HomeMy WebLinkAboutMiscellaneous - 10 HEATH CIRCLE 4/30/2018t archadeck°
America's Deck &Porch Builders`"
3 August 2017
Building Inspector
120 Main Street
North Andover, MA 41845
Dear Mr. Belanger,
We have terminated our contract for the deck and porch project at 10 Heath Circle and are no
longer working there. Please cancel the building permit.
Sine ,
Jam y
CS #066851
General Manager
Archadeck of Suburban Boston
V/;t
Archadeck of Suburban Boston • Telephone (781) 273-3500 • (800) 696 -DECK • FAX (781) 273-3536. 16 Adams Street • Burlington, MA 01803
nemass.archadeck.com • subboston@archadeck.net
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Newhouse & Sun
3 West Jamaica Ave.
Wilmington, MA 01887
Attn: Mr. David Newhouse
Lt. 07089.01
Page I of 1
January 14, 2009
Job No. 07089
Re: Site Observatio oncernDSpeciModifications tothe Residential
Dwelling Kno n---10 Heathh Andover, MA
Dear Mr. Newhouse,
As requested, I visited the subject address on November 29, December 6, 2007, January 9,
February 26, April 8, 2008 and finally on January 14, 2009, to assure that the construction
of the attached garage and the living space above was performed in accordance with the
structural requirements of the Massachusetts Building Code.
During the process of construction some structural changes and enhancements were
discussed and addressed. These alterations were not necessarily representative of the
framing plans of record. However, these minor field changes were performed in
accordance with structural design and code guidelines.
It is my opinion that the garage addition at 10 Heath Circle, North Andover, MA, as
observed on January 14, 2009, meets or exceeds the structural requirements found
in the 6th and 7th Edition of the Massachusetts Building Code.
Please feel free to copy this letter to building officials as needed and call if you have any
questions.
Regards,b
1":.
OF Jki't ;
STH
v� J`Si
o` PAUL A.
PHELAN JR.
o STRUCTUR "
No.42535
CIS
Paul A. Phelan, Jr., P.E.
12 SLEIGH ROAD ♦ CHELMSFORD, MA 01824 . PHONE: (978) 256-4014 . FAX: (978) 250-3764 . email: paulphelan@comcast.net
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........ 8.124,W,?.c ........ )4-
..... ................ I ...
has permission to perform ....... s�.�& ........... .........
wiring in the building of ............. ..........................................
at ..... / fi,.A�� ...... ...................... I North Andovei, Mass.
.... ..... 6 Y1.1.11 . ............
-NSPECMI
Lic. No. A9.24 ............. / iLEXCMIi�C�AL /i;I;I;!n
Check #
85�1
Commonwealth of Massachusetts Official Use Only
Department, of Fire services Permit No. FS -31
BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked
[Rev. 1/07] IPA\/Pl,l�nYl
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 INFORMATION) Date: . I L (o ( ,
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 60 v
Telephone No. �_ & I
Owner's Address S A—%4
Is this permit in conjunction with a building permit?
Purpose of Building
Existing Service Amps / Volts
New Service Amps / Volts
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work:
Yes [� No ❑ (Check Appropriate Boa)
Utility Authorization No.
Overhead ❑ . Undgrd ❑ No. of Meters
Overhead ❑ Undgrd ❑ No. of Meters
(A Y m-7
C._
-ciao y uescrea, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: .
(When required by municipal policy.)
Work to Start: Z. t�6C-A'e-_ 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 covers s m force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and enaldes o p )
p ofperjury, that the information on this application is true and complete -
FIRM NAME: ✓S C A4 -�,LC G{Z s6yWt
LIC. N9.:
Licensee: N( V -,q A-6 t_ /14, c.0 �, Signature
(If applicable, enter "exempt " in the license number line.) LIC. NO.: f✓ 7 �(��
Address: � P C6cr g j„t „r P-4, sive Bus. Tel. No.:� 3�Z- Zr�4
*Per M.G.L c. 147, s. 5', 61, curity work requires Department of Public Safety " S" License: Alt L cl. 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: $
J i
r
� Ell` ��
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Nrashington Street
Boston, MA 02111
{ 1 www.n2ass.gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Ltlbly
Name (Business/Organiration/individual); 6 \M,,,14c-C (LVL C -e
Address:_ -5 Pv-�s
1241
City/,State/Zip: � bS�o,J .v1l O3'cq t Phone #; _02c -
Are
2c
Are y an employer? Check.the appropriate box:
1. I am a employer with P 4. ❑ 1 am a general contractor and I
Type of project (required):
employees (full and/or part-time).*
2. ❑ i am a.sole proprietor. or partner_
have hired the sub -contractors
Iisted on the attached sheet. x
6 ❑New construction
7• ❑ Remodeling
ship and have no employees
These sub -contractors have
8. ❑ Demolition
working for me .in any capacity.
[No workers' com . insurance
p
workers' comp. insurance.
5. ❑ We are a corporation and its
Building addition
required.]
3. ❑ 1 am a homeowner doing
officers have exercised their
10.❑ Electrical repairs or additions
all work
myself. [No-worke'rs' comp.
right of exemption per MGL
c. 1.52, § 1(4), and we have no
11.❑ Plumbing repairs or additions
12. Roof
❑ repairs
insurance required.] t
9 ]
employees. [No workers'
13 ❑ OtherA. -
comp. insurance required.]
-- —i � � 1„w,L wso nn out the section below showing their workett' 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.
4contmctors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. p^„?ici irwmation.
I am an employer that is providing workers' compensation insurance for my employees: Below is the policy and job site
information
insurance Company Name:A 0 nJ Ems- k ti
Policy # or Self -ins. Lic. #: Expiration Date:
Sob Site Address: City/State/Zip-
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi under the pains and penalies of perjury that the information provided above is true and correct
7 �'-•C�SS :�
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License 4
Issuing Authority (circle one):
I. 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 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 comple=tely, 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 numberlisted below. Self-insured companies should enter their
self-insurance Iicense number on the appropriate line.
City or Town Officiais
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which wiIl 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, IIIA 02111
Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE
Revised 5-26-05 Fax # 617-727-7744
www:mass-gov/dia
D a t e. X -.:i ........
TOWN OF NORTH
PERMIT FOR GAS INSTAILLATION
This certifies. that UX�
has permission for gas installation . 5� �, �b : . :--. . 1--.11,3 .....
in the buildings of ... 73An ............................
at ............. North Andover, Mass.
.1. L ... . . L ---, '
Fee.3 7. Lic. No. .. .... ?q. : ........
GAS INSPEC(OR
Check 4 J—f -5
6670
r,
MASSACHUSETTS UNN ORM APPUCATON FOR PERMIT TO DO GAS FnTJNG
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations
^/ Owner's Name
New enovation Replacement D
Name of.Licensed Plumber'or Gas Fitter ;(� Z/W C_
Date
Permit #
Amount 77' ,
Plans Submitted
Check one: Certificate Installing Company
Corp.
��. 0 Partner.
[a rm/Co.
INSURANCE COVERAGE
ne
I have a current liability Insurance, policy or it's substantial equivalent. Yesck o: i
If you have checked es please indi the type coverage by checking the appropriate box. No�
Liability insurance policy Other type of indemnity E Bond 1
Owner's Insurance Waiver: 1 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.
Signature of Owner or Owner's Agent Check one:
Owner 13 Agent 0
t hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas dd ch )c}�f the_..Qeneral Laws.
—an
By:
Title
City/Town,
APPROVi ED (OFFICE USE ONLY)
of Licensed Plumber Or Gas Fitter
37'-_
I - 11:�7
t
Date.
I,ORTPI
TOWN OF NORTH ANDOVER
0
PERMIT FOR P'tUMBING
SA us
This certifies that ... ...........
has permission to perform . ./L -r ...... ovf c. I - f. r, -,� .............
plumbing in the buildings of ... Ko 41 k'� 1� .....................
at ... 10 -r / ", /
...... ............... , North Andover, Mass.
- - "It ...........
Fee.'?�. Li.c. No. ... ......... t :��
PLUMBING INSPECTOR
Check # 5-)-C7 Z- I I
7960
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
/flevIl Cid, ��R� Date �.� a 9
Building Location /0
Owners Name �l1Gi� permit
T pe of Occupancy ,�%w �� Amount
__ GTl
New Renovation
Replacement ' 13
1.ra
Plans Submitted Yes❑ No
El
krrmi or type)
Installing Company Name Q%N �f� Check one: Certificate
Corp.
Of
Address / '46//'/e
A ❑ Partner.
Business elephone)r G 7 7
1�hXMI/Co.
Name of Licensed Plumber: ?/�,[�� �� �� O0/.,0 �?
Insurance Coverage: Indicate the a of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity Bond
11
Insurance Waiver. I, the undersigned, have been made aware that the
three insurance licensee of this application does not have any one of the above
Signature Owner ❑ F1Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massach etts State P binge anir 1429f the General Laws,
City/Town
APPROVED (OFFICE USE ONLY
Type. of Plumbing License
9"Z42
icense umoer Master Journeyman
F
0
1-:7
Date .... ... �Z ......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
. . . . ... .... .
This certifies that . . . .. ..... 40 .... ...........
has permission to perform
wirin the building of . . . . . . . . W—".� . ..........................
al" W( ............. . North Andover, Mass.
A
at.. ......
Fee... Lic. No. .. ......... ..................................................
Check it _1-7��- ELECTRICAL INSPECTOR
5262
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULA
APPLICATION FOR PERMIT TO
All work to be performed in accordance with the M
(PLEASE PRINT IN INK OR TYPE ALL INFO
City or Town of: North Andover
By this application the undersigned gives notice of
Location (Street & Number) 10 Heath Circle
Owner or Tenant Mark and Debbie Bohrer
Official Use
/Only
Permit No.
Occupancy and Fee Checked 47 100
-
tev. 11/991 (leave blank)
RFORM ELECTRICAL WORK
isetts Electrical Code (NEC), 527 CMR 12.00
Date: June 3, 2004
To the Inspector of Wires:
To- perform the electrical work described below.
Telephone No. 978-682-8144
Owner's Address Same
Is this permit in conjunction with a building permit? Yes ❑ No X (Check Appropriate Box)
Purpose of Building Residence Utility Authorization No. 68162
Existing Service 100 Amps 120/240
New Service 100 Amps 120/240
Number of Feeders and Ampacity
Volts Overhead X Undgrd ❑
Volts Overhead ❑ UndgrdX
No. of Meters 1
No. of Meters 1
Location and Nature of Proposed Electrical Work: Relocate Electrical Service to Underground
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed Fixtures
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Swimming Pool Above ❑In-El
rnd. rnd.
o. o Emergency ig ng
Batte 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
Heatums
Number
Tons
KW..........
of DetectSelf-Contained
elf-Cle to nDevices
No. of Dishwashers
Space/Area Heating KW
Local ❑Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
ecuritysystems:
No. of Devices or Equivalent
No. of Water KW
Heaters
No. Of o. 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.
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 X BOND ❑ OTHER ❑ (Specify)
Estimated Value of Electrical Work:
(When required by municipal policy.)
(Expiration Date)
Work to Start: Inspections to be requested in accordance with MEC 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: Landers Electrical Co., Inc. LIC. NO.: A5912
Licensee: Vincent B. Landers, President Signature . a �Lj✓ ; . ,�_ d < LIC. NO.: A5912
(If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 978-686-3828
Address: 1000 Osgood St., No. Andover, MA 01845 Alt. Tel. No.:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance cove-r111age normally
rnrn+i—A 1k+. 1— Rv my nir+nnfi+rn lwlnm T +1. io rcrn+iwmnr4 T nm 41+n /nhnnlr nnnl n ns:mnr (n,�++/mGnr'n n�{..rnyn►f�
. IV
ot" OWN
Date..
.........................
OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...................
. ..................
�,re—
has permission to perform .... ................ e. 5;0,fe . ... 4
wiring in the building of ................. .....................................
at ...... ....... r4e ......................... North Andover, Mass.
Lic. No. .........
Check* Z-
7869
Ar
VA
N Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. 7
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 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 ININK OR TYPE ALL INFORMATION) Date:—/,2- -2-7- G�
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
Owner's Address
Is this permit in conjunction with a building permit? Yes
Purpose of Building �-, I N G Ie F0lM
Existing Service Amps / Volts
New Service Amps / Volts
Telephone No.
No ❑ (Check Appropriate Box)
Utility Authorization No.
Overhead ❑ Undgrd ❑
Overhead ❑ Undgrd ❑
No, of Meters
No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: �j �e ,9>P _ 11C4117 4 yy fid
Comnlntinn of tho fnlln—i— mhlo
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
.--.- ....,y �v .nc trw ec.vr UJ rr trey.
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑In- E]
rnd. grnd.
N5. 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
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
Alerting No. of Devices
g
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
No. of Water KW
Heaters
Heating Appliances KW
No. of No. of
Signs Ballasts
Security Systems:*
No. of Devices or Equivalent
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
00 Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: 56� (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete.
FIRM NAME: LIC. NO.:
Licensee: rt, w� Signature LIC. NO.:
(If applicable, enter "exempt" in the license number line. Bus. Tel. Ny�ei
Address: /-2 CG�JCh RA Clie'11l�o�/% / Ci y Alt. Tel. 1'
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. 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. $
The Commonwealth of Massachusetts
f Department of .Industrial Accidents
.. •
Office of Investigations
gto
600 Washington Street
Boston, MA 02111
i www.rnass.gov1dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/individual):
N
Address:
City/State/Zip: 66 MISFOM / o 17) V Phone #:.
Are you an employer? Check the appropriate box:
Type of project (required):
LEI ❑ I am a employer with
4. ❑ I am a general contractor and I
6. Q New construction
2.0 employees (full and/or part-time).*
I am a.sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet. t
7• ❑ Remodeling
ship and have no employees
These subcontractors have
8. Q Demolition
working for me .in any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5 ❑ We are a corporation and its
g, Q Building addition
required.]
officers have exercised their
10 Q Electrical repairs or additions
P
3. ❑ 1 am a homeowner doing all work
right of exemption per MGL
I LM Plumbing repairs or additions
myself. [No -workers' comp.
c. 1.52, § 1(4), and we have no
12.❑ Roof repairs
insurance required.] t
.employees. [No workers'
I3.❑ Other
comp. insurance required..]
•Any applicant that checks boz # 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. #: Expiration Date:
Job Site Address:
City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations of the DIA for insurance coverage verification.
I do hereby certify under the pain and penalties of perjury that the information provided above is true and correct
Phone #: 1777 -
Official
` 7 -
ficial 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 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 446 or 1-8.77-MASSAFE
Revised 5-26-05
Fax # 617-727-7744
www.mass.gov/dia
10 Heath Circle
North Andover, MA 01845
June 27, 2008
To: Peter Murphy
Electrical Inspector, Town of North Andover
This is to inform you that Wink Electric is not going to be performing electrical
work for my addition. Ken Wink pulled the electrical permit for the electrical work at 10
Heath Circle in December 2007.
David Newhouse is hiring a different electrical contractor to perform the work.
Please call me if you have any questions. Thank you.
Sincerely,
Mark Bohrer
Cell 978 289 0393
Home 978 682 8144
Date .........
0, TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ................ 5 .....
has permission to perform ... —4,;77enwir,.1 ..........
wiring in the building of ............ . ...............................................
at .......... ............................ . North Andover, Mass.
Lic. No. /.7.3.-
... ... ... ......... i�i4
Check # I
8378
Commonwealth of Massachusetts Official Use Only
9 7J9
Department of Fire Services Permit No. -- f{
Occupancy and Fee Checked
r 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 I
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: _ —
City or Town of: NORTH ANDOVER To the Inspector of Wires, P
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number)1C, ! , N d
Owner or Tenant
Owner's Address S C, /''% t
i(
Telephone No.
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Buildingse(r c e ('�.�, h Utility Authorization No. � 3 71' 7
Existing Service —�/ V Amps f % Q�Volts Overhead ❑ Undgrd No. of Meters _L
New Service OPV U Amps 110/ OVolts Overhead ❑ Undgrd No. of Meters _L
Number of Feeders and Ampacity 5i'ftIVLi--r ,b&1vco,
Location and Nature of Proposed Electrical Work: ,?o 6a f v "C -e V D q fz. J -C Cin
R
10AA2 al r may. do Ne --r, V- a � -
C'mm�letinnnfthofnll.n,.,:.r.t hh. 1 JL— L
No. of Recessed Luminaires
- - - ----' 'v - -
No. of Ceil: Susp. (Paddle) Fans
1
•.-y .� y aneeaw ea.avr v rr trra.
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires Q
Swimming Pool Above ❑ In- ❑o.
rnd. grnd.
of Emergency Lighting
Battery Units
No. of Receptacle Outlets 3
No. of Oil Burners O
FIRE ALARMS
No. of Zones
No. of Switches f
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges /
No. of Air-Cond. a Tons �J
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totais:
Number
........................................
Tons
KW
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW C)
Local❑ Municipal
Connection ❑Other
No. of Dryers 1
No. of WaterT
Heaters U
Heating Appliances 0 KW
No. of No. of
Signs Ballasts
Security Systems:*
No. of Devices or Equivalent
Data Wiring:
No. of Devices or E uivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
^l Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: Q (% V (When required by municipal policy.)
Work to Start: -� V -G Cf 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 X BOND ❑ OTHER ❑ (Specify:)
I certify, under the ains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: 0,1,-J f ,�r— 10 E, -,,c . LIC. NO.: ES 7 9 3S^
Licensee: JLo ¢ L -J � h Si ature � LIC. NO.: 17 J -? D
(If applicable, en r "exempt " in the icense number line) Bus. Tel. No.: 7 f y
Address: 0, i�p x G Q` S TZ -Wy. b"r `/,/11 C-,� 7 , Alt. Tel. No.: P 13 -7S- - 71 d
*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: $
s c pT'l 9 7 F 3:7 .—s X72,2)
I
ga)j*-
"Oen/c. 3 —14 — / / PIA7
y
M
5
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):
Address:
a �Y_ GG,�-
VI cLr,C
J
City/State/Zip: �v (ks12 yK..i //1"' 0l8tlbone #: /Q 7 K) 4 7
Are you an employer? Check the appropriate Vox:
1. 54) am a employer with _7 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. t
3. ❑
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
These sub -contractors have
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
S. ❑ Demolition
9. ❑ Building addition
10AElectrical repairs or additions
11. ❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
r y uFy= = i uiat wu"rz uv,. ,t, ,uusL also mi out me section Mow snowing 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. I
Insurance Company Name:_ 1-Y(,kV't,�(J� S
Policy # or Self -ins. Lic. #: -� (� U IJ DO 6 07M,) - I "Q Expiration Date: —0
Job Site Address: / Ato,�- (� c City/State/Zip: /%.
y
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�er thepa!paqpenalties 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 #:
Date.
8875
TOWN OF NORV/A'NDOVER
0
PERMIT FOR PLUMBING
SS,4CHUS
This certifies that ZAIOYC�1�1� r� ... IA' ...............
has permission to perform
...........
plumbing in the buildings of . P4 .................
at ....... ... North Andover, Mass.
Fee. Y Lic. No.. 2-111:� ..........
PLUMBING INSPECTOR
Check ff ? 3 )
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Prim or T )
Mass: DateJ6�- •--. 20 j L Permit #
Building Locatlon/� ���R%%� �.6k Owner's Name"
Type of Occupancy Re.51t>C;f1%//9Co
New p -Renovation O Replacement 0 Pians Submitted: Yes O No
FIXTURES
Installing Company Name
Address Lic.
Business
Name of Licensed Plumber
BRADFORD PLUMBING &
HEATING MECHANICAL INC. -
#12580 Tel. #(978) 521-0262
P.O. Box 5269
BRADFORD, MA 01835-0269
one:
Corporation
D Partnership
D Fkwco.
Certificate
Za C
INSURANCE COVERAGE:
I have a c u*rrer# liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No O
If you have?heLked yes, please indicate the type coverage by, checking the appropriate box
A liability Insurance policy Other type of indemnity 0 Bond Q
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws. and that my signature on this permit application .waives this requirement
Check one:
Owner -0 Agent ❑
Gnhaf�sra of A..nnr wr A.,..w. .. Awww�
r nereoy cerury mat 211 01 the details and information 1 have submitted (or entered) in above application are true and accurate to the best of m
knowledge and that all plumbing work and installations performed under the y
pertinent provisions of the Massachusetts State Plumb' a and Pet of issued for this appGgtion will be in compliance with all
m9 Chapter i42 of the Genera! Laws,
Smgniture of Licensed Plumber
Title /
fiype of License:
MasteJou
rneyman DCOown 1 0YWtOFFIC USE ONLY) license Number 11519
R
a!
o
a
m
10 Heath Circle
North Andover, MA 01845
March 7, 2011
To: Gerald A. Brown
Building Inspector, Town of North Andover
Jimmy Diozzi
Plumbing Inspector, Town of North Andover
This is to inform you that Pat Yeo of Pat -Mor Mechanical is no longer doing
plumbing work for my addition project at 10 Heath Circle. Pat Yeo had the plumbing
permit for the project.
We hired Bradford Plumbing of Haverhill MA, to do the remaining plumbing
work.
Please call me if you have any questions. Thank you.
Sincerely,
ark Bohrer
Cell 978 289 0393
Home 978 682 8144
Date ... �—d4?. -/o ..... .
1-01 19M TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that k -R -.v 1. <-.11.L .........
has permission for gas installation K 1*(<,�nd)
in the buildings of . 6A� --.-e . . ..............................
at 14:�'. . ....... I North Andover, Mass.
Fee. Lic. No.*�. ..................... �S...
GASINSPECTOR
Check # 17 -le-,
7'1 05
.&A
MASSACHUSETTS UNH ORM APPLICATION FOR PERMIT TO DO GAS FITTING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations
Be h %tet%✓ Owner's Name
New ❑ Renovation Replacement
Date lbo /,p
Permit # ` U
Amount $ 3L
Plans Submitted
NameortYPe) /1Y%w /'/"A%>CeJ
Name of Licensed Plumber or Gas Fitter
Check one: Certificate Installing Company
Corp.
Partner.
im>/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 0�:—_No 1
If you have checked Les, please Indic e type coverage by checking the appropriate box.
Liability insurance policy 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.
Check one:
Signature of Owner or Owner's Agent Owner Agent
L �_L_. _ �•L-.t__ _11
- •-� J __ j u=u — V. u.,, U�x LLQ aiiu uu-tuauvu 1 have summuea kor enterea) in above application are true and accurate to the
.best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Co an(�Chapte,42 of neral Laws.
ICity/Town
I AYYKU V hl.) (OFFICE USE ONLY) I
SignaWof Licensed Plumber Or Gas itter
Plumber -
Gas License Number
aster
0 Journeyman
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SUB-BASEM ENT
B A S E M ENT
1ST. FLOOR
2N'D. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
.8-T fl. FLOOR
NameortYPe) /1Y%w /'/"A%>CeJ
Name of Licensed Plumber or Gas Fitter
Check one: Certificate Installing Company
Corp.
Partner.
im>/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 0�:—_No 1
If you have checked Les, please Indic e type coverage by checking the appropriate box.
Liability insurance policy 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.
Check one:
Signature of Owner or Owner's Agent Owner Agent
L �_L_. _ �•L-.t__ _11
- •-� J __ j u=u — V. u.,, U�x LLQ aiiu uu-tuauvu 1 have summuea kor enterea) in above application are true and accurate to the
.best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Co an(�Chapte,42 of neral Laws.
ICity/Town
I AYYKU V hl.) (OFFICE USE ONLY) I
SignaWof Licensed Plumber Or Gas itter
Plumber -
Gas License Number
aster
0 Journeyman
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 LeQibh
Hanle (Business/Organization/Individual): 7X�v�/��
Address:_ &.//�/yI i` /'7—
City/Stat e/Zip:__ ��--4
`-'nk hone #: �;79
Are you an employer? Check the appropriate box:
nr-4
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. [� �'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.]
` "- , applicant that checks box #i mus! also fill out the sectio-- bet. E, cnnp.;nn "..;
Type of project (required):
6. ❑ New construction
7.4emodeling
8. ❑ Demolition
9. ❑ Building addition
10 Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
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. #:
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 theimposition 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 pa' s andpenalties of perju?y that the information provided above is true and correct
Simature: 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):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
I
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
br 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 coinpliance with the insurance coverage required."
Additionally, MGL chapter 152, §25CM 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 pernnit or license is being request 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 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
umber
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-72.7-4900 ext 446 or 1 -877 -MASSA -FF,
Revised 5-26-05
Fax # 617-727-7749
wvvv7.mass._gov/dia
Jan. 20. 2010 10:53AM
To: Gerald A. Brown
Building Inspector, Towyn of North Andover
Jimmy Diozzi.
Plumbing Inspector, Town of North Andover
No. 1 iqj r. I
10 Death Circle
North Andover, MA 01845
January 20, 2010
This is to inform you that Ralph Flodin Plumbing is no longer doing plumbing
work for my addition project at 10 Heath Circle. Ralph Flodin pulled the plumbing
permit 'for the project.
We have hired Pat Yeo of Patmor Mechanical, Peabody MA, to do the remaining
plumbing work.
Please call me if you have any questions. Thank you.
Sincerely,
Mark Bohrer
Cell 978 289 0393
Home 978 682 8144
� r ro.), 6 -
f'q� yeo
0
SACHUS
This certifies that
Date/—"7-0 7/0
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
has permission to perform A -e� *'*'* 0 *
plumbing in the buildings of eqA':�o .. ....................
at LA-- **'***'** North Andover, Mass.
Fee. Lic. No/.'I/Z*4�1 ............. ..........
PLUMBING INSPECTOR
Check#
8465
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location y1,�9 /fes i��✓yt�
Date % Ll,�
Permit # 4
Owner Amount
New Renovation 13 --"---Replacement ® Plans Submitted Yes 'r- No
>k`><MTI TR IW c
(Print or type)
Installing Company Name _ ar"-,;;',
Check one: Certificate
❑ Corp.
Partner.
M—ft,o.
Name of Licensed Plumber:!j"¢�i r r�
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy 1�1 Other type of indemnity Bond F
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner. Agent El
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations perf ed er t Is for this application will be in
compliance with all pertinent provisions of the Massachusetts State Pl bing an 42 of the General Laws.
By:
Signature o rcens
Type of Plum ' icense
Title 017-4 ��
Cit rceDEMOum �r Master Journeyman
[APPROVED (OFFICE USE ONLY
The Commonwealth of Massachusetts
Department of industrial Accidents
Office of Lnvestigations
U1 600 Washington Street
Boston, MA 02111
wwn+.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): �j� Z;Nol-
Address: %/� J'��yi , ' % /�✓i�(.��P
City/State/Zip:
Phone #:
Type of project (required):
6. ❑ New construction
7. emodeIing
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 affidavit indicating they are doing all wort: and then Wcakers compensation hir outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site
information.
Inaturance Company Name:
Policy # or Self -ins. Lie. #: Expiration Date:
Job Site Address: /e� %�4a*�4' G' d City/State/Zip: �—lt
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 rtmter th�n and ofperjury 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
Vit . VAA
Contact Person: Phone #:
Are you an employer? Check the appropriate box:
1.0 I am a employer with
4. ❑ I am a general contractor and I
emes (full and/or part-time).*
have hired the sub -contractors
2. am a sole proprietor or partner-
listed on the attached sheet T
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.]
*Any applicant that checks box #1 must also fill out the sectio below s:, , ." , +�
Type of project (required):
6. ❑ New construction
7. emodeIing
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 affidavit indicating they are doing all wort: and then Wcakers compensation hir outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site
information.
Inaturance Company Name:
Policy # or Self -ins. Lie. #: Expiration Date:
Job Site Address: /e� %�4a*�4' G' d City/State/Zip: �—lt
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 rtmter th�n and ofperjury 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
Vit . VAA
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 -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 permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
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 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
www.mass_gov/dia