Loading...
HomeMy WebLinkAboutMiscellaneous - 11 SAUNDERS STREET 4/30/2018 11SAUNDERS STREET 210/029.0-0022-0000.0 DateR'/ Th TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Hu This certifies that.w!.. ...'.'' 4, ...................................................... ...... ................................. has permission to perform........�&-Q..........4..................t r...._.................................. ...... ... .... .... ... plumbing in the buildings of...../? &!�4.esLLL ................................................. at....... North Andover, Mass. Fee.,r!v) .....Lic. No. .. ..........!�k.............................................................. L,4 PLUMBING INSPECTOR Check J �1�� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE PERMIT# JOBSITE ADDRESS Lii SIt OWNER'S NAME POWNER ADDRESS _ ! TELFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL UI PRINT CLEARLY NEW: Ell RENOVATION: REPLACEMENT:E] PLANS SUBMITTED: YES® NOMI FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 1 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM _� i ; _- ( ! �._ ( ^ ► _._ f ,_ __-( _ DEDICATED GAS/OIL/SAND SYSTEM __ __J DEDICATED GREASE SYSTEM __! _..._.._f !Lj DEDICATED GRAY WATER SYSTEM -- _ DEDICATED WATER RECYCLE SYSTEM _..._i _�_( DISHWASHER DRINKING FOUNTAIN _ f I f .___.! FOOD DISPOSER FLOOR/AREA DRAINEll, INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ____. _ _! f _.. ROOF DRAIN ( ._-_..� ! i (. _.__.t _! � .-..� ! SHOWER STALL SERVICE MOP SINK TOILET i aJ URINAL WASHING MACHINE CONNECTION ! ( r WATER HEATER ALL TYPES WATER PIPING OTHER lir r INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[ NO Ell IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 01-� OTHER TYPE OF INDEMNITY E] BOND 0 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 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 com ia» a with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ! ik\•cfn N�c.cc,vt LICENSE# ��`�4 SIGNATURE mpo"' JP Q CORPORATION FjJ#=PARTNERSHIP # LLC COMPANY NAME ®�� ° ,� � ; ADDRESS 8 N CITY - L� _ STATE �ZIP 01%,A,.4 TEL ^� `l-Z 4 FAX II CELL�l�EMAILE.7 'herr - -.- ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECT F NOTES Yes No 3 /1(6 iff- THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT 3"K PLAN REVIEW NOTES a The Commonwealth of Massachusetts - Department oflnrlustrialAccMiks Office of Invesfigations 600 Washington Street Boston,MA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit:Builders/Contractors/ElecfricianslPlumbers Applicant Information Please Print Legibly Name(Business/organization/Individual): \�� �����r•�T 1—�r�rvTTrl\ Address: 44- a City/State/Zip: \A h Vic. Phone#: 5 'l -(OS-1 Are y an employer?Check the appropriate box: Type of project(required): 1.Ld"I am a employer with 4. ❑ I am a general contractor and I 6. W,,,cdo. nstraction employees(full and/or part-time).* have Hired the sub-contractors 2.E] I am a sole proprietor or partner- listed on the attached sheet,t �• ling ship and'have no employees These sub-contractors have 8. El Demolition working for mein any capacity. workers'comp.insurance. g, E]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.E]Electrical repairs or additions required.] officers have exercised their 3.❑ 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.❑Roof repairs insurancere ed.] employees.[No workers' comp.insurance required.] 13F]Other KAny applicant that checks box A must also fill out the section below showing their workers'compensation policy information. i'Homeowners who submit this affidavit indicating they ke doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must aftached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employe'that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name% Policy#or S elf-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 regniredunder Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office sof Investigations of the AIA for insurance coverage verification. I do hereby certo under th pains and penalties of perjury that the information provided above s true and correct. - ,�, / Date: 02 f Signature:1 �W Phone# Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: - Information and 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 ofhim,. 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 lobal licensing agency shall withhold the issuance or renewaI 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 au LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be,sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be-sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current Policy infomnation(ifnecessary)and under"Job Site Address"the applicant should write ,all locations in .(city or town)"A copy of the affidavit that has been officiaRy stamped or mm arked by the city or town ay 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 ox 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 youin advance f please do not hesitate to give us a call. or your cooperation and should you have any questions, The Department's address,telephone and fax numb or: Tho Co 4zawealthOfMas arhwetts - Department o.£lduAdal,Accidents OffXce ofbmstzgatjo.iu�s 6.90 Wash oi.Sjre�t Boston,MA.02111 TO.# 617-7-2.7-4900 oxt 406 or 1-877-MASS A. Revised 5-26-05 Fay,#61.7-727-7749 WWW.MuS,9¢v1dia TOWN OF NORTH ANDOVER Office of the Building Department � NORTi1 q O �.��..ED Community Development and Services o� y '''- -+` °m 1600 Osgood Street, Bldg. 20,Suite 2035 '" z 70 North Andover, MA 01845 �.9 ADRA7E0/.PR�,(5 SSACHUS� Gerald Brown, Inspector of Buildings August 18, 2015 To: Michael R.Jankowski Fr: Gerald Brown Re: 11 Saunders Street—Durso and Jankowski Insurance Agency Dear Mr.Jankowski, A Temporary Certificate of Occupancy was issued for your business on March 16,2015. As stated on the Temporary Certificate of Occupancy it was valid for sixty days,and expired on May 18, 2015. In order to obtain your Certificate of Occupancy there were conditions that needed to be completed. The outstanding conditions were making the bathroom and the office handicap accessible. The conditions outlined are necessary to be in compliance with 521 CMR,Section 3.4, Change in Use. A Building Permit(659-15)was issued on February 18, 2015 for the bathroom, and on January 28, 2015 plans for the handicap ramp were submitted to the Building Department. For the bathroom to be compliant based on the Post Installation Variance the plumbing must be changed to cast iron piping eliminating plastic piping from the main to the half bath toilet and sink. Please have your contractors contact our offices to schedule the necessary inspections. Sincerely, l Gerald Brown Inspector of Buildings 1 1�P &lt 2)I ►gs TOWN OF NORTH ANDOVER t10RTFl Office of the Building Department OF�IUED 16'q.�.O Community Development and Services 02. ° 1600 Osgood Street, Bldg. 20, Suite 2035 North Andover, MA 01845 ��SSACHUS���� Gerald Brown, Inspector of Buildings August 18, 2015 To: Michael R.Jankowski Fr: Gerald Brown Re: 11 Saunders Street—Durso and Jankowski Insurance Agency Dear Mr.Jankowski, A Temporary Certificate of Occupancy was issued for your business on March 16,2015. As stated on the Temporary Certificate of Occupancy it was valid for sixty days, and expired on May 18, 2015. In order to obtain your Certificate of Occupancy there were conditions that needed to be completed. The outstanding conditions were making the bathroom and the office handicap accessible. The conditions outlined are necessary to be in compliance with 521 CMR, Section 3.4,Change in Use. A Building Permit(659-15)was issued on February 18, 2015 for the bathroom, and on January 28, 2015 plans for the handicap ramp were submitted to the Building Department. For the bathroom to be compliant based on the Post Installation Variance the plumbing must be changed to cast iron piping eliminating plastic piping from the main to the half bath toilet and sink. Please have your contractors contact our offices to schedule the necessary inspections. Sincerely, Gerald Brown Inspector of Buildings TOWN OF NORTH ANDOVER Office of the Building Department O��SiED pORT/1 Community Development and Services t 1600 Osgood Street, Bldg. 20, Suite 2035 North Andover, MA 01845 ADRA7ED I,r GJ q SSACHUS�� Gerald Brown, Inspector of Buildings August 12, 2015 To: Michael R.Jankowski Fr: Gerald Brown Re: 11 Saunders Street—Durso and Jankowski Insurance Agency Dear Mr.Jankowski, A Temporary Certificate of Occupancy was issued for your business on March 16,2015. As stated on the Temporary Certificate of Occupancy it was valid for sixty days,and expired on May 18, 2015. In order to obtain your Certificate of Occupancy there were conditions that needed to be completed. The outstanding conditions were making the bathroom and the office handicap accessible. A Building Permit (659-15)was issued on February 18, 2015 for the bathroom, and on January 28, 2015 plans for the handicap ramp were submitted'to the Building Department. The bathroom has not been inspected by the Electrical, Plumbing, and Building Inspectors and the ramp needs to be inspected by the Building Inspector. Inspections need to be completed and signatures recorded on the building permit card in order to obtain your Certificate of Occupancy. A Please have your contractors contact our offices to schedule the necessary inspections.\ w/ <;1 ,t' Cplee r l�� /j/�/Q/R/ � Smce7 / Ill Gerald Brown Inspector of Buildings - - - vj 'l/��Ov.r �.•t49 SS�[NU`+E TEMPORARY CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Valid for 60 Days from March 16, 2015 Building Permit Number 659-15 on 2/18/2015 Date: March 16, 2015 THIS CERTIFIES THAT THE BUILDING LOCATED ON 11 Saunders Street MAY BE OCCUPIED AS an insurance office Durso & Jankowski IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Outside work to be completed prior to final CO issuance. Certificate Issued to: Building Inspector Fee: PrePaid$100.00 Receipt: 28495 Check : 2692 o`NORTH 1N 'tib°4r..rrrt19 SSAClM15E TEMPORARY CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Valid for 60 Days from March 16, 2015 Building Permit Number 659-15 on 2/18/2015 Date: March 16, 2015 THIS CERTIFIES THAT THE BUILDING LOCATED ON 11 Saunders Street MAY BE OCCUPIED AS an insurance office— Durso & Jankowski IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Outside work to be completed prior to final CO issuance. Certificate Issued to: Building Inspector Fee: PrePaid$100.00 Receipt: 28495 Check : 2692 . O ,SSACHSEt TEMPORARY CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Valid for 60 Days from March 16, 2015 Building Permit Number 659-15 on 2/18/2015 Date: March 16, 2015 THIS CERTIFIES THAT THE BUILDING LOCATED ON 11 Saunders Street MAY BE OCCUPIED AS an insurance office— Durso & Jankowski IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Outside work to be completed prior to final CO issuance. Certificate Issued to: Building Inspector Fee: PrePaid$100.00 Receipt: 28495 Check : 2692 521 CMR: •ARCHITECTURAL ACCESS BOARD E 4 r a. Where the cost of constructing an addition to a building amounts to 30%or more of the full and fair cash value of the existing building,both the addition and the existing building must be fully accessible. 11 3.3.3 Alterations by a tenant do not trigger the requirements of 521 CMR 33.1b and 33.2 for other tenants. w? However,alterations,reconstruction, remodeling, repairs, construction, and changes in use falling,. within 521 CMR 33.1b and 33.2,will trigger compliance with 521 CMR in areas of public use,for ,.' the owner of the building. i I• 3.3.4 No alteration shall be undertaken which decreases or has the effect of decreasing accessibility or usability of a building or facility below the requirements for new construction. I 3.3.5 If alterations of single elements,when considered together,amount to an alteration of a room or space in a building or facility,that space shall be made accessible. +'I, 3.3.6 No alteration of an existing element,space,or area of a building or facility shall impose a requirement for greater accessibility than that which.would be required for new construction. i 3.4 CHANGE IN USE When the use of a building changes from a private use to one that is open to and used by the public, an accessible entrance must be provided,even if no work is being performed. When a portion of a building changes use from a private use to one that is open to an used by the public,then an accessible route must be provided from an accessible entrance even if no work is being performed. 3.4.1 RESERVED FOR FUTURE ACTION: Changes in use,from private to public,in private residential homes where no work is being performed. 3.5 WORK PERFORMED OVER TIME When the work performed on a building is divided into separate phases or projects or is under separate building permits, the total cost of such work in any 36 month period shall be added together in applying 521 CMR 33,Existing Buildings. ' 3.6 MULTIPLE USES When a building is occupied by two or more uses,the Regulations which apply to each use shall apply to such parts of the building within that use. 3.6.1 521 CMR 33,Existing Buildings shall apply based upon each use and not on the entire building. Example: If a three story building valued at$300,000 has one floor of retail use and two floors of s residential use,the full and fair cash value of the retail portion shall be mA of the total value which would be$100,000. . r t 3.7 PARTIAL APPLICATION When only a portion of a building is subject to 521 CMR,the full and fair cash value shall be prorated I r, by the ratio of the square footage of that portion to the square footage of the whole building. Example:Where the whole building is 100,000 square feet,the full and fair cash value is S 1,000,000, ! and the part subject to 521 CMR is 10,000 square feet(one-tenth of the total),then the full and fair cash value of the part subject to 521 CMR would be one-tenth of$1,000,000 or 5100,000. 3.7.1 If the Board determines that such proration would cause an inequitable result, the Board may otherwise calculate the full and fair cash YXue of the portion of the building. t• '; 4/3198 (Effective 3/6/98)-corrected 521 CMR-8 I ��� ✓��w�v�� v� � �V�V�7J�V��G�� V�V�i11�7W�G ' Board of State Board of Examiners of Plumbers and Gas Fitterli—S 1000 Washington Street • Boston • Massachusetts • 02118-6100 VARIANCE FROM STATE PLUMBING CODE POST-INSTALLATION $86.00 application fee payable to "Commonwealth of Massachusetts" THIS APPLICATION MUST BE FILLED OUT AND SUBMITTED BY A LICENSED PLUMBER PLEASE PRINT CLEARLY (Sectionl)APPLICANT INFORMATION:(Only the licensed plumber of record may complete this application) Applicant/�e: Firm Name(if applicable): D Date: Title or Position with Firm(if ap able): Plumbing License Number: Plumbing Permit Number: Master#:I % Journeyman#: Stree `ddress: City/Town: State: Zip Code: 4 t q �� .n A7 6961W Cell Phone: Work Phone: Emaik. ALL OF THE FOLLOWING ITEMS MUST BE INITIALED. IF LEFT BLANK, THE FORM WILL BE DEEMED INCOMPLETE AND WILL NOT BE ACCEPTED. 1.1 have included with this application written documentation that the local Board of Health has been petitioned INITIAL BELOW regarding this variance request.*(variance requests for City of Boston must include petition to Inspectional Services) Note:No Board of Health petition is required for buildings owned,used or leased by the State of Massachusetts. 2.1 have included all necessary supporting documentation regarding this variance request. INITIAL BELOW kr--K—�A 3.1 have included a non refundable check for$86.00 payable to the Commonwealth of Massachusetts. INITIAL BELPW Note:No payment is required for buildings owned,used or leased by the State of Massachusetts. --f, 4.The unusual or extraordinary circumstance or established hardship that warrants special terms or conditions is INITIAL BELOW clearly stated in(Section 5)on the second page of this application W-T.�r 5.1 understand that this variance request is for one instance at the location information stated in(Section 3)of this INITIAL BELOW application. . --T.k.INITIAL BELW 6.I certify that I am the plumber responsible for the work outlined in(Section 5)of this variance request. BE LPW I certify that the work performed violates specific provisions of MGL Chapter 142 and/or 248 CMR as cited by the INITIAL BELOW inspector in writing which,I am providing to the Board. V�_t_ 8.1 certify that I understand how the provisions of MGL Chapter 142 and/or 248 CMR have been violated and that I INITIAL BELO will ensure all of my future work will conform to those requirements V1j 4 * "Additionally,any response by the Board of Health or Health Department must be provided,however,the Board may waive this requirement so long as the petition was made in a timely manner." TEL: 617-727-9952 FAX: 617-727-6095 TTY/TDD: 617.727.2099 http://Www.mass.gov/dpl/boards/pl 9.`1 certify that I notified the inspector immediately when the work was discovered to be non-compliant and ceased INITIAL BELOW all,non-compliant work since that time, � A 10.1 certify that the non-conforming work is subject to immediate removal if the Board,in its discretion,rejects this INITIAL BELOW application. (Section 2)OWNER OF THE PROPERTY WHERE THE VARIANCE IS LOCATED: Individual Name: A m Name if applicabl ): Mi z 66 Street Ad ss: City/Town: e: Zip Code: Il Phone- W rk /one: Email: 4102 0 O (Section 3)LOCATION OF VARIANCE:(Please leave blank if this information is the same as in Section(2)) Name of proposed or current occupier of the building: Street Address: City/Town: Zip Code: (Section 4)ADDITIONAL INFORMATION: Name of Plumbing ++Inspectorr: Date Inspector w informed of this Variance Request: nr. to m AC-1 Plumbing Code Section(s)Relevant to this Variance Request: (Section 5)VARIANCE INFORMATION:(Please explain in detail the established hardship relative to this variance request) Plumbing Code Section(s)Relevant to this Variance Request: �r Eg,"By checking this box - I hereby certify under pains and penalties of perjury that the information entered on this application request, including supporting documentation,is true and accurate and is filed in accordance with Chapter 142,section 13 of the General Laws and 248 CMR,the Massachusetts State Plumbing Code. I certify that all work performed prior to this request for a variance meets the requirements of 248 CMR and that I am only seeking a variance for work that has not yet commenced. I also certify that I understand that this is a request for the Board to allow an exception to the requirements of the Massachusetts State Plumbing Cod�an doe not consti ute,an appeal of an inspector's decision. Signature of Applicant Date: Durso & Jankowski Insurance Agency, LLC TD Bank lent 198 Massachusetts Avenue 53-7054 3080 North Andover,MA 01845 2113 Phone 978-688-7000 FAX 978-794-0313 3HTY-SIX DOLLARS and 00 CENTS DATE AMOUNT 04/16/2015 $86.00" Commonwealth of Massachusetts ,1000 Washington Street Boston, MA 02118-6200 Variance Application AUTHORIZED SIGNURE (7...nn �nnn... .■ � • � nnr • r.• nn• n • n � rn r..� Sawyer, Susan ,. rte,, From: Sawyer, Susan i Sent: Monday, May 11, 2015 11:27 AM �L To: 'harrybi11317@gmail.com' Cc: Grant, Michele Subject: 11 Saunders Street Attachments: 2O15O5111138.pdf To whom it may concern, This correspondence is in regards to a request for a post-installation variance from the State Plumbing Board,for 11 Saunders Street, North Andover, MA. This email is to acknowledge that the North Andover Health Department has received the document dated 4/27/15 in regards to the bathroom and associated piping of waterlines and vents.This office has no issue with the request as written. Thank you, Susan Susan Sawyer Public Health Director Town of North Andover 1600 Osgood Street Suite 2035 North Andover,MA 01845 Phone 978.688.9540 Fax 978.688.8476 Email mailto:ssawyer@townofnorthandover.com Web www.TownofNorthAndover.com 1 Date... ./. /..'J............... l �gORTM, TOWN OF NORTH ANDOVER PERMIT FOR WIRING 8`4AC14U5� I/ This certifies that ....................../ . ............................... ...... ..........................................:... has permission to perform ........... , v e vv\.o wiringin the building of............................ .....I. ...................................................................... at ........ S , ..� �.�s Andover Mass. Feelh,w.......Lic.No:4i.Il p .....M. ............. / ..... ... ... .. .. ... . ELE AL INSPECTOR Check# 2 2 42-4 uv� ►y � I l � t Official Use Only Commonwealth of Massachusetts LN L Department of Fire Services Permit No. /�l� `� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] eaveblank 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 PRINT IN HK OR TYPE ALL INFORMATION) Date: 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 e cribed below. Location(Street&Number) SC►�� Owner or Tenant Cr� l Telephone No. Owner's Address k S —1-0�jj (, ` Is this permit in conjunction with a building permit? Yes PNo ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service 6 Amps 1'2,p / X q()Volts Overhead Undgrd❑ No.of Meters —k New Service )a Amps 1,.26 /2R6 Volts Overhead Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Lo 10 t6 agetj Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- Elo.o mergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No, of Zones No.of Switches No.of Gas Burners t No.of Detection andInitiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons Disposers Heat Pump Number Tons KW No.of Self-Contained No.of Waste Dis p ( Totals: .........................����"��� Detection/AlertingDevices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection No.of Dryers Heating Appliances KW Security Systems:* s: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 No.of Devices or E u valent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Ele tri al Work: (When required by municipal pdlicy.) 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 c v rage is in force,and has exhibited proof of same to the permit issuing office. CBECK ONE: INSURANCE BOND ❑ OTBER ❑ (Specify:) I"certify,tender the pain a d penalties ofpe ju ,t1 at the information on this application is true and complete. FIRM NAME: " i fj A LIC.NO.: Z5 / O Licensee: Sigiature f LTC.NO.: (If applicable,e er "ex mpt"in the license number line Bus.Tel No.• Address: c 9 f Alt.Tel.No.: IF *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 F 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 n Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass R Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comme rf /"�/r A / Inspecto s Sign ture: Date: ROUGH SPECTION: a Pass M Failed Re-Inspection Required($.) ❑ - Inspectors Comments: Inspectors Sig ture: Date: FINAL INSPE Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Com ents: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations kvi 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly Name(Business/Organization/individual): J Address: ?2 U0Z Q L Pr7Q 0 Da City/State/Zip: �1 U(5 Phone#. 64 61-C11 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 lamployees(full and/or part-time).* have hired the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. E]Demolition working for me in any capacity workers'comp.insurance. y ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]i employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Horkeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up?b$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 InvesMUions of the DTA for insurance coverage verification. I do hereby certi rider thea s a p nalties ofperjury that the information provided above is true and correct. Signature: Date: f Phone#: l'a C 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#: 1 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 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 CoxnToRwealth of Mossachmetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Teel,#617-727-4900 oxt 406 or 1-877,7MASSAFE Revised 5-26-05 Fax#61.7"727-7749 wwwjUass,govfdia l :: OMMONWEALTH OF MASS ►CHUSETTS _` . BDARI�� � fLECr C"I ANS ISSUES THE FOLLOW I :L'fCEt3SE AS REG `. OURNEYMAELECTR'I CI AN ?Q' KEU I N P CARNEYW.. f jW 3 WOODLOD DR �J N; READ l I NG MA O l 864 25 8 23164..E o7/31/lb : ,: . 39369 e Date....)11.1707 11� .. r; - n "0Rr"' TOWN OF NORTH ANDOVER r F 9 PERMIT FOR PLUMBING $sACMUs� ' This certifies that...... ...............el........ .IGI .. :. ................................ has permission to perform.�e... .......�'� ...... plumbing in the buildings of..... ............p... . ... ........................................................ .. at...............1..1...... c .. .f 5.........C�........... North Andover, Mass. Fee.).`�r').►`�DLic. No. 11ll�...... ...!.-.. .................................................................... PLUMBING INSPECTOR Check# r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _ CITY GMA DATE // -v c'i3 PERMIT## I� JOBSITE ADDRESS L/ S��/✓� S /2i� OWNER'S NAME 11M eAO jr OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL�— PRINT CLEARLY NEW:❑ RENOVATION:REPLACEMENT: 0" PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7 FLOOR BSM 1 2 3 1 4 5 6 7 6 9 10 1 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM �— DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN . SHOWER STALL SERVICE/MOP SINK i TOILET URINAL 2 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING Z� OTHER /af coc INSURANCE COVERAGE: have a current IiabilitV insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES E- -IqO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 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: OWNER ❑ AGENT ❑ 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 mpliance all Pertine ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. %� PLUMBER'S NAME J"�"`� � ''/«' LICENSE SIGNATURE MP E>-,JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME ADDRESS CITY _ � � /L - STATE ZIP d/�Sf. TEL `% FAX CELL cI7 cY6`7- EMAIL The Conn-nonwecalth ofMa,sachuselfs r.•`".�-`.•�•`•.�r De�7a1'tF12EdF1 of.�JPC�P13'YF'PIYl.I�CC.EC�eFPts. Z Office of�nvestigtatiotrs , J 600 F1<traslflngtot$ SFt•eet Boston, AIA 02111 1 �j Workers' Compensation insurance Affidavit: Builders/Con-rac crs/Electr ians/Plumbers ARplicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: . Phone#: kr-e you an employer? Clrecic tite appropriate box: 'Type of project(required): ❑ I am a employer with 4. ❑ I am a general contractor and I 6 F1 New constructionemployees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑ Remodeling E-1 I am a sole proprietor or partner- ship and have no employees These sub-contractors have g. E] Demolition working for in an capacity. employees and have workers' i g y p ty. 9. ❑ Building addition I j [No workers comp. insurance.1 comp. insurance , required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions officers have exercised their t .❑ I am a homeowner doing all work 11.❑ 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 13.❑ Other employees. [No workers' comp. insurance required.] uiy applicant that checks box III must also fill out the section below showing their workers'compensation policy information. :iomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. .ontractors that check this box musCattached an additional sheet showin.a the name of the sub-contractors and state whether or not those entities have iployees. If the sub-contractors have employees,they must provide their workers'comp.policy number. arae cart eraplo)rer•that is providifie tt,or•Icer•s'cor;tpe;tsatioaa iarsurance for iiiv ea;tplovees. Below is the policy mrd job site formation. tsurartce Company Name: olicy# or Self-ins. Lic. #: Expiration Date: )b Site Address: City/State/Zip: .ttach a copy of the workers' compensation policy declaration page(showing the policy number r:nd expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the fonn 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 cerfr Mader the paints and penalties of peajury that the information provided above is true and correct. li nature: Date: 'hone#: Offcilai use only. Do not write in this area,to be completed by citjt or town offaciaL City or Town: Permit/License# Issuing Authority (circle one): I.hoard of Health Z. Building Department 3. City/Town Clerk .Electrical )inspector . Plumbing Inspector 6. Other Contact Person: Phone#: Date...��..h .►. ............... • OF NORT/�{� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .... .. �?.......m' . has permission for gas installation . �1�° ......:5.6.4P.. -`�� . . .. I' '4 inthe buildings of....... r 4 .P.... ................................................................................. at...........�........`1.'• c P 2vS...--� ..:........ r.. , North Andover, Mass. Fee..11. ..-R... Lic. No. .A.� .... .......................................................... GASINSPECTOR Check# r) ( !+ Lir J (1 p 1 VA— INSUR 1 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.192 YES [:�❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Zj,� OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 192 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT ❑ 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli ce with all inept plo " ' n of the s Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t� PLUM BER-GASFITTER NAME LICENSE SIGNATURE s MP MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME ,e;'t ADDRESS (v c Qti d ��/ r"� CITY wi / STATE ZIP a/ �_ TEL FAX — CELL`?? ' Sf�Si '`�/�/ EMAIL��S��r/G�✓�� Qc��� �f ,��j -L, y n .,, Expiration Date: )b Site Address: City/State/Zip: ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of IIGL c. 152 can lead to the imposition of criminal penalties of a ne up to $1,500.00 and/or one-year imprisonment, as %veil as civil penalties in the form of a STOP WORK ORDER and a fine up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivest.igations of the DIA for insurance coverage verification. do hereby certify under-the pains acrd peva/ties of perjury that the hiformation provided above is ince and correct_ r ienature: Date: hone 9: -- Ofcia use only. Do not write in this area, to be campleted by rill%or tofu.$ offcC11gL City or Town: Permit/-i-icense 9 Issuing Authority (circle one): L Board of Health 2. BuildincF Department 3. City/Town Clerk 4. >I,t.lecirical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone #: -` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE I ! / PERMIT t - uvp JOBSITE ADDRESSI /l •Qs� rr_ OWNER'S NAME r —� GOWNER ADDRESS I I TEI.r ___jFAX PPE VT OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL F1 RESIDENTIAL CLEARLY NEWT-1 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NOF APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER D — (- � _ _. _ _ . . _ [ I L. _ BOOSTER _ CONVERSION BURNERCOOK STOVE -� DIRECT VENT HEATER DRYER FIREPLACE } FRYOLATOR ED T S FURNACE ry _ GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER j J ROOM/SPACE HEATER _ ROOF TOP UNIT _ TEST UNIT HEATER I - UNVENTED ROOM HEATER `1. WATER HEATER Zt OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY F-3 OTHER TYPE INDEMNITY E] BOND F 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. R CHECK ONE ONLY: OWNER Q AGENT 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. PLUMBER-GASFITTER NAME LICENSE# ( SIGNATURE MP 0 MGF El JP 0 JGF© LPGI CORPORATION D#=PARTNERSHIP D# LLC # COMPANY NAME:�~ ��ADDRESS J CITY _ 11 STATE=ZIP TEL FAX CELL 1EMAIL ROUGH GAS INSPF4QTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES CS �J—/ Yes No //z THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ A)D ag) 4aJ FEE: $ PERMIT# ►�'� ���'� e PLAN REVIEW NOTES y '• The Commonwealth of Massachusetts - -' Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 U1. www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Nalne(Business/Organization/fndividual): Address: O/-1-,2 City/State/Zip: Phone Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction emple;(full and/or part-time).* have hired the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet. F1 Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition wonting for me in any capacity. workers'comp.insurance. g• ❑Bg addition [No workers' comp.insurance 5. El We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance �ired.re q ur 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. i Homeowners who submit this affidavit indicating they hie doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: �L'���1✓` / S" Policy#or Self-ins.Lic.#: Expiration Date: /a1r Job Site Address; // �— 1City/State/Zip: y /�..v0 av Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a flue 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. Ido hereby certiry under thepains andpenalties o perjury that the information provided above is true an correct. - Si afore: Date: /i �Z 3 Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: Information and 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 employeris 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 cavy workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. 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 CommonwalthofMassarhmetts Department of Industrial,Accidonts Offlce of Ilmstigatzons 600 Washington Stxeet Boston?M. A.02111 Tel,#617-72,7-4900 ext 406 or 1-877,MASSA FB Revised 5-26-05 Fax#617-727-7749 wv w.xnass,govaa 1.1111111M 4 �.i l.0 l h ISSUES THE ABOVE LICENSE.TO t NTEL FLSC�PIILL.ER v 6 OLD. .YA.NKEE R0 ci HA I"RHIL.. IIp OL832- 1(167 1288 05/01/14 147729 � �� Date... C. .�"/.C...... . _ NpRTh 1tip 3? �` TOWN 0 NORTH ANDOVER O D ` t - ' PERMIT FO -GAS INSTALLATION s a y .yr�....... �9SSACMUSE4 This certifies that . , '�1.�.�1/ �. ,��- �'� . . . . . . . . . . . has permission for gas installation . . . .`. . ��.� .':��. . e A. . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . rat . . . . . . . . . . . . . . . . . , North Andover, Mass. Fee. 2 !. . . . . Lic. No..� k . . . . . . -. ..--,� . . . . . GAS INSPECTOR Check# 5 � 3u Location J/ SAV'va'PR4 No. .3 -:3 Date �a0 TOWN OF NORTH ANDOVER f A �,� Certificate of Occupancy $ ,SJwCMUSEt Building/Frame Permit Fee $ ' ! Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # -3-33 Building Inspector MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) n RT)A A N 00V(—TZ- . Mass. Date Permit # �� J-v Building Location H S A IA II O L KS ST Owner's Name_1d5EPl4 b i til L U :`[_ MOZH A0pOWCO rIA Type of Occupancy. QESS DENTIA (,.. New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑ N a N W In }'= Y Q Z • v. N N V N w V7 ¢ N O z (n W W N a O a m CC Z O W o Q a O O Z. N 0 W Q = W 00 O. W W Z W F- N a V N Q OC p � 0 N Z j F' Z �, W W tl 0 > 4 }- U J N W 1' a W Q C E' > 0 m Z O Z W 0 _ Q W > 0: W n 2. Q rL Q 0 0 W 0 �y It '.= O tl Y U. a U L y p 6 F O SUB—BSMT. BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR _ 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name BAY STATE GAS COMPANY Check one: Certificate # Address 55 MARSTON STREET DC7 Corporation 1862 LAWRENCE, MA 01840 ❑ Partnership _ Business Telephone 9 T$—6 8,7-110 5 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have a current liability insoura❑nce policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy P< 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 requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent El I hereby certify that all of the details and information I have submitted(or entered)in abo pplication are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application will>�in mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S. F--FT T e of License: Plumber Signature of Licensed Plumber or Gas Gasfitter Master License Number 374"'5 ym FILE SE ONLY Journeyman i BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO DO GASFITTINQ NAME TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIG NO. PERMIT GRANTED DATE _,19 GAS INSPECTOR r i TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVAT5 OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. DATE ISSUED. ic SIGNATURE: Building Commissioner/122wor of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Prop Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number Uj 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Dk6d Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R redProvided Re red Provided v 1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic ISTric : res 114 O rn 2.1 Owner of Record //ill& V-d ff, Name Print) Address for Service: W Signature Telephone 2.2 Owner of Record: � O Name Print Address for Service: 0 M Signature Telephone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licens Construction Supervisor: License Number in Addre & 7 G41 Expiration l5ate Signature Telephone 3.2 Re stered Home Improvement Contractor Not Applicable ❑ v _ a4v /G3 3 Sr� Co p y Name rn C�D Registration Number r Addr s r cT x(00 F —(07,37 Expiratio Dat n� Signature Telephone "' I SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OMCIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee Multi lier 2 Electrical (b) Estimated Total Cost of L7/ a Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC ,f-- 5 Fire Protection CCC 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO-BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, ,as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I> as Owner/Authorized Agent of subject properff Hereby declare that the statementsd information on the foregoing application are true and accurate,to the best of my knowledge and belief Prime, n Signature of Owne A ent 10V Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST2ND 3 SPAN DUMENSIONS OF SILLS DM ENSIONS OF POSTS DIMENSIONS OF GIRDERS 1 HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CH ANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE w i BOARD Of BUILDING REGULATIONS '' License: CONSTRUCTION SUPERVISOR i Number: CS 022,680 Birthdate:D6/09h 939 Expires:06!09/2004 Tr.no: 26824 Restricted: 00 ARTHUR J WALSH JR �j 55 PLEASANT ST N ANDOVER, MA 01845 Administrator f-f �� 1/IO'IYI/I72Og2C/1 M�il�(,Q4DCLCfcccrse�Cp • i` Board of Building Regulations and Standards } HOME IMPROVEMENT CONTRACTOR Registratlon: 103358 'o 'Expiration: 7/7/2004 Type Private Corporation k A.J.WALSH&SONS,INC. { Arthur Walsh,Jr. 55 Pleasant Sty N Andgver,MA 01845 _ Administrator The Commonwealth of Massachusetts m I z a _ u r Department of Industrial Accidents F< Office of investigations Boston, Mass. 02111 Workers'Compensation Insurance Afdavrt Name Please Print Name: Location: !t' City ` 101 L r� � Gc� Phone # �V '4W' 16-737 I am'a homeowner performing al work myself. 0 I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: Cil n" Address � �d , - City /1i Phone#: F 37 Insurance.Co. l/N Company name: Address City Phone#: Insurance Co Poles# FaiNre to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to$1,500.00 and/or one years'imprisonment-as w.ell_as_chnI.,penalties in1hefnrmnf-a_STOP WORK.ORDFR..and_a fine_cf.(.$100..O.0)_aslay against-me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify un er the pains and penalties of perjury that the information provided above is true and correct. / Signature C> v Date —� G/ Print name �i-YWi� Phone Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept ❑Check if immediate response is required F� Licensing Board F� Selectman's Office Contact person: Phone A- Health Department Other NORTH And Town o ®verf No. 33 '= '4 W 0 LA1116 lover, Mass, co C:"'C..".C.' k. 0RATED P' C5 U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT....... .. .. .*................. ....................................................................... BUILDING INSPECTOR .... .......... .. .. ... .... 4/o Foundation has permission to erect..... .......... buildings on ..... ......S-4m.male.00-�P..........qx0A...%......... Rough ...... .... ... ........ to be occupied as.......cv..4o�g........A H........ Chimney ..................................................................... provided that the person acceptin his permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of 02 * Buildings, in the Town of North,Andover. 1 0700 to— PLUMBING INSPECTOR / jt so VIOLATION of the Zoning or Building, Regulations Voids this Permit. Rough Final PERMIT EYLPMES, IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S4T]� Rough Service BUILDINGINSPECTORFinal Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE j Smoke Det.