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Building Permit #742 - 171 CORTLAND DRIVE 5/21/2010
BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Issued: Date Received IMPORTANT: Applicant must complete all items on this naize . I LOCATIONr. l Pin A& & ms s PROPERTY OWNS AX -1 MAP 210 ,,., PARCEL: ZONING DISTRICTJ� Historic District yes / v° (;I ' . a A ao - Machine Shoq Villaae ves TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family -'- Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer OWNER: Nam DESCRIPTION J; 11(5rt ` o WORK TO BE PREFORMED: Please Type or Print Clearly) ZMKl� Address: l7/ 601rU-ZA-Ac] i2o f CONTRACTOR Name: f l%Cl Phone: Address: v`f Pl i lw (/i';&�) 0/� Y Q �6 Supervisor's Construction License: *(-105g; Exp. Date:_ ,3 Home Improvement License. Exp. Dater Ir4*( Phone:��� Address: -29 C3re-C4 460 VJ4J P12 4[4[V Reg. No. 7 FEE SCHEDULE.- BULDING,P�E/RMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BAS/ED ON $125.00 PER S.F. Total Project Cost: $`-K - FEE: %$— Check Check No.:�&46 0 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have acce t anty fund $ignatureMof Agent/Owner� _ Signature of contract Location No. �''Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ �'�b'••° •'.�' Building/Frame /Frame Permit Fee $ 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # ;q �YV v 23 yl Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tarining/Massage/Body Art Swimming Pools Well Tobacco Salesj Food PackagingAales' ,, Private (septic tank, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM r ' DATE REJECTED „ _, DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature V COMMENTS d HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer:. Signature: '• •� Located 384 C .FIRE DEPARTMENT "Temp Dumpster on site yes no Located at 124, Ma iy Street Fire Department'`signature/date COMMENTS good Street Dimension Number of Stories:_ Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.:_ ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine Doc.Building Permit Revised 2010 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2008 N 6 z E7 71, o o w° a U) o w z G w° U �, w o w '� o a: G w a. a W o w cn 0 i�. a O a°' cn w G ca � V) . i o cn I Fit 11 1; POWN ii I M L 0 oc i- zCD o. O CO) � C CD cm I � C COD p T3 O CO) O O 'E m m co 0 CD CLy=CD .+. y+ .0 O O O cc O d CL C Q ca o env D c Z CD 0 CL V y O C C C c C. E :.0 L O y pca cc 0 a� ;ate m `c mC o� Ea C: • m O \ :y► m 1+ 0 fl. co, V E Z ;( «EE m c E a;:. L \O ' C13 � a �J L Me p r y :m3 C O y Cm O A : L 'O Co �• y O C O �jm E y v �T� w o.P a.:m L = O CI bcoa y J W W O m ^ � P-4 qC� v H � Z LO O of F- Q m O O. N O C .0 = m : o� 3 d O N Or H N WSJ. - O W CO �.'C..'C= Z � LL 'y O R A `� O H y a.Z C = Z . ce Z Oui 1 \ V O a O ® C -o-0 V . _ m H O ca POWN ii I M L 0 oc i- zCD o. O CO) � C CD cm I � C COD p T3 O CO) O O 'E m m co 0 CD CLy=CD .+. y+ .0 O O O cc O d CL C Q ca o env D c Z CD 0 CL V y O C C C c C. E BOARDWALK NORTH A Division of Data Industries, Inc. 24 Orchard View Drive Londonderry, NH 03053 TEL (603) 437-2500 boardwalknorth.com Purchase Agreement (for office use only) Office ................... Order NO ................. Checked by .............. Name of Purchaser(s) DIANE HINZELMAN Phone No. Daytime Phone No. Address 171 CORTLAND DR. NORTH ANDOVER MA (HlsorHer's) 01845 (No.) (Street) (City) (State) (bp) Mailing Address if different SAME. Email 978-794-0927 WORK SPECIFICATIONS We will furnish and install the REMODELING PROJECT PAGE 1 OF 4 as specified below: An1► .I 1 ;••u • �� DRAWINGS DATED MAY, 201 0, TUE PROPOSED ROOM TO INCLUDE: MINOR DEMOLITION, FRAMING DOORS WINDOWS, ROUGH AND FINISH ELECTRICAL, HEATING, INSULATION DRYWALL (MUD. TAPED. & SANDED AND READY FOR PRIMING) RANDOM SWIRL SOFT TEXTURED SAND FINISHED CEILINGS (OR SIMILAR TO EXISTING), AND ALL THE NECESSARY INTERIOR FINISH CARPENTRY. ALSO INCLUDES MODIFYING INTERIOR WALLS TO INCLUDE: PATCHING DRYWALL AND CEILINGS WHERE NECESSARY AS A RESULT OF THE REMODELING EFFORT, AND REMOVAL AND RELOCATION OF ANY EXISTING 110V OUTLETS AS DEEMED NECESSARY BY THE COMPANY. FINISHED ROOM: DEMOLITION 2. CREATE AN OPENING IN THE GABLE END WALL TO ACCOMMODATE THE PROPOSED WINDOW, CEILING SUPPORTS (AS DETERMINED BY THE COMPANY), AND ELECTRICAL OUTLETS (AS NECESSARY) TO ACCOMMODATE THE PROPOSED REMODELING EFFORT, PER THE CONCEPTUAL/ CONSTRUCTION DRAWINGS DATED MAY, 2010. FINISHED ROOM: WINDOW 3. PROVIDE AND INSTALL (1) PARADIGN (OR SIMILAR, AS DETERMINED BY THE COMPANY) DOUBLE MULLION, DOUBLE HUNG WINDOW, WITH LOW E GLASS, AND SCREENS WHERE APPLICABLE, PER THE CONCEPTUAL/ CONSTRUCTION DRAWINGS DATED MAY, 2010. Remarks: This contract supersedes all conversations, statements and Price and Payment— 38 936.00 agreements expressed or implied, between the parties, their agents Cash price .................................... $ and representatives. Purchaser(s) authorize Boardwalk North to investigate credit worthiness. All work started above to be completed in a workmanlike manner according to the floor plan, job specifications and terms and con- ditions as stated on the back of this form. Payments to be made as the work progresses as per the Payment Schedule which is attached and made part of this Contract: IDate OvRer Date Owner 05/19/2010 By: Date and rth Representative BOARDWALK NVRTH Name of Purchaser(s) A Division of Data Industries, Inc. 24 Orchard View Drive Londonderry, NH 03053 TEL (603) 437-2500 boardwalknorth.com DIANE HINZELMAN Phone No. Purchase Agreement (for office use only) Office ................... Order NO.. . . Checked by .............. Daytime Phone No. Address 171 CORTLAND DR NORTH ANDOVER MA (HlsorHer's) 01845 (No.) (street) (City) (state) (Zip) Mailing Address if different SAME. Email 978-794-0927 WORK SPECIFICATIONS We will furnish and install the REMODELING PROJECT PAGE 2 OF 4 as specified below: FINISHED ROOM- Ef .ECTRICAT. d PROVIDE AND INSTALL (4) RECESSED TIGHT FIXTURES, TIED INTO A SINGLE. POLE SWITCH, WITH THE SWITCH BEING A DIMMER CONTROL UNIT, (1) FLORESCENT CLOSET TIGHT FIXTURE, AND A CEILING FIXTURE TO SUPPORT THE CUSTOMER -PROVIDED LIGHT, WITH A SINGLE POLE SWITCH. ALL PROPOSED WIRING TO BE TIED INTO THE EXISTING ELECTRIC PANEL. (SEE ALLOWANCE SCHEDULE). FINISHED ROOM: HEATING 5. HEATING FOR THE PROPOSED ADDITION WILL BE VIA INSTALLATION OF NEW SUPPLY AND RETURN LINES TIED INTO AND/OR VIA AN EXTENSION OF THE FORCED HOT AIR (FHA) HEAT, TIED INTO THE EXISTING ZONE. FINISHED ROOM: FLOORING 6. PROVIDE AND INSTALL NEW PRE -FINISHED HARDWOOD FLOORING, SIMILAR TO THE EXISTING SECOND FLOOR FLOORING, INSTALLED OVER THE EXISTING SUB FLOOR (OR SIMILAR AS DETERMINED BY THE COMPANY) (SEE ALLOWANCE SCHEDULE). FINISHED ROOM: BUILT-IN CABINETS 7. PROVIDE AND INSTALL BUILT-IN DRAWERS AND BOOKCASE, SIMILAR TO EXISTING, PER THE CONCEPTUAL / CONSTRUCTION DRAWINGS DATED MAY, 2010. (SEE ALLOWANCE SCHEDULE). FINISHED ROOM: BENCH SEAT 8. PROVIDE AND INSTALL A BENCH SEAT, (WITH SEAT CUSHIONS TO BE PROVIDED BY THE CUSTOMER), PER THE CONCEPTUAL / CONSTRUCTION DRAWINGS DATED MAY, 2010. (SEE ALLOWANCE SCHEDULE). Remarks: This contract supersedes all conversations, statements and agreements expressed or implied, between the parties, their agents and representatives. Purchaser(s) authorize Boardwalk North to investigate credit worthiness. All work started above to be completed in a workmanlike manner according to the floor plan, job specifications and terms and con- ditions as stated on the back of this form. Price and Payment— Cash price .................................... $ 38,936.00 Payments to be made as the work progresses as per the Payment Schedule which is attached and made part of this Contract: Dat ow r Date ow 05/19/2010 By: Date Boardwal North Representative BOARDWALK NMN A Division of Data Industries, Inc. 24 Orchard View Drive Londonderry, NH 03053 TEL (603) 437-2500 boardwalknorth.com Name of Purchaser(s) DIANE HINZELMAN Phone No. Purchase Agreement (for office use only) Office ................... Order NO .................. Checked by .............. Daytime Phone No. Address 171 CORTLAND DR NORTH ANDOVER MA (His orHer's) 01845 (No.) (Street) (City) (State) (zip) Mailing Address if different SAME Email 978-794-0927 WORK SPECIFICATIONS We will furnish and install the REMODELING PROJECT PAGE 3 OF 4 as specified below: FIN19HED ROOM- DRYWAI.I. 9. PROVIDE AND INSTAI.1.. NEW 1/2" GYPSUM WALLBOARD (DRYWALI) ON THE INTERIOR WAT IS AND CEILINGS OF THE PROPOSED FINISHED ROOM, TO INCLUDE; PATCHING AS NECESSARY RESULTING FROM THE REMODELING EFFORT. ALL DRYWALL TO BE FILLED* SANDED AND FINISHED TO A PRIME -READY STATE. FINISHED ROOM: MILLWORK AND TRIM MOLDING (INTERIOR) 10. PROVIDE AND INSTALL NEW INTERIOR WINDOW AND DOOR MOLDINGS TO BE 2-1/2" INCH, PRE-PRRAED, WINDSOR STYLE. INTERIOR BASEBOARD MOLDINGS TO BE 3-1/2" INCH, PRE -PRIMED WINDSOR STYLE. PAINTING 11. ALL PRIMING, PAINTING, STAINING AND/OR PREPARATION THEREOF TO BE COMPLETED BY THE CUSTOMER OR WILL BE QUOTED SEPARATELY UPON REQUEST. PLANS 12. FINAL CONSTRUCTION DRAWINGS, ENDORSED THEREIN, SUPERSEDE ALL CONCEPTUAL DRAWINGS GENERATED DURING THE DESIGN PROCESS. DEBRIS REMOVAL 13. INCLUDES REMOVAL OF ALL DEBRIS. NOTE: THE NEED FOR ANY ENGINEERING REPORTS SUCH AS PLOT PLANS, OR VARIANCE -REQUIRED PLANS AND/OR STUDIES DUE TO EXISTING CONDITIONS, WILL BE QUOTED SEPARATELY UPON REQUEST. Remarks: This contract supersedes all conversations, statements and Price and Payment— agreements expressed or implied, between the parties, their agents Cash price .................................... $ 38,936.00 and representatives. Payments to be made as the work progresses as per the Payment Schedule Purchaser(s) authorize Boardwalk North to investigate credit which is attached and made part of this Contract: worthiness. / �L aR• _wL4U'P Date/ All work started above to be completed in a workmanlike manner OvAer according to the floor plan, job specifications and terms and con- ditions as stated on the back of this form. Date Owne AordWorth 05/19/2010 By: Date Representative BOARDWALK 2 Division of Data Industries, Inc. (for office use only) 24 Orchard View Drive Office ................... Londonderry, NH 03053 Order NO.. . *''*''*''*''* O....:........... . N=H TEL (603) 437-2500 Checked b boardwalknorth.com Purchase Agreement Name of Purchaser(s) DIANE HINZELMAN Phone No. Daytime Phone No. Address 171 CORTLAND DR NORTH ANDOVER MA (His orHer's) 01845 (No.) (Street) (City) (State) (zip) Mailing Address if different SAME. Email 978-794-0927 WORK SPECIFICATIONS We will furnish and install the REMODELING PROJECT PAGE 4 OF 4 as specified below: BiJR.DING PERMITS 14, INCLUDES ALIL THE NECESSARY BIJILDING PERMITS_ B1TI11.1DING PERMIT FEES AND APPIACATION THF.RFOF EXCEPT AS NOTED, NOTE: SURVEY AND/OR CERTIFIED PLOT PLANS, ZONING BOARD, AND/OR CONSERVATION COMMISSION APPLICATIONS) EFFORT TO BE QUOTED SEPARATELY UPON REQUEST. Remarks: This contract supersedes all conversations, statements and Price and Payment— agreements expressed or implied, between the parties, their agents Cash price .................................... $ 38,936.00 and representatives. Payments to be made as the work progresses as per the Payment Schedule Purchaser(s) authorize Boardwalk North to investigate credit which is attached and made part of this Contract: worthiness. .. ,A 4 / ilu� �• //YhP.f�yYl(7 Date r I —/n All work started above to be completed in a workmanlike manner —/\1 Owner according to the floor plan, job specifications and terms and con- ditions as stated on the back of this form. Date Own r 05/19/2010 By; Date 6/Bo'ar11WaNYVkNorth Representative Energy Code: Location: Construction Type: Project Type: Heating Degree Days: Climate Zone: Construction Site: 171 Cortland Dr North Andover, MA 01845 REScheck Software Version 4.3.0 Compliance Certificate 2007 IECC North Andover, Massachusetts Single Family Addition/Alteration 6322 5 Owner/Agent: Diane Hinzelman 171 Cortland Dr North Andover, MA 01845 978-794-0927 Designer/Contractor: BOARDWALK NORTH 24 Orchard View Dr Londonderry, NH 03053 603-437-2500 �Co"prance PassesCompliance: Maximum UA: 35 Your UA: 35 Ceiling 1: Flat Ceiling or Scissor Truss 224 38.0 0.0 7 Wall 1: Wood Frame, 16" o.c. 343 19.0 0.0 19 Window 1: Metal Frame:Double Pane with Low -E 27 0.320 9 Compliance Statement: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the 2007 IECC requirements in REScheck Version 4.3.0 and to comply with the mandatory requirements listed in the REScheck Inspection Checklist. Name - Title Signature Date Project Title: Report date: 05/19/10 Data filename: S:\COMPANY PROJECTS by NAME\2010\HINZELMAN\Sales Documents\Hinzelman.rck Page 1 of 1 0 I Boar o ui Wng�egufaalont's/an t�drs� One Ashburton Place - Room 1301 Boston, Massachusetts 02108. OCT ;A Home ImprovemegContractor Registration Registration: " 161542 Type: Private Corporation Expiration: 10/27/2010 Tr# 276787 DATA INDUSTRIES, INC. EDWARD STEWART 24 ORCHARD VIEW DR.r 4 LONDERRY, NH 03053 :)PS -CAI 0 50M-07/07=PC8490 �' xe e,.momure a a�✓�%aaoac�ivae�Ca Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration.' 161542 �Ecpiration 10/27/2010 Tr# 276787 •?,^ % Type Privbte Corporation DATA INDUSTR4ES'NC1, 4j EDWARD STEWP,'Rh - 24 ORCHARD VIEVI ;b12: , LONDERRY, NH 03053 Administrator a,t Update Address and return card. Mark reason for change. Add R 1 Li ress L_j enewa L_j Employment L_j Lost Card License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston, Ma. 02108 . °ACORDM CERTIFICATE OF LIABILITY INSURANCE o6ioiio 0 RIIOUC R 603)432-3666 FAX (603)432-6076 Lakeside Insurance Agency, Inc. & C&G Insurance :One Wall Street Windham, NH 03087 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # .SURER Data Industries, Inc. dba Boardwalk North 24 Orchard View Drive Londonderry, NH 030S3 INSURER A: Peerless Insurance 24198 INSURERB: Excelsior Ins. Co. 11045 INSURER C: INSURER D: INSURER E: V THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. lNqRrDATE DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE (MM1DD[YY1 POLICY EXPIRATION DATE IMMIDDIM LIMITS GENERAL LIABILITY CBP8445959 06/01/2009 06/01/2010 EACH OCCURRENCE $ 1,000,00 0. DAMAGE TO RENTED $ 100 00 rA X COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR � a MED EXP (Any one person) $ 15,00 PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: 000 00 PRODUCTS - COMP/OP AGG $ 2 91 POLICY JECOT LOC AUTOMOBILE LIABILITY X ANY AUTO BA8446 S S9 06/01/2009 06/01/2010 COMBINED SINGLE LIMIT $ (Ea accident) 1,000,00 ALL OWNED AUTOS BODILY INJURY $ (Per person) A SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ (Per accident) NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) - GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY X OCCUR F-1 CLAIMS MADE CU8446959 06/01/2009 06/01/2010 EACH OCCURRENCE $ 2-1000,00 AGGREGATE $ 2,000, OO $ $ DEDUCTIBLE RX RETENTION $ 10,00C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY WC8446359 06/01/2009 06/01/2010 $ X WCSTATU- OTH- E.L. EACH ACCIDENT $ 100 00 B ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYE $ 100 00 E.L. DISEASE - POLICY LIMIT $ 500100 If yes, describe under SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS overing residential carpentry and related operations to be performed by the named insured during the olicy period. orker's Compensation statutory coverage is provided for New Hampshire. Executive Officers have lected to be excluded from Worker's Compensation coverage. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. For Information Only AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) ©ACORD CORPORATION 1988 The Commonwealth of Massachuseas Department o f rndush ial Accidents Office ofinvestigations 600 R/aMiin; on Street Boston, M4 02111 www-Mass-gov/dia Workers' Campensation Insurance Affidavit: guilders/Contractors/Electricians/P cant Information lumbers li Tv Name (Business/organiza6on/Indididual): Address: City/State/Zip: �A1�gZAl 1j14 Phone #: &-j` 14 37— Zee''�J Are you an employer? Check th :=roprmte bon: amaemployerwith 4. ❑ I am a ge, 2. ❑employees (full and/or part-time).* I am a sole contractor and I have hired the sub -contractors proprietor or partner- ship and have no employees listed on the attached sheet. I working for me in any capacity. These sub -contractors have workers' com insurance. [No workers' com : ' p insurance P . 5. ❑ We are a corporation 3 • ❑required.] ,I am a homeowner doing all and its officers have exercised their work Myself [No workers' comp. insurance right of exemption per MGL c. 152 ' � 1 (4), and we have no remired. t q ] employees. [No workers' comp Type of project (required): 6. ❑ Nein construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.11 Electrical repairs oradditions .1 LEI Plumbing repairs or additions 12•7 Roof repairs ` � Y ar a -Rt that checks boy: ul m r . insurance required.] � 13 ❑ Other t Home ust a.so Je out the 5, --ft ` ir�tot! notrr_.. fz. owners who submit this affidavit indicating the;, are on a( work and = w= --s' com'-....s-'*:cn s Contractors that check- this box must attached an additional sheet showing , .... Wfo n eon then'hire outside contractors must. submit a new afidavii indicating such. b the name of the sub -contractors and their w-4, ____ - " -- . •,.f,",yG[ trim is providing workers' ensati compon insurance or m informa io& .f y mPloyees Insurance Company Name: —r• r -•••.y uuarmanon. Below is the policy and job site Policy # or Self -ins. Lic.L%gwtl, p 17 �� � " ' F-xpiration Date: Job Site Address:( � O� Attach a copy of the workers' compensation policy declaration page (sho Cn/S/Zip: Opt Failure to secure coverage as required under Section 25A of M e Policy number and expiration date). fine up to $1,500.00 and/or one-year imprisonmen as well as Glc. 152 can lead to the imposition of criminal Of up to $250.00 a day against the vi lator. Be advised that a co Penalties m the form of a STOP WO penalizes of a Investigations of the DIA for ' RK ORDER and a fine �f �#overage verification. PY of this statement may be forwarded to the Office of 1 do here cerk er by s P • s ofPerlur"hat the informationprovided above islvwe and correct Siffiatnrr.- Df ficial use only. Do not write in this area, to be completed City or Town: Issuing Authority (circle one): bJ' city or town offciaL P ermit/License . 5, I. Board of Health 2. Buiidinte Department 3. Ci'Town / 6. OtherClerk 4. Electrical inspector 5. Plumbinb Inspector Contact Person: Phone #: 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 ofanother 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 loocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to c onstruct 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 umli acceptable evidence of compliance with the ingurme requirements of this chapter have been presented to the contra..eting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), addresses) and phone number(s) along with their certificate(s) of incnirance. Limited Liability Companies (LLC) or Limited Liability partnerships (LLP) with,no employees other than the members or partners, are not required to carry workers' comp ensation 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 sore to si m and date the affidavit. The affidavit should be .returned to the city or town that the application for the permit or license is being reaues txd, not the .D, --n& hent. of Industrial Accidents. Should you have any questions regardimg 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 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 burn leaves etx.) said person is NOT required to complete this affidavit The Office oflnvestigations would like to than 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,fammumbez_. . The CQmmonvrAth. etf Massachusetts Department of Eadusstriaal Accidents Office of Inrestidatons 600 Washington Street Briton, MA 0.2111. Tel. ## 617-72.7-4900 ext 406 or 1-9 77-MASSAFE Revised 5-26-05 Fax # 617-72.7-7749 mmm,.mass.-gov/dia. N ................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING �S$ACMUSE` This certifies that ...........:. '/ ............................................... has permission to perform.......{...........:............................................................ wiring in the building of ... :.!..:. . . j at ,1.... 1..... -:....'. f:�:^..:..:.....r............... a ......, North Andover, Mass. r Fee .v6. 'o'.. Lic. No. . �. ' /.. �.......... ~ ; LECTRICALINSPECTOR _ Check # tJ Commonwealth of Massachusetts wuqw� Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked ;ev. 1/07] APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC , 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To By this application the undersigned gives notice of his or her intention to perfo xhthe e Ielectrical wpector ork ddies nbed below. Location (Street &Number)_ Owner or Tenant✓,..�,,�L L . �� Owner's Address �/� /t, �._ ,l / n ,, Telephone No. Is this permit in conjunction with a building permit? Yes NLULLVE— ' Purpose of Building NO ❑ (Check Appropriate Box) C Utility Authorization No. 762 A 06 oZ Existing Service Amps / Volts ❑ Undgrd ❑ No. of Meters New Service i "��s OverheadAmps Volts Overhead ❑ Undgrd 59 No. of Meters J Number of Feeders and.Ampacity 4172 JL,w.. _ . _ -& _ Location and Nature of Proposed Electrical Work: of Recessed Luminaires No, of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers Completion of the follouin No. of CeiL-Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool Above In - VT d. ❑ d. ❑ No. of Oil Burners No. of Gas Burners No. of Air Cond. Total Tons Hf�� er ons KW .__. ....__._... _._._..__._. Space/Area Heating KW table mgy be waived by the Inspector of Wires. No, of Total Transformers KVA Generators KVA I , o mergency ig Battery Units FIRE ALARMS No. of Zones No. .of Detection and Initiating Devices No. of Alerting Devices 11 o. of Dryers Heating Appliances KW Security Spps .t o. of Water KW Noof No, of Dei Heaters No. of Data Wiring; Signs Ballasts . f11- o. Hydromassage Bathtubs INo. of Motors OTHER: Devices .al ion ❑Other or Equivalent 1W or Eouivalent Total HPi eiecommunications No: of Devices or Attach additional detail if desired, or 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 &d– BOND ❑ OTHER ❑ (Specify:) I certify, under the ains and enalties o p ) P (perjury, that the h1 ormation on this application is true and complete. FIRM NAME: t�,r► � a,►/�o� c�, c, ✓� LIC. NO.: Licensee: rdr.., �ot,//'�✓I Signature ��� (If applicable, enter,, pt " in the license number line.) — i�� LIC. NO.: ,3 Address: IJ��/1 Bus. Tel. No.: Per M.G.L c 147, s. 57-6 1, security work requires D—�� Alt•. Tel. No.: epartrrrent of Public Safety "S'" License: Lic. No. iA%3— 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 (c Owner/Agent heck one) ❑owner El owner's agent Signature Telephone No. PERMIT FEE: S <d-,0 w ,M P4&�t . �--W-e 4A a r' y r e' The Common weallh of Massachusetts k j jr Department of Industrial Accidents Office of Investigations . a 600 Washington Street llii+� .\41 Boston, MA 02111 { r Workers' Comwww .mass gov/dia . pensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le�bly NBIlIe (Business/prganizationi[ndividuat); (v ! I� � � �l Address: �C City/State/Zig:_ Phone Are l* -an employer? Check the appropriate box: F 1. I am a employer with "� 4, ❑ I am a general contractor and I employees (full and/or part-time).* 2.R have lured the sub -contractors I am a.sole proprietor or partner- ship and have no employees listed on the attached sheet, t These sub -contractors have working for me .m any capacity. Mo workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.) 3. ❑ 1 am a homeowner doing officershave exercised their all work right of exemption per MGL myself. [No -workers' comp. c. 1.52, § 1(4), and we have no insurance required.l t .employees. [No workers' comp. insurance required.) *Anv nnnl 1-t 0-1 ..m. -..L. Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other homeown1111 out me seeaon below showing their workers' 'compensation policy information. ' er¢ who submit this affidavit indicating they are doing all work and then hire outside contraetors must submit a new affidavit indicating such. ;Contractors that check this box mustatteched an additional sheet showing the name of the sub -contractors and their workers' oomp . olirmation. � P cy info ! am an erjpkyer that is provufing:workers 9 compensation irxsurance for pry employee Below is the policy and job site infornWio2 Insurance Company Name: Policy 9 or Self4ns. Lie. 4: lv Expiration Date: Job Site Address:_ �� Cd✓ Glia/�! ��` City/State/Zip: 0 '� 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 MOL 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. ! do hereby certafy under the pins acrd pena<ties of perjury that the infnrmation provided above is true and correct 3. Offtciat use only. Do not write in this area, m be completed by city or town. ofjiciaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 6. Other 5. Plumbing Inspector Contact Person: Phone #• t . 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, assodiation, 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 liednsing 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, by 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 can y 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 permit or license is being requested, not'the Department 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 numberlisted below. Self-insured companies should enter their Self = insurance -license number on the'appropriate line. • City or Town Officiais 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 per-mit/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 policyinformation (.if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of tame 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. When 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 hike 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 Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia Date..? .-/ t. -/c. 7 V" TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... /4 ............. has permission to perform ....... -I- .� ............ ............. plumbing in the buildings of ............ Y a t ....................................... North Andover, Mass. Fee. Lic. No../V7 .......Q0 ...... . ...... PLUMBING INSPECTOR L - Check # 8077 t^' MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING t (Type or print) ( f NORTH ANDOVER, MASSACHUSETTS 11 Date ° �" /0 Q7 Building Location Owners Name Permit # 7 Amount Z L, o, — Type of Occupancy New 1:1 Renovation ri Replacement E] Plans Submitted Yes No ❑ INK TURES r MMW mmm MMMMMM MMWWMWWMMM MW WMWNMMMNWMMWMWMMNWWMW MW .t WWMMMWMMMMMMMMMMWWMMMWMW� MMMMON mmm (Print or type) J� / / Check one: Certificate Installing Company Name /`7 11 Corp. Address zo Ilf Partner. 0 v Business Teleph6ne f„ – 9 S � Firm/Co. Name of Licensed Plumber: _ fit r T �p 7 Insurance Coverage: Indicates the t pe of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature 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 withall pertinent provisions of the Massachusetts State.,Plumbiriz Cod and h r 142 e General Laws. J� BySignature or Ocelisea Flu m er Title Type of Plumbing License City/ icense um er Ma APPROVED ster JourneymanVED (OFFICE USE ONLY u The Commonwealth of Massachusetts ki )� Department of Industrial Accidents Office o Invesd aliens f g i' a 600 Washington Street Boston, MA 02111 w9=nxassgov/dia Workers' Compensation Insetrance Affidavit: Builders/Contractors/Eleetricians/pinmbers lAicant Information Name (Business/Organiza6onllndividual); Address: C4y5tate/Zip: Phone #.-. Are you an employer? Check the appropriate box: I.❑ I am a employer with 4. ❑ 1 am a general contractor and I 2. ❑employees (fun and/or part-time).* I am a sole proprietor or have hired the sub -contractors listed partner. ship and have no employees on the attached sheet = These stab -contractors have working for mem any capacity, [No workers, comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 3.❑required.) 1 am a homeowner doing all work officers have exercised their right of exemption per MGLmyself .[No•workers comp, insurance c. 152, § 1(4),'and we have no required.] t em Io ees P Y [No workers' COMM insurance re wired_ Type of project (required): �.. ❑ New construction . 7• ❑ Remodeling 8. ❑ Demolition 9. [] Building addition 10.❑ .Electrical repairs or additions I I .❑ Plumbing repairs or additions 12.❑ Roof repairs q ] 13.❑.Other I 'Any eppiieatrt tient checks bo>l<# l must also fill out the section below showing their workers' 'compensation policy mformahon t Homeowneta who submit this afdavit indicating they are doing ail work and then hiie outside conuactots xCvntractors that check this box must t7aeited an additional shoot must submit a new'aMdavit indick* such showing• the name of the sub -contractors and their workers' comp. I am an employer that is ro ' - F psTig irf rtg:workers nmistion. information p ; ur compensation insuranceforiM employees Below is theP �o ' }' medjob site . Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: ------------- Job Site Address: Attach a City/state2ip: 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 MCiL c. 152 can lead to the imposition of crirrrinal penalties of fine up to$1,500.00 and/or .,year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a a 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 fine investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofPerj r that nrntation pro rovided above is true f and rortea oOkiat use only. Do not write in this area, to be completed by d j, or town of c iaaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitY/Town Cierk 4. Ele 6. Other ctrical Inspector S. Pine...... Contact Person: Phone #• Information and Instructions Massachusetts General Laws chapter 152 requires all emp 3 oyem 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'foreping engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or tnrstee of an individual, partnership, association or other legal entity, employing employees. 'However the owner -of a dwelling house having not more thin three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do mai-ntenance, 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." MOL 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 insumnce'coverage required." Additionally, MOL chapter 152, §25C(7) states "Neither t3he commonwealth nor any of its political subdivisions shall enter into any contract for the performmrece. 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 -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 city or town that the .application for.the permit or license is being requested, nottthe Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please can the Department at the number. listed below, Self. -insured companies should enter their self-insurance license number on the appropriate line. City or Town Officiais 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 permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple perinit/license applications in any given yqw, need only submit one affidavit indicating current policy infonnation (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 1'ke to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Depictrnent's address, telephone and fax number: The Commonwealth of Massachusetts Department of lndustzial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TeL # 617-7274900 ext 406 or 1-8.77-MASSAFE Fax # 617-727-774 Revised 5-26-05 www-mass.gov/dia Date.... TOWN OF NORTH ANDOVE .PERMIT FOR GAS INSTA=ION This certifies that ....... Ix... has permission for gas installation .................. ......... in the buildings of .... Tef-44 at ............... 44- ... ......... GAS Andover, Mass. Fee. ./5? Lic. No../. G 1� SPECTOR Check # 9 `� L 6765 MASSACHUSETTS UNIFORM APPLICATON FOR Pyr To Dp GAS FrrrjNG (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Lgqations l / Permit # U e- Owner's Name Amount F711-11 — New G SU B -BASEM ENT BASEMENT 1ST. FLOOR Z D. FLOOR 3RD. FLOOR LTH. FLOOR iTH. FLOOR iTH. FLOOR rA FLOOR. ITH. FLOOR DReplacement ❑ Plans Submitted ` Name or.Licensed Plumber or Gas Fitter Nit' r �„r,. A Y /I--- // Check one: Certificate Installing Company Corp. Partner. 0 Firm/Co. INSURANCE COVERAGE I have a current liability Insurance, policy or it's substantial equivalent Check on If you have checked Yes, please in d e the e cove Yes U Liability insurance policy ty Other rage by checking king the appropriate box. ty NoO UP- o m emmty U Bond 1 Owner's Insurance Waiver. 11am aware that the licensee does _no_thaVe the IInsurance coverage required by Chapter 142 0 Mass. General Laws, and that my signature on this permit application waives this requirement ' P f the Signature of Owner or Owner's Agent Check one: wner , Agent i hereby certify that all of the details and information I have submitted (or enOtered) in above application e and best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in accurate to the compliance with all pertinent provisions of the Massachusetts State Gas Code and Ch er .14 of th eneral Laws. By: Title City/Town, _ APPROVED (OFFICE USE ONLY) ❑Signature of Licensed Plumber Or Gas Fitter Plumber I — ,'r -, Fitter (cense umber Wmlizter 0 Journeyman � w ' rA ra o 0 F G7 d .. Z1. W C W ItU traa w E. 96, O5. d w [- W W V F W S Z 3 c Q o w 5 n Name or.Licensed Plumber or Gas Fitter Nit' r �„r,. A Y /I--- // Check one: Certificate Installing Company Corp. Partner. 0 Firm/Co. INSURANCE COVERAGE I have a current liability Insurance, policy or it's substantial equivalent Check on If you have checked Yes, please in d e the e cove Yes U Liability insurance policy ty Other rage by checking king the appropriate box. ty NoO UP- o m emmty U Bond 1 Owner's Insurance Waiver. 11am aware that the licensee does _no_thaVe the IInsurance coverage required by Chapter 142 0 Mass. General Laws, and that my signature on this permit application waives this requirement ' P f the Signature of Owner or Owner's Agent Check one: wner , Agent i hereby certify that all of the details and information I have submitted (or enOtered) in above application e and best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in accurate to the compliance with all pertinent provisions of the Massachusetts State Gas Code and Ch er .14 of th eneral Laws. By: Title City/Town, _ APPROVED (OFFICE USE ONLY) ❑Signature of Licensed Plumber Or Gas Fitter Plumber I — ,'r -, Fitter (cense umber Wmlizter 0 Journeyman \U The Commonwealth of Massachusetts Department of Industria[ Accidents . Off1ce of Investigations 600 Washineaton Street Boston, M4 02111 W WKI. P"MS.g Workers' Compensation Insov�diQ urance.A�davrt; guilders/Coniractors/Eleeir6ciia Acant Information ns/Plumbers -------------- Name (Business/Organization/Individual): Address: City/State/Zig: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I an. a employer with 4. I am a o employees (full and/or part-time).* ❑have hired I s� mor and I 2. ❑ i am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work Myself [No, workers' comp. insurance required.] t contractors listed o' the attached sheet I These sub -contractors have workers' comp. insurance. ❑ We are .a corporation and its officers have exercised.their right of exemption per MGL C. IS2, § I, (4) and we have no employees. [No .workers' comp in Type of project (required): .6. 0 New construction 7• ❑ Remodeling . 8. ❑ Demolition 9. ❑ Building addifi.m 10:❑ Electrical repairs or additions ' l.❑ Plumbing repairs or additions 1240 ' Roof repairs *Any applicant_that checks box # i .must also -fill out the section below sho suranee required.] I I3 ❑ Other t iiomeowuets Who suhnui •flus a— section indicarilk., titej- ate �i1iE?� :? wing their workers' compensation policy mrormahon. r t h E ing he then hire: Outsi& ContraoiorS 111rr$l Nlibmll 8 nCW arnLiaVIt lildlcxun such. Contractors that ehcci: this box.—_ust attached an additional sheet showing the "n, of the s; b-ocnaactots and their w��v-. _-- - r,. S^ n ..f.sirycr u[fa rs' provuune worriersra co .. y nnonrlalt0tt. nformation. mPafion insu ince for int' employers. Below is theofi P cy and job site Insurance Company Name: Policy # or Self .ins. Lic. #: Expiration Date: Job Site Address: Attach a copy of the workers' compensation Dile decta n City/State/Zip: Failure to secure coverage as required under Section 25A of MG pabe (showiQg the policy Dumber and expiration date). fine up to $1,500.00 and/or one-year imprisonment; as well as civlc 1$2 can'cad to the imposition of criminal penalties of a of up to .S250.00 a day against the violator. Be advised that a penalties in the form of a STOP WORK ORDER and a fine Investigations of the DIA for insurance coverage verification. copy of this statement may be forwarded to the Office of 1� .... u�C pun, ana penalties of perjury' that the information provided above is true and correeL DfJlcial use onip. Do nor write in this area, to be completed by city or town ociaL City or Town: Issuing Authority (circle one): PermitlLicense I. Board of Health 2. Building Department 3. C''own /T 6. Other.Clerk 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone#: 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 inclurii-ng 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 ap artments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, constriction 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 ar local licensing agency shall withhold tie issuance or renewal of a license or permitto operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence mf 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 worll< 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 c-errifrcate(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 affrcla.vit may submitted to the Department of lndustrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. Theaffidavitshouid be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents, Should you have any questions regre-vrding the -lam, or. if you are mquimd to obtain a workers' compensation policy, please call the Department at the nm i-mber:listed below. Self insured 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 foryou to fill but in the event the Office of investigations has to contact you regarding the applicant. Please be sure to fill in the pennit/iicense number which will be used as a reference number. In addition, an applicant that must submit multiple pennit1icense applications in arty given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Ad&T-ess- 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 Iicenses. 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 07 commercial venture (i.e. a. dog iicense or permit to burn 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 fay, number. The Commonwealth of Massachusetts DtPartment of 1xidustrial Accidents 4f ce of Lnvesfigatitons 600 WashLington Street Boston; MA 62111 Tel, 4 617-727-4900 C= 406 c r 1-877 MASSAF'E Revised 5-2645 Fax 4 617-7-7-7749 . w m mass.gov/dia