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Miscellaneous - 116 BRIDGES LANE 4/30/2018 (2)
116 BRIDGES LANE 210/104.D-0078-0000.0 � � _ 6/2/2016 Date:June 02,2016 20506 This is an e-permit.To learn more,scan this barcode or visit northandoverma.viewpointcloud.com/#/records/20506 . � TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that Stephen G Hogan has permission to perform indirect water heater plumbing in the buildings of MAGLIOCHETTI, MICHAEL J at 116 BRIDGES LANE, North Andover, Mass. Lic. No. 19523 1/1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE PERMIT# �itI U�U JOBSITE ADDRESS Il i OWNER'S NAME2oCl{e POWNER ADDRESS jjjjI Y(` TEL EFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL PRINT �-�/ CLEARLY NEW[] RENOVATION: j REPLACEMENT:2 PLANS SUBMITTED: YESE] NO2- FIXTURES 02FIXTURES-1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM_= DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM I DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK _ LAVATORY I _ _ ROOF DRAIN SHOWER STALL . SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION , WATER HEATER ALL TYPES 1.2 WATER PIPING OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW. LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on'this permit application waives this requirement. CHECK ONE ONLY OWNE EI AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information Ihave submitted or entered regarding this application ar t a acc ate to th st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co ian w is II Pert' t vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME L§LtPHEN HOGAN_ _ LICENSE# 10808 - SIGNATURE MPED JPEj CORPORATION# 3403 PARTNERSHIPQ# LLCE1# COMPANY NAME ATLAS GLEN-MOR ADDRESS 295 EASTERN AVE CITY CHELSEA --:=1 STATE ZIP 02150 — TEL 8004331616 R FAX 617 887-7330 CELL - EMAIL JAGMINSTALLATION@PETROHEAT.COM t I e-e- 1/Y1L ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES r 1 i t a e I d The Commonwealth of Massachusetts Department of Industrial Accidents r I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia 11-orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual):Atlas Glen-moi Address:295 Eastem Ave City/State/Zip:Chelsea,MA02150 phone#:800-433-1616 Are you.an employer?Check.the appropriate:box: " Type of project(required): l71lJ71 I am a ernployer with 12,0 em ]oYees full and/or part-ti « _ 7. Q New construction 2.�I am a sole proprietor or partnership and have no employees working for mein $. Remodeling any"capacity.[No workers'comp.insurance"required:] . - 3.0 i am a homeowner doingall work self t 9. El Demolition my [No workers'comp.insurance required.] 10 Q Building addition 4.1 I am a.homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs or additions " proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑1 am a general contractor and i have hired the sub-contractors listed on the attached,sheet. 13.Q p Roof repairs These sub-contractors have employees and-have workers'comp.insurance.t 6.Q 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 41 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-contractors have employees,they.must provide their workers'.comp.policy number. I am an employer that is providing workers'compensation insurance for my,employees. Below is the policy and job site information Insurance Company Name:New Hampshire:Insurance Company Policy#or Self-ins.Lic.#:258-89-049 Expiration Date:10/1/2016 Job Site Address: i City/State/Zip: Dr-VVj ver. Attach a copy of theworkers1comitAsationpolicy declaration page(showing the policy Marnber 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 WOR.K 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 here cert under the,pains a ena 'es ofperJury that the information provided a ove is true and correct Si nature: Date: Phone#:61'r-8877-7395 .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 S.Plumbing Inspector 6.:Other Contact Person: Phone#• - - ACO® � DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 09/294015 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 INSUIRER(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 - - -- CONTACT - Marsh USA,Inc. NAME: PHONE.' - - FAX. 1166 Avenue of the Americas A/c No Ext): Alc No): New York,NY 10036 E-MAIL Attn:NewYork.ceRs@Marsh.com. ADDRESS: INSURERS AFFORDING COVERAGE NAIC# 073389-PETRO-ACORD-15-16 : INSURER A;Commerce and Industry Insurance Company 19410 INSURED - - - - - INSURER B:New Hampshire Insurance Co - - 23841 PETRO HOLDINGS INC DBA ATLAS GLEN-MOR INSURER C:NIA N/A 295 EASTERN AVE INSURER D NIA NIA`. CHELSEA,MA 02150 INSURER E:N/A N/A INSURER F: - - COVERAGES CERTIFICATE NUMBER: NYC-007977061-07 :REVISION NUMBER: THIS.IS TO CERTIFY THAT THE POLICIESOFINSURANCE 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 - - ADDL SUBR - POLICY EFF POLICY EXP - LTR TYPE OF INSURANCE INSD WVD - POLICY NUMBER MMIDD MMIDD LIMITS - A X COMMERCIAL GENERAL LIABILITY 360-25-05 . 10/01/2015 10/15/2016 EACH OCCURRENCE $ 1,000,000 ACLAIMS-MADE.�OCCUR 3602506(NY) 10/01/2015 1010116 -PREMISES 20Ea occurrence) $ 100,000 A X, XCU 4807464 10/012015 101012016 MED EXP(Any one person) $ 5,000 _.. ._- . X COntraCtU81 - -- PERSONAL&ADV INJURY $ 1,000,000- GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 5,00,000 POLICY�Ea LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: SIR $ 1,000,000 A AUTOMOBILE LIABILITY 72046-98(AOS) 10/01/2015 10/012016 COMBINED SINGLE LIMIT g 2,000,000 Ea•acddent A X ANY AUTO 72046-97(MA) 10/0112015 10/012016 BODILY INJURY(Per person) . $ . A ALLOWNED SCHEDULED 194-95-31(VAonly) 101012615 10/012016 BODILY INJURY(Per accident) $ AUTOS AUTOS. HIREDAUTOS NON-OWNED - PROPERTY DAMAGE. _ $ AUTOS _ Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS=MADE - - - AGGREGATE $ - DED RETENTION$ $ B WORKERS COMPENSATION 258-89049(MA,ND;OH,WA WY) 10/012015 10/012016 X PER. 0TH- B AND EMPLOYERS'.LIABILITY -: - - - STATUTE ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE 012948291(CT,MD,NY,R(,SC) 10/012015 10/012016 E.L..EACHACCIDENT $ 1,000,000. OFFICER/MEMBER EXCLUDED? N/A - - - B (Mandatory in NH) 012948299(NY,ND;OH,WA,WY) 10/012015 10/012016 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 B. If yes,describe under DESCRIPTION OF OPERATIONS.below 059901256(NJ) 10/01/2015 10/012016 E.L.DISEASE-POLICY LIMIT $ 1,000,000 B Workers Comp Continuted 059901257(VA) 10/012015 10/012016 SEE ABOVE DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of NORTH ANDOVER THE EXPIRATION DATE. THEREOF, 'NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. - AUTHORIZED REPRESENTATIVE -of Marsh USA Inc. David A.A.Cobleigh @ 1988-2014 ACORD CORPORATION. All rights reserved.. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD COMMONWEALTH OF:MAS�SA�HUSETTS � ° Bfl_AR13 OF° PLUMBERS AND GASFITTERS ISSUES T.HF FOLLOWING LICENSE REGfiSCERED AS A PLUM8ING CORP STEFHEN G HOGAN �� y 3a Y s PETRO FiOLD1NGS INC � ���� � a � 295 EASTERN 14VENUE a CHELSEA; 3403 � �#�ID1/2fl18 34255 # x �C MINIONIAI►EAl.T i OF A. ACHUSETT ..�. • • •. - • • +..,,. i a &OAf3a� z '' A h PLUMBERS AN GASFiTTER ISSUES THE FOLL'OWaNG 1_TCENSE , LICENSEt�AS A JOl)12NEYIIIt1EN Pl.-l`}MBE�,2, f � �'} Ili > t t // q 103 BURRQUGHS RD tiu' 1: 19`523 t>5/01/2018 � 44335 :�COMIUIONUfIEALTH OF.aMASCt�t#SET�S PLUMBERS AND GASFTTERS _1 ISSUESrTHE FOLLOWING LICENSE d r 661=I�C.SED AS A MAS7�R UMBER—," STEPHEN G HOGAN ` 'CMZ 109 BURROUGHS "MW to T ' BRAINRI=E,ICIIA 02184 1577 l `z ' U 3 10808'' Q5l01/2018 44333 s `•� I��p��«. Lc�l����s�cJi. INSTRUCTIONS: This form is used to verify that all.-necessary approval/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the =1 - .applicant and or landowner from compliance with any applicable requirements. .■■...■■■■■..■.....■rrr..r.■rr.■r....■ar..■..�r..r...r.r.r..rrr...r.�.�..s■ APPLICANT' (fi)d1n6L UO QJe HONE.- ASSESSORS" ONEASSESSORSMAP NUMBER LOT NUMBER SUBDIVISION LOT NUMBER �C�TREET -STREET NUMBER � .....mr.. a.r.a..r ■a..rr....r...r.r....r.a.a...■ ■■.■a...a.ar.a.r.r .....■ OFFICIAL USE ONLY .................■mmommommommason ma.ama.a.omwas....ammo...................... . RECOADAENDATIONS OF TOWN AGENTS own.aa.a.rarmammon.r.■ram....■r.. ...■■aa■■r■.a.raamar...raraaa....r......r■ DATE APPROVED CONSERVATION ADMINISTRATOR DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS DATE APPROVED FOOD INSPECTOR-HEEA'LTH DATE REJECTED A DATE APPROVED SE INSPECTOR-HEALTH:r DATE REJECTED PUBLIC WORKS—SEWER/WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT i DATE REJECTED COMM IM RECEIVED BY BUILDING INSPECTOR DATE r i t $ Q Z c o' Stn i V 0 1 o.. f 5 G1 T p `�1yt g V it �. 07- NOTE:THrS 7.NOTE:THES PLAN WAS DRAWN FOR MORTGAGE PURPOSES ONLY AND IS MOTTO BE .-MORTGAGE, AN LOINSPECTION RECORDED,OR CONSTRUED AS AN INSTF"MENT SURVEY. H,y ELV NOT TO BE USED FOR ERECTING FENCES OR ISSUING BUILDING PERMITS. IN DEEDREFERENCE: 13K. 103 P-.3`4I PLAN REFERENCE: Pt A^' ^�a 8 a r Z MASS. f�jORT� H +� J I CERTIFY THAT THE STRUCTURE ON THIS PLAN IS LOCATED APPROXIMATELY AS SHOVO4 AND THE LOCATION CONFORMED TO THE ZONING LAWS OF THE CITY OR TOWN OF !V o Trt .grv,�oma£K 04 EFFECT WHEN CONSTRUCTED(WITH RESPECT TO S , COUNTY DIMENSIONAL REQUIREMENTS ONLY)OR IS EXEMPT FROM VIOLATION!ENFORCEMENT , AC-ION UNDER MASS.G,L.TITLE VII,CHAP.40A.SEC.7. UNLESS 07FfERYYIS✓ NOTED OR SCALE: 1 " 60 j pv _ z 8 , 2 D o v SH00iN HEREON- 1 HEREBY CERTIFY THAT THE STRUCTURE SHOWN ON THIS FLAN DOES NOT LEE WITHW `'HE SPECIAL FLOOD HAZARD AREA AS SHOWN Or.THE F.F.S_MAPS FOR THE CITY OR ,JAMES C. VAFIADES—REG-_ LAND SURVEYOR ':NOF "-A7-r4 A N poV6 ~-JUHE 15, r 7 83 COMMUNITY PANEL N0.25- "9S oa/�= � 256 WORCESTER LANE, WALT!>'AM, MASS. Date... ................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that .............................. .................. .....P................................................... has permission to perform of.......... winng in the buildinj. .............. ...................................................... at ........ . I. .. .. ... AZA ..........,Jorth Andover,Mass. Fee.:: ......... Lic.No. .............. ......... Check# 114.58 Commonwealth wealth of Massachusetts Official Use Only Department of Fire Services Permit No. —I Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 aeaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK j All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN NK OR TYPE ALL INFORMATION) Date: 51X4 11-3 City or Town oh NORTH ANDOVER To the Inspecto of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) //6 �jL-1S Owner or Tenant j,?/?/ /7 f,¢c;f,0 C.6 07, Telephone No.9/&—V5/ Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building &.1, 1-74 Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd[I No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �,� y �` lCt r,�j_ .C/ Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires $ No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. E] Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No, of Zones No.of Switches No.of Gas Burners No.of Detection and InitiatingDevices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: "'"'"' """""""..""'""""'" Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Si ns Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent " OTHER: Attach additional detail if desired,oras required by the Inspector of Wtres. Estimated Value of Electrical Work: 60 ` a (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof ofkliaility insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that suchage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCEBOND ❑ OTHER ❑ (Specify:) Icertify, underthepainsandties ofperjury,that the information on this application is true and complete. FIRM NAME: . LIC.NO.: Licensee: 14,6 F,� Signatur LIC.NO.: 9;t'tjoff' $ (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.- Address: /S wille4-4pl Ar_ 4 y'S 6.o a Alt.Tel.No.!Y78-y .2 *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: ti Inspectors Sig ,ature: Date: ROUGH PECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: � ` Date: -3 FINAL INSPECTION. Pass RE Failed Re-Inspection Required($.) ❑ Inspectors Comments: PF 47 Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com L � � The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 UT www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Organization/Individual): 6US�i ,civ �S �J✓� /� -r/ o Address: City/State/Zip: ^ Phone Y0� -12 Areyou an employer?Check the appropriate box: Type of project(required): 1.[I=a employer with 4. F1I am a general contractor and I 6. E]New construction employees(full and/or -time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers'comp.insurance. Y p tY• 9. E]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3. I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ,✓ Insurance Company Name:. 4- Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attaeli a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Faille to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby c t under a pains and pen ' s of perjury that the information provided above is true and correct - -Signature: 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#: J Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department off dustrial Accidents Office ofInvestigatlons 600 Washington Street Boston,MA.02111 Tel,#617-727-4900 ext 406 or 1-877rMASS-A.FB Revised 5-26-05 FRY#617-727-7749 www.mass,govfdia 09853 Date . . . . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING a .3 This certifies thaA''6�v ). PIUYt 6 44, has permission to perform . . I . . � . plumbing in the buildings of. � !'.c.. .� . . . . . . . . . . . . . . . at . . . : . . . . . . ,North Andover, Mass. Fee P7 . . . Lic. No. ,� . . �?. . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check# aoZ i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY r( MA DATEPERMIT# JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS J TELE _..__IIFAX — ! TYPE OR OCCUPANCY TYPE COMMERCIAL DI EDUCATIONAL 0 RESIDENTIAL[ I PRINT CLEARLY NEW: 0 RENOVATION: REPLACEMENT:ER' PLANS SUBMITTED: YES EO NOD 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 GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM E ( . . t __ ( l ( I _ ( ! ( _. ! ! DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _vl � ----..__1 ( l _ _l I _-.__i= _._..____J FOOD DISPOSER I .._I I FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN _ ! _.__..._ i ! _...__. i 1 _ i ___.._. I � _._.. J �i __.-.._ I 1 _I ____ SHOWER STALL SERVICE/MOP SINK TOILET URINAL _....._._J _........_.1 WASHING MACHINE CONNECTION J, J W,ATERHEATER ALL TYPES _i s .-? _-- ( _-� _11 -.____J _-....._.1 TER PIPING _{ f -- _( _( ? OTHER __ __ i __.___.. ._____( _ _ € INSURANCE COVERAGE: 0 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES _.! NO D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Q BOND �I 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 E-11 f SIGNATURE OF OWNER OR AGENT f hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge j and that all plumbing work and installations performed under the permit issued for this application will be in compli rice with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. z PLUMBER'S NAME[-I. - LICENSE# f SIGNATURE MPV JPCORPORATION Q_I# PARTNERSHIPP# LLC 1 COMPANY NAME _�_� ; ADDRESS CITY ' .___. _- - 1 STATE ZIP f TEL FAX - T CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES t The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston,MA 02111 Uf www massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): ZZ e' r, s/T/7a/I Address: �D CA S C o ST City/State/Zip: 6, &y, Ggr O-6 Phone#: -2 s-- Are yo an employer?Check the appropriate box: Type of project(required): 1.1 I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.1 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers'comp.insurance. Y p tY• 9. E]Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.F1 Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.[i Other *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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy anal job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Hereby certio under the pains and penalties ofperjury that the information provided above is true and correct. Signature: 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#: h r 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 permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 TeX.#617-727-4900 ext 406 or 1-877rMASSAFE Revised 5-26-05 Fax#617-727-7749 wwwxnass.goV1daa r i COMMONWEALTH OF-MASSACHUSETTS ti I fir; •a: • • ._• • . • f..ri�! , ', { I .- 4 L dCE,NSED ASA MASTER RLUMBER ti a ` ISSUES THE ABOVE L'ICEN�SE O P. ' THOMAS J=� CASH'MA.N` l.O��CASCO'sST n , LER=ICA ...-M,A"' 0?1862 1,0 17 _ ' 15630 0.5%01/14' 142759 . . . .• _�• - � ';:tom I 9321 - Date. .�/k- .? . ORT TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 40 s w ,SSACNUS� This certifies that . . . . . . . �'. . k has permission to perform . bi .�/.,�. /. /. ! . . . . . . . plumbing in the bu ldingso . . . 9 /,O�. . ... . . . . . . . . . . . . . at. .M/ . 1"!. . . . .1. . . . . . . . . . . ... .. North Andover, Mass. ,,/ ./ Fee. Lic. No.. . . . PLUMBIN NSPECTOR Check # 7�s� ! MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK \ CITY MA. DATE , ,�_ f, PERMIT# 4 / JOBSITE ADDRESS t �2 1 8 a e s Liv OWNER'S NAME 1 p OWNER ADDRESS S � TEL FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[� PRINT NEW:❑ RENOVATION:❑ CLEARLY REPLACEMENT: � PLANS SUBMITTED: YES ElNO ❑ FIXTURES Z FLOOR BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIL/SAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY f ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which,meets the requirements of MGL Ch.142. Yeses No❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY A OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE BOX ONLY: OWNER ❑ AGENT ❑ Signature of Owner or Owner's 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 9f the General Laws. PLUMBER NAME —5�4/ 6—,V—tA1eD SIGNATURE < LIC# /3 6 MPqo JP❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME J>FY6-,-:) ADDRESS: 'J"'96 ''S<5-k' r)r) CITY STAT&4t4 ZIP©L u Y EMAIL TELCELL�� lS` 9) FAX ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES r+ Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ /� / ,� 3 /L- FEE: $. PERMIT# PLAN REVIEW NOTES .1 The Commonwealth q fMassachusetts ..Department oflndustrialAccidents Office ofInvestigatioxv 600 Washington Street Uers'. Boston,AM 02111 www,massgov/dia. mpensation Insurg.nee Affidavit:Builders/Contractors/.Ul()ctricians/Piumbers A licant Tn�£ormation .'lease Print Le ibl Name(Business/Organization/Individual): - yt Address: -City/'State/Zip:Z�,� �� O�tY Y1 Phone#: . 5' 0 �S Are you an employer?Check the appropriate box: 1.❑I am a employer with 4. ❑I am a general contractor and I Type of proj ect(required): - employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. I am a sole proprietor or partner- listed oa the attached sheget,t 7. ❑Remodeling ship and have no employees These sub-contractors have Working for me in any capacity, workers'comp,insurance. 8' ❑Demolition [No workers'comp.insurance 5. ❑ We aie a corporation and its 9• ❑Building addition required.] .officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.�Plumbing repairs or additions Myself.[No workers' comp, c.152, §1(4),and we have no insurance required.]f employees.[No workers' 12.❑Roofrepairs comp,insurance required.] 13•❑Other , Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. 1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub contractors and their workers' rs com , olic i p nformati Jr am an em to er _ P Y on. tlta ' t' rs P ,V providing " worke p rs compensation ompensation insurance or rat e information. f m to ee .f ron. Y p s Belo • Y w is tlzepolicy and job site Insurance Company Name: Policy#or Self-ins.tic.#: Expiration Date: — Job Site Address._ 6 L N City/State/Zip- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration Failure to secure coverage as required under Section 25A ofMGL c.152 can lead to the imposition of criminal p n date). Em" `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 of �f up to$250.00 a day against the violator. )3e, dvised that a copy of this statement maybe forwarded to the Office of kvestigations of the.DTA for insurance coverage verification. -do hereby certify un fit pains andpenaltieso.fP J er;urY tltatthe inforntationprovide i nature: daboveistrue and correct. • Bate: hone#: S Official use only. .Do not Write an th!s area,to be completed by city or town official City or Towns bsuing Authority circle one): Permit2icense# 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumb' 6 Other EleI . mg Inspector '2ontact Person e Information and Instructions structions 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"everystate 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers;compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)andphone numbers)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with noemployees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation.o£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. PIease be sure to fill in the permithicense number which will be used as a reference number. In addition,an applicant that must submit multiple pemut/licease applications in any given year;need only submit one affidavit indicating current policy information(Muccessary)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 notrelated to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOTrequired 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: Tue C01-UMo!Aw6ajJjj-ox Massac"a setts DcPatitmeiat of Xndustda1.A.ccidents 0f C8 OfInVe0gatilvns 600 WashiWon Street BostQ.a MA. 02111 Tot.#617-727-4900 ext 406 or 1..877-M-ASS.A,FE t2evised 5-26-05 FaX#617-727-7749 Date.°C °?.. � ,..... t NORTH °f,"`° '•�"° TOWN OF NORTH ANDOVER 5.. FO ti. PERMIT FOR WIRING SSACMUS� e }-- This certifies that ... ... .................................................................................... is v- has permission to perform ........ � wiring in the building of ........a�. }` at to I�lel;� ........................................... North Andover, ass. :- .9... Lic.No.4 ............. 7 . j ELECTRICAL INSPECTOR ' Check # —1 tl 0684 Commonwealth of Massachusetts Official Use Only - Department of Fire Services Permit No. 6oe4 BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINTININK OR TYPE ALL INF0"ATIOA9 Date:_Z 21 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 11c - B it )iq E 5 LR N r- Owner or Tenant _M t 1t E f�A G LA©C i.k C-M-1 Telephone No. 97� 6 2 1 - )-73y Owner's Address I 1 6 t3 iL1 7G C 5 LA 1V C_ ,'' Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building '_C51%`>E/v CC, Utility Authorization No. Existing Service Amps / Volts Overhead ,❑ Undgrd ❑ No.of Meters New Service Amps / Volts -",Overhead' ❑ Undgrd ❑ No.of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: 13 2 �` ATh1YCUOM F-GAA,D rEL Com letion of the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires Z No.of Ceff.Susp.(Paddle)Fans No.of Total =� Transformers I7A No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- o,o mergency ig g In- d. rnd• Batte Units No.of Receptacle Outlets Z No.of Oij Burners i FIRE-ALARMS No. of ZonesNo.of Switches No.of Gas Burners No. of Detection and Initiatin Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump J.Number Tons KW No.of Self-contained Totals: Deteetion/Alertin Devices No.of Dishwashers Space/Area Heating KWLocal❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems: No.of waterNo. No.of Devices or Equivalent of Heaters KW Si s Ballasts Data Wiring: f. No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total Hp Telecommunications Wiring: OTHER: No.of Devices or E uivalent Attach additional detail if desired, or as required by the Inspector of Wires. �2DC),Qv Estimated Value of Electrical Work: (When required by municipal policy.) Work to.Start; 2 Z5_1 t 2 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 enalties of perjury, that the information on this application is true and complete. FIRM NAME: Licensee: LIC.NO.: MA vILG J• M� .y i Signature (If applicable, enter exempt"in the license number line.) LIC.NO.: /y2 Z C Address: 4 y 2 F A&Lw c o'b �� B D�ati� c� 3 S Bus.Tel;.No.: 9 79 Per M.G.L c. 147,s. 57-61,security work requires D ty„ „ Air.Tel.No.: o. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insuranceense: Lic. coverage 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: $ . G' ���. ��G���L � ���� � ! Z �Z� 1 h The Commonwealth of Massachusetts k j f Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.nwss.gov/dia . Workers' Compensation Ins wance Affidavit. Builders/Contractors/Electricians/Plumbers Ac P icant Information Please Print LeQtbly Name(Business/Organization/individual): �&AtLC MZ, _,j CC Address: `-1 u\2 oo 62H 7 FO0— MA City/State/Zip: Phone #: .17$ - 5 t y -S 81 6 Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4, ❑ I am a general co7sheet T�of project(required): employees(full and/or part-time).* have hired the sub• ❑New construction 2. I am.a.sole proprietor.or partner_ listed on the atta7• Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity, workers' comp.insurance. [No workers co m .insurance 5. 9 ❑ Building addition p ❑ We are a corporation and ifs required.] officers have exercised their 10.0 Electrical repairs or additions a 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No-workers'comp. c. 1.52, §1(4),and we have no 12. } insurance required.]t ❑ Roof repairs i '! q ] employees. [No workers' comp. insurance required.] 13.❑Other — Any applicant that checks box'tl t must also fill out the section below showing their workers'compensation policy in Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 4contractors that check this box must attached an additional sheet showing.the name of the sub-contactors and their workem'comp•p_�u ioformation. I am an employer that is providing:workers'compensation insurance for my information employees: Below is the policy and job site Insurance Company Name: Policy#or Self-ins. Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a 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 infnrmadon provided above is true and correct Si titre: / - Dom; 2 2t• /2 Phone#: 5 7 r -`/i y t 5-_R'l 6 ficial 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): I. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions ` Massachusetts General Laws chapter 152 requires all emp it oyers 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'covemge required." Additionally, MGL chapter I52,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority," Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the • members or partners,are not requiredt 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,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 appropriste'Iine. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating-current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or ' town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each : year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 42111 Tel. #617-727-4940 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-7745 www.mass.gov/dia Location No. Y6 Date TOWN OF NORTH ANDOVER ~ s 1 Certificate of Occupancy $ Building/Frame Permit Fee $ sic usE Foundation Permit Fee $ Other Permit Fee E } $ 3S TOTAL $ Check # 1,3) 4 6 Building Inspector R TOWN OF NORTH ANDOVER BUILDING DEPARTMENT � APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE.OR TWO FAMILY DWELLING ITI BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioneffl for of BlJiftdin2 Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Lod "?) Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Reqwred Provided 1.7 Water SupplyM.GL.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: j Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record " M NGLoChdA jq a e(Print),'- Address for Service: qq@ ,SCS Sig elephone lz� 2.2 Owner of Record: Name Print Address for Service: M Signature Tele hone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: r License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ II Company Name P Y Registration Number Address Expiration Date Signature Telephone I a v i SECTION 4-WORXERS COMIPENSATION(MLG.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building rinit. Si ned affidavit Attached Yes.......❑ No.......0 SECTION 5 Description of Proposed Work check an a ticable New Construction ❑ Existing Building 0 Repair(s) ❑ Alterations(s) ❑ Addition 0 Accessory Bldg. Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: ` e0 e Q ltuo , SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be Completed by permi applicant 1. Building (a) Building Permit Fee 14 Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on M 1 lative to work authorized by this building permit application: / Sigr a t e o ier Date SECTION 7b WNER/AUTHORIZED AGENT DECLARATION I, ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name c Si ature of Owner/Agent Date NO. OF STORIES SIZE r' BASEMENT OR SLAB RD SIZE OF FLOOR T VIBERS 1 s. 2 3 SPAN DUVMNSIONS OF SILLS DIMENSIONS OF POSTS DiINIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHEVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE ruKM U LQ'1* KE:LE A6E; P C1K1V1 Co(lA, ;s,.J- INSTRUCTIONS: This form is used to verify that all-necessary approval/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the -a2)--0 applicant and or lmdowner from compliance with any applicable requirements. APPLICANT M)I)L11 - L, O U►e HONE f� ASSESSORS MAP NUMBER LOT NUMBER SUBDIVISION LOT NUMBER r�TREET I C 'STREET NUMBER ........ .............................. ................................. OFFICIAL USE ONLY I..........................■..'..■..............■............................. . RECONWENDATIONS OF TOWN AGENTS ON",WIND on DATE APPROVED C I NSERVAf1ONADMD0TRAT0R (�) - /► _/.� ! /� DATE REJECTED COIvIIv1II4TS DATE APPROVED TOWN PLANNER DATE REJECTED COMW ENTS DATE APPROVED FOOD INSPECTOR-'HEALTH DATE REJECTED DATE APPROVED SEPTIC(INSPECTOR-HEALTH DATE REJECTED CON v1ENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE li Q 2 ` \ V d � 1 I � ti Ppe` y`\���\ �� � r� s•� � � . maws VIRA a o- 3 0,-93 � •� �. a 7- /U � V NGTE:THIS PLAN WAS DRAWN FOR MORTGAGE PURPOSES ONLY AND IS NOTTO BE MORTGAGE LOAN INSPECTION RECORDED,OR CONSTRUED AS AN INSTRL/MENT SVRVL-Y. rjCT TO BE USED FOR ERECTING FENCES OR ISSUING BUILDING PERMITS. IN DEED REFERENCE: 13K- 14-7 3 PC-3'4I PLAN REFERENCE: F't ^JD B o J z DaVF MASS. I CERTIFY THAT THE STRUCTURE ON THIS PLAN IS LOCATED APPROXIMATELY AS SOWN AND THE LOCATION CONFORMED TO THE ZONING LAWS OF THE CITY OR TOWN OF S E COUNTY /V o Z tN Iri EFFECT WHEN CONSTRUCTED(WITH RESPECT TO 1� 01MENSIONAL REQUIREMENTS ONLY)OR IS EXEIhjPT FROM VIOLATION!ENFORCEP.iENT „ _ AC-ION UNDER MASS-G.L.Tr LE VII,CHAP 40A,SEC.7. UNLESS OTHERWISE NOTED OR SCALE: 1 - �O �U IVB Z g SHOOiN HEREON- I HFRESY CERTIFY 7HAT THE STRUCTURE S-IObVN ON THIS PLAN DOES NOT LIE ViITWN TH>e SPECIAL FLOOD HAZARD AREA ASSHOWN ON,THE F.ES_MAPS FOR THE CITYOR JAMES C. VAFIADES—REG_ LAND SURVEYOR Toe NOF f-/pRTN A xO0VE 256 WORCESTER LANE, WALTHAM, MASS. GATED! J v N F t S J 1 93 COM)illAliTY PANEL NO.Z j:' c.9 g �: i Workers'Compensation Insurance Affidavit w- r—.7. Please Print Name: mq� C (Oeke,* CLocation: / Ci I Phone aam a homeowner performing all work myself. �1 am a sole proprietor and have no one working in any capacity IONE am an employer providing workers'compensation for rrlmy employees working on this job. 1 tJ C—ompany name Address °"� Ci Phone# �V Insurance Co. r. Uq(a19S ,-LrdU1Q + I company name: Address City _Phone#: Insurance Co Policy# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisbnment'as well as civil penalties in the form of a STOP WORK ORDER and a rine of($1 oo.00)a day against me_ understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify*unci t pains and penaN' of perjury that the information provided•above is bye and correct Signature Date / 6 I / ►� v Print name Phone#JI Official use only do not write in this area to be completed by city or town official' 0 Building Dept ❑Check if irnrnediale response is required Building Dept ❑ Licensing Board El Selectman's Office Contact person. Phone#: I] Health-Department Other FORM WORKMAN'S COMPENSATION ae FORTH ® ® '. .4:.. Ando* ver W.. VO 10� A No. c2q(V _ 0i X�a9p qaO o - CA l doves 1V1ass. COCMICMEIA. V 1 ORATED H BOARD OF HEALTH PERMIT T D . Food/Kitchen Septic System A ....MA. �,��C '` . .......... BUILDING INSPECTOR THIS CERTIFIES THAT.. � ...... ... I..`!... . , Foundation has permission to erect. I ...... buildings on ... 0#..... ........`/4 Rough to be occupied as........ i♦rN ��� �� Chimney ............................................................................................. provided that the person accepting this permit shall in evory respect,conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. of leo Y p 3 ire 69� PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION ST ELECTRICAL INSPECTOR Rough .......... Service BUILDING INSPECTOR Final Occupancy Permit Required t0 Occupy Building GAS INSPECTOR i Display in a Conspicuous Place on the Premises — Do Not Remove RoughFina, No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. 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