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HomeMy WebLinkAboutMiscellaneous - 103 MILLPOND 4/30/2018N I -+ O D w b � � P z o � 0 /� 94UL Date .... 5^ r� -.. leg TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................. ..................................... has permission to perform .......... .............................................................. wiring in the building of .. Y 3 n L � A �A,,..Northj Andover, Mass. at ......................................................... .....................� .......................................... ' �a �k, g Fee ................ . Lic. No. Ll a l z .............. ELECTRICAL INSPECTQR� Check # 7 ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the 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 u 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 requiredin 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_ofWires abandoned -and -inv.alidif 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 puipose by establishing an automatic four-year extension to certain permits and licenses concerning 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. 4f �' ule - Permit/Date Closed: Z - *** Note: Reapply for new permit ❑ Permit Extension Act - Permit/Date Closed: t aUePartmenl o� ire �ervicea WAaw BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. J��2, Occupancy and Fee Checked [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: S — / 3— 10 City or Town of: A A n Ao co c, e— 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 !Yl , (1 Pon a R o a J Owner or Tenant L)e hn S v) l k V a n Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of BuildingA)pu/ 60 , 00/- 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: W rQ I �jf i G i A j` �-r,04 h GO 4 lot' lAoi� W a +e,— 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 A oveIn- Swimming Pool rnd. ❑ r- d. ❑ o. o Emergency Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burnerso. 1 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 I Tons KW ......... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Mupal El 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 Eg uivalent OTHER: Attach additional detoil ifdesired or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [4 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete'. FIRM NAME: DM I D E LECT RI CAL COI-trPAeTINU LLC- LIC. NO.: I 1 (03)q Licensee: D AQ 1 D 14A 6 4 t4 iq Signature LIC. NO.: (I. f applicable, enter "exempt " in the license number line.) Bus. Tel. No. : `1 Address: R 7 F3Et- M DuT -5-r. No RrN /}NDo\I E� BSI S Alt. Tel. No.: `? ? S-3-7 S 57 3,1 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's aent. Own nt PERMIT FEE: $ Signaturetura Telephone No. This certifies that ......�j.Ij has permission to perform . f./.jy� .................. wiring in the building of .�✓. ...................... at .. j.�j. .//1 !� �_.��( ............ , North Andover, Mass. Fee . �. —49Z.. Lic. No.., ' ELECTRICAL IN� EC,T�OR C'veck � 11248 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the f 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. 01 c. 166, § 32, an 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 ofongoing corlstmction 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 precitding 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 puipose by establishing an automatic four-year extension to certain permits and licenses concerning 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. ule 8 — Permit/Date Closed: 2 % % *** Note: Reapply for new permit 0 Permit Extension Act — Permit/Date Closed: Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. I �- Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASE PRINTW)NK OR TYPEALL INFORMATION) Date: i/ Z? 6 /-20 a 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) /O 3 Hi i /t PGI Owner or Tenant ka e n A. /e 0 Telephone No. Owner's Address /0 3 H; l/ Is this permit in conjunction with a building permit? Ys Purpose of Building %%y, It i q Volts Overhead ❑ Overhead ❑ Existing Service Amps New Service Amps Number of Feeders and Ampacity No ❑ (Check Appropriate ]Box) Utility Authorization No. Volts Undgrd ❑ Undgrd ❑ No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: /t(,c S -{t f� Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires t-� No. of Ceil: Susp. (Paddle) Fans / No, of Total Transformers KVA No. of Luminaire Outlets U No. of Hot Tubs Generators KVA No. of Luminaires 0 Swimming Pool Above ❑In- Elo. rnd. rnd. o mergency Lighting Battery Units No. of Receptacle Outlets I No. of Oil Burners / FIRE ALARMS No. of Zones / No. of Switches 4-1 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 1--- ­­ * KW — ­ ** No. of Self -Contained Detection/Alerting Devices � No. of Dishwashers S ace/Area Heating KW rf p g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW d� Securitio o DeviIc : or Equivalent No. of Water KW Heaters No. of No. of Signs - Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs I No. of Motors Total HP / Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as regaaired by the Inspector of 97res. Estimated Value of lectri al Work: d, / 2 O o (When required by municipal policy.) Work to Start: 2C d0Q Inspections to be requested in accordance with NEC Rule 10, and upon completion. INSURANCE C VE GE: 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 [0 BOND ❑ OTHER ❑ (Specify:) I certify, under thepains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: �r� ,,,�i d. M 4 LIC. NO.: e s% (y 71 Licensee: '-U0L v:a( A N(,c 4flL!;tL ,/ Signature 1/ 4-, LIC. NO.: (If applicable, enter "exempt" in the licen a atm er line.) L_ Bus. Tel. No.. %�9 ,rs )� DS3 Address: �' 9Z�t--5J. Y�� a VFX O 506 0 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. � OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the 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 / 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 concerning 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 ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: - Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH SPECTION: s Failed ' Re- Inspection Required ($.) ❑ Inspectors Comments: 12 Inspectors Signature: Date: - 7 - FINAL INSPECTION: FINAL Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: ' Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com im The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 , www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information nn Please Print Legibly Name (Business/Organization/Individual): ay : d l+ • �( �� 1,"S 7'e Address: 3c" /� c CSL , 5 � _ City/State/Zip: A-) 4 Phone #: 776 -8S-)— `t! `r± s 3 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. 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 rrequired] 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. El 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. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Dontractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site tformation. isurance Company Name: olicy # or Self -ins. Lic. #: Expiration :)b Site Address: City/State/Zip: .ttacit a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). aihi�q to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne upj o $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. zone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # 111261201 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 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 �1 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 .evised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia N° 9670 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . V.'.' ®� ` S. v ` has permission to perform .. cc�� .-:� .. .... . plumbing in the buildings of .. tin�.�t. ....................... at ....1 P .-3t. . -�Y\I t1..1 ? ........ . , North Andover, Mass. Fee .q ltj). O.. Lic. No.. 1-; Z,3-1 ........ '.C. A PLUMBING INSPECTOR Check # \ OR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY �Q MA DATE // kS . ! PERMIT # JOBSITE ADDRESS (' OWNER'S NAME /) POWNER ADDRESS :TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY ,-�/ NEW: © RENOVATION: VI REPLACEMENT: ® PLANS SUBMITTED: YES M NOQ 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/OIL/SAND SYSTEM( DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I _._._.__..( ___..._.._f 4 ._..__J f _f( ! __.._1 ._..___._( _ __... (J — I DISHWASHER _( _...__.� ..__.._! __._. i ! I # ! --ji _.! DRINKING FOUNTAIN...._...._! ._-._-__1 FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET _ _I _____I __j URINAL WASHING MACHINE CONNECTION 3 ! ..._..7 _. _-J ______! _._1 _...._.- i .-._-, i ---I 1 r— . _,- WATER HEATER ALL TYPES WATER PIPING _ _i _- I _ f _ # ? _I _. .__� � _. ( _ _ _} .! I E OTHER INSURANCE COVERAGE: I have a current liability insurance its MGL Ch. 'NO Q policy or substantial equivalent which meets the requirements of 142. YES 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Q BOND Q 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 J® 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBE 'S NAME LICENSE # I SIGNATURE MP _ f JP [-jl CORPORATION F]# _ _ PARTNERSHIP _I # ._+I LLC € _j COMPANY NAME �,J�p,�q� ADDRESS CITY.�P,i'�/tij STATE 4 ZIP �3 i I TEL - D - _ p -- - _ FAX CELL �EMAIL _ _.Ct,. o r -1z W a w W LL i The Commonwealth of Massachusetts Department of Industrial 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: 15 City/State/Zip: �J H Phone #: 1 q r' Fio L4— 330-3 Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. $ 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.] i 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 I Q?J 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. 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:_ I o3 Im i I[!Pc�%210( City/State/Zip: Klj Dr4 {t 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/ ear imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a against t violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations the DIA fo ' rance coverage verification. f do heroy certify u rdie pains that the information provided above is rite and correct. rlara• // r.5 7 L►— Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other 11 Contact Person: Phone #: 11 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. Anew 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 o Date . ate. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .................... has permission to perform .... plumbing in the buildings of ................. at... 42. oxr . ......... North Andover, Mass. Fee.pj-.... Lic. No.24;.I/.� . ........ b -MB-1-ING INSPECTOR Check# 72 (to 859.9 46 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING ('Type or print) NORTH ANDOVER, MASSACHUSETTS Building Owner Date Permit # Amount �2 New ❑ Renovation ❑ Replacement ®/ Plans Submitted Yes ❑ Ti`YV11FTF*1Mo No 11 (Print or type) Check o e: Certificate Installing Company Name_ �� [ Address—/a 64. � � I T V c � �,, I,/r�L. M.4 n i AL1// r—� Name of Licensed Plumber: t1—'r 4 / ( 0&41" Insurance Coverage• Indicate the type of msurance coverage by ❑— ch the —appropriate box:Liabili insurance policy Other type of indemnity o. Bond ❑ Insurance Waiver: L the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ ❑ Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations perfonmec�mder Pepo Issued for this a Iication will be in compliance with all pertinent provisions of the Massachusetts Sta bing Code of the General Laws. [APPROVED . rgnanrre o rcens e Type of PI License y/Town 3 icense umoer�'�"— Master ❑ Journeyman (OFFICE USE ONLY The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 T1'aslsington Street Boston, MA 02111 www.rnassgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers p Aplicant Information Please Print Legibi Name (Business/Organization/Individual): �� /,✓� t 1� Address: City/State/Zip: x�et /,,e. OQ VPhone #: S ) r �-oq-310 ; Are you an employer? Check the appropriate boa: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I e=loyees (full and/or part-time).* have hired the sub -contractors 2. 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.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption MGL myself. [No workers' comp. per C. 152, § 1(4), and we have no insurance required.] t employees. [No workers` COMP. insurance required.] - ��..............—......,.,.. -. — =W ILLI UUL me SC 032 thiol, c Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0EI trical repairs or additions 11 Q1 lumbing repairs or additions 12.0 Roof repairs 13.❑ Other Wb �� wo �:.„�' co::.r..::sat on poiic;' o bon T uomeo;; ne s who submit this affidavit indicting They are doing aJJ 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. poiicy information. lam an employer that isproviding 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: 10 7 /'�) , 1� %] U rte/ t City/State/Zi 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. t do hereby certify under ins hnd p 1iAties of perjury that the information provided above is true and correct 2,K FST J A) 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Xa Contact Person: Phone #: e� 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 ofhire, 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 rcturned to the c6ity or town that the application for the permit or license is being requested, not the Depwrof Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid. affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of industrial Accidents Office of Investivat ons ft 600 Washington Street Boston, MA 02111 Tel. # 617-72.7-4900 ext 406 or 1-8.77-MASSAFE Fax # 617-727-7749 Revised 5-26-05 vcru*vt7.masso dia _C w Date..?. f1.�........ o? TOWN OF NORTH ANDOVER � L • PERMIT FOR GAS INSTALLATION i SACMUSEt _ This certifies that ef11319 ................... . has permission for gas installation .. } f-3 ................... in the buildings of ... ........................ . at North Andover, Mass, Fee. 30. Lic. No.,?�J/6... � �J�.......... GAS INS�T A Check # ?I y<i 7209 I MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations �'Q 1-2?., /��j✓1 /2 �iil.U I'LJrw ^ Owner's Name New ❑ Renovation ❑ Replacement Datej /%�/�(,, Plans Submitted ❑ Permit # Z Amount $ '3 G (Print or type) /� Name / 3 Name of Licensed Plumber or Gas Fitter _ z7a4✓f 194 yL 1 Check one: Certificate Installing Company Corp. Partner. [J-Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or ' ' Ulistantial equivalent. Yes No If you have checked ,yes, please' ' e the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond13 Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent — —.Y —.Y ��.u.y uiaL all U1 iuc uaaub aau miormauon i nave suorninea (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Pe Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas ankha142 o -6F - Like Laws. I APPROVED (OFFICE USE ONLY) Sign ure of Licensed Plumber Or Gas Fitter umber :Z6 31S Gas Fitter 771cense Number Master r-'Ld6urneyman vs a rn � p F is C' y W p U GCW7 w 6 x W hdd�. A O a j d F Z ¢ x w a C c] w V x d w > w z a < O O W B o ° > � F o SUB-BASEM ENT BASEM ENT 1ST. FLO O R 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8.TH. FLOOR (Print or type) /� Name / 3 Name of Licensed Plumber or Gas Fitter _ z7a4✓f 194 yL 1 Check one: Certificate Installing Company Corp. Partner. [J-Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or ' ' Ulistantial equivalent. Yes No If you have checked ,yes, please' ' e the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond13 Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent — —.Y —.Y ��.u.y uiaL all U1 iuc uaaub aau miormauon i nave suorninea (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Pe Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas ankha142 o -6F - Like Laws. I APPROVED (OFFICE USE ONLY) Sign ure of Licensed Plumber Or Gas Fitter umber :Z6 31S Gas Fitter 771cense Number Master r-'Ld6urneyman `� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AL4 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): P a—Address:/�(,t% lid, �t L/ 6 ,i City/State/Zip: 7� � �Yy� Q f X qO phone #: � fid -- 66�0 tl- � /U �?_ Are you an employer? Check the appropriate box.- ox:am ama employer with 4. 111 am a general contractor and I em ees (full and/or part-time).* have hired the sub -contractors 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.] 3. ❑ I am a homeowner doing all work officers have exercised their 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. ❑ El al repairs or additions 11. lambing repairs or additions 12.0 Roof repairs 13. ❑ Other .. -. r-�_ �W :. u ••-: L,V "m UU11L me seu-noc: aeicw sdov m— +c=r •,, g; 'compensation policy nfo titian. T Homeowners who submit this affidavit indicating they are doing all wort: 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 certify under a pains and "'al 'es of perjuormation provided above is true an/�d'�correct Signature: `/ } Date.: Phone #: 4 .7 e 61 % U 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 Instr t Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee s; defined as "...every pe=rson 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 coxnpliance 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 pemrrmit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regardim><g the law or if you are required to .obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permittlicense applications in any given year,. need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. . The Office of Investigations would Ince 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 # 617-77-77-7749 urvrw.mass-gov/d a Date.. . /. ........ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Io S9S SArm S This certifies that ..................... has permission for gas installation .. ........ I/ in the buildings of .5-,. .............................. at North Andover, Mass. Fee.. 3.° :7-.. Lic. NO.-/./* ....... �AS INSPECT66 Check #: 7015 MASSACHUSETTS UNIFORM APPUCATON FOR PU;MW TO DO GASG (Type or print) Date 476 O NORTH ANDOVER; MASSACHUSETTS Building Locations kph , , f -'D6 , uy%C.11 Owner's Name New EI Renovation Replacement El Plans Submitted Permit # 7el .) Amount $ 3 p (Print or type)Q' ^ Check one: Certificate Installing Company Name Ey L l � �.[� 1 n Corp. 1-1 Partner. irm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No If you have checked Yes, please in ate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 1:1 Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent I nereoy certity that all of the details and intormation I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed undeypermit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Stat G!> Ve a� -1-2-61`t1-ie General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Plumber Gas Fitter ®—Uas er Journeyman sed Plumber Or Gas itter icenLise Number 9 U F z z c F w Il w d w c 0 ;Do z H w wa w x w w H �, a x d x x x a wU x LL z W U 0 >z "0 1z- U W= 3 A x o 0 10 14 U a> a F o SUB-BASEM ENT B A S E M ENT IST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6 T H. F L O O R 7TH. FLOOR 8TH. FLOOR (Print or type)Q' ^ Check one: Certificate Installing Company Name Ey L l � �.[� 1 n Corp. 1-1 Partner. irm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No If you have checked Yes, please in ate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 1:1 Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent I nereoy certity that all of the details and intormation I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed undeypermit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Stat G!> Ve a� -1-2-61`t1-ie General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Plumber Gas Fitter ®—Uas er Journeyman sed Plumber Or Gas itter icenLise Number " The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AL4-02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: Dc, City/State/Zip: (- a3�Phone #: G'3 Are you an employer? Check the appropriate box: 1. ❑ I am a - mployer with 4. E3 am a general contractor and I e oyees (full and/or part-time).* have hired the sub -contractors 2. am a sole proprietor or partner- listed on the attached sheet. $ ship and have no employees These sub -contractors have working for in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §.1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I I.Cg-PI"umbmg repairs or additions 12.❑ Roof repairs 13.❑ Other .:,y appiicMIL ;a. caecrs Dci: a; : -,;st also :ui 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 ceE,4& under the information provided abovet^s 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 toprovide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the _ receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartrnents and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability .Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial 40 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 permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in— (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealtrh. of Massachusetts Department of Industrial Accidents office of Investiptiions 600 Washington. Street Baston, MA 0.2111. Tel. # 617-7274900 ext 406 or 1-877-M-ASSAFE Fax # 617-72.7-7749 Revised 5-26-05.mass.gov/dia ,1r.....: , 77777 t. M1+Y..: '�Y`".1m..r�{� '�.�•'. , _ moi, ..� It , �tilu' �1 .v ... ,,. ..: „•.. :..r..,,' ...�n; � Wit,• �:;: `' • ` , •'• :: ; :+:. •; 03/1/2009 ' : k03f1.1%202Eti w y. , ,' .L'C1�103t119b R :.. { r r-• v • JPP' �.�' r, ti , sSL62 ' . - ..oa/2i/20o9 98/21/20lo pu* ADDITIONAL INSURED; TOWN OF No. ANDOV R, MA,•,,; . , "' ;;;;;;;;,;,;,' ;...,.:. ' . TOWN -OV -No. ANDOVER ". • :.. • :: `':::..;.:; :�. w :..., , No ANDOVER, -MA MO .. ., - •. ", ` MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO OO GASFITTIH. G (Print or Type) l NORTH ANDOVER Mass. Date `i kuilding Location �'�� Permit ti •� Owners Name .f New Renovation Replacement El Plans Submitted FIXTURES (Print or Type) Installing Company Na lj Address - - Check one: Certificate Q Corp. Partner. Firm/Co. Business Telephone: S"� y 6 ax- 2` f Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of insurance coverage by checking appropriate box: Liability insurance policy [�Rrj Other type of Insurance Waiver: I, the undersigned, have this application does not have any one of the Signature of owner/agent of property indemnity Q Bond E] been made aware that the licensee of above three insurance coverages. Owner 0 Agent 0 I 1 hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that at! plumbing work and Installations performed under" Permit iuced for this application will -be in compliance •ith all peatinent provisions of the Massachusetts State Cas Mode and Chapter 142 of the General Laws. By TYPE LICENSE: Plumber Title Gasfitter Signature Lice ed City/Town: Master Plum o G fitter Journeyman APPROVED (oFr=lc>_ vse ONLY)License Number i (Print or Type) Installing Company Na lj Address - - Check one: Certificate Q Corp. Partner. Firm/Co. Business Telephone: S"� y 6 ax- 2` f Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of insurance coverage by checking appropriate box: Liability insurance policy [�Rrj Other type of Insurance Waiver: I, the undersigned, have this application does not have any one of the Signature of owner/agent of property indemnity Q Bond E] been made aware that the licensee of above three insurance coverages. Owner 0 Agent 0 I 1 hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that at! plumbing work and Installations performed under" Permit iuced for this application will -be in compliance •ith all peatinent provisions of the Massachusetts State Cas Mode and Chapter 142 of the General Laws. By TYPE LICENSE: Plumber Title Gasfitter Signature Lice ed City/Town: Master Plum o G fitter Journeyman APPROVED (oFr=lc>_ vse ONLY)License Number ' � a2385 Date . /-/%- :... . HORTM 'TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION x, . ; a �9SSACMUSESAy a: This certifies that C. ................. . has permission for gas installation .t........ ,wee 0 in the buildings of .... s? !? S............................ at . J. 0-7.. ... ort ndover, 1VIaj. Fee...... Lic. No..//. . ✓Wj/�!� ..n . • G. INSPECTOR .-. WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File A J 1)I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) t NORTH ANDOVER Mass. Date Ak lhuilding Location'/�,� ��/� .�+,�� Permit # .11310FV Owners Name,�� • :F New '-t,;K Renovation Replacement Plans Submitted FIXTURES ;i'rint o'' -r..--) Installin Address Business Name of Check one: Cerlif;:cate Grp• Partner. iu , ..;'/Co. Telephone: Licensed Plumber or Gas FitterLl�jjs7 Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy [Other type of indemnity Q Bond lnsuruce Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner F] Agent F1 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations petfomted under' Permit izseed for this application will -be -in compliants with all Patlnent provisions of the Massachusetts State Cas Code and Chapter 142 of the Central Laws. By Title City/Town: APPROVED (OFFICE USE ONLY) TYPE LICENSE: Vt,4.. umber sfitter S Sgnature of Licensed ster Pl�ei or���itter urneyman License Number z � to to a_ v _ . ttt Ul � � cc � m x N o tat < +r a o a o z ua . a CrL m m r w m o a o I cc ut y t- LU ul o w z a z a "' w '� Q Ir - o t- x z a w e z a a -• r yt". rn o at z o z w o (Ai Q to> C kt 2 6 a 4 Q O O w O W E- CC x O u. a O -A U tL > Q C6 Sua-13SWIT. BASEMENT IST FLOOR 2ND FL.0OR 3,1113 FLOOR 4THFLOOR 51711-1 FLOOR + 6TH FLOOR TTI{ FLOOR 8TH FLOOR ;i'rint o'' -r..--) Installin Address Business Name of Check one: Cerlif;:cate Grp• Partner. iu , ..;'/Co. Telephone: Licensed Plumber or Gas FitterLl�jjs7 Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy [Other type of indemnity Q Bond lnsuruce Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner F] Agent F1 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations petfomted under' Permit izseed for this application will -be -in compliants with all Patlnent provisions of the Massachusetts State Cas Code and Chapter 142 of the Central Laws. By Title City/Town: APPROVED (OFFICE USE ONLY) TYPE LICENSE: Vt,4.. umber sfitter S Sgnature of Licensed ster Pl�ei or���itter urneyman License Number --►© 2380 • �.-,r..., �..._ .--._._...:..-..rte-- - �,a3:,,: Date f . .......... ,apeTH TOWN OF NORTH ANDOVER PERMIT FOR GASINSTALLATION • � p gs9SSAC MU`�ES [tl This certifies that . ms%? y. ... .......... . has permission for gas installation ...% .' f/.' ... .... ...... . in the buildings of .... v�?. ......................... at ..,� . �''. { . f. { �G ........... North Andover, Mag -- Fee. �-?...:. Lic. No -7.1.r � u... ........................ . GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD:.File i��l•.cl�� a Vo 4C (jOW 0WC&lt# of AgZgUC4Ugrttg r) V ,,/Sqfety Orrice Use Only Y ��FPermit No. 4/ BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy 6 Fee Checked mw (Icave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be parkwmW in accordance with the Massachusetts Electrical Code, S27 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL /INNFORMATION)&2juE-K Date City or Town of r �h To the Inspector of Wires> The undersigned applies for a permit to dw electrical work describeo below. Location (Street 6 Number) i / ma Owner or -Tenant Owner's Address Is this permit in conjunction with �a, bui permit Yes No : (Check Appropriate Box) Purpose of Building ISL -��-� Utility Authorisation No. Existing ServkeQ�_1 l lMps-QSJ.C:JL2 r Volts Overhead ❑ Undgrd No. of Mete New Service A r / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Laxation and Nature of Proposed Electrical Work I r r� ! �r! T�l OTHER: DEC j b" IQ9F INSURANCE COVERAGE: Pursuant to the mquinnterft of Masswhusm General Laws " I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES n NO m 1 have submitied valid proof of same to this office. YES U NO LJ it you have checked ES, please indicate the type of eworap by checking the appropriate box. INSURANCE LJ BOND ❑ OTHER❑ ('lens Specify) (Expiration Date) Estimated Value of Electrical Work $ Work to Start Sianed under the wnaltim of oeriurvr FIRM License lddres IRipection Date Requested: Rough Final LIC. NO. 3 LIC. NO. No.L013 Alt. Tel. No. DWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substanlidl equivalent as required by Massachusetts general Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephorhe No. _PERMIT FEE f (Signature of Owner or Ap W TOTAL No. of l ighting Outlets No. of Hot Tubs No. of Transformers KVA AboveIn- No , of Lighting Fixtures Swimming Pool grrid. Q grnd. 1:1Generators KVA No. of Emergency Lighting No. of Rece acle Outlets No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Ota No. of Ranges No. of Air Conditioners Tons Initiating Devices of Sounding Devices Heat Total TotalNo, No. of Dis )sats No. of Pumps Tons KW No. of Sell Contained DetectrorJSoDevices No. of Dishwashers KW SpacelArea HeatingMunici Municipal Local❑• Connection ❑Other No. of Dryers Heating Devices KW 1140.01 o. ow Voltage No. of Water Heaters KW Signs Ballasts Wiring�. .. _ . No. Hydro Massae Tubs No. of Motors Total HP OTHER: DEC j b" IQ9F INSURANCE COVERAGE: Pursuant to the mquinnterft of Masswhusm General Laws " I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES n NO m 1 have submitied valid proof of same to this office. YES U NO LJ it you have checked ES, please indicate the type of eworap by checking the appropriate box. INSURANCE LJ BOND ❑ OTHER❑ ('lens Specify) (Expiration Date) Estimated Value of Electrical Work $ Work to Start Sianed under the wnaltim of oeriurvr FIRM License lddres IRipection Date Requested: Rough Final LIC. NO. 3 LIC. NO. No.L013 Alt. Tel. No. DWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substanlidl equivalent as required by Massachusetts general Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephorhe No. _PERMIT FEE f (Signature of Owner or Ap W