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HomeMy WebLinkAboutMiscellaneous - 102 WAVERLY ROAD 4/30/20181-1 This certifies that .... J. P has permission for gas installation. 04e'�e . ....... in the buildings of ... ve.'J'j� .......................... at .... ) P?r- WO� ......... North Andover, Mass. Ip Fee......... Lic, No .......... Hb .................... ... GASINSPECTOR Check # -+Sl� M" Mo.: BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER l),t A(R IIL -3— TI JAL j I i — I 1 L------J- INSURANCE I _ I I - -_ INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [—]-[ AGENT �( SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge � and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME�5y�:T� 1 LICENSE # 2C1J SIGNATURE "1l MP 0 MGF [-:-][ JPDalJGF LPGI CORPORATION j�J # =PARTNERSHIP 0#= LLC [A#= COMPANY NAME: ADDRESS CITY STATE ZIP _®� �7 TEL FAX j CELL EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY-- iJl _ MA DATE 2 PERMIT# JOBSITE ADDRESS OWNER'S NAME GOWNER ADDRESS -rAl� TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:RENOVATION:©__I REPLACEMENT: EJ PLANS SUBMITTED: YES F—] NO E] APPLIANCES 7 FLOORS- I BSM I 1 1 2 1 3 1 4 1 5 1 6 7 1 8 1 9 1 10 1 11 1 12 113 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER l),t A(R IIL -3— TI JAL j I i — I 1 L------J- INSURANCE I _ I I - -_ INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [—]-[ AGENT �( SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge � and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME�5y�:T� 1 LICENSE # 2C1J SIGNATURE "1l MP 0 MGF [-:-][ JPDalJGF LPGI CORPORATION j�J # =PARTNERSHIP 0#= LLC [A#= COMPANY NAME: ADDRESS CITY STATE ZIP _®� �7 TEL FAX j CELL EMAIL 0 H O z 0 H U W a A W O N ❑ W } ~ W F-4 a Z U w ft co a 5 a CO ® w W z c g a a a H a IL a �+ CO) w s w F— LL rA W H O z \ z o H � rA c� °a 0 The Commonwealth of Massachusetts Ln Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 VV www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �,P S Address: l K-4- 64at_-TckJ C i 11-- City/State/Zip:Q�J4 � � y X ff 0 �4 lnG Phone #: ? Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ Ne nstruction loyees (full and/or part-time).* have ]tired the sub -contractors emodeling 2. I am a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. Building addition [No workers' comp. insurance 5. El We are a corporation and its 10. El Electrical repairs or additions required.] 3111 am a homeowner doing all work officers have exercised their right of exemption per MGL I L ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12.E]. Roof repairs insurance required.] t employees. [No workers' 13. ❑ Other comp. insurance required.] *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and 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 requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce�tt under fiie pry's 4pen yflieeof perjury that the information provided abo^veiis true and correct JA data• e_//_? j-4 5,3-q(0( Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitUcense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The 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 Intvestigations 600 Washington Street Boston, M.A. 02111 Tel. # 617-727-4900 eyt 406 or 1-877rMASSA B Revised 5-26-05 Fax # 617-727-7749 www.mass,govldia .y� • /' , %` r This certifies that ..... Jce-,-�. . s6zv-z ....... r .... ....... has permission to perform . -6(4 ...... .... . plumbing in the buildings of ... ...... at . . ....... North Ando e A4ass. Fee . .... Lic. No. ...... .............. PLUMBING INSPECT4 Check# „,. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _ _ u! MA DATE PERMIT # JOBSITE ADDRESS ®_ I OWNER'S NAME POWNER ADDRESSd— !TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL,01 EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO[' FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM ! .,_-..._f _ .1 _.._ ! .._w.___(. ___,.} _i ... _._ .___- .__._..._I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK ! I _--- _-.__ ___......_( __-._-(-__-__-!-------- i LAVATORY L_JL ROOF DRAIN SHOWER STALL SERVICE /'MOP SINK TOILET i (_._ _.._!i � _.._ ._+ .Y___( .--_-_-_1 ___ ______f ___ i --j _.__ (..-__-_ _.,_...- WASHING MACHINE CONNECTION-_` --- WATER W TER HEATER ALL TYPES I !1 WATER PIPING _! - _ J . _.._._._I -! OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESE] NO E1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [jK OTHER TYPE OF INDEMNITY E( BOND M 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 Ell AGENT 10 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will b compli ce iII P rti nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ 4 _ . -_ ,. ......TJX-_ _. ,.I LICENSE # j SIG TORE MPO JPB CORPORATION 0# PARTNERSHIP 0# _ -_ ± LLC _( COMPANY NAME S IN ADDRESS ( _j-( f/l, kv CITY - -- _ _.._..._.. { STATE ZIP ('j L � —. _ it TEL C\ - to t FAX ; CELL EMAIL oo z 1/1 ❑ } w a iii w LL �t r \L The Commonwealth of Massachusetts Department of Industrial Accidents Offtce of Investigations 600 Washington Street Boston, MA 02111 SV www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information C Please Print Legibly Name (Business/Organization/Individual): _TQ S> Address: ( ( VV� 0ti1l 10 CC(Q-- City/State/Zip: Phone #: ��f `C s�3— Cl W? Are you an employer? Check the appropriate box: 1. ❑ 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. L 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 amhomeowner doing all work right of exemption per MGL .a. myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] 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 that 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 and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy anti 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 herebyc t� ccnde the p*nVnifleTes of perjury that the information provide (d��above is true ana correct. Phone #• V 7 Ft — q 5-3 - 6L(p ( i Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia Date 2 ...... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... jo--� � "0*. ........... ....... .................... has permission for gas installation. ...................... in the buildings of. .... ............ at. .4�Z ...... North Andover. Mass. Fee Check #CD 429/t� GASINSPECTOR 8600 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY �t�� _ MA DATE �/, PERMIT #� JOBSITE ADDRESS J OWNER'S NAME k� �19G e LiC9 GOWNER _. - ADDRESS _ _ _ TE=FAX^� TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL CLEARLY NEW: RENOVATION: PLACEMENT: F PLANS SUBMITTED: YES Q_I NOEJ APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE .1 —..,_ 1 n DIRECT VENT HEATER.P�: DRYER FIREPLACE J 11�-,`.-_I l =_T.1 J __ 1 J ... FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT --- OVEN .. POOL HEATER I f C _I ROOM/ SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHt-R lT l- j _— 1 T. .... _ INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 0 ❑_I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAG Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY E. BOND _I 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 E] AGENT�_Ij SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in ompliance al rti t rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. P PLUM BER-GASFITTER NAMES �L �fZ.- LICENSE # l .,_ SIGN RE MP 0 M G F JP JGF ©LPGI �( CORPORATION 0# PARTNERSHIP# 1 LLC E]# COMPANY NAME:�J7,�J-,S- ,__ ��e 3` ADDRESS K t V J&, Ad Q- ' CITY STATE ZIP TEL - FAX[_ --._J CELL _s�1.--- EMAIL .-. { The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UT. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): T ` P � S` - S E �()(_. Address:__ (( L t t\, City/State/Zip: .10 Phone #: 73 ( ? ' �3 —cC �O C Z Are you an employer? Check the appropriate box: I. Dam a employer with 4. [JI 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. I 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 that 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 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 rte icnd r tl p ' s a p alties of perjury that the information providedab ve iiss true and correct Signature: Date: �l (�/ Phone #: U A- � / ` 26:? ^ q tP L Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License H. Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 021,11 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www,mass.gov/dia `s �/ /. ,. 1, i, i I i 9 Enter construction cost for fee cal - North Andover Fee Cakulatlon Construction Cost $ 70,000.00 m $ - $ 840.00 Plumbing Fee $ 105.00 Gas Fee 100 comm. $ x'_100.00 , Electrical Fee $ 105.00 Total fees collected $ . 1,150.00 102 Waverley Road 375-13 on 11/6/2012 Remodel Kitchen and Bathrooms - jai abb3 � o �„ 185 -1 Date..�,-,2 TOWN OF NORTH ANDOVER PERMIT FOR MECHANICAL INSTALLATION This certifies that .6 ..1f A— ............ has permission for mecha i I i t Ration �?aF ...... IL Vica ins a in the buildings of 44- .......... North Andover, Mass. Fee.. �� .... Lic. No.�-?.4?. ..... ............. GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Microsoft Word - SM pen -nit # l.doc - sheet-metal-permit.pdf 0 http://www.beverlyina.gov/docs/dm/sheet-metal-permit.pdf Commonwealth of Massachusetts Sheet Metal Permit Dat Permit il fatlnTated Job Cost: I'eTa�rlTt 1 tre: S / Plans Submitted: YES \t) x Plans Reviewed: YES NO BusiTless .I iceiise J-9 ` Applicant I,icerise. ; 01"0 B� ... .......... ........_..... Business lilformaliOrT: \aiiie: 0. l I 91A Street: jol Co&j 5C C,ttV;"ToIN`T: �iUt Lynn tV �,Tbr.� _ ........ I"elepholle: �1 �' 6 5 -7 — �y Property E)v iie��r Jot) Location hiforrT) atiioTl. C,Tty;Towii:Ne✓O VC1lK_ ........_ Telepllone: Photo LD. regllireci :'" {�'opc of 1'hato 1_l _attached: YES - NO a ff Liitia l .1-1/(0 1-1/ 'T-1- Iresiricted licerTse .1-2 / M 2,restricted to dwell�> ..,to clat tip to 10,000 sq. ft. 1 2 -stories or less Residential: 1-2) family \Vltiltl-f llllily Condo 1Tow-iihouses Other Commercial: Office Retail 11ldils.trial Educat oral Institutional 1idler ...... Square Footage: under 10.000 sq. ft. vx" over 10.000 s(l. ft. Number of Stories: Sheet metal work to be completed: New \Vorl.: d RenovatiOil : HVAC Metal Watershed Roofiiw Kitchen Exhaust Systeul Metal C11i11111CV ", Velits :lir Balancing Provide detailed &,cription of work to be done: U 6UD �R� �uC k-(— C 1/J ��..� �_C _.._. tL r �►I� vvV SG7� o oUt✓ 6 ZA Z 1 of 2 2/22/201.3 7:21 AM Microsoft Word - SM permit # l.doc - sheet-metal-permit.pdf n w http://www.beverlyma.gov/docs/dm/sheet-metal-perm it.pdf INSURANCE COVERAGE: I have a current liabili insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes No If you have checked Yes, 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 112 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only owner [j Agent L] Signature of Owner or Owner's Agent By checking this boxi7, 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 sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Elate Date Duct inspection required prior to insulation installation: YES NO Pro2ress Inspections (`atilt} eilts Final Inspection ..__ ___ Type of License: 6y—._flaster Title ElMaster-Restricted City!Town — ❑Journeyperson Ferro t Rjourneyperson-Restricted Fee S Inspector Signature of Permit Approval 'f Cottttttettts ` Signature of Licensee License Number: 011508 Check at www.rnass.cjov1dvI 2 of 2 2/22/2013 7:21 AM Microsoft Word - 99 HVAC FORM.doc - HVAC-Form.pdf http://www.townofnorthandover.com/Pages/NAndoverMA Buildin... TOWN OF NORTH ANDOVER 1600 OSGOOD STREET Building 20 Suite 2-36 NORTH ANDOVER MA 01845 FURNACES, BOILERS, ROOF TOP UNITS, AIR CONDITIONER EMERGENCY GENEREATORS The undersigned applies for a permit to install the following at: Location 16b �UA (1(5-4 Z - Owner of premises :7LI)1644)1y' V67J 4 -1 Address Vicon,&C�� '10 Name of mechanic Ll -K Address Building occupied forT)v" CLL' k) Material of building Kind of fuel 6A-5 Chimney_, . . . _,_No. Of flues _— Size-- Chimney Thickness— -PuC-- Lini ­ . . . .. ........ If steel stack location Diameter —Height DESCRIPTION OF HEATING APPARATUS Kind of heater O-"Cj- how many make A mev,, —Nv tk&O BTU Input Location in building �"G-JACW Protected against fire as required N How protected Make See the State Code (Pertaining to Chimneys, Smokestacks and Heating Apparatus) ROOF TOP UNITS OR EMERGENCY GENERATORS Aleig Dimension Length 'vVidth Height Location of building how supported Size of roof timbers Material of roof timbers Span of roof timbers Distance on center Protected against fire as required How protected AIR CONDITIONS Kind of apparatus .5 Pt -I I make I�M44v(, I CAS ST?,A) 0 A4?4 I NAG FY RNI REVISED 19 1J,1 1 of 1 2/22/2013 7:07 AM CERTIFICATE OF LIABILITY INSURANCE DATE IMM/DD/Y 1/10/2133 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS IPPON THE CERTIFICATE HOLDER. THIS ! CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: CoTrmeL'Cial Accounts PHONE {f)17) 328-8600 AX JAIC No: (617)328-6422 James J. Sullivan Insurance Agency, Inc. E-MAIL ADDRESS: 151 Hancock Street I INSURER(S) AFFORDING COVERAGE NAiC r - INSURER Arbella Protection ins. CO. 141_360 INSURERB:Twin Cit` Fire Insurance Co 29459 ! Quincy LMA 02171 INSURED INSURER C: Robert G. Beaulieu INSURER D: 20 Beacon Street INSURER E : ! , INSURER': I WilmingtonMSA 01887 COVERAGES CERTIFICATE NUMBER:2012 Cert REVISION NUMBER: E THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTAND!NG 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 !S SUBJECT TO ALL THE TERPJS. 9 EXCLUSIONS AND CONDITIONS OF SUCH ?GLiCIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CL AIMS. INSR' ADDLSUBR! POLICY EFF POLICY EXP ' LTR TYPE OF INSURANCE INSR i'✓dVD' POLICY NUMBER fRAI - YYY`' 'MMfDD�^,'YxP I LIMITS i GENERAL LIABILITY0 1 I EACH OCCURRENCE S 1 , 000 , 0 Ok DA!b1HGE TO RENTED COMMERCIAL GENERAL LIABILITY i j I n O.,CI o?c c -- I S 10C,0, �MISE„a occurrence) I A (CLAIMS-MA.DE OCCUR ! i 18500025202 I7/GOi2Gi2 7/20/2013 -rc o, I^ 5,�iOCI MED EX, (A.ny one person) a 1 PERSONAL3.ADV INJURY I S , OGO , 0001 I GENERAL AGGREGATE S 2,000,000 GEN 'LAGGREGATE LIMIT APPLIES PER : X POLICY I PRO PRODUCTS - COMPIOPAGG 5 2, 000,0001, AUTOMOBILE LIABILITY I { p AiNY AV IG 1 '1 I ! CO(viBINED SINGLE LI.M1, !Ea zccidena �� S _ GO oG^l Ba V INJURY (Der Menson: S i�H` ( I S BGDi_, JURY (Per ALLCI4�NED X SCHEDULED € AUTOS AUTOS ISIi/2012 18/1/2013 X NON-OWNED —j{ILJI PPReCPcEcPdeYnrAMAGE � q I HIRED AUTOS AUTOS i I S X i UMBRELLA LIAB X I OCCUR u F COG 000` EAC. OCCURRENCE I S 1- , r ! ' EXCESSLIAB A CLAIMS-MADEP,GGREGATE ! X4600033416 17/20/2012 7/20/2013 ; S 1,000,0001 10,0001 DED RETENTIONSLl1 I g I WORKERS COMPENSATION I AT X X X =R AND EMPLOYERS' LIABILITY Y! N. I TORY LIMITS i I AiJY Oe`FIROPRIETORIP,4RTN=R,,EXECUTiVE^!' CPRiMEMBER EXCLUCED% N,;A I L r - ,_Q 0iJ j (MandaEtoyinNHI 5/=%2012 i : S%iJ2013 ELDISEASE - EA EMP OYER S C, ! If yes. describe under - ! DESCRIPTION OF OPERATIONS below j E.L. DISEASE - POLICY LIMIT S X00 , OOOX I i !t 1 I 1 ! I gg I I DESCRIPTION OF OPERATIONS / LOCATIONS i VEHICLES (Attach ACORD 109, Additional Remarks Schedule, "mora space is required) 1 1 i i CERTIFICATE H01 nFR CAi'NrFI I ATION ACORD 25 (2090i05) IN.9(125 nnsnnrl r.'. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRAT:Ok' DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUT.-:OR.2ED REPRESENTA T IV- a1T:es u11 v S . ^ 1( . ,i ^..�..C..1!:.. C .... - 1. ;c f.`r8-2ri,iIDs CORD CORPORA I IUNI. Alt rigyYS 7eSe7Vec,. ?"?sem a^i`. ^r!'; rr.:r_ a.... Inn, c. c. rnrec-'rnrarin.=-.ac ^f Ge".r?�r` :Signature ,1 L € N M':. o c 3 to r, mEno m O n zOD -�_:• Os Gi n � rn O CD z �a z m �cn� m D D =mm -ri r mCi- a Moz r m • r n.Nmm M-jx> 00 m m co Cn n :Signature ,1 L A F- 16-06 Date.................................. y 'y TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........... has permission to perform .... Ave ... IR F,-xl? IF wiring in the building of .... M . ...... /Z ..................................... .............. . North Andover, Mass. at ........... ........... .......... 9 ... le Fee..:4��.. Lic. No. ........... Checl# ELEcmicAL I R 87-2 J . r Commonwealth of Massachusetts Department of Fire Services r` BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. & 9 7z -- Occupancy z_.,Occupancy and Fee Checked [Rev. 9/051 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code ffq, 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: O b City or Town of: &, 1-I/,P 0 Ve A • To the In pe for of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) � ,;�— ul k ill C y �, b - Owner or Tenant i7A-R a Telephone No. Owner's Address Is this permit in conjunction with a building permit? r Yes ❑ No 0� (Check Appropriate Box) Purpose of Building Utility Authorization No. // 3 �k ;,- Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 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- El rnd. grnd. No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. o Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number. Tons W KW No. of Self -Contained Totals: Devices No. of Dishwashers Space/Area Heating KW Local ❑ Mun1c�pal El Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Elect ical Work: (When required by municipal policy.) Work to Start: p Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C AGE: 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 equiva ent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the p rmi suing ffice. CHECK ONE: INSURANCE n- BOND ❑ OTHER ❑ (Specify:)�j4/vt+(!/ r U 1 certify, under the pains and penalties of perjury, d the information on this application is true and com let . FIRM NAME: J /(/ N //V® C LIC. NO.: Licensee: V �1 �j/� �Bt f f -div¢//C> Signature LIC. NO.: C` (Ifapplicable, It, "e ,emp " in th� se number line.) // Bus. Tel No.: Address: �� 1/ it G� Alt. Tel. No.. *Security System Contractor License required for this work; if applicable, enter the license number here: 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: $ a al z 0 0 0 0- a • D � Z W ^ u L L W < `�J r x 0. z J 0 v Y (i j d o _J .W W 3 ` L Q a L < H O r n 4 < J J J U N d Z Z O <Z w 1:, M r N I 0 j 0 0 < J W W W • ra J r r W Z 0 0 0 3 I Z Y O W W W 0 O r r r O Z • N 0 Z J W W W Z 0 9 < tl�g a I S i z o • J ; z � z 0 0 o = 0 ° W: o o� � 0 �, r 0 ac 0 L c o 0 • L o n n n n uO 0 r J z L S J Z Z Z 0 0 L Z W b • wL a, r L < a O O O I 0 W W Z W n W h m• m • ■ C M N < I W N < O N L Z o e a o x i I a a a a go 0 X L W WO A < s Wo A u z a o �CZ , 0 P o 'Z z 0 SIO I r o d I� a N a z j z D n 0 / W < A N O Z a m L Z �� 0 0 0 W I O Z Z m m r Z ZO L r o o ra N W J 0 �' L < U U ) a W C r 0 r K p a a N I W< YI J 3 O H U W = I Z I I W 0 J O W W 0 0 W Z Z < r L L O n n n p < a J_ J I 0 N M a J L W C U U U L O O O j 0 H L L V W < Y W F O < < < O J J J m 0 m W .•W 1�- . 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