HomeMy WebLinkAboutMiscellaneous - 102 PLEASANT STREET 4/30/2018Date.................... 9..............
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........................................................
has permission to perform ..... ..............................................
wiring in the building of ......
............
.................................................................
at 2..� .........
....................... orth Andover, Mass.
c Fie .............. Lic. No 1--2,'l 311-1-2 la .................... . . .. ....
L sp c
ELECTRICAL INSPECTOR,
Check
9065
-C\- Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code MEI), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: n a
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives7WAn4
'e of his or her intention to perform the electrical work described below.
Location (Street &Number) `k )r-4,'-114;
Owner or T
Owner's Address
WE
Is this permit in conjunction with a building permit? Yes ❑ No
Telephone No.
(Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts
New Service Amps / _ Volts
Overhead ❑ Undgrd ❑
Overhead ❑ Undgrd ❑
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:o�tP�7A�—
No. of Meters
No. of Meters
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of 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- ❑Wo—.—oT
rnd. grnd.
EmergencyWo-.-o Lignting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
of
No. InDetection and
Initiatin Devices
No. of Ranges
g
No. of Air Cond. Total
Tons
No. of Alerting Devices
Heat Pump
Number
Tons
KW
No. of Self -Contained
No. of Waste Disposers
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Y
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water
KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
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 if desired, or as required by the Inspector of Wires.
Estimated Value qf Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE k BOND ❑ OTHER ❑ (Specify:)
I certify, under the a. s and enalues of perjury, that the information on this application is true and complete.
FIRM NA E: ( Qh Q n Eto r +6 L Lk(r; NO.: ` rCY� 6�
Licensee: i ignatur LIC. NO.: -3 t 3
(Ifapplicable nter `e empt" in the license num er line. 1 Bus. Tel. No.
Address: rP adson . N C)c�51 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 PERMIT FEE: $
Signature Telephone No.
M
TOWN OF
PERMIT FOS
Date ... . .......
ANDOVER
INSTALLATIOl
This certifies that -
has permission for gas installation
in the buildings of .........
.................................
at .............. .... ............ North Andover, Mass.
Fee. -.P ..... Lic. No. ..........
GAS INE60R
Check #,.
6992
MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS
�/ G
(Type or print) Date �U o9
NORTH ANDOVER, MASSACHUSETTS _ �(,
Building Locations P1-6�4.r �/1 � �� Permit t,
Owner's Name Amount $ c3 -
New Renovation ❑ Replacement ❑ Plans Submitted ❑
(Print or e) Check one: Certificate Installing Company
Name_ _24,11r) Ls D UclffspC PL (r t 4-/�. ,
,� Corp.
Address I USS 7It - �� h�N4 t�-�- /V//I # ` ❑ Partner.
usmess e ep one 663 5 7 ],F— E]Firm/Co.
Name of Licensed Plumber or Gas Fitter. �(/(f ryy C- ®t/C./f,5r/jLL
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes rM No
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy M Other type of indemnity 1:3 Bond
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent
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 i allations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massadsetts Stale Gas Codelpnd Chapter 142 of the General Laws.
(OFFICE USE ONLY)
£ IUis,r,IA
Signature of Licensed Plumber Or Gas Fitter
Plumber // -2 y(1
Gas Fitter License Numerr
Master
Journeyman
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SUB-BASEM ENT
B A S E M ENT
1ST. FLOOR
2N.D. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
8TH. FLOOR
(Print or e) Check one: Certificate Installing Company
Name_ _24,11r) Ls D UclffspC PL (r t 4-/�. ,
,� Corp.
Address I USS 7It - �� h�N4 t�-�- /V//I # ` ❑ Partner.
usmess e ep one 663 5 7 ],F— E]Firm/Co.
Name of Licensed Plumber or Gas Fitter. �(/(f ryy C- ®t/C./f,5r/jLL
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes rM No
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy M Other type of indemnity 1:3 Bond
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent
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 i allations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massadsetts Stale Gas Codelpnd Chapter 142 of the General Laws.
(OFFICE USE ONLY)
£ IUis,r,IA
Signature of Licensed Plumber Or Gas Fitter
Plumber // -2 y(1
Gas Fitter License Numerr
Master
Journeyman
Z
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, A"-02111 < .
www.massgov/dia
Workers' Compensation Insurance Af 'davit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): DoyLL--- DM-L-SJLr 46 � -RIGt
Address: ROY
City/State/Zip: (.o luo9 62LXLI P- /{ Phone #: 6 6 i y 7 /
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
..,y ap o..t that checks box 91 . till out the section below showing their workers' compensation policy information
fi Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such..
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine .
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby
under the pgins and penalties of perjury that the information provided a¢ove is true and correct
��A1A�711�
Phone #: G .�� y t7 l
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
6124,
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 #:
Are you an employer? Check the appropriate bog:
L ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. I am a sole proprietor or partner-
listed on the attached sheet. t
ship and have no employees
These sub -contractors have
working for 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
..,y ap o..t that checks box 91 . till out the section below showing their workers' compensation policy information
fi Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such..
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine .
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby
under the pgins and penalties of perjury that the information provided a¢ove is true and correct
��A1A�711�
Phone #: G .�� y t7 l
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
6124,
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
i
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity; or any two or more
of the foregoing engaged. in a joint enterprise, and including the legal representatives of a. deceased employer, or the _.
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartrnents and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of.
insurance. Limited Liability Companies (LLC) or Limited Liability.Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should .
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
._ City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permittlicense 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
Roston., MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax # 617-72.7-7749
Revised 5-26-05 "r"rm7:mass.govfdia
Date.)
- // ° .........
TOWN OF NORTH ANDOVER/'
W PERMIT FOR GAS INSTALLATION
�9SSACHUSEtt
V
This certifies that ... P"m m, e! j ......... .
has permission for gas installation . 4 7,11V S:../. /I. r. T-,6. .......
in the buildings of
................................
at ........ North Andover' Mass.
Fee.. Lic. No... ......
GAS INSPECTOR
Check #
Ti 30
�
MASSACHUSETTS UNIF RM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or46
fC amass. Date 6 20BE Permit # >' 3 0
Location �(j �- Owner's Name,,
Building y
Owner Tel/41)
omTypeof (3ccupancy j I New noon Replacement ❑ Pian Submitted: Yes ❑ No
FIXTURES
16
U5
W � � � a z �
0 a 3 S a u
'SUB a
+-r-E
rt� FMF� I I I 1 1+
installing Company Name (` h (zm ' ` t f ` N 6— Check one: Certificate
Address 1' �t , r� l y ❑ Corporation
_ �. U l� r r ' a - t ` �! ❑ Partnership
i
Business Telephone
Name of Licensed Plumber or Gas Fitter t- u
INSURANCE COVERAGE: . .
I have a current btllty Insurance policy or He substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑ box..
If you have checked M. please indicate the type coverage by the
the appropriate
A liability insu ce policy Other type of indemnity ❑ Bond ❑
OWNER'S SU NCE WAIVW: i am. awarq_9 'u'�e_ilt nsaa daes_not have the Insurance coverage required by Chapter 142 of the
1plication waives this requirement.
Mae Check one:
Owner ❑ Agent ❑'''"r
Signa ure of bi ner or Owner's Agent
1 hereby certify that all of the details and information 1 have submitted (or on
t ve a "iication are true a aasurate to the best of my
knowledge and that all plumbing work and installations performed under the pe Issued for is application will in compliance with all
)eMnent provisions of the Massachusetts State Gas Code and Chapter 142 o General w
By Type of License:
•Plumber Signature of Licensed �P �-r^�1 �3or Gas Fitter
Title • -Gas litter 6: J
• •!utas License Number
Clty/Town umeyman
APPROVED (OFFICE USE ONLY)
til as"10111sm" - Uvp all flit: lit 'ot I'lliflic
1341ard 44Btlildill'-. Rcutilit tion, and stmidard,
UDC"
License: CS SL 100997
Restricted to. RF,WS,SF,DM
REEVAN PARMA
14 WAYNE ROAD
PEABODY, MA 01960
Expiration: 6/512012
Tr= 100997
044, 6-
6---�'wve(ZIW
Board Of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 160945
Expiration: 9/15/2010 Tr# 274725
Type: Individual
REEVIE PARMA
REEVIE PARMA
14 WAYNE RD.
PEABODY, MA 01960
Administrator
Co", non+veait� c`
Di J'sion cf Regiszu.ion
Board of Plumbing
RE. -VAN MARK PARINIA
i4 WAYNE RQ
PF--AB('JDv: MA 01960
Journeyr-r-an
GF5053-J
License No.
Expkaticn Date. c r,. ?.j -
til as"10111sm" - Uvp all flit: lit 'ot I'lliflic
1341ard 44Btlildill'-. Rcutilit tion, and stmidard,
UDC"
License: CS SL 100997
Restricted to. RF,WS,SF,DM
REEVAN PARMA
14 WAYNE ROAD
PEABODY, MA 01960
Expiration: 6/512012
Tr= 100997
044, 6-
6---�'wve(ZIW
Board Of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 160945
Expiration: 9/15/2010 Tr# 274725
Type: Individual
REEVIE PARMA
REEVIE PARMA
14 WAYNE RD.
PEABODY, MA 01960
Administrator
'ACORD.. CERTIFICATE OF LIABILITY INSURANCE
,,,
DATE (MM/DD/YYYY)
01/04/2010
PRODUCER 781, 438.5000 FAX 781.438.5028
New''Engl and Heritage Insurance Agency Group, Inc.
335 Main Street
Stoneham, MA 02180
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC #
INSURED N E F P INC DBA
DBA: Yankee Fireplace & Grill City
140 SOUTH MAIN ST
MIDDLETON , MA 01949
INSURERA: National Grange Mutual 14788
INSURER B:
INSURER C:
INSURER D:
ENSURER E:
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
DD'
NSR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE MM/DD/YYYY
POLICY EXPIRATION
DATE MM(DDIYYYY
LIMBS
GENERAL LIABILITY
BPB1906S
12/31/2009
12/31/2010
EACH OCCURRENCE S 1,000,000
_
Ea omurrence$ 50,000
COMMERCIAL GENERAL LIABILITYPREMISES
MED EXP (Any one person) S 5,000
CLAIMS MADE a OCCUR
PERSONAL & ADV INJURY $ 1,000,000
A
X
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $ 2,000,000
POLICY PRO- LOC
JECT
AUTOMOBILE
LIABILITY
M1B1906S
12/31/2009
12/31/2010
COMBINED SINGLE LIMIT $
(Ea accident) 1,000,000
ANY AUTO
BODILY INJURY c
ALL OWNED AUTOS
X
SCHEDULEDAUTOS
(Per person)
A
X
HIRED AUTOS
BODILY INJURY $
X
NON -OWNED AUTOS
(Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT S
OTHER THAN EA ACC $
ANY AUTO
AUTO ONLY: AGG $
EXCESS / UMBRELLA LIABILITY
CUB1906S
12/31/2009
12/31/2010
EACH OCCURRENCE $ 1,000,000
AGGREGATE S 1,000,00
OCCUR F_1 CLAIMS MADE
S
A
$
DEDUCTIBLE
$
X RETENTION $ 10,000
WORKERS COMPENSATION
W1096943
01/05/2010
01/0$/2011
X I Tw&,S MITS I I ER
AND EMPLOYERS' LIABILITY Y I N
ANY PROPRIETOR/PARTNER/EXECUTIVE❑
E.L. EACH ACCIDENT $ 500,000
E.L. DISEASE - EA EMPLOYEEI $ 500,000
A
OFFICERIMEMBER EXCLUDED?
(Mandatory in NH)
E.L. DISEASE - POLICY LIMIT I S 500 000
If yes, describe under
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
For Insurance Purposes Only. Specimen Copy.
CERTIFICATE HOLDER CANCELLATION
TOWN OF N. ANDOVER
ATTN: GAS INSPECTOR
146 MAIN ST
N. ANDOVER, MA 01845
25 (2009/07) -
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
ell
D1
The ACORD name and logo are registered marks of ACORD
All rights
The Commonwealth of Massachusetts
Department of Industrial Accidents
i
Of of Investigations
600 Washington Street
„{ r Boston, MA 02111
www. mass.govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please %a-P,,rint Legibly
Name (Business/Organization/Individual): 05 � / rJr L L 1 / P, L' � 4 Gk i %
/ " `--
Address: `VO 1Syc)7_H AO /N S
Citv/State/Zit): /fi /0DZ 7U PJ,M 0/W7Phone#:
Are you an employer? Check the appropriate boa:
Type of project (required):
1. [9'i am a employer with / ;2--
4• ® I am a general contractor and I
6. F1 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.
7. ❑ Remodeling
ship and have no employees
These sub -contractors have
g. Demolition
working for me in any capacity.
employees and have workers'
comp. insurance.t
9 Building addition.
[No workers' comp. insurance
required.]
5. We are a corporation and its
10.Q Electrical repairs or additions
3. ❑ I am a homeowner doing all work
officers have exercised Their
11.0 Plumbing repairs or additions
myself. [No workers' comp.
right of exemption per MGL
12.0 Roof repairs
insurance required.] t
c. 152, § 1(4), and we have no
employees. [No workers'
13.0 Other b, --,JS_ Zr s
coma. insurance reauired.]
roc L
4 *Any applicant that checks box 41 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.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -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
infnrmatinn_
Insurance Company
Policy # or Self -ins. Lic, #: U) / b ? (0 1/ y3
Expiration Date: G i' J �? 0 /V
Job Site Address: /� 0 � SJ7 !U� City/State/Zi /� ./
I
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 a&ainst the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the A f insurance coverage verification.
I do hereby certifyAinder jlie pains 14d)penties ofiefjury that the information provided above is true and correct.
Phone #:
970-�� /SO
Official use only. Do not write in this area, to be completed by city or tmvn 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 #•
Location
No. Date
4.
TOWN OF NORTH ANDOVER
W1 A
a
�i
Certificate of Occupancy $
Building/Frame /Frame Permit Fee $
s�CHUS 9
Foundation Permit Fee $
Other Permit Fee
/ TOTAL
Check # 14/ Z3
17682
' ~ Building Inspdcfor
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER:7 DATE ISSUED: .04
/0
SIGNATURE:
Building Commissioner/I for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address-
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide ReqWred Provided
ReqWred Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public ❑ Private ❑ pone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
J�Jza,,�
Name (P 'n0 Address for Service:
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
l
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 LicenConstruction Supervisor:
Licensed C.Mstruefion Supervisor:
� � C
Address
Vvla
Signature Telephone
Not Applicable ❑
D�i 7ir� p
License Number
Expiratiod Da
3.2 Registered Home Improvement Contractor
Not Applicable ❑
/ ��✓ 0
Company ame
]rjm / 6)'
Registration Number
CO p GA
/ate
Addr s
_ ' ��j
Expira on
Signature Telephone
SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6)
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 .......❑ No ....... 0
SECTION 5 Description of Proposed Work check au applicable)
New Construction ❑
Existing Building ❑
Repair(s) ❑ •
Alterations() ❑_
Addition ❑
Accessory Bldgg ❑ "
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
I. Building
Estimated Cost (Dollar) to be
Completed b permit applicant
#,QFFiCiAL
, 1 _
(a) Building Permit Fee
' Multiplier
USII+ Qii; '
u '
2 Electrical
(b) Estimated Total Cost of
Construction
,
3 Plumbing
Building Permit fee (a) X (b)
cT�
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
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 q to act on
My��rs r tive toiwork auth d y this�uilding a rmit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, As Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
Signature of Owner/Agent Date
NO, OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TINMERS 1 sr2ND 3
SPAN
DRVIENSIONS OF SILLS
DIN ENSIONS OF POSTS
DR%4ENSIONS OF GIRDERS
HEIGHT OF FOUNDATION _ THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIlVINEY
- IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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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:
(Location of Facility)
Signatu of Permit Applicant
Dat
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
A
CS # 022680
HIC# 103358
Propomil =
A. J. Walsh & Sons
55 Pleasant Street
North Andover, MA 01845
e # of
978-688-6737
or
1-866-AJWALSH
ProposalSubmi� / Job Name Job #
Address/ D Job Location V /42n 0
Date C1U 1 p -1 abate of Plans
Phone # / I Fax #
Architect
with payments to be made as follows: 1�010
CK/ .5yO911
Any alteration or deviation from above specifications involving extra costs will be
executed only upon written order, and will become an extra charge over and
above the estimate. All agreements contingent upon strikes, accidents, or delays
beyond our control.
I
Respectfully
submitted L
Note — this proposal may be withdrawn by u if not accepted within days.
21cceptance of J)roponl
The above prices, specifications and conditions are satisfactory and are L'Signature
hereby accepted. You are authorized to do the work as specified.
Payments will be made as outlined above.
Date of Acceptance Signature
&.'. NC3819 MADE IN USA
The Commonwealth oflVMassachusetts
u=l -- De artrnent o Indarstrial Accidents
Office ofinlrestigatfons
600 Washington Street, 7" Floor
F% Boston, Mass. 02111
Workers
ectrical Contractors
❑ I am a homeowner performing all work myself Project Type: ❑ New Co
❑ I atn a sole proprietor and have no one working in any capacity.❑ Building
❑ I am an employer providing worker 'compensation for my employees working on this fob.
�loel- 76-72
LJ i —i a allJU yivlulcwl, geuerat contractor, or nomeowner (circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
comvanv:.name:
comyany name:
address:
city:
phone #
insurance co ohc #
AttaClr:add�6opalseet?"aifne5�e+.iFt;Fggf�MZ�sa4 w 1
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up o S1,500-00 ..•
one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. 1 understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herehy certi under the pains and penalties o perjury that the information provided above is trite and correct.
Signature Date A'71 --0 `7
Print name - fill ! (W)k -� �
Phone # G / OO 03
k'F . ;ate? . r_...h:u!is3l'i�xY��`•'3�.-.taR'iafsi�%`t�-::%..rt-.
_ ..w+�.00.v..£�r.-VIA
official
official use only do not write in this area to be completed by city or town official,
�r
city or town: permit/license # ❑Building Departmentg
❑Licensing Board
Elcheck if immediate response is required ❑Selectmen's Office
❑Health Department
contact person:hone #• ❑Other
(revised Sepi. 2007) p '
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", 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, constriction 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 section 25 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, 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.
' JY Y h7 -4 4 iF .s"T�'Y I .�'� y�+1.P "���St �� l 13�v�•k��'�'� 4
' r�r�„° � r� tis „u��`�'��'t� �'' �. ���`����1�"'�;. �t't" �` �•2ti �t�' � 4
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please
supply company name, address and phone numbers along with a certificate of insurance as all affidavits 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.
;t rt� s .,;.+ � F -s£ nt � rsar � - tlshl" " gid(-�' 7 � y�".tt•�x � .mer" "G"�"' +�' S ) ��` � 'e=�`4e's* i ",� SstSni.'i ct"�'� - F. 'fA1=
s a t,a; 1 i .LS' �rd�i. I ��'��r'rka �5� A 4 v I" ` �itr•�tn i' f1 i � �• ��: r we.,tp'�wv tinr.:v;i,!n. is
City or Towns
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. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
i"Jy. t ,, { t ,.:y ? t e ✓, } s r i ;• r'_ t A a '.s ♦ vy%. � IM
f [1 4� oa ��1^� .. e , 4 .nx..,k:.,.�r..� .� 5'.;.. �.rr. 1:.., moi_ , }u ..5. Y z.,,� „�A�*�a'.axw"b�;.
The Department's address, telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street,7'h Floor
Boston, Ma. 02111
fax #: (617) 727-7749
phone #: (617) 727-4900 ext. 406
i BOARD OF BUILDING REGULATIONS'
License: CONSTRUCTION SUPERVISOR
ti
Numq,S 022680
BI -1939
06 Tr. no: 71.0
ARTHUR J WA
55 PLEASANT S
N ANDOVER, MA
Commissioner
�0and .of!,
'ding Reg
�HQMJE, IMPROVEMENT
or
-p
W