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Miscellaneous - 114 COACHMANS LANE 4/30/2018 (2)
114 COACHMAN'S LANE 2101064.0-0061-0000.0 I 7 7 b G Date.. .� . - . .. .... HpR TIy pf o? TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION • p9 • ,no•�� Sy SACHUSEt - This certifies that . . .T->.'AqG! has permission for gas installation .fie-(?��-�-. . .al.Y 4 . . . . . . . in the buildings of �V.e . . .I : �. . . . . . . . . . . . . . . . . at Ji It. 5. . .� n. . . . . . . ., North Andover, Mass. Fee.,S.,' . . Lic. No..l GAS INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING Cityfrown:1V (J'r/✓ MA. Date• A0 I'Permit# Building Location: 114 r-6126hdW4�1 dil Owners Name:A/ Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential [� New: ❑ Alteration: ❑ Renovation: ❑ Replacement: Plans Submitted: Yes❑ No❑ FIXTURES U)Lu vi Lu U) = F m 2 O W W 0 U) FN- O = W W Z z q Z F) � w W R O I— O u5uj U) w m 0 I— W O Q I— O q W U9 V W W � Z ~ _ W H 0 = 1i Z W Z > U W Q O J W N W N z W O j Q d' W W m > O Z O W Z Z W Q F a C G u. 0 0 z z g O a � m I— > > > 3 O SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3KuFLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 -FLOOR 8 FLOOR Check One Only Certificate# ►'' Installing Company Name. �- orporation Address: ity/Town: State: ❑Partnership Business Tel• Fax: ❑Firm/Company Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: I have a current liabilitv insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes[�o❑ If you have checked Yes.please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Othera tYP of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Acient By checking this box❑;I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State PI u ing Code and Chapter 142 91 he General Laws. By Type of License: ❑Plumber Title �❑�Gter Fitter a ure of Licensed lumber/Gas Fitter Ly'Mas C' gown ❑Journeyman License Number: 9(JO APPROVED OFFICE USE ONLY) ❑LP Installer ' G Fire&Water—Cleanup&Restoration`' SERVPRO of Billerica/Tewksbury 978.663.9833 SERVPRO of Lawrence 978-688-2242 SERVPRO of Lowell -s 978-454-7577 SERVPRO of Salem/Plaistow 603.893.9700 SERVPRO of The Andovers 978-475-1199 Toll Free 800-535.6322 3 Like it never even happened.® Independently Owned and Operated Date.. � A 40RTH pfto ,°bhp 1 3� �` TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION �9SSACHUSEt n This certifies that . . . . ? t' . . . . . . . . . . . . has permission for gas installation,-!4-7'5 ... :. . . . . . . . . in the buildings of . --p,. . . . . . . . . . . . . . . . . . . . . . . . . . . at - -� --:-: ,, North Andover, Mass. Feer''-.. '. Lic. No.�i4/i. . . . �. �j �. . . . . . . . . -GAS INSPECTOR Check# X. 47 d5 6943 MASSACHUSETTS UNIFORM APPUCATON FOR PERMTI'TO DO GAS FITTING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations �l ���%�.v,�.Ow�-a Permit# Amount$ - ctr- Owner's Name New❑ Renovation Replacement �' Plans Su miffed x w w w O U M H x x m ~ a H H z z c z w OF � d x v w z d o W C7 F Z F d xi �" W VW, W W F °w F �; 0: W > W F" i v1 WOcq z O Z O rA .= x O x 3 C U J U a > q a F O SUB -BASEM ENT B A S E M ENT IST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8-T H . -FLOOR (Print or type) / P _J �[�/ Check one: Certificate Installing Company Name v�/?`%LLL M Corp7` Address (�v !�� El Partner. 77smess'la ep one ` 7 R` Z ® 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 Er No❑ If you have checked Les,please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 13Bond 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 a I hereby certify that all of the details and information I have sub 'tted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and inst atio pert ed under Permit Issued r this appli tion will be in compliance with all pertinent provisions of the Massac se tate Code and C pter 142 o e Gener WIS. Signature of Licensed umber Or Gas Fitter By. Q Plumber Title City/Town ❑ Gas Fittericz ense N er [Master APPROVED(OFFICE USE ONLY) Journeyman ..r.....r��.�•eru7� ofA2=achugetts `�j • 1 D�'P° e1Zt Qf Industrid Accidents - �; 600 Nrashiugtnn Street B&SIOn, MA 62111 t' ? Workers' Compensation fnsitranee �W nssgov1&0 , A' 'cat Infflr�ation Aft d�srit: Briers/Coatr'acfors/EiecEricians/Piwmbers Please Print Leeibi NBIItB (Btisincsa/p�}�fion/Individua►)' • Ad�ress: City/S ta&21p: Phone k. Art youali employer?Cheek.the a . co regi PP P to•boz. I.Q I,am a employer p oyer with 4. Q I ata a general contractor Type of Pro1ed(regnimd):. 2.j] employees(full amdlar p�•* have Ind the s&rb- and I Z am.a.sole P cattt<acOrs 6• New const:action . Pe no m ar or partner. liste=d on the attachmd t 7. Ship and have no em I ees sheet Q'Rem ling warlring for me in P T'kt su&co cfty. ra have (No wod=,co , �' woricez' comp.insurance. g' Q Demolition MP nzstaars:x.. �. � We: are R.CDIpOsatiop and hS 9' Q Bw1ding addhim 3•❑ required.) Officers have exercised$heir 1 tiin a homeowner doing ail work 10•(].B}e,,.�cal rap or additions myself[No•warkiml of ecccmptu n per MOL 1!.�]Phrmb' P c 1 Z §I ¢• ► repaire or additions .t ( j,and we have no 12. .•emplcyexs:[No wad=, Q Roof repairs 'AnyappHc=thgr P• h1suran required.] 13.I].pther r#MC6 bw!#I mna eiso flit am ilhe r i:tjan blow ahovuieg thnirworkert'ii° action oi' 1 Fi°0WWUMF Who Mbmit this affw". ind SCaatractors that them.this bQx rnuatattaoh�to aft doing W° 'end bile nutaii cmtnacto� ey tnfornut�a ' I ire:: �' the Herne ai'+tdnvit � shaarsho submit a as easpfnyer rhe is flnattuttagCIc ;wo,.G..Y of the suh.cmttreotnrs end timir woricc�'ccs , •:icr,� arnwtinr_ �iatirarrae jor iup.entpJm,�; B�1 eW.h•.&C F" aadiob saw Insumnee C MPMY Name: Policy#or Self ins. Lie.#: Job Site.Ams: Expttatton Date; Attach a copy of the work.VCitylstntez�►P• mpeasataon paii¢y dxFaratioa page(showing.the policy Dumber and e Failure to seettre coverap as required under Section 25A of xpisation fine up to V1,500.00 and/or on�y,,,im 1vIC�L c. 152 can lead to the imposition of a�tirrat of up to 5250.00 a leo as wolf as civt'I penalises in the form of a Peres of a. �3 against tfte violator. Be advised that a c SMP WORK ORDER tail/a $ne investigations of the DIA-for ins ropy of this statement�,be forwarded to the urance coverage verincatifsn. OfFice of I do hereby certify under the pains acrd peaaliiz of perjroy Ah,,rhe ufonn�i°n Provided above h tragi and¢arr�i S7 :. Date: Phone#: 4fficial use o* do not write is this arm¢,rio he mmptemad by t*y or k►wn o,,�rc ( Csiy or Town; Issuingd Authority Permit/U=Wse# rtty(cirr.Ie one); I. Board Df K a! t6 1 SaifiRgf.Otber DertrtY170w n C ark 4.Efecrj-ical Ius r P� 3.PI um6' nig inspector asPedor CDRfBat Persair: e Phon #: lntormat on a r!C! Itstructions Massachusetts General Laws chapird 152 requims all emp Ioyars to provide worked' compensation for deco employers. to Pursuant to this statute,an ar*yee is defined as"..:every person in the service of another under any contract Aim, express Or.iinplie:d,oral or wriitzn." it An rmplayer is defined as"an individuzl partnership,asscxiation,corporation or other legal entity,or grey two armour of tine famping engaged in a joint enterprise,and includi"g the legal rcpr==n::6ves of a deceased employer,6r$e receiver ort u;ta-of on individual,partnership,"assockiain or other legal rarity,employing employees.'Howe=the owner-of a dwelling,house having not more than thr=apartments and who resides therein, or tine ocxupant of the dwelling house of another who,employs persons to do mxL:im= M,.construction orrepair wcirlt m such dwclhrghouse or on the grounds or"building appurienaat thereto shall oat b=au=of sucb ecaployment be d.,�-need to bo an employer." MGL chapter 152,925C(6)also states that"every state a>r;Drat 6censiap ageacy shall wi&hold the is=anceor renewal of a iic:ease or permit to operate a business or oto construct baiid'mp in the commonwealth for any app)tacaat who has qot produced acceptable evidena s-F easap ante wfdh the, asaraow coverage regained." A.ddkimliy,MGL chapter 152,§25C(7)states"Neither'tkie'oormnonwealth nor any of its polificgl subdivisions shall enter into arty contract for the.pmi'ormance ofpublic worms witil•acceptalile evidm=of cornpli n=witb tier insim M%Pnremerrts.of this chapter have been prod tn.tlz c:cxT*xc:tmg authority." Appliicants Please fill out Elie workers'.compensation•afndavit oompiatety,by checking the boxes that apply tn.your situation and,if necessary, Mpl3'sub-cotraactor(s)cffime(s add=s(rg):read phone numher(s)along with their cmrtife=*S)of insu� Limited"LiaMlity Companies (LLC)or Limited Inability.Parfnersliips(LLP)wkh no employees othe rune the memb=-or pmt=,arc not -to=my work='cflTnp=safim insaczce. Ifan LLC or-LLP do=have employees,a policy is mgiiired. Be advised that fhis affrcla*h may be submitted to the Department of Industrial .Accidents for confirmation of insuran::coverage. Aim*l)we sure to sign and date the affidavit. The affidavit should be returned urneed to the city or town best the appfim6im far the pandit or ti==is being requested,nottht Department of Industrial Acaidenta Should you have any quesEions.re g the law or if you are r mpimd m obtain a workers` oMpensation poHay,please tail the Dopar'ment atthe•nu tuberfisted below. So}f-iasurod comgaaiesslreceld entathe�r l' V "�;. self-insLZiitC CH==Humber an MSG 8ppr'oprlate'tire. City or Tower Officials Please be sure tisat the affidavit is comp}et and printed lrg-bly. Tho Departint hes provided a space ate botomn of the affidavit for you to fill out in.the event the Officc of Investigatiatts has to contact you regarding the appli=i Please be surato fill in the permittlicense number whid v+,-ill be used as a reference number. In addition,an applicant bear must submit multiple permit/jicensc applications in any given year,need only submit on:affidavit indicting-ciarent policy:informafim(if necessary)and under"Job Site Address"the appiicsntshould write:"all locations in (city or twn)"A copy ofthe afcidavit that has ben 056aily stamped or marked by tine city or town may be provided to the applicant as proof fhat"a'valid af8dMA is on Me for fug permits or licenses. A new afndavif must be fDed out each year. Wheys a home owner or citizen is obtaining a tic;ris= or p it not related to any business or commercial vwhse (.e. a dog li6m=or permit to bum leaves atc.)said person is NOT.r•equhd to.compiett this afndaviL Tho Oft=of investigations would Hice to thank you in ad%rw=for your coopbrzdon and should you have any quz ions, pleas✓do not•hesitate to give us a call. The DqurtmorR's address,telephone.and fax number. The CornmmyAetAlth of cliuseds IDcpartine of lmdustrW Accidm3ts Officeof ruveafiptions _ 600 Washington Street Boston, MA 0.2111 TeL#617-7274900 b t 406 or 1-977-MASSAFE Fax 0 617-727-7749' ftrvised -26-45 WWWMI2gP.gov/dia w Date.....`... ....................... NORTI� TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHU This certifies that(....:. ......................................................... has permission to perform ........................................................... wiring in the building of......./X .................................................... ........ ...........................U......... ... North Andover,Mass. ?5�............. Lic.No- Fee. P.Ale. . . ............. I�AL INSPWMR Check # 8776 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked U0 t 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(ME ),527 MR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION Dat � 2 D City or Town oh NORTH ANDOVER To.the Insp ctor o Wires: By this application the undersigned gives notice of his or her intention to erfotm the electrical work described below. Location(Street&Number) �p� ��- l�NZ Owner or Tenant / /4.1) 3 Telephone No. Owner's Address Is this permit in conjunction with a b g pe mit? Yes Purpose of Building �iN ,� fTX '%I 1 r NO (Check Appropriate Box) Utility Authorization No. Existing Service 200 ps �Jl I ��G olts Overhead ❑ Und d �' No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion o the followin table may be waived by the Inspector o Wires. No.of Recessed Luminaires j0 No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVp� No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming pool Above ❑ In- ❑ o.o mergency ig g d rnd. Batte Units - No.of Receptacle Outlets q No.of Oil Burners FIRE ALARMS No.of.'.ones No.of Switches No.of Gas Burners No.of Detection and Init'atin Devices No.of Ranges No.of Air Cond. TotTons No.of Alerting Devices No.of Waste Disposers /; P "._.__„.." . Heat Pum Number "Tons KW No.of Self-Contained Totals: - """""""" Detection./Alerting Devices y No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No.of WaterNo.ofo. No.of Devices or Equivalent Heaters KW SiMs Ballasts . Data Wiring: No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: `�j.y ©-0 Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of lectrial Work: /�J�J (When required by municipal policy.) Work to Start: 2 O Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE VE G : 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 ❑ (Spec I certify,under the pains a aloes o er'u th t the in rma ' n on this application is true and complete. IP 1 ry, FIRM NAME: / /!d.g iJ tg .•�'�-- Ct�� LIC.NO.: 2660111— Licensee: ,cam Signature (1f applicable, enter"exempt"in t e license number line.) LIC.NO.: O/Yj f !ti Address: Bus.Tel.No.:-e79-egS�-2-067 *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Alt.L cl.No. 3��"�L 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: ;-T6- ti r �. �, Y r' ��� .. r. �/ �J �/ .. Alk The Commonwealth of Massachusetts nitk- ( Department of Industrial Accidents Ogee of Investigations tiitig;h 600 Washington Street Boston, MA 02111 ' www.mass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lembly Name (Business/Organization/Individual); t 1 , (C Address: 'ZS- . 5 City/State/Zip: , Phone #: . Are you an employer?Check the appropriate box: I. 121 am a employer with 4, ❑ 1 am a general contractor and I Type of project(required): 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.t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me.in any capacity, workers' comp.insurance. [No workers'comp, insurance 5. ❑ We are a corporatism and its 9* ,❑-,Building addition required.) officers have exercised their 10.2 ftectrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions myself.[No-workers'comp. c. 1.52, §1(4),and we have no 12. Roof insurance required.]t ❑ repairs eq ] employees. [No workers' comp. insurance required_] 13.[]Other Any applicant that checks bort#1 must also fill out the section below showing their workers'compensation policy information Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors[fair check this box must flatbed an additional sheet show ii the name of the sub-ronteactom 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. V�5 Insurance Company Name: ee, Policy#or Self-ins.Lie.#: Expiration Date: V 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 e. 152 can lead to the imposition of criminal penalties of a- fine up to$1,500.00 and/or one 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�e�rt/ify�unQder the pains and aides ofperjury that the information provided above is true and correct 5i ture: (/��`(, o Date: � 7, O q' Phone#: X [FIssuinag only. Do not write in this area,to be completed by city or town official n Perwit/License# r hority(circle one): Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 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 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 cordractmg authority." Applicants Please fill out the workers'compensation.affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cavy workers'compensation insurance. if an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of industrial Accidents for confirmation of insurance coverage.. Also be sure to sign and-date the afdavit. The affidavit should be returned to the city,or town that the application 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 numberlisted 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 valid affidavit is on file for future permits or licenses. A new affidavit must be friled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT.required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel.#617-7274900 ext 406 or 1-8.77-MASSAFE Fax#617-727-774 Revised 5-26-US www.mass.gov/dia Date. �d._©1 "aRTM TOWN OF NORTH ANDOVER o� ,�.o ,•�tia PERMIT FOR PLUMBING 4 ♦ i ♦ � a t �7SSACMUS� This certifies that . . . . . .� `�"?" . . . . �` ',,`.:""/"�• • • • • • • • • • a has permission to perform plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . at . . . ! . �. . .�-* +: ��,, +-'- :�`. . . . . . .,.�North Andover, Mass. Fee. . .Lic. No. f PIUMBINGGNS�ECTOR Check # 8078 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS f / Date Building Location 1 y eo( 'C M 4,j Owners Name �� K (' C�r' Permit# 464-44 f S Type of Occupancy Amount New Renovation Replacement E] Plans Submitted Yes ❑ No FIXTURES Cr G H yy W v� U D a v� p rn o w z z a 3 a a z A W w x F U A Q x as SMlM IST IUM MHiOCIR of lit `i —5M qAOM 6M It" '7M IUM 9M HBM (Print or type) �^ Check one: Certificate Installing Company Name 71 uS 0 I'1 �N �-� Corp. V r 11 Address d tjb f/L /vl/L ✓L Q"Partner. 4v,,jc7Tl /N/\ 4 Business Telephone Firm/Co. Name of Licensed Plumber: uv Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond F Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance • Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge.and that all plumbing work and i tions /rformed under P it Issued for this application will be in compliance with all pertinent provisions of the Massachus tt Stat lumbi de Chapter 142 of the General Laws. By: igna ure of LMnsecium er TitleType of Plumbing License City/Town 2,2_0 -� 1 icense Numoer Master ❑ Journeymant APPROVED(OFFICE USE ONLY �Jv • - ..:. The Commonwealth of Massachusetts k� ! Department of Industrial Accident; tl Office of Investigations ia4tw GDD krashington Street Boston, MA 02111 www_nwss gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Eiectrir-ians/Pfambers _Applicant Information Please Print Leobty Name (Business/Orgsnizafion/Individual): A-Its V �J M 1 N (r-- L L Q ' Address: �O 0 i.J�J� �A /I /L City/State/Zip: 4/11 h /� G1�3� Phones'6 C�3 Z Are you an employer?Cheek .the appropriate box: I.❑ I am a employer with 4, T�of prep(required): j] 1 am ti general contractor and I el ployt:es(foiland/or part-time).* have hired the sub-corttractorsb Naw construction 2. m.a:sole proprietor or partner_ listed on the attached sheet.# 7• ❑Remodeling ship and have no employees These subs-contractors have workingfor in an 8 Q Demolition y capacity, workers' comp.insolence. [No workers'comp.insurance S. 9. []Building addition p ❑.We are a corporation and its required.) officers have exercised their 10•Q Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.Plumbing repairs or additions myself.[No-workers'comp. c, 152, §1(4),and we have no insurance re uired. t I2.0 Roof repairs q I. employees. [No workers' !3.[�.Other COMP. insurance required.] •Any applicant that checks boi t must also fill out the section below showing their workers'6ompensation policy information, t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit rndioatiug such ;Contractors that check this box must M! an add;•tioual shestshowing Ette name of the sub-contractors and their workers'cep p,po;ic.,infomration. I ant an employer that is providing:workers'compensation insurance for information. rrry.employee; Below i;the policy and yab site . Insurance Company Name: Policy#or Self-ins.Lie.4: Expiration Date: Job Site Address; City/state/Zip- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration da*4 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 Investigations of the DIA for insurance coverage verification. Office of I do her ( c un de the pains saand pe 'e5 of perjury that the information provided abo is true rorreeL Si owe: Date: S Zv d Phone74- E only. Do not write in this area,to be completed by city or town official n: Permit/License# thority(circle one):Kealth 2. aniltfi ung De rtment 3.Ci /ToPa ty vvn Clerk 4. Ekectrica!Inspector 5. Plumbing Inspectorrson: --- 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 ortustee of an individual,partnership,associatiori 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 appurtenerit 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 ite construct buildings in the commonwealth for any applicant who has not produced acceptable evidence.of compliance with the insurance coverage required." Additionally, WGL chapter 152,§25C(7)states"Neither t3he 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 compl4ntely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es),acid 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 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,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 numberlisted below. Self-insured companies shoL.Sld entertheir self insurance-license number on the'appropriate line. City or Town Officiais 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 be m.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.When a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a flog 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 as a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industdal Accidents i. 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#617-727-7749 www.mass.gov/dia Date.. 6!.... . . TN Of o� '`' �D I TOWN OFIN R H ANDOVER F S • PERMIT FOR GAS INSTALLATION h �9SSACHUSftt This certifies that.. ...�.... . .. .. . . . .1' has permission for gas install_ation._.... . . . . . . . . . . . . in the buildings.of . . . - err? . . . . . . . . . . . . . . at r!' . : ' !`' . . ., } orth Andover, Mass. Fee . Lic. No ///- GAS ItPE�WR Check#"�O e7 6786 MASSACHUSETTS UNIFORM APPLICA'MN FOR PERM TO DO GAS F1TI'ING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date 2 o d f Building Loqations / C04C�4 Permit# Owner's Name Amount S New Renovation Replacement ❑ Plans Submitted u ni U rA W, cc O 0 F Fa+ Z C p O Z O W O F H z = e x a c > w y 'o x z c14 z < a c c z w c sU B -BA x 3 o w S C7 SEM ENT .� U > a _ B Ao+ F O SEM ENT 1ST. FLOOR 2N D . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . .FLOOR. 8TH . FLOOR (Print or type) Name P�v M/rj I,.. L I—L Check one: Certificate Installing Company U r7 Corp Address /YI/LL c!£sf PIT3 ®Partner. usmess a ep one s L.� n E] Firm/Co. Name of.Licensed Plumber'or Gas Fitter 0 /�� o INSURANCE COVERAGE I have a current liability Insurance policy or it's substantial equivalent Checff If you have checked es please i icate the a cove Yes No� Liability insurance oli type by checking the appropriate box. p �' Other type of indemnity n Bond 13 Owner's Insurance Waiver 1 am aware that the licensee does ave the Insurance coverage required by Chapter 142 of the Mass. General Laws,and that my signature on this permit application waives this requirement Signature of Owner or Owner's Agent Check one: nt I hereby certify that all of the details and information I have submitted(or enntOwner ed)in above application a and best of my knowledge and that all plumbing work and ins tions p donned under Pe ' Issued for this application will be in accurate to the compliance with all pertinent provisions of the Massac usetts as Code 2h r 142 of the General Laws. By: 11n re of Licensed Plumber Or Gas Fitter Title Plumber City/Town, Gas Fitter ZZb J3 icense um er Master APPROVED(OFFICE USE ONLY) �/J'oumeyman The Commonwealth of Massachusetts wnt o Depart f Industrial Accidents. ,...,� Off1ce o 1;�.,y i , .f IrcvestiQatio ns 600 Wa sh in,01on Street ' Bostoez, hL4 0111 Workers' Compensation Insurance.A:�ficiavjt; guilders/Contractors/Eiectri " ci A Iicant Information ans/Plumbers Pease Print Leaibiv Name (Business/OrganizationMdivi dual): f y j 41 L Address: City/State/Zip: ✓ r- , r ol�1v Phone#: /��� ,�'�� 03k2— Are you an employer?Check the appropriate box: 1.01 .❑ I an a employer with 4. Type of project(required): IAM ---- ❑ I a general contractor and I Ployees(rill and/or part-time).* have hired the sub-contractors ❑ 2 I am a sole proprietor or '6• New construction partner- listed ori the attached sheet $ 7. [] Remodeling. ship and have no employees These st,t,b_contractors working forme in any capacity. workers 8 ❑ Demolition [No workers' comp. insurance �. [] We are a comp. insurahave nce. corporation and its 9 ❑ 9uilding addition required.] officers 3.❑ I an a homeowner doing all work right of xemptioner have exercised.their 10.❑El cal repairs or additions Myself. [No workers comp. c 152, �1 4 ��� MGL 11. Plumbing repairs or additions insurance required.] t O� a have no MPloyees. [No.workers' 110 Roof repairs comp• insurance required.] 13.❑ Other *Any appficant.thar checks box#I.must also fill out the section below showin 'iiomeowoers whu submit•this a,�idavtt in'licarinG U-jeg art Goitt•E.!! ,ya; g their workers'compensation policy lzrmation. tConuactors that ehcci;this box must attached an additional sheet showirt�t =. fn_n nrre out'&aonuaoiurs must submit a nnw amciat,ii inti n he ramp of the s rb connaetors and their workers'coin , such I am an employ Cr tl: 4s providing wor/ters'co ettsation i P Policy inionnat,on. information insurance for mJ'employees. Below,is theoft P cJ and job site insurance Company Name: Policy#or Self-.ins. Lid.#: Expiration Date: Job Site Address: Attach a copy of the workers' compensation tic decla City/Starr/Zip' policy . ration page(showinu the oil nu Failure to secure covers a as re Policy number and € required under Se expiration Section 25A of P state}. fine up to $1,500.00 and/or one-year imprisonment as well MGL c. 152 can lead to the imposition of criminal penahies of a of up to.S250.00 a da againstas civil penalties in the form of a STOP WORK ORDER and a fine Investigations of.the DIA for nsum. ce�overagedv nfi,arson.t a copy of this statement may be forwarded to the Office of 1 do hereb� ' , J u r the paint¢¢/nn��•��`e es of perjurJ' tAX the inform�n Prnvr'ded above true' Signature: �� �"'�� d correct r� Date: 2-0U Phone#: d S�2 0 3 2._ ofcial use onip. Do not write in this area, to be completed by city or town official City or Town;: Issuing Authority(circle one): Permit/License I. Board of Fiealtit 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing 6. Other b Inspector Contact Person: Phone# Information and Instructions c Massachusetts General.Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined.as"..aver-y 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 includirr.g the legal representatives of a deceased employer,orthe receiver or trustee of an individual,partnership, associati on or other legal entity,employing employees. However the owner of a dwelling house having not more than.three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maim--nance,constriction 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 a r focal licensing agency shall withhold the issuance or renewal of a license or permit,to operate a business or to construct buildings in the commonwealth fror'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 worllc 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-contra.ctor(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 maybe submitted to.tire Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. Theaffidavitshould 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 regm-rding the 1mv,or,if you are rcquirrd to obtain a workers' compensation policy,please call the Department at the nrzrnber:listed beloLv. Self insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the.$ftidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit foryou 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/liceme 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 starnped 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 burnleaves etc.) said person is NOT required to complete this affidavit. The Office of investigations would like to thank youin 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 far, number: The Commonwealth of Massachusetts Department of lmdustrial Accidents Office of lEzvesfigafioas 600 Washdxig•ton Street Boston, MA (12111 Tel 4 617-727-4900 e)-t 406 Qr 1-877-MASS.AFE Revised 5-26=05 Fax 0 617-727-7749 VuM'.Mass.gov/dia 1tM O'MOwT",y I�� ?•,..e ooh DirectorTown of W Main Street, 01845 '• X NORTH ANDOVER ��� BUILDING ...... ' CONSERVATION •° 8` DIVISION OF HEALTH PLANNING PLANNING & COMMUNITY DEVELOPMENT CHIMNEY APPLICATION AND PERMIT DATE to PERMIT #�' LOCATION �� C6 OWNER'S NAME I L . IS r BUILDER'S NAME MASON'S NAME MASON'S ADDRESS ,Gf ✓1 ��,/t�I�`` C �`�P/� MASON'S TELEPHONE r MA'T'ERIAL OF CHIMNEY C� INTERIOR CHIMNEY 2( AC_L EXTER�OR CHIMNEY 7S j,— NUMBER AND SIZE OF FLUES ' �) -� / Z - THICKSO ����SS OF HEARTH Will ch- rnney or fireplace conform to requirements/ of the code and have rules and regulations been received: DATE )U u, ` i t - . , �<J �TLR OF=, A - # �aS G� SON � *0V EST. CONSTRUCTION COST/CONTRACT / CT �i r PERMIT GRANTED �� - q6 FEE �v ROBERT NICETTA, BUILDING INSPECTOR / // z/ INSPECTED REMARKS SOLID BRICK REQUIRED THIS PERMIT MUST BE DISPLAYED ON THE PREMISES i MASONRY SYSTEMS INC 2 NEW ENGLAND WAY/AYER,MA 01432/800-343-1501/FAX 508-772-7456 f � S 31,C) 'D D V06 q� Leading Producer Of Concrete and Masonry Coatings Datec:9.. 40RT" TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING CHUS This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . . . . . . . . . .: . . . . . . . . . . . . . . . . . . . . plumbing in the buildings f o . . . . . . . .". I . . . . . . . . . . . . . . . . . . . . . . . )f . . . . . . . . North Andover, Mass. . . . . . . . . . . . . Fee . . . . .Lic. No. . . . . . . . . . . . . . . . . . . . . . - - -�P�1,6y-aIZNG INSPECTOR Check 6P3$ IVIAbSACHUSETTS UNIFORM APPLICATION FOR-PERMIT TO DO PLUMBING 4,?,3 / (Print or T pe) Mass. D to Building 20 Per It # C�Lr Loc tion - er' me !� f Type of Occupancy �.J New❑ Renovation ❑ Replacements Pians Submitted: Yes❑ No❑ FIXTURES B.P. # SEWER # SEPTIC # . N Z Z �-- Ln 0 z Ln ¢ } _ z z cn W w W u z CT m ¢ u7 . to tQ z ., z a w 0 w ¢ .N g ¢ o a Z ¢ > O v=i Ln D f— z a O z Z Y ZD w SUB-BSMT `� u' c� o ¢ 3 rr m o 0 BASEMENT 1S7 FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FL00 stalling Company Name . Check one: Certificate . idreas ❑ Corporation ,i Usines-. Telephone ❑ Partnership 'me oticensed Plumber or Gas Fitter tr- Firm/Co. NSURANCE COVERAGE: have a current ii bility Insurance policy or Its substantial equivalent, which meets the requirements of MGLCh. 142. Yes No ❑ f you have checked ves, please indicate the type of coverage by checking the appropriate box. ' liability Insurance policy l Other type of Indemnity ❑ Bond ❑ iWNER'S INSURNACE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 42 of the Mass.General Laws, and that my signature on this permit application waives this requirement. ignature of Owner or Owner's Agent Check one: Owner ❑ Agent 0 reby certify that all of the details and lnformatlon I have submitted (or entered)In above,appllcation are true and accurate to the best of cnowledge and that all plumbing work and Installations perforZcf ,,,r the permit Issued for thi a Ilcation will be In compliance with eminent provisions of the Massachusetts State Plumbing Codeel Law .Brtle of Licensed Plum er City/Town 4PPROVEb(OFFICE USE ONLY) Type of License p,I4ta�ster OJournsymari License Number--T2 3-3 BELOW FOR OFFICE USE ONLY y FINAL INSPECTIONS 4 PROGRESS INSPECTIONS Fla N0. APPLICATION FOR PEIIMIT TO 00 PLYMBINO RATE a TTPE OF II ILO1No LOCATION OF IMLOINO PLIII PIM MOT ORANTEO ` OATS .............If PLUMPING INSPECTOR