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Home My WebLink AboutMiscellaneous - 1 HIGH STREET 4/30/2018 (2)-Date:� T �OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies t h a t ......... has permission to perform -PJe'(:t_. . ........................ plumbing in the buildings of .................................. at.. / ... /// '.5 .1. . �. -� .......... .... North Andover, Mass. Feel-�/ , YU . ->- 2 — I 'q— ' 1'1*-'�) - � Lic. No..�� ...... ...... ........ BIN* r-�R PLUM* ' G IN PIECT Check # 7743 FIXTURES MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City%Town N. ANDOV67e -----I,MA. Date: 5- 4-1 -(A-jPermIt# Building Locatlon I H i a t4 �=5r I Owners Name: Type of Occupancy: Commerciallo Educational Fj Industrial F-1 Institutional F] Residential New: ❑ Alteration:L] RenovationTCA R4"1eplacement: J Plans Submitted: Yesi No; FIXTURES INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 YsR]NoL�j If you have checked Y S, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ❑ Other type of indemnity F] Bond Ir -1 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 Owner's Agent Owner F j 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 n mwieage ana uiai an pwmoing wont ana msanauons pertormea unser the permit Issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of vfe General yaws. BY I Type of License: Title 0 Plumber Signature Licensed Plumber _ City/Town� Master 0 Joumeyman �] License Number: ar-�a�} APPROVE (OFFI �SO �...�. z z Y 0 V 0 W z ul Z caIx�l'—W_aZ�-v� ~ z H z J 90 0 Z ga o y w o a z W 2 d W z ca W y z 0 a v Q o 0 3 x aQ LL W Y =W rn W w W1x til Q Q co Q co Nw c0 JOQOH> CD x Y 5 g 0a 0= x 0 zQrz 3 H 3 H_ 3:1 0 u. rn rn z SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 3 FLOOR C FLOOR 5 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR Check One Only Certificate # � Installing Company Name: f 1-44, Address: City/Towni State: MA a Corporation Partnership Business Tel: ,� D aq2323� Fax: �� I q z. 515'i a Firm/Company �— Name of Licensed Plumber. Ok IJJ�IkAAiE't INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 YsR]NoL�j If you have checked Y S, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ❑ Other type of indemnity F] Bond Ir -1 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 Owner's Agent Owner F j 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 n mwieage ana uiai an pwmoing wont ana msanauons pertormea unser the permit Issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of vfe General yaws. BY I Type of License: Title 0 Plumber Signature Licensed Plumber _ City/Town� Master 0 Joumeyman �] License Number: ar-�a�} APPROVE (OFFI �SO �...�. BUILDERS,Nr4 TA COMMERCIAL CONSTRUCTION:; To: Town of North Andover 1600 Osgood St. North Andover, Ma 01845 Attn: Gerald A. Brown James Diozzi Re: One High St North Andover, Ma 01845 Bathroom revisions / Converse Building Permit # 675 Date of Issue 5/16/2008 To whom it may concern, Please be advised that the general contractor of record of the above referenced project, Vantage Builders, has made a substitution with reference to the plumbing subcontractor. This change was solely based upon schedule deadlines. The current plumbing subcontractor of record is Wambolt Plumbing; the alternate plumbing sub -contractor for this project from May 27th, thru completion will be Willwerth Plumbing. Thank you for your attention in this matter. Please feel free to contact me with any/all questions regarding this or any related issues. Somerset Court, 281 Winter St., Suite 340, Waltham, MA 02451 Phone 781-895-327o Fax 781-895-3271 Online www.vb-inc.com Date.7//X� k. TOWN OF NdRTH ANDOVER PERMIT FOR PLUMBING This certifies that has permission to perform ... P/P 5z� .. ............... plumbing in the buildings of �'jno..f ....................... at ... .............. North Andover, Mass. Fee ? ........ Lic. No.P. 7,7 � . .......... ....... PL Ma I N S P E (�T�R Check # 3-) <7 7779 y 'MASSACHUSETTS. UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or T ) ,p N0Mass. -Dateice).Permit* % 7. Building Location Owner's Name Y1V Type of Occupanry VlJ New Renovation ❑ Replacement ❑ Plans Submitted: Yes O No MOOOO FIXTURES [J Installing Company Business Name of licensed Plumber NG. Check one:. 030,Corporation O Partnership O Firm/Co.• Cerk►ee2+c INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142: Yes fi]Y No ❑ It you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability insurance policy [jjs Other type of Indemnity ® Bond O OWNER'S INSURANCE WAfVER: 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 O Agent O I hereby certify that all of the details and 'information I h knowledge and that all plumbing work and installations pertinent provisions of the Massachusetts State PlumbiF By gnat application are true and accurate to the best of my for this application will be in compliance with all feral Laws. Title 1--i OtyfTown Type of License: Master Journeyman (O IONLY) !;cense Plumber z as N O W z O x Z > yr W Y_ J N 4 .< N _ O O ¢ O W 6 Y< 1 z `& 1+ MOO W_ h al h U w m N a 3 x1W.J, = ¢ m ¢ m W ¢ 3 < W _ N a < Ce y rt a fL ¢ s S ~ h W O O ' �' 'J C 1- < 7�C W LL Ji 1C EC W t1vol h V> h O x o m O N h= O p N Z= .W h O V 2 < < < x < < o < .� .j < ¢ ¢ a < o < h 1 a Y -J m o SUB—BSMT. BASEMENT 1ST FLO 2NOFLOOR 3RD FLOOR 4TH FLOOR STH FLOOR eTH FLOOR 7TH FLOOR STH FLOOR Installing Company Business Name of licensed Plumber NG. Check one:. 030,Corporation O Partnership O Firm/Co.• Cerk►ee2+c INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142: Yes fi]Y No ❑ It you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability insurance policy [jjs Other type of Indemnity ® Bond O OWNER'S INSURANCE WAfVER: 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 O Agent O I hereby certify that all of the details and 'information I h knowledge and that all plumbing work and installations pertinent provisions of the Massachusetts State PlumbiF By gnat application are true and accurate to the best of my for this application will be in compliance with all feral Laws. Title 1--i OtyfTown Type of License: Master Journeyman (O IONLY) !;cense Plumber i N i 0/ I IC 49 .9 O o W i 0/ I www.svdesign.com 126 Dodge Street Beverly, Massachusetts 01915 t 978 .927.3745 f 978 .927.6365 Siemasko + Verbridge Architecture Interior Design February 27, 2008 Mr. Gerald Brown Town of North Andover 1600 Osgood St North Andover, MA 01845 Gerald, This afternoon, I had a phone conversation with you regarding an interpretation of the code as it relates to the Converse first floor renovation project at One High Street: My question was, since the work had to be undertaken as a result of the flood, and the previously existing bathrooms were not accessible, we were unsure if we had to alter the design to provide an accessible stall within the rest room. You determined, as we already have an accessible stall within the Men's and Women's washrooms down the hall (room numbers 142 and 140), we are not required to have an accessible stall within the Men's and Women's rooms (135 and 136). Per this phone conversation, we are going to proceed with rebuilding the previously existing bathrooms as they were. _ t Siemasko + Verbridge Architecture Interior Design www.svdesign.com 126 Dodge Street Beverly, Massachusetts 01915 t 978 .927.3745 f 978 .927.6365 15 February 2008 Office of the Building Inspector 1600 Osgood Street North Andover, MA 01845 Re: Renovations to the Converse, Inc. 4th Floor One High Street, North Andover MA To Whom It May Concern: Siemasko + Verbridge, Inc. has reviewed the proposed new 4th floor workstation layout designed by Office Environments for the planned renovation to the Converse office building. The layout complies with Massachusetts State Building Code 780 CMR and all other applicable codes, with any exceptions noted on the attached partial floor plan. The partial floor plan represents the entire scope of new work that was reviewed. We' have also noted an existing condition that does not meet egress requirements. In order to correct this, existing workstation #1 (as noted on the plans) would need to move away from the wall to accommodate the 44" aisle requirement. Sincerely, Siemasko,WVerbridge S. Siemasko, AIA PACommercial, Current\Converse 2008 Space Planning\02 - General Correspondence and .Project Info\2008 02 15 Letter to Building Inspector 4th Floor.doc Location 6�r No. Date TOWN OF NORTH ANDOVER 0 6. Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee ly-11, $ TOTAL Check # ' 217 6 7 Q"�� ?, - Building lnspector::,_�j ROBERT M. PEYSER Attorney at Law 442 MAIN STREET • SUITE 300 • MALDEN, MASSACHUSETTS 02148-5122 TELEPHONE (781) 324-4418 • FAX (781) 324-6906 OF COUNSEL TO RODMAN, RODMAN & SANDMAN, P.C. December 16, 2008 Building Department Town of North Andover 1600 Osgood Street, Suite 2-36 North Andover, MA 01845 Attention: Jeannine McAvoy Re: Vantage Builders Inc. Dear Ms. McAvoy: Thank you for taking the time to let me know that there are permits issued for the Converse Rubber building renovation which list Vantage Builders Inc. as the contractor. I am enclosing the $5.00 check which we discussed. You kindly stated that you will fax the necessary pages (applications and permits which name Vantage Builders Inc.). My fax number is (781) 324-6906. Thank you for being so helpful. Very truly yours, Robert M. Peyser RMP/sq Enclosure Date//::7/W/ ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . .... S. '. / .. . .............. has permission to perform �P.v .... I/ — — ---------------------- wiring in the building of ....................................................... ...... -,O� ...... .......................... North Andover Mass. u ,� . . .. ....... Fee..V.5..� ....... Lic. No . ............. ............ . z ELECTRICAL INSPE R Check# -5-oo,� (A 9'1 H _la ' Commonwealth of MassachusettsOfficial Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank 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 PRINTW INK OR TYPE ALL INFORAM TION) Date: City or Town of: NORTH ANDOVERTo the ' By this application the undersigned gives notice of his or her intention to perform the ele tr.cal wo Wirrk described below. Location (Street & Number) Owner or Tenant �; y�th. r� r l Owner's Address Telephone No10 3!6 � Is this permit in conjunction with a building permit? Yes Purpose of Building - �c El No � (Check Appropriate Boz) r Utility Authorization No. Existing Service /IJ A Amps / _Volts Overhead ❑ Undgrd ❑ No. of Meters New Service: tfAmps _ Z _Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 7 - Completion of the ollowing table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susg. (Paddle) Fans No. oTotal . No. of Luminaire Outlets Transformers KVA No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ �_ Ej o, o mergency ig g d• d- Batt= Units -- No. of Receptacle Outlets No. of oil Burners FIRE ALARMSNo. of Zones No. of Switches No. of Gas Banners No..of Detection and No. of N Ranges Initis Devices g o. of Air Conti. T°� Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW p Totals: "'___'_•.. LmE _._. No. of Self -Contained _. Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal Connection ❑Other No. of Dryers Heating Appliances KW Security Systems - No. of Water KW No. of of No. of Devices or Equivalent o Heaters Si s Ballasts . Data Wiring: No. Hydromassage Bathtubs No. of Devices or E Equivalent No. of Motors Total HP Telecommunications Wiring; OTHER: No. of Devices or E uivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: a,'O (When required by municipal poIicy.) Work to Start.Inspections to be requested in accordance with MEC Rule 10, and upon completion. CE CQf RAGE: INSURANUnless 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 EEr BOND ❑ OTHER ❑ (Specify..) I certify, under the pains and penalties o f perjury, that the information on this application is true and complete FIRM NAME: L G7to ' Licensee:LIC. NO.: / 1 TER tvC �C Signature (If applicable, enter "exempt " in the license number line.) LIC. NO.: Address: 13 1 W;7— 1-'�,c3 1�. �,��►�s i�� e,;� ?y�i Bus. Tel. No.:&aE]91N!1 v *Per M.G.L c 147, s 57 61, secunty work requrres Dty Alt. Tel. No.: o. OWNER'S INSURANCE WAIVER: I am aware that Licensee does not ehave 'the liability insurance lcoverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent Owner/Agent Signature Telephone No. PERMIT FEE. $ The Commonwealth of Massachusetts .'� Department of Industrial Accidents Office ofInvestigations 600 Washington Street Boston ,l tLA -02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le6bly Name (Business/Organization/Individual): Address: City/State/Zip: h �' ,2� Phone #: Are you an employer? Check the appropriate bog: 1. El am a employer with 4. ❑ I am a general contractor and I employees (full and/or part_time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- Iisted on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5• ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1 (4), and we have no insurance required.] t • employees. No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. [1 Other 7C ze, , .zany a yaa. n..a — cwk.b OUX — uSL Faiav 1111 out me 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. :Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: ` Policy # or Self -ins. Lic. #: '7-)`6 4 3 y /3 Expiration Date: ,J Job Site Address: e0uZ i>!z�il.t City/State/Zip: A1, p",„tom /11W 61p4y; Attach a copy of the workers' compensation .policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the�aurs and penatfies of perjury that the information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartrnents 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 Vocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, 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 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; 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 number listed below. Self-insured companies should enter their self-insurance license number on the appropriate Iine. 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 f 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 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 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 like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth. of Massachusetts DTartment of Industrial Accidents Office of Investigations 640 Washington Street Boston , MA 02111 Tel. ## 617-7274304 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax 4 617-72.7-7749 unA-A1.mass.. aou/dia /iCORU® CERTIFICATE OF LIABILITY INSURANCE OP ID 01 DATE (MMIDD/YYYY) �..� ELECT -2 11/09/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION TYPE OF INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE A. W. Bucci & Assoc., Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1350 Division Rd., Ste. 101 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. West Warwick RI 02893 GENERAL LIABILITY Phone:401-558-0101 Fax:401-558-0167 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: St. Paul Travelers INSURER B: Beacon Mutual Insurance Co. INSURER C: Electro Standards Lab. Inc 36 Western Industrial Dr Cranston RI 02921 INSURER D: INSURER E: COVERAGES 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. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATECMMIDD� IRATION DATE MOLICY MIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A X COMMERCIAL GENERAL LIABILITY TT06301328 11/01/09 11/O1/10 PREMISES(Eaoccurence) $ 250000 CLAIMS MADE F_X] OCCUR MED EXP (Any one person) $ 10000 PERSONAL &ADV INJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OPAGG $ 2000000 POLICY PRO LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 A X ANY AUTO BA-6727LO75-07 11/01/09 11/01/10 (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ BODILY INJURY $ HIRED AUTOS NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ - (Per accident). GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS IUMBRELLA LIABILITY EACH OCCURRENCE $ 5000000 A X OCCUR F—I CLAIMSMADE TT06301328 11/01/09 11/01/10 AGGREGATE $ 5000000 $ DEDUCTIBLE $ X RETENTION $ 10000 WORKERS COMPENSATION- AND EMPLOYERS' LIABILITY Y / N TORY LIMITS ER E.L. EACH ACCIDENT $ 1000000 B ANY RIETOREXCLUDR/E ECUTIVE� 3174 11/01/09 11/01/10 OFFICER EMBER L—I E.L. DISEASE - EA EMPLOYEE $ 1000000 (Mandatory in NH) If yes, describe under E.L. DISEASE -POLICY LIMIT $ 1000000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Electronic Mfg. --Other CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL I IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Proof of Insurance REPRESENTATIVES. ACORD 25 (2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Date./o -,:;p '-- - "-)/o ................................ TOWN OF NORTH ANDOVER 0 40 1.04 PERMIT FOR WIRING This certifies that ................................. ........... ...................... has permission to perform,.Z-.e ..... ... '. %.,e ............................... 4 wiring in the building of ...... I ...................................... at -14".1 ........................... North Andover, Mass. 0�j- 71 ............... Lic. No.P.Zil ............... 4 , Fee/ ...... ELEcrRICA ? Check # 9-0 H N r� Wo (1) (1) LO LO — OD (Y) 0) N OD 1 (1) (1) 00 SR �x (D LL M LD Lo N U) cy) 00 00 AM Oo C-) M CT3 E co (n Z a) C: cn . aC: 7�5 cu —j E 0 It (0 0 C? (Y) (D m C) x Z 0 E Co "I U) Commonwealth of Massachusetts Official Use Only ' . Department Permit No. nUy P ent of Fire Services � 9 BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked tg �•` [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WO All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 52 CMR 1 00 RK (PLEASE PRINTW INK OR TYPE ALL INFORMATION) Date: �--/<5 F 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)_ 1 f14W I�Zy Owner or Tenant Owner's AddressTelephone No. Is this permit in conjunction with a building permit? yes No 6lp�'�=�G� �� ❑ (Check Appropriate Boa) 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:�Illy�� f . Com letion of thejbllowing table may be waivedby the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Sus No. of To gs. (Paddle) Fans talTransformers KVA . No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In_ o. o mergency ig g d. � Batte Units -- . No. of Receptacle Outlets No. of OR Burners FT��E ALARMS No. of sones ' No. of Switches No. of Gas Burners No, of Detection and Initis ' Devices No. of Ranges No. of Air Cond. T°+� Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number _ons ]KW p Totals: _ No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area p Heating KW Local❑M ' citi1 ❑OtherConnecon No. of Dryers Heating Appliances ]KW Security Systems: o. of WaterNo. of No. of Devices or E uivalent Heaters KW o. of Data Wiring: SiEll s Ballasts . No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total Hp Telecommunications Wiring: OTHER: No. of Devices or E uivalent Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) Work tort: Sta Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE OVERAGE: 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 BOND OT ❑ HE R ❑ (Specify:) (P I ceritfy, under the sins and enaltces o ��) P P fperjury, that the information on this application is true and complete FIRM NAME: G�cf/s' .� �- �j/up' —�i�r;"� �t ..4. LIC. NO.: ho Licensee: �, f Signature (If applicable, nter "exem t " i .the lice number line.) � LIC. NO.:,37 Address: P!! �,�ey /'''�5'fd�,✓� 11 Bus. Tel. No.:, f` *Per M.G.L c 147, s. 57-61, securitywork requires D AIL Tel. No.: Department of Public Safety "S".License: Lic. No. OWNER'S INSURANCE WAIVER; I am are that the Licensee does not havepe liability insurance coverage normally required by law. By my signature b ' I reb quirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Tehone No. �� ' i lep �. PERMIT FEE. �S 11" , "r M The Commonwealth of Massachusetts Department of Industrial Accidents �- O I ice of nvestigattons 600 Washington Street Boston,tA 02111 www.massgovldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Naive (Business/Organization/Individual): 46GE& L2 Address: /I" City/State/Zip:If/�i,� Phone #: ce5,.�7 Are you an employer? Check the appropriate bog: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t t A.. —i:. aL_ _L__ workers' comp. insurance. We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §.1(4), and we have no employees_ No workers' COMP. insurance required.] Type of project (required): 6. Q New construction 7. [aRemodeling 8. ❑ Demolition 9. ❑ Building addition 10. r_1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other - —�-rr_.--•-• -• -- ��-� �� .r, ,.,uo. wov Ani kim Ane seGuon De10w sn0wmg then' workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name: Policy # or Self4ris. Lie. #: 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. Ido hereby certify un r the pain�and Penalfies of perjury that the information provided above is true and correct a-3, Official use only. Do not write in this area, to be completed by city or; town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person: Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 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 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 apartiments 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 local licensing agency shall withhold the issuance or renewal`of a ficense 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-contractor(s) 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 cant' 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 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 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, Y 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 Reston., MBIA 0.2111 Teal. # 617-7274,900 ext 406 or 1-877-MAS.SAFE Fax # 617-727-7749 Revised 5-26-Q5 VV't�'W.1na&s.aov/dia Date ...... l.— I I- to ......................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... E ... i ... z, -,.v ...... ... . .... ....... has permission to perform ......... 7� ..... .................................... wiring in the bu ilding of ......... ........................................... at ........ / ..... X(V**./-lW ....... 5; . ........................... North A7ndaov r, Mass. FeeJ1.5 ......... Lic. No./V/4" . ..... .... .......... . ............. 'ELEerRICAL INSP c�OR Check # -52V 2- -7e 9198 �q�aa// Commonwealth ol //'%aachaaelb Official Use Only Acc� cc77 Permit No. ! < part~d of im SelUicei a Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) 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 IN INK OR TYPE ALL INFORMATION) Date: �/„7//0 City or Town of: Ale;2,/11 hj e%✓,7 To the Inspe for of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant Telephone No. Owner's Address / fi'T'/t S; ttJe:r i// A�s�v€i1 /✓!r"I: !�%�r/� Is this permit in conjunction with a building permit? Yes ❑ No 0� (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service /✓/q Amps / Volts . Overhead ❑ Undgrd ❑ No. of Meters New Service �dLj_ Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity V)Jl Location and Nature of Proposed EI ctrical Work: Completion of the folldwinQ table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o Emergency Lighting Ba* Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I 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 p Heat Pump Number Tons .... . . . KW ... ...... No. of Self -Contained Totals: Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances Kms, SecuritySystems:* Devices es or Equivalent No. of Water Kms, No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent I0 No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsNo. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: orA (When required by municipal policy.) Work to Start: /Z/ ? d Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE RAGE: 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 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: l6ee :�c S'fi�, LIC. NO.: / Licensee: 64014 [ dnZzAle Signature .AzLIC. NO.: Alh (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.:az -//I,/ Address: 21, &X5-,7 la . luo &G�L✓sr—t o If ., a.?%2/ 2/ Alt. Tel. No.: *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 a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $ r. I, I'C9 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 4 �s. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant. Information Please Print Legibly Name (Business/Organization/Individual):�,�: Ire —,1(116 �%'/�:,/11,?✓�S �f9� Address: 34 znsv7l,.ti City/State/Zip: % vd 90?; Phone 9�i3 -//C Are you an employer? Check the appropriate box: 1. 0 I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors Z. ❑ 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. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t workers' comp. insurance: 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.Q Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 5 Av1 'S V? gyr2 t -1,,S Policy # or Self -ins. Lic. #: 7-7-6 63 613,2,? Expiration Date: 11161116 Job Site Address: / 11-ZI-W . �� i 1e 1r11 f AJ1J ✓V .,,t City/State/Zip: /V,<FfTifMVr,,C /w ©/S/S� Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. : /A; 71 Official use only. Do not write in this area, to be completed by city or town offcciaL 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 #: 40 4 .'mla /' X'/�' - / Date.. . ............ . ............ TOWN OF NORTH ANDOVER PERMIT FOR WIRING T his certifies that ........ ........ ..... . .............................. has permission to perform .1 -4 ..... Z.9 .............. .............................. 1-4 wiring in the building of ....... ... ................. ....................................................... at./ ..... ......... North Andover Mass. Fee47S. .......... Lic. NoAll.9m ........... L PEKEri �c� i�s Check # ---Ivicas-� 9202 I V Commonwealth of Massachusetts Official use Only Department of Fire Services permit No.lip �,_t BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] leave blank ' APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code EC 527 CMR 12.00 (PLEASE PfiINT RV 1Ax OR .TYPE ALL INFORW TION) Dater City or Town ofa O V�-t fJ [�j-O DO UL—YQ,_ To the Inspector of Fires; By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) l Owner or Tenant : Telenhone No. Owner's Address: i. 1 l L C� Is this permit in conjunction with a building permit? Yes ❑No (Check Appropriate Sox) Purpose of Building: j� �� ty Authorization No, Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps Volts Overhead ❑ Und rd ❑ No. of Meters _ Number of Feeders and Ampacity vVUI - qO PVA Location and Nature of Proposed Ele'ethical Work: (�1 l - I'i' A - c -r ) Hill— A A No. of Recessed Luminaries ••s No. of Ceil.-Susp. (Paddle) Fans .cwoc mu ae waive" aY ine z!i eCiar a w[res. °� ° otal Transformers KVA No. of Luminaries Outlets No. of Hot Tubs Generators KVA No. of Luminaries Swimming Pool Above ❑ - El rnd. rnd. o mergeney g ng Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones N" ^r_e..;s^►1eS No. of Gas Burners o. of Ve'tection an Initiating Devices No. of Ranges No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers eat Pump Totals: I Number ons o. of SelfwContained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW muwc?' L1 Local Conne cion Other No. of Dryers Heating Appliances KW - Seem ity Systems: Ne. of Devices or E valent til No. o a er, Heaters o. o. of Signs Ballasts Data Wirin No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsWiring: No. of Devices or Equivalent OTHER: �+u"cis ""aruwrar act an'i aesrrea, or as regtarea by lite Inspector of Wires. Estimated Value f El ctrical Work: S � ti0 D (When required by municipal policy.) Work to Start: 1 O inspections to be requested in accordance with MEG 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 Z BOND ❑ OTHER ❑ (Specify:) Netherlands Ins. Co. 3-25-10 I certify, under the pains and penalties of perjury, that the utferm is on INK application is true and complete- FIRM ompleteFIRM NAME: Cranney Electric Co., Inc. LIC. NO.: Al 1918 Licensee: Brian rauney gnatureLIC. NO.: E25704 (if applicable, enter "exempt " in the license number line.) Bus. Tel. No.: t -97A-750-6900 Address: 10 Rainbow Terr., Danvers, MA 01923 Alt. TeL No." OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not hams the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement I am the (check one) ❑ owner 0 owner's agent. OwnertAgent Signature Telephone No. PERMIT FEE: $/ ; °- Date.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......... has permission to perform wiring in the building of ........ ......................... I ................... at ... ................. ........... North Andover' Mass. ............. Fee49 Lic. NA/ -279:7 . ........... Check # �.�t��CA� �:SIPECV 9036 Commonwealth of Massachusetts official Use Only Department of Fire Services Permit No.� BOARD OF FIRE PREVENTION REGULA Occupancy and Fee Checked TIONS [Rev. 1/07] (leave blank 'f 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 PRINTININK OR TYPE ALL IN F O RMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigried gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit?-C��J Yes No (❑ (Check Appropriate Boz) Purpose of Building nUtility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters New Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters Number of Feeders and. Ampacity Location and Nature of Proposed Electrical Work: -- --•- �.u. Estimated Value of Electrical Work: y utuireu, or as required oy the Inspector of Wires. 56 ` - � (When required by municipal policy.) Work to Start:`� VE Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C GE: 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 e BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury, that the information on this application is true and complete - FIRM NAME: �iV , _:Gly (CAI— LIC. NO.: Licensee:l[lC (..t? i s Signature ; LIC. NO.: (f I apP ' licable, enter "exempt in in the license number line.) ' Bus. Tel. No.: '72 u Address: `��1S i'�>a ��t�''n S i , u i.i i`T 1 e 4.. �. l � —G`'- I' Alt. Tel. No.: ?Z i *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 Signature Telephone No. PERMIT FEE: r 4 2 17-d �� 73 -119 - [C) The Commonwealth of Massachusetts k� ! Department of Industrial Accidents Office of Investigations illy 600 Nrashington Street `.a�tt i Boston, MA 02111 www.nzdss.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plambers Aliplicant Information Please Print Le -Aly Naive (Business/Orgwization/lndividual): Address: City/State/Zip: Phone #: . Are you an employer? Check.the appropriate box: 1. ❑ I am a employer with 4. ❑ I 2.0 employees (full and/or part-time).* I am.asole proprietor or partner- ship and have no employees working for me .in any capacity. [Na workers' comp. insurance required.] I am a homeowner doing all work myself. [No-worke'rs' comp. insurance required.].t ►An ..1:.... .z_. am a general contractor and I have hired the sub -contractors listed on the attached sheet x These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 1.52, § 1(4), and we have no employees. [No workers' comp, insurance required_] Type of project (required): 6. Q New construction 7. ❑ .Remodeling 8. Q Demolition 9. Building addition 10. ❑ Electrical repairs or additions 11.[] Plumbing repairs or- additions 12.M Roof repairs 13.❑.Other nu out Inc section below showing their workers' 'compensation policy information. r Homeowners who submit this affidavit indicating they are daring 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 acme of the sub -contractors and their workers' comp. policy information. lam an employer that is.providing:workers' compensation h2surancefor IM employees: Below is the inforpolicy and job site . mation Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip.- Attach ity/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 certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date Phone #: Official use only. Do not write in tits 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. Plum 6. Other bing 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 including the legal representatives of a deceased employer, or the receiver or t mstee,of an individual, partnership, association or other legal entity, employing employees. 'However the owner of a dwelling house having not more than three apartments and who resides therein; or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance'coverage required." Additionally, MOL 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 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, 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 nurnber listed below. Self-insured comoanies should enter their self insurance license number on the'appropriate line. City or Town Officials Please be sure that the affidavit is complete acid 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 vvilI be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating -current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT. required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-9.77-NIASSAFE Revised 5-26-05 Fax # 617-727-774§ www.mass.gov/dia ,, 9698 U, Date ..... Ao- 12- — 1'e? ............................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... t— ........................................................ .......... has permission to perform .......................................................... wiring in the building of ......... een.,V.4� .................................... at ........... / ...... 11�,K ............................... .. North jUdover, Mass. Fee .... No./J./7A)f ................. .... Check # -�0177 EATIUCAL INSPECMR <C\ Commonwealth of Massachusetts Official Use Only Permit No.tC A Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] leaveblank 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 IN INK OR TYPE ALL INFORMATION) Date: 10-7-10 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) One High Street 2"d and 3`d floor Owner or Tenant Converse Owner's Address same Is this permit in conjunction with a building permit? Purpose of Building Small office renovation Existing Service Amps Volts New Service Amps Volts Number of Feeders and Ampacity Telephone No. Yes ❑ No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Location and Nature of Proposed Electrical Work: Small office renovation; installing 8 outlets, lights existing add 1 furniture whip feed Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In -1:1 rnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets 8 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches 2 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 Pump Totals: Number Tons 1.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 Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: ASAP 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the inform ' on this application is true and complete. FIRM NAME: East Coast Electrical LIC. NO.: Licensee: Robert Walker Signature LIC. NO.: 17176A (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 978-692-3232 Address: 2 Lan Drive Westford Ma 01886 Alt. Tel. No.: *Security System Contractor License required for this work; if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $125.00 lfJ. /z- 1C2 L b_ 9/, -moo /a -z- 96bl Date TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... has permission to perform ... wiring in the building of ... ,� .......................................... at../ .... NorthAhdove�r,,Mass. Fee/!�:�� ..... Lic. No ECM16��' �4SP Check # _ Permit No. i Department of Fire ServicesOccupancy and Fee Checked r BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank) 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 Townof- N®RT H[ notice of his or ANDOV ER To the Inspector of Wires: below. By this application the undersigned gives her intention to perform the electrical work described Location (Street & Number) z ze>/ Telephone No.+ xi 7.1&I Owner or Tenant 4cwvz^ ' Owner's Address65 �7/ Is this permit in conjunction with a building permit? Yes F] No l (Check Appropriate Box) Purpose of Building 617'z;�, Utility Authorization No. Existing Service Amps %i A Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps J Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity 1/01 Location and Nature of Proposed Elect ical Work:'�Mt' �11i�� sa>zI 3a2 VAP%c1r� ct''iYs'=-eFecL A,104 Ce sz�, ?� � aN� 1 acn rrs �, �z<v ��t� �'— d > �-f zs czar 4b f I 9 /� ' 4 �i' L Completion of the following table may be waived by the Inspector of Wares No. of Recessed Luminaires No. of Ceil.-Susp No. of Luminaire Outlets No. of Hot Tubs No. of Luminaires Swimming Pool No. of Receptacle Outlets No. of Oil Burn( No. of Switches No. of Gas Burn No. of Ranges No. of Air Cond No. of Waste Disposers Heat Pump Totals: u N No. of Dishwashers Space/Area Hea No. of Dryers Heating Appliai No. of WaterNo. Heaters KW of Si ns No. Hydromassage Bathtubs No. of Motors OTHER: (Paddle) Fans Transformers KVA Generators KVA ❑ In�,-- IAo. of x.merg „a ❑ RattervUnits ;rs FIRE ALARMS I No. of Zones No. of Detection and .ers Initiating Devices Total No. of Alerting Devices Tons iviwnicipai Other ting KW 11 Local ❑ Connection ices KW No. of Devices No. of Data Wiring: Ballasts No of Devices or Equivalent Total HP I No. of Devices or `%•14ttach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: � i°� (When required by municipal policy.) ' Work to Start: t Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C V RAGE: 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 0— BOND ❑ OTHER ❑ (Specify:) X certify, under the pains and penalties ofperjury, that the information on this application is true and complete. " LIC. NO.: A44 -LI, NAME: J4 l f e Licensee: &),4t —e-Ccs✓C ft►( Signature (If applicable, enter "exempt" in the license number�line) Address:/ lrf',/L+� _ LIC. NO.: Bus. Tel. NO.:-�u) t Alt. Tel. No.: *Per M.G.L c i 47, s. 57-61, security work requires Department or ruonc 0-ov 0 Lluvu— 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 Owner/Agent Telephone No. PERMIT .FEE. $Si nature g I G r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Ll Please Print mbers ibl Applicant Information Name (Business/organization/Individual): Address: 3e fss"' vv City/State/Zip: G y ��d l Phone #: KV4 ") Are you an employer? Check the appropriate box: 4. ❑ I am a general contractor and I 1. [A'I_am a employer with employees (full and/or part-time).* have hired the sub -contractors listed on the attached sheet. 2. ❑ I am a sole proprietor or partner- These sub -contractors have ship and have no employees working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5• E] we are a corporation and its officers have exercised their required.] 3. F1I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no employees. [No workers' insurance required.] comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. E] Building addition 10.❑ Electrical repairs or additions 11. E] Plumbing repairs or additions 12.❑ Roof repairs 13.0 -Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �' % h'u ' ✓€� �' Policy # or Self -ins. Lic. #: Expiration Date: �a Job Site Address: 01 %�'� l�"i /V�'��' 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 certify under the pains andpenalties of perjury that the information provided above is true and correct. 6) 1 Gly% 3 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone 9 5 1 Date ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING PC VEZ-C, --a- This certifies that .......................... ...... has permission to perform . ..... ..... ...................................................... wiring in the building of ....... ......................................... ... ... ....... ...... .. .. ...... at ................. / ............... ......... North Andover, Mass. Fee.(. Z.' ............ Lic. No. .. ......... vl�.i ............. �2z Check 4t // 7P 0 A r� Department of Fire Services Permit No. 7 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leaveblank 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 IN INK OR TYPE ALL INFORMATION) Date: ?- - \ g - ID 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) \ �a'� cx�. �� '7.,%,,, �-\,r Owner or Tenant C-L-,V\-\.7Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building C)%S�2, ` Utility Authorization No. Existing Service Amps Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Completion of the following table may be waived by the Inspeckr of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. rnd. o. o Emergency ig mg 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 Pump Totals: Number ........................................................... 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 Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP7-1 Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: aC)Cj (When required by municipal policy.) Work to Start: -3 - n . 10 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under k pains and penalties o perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: A k3�93 Licensee:��e��Wha Signature LIC. NO.: _ 5 1 (If applicable, enter ` xemptin the license number line. Bus. Tel. No.• -) R1 - }b -a9 L Address: �Oen�tc ,A\- ��V rUCX), Alt. Tel. No.: 611 - al J.- J a3 ) *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 Owner/Agent PERMIT FEE. $ Signature Telephone No. w y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): , �t �c 5 �` ee� r`. QcA�S CA-, Address:+, r� `� •� 1 City/State/Zip: b33`-llPhone I Q) C Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. � We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. [Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. [1 Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: ,; Job Site Address: Expiration Date: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). yFailure 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 cCblKloll� '�Oe pains lties of perjury that the information provided above is true and correct. Signature: �( Date- a� - l9 — i 0 Phone #: " - 1 - a -C )� - aqq L Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone BURT , H ILL Date. 3. /A. TOWN OF NOk,�TH NDOVER PERMIT FOR PLUMBING This certifies that ..................... has permission to perform .. IA–. 777:--�.4-k/.: .......... plumbing in the buildings of . . .61AI. �-. :I�a S.—C ................ at ... .................. North Andover, Mass. 0 C—. 11 Fee. �./J7—Lic. No.. ......... ....... P UMBING INSPECid'R Check # Z' MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO. DO PLUMBING (Print or Type) /� , Q✓at�/clj�`e/ MA Date 3 20/0 Receipt#Permitil Building Loca ✓ A;94 S7 Owner's Name CO�✓l/�slr�. ___-___ Map: Lot: / Zone: Type of Occupancy C O o—Z" New ❑ RenovationX Replacement ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES Installing Company Name DAN -CEL CO. INC. Check one Address gRAWFORD ST WATERTOWN,MA. �'I Corporation Estimate Valueof Work: _ ❑ Partnership Business Telephone 617 923 1011 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter_DANIEL B CELLUCCI Certificate 398C INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes U No ❑ If you have checked y s, please indicate the type coverage by checking the appropriate box. A liability insurance policy)U Other type of indemnity ❑ Bond ❑ 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. Checkone: Owner ❑ Agent Q Signature of Owner or Owner's Agent I here�y certify That all cf the detail and information I haye submitted (or entered) in above application are true and accurate to the best of M knowledge -'and that-all-plumbing'xork and installations pertormed under tha permit issued fnr this application will'be in compliance with all pertinent provisions of the Massachusetts State Plumbing and Chap 2 �fe �al Laws. ! By- -- ---- -- SignatureofLicense Plumber Title Type of License: Master 0 Journeyman ❑ City / Town _ _ APPROVED (OFFICE USE ONLY t License Number hR57 Revised 05)17/00 bion �iiiiQiiiin iiiioiiii ::::B::�MMMMMMMMgEee ��a::e=eeeime�a Installing Company Name DAN -CEL CO. INC. Check one Address gRAWFORD ST WATERTOWN,MA. �'I Corporation Estimate Valueof Work: _ ❑ Partnership Business Telephone 617 923 1011 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter_DANIEL B CELLUCCI Certificate 398C INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes U No ❑ If you have checked y s, please indicate the type coverage by checking the appropriate box. A liability insurance policy)U Other type of indemnity ❑ Bond ❑ 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. Checkone: Owner ❑ Agent Q Signature of Owner or Owner's Agent I here�y certify That all cf the detail and information I haye submitted (or entered) in above application are true and accurate to the best of M knowledge -'and that-all-plumbing'xork and installations pertormed under tha permit issued fnr this application will'be in compliance with all pertinent provisions of the Massachusetts State Plumbing and Chap 2 �fe �al Laws. ! By- -- ---- -- SignatureofLicense Plumber Title Type of License: Master 0 Journeyman ❑ City / Town _ _ APPROVED (OFFICE USE ONLY t License Number hR57 Revised 05)17/00 I NO m IO z y IN 14 z ` T x O 7D m > m 1m 11 V N v N T � V _r o n 1 m O t m z I r m O T o T _� o a a V O y ,On m o c o rA O m A O > z �o r T � z A ` x O 7D m N N 2 N T m n 1 Z t I Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............. �EIL5 ....... 7 .............................. has permission to perform ....... d4..g L Z��.7 -- P ................................. wiring in the building of ............ .................................... at ............... / ...... ....... �= ..................... . North,�kndove' , Mos. Fee./ Lic. No..A�3..ov.73. ......... I ECTOR 'POCAL iiip Check # 9387 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. _ 7 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked 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 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) Owner or Tenant _ „�rS Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes ® NO E] (Check Appropriate Box) Purpose of Building e C . � i ° N Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters _ New Service Amps ____L_Volts Overhead ❑ Undgrd ❑ Numb f F No. of Meters er o eeders and.Ampacity Location and Nature of Proposed Electrical Work: R No. of Recessed Luminaires Completion of the ollowin No. of CeiL.-Sus p. (Paddle) Fans table may be waived by the Inspector of Wires. 0.0 Total { No. of Luminaire Outlets No. of Hot Tubs Transformers "TA Generators KVA No. of Luminaires Swimming Pool Above Im- d• ❑ ❑ o, o mergency —Igg --, No. of Receptacle Outlets d. No. of Oil Burners B atte Units FIRE ALARMS rlo °f Zones No. of Switches No. of Gas Burners No. of Detection and No. of Ranges No. of Air Cond. °tal Initiatin Devices Tons No. of Alerting Devices No. of Waste Disposers eat Pump Number Tons _ _ _.___.__ .__ . K.—W—Totals: No. of Self -Contained No. of Dishwashers Space/Area Heating. KW Detection/Alertin Devices Local ❑ Municipal No. of Dryers No. of WaterNo. Heating Appliances KW Connection Other Security Systems:* No. Devices " Heaters KW of No. of of or Ram—lent Data Wiring: No. Hydromassage Bathtubs Si s Ballasts No. of Devices or E uivalent No. of Motors Total HP Telecommunications Wiring: OTHER: of Devices or Equivalent Estimated Value of Electrical Work: i,,> tJ G Attach additional detail tf desired, or as required by the Inspector of Wires. Work to Start (When required by municipal policy.) -5 - - 1 y 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 R BOND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenalties ofperjury, that the information on h' application is true and complete. FIRM NAME: Licensee: �i Signature LIC. NO.: %3 . (If applicable, enter ` em t " in the license number line.) ^ LIC. NO.: Address: ,� �- .1� �a �� . X v `U �? U Bus. Tel. No.: -)-PI )-C7 -)_q4( *Per M.G.L c 147, s 57-61, security work requires Dty Alt. Tel. No.: 6-j a d =SaT-E OWNER'S INSURANCE WAIVER: I am aware that the Department a doles not ehave 1 the liability Lic. No. required by law. B m signature y q ty insurance coverage normally By y gnature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent Owner/Agent Signature Telephone No. PERMIT FEE: $ I H N The Commonwealth of Massachusetts Department of Industrial Accidents Office oflnvestigations _600 Washington Street Boston, MA 02111 www.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibiy Name (Business/Organization/Individual):_211 Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate bog: 1. ❑ I am a employer with 4. ❑ I am 'a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. I 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.] 3. ❑ I am a homeowner doing all work officers have exercised their 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.) - — --.-- .-...• ......�....,vn -. — n:JV ill: QUI CCe $-=on oeinav ShOlvI n :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 12.0 Roof repairs 13.❑ Other t Homeowners who submit this a`'davit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: A 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 ' urance coverage verification. I do hereby a un t ins a d pen tie pe rj that the information provided above is true and correct Si ature: _ I v Date: � - Phone Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other 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 including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the . dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, 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 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, 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 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 permittlicense 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 r 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 homeowner 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 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 fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-72.7-4900 ext 406 or 1-877-NIASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.govfdia ..... .. .... ..... ......... 0-0"I " -I TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............. ....... b . . . . . . . . . has permission to perform .... . 6nr/-./A0Pf .................. ..................... . ..... .......................... wiring in the building of ......... ....................................... .at .......... / ...... ..... :� .................................... .. Nprth Andover, Mass. ic. N 1.2-6.V�V ................... Feel ................. 0 . ...... ..... ..... . ........... .. ........... i ...... ELEC+RICAL INSPECMR Check 8162 [Iy `%--...nffwrwCdlLn or Massachusetts Official UseOnlyRF" Department of Fire services Permit No. 62- BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked v. '1/07] (leave blank 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 W WK OR TYPE ALL W OPUL4TlON) Date: a �� City or Town of: NORTH ANDOVER To the inspector of Wires: By this application the undersi notice of hor invention to Location (Street &Number perform the electrical work described below. / Owner or Tenant/ t 7-®p /047,p—_�byl 1 d -2r••• �--t✓ Telephone No. Owner's Address Is this permit in conjunction with a building permit?.�► Purpose of Building, yes g No ❑ (Check Appropriate Boz) '�� ! 9 Utility Authorization No. Existing, Service Amps / Volts Overhead ❑ Undgz•d � No. of Meters New Service Amps / Volts Overhead ❑ Underd El No. of Meters Number of Feeders and Ampacity " iafaiou and Ngture of Proposed Electrical Work: Completion of the folio "n table may be waived by the Inspector of tiYires. 9 PNo. Recessed Luminaires No. of Cet1.-Suis No. of p. (Paddle) Fans Total Luminaire Outlets Transformers KVA No. of Hot Tabs Generators KVA 3 No.Luminaires ,� Swimming Pool Above ❑ in_ o. o mergency �d d ❑ Batte Units r Receptacle_ OutletsNo. of OR Burners JP FIRE ALARIMS jNo: of ?ones Nn. of Switches Nn. of Gas Bug.o. o Detection and No. of Ranges Total Wtta Devices g No. of Air Gond'_ Tons No. of Alerting Devices No. of Waste Disposers eatPumPNumber Tons Nn, of e1fContained Totals: Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local ❑ Mnnicipal No. of Dryers g�� A Connection ❑ Other Heating Appliances KW Security Systems..* Nn. of Water N Heaters KW o. of No. of No. of Devices or E uivalent Si s Ballasts . Data Wiring: No. H dromassa a Bathtubs No. of Devices or E uivalent y g No. of Motors Total HP Telecommunications Wiring: OTHER: No. of Devices or E atvalent Attach additional detail if desired, oras required by the Inspector of Wires. r Estimated Value of Electric Work: ��_ Work to Start(When required by municipal policy.) U Inspections to be requested in accordance with MEC Rule 10, and upon coletio mpn. _ 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 CHECK ONE: INSURANCE Bpm exhibited proof of same to the permit issuing office. T cerfify ❑ OTHER ED (Specify-) , under the pains and penalties of perjury, that the. infortn FIRM NAME: ation on this application is true and complete ��-/ Licensee:lg:aatare /1,tgh %%(i S LIC. NO.: 6 (If applicable, enter "eze n ' in 1� license nu er_� lji je.) .ems/_ LIC. NO.: Address: Bus. Tel. No.- Oj 9417- 07yj *Per M.G.L c. 147, s 57-61, security work SS% Alt. Tel. No.:requires Dpment of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage.normalIy required g law. By my signature below, I hereby waive this requirement I am the (check one) ❑ owner ❑ owner's aged Owner/Agent Signature Telephone No. PERMIT FEE: $ d The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www masSgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lepibiy Name (Business/Organization/Individual): i Address: 31 � a EATU,+ City/State/Zip: O.A1 Phone #: Are y an employer? Check the- appropriate bog: 1. Ir 1 am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet $ ship and have no employees These sub -contractors have j 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 t)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. F1 Building addition 16lectrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof, repairs 13. ❑ Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information: f Homeowners who submit this affidavit indicatink they are doing all work and then hire outside contractors must submit a new affidavit indicating such. teontractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am- an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: P' a: G), Policy # or Self -ins. Lic. #: t'0 Expiration Date: Job Site Address: �� V� City/State/Zip: (�h,�OVtrM, Attach a copy of the workerscompensation policy declaration page (showing the policy number and expiration. date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify undeer tth, a pains and penalties of perjury that the information provided above is true and correct '..a f soS Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #i n 41 TRW 90;4 S* us ate. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that 4A (. 4—. Py. ......... has permission to perform .... R --f ................... plumbing in the buildings of L.---( I's.- ................ -th Andover, Mass. at ..... �!. A/ / I .................... Not Fee.3s-'I.. �Lic. No.. ........ . .. PLu 6 ING INSPECT(rR Check # 172L? 7739 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (please type or print) Alny A i'Jamer Mass. Date: 9%1L IDe Building Location: _�h�� Permit:_? 3_ MN Av ., Owner's Name: Nt•: k Dat,,, ----2 -1,3 - "-� .......................... 7 TOWN OF. NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that .............................................................................................. has permission to perform ................................. wiring in the building of .... ............................................... at ......... ....................................... . ............ . North Andover, Mass. 4? .......... .......... Fee ........... Lic. No . ....... ...... ..... . ..... ICAL INSPB&MR Check# -?z, 7210 E 0 o 'D co E 0 'D 010 0 'D H N 0 E o w 0, LL: 0 0 0 0 a! 0 cp m 0 m M CL U CL > 0 C, 0 a: _V Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked /a15 BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] (leave blank) 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 IN INK OR TYPE ALL INFORMATION) Date: 1'—e / 3 City or Town of. NORTH ANDOVER To the Inspector of ices: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) / /�iLjlSY!!Lve 7— Owner Owner or Tenant ee liZO& S L JJ Telephone No. �78 • Owner's Address / Ski -1/N4o Up4 Is this permit in conjunction with a building permit? Yes EJ No, ❑ (Check Appropriate Box) Purpose of Building �i4xle `e 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: Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool rnd. ❑ rnd. ❑ o. o Emergency Lighting 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 g No. of Waste Disposers Heat Pump Totals: Number Tons KW No. o 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 Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or E uivalentaO-u No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalentC4 OTHER: Attach additional detail if desired, or as required by the Inspector of Rires. Estimated Value of Electrical Work: /!�7k (When required by municipal policy.) a� Work to Start,g�'p/3,x$7 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: S LIC. NO.: Licensee: Signature LIC. NO.: (If applicable, enter "exempt" in the License number line.) Bus. Tel. No.: Address: Alt. Tel. No.: *Security System Contractor License required for this work; if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, 1 hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ,9) ��j enc :1 2, • 7 7,00,9f-�7* The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 o J www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 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. ❑ 1 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 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Job Site Address: Expiration Date: 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 certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: -TOWN OF NORTH ANDOVER PERMIT FOR WIRING Ll J; A a ibis certifies that ................................................................................ 11A. has permission to perfo . ...... ... ..... ....................................... wiring in the building of .... �.-. A�, -:�- -e 0,o V t S C — - ...................................................... at ....... 6&� ....... North Andover, Mass. Fee./ .. . .. ..... Lic. No. ... .................. ELEcrR icAL INSPEC*)R Check # 7996 71 Commonwealth of Massachusetts official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank 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 IN INK OR TYPE ALL INFORMATION) Date: JAV6k City or Town of: NORTH ANDOVER To the InsA ctor of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant �f 0A. Vf/CS'P Telephone No.CLFI WS -,m/ Owner's Address / 12b Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building 6/'�e4 Utility Authorization No. Existing Service lY/f Amps New Service Amps Number of Feeders and Ampacity Location and Nature of Proposed Volts Overhead ❑ Undgrd ❑ No. of Meters Yolts Overhead ❑ Undgrd ❑ No. of Meters Work: Aa P-162 7r. , I ^F �f,-/1-4 AJ z_- No. of Recessed Luminaires -- •- ----�• •••� No. of Ceil: Susp. (Paddle) Fans .. n.uy uc W"Ima Uy Ine Ins eczor of Wires. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. grnd. o. of Emergency Lighting 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 InitiatingDevices No. of Ranges No. of Air Cond. Tons IDetection/Alerting o. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KWo. of Self -Contained Totals: Devices No. of Dishwashers Space/Area Heating KW Local El [ Connection--]Other Connection No. of Dryers Heating Appliances KW Security D No. of Water aeaters No. of No. of tio. vices or Equivalent KW Signs Ballasts Data Wiring: No. of Devices or Equivalent 4do No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications iring: No. of Devices or Equivalent OTHER: . aAttach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: AD (When required by municipal policy.) Work to Start:,? d Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C GE: 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 0" BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: 'L� C LIC. NO.: Q lR Licensee: 4)Az;V 1 o iyez,4.f Signature LIC. NO.: c/!c— (If applicable, enter "exempt 11 in the license number line.) Bus. Tel. No.: Address: 2Z GI £S :fyv �'� ,ys� .; CIi, ,11 - Alt. Tel. No.: *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 Signature Telephone No.PERMIT FEE. $ Q" � t ti� r. r i lur l ! `Mf The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 { www.nxass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant Information Please Print Legibly Name (Business/Organization/individual), Address: _?t'_ City/State/Zip: C1211AX'i6kf ;/� 1 6292/ Phone #:4,61)1 It I/,/V Are you an employer? Check the appropriate box: L (-i am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a.sole proprietor or partner- listed on the attached sheet t ship and have no employees These su&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. D I am a homeowner doing all work right of exemption per MGL myself. tNo workers' comp. c. 1.52, § 1(4),r and we have no insurance required.] t employees. [No workers' comp, insurance required..] Type of project (required): 6.❑Zodeling construction 7. 8. Q Demolition 9. Q Building addition 10.0 Electrical repairs or additions 11.Q Plumbing repairs or additions 12. Q Roof repairs 13.❑ Other -Any applicant that checks bort #I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are daring all work and then hire outside contractors must submit a new ai-iidavit indicating such. lContraetors drat check this box must attached an additional sheet showing the name of the sub -contractors and their worker;' comp. Policy information. I ant an employer that .is providing workers' compensation insurance for my employees. Below isthe policy and job site information. Insurance Company Name: 12t1wax-c es u Policy # or Self -ins. Lic. #: l _# U/i 513 / 7 t .2 Vs? Expiration Dater 6 6 /'H Job Site Address: A C' dT& ,�&Lfa 4,4 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 $4500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct Sigrtature: Date: n7//,3 %d,P Official use only. Do not write in this area, to he 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 #: 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 ofthe'foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. 'However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence at 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 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, 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 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 permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating,current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of'the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a 'valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call.. The Department's address, telephone and fax number, The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Faxl# 617-727-774 www.mass.gov/dia Dat TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .7�. ............ has permission to perform ................... plumbing in the buildings of )-.-r .................. at .... /. -th'Andover, Mass. ......................... Not Fee 149,�! Lic. No. PLUMBING INSPEdo� Check # 7663 Jo2 MASSACHUSETTS; UNIFORM APPUCATfON1 FOR PERMIT TO DO PLUMBING iPt m or Type) IN To Date 2a� Permit Budding Location Owners Name &&Y -4L A-V, dulxxl - m.e� Type of Occupancy_ C?-1=-�}-T r-�— New Q Renovation 00' ReplamnerTt O Plans Submitted: Yes O No O FIXTURES InsWfg any Name� 6,/it—_4 we c T Check One: Certificate Addren �. P �A V �I 4J c� ✓ O Corporation 'j0Ef Lira -1 c��ti. 0 c.s ❑ Partnership Business Telephone t_ ati'LR - 2 _ O FkWCo. Name of Licensed Plumber _� CAJ o c_S �,:� [i+lr+n C/ INSURANCE COVERAGE: 1 have a <xs<rer� kTs�ance polky a Rs sututarelat equivelerd whkh meets the req kements of MGL Ch. 142 Yes U1, No O If you have checked yes. please the type covaw by the appropriate book.. A liability kamrance pd Other of Md O Bond O �Y type Y OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the kis once coverage mquked by Clapter 142 of the Mass. General laws, and that my signature an this permit appkadw Wahres this req *anent. Check one: Owner O Agent O . 1 lure at Owner or Owner's Agent 4. I hereby certify flat all of the details and ir"nutim I law mbrrTfitl b!wfedps and MA Ai pg wWork WW*UWW ra vedQ!�d-4 patinerTt ProMisions d the Massactuueas State Fkm*i g Cbm and ) in ab6ra application we live ud accurate to the gest of my nit1'ssuee for trTis ----------iv4belnC0MP68ftWWM&1 of the Geiieral•�aiwi TAIe Type of I ioenw: MasW LT Jouineys�wi•❑ 11 -AJ, a WUM Date ...... ... .... . .. ... ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ........................................ .............................................. has permission to perform ....... .. 7?,.,2 'e= ........ .................................. .............. P tv Ve /2 S"�f- - wiring in the building of ........ .................................................................... at ........... e ... -... 9 /1 M ..... �.7— .. ...... ................................ . North Andover, Mass. 411& / Z AZI "!52 Fee .... /.�� ....... Lic. No . ....... f,4 ... .................. ...... ELEcTRicAL INSPECTOR Check H,? 412 7997 Commonwealth of Massachusetts Official use Only Department of Fire Services Permit No. 2 9l �? 7 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/991. leave blank 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 IV INK OR TYPE ALL INFORMATION) Date: j of City or Town of. �e� Nmdd.r�i� To the Inspector of Wires. By this application the undersigned gives notice of his` or her intention to perform the electrical work described below. A Location (Street & Number) (� {��/ Owner or Tenant Cts t\NfeLSe-=:::f Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No (Check Appropriate Box) Purpose of Building Cfj mmP-� t ct\ 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: _�-��- Com letion o the. following table may be waived by the Inspector of Wires. No. of Recessed Fixtures No. of Ceil.-Sus (Paddle) Fans p• No. of Total Transformers KVA No. of LightingOutlets No. of Hot Tubs Generators KVA No. of Lighting Fi=res ,. Above❑ ❑lNo. Swimming Pool rnd. grnd. oEmergency Lighting Battery Units l No. of Receptacle Outlets I No. of Oil Burners FIRE ALARMS No. of Zones' No, of Switches No. of Gas Burners No. o Detection and.Initiating Devices No. of Ranges No. of Air Cond. Tons! No. of Alerting Devices /0 No. of Waste Disposers P Heat Pump Totals: Number Tons No. o e! ontained. Detection/Alerting Devices No. of Dishwashers S ace/Area Heating, KW P g Local ❑ Mumectio ❑ Other, Connection No. of Dryers Heating Appliances I{yy Security Systems: No. of Devices or Equivalent No. o atero. Heaters, KW o o. o Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring:. No. of Devices or Equivalent OTHER: .Attach additional detail if -desired, or as required by the Inspector OJ wires. 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: 1NSURANCE`(�—BOND ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical Work- Ik VO 00 (When required by municipal policy.) Work to Start:' Inspections to be requested in accordance -with -MEC Rule 10, and upon completion. 1 certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: S. Donnelly Electr-1c., Ine. ..I.. LIC. NO.: 12549A Licensee: Steven Donnelly- Signaru � 'l� LIC. NO.: 23980E 7japplicable, enter ..etentpt - in the license num�ber rine.)) Bus. TCL No.. 8-9 t— 7 417 Address• 31 Bedford Street, Lakeville,NA 02347 AIL Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not henle tiie liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement I ani the (check one) ❑ owner ❑ owner's a ent. Owner/Agent - -- F or; DA rr-r t; >; C. c f�K J- eg� 3--Ze—,egg it/ y The- Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contracfors/Electricians/Plumbers Applicant InformationPlease Print Leei V Name (Business/Organization/Individ(u�ai)': 1 c, Address: �� t� EATe.-+ City/State/Zip: O1 Phone #: 1,3' an employer? Check the�appropriate bog: ArZ�I 1. am a employer with 4M_ . 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. � ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. ,1 [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 rays elf. [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. Q Demolition 9. Building addition I O$Mectrical repairs or additions= 11.0 Plumbing repairs or additions 12.E Roof. repairs 23.0 Other *Any applicant that checks box #1 must also fill outthe section below showing their workers' compensation policy information: t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information I amt an employer that is providing workers -compensation insurance for my employees.. Below is the policy and job site, ; .. .. . information.. ' Insurance Company Name: G), Policy # or Self -ins. Lic. #. Expiration Date: 60, 1Q, 68 Job Site Address: h City/State/Zip: N o �,m�,.. Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration. date):. Failure to secure coverage as required under. Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a. fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the.Office of Investigations of the DIA. for insurance coverage verification. I do hereby certify under the pains, a,�nd penalties of perjury that the information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health Z. Building Department 3: City/Town Clerk 4, Electrical Inspector 5. Plumbing Inspector 6. Other Contact -Person: Phone Date ........ 3 ......... F-!��.7. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .4491,.0,A4R2.,V7A- ra. I E'471�0-4 r C- e- r- .................................................... has permission to perform ........ ........ wiring in the building of ....... ....................................... at .............. / ........ 1q. ...... ...................... . North Andover, Mass. Fee ... /1�� ....... Lic. No. ........... ELECETRICAL INSPECTOR Check 4 7240 "` The Commonwealth of Massachusetts Office Use Only Permit No. Department of Public Safety Occupancy &Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 ,i 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts -Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPEALL INFORMATION) Date FEBRUARY 19 2007 City or Town of NORTHANDOVER To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) ONE HIGH ST Owner or Tenant CONVERSE Owners Address same Is this permit in conjunction with a building permit: Yes❑ NoE Purpose of Building Office Utility Authorization No. Existing Service Amps Volts Overhead Undgrnd❑ New Service Amps Volts Overhead Undgrnd Number of Feeders and Ampacity Location and Nature of Proposed Work OFFICE FURNATURE RECONFIGURATION (Check appropriate box) No. of Meters No. of Meters No. of Lighting Outlets No. of Hot Tubs Total No. of Transformers KVA Above in - No. of Lighting Fixtures Swimming Pool rnd rnd El Generators KVA No. of Emergency Lighting No. of Receptacle -Outlets No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and No. of Ranges No. of Air Cond. Total tons initiating Devices Heat Total Total No. of Disposals No. of Pumps Tons KW No. of Sounding Devices No. of Self -Contained No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices No. of Dryers Heating Devices KW Local Munic. Conn. Other No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring\ No. of Hydro Massage Tubs No. of Motors Total HP Other: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws: YES NO ® I have a current Liability Insurance Policy Including Completed Operations Coverage or its substantial equivalent. r YES NO I have submitted valid proof of same to this office. If you have checked YES, please indicate the type of coverage by checking the appropriate box: 1 INSURANCE Q BONDQ OTHER[-] (Please specify) Aon Risk Services, Inc. of Mass 4-1-07 .�I Expiration Date Estimated value of electrical work $ NOT TO EXCEED 20,000 Work to start 2/26/2007 Inspection Date Requested:Rough Ces will call Final Ces will call Signed under the penalties of perjury: FIRM NAME Consolidated Electrical Services LIC. NO. Licensee Lawrence D. Pantano Signature LIC. NO. 17502A Address 661 pleasant Street, Norwood, MA 02062 Business Telephone No. 800-742-7240 Alt nate Telephone No. (781)769-7110 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not havdhe i urance coverage or it's substantial equivalent as required by Massachussets General Laws, and that my signature on this permit application gives this requirement. Owner []Agent (check one) Permit Fee $ 125.00 (Signature of Owner or Agent) Telephone No. IN Date ..... 7 ............................ TOWN OF NORTH ANDOVER -vow PERMIT FOR WIRING This certifies that ...... CO/V60z, .......................................... ...................... has permission to perform ..... .......................................................................... wiring in the building of ......... 4�vy&:.'e.s'g ....................................... ............... at ........... 5.>� ..................... North Andover, Mass. f2- Lic. No..j..7 5 io 1- 14 Fee. ......... ....... ....................................... ........ ... ELECTRICAL INSPECTOR V Check # 7231 4 The Commonwealth o Massachusetts Ofr se Only f 1 Permit No. Z� Department of Public Safety Occupancy & Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts -Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) City or Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) One High Street Owner or Tenant Converse Owner's Address same Is this permit in conjunction with a building permit: Purpose of Building Office Existing Service New Service Number of Feeders and Ampacity Location and Nature of Proposed Work Amps Volts Amps Volts Office renovations Date Febuary 20 2007 To the Inspector of Wires: Yes❑ No[R] (Check appropriate box) Utility Authorization No. Overhead Undgrnd❑ Overhead Undgrnd❑ No. of Meters No. of Meters No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures 11 Swimming Pool Above In - rnd rnd Generators KVA Receptacle -Outlets No. of Rece P 10 No. of Oil Burners Ba of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones Ranges No. of Ran g No. of Air Cond. Total tons No. tDetection and Initiain Devices No. of Disposals Heat No. of Pumps Total Total Tons KW No. of Sounding Devices 2 No. of Dishwashers S Space/Area Heating P 9 KW No. of Self-contained Detection/Sounding Devices No. of Dryers Heating Devices KW Local F1 Munlc. Conn. Other No. of Water Heaters KW No. of No. of LowVoltage Signs Ballasts Wlrin No. of Hydro Massage Tubs No. of Motors Total HP Other: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws: YESx NO 1 have a current Liability Insurance Policy Including Completed Operations Coverage or its substantial equivalent. YES NO I have submitted valid proof of same to this office. } If you have checked YES, please indicate the type of coverage by checking the appropriate box: INSURANCE Q BOND[-] OTHER[:] (Please specify) Aon Risk Services, Inc. of Mass 4-1-07 Expiration Date Estimated value of electrical work s 9,950.00 Work to start Inspection Date Requested:Rough Ces Will call Final Ces will Call Signed under the penalties of perjury: FIRM NAME Consolidated Electrical Services LIC. NO. Licensee Lawrence D. Pantano Signature LIC. NO. 17502A Address 661 pleasant Street, Norwood, MA 020 Business Telephone No. 800-742-7240 A4Xernate Telephone No. (781)769-7110 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does nothavethe insurance coverage or it's substantial equivalent as required by Massachussets General Laws, and that my signature on this permit application waives this requirement. [:]owner ❑Agent (check one) Permit Fee $ 156.42 (Signature of Owner or Agent) Telephone No. 5r,4 f� L, ectt� oAc A -3 Zi 0 7 �� Date ..... ��,�,7nf2.7... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... ............. has permission to perform ............ wiring in the building of .... f��-f - . . ..................................................... ...... ....... / ............................. . North Andover, Mass. F e e ........... 4i �SPEC;i� Check # 7670 +:s ,C—\ Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/991 leave blank 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 IN INK OR TYPE LLJWFORMATION) Date: 1) —as --O-) City or Town of: ex r' ►�rdp\gg— 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) 1�"� r) � l Owner or Tenant At\�rZr,5� Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes NJ No (Check Appropriate Boz) 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: Cmmnletion ofthe following table may be waived by the Inspector of lVires. No. of Recessed Futures No. of CeiL-Sus (Paddle) Fans P- No. o Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Above n -o. Swimming Pool rnd. ❑ rnd. ❑ o Emergency Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones' No. of Switches y No. of Gas Burners No. o Detection and Initiatin Devices No. of Ranges Tot No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers P Heat Pump Totals: Number, Tons!_ KW _ - No. oSelf-Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW ipa Local ❑ Municl ❑ Other Connection No. of Dryers Heating Appliances KW eC No. ritof Devices or Equivalent No. of Water, Heaters o. o o• o Signs Ballasts Data Wiring: No. of Devices or Equivalent No. a Bathtubs Hydromassage y g No. of Motors f Total HP 3q 1 `/ Telecommunications Winug: No. of Devices or E uivalent OTHER: Attach additional detail ,J desired, or as required oy the inspecror oj n•ires. 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 e.,hibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical Work: 3000 (When required by municipal policy.) Work to StartI 5�� Inspections to be requested in accordance with NEC Rule 10, and upon completion. I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: S. Donnelly Electric, Inc. t LIC. NO.: 12649A Steven Donnell / 23980E Licensee: y Signatui-et�,K..� ' l _LIC. NO.: (If applicable, enter "exenzpt - in the license number line.) Bus. Tel. No.- 508-9 7-0743 Address: 31 Bedford Street, Lakeville, MA 02347 Alt. Tel. No.: _ OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not hm�e the liabuity 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/AgentPERMIT FEE: S /�- oe—_�___ Tolnn hnnP Nn I q, Hwy �aCCJ4 !!� /-c j-12--dS /��