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Miscellaneous - 1060 OSGOOD STREET 4/30/2018 (3)
isuiLDING Date,-?/./Z.,/*. .. ........ NOItTM TOWN OF NORTH ANDOVER O � A • PERMIT FOR GAS INSTALLATION SACH This certifies that has permission for gas installation . . �! ?.�. . U?.`I. . . . . . . . . in the buildings of . . . 4J °r!. . . //0!7 rc�i . . . . . . . . . . . . . at . ./a.�o Ot aac. . 57 , North.,Andover, Mass. Fee.��:o?. Lic. No..�b-SAL . . . .. F GASINSPECTOR Check# 13518 t 8093 r ' • MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town:. 4 , MA. Date: ' Ica — Z-01Z, Permit# Building Location: L to Owners Name: J G M rr Il)t CIA L Type of Occupancy: Commercial, Educational❑ Industrial ❑ Institutional❑ Residential❑ New: ❑ Alteration- Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES Lu 5 Z w Y F- m W= W ° (0 ow mo w F- c9 -1 o w W oZ zOW L wrYOF- n o Lu 0 w g m o O > co v Z to c� ~ w (� O Q W = LL W z = I- Z W W Z O J fw- h O z J (w7 LL = W H W W C) f] I=L (9 C7 = = m > O Lu 0 Z O W Z Z W a I-- (J O a 0 F- > > > O SUB BSMT. BASEMENT 151FLOOR 2 N u FLOOR 3 FLOOR 4Tm FLOOR WH FLOOR Uff FLOOR ' 7m FLOOR >3 FLOOR �"' Check One Only Certificate# Installing Company Name: 7 I (11 /f �. Corporation Address. 6 1- 1V- L City/Town: N, t' c+' State:b��1 c�, El Partnership Business Tel:`l /�"'(. "-(IB 6 Fax:?7�"—0?-(-3od Firm/Company Name of I_.icensed Plumber/Gas Fit ef���, �j t 14 '01 [IfNSURANCE COVERAGE: ave acurrent Iiability insurancepolicy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes❑ No❑you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner EJ Agent El By checking this box❑,-I hereby certify that all of the details information I haveMr. d)regarding s a • tion are true and accurate to the best of my Knowledge and that all plumbing ork and installations peermit iss for s plication will be In compliance with all Pertinent provision of the Massachusett State Plumbing Code ne LawTy of License: FAPPROVECD Plumber 71y, ❑Gas Fitter ignature of Li /Gas Fitter aster ❑Journeyman License Nu er: /. 6-701 ❑LP Installer 4 ' a The Commonwealth ofMassachusetts Depar*nent of industrial Accidents Office ofInvestigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leg=ibly • ' Name(Business/Organization/Individual): j ( Ns t 4-- Address: City/State/ZiP: , . .�- A Phone#: r2. you an employer?Check the appropriate boa: I am a employer with4. ❑ I am a general contractor and Ir7. E] f project(required):employees(full and/or part-time).*' have hired the sub-contractorsNew construction I am a sole proprietor or partner- listed on the attached sheet. Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. [No workers comp.insurance 5. 9. ❑Building addition p ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.El.I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp, c. 152,§1(4),and we have no insurance required.]t 12•❑Roof repairs q ] employees. [No workers' COMP.insurance required.] 13.❑Other *Ary applicant that checkss box ul must also fill out the section below, sho in.—ile T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submita eco 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 information. employees Below is the policy and job site Insurance Company Name: /'�-e re Policy#or Self-ins.Lie.#: ,� / Expiration Date: H Job Site Address: -t I por r-- �J 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 imprisonmen, well as civil penalties in the form of a STOP WORK ORDER and a fine of up 0.0 a against the 'olator. Be v' ed that a copy of this statement may be forwarded to the Office of Inv ligations of the D for ins ce cover e v rification Ido here b rtify and n Pena operjurer that the information provided above is true and correct: Sitanatur • • Date: ( 2_ Phone#: — 34— 1 QP Official use only. Do not write in this area, to be completed by city or town official City or Town: PermitlLicense# Issuing Authority(circle one): L 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 6r 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 6r building appurtenant thereto shall not because of such employment be deemed to bean employer." MGL chapter 152,'§25C(6)also states that"every state or Iocal 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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,.are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required Be-advised that this affidavit maybe submitted.to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date-the affidavit. The affidavit should be�r.`tamefto the,City or tOCari:tera,the ayp1.sCauy?fv:the pern�5t'or 1',^.e,_�5e is bemn 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 pemrit/lice'nse 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 f6r 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. #617-72.74900 ext 406 or 1-8.77 MASSA.l{E Revised 5-26-OS Fax#6.17-727-7749 wwm,.mass..gov/dia •• (a�` n = O '� COMMONWEALTH OF MASSACHUSETTS rolilriw• r _ . •. SHEET METAL WORKERS AS A JOU RNEYP ERSON-UNRESTRICTED T S ISSUES THE ABOVE LICENSE TO: " r� s. MARTIN A FLINT Q)- 100 MACY ST c, 3 SUITE 169 d C AMESBURY MA 01913-4315 12426 06/28/12 19441 9LICENSE NO. • DATE SERIAL NO. r. i c: f. o X t. G 7:3 -v DIRECT DRIVE CENTRIFUGAL UPBLAST - DU SERIES ROOF OR WALL APPLICATIONS FEATURES .I VARIABLE SPEED CONTROL STANDARD WALL OR ROOF MOUNTING * QUICK LATCH COVER I dv) " EXTERNAL WIRED DISCONNECT SWITCH 1 I V f t • LEAK PROOF DRAIN UL-762 COMPLIANCE(EXCEPT DU-10H) C �� � h-c fes, 7=u MAX C SP WT 1PH AM CURB 12"H DAMPER DELUX MODELS HP RPM 1/8" 3/8" all 5/8" 3/4" 1 1" LBS 115V MODEL!LIST MODEL/LIST DU10H 1/15 1600 493 398 280 204 -- 30 $513 - p00.17.5 $87 1-12 $49 DU12H 1/7 1500 705 567ffl 385 294 - 50 700 -- DU25H 1/4 1060 746 538 sm I - - -- 60 804 -- DU30H 114 1600 1201 1080 942 864 677 50 816 -- POD-19.5 $97 1-15 $63 DU33H 1/3 1725 1290 1181 1051 984 831 50 849 948 65ar gam. { DU76H 3/4 1175 2474 2218 2083 1931 1772 1348 60 1001 -- POD-23 $109 1-19M$7 DU85H 3/4 1625 3306 3144 3063 2969 2875 2685 60 1124 1125 AVAILABLE FROM THE FACTORY IN 5 WORK DAYS ""REQUEST 18"HI CURB WHEN OVER A COOKING SURFACE _ DIMENSIONS DU SERIES FAN ROOF CURB -f SIZE W HT C OPEN OD WT t 10 17.8 14.5 19 1317.5 30 !1T 12 22 18 19 13 17.5 40 2.0 25 25.5 25.3 21 16 19.5 50 30 25.5 25.3 21 16 19.5 50 33 25.5 25.3 21 16 19.5 50 75 31.9 30.5 24.8 20 23 60 85 1 31.9 30.5 1 24.8 20 1 23 60 1/12/10 Page 5 Return to Index i 7 G J Date. .1l c+Z.3�.4. . ..... . HORTN - 3? TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION . 9 SAcMUSESS / �� //-�' Itihis certifies that . // 1./. .i.�l�. . . . . . . .�. t. . . . . . . . . . . . . . . . has permission for gas installation . . .r(-.n 11 t4 C.Y. . . . . . . . . . . in the buildings of . . .j/--1.51'." Re:r.... . . . . at ./Z)6 Q . .4�f 5,Q EI. �. . . .(; . . 4 . ., North Andover, Mass. Fee. . S s.. Lic. No.9.14. 1� GAS INSPECTOR Check# i VSs- ' MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFI'TING (Print or Type) AlG/2 f A /��0���, Mass. Date 5.�-- Permit# - Building Location Owner's Name P R V ID LSA tA Ll ALL `. l I of u pw beep Type of Occupancy_ M New ❑ Renovation ❑ Replacement Plans Submitted: Yes ] No N S N W N Y z y a N 0 a' W 1- y m Z 0 Q z O W < ¢ ¢ C O ~ < m O F W W C d C < Z t' N 0 W W < = C W W J = < 2 ¢ rC 0 6 W f" WUJ U = N m Z P o Z W O U!~ Z < W W O Z < z < < O O W O 1,- CC '7 O t7 S rL a G Ct J t) ¢ > Q d F` O SUB—BSMT. BASEMENT 1ST FLOOR 2HDFLOOR 3RD FLOOR 4TH FLOOR r STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name �1LfJ� �LllM�/Alli"Ir t�g4TING Check one: Certir4 ate Address TO. box (003 -XL Corporation M AJ%XN ES"t� KA d L R 4 ❑. Partnership Business Telephone Q ;a— 5 a(p— I"15 1 0 Firm/Co. Name of Licensed Plumber or Gas Fitter 5070 M 1 L M9 INSURANCE COVERAGE: have a current�liability insou a ce policy or its substantia) equivalent which meets the requirements of A.GL Ch. 142. Yes If you have checked rimes, please Indicate the type coverage by checking the appropriate box. A liability insurance policy)i( Other type of indemnity❑ 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 re luirement. Check one: owner[] Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information 1 have submitted(or entered)in above application are true and accurate )the best of my knowledge and that all plumbing work and installations performed under the permit issued for this applicationwilLbe in comp lance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gener I Laws/ n !( r 13y T of license: j Plumber Signature of Licensed lumber or Gas rtter Title .Gasfitter ster License Number `t City/Town doumeyman APPROVED( 1 . NL Location/No,. Date A) � d NORTh TOWN OF NORTH ANDOVER O9 `.i ' Certificate of Occupancy $ ♦ i ; cMust<�'' Building/Frame Permit Fee $ Foundation Permit Fee $ * Other Permit Fee $ TOTAL Check # 224 (, 2 �y_ Building Inspor ' Noel TOWN OF NORTH ANDOVER � SIGN PERMIT DATE: October 2. 2009 PERMIT: S03-2010 THIS CERTIFIES THAT JASMINE'S FAMOUS ROAST BEEF & SEAFOOD has permission to erect. 11" x 120" WALL SIGN AND DIRECTORY PANEL on 1060 OSGOOD STREET - UNIT #1 provide that the person accepting this Permit shall in every respect conform to the terns of the application on file in this office, and to the provisions of the Codes and By--Laws relating to the Sign Regulations in the Town of North Andover. Violation of the Zoning of Sign Regulations, Section#6, Voids this Permit. INTERNALLY ILLUMINATED SIGNS ARE PROHIBITED Inspector of Buildings a 0 Y spueo ssawsne♦ woa•suospueiewwe4@nojui:Iiew•3 woo-suospuejewweq•mmm Adak algea6ue43 saiJoWauipuolAd♦ POU-S£909:XVJ (946L)NJIS-LES'0084 s2uoaj aaooe♦ 9LOE0 HN'AVH13d(961 X09 Od)'1S 39(1119 1L saa3391 Ieuoisuawla sfiwumV a!1 j0e9♦ --—— su6ig lesial 13♦ JNI1NItid �d11�10 5 NS�✓�SS NIS su6Ig paAJ83♦ o® 00 0®9 '133 Is sufiis 1e0i7god♦ �fj Ajapiwgw3♦ 71`J1 �l �.s}FQQ e sdeo 9 s1Jl45-L♦ E'G SolOd 9 s6e ♦ t , t F 9 5 saa3sod auuee♦ S 3 r caraA Cy-Boo sdejM 813i48A♦ .� .to sleoaplAwA• 1NKIISMd %�� ������� c� �r?yc-1 fiwgwad�e PG 4 SIGN PERMIT APPLICATION 1600 Osgood Street Building 20, Suite 2-36 TOWN OF NORTH ANDOVER J A5 M l Fik�tou.s KoA,5 `r <-L-A.-enD F t e K. t+jk(1-k t4 A F__ b3A Site Owner '16c13GELD GJA lJ J D PQ UL oS Applicant 5&W-,! Tel2- ei c Site Address /D&O -Lu N 0- 0 0560-bD Size of Proposed Sign X ( ��� St 610 P1 1ZZEcTdd-+Lf �i�I�-S�-L_ 1 t , $SS"rx '30, 90 'r May Parcel Illumination: a Not illuminate b) Interna y i uminated How attached: a) Against the wall c) Externally illuminated b) Roof t/ c) Ground Materials: l2 1Cs� b tip &Ry �D WAIL d) Other p j VZ � P I��Z t t)q e e�,L-LL u(N Lt " Proposed Colors: Background DA 12K � � -�'`,`y�v� ��Np��� �`� F Lettering 10 QV Y Cos of Sign 1 zSD ti� Border jy 07 Note: No permanent/temporary sign shall be erected, or enlarged until an Required Attachments: application on the appropriate form furnished by the Sign Office has been Photographs of building filed with the Sign Officer containing such information including Material sample photographs,plans and scale drawings, as he may require, and a permit Color sample for such erection,alteration, or enlargement has been issued by him. Site or Plot Plan Required for all free-standing signs) Such permit shall be issued only of the Sign Officer determines that the awmgs of proposed sign sign complies or will comply with all applicable provisions of the By- t er, specify Law. Will sign overhang any public road or walkway Yes O No If Yes, Name of Agency who will provide liability insurance: AN INCOMPLETE APPLICATION WILL NOT BE ACCEPTED DATE FILED: q11�/� Receipt # Check # Revised 10.31.2006 Form Sign Permit Application SIGNATURE OF APPLICANT HAMMAR AND SONS, INC. 343 Town of North Andover 9/18/2009 6240•Licenses/Permits/Corp.Filings 30.00 &Q, moo, XZW Pentucket Bank-Checking 30.00 Page 2 of 2 30.$1_in JASMINE'S FAMOUS «? ROAST BEEF & SEAFOOD BMW `�bw` yasmin�9/� °i' 9-1409 o.on.a• Jusm aws famous most beef mnora.e.: m .. ALM 9/14/2009 �i�Dt s?�:� i��F' f Date.Vv?��G.`.'. ... .. .. HORTM o? TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION SSACHUSE I f This certifies that . . . .lit .r S.0 v . . . .f.'.�-� . . . . . . . . . . . . . . . . . . . . has permission for gas installation . , !A".�c .7.o.I-e.`` . . . . . . . in the buildings of . �!f?'e+.'tt . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . North Andover, Mass. Fee. ? . . Lic. No./?.. . .`. . . . .-.r. .�.- 1. . . . . . . . GASINSPECTOR Check# C) 69 , S ,d MASSACHUSE M LN+FORM APPLICATON FOR PERMIT TO DO GAS(TYPe or print) I'�iG NORTH ANDOVER, MASSACHUSETTS Date Building Lo .rations L0toV S�r �j G� Permit# 4 tnHos7�!r<OS Owner's Name Amount$ New❑ Renovation Replacement .Plans'S ubmitted � � a w W. Z , C W O O F 4a ` a � o Z D w b C w z F o c a z p F F W UW F `-! w a ti w SUB -BASEM ENT _ BASEM ENT p tST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR H . FLOOR 6TH . FLOOR 7TH . FLOOR. STH . FLOOR. (Print or e) Dr tt . Name ��SCO lv�b Oneck one: Certificate Installing Company Address ? 0 0,Corp. usmess 0 Partner. a ep one _ , 1 y Name ofLicensed Plumber�or Gas Fitter PIF6YCO. INSURANCE COVERAGE I have a current liability insurance policy or it's substantial equivalent, Check one: If YOU have checked vesYes ,please i nate the type coverage by checking the appropriate box❑ Noo Liability insurance policy Other type of indemnity Owner's Insurance Waiver. I am aware that the licensee do Bond 0 Mass. General Laws,and that my signature on this ermit nom'a the Insurance coveragere wired b P aPPli on waives this requirement 9 Y Chapter 142 of the Signature of Cwvner or Owner's Agent Check one: I hereby certify.that all of the details and information I have submitted(ar ened)in 1 aAgend pplicationD best of my knowledge and that all plumbing work and installations performed under P compliance with all pertinent provisions of the Massachusetts grate Gas Co are true and accurate to the Permit Issued for this application will be in • � and Chapter.142 of the General Laws. Title Signature of Licensed Plumber Or Gas Fitter Title , City/Tovvn.. ------------ Plumber �L a Gas Fitter License um er Master APPROVED(OFFICE USE ONLY) Journeyman I ~...,•t�-CQtr� of Massachusett De art cft f Of Industrial Of Ice of Invesfigatiorrs 600 Washing1,Street Bostosi , M14 (12111 Workers, Compeasatioa IRS urant:e. A ficant Iaformat.10i A'davit: .Builders/Contractors/Electricia.ns/plumb,ers Name (business/Or Please print Leaibl�, ,^.11€anizationMdividual): C� ( .� �ess: rr V 110 7 V t �Tt Ad dr CIfy/StELte/zip: 1 L4bp� Are you an empioyer. Check the appropriate box: 7� 1.❑ Ian. a employer with 4. ❑ I am a a Type of project ployees(full and/or part-time).* have hire eel contractor and I 6 (required): 2. ain a soler d the sub-contractors ❑ New construction v p oprietor or partner- listed am the attached sheet t 7. Ship and have no employees Theses 0 Remodeling. working forme in any capaci sub-con�ctors have capacity. workers' comp. insurance. 8. ❑ Demolition [No workers'comp. insurance S. 0 required_] ❑ We are a corporation and its 9' Building addifion oCers have exercised.their 10:0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of eX"mption „ Myself [No.workers' Per MGL 11.11 Plumbing r„ insurance required.] tP c. 1$2, §1(4),and we have no -, -pairs or additions 'employees, [No workeis' i2'❑'Roof repairs tAnv appli=t.thar eheeka box#I.must also fill out the section below p oinsUranCe required_] 13.❑Other rlomcowoers who submit:tliis a,��devit indicatittEG they arc u'uiE!,t,.�_.;c:!1 ng their workers'compensation policy iniormatioa. iConuacwcs that chec};this box. etau thea hire outside conirr�ciurs mus( ,info n new must attached an additional sheet showtrtg the name.of the st:ircc,;tr=tots and to stnpal.ince �oeah. I ern e?tz e'sploper that is APGVidi►ia wOrfe*5 CommPEc air workers`comp.poli ,info C �stitZ % c5 cmation. igformadoiL -•ersurance for n9'e�playees Below is the poficy,axdjob site Insurance Company Name: Policy#or Self.ins. Lic.#: Expiration Date: Sob Sit`Address: /O(Q �s�'� s'f'-�- Attach a Copy of the workers' compensation policy deciar-alien Q City/Stat-zip: lobe(showing the policy + .Failure to secime coverage as required under Section 25A of fine up to $1,500.00 and/or one-year im P p number and expiration ifate). MGL c. 152 can lead�the Of u to.S� pnsonment as well as civil penalties in the form of a STOP of WOp criminal penahies of a p 50.00 a day iMPOsition against the violator. Be advised That a eo Investigations ofthe DIA for insurance coverage vet ificati.on. of this stateiiient ma, SER and a fine be forwarded to the'Office of Ido hereby,certif under the pater and Peer of perjuri,rj.,Z the information Si oriature: f c. inn provided above is true and correct Phone#: Date: / o Dacial use nnlp. Dn nG1 write in Iris area, to be.cornpletg�.d.h,City Yy or town official City or Tow¢: Issuing Authority(circle one): Per'mitlL,tcense I. Board of Health 2. $undine De fi. Other b pa rEment 3. City/Town Clerk 4. Electrical Inspector 5. Plumbine Inspector Contact Person: Phone JLULVI III aLIUU cw jj(a :Ljjgti"uCriQnS Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. F A' Pursuant to this statute,an employee is defined.as"..every person in the service of another under any contract of h ire, express or implied,oral or written. An employer is defined as"an individual.,partnership,association, corporation or other legal entity,or any two ar 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, associati on or other legal entity,employing employees. However the owner of a dwelling house.having not more than.three ag artments and who resides therein, or the occupant of the dwelling house of another who employs persons to d maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant th=eto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state ar local licensing avenc} aha!]withhold the issuance or renewal oft license or permit,to operates businessor- to construct bulidings in the commonwealth for-any applicant who has not produced acceptable evidence of compliance with the,asurance coverage required" Additionally, MGL chapter 152, §25C(7) states"Neither -the commonwealthnor any of its political subdivisiansshall enter into any contract for the performance of public worms until acceptable evidence_ of compliance with the insurance requirements of-this chapter have been presented to the ceontractm,authority.". Applicants Please fill out the workers'compensation affidavit compZ-etely,by checking the boxes that apply to yow situation and,if necessary,supply sub-contra.ctor(s)name(s),.address(es).am.d phone n umber(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 advisedthat this affficl-avit may,be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also The sore 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 ae�} giiesfions regi-i�ng the ijaw or if you are required to obtain a workers' compensation policy,please call the Qepartrnnent at the ntL-rnbcr:listed below. Self-insured companies aiies should enter their self insurance lime se number on the appropriate line. City or Town Ofuciais Please be surge that the aft rdavit:ts complete and printed}es__rbly. The Department has provid--d$space at the bottom of the_affidavit foryou to fill but in the event the Office of'Investigations has to contact you regarding the applicant. Picase be sure to fill in the permitliicense number which will be used as a reference number. In addition, an applicant that mu&submit multiple perrnitfiicense applications in arty given year,need oniy submit one affidavit indicating current policy information(if necessary)and under"Job Site Ad&ress"the applicant should write"all locations in (city or fawn)." A copy of the affidavit that has been officiaijy 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. VA= a home owner or citizen is obtaining a Iicensy or permit not related to any business or commercial venture (i.e. a.dog license or permit to burnleaves 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 fay,number. The Commonwealth of M=ac husetts Department ofLmduustrial Accidents Office of Eavesfipt iEons 600 Wasb�i gton Street BQstoti; MA 02111 Tel. # 617-727-4900 art 406 or 1-S777 MASSAFE Revised 5-2645 Fay,4 61 7-72.7-7749 u'�'-mass.Dovlaza d Date..L �' TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING .� SACMUS� i This certifies that . . . .LA— :e:'. c: . �• • • • • • • • • • • • • • • • • • • • has permission to perform . . .i A.� .� . . . . . . . . . . . . . . . . plumbing in the buildings of . 6�if*9)- °'/ ! at . /L?lG. . • . `• •�t.G `. - • • • - . . . . . . . . . . North Andover, Mass. Fee. �i. �'. Lic. No..0.`/!?. . . . . . . . . `�: �!. . . . . . . . . PLUMBING INSPECTOR Check # J `� 8226 i�l I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS ii Date S's+ I q Building Location 10 Owners Name � h I B fe Permit#--I--L-�t Amount �'�-- _ �,,,� Type of Occupancy Plans Submitted Yes No e New Renovation r Replacement b�+ ❑ FIXTURES cc Z cc � p 0. W w w U r KDME 1ASEVINr Er Rf m 3M FLOCR 4M FLOOR 5)(l')(Hfm 6M K'jOCR - 7MR"8M"M (Print or type) f Check one: Certificate Installing Company Name �2.S co p l o nt i PC) � Corp. Address 1 C) r Partner. MA 61-:6o usmess Telephone 617 — r Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy � Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this applicati threeinsurance on does not have any one of the above Signature Owner ❑ Agent a 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 performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus tts State Plumbi g Coand Chapter 142 of the General Laws. By: igna UFF 37 i7censecluillo Title Type of Plumbing License I City/Town icense NumDer Master Journeyman ri APPROVED(OFFICE USE ONLY Me Commonwealth of Massachusetts kj f� Department of industrial Accidents Office o Investigations itis i 600 Njashington Street Boston, MA. 02111 r www M=s you/dia . Workers' Compensation Insurance Affidavit- Builders/CoatractorsEieetricians/piumbe A• licant Inforamation / rs Please Print Leg�ib Name (Business Cprgenizafion/individual): LOLS.0 c' �( � c Address: city/<state/zip:-�b � til a (ctChone#: . cC Are you an employerY Check.the appropriate box: t.❑ I am a employer with 4. ❑ 1 am a F�Ej ject(required): general contractor and I Ployees(full andlarpsrt-time).* have b;Erad the sub-contractorscorisrtrvcction 2• I am.asole proprietor or peer- listed on the attached sheet x deling ship and have no employees These sub-contractors have working for me in any capacity, worker' comp.insurance. 8- ❑Demolition [No workers'comp•insurance 5. ❑ We are a corporation and its 9. ED Building addition M.9m�') officers have exercised th10.0 Electrical 3 ❑ 1 am a homeowner doing all work eir right of exemption per MGL 1 I'[] Plumbing rcP�s or additions M Ii~[No-workers' repaim or additions insurance u camp. r �� §I(4j,and we have no 1 ne-j.t .employees. [No workers' 12.❑ Roof repairs comp. insurancercquired.] 13.❑.Other 'Any app[i err that checks bo>L t{f mutt also Tilt out the section below showing their workers'compensation oi' t Homeowners who submit this Rfi suit indicating they are doingall Pon;infonr�etion 1Carroactors ttnar cheat this box must "'° and then hire outside contractors moat submit a new affidavit indicating such atmabed an additimnst sheer showing Eine mono of the sub-comryors and their wo rldrs'Dema.prii.,informedon. 1 aon an errraPioyer tkm w�Ptrrg:worlcers' or comp � ensari�►n nsuranee �nformattiom f nF.Mployam Below is aePolicy and job site . Insurance Company Name: ' Policy#or Self-ins.Lie.#: Expiration Date: Job Site Addrms: /[��,t�1T City/State/Z'ip: Nr.A"ic)d. Attach a copy of the workers' tanrpeusafion policy declaration Page(showing the policy number and e Failurenuto secure coverage as required.under Section 25A of MGL c. 1S2 can lead to the imposition of criminal-ration dafea fine up to'$1,500.00 and/or one-year imprisonment;as well ss civil penalties in the form of a STOP WORK p pies of i of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the ORDER a fine Investigations of the DIA for insurance coverage verification. Office of 1 do hereby certify under the Pains and enaltim o P TPerlury that the information Provided above is true and correct Si tore; f Phone Dfficia1 use Only. Do not write in tftis arq to beco"FAMed by city or town.official City or Town: _ Issuing Authority(circle one): Permit/License# I. Board the'- of Health L Building Department 3.City/3'own Cleric 4.Electrical InspectEPiurnbingti.Other ector Contact Person: Phone#: Information a. end Instructions �< Massachusetts General Laws chapter 152 requires all emp 3 overs 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,assodiation,corporation or other legal entity,or airy two or more of the'foregoing engaged in a joint enterprise,and includi"g the legal representatives of a docessed employer,or the receiver ort ustee-of an individual,partnership,associatioin or other legal entity,employing employees: 'However the owner•of a dwelling house having not more than three apa-rtments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maimtenance,construction or repair wont m 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 os local licensing.ageney shall withhold the issuance or renewal of license or permit to operate a business or to construct buildings in the commoiawealtb for any applicant who has not produced acceptable evidence.o9F compliance with the insurance'coverage required." Additionally, MGL chapter 152,§25C(7)states"Neither tits commonwealthnor any of its political subdivisions shall enter into any contract for the performance of public worts until acceptable evidence of compliiincx with the insriraricc requirements of this chapter have been pressmited to the contracting authority". Applicants Please fill out tfie workers'compensation•affidavit compi---tely,by checking the boxes that apps' to your situation and,if necessary,supply sub-contractors)name(s),address(es),acid phone number(s)along with their certificates)of i insurance. Limited Liability Companies(LLC)or Limited`Liability Partnerships(LLP)with no employees other than the members or partners,are,not required°to cant'workers'cornpensation 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 Awiderits 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 arc required to obtain a workers' compensation policy,please-call the Department at the nurnber.listed below, SeIf inswre cr•npariies Eho d eri+Pr+h�-ir self insurance-license ournbeer 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.currt-nt policy information(if necessary)and under".lob Site Address"the applicant should write"all locations in (city or town)."A copy oftbe affidavit that has been.officiaily starnped or marked by the city or town may be provided to the applicant as proof that a valid affidavirt 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 perinitnot related to any business or commercial venture (i.e. a dog license or permit to bun leaves etc.)said person is NOT required to complete this affidaviL 7brOffice 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 1xidustrial Accidents Office of Investigations ' 600 Washington Street gusto MA 02111 TeL 9 617-7274900 Ext 406 or 1-9.77-MASSAFE Revised 5-26-05 Fax 4 617-727-7749 www.man.gov/dia Date ... ........ ......... 4, TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............................................... has permission to perform .....gx4!! tloo..... wiring in the building of .................... e. at./Pklo........ ..................... North Andover,Mass. Fee.ALic.No. tl.......... ' e �8 . .. ... ........... ZI ...... LECTRICAL INSPE R Check 4 3 z 9021 Commonwealth of Massachusetts Official Use Only �+ Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] Qeaveblank APPLICATION FOR PERMIT TO PERFORM ELE All-work to be performed in accordance with the Massachusetts Electrical Code(MEC,527 CMR TR�CA ooWORK (PLEASE PRINT EV DX OR TYPE ALL INF0" TION) Date: City or Town of: NORTH ANDOVER To the �Inspector �Wires: By this application the undersigned gives notice of his or her intention to perform the e electrical work desnbed below. Location(Street&Number) /p 4:0 Owner or Tenant �T-- s _ Owner's Address CP r= Telephone No. Is this permit in conjunction with a building permit? Yes /,=- 4 � NO ❑ (Check Appropriate Bog) Purpose of Building s . n 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: C C G .d.y C S Com letion of the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans No.of Total No.of Luminaire Outlets Transformers KVA No.of Hot Tubs Generators KVA No.of Luminaires Above Swimming Pool ❑ �' o•o mergency ig g CL rud. Batte Units No.of Receptacle Outlets i 4 No.of Oil Burners FIRE. ALAILivr, No.of?ones No.of Switches No.of Gas Burners NoAf Detection and No.of RangesInitiatin Devices No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number ons KW o.of Self-Contained Totals: "--'___.._.__--._._. No.of Dishwashers �^ Detection/Alertin Devices Space/Area Heating KW Local❑ Municipal No.of Dryers Heating Appliances KW Security Connection ❑ Other Systems; Au.of water No.of No.of Devices or E uivalent Heaters KW o.of Data Wiring: Si s Ballasts . No.of Devices or E nivalent No.Hydromassage Bathtubs No.of MotorsTotal HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent Estimated Value of Electrical Work: Gam' Attach additional detail tf desired, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start 9- 2/-eS Inspections to be requested in accordance with MEC Rule 10 an INSURANCE COVERAGE: Unless waive d upon completion. d 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 proof of same to the permit issuing o undersigned certifies that such coverage is in force,and has exhibited office. CHECK ONE: INSURANCE Er'BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury, that the information on this application is true and complete- FIRM NAME; ,9/ j— vt_rz_ LIC.NO.: Licensee: �/o��� b — 2G GZ Si,-nature (If applicable, enter exempt"in the license number line.) LIC.NO.: GLNO.: eF3]� Address: 7,Ci3��,��,w�._z 2� Bus.TeL IVa 7.11 *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Alt.TelLicNo.: _h'--- OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the Ii nse: required by law. B m signature ty insurance coverage )rma-1 yl Owner/AgentY Y Mature below,I hereby waive this requirement I am the(check one) owner ❑ owri, ;s agent Signature Telephone No. PERMIT'FEE: $ - '�.. �; /�l!� � �� ��'� r�� n �-(, D✓l -� ,. c .+ �. r The Common wealth of Massachusetts 1 ! Department of.industrial Accidents ; r Office of Investigations 600 6TH ashington Street Boston, MA 02111 {\` www.massgov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Eiectricians/Pinmbers Applicant Iaformation Please Print LeQibl Name (Business/Organization/individual): Address: — �O��n 2� City/State/Zip eo%: �G© 7 Phone #: . Are you an employer?Cheek.the appropriate box: 1.Q I am a employer with 4 Type of project(regained): ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-con ors 6. New construction 2.❑ i am.a:sole proprietor or partner- listed on the attached sheet. x 7. Q Remodeling ship and have no employees These salt;-contractors have working for me in any capacity, ,.�.., w°rkers' comp.insurance. g' ❑Dem°Iman [No workers'comp. insurance 5. M We are a corporation andifs 9. ❑Building addition required.] officers have exercised their 10.0-flectrical repairs or additions 3.Q I am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions myself(No•work=' $comp, c. 1.52, §14),'and we have no insurance required.]ired t .employees. [No workers' 12.Q Roof repairs comp. insurance required.] 13-El Other " •Any applicant that checks boor#I must also fiat out the section below showing their workets'com t Homeowners who submit this affidavit indicating pensation policy information they are daring all work end then hire outside contractors must submit a new affidavit indi such. ;Contractors that check this box must attached an additiottal sheet showing.the name of the sots-contractors and their%mri 'eom • B I amt an employer that is providtng:workers,compensation insurance or P policy infomtatioa. information f ny employees: Below is the Policy and yod site . Insurance Company Name: Policy#or Self-im.Lic.#: Expiration Date: ------------ Job Site Address: /d A City/StateAzip: Attach a co of the + e workers compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required.tinder 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 the p and penarlties of perjury that the information provided above is true and correct " Sitmature: Date: 01 Phone#: _ >> 7 [Iss7uing u�use only. Do not write in this area,to be comrpleted or town official by� ff or Town: Permit/License# Authority(circle one): ard of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5Plumbing Inspector heract Person: Phone#: -er ;+.: Information and Instructions 4. Massachusetts General Laws chapter 152 requires all emp Ioyers 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 includirng the legal representatives of a deceased employer,or the receiver ort ustee 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 compi4entely,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' mrnpensation 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 af;tidavit. The affidavit should t 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 nur-nber.listed below. Self-insured companies should enter their sett=insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete acid 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 permitnicense number which%-ill 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 policyinformation(if necessary)and under"Jab 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 fume 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. J The CO=Onwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel.#617-7274900 ext 406 or 1-8.77-MASSAFE evvised 5-26-05 Fax#617-727-7749 www.mass.gov/dia