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HomeMy WebLinkAboutMiscellaneous - 1007 OSGOOD STREET 4/30/2018I a •.fie.. CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 232 (9/30/2009) Date: February 6. 2009 THIS CERTIFIES THAT THE BUILDING LOCATED ON 1007 Osgood St MAY BE OCCUPIED AS _ tenant fit up — Beabe Gallery IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Great Pond Crossing. LLC 865 Turnpike Street North Andover Ma 01845 —,Z�;74e Building Inspector O E-� LO ;w V N 0 z o w o o o m c O 0 0Q°! I; C H _O G Cc O V C3 a: R W \ •= O ll.M cyoco 0 w° cin :3x a w°0 w ° C N `t W: m 60, you Ci cm U) cn N 0 z o m c O 0 0Q°! I; C H _O G Cc O N 0 z 5 CD F. f L J f �1 L a� O O � v Z m O y CD— W cm IQ W .� y CD�. .E m m CD 0 co CLF— co CD Cc CV d E:co �a O. cc vCc J 'fl D ca ts CD /� C. V ca cc C _cc 0. 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LECTRICAL INSPE Check #'`x,7/'2 -0 X Commonwealth of Massachusetts Official Use Only B 1A Department of Fire Services Permit No.NEI BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev. '1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: v %",6 0 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice o0or hi her intention to perform the electrical work described below. Location (Street & Number)S Owner or Tenant Owner's Address Is this permit in conjunction with a builKmper Purpose of Building ,t�,,�� �i�ah — Existing Service /P19 Amps /,,l / Volts New Service Amps / Volts Number of Feeders and Ampacity Location. and Nature of Proposed Electrical Work: Telephone No. Yes ,�f7�No El (Check Appropriate Box) Util ,tFAuthorizadon No. 1,16 � 2f `] Overhead ❑ Undgrd No., of Meters Overhead ❑ Undgrd ❑ No. of Meters Oa mtJ -11—ch aaataonat aetau desired, or as required by the Inspector of Wires. Estimated Value'��Elec ical Work: /l�� O O O '/(When required by municipal policy.) Work to .Start: AOt/ % QLf Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO RAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov rage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalde of perjury, that the informado on this application is true and complete. FIRM NAME: A/ /� IC. NO..-,ZfaXJ, Licensee: 90 V r Signature LIC. NO.: (If applicable, enter -e pt' t1 licens rrtb re�line.) Bus. Tel. No.97 Address: /� ,} /,�„ Alt. Tel. No.: 8 *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: $ ,1©;�5f Nl !L�aaie m oe waivea o ns the Iector o Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans ° °f Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs _ Generators KVA No. of Luminaires Swimming Pool Above O - ❑ o. o mergency Lighting arrid d. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. o Detection an Initiating Devices No. of Ranges No. of Air Cond. l Tons No. of Alerting Devices No. of Waste Disposers HeatPump __umber ons No. of Se -Contained Totals: _ _ Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* o. of Water o. of o. No. of Devices or Equivalent Heaters KW _ of Signs Ballasts Data . No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total Hp Telecommunications Wiring: No. of Devices or E uivalent OTHER: .4- Oa mtJ -11—ch aaataonat aetau desired, or as required by the Inspector of Wires. Estimated Value'��Elec ical Work: /l�� O O O '/(When required by municipal policy.) Work to .Start: AOt/ % QLf Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO RAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov rage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalde of perjury, that the informado on this application is true and complete. FIRM NAME: A/ /� IC. NO..-,ZfaXJ, Licensee: 90 V r Signature LIC. NO.: (If applicable, enter -e pt' t1 licens rrtb re�line.) Bus. Tel. No.97 Address: /� ,} /,�„ Alt. Tel. No.: 8 *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: $ ,1©;�5f C . . 4 �� � C .. s t �.-. ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Rashington Street Boston, MA 02111 K-1 www.mars.gov/dia Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers A�olicant Information Please Print Legibly Name (Business/Organization individual): Address: City/State/Zip: Phone #.-. Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4, j] I am a general contractor and I 6. ❑ New construction employees (full and/or part-time):' 2. I am .a.sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. t 7• ❑ Remodeling ship and have no employees These sub -contractors have 8. Q Demolition working for me .in any capacity, [No workers' comp. insurance workers' comp. insurance. 5.,E] We are a corporation and its q. Building addition required.] officers have exercised their 10.0 Electrical repairs or additions 3. ❑ I ain a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself, [No -workers' comp, c. 152, § 1(4), and we have no 12,0 Roof repairs insurance required.] t employees. [No workers' 13-M Other comp. insurance required.] _^ny appmcam ulat cn=" box it l must also fill out the section below showing their workers' compensation policy information. t Homeowner¢ who submit this affidavit indicating they are doing ail work and then hire outside conuaetors must submit a new affidavit indicating such. 'Contmctors that check this box must attached an additional sheershowing• the mame ofthe subcontractors and their worker ' camp. 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/Statem. p. 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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I'do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date. Phone #: Of j`lChd ase only. Do not write in this area, to be completed by. city or town ofciat 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 1,52 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 individuals, partnership, association, corporation or other legal entity, or any two or more of the"foregoing engaged in"a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. 'However the owner "of a dwelling house having not more than three apartments and who resides therein, or the occupant of the. dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because -of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage" required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation" affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es),.and phone nurnber(s) along with their certificate(s) of msurance. 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, notthe 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 i self-insurance- license number on the appropriate line: City or Town Officials ' L 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 permitllicense number which will be used as a reference number. in addition, an applicant 6 that must submit multiple permit(license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in - (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that -a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call: The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations " 600 Washington Street Boston, NIA 02111 Tel. # 617-7274900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-774 www.mass.gov/dia Date. . „oR,,, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... � j-?. �..... C.`:.' P.i�v? has permission to. perform ... 1 plumbing:in the buildings of .. l?1. .................... at ......... ...... , North Andover, Mass. Fee./. `�.... Lic. No. %........ ........ ......... r PLUMBING INSPECTOR Check # f 2 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date l0 3 _ Building Location / ® 6 US�60 c' 3'f Owners Name -,1 14.tr &2 d=j Permit # `. Amount Type of Occupancy e'n 7h M -e A I G New Renovation Replacement Plans Submitted Yes No rl FIXTURES (Print or type) p y 'A C❑ Corp. heck one: Certificate InstallingCom an Name Address - ox aao 6, 13 Partner. 8�t usmess Telephone cl 4k'5'0;- Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type 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 ignature IOwner ❑ 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 Massachusetts State P mbing Code and Chapter 142 of the General Laws. By: Signature of Uicensea Pium er Title Type of Plumbing License City/Town icense IN um er Master ® Journeyman ❑ APPROVED (OFFICE USE ONLY Date. 7. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that has permission for g installation in the buildings of ....................... at North Andover, Mass. Fee.R?. Li, o..1-3 GAS �'.I INSPECT. �E6�R ......... Check # i�- 0 6190 MASSACHUSETTS UNIFORM APPLICATON FOR PERNUr TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date l© - Z-9-10 9 Building Locations ��� f5 cIOO G� s I � Permit # `'' 70 Y -n C e IT l Owner's NameAmount $ e <JPw-so New® Renovation 1:1 Replacement Plans Submitted Name or type) Ch k o� Certificate Installing Company Corp. Address Py 3o?r Partner. usmess a ep one 9/9 e l R,57-- 7-; Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance, policy or it's substantial equivalent. YesNoO If you have checked es please indicate the type coverage by checking the appropriate box. ED Liability insurance policy ® Other type of indemnity D Bond 13 Owner's Insurance Waiver: lam 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 0 Agent 1 herehv ePrtifv that all nFthu A.+t ;i. --A • - - -- - - -••- - • ••— -V1111«VU kLPI omcrea) in aoove appiwatlon 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 Sf" Code and Chapter 142 of the General Laws. 11. By: Title City/Town APPROVED (OFFICE USE ONLY) `Signature of Licensed Plumber Or Gas Fitter Plumber «6' 7-c. Gas Fitter License Number Master 13 Joumeyman � x � 0� Z w e x . ex Hx ax wx > -ItZ a 0 >G UNw vvFi� o x 3 a cww7 >wwa A a F o SUB -BASEMENT BASEM ENT J 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR Name or type) Ch k o� Certificate Installing Company Corp. Address Py 3o?r Partner. usmess a ep one 9/9 e l R,57-- 7-; Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance, policy or it's substantial equivalent. YesNoO If you have checked es please indicate the type coverage by checking the appropriate box. ED Liability insurance policy ® Other type of indemnity D Bond 13 Owner's Insurance Waiver: lam 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 0 Agent 1 herehv ePrtifv that all nFthu A.+t ;i. --A • - - -- - - -••- - • ••— -V1111«VU kLPI omcrea) in aoove appiwatlon 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 Sf" Code and Chapter 142 of the General Laws. 11. By: Title City/Town APPROVED (OFFICE USE ONLY) `Signature of Licensed Plumber Or Gas Fitter Plumber «6' 7-c. Gas Fitter License Number Master 13 Joumeyman Date..................... ° TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... . ...................... ............... has permission for gas installation ...... . ...... . .......... . in the buildings of............. ................._............ at .............. .................... North Andover, Mass. Fee......... Lic. No........... GAS INSPECTOR Check # me MASSACHUSETTS UNH ORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) Date i I NORTH ANDOVER, MASSACHUSETTS Building Locations /00 S `� �0 Permit # Owner's Name Amount $ \ \ S Ne� Renovation ❑ Replacement ❑ Plans Submitted ❑ (Print or type Che Name k one: Certificate installing Company �l`11V�A�.�� � �2o�ehcke2 �� Jrn� �- ��� \ �Corp. A dress � � � J E] Q-4 um sess TTelephone 3 C�" _ ❑Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Che e: 1 have a current liability Insurance policy or it's substantial equivalent. Yes UQ -No If you have checked Les, please ' icate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity13Bond ❑ 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 Aeent n.,,.,o,. M .. ___. n I hereby certify that all of the details and information I have submitted ( best of my knowledge and that all plumbing work and installations pe compliance with all pertinent provisions of the Massachusetts State Qas By: Title City/Town APPROVED (OFFICE USE ONLY) application are true and accurate to the Issued for this application will be in 142 of the General Laws. Signature of Licensed Plumber Or Gas Fitter / ❑ Plumber / ❑ Gas Fitter License Number ❑ Master ,p"9, Journeyman O o Ze G C N o0 X a Oq v� F w P40 D p W F , F Wi0 GZ C7x z W o> m z' W# aoW o x 3fiQ o a W.4 > o a SUB-BASEM ENT = o B A S E M ENT PST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type Che Name k one: Certificate installing Company �l`11V�A�.�� � �2o�ehcke2 �� Jrn� �- ��� \ �Corp. A dress � � � J E] Q-4 um sess TTelephone 3 C�" _ ❑Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Che e: 1 have a current liability Insurance policy or it's substantial equivalent. Yes UQ -No If you have checked Les, please ' icate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity13Bond ❑ 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 Aeent n.,,.,o,. M .. ___. n I hereby certify that all of the details and information I have submitted ( best of my knowledge and that all plumbing work and installations pe compliance with all pertinent provisions of the Massachusetts State Qas By: Title City/Town APPROVED (OFFICE USE ONLY) application are true and accurate to the Issued for this application will be in 142 of the General Laws. Signature of Licensed Plumber Or Gas Fitter / ❑ Plumber / ❑ Gas Fitter License Number ❑ Master ,p"9, Journeyman Date ....."..�.9 &.7 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .............:...... ...................................................... has permission to perform ... .;r .............................. wiring in the building of......�........................................................................... at .... � �.'. .6�.�....... �'....... ,North Andover, Mass. Fee../.7'? ......... Lic. Nod 1.....1� ......................: ........ ................... ELECnucnL;IxsP C'rox Check # &off 9�;3 7474 Commonwealth of Massachusetts Official Use Only nl Permit No. / y2 `7- Department of Fire Services Occupancy and Fee Checked_ r` BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: ;— '-O City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her Mention to perform the electrical work described below. Location (Street & Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps / Volts New Service /5'0 Amps 4(2 / 20 Y Volts Number of Feeders and Ampacity 3 k . `5 fi Location and Nature of Proposed Electrical Work: Yes ❑ No ❑ (Check Appropriate Box) Utility Authorization No. A y r� Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ ,f Undgrd ❑ No. of Meters i Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Sus Paddle) Fans p' (}� : No. o Total Transformers KVA No. of Luminaire Outlets No. of Hot TubsGenerators KVA No. of Luminaires Swimming Pool Above ❑ 11"' El rnd. rnd. o mergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of,Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. otal Tons No. of Alerting Devices g No. of Waste Disposers p eat Pump Totals: Number. ons No. oSelf-Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ unicipa [] Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW Heaters o. of No. or— 'Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. (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 cove ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Q BOND ❑ OTHER ❑ (Specify:) I certify, under the p ins and enalties e[perjurv, that the information on this application is true and complete. p FIRM NA E:&—r-,� C-- LIC. NO.: Licensee: �� Signature LIC. NO.: 7 Z ��-- (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.'a f af— Address: 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, 1 hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ SignatureturaTelephone No. A16 4 The Commonwealth of Massachusetts M Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): (at "U r k�+� c Address: City/State/Zip: 5,1 e Gt�t,f J�� 030 2 �( Phone #: Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I ployees (full and/or part-time).* 2. I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance 5 • ❑ required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. # These sub -contractors have workers' comp. insurance. We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1 l.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box # t must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp: policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. Job Site Address: Expiration Date: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerni�l under the pains and penalties of perjury that the information provided above is true and correct. giunature-%�2_ Date: Phone #• ?7 9-17 f—// l Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: i �2i � r.s¢ , gcb /r-- Date ..1�.—�. fl� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .../.� .,...:-"-*!......... • • • . . has permission to perform - �-r-' `�`�!.. • .. plumbing in the buildings of at .�'-. ......... North Andover, Mass. Fee%�.r�%. Lic. No.,./.1• r PLUMBI�NL'i"INSPECTOR Check # [f MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) V NORTH ANDOVER, MASSACHUSETTS V / Date �j )0 7 Building Location LQOwnersName G�2+9� (�i�S) Perm /� Amount jCP �(1y 1/n V)n/\PR eVAAS� TweofOccuoancy l '0mr%A2(1Ntg1 ,, \)A 1� i - New Renovation E] Replacement 0 Plans Submitted Yes No FIX'T'URES (Print or type)( _ --Check one: Certificate Installing Company Name 2w-AuJ\ 1' f}VChU1@Z '� W ` � o Corp. Partner. Firm/Co. Name of Licensed Plumber: aty"C .1 Insurance Coverage: India type of insurance coverage by checking the appropriate box Liability insurance policy Other type of indemnityEl 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 7, Owner 1 hereby certify that all of the details and information I have best of my.knowledge and that all plumbing work and compliance with all pertinent provisions of the Massa usg$ 11 Agent ted (or entered) in above application are true and accurate to the derformed under Permit Issued for this application will be in umbing Code and Chapter 142 of the General Laws. By: Sign 9 kens un Type of Plumbing Li Title City/Town 17cense N um er APPROVED (OFFICE USE ONLY cense Master Journeyman