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HomeMy WebLinkAboutMiscellaneous - 105 MILLPOND 4/30/2018 105 MILLPOND 210/095.A-0105-0000.0 1 1� J Date.Z .'.t.t.�?.................. AORTN o? - °m TOWN OF NORTH ANDOVER * = PERMIT FOR GAS INSTALLATION S3ACNU5�. This certifies that ... . ........................................... has permission forgas installation ......... .......... ht..e�.,�........................ in-the buildings of....--- .rtP. ..................................................................... ................................. North Andover, Mass. Fee..... r.... Lic. No. ...IM GAS INSPECTOR Check# 8.34 4. MASSACHUSETTS UNIFORM AF PLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK � A CITY; lho( ��'(��Ontn�� =7 MA. DATE: PERMIT J# '7 JOBSITE ADDRESS: 16 I r 1 t I' 1 e �ll d OWNER'S NAME: �` '(t Ain 1 1C�cS GOWNER ADDRESS: I d L`�t �I . TEL:97 •V V I M FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL El EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:.❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO APPLIANCES-1 FLOOR Bsmt 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 17 FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER w INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0500NO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY [V' OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee oes not have the insurance coverage required by Chapter 142 of the. Massachusetts General Laws,and that my signature on this p rmit application waives this requirement 1 CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that.all plumbing work and installations performed Ender the permit issued for this application will be in compliance all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME: a r y-, M, LICENSE#1 _5S 9 SIGNATURE COMPANY NAME: ADDRESS:—7.1 STI CITY: STATE: A ZIP:- G tcl 4 FAX TEL$ ���"ZJ �/ 3 CELL: 936. Z/ S 3 EMAIL: MASTER JOURNEYMAN❑ LP INSTALLER❑ CORPORATION PARTNERSHIP❑# LLC[]# k Poo s� 1 ! +"w Department of Industrial Accidents Office of Investigations ' 1 Conga ss Street,Suite 100 Boston,MA 02114-2017 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information I Please Print Legibly Name(Business/Organization/Individual): A C-01 1j-:7 i (Q R a.7'(yui_ Address: 31 S r- I City/State/Zip: l'�4`r O-e_A' 0tAJ Phone#: ���7�9—" 9-2e-- Z 15 3 Are you an employer?Check the appropriate bog: Type of project(required): 1.[E I am a employer with 3 4. Q I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.Q I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, Q Demolition workingfor me in an capacity. employees and have workers' y P t3' 9. ❑Building addition [No workers' comp.insurance comp.insurance.: required] 5. Q We are a corporation and its 10.❑ Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.Q Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.Q Roof repairs insurance required.]t c. 152, §1(4),and we have no r employees. [No workers' 13. Other 1 l✓�p CQ 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide tieir workers'comp.policy number. I am an employer that is providing workers'compensation insurancefor my employees Below is the policy and job site information. #0(1 `ri�Yd- -ins. Insurance Company Name:Policy#or Self Lic.#: 1?1+() O� >6 Expiration Date: 3/d Y / Job Site Address: R00J I City/State/Zip: 1T1 \(,LUU �A4 9 61 NY 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 cert& under the pains and enalties o er that the in ormation provided above is true and correct. Si afore: ._. -- __ _ _.... -- — -Date Phone#: Official use only. Do not write in this area,to be co leted by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: i IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policypes)must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsemsntG:). PRODUCER CONTACT Bernadette M. Davis, CPCU NAME: EA Stevens Company, Inc. PHONE (781)322-2324 FAX 3 89 Main* St., EMAIL A/ No)-(781)397-7672 P. O. Box 188 ADDRESS:bernadetted@east-evensins.com Malden INSURER(S)AFFORING COVERAGE NAIC d MA 02148 INSURED INSURER ASartford Fire Insurance Com an 19682 MAGNIFICO BROTHERS PLUMBING INSURERB.Saf ty IIIc 9454 INSURER Cit Fire HEATING & GAS FITTING LLC 9459 31 FOREST STREET INSURER D MIDDLETON INSURER E MA 01949 INSURERF: COVERAGES CERTIFICATE NUMBERNaster 2014-15 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEDBLOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE P CONDITION PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_ INSR LTR TYPE OF INSURANCE �pEFF MD EXP' GENERAL LIABILITY 1 SR D POLCY NUMBER MDMLIMITS EACH OCCURRENCES 1,000,000 S COMMERCIAL GENERAL LIABILITYDANWGET5WE9TM- A CLAIMS-MADE a]OCCUR SSBAUg5370 /24/2014 !24/2015 PREMISES Ea occurrence S 300,000 MED EXP(Any one person) S 10,000 PERSONAL&ADV INJURY S 1,000,000 GEN 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 R POLICY PRO- PRODUCTS-COMP/OP AGG S 2,000,000 LOC 5 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident S 1,000,000 B AALL NY AUTO OWNEDBODILY INJURY(Per person) S AUTOS Sx AUTOS 053635 053635 /24/2014 /24/2015 BODILY INJURY(Per accident) S $ HIRED AUTOS g AO OSWNED PROPERTY DAMAGE ffi - . --- I Per accident S S X UMBRELLA LIAB OCCUR EXCESS LIAB EACH OCCURRENCE 5 1,000,000 A CLAIMS-MADE AGGREGATE S 1,000,000 DED RETENTIONS 10,00 8SBAUQ5370 /24/2014 /24/2015 C WORKERS COMPENSATION 5 AND EMPLOYERS'LIABILITYVYC STATU- DTH- ANY PROPRIETORIPARTNERIEXECUTIVE Y/N OFFICER/MEMBER EXCLUDED? ❑ N/A E.L.EACH ACCIDENT $ 500,000 (Mandatory in NH) 08MCRJ9050 /24/2014 /24/2015 Ir es,describe under E.L.DISEASE-EA EMPLOYE S yy 500 0 DESCRIPTION OF OPERATIONS 00 ONS below E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required) CERTIFICATE HOLDER CANCELLATION TTHE"I' ULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Hartford Fire Insurance Company ACCORDANCE WITH THE POLICY PROVISIONS. One Hartford Plaza Hartford, CT 06155 AUTHORIZED REPRESENTATIVE Thomas Cares, Jr/ML - ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. Ali rights reserved. IN-R095 oninnst m Tha IIfIntia 1 noun onrl Innes a,n cnicto,aA mor4c�f A!`11Rr1 x COMMONWEAILTH«OE MASSACHUSETTS BOARD OF - `PLUMBERS AND GASFfTTERS ISSUES THE FOLLOWING LICENSE �a REGISTERED AS A PLUMBING CORP t 1 Y MARK MAGN I F I CO MAGN I F I CO BROS PLB&HGT,GAS F I TT f 31 FOREST ST � :N MIDDLETON1 MA 01949-2015 3 2 6.6 b5/01/16 204666 � . COPIAMONWE4LTH OF MASSACH64iTs. c, s BOARD OV"­- PLUMBERS PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE !�' w LICENSED AS A MASTER PLUMBER MARK B MAGN I F I CO 31 FOREST STREET ui ' MI DDLETON MA + 5 - . 13559 0.5/01/16 204667 CO"A."ONWEA!rP ^� !=SSA a k_ CHtJSETTS M BOARD OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE '' LICENSED AS A .JOURNEYMAN PLUMBER F4ARK 8 MAGN I F I COVf La 31 FOREST ST � - I' I:00LETON MA 01949-2015 if •_25002 05 01116 2x4568 x q- _ v a K .tF i t + n. pl T Y,i - 3 x . , a Commonwealth of Massachusetts Official Use only .. k1w IDepartment of Fire ServicesPermit No.Occupancy and Fee Checked 1 j �i7) BOARD OF FIRE PREVENTION REGULATIONS [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 1K �-- - - -""-_rA1JZ TN,L_A OR TYPE ALL INFORMATION) Date: ��,8 24- 216L5- To 16J 5To the Inspector of Wire : c work described below. Date "�! 2� ephone No. d F V"40R m TOWN OF NO Appropriate Box) PE NORTH ANDOVER 10. 3 RMITFO R g WIRING No.of Meters ss�CHUSES ! No.of Meters NIX This certifies' fies that . � � / T 6�/�-C E has pernlission to e ............ �/ /��• P ......... dorm r , ,........ ...................v e �� ^S• 72-GTion/ •' be waived b the Inspector o Wires. �= wiring in the buildin —*—f�g •• ......................:...................... g of.................... �Q ............:....... Total at ........ rs KVA ....................... rs KVA � Fee .� ........................................North o ....�.......Lic.No. /j/�3� /�v al'ss;/ Uer ency Lighting ....... nits �1 Check# ELECTRICAL INSPECTOR { �~ +ALARMS NO.of Zones ' � Vif Detection and 319 initiating Devices A Alerting Devices14 No.of Waste Disposers bf Self-Contained - . action/Alertin Devices No.of Dishwashers Space/Area heatipal ng KW l❑ Connection ❑ other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Eq uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 00.Qty (When required by municipal policy.) 20/jlnspections to be requested in accordance with MEC Rule 10,and upon completion. Work to Start: 2r2!�. 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 covers 's in force,and has exhibited proof of same to the permit issuing office. NCE BON CHECK ONE: INSURAD ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: L&-- LIC.NO.: //232 Licensee: /A,1 Z5Vz!kVS Signature LIC.NO.,E ZS 2 (If applicable, enter�'inthel- sen bene. Nv��� Bus.Tel.No. - 4-n80'57 Address: Alt.Tel.No.: — �' *Per M.G.L c. 1.47,s. 57-61,security wo 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. :� _t y. �/ i. 1 1 COMMONWEAL off OF MSACHItSETTS o 0 0 BOAR© F , ELECTRtLIANS {$SUES THE FOLLOWING LFCENSE AS A< FtEG I STEREOS MASTER ELECT/R IIC I ANS EVAN S. ELEC CORP �AtwE;RS_ MA,01923 1379 11232 A b7131/lb $0183 _.. COMMONWEALTH.OF M/1SSACIU'SETTS - o 0 EL> CTR1 C I"ANS ISSUES THE FOLLOWING LICENSE AS A REG JOURNEYMAN E L E --'1C112 . AN' � JAMS$ S. EVANS � 1 v� fig. t 1 IPSWG}i DIVER RpAt1fcF.F J DANCERS MA 01923 137 2532407I3?�tb 80182 . . The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations y 1 Congress Street,Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):Evans Electric Corp Address:11 Ipswich River Road City/State/Zip:Danvers, MA 01923 Phone#:978-766-8751 Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 3 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition workingfor me in an capacity. employees and have workers' y p �'- .. 9. E] Building addition [No workers' comp.insurance comp.insurance.* required.] 5. ❑ We are a corporation and its 10.❑✓ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no 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. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:The Hartford Policy#or Self-ins.Lic.9:08WECCK6019 Expiration Date:8/31/16 Job Site Address:105 Mill Pond City/State/Zip:N.Andover, MA 01845 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 herebZc4rtify under tJQ pains and a alties o perjuryat the information provided above is true and correct Si ature: 1 Date 2/23/15 Phone#:978-766-87 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#: Date g.. ........... 0* -4 TOWN OF NORTH ANDOVER PERMIT FOR WIRING gB�CHu This certifies that .......... ..............................j... ....... perform less 11�c"has permission to pei , Im .......................QA n . .................................. .... ............................... wiring in the building of.............. Y .................................................................. at .................. North Andover,Mass. ....1.05............................. ....................... 4ee,..............................Lic.No N... ........................ ... .......... cnucAL INspEcroR Check. no 11809 ` Commonwealth of Massachusetts oifieial_useOnly Department of Fire Services Permit No. �I Occupancy and Fee Checked : BOARD OF FIRE PREVENTION REGULATIONS .[Rev. 11o7j (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 ININK OR TYPE ALL INFORMATIOA9 Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his r her intention to perform the electrical work described below. Location(Street&Number) 6,r e lU,p Owner or Tenant CIIAE j EE-3 04 US E2 Telephone No. Owner's Address Is this permit in conj unction with a building permit? Yes ❑ No M (Check Appropriate Box) Purpose of Building C6Alp a Utility Authorization No. Existing Servicep)dU Amps lvIO /07Y6 Volts Overhead ❑ Undgrd n No.of Meters / New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: XU-1AC C ��-�L �� �r�L •�•�S y�yg Completion of thefollowing table may be waived by the Inspector of Wires. / No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No,of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA � No,of Luminaires Swimming Pool Above ❑ In- Elo.o mergency Lighting \ rnd. rnd. Batte Units C1 No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burgers No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. TotalTons No,of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: ""'"""'"" Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other \{� Connection No.of Dryers Heating Appliances KW Security Systems:* !J No.of Devices or Equivalent f No.of Water KW No.of No.of Data Wiring: cJ� Heaters Signs - Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: V-1Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work:1-f©®I (When required by municipal policy.) Work to Start: (F"O�o)' & 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 Ky the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The �( undersigned certifies that such c verage is . force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under thegins and penalties of perjury,that the infnrhZation on this application is true and complete. FIItM NAME. . +�ri5 C®U-/C,6 LIC.NO. 5�6 Licensee. y9 d-t3 ��p(/Ypy�a, siN Sign �`��,IC.NO.: (If applicable,ent r "expqpPin the lice pnum4eirlimiBus.Tel.No.•� l7 5Gd V5aIO� Address: (Ali- D1J rL7-' ®� 6 Alt.Tel.No.: *Per M.G.L 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, fine 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 0 Failed❑' Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass R Failed❑' Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: i ROUGH INSPECTION: Pass 0 Failed❑' Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass(] V Failed Re-Inspection Required($.) ❑ Inspectors Com nts: InspectorSignature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com 4 ,1 The Commonwealth ofMassachuse Its - 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/OrganizatiorAndividual):\,—j,417 E5 Address: 65 Z— ,—,C R© If City/State/Zip: l p-4 O.�evG i J 0 Phone#: ��� ! © �`�"1a 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 ployees(full and/or part-time).* have hired the sub-contractors 5-194--am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling 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 required.] officers have exercised their 1 T11.Jectrical repairs or additions i3.❑ 1 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 12.0.Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 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 anew 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: „#&ttach 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 Vof 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. Ido hereby cert jq ur s d pe ties ofperjury that the information provided above is true and correct. - Phone#: x y 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#: �d Information and. Instrnctions'," y. 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-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 G 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: P P The Cox onwealth of Massachusetts Department ofladustrial Accidents Office of Investigatitons 600 Washington Street Boston,MA.02111 Tel.#617-727-4900 ext 406 or 1-8777MASSAFE Revised 5-26-os Faze#61.7-727-7749 wwwanass.govaa r COMMONWEALTH OF MASSACHUSETTS ",• B 0 0 0 0 BOARD OF ELECTRICIANS I I SSUE.S.THE FOLLOWING L'ICEN'SE AS-,:A RSG ''JOURNEYMAN ;>ELECTRICfAN '�' jJAMES S KOUYOUMJIAN = ,1 65 LowE - RD ..I NORTH READING MA 01564 t 635' � 51-61 E �07/3v1/16- 27440...-� e f Date. gip/ Nq 42u5 NORTH 3:0f,,�- hoaL TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMUS� This certifies that . . . . . . . . . . . . . . . has permission to perform . .!�� . . . . . .r . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . ? . . . . . . . . . . . . . . . . . . . . at 5. . �??t.!.l. �'��:. . . . . . . . . .`— , North Andover, Mass. . . . . . . . . . . . . . : G. uMBING INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer A - MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) t f'.,-. NO.ANDOVER ,MA Mass. Date�� - t9 Permit9 a Building LocatlonZai�MILLPOND Owner's Name NO.ANDOVER, MA Type of Occupancy RES New ® Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑ (L N W N Y Q vi V) h U to x Q1 R 0 N r F., W W ¢ O U m H In N Uj 2 J C F- !< 2 L .O F- w -K0 W < tt O_ O — F- s ur < = y 0 > W of ¢ w z v W W ►- x W ... i J > U. H V F- M J F' F W O W to -KW _ ., C F- C 1 m< O O W a' 0 F- w > t w -< 0 �1 .' 0 c7 _ W a 3 o d J U ¢ > a a F' 0 SUB—aS1.MT, BASEMENT ISTFLOOR 2ND FLOOR I ' I I . I i ORO FLOOR I_ I I A" 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name CALLAHAN AIR CONDITIONING Check one: Certfflcate u Address 91 B . ,MONT STRFFT ❑ Corporation NO.ANDOVER,MA. 01845 ❑ Partnership Business Telephone 508-689-9233 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter JOSEPH KEVIN CALLAHAN INSURANCE COVERAGE: I have a current Ilablltty Insurance policy or fts substantial equivalent which meets the requirements of MGL Ch. 142 Yes RI No O If you have checked Yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy f] Other type of Indemnity O Bond D 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: Owner-0 Agent ❑ Signature of Owner or Owner's Agent � I hereby cartify that all of the delals and information I have submitted (or entered) In ove appticallon are true and accurate to the best of my knorviadge and that all plumbing work and InsiallaUcns performed under the permit sued for this applrcatl will b In pllnnce with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the neralWLLUaw BY Type of Ucense: app= 1'77 gnatur o c nse um a or Gas Fitter Title ttosler Ucense Number M-3440 City/Town ourneyman M('flc7vf-.fST�i� p . 1 ""orw0 .b�evt^r,ia�+�+rm,.z-.,�.,, • r /-/ 2 Date ? �.t ... NORTH TOWN OF NORTH-ANDOVER ,n141 O PERMIT FOR GAS INSTALLATION 9 i i t i .� ♦ H �9SSACHUSEtAy 41J This certifies that . . c • . }'j c. • • • . • . has permission for gas installation . . �' < iz.� . . . in the buildings of . . //!I. . . . • . at . . . . . . . . . . . . . . . . . . . North Andover, Maw. CU Fee. .?-:>. .'. . Lic. No..3 Y.Y . . . GAS INSPECTOR `cis WHITE:Applicant CANARY:Building Dept. PINK:Treasurer GOLD:File MASSACHUSETTS UNIFORM APPLICATION FOR PER TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS �r _ gjowners /, 1Date Building Location p Q� / Name/Pr` i0l'/�' V �' Date #_ - 42 OC) Amount o2 ; Type of Occupancy New ® Renovation ® Replacement � U Plans Submitted Yes No FIXTU M Lncnw zLn d z w F a a a a d F d d mill SLRES C M FUltlt 2M ROM 3M FIOQt 4M I11M 5M HDM 6M FIOCR Mi FTmt gm H OCR (Print or type) Check one: Certificate Installing Company Name ° /^� !�'I �C��/L�{� Corp. Address d Partner. Business Telephone �Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 0/ Other type of indemnity 11 Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature 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' llations performed under it Issued for this application will be in compliance with all pertinent provisions of the Ma., State lu g Code d Chapter 1AZjgtjhe General Laws. By: o kens um e Type of Plumbing License Title City/Town icense Numoer Master Journeyman APPROVED(OFFICE USE ONLY