OTHER INSURANCE COVERAGE: I have a current llitllty Insurance policy or its substantial equivalentwhich masts the requirements of MGL Ch. 142. vEs NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHERTYPEOF INDEMNITY _. BOND - OWNER'S INSURANCE WAIVER; Ism aware that the licensee does not have the insurance coverage required by Chapter 142 ofthe Massachusetts General Laws, and that my signature on this permit application _M"this requirement. CHECK ONE ONLY-. 01NNER ._..:; AGEj� SIGNATURE OF OWNER OR AGENT I hereby that all of the details and information 1 have submitted or entered regarding this application are true and accraate to the best of my knowledge and that all plumbing work and installations perforated under the permit issued for this application will be in compl'iancs wttis ail Pertinent provision of the Massachusetts State Plumbing Code and Chapter 942 of the General Laws. ,fir PLUMBER'S NAME THOMAS HALLORAN LICENSE # 24833 SIGNATURE !' MP .. JP CORPORATION = : `# PARTNERSHIP:. # LLC_ :4 COMPANY NAME 1�t HALLORAN PLUMBING ADDRESS 826 DALE ST 1 CITY NORTH ANDOVER STATE MA ZIP 01845 TEL 978-685.9504 FAX CELL EMAIL L 1 Ti r I A - Date...... .... .. ....... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that c,. A -L .............................................................................. . ............................ has permission for gas installation ....... LKO-o'A 6-a— M� e -P, P— I ......................................... in tfi'e buildings of ......... .......................... ............. ............................... at ........ -n ...... ...... Sk-,eA-� .................. . North Andover, Mass. . ..... ....... ....... ... ....... ....... ....... Fee ... Lic. No.1,14,8��.. 0.0 ... GASINSPECTOR Check# 8952 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY NORTH ANDOVER MA DATE IV—d- &`4-? PERMIT # B 96 k", �, �;VF JOBSITE ADDRESS 910 1W,4 /0,t/ OWNER'S NAME (CIZ OWNER ADDRESS TEL FAX TYP1uOR OCCUPANCY TYPE COMMERCIAL:_ EDUCATIONAL ^_ RESIDENTIAL-, •PRINT CLEARLY NEW: _~ RENOVATION:: ..; REPLACEMENT: _ PLANS SUBMITTED: YES:-"" NO+G APPLIANCES Z FLOORS— BSM 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 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 liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ice` NO , I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 5 _ _ ' 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 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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE # 24833 SIGNATURE MP .... MGF ;- JP : JGF LPGI _ CORPORATION # PARTNERSHIP # LLC # COMPANY NAME:T.HALLORAN PLUMBING ADDRESS 826 DALE ST. CITY NORTH ANDOVER STATE MA ZIP 01843 TEL 978-685-9504 - i \ FAX CEL&Xy EMAIL �j�oAlt - 4 L /i The Commonwealth of Massachusetts Department of Industrial Accidents R Office of Investigations ' 600 Washington Street Boston, MA 02111 , www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Naive.(Business/Organization/Individual): ' %�,0,oy o 1 Address: ga0 6. D La-= Sr 6111j� 2� City/State/Zip: A/ 014- Phone.#: �'7Y Are you an employer? Check the appropriate box: 1. ❑ I am a employer with ' , 4. E]I am a general contractor and I employees (full and/or part-timey.* have hired the sub -contractors 2.0 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. employees and have workers' [No workers' comp. insurance comp• insurance.$ required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comp. insurance reauired.l 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 `4l3.❑ Other "Any applicant that checks box #1 must also fill out the section below showing their workers' compensation poficy 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number./. I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy 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 cert4 under the pains and penalties ofperjury that the information provided above is true and correct. Signature: '7� Date' Phone #: City or Town: not write in this area, to be completed by city or town off ciaL Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.. Other Contact. Person: Phone #: 9 v � m -qc > r n� • � D L °vI a �. 3 D oa c C m D z r ;oc;) ZD o z �N 00 cn m Ul .. o na C CD • 6� Ch Signature 10732 Date ..... ........ TOWN OF NORTH -ANDOVER 7 This certifies that .......... Ie 51/W �/ ....... .......................................... has permission to perform ..... Art',& -nn", IV plumbingin the bu,ld,pgs of ............................................................................................. at... ..... .... ......................................... ... ......... , P�orth Andover, Mass. Fee'4.��O ...... Lic. No. .. ......... .... ... ........ . ..... .. ....................... ..... ..... ... PERMIT FOR PLUMBING LUMBINqN�PE�T6R Check # -C\- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY I North Andover MA DATE 8/15/2014 PERMIT # F JOBSITE ADDRESS 1396 Main Street OWNER'S NAME St. Pauls Episco al POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL El PRINT CLEARLY NEW: ® RENOVATION: Q REPLACEMENT: PLANS SUBMITTED: YES[] NO R�j FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE i DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM _ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR INTERIOR 1 KITCHEN SINK LAVATORY 2 ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING 1 OTHER 3 bav sink 1 Veg sink 1 INSURANCE COVERAGE: I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E] OTHER TYPE OF INDEMNITY [] BOND El OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of th Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK 0 ONL OWNER N SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this pplication are true nd c to t the be my k wledge and that all plumbing work and installations performed under the permit issued for this applicatin compli nc w' all rtine ro ion the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. \\ PLUMBER'S NAME TimothyA Giard LICENSE # 10301 - S� ATURE MPED JP D CORPORATION # 3443 PARTNERSHIP# LLC ®# COMPANY NAME Timothy A Giard Plumbing &Heating ADDRESS 127 North Main St CITY North Andover STATE MA ZIP 01845 —� TEL 978-689-8336 FAX CELL 978490-7108 EMAIL TGiardplb@ ahoo.com W F z° 0 w a a z w O Z z }El o w � w O a x W a 0 w W d N ra M w a � U J CL a e� Q T w x w I-- a W F z z 0 F U W a rA V a a x c� 0 x The Coinmon-wealth U)` �E Cf�3liC sfa ci`t'S De/Jtrrfineal cj'liidifsi,-irl-Accirleiits Office of hweslib otioifs 600 U,'asjiingiou Street Boston, %L4 02111 iinviii.mass.gov1dia Workers' Compensation Insurance Affidavit: Builde>i-s/Couto-actor-s/Electi-icians/Pluatr;ibei-s Micaut Information Please Print LegibE- Nfame (Business/Organization/Individual):_ j Wdress: Ai -ity/State/Zi 7re oar an employer? Check the appropriiate box: JV I am a employer with 4. [] 1 am a general contractor and I employees (full and/or part-time).'' have hired the sub -contractors 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. employees and have workers' INo workers' comp. insurance comp. insurance., required.] 5. ❑ We are a corporation and its I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per 1v1GL. insurance required.] t c. 152- 1(4). and we have no employees. fl`,ic• workers' comp. insurance required.) Cl M nolams Type of project (required): 6. ❑ New constniction 7_ ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11-❑ Plumbing repairs or additions 12_[] Roof repairs 13.❑ Other y applicant chat dtecks box 411 must also rill out the section below showing their workers' compensation policy information. rneowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. nractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have loyees. If the sub -contractors have employees, they must proVidc their xvorkets' comp. policy number. n an employer t/b2t iS providing workers' cnrrtpensation i.nsurr,nce for einplouees. Below is the policy and job sire wmation. Trance Company Name: icy fil or Self -ins. Lic. If: L=:xpiration Date: Site Address: — _ City/State/Zip: ach a copy of the workers' compensation policy dec€aration page (showin the policy n€ tuber and expiration date). Lire to secure coverage as required under Section 25A of -MGL c. 152 can lead to the imposition of criminal penalties of a 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 in tp to S250. against the violator. Be , vised that a copy of this statement maybe forwarded to the Office of estigatio s of the DhA for insurance cove4-Vverification. here y cerdfy un er the ai rent per leof perjury Mai the itilormation provided above Is trite and Correct: natur Date: the ll: Of -tial wve Only. go not write iii ;his arer" 10 be cofiiplet6d by city or t.fm", OffilCin-1 City Or P o�5'ii: _------ ----^— Permilr ;cense i, issuing Authority (circle One): L Board of )t-;!ealth 2. TBuildi.iD Depari-anent _s. City/Tov: c� u.ief-1: 4. C.deet: is € inspector- :i. -plumbing Inspector 11414 Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING - This certifies thff ............................................. has permission to perform.. -Plf"'K .............................................. plumbingin the buildings of ............................................................................................. at,��% ..... 1.40 ... .. ... .. N rth Andover, Mass. A ................... ....... ...... Fee;%,�.(?)... Lic. Nol . ..................... ........... ... ..... .... Check PLUMBING INSPECTOR 10 -CN- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY North Andover MA DATE 10(13/15 PERMIT # JOBSITE ADDRESS 396 Main Street OWNER'S NAME St Pauls Episocal POWNER ADDRESS TEL IFAX TYPE OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: (] RENOVATION: REPLACEMENT: ov PLANS SUBMITTED: YES[] NO[j 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/OIL/SAND SYSTEM-' _L _, DEDICATED GREASE SYSTEM-� L --j DEDICATED GRAY WATER SYSTEM o -� DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN i FOOD DISPOSER I FLOOR /AREA DRAIN _ INTERCEPTOR INTERIOR KITCHEN SINK u jai LAVATORY ROOF DRAIN SHOWER STALL I` SERVICE / MOP SINK 1 i .a _ Lj_ TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1i WATER PIPING OTHER I Replacement Boiler 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 CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ej OTHER TYPE OF INDEMNITYE] 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 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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Timothy A Giard LICENSE # 10301 SIGNATURE MP(3 JP[I CORPORATION# 3443 PARTNERSHIP(# LLC E]# COMPANY NAME Timothy A Giard Plumbing & Heating ADDRESS 127 North Main St CITY North Andover STATE= ZIP 01845 TEL978 689-8336 FAXI CELL 978 490-7108 EMAIL TGiard Ib@yahoo.com j� W F z z 0 F a z a d z w � Qs O El z a d❑ z r o w W o at Z W 9LLU O Q a V) ;To w d 3 U) a O z w a as � J IL CL vj a � W = W H LL W F °z z 0 H U W a C7 a a Lx7 O a This certifies that Date ... /4 3. k .......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ........................ .. ..................... y ...... --z )-.A .................. has permission for gas installation ..... . .................................. inthe bu*ldl f ..... ................ .............................................................................. at.,34;,os 74 v-- N rt A over, Mass. ........................................................................................ Fe&,P .. P.. Lic. No/ .. ..... ..... .. .............. .............................. bGA AINSPECT R Check# 10218 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 1 North Andover MA DATE, 100/13/15 PERMIT # JOBSITE ADDRESS! 396 Main Street OWNER'S NAME ! St Pauls ".G OWNER ADDRESS j TELT JFAXF TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Ej RESIDENTIAL CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES O, NO APPLIANCES 1 FLOORS- BSM 1 2 1 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _ -j �t_ (' __.J ! I _—f —S 1 ! i _ 1 _., ___..1, _.�1 BOOSTER �� _ _ j i �—{ _�� T '_ J� CONVERSION BURNER COOK STOVE I ., _. � --- J . i DIRECT VENT HEATER._.._..J .-_....,.__j m _ _i : I'_ (-�._j ._._._.( «____j I --j —J....,_..J DRYER] FIREPLACE 1 __.( _) � .�_1 FRYOLATOR �) - _ I l �J . _ _ j;�� .—_1 _-____1 FURNACE --------j'---_j --- 1. -J __.1- .J -i __j i ___...1.__j GENERATOR _1— —1.—.1,._.._J --j _ I _J GRILLE INFRARED HEATER LABORATORY COCKS j __j ___1 ___j '___j , –J I'__._.1 _._._j ---J. ..___j ___j ^.._. (___a ' MAKEUP AIR UNIT OVEN POOL HEATER --J--i ____j —.j ___j ___j _j --j _ :�_1 __. I _—j __j ROOM / SPACE HEATER ___j —j _..___I i . I –..-...j __( —j .wJ _-____! __._S' I ROOF TOP UNIT --J --j__�. ! ._j __j__—.1 '� 1. TEST -..�_I . _ 4 __ j __.. _j - - i i __j ._._._.l. -i n._._J UNIT HEATER _,_..i j -_._.j ....--._j ___j __j ;__j ___j__-_(;^.Tj ,._.,_j ___jj .. _.1 � j UNVENTED ROOM HEATER�_� WATER HEATER _ OTHER i .. m.-... j _ I -2--1 __j J _ T I i -3--j _j -j ____j - 1 INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES � NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [ZI OTHER TYPE INDEMNITY s 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 Q AGENT 1 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information 1 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 ! Timothy A Giard LICENSE #;1030 SIGNATURE MP10 MGF JP 0 JGF jD LPGI CORPORATION# ��3443 PARTNERSHIP # LLC []# COMPANY NAME:'Timothy A. Giard Plumbing & HeatingInc ADDRESS P.0 Box 782 CITY North Andover STATE Ma ZIP' 015 TEL 978 689 8336 T FAX 14778 689 8300 CELL 978 490 7108 EMAIL, tgiardplb@yahoo.com F z z 0 H U W Pr z fir ya o W z O y� w >- m a O U w z a � M w z a cc> w Ix w a a 4W w W z a V" ZO 0.i a Q Z V x CL E a CL a 2 w H LL. W F 0 z 0 N U W4 a c�7 x c7 O x x C4, C, q 8 E "g, V C, CD go 0 Er 0 C, r= Ep tiq C/I c", 0 0 0 cr 0 CD 0 CA M. 0 0 - ;j CD :R CD '0 0 aq CD CD > 0. 17� - 9 co 0 CD - C, CD �g 0 0 0 8 g --0 P. 'C' CL a CD c-, 12-, > C'D P. M.,O 4, CAD CD M 00 '00 C� �CD C=D, C, C�- CD Ft -- 05 a 0 0 t-� "0 -h F t:'r, C' E� E� 'CD co CD 0 C, rl '10D COD C-0 C, CD 0 Ei, 0 m �:, 0 :9 0 B3 0 I CD U, ej (a, CD CD 0 0 0 O� C" 0' 0 8 C -i FD 14 PC CD C —6 - D a C, C"D rl 0 F" — CN Et c, "C" COD, S, CD ZE ON Date. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... J. has permission to perfonn .............. wiring in the I * din . . . . . . . . . . gof..5� at .... ................. rl�orth Andover, Mass. Feel").—.. Lic. No.j.%50�.. . E RICAL IN PECT Check # 31 2-�� 11252 .1 Commonwealth of MassachusettsOfficiatyUseOnly Department of Fire Services "No' BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASEPRINTlNMK OR TYPEALL MORhUTIOA9 Date: J(- ?- R IZ City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) ( J..3 044 A i 0 "t`, Owner or Tenant C Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes 2 No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. ` Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 1 v Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell: Susp. (Paddle) Fans No, of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- El No. o Emergency Lighting rnd. rnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No, of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat PumpNumber Totals: " Tons ......................... KW ..................... . No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: � 1 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 MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit 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 undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [9 --BOND ❑ OTHER ❑ (Specify:) Icertify, under thepains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME:.41 \ L LAD LIC. NO.: Licensee: Signatu LIC. NO.: (If applicable enter " empt" in the license nzzmber line.) Bus. Tel. No. • %� `42,3 -��1 U% Address: tw c Q.3 l Alt. Tel. No.: ^03 2 L923. *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. 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 PERMIT FEE. $ Signature Telephone No. 1\ 11151 Ikn-- ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed �^ on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: ***Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass IM Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass F?1 Failed M Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass F Failed M Re- Inspection Required ($.)' ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 bwww mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: PAR City/State/Zip: bA l Phone #: 7e of / Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I �mployees (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 l l.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. x contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site :formation. isurance Company Name:, olic� # or Self -ins. Lic. #: Expiration Date: )b Site Address: City/State/Zip: .ttath a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby cgtify under the pain&aa4fwaalt�s ofperjury that the information provided above is true and correct. Official use only. Do nofwrite 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 #: O, R'"D o A BUILDING DEPARTMENT Community Development Division _Saint Paul'. s Church (. 396 Main Street -7 North Andover, MA 01845 Thank you for allowing the Building Department to perform our annual. certificate of --inspection required by state law 780CMR. Due to the age and assembly use occupancy with a residential unit, several issues were :observed.. • Illuminated Exit signs and emergency lights are typically nonexistent throughout the building. • Egress doors are extremely difficult to open and panic hardware needs to be installed as needed. • Carbon monoxide/smoke detectors should be installed as needed: • The second egress at residential unit located within the church is in disrepair needs correction. • The 3rd floor bedroom areas shall be vacated and this area should only be used as storage because no 2nd egress is provided. It is the building departments recommendation that the church retain an architect and or`design professional familiar with churches to assist your organization with beginning to repair:these deficiencies. The next certificate of inspection is due next year and all the deficiencies' niust be_ addressed before this time. We will be monitoring your progress.. Thank you for your attention to this matter. If you have any questions, please call the office of the Building Department at 978-688-9545. Very truly yours, Gerald Brown, Inspector of Buildings Building Department 1600 Osgood Street, North Andover, Massachusetts 019445 Phone 918.688.9545 Fax 918.688.9542 Web www.t6wnoinorthd6dover.com Date ... /. TOWN OF NORTH ANDOVER I PERMIT FOR GAS INSTALLATION -ISS CHU This certifies that .... .--r ............. has permission for gas installation .... ............ in the buildings of ... 0 ......... at —3c7' I. North Andover, Mass. ........ .................. Fee.4-. Lic. No../'�-� L .... .... ASINSPECTOR Check# 6256 r MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) Date Z/ U NORTH ANDOVER, MASSACHUSETTS Building Locations L !_ . ��/% I✓� r Permit # Amount $ 2 7 Owner's Name �- I,- AU G ( C 171 New [3 Renovation D Replacement Plans Submitted D (Print or type)` T Check one: Certificate Installing Company Name ..l —e j�� Aj Corp. Address _.S � �� � �--- ��- , ElPartner. Business I a ep one 13-Firm/Co. Name of Licensed Plumber'or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance,policy or it's substantial equivalent. Yes No� If you have checked Les, please indicate the type coverage by dliecking the appropriate box. Liability insurance policy L Other type of indemnity D Bond 13 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: Signature of Owner or Owner's Agent Owner 13 - Agent13 I herehV rPrt;A, *k.* oii -,rth- A-+-:] lilLLVUkV, entereu) in aoove appucatlon 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 Stas Code and Chapter 42 oofZhe eneral Laws.. By: . Title City/Towns APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber R""Q 3 6 Gas Fitter ricense lNumuer 13— Master Journeyman Ed w v�' W d O OG V x F y C W Ew., d z C7F z w > x m z O z w p x O x z 3 a 0 d o W > o a o SUB -BASEMENT .da BASEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR a 7TH. FLOORI 8TH. FLOOR - (Print or type)` T Check one: Certificate Installing Company Name ..l —e j�� Aj Corp. Address _.S � �� � �--- ��- , ElPartner. Business I a ep one 13-Firm/Co. Name of Licensed Plumber'or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance,policy or it's substantial equivalent. Yes No� If you have checked Les, please indicate the type coverage by dliecking the appropriate box. Liability insurance policy L Other type of indemnity D Bond 13 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: Signature of Owner or Owner's Agent Owner 13 - Agent13 I herehV rPrt;A, *k.* oii -,rth- A-+-:] lilLLVUkV, entereu) in aoove appucatlon 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 Stas Code and Chapter 42 oofZhe eneral Laws.. By: . Title City/Towns APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber R""Q 3 6 Gas Fitter ricense lNumuer 13— Master Journeyman Location M 4 7, No. 7-0 2 Date S- 2-9-9 a TOWN OF NORTH ANDOVEME 0 "60 LM Certificate of Occupancy $ ftl Building/Frame Permit Fee $ Foundation Permit Fee $ CHU Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ ps TOTAL $ %/Building Inspector 9812 Div. Public Works _� v 1 O Z m j > y C 3 m 1 G G m a 0 � n f r � n 0 A p(� t 1 I 0 A � 0 r v > > N N c r. O 0 r a > 0 2 >> A m A m m m> C p m A z > 3 m A x -1 m n N z ran 0 f z A Yj > O O m H C m Fs j N m r O fn fn F r W z 0 0 m m N Q(� I .C.1 1 .c1 n n j i J 1 O O 1 Z z I N N W 0 N i O _ Z Z N i � t t 1 c t n 0 0 r Z � U► w OA A p 0 > m > r nA 0 ? _ > z f r N C O Z>> 0 n ZA -1 0 A m c N c r. 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AP -NORTH ANDOVER BUILDING •t ;� Massdchusetts o 1845 CONSERVATION DMISION OF HEALTH - Pt.Nc PL.A"NNING & COMMUNITY DEVELOPIMENT i 'i KARENZ H.P. NELSON. DIRECTOR In 1C: C:CC:2nCr 'b1(lI i11C' �iiJ+Sig �S ^.i ,'riL�.L S ;r', S cond-it;cn- of Building Permft Numbe' s (hct :^e �c�ris resul(inc from (his work shzll be disposer' of ... �rcne:i. airs;: solid ;(e ._`,^sc.:cc:. ( as ._ :...c: by .140i.. c ,I.,, S i ne debris will be disposer' of i::: `rAcphcznt,.. s/_2� Date NOTE: Demolition permit from the Tou3 of North Andover must be obtained for this project through the Office of the Building Inspector. Location - 7-12- W No. — 2� Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Framell.permit Fee $ 10 -G8 - Foundatio6p.ermit Fee $ CHU Other FrXmit Fee $ SgWer Connection Feel§ $ ater d6nnecti U)Fee $ TOTAL At, $ Buildinb In's-pe'C"tor Div. 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