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Miscellaneous - 1020 SALEM STREET 4/30/2018
Date .... 7.11�.`.4..7.................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ..... l <............ �0T.......... .......:. ......................................l!........... �Ihas permission for gas installation ....l,���a ���:..................................... inthe buildings of................................................................................................................... at .../0.Q....... .I-eqe,f...... ..........:....:........ Northdover, Mass. Fee: n.C?v... Lic. No. /..hof. .... ...... ............................... GA INSPECT0 Check # _ 9407 ,0636 Date ..... j.s`../#...... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ..... .. !v.....-�t.01,6...........:................................................... Chas permission to perform ....... lr....S'.1,...................................................... plumbing in the buildings of............................................................................... . .............. at.... /.DSD......................................r!..., Ndrth Andover, Mass. Fee V7 ... Lic. No. ,laP.. lY ..............................:..:................... ............. PLUMBING INS, l CTOR Check # l ii MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK a CITY (�JUDlCn�- DUIZ- _ MA DATE / f PERMIT # JOBSITE ADDRESS `elo* OWNER'S NAME 11 GOWNER ADDRESS TE�— —__ FAX _ TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL ®, CLEARLY NEW: [Q RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES F1 NO0 APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER_ -- DRYER FIREPLACE FRYOLATOR FURNACE GENERATORf GRILLE INFRARED HEATER~-r— LABORATORY COCKS (� I [� ! _I TJ [ I r � L-- MAKEUP AIR UNIT OVEN POOL HEATER _ 1 J _ ROOM/ SPACE HEATER T I _ _ _ ROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER .... ........... .._........... ........ ......... ....... ..... ... ............ _.... r'—- J _ ~ _ INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO 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 0 AGENT 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 ac ate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli ic th II Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i PLUMBER-GASFITTER NAME= S _ LICENSE # SIGNATURE MP &I MGF EjI JP ® JGF [] LPGI CORPORATION ©# = PARTNERSHIP 0#= LLC ®#= COMPANY NAME: (w I M. 01►OS oh ADDRESS CITYU'i STATE ®ZIP [TEL -z FAXI CELLEMAIL i O O H W a w 3 Z ❑ O Nrl W >- � W O w O H o- Z w a F- W a w cn a W w f� O w c W a grn a a U J F., a a Q � w X: w 1- LL W H O tit H U W a cn C7 � G The Commonwealth ofMassachusetts - Department of IndustriglAccidents Office ofInvestigations 600 Washington Street Boston, MA. 02111 w www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/0rganization/fndividual): Address: City/State/Zip: 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. ❑ New construction employees (full and/or part-time).` have hired the sub -contractors �• El Remodeling 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. g• El Building addition [No workers' comp. insurance 5. El We are a corporation and its 10.E] Electrical repairs or additions required.) 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] employees. [No workers' 13.❑ Other comp. insurance required. xAny applicant that checks box#1 must also fill out the section below showingtheir workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors that checkthis 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 Policy # or Self -ins. Lie. 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 ofMGL o. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP -WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certlo under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: 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 Instruction -8 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 j oint 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LL C or LLP does have employees, a policy is required. Be advised that this affidavit maybe 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 no. 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 (ifnecessary) 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. Anew affidavit must be filled out each year. Where a homeowner 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 ofInvestigations 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 Massadhosetts Dep.afteut offadustrial .Accidents Office ofInyestigat ions 600 WasWWon Sixeet Boston, MA 02111 Tol, # 617-727,4900 ext 406 or 1-87TMASS-OF, Revised 5-26-05 Fax # 617"727-7749 vt��r_maee anz�lil;a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY MA DATE 1/ 16 t I PERMIT# JOBSITE ADDRESS fU ZfI Sr OWNER'S NAMEii'Ni�jj �tJ�� w POWNER ADDRESS TEL FAX E— TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION: D REPLACEMENT: Q PLANS SUBMITTED: YES Ell NOD[ FIXTURES Z 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 GAS/OIUSAND SYSTEM ! f _I --J f _( DEDICATED GREASE SYSTEM_ _J DEDICATED GRAY WATER SYSTEM I _ ( I _T (_— _ _i _ _ f I i (_ _i E t DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREADRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK I _._-_1 _—_-j LAVATORY ROOF DRAIN SHOWER STALLL ___l _.___.-1 ___i _,.-_ SERVICE ! MOP SINK TOILET i _i f _—.J= ._._._ ._ ___ _ 1 _____ ____1 _-- .___.J _-__-.1 URINAL l ..._.._ 1 _-- I _-._. -_-.. i _..__._i __..._1 .__...._.._i _---__.1 # i _-_._. 1;"JASHING MACHINE CONNECTION WATER HEATER ALL TYPES UJI I -__. _j I I ? WATER PIPING OTHER -------------- f _____I ..-- _.-._) ._.... _-.-.? _ __. I _ i INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES _., -; NO Ell IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY, OTHER TYPE OF INDEMNITY 0 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 Q AGENT X01 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 be in compliance ith all Pertinen ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME p�l!� C. 00—___IILICENSE # D I SIGNAT E MP [ja JP �]._i CORPORATION [7]# PARTNERSHIPP# ; LLC COMPANY NAME LSU/ C CJIVS ADDRESS (J u• 700 CITY (�/ _ _-_i STATE ZIP �� , l� TEL "ZZ� FAX --� cICELL-EMAIL.7L._�w��.-� 0 El z w m ui w LL t1 a lcx The Commonwealth ofMassachusetts - Department oflndustriglAccidents Office of Investigations 9 600 Washington Street Boston, MA. 02111 www.mass govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant 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. ❑ I am a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors 7• [J Remodeling 2. F1 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. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11. E] Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] i q ] employees. [No workers' 13. ❑Other comp. insurance required.] '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. tContractors 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 wopkers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lie. #: Expiration Pate: 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 maybe forwarded to the Office of 'Investigations of the DTA. for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Simature: Date: Phone #: 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 C'nntact Percnn: Phone #: I Information and Instruction's 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 employes." 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. De advised that this affidavit maybe 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 retumed 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. Anew affidavit must be filled out each year. Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license orpermit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations wouldlike 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 mass dhwotts Dep.artrnent offndustr%al Accidents. Office of I"estigation,s 600 Wasbingtw Street Boston, M.A. 02111 TQL # 617-72.7-4900 ext 406 or 1:-877,MASSAF,E Revised 5-26-05 Fax# 617-727-7749 I DateS,� ..��.?. �2.,. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that -ZIYT. ......................E..\,% -.- ............................... has permission to perform ...... ........................................... wiring in the building of ....... V./ .......... . ...................................................... at ...../ Z-� ......... ............ rth Andover, Masi. ... .................. S. ......... -7,,-00 Fee...6-�:7�.. Lic. NoJ..q.11-,6 d ................... ... ....... ......... ICAL ELE: INSPECTOR Check # 1070 . 7 10838 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical C) Code , 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 5 AV Id City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant A V1 he Owner's Address Telephone No. 17g -%(01 — ( 61 (p Is this permit in conjunction with a buildingermit? Yes No ❑ (Check Appropriate Box) Purpose of Building 1 m I t Utili , Authorization No. Existing Service )C)C) Amps QQ 19qO Volts Overhead Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity and Nature of Proposed Electrical Work: Ct1', Cmmnlptinn of the fr llnwinQ table may be waived by the Inspector of Wires. 4 Attach additional detail if desired, or as required by the Inspector of Yi'ires. Estimated Value of lectrical Work.. l06 (When required by municipal policy.) Work to Start:,,) r 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 surance 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 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains anti penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee:Signature F, LIC. NO.: lql& (o (Ifapplicable, enter "exempt" int license umber line.) Bus. Tel. No.:7 I 77 ) Address: KpI M USP •/ 01A 1Alyi1ory. N A- Q� �� Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work required 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. of Total No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans Transformers KVA Tran No. of Luminaire Outlets No. of Hot Tubs Generators KVA . No. of Luminaires Above Fi In -o. Swimming Pool rnd. grnd. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Detection andInitiating No. of Switches No. of Gas Burners Devices No. of Ranges Tot No. of Air Cond. Tons No. of Alerting Devices Heat Pump Ner Tons KW No. of Self -Contained No. of Waste Disposers P Totals:J ............ I Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Municipal Local ❑ Connection El Other No. of Dryers Heating Appliances KWSecurity Systems:X No. of Devices or E uivalent No. of WaterKms, No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: 4 Attach additional detail if desired, or as required by the Inspector of Yi'ires. Estimated Value of lectrical Work.. l06 (When required by municipal policy.) Work to Start:,,) r 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 surance 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 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains anti penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee:Signature F, LIC. NO.: lql& (o (Ifapplicable, enter "exempt" int license umber line.) Bus. Tel. No.:7 I 77 ) Address: KpI M USP •/ 01A 1Alyi1ory. N A- Q� �� Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work required 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. • r —,IU�tilr.l.Ci.�.��.ct�!•..l�t.�Cr�y-rL�i�J•.�F'.U.�,l,•�.•L`+t�®p�. .yt •�,�•I.YF'Jl,.l!t�a.fl.l,�.l'i.1C�AJ'�®�1.: M �nspec#Qxs' p�+ze�ats: yc.., - v , {xns�ec#oxs5 z atuze 'o iiials} Date - — - 2•MAL7>�e+DNb .'asset7--aiSet��e3nspectio�equixe �'nspectas•�' commenfs: . (ffis&ctoxs' Pignata a •-)zo xxtzfiaTs) pate 'y �'asset�—� � �iai�ec�•-j � ate-�s�eeizo�xe�uire�T(��0.00)�[ � )'nsliectoxs' comments: (lnspectoxs�,�ignafuze-ao��aTsj date . ATE, CAUIGRR D MATIONA I, C-10-131. NAME: '• .�-!.'(I7J..GtiiJI..LOJ.Y •'•17•x.144 Yl.l.r1: , assed--[ ) aile •-j P'e-Inspedlo'nrequired ($50.0D)�� � zspectoxs' eoJonme�tfs: - (fuspecfoxalftaaiure-ioi lfiais) Pate ase ~1a1XerT--� ateuspecizonxeguixe� ($50.OD) �[ pectoxs' cozitxa€�s: • 5 ' -ohspeetoxa'Szgnaiuxe-xtoxnpdals) - Pate O T'AGOAM �O EE E)MV-D O'UTAM MFT ONBITE IF TRE APXA TO DE SEECTUD Xg NOT s ; The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: " Q, n C y T Q 170 Phone #: Ij� h 7 q3'f 1-771 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I _ pniployees (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 me in any capacity: workers' comp. insurance. [No workers' comp. insurance 5. EJ'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. modeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roofrepairs 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 tie 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 cWrtffy under the pains and the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # 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 -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe 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 604 Washiugton Street Boston} MA. 02111 TeX. # 617-727-4900 ext 406 or 1-877rMA.SS.AFB Revised 5-26-05 Fax ## 617-727-7749 www.mass.govfdia Date ... ... .C.... 9416 MpR7M , TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSACMUS� �J This certifies that .... ,Q has permission to perform .!.!!''9.........y. plumbing in the'buillddin-gs of .. A10�7tC,% ............ ..... . at ... �O v. ✓,. 4.... . . Sr ... , N owl ndo er rMass. Fee. Lic. No.. A /.A - PLUMBING 1 SPECTOR Check It v V \-~ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY O { MA DATE 211 PERMIT# 61H �p JOBSITE ADDRESS O;2 ' "� OWNER'S NAME POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMER L EDUCATIONAL RESIDENTIALd PRINT CLEARLY NEW: ®1 RENOVATION REPLACEMENT: ® PLANS SUBMITTED: YES © NOD FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE ! I DEDICATED SPECIAL WASTE SYSTEM _. R DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM J ! DEDICATED WATER RECYCLE SYSTEM{ DISHWASHER ( __J ____•.� DRINKING FOUNTAIN _ ___,-,._► FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR INTERIOR Y_I KITCHEN SINK LAVATORY ROOF DRAIN 11--i SHOWER STALL / ! SERVICE / MOP SINK TOILET_ j URINAL !� WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER .! -1 I_ J INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES F_ NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ®i 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 0 AGENT P1 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'S NA I f o f' ^ LICENSE # G SIGNATURE MO JP CORPORATION ©# PARTNERSHIP# = LLC �# COMPANY NAM �, _ */ ADDRESS 6 CITY JISTATE ZIP C (S-y:,T TEL F W� GIs ( CE ��� EMAIL v V \-~ v ' H °z 0 H U W Pi d z w kl �• �( , , o ❑�Z z } IV o w O W a a* z wLU o a W 5 CO a LUw 3 0 o aa, w a U J a 0- < Q di x w � a Ey V W P.i b P� 7 a a x x° The Commonwealth ofMassachusetts . - Department oflndustriglAccidents Office of Investigations 600 Washington Street Boston, MA 02.111 www.massgov/clra Workers' Compensation Insurance Affidavit: Buildelrs/Contractor6/Electiicians/Plumbers Applicant Information Please Print Legib Name (Business/Organizationffndividual): L Address: P,0 2(s* City/State/Zip:_ kfi • (�y� �<1� l 1 v1 Phone #: Are Pu an employer? Check the appropriate box: Type of project (required): 10 I am a employer with 4. ❑ I am a general contractor and 1 6. ❑ new construction employees (full and/or p -time).* have hired the sub -contractors 2111 am a sole proprietor or partner- listed on the attached sheet. x 7• Remodeling ship and'have no employees These sub -contractors have 8. E] Demolition working forme in any capacity. workers' comp. insurance. 9, El Building addition [No workers' comp. insurance 5. El We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing. repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] i employees. [No workers' comp, insurance required.] .13J] Other ?Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. 7 Homeowners who submit this affidavit indicating they bre 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 em loyees Below is the policy andjob site information. _ I Insurance Company Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: N�o City/State/Zip: 0 /] , /x -,d 14A 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 o. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year impriso ent, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to day against t violator, e d ' ed that a copy of this statement may be forwarded to the Office of Invest' ations of th DIA fax aiw co era ve ification. Ido hekhy cert k— 1 that the information provided above is true and correct. Official use only. Do not write in iliis area, to be completed by city or town official. City or Town:. Permit/License # Issuing Authority (circle one): 1. Board of health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone w• 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 ofits political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapterhave 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), addresses) andplaone numbers) 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. Iran 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 Ofcials 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 (ifnecessary) 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 maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filied 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 orpermit 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: Tho oonwaalt oassaeusPtts Dopaftent of InduMal .A celdonts 4fAce o T� esti atXQ.AS 600 Wasb.%>u&a Stxeet Boston, MA 021X1 TOL # 617-727-4900 ort 406 Qx 1-877:MASS.AFF, Revised 5-26-05 Fax # 617"727-7749 WWW'Mass,gova'a r Office Use Ottty 7e : - 01 LIInIIIaumlan of �a Xztts Permit No.77 �r �egarlt>i�i .� 11tt.6iit lc «=pwv y a Fee Chocked : _ Ty - 3190 :.. (leave wartfd BOARD OF FIRE PREVEMON REGULATIONS 527 CUR 1200 APPLICATION F 1. OR PERMIT TO PERFORM ELECTRICAL WOR AIt work to be performed in acoordartce with the Massausetts E.'ectricai Cade, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) - Date QM or Town of NORTH AN[�O To the4"6ivr of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) %tj 20 ,A Lr --Al 1 Owner or Tenant �� 1%l I f Cwner's Address log Is :his permit in Conjunction with a building permit: Yes _ No (Check Appropriate s Purccse at Building_ Utility Authcrization No. v Eais;irg Service Amos_Vcas Cverread Uncgrna oC No. of M eters / New Ser,/ice Amps T� /pits Cvemead Undgmd L_ No. of Meters Numoer of Feeders and Ampacity Location and Nature at Proposed Elec rcai 'Ncrx ' Total Nc. of Ligating Cuaets No_ 7f -=s i No. at 7canstarmers KVA Cove.--. ^_ _ No. cr L:,,t:ng = xtures -:^y �•---a — --rc. _ i Generators KVA I No. at _rnergency tUgnang No. of Receotac:e Cuttets No. at Cil Burners { 3arery Units No. at Swttca Cutlets No. at ^-as Burners I FIRE ALARMS No. of Zones No. at Ranges i _ .otat No. at Cetection ana No. _:4.r C:r.c. _rs initiating Cavitas -eat ' ;a,:at No. at Oisccsats Nc.ci -.—=s 7or.s C:t No. at 'Zisnwasners =ace,Area ^.g .SN No. at Sounaing Cevices No. a. Sart Cantatnec Cates:cvSouncing Zev:ces m ^ .(`:/ No. at Crvers ea.nq ::awces . � — Munic:oai 'Cat '–'Other _ Cannec::on '— No. or No. a: I Law :cttage No. of water Heatersi0N i Signs Ba:Iasts Win^g No. HycroMassage Tuba I No. at Mctcrs .crai i-iP C', -i _ ; . iNSI;RANCE CCVEPAGc: pursuant ;o :ne-ecc:re:7ents --- -. assaCn--'$et:S yer•erat 'I-aws Zzn-=:etec C=era:cens Coverage or _ :ts su=scanaat ecutvatent. YES NO _ I nave a current Liantiity Insurance Patio/ .nc_c:rg C `ice. YES' V NO _ :`. :cu nave cnecsee YES. -,tease inctcate :Me ype f coverage av rave suomtttaa valid proof of same to trio aaecxtng the accrccnate box. INSURANCE X BONO — OTHER ;Please S=ec-ty) (E.co,raaan Oatet =sarrtatea Value of Electrical Work S / �% / to Stag tns=ec-on Ca:a Aecues:ec: Rough 4 Final Signea unser the Penalties of per)ury:'` � —, C� Imo-+ 'FQk2 LIC. NO. ;:"RM NAME �Urz/� OyJ�� ag a-t.re _ LIC. NO. .l4L�— Licensee -al. �.� ,nlJ Y"/ Sus. No. Alt.- . Accres3 CWNE'S iNSUSANCE WAIVER: I am aware :.hat :'e L:cer.see Sees rct rave the insurance o=verage or its suostannal eautvalent as -e- Rwaives tats requirement- Owner A ac cutrea by Massac.'tusetts General Laws. ana that .7v S:gna:ure en :n,s ::efT-lt Ciicaaen (Please cnecx one) ^^(��\) -eteororte No. PE_RM)TFE=S JJ, (Signature at Owner cr Agent) c %W 1351 Date... W TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ ........P.qC A-e.fL................................ .............. has permission to perform ..... . .......................................... wiring in the building of ....&'.�: ... ...... (.0.1-.1sl ................................ at.1 0 �) (-) sc-t I -f o' S f . .......................................................................... . North Andover, Mass. 0/` ... Lic. No.,/�,/V6 .............................................................. ELECTRICAL INSPECTOR 1 102 /6 &'.42 �q36-00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer -ell `'.N 1483 TOWN OF NORTH ANDOVER PERMIT FOR WIRING 'S 4v4PC`v f_R_This certifies that ................... .....................'............. .............................. has permission to perform .............. W ......k. U N ... �..................................... �n , wiring in the building of ........�✓� ��CI,P.... ............................. 1 S. a lT Tv at .... f �.C1�.1..........,..................... ...................... ,North Andover, Mass. Fee.36. D........ Lic. Nq_: Vy, ..........................................�;.................... ELECTRICAL INSPECTOR 0RiNAWEko0UW0,j WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 7,; ` �i17%%i%it'�J%L'�i7f 057 W.45S,4C7, >!.S` 77 S ?ie rrsurt 4;1-#& 5404 BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Office se Onk WS Permit Na —4V� 1 Occupancy & Fee Checked APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK'` All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00' (Please Print in ink or type all information) Date To the Ir(spedor of, Wires: Town of North Andover The undersigned applies for a permit to perform the electrical work described Location (Street & Owner Owner's Is this permit in conjunction with a building it No ❑ ( e 17 ck propriate Box) —7�Y C� 7 Purpose of Building7c Utility A horization /v Existing Service Amps its Overhead Undg d ❑ of Meters New Service Ps % Voits Overhead Undgmd No. of Meters Number of Feeders and Ampacity ` Location and Nature of Proposed Electrical Work INSURANCE COVERAGE. Pursuant to the requiremen6ts of Ma achusett General Laws I have a current Liability Insurance Policy including Completed Ope ions C verage or its substantial equivalent YES k NO = have submitted valid proof of same to the Office YES ---kNO= If you checked YES please indicate the type of coverage by checking the appropriate box INSURANCE .0 BOND = OTHER = (Please Specify) (Expiration Date) Estimated Value of Electrical Works Work to Start / Inspection Date Resquested �- Rough Final Signed under the enaltles of perjury: FIRM NAME `i ��� LIC. NO. Licensee `��dSignature LIC. NO. Q / Bus. Tel No. Address! Aft Tel. No. OWNER'S INSURANCE WAIVER: 1 am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMIT FEE b (Signature of Owner or Agent) Total No. of Light8ng Outlets No. f Hot fuse No. of Tra sfo ers KVA Ab❑ In 13No. lGeneratoA of Lighting F" res Swim in Pool grn,0 gmd ❑ KVA No. of Entgeray Lighting No. of Receptacles Ou No. of O Burners Batte U its No. of Switch Outlets No of Ga Bumers FIRE A RMS No. Zone No. of etection and Total No. of Ranges No of Air C nd Tons Initiating Devices . Heat Total Total No. of Di al No. Pumps ns nWZ No. of Sounding Devices No./ of Self Contained No. of Dishwashers Space/Area H atin KW Detection/Sounding Devices ❑ Municipal ❑ Other No. of Dryers Heating Device KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wiring No. Hydro Massage Tuds No. of Motors Total HP INSURANCE COVERAGE. Pursuant to the requiremen6ts of Ma achusett General Laws I have a current Liability Insurance Policy including Completed Ope ions C verage or its substantial equivalent YES k NO = have submitted valid proof of same to the Office YES ---kNO= If you checked YES please indicate the type of coverage by checking the appropriate box INSURANCE .0 BOND = OTHER = (Please Specify) (Expiration Date) Estimated Value of Electrical Works Work to Start / Inspection Date Resquested �- Rough Final Signed under the enaltles of perjury: FIRM NAME `i ��� LIC. NO. Licensee `��dSignature LIC. NO. Q / Bus. Tel No. Address! Aft Tel. No. OWNER'S INSURANCE WAIVER: 1 am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMIT FEE b (Signature of Owner or Agent) CERTIFICATE OF USE & OCCUPANCY Town of North Andover FILE Building Permit Number 565 Date June 3. 1998 THIS CERTIFIES THAT THE BUILDING LOCATED ON 1020 Salem St MAY BE OCCUPIED AS Single Family Dwelling IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. /lot,T CERTIFICATE ISSUED TO Belford C nstruction Inc o .,, •, o` 1049 ADDRESS34 1 ce Building Inspector n 6 z P A M 0 w a MA H z 0 0 z 0 U �ffl O O co O v Z O CL O y C C ICD =CM O•— ca p 'C O L-4 CD 'E m m CD CO. CL = O� CO CD L d ca 0 cc c ■C CD C Z tsO V W � c c— '- c _h 1 a v E q lu c� w a o x o r�G o rx z 1�1 9 ° ra cn � M 0 w a MA H z 0 0 z 0 U �ffl O O co O v Z O CL O y C C ICD =CM O•— ca p 'C O L-4 CD 'E m m CD CO. CL = O� CO CD L d ca 0 cc c ■C CD C Z tsO V W � c c— '- c _h 1 o c� o C N` O C C3 C3 o, c ev w ;z _o t sz. c m o t CC OL E c rd w w U! S% m c :r E O N � - 3 r.+ CD N c a y O C O y Em m o- cm CLCO y O O CD 'it O! ::,o c_ C yQ � V NZcm O ap c0 C C a E c = m mho w h m o F- CD ••- oc 0 .. 066LU Z CM ca CL a o Q F- t wLCOO C M 0 w a MA H z 0 0 z 0 U �ffl O O co O v Z O CL O y C C ICD =CM O•— ca p 'C O L-4 CD 'E m m CD CO. CL = O� CO CD L d ca 0 cc c ■C CD C Z tsO V W � c c— '- c _h 1 N,r Y OF . FArKUN y Na 37045 V Ocs', do t� .39_ , �kIsriNc --; ---- ficIJNpa710;x`1. 30- 4#' T LOT 1 1.00 Ac 175.00' N6110" 1'27"W SALEM STREET THIS PLAN IS THE RESULT OF A SURVEY PERFORMED ON 12/22/97 BASED ON THE. INFORMATION SHOWN ON PLANS OF RECORD ESSEX NORTH REGISTRY OF DEEDS_ AS—BUILT FOUNDATION LOCATION PLAN ASSESSOR'S MAP 104D LOT 32-1 NORTH ANDOVER, MASSACHUSETTS Scale: l "=60' — Dec.23,1997 Prepared for BELFORD CONSTRUCTION NEW ENGLAND ENGINEERING SERVICES, INC. 33 Walker Road—Suite 22—North Andover,MA. 01845 Tel.(508)686-1768 PERMIT NO. APPLICATION FOR PERMIT TO BUILD — NVRIM ANL)UVER, M^3b. MAP 440. �LOT Nq. I Z RECORD OF OWNERSHIP DATE BOOK PAGE ZONE p SUB DIV. LOT NO. OCATION b f PURPOSE OF •UILDING OWNER'S NAME i7 4�i - �% • �N <' MI NO. OF STORIES fi2ET ', r f --�� OWNER'S ADDRESS ' J� DJf BASEMENT OR SLA■ ARCHITECT'S NAM[ m ^ AQ®�\`ftllnt[1P BUILDER'S NAME 1V7„✓� S12[ OF FLOOR TIMBERS IST X In !NO �� )Q !RD � g C� SPAN� •ti DISTANCE TO NEAREST BUILDING f DIMENSIONS OF SILLS c%6 — POSTS '71 DISTANCE FROM STREET f e DISTANCE FROM LOT LINES — SIDES i REAR 2i: ///..f GIRDERS AREA OF LOT J /� f�� FRONTAGE ��� HEIGHT OF FOUNDATION / THICKNESS /6// tf BUILDING NEW +' T '- SIZE OF FOOTING if X If BUILDING ADDITION MATER:AL OF CHIMNEY �+ IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND Q WILL BUILDING CONFORM TO REOUIREMENTS OF CODE Ii BUILDING CONNECTED TO TOWN WATER P BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER K) IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PALL 1 FILL OUT SECTIONS 1 - 7 PAGE 2 FILL OUT SECTIONS 1 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR OAT[ FILED SIGNATURE OF OWNER OR AUTHORIZED AGENT FEE PERMIT •RANTILD 0 Pam --s._=�.__ _ = --- _---_._._�-. _—ter—•- -----_. PROPERTY INFORMATION LAND COST 134:2 EST. BLDG. COST LJVCJ EST. BLDG. COST PER SC. FT. r 9' EST. BLDG. COST PER ROOMEST. BLDG. COST ROOM ! SEPTIC PERMIT NO. �e� - 4 APPROVED BY Ailrm � O*,�M Owners Tel # f 7,.�377SZ Contract Tel# 67 7S -L Contra. Lic # (g 1,q 1 0107 HIC # v, y C d CO) CM) CD az y o. � 0• ? O CL as H ato -0 aCD v c� o Q Q CD cc CD C O y �. CD �O y 0 C C) CO) O 'o Z co � O CD /O�� \Y 1� C C? O 0Z V O --MOQ acSa y CO) Mme m �' x N w Z 0 �'fl .rte ft y� NCL T =r CL 0 m m -, O m y O y O " � �m� m a > > N O 0. O cc p O0 O N. n W O o =' =.0 C d � cc o�� = O m N e'► CD m O C CL m H xv O N O N � w O. _ C t7 : / M to CL N :1 OCOO N GN 0 N O m N .di CD :1 • :O :� 0 oo: . =r N : � O CD ,... Cm a CD Z ;w y o CD m m C-2 C O � O 1p . r o V x ro 9 CA �' x ro w a. wFL 171 x w rA M 0=3 0 O C FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. " "`****'"""`***APPLICANT FI S OUT THIS SECTION************ APPLICANT G �! % (� PHONE �S -J�- LOCATION: Assessor's Map Number O % PARCEL 32 SUBDIVISION LOT (S) STREET____!�/(e /'yj ST. NUMBER * ************************OFFICIAL USE ONLY NDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR COM PLANNER COMMENTS \(:�- FOOD INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED r_. DATE APPROVED�--- DATE REJECTED DATE APPROVED DATE REJECTED TH DATE APPROVED 7 DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS((/ DRIVEWAY PERMITu� `Zo FIRE DEPARTMENT -/7- RECEIVED BY BUILDING INSPECTOR J DATE Kam of()s 0_� _ T I} ' A '�tty 1. ll3 I fF f r; "WWA . NO �r y M " c's �€ + ',�} 7 1 ? 1 I , 'To�unlof �Jor AndyrOi�l�iassa� setts 'Mt , k j i. Form t r f a i# t tp , F.'_ Y `�BO/...I� OIHEI I .�� ��.f •�}. O F.c 4 �"r�P1y ! 9 . � � A -P• .I '.i..t � L"w.+17F '�` ,7 "�i `nS F ,��`'}9 yy - t ,y �4. G 3 tai � I i it + I ,�t ' #: MAPPY_I'VIA �F -i.{7� Y �� SS^CHt15Ej I i r :� � f� �#I� I y ,-k9.. ql rI ' SOIL A13 O Fib �tSEWA 'E'pISPpSA,� SYSTEM k "Sj'� ° F �k� •, atl� �. {3f I� .4 � x.,4.. 7'`y ir Applicant �Te�t No' 1 Ap f f kMc , I t _1 1 k w fay 'ar`'^'",.n!! �.I ljdtc'ra`�1 t t 1 1 I } -Si.te Location t+lrE � ASI ( Reference �Plr�s a14¢ I f • "'",�.. r,l,k'??+k."^^�*t�.?.l?t x;>a�r i Permissions Is gantpdforttft!Id;y Qil�ab. oe e}7d�s osa s ste , o be nsta I y } }:Hp�� fin{ accor&kf,, Mrd • e- ! t F � t�'����'.� ,�: "G. r'�'r�-.�� '. S •�"m `� w+11 ���'�� j�l �,�1��" 4 � �a �J y� "�'S 4'r i s .' .'.�- :.� ,1 j=,, � � 1 ';;�ri*1��K�r� ":�'��"'�'t�r'�'���_;�s.�'�i� ���� �>� �'a•'k�r +• �i+. i` �r:.9''{ t _ �_. y" j "i�N.?+RCi of H �I TH AF ,t k x a t rTM + t� Y4 ;F jYr .jj;Y x yyT , '�a;Ssterr#4Rermrt 1 .:�% ,i 1� i k3 5 ^S. .�jb•+ tS".l p' y �iI _ t44��-i"' t'�. . -tFs+s,.� ,�. Xyj 2 a.,.�:.�axe�r: :�. �uk'`�`=.`t' '�.; m r,'3,r�����7't! ?3�'t•'°�'�* <�.-. tpi' '�' I.I� Pfi" i iij tl t I ': 1 tt I J 1 r - 1� I f P I .It IJI f( 1 1 APPLICATION FOR WATER SERVICE CONNECTION North Andover, Mass. 19 (C Application by the undersigned is hereby made to connect with the town water main in d/CL �� Street, subject to the rules and regulations of the Division of Public Works. The premises are known as No. 6)00 5 . Street or subdivision lot no. A 6, Owner Contractor We 7S - S ;7-5 2 Address Addre �Applicant"s �igna ure PERMIT TO CONNECT WIT WA ER MAIN �� The Board of public Works hereby grants permission to to make a connection with the water main at r-- subject to the rules and regulations of the Division of Public Works. Inspected by Date Street oa of ublic Works By See back for rules and regulations RULES AND REGULATIONS GOVERNING THE INSTALLATION OF WATER SERVICES 1. No persons shall tap or in any way tamper with water mains which are part of the distribution system of the Town of North Andover without a valid permit from the Division of Public Works. 2. All water services shall be installed a minimum of five feet below the finish grade. 3. No water services shall be backfilled without inspection by a representative of the D.P.W.—Telephone 687-7964. 4. Service connections shall be 1" type k copper tubing. 5. All fittings shall be brass flange type Mueller or equal H 15202 Corporations H 15212 Curb stops H 15402 Three part unions H 8185 stop and waste valves 6. Curb boxes shall be installed at the property line and shall be of the Erie Type with 4'/2 foot rod and brass plug type cover. W Growth Management Bylaw Exemption Statement Town of North Andover Building Department This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information as requested below. Name of Applicant on Building Permit (below) Address of Property for Permit (below) �3 1_-02J Coni rUL "ion mac- _ /0 -?40 -1- Map and Parcel : MID Purpose of Application (check below) Ph ,A Number of Applicant: Single Family Two Family 1 the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth Management Bylaw. I also understand providing this form does not absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance of the Building Permit. Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building Department and is only officially accepted when the Building Permit is, issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement, restoration, or reconstruction of a dwelling in existence as of the effective date of this by-law, provided that no additional residential unit is created. The lot(s) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning Bylaw. This application is for dwelling units for low and/or moderate income families or individuals, where all of the conditions of 8.7.6."re met and/or represents Dwelling units for senior residents, where occupancy of the units is restricted to senior persons through a properly executed and recorded deed restriction running with the land. For purposes of this Section "senior" shall mean persons over the age of 55. This application is a part of a development project which voluntarily agreed to a minimum 40% permanent reduction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open space and/or farmland. The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the Planning Board that will ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adj cent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. This application represents a lot which is ready for building permits,(i.e. all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per Development until such time as the Development Schedule accommodates issuing building permits. Applicant must supply approved form U with this EXEMPTION. Please provide any and all information that would assist the Building Department in making a determination' that your application is allowed one or more of the above EXEMPTIONS. By signing below I attest to the accuracy of the information provided and that the attached building permit is allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or inaccurate information, or the checking off of an above item which does not comply, whether done to my knowledge or not, is groun or al by the Building Department to issue a Building Permit. e> - icfn-atLfre of owner or Authorized Agent who signed the Attached Building Permit Date This form must be attached to the Building Permit upon application for such permit. GEORGE PERNA DIRECTOR TOWN OF NORTH ANDOVER, MASSACHUSETTS DIVISION OF PUBLIC WORKS 384 OSGOOD STREET, 01845 DRIVEWAY PERMIT Date: nc 2- /997 LOCATION: BUILDER: OWNER: Telephone (508) 685-0950 Fax (508) 688-9573 phone: phone:27 The North Andover Superintendent of Highway Utilities & Operations MUST be notified of the grade and set -back from street established in any driveway entry onto any street or way maintained by the TOWN. Call the Highway Superintendent's Office, before finish grading and surfacing for approval of such entry. FAILURE TO COMPLY AND OBTAIN APPROVAL VOIDS THIS PERMIT. ■ Remarks: Approval: `3d jov Ys M2955 PG 309 TOWN CLERK RORTB ANDOVER 10 11�sbboxl(�YddTOWN of NORTH ANDOVER �: aler.'ff1-111Z'L MASSACHUSETTS A yfud ARYns copy, �O.,j-«sem OL boomaw,4—a � BOARD OF APPEALS 4bwnClark NOTICE OF DECISION AM, App"i ,hall be tiled vithin (20) daps after the data of filing this aotios la JUL 14'97 AM11:55 the Office of the Town clerk Property: 1026 Salem Street Pacific Realty Trust #Datte April 29, 1997 172 Foster Street n: 00 - [NorthAndover 018-4 Hearinq: 4117/91 The Board of Appeals held regular meeting on Tuesday evening, April 17, 1991 upon the petition of Pacific Realty Trust requesting z Va-:4ance under Section. 1, Paragraph 7.1'and Table 2 of the Zoning By Law seeking relief from the required lot dimension. The following Q, members were -present and voting: Raymond Vivenzio, John Pallone, k Robert Ford, Scott Karpinski, and Joseph Faris. O The hearing was advertised in the Lawrence Eagle Tribune on March 26, 1997 & April 2, 1997 all abutters were notified by regular mail. Upon a motion by John Pallone, seconded by Ravmond Vivenzio to grant the petition as requested in R-1 Zoning District seeking relief from the lot dimension area to create two separate lots. It was determined that the unique shape and topography and wetland on this parcels would create a hardship for the petitioner. Votina member were: Raymond Vivenzio, John Pallone, Robert Ford, Scott Karpinski and Joseph Faris. Petitioner has satisfied the provisions of Section 10, Paragraph 10.9 of the Zoning Bylaw and that the granting of this variance will not adversely affect the neighborhood or derogate from the intent and purpose of the Zoning By law. The variance is in keeping with the general harmony of the area and is compatible with the lot size and number of homes in the neighborhood. Note: The granting of the Variance and/or Special Ps=it as requested by the applicant doss not necessarily ensure the granting of A Building permit at the applicant must abide by all applicable local, stata and federal building codec and regulations, prior to the issuance of t building permit as required by the Building Co isaioner. I� ;f BK 4745 PG 310 TOWN OF NORTH ANDOVER MASSACHUSETTS BOARD OF APPEALS NMCX OF D1=81OY Mevieed per W.I. Chapter 60.6, ►erprph 7.5.6.4. Modification of the decision (To clarify the 2M'e Intent) Property: 1028 Salem Street i Pacific Realty Trust Date: April 24, 1997 72 roster St 1petition: 005-97 North Andover MA 01845 lHearing Date: 4/17/97 L� The Board of Appeals held a regular meeting on Tuesday evening, April 17, 1997 upon the petition of Pacific Realty Trust requesting a variance under Section 7, Paragraph 7.1 and Table 2 of the Zoning By -Law seeking relief from the required lot dimension. The following members were present and voting: Raymond Vivenzio, John Pallone, Robert Ford, Scott.Karpinski, and Joseph Faris. 1; The hearing was advertised in the Lawrence Eagle Tribune on �. March 26, 1997 i April 2, 1997 all abutters were notified by regular mail. Upon a motion by John Pallone seconded by Raymond Vivenzio to Grant the petition as requested in R-1 Zoning District seeking relief from the lot dimension area to create two separate lots. Lot #1 to be 43,560 square feet (one acre) il! and lot t2 to be 72,902 square feet (1.7884 acres) and a Parcel "A" 50 foot right of way as shown on plot plan for Pacific Realty Trust, dated February 13, 1997. It was determined that the unique shape and topography and wetland on this parcel would create a hardship for the petitioner. is Voting members were: Raymond Vivenzio, John Pallone, Robert Ford, Scott Karpinski and Joseph Faris. The petitioner has satisfied the provisions of Section 10, Paragraph 10.4 of the Zoning Bylaw and that the granting of these variances will not adversely affect the neighborhood or derogate from the intent and purpose of the Zoning By law. The Board finds that the applicant has satisfied the !'I 3.� 11. j BK 4795 PG 311 provisions of Section 9, para. 9.1 of the Zoning Bylaw and that such change, extension or alteration shall not be - substantially more detrimental than the existing non- conforming structure to the neighborhood. Motes Thor granting of the Variazoe and special Permit as requested by the.gpplicant does not necessarily ensure the granting of a Building permit as the applicant must abide by all applicable local, state and federal building codes and regulations, prior to the issuance of a building permit as required by the Building commissioner. BOARD OF APPEALS, William 1 ivan, Chairman ESSEX N©RTWRERY p A LAV;/F;EN,CE, ; 13 Ass. G r A TRUE CO,�Y; ATTES7'. C74;� REGIS-reR OF DgED // aaa (g7r)f 37-2.33s j�. r —1 II I I I I II I I I I I I I I I I I I I I I I II �I II I, I I I I II II I I II I I II I � II I I � I II II I� � I I I I I I I I II I � II LJ I I I I I I I I I I I I I I I I I I I I I I i I I I I I I II I I I I I i i I I I II I I I I II L _J .Fmm- mil m mmmF11M mm-i�mm:l �MINIM ■■■ �_ mmm ■MINIM :CGCG .� Ml Ml Pet mVN DY, NOW �VAION fi Obit HOOFF-p I I----------- i I IL ---------- LJ I,0'f' 3n -I 3I 16 11 -I 1 -0111 1151191 %WOU; -WX UVAION ► �: -romp HOOpFI12 0 r II H I I --- II II II II II fl II II II II II II II II II II II II II II II Fw,tcf Itu: SM W O L.- L 8 ~ 03PF- -T*,:I" WA 51ft1' lWf 5P-1 1/8"o-11,0111 13UILMI2 OF FINF- HOMF-S I,�Ff ANP kl(Aff R.VAION5 fOn HOOPED 1A RON IN II T-01 IN IN Ki r ---1 i � I I � I -N I I i t W-21- I II � ---�; II,I I ilii I —I � l i r- -- -.I I I� i l l I ! � l i j l u� - ------------ L � I j � � �I/ I I c, (! i t i it------ — — — — — - — =�-----------------t--1------_-._._i_I W-01 ... . .......... ---- -- - -- __ --- .....- I - -- ----- __ ___ _� - nre --- PAM iter: _._.10f1 512+ V 16 1'-0';' 7/V 97 VOM vyl FIP5f PLOa P�AN 7OCA9 HCOFrk9 r , J r PA cn C� ill I fi � i • c'j I I , O I I � _..l2'-01 v1 , 21-01 I ! 26-0u --- - ----------------- -- --------- —--- — -a 1PUILn�i2 Off= FiN� N(iME' 5) �� it �1 Fliz5t ri.0N PLAN -ronn_NOon J r PA cn C� ill I fi � i • c'j I I , O I I � _..l2'-01 v1 , 21-01 I ! 26-0u --- - ----------------- -- --------- —--- — -a 1PUILn�i2 Off= FiN� N(iME' 5) �� it �1 Fliz5t ri.0N PLAN -ronn_NOon m 0 13LAII-t9r::R OF INF- Hc `E 0 51 TAMING PLM -5 _ N©Op�I� 0 -* - ----- i I I I O2x I I i i i elb, of- ZZ i � I _ z ( T'X12't�7lE I � I i f� w I I I I ♦ i � I I I I � r,xv,mom I I � I I I I D Q�Q g N 1 CC) � N � i Q � XNc�i 82 Qt / 4 � DD 11 N O NNN ` X X M� -Gy ttt"' X .7p �z V\ Sy zg D IM W I. L- 0 eA 5TMf Wf V-1 A5 NOT12 nAn; 7/ 3 / 91 o f mvmw, E3UL,M-I;Z OF FINF, HOMI1 5 P00F PI AN & PULPING 5�Cf, -rorlp HOOpFIp 0 -* - f� w ♦ Vii. � Date ............................................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............................ (o�Aj&*-*�- ....... **"**'** ... *"**""***'*"'****'***'*'*'******"'*'*************'****'*** has permission to perform ........... ......... ........................... N wiring in the building of ...... ... ....... .............................................................. it ..... .1.c) ...... ....... ........... orth Andover, Mas4 .... ...... .... .. ............................. FeO........... Lic. No. ......... ....... ...... . . ..... Z�C* **cA"L**' 711- aINSPECTOR Check # 4-- q5b-14 VA 0172 613 --r Commonwealth of Massachusetts Official Use Only o 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 (MEC), 527 CMR 12.00 (PLEASE PRINT INM OR TYPE ALL INFORMATION) Date: 7-11-1 Y City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 10 a0 .SA Ie i S4. Owner or Tenant Anon 'v ,ren Telephone No. q7, - 01p8- 7890 Owner's Address /0 ot6 5,i're,, S'�. A- 4n aver Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building re5;jen Ce Utility Authorization No. - 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: �e Completion ofthe_following table may be waived by the Inspector of Wires. No. of Recessed Luminaires d' No. of Ceil: Susp. (Paddle) Fans TransTotal Trsformers KVA No. of Luminaire Outlets 3 No. of Hot Tubs / Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. grnd. No. of Emergency Lighting Battery Units No. of Receptacle Outlets q 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. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number � ...__ Tons ......................... KW ' ' " ' No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of 97res. Estimated Value of Electrical Work: 3, o oy- (When required by municipal policy.) Work to Start: 7- 1-iY 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 VBOND ❑ OTHER ❑ (Specify:) 1.t'ct6r'l,4 Icertify, tinder thepains and penalties ofperjury, that tine information on thisapplication is true and complete. FIRM NAME: , TO e f S%►+ r' trl Pc frr"c LIC. NO.: Licensee: To e I r,,4 'l4 Signature LTC. NO.: i ;L3 -9L 9 6 (If applicable, enter "exempt" in the license number line.) Bus. Tel. No. • y 2 -F f I JP 03fd Address: 179L /a?e.Weli4c Yl. 1*714, OPW6 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. 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. $ y -� Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the j permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an Ad electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses conceming the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ r Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: _Z3 � Inspectors Signature: Date: FINAL INSPECTION: Pass M V Failed Re- Inspection Required ($.) ❑ Inspectors Comm4h). : Inspectors Sig ature: Date: CI DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts - Department ofIndustrial Accidents Office of Investigations quo - 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLyibly Name (Business/Organization/Individual): e( S"► �i L 1.0 C 1,C Address: City/State/Zip: 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. El New construction oyees (full and/or part-time).* have Hired the sub -contractors 7• ❑Remodeling 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. g F1 Building addition [No workers' comp. insurance 5. El We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] i employees. [No workers' 1311Other comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they aie 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 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 requireclunder 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 z 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 certo urtde P1 s and penalties ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple 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 fillgd 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: Tho Gomi4onwealth of Massachusetts Depaftent of J dustrial .Accidents Office of Westigations 600 Washington Stxeet Boston? MA 02111 Tel # 617-727-4900 eyt 406 or. 1-877:MASSAFF Revised 5-26-05 Fay, # 617-7277749 wwvanass,gov/dia N u 0 LL uj 0 w Ln z 0 LL. a- Lry LLI C-4