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HomeMy WebLinkAboutMiscellaneous - 100 OLD VILLAGE LANE 4/30/201811704 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ........................................................kv has permission t perform ....... ............................................................. plumbing in th bV Dff Of ui plumbi . ..... .................................................................. at ....... ..c.).0 .......... k ....... ov- -Lr-) ..................... North Andover, Mass. . ... . .... ....... ... .... Fee ...... 3.b. ........... Lic. No.!> ..................... ................................................................................. � PLUMBING INSPECTOR ChedL, 11 , , 4 � 12- M� P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY 4 _ MA DATE --L -71?l PERMIT# JOBSITE ADDRESS V OWNER'S NAME— OWNER ADDRESS TELT— FAX OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL NEW: RENOVATION: © REPLACEMENT:' FIXTURES 7 FLOOR- BSM BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP ATYPES TOILET URINAL WASHING MACH W TER HEATER WATER PIPING RESIDENTIAL PLANS SUBMITTED: YES �]I NO© 10 111 1 12 1 13 1 14 - INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES`n NO �__l IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Ell BOND Q OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT �(]I SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co nc with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBES NAME i/ /d�� JLICENSE # SIGNATURE R' IMPo JP Q CORPORATION &#�PARTNERSHIPD# LLC COMPANY NAME J ADDRESS CITY_ ' I STAT -- E I ZIP O f` �� TEL 4- FAX L= j CELL [ �� EMAIL A on z LLI CL ui w LL 0 The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 . * , I www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERAUTTING AUTHORITY. Applicant Information Please Print Le:Jbly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. E] I am a employer with employees (full and/or part-time).* %. ❑ New construction 2. ❑ I am a sole proprietor or partnership and have no employees working for me in g. ❑ Remodeling any capacity. [No workers' comp. insurance required.] 9. ❑ Demolition 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 10 Building addition ❑4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11. ❑ Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5. I am a general contractor and I have hired the sub -contractors listed on the attached sheet. ❑ 13�. F1 Roof repairs These sub -contractors have employees and have workers' comp. insurance.$ 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 14. ❑Other 152, § 1(4), and we have no. employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submif this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must -attached an additional sheet showing the name of the sub -contractors and state whether or not. those entities have employees. if the sub-conhactors have employees, they must provide their workers' comp. policy number. 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. 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 MGL c. 152, §25A is a criminal violation punishable by 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. 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 #: 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 o'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 foi• 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Date .....�—�1!-F.. �. ............. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that c C....i"4e.�v.~....................................... ..:... ...,\... has permission for gas installation .... o lr ............ in the buildings of.. . ��l`-....................................................... at ....... �,( Q.)( .: .�- .:.......,North Andover, Mass. ................... ......................... Fee ....... a.".. Lie. No. Ii�03 ............................................................................ Check # Z GASINSPECTOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER r� INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES VO El 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER E3 AGENT 0 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application and that all plumbing work and installations performed under the permit issued for this application will be in Massachusetts State Plumbing Code.and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME _ _ �I LICENSE # are true ano accurate to the Dest or my Knowe complia wi all P rtinent vision of the SIGNATURE MP 0 MGF 0 JP ® JGF [] LPGI © CORPORATION W# PARTNERSHIP ©#= j LLC []#( -Ill COMPANY NAME:-✓r.>9GS_ ADDRESS ��, d(7,/ -� - - CITY uv P1/ _ __- _—I. STATEZIP�,rTEL FAX � _ CELL EMAIL 41 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE I PERMIT # JORSITE ADDRESS 1160 Q IC VC OWNER'S NAME — OWNER ADDRESS TELE -_FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL] EDUCATIONAL RESIDENTIAL5 CLEARLY NEW: E3. RENOVATION: El REPLACEMENT:)9 PLANS SUBMITTED: YES 0 NO F APPLIANCES 1 FLOORS- BSM' 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTERS _ CONVERSION BURNER COOK STOVE ! DIRECT VENT HEATER - DRYER FIREPLACE --- FRYOLATOR —_-- -- E-1 E -- FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER r� INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES VO El 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER E3 AGENT 0 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application and that all plumbing work and installations performed under the permit issued for this application will be in Massachusetts State Plumbing Code.and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME _ _ �I LICENSE # are true ano accurate to the Dest or my Knowe complia wi all P rtinent vision of the SIGNATURE MP 0 MGF 0 JP ® JGF [] LPGI © CORPORATION W# PARTNERSHIP ©#= j LLC []#( -Ill COMPANY NAME:-✓r.>9GS_ ADDRESS ��, d(7,/ -� - - CITY uv P1/ _ __- _—I. STATEZIP�,rTEL FAX � _ CELL EMAIL 41 _ 191 Cd w UL- -4 -4 4 The Commonwealth of Massachusetts Department of IndustrialAccidents f s 1 Congress Street, Suite 100 Boston, MM 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information / Please Print ] NaMe (Business/Organization/ludividual): Address: 2-2,7 A-( Phone #: 7 7&- L�2 f—n L% Are you an employer? Check the approprlate box: Type of project (required): 1.zTI am a employer with _ -�. employees (full and/or part-time).* 7. Q New construction 2. I am a sole proprietor. or partnership and have no employees working for me in 8. 0 Remodeling any capacity. [No workers' comp. insurance required.] 9. ❑ Demolition 3. ❑ I am a homeowner doing all work myself. [No workers' compAnsurance required.] t � 4. ❑ 1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers' compensation insurance or are sole 11'. Q Electrical repairs or additions proprietors with no employees. ' 12. ZPlumbing repairs or additions 5.FJ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors bade employees and have workers' comp. insurance.*13. Roof repairs 6. Q We are a corporation gnd its officers have exercised their right of exemption per MGL c. 14. Q Ocher 152, § 1(4), and we have 40..employees. [No workers' comp. insurance required.] *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 state whether or not those entities have employees. If the sub-conlrac'tors have employees, l iey must provide their workers' comp. policy number. I aril an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company N Policy # or Self -ins. Lic. #: r I Expiration Date: �M y� Job Site Address: ,00 I \ V t&sj ��1. City/State/Zip: M14- ° t Ay l 4 Attach a copy of the workers' c*ompepsationqolicy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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 ofup to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verincauon. I do hereby r y un jor the pains and penalties of perjury that the information provided above is true and correct. 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 #• I Information and Instructions T, 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,' any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver •o"r trustde 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 common fealth 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 foi• 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-insuraiice 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia ISSUES TfHE FOLLOWING LIfNSE,. �tfrFS AS A h�ASTER Plt1MBER .' 1 f PATHl K I MELVI{V' 227 MAIN: .Nd N AN DOV.-E ? hSA 0.1$45 2510 204075 RIPJA. CONTROL # J j„ 2 6 IMPORTANT If your license is lost, damaged or destroyed; is inaccurate; or needs to be corrected, visit our web site at'mass.gov/dpi for instructions to ensure the proper mailing of your Renewal Application and any other correspondence: This license is subject to Massachusetts General laws and regulations. Your license is a privilege, and cannot be lent or assigned to any person or entity under penalty of law. Keep this license on your person or posted as required by law and/or regulations. 11160 Date.! ...-� i TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .......................... .. has permission to perform ..../�-': �"° ..... �"'' a .` �-..................... plumbing in the buildings of ....7.W 6Q Old !./ .............................`J-...., North Andover, Mass. Fee. ....... Lic. No. J? 2.3 `� . .......................:......................................................... Check # 3 a �a-y" PLUMBING INSPECTOR <:;1�1I5 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK PERMIT M_% =3 # I MA DATE S` CITY o ,� OWNER'S NAME JOBSITE ADDRESS tf �r:J V1�%��� � Q(, TEL ID OWNER ADDRESS 1 EDUCATIONAL El TYPE OR OCCUPANCY TYPE COMMERCIAL Q PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: Q — FIXTURES -1 FLOOR—� I BSM BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR 1 AREA DRAIN INTERCEPTOR (INTERIOR) r -- LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK URINAL '��(ASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING _ OTHER— RESIDENTIAL PLANS SUBMITTED: YES ® N0[' g 10 11 12 13 14 INSURANCE COVERAGE: 1 have a current liainsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ._ . NO 01bilit IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITYE11 BOND OWNER'S INSURANCE WAIVER: I am aware that the Ion this does not hav the insurance permit on waives this requirement. Massachusetts by Chapter 142 of the Massachusetts General Laws, and that my signature p I AGENT �[�f CHECK ONE ONLY: OWNER SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I nave der the permit issued entered th s 18 3a applicationpw'ill be nacompliancd a th all Pert! he best of my knowledge �he ge and that all plumbing work and ins performed Massachusetts State Plumbing Code and Chapter 142 of the General Laws. SIGNATURE PLUMBER'S NAME � ' LICENSE # J -- MP © JP CORPORATION C1]#=PARTNERSHIP 0]� _ �# LLC �J [SK COMPANY NAME ` ADDRESSi CITY STATE �` ZIP FAX CELL 1_._ EMAIL _._._. d❑ Iii w Lu r+s The Commonwealth of Massachusetts . Department of IndustrialAccidents _.:;.r ..:, r 1 Congress Street, Suite 100 Boston, MA 02114-2017 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNHTTING AUTHORITY. Name (Business/Organization/Individual): Address: City/State/Zip: /�l/�°I✓I,_ /�f `'� `71 Phone #:7 1 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with ! employees (full and/or part-time).* 2. ZI am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.❑'I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.# 6.F-1 We are a corporation and its officers have exercised their right of exemption per MGL o:- 152, § 1(4), and we have no. employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. Fj Remodeling 9. ❑ Demolition 10 ❑ Building addition I LE] Electrical repairs or additions 12.0 Plumbing repairs or additions 13. E] Roof repairs 14.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submif 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 subrpontractors and state whether or not those entities have employees. If the sub-coritraciors have employees, they must provide their workers' comp. policy number.' 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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Y do hereby certify oder the pains and penalties ofperjuty that the information provided above is true and correct. G v c;.,,�,,,,a• �.�� iJ 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 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 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 foi• 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Z Date ......�-�...b.:Th.`.S.......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION i This certifies that ..................... '�...... ... -.' �e.rs ............................................................................. has permission for gas irnstallation .......�P.. M. .... inthe buildings of. .................................................................... at..../w ��� J/"1...., North Andover, Mass. .................................................................. Fee..... Lic. No.. -323..... ...................................................................... p, GASINSPECTOR Check # 3 ! ;L' G 1. TYPE OR PRINT CLEARLY MASSACHUSETTS UNIF®tM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -.1 - 'q.. CITY _ MA DATE �� PERMIT # ` 1PI b JOBSITE ADDRESS �Jr� OWNER'S NAME\ OWNER ADDRESS OCCUPANCY TYPE COMMER IAL [] EDUCATIONAL NEW: [Q RENOVATION: _ REPLACEMENT: APPLIANCES 7 FLOORS- _� BSM BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER_ ROOF TOP UNIT TEST UNIT N'f--ATER UNVEN (ED ROOM HEATER WATER HEATER RESIDENTIAL PLANS SUBMITTED: YES D NO 10 1 11 1 12 1 13 1 14 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES [] NO [� I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY Ej BOND F OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER LI AGENT El SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME . _ z__�� LICENSE # SIGNATURE MP El MGF El JP ® JGF 0 LPGI © CORPORATION E]# = PARTNERSHIP ®#= LLC ®# COMPANY NAME: _ ADDRESS CITY _ 1 _ __ �I. STATE ZIP E=TEL FAX CELL _ =EMAIL — - -� Im FA M The Commonwealth dust�lAc Accidents Department of 1 Congress Street, Suite 100 Boston, MA 02114-2017 .` www.mass.gov/dia ensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. Workers Comp please Print TO BE FILED WITIA THE PE TTING AUTHORiT i'• -- -A! -- I Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: employees (full and/or part-time).* 1 ❑ 1 am a employer with _____— forme in 20 1 am a sole proprietor or partnership and have no employees working any capacity. [No workers' comp. insurance required.] all work myself. [No workers' comp. insurance required.] t conduct all work 3.E] I am a homeowner doing n MY property -I will ing rs to 4 ❑ 1 am a homeowner ensure that all contractors eithewill be r ha e workers compensation insurance or are sol e proprietors with no employees. 5 Q I am a general contractor and I have hired the sub -contractor listed onanthe attached sheet. These sub -contractors hale employees and have workers' comp. We are a corporation and its officers have exercised their right of exemption per MGL c. k s' comp insurance required.] Type of project (required): 7. [] New construction g, C] Remodeling 9. ❑ Demolition 10 (] Building addition 11.❑ Electrical repairs or additions 12. [] plumbing repairs or additions Q Roof repairs 14. ❑ Other 6 to ees. [No wor er 152, § 1(4), and we have no. emp Y , *Any applicant that'davit indicating such - box #1 must also fill oute sear domglOr showing their workers' compensation policy information st submit a new all work tale theme of the sub contractors and state whether rs MU or nO those entities have I Homeowners who siubmit this affidavit indicating Y _ TContractors that check this box must attached anadditional sheet �lae thea vyorkers' comp. policy number. p and ob site employees. If the sub-corilractors have employees, ensation insurance for my employees.' Below is the policy .1 I am an employer that is providing workers' comp information. Insurance Company Name: Expiration Date: Policy # or Self -ins. Lic. #: City/State/Zip: Job Site Address: a showing the policy number and expiration date). Attach a copy of the workers' compensation policy declaration Page ( a fine u to $1,500.00 Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by p F ageas as well as civil penalties in the form of a STOP WORK ORDER and a fine of up r i saran 0 a and/or one-year imprisonment,be forwarded to the Office of Investigations of the DIA for insurance day against the violator. A copy of this statement may coverage verification, under tale pains and penalties of perjury that the information provz I do hereby certify nate, ane If* trial. . official use only. Do not write in this area, to be completed by city or town off Permit/License # City or Town: inspector Issuing Authority (circle one): p 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. pluplumbingIns p Oth x — U. a Phone Contact Person: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' Pursuant to this statute, compensation for their employees. an employee is defined as "...every person in the service of another under any conix' x 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 T+ 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) alongwith their certificates) 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 cityor town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regardingthe law or if you are required to obtain a workers' self-insurance licenon compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their se number 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 wxite "all locations in ficially stamped or marked by the city or town may be provided to the town)." A copy of the affidavit that has been ofor 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 02148-2 Date... ,�....... .... TOWN OF NORTH ANDOVER RMIT FOR WIRING This certifies that Lay.V4.42 4 SO4�6-s has permission to perform ...... /a. �� �� ✓P �^" ° ��-K, wiring in the building of ................ ..... I.11.P � c,1�. p................................................................... at ....�v......f.!,.� !� / ^%"' North Andover, Fee 55 ""..... Lic. No.1`� ,,ra.................. Check # / / � .,.,..........�.............�.. S. Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Oficial Use Only Permit No. / 33 '13 Occupancy and Fee Checked [Rev- 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: S ,;� �—, — J 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) %Cip 0/-0 pi,6Zr4.p Zc,— Vn/49- Owner or Tenant SNQ+1-K L('e 0 L ff Telephone No. //;Y Owner's Address SAMe Is this permit in conjunction with a building permit?Yes No ❑ (Check Appropriate Box) `j -c e R Purpose of Building K, i✓ t-, c�& Utility Authorization No. - Existing Service 00J Amps d / o Volts Overhead ❑ UndgrdM No. of Meters — New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters _ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �'fyN� %� t Te 44e rJ Completion of'the lollowink table may be waived by the Inspector of Wires. No. of Recessed LuminairesNo. D 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- ❑ El o. o Emergency Lighting 42 rnd. rnd. Batter 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 p Heat Pump Totals: Number Tons """"".............. KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal El Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofpe-rjury, that the information on this application is true and complete. FIRM NAME:. �B/zy MC. NO.:_�— Licensee: 'IT.1t ( L ( Signature IC. NO.: (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: Address: , t�7-6t� rS -Z (-l J itCC(/ 4 O P6 Alt. Tel. No.: *Per M.G.L c. 1 74 , S. 57-61, security work requires Department of Publiafety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ Jnj Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8—Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act—Permit/Date Closed: Trench Inspection Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: l Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INS CTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: 42 Inspectors Signature: Date: g i r FINAL INSP CTION: Pass M V Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: —/J -- DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com f The Commonwealth of Massachusetts Department oflndustirialAccidents 1 Congress Street, Suite 100 Boston, MM 02.114-2017 yJ.y,`t www nass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNHTTING AUTHORITY. Name (Business/Organization/Individual): Address: Lt 1 S S t L�%� / City/State/Zip: Are you an employer? Check the appropriate box: Phone #: �D 0 U 1. Q I am a employer with employees (full and/or part-time).* 2.I am a sole proprietor or partnership and have no employees working for me in /Vny capacity. [No workers' comp. insurance required.] 3.FJ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. _ 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.# 6. ❑ 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): 7. ❑ New construction 8.Remodeling 9. MDemolition 10 Building addition I LFJ Electrical repairs or additions 12.0 Plumbing repairs or additions 13.E] Roof repairs 14. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i homeowners who submif this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, 'they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: 1/1(-!,;> Policy # or Self -ins. Lic. #: 3 lG Expiration Date: �l Job Site Address: Idy 061 V� LC _ktl -e 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 MGL c. 152, §25A is a criminal violation punishable by 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. 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. 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 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 01 ELECTRICIANS ISSUES THE FOLLOWING LICENSE Aj A REG JOURNEYMAN ELECTRICIAN DWARO J SANTOS III 141 THIS5ELL AVE APT 17 ACUT MA 01826-5113 ' a4Lr t r%7/91 !1L Ir l Il i NORTH ANDOVER BUILDING DEPARTMENT 1600 Osgood Street North Andover Tel: 978-688-9545 Fax: 978-688-9542 .BUSMS'SFORM FOR TOWN CLERK DATE /av NAME. ADDRESS: 0 b ai ZONING DISTRICT: TYPE O U F BUSINESS BUILDING LAYOUT AVAILABLE PARKING SPACPS:, ZONING BYLAW USAGE: YES NO SIGNATURE BUSINESS FORM FOR MWN CLERK / c 2.40 Home Occupation (1989132) .An accessory use conducted within a dwelling by a resident who resides in ' the dwelling as his principal address, which is clearly Secondary *to the use. of the •buuilding for Ii1ring purposes. Home occupations shall include, "but not limited to the following uses; personal services such as furnished by an artist or instructor, but not occupation involved with motor vehicle repairs, beauty parlors, animal kennels, or the conduct of retail business, or the manufacturing of goods, which impacts the residential nature of the neighborhood. 4. For use of a dwelling in any residential district or multi family district for a home occupation, the following conditions shall apply: a. Not more than a total of three (3) people may be employed in the home occupation, one of whom shall be thea ow ier of thd home occupation and residing in said diw0 ing; b. The use is carried on strictly within the principal building; c. There shall be no exterior alterations, accessory buildings, or display which arc not customary with residential buildings; - d. Not more than twenty-five (25) percent of the existing gross floor area of the dwelling unit. so used, not to exceed one thousand (1000) square feet, is devoted to 'such use. In connection with such use, there is to be kept no stock in trade, commodities or products which occupST space beyond these limits; C. There will be no display of goods or wares visible from the street; f. The building or premises occupied shall not be rendered objectionable or detrimental to the residential character of the neighborhood due to the exterior appearance, emission of odor, gas, smoke, dust, noise, disturbance, or in any other way become objectionable or detrimental to any residential use within the neighborhood; g. .Any such building shall include no features of design not customary in buildings for residential 09913- �l} Date ...!/"1..� � .. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .... ? . (.... f .... . . l�......... . has permission to perform .r_e On 0.14. 4 plumbing in the buildings o�j .1�� �,1.�A✓ I .. Qi.. �,I C� ... , North Andover, Mass. at .. � ��... &. ........... Fee 37.77 ... Lie. No. ..... PLUMBING INSPECTOR Check # V MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY I NORTH ANDOVER - _ - I MA DATE4/19/13 PERMIT # I JOBSITE ADDRESS 1100 OLD VILLAGE LANE OWNER'S NAMEJ ROCHWARG POWNERADDRESS . - -- -- _._ _ _. .... _ . _._... - _ - TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL0 PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: 0 PLANS SUBMITTED: YES ❑ NO❑ FIXTURES Z FLOOR- eSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY 1 ROOF DRAIN SHOWER STALL 1 SERVICE / MOP SINK TOILET 1 MOMS URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER .. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICYE] OTHER TYPE OF INDEMNITY ❑ BOND 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance withalTyrent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. v PLUMBER'S NAME I MIKE CAPELESS LICENSE # 15851 SIGNATURE MP0 JP❑ CORPORATION ❑#PARTNERSHIP❑# LLC❑# COMPANY NAME BOILER-GUY/MIKE CAPELESS ADDRESS 160A PLEASANT ST CITY NORTH ANDOVER STATE MA ZIP F01845 TEL FAXI CELL 978-382-1017 EMAIL A MAW V ACoO tf CERTIFICATE OF LIABILITY ) INSURANCEDATE 04/18/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Matthews Insurance Agency Inc 182 Parker St NCONTACT AME : PHONE(978) 681-1112 Fy No): (978) 685-3855 Lawrence, MA 01843 MAIL DD ARESS: LIMITS INSURERS AFFORDING COVERAGE NAIC q INSURER A: Atlantic Casualty INSURED Michael Capeless 105 Tyler St INSURER B: Arbella INSURER C: Methuen, MA 01844 INSURER D: COMMERCIAL GENERAL LIABILITY INSURER E: INSURER F: 08/07/2012 bVYCRA%3M0 LaH III -ICC II- NIIMRFR• 001,ne u►o uanre. THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTRR TYPE OF INSURANCE ADOL SUER POLICY NUMBERPOLIICY EFF IMMIDDIYYYYIDfYYYl IPS CYY EXXY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY L143000684 08/07/2012 08/07/2013 DAMAGE TO RENTED E 100,000 F__1 P�RBMISES (Ea occurrence) CLAIMS -MADE OCCUR MED EXP (Any one person) $ 1,000 PERSONAL& ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 1,000,000 GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS - COMP/OPAGG $ 1,000,000 POLICY JECI PRO• LOC ) $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT a accident) $_ I BODILY INJURY (Per person) $ 300,000 ANY AUTO HC357357 08/30/2012 08/30/2013 ALL OWNED SCHEDULED AUTOS AUTOS I BODILY INJURY (Per accident) $ 300,000 NON-OHIRED AUTOS AUTOSWNED PROPERTY DAMAGE $ 300,000 Per ccident S UMBRELLA UAB OCCUR EACH OCCURRENCE S 1,000,000 ..HEXCESS LIAB CLAIMS -MADE x1111463 02/23/2013 02/23/2014 AGGREGATE $ 1,000,000 DED I I RETENTION S WORKERS COMPENSATIONI WC STATU• OTH. AND EMPLOYERS' LiABIUTY Y / N E E.L. EACH ACCIDENT S 100,000 ANY PROPRIETORIPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? N/A 890911-0937696 111/17/2012 11/17/2013 E.L. DISEASE - EA EMPLOYEE S 100,000 (Mandatory In If yyes, descn'be and under E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) Heating or combined heating and air conditioning systems or equipment, installation, servicing or repair, plumbing Town Of North Andover North Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. rcn ioaa_,jn4n AcnDn ('noonDAT1AN Au A -k+ .ems ---A ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD lcx The Commonwealth of Massachusetts Department of Industrigl Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibly Name (Business/Organization/individual):��� Address:��QGC,ISSV1� City/State/Zip: A(1V_M &,4A DC1(Je_ Phone #: �� `,�� / Q 1 :�) Areybu an employer? Check the appropriate box: 1. I a employer with 4. El am a general contractor and I Type of project (required): ��mployees am _ 6. ❑ New construction (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. �• F1 Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its g, E] Building addition [No workers' comp. insurance required.] officers have exercised their 10.❑ Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work right of exemption per MGL I L ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roofrepairs insurance required.] t employees. [No workers' 13. ❑ Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:._4_CLARt1C 4Ae�me_ Policy # or Self -ins. Lie. M Expiration Date::// Awl Job Site Address: �tlEfflqk_, � City/State/Zip: J (Q A'VI�J�.I( � / Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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. X do Hereby cert under the ofperjury that the information provided Obove is tate 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 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 retumed 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, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Ga onvuoalth of Ma Department Qf IndusWai Accidents Office of Investigations 600 Washington Street Boston, MA. 0211 t Tel. # 61.7-7274900 ext 406 or 1-877�,1M.ASSAFB Revised 5-26-05 Fax # 617-727-7749 wwwa-Rass,gov/dia Division of Professional Licensure: License Search The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Home State Agencies A -Z Topics Home > Division of Professional Licensure i Check A Professional License By the Division of Professional Licensure LICENSEE Name:MICHAEL N. CAPELESS METHUEN, MA "This Licensee has additional Licenses, click here to view them.— Licensing Board: PLUMBERS Et GASFITTERS License Type: MASTER PLUMBER License Number: 15851 Status: CURRENT Expiration Date: 5/1/2014 Issue Date: 9/16/2011 Exam Date: 9/16/2011 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Wednesday, April 24, 2013 at 11:21:51 AM. © 2007-2011 Commonwealth of Massachusetts Page 1 of 1 Mass.Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATED INFO Disclaimer Regarding Website License Searches Enforcement Process Glossary Glossary of License Status Codes More Site Policies Contact Us http://license.reg. state.ma.uslpubLiclpubLicenseQ. asp?board_code=PL&type class=_M&1... 4/24/2013 Date ..../... TOWN OF NORTH ANDOVER PERMIT FOR WIRING r This certifies that ................................... ta... &r ............................................. has permission to perform .... ............................................ wiring in the building of..,.... , \e.1 ............................................................ G at .......... North Andover -Mass. Fee.5-5 ........ ........ Lic. N LECMUCAL INSPE OR Check # 11533 � commonwealth of Massachusetts O i is �r se 0 Department of Fire Services Permit No. ' 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 IN)NK 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 orb intention to perform the electrical work described below. Location (Street & Number) j O O 01—b 11(r L' A �►/ Owner or Tenant S U _� A 1_0 /Co C,/n 1.4 A 6— Telephone No. Owner's Address S Am Is this permit in conjunction with a building permit? Yes 5 No ❑ (Check Appropriate Box) Purpose of Building -h &l L 7, t' I P? 6, 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: /5 /v -/-A %Z t m 4) L�— /'mlatio" nfthe fnllnwina tnhle may he waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Sus Fans p (Paddle) ol Total TransTrsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires AboveIn- Swimming Pool rnd. ❑ rnd. El o. o mergency Ug ting Agttery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones 3 Gas Burners No. of Detection andInitiating No. of Switches No. of Devices No. of Ranges Tot No. of Air Cond. Tons No. of Alerting Devices Heat Pump Number Tons No. of Self -Contained No. of Waste Disposers p Totals: I.KW Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Municipal Local ❑ Connection F]Other No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or E uivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or E uivalent OTHER: 1J W V Attach aaautonat aetau V aesirea, or as requireu uy tuie itisp6 .v. J •• �• ��• Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. �f FIRM NAME:. L� W fT ..6 '4 �J�i' 2 �- LIC. NO.: 6 30 X00 Licensee: h7 Signature LIC. NO.: / 7 (If applicable, enter "exempt" in thelic nse number line) I, Bus. Tel. No.• 5T— '�5t ' 7 d Address: /,4"3/ Q t✓�/3 /-VP E4f _)%'-P ' 6 '7S1�-7Q Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Deparffnent 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/AgentPERMIT FEE: $ Sion n tore Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the q permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: —1 Inspectors Signature: Date: FINAL INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comme s: n. Inspectors Signa re: Date: M DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts - Department ofIndustrial Accidents Office of Investigations IV 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers 711......,. 'D --*-4- T __;U1, Name (Business/Organization/Individual): ��/ 6)4 g,� / VS City/State/Zip:, 101 Phone #:� - 7 �' ✓ I Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I pinployees (full and/or part-time).* have hired the sub -contractors listed on the attached sheet. t 2. VI am a sole proprietor or partner- ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its [No workers' comp. insurance officers have exercised their required.] 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. t 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. ❑ Building addition 10.0 Electrical repairs or additions 11.0 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. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. sheet showing the name of the sub -contractors and their workers' comp. policy information. #Contractors that check this box must attached an additional I am an employer that is providing workers' compensation insurance for my employees. Below is ihepolicy and job site information. Insurance Company l 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 requiredunder 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 cer ' un��r the pal p;��t ry iliathe information provided above is true and correct. aw)/I Z) Date. L/ � � i L/ C / Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitfUcense # 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 ofhire,• express or implied, oral or written." An employeiis 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 Corr Mwealth, of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston., MA 02111 Tei, # 617-727-4900 ext 406 or 1-877:MASSAFB Revised 5-26-05 Fax # 617-727-7744 www.mass,goVMa CbMMONWEEAUH OF,MASSACHUSETT$ OWELECTRICIANS ' AS A: REG JOURNEYMAN ELECTRICIA,, o , ISSUES THE ABOVE LICENSE TO EDWARD, G HAJJAR JR; I L' 1200 `.SALEM: ST, ' Ip,�3 NORTH --ANDOVER,, . 'MA 01845-4 92 OIL _3 815010 -A 'COMMONWEALTH OF MASSACHUSETTS OF ELECTRICIANSa ` REGIS.TERED,MASTER ELECTRICIAN c ISSUES THE ABOVE LICENS TO ''�, fi. EDWARD,: GrAJIJAR -,JR i } 1200 SALFEM' ST r NORTH<;AN OVER _-MA' 0,1845-49,24` :.: � !J JI /J Date ... li!5� L zt� ..... .... . . ...... I r�-' *.* , - ' TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............. PE ... Ce"'u.'s-.cp ..... A?S�-71,?I. has permission to perform .... 'Zk-1Z wiring in the building of .................. ........................................ ctb 0 at ..... VL;d r ............................... 11 North Andover, Mass. 'f ...... e - Fee .... .... Lic. Nok;12.'� ............ �7 EL CTRICAL INSPECTOR Check # (m o monweaIg of Maieac4ueefid Official Use Only 2epartment o f Jire Serviced Permit No. 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: 1.9- / eye — pj GUY -off- Town of:T� p >�'p��,� 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����� Telephone 1�Io c 1D13 Owner's Address�7�/ . Is this permit in conjunction with a building permit? Yes ❑ No D (Check Appropriate Box) Purpose of Building 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 ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of CeH. 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. grnd. o. of Eifiergency Lighting Battery Units No. of Receptacle Outlets No, of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pum Number Tons ""' KW "' No. of elf -Contained "•�•��......"••' Totals Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW, Security Systems:* No. of Devices or Equivalent No, of Water KW No. of No, of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or 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:�,;� grispections 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 ofperjury, that the information. on this application is true and complete. FIRM NAME: �t^�B/1'L D SJ -90& /� . &6RLIC. NO.: Licensee: Signature LIC. NO.: (If applicable, enter "exempt" in the license number line.) // Bus. Tel. No.',!7 Address: fl /ts % k' 2, j '0 4k 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: $ aq Date.. //..?.:�.3........ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ..b-1 : �:. r... .................. •f has permission for gas installation .(1.-14. r . �!!'.;ll . ��..'...... . in the buildings of ..il� ............................ at :/..'.. i .`... , North Andover, Mass. Fee... ? .:... Lic. No. •r GAS INSPECTOR Check # 1 • 45.0 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO'DO GASFITTING _ _ (Print or Type) Iy , ifV► ,Mass. C2 FaVZ�.Y Date 1�1 Permit it b �I Building Location //)Q 011 (4 l lU .e" C /,1 Owner's Name . U 5�I P1 tY �LLrich C'V'-6'Ye D /Ll Com- Type of Occupancy New p Renovation Ey Replacement 0 p4m Submitted: YesO No a' Installing Company Name YANKEE GAS Check one: Certificate Address 140 SOUTH MAIN STREET [X Corporation 103C MIDDLETON, MA 01949 [. Partnership Business Telephone 978-774-2760 C Firm/Co_ Name of Licensed Plumber or Gas Fitter WILLIAM R. HARRTS INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which rnee's the requirements of MGL Ch. 142. Yes IX No O If you have checked yes. please Indicate the type coverage by checking the appropriate box A liability Insurance policy 13 Other type of indemnity O Bond O 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. Check one: OwnGJ Agent O Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in above av>ka6u+ are true andaccurate to the best of my knowledge and that all plumbing worts and installations performed under the permit ' for this � ' n � �.comp6a with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the taws gy Tof Lrcense: Plumber Signature of tuber ar rtter Title jGasCtter Master License Number 3785 Qty/Town Journeyman APhxNEff—(6Trn—LT§FWN-LW— h W d 7L Z T. in N cc N ¢ O Z rn z t W W rll. Q O 0 Cl f S 0 ¢ !. < y= Z o r c m W d c < N� W W h j .. < Q Q¢ F O h V �wj _ N O F' _ W m � 2 %6 0 F W O M W S a1161 id > S11.18—BSMT. 8ASEMEHT 1ST FLOOR 2ND FLOOR ff 1 3RD FLOOR 4TH FLOOR STH FLOOR I 6TH FLOOR 7TH FLOOR BTHFLOOR Installing Company Name YANKEE GAS Check one: Certificate Address 140 SOUTH MAIN STREET [X Corporation 103C MIDDLETON, MA 01949 [. Partnership Business Telephone 978-774-2760 C Firm/Co_ Name of Licensed Plumber or Gas Fitter WILLIAM R. HARRTS INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which rnee's the requirements of MGL Ch. 142. Yes IX No O If you have checked yes. please Indicate the type coverage by checking the appropriate box A liability Insurance policy 13 Other type of indemnity O Bond O 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. Check one: OwnGJ Agent O Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in above av>ka6u+ are true andaccurate to the best of my knowledge and that all plumbing worts and installations performed under the permit ' for this � ' n � �.comp6a with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the taws gy Tof Lrcense: Plumber Signature of tuber ar rtter Title jGasCtter Master License Number 3785 Qty/Town Journeyman APhxNEff—(6Trn—LT§FWN-LW—