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Miscellaneous - 100 RALEIGH TAVERN LANE 4/30/2018
E -:• C t Lh't:-=:/,,naihardoverma.vlewpointrloud com(4,4-ecor al"X.'S4-iAIM Town of North Andover, MA 4 =ez cr � ® - 20544 -Plumbing Permit - in conjunction with a Building Permit [commercial or Residentlab - TIMELINE submission received /"� Your request is in progress 1 82016 a<9:21am [1 �/j We'll le: you know of any updates via email. Feel free to check the i� Plumbing Permit Review statusat any time by coming back to this page. - in Progress _ . . 0 Permit Fee _ ....-. , .. .... a prnlit IcsU91_e 7. - Richard Bowman 100 RALEIGH TAVERN LANE, NORTH -- - ANDOVER, MA WONDOLOW510, DAVID - - - - - Attachments - -OT8BZWI001F WedJun Gu 20I6_13:33:.PCF - - Primary Contractor Search for your contractor using the search bar below. Either the Finn's Name or licensees is - - - required. A IMM 5: CPO/ 6 Date ...../ TOWN OF NORTH. ANDOVER PERMIT FOR WIRING This certifies that .......... has permission to perform ............ . ..................................... .................... wiring in the building of .......... ................................................. at k, ........ North Andover, Mass. ............... �4 r /,) ...... Fee... 47..S . . . .......... Lic. No/— ............... .................................... ELECTRICAL INSPECTOR Check # 130-63-) a.`� � _ Corr wn-wa l'z o� Pjamadlut6g& atY.tciul Use Only y-• - � lca `" Permit i<io. - 2epar4-m-w : o/ &., &errr. r Occupancy and Fee Checied . ' BOARD OF FIRE PREVEi11 i0i1 REGULATIONS ev. i/D7j (leave Mani:} Ai PIPU"A',- y fL:,g�� } �(tJ`f? (_ �s -,,.. _ _ Slur ...i• 1 J_ w _ r.:(1` po'! if �! 1. S� �J�L s:i �`�n : � p ���' �1 r '� r 1 Tui �'� !✓r All «orI. to be perFarned in accordance wlth the it • . ,� R if- ( t L ,: �aL iassaebusetts Eleelrical Code (RnEC). 527 OmR 3240 rimj, Quit.LQ!i1'r4TYQi)9 ri'2zae If �1/ to /� i 1Qr`g!'pBQ' 3jU'ES: O Sy this application the undersigned grids notice ofhis D, -her intention tD perfomt the electrical worts described below. .ae:tin (5��eet i00 12 f(,� ��n ke, Gimn,sr o.:- :amt IDty t 0 •t- L_,e 51 Z c. (/tib n c .^ 9 -- ,©�� S � r = eiepho.=e i�Io. swag -s Address 's Eh is gerrtit is cosi- ncii vPtI-a uwr aC pe• � � C !;D {fi.32£rprC7=?48 I�'Dr� urpose o BuRdia-b 'J t 1 ! =f= +`=�' ric ai �3iiDis l �� a. le ,a?s'Tt:t�g Ser•e Amps / `'o_ft cele: s'� �see � � .. . J~e = = i~ID. a: P:�erer3 i iew Service .-' =-ps/ r%; ,� rr I*1liiucbl94° of Feeders �F`L� P-10- �3' RL-:er s 2uc ypu L er- ion and 1 101-ure of' -Prop -.sed ;f` L.Gv.n �Ay 1�111,,-i k( W IZ-,"Iq 4:: fable nrgi, be wail;e r ;D f '.�$LaiaLU2S 32r-'-eu ii",ts r the lirspector' o; li'ir2s a. oar +et L.,b Devices ;Siinated i+aIue or EIec�ical i�iorlc h tch additional d 0eroih desn 2d, or s re rured bre te Inspector 0f JV rrs;1ACC- (ltrhen£eq�dby7nunicipal policy.) vii orlc to Sty _: i baa J r S inspeetlons io be reque�d in accordance un;h I C Rule I0, and upon completion. Unless waived by tite ov,=ner. no t�e_i- it for the performance ofeiectricai'vork may issue unless ,4- flcensee provides proofoF Iiabift, insurance including ``corrtpleted opei—,don" coverage or its substantial equivalent The tneersigned cerdZes that such co`,er"Pe is in iDrcc, and has c;d bii+d p =HCO molof same to the panni: issuing arirce. IONE,- INSiiRAI�ICE ® BOi�t� 17OThR {� (SPeclj'-) ted ti y under fire pains acrd Dana ifres 0i'Peri ry, Mau K1a1� fFJs �IFa10i? Oii ifzls L?RO ICaffoR iS:i lL� and iscors pja'p- LI_ - 2 C. t\t?.: is J 19 .iceassc: e v r L--�j�! ✓r'u— vl,_ n�..F3S�Lf/ j no�iicable, s�rrer "genrDl"fic2»se aru Cr �} q� eacrsss: Yi) % 6tit t /I/L• (� Buis. el. NLTJ W . (a, 7 - % %t> aerM.G.L c 1`'7.s.57-61,sectut �•�,o,L,�aurres e• � `G'=a=.ilo.: S��-e�' �5�3i �`Y art ment of Public S�� "S" License. Lic. No. Ii'II 'S =tZiS J - ? '•�� z� 7 �, e i art aware ifia the Licensee does Jjai IJave the IiabiUty insurance cover2ge normally :ouired by lack% By rty signature below, I hereby waive this requirement. I am tete (check one) Q ower 1•.r�:Eil ' Je3L [J— owner's agent. e p-Mahane ISD. b: 00 P_z EdeneN Rens L ..C2 Q.dar_`mac r ko. of Receptacle Gi) . a. l'i0_ Dr y:/Ei^_�9S � °-mss 8u:zsrs NC, 0 Ga �=was 'otai Ir�ro.a t ID. 4'z_' `1i�i SLC moi`?S DSnaJ =ea; ama-p I t - WO. 0-f D.-Ishwasher5 �iCtpaCC'fE cyz c'q+; r 'S ( dr.c rvv No. o= �7 r rr No. ar �Jdroirass.-g Santa 175 i}iro. of r'4D:43rS fbtel `? fable nrgi, be wail;e r ;D f '.�$LaiaLU2S 32r-'-eu ii",ts r the lirspector' o; li'ir2s a. oar +et L.,b Devices ;Siinated i+aIue or EIec�ical i�iorlc h tch additional d 0eroih desn 2d, or s re rured bre te Inspector 0f JV rrs;1ACC- (ltrhen£eq�dby7nunicipal policy.) vii orlc to Sty _: i baa J r S inspeetlons io be reque�d in accordance un;h I C Rule I0, and upon completion. Unless waived by tite ov,=ner. no t�e_i- it for the performance ofeiectricai'vork may issue unless ,4- flcensee provides proofoF Iiabift, insurance including ``corrtpleted opei—,don" coverage or its substantial equivalent The tneersigned cerdZes that such co`,er"Pe is in iDrcc, and has c;d bii+d p =HCO molof same to the panni: issuing arirce. IONE,- INSiiRAI�ICE ® BOi�t� 17OThR {� (SPeclj'-) ted ti y under fire pains acrd Dana ifres 0i'Peri ry, Mau K1a1� fFJs �IFa10i? Oii ifzls L?RO ICaffoR iS:i lL� and iscors pja'p- LI_ - 2 C. t\t?.: is J 19 .iceassc: e v r L--�j�! ✓r'u— vl,_ n�..F3S�Lf/ j no�iicable, s�rrer "genrDl"fic2»se aru Cr �} q� eacrsss: Yi) % 6tit t /I/L• (� Buis. el. NLTJ W . (a, 7 - % %t> aerM.G.L c 1`'7.s.57-61,sectut �•�,o,L,�aurres e• � `G'=a=.ilo.: S��-e�' �5�3i �`Y art ment of Public S�� "S" License. Lic. No. Ii'II 'S =tZiS J - ? '•�� z� 7 �, e i art aware ifia the Licensee does Jjai IJave the IiabiUty insurance cover2ge normally :ouired by lack% By rty signature below, I hereby waive this requirement. I am tete (check one) Q ower 1•.r�:Eil ' Je3L [J— owner's agent. e p-Mahane ISD. b: 00 Address: �/ 0 3 -C) 4.- ?17 V City/State/Zip: M t (» (,, 7L'^/ (9 ( 9L/� Phone #: C/ '� �r p '� 7C) Are you an employer? Check the appropriate box: Type of project (required): I Z I am a employer with .3 4• F]I am a general contractor and I employees (frill and/or part-time).' have hired the sub -contractors 6. ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g_ ❑ Demolition working for me in any capacity. employees and have workers' insurance.k 9. E] Building addition comp. [No workers' comp. insurance required.] 5. (] We are a corporation and its 10.(fElectrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comp. insurance reauired.l *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 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: H C%f l �1J2- Policy # or Self -ins. Lic. #: CJ L C ( �sq (� Expiration Date: Job Site Address: w �'��� �� t�—C City/State/Zip:.-- Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). d (� Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi& ureAthe s andpenalties ofperjury that lite 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 # q /-7/!(0 Issuing Authority (circle one): I. Board of (Health 2. Building (Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person:— Phone #: The Commonwealth of Massachusetts Print Form Department of Industrial Accidents ' Office of Investigations I Congress Street, Suite 100 Boston, AM 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): `L' m ni E /-�- 4�G eC7 4 / C/r C.._... Ct? (// (feS 70/7c_ Address: �/ 0 3 -C) 4.- ?17 V City/State/Zip: M t (» (,, 7L'^/ (9 ( 9L/� Phone #: C/ '� �r p '� 7C) Are you an employer? Check the appropriate box: Type of project (required): I Z I am a employer with .3 4• F]I am a general contractor and I employees (frill and/or part-time).' have hired the sub -contractors 6. ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g_ ❑ Demolition working for me in any capacity. employees and have workers' insurance.k 9. E] Building addition comp. [No workers' comp. insurance required.] 5. (] We are a corporation and its 10.(fElectrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comp. insurance reauired.l *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 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: H C%f l �1J2- Policy # or Self -ins. Lic. #: CJ L C ( �sq (� Expiration Date: Job Site Address: w �'��� �� t�—C City/State/Zip:.-- Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). d (� Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi& ureAthe s andpenalties ofperjury that lite information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # q /-7/!(0 Issuing Authority (circle one): I. Board of (Health 2. Building (Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person:— Phone #: MR COMMONWEALTH OF mA CH ..00MMONWEALTH.oF.MASSACHUSETTS I6 STATE OF NEW HAMPSHIRE BUREAU OF ELECTRICAL SAFETY & LICENSING NAMEXEVIN 1.10258 M 2. 3. v 4V EXPIRES: 0913012014'.. l.Crl 1 Ir n,. -A I C Ur LIA01L1 1 T IM.*sUMAN%.#C 1/18/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT Frances McEvoy NA Sennott Insurance, SIA, Inc. PRONE (978)953-1614 Fax (978)887-2404 A/C No E-MAIL ADDRESS: fran@sennottinsurance.com 16 South Main Street P. 0. Box 457 Topsfield MA 01983 INSURERS AFFORDING COVERAGE NAIC # INSURER AContinental Western Ins Co INSURED INSURER B Citation Ins Co 40274 Emmett Electrical Services Inc. INSURER C$artford IIIc Co PO BOX 794 INSURER D: INSURER E DAMA E TO RENTED 50 000 PREMISES Ea occurrence $ Middleton MA 01949 INSURER F: COVERAGES CERTIFICATE NUMBERCL1511254290 REVISION NUMBER: 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. INSR LTR TYPE OF INSURANCE ADDL UBR POLICY NUMBER POLICY EFF MM/DD POLICY EXP MM/DD LIMITS A $ COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑$ OCCUR EACH OCCURRENCE $ 1,000,000 DAMA E TO RENTED 50 000 PREMISES Ea occurrence $ MED EXP (Any one person) $ 5,000 BOA 5056261 - 13 8/1/2015 8/1/2016 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: $ POLICY ❑ jE T LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY EOMaBBIINBDtSINGLELIMiT $ 1,000,000 BODILY INJURY (Per person) $ B ANY AUTO ALL OS $ SCHEDULED AUTOS AUTOS BBRV22 8/1/2015 8/1/2016 BODILY INJURY Per accident $ ( ) $ HIRED AUTOS $ NON -OWNED AUTOS PROPERTY DAMAGE Per..Zt $ PIP -Basic $ 8,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED I I RETENTION $ $ C WORKERS COMPENSATIONPER AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVEE.L. OFFICER/MEMBER EXCLUDED? F`N] (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A 08WECEH9576 6/22/2015 6/22/2016 OTH- $ STATUTE ER EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Project: David Wondolowski 100 Raleigh Tavern Road North Andover, MA 01845 %.cn i irn,w r c nVL (978)688-9542 Town of North Andover 1600 Osgood Street Building 20; Suite 2035 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. AUTHORIZED REPRESENTATIVE McEvoy/FMV�''�. ©1988-2014 ACORD CORPORATION. All rights reserved. s� Date... /.'.7�'.... . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ....... `1.. nr has permission for gas installation .......... ...... in the buildings of _ .......... at ��'' ..�� ....-r orth Andover, Mass. Fee,. .... ' (k �� ' `. ..... . �. Lic. No.C.j . � ... // �,. . GAS INSPE&0O9 Check # s i 1 MASSACHUSETTS UNIFORM APPLICATON FOR PERMUT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date -9` -ay -o9 Building Locations 00 RAL �r&# -7-AV r kA L-/./ a Permit Amount $ N f A N �)U v i MA. Owner's Name P -. pA v,� ln/dw Dom to e✓S�� New ❑ Renovation Replacement Plans Submitted (Print or type) n lL�" �l4�Check one: Certificate InstallingCompany Name Corp. Address C l�L/'�iS'%�s� E] Partner u�s'mess le ep one 7 _ ff Firm/Co. Name of Licensed Plumber or Gas Fitter CN)t?/9 611 INSURANCE COVERAGE Checff I have a current liability Insurance policy or it's substantial equivalent. Yes No 13 'Vi you have checked yes, please Cate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond 1 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent 0 i nereoy certtry tnat au or the aetans and mtormation 1 have subtrutted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance -with all pertinent provisions of the MassacAsegs State Gas Code and Chapler 142 ctf the General Laws. (OFFICE USE ONLY) Signature of Licensed Plumber 6r Gas Fitter Plumber a? �0s- Gas Fitter License Number 0 Master Journeyman �� Z� W a Ri 0 F W U x N z z F a w U Q x W z vx� a wo z Q C ax U z W z U O rFi w > z o p W F x o x LT. 3 o c� U a > a a H o SUB-BASEM ENT B A S E M ENT 1ST. FLOOR 2ND. FLOOR 3RD: FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8.TH. -FLOOR (Print or type) n lL�" �l4�Check one: Certificate InstallingCompany Name Corp. Address C l�L/'�iS'%�s� E] Partner u�s'mess le ep one 7 _ ff Firm/Co. Name of Licensed Plumber or Gas Fitter CN)t?/9 611 INSURANCE COVERAGE Checff I have a current liability Insurance policy or it's substantial equivalent. Yes No 13 'Vi you have checked yes, please Cate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond 1 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent 0 i nereoy certtry tnat au or the aetans and mtormation 1 have subtrutted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance -with all pertinent provisions of the MassacAsegs State Gas Code and Chapler 142 ctf the General Laws. (OFFICE USE ONLY) Signature of Licensed Plumber 6r Gas Fitter Plumber a? �0s- Gas Fitter License Number 0 Master Journeyman �� Z� nonwea m of1Vlassachusetts :t Departrrrerzt of Industrial Accidents :r� _ i� �, mice af.Im�ssti; adores - . 640 MlalSjjh MM Street Bos om, ,MA 02111 tH'IsnV-t!2¢£S.bQOv/dilOrieLs° Compensation iairnee. dA 'cant Iaftr�aton. avit RwIders�_ C, on actorsEectricia . as/Pimbers N .. BIIle i sincsslOrgaaizabonAndividualj: �r Pieces Print L 'bf �, (/, _ 101 QV Ades: ------------- City/Stafe • -.... ZiF:�C�s�o2d,?8- 3a g • Are you an eau io.3c) P yerT Cheok.the aPProprinte-box: 1.E7 r, am a ompimfw with 4. TyPe of Projeet (regd 1 R a =enwai /Mnpioyors (furl and/or 2• I am .azole. - ]' � or Conor and I have bire:d the sub- 6. 0 Now construction . 'the Pig'- S* and have no em I P �3'e Iistad anattached ! 7. du"t �"Remodeiing The� st6-contact= have - [No work' oa m any mP mp. iasurence .. wori:mcs' comp. in 8 L] �moirtiorl $. (] VJc s�ran`i g, Q Bur7d' arc a. corporation mg addition required.] 3•(] I am a homeowner W1 work and its ofi>� have exercised their 10•C El=trical Ir -Pain; or additi ''eP ons right of exemption MOL m)sol£ [No•w.ark6s' insurance. P' d -].t par 11.0 Plumb' TeP oradditions 4 �2, § 1(4L'and•we have no 12.[] Rooft;*n arttPiaym�s [No work' ' "Iim. tf,at �P• n'isurancerrquired.] 1317.0ti. checks hoz t� f must also fait out thn seeEimi beiow s 6�vuie _ ;� sebmit this ata wh kaBicming g thairwotkatc' cotop� fhey arr 6aing all wns}c . n pcy informetioa earl this box must aetzdMd an adcUtiaasl end fhmi kite omaide eonu wim ekes showi� the ......� Ord, -= ots Vubmit a new afndavit ittdioe such' - I arF csr es.oaa d fhev wntb..c i+ifar�on: r~ � �n�uraurg.roar�..-s' c�;�s�-s�r� �isrira�rce�oriuy. e�vlme�; B 1 ~� �:: � moa. Insurance Company `:ser'a aaQ;iob Shp. pany Nairne: Policy # or Serf' -ins Lie. #: - .. �ph'aion L?atc: Job Site Addramg: ; Attach a copy of the workers' co �tt3'�2fp. mPeatsation poiicy d'ee'Earation showing Fai'iure to Sean's covers a as (showing the porIcy nn. bmr and e fine fa g fequired under Sma ion 25A of MCjL C. 152 can xPiration dsfe�, . up i;1,5D� DO and/or one-year im to the imposition of criIIrinar p�sities of a of up to $250.00 a onm as h civil pwolfim in the form of a �3 inst•the violator. 8e advised that a c STOP WORK ORDER and a fine Investigations of tine DIA -for ins opy of tris statement may be forwarded to the rastsce coverage verity"t�tion: Ofi'im of I do hereby cern « the pains acrd err p alii� ° tibar the uifnrm�oa m ' . Si p vrded cbwe is dnrce and carred Date: 4fj'iciQl rrse nniy. do not write in. this arrq m he compir" e�ir�,�[ Cray or Town: Issuing "tho ' Permit/L:icaose # b '�3' (cirefe one): 1. Board of Iieatth 2 Bni4#iRg Depmr went 3. City/Tov v am* 4 Eh � Ins 6. Otber peaor S. Plumbic Iuspecfer Contact Person: Phone #: intormanon aE nd instructions Massachuseffs Central Laws chapter 152 requires all emp;oyets to provide workers' compensation for their employees. Pursuant to this stafrste, an entpinyee is defined as "..every person in the service of another under any contract ofhire, express or implied oral ar writtcL" I An employer is defined as "an individual, partnership, asscxiation, corporation or ofher legal entity, or arty two crmom of tht'famping errgagod in a joint en(m-prise, and includii"S the Iegai represe siives of a daeeasesd employer, 6r$e receiver artnstee•of an individual, partnership, asgocistioIn or other legal entity, employing eanploye m •Howeverthe owner of a dwelling house having nat more than ih= apartments and who resides therein, or the occupW of dye dwelling house of another who employs persons to do ma_jMtenance, construction or rear work oa such dwelfthouse or on the grounds or building appurtenant thtsetn shall na-t b== of sucb a mpioynient be dewed to be UZI employer." MGL chapter 152, 92.5C(6) also slates that "every state or local licensing agency shall withhold the icmanwor reeewal of a lieense or permit to operate a besmess or *o construct baildiup in the commonwealth for any apple apt who has riot produced anaepisisic vvilienee d -F compisance wig fhe.insarsnce coverasetz4aired" A.ddidw liy, MOL chapter 152, §25C(7) states "Neither idle cmumonwealth nor any of it-politic:W subdivisions shell enter into any contact for the perfatsrrearee of public woi ie anti' •axepbbI,_- evidence of cotmpifikwe with the intranet rsc}rmerneptts .of this chapter have beat prod ta.the c:RTtt-8�ing may,* Applicants Please fill out flit workers' ,cantpensa#iort afr'idavit campi4Mtaty, by tracking the boxes ffsat apply to. your situation and, if necessary, supply sub=contraetnr(s) rffimes(s), addrM&s(r9):2md phone •number(s) along with their certificate(s) of insurance. Limbed'Liability Companies (LLC) or Limited Liability. Partnerships (LLP) with no campioyees oiherthen the • . members or partrrers, arc not rcquir ad,w cany.workers' ccaTnpenszfim instum = Ifan LLC or'LLP dohs. have ompioyees, a policy is mquirad. Be advised that oris of id.- vit may be submitted tr, the. Department of Industrial .Accidents fnr confirmation of insraanc a coverage. Ain E>e sum to sign and .late the afg'idevit, The a$rdavit should be :retume.d to the city or lawn Out the application for the pamf or Tic:ense ie being re4u..sted, not the Daparlmemt of Industrial Acaidenta Should you have any questions regal -cling the .law or if you are required to obtain a workers' . otimpensation policy, picnarcail the Department at the-nuomber. iisbed below. Self insured mngmim sireuid ernetheir selfixrm=71c eHerres: nurttliw an Ific, i pprapsiate iii. City or Town Offaiabs Please be sort that the affidavit is complete: and printed irg lbiy. The Depaslrrreztt hasprovided a space at the bottom of the affidavit for you tc fill out in, the event the. Ofnce of lnvestigatiam has to contact you mprding $re apprrsnt Please be Suez to fill in the pMrMit/Iicm= number which w- ll be used as a reference number. In addition, an applicant that must submit multiple parmit/license applications in any given year, need only submit one.affidavitr� fidavit inding=Tc;nt policy informsfion (if necessary). and under "Job Site Adds -ems" ti: applicasrt should writ.e "all locations in (city or tower)." A a.mY of -the affidavit that has beecn.offi6zli siamped or merited by tine 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 affidavitmust be Med out each year. Wheys a home owner or citiz= is obtLinn. a license.. or permit not rehrted to any business or commercial vmtrae (i.e. a dog lice rm or permit to bum leaves etc.) said persot•1 is NOT .mpii rd to•compieto this affidavit. Tho Ofim of invesiittions would ItIm to thank you in adww= for your cooperation and should you haava any queshorm, please do not. hesitate to give us a call. 'Cite De nrtamant's address, telephone.and fax number The Commonwma th of Niassaci�usetfs Dcparttnztct of lmdustrW Accid=ts 4fnce atf Euvestiga ions _ 600 Wasbinaton Stzect Boston, RIA 42111 TeL # 617-727-4900 =' t 406 or 1-8.77-bfASSAFB R..viscd 5-26-05 Fax :9 61 7-727-7741 www.naass.gov/dia w Date. . TOWN OF NORTH ANS°OVER PERMIT FOR PLUMBING This certifies that......--: .. • • . • .. • . has permission to perform .� ���................... plumbing intthhe buildings of .........:........ ? ...... at /.... /�-.G :..... !-(�- --�� /,orth Andover, Mass. uL G \ ` \ Fee.'.%.:�'.. Lu.....��.5. No.....�. .,�_.... .�._....... . --PLUMBING S� TOR Check # 8233 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Location /®O )CAL,6-r6 q VWCM Owners Name D1411iE Permit # �. Amount _ L�-j1 0,53 Type of Occupancy New Renovation Replacement 13Plans Submitted Yes No ❑ FTXTI TR F c (Print or type) Installing Company Name Address C AF eV. Check one: Certificate ® Corp. Partner. [3"Firm/Co. Name of Licensed Plumber: —C I'f "IC t S 6LoXA :<�, Insurance Coverage: lndicate the a of insurance cofverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond W Insurance Waiver: I, the undersigned; have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work. and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Mc setts�tatelumbin�r142 of the General Laws. By: Signature 37 Lieciisto,u er Type of Plumbing License APPROVER (OFFICE USE ONLY Title �^1�� D� City/Town icense 1NUMDer Master ❑ Journeyman I Y L:' 9C;:�� 6 ? Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING 16 This certifies that ............................................................................................. has permission to perform A. ....... wiringin the building Of .. ... ... .................... ......................................... at ....... ....... North Andove M ... . . .... .... . . Fee ...................... Lic. N��. °..`........................... Check # 9Q261 Commonwealth of Massachusetts Official Use Only it No. Department of Fire Services Permg` 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: !&, ®j., 2,3 .zoo Q 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) ! d Q QZ� Owner or Tenant Pcv1 t'` lA.r' 0 tjo(�Y—i Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes Ljj� No ❑ (Check Appropriate Box) Purpose of Building YIvV,�,,w„ ��y� Z l . Utility Authorization No. Existing Service _Z,4,V Amps / Volts Overhead ❑ Und rd g ❑ No, of Meters New Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: EN table may he waived h„ rho T.—-- ,,,, m.--_ No. of Total Transformers KVA Generators KVA o. o mergency ig g Batte Units FIRE ALARMS No. of Zones No. .of Detection and Initiatin Devices . No. of Alerting Devices No. of Self -Contained Detection/AlertingDevices Local ❑ Municipal ❑Omer Connection Security Systems: No. of Devices or Equivalent Data Wiring: No. of Devices or Equivalent Telecommunications Wiring: No. of Devices or Equivalent Attach additional detail if desired, oras required by the Inspector of Wires. Estimated Value of Electrical Work: �19W . Ocu,- (When required by municipal policy.) Work to Start: O&P 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 t e pains andpen ties ofperjury, that the information on this application is true and complete. FIRM NAME: Licensee: I Si LIC. NO.: ZW 4-1 A Signature LIC. NO.: (If applicable, enter "exempt " in the license nuniber line.) Address: i Bus. Tel. No.: . S *Per M.G.L c. 147, s. 57-61, u work requires Alt. Tel. No.: security q Department of Public Safety S License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ No. of Recessed Luminaires (� Completion of the No. of Ceil: Susp. (Paddle) Fans No. of Luminaire Outlets No. of Hot Tubs No. of Luminaires d. Above )n_ Swimming Pool rn ❑ No. of Receptacle Outlets No. of Oil Burners No. of Switches Z No. of Gas Burners No. of Ranges No. of Air Cond. Total Tons No. of Waste Disposers - H=Appliances .No. of Dishwashers S No. of Dryers No. of Water Heaters KW Heating Appliances KW No. of No. of Si s Ballasts . No. Hydromassage Bathtubs No. of Motors Total HP OTHER: EN table may he waived h„ rho T.—-- ,,,, m.--_ No. of Total Transformers KVA Generators KVA o. o mergency ig g Batte Units FIRE ALARMS No. of Zones No. .of Detection and Initiatin Devices . No. of Alerting Devices No. of Self -Contained Detection/AlertingDevices Local ❑ Municipal ❑Omer Connection Security Systems: No. of Devices or Equivalent Data Wiring: No. of Devices or Equivalent Telecommunications Wiring: No. of Devices or Equivalent Attach additional detail if desired, oras required by the Inspector of Wires. Estimated Value of Electrical Work: �19W . Ocu,- (When required by municipal policy.) Work to Start: O&P 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 t e pains andpen ties ofperjury, that the information on this application is true and complete. FIRM NAME: Licensee: I Si LIC. NO.: ZW 4-1 A Signature LIC. NO.: (If applicable, enter "exempt " in the license nuniber line.) Address: i Bus. Tel. No.: . S *Per M.G.L c. 147, s. 57-61, u work requires Alt. Tel. No.: security q Department of Public Safety S License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ fo i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 c j www.nzass.gov/dia . Workers' Compensation Insnmrance Affidavit: Builders/Contractors/Electricians/Plumbers Aaplicant Information Please Print Legibly Name (Business/Orgmirafion/[ndividual): Address: ', �--7 2— City/State/Zip City/State/Zip Phone Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ 1 am a general contractor and I ject (required): 2$ employees (full and/or part-time).* I am a:sole proprietor or partner_ have hired the sub -contractors listed on the attached sheet x construction ` 77-pemodeling ship and have no employees These sub -contractors have .Qemolition working for me .in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9' ❑ Building addition T�9required.]10. red-) 3. ❑ I am a homeowner doing officers have exercised their Electrical Q repairs or additions all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No -workers' comp. insurance c. 152, § 1(4), and we have no 12.7 Roof repairs required.] t employees. [No workers' 13.❑ Other comp. insurance required..) - -rr — ••• •• �• »." ns wx must arso nu out tnc seehon below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicting they are daring all work and then hue outside contractors must submit a new affidavit indicating such. 1contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy infamlation. t ant an employer that is providingmarkers' compensation iftSUrMCef0r my employees: Below is the policy and job site information Insurance Company Name: ' \ %1A, Policy # or Self -ins. Lic. #: Expiration Date: Sob Site Address: t A-- City/State/zip: m � a� c.ss�.- o t t>vi i Attach a copy of the workers' compensation po icy declaration page (showing the policy number and expiration dale). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a - fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerftfy under the p 'ns an¢penaU es of perjury that the information provided above is true and correct Si tore: Date.- Phone ate.Phone #: ------------------------- �ciat use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # lssuing 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." r 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 ortmstee 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 pennit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT_required to complete this affidavit The Office of investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The.Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia -' The Commonweauk of Massachusetts Department of Industrial Accidents Office of Investigations 600 Nraskinan Street Boston, M4.82111 www mmsgov/dia Workers' Compensation Insiirannce Affidavit: Sanders/Contractors/Elec�triciaasfpfnmbers Aicant information . NaMe (8usiness/prbwiza6ar gndividual): Address: o q CE'/ py trranee r'equn�] *Any ap wn ent tlmt Checks bo> # I must also fat out the section below showing their workers' bompensation policy information t Homeowners who sohmis this affidavit indicating they, alt d n all ;Cantractnrs that coxal this box must , g woig and then hire otasitle contractors must submit a new Affidavit indioating such atraobed s i sitditiana sheet showing Ehe mum of the sub- cotnraetors and their workers' eernp. poli^• information. oral an er4ploYer t�ta i°rso..� :;ooF%cers' compensation 'nswanre or iafarrnafio2 f m3' enrploYeaL- Below is the Pot '. and job sitr . Insurance Company Name: Policy # or Self -ins. Lie. #: Expitstion Date: Job Site AAA -- I I- dre Attach a copy of the workers' com Crty/State/Zip. peasatiots policy declogtion page (showing the policy namber and expiration dafe), Failure to secure coverage as required under Section 25A of MGL C. 152 can lead to the imposition of criminal fine up to $1,500a d y and/or one-year imprisonment; as well Ms civil penalties in tate form of a STOP WORK ORDEand of i . In es to tionsS250.00 a day against the violator. Be advised that a copy of this statement may be to to the a fine Investigations of the DIA for insurance coverage Verification. Office of I,r L___s y 777 -aur me pains and pen of perjary that foe informad,11- Pr-,ided above is true and coned Ojf`iciat use onfY. Do not write in tins area, tD be CO3VkM,_ or tppn o 63' Y CW Ctty or Town Pertnit/Licenm # Issuutg Authority (circle one): I. Board of Health 2 Building Department 3. City/Town Clerk 6. Other 4. Electrical Inspector S. Plumbing Inspector contact Person: Phone #: FAoemployer? Check.the appropriate box: em 1 er wi#lt oY 4. ❑ I am a genes contractor and I:em Pref (regalP (full and/or part-time).* have hired the s &cantsactorsew construction rietoror prop partner- ship and have no employees listed on the attached sheat 3emodeling These sub ..am.asole working for me in any capacity. workers' comp. iasttrartce -contractors have workers' comp. insurance. 5. ❑We arc a corporation and its emoiition�Na ilding addition Fno�r ImJed)ofncers am a homeowner doing ail work have exercised their right of exemption per MOL ectrical repairs oradditionsI mbing (No•workinl coinsuiance u t !,] C, L52, §i(4),and we have no employees [lYo workers' repairs or additionsmysel£ of t epairser trranee r'equn�] *Any ap wn ent tlmt Checks bo> # I must also fat out the section below showing their workers' bompensation policy information t Homeowners who sohmis this affidavit indicating they, alt d n all ;Cantractnrs that coxal this box must , g woig and then hire otasitle contractors must submit a new Affidavit indioating such atraobed s i sitditiana sheet showing Ehe mum of the sub- cotnraetors and their workers' eernp. poli^• information. oral an er4ploYer t�ta i°rso..� :;ooF%cers' compensation 'nswanre or iafarrnafio2 f m3' enrploYeaL- Below is the Pot '. and job sitr . Insurance Company Name: Policy # or Self -ins. Lie. #: Expitstion Date: Job Site AAA -- I I- dre Attach a copy of the workers' com Crty/State/Zip. peasatiots policy declogtion page (showing the policy namber and expiration dafe), Failure to secure coverage as required under Section 25A of MGL C. 152 can lead to the imposition of criminal fine up to $1,500a d y and/or one-year imprisonment; as well Ms civil penalties in tate form of a STOP WORK ORDEand of i . In es to tionsS250.00 a day against the violator. Be advised that a copy of this statement may be to to the a fine Investigations of the DIA for insurance coverage Verification. Office of I,r L___s y 777 -aur me pains and pen of perjary that foe informad,11- Pr-,ided above is true and coned Ojf`iciat use onfY. Do not write in tins area, tD be CO3VkM,_ or tppn o 63' Y CW Ctty or Town Pertnit/Licenm # Issuutg Authority (circle one): I. Board of Health 2 Building Department 3. City/Town Clerk 6. Other 4. Electrical Inspector S. Plumbing Inspector contact Person: Phone #: Information a nd Instructions Massachusetts General Laws chapter 152 requires all emp 3oyers 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 wry" An employer is defined as "an, individual, partnership, assadiatiint, corporation or other legal entity, or any two ormore of the'foregoing engaged 'm a joint enterprise, and includi"g the legal representatives of a deceased employer, or the J_ receiver ortmster of an individual, partnership, association or other legal entity, employing employees. 'Howeverthe 7 2> 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 shat not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states fhat "every state or local licensing agency shad withhold -the issaance or renewal of a license or permit to operate a business or *:o construct buildings in the commonwealth for any applicant who has not produced acceptable evidenceair compliance with the insurance coverage required." Additionally, MOL chapter 152, §25C(7) states "Neither tkm commonwealth nor arty of its political subdivisions shall enter into any contract for the performance of public wort- until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the cox tracting authority." . Applicants Please fill out the workers'- compensation, afzrdavit compi�tely, by checking the boxes that apply to your situation and, if necessary, supply sub-contrctors) name(s), address(es). mind phone nuvnber(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, arc not rrequiredto carry workers' co-rnpensation insurance. Van 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 lz�e 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 r+egaa-ding the law or if you are required to obtain a workers' compensation policy, please -call the Department at the number. listed below, Selt-issri*pd E�arap��iPs stre,ld er!+� d, selt--insurance-license number on the'approjo iate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department hes 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 permitlIicense number which %%-ilI be used as a reference number. In addition, an appiicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicatfr g -current policy :informafion (if necessary) and under "Job Site Address" tare -applicant should write "all locations in(city or town)." A copy oftthe affidavit that has been .officially sta=mped or marked by the city or town may be provided to the applicant as proof that a valid affrdak is on file for f tam permits or licenses. A now 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 per init'to bum leaves etc.) said pm'sbn is NOT, required to complete this affidavit The Office of Investigations would lilm to tlmk you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Depamnent's address, telephone ana fax number: The Commonvuealth of Massachusetts Departwcnt of Industrial Accidents Office of Inveatiiptions 600 Washington Street Boston, MA 02111 TeL # 617-727-4900 ext 406 or 1-977-MASSAFE Fax # 617-727-7744 Revised 5 -2t, -Q5 wwwman.gov/iiia Date.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACMUSE� /f This certifies that ....... �7 .................................... has permission to perform .... wiring in the building of at / Fee./ Lfjic. Nor Check 4 -4 553' ........... I ............................................................... U.A.4-North Andg-ver, Mass. �jE.. . ........ ? .. . ..... ....... LECrRICAL INSPECTOR ;5 _ Commonwealth of Massachusetts a : A- Department of Fire Services BOARD OF FIRE PREVENTION REGULATIC APPLICATION FOR PERMIT TO All work to be performed in accordance with thl K (PLEASE PRINT IN INK OR TYPE ALL INFORMAL City or Town of - By this application the undersigned gives notice of his r h Location (Street & Number) 00 d Owner or Tenant Owner's Address Official Use Only Permit No. tR Occupancy and Fee Checked S [Rev. 11/99] (1PavP hlank) :ORM ELECTRICAL WORK tts Electrical Code (MEC), 527 CMR 12.00 Date:�l �' /-0 ' ?" cj _ Tathe Inspector of Wires: to perform the electrical work described below.,, No. v Is this permit in conj u tion with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Buildings � AJ&Z.1X— 7;479� Utility Authorization No. Existing Service gvU Amps ZOO L_11,0 Volts Overhead Er�, 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. /�C-�� •�+ ���� ���� G�-/%7zd Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Fixtures No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above E] In- E] rnd. grnd. No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number I. I Tons KW No. of Self -Contained etection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances g pP KW Security Systems: No. of Devices or Equivalent No. of WaterKms, Heaters No. of No. of Signs Ballasts Data Wiring I No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP / Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail ifdesired, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) (Expiration Date) 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. I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete. FIRM Licensee: (If applicable, etu Address: OWNER'S IN; required by law Owner/Agent Signature _ P Signature �t the license number line.) JKAfNUE WAIVEK: t am aware that me Licensee does By my signature below, I hereby waive this requirement. Telephone No. LIC. NO.: LIC. NO.: Bus. Tel. No. «1'6, 7 97 Alt. Tel. No.: not have the liability insurance coverage normally I am the (check one) ❑ owner ❑ owner's agent. PERMIT FEE: $ f i Location No. -S Date Check # �3 17850 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ I U Foundation Permit Fee $ Other Permit Fee TOTAL $ -/00— Building bd–" Building Inspector f. TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVAT5 OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: 3 �7 S— DATE ISSUED: l�/3,DZo SIGNATURE: C Building Commissioneffl for of Buildings Date SECTION 1- SITE INFORMATION ti N r E` ,'1 1.1 Property Address: i0 0 / ?,?Ie /t1 7g Ur,,�ti 1.2 Assessors Map and Parcel Number: n V1 toc( Map Number Parcel Number 1.3 Zoning Information: -/&/s� 141,7'e Zoning Diairic-t Proposed Vse 1.4 Property Dimensions: jq at Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided .1.7 Water SuoobPlS GL.C.40. 54) 1.5. Flood Zone Information: / Public 0 Private ❑ Zone Outside Flood Zone (2/ 1.8 Sewerage Disposal System: _ / Municipal ❑ On Site Disposal System E✓ SECTION 2 - PROPERTY OWNERSIUVAUTHORIZED AGENT I' i s t e5 IN O 2.1 Owner of Record L este 100 1e7*1VJ 4 -751 12, 10911"%vim Name (Print)Address for Service it sj=L4@ //7 721 /,L 7 Signature Telephone 2.2 Owner of Record: yiG1 !)v eq- le Name Print Address for Service: 6/7 PZ/ AW7 Si re Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: 7 b Addre l'-7-�T yzD �17� Sig Telephone Not Applicable ❑ C,5 0'/-6'7 License Number /L�/� Expiration Date 3.2 Registered Home Improvement Contractor -.Iva Sam e 4's1wve Not Applicable ❑ Compan- Name Registration Number Address Expiration Date Signature Telephone 09 M X ic z O SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 2506) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......0 No ....... ❑ SECTION 5 Descri tion of Proposed Work check all applicable) New Construction ❑ Existing Building 0 Repair(s) ❑ Alterations(s)11Addition ❑ Accessory Bldg. ❑ Demolition 11Other 91-Specifye dri �i p4��j,1 Brief Description of Proposed Work: P,th,nc1L /4, 6ef- /"- SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be l ) Completed by permit a licant ffF 1. Building t7 y01� (a) Building Permit Fee Multiplier 2 Electrical 300 ' (b) Estimated Total Cost of ' Construction 3 Plumbind 30 U Building Permit fee tel X tbl 4 -Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 00 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner I Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, V-71111 r't/0 1 as Owner/Authorized Agent of subject pr rty Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief L�s& Print Dime Si 7g nature o er/A g ent Date NO. OF STORIES SIZE J S' . 7/, BASEMENT OR SLAB SIZE OF FLOOR TIMBERS I ST2ND 3RD SPAN DA ENSIONS OF SILLS DRvIENSIONS OF POSTS DEVIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY > C -le' IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE U• The Commonwealth of Massachusetts Department of /ndustdal Accidents Mice of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # 71 I am a homeowner, performing all work myself. 0 I am a sole proprietor and have no one working in any capacity © I am an employer providing workers' compensation for my employees working on this job. Comlranv name: 'qU /0h 7tO /YbA Address - 314 S? Lot cl E4 , Cu. hol, 4�2 /2ti//0yz �4 Phone #- 92� 7 2J b..3 % y ' Companv name: Address Ck.. Phone # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years' imprisonment -as wedl.ss.dvil.penaltiesin3hafmn -Ufe..STOP WDRK ORDERand_a.fine of.(.31t)0.00)-ad* against.me. I understand that a copy cf this statement may be forwarded to the Office of investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is (rue and correct. • - - � _�_ _� �� �i � %�v� _ . - - it — —i MI' 11 W • _,4 Official use only do not write in this area to be completed by city or town dftal- City or Town Permit/1-icensina ❑ Building Dept []Check if immediate response is required ❑ Licensing Board ❑ Selectman's Office Contact person: Phone #: ❑ Health Department ❑ Other North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: %0 (Location of Facility) NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector N William Mckay Construction 36 Second Street North Andover, MA 01845 NAME/ADDRESS Dave Wolkowski Raleigh Tavern Lane North Andover, MA 01845 Estimate DATE ESTIMATE NO. 11/28/2004 48 C'ustor�er YV1lliarw /WIav LoNs�rct�o�V PROJECT ITEM DESCRIPTION QTY COST TOTAL Labor Remodeling of Bathroom and master bedroom t � t 10,000.00 10,000.00 TOTAL $10,000.00 C'ustor�er YV1lliarw /WIav LoNs�rct�o�V U �fze i�oon�xovzuiea� o�.�adac%ucelt ' ,p., �\ Board of Banding Regulations and Standards ,P- HOME IMPROVEMENT CONTRACTOR Registraliopt;.. 143163 {► - 6f2,1/2006 T1► _ DBA. WILLIAM McKAYCONS7 WILLIAM McKAY ' 36 SECOND ST C �..,.,-. -moi �T�*✓ . N. ANDOVER, MA 01845 Administrator 3 ,1 ----~'' ---- r�--- OCT -29-2004 05:39P FROM:Eileen Corbett 7815440053 T TO:16174975055 P:1/2 CA m m x CA m C) F d C CA CM) � d .0 O CD Co CD CL C7 ? O C CO) aUM CD d ooCD Q� O cr=r.c d CD CD o CD C C H. �.O CD CL0 CO) C I C2 CO) O CD CD z� o� CD 0 n O z cnC o� = z CL Q m y O a O T Z ? a =+m Ca 0, e§4 S' 3Emm a > > y m � O O O O r�_q EL aom �V+ ' ate^' m O "a: - CD C �OO _ ti A :4 O p� H CA CL Q 0 dW-6a CosJim s y N �H�CD CD m N 1 o 0 �IF o G! v Ea :O o i�I . � oErr G b y G � m C CO) � do f s -- :. Vim:mb Dip• a,S o CD .5 y o tri G b y G C G b Imi 0 9 0 P=h a 11 Date ..... / . / ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ........... I ................................................ ................................ has permission to perform .................................................. wiring in the -building of ...... .z� .... North Andover, Mass. an;l Fee... ... Lic. No .............. ........... r tL'ECTRICAL INSPECTOR Check# 91 5472 THE COMMONWEALMOFMAS94CHUSE77S Office Use only j DEPARTNIEW0FPUX1CSAFVY Permit No. �� -- i -) —/ BOARD OFFIREPREVEMONREGULAHION 527CW 12 Q9 ' ' Occupancy &Fees Checked APPLICATTONFOR PERMIT TO PE RM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSAC SSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date F 0 Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical wolik desghbed below. Location (Street & Number) Owner or Tenant Owner's Address Is this permit in conjunction with a building permit Yes E:]�1Qo El (Check Appropriate Box) Purpose of Building CP Existing Service Amps Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Utility Authorization No. ,&verhead Underground No. of Meters Overhead Underground No. of Meters No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA round 0 Zround No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pum s Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW Connections ,No. of Water Heaters KW No. of No. of I Si s Bailasis No. Hydro Massage Tubs No. of Motors Total HP L IfmIIarlOe PIIISUBnitOt11e1eC]llft2lnefllSOfMa1'SaClII19eU.S�i1PI'dll.clwS. Ibavea Iiab1` kmm=Pblicyi kx&gCompleteOpaati mCc)mn eorzatstt IhavesubmittedvandproofofsainetotheC»Iio~ YES did tgtheapp Dam—& boX INSURANCE [Lr BOND 011 -ER (Please Spet*) .A alent YES ED NO ED Fyou have dted®d YES, pleae indira1e the type of coverage by Estimated ValueofFdechical Wolk $ Final uta . %♦ h�� Al Tel No. OWNER'S INSURANCE WAIVER; I atn aware that the I XXIme does not have the irmuarre covaagz or its substantial etltrivalertt as ternmed by Massadlusetts General Laws and that my signattue on d m peau application waives this tegtrumrtett (Please check one) Owner Agent Telephone No. PERMIT FEE $ Signature ot Uwner or gen Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . 1jn�yavC.� SL 34YA `� �'i"` has permission to perform .............. .. . W. Ory � a CtJ plumbing in the buildings' oft........ �� .........s . [ ...... . at ../Po .. Ra f �.�`�... �'�.['` �''� . L�J' , N h Andover, Mass. Fee ..[`�.�.Lic.No..����...�.�tdL"'Zf,�!EI�C.�tr�.!v�-.-.�_ PLUM ING INSPECTOR Check # oZ 6277 MASSACHUSETTS UNIFO (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location New APPLICATION FOR PERMIT TO DO PLUMBIN "'OUrs Name Type of Occupancy Renovation Replacement 0 Date Permit # \Ajov\,do Cc7.,vm- KI Amount Plans Submitted Yes No ❑ FIXTURES (Print or type) Check one: Certificate Installing Company Name A Do Rti c�1 PuM6;� 1-� � � Nom_ � Corp. + _ Address ?3 c? -7 �'7° amP er. /' , 'Business Telephone Frm/Co. f Name of Licensed Plumber: � Arm Insurance Coverage: Indicate the t e of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner D Agent El I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. BY Signaiure 01 Licensedum er a Type of Plumbing License j Title //J r City/Town cense um er Master oumeyman APPROVED (OFFICE USE ONLY 111���111