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Miscellaneous - 1132 SALEM STREET 4/30/2018 (2)
1132 SALEM STREET 210/106-A-0052-0000.0 I Date ... -j ' d.......... 10523 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING A-10 Thiscertifies that........................ .......................... ............................................. has permission to perform... -i............................ .4................................... plumbing in the buildings of ........ ....................................................... at.....)A...3z.....S ..0...§ ........................................., North Andover, Mass. Fee ..........Lic. No. .... .....0.0......................**** ** ................ Check# <27j� PLUMBING INSPECTOR r� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CW)' �A�0✓t N A DATE PERMIT# I 1 17 vJOBSITE ADDRESS 57 OWNER'S NAME P -4.6 aq P OWNER ADDRESS FAX A - TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL go PRINT CLEARLY NEW: Fil RENOVATION:4 REPLACEMENT: Q PLANS SUBMITTED: YES NO,O-! FIXTURES-1 FLOOR—► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM Ei ,._,__( _,____( DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) _ E i f ___--0 _--- I ( _...._-_i --__I KITCHEN SINK I _____J LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTH R INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ; NO Q f IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW J LIABILITY INSURANCE POLICY DQ OTHER TYPE OF INDEMNITY 0 BOND M OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Q CHECK ONE ONLY: OWNER a AGENT 1 N 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 an c ate to the best my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp' c h all Pertin r islon of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. y PLUMBER'S NAME ISG Wr (a I LICENSE# NAT RE MP JP CORPORATION 0#=PARTNERSHIP -f# __ i LLC j COMPANY NAMEjM., I PoR. Lv ,VC ADDRESS 5Z rroj f��S`� �2 CITY p��V ►�(� -_ _ ___--(STATE _MSI ZIP Q �(L --II TEL 7 — (� --3 E 7 FAX —�CELL .... EMAIL LJ __.t�,0-2 ._CU.__.GM/l�t�_� ---------------- _-- 1 ROUGH PLUMBING INSPE TION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No ` O THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ / FEE: $ PERMIT# PLAN REVIEW NOTES ,b ' The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street .Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly NaMe(Business/Organization/Individual): Tj/✓of r S, t/—/ 00&TO Address: 52 -Ffot-'T 5r 2 City/State/Zip: : ,:/y!/� nct t S Phone#: T78- A 7- 376-7 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. El am a general contractor and I * have hired the sub-contractors 6. ❑New construction employees(full and/or part-time). 2. I am a sole proprietor or partner- listed on the attached sheet.# 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9 ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.N Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t 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. 7'Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c un the pa' s andpenalties of perjury that the information provided above is true and correct Signature: Date: Phone#: 7.67-37(07 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 w Q _ 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 employeiis 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The CoMTORwealth of Massachusetts Department of Industrial Accidents OBice of Investigations 600 Washington Street Boston,M,A,42111 Tel,#617-727-4900 ext 406 or 1-877:M'ASSAFE Revised 5-26-05 Fax#617-727-7749 WWW.uass.9ov/dia. Division of Professional Licensure: License Search Page 1 of 1 The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES ........................................................................................................................................................................................................................................................................................ Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency More... LICENSEE Name:TIMOTHY J. LIPORTO REFERENCES& BEVERLY,MA RELATED INFO Jr.4f! S�<Act�:1t; Disclaimer Regarding "This Licensee has additional Licenses,click here to view them." Website License Searches _ Glossary of License Status Codes Licensing Board: PLUMBERS Et GASFITTERS License Type: JOURNEYMAN PLUMBER More... License Number: 31179 Status: CURRENT Expiration Date: 5/1/2016 Issue Date: 3/10/2008 Exam Date: 3/10/2008 { School: 3 This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Tuesday,May 06,2014 at 12:44:15 PM. ©2007-2011 Commonwealth of Massachusetts Site Policies Contact Us i http://license.reg.state.ma.us/public/pubLicenseQ.asp?board_code=PL&type class=_J&lice... 5/6/2014 Date....�...�.�..��.�.................... � NOwTN TOWN OF NORTH ANDOVER 9 PERMIT FOR GAS INSTALLATION This certifies that.......1.. ��' ... ....................... .....A,. ........................................ .................... has permission for gas installation .1f.� .I�YA, t . . ............... .... in the buildings of.......... ..L..R�.......L&C,-(r.-................................................................. at..... ......�-�-'SA..... ............. North Andover, Mass. Fee..?�..5. ......... Lic. No.3.1.1.1. ......... ...................................................... �} GASINSPECTOR Check# o3 9275 �, �n...� - ��` ✓� '��Z����`.� �. VIAS ACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY { d tiQGV t m MA DATE PERMIT# JOBSIEADDRESS OWNER'S NAME 7 _ OWNER ADDRESS TE q , ,. 7��7_ �G 7 _ FAX�. TYPI,OR. OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL,3 PRINT CLEARLY NEW:E] RENOVATION: REPLACEMENT:® PLANS SUBMITTED: YES 0 NO ?51 APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER _ CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE - GENERATOR J GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER �- OTHER __f -- ^� - INSURANCE COVERAGE ha?e a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ED OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER E-11 AGENT D SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true an rate to he best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp' ith all P i rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASATTER NAME TiMU1't/ ' Li IPu(,,ir9 LICENSE# 3117 SIGNATUR MP 0 MGF 0 JP ® JGF 0 LPGI Fj CORPORATION©#L=PARTNERSHIP®#=LLC®# COMPANY NAME: /t!t L�TOu �Lci� IL� ADDRESS CITY � __ STATE ZIP O1 TEL 97 - ( 671 j FAX CELL EMAIL 1 u1ZF0 2 6_ /C r( ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTO R USE ONLY FINAL INSPECTION NOTES Yes No 0 0 THIS APPLICATION SERVES AS THE PEI MIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NO ES • � c Date.........1......z.v.............. &OR TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,88AC c HU This certifies that ...........V�f A/ .5�............. .. ............................................ has permission to perform ............. ............ .................................... wiring in the building of.......... ..5-.A... ..............d '.....e-. 7 ...................................... at ........ ........... .. ..... . ..........................North Andover,Mass. ................. Fee.. Z. ......... Lic.No. .............................. LECTRICAL INSPECTOR ,,JCheck# /,r / 762 1, 1873 Lam, `. CQrE�Incitfvealth of Massachusetts Official Use Only Permit No.��6 NiLARNMIM Department of Fire Services Occupancy and Fee Checkedk11 J91 _ BOARD OF FIRE PREVENTIOV REGULATIOP S (Rev. 9/05) (Icave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accord9ho +ith IV the Massacilusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK ORPE ALL INFORMATION) Date: cl 1 aG 1 13 City or Town of: � 1y1 Joy-p—V To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) (_� S S ic,�I-e 0_1 I Owner or Tenant -W, Telepbone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building 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: `P40 �r Completion of thefollowing table may be waived by the Ins ector of Wires. = - No.olFRecessed Luminaires No.of Ceil:SuT sp.(Paddle)Fans r o ota �— ransformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above EJ n- El o. o Emergency Lighting rnd. rnd. BatteryUnits No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No.of Gas Burners o. of Detection and Initiating Devices Total No.of Ranges No.of Air Cond. Tons No. of Alerting Devices No.of Waste Disposers eatump 5um er ons o. o e onta ne Totals: Detectibri/Alerting Devices No.of Dishwashers Space/Area Heating KW Local EjMunicipal ❑ Other Connection No.of Dryers Heating AppliancesKW ecurity ystems: No.of Devices or Equivalent No.of Water KW o.o o. o Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Devices ons No.Hydromassage Bathtubs No.of Motors '1 otal HP Telecommunications irmgg: No.of DDevices or. uivalent OTHER: ot Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liabi ' insurance including`completed operation"coverage or its substantial equivalent. The undersigned certifies that such coy rage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Speci :) I certify,under th ains and penalties o e 'ury, tha .he informa ' n n this application is true and complete. FIRM NADV: ` LIC.NO.: Licensee: ignature_ LIC.NO. (Ijapplic ent `ez 't' t e berne.1 Bus.Tel.No.. It a0SU !J Addres . ' Alt. Tel.No.: *Security System Contractor License required for this work;if applicable,enter the license number here: OWNER'S INSURANCE WA.TNrER: 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 _ Signature PERMIT FEE: $ure Telephone No. (1�'" r � I� � �� '�l S��/ ��� � �� "/ ��• us �, 5 ��` The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 U1 1 4vww:mass.gov/dia Workers' Compensation Insurance Affidavit: BuUders/Contractors/Electricians/Plumbers Aivlicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State4Zip. Phone#: Are y u an employer?Check the app' priate bog: r6. n[] f project(required), w 4. [] I am a general contractor and I1. I am a employer with � New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑Remodeling 2.❑ I am a sole proprietor or partner These sub-contractors have ship and have no employees 8. ❑Demolition employees and have workers' working for me in any capacity. 9. ❑Building addition workers'com insurance comp.insurance. [No P• MS. We are a corporation and its 10.❑ Electrical repairs or additions requtred.] officers have exercised their 11.❑ Plumbing repairs or additions 3.❑ I am a homeowner doing all work myself..[N comp. c. 152, §1(4),and we have no right of exemption per MGL [No 12.0 Roof repairs insurance required.]t 13.[] Other employees.[No workers' comp.insurance required.] *Any applicant that chocks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavic.indicating such. :Contractors that check this box must attached an additional sheet showing then of the sub-contractors and stale whether or not'those entities have loyees,they must provide their workers'comp. number. employees. If the sub-contractort have omp X am an employer that isproviding workers'compensation Insurance for my employees. Below is.the policy and job site information. � � .'. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job.Site Address: ,��t"1 City/State/Zip: �?'? d Attach a copy of the workers' compensation policy declarati.n page(showing the policy number and expiration date). Failure to coverage` ecure as.r uired under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a rs g eq fine up to$1,50.0,00 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. X do hereby certify the ants and enalties ofp Wry that the information:provided above Is true and correct Si ature• Date: ,)411 APhone#• ojylccial use only. Do not write in this area,to be completed by city or town offlclaL 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 00 12 Date -`3./- . . ./.tom TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING t L � r This certifies that . . ., . . has permission to perform . .t / plumbing in the buildings of. . MS P L�� . . . . . . . . . . . at . -/-/-3. Z. —- -�y'�,,�,. �._t.-; . . . . . . . .North Andover, Mass. Fee . . . . . Lic. No. ./,),&// . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check 4 J<:l SN_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE a PERMIT# w JOBSITE ADDRESS OWNER'S NAMEL C.Tjd ,2z P OWNER ADDRESS3 _ M .�......_. �.. •.� � TEL FAX�y E TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL Q RESIDENTIAL Le PRINT CLEARLY NEW: Q RENOVATION:0 REPLACEMENT: ® PLANS SUBMITTED: YES NO[--,]I FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _I= __I ._____...€ I I ( ._.._ B -,____.f _ ___ _( __-.__..I —_.) __ i I CROSS CONNECTION DEVICE _. _.____ -..._.._..__. DEDICATED SPECIAL WASTE SYSTEM _____.I .._.__ _T-.. f DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM _..___-_J -._.._._.._f ._.__._! ( ..._.__.._..� E .--_( DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM Ell _.._._._..._DISHWASHER .._____ DRINKING FOUNTAIN __._ _. � ._-...-.--.� ._____1 __._.1 _..._.._f ._.....1 FOOD DISPOSER _.._. f . ( I ..__.__.( i ( _-_-- FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) _t .-_--__.f KITCHEN SINK -_-----J _____I _ I .._-_.....,i -..._..__I ______—f ( _..._......_� LAVATORY ._.._.___f _.__...._4 .______1 _____I _____.1 ROOF DRAIN F77-1 - __( SHOWER STALL SERVICE/MOP SINK TOILET' ____¢ ______..� URINAL I 1 1 -----I .._.... _[ - --- - - f ..__.._.._f ....... f .... WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _1 i , _ . J= WATER PIPING __-_ ' ___{ .._ f _f _ ., ____� T- f I OTHER _ � ..�E _! _.I INSURANCE COVERAGE: 6 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[___11 NO 0 OF YOU CHECKED YES,PLEASE INDICATE T TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 01 BOND Q OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER _1 AGENT Q SIGNATURE OF OWNER OR AGENT f 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 fr/lassachusetts State 4PIu ,2�PLUMB 'S NAME LICENSE# -( f SIGNATURE n/IP JP Q CORPORATION 0# PARTNERSHIP]# t ; LLC� I COMPANY NAMEi t =__M_�GG ADDRESS CITY .J. �.n,�,�lp STATE ZIP 'zf �� TEL L-3 �j- y_I FAXCE ` LL _�EMAIL - (� ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES i' II The Commonwealth of Massachusetts 07 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLyibl A Name(Business/Organization/Individual): vl SkAIOOJ Address: V. 0. o x S City/State/Zip: a" _/rvU4)d IP 1), N° 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. ❑ ew construction �mployees(full and/or part-time).* have Hired the sub-contractors 2.[1Q I am a sole proprietor or partner- listed on the attached sheet.t Remodeling ship and'have no employees These sub-contractors have _ 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.E]Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they afire doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cert! r the pains a:2: alt! of erjury that the information provided ab o a is tr a and correct. Si ature: Date: 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#: i 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 Commonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston,MA 0.2111 Tei.#617-727_4900 ext 406 or 1-877rMASSAFB Revised 5-26-05 Fax##617-727-7749 www.mass.govldia Date ......l...�. ,1.................. NORTH� TOWN OF NORTH ANDOVER PERMIT FOR WIRING BSACMJ5� ` p This certifies that .................. h. ............ .�� .'' -'.......................... . has permission to perform n d& 1 \ :FM .,,,,., ....................................... wiring in the building of................ .i" �,� . .................... ................................................ at ......�. �` tM orth Andover,M ss. . ................................................................................ FeN2''"....Lic.No. 1 ,a. n ........................... .................. .. ...... .. ........ EL cnicALINSPECTO Check# ' ase 14 1 1170 )6 r , a Commonwealth of Massachusetts Official Use Only r ,11�1 Department ®f Fire Services Permit No. Occupancy and Fee Checked * OARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN NK OR TYPE ALL INFORMATION) Date: 7- 3— /-3 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) //3a 5a(e M Sf Owner or Tenant `p n Sn��� q Telephone No. Owner's Address Is this permit in conjunctionWitha building permit? Yes No El (Check Appropriate Box) Purpose of Building \" Utility Authorization No. Existing Service ;WO Amps Q (Volts Overhead M 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: —mitt-on A rbio m aA0 066:6:: ,s .� w5 eJ �r n eI UAA. !5 Completion of the following table may be waived by the Inspector of Wires. No.of Recessed LuminairesNo.of Cell:Susp.(Paddle)Fans No.of Total /S Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above o In- o.of Emergency Lighting No.of Luminaires Swimming Pool rnd. grnd. ❑ Battery Units No.of Receptacle Outlets f_.2v No.of Oil Burners FIRE ALARMS No. of Zones �l No.of Switches � _ No.of Gas Burners No.of Detection and ..� Initiating Devices No. of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers HeatPump I Number I Tons IKW No.of Self-Contained Totals: ......."""".. Detection/Alerting Devices k No.of Dishwashers Space/Area Heating KW Local El Connection ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No. of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: d Attach additional detail if desired,or as required by the Inspector of 97res. Estimated Value of Electrical Work: &4;6000 (When required by municipal policy.) W, ork to Start: 7-3-13 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE;4 BOND ❑ OTHER ❑ (Specify:) Icertify,itnder ill ep s and�nalti s of. . ry,that the information on this application is true and complete. FIRM NAME: , i t LIC.NO.: /136?r-,/ Licensee: Ori Signature LIC.NO.: /136R' & (If applicable,enter,'exempt"inhe ense number line.) Bus.Tel.No.• 7 2" Address: 73 JGri K ner V_� Alt.Tel.No.: 9 7 - D - 40-26' *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 Signature Telephone No. PERMITFEE:$ Z.-- ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§'31,,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166, §32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and IWIvalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Won written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated up :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 Chanter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass[N Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ 1 Inspectors Comments: Inspectors Signature: Date: ]FINAL INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comm - 1 Inspectors Signature: U rZ Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com y 1 r �\ The Commonwealth of Massachusetts Department of Industrigl Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):_ eu-q eley4rK Address:__ 7� ri�iler' ed City/State/Zip: a kl2l'o Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with --1- 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.# �• Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.El I am a homeowner doing all work right of exemption per MGL 11.El Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 'i'Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site Information. 1 Insurance Company Name:. �Or�o� �—�pd��,v►�1 Policy#or Self-ins.Lic.#: c / Expiration Date: Job Site Address: ���J� .Ci,l flit') City/State/Zip: �� 41y/ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requireclunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine 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 certi r the 'ns 7enalties ofperjury that the information provided above is true and correct - Signature: u Date: q 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 M. �Y Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire, express or implied,oral or.written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-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. 5 The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, r 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 ofInvestigations 600 Washington Street Boston,MA,02111 Tel,#617-727-4900 ext 406 or 1-877,7MASSAEE Revised 5-26-05 Fax#617-727-7749 wwwanass,govldia y OOMMOMVEALTH OF MASSACHUSETTS 1 • 'Y00 ELECTRICIANS ' - ASAREG JOURNEYMAN ELECTRICIA IS ISSUESr E PBVE LICENSE t0 " CHRISTPHER :Q `W PERRY Q l a ` 11 MT PLEASANT :ST °'r `�--•'"�q A 0 1:85 0 2 2 07/31/13 _ 8682 11 W9' B ° s .qa i Date .' . •• g • s�����=ail. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION w This certifies that . . KF .b oz>-j . . . .F '•fin , , , , . . has permission for gas installation . . . ... . . . .. .1'VRr�L , , , , La� _ in the buildings of.f�. �-. . . '�14PI.- .�'7.. . , , . , . at . A5.10 x1 L. KJ. ?N. . . . , North Andover, Mass. Fee .,�a�' Q . . . Lic. No.f3�e//. . . . . . . . . . . . . . . . . . . . . . � GASINSPECTOR Check# 8749 �0-� = MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY _ � MA DATE PERMIT# JOBSITE ADDRESS S S OWNER'S NAME GOWNER ADDRESS TE FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ® RESIDENTIAL _ PRINT CLEARLY NEW:[I RENOVATION:01 REPLACEMENT:® PLANS SUBMITTED: YES Q No E] APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE .. I - I _ - , DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE � 1 =- -- —. —_ ----- - _ GENERATOR GRILLE INFRARED HEATER ----- _ _ -- LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER _ __ 1 _ ..... - ❑ - 1.- ROOM/SPACE HEATER .I _ L_._. ROOF TOP UNIT TEST — UNIT HEATER UNVENTED ROOM HEATER WATER HEATER -- OTHER L-A TI _I J It_._ - INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ONO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY �_I OTHER TYPE INDEMNITY [{ BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ® AGENT SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to-he best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp" ce with all P�' ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4R!jz 99, PLUMB -GASFITTER NAME ja c LICENSE#_ I L.._� SIGNATURE MPMGF JP D JGF I LPG] _,.-( CORPORATION _1# PARTNERSHIP[�I# LLC .__f# ❑ ❑ ❑ ❑ COMPANY NAME: �,� ----------_I ADDRESS '.�_ a2C CITYSTATE ZIP (�_ .. IV.� � TEL FAXCELLD�,. ..J EMAIL .- !ra v � III ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES -7111 a e.. ff The Commonwealth of Massachusetts - Department of IndustriqlAccidints 1B U9V Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): (r-))Y1��)(.)C)a ry\it, Address: V - G t R ©k 1� City/State/Zip:�� j' Phone#: (p� r,� O_-. Are you an employer?Check the appropriate box: Type of project(required): 1.❑ am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 1 7. ❑Remodeling 2. I am a sole proprietor or partner- listed on theattached sheet. p p ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 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.]r employees.[No workers' 11dother 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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. (Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un iepains andpen per' ry that the information provided ab ve is true nd correct. Simature: Date: ( 2 / 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#: �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-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. _ The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office o£Investigations 600 Washington Street Boston,MA.02111 Tel,#617-727-4900 ext 406 or 1-877rMASSAFT Revised 5-26-05 Fax#617-727-7749 www.mass,govldia '1199 Date. .. . ... NORTH TOWN OF NORTH ANDOVER pf „ o 'IN PERMIT FOR MECHANICAL INSTALLATION f SACMUSE�t This certifies that . . . . . • . . . . . . • . has permission for mechanical installation . 1.7. Yl .. . . . . . . . . . . . . in the buildings of .7.) . . . . . • . . . . • . • . at ./.,�. ,�Z• • •����� w. • •�7• • • • • • •, North Andover, Mass. Fee. /!2 Go. . . Lic. No.. 14.i.s . . . . . . . . . . . . . . . . . . . . GASINSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer Commonwealth ®f Massachusetts Sheet Metal Permit Date :A-5F��, ����� Permit# Estimated Job Cost: 0 Permit Fee: $ Plans Submitted: YES i/ NO Plans Reviewed: YES ✓ INTO Business License# Applicant License Business Information: Property Owner/Job Location Information: V C (Kl. Name: Name: /1 / Street: ,D < Street: City/Town: �4'kl U18-,;?� City/Town: Telephone: �� ��' /4 Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES V_�NO Building Type: Residential: (P2 family V Multi-family Condo/Townhouses Commercial: Office Retail Industrial Educational Institutional Building Cubic Footage: under 35,000 cu. ft. over 35,000 cu. ft. Sheet metal work to be completed: New Work: ✓ Renovation: t( HVAC L/ Metal Roofing Kitchen-Exhaust System Chimney/Vents Provide brief description of work to be done: 11�-tet-- r � r. G INSURANCE COVERAGE: 1 have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes lido❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy F� Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 112 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 Owner's Agent By checking this boxEl,1 hereby certify that all of the details and information I have submitted(or 1.entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Progress Inspections Date Comments Final Inspection Date Comments Type of License: By Master Title ❑ Master-Restricted Cityrrown ❑Journeyperson Signature of Licensee Permit# OJourneyperson-Restricted License mber: Fee$ El Check at www.mass.gov/dpi Inspector Signature of Permit Approval i Sheet Metal Commercial Guidelines/Life Safety/Critical Systems ` Inspection Checklist Yes No N/A, Set of stamped engineering documents and detailed description of mechanical system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper journeyperson-to-apprentice ratios Fire dampers with access door properly installed and checked for operation Smoke and combination fire/.smoke dampers with access doors properly installed- actuator checked for proper operation(May also be verified by fire department during fire alarm testing) Duct smoke detectors with access doors properly located (May also be verified by fire department during fire alarm testing) Smoke/atrium exhaust systems installed and operation verged (May also be verified by fire department during fire alarm testing) Stair pressurization systems installed(where required) and operation verified(May also be verified by fire department during fire alarm testing) Grease/kitchen hood exhaust system installed with all seams and connections welded airtight with properly located cleanouts.Proper 616.'j antes,fire rated enclosures and pressure testing required: it�es.l:aint3 instalII �l%.zo`required'on equipment and >>{t1.3,; r:fly. - .•.. _ .. .. Duct penetrations in fire•tatc tall=s and floors sealed Metal roofing systems installed watertight using proper materials and fasteners Flexible duct rains installed 6'-0"maximum length Ductwork installed using proper hanger spacing,hanger stock,threaded rod and angle iron Ductwork/plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining Volume dampers installed for each supply air branch duct New/clean-properly sized filters installed(final inspection) Testing and Balancing report complete(final sign-off) r c Sheet Metal Residential Guidelines/Inspection Checklist 'Les No N/.4 Detailed description and sketch of sheet metal system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper joumeyperson-to- apprentice ratios Equipment sized per heating/cooling load calculations Duct work sized per manual "D"calculations Bath/shower rooms contain mechanical exhaust fan vented outdoors Electric dryer exhaust properly installed maximum total run 35'-0", maximum flexible run 8'-0" Flexible duct runs installed 14'-0"maximum length Volume dampers installed for each supply air branch duct Ductwork installed using proper gauges and hangers Ductwork/plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining New/clean-properly sized filter installed(final inspection) Testing and Balancing report complete(final sign-ofo The Commonwealth of Massachusetts 12rm Department of Industrial Accidents Office of Investigations I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information C Please Print Lezibly Name(Business/Organization/Individual): �o l/�/ ✓ � ?'� � � �(� Address: S3 City/State/Zs a/ Phone#: Are an employer?Check t e appropriate box: Type of project(required): L I am a employer with 4 4. ❑ I am a general contractor and I employees(full and/or part-time). * have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have g, []Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance.: 9. Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑ oof repairs insurance required.]t c. 152, §1(4),and we have no �}- employees. [No workers' 13. Other 1 ' comp.insurance required.] *.any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �C /C�`j � cu Policy#or Self-ins.Lic.#: (� �� �g // Expiration Date: 91/// Job Site Address: �_� � / c _City/State/Zip: Q(g � Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby erti u r the pa' d penalties of perjury that the information provided abo a is true and correct r Sianaturek Date: Phone#: 33 r l®T 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#: i JACORD- CERTIFICATE OF LIABILITY INSURANCE D^ o13 ► PrDUCER J.E.Schindler InsAgy Inc THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION One Wall Street ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 5th Floor HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Burlington MA 01803-0000 (781)272-7505 INSURERS AFFORDING COVERAGE NAIC# IN SURED INS R RAACE American Ins.Co. Main Street HVAC,INC. INsuRER s.Commerce Insurance Co. BOX 334 INSURER C:The Hartford Dunstable MA 01627- IN R INSURER OVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. msit ADD POLICY NUMBER POUCY EFFECTIVE POLICY EXPIRATION nIUMMIRANM =pamnong LjMms GENERAL LIABILITY 08 SBA VUB747 DW 0811112012 08/11!2013 EACH OCCURRENCE s 1,000,000 X DAMAGE TO RENTED S 300,000 MMERCUU GENE ILnY CLAIMS MADE I X OCCUR MED EXP one s 5,000 PERSONAL&ADV INJURY S 1,000,000 1 99NERALAGGRE TE s 2,000,000 'LAGGR UMITAP SPER: PRD P/OPA $ 2.000,000 POC PRD B1 AUTOMOBILE LIABILITY RZV405 11/20/2012 11/20/2013 COMBINED SINGLE LIMIT ANY AUTO (Ea acddenl) S ` ALLOWNEDAUTOS BODILY INJURY X y 50,000 1 SCHEDULEDAUTOS (Per person) 1 HIREDAUTOS ' NO"WNEDAUTOS (Perscri INJURY S 100,000 I I PROPERTY DAMAGE $ 100,000 (Per aacideM { GARAGE LIABILITY AUTO FAACCIDFNT S ANY AUTO OTHER THAN EA ACC S II AUTO ONLY: A $ EXCESSIUMBREUA LIABILITY EACH OCCURRENCEg OCCUR F CLAIMS MADE AGGREGATE S S DEDUCTIBLE RETENTION s S AIWORKERS COMPENSATION AND 6562UB4737P85811 06/11/2012 08/11)2013 X WC srATU- OTH- EMPLOYERS'LIABILITY PR -• ANY PROPRICTORIPARTNER15MCUTIVE F-L EACH ACCIDENT S 100,000 OFFICEWMEMBER EXCLUDED? E.L.DISEASE- EMPLOYEES 100,000 If yes.describe under P V i E L DISEASE-POLICY LIMIT S 500,000 OTHER I i I DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS 1 i f CERTIFICATE HOLDER CANCELLATION A1000873 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION I DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN for Office Use NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO$O SHALL _ IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVE& AUTHORIZED REPRESENTATIVE ACORD 25(2001108) 0 ACORD CORPORATION 1988 I SHEET METAL WORKERS AS A MASTER-UNRESTRICTED ISSUES THE ABOVE LICENSE TO: i ; PAUL E 0 LOUGHLIN d? j 310 MA-IN ST Nq PO BOX 290 DUNSTABLE MA 01827-029 1695 07/28/13 21995 r • i Tj • e • ' COMM ETTS Y . yj}; MMM 60HERM 3HfET METAL WORKERS '' ASA BUSINESS ISSUES THE ABOVE_LICENSE 70: r PAUL E;; 0 'L:OU'GHLIN m.• MAIN STREET HVAC INC 3.1' 0 MAIN': .ST ' PO B0X 3.34 DUNSTA-BLE MA U1827-0000 ` 184 01/06/15 304737 Al 4D, amm1 = "uMa�,`�R11 7271 iCENSJE t P.r .. l'•.� r IIS4885R_ * +c w 23=2014,07 23;19 ` "GLASS HEST HGT }SFX +• ' DNI B OLOUGhLIN -PAUL E 310 MAIN ST' ' � �� r _,,.,,,_,.: " •� '.DISTABLE,MA ? �� Al OO Ab Md y� 71 A Vic t IV 7�T7 .. . . t . �° t ! Ott r KIs . ^_ Kik �. ;\ .� •, .„4- 4 �. � �� � � ,. Date. . . NORY TOWN OF NORTH AND VER 41 PERMIT FOR GAS INSTALLATION • a 9 '�9SSAC NUSEt,( This certifies that . . . . . . ."`.`?. . . . . . . .-J . . . . . . . . . . . . . . has permission for gas installation .. -r - . . . . . . . . . . . . . . . in the buildings o `?- /-f . . . . . . . . . . . . . . . . at �� .'� . . y . . . . . . .-- . ..6, North Andover, Mass. Fee2z; . .77. Lic. No 3". .a .�.. :. . . . . . r�AS INSPE )w Check# G.3 70't7 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date �jp✓, /02 ®© 9 NORTH ANDOVER,MASSACHUSETTS Building Locations 11A? Jr,4AM ,S"���ef Permit# 7 .Amount d Owner's Name &1e, Z�r44 New❑ Renovation Replacement ❑ Plans Submitted ❑ rA k W w w ° ° w F C7 F ZH Qz x W C 0 x O O w FFz Q cx Q Q O O W O W F 7 3 C C7 .7 U CC > SUB -BASEM ENT B A S E M ENT 1ST. FLOOR J 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH : FLOOR Name rint or type) J;1/,v 1 !2 1��� , jc�` Check one: Certificate Installing Company d ❑ corp. Addressd�7a ��^������'► '/ ElPartner. .1;�r` A-11 iness'Te ep one ❑ Firm/Co. a Name of Licensed Plumber or Gas Fitter V0/114 zr Aon INSURANCE COVERAGE Check one: �* I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked,Yes,please indicate the type coverage by checking the appropriate box. Liability insurance policy IT 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 ❑ 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 plumbingwork and installations performed under Permit Issued for this application will be in P PP compliance with all pertinent provisions of the Massachusett St to GasC��d Chapter 142 of the General Laws. i ignature of Licensed Plumber Or Gas Fitter By. � Title Plumber gyp , 7 City/Town ❑ Gas Fitter License..Nurn5er ❑ Master APPROVED(OFFICE USE ONLY) Journeyman II The Commonwealth of Massachusetts Department of Industrial Accidents. Office of Investigations 600 Washington Street Boston, M4-02111 . www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl v Name (Business/Organization/Individual): Address: Xe City/State/Zip: 0%9�7 Phone#: 97.- Are you an employer? Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.[ 1 am a sole proprietor or partner- listed on the attached sheet. $ 7• Dlemodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. F-1 Building addition [No workers' comp. insurance 5• El We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 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 insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.]. *—.y applicant that checks box#1 must also 811 out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: A Policy#or Self4ris.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a co of the ' copy workers compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine . of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct Signazure: Phone#: Official use only. Do not write in this area,to be completed by city or town offwiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity;or any two or more of the foregoing engaged.in a joint enterprise,and including the legal representatives of a deceased employer, or the . receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartrnents and who resides therein,or the occupant of the dwellinghouse of another who em loys rsons to do maintenance,construction or repair work on such dwelling house P Pe or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to,construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." � Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability.Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. _ City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or Iicenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us`a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington.Street Boston,MA 0.2111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Fax # 617-72.7-7749 Revised 5-26-05 . v*nArw.mass.govfdia 9558 Date.... ......................... NOR7M °��"`°-;•14,° TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,r-•�" CHusf� ,LGc T This certifies that ..........5. !/ .. ...... ............................. has permission to perform ��w 1' pUS .............................. ............................. .. . wiringin/the building of.........................................................-......................... at....1../s. `...A7., 6 1..:....... ...................... .. North Andover,Mass. Fee... . "Lic.No.c�2.9'1. �............. . ...... LECTRICALINSPECT9` i Check # � _ { i p (//��ommonwealtk of Mamac4aJetti Official Use Only 2cc� Permit No. q_ epartment o f-7ire Servicee Occupancy and Fee Checked r BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORAM TION) Date: -7- 30- 10 City or Town of: Alocfkfiver To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 1 1 �z :5,%Je'w 61- Owner or Tenant FF� ,; V., G Telephone No. � Yoe Owner's Address , &'�4 Is this permit in conjunction with a building permit? Yes Y No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. 9 3 k/A ctl p2 Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service 2QQ Amps /2 0/25/OVolts Overhead� Undgrd ❑ -No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �o p �d9 3 he APhi 5 ewle � ©V.3L, Completion of the following table may be waived hy 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 Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pum Number I Tons KWNo.of Self-Contained Totals: I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Connection Heating Appliances Security Systems:* t No.of Dryers g pp KW No.of Devices or Equivalent No. of WaterKW No. of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.H dromassa a Bathtubs No.of Motors Total HP Telecommunications Wiring: y g No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cover ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the az s andypenalties of pegury,that the information on this application is true and complete. FIRM NAME: Qenwiler h G� r LIC.NO.: 29q7d6 Licensee: Par 1- d--' Signature A 62 IC.NO.: 2 7m2 (If applicable, enter "exempt"in the license timber line.) Bus.Tel. No.:4'7S^147`Z -f/1 Address: �9 Uehi- 0 yo FAlt. Tel.No.: *Per M.G.L. c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lie.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ � I 5-P,- /l Date. . i �'�'$• :'tio TOWN OF NORTH ANDOVER a p PERMIT FOR PLUMBING SSACMuS� This certifies that l . . . . has permission to �� -~� plumbing in the buildings of . . . . . . . . . . . -!. . . . . . . . . . . . at . _. . . . . . . . . . . . . : . . . . . . . . . .. North Andover, Mass. Fet?2_ 11. . . . .Lic. NW4!�-?. NG INSPECTOR . . . . . . . Check # 112 8290 •4 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or Pmt) NORTH ANDOVER,MASSACHUSETTS Date Ag gggy.,7 Building Location /�� b /��, Permit# Owner OV-1 ��®�?f�y Amount New 0 Renovation a Replacement Plans Submitted Yes ® No FIXTURES Gr or 1z rf Cr 06 suga vIC WMMENr �II� 3M KOM 4M HDM 5TH HIM 6TH EUXIR �- 7ME10M s><tHit" (Print or type) Check one: Certificate Installing Company AYName /—o0//p � Corp. Address l� Partner. Cll%rn.irsfe.� /�Jj1 Gs '7 Business Telephone `-�`j�f,Yj�� `� Firm/Co. Name of Licensed Plumber: Insurance Coveraee: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy El Other type of indemnity ❑ Bond Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner 0 Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachuwfts State Pluode and Chapter 142 of the General Laws. 6 4 By: i e o icens um T of Plumbing License Title Type g O City/Town icemse lNumber Master ❑ Journeyman APPROVED(OFFICE USE ONLY ,36 !/YJ }'b The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organiration/Individual): r/��'., V,�L, Address: 70 If,WX City/State/Zip: G✓//",rJ,r 0,0-7 Phone#: Are you an employer? Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction mployees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7• [remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for in any capacity. workers' comp. insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El 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.]t employees. No workers' 13.❑ Other COMP. insurance required.] *.... applicant,that checks box 41,must also fill out the section below showing their workers'compensation policy information- Homeowners j t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under.Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signafore: /3 Ore~ Date: 44/ 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. Putsuant 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,constriiction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to,construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability.Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. _ City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant ; that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current e policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the . applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc-)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us`a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations / 600 Washington.Street Boston,MA 0.2111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 vvurw.n ass..govfdia 5993 _ ' Date.................................. 1 t NORTI{, :i TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACMUS� :% i . ...... This certifies that .� •4::�-'......... ..<.�.:�.,...-w...�.�...................-f.. -F... has permission to perform wiringin the building of............................... ..... ... ........................................... at........................................................../...... ............. ,North Andover,Mass. 11 Fee ...... Lic.N - 6�b.. ............... o. _._..kt �cf-�!..................... . ELECTRICAL INSPECTOR t rh Check # �1 4� otfical use unly P - Na s13 J. PAY �� � { �f► Occupancy&Fee Check r BOARD OF FIRE PR- FVENPON REGU ATIONS.627 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM! ELECTRICAL WORK A! F.cn 3c to be W etfcrrnad in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print In ink or type all inforrrt•tion) Date To the Inspector of Wires: Town of NOPth Andcavor The undersigned applies for a parmit to perform the ek:\Arical work described below. Location(Street&Number {(3 Owner or Tenant Owner's Address_--U 1 '17 Is this permit in conjunction with a building permit Yes ❑ No ❑ (Check Appropriate Boa) Purpose of Building_-- Utility Authorization No. E)dsbng Service Amps . -- c" Overhead ❑ Undgmd ❑ No.of Meters New Service _:Amps Vaits Overhead ❑ Undgmd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Velork Total No.of Li hong Outlets No.of Hot fuse No.of Transformers KVA i Above ❑ In ❑ Generators KVA No.of Lighting Fbdures Swimming Pool grnd ❑ and ❑ No.of Emergency Lighting No of Receptacles Outlets No.of Oil Bumers Battery Units No.of Switch Outlets No of Gas Burners FIRE ALARMS No.of Zone Total No.of Detection and No.of Ranges _ No of Air gond Tons Initiating Devices Heat Total Total No.of Diposal ,� No. Ponos Tons ICVd No.Of Sounding NoJ of Self Contained es No.of Dishwashers Space/Area Heating KW Detection/Sounding Dunces ❑ Municipal ❑ Other No.ofDryers HPatin Dg ovi�-es KW Local Connection - No.of No.of Low Voltage rx No.of Water Heaters ^KW _ Si ns — Bailases win' No.Hydro Massage Tuda — No.of Motors Total HP _ OTHER: INSURANCE COVERAGE. Pursuant to ttne req_:ieerri-eWs of Massachusetts General Laws 1 have a current Liability lesurarca Policyie:cludi ple ed Operations Caveragc or its substantial equival �YESS NO =have submitted valid proof of same to the Offe f•�' NO = if ycu have checked YES please indicate the tyerage by checking the appropriate box "O INSURANCE = BOND = OTHER = (Plea. ifh�—_ -- (Expiration Date) rtm Estimated Value of Electrical t5lgrtcs—l ------ Rough Final t Work to Star /({^_��� InspectiOn Date Rosgpested - 9 Signed under the Penalties of P� LIC.NO perjury: ^ - FIRM NAME _� �`'' - _ ! _LIC.NO. f_i�ensee �..`"'C �s'�.1..�_1—�_ c/ � ._—__.�.�__._Sic�nTture — �• — Eus.Tel No. 7lI y��—d��� Tal.NO..�s�'`�=7 7/, ,Rddress 6 'V — OWNER'S INSL`ZANCE W:��VFCt: i a^�.c:;::'2`!:a!t'..e:_!can s eror5 rest hate iht:Insurance cove!�:js or its substantial equivalent as required by Massachusetts tag eea!Laws.Ancl tI:?t r.:i s°�n..lcer�:,,:':.`.•s <r"`e,�plicatlun w ivy thL.tit`c;ufrernent. Ovrner 1t;en! (Please Check one) (Signature �e7r of n•,v:eer Or f: — — -- — -- Telephone No._ __PERMITfEE b . Official Use Vnly Pefrttit Na te,�yrt t Res S440 Oecupeney&Fee Checke> BOARD OF FIRE M.EVENT!ON REGULATIONS 527 CMR 12:00 O APPLICATION F-OR PERMIT TO PERFORM ELECTRICAL WORK Ail V:��to be performed in accordance With Massachusetts Electrical code 527 CMR 12:00 (Please Print in ink or type all Infonwiioti) Dante To the Inspector of Wires: Town of North AndovOr. The undersigned applies for a permit to perform the electrical work described below. Location(Street&NumbeI Owner or Tenant > n G., owners Address `'� ` `` Is this permit in conjunction with a building permit Yes ❑ No ❑ (Check Appropriate Boot) Utility AuthoriI No Purpose of Builth Eoosting Service Amps Vans Overhead ❑ Undgmd ❑ No.of Meters New Corvitp —� Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed tElectrical Nlork (� iw� o U� ` Lift p w�R- ten.. �y�dl-C �C-Vt Yr Total No.of Transformers KVA No of Lighting Outltse - No,of Hot fuse Above ❑ In ❑ No of Lighting FUGuresSwimming Pod grnd ❑ rnd ❑ Generators TNA No.of Emergency Lighting O No.of Oil Bum Battery Units No of Receptacles Outlets _Switch Outlets No of Gas Burners FIRE A No.of Zone No.ofc Total No.of Detection and No of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No.of Sounding No.of DiposaI r No. Pum s Tons KW NoJ of Self Contained No.of Dishwashers Space/Area Heating KW Detection/Sounding Devices ❑ Municipal ❑ Other No of Dryers Heating Devices KW Local Connection NO.Of No,of Low Voltage No.of Water Heaters KW _ Signs Bailases Wiri No Hydro Massage Tud^ No.of Motors Total HP OTHER: INSURANCE COVEf<AGF. Pursuant to the req:rirernori&s of Massachusetts General Laws 1 have a current Liability Insurance Policy ir,ciudi pleted Operations Coverage or its substantial equivai t NO = ate bort have submitted valid proof of same to the (-, NO = if you have checked YES Please indicate WW ttife o coverage by checking the appropriate INSURANCE = BOND = OTHER = (Ple , 'M (Expiration Die) 6-4 Estimated Value of Electrical Work$ J -t°�—_ Rough Final Work to Start s- �# _� nnspectl+gin DAts Rosgtrested Signed under FIRM NAME the Penalties of - ���. LIC.NO LIC.NO. 3�'G+��G _Signature taus.Tel No. 7 S/ — '/��—6��S �.—11—� S._ _ Alt Tel.No. 9V 2 9 -t. !'7 & 7 4. — Address SO N s, OWNER'S INSURANCE 11.,:VlrR: 13M a E*'::tt('^!_lcen does no! hays it*.Insurance coverage or its substantial equivalent as required by Massachusetts OGpfEerBi Laws.And that,.. Cnctu&ar r^. ya.icatiun we.vus this rK..utrenserrl: Owner Bent (Please Check one) (SlgnatureofOwnerorA3enti Telephone No. __PERMITTEE S 0 a — f� 0 Date. . . . . . . . . . NORTH TOWN OF NOR T,}i ANDOVER p PERMIT FOR PLUMBING i �SS�CMUSf� This certifies that'. has permission to perform plumbing in the buildings of . . . . . .V--I. — � "X/. . . . . . . . . . . . at . . . . . North Andover, Mass. ... . . . . . . . . . Fee S` -Lic. No.. UMBIN N_ ECTO Check # �c3.�� 8254 r =� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS f`J?Z S /Prn S7� { // Date Building Location Owners Name �/� $ h(� Permit# G�52r/ / Amount Type of Occupancy re S j cJey`Tr eL. New Renovation ReplacementUJPlans Submitted Yes No FIXTURES W w x c4 0 `n U c x w w E:• a � q q a 1EFLOCIR 3M lLOCR 4M FL M M FLU R 7M NLOM sl��t (Print or type) // he Check one: Certificate Installing Company Name 1 il QYI P 6- ❑ Corp. Address '?5 ROC 1110,�a, -y 11L[Y Partner. �. nc�D►'tC�n�T c /�C/f n of Business Telephone / ) 3 (I g f 0 I © Firm/Co. Name of Licensed Plumber: r"A vt L4 p Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy � .Other type of indemnity Bond ❑ Y Insurance Waiver. I,the undersigned,have been made aware that the licensee of this appli threeinsaance cation does not have any one of the above ta Signature Owner ❑ Agent I her .y 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 t MasfuO tate Plumbi Code d Chapter 142 of the General Laws. By: ignense erTitlembing License City/Town icense Numoer Master rM Journeyman ❑ APPROVED(OFFICE USE ONLY The Commonwealth of Afassachusettr i Department of Industrial Accidents -- �#��-� ! dffice o,f InvestiQationc L b sa GDO raskington Street i Boston, MA. 82111 c i Workers' Compensation www-ft ass gov/dia . Insurance Affidavit: Builders/Contrat / corsEiectriciaas/Plambe Applicant Information rs Please Print Leeibl NMO (BusinmOOrganirafiorOndividual): Address: City/State/Zip: Phone# . Are you an e1Rpl0yer4 Cbeeklbe appropriate box: 1•❑ 1 lira a employer with 4 Type of project(required):' ❑ lama ---__ general contractor 2.❑ employees(full and/or part-time).* have hired the sub-eontracors �. ❑New construction I am.as ole proprietor or partner- listed on the attached sheet 3 7• ship and have no em to ees ❑Remodeling employees These sub-contractors have 8. Q Demolition working for me in any capacity, workers' comp.insurance. [No workers'comp.insurance 5. ❑.We are a corporation and its 9. ❑ Building addition required.] officers have exercised their 1Q•❑Electrical repairs 3.❑ 1 acct a homeowner doing all work right of exemption per MDL 1 I. °r additions Myself[TIo workers'co 0 Plumbing repairs or additions insurance uired. .t c t52, §I(4),and we have no 12. Roof •employees. [No workers' ❑ tepaira comp. insurance uired. I317.pmcr ;Any iicartt that aPP wits bo><<#t must ais t o fill out the section below sh ' Homeowners who sohmit this affidavit indicatingthey andoing an work B their workers aompensatiori porky infortnatiori 3Ccnft t w that ch °i g and then hire outside contractors must submit a new affidavit indi i ark this box must attached an additional aheot showing.Etre name of the sub-crontraetors and their workers carap. �6 such. alit . pork;•information. an employer thi it Prolddrlrworkerr'compensation insurance or in,formation. .f m'en3P10ye= Below is the policy and job site . Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: Attach a copy of the workers''comt C"t�zm pensation policy dechtratioo Page(showing the policy number add expiration date), . Failure to secure coverage as required under Section 25A of MGL C. 152 can lead to th fine up to$1;500.00 and/or one-year imprisonment,as well$s civil e imposition of criminal penalties of a penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 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 rage coveverification. _ Ido hereby cer gry under the pains and penalties of perjury that nrn�uttionrn be f p vided above is[rue and romed Si Lure: Date: Phone k OJ j`JCW use a*. Do not write in this area,to be cnmpler d or town.o by city ffui City or Town: Permit/License# Issuing Authority(circle one): L Board of Health 2.Building Department 3.C' /Town Cl ark6.Ot6er 4. Electr' cal Inspector or 5. Plumbing Inspector Contact Person: Phone#: Information a. end Instructions Massachusetts General Laws chapter 152 requires all emp 3oyers 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,men ciiatian,corporation or other imgal entity,or any two Or MOM of the'foregoing engaged in a joint enterprise,and includia-ig the legal representatives of a deceased employer,or the receiver ortntatm-of an individual,partnership,associatioin or other legal entity,employing empioyees-.'However the owner•of a dwelling house having not more than three apa--c=ents and who resides therein,or the occupant of the dwelling house of another who employs persons to do maizttenimce,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of snob employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state os-focal licensing agency shall withhold the issuance or renewal of license or permit to operate a business or *o construct buildings in the commonwealth for any applicant who has not produced acceptable evidence-of compliance with the insurance coverage required." Additionally, MOL chapter 152,§25C(7)states"Neither the commonwealth nor airy of its political subdivisions shall enter into any contract for the performance of public work until evidence of compliance with the insurance requirements of this chapter have been presented to the cordaacting authority" . Applicants Please fill out the workers'compensation.affidavit complf--trly,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es).s.nd 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,arc not requred°to cavy workersco=npensation 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 Ere 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,pleawcall the Department at number listed below. Self:w-Lcrired c�olnpn;--s_hoLlid en+--th* self insurance-lieense number on the'appropriate,Ime. City or Town Officials Pie=be sure that.the affidavit is complete and printed legibly. The Department hes provided a space at the bottom of the affidavit for yoir to fill out in the event the Office of lnvestigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which w-iII be used as a reference number. In addition,an applicant that must submit multiple permit/liomm applications in any given year,need only submit one affidavit indicating,current policy information(if necessary)and under"Job Site Addr-ew"the applicant should writz"all locations in (city or town)."A copy of'tbe affidavit that has been.official3y starnped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for f to m permits or licenses. A new affidavit must be filled out each year. When a home owner or citizen is obtaining a iicerrse or permit not related to any business or commercial venture (i.e. a dog license or permit'to bush leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of lmdustTial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TeL #617-727-4900 ext 406 or 1-8-77-MASSAFE Revised 5-26-05 Fax 4 617-727-7745 www.mass.gov/dia Date. .lQ.//L� ��'l, . .. . . .. HpRTM iy� ?pya„ao ,e�1,o 3 TOWN OF NORTH ANDOVER OYER O D 40 PERMIT FOR GAS INSTALLATION s h SA US This certifies that . . 4 i.lea//.ral- �,/�!`'� has permission for,gas installation . . . .r. .. . . . . . . . . . . . . . . . . . . . . . . in the buildings of . . jij�t�, , , S 1��,� .. . . . . . . . . . . . at . . . . . . . . . . . .. North Andover, Andover, Mass. Fe 30C, �� . Lic. No.� .5 �l'. .f . . . . . . . . . GASINSPECTOR Check# 6957 O MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations 1132- S a/e.,n Permit# Amount$ Owner's Name - / New© Renovation Replacement Plans Submitted U . v z zO w ° Oww Uz M �-116 n PW wz > G z > OOz z U > xx o SUB-BASEM ENT B A S E M ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR I5TH . FLOOR 6TH . FLOOR 7TH . FLOOR ST H . -FLOOR (Print or type) � Check one: Certificate Installing Company Name M A r%,t e l Lg u re-n Gl D 1:1 Corp. Address _9 5 fR OCk1nahQrn Rd L.onQ�on orru. El Partner. Nh4 03053 business Te ep one L&03) Z 3 y- _ _ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have.a current liability Insurance policy or it's substantial equivalent. Yes 0 No If you have checked yes,please indicate the type coverage by checking the appropriate box. 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 Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Cignature of Owner or Owner's Agent —]Owner Agent Iereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the sof my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in ` e with all pertinent provisions of the assachuse State Gas Co khapter 142 of the General Laws. ignature of Licensed Plumber Or Gas Fitter ®` Plumber /3 Y-33- [3 Gas Fitter License.Number © Master �-E USE ONLY) Journeyman • �••.� ��r�rrtC1/2W�LLLI`fi Of 1iIQSSaCF!llSeL'td' I l f DPP�nt of.fn�lustrial Arrident�' 0-IOI —e of Investi;afiorrs r 600 XC=iiin,.,on Street Boston, AL4 ,92111 Workers' compenation ins' ""H'_�ss,0Vv/dia . ' nIicant Information ursaee Af�iciaviLSuers/Contrac£orsoecfrici$as/Pinmir-rs ' Piease Print L NBIQe(Sttsincss/p i onnndividoaf)' /�/t e�Ibf Address: 9 3 /2pc CityLStatr/Zag• Phew Are yon as empEoYer•1 Cbeak.the appropriatez; I: I am a employer with 4. ❑ 1 stn a- Typo of project(regairm):' employers(fail and/or * boners/contractor and I - ) have d the subs-eortiza 6 . El carisbmc6on . 2.[]I am.11sole.praprietor or Pier- iistad ship and have no employees . Thome°n the attached sizeet x 7. []:Remodeiigg working fior me ar sub-co w have [No work='co �'�anm workem, comp insurance. 8' Q Dsmolition- mp.iasurarsce.. 5. Q We ars a cm ==ion and its 9' El Bw7ding addition ���� 3•❑ I am a homeowner doing all work ri have exercised weir !0•❑Mectrical repairs or additions myself[No•warkis, of exemption per MGL 11.0 Plumbi sraP' LS2, §1 4''and•we have na nS t centra or additiam merrce•regnirrrd.]'t °mPjcrye+es [No work=' 12.[]Raofr pairs ;Any applioamtc �P• irisursncerequired.,) 13.[].Otirer' checks bot"!F must abro Fitt ottttbe srfion below showing theirwotkert'is fi°me°wuet€a�ho sabtnnit @tis stn iavit indit.•e ng prey an doing am onq--tion policy iu{ Cartnactots that Abe*LF b b,,must �"��'erYd then him owside conuaetuty ouist +eeir sn additiooai sheertdtowing tEte netne 6ft1>w att- �and submit a new affidavit indiadi,such I On.an � fir irlf0 --�.N lE'�f1OVla'tfla:101 1 Insra'ance Company Name: Pormy#or Ser-inn, Lic.#: Sob Site A driress: E7`-{'nai'°rt Date Attach a C . copry of the workers, ca,ut floc nY�»lZrp. Pew do . Pow'declaration Failur a to secw a coverage as required under 5rc�ion?SA of P (sbowra4,the poi<cy number and e fine to i�iGL c. i 52�n lead to the' . xpirafioa UP 1,SDQDO and/or one-year lead as weir a_s civrl rmpasition of mirnirral Potahim of a. Inve�sti tD S2S0.00 a day agairist tine violet r. Be advised first a c of izes m the,form 0111 SMI WORK ORQ£R and a fire gabOns of the DIA-for insurance coverage verification, Cement May be forwarded to the Office of I do her d5,certify render the pains acrd periaifiw of perjw-y tYt�the irrfarmatioa provided abm�e jrd�and eor>r� 5i Phone#: Date: Oficial use only. Dv not.write in&ir �r41n he Ma ptera r by or town official City or Townc issuing, Pertait/L:icanse# Autho i rrfy(circle one): 1. Board of Hesttb 2 Bmilriing Dapr$r•Ement 3. ' 6.Other Cn•3'lT own Clerk 4 E Iectrical I asp,or S. Pluatbioe InspectDr Contact Perron• Phone#: information & fict instructions o, Massachusetts General Laws.chaptcr I S2 mgt&m all amp Ioyats to provide workers' compensation for thou employcts. Pursuant to this strditte an " v fn ee is defined as ...a in the .. .-- emP J' a s^rvice of another under contract ofh' �' Pin � �, r mss or implied,oral or writt.-n." I' An empiaper is defined as"an individual,pertnership,association,corporation or other legal entity,or any two ormore, of thelarm-ping engaged in a joint enterprise,and includi"g fat legal rapreer�tives of a deceased amployer,brtht receiver errbmstee-of an individual,partnership,asaocia6C>ia or other legal-antity,employing employees.'Howemthe owna,of a dwelling house having not more than three apas-trn=s and who resides therein, or the occupant of 6e dwelling house of another who:employs parsons to do me_-ante n=ce,oonsnuction or repair work as such dwellinghouse or on the gtounds or building appur(cr=thereto shall nart bezzust of such craployment be deemed to be an employer." MGL chapter !52,§?5C(G)alp states that"ovary state err locaF 6ecFang agency shall withhold the issaanwor renewal of a;license or perk to operate a busies or to construct bail mp m the commonwealth fiv any appficaut who has not produced mmeptabte evidence of mmpfsanc a wj&tbe.hma rance.'coverasae faired" . . Additionally, WOL chapter I 5§25C(7)states`Neither t,o commonwealth nor any of its polificgl subdivisions shall enter i= any contract for the ee of public worie MU1•sccepfaiik mdanux of compliance with the instm= requirements.of this chapt cr have been presontea to.tim COt13actiri9 au a rity." kppiicaufa Please fill out thio workers'.=npcnsation.affidavit oompic—tely,by checking the boxes fist apply to your situation and,if necessary,supply suircontractor(s)name(A. addr=ss(cs):Arid phone numbet(s)along with th'rartifuete(s)of inarasazice. Limitad'Liabik Companies(LLC)or Limikea Liability.Parinerships(LLP)with no eraployecs othertim the members orparincrs,arc not requir to carry workers'ccibirip=mdjan insurance. lfan LLC or LLP does have ompioyees,a policy is required. Be advised that this afncIavi<t only be submitted to the Departmanb of Industrial A=idm= for confirmation of insurance coverage. Also.13we sore m sign and date the affidavit The affidavit should be returned to to city or town that the appfi=iion for tie pearnif.or license is being requested,notthe Depw tmam of Industrial Aceidants. Should you have airy questions.rePw%iing the law or if you am requined to obtain g workers` oonipensation paGoy,please-call the Department at tic'nvoMber.fisted below. Self insured mmpani&-slr_uid enter their self'insurancc•Ficmrsc rurnabw on tiso'sppr oprism ruff. City or Town Otficials Please be sure that the affidavit is compleft and printed 6gibly. The Department has provided a space at the bottom of ffm affidavit for you to fill out in the event the 0bnctof lnves€igaiions has to contact you regw-&ng the applic mi Please be sure to fi71 in the permit/license number which w-M be used as a reference number. In addition, an appiicard that must submit multiple permit/liccOnnse applications in arsy given year,need only submit one.af &vit indicating-currwn policy,information(if necessary)and under"Job Site .Addy-ass"the applicant should write"all inions in (city or t %rn)"A abpy ofthe affidavit that:has betm.officiaily stamped or marked by The ck or town may be provided to the R pplicant as proof that a valid affidavit is on n-ie for fug permits or licenses. A new affidavit mug be Med out each year. Wheal a home owner or citizen is obtairring a Iicexrs= or p=it not rchitcd to any business or commercial VMture (Le. a dog license or permit to bum Ieav=art.}Said Pml;&n is NOT.mquimd to-completz this affidavit The Office of Investigations would Ii'3ce to than[c you in advsaice foryour eoopi-ration and should you have any questions, please do not.hesitate to give us a call. { Tim Department's address,telephone and fax number. Me Commonvimmltil of Massachu Dcpart zreit of lmduqtraI Accidents Office-Of Eavcsdgafians _ 600 Washington Strict Boston, MA t?k2111 Tel#617-727-4900 i=406 or 1-977-MASSAFE Fax 9 61 7-727-774 lLvised s-25-Q5 www.mass.govidia x Date. ` ........... A NORTp, TOWN OF NORTH ANDOVER PERMIT FOR WIRING �,SS^CMUSEt This certifies that--��'� / _......... ....................................................................... Vr has permission to perform.�-�.-'.—...-:.c....;...:c.......:-:,..............�:.,......... �:.................. ,.. �,.�srmg/in the building of.................� .-:��?::�'..:��:-C............................... at.... . -r'.....:.....< .... ............... .. North Andover,Mass. Fee�1�U............... Lic.N���.7��1�. `. ..�......... ............... ........... ...::.. ! ELECTRICAL INSPECTOR Check 9069 .. Commonwealth of Massachusetts Official Use Only 0 Department of Fire Services Permit No.- 90 9 Occupancy and Fee Checked 7t' BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC) 527 R 12.00 (PLEASE PRINTININK OR TYPE ALL INFORMATION) Date: �J �� 9 City or Town of: NORTH ANDOVER :�" To the Inspe or of Wires: By this application the undersigned gives notice of his o her intention to perform the electrical work described below. Location(Street&Numbbe ` �— Owner or Tenant Telephone No. Owner's Address p Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service '?bO Amps ,!��,29( Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Und rd g ❑ No.of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: .4�e p, s om leti of the followin table may be waived bV 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- o.o mergency ig g grnd. rnd. ❑ Batte Units —. No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones t No.of Switches No.of Gas Burners No..of Detection and Initiatin Devices on . No.of Ranges No.of Air Cond. TotTs No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems: No.of Water No.of No.of Devices or E uivalent Heaters KW No.of Data Wiring: Si s Ballasts. No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Eq uivalent I ' Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal.policy) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pgzns and penal ' sof erjury,that the information on this application is true and complete. FIRM NAME: -C LIC.NO.: Licensee: �'ja� s; Pte- Signature LIC.NO.:/�Q3U (If applicable..g rte"xem in the ice a mber1ae.) Address: ���r��4i— .S'o•-� O, � Bus.TeL NViod *Per M.G.L c. 147,s. 57-61,securitywork re es „ „ Alt.Tel. q eparhnent 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 Signature Telephone No. PERMIT FEE:$ 4Y The Commonwealth of Massachusetts ki 1 Department of Industrial Accidents Office of Investigations tsVU 640 Washington Street Boston, MA 02111 wwx.nzass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers kc plicant Information Please Print Le—vibly Name(Business/organirafion/Individual): Address: City/State/Zip: Pbone #: . Are you an employer?Cheek.the appropriate box: 1.❑ I am a employer with 4, FE]Remodeling ject(rewired): ❑ 1 am a general contractor and Iconstruction employees(full and/or part-time).* have Dred the sub-contractors 2.❑ 1:am a.sole proprietor or partner_ listed on the attached sheet, t ship and have no employees These sub-contractors have 8. Q Demolition working for mein any capacity, workers' comp. [No workers' insurance. g ❑ Building addition comp. insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.[] Plumbing repairs or additions myself. [No-worke'rs'comp. c. 1.52, §1(4),and we have no 12. insurance re uired. .t ❑ Roof repairs q ] employees. [No workers' 13_n mer comp. insurance required_] 'Any applicant that checks borf 11 I must also fill out the section below showing their workers'''compensation policy information, t Homeowners who submit this affidavit indicating they are doing all work and then hoe outside tnuKors must submit s new affidavit indicating such. con xContraetors that check this box must attached an additional sheet showing the I- a of the subcontractors and their work='comp.policy infomradon. 14M an employer that is.providing:workers'compensation insurance for my employees. Below is the information. policy and job site Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a- fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a.co of this statement ne py t may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct L Signatore: Date: Phone#: Fi-cial only. Do not write in this area,to be completed by city or town official n• Permit/License# hority(circle one):Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbin Ins g pector son: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, (� express or implied,oral or written" An employer is defined as"an individual,,partnership,association,corporation or other legal entity,or any two or more of the'foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association orother 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 numbers)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. 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 app.Eication for the permit or license is being requested,notthe Department of Industrial Accidents. Should you have any.questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which Nn,ilI be used as a reference number. in addition,an applicant that must submit multiple permit(license applications in any given year,need only submit one affidavit indicating current policy information(.if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT.required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. wt The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel.#617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-770i rvww.mass.gov/dia e