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HomeMy WebLinkAboutMiscellaneous - 1004 SALEM STREET 4/30/2018 (3)J ❑ L7 w 0 'dp rn,Ob N -i O y �' IS( vrni- ci 0 CD co a N .OsN y .meq M M• '��` y w. O N p b w ry c+ O O y CD C� CP tz. CD m CD o O� 00 vmi w a o A. w R. CD C-. . C .'-7•'. n• � � � O p � O O O •y Ory ❑ ° pcNo W 0~ n y .r � a w rn N CD 0 ID � ti• y p M. CD p 'ccoo'] y CL o•wao o o poea op: aCD w �'•, ao o y oo co w o 9 � 0, "" p y O�� 0 0 ca oA 50' pywi �. O O wcr CD �fD ' kSb CRD C wp''06 N O No " CD cm, m w o p .gym„ wy rw o CD ~.CCDa cc eco a n0, 0,999 o 0,g co p, g C o� 0 5'0 'D Co p w 0 GD cM9 � �3. O �Oy "h O rl CRD b � y P O 0 CD CD 0 g O rn qQ N O N O• rT ti FT N co � N n C, o Exq"cnX000 o 0,00 `o- w f< co �o �a� N O_. m coo CD CD Ny p din., O �a a B cI y °` w `C,Na 0W�W W .,Nw r "i 0365 10365 Date.................. ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING G � pe r -/ , This certifies that ..... z� .......... r. el ....... // ....................................... .. ........ ..... .. ...... ,- - — e- — 02 1 /-1 - has permission to perform ..... ................................. / . . ................. wiring in the building of ............... A .. C & ......................................................... at.... .......... ................ 5 ... I ................. . North Andover Mas Fee .k5 ........... Lic. No./.Z. ... 9 X/0 .1 ........ ......... / LECTRICALINSPECTOR Check # ti Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. hl Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINTININK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. I Location (Street & Number) 100 W 61L een St Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building -C f Utility Authorization No. / Existing Service .25,0 Amps RO/ �—) �Nolts Overhead.. Undgrd ❑ No. of Meters I New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: n r 1Y1 , Completion of the follawing table may be waived Jap, the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Sus addle Fa p• (Paddle) No. of Total Transformers 4 KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above [I'In❑ d. grnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS JNo. of 44es No. of Switches ! f . No. of Gas Burners NO..Inof Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained No. of Waste Disposers p Totals: ......................... ]...................... Detecoon/Alerting Devices No. of Dishwashers Space/Area Heating Local Municipal ❑Other Connection No. of Dryers Heating Appliances KW Security Noo Devices or Equivalent No. of Water KW No. of No. of 0 Data Wiring: Heaters Signs Ballasts . No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecom of Devices or E uivucaons alent OTHER: �qq Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Valu. of lec ' al Work: y (� (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 ov rage is in force, and has exhibited proof of same to the permit issuing office. ANCE CHECK ONE: INSURBOND ❑ OTHER ❑ (Specify:) I certify, under thepains and penalties of perjury, that the i ation is true and complete. FIRM NAME: LIC. NO.: Licensee: ; ��1C; t,c ' ti nat _ LIC. NO.: j ?jq 13 (If applicable, er "exempt,"t re ' ense nunMr lines /�� 41. 'Bus. Tel. No.� f Address: _i � P r 4t "I Z h t� r1 / " I I Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ {' i www." ass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers At Plicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip:, Phone #: . Are you an employer? Cheek.the appropriate box: L ❑ I° am a employer with 4. [1I am a general contractor and I Type of project (required): [7.. employees (full and/or part-time).* 2. ❑ I am.a.sole proprietor. or partner- The Commonwealth of Massachusetts 6. Q New construction ❑Remodeling Department of Industrial Accidents � - Office of Investigations y;W ,, 600 Washington Street Boston, MA 02111 {' i www." ass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers At Plicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip:, Phone #: . Are you an employer? Cheek.the appropriate box: L ❑ I° am a employer with 4. [1I am a general contractor and I Type of project (required): [7.. employees (full and/or part-time).* 2. ❑ I am.a.sole proprietor. or partner- have hired the sub -contractors listed on the attached sheet. $ 6. Q New construction ❑Remodeling ship and. have no employees These su&contractors have 8. Q Demolition working for me .in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its g, ❑ Building addition required.] officers have exercised their 10.❑ Electrical repairs or additions 3. ❑ I ,im a homeowner doing all work right of exemption per MGL '° 11.❑ PIumbing repairs or additions myself. [No•workers' comp. c. 1.52, § 1(4),' and we have no 12.[] Roof repairs insurance required.] t employees. [No workers' 13•❑.Other comp. insurance required.] -11y appiiaarn inat checks box# i must also fill out the section below showing their workers' bompensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 4Contractors that check this box mustattached an additional sheet showing the name of the sub -contractors and their werkem' comp. polis; -,n&m, adon. 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 4 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 Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a - fine up to.$1,500.00 and/or one-year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against -the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under thepains andpenalties ofperjury that the information provided above is.true and correct r Sitmature: Date: Phone #: Official use only. Do not write %a this area, to be completed by cit, or town official City or Town: Permit/License # Issuing Authority (circle one): , I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Otber Contact Person: Phone #: i 7764 Date...: 3.: �.!........ HpRTM of �` TOWN OF NORTH ANDOVER • - PERMIT FOR GAS INSTALLATION �,SSACHUSEtS This certifies that ... ``.......`�.....1 ............... . has permission for gas installation . A?. . 1? .- ............. v in the buildings of .. �. !Z��.� ?-- ................... . Cx� s .,M Sty at `:(............. .<........ , North Andover, Mass. Fe �4.7- (D . Lic. No. � �. 2.' 2 ... ... . GAS INSPECTOR Check # 2 �j b( CIYTI loco MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING c Lu City/Town: y�/��/ MA. Date: 7A Permit# Building Location: l C/ 7 SALii 1 -S7 Owners Name:1jeL?a Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: 2r"' Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ CIYTI loco INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No ❑ If you have checked Yes, pleas71ndicat e a type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity Y❑ 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 _Signature of Owner or Owner's Agent Owner El Agent E] By checking this box ❑, 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 -�•••r••�••�� •••••• a•• • ���������� N—�Q u1j uUIV M.1bbauiuseas mace riumomg coae,ano Wapter 142 of the General Laws 6 �� s Type of License: By a — (Wumber Title a Q ❑ Gas Fitter Signatur o , ensed Plu er/Gas Fitter k1master l J cit gown Journeyman License Number: APPROVED OFFICE USE ONLY ❑ LP Installer i 1 W Z c Lu Q U) CoQ 0 v = _ C Z = 1--Z 0 W w 0 O Lu F- O w O tY w F- O W N W g O m O w W p O Q H Lu X to 0 w 0 W a~ w N 0 Q w = LL Z W 5 N _j F- H 0 Z —t O LL 1-- W H W W U o o tQ7 _ W0 IL tW- > > > O SUB BSMT. BASEMENT — 1 FLOOR 2 NUFLOOR 'S 'FLOOR 4 Tm FLOOR 5 FLOOR 6 FLOOR 7 FLOOR 8TH FLOOR Installing Company Name: CAL A,& � � 14 ( Check One Only Certificate # [�� 'Corporation Address: 91{ �Eayoa a City/Town: 2 State:❑ �} �i/ Business Tel: %gyp (��s 7 l�-� Fax: Partnership Name of Licensed Plumber/Gas Fitter: r� r. EFF LT ❑ Firm/Company INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No ❑ If you have checked Yes, pleas71ndicat e a type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity Y❑ 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 _Signature of Owner or Owner's Agent Owner El Agent E] By checking this box ❑, 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 -�•••r••�••�� •••••• a•• • ���������� N—�Q u1j uUIV M.1bbauiuseas mace riumomg coae,ano Wapter 142 of the General Laws 6 �� s Type of License: By a — (Wumber Title a Q ❑ Gas Fitter Signatur o , ensed Plu er/Gas Fitter k1master l J cit gown Journeyman License Number: APPROVED OFFICE USE ONLY ❑ LP Installer i 1 9058 Date.2:3.. .�... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ..C.�i.�E.S �'!� ..�..`-..F� {............... . has permission to perform . iOL�a,, t)`dy :....... plumbing in the buildings of ...4-1 �!.............. . at ... ! o. 04 . 5�.� e-+^...- ( .......... North Andover, Wass. Fee ?: 5 U.. Lic. No.. A . .... � . . PLUMBING INSPECTOR Check #— rOccupancy: ACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (, %/2 MA. Date: /I <,. Permit# ff 1 Owners Name: mmercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: L] Alteration: ❑ Renovation: ❑ Replacement: � Plans Submitted: Yes ❑ No FIXTURES Installing Colrpany Name: C,q 1��{—/cJ Check One Only Address: / ,J I,. /u Corporation eL-�`U _ City/Town: l 2State:� n �+/ \ ❑ Partnership Business Tel: • `� �y �( 2 Q i Fax r _ ❑ Firm/Company Name of Licensed Plumber: J ;T A �, n I INSURANCE rrniGonr`�. DEDICATED Ln o: H z � z w >Uj N W C LU v¢i 0 Q Z z a 2 z ~ `n 'Q df H L w U H I w 4¢' O CO N cc cti Ln } w Q Q vi -i Y 3I OLn a H O ¢ LL r-- w p O o w Z w `,j` z U ° LL w U Q x 1.- Q Cn a OF- O U F- Z O Q "- O O a Z ¢ Z 2 ti w f- w t- w ¢ m m o o LL i 3 °� X 3 3 3 0 SUB BSMT. BASEMENT 1sT FLOOR 2ND FLOOR 3RD FLOOR 4' FLOOR 5T" FLOOR 0 FLOOR 7T" FLOOR ST" FLOOR Installing Colrpany Name: C,q 1��{—/cJ Check One Only Address: / ,J I,. /u Corporation eL-�`U _ City/Town: l 2State:� n �+/ \ ❑ Partnership Business Tel: • `� �y �( 2 Q i Fax r _ ❑ Firm/Company Name of Licensed Plumber: J ;T A �, n I INSURANCE rrniGonr`�. DEDICATED Ln Z � N W C LU v¢i Q Z o df L w I I - a (D 3I Certificate v I have a current liability insurance policy or its substantial equivalentwhich meets the requirements of MGL. Ch.142 Yes No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy•]r Other type of indemnity ❑ Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Si nature of Owner or Ors Agent Owner ❑ Agent ❑ hereby certify that all 6M. 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 t�: ork 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�leApneral Daws. - e� BY.fk f .f' Type of License: Title Signature'bf censed Plumber --7— O Plumber/ lity/Town Q aster APPROVED (OFFICE USE ONLY) ❑Journeyman License Number: J �� r I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town, 122 MA Date: Permit# Building Location:_ Cj(j L/ S� 1e- M,�( Owners Name: CCL g,- Type of Occu ncy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES 00, DEDICATED A !� ►w- ? SYSTEMS iz v j rn N O z a Cd r Y 'Q 'n v U hP. w p ❑ w cn Z Q Q w C7 CG CC Z d m vi a w M F w l" v� L Z O d d x N Ln LU 0 H Q y ❑ ¢ Z a Z vNi L7 ii X Q a d = O cr w ❑ ❑ w w Z W S _� Q tr Q ¢ cn v^ai O ~ v O Q O �' a U �" df O w a m m o❑ LL x° g g 3 3 3 0 ° ,- •SUB BSMT. BASEMENT 1sT FLOOR 2ND FLOOR 3RD FLOOR 4T" FLOOR 5T" FLOOR 6T" FLOOR 7T" FLOOR 8' FLOOR lt1Sl:all'ingCrjnipz;Pp i+i8ma• © \ Chc..!:One on1 C r:i6'EC`-Ite • Address 'Dc�Sa� �S�) El Corporation City/Town: O iia State: �G` Business Tel:' .ZC 7 3 747 Fax: I 3 El Partnership � � =� S `7 SrG_7 �—� �� / /) Il ❑Firm/Company Name of Licensed Plumber: 11:21 1 INSURANCE COVFRnrn- 1 have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑ If you have checked Yes, please indi a the type of coverage by checking the appropriate box below. A liability insurance policy. Other type of indemnify ❑ 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 Si nature of Owner or Owner A ent Owner ❑ Agent ❑ 1 hereby certify that all of the details and Information 1 have submitted (or entered re ardin th' Knowledge and that all p!un,bing work and installations performed under the per issued r ` is apcacationrwill be in compliance with all . r Pertinent provision of the Mass �hvsetis Slate Plumbing Code and Chapter 142 . t er i Law , ry iy j. Type of License: 'itle ❑ Plumber at re ice sed Plumber !ty/Town ❑ Master ' PPROVED (OFFICE USE ONLY) (ourneyman License Number: 66MM61 WEALTH OF -Id t moo:••-• J IN PLUMBERS AND GASFITTFR I' LICENS&PEAS A J( 15 E THE ABOV ;TE PAUL _ T HOYT 6G PLEASANT ST A STONEHAM t MA 02180-383 E Fold, Then Detach Along All Perforations J S t Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, 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 confumatior 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 Comononwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 0211 X Tel. # 61.7-727,4900 ext 406 or 1-87 x:-MA.SSAFE Revised 5-26-05 Fax # 61.7.727-774.9 wvw.mass.govfdia ■w IV/cU/ZUII 1;1:44 FAX 181 933 9445 MARTINI INSURANCE 001/001 -COW. CERTIFICATE OF LIABILITY INSURANCE OP ID DATE(FMDDNM HOYT-01 10/20/11 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Martini Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 6 Common Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR PO Box 565 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, Woburn MA 01901-0665 Phone: 781-935-0220 Faxo781-933-9445 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Travelers INSURER e: Hartford Insurance Company_ Hoyte Plumbin & Heating Inc INSURER I. T:foOIAZN Indemnity co of IL - 66 Pleasant 5 reet Apt IFA INSURER Stoneham MA 0 180 INSURER R, COVERAGES THE POLICIES OF INSURI.NCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWTHSTANDINO ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSUIIANCF AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AOOREGATI• LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. EFF1 TR NRR TYPE nP INC11Ramri POLICY NUMBER EXPIRATION oa MMlD�E IMMIDDlyYI LIMITS GENERAL LIABILITY A X COMMERCIAL GENERALLIABIUTY I6802551NS38ACJll 04/20/11 04/20/12 I•• I CIA]] AS MADE OCCUR GEN'L AOGREC.AT6 LIMIT APPLIES PER: POLICY JEC LOC AUTOMOBILE UADIUTY C ANY AUTO BA2A05102111ATJF 05/31/11 05/31/12 ALL OWN_D AUTOS R S0HEDULEDAUi05 X HIRED AVOS X NON-OWIIED AUTOS GARAGE LIABILITY 7 ANY AUTO EXCESS/UMBRELLA LIABILITY IOCCUR Cl CWMS MADE DEDUCTIBLE RETENTION S IWORKERSOOMPENSAMONAUD 8 EMPLOYERS' LIAUIL ITY OBWECLE1876 03/04/11 03/04/1: ANY PROPRIETORIPARTNERIEXECUTIVE OFFICER/MENIBER EXCLUDED? I EXCLUSIONS ADDED BY Re: Plumbing CERTIFICATE HOLDER CANCELLATION EACH OCCURRENCE 31000000 PREMISES awowwce S 300000 MED EXP (Any oro perwA) - 5 5 0 0 0 _ PERSONAL& ADV INJURY $ 1000000 GENERALAGGREGATE $ 2000000 PRODUCTS • COMP/OP AGG 120000 0 O COMBINED SINGLE LIMIT E (Fe erCdem) 0 ACORD CORPORATION 1888 BODILY INJURY S 100000 (Per perten) BODILY INJURY s300000 (Perexidenq PROPERTY DAMAGE S 250000 (Perexldentl AUTO ONLY - EA ACCIDENT S OTHER THAN EAAOC $ AUTOONLY� AGG I EACH OCCURRENCE S AGGREGATE S S 3 S� Dim TORY LIMIT ER ER E.L. EACH ACCIDENT S 500000 E,L.DISEASE .EAEMPLOYE S 500000 E.L. DISEASE -POLICY LIMIT S 500000 CERTIFICATE HOLDER CANCELLATION TOW14147 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEAPOP, THE ISSUING INSURER WILL ENDEAVORTO MAIL 10 DAYS WRITTEN NOTICE TO TNF CERTIFICATE HOLDER NAMED TO TWE LEPT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AOENTB OR Town of North Andover 1600 OegoOd street North Andover MA 01845 REPRC�rnES. 1 (l-- ACORD 25 (2001108) 0 ACORD CORPORATION 1888 /1 7 Date. � . �..... . TOWN OF NORTH ANDOVER o PERMIT FOR PLUMBING This certifies that ...!.. 1�.`. `. ! �. a............ has permission to perform .....P e `t ` `. `.. . plumbing in the buildings of .. & .. �`. `. .................. at .. ��! o L�.. S.......`. `... .. , North Andover, Mass. Fee.Lic. No.. 2� 3 r s.. ......... . PLUMBING INSPECTOR Check "/t FIXTURES MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: /(/ �MA. Date: Permit# Building Location: lli U -S' erll "• � -) Owners Name: a r P DEDICATED Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes 3�'No ❑ FIXTURES INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy [� Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title ❑ Plumber Signature of Licensed Plumber City/Town ❑ Master License Number: 302 %r APPROVED OFFICE USE ONLY �lourneyman —� DEDICATED SYSTEMS � Z H Z w 0 u V, D > _cc z in z_ 9 x a V) = u, a w )ii z D a e s W a = 0 L Q W Z �' w Z~ p a E- a LA LU R R O m w j W H Y oC Qa' W a z J vim) v� z U x a LL = w 3 3 W H > bud" O D: 3 0 Q L!J V) J Q = W W � Uj d� V) W LU s O o 0 >> 0= g 5 o a �¢Z LA a s u a= a Q Co m O LL 2 X C Ln v) H 0 3 3 3 0 SUB BSMT. BASEMENT 1sT FLOOR I 2ND FLOOR 3RD FLOOR 4T" FLOOR ST" FLOOR 6' FLOOR STH FLOOR 8T" FLOOR Check One Only Certificate # Installing Company Name: � I -q 1-D1 L El Corporation J � / / Address: a?�lo S�o��/�/�EJCity/Town:.4SAb✓/'r)k&%-) State: rno� El Partnership Business Tel: g7�'- a-s� 3� Fax: e-e-/� g7F�33 -,�3 7 /Com an p y Name of Licensed Plumber: , INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy [� Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title ❑ Plumber Signature of Licensed Plumber City/Town ❑ Master License Number: 302 %r APPROVED OFFICE USE ONLY �lourneyman —� www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Prinf Legibly Name (Business/Organization/Individual): e �3 ?/(/1*" Address: r\ %L `--- City/State/Zip: ,ds % k v /!1 k,., 0, g 7 Phone #: Are you an employer? Check the appropriate box: The Commonwealth of Massachusetts c ; Department of IndustrialAccidents 11; I� 4 34 Office of Investigations i 1- 600 Washington Street a, e a l& Boston, MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Prinf Legibly Name (Business/Organization/Individual): e �3 ?/(/1*" Address: r\ %L `--- City/State/Zip: ,ds % k v /!1 k,., 0, g 7 Phone #: Are you an employer? Check the appropriate box: 1. ❑ I ama' employer with 4. ❑ I am a general contractor and I ployees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. # ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.[] Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant tliat checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors acid their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance'coverage verification. I do hereby certify under thepainsand penalties of perjury that the information provided above is true and correct Signature• (l!i "o l/, Date: 2 /7 / I Phone #• q 7 O Kot 7— cSZo -7 v� 1 f 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 t 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 cavy workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confinnation 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 pennit/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 pen -nit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Dgpartment of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 42111 Tel. # 617-727-4900 ext406 or 1-877 MASSAFB Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia COMMONWEALTH :OF MASSA USE w E f t, - ' IN PL -`UMBERS AND GASFITTERS LICENSED AS A JOURNEYMANPLUM BER, . ISSUES THE ABOVE C10EN$E TO. '' CHRIS_B BRENNAN 2,316 STOWELL RD ASHBURNH.AM_ MA 01430--1102_ 5, } 7.765- . 77 W� Date/,-� -. 6C2. - 5.a ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... �� 1UseP-.,vy-,zr ................................................................................ has permission to perform .,Uje .. ... t z. wiring in the building of ... 110A. ................................. at ....... k ...... H./Z .17-w ........... ...... North Andover, Mass. 'M . . Fee./A.9 .......... Lic. No.. ........ Check # Commonwealth ®f Massachusetts Official Use Only Department of Fire ServicesPermit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked UV[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 WINK OR TYPE ALL NFORW TION Date: ' City or Town of: To the Inspector of Wires: By this application the undersi ed gives no ' e of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant rjc�iv/sUL Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ BLDG PER RT # Purpose of Building Utility Authorization No. 1 9 Existing Service 00 Amps / y�ovolts Overhead [G�' Undgrd ❑ No. of Meters New Service Amps Q /, �/- O Volts Overhead P- Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:100, Completion of the following table may be waived by the Inspect fres. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total _ Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- o. o mergency ig mg rnd. rnd. Batte Units No. of Receptacle Outlets No. of Oil Burners FIREALARM No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiatin Devices No. of Ranges No. of Air Cond. TonsTotaNo. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons. KW No. of Self -Contained Totals: "' Detection /Al ertin Devices No. of Dishwashers Space/Area Heating KWLocal ❑Municipal ElOther Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Water No. of Devices or E uivalent No. of No. of Heaters � Signs Ballasts Data Wiring: ;. No. of Devices or E uivalent 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. 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 covera e s in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I cert, under the pains and pe aloes of perjury, that the in matio on this application is true and complete. FIRM NAME: - LIC. No..V�� Licensee: Signature LIC. NO.: L' j (If applicable, en "exempt" in the license number line) Bus. Tel. No.: Address:/P'G- �"- Alt. Tel. No.: S *Per M.G.L. c.147, s. 57- , secur' work requires Department of lie Safety "S" Licen LIC. NO.'S OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No.PERMIT FEE: $ ,Q s?F 5,7z) � ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL FINAL INSPECTION: Passed — [ ] Failed — [ J Re -inspection required ($50.00) -[2. nspectors' comments: (Inspectors' Signature - no initials) Date 3. UNDER GROUND INSPECTION: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 4. INSPECTION —SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed — Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 5. INSPECTION - OTHER: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. The Commonwealth of Massachusetts Department of Inrlustrial.Accidents Office of Investigations 600 Washington Street Boston, MA 02111 w4 z�. www.mas..gov1dia Workers, Compensation Insurance Affidavit: Buidders/Contractors/JEleciricians/JPlumbers NaMe (Business/Organization/Individual):_ Address: /y�/rDPc City/State/Zip:s F9L./�% L X/ one #:�f�� Are you an employer? Check the appropriate box: L ERI'am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling . 8. ❑ Demolition 9. ❑ Building addition 10. F1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other *Any applicant that checks box41 must also fill out the section below showing their workers' compensation policy information. T Homeoviners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and joh site information. Insurance Company Name:. Policy # or Self -ins. Lic. #:. Job Site Address: Expiration Date:. City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido Hereby cer nd��M�p n ne�es ofperjury that the information provided above is true and correct. visa Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone fl;