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Miscellaneous - 114 STONECLEAVE ROAD 4/30/2018
114 STONECLEAVE ROAD 210/104.B-013&0000.0 1 Qs 11654 OF NOprN,�O TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING CHU This certifies that..6..��R.A... ........ ....... ... ......... ....... .. ..... ..... - has permission to perform............. .................f..................................................... plumbing in the buildings of.............. .......................................................... at.....I gS6 uj....�,Cp, ........I................................... ................................................ North Andover, Mass. Feek.6..........Lic. No. . ................................................................................. PLUMBING INSPECTOR Check ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY . Iq w MA DATE PERMIT# /& JOBSITE ADDRESS / << S?a a t. OWNER'S NAME POWNER ADDRESS TEL 7A (p S?$' 7 VJIFAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL fl PRINT CLEARLY NEW: 9 RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES Q NO MI FIXTURES Z 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 GASIOILISAND SYSTEM _ --j! L—A__j 1 € — -___4 _ _I --II I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM I € € _ f €L.J _. € DEDICATED WATER RECYCLE SYSTEM 1 _._•___-� -__� ___ __ _ ( —__i —_� —�� ,_.__�( ____( _! DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN _( I ► [ J _ a __ v_ I _ ._ .-._-1 ( ____._1 INTERCEPTOR(INTERIORI ____-J _.. € __jj __j KITCHEN SINK LAVATORY _€ ._w-1 -! I _! ROOF DRAIN ! � �I —_ ! J 1 __...__I ._ _ _I _�€ f j SHOWER STALL [- _._1= __.. _ ___l __. _! SERVICE/MOP SINK l ____(1 I== f TOILET I ( _ __I URINAL I v__ WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES k_NO DI IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 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 0 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C� / p��, PLUMBER'S NAME 1 r I1M 0 k� LICENSE# F--7--391- I �i+Yr+� SIGNATURE MP 0 JP CORPORATION -.1#PARTNERSHIP®#®LLC #1 3 J COMPANY NAMEpcNJ< 11ADDRESS CITY -)STATE ®ZIP Iy/S/G 3 TEL FAX L CELL 302 01 EMAIL 13 7/ pq OP) r ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Z)/)Yes No i'�P .� �� ��O THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: PERMIT it PLAN REVIEW NOTES j The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 . '"t www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly t•' Name(Business/Organization/Individual): Lr ck Pi- �6C Address: 7 IW7 �L- s �s City/State/Zip: Aeop e,-ell o I Phone#: Are you an employer?Check the appropriaie box: Type of project(required): 1.F-1 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2-W I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 4.FJI am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.NPlumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ � 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must-attached an additional sheet showing the name of the sub-contractors and state whether or not,those entities have employees. If the sub-coriiractors have employees,they must provide their workers'comp.policy number. Iain an employer tfiat 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 MGL c. 152,§25A is a criminal violation punishable by 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.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 Si ature: Date: 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'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 burn leaves etc.)said person is NOT required to complete this affidavit. li The Departments address,telephone and fax number: The Commonwealth of Massachusetts ! Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Date..............I.Z.�P...� r t �NOarry TOWN OF NORTH ANDOVER o s PERMIT FOR GAS INSTALLATION S S i. sACHUs� IY This certifies that .......................................................�� �t{ . ......... .. ....... has permission for gas in tallation--. `'......` •Z ............................................... inthe buildings of.....f.. 1..! . ................................................................................ r at.......... .�..` .......- .?n p;c P J�-.....................North Andover, Mass. Fee...W).. Lic. No. . (�� r 10 GAS INSPECTOR Check# �(Uj� � . ' 68 M �- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY N• MA DATE �'a GPERMIT# (A JOBSITE ADDRESS !y S 6thi c-beae, OWNER'S NAMEI'►'�t lT OWNER ADDRESS TE )F 6-fr 4 7 Y3 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[ EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:El RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES E] NO APPLIANCES-1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER _ —T—� I COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR _ I ------ -- - - FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT 1_ OVEN (- POOL HEATER _ I _- ' ROOM/SPACE HEATER _ _ _ __ ROOF TOP UNIT J _ I _ TEST UNIT HEATER UNV NTED ROOM HEATER - WATE4R HEATER OTHERJ _ _ III_ __j INSURANCE COVERAGE v have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES ONO [� IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY (A OTHER TYPE INDEMNITY E] BOND Eil OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT SIGNATURE OF OWNER OR AGENT 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 II Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME lr�l� LICENSE#F5-3 sill SIGNATURE MP ED MGF El JP 29 JGF Q LPGI© CORPORATION©#=PARTNERSHIP®#©LLC H# COMPANY NAME: C�c�ck�c y /�L }-1 _ ADDRESSIN Y7 CITY ar PJ T� STATE ZIP D/�/ - TEL —moi 7F-x/.33 FAX q CELL 9 fid'•S oz oa EMAIL 80 chl-t' S _ yG "�6 • Co m - --- ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTIONAVOTES Yes No .S' THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of IndustrialAccidents 4 s 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNIITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): /3 cu C IS�C I Address: 7 ka I e 1 l6�— City/State/Zip: Pe,pugertft o/ Phone#: Vx/3 Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.�&I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself,[No workers'comp.insurance required.]t ❑4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.®,Plumbing repairs or additions 5.FJ I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.instrance.1 13.0 Roof repairs 6.FJ we are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other ` 152,§1(4),and we have no.employees.[No workers'comp,insurance required.] `Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submif 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-codtiaciors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurancefor my employees.•Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: I �f�1Q1' D A J City/State/Zip: 4 Oa1 J Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under thepains and enalties ofperjury that the information provided above is true and correct. Si ature: Date: oZ 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 x 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 lure, 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 bean 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts ' Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia 4 4 _COMMONWEALTH OF MAS ACFiifSETTS 'e o o - o 0 BOARD OF PLUMBERS ANQ GASFITTE;RS iIwSSUES THE FOLLOWING Lfi- NSE i I CE�t.SEO,: � A JOURNEY•.:,"1AN #?LUM8Ek•. "ALF: EW T BUCKLCY I101 � r 7 MOTEL .PL j i ';' <Z r� iw rPEREL MA 01463-1526 '. 1738. a5/o h/;6 -207N8 ALBUC-1 OP ID:JB CERTIFICATE OF LIABILITY I N S U RAN C EDATE(MM/DD/YYYY) 02/25/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Phone:978-433-2728 CONTACT Brown&Brown(Pepperell) Fax:866-848-6097 PHONE FAX P.O.Box 1497 A/c No Ext: A1C No Pepperell,MA 01463 E-MAILs: House ADDRE INSURERS AFFORDING COVERAGE NAIC# INSURER A:Liberty Mutual Insurance Co 23043 INSURED Al Buckley Plumbing &Heating INSURER B: 7 Hotel Place Pepperell,MA 01463 INSURERC: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR- POLICY EFF POLICY EXP LIMITS - LTR POLICY NUMBER MMIDD MMIDD GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CCP8104151 12/28/2015 12/28/2016 DAME Ea'occurrence MAGE ( RENTED $ 50,000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea acc dent ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITSI ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION TNORTHA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 146 Main St. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD T%ORT1y O t'LA D , O �� # I � A- # 79goA�no ��y.(y �SS.�cHus�� BUILDING DEPARTMENT Community Development Division February 9,2009 Richard and Joanne Adams 114 Stonecleave Road North Andover MA 01845 Re: Extension of Building Permit Please be a advised that I am agreeing to a six(6)month extension for Building Permit#172, issued on September 9,2008 and due to expire on March 9, 2009. This permit must be activated by September 9,2009. Please let me know if you have any further questions. Regard, Gerald A Brown, Building Inspector Cc:File 1600 Osgood Street,Suite 2-36 North Andover,Massachusetts 01845 Phone 978.688.9545 Fax 978.688.9542 Web www.townofnorthandover.com J y 1 ' J Richard and Joanne Adams 114 Stonecleave Road North Andover,MA 01845 January 30 2009 Town of North Andover Building Department 1600 Osgood Street Building 20, Suite 2-36 North Andover, MA 01845 RE: 1135 Salem Street,Map 106A,Parcel 44 Request a Extension of Existing Building Permit Dear Gerald A.Brown,Inspector of Buildings: On behalf of Richard and Joanne Adams,I respectfully request an Extension of our existing Permit to Build,which was issued on 09-09-08 and expires on 03-09-09. We were granted the permit to allow for the construction of a single family dwelling -On the 1.17 acre. Due to the state with the economy and finances the way they turned,we were unable to get the permitted house started. We therefore respectfully request a six month extension on this Permit. Sincerely Richard Adams ✓{y� DG Joanne Adams \` i i 1 tv 40O N RTN a Town Of Andover . 4 . . . .PERM,:IT To IL r� � o * over, Mass. 4 eresecww�c«ti��• a0AR1)Ol ftxdllCiti9teri no� ..... . � 1l�••.... 7.. .4.. .:f......... ................ ...... iuuxm Mt peraih fA erect...................................... `r �r ....,..' .......................... er= ett 0lli_� _ Rod ilii. �1l� 0� ! tl WAkO b ft>a et MM AUMM. p�, _ � 8,� �nn�-��� gum I V"ON a the bn"(r sun"Aepvwm il"Ifak M-, PERMIT E)GYMS IN 6 MONTHS 04LESS GONSMUCTI )N STARTS, Routh »....... ..ter .Gen..w�..MG- Ser. Runt Obd .PematleqWred to Owo unglkpbycAs aysp r,�, Routh bat�1N� on Me Awnbes DoNflemme Final I+� aDry Weil TO Be Date fin uWA .. .. Und hmpKbd and APPWW alt Q inspe or. SEE REVERSE SIDE Richard and Joanne Adams U.S.,POSDrGE 114 Stonecleave Road III I�I III II II II III " r,i�oru P"_ D,:E� M� r North Andover,MA 01845 9 FEB 02.'09 VNfT Et1571TE5 RMOUN( _ nnnn IIII�IIII�I A" (11845 f!OOF6896-06 ooC� • 1 � a i dI Town of North Andover Building Department 7007 3020 1702 386 565 1600 Osgood Street Building 20, Suite 2-36 North Andover, MA 01845 + i jwiw•=�i lil1.fIII11H111111♦illloll11111lls►,111}11121ifil,'i,,,111YISd ��II --- r- - -- - - - - - -- - - - � - -- - - __.-,_ _ i z RICHARD AND JOANNE ADAPTS RECEIVED OCT 0 7 2009 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 114 Stonedeave Road NorthAndover,Ma 01845 (978)685 6743 Jetadamsftmcastnet October 2,2009 Susan Sawyer Health Director 1600 Osgood Street Building 20,Suite 2-36 North Andover,MA 01845 Enclosed is a letter of confirmation that Richard and Joanne Adams,of 114 Stonecleave Road, will be updating our Septic System. We wish to go forward with the construction of the addition, of the 12 X 12 porch,which occupy a Hot Tub. If you need any further information,you can contact us by e-mail or 978 685 6743. Sincerely, Richard D Adams 4"Z Joanne E Adams ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r CITY MA DATE I�`15- 17 PERMIT# JOBSITE ADDRESS STOP C Cit OWNER'S NAME GOWNER ADDRESS H $-rQlneCl II• OV TEI ��FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL R( PRINT CLEARLY NEW:[1 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES Q NO APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _ _:::]L: _._. .. ` LF-::i :j E:J L: . 1 - 1.—j BOOSTER - BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER _. -- DRYER _ FIREPLACE FRYOLATOR FURNACE GENERATOR — GRILLE -- INFRARED HEATER _ _ —r 1 LABORATORY COCKS MAKEUP AIR UNIT OVEN . (- POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST _�_�-I_ _ 1_ _ ( - _ I UNIT HEATER INVENTED ROOM HEATER WATER HEATER —rJ —,-,1 L_ -- -- -I --- - - - - - - *)THE R -- - - —I�-( INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 "YES VINO 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [z OTHER TYPE INDEMNITY EI BOND El OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass use I Laws,and that my signature on this permit application waives this requirement. < CHECK ONE ONLY: OWNER M AGENT Elf SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true a accura 4he best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co ian a with all a Hent provision of the Massachusetts State Plumbing Code.and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I�,� iCQ LICENSE# SIGNATURE MP© MGF D JP ® JGFLPGI CORPORATION Q#=PARTNERSHIP©#=LLC[j#= COMPANY NAME: J. �"+! 1ADDRESS CITY h _ _� STATEMZIP FAX CELL EMAIL p �: 15 157 - �NPS ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION N TES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES a Date. 1 a ��►OiiT/�1 TOWN OF NORTH ANDOVER _ 9 PERMIT FOR GAS INSTALLATION CHU .w This certifies that ..........p: 1.FS. ` ...... ..4r- ................................. v' , has permission for gas installation .t � ... ..,,,�,,�,, c............ i in the buildings of........AAAM:a............................................................................ i at...... . . .... ..:....?...•:.�;C,�;�.�.�rL-.......�...............North Andover,Mass. Fee .. ' Lic. No. 2-.11..... i GASINSPECTOR Check# t`"[� 1 6+ 1 J The Commonwealth of Massachusetts Department of Industrial Accidents M r X Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers,Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE pERMIT'TJ[NG AUTHORITY. Applicant Information Please Print Le>sibly Name(Business/Orgariization/Individual): i '('6 � Address: I S hC'Q i� �^ --hue City/State/Zip: Phone#: Are y u an empIoyeri Check the appropriate box: Type of project(required); 1. I am a employer with employees(full andlor parE time).* 7. ❑Nevi construction 2.❑I am a sole proprietor or partnership and have no employees Working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 1l.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no emplo yees. 12.dumbing repairs or additions 5.❑I am a general contracto'and I have hired the sub-contractors listed on the attached sheet. 13% Roof repairs These sub contractors have employees and have workers'comp.insurance t 14.Q Other 6.FJ We are a corporatioii and its.officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no emp 'loyees:[No workerscomp.insurance required.] *Any applicant that checks box#1 wrist also fill out the section below showing their workers'compensation policy information. Homeowners who su"''I ''I his affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors that check finis box must attached additional sheet showing the name of the sub-contractors and state whether or not those entities,have es,they must provide their workers'comp.policy number. employees. If the sub contractors have employe X am an employer that is providing workers3 compensation insurance for my employees. h.elow is the policy and job site information. Insurance Company Name: Q _ Expiration Date: Policy#or WNW.Lie.#: �� � �� [� _ I ST6�eCl� AA J l Q MpP City/State/Zip:/►rt Job Site Address:T_ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by a fide 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.A copy Of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. X do hereby e i nder tliepains andpsnalties of perjury t/tat the information provided above is true correct. IDD Si ature: Phone if: 2 �~ Official use only. Do not write in this area,to he 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 Phone#• Contact Person: r w o f- 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 hixe, express or implied,oral or written." i .An employer is defuied as"an individual,partnership,association,corporation or other legal entity,or any two or more ofthe foregoing engaged in a joint enferprise,and including the legal representatives of a deceased employer,or the receiver'&,trustdd pi'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 bd deemed to be an employer." I 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(1)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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit 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' compensatioil policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. hh I City or Town Officials • I 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 Department's address,telephone and fax number: f- The Commonwealth of Massachusetts, F, Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext.7406 or 1-877-MASS.AFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia l :COMMONWEALTH OF MASSACHISETTS BOARD;OF 1 PLUMBERS AND GASFI7TERS. ! ISSUES THE FOLLOWING LICENSE L AN LP GAS INSTALLER 1 + ..DONAL.b W FOURNjw I # 1 48 PROSt'.ECT ST SHELBURNE FLS .;MA 01370-13 127 0;/01/.tb _:r < 20830 j ti JOHNG-1 OP ID:BB CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDDNYYY) 12/1512015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDEN, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsamant. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). Brown&Brown(Merrimack) Phone:603-424-9901 •NA I 309 Daniel Webster Highway Fax:866-848-1223 PHONEE>d: N W9,N2- Nn Merrimack,NH 03064 E-MAIL House ADDRESS: INSURER AFFORDING COVERAGE NAIL R INSURED L&G Propane,Inc. INSURER A:HDI-Geding America Ins Co 41343 John G.Maclellan Inc, elsuRERR: 1187 Main Street iNSURERC: Tewksbury,MA 01876 I43URERD: INSURER E. IN F; COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, L R TYPE OF INSURANCH POLICY NUMBER MIDD ITR POLICYEFF PO LIMITS OEN@RAL L"14rY EACH OCCURRENCE 5 2,000,00 A X COMMERCIAL GENERAL LIABILITY EGGCDOOD222415 10/0912015 10/09/2016 PREMISE10 KlzNTED S Ea=yaar4 S 100,00 CLAIMS-MADE X❑OCCUR MED EXP(Any ono person) S PERSONAL&ADV INJURY $ 2,000,00 GENERALAGGREOATE $ 2,000,00 GES"L AGGREGATE LIMIT APPLIES PER PRODUCTS,COMP/OP AGG S 2,000,00 POLICY PRO- IAC $ AUTOMOBILE LIABILITYEOMBI E LIMIT lonn 2,000,006 A ANY AUTO EAGCDO00222415 10/0912015 10/0812016 ALLOWNED SCHEDULED BODILY INJURY(Perparaon) 8 AUTOS X AUTOS BODILY INJURY(Pet aoddent) E X HIRED AUTOS X NON•OWNED PROP AUTOS X MC380NICL Peraozid 3 S X UMBRELLA LIAR X OCCUR EACH OCCURRENCE S 4,000,00 A EXCESs UAB CLAIMS-MADE MG0000222413 10/09/2015 10/09/2016 AGGREGATE $ 4,000,00 DED X TENTIONS 0 $ WORK ERS COMPENSATION WCSTATU OTH- AND EMPLOYERS'LIABILITY Y/N X A ANY PROPRIETORIPARTNER/EXECUTNE EWGCiD000222415 10/09/2016 10/09/2016 EL EACHACCIDENi $ 1,000 OFFICERMEMBEREXULUDED7 NIA ,00 (Mandatory In NN) Ify describe under E.L.DISEASE•EA EMPLOYEE $ 1,000,00 DESCRIPTIONOFOP R PIONSbelow E,L,DISEASE-POLICYLJMIT $ 1,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VENICLES(Attaoh ACORD 101,Additional Remarks Sahadulp,If more apace is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 6E CANCELLED BEFORE Town OF North Andover THE EXPIRATION DATE THEREOF, NOTICE 1MLL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIMD REPRESENTATNE ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD _16"N Commonwealth of Massachusetts ' Official Use Only u l � `` Department of Fire Services Perrot No. 4L t v BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/071 neave 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 (RLEASEPMT IIVDX OR TYPEALLWORM14T1019 Date: City or Town of: NORTH ANDOVER To.the Inspector of Wires: By this application the undersigned gives notice of his or her intention to rfo the electrical work described below. Location(Streetumber) l `C /e Owner r Tenant C Owner's Address O0 C Telephone No. (g�-671 Is this permit in conjunction with a building permit? Yes Purpose of Building El NO (Check Appropriate Bog) Utili Authorization orrzation 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: Completion o the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total No.of Luminaire Outlets Transformers Cpl No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In o.o mergency g d d. 0 Butte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMR No.of Zcnes No.of Switches No.of Gas Burners No.of Detection and No,of es Initiatin Devices . / Rang No.of Air Cond. Total Tons No.of Alerting Devices No:of Waste Disposers eat Pump Number Tons KW No.of Self-Contained Totals: __ Detection[Merdw Devices No.of Dishwashers Space/Area Heating KW Low❑ Municipal Connection Omer No.of Dryers Heating AppliancesKW Security Systems:* _ No.of Water No.of No.of Devices or E uivalent Heaters KW No.of Data Wiring: Signs Ballasts . No,of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total Hp Telecommunications Wiring: OTHER: No.of Devices or E uivalent lze Attach addi onal det if desired,or as required by the Inspector of Wires. Estimated Value of Electrical W k: Work to Start (When required by municipal policy.) 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 pains and penalties o perjury,that the informadoj on this application is true and complete. FIRM NAME: LIC.NO.: LZ G Licensee: Q �, Signature (If applicable,enter "exempt"in the license number line.) LIC.NO.: Address: f Bus.TeL No.: *Per M.G.L c. 147,s.57-61,security work requires Departiment of public Saf "S"Lic ``e'/Alt Tel.No.: o. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does notve the IiabiIity 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. PE RMIT FEE: $ IL i r i i I t Data �,�- 1. NOR71y TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SA HUS ,/ L This certifies that .((/ has permission to perform .-�� 1. .T�L. . �M/ , plumbing in the buildings of ._D,(44L . . �4.. . . . . . . . . . . . . . . . . . . . at.'/ North Andover, Mass. // ZY' 2 �" l ,Q Fee. .�..��Lu. No-3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .�?. . . PLUMBING INSPECTOR Check # 946 NOR7H TOWN OF NORTH ANDOVER p PERMIT FOR WIRING a�a This certifies that ... e.. . .......... has permission to perform ......��1 .... w '!.. ......................... wiring in the building of./— ........................................ R� -at.....,/���...�,r 7�r� ...l.. C.r �'-................... . orth Andover ass. .. y Fee. r....... Lic.�5�....1.dt. �...... . ,l .... ... ELE CAL PECTO Check #��� The C'omm.onweidth of Massachusetts Department of industrial Accidents Office of£nvestigations 600 Washington Street Boston, MA 02111 www Massgovldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AnDlicant Information Please Print Lembly Name,(Business/Or,-=zation/Individual): Address: City/State/Zip: Phone : Are you an employer?Check the appropriate box: 1•❑ I am a employer with 4. Type of project(required): ❑ I am a=� contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 ❑Nein construction 2.❑ I an a sole proprietor or partner- listed on the attached sheet 1 7. ❑Remodeling ship and have no employees These sub-contractors have working for me in an capacity. workers' comp.insurance. 8. Demolition Y ap ty. [No workers' comp. insurance �. ❑ We are a corporation and its 9 ❑Building addition required-] officers have exercised their 10•❑Electric repairs or additions �. El.I am a homeowner doing all work right 01 exemption per MGL 1 1.❑Plumb' g myself [No workers'comp. c. 152>§1 C41 �r P�or additions 12.7i :and we have no nsurance required.) t employees. [No workers Roof repairs coma insurance requirrd] 13•7 Other 'Any 2PP h----t t~at,ch—eek-box=..l m,- oui � lQ4S.^.Cn W� IIameown�s who submit This — ' OO.rY......-...-- mdacatm � �are d�..... U +Contzactor thzt r w„ g a"w"„�a M"him otffiide eon ac;o.s 11 u ,submit a new affidavit indicting such. ' this box must attached an additional sheet showing the name of the sub-contra,-tots and their woricecs'conn.Policy iaformatiaa. 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.r Expiration Date: Job Site Address: City/State/Zip: e Attach a copy of the workers'compensation policy declaration.page (showing the policy number and expiration date). Failure to secure cavernae as required under section 25A of MGL c. 152 can lead to the imposition of fine up to$1,500.00 and/or one-year imprisonment,as well as civil of tip to S250.00 a day against the violator. Be advised that a co panaltz„s m the form of a Scriminal penalties of a TOP WORK ORDER and a fine Investigations of the DIA for insurance coverage verification. PY of this stat„-mit may be forwarded to the Office of I do hereby certify under the pains and pees ofPc7u3'th4rt the information provided above is true and correct ' Signaturr!: - Date:--- ,-,Phone ate.:--,Phone#: FOther only. Do not write in this area, to be completed by city or toxin of iciaL n: Permit/License# hority(circle one): Health Z.Building Department 3. City/Towu Cleric 4• Electrical Inspector 5.Plumbing a Inspector son: 1"n, on 'i Date. . !/:.� . .�.1..... HpRTp pf «ao ,°,ti0 TOWN OF NORTH ANDOVER p D • PERMIT FOR GAS INSTALLATION SACHUSEt� } F This certifies that . . :�.'. `.' `. .%`f/.. . .... ... .. has permission for gas installation .. . !'_< . . . . . . . . . . . . in the buildings of . . . :r. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . ��` �J —� . . ., North Andover, Mass. ry- Fee:z Lic. No..�-?-'/ 6 GGAS•INSF4C`T6R Check# 45 '13 I ' I I MASSACHUSETTS UNIFORM APPLICATON FOR PERMfr TO DO GAS Ff rnNG i (Type or print) Date # NORTH ANDOVER,MASSACHUSETTS Building Locations /L STU/' �s�c . Permit# Amount$ � er's Name QI�C/c ���� New rLT, Renovation Replacemr ht 0 Plans Submitted w � C ° F y 9 O w x O H ca w 0 a > zz Ga � Q x a � � � a w A � a w r� 0 F O 3 A c7 U a > A a H 10 1 SUB-BASEMENT B A S E M ENT IST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH . FLOOR 5TH. FLOOR 6TH. FLOOR _ 7TH . FLOOR 8TH . FLOOR (Print or type) // Check one: Certificate Installing Company Name eG•`�i'�c� ����``mss CO 0/ /IVl ❑ Corp. Address Lz rLPy G �< ccK ..,J'c—• ❑ Partner. Business Telephone ;7E/ 26 S' 3 yt 0-Firm/Co. Name of Licensed Plumber or Gas Fitters INSURANCE COVERAGE Checkane• I have a current liability Insurance policy or it's substantial equivalent. Yes tr No[] Ifyou have checked M,please indicate the type coverage by checking the appropriate box Liability insurance policy r-1Othertype 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 plumbing work and installations pedbrmed under Permit Issued for this application will be in compliance with all pertinent provisions ofthe Massach tate&Code and Chapter 142 ofthe General Laws. By. Signature of Licensed Plumber Or Gas Fitter Title ❑ Plumber 13 ,15-(, City/Town ❑ Gas Fitter License Nurnwr ® Master APPROVED(OFFICE USE ONLY) ❑ Journeyman l