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Miscellaneous - 1171 TURNPIKE STREET 4/30/2018 (4)
V Location ` ! ! U �►J I�e ST No. �'� ' 01 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ �,SSACMU 5Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ C 5 TOTAL $ Cp Check # 156U'5 Building Inspector LU `w O z 2 z JULO z 0 z O U J a a �i W a Z V5 0 d c I _C .= U a)EE co v O `y .0 ca. QL- w 00 ca U ��• //•�_ !all �CcCU c I _C .= U a)EE co O O `y .0 ca. 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O Qw CIO as Ao4c,:6 ¢� I >i�';i�s ;t ��`! fir• Uncle ■ E ■ Bobs ■ �> .s self ■E u u Date /Z1 �6 >-- - e -6R- 0;, Date ...... (.4... ... Z zv TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that...,..?2.J.Twt�:..........-�.L-G , ..................... has permission to perform ......Re L�`�........ U� �oB S Si'oe,i wiring in the building of..................................................................... ............................ j k� �`''....... ...... North Andover, Mass. at.....71........j..t/......................................... Afee.....Z' �Zs� ... Lic. No.....I. ?77......� '1......... CTR CAL INSPECTOR Check # 12472 C,ommonwealtk olcc/wiackudetfa A NEW 2epartment of77 ire Service BOARD OF FIRE PREVENTION REGULATIONS official Use Only Permit No. Occupancy 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 ElectricaM�SM CMR l 2.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:\ City or Town of• �' �)-L� 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) Owner or Tenant DN Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appr priate Box) Purpose of Building Utility Authorization No. i Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. olf Meters New Service Amps / Volts Overhead ❑ UndgrdF No. of Meters i Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires No. of Ceil: Susp. (I No. of Luminaire Outlets No. of Hot Tubs No. of Luminaires Swimming Pool Ar No. of Receptacle Outlets No. of Oil Burners No. of Switches No. of Gas Burner! No. of Ranges No. of Air Cond. Heat Pump Numt No. of Waste Disposers Totals: No. of Dishwashers Space/Area Heatin Heating Appliance No. of Dryers No. of WaterKW No. o Si ns Heaters No. Hydromassage Bathtubs No. of Motors table may be waiLd1by the Inspector o/ Wires. INo. oI luta, 'addle) Fans Transformers I KVA Generators KVA iove ❑ in- ❑ nd. grnd. FIRE ALARMS INo. of Zones o. of Alerting Devices er Tons K�'�' Detection/Alertirk Devices Local ❑ umcipa Other g KW Connection KW v No. of bei No. of Data Wiring: Ballasts No. of Dei Telecommun Total HP No. of Del OTHER: At additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) . Estimated Value of Electrical Work: Work to Start: �S' Inspections to be requested in accordance with MEC Rule 10, and upon completion. for the INSURANCE COVERAGE: Unless waived by the o owner, no permitopetat on rcoverage or is formance of substantial equivalenttrical I work may s ss The the licensee provides proof of liability insurance incl g"completed 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:) atin I certify, under the pains and penalties ojperjury�tht the informationnon this applies true aInJdCe NOlet—e-- FIRM NAME: LIC. NO.: --- Bus 0�� L Signature b 3 $' l Licensee: _,tt . Tel. No.: LI a (If applicable _enter " empt" in the-fleese nu er\line. ,` 0 3 �, Alt. Tel! No.: Address: a �requiresPublic Safety' S" *Per M.G.L. c. 147, s. 57-61, security wocaaware tDhatptha Licensee does not have the liability insurance coverage normally OWNER'S INSURANCE WAIVER: I signature below, l herebywaive this requirement. I am the (check one ❑owner owner's a ent. required bylaw. By my g q PERMIT FEE: $ Owner/Agent Telephone No. I Signature Ttf'16A 0 -/t- ,p (c )5��Ze ffS '9 rhe commomalth of.Massaehusetts Departmentofflidg ftiglAccidents Office oflnvestigations 600 Washington Street .Boston, .ZY.IA 02111 vmmass gov/dia WnArPvO Com-nengalzon lCnsuxance Af6ic avi : Suiicie ° /Co;n °ac ox /Elec cxansl1'>�oTiex•1 Cxiy/SiaielZzp: ^� Phonon: re you an! employer? Check the appropriate box: 4. [l I am a general contractor and I 1. am a employer with employees (t'u11. and/or paxt time).* have hired the sub -contractors 2.E] I am a sole proprietor or p artnex listed on the attached sheet. ship aud.'have no -employees These sub -contractors have working forme in any capacity. workers' comp. insurance. 5, ❑ We are a corporation and its [No workers' comp. jnsurauce required.] officers have exercised.their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself [No workers' comp. insurancerequared.] ? c. 152, §1(4), andwehaveno employees. [No workers' comp. insurance required.] Type of project (required): 6. 0 New constructlon f 7. [] Remodeling 8. [( Demolition 9. ❑ Building addition 10.[1 Electricalrepairs or additil xis ILL] Plumbingxepairs or additions 12.[] Roofrepairs 13.[] Other I MW applicant that checks box#1 must also fill atthe section bel6w showingtheir Workers' compensationpoHcy information. i Homeowners who sabmit�tbis affidavit indicating&mey go doing allworKand then hire outside contractors must submit anew affidavit indicating suoh, TContractors that check -this box must attached as additional sheet #mowing the name of the sub. -contractors andihek workers' comp. policy information. I am an emyfoyer'tiiatzsp�oviding>vovker s' compaisation insuranceformY employees Beroty isthep01icy ancijob f informallon. n n— .1) ^ Insurance Company Policy # or Selz ins.Lic. #: Expiration 17 ate: lob Site Address: Attach a copy of fAa workers' comp ensation.-p olicy declaration page (sh.ow' 9 the policy number and expixaiion�. crate). Failure to secure coverage as xequft dunder Section 25A ofMGL o.152 can, lead to the imposition of eriminalpenalizes of a fine up to $1,500.00 and/or one-year ixnprzsontn ent, as well as civil penalties in the form of a STOP WORK ORDER. and a #me of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of investigations of the DIA for insurance coverage verification. I do bare ties ofperjury that the information providecl above is true and correct - Si afore: Date: o Oficial use only. Do not write in this area, to be completed by city o� torvxa 0 lei I City or Town: perminicense # Issuing Authority (circle one): 1. Board of Health. 2. Building ]Department 3. City/7Cowa Clerk 4. Electrical Inspector 5. Numbing Inspector 6. Other -ox.,,,, o 44. Information and instructions Massachusetts General Laws chapter 152 requires all employers toprovide 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 orwxitten." Au enTloye� is defamed as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and includm9the legal representatives ofa•deceased employer,, -or the receiver ortrustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having notmoxe than three apartments and who resides therein, dwelling house of another who emplor the occupant ofthe oys persons to do maintenance, consixuction orxepair work on such dwelling house or an the grounds or building appurtenant thereto shall not because of such employment be, deemedto bean employer_,, MOL 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 requ7 real:' 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 b con presented ta the contracting authority Applicants Please fill out the workers' compensation affidavit completely, by checking iiia boxes that apply to your situation and, if necessary, supply sab-coniractor(s) name(s), addresses) and photonumber(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than, the members oxpartners, arenotrequkedto caryworkers' compensationinsurance. 7fanLLC orLLP doeshave, eznployees,apolicy isrequired. Be advised thattbisaffidavit may besubmitted tothe Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit: the affidavit should be retuned 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 xequired to obtain. a *oxkexs' 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 thatthe affidavit is complete andprinted legibly. The Department has provided a space at the bottom . of the affidavit fox you to .11 out in the event the Office of Investigations has to contact you regarding the applicant. Please be -sure to JM lathe pemsit/license number whichwill be used as a reference number, In. addition, an applicant thatmust submitmultiple permit/Iiceme, applications in any givenyear, need only submit one affidavit indicating current Policy information (ifnecessmy) and under "Jbb Site Address" the applicant shouldwrite "all locations in (city or towar): ' A copy a the affidavit that has been of�fxcially stamped or marked by the city or town may be provided to the applicant as Pzoofthat a valid ofCxdavit is on Ea £ox future permits or licenses, A new affidavit muist be filled out each Year. Where a home owner or citizen is obtaining a license orb emit not related to any business or commercial venture (I a. a dog license orpermit to burn leaves eto.) said person is NOT require d to complete this affidavit. The Office bf Investigations' would like to thank you in advance for your cooperation and should you have any cpostfon s, please do not hesita%to give us a call. The Department's address, telephone mirk fax number: The CM-MOUNealthOfM'as-9achmettIq - DOpa-rt ent of1hJu&&1 AucjdogN (Mce ofImstzgattona 6bG Waftgtoa reef Ba9Qn, . 021.11 Te14 # 617-72Z-4900 W406 or 1-877-M _ Revised 5-26-05 Fax # 617-727-7749 Date ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that Awso� . . ......................... has permission to perform t. ..AII . ........................... ..... Akir.n ...... v wiring in the building of...... ..... ff: . ...................... at ... ....... 7.47:;Nelta- . . ....... ................. . dover, Mas Fee ....... 4,5..!n Lic. No. rte............. . ....... . .. ....... E aCTRICAZ NSPECTOR . Check# 41�--4g-3 Commonweb/th of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy 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 Cod (MEC , 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: U 0 VS City or Town of: NORTH ANDOVER To the Ins ector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 71 J UP,#PI a .ST o Owner or Tenant i) rJC1 E &15S %F f S -to A011 Telephone No. 76 - 681 7 797 Owner's Address //7I To&jPtK£ s'T Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building ! 'To Q,Ag 6C Utility Authorization No. i - Existing Service Amps / Volts New Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters� Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: CN't1 n) L f - O U t r�et"'A 2►7h Cmmnletinn nfthe fnllnwinu tahle may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool rnd. grnd. El o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of kones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons KW .......... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal El Other Connection No. of Dryers Heating Appliances KW Security Systems:' No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Mres. Estimated Value of lec ;cal Work: D 0 (When required by municipal policy.) Work to Start: j 3 O Zvt Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C VE GE: 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 Dh BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: j -J �✓ %> �' E7 .0 /Doi LIC. NO.' /73&rX Licensee: to f,+,`/ Sig ature LIC. NO. (If applicable, enter "exempt" in the license number line) Bus. Tel. No.: Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. � OWNER'S INSURANCE WAIVER: 1 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 withthe provisions of M.G.L. c. 143, § 3L, the �r f 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, as { 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 ❑ S ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass [E Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: w Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass CE Failed Re- Inspection Required ($.) ❑ Inspectors Comments: a Inspectors Signature: Dater ROUGH INSPECTION: Pass IN Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: v - Inspectors Signature: Date: ]FINAL INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Com a ts: f - } Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidents a a I Congress Street, Suite 100 Boston,'1VI4 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le2iblV Name (Business/Organization/Individual): Address: i I City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. [-11 am a employer with employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 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 ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ 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. insurance.t 6.❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] *E'7v annlicant that checks box 41 must also fill out the section below showing their workers' comnensatim Type of project (requir 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12. ❑ Plumbing repairs or r additions 13. ❑ Roof repairs j 14. ❑ Other information. T 11omeowners 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 thepolicy and job site information. Insurance Company Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up tol$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 I do Hereby certify under the pains and penalties of perjury that the information provided above is true and correct. I Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2: Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each " year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. fr, 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 i goaWm�V�9 T&ow ��� - AAw of 64& CW;w gAwinlal FP6 (rev. 3/00) APPLICATION FOR PERMIT City or Town /(/ DIG SAFE NUMBER C Date Start Date: In accordance w' h the provisions of M.G.L. Chapter 148, as provided in Section AM application is hereby made by ��/ /n name ff ppe-rsonn,, Firm or Corporate n) Address l� ��',GI/j7�,P/� c�/`S` /�}d.��x/� /,� 42715 (Streator P.O. Box) (City or Town) For permission to (state clearly purpose for which ermit is requested) n ,C rt�t Name of competent operator (if Applicable) h J ,�-+�H't�'Z� Cert. No. Date Issued -rejected By (Signature of Applicant) Date of • • • Due -------------------------------------------- 3/00) City or Town_ Date _ ?- Permit Permit 1'Vumber (if applicable) PERMIT DIG SAFE NUMBER Start Date: In accordance with the provisions of M.G.L. Chapter 148, as provided in to for Restrictions: at Fee Paid $ _ name of person, Firm or Corporation) /4,i (Give location by sbebt and no,, or describe in such mantfer as to provide adequate Identification of location) This Permit will expire on Signature of Official Granting Permit Title this permit is granted No This permit must be conspicuously posted upon the premises The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 k www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): New England Safety Systems Address: 680B Richmond Street Taunton, MA 02718 Phone #:508-880-2545 Are you an employer? Check the appropriate box: 1. ❑✓ I am a employer with 23 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.Q Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 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 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: Hartford Casualty Insurance Co. Policy # or Self -ins. Lic. #:08WECCG6405 Expiration Date:11-18-15 Job Site Address: 1171 Turnpike Street City/State/Zip:N. Andover, MA 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 painYan p al ' of perj that the information provided above is true and correct Signature: Date: &" Du--- .u.508-880-2545 ; 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 #: Date ... . .7) . TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ............................................................................................................................ has permission to perform ..... .. ...... . 7� .............. ....... ....... wiring in the building of .............................. .......................... ....................... at ........1.. ...t ............. \.(-.a ....................... ............. . N��, Andover, Mass. Fee Lic. No. ................. ELECTRICAL INSPECTOR 6eck # 17-1 13161 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 1 � � kp i Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts ElectricaAlnspec 7C,,527 CMR 12.00 (PLEASE PRINTINIMK OR TYPE ALL)NFORMATION) Date: City or Town of. NORTH ANDOVER To ther of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) rc o; S-E— Owner or TenantlJ�t. i�,� '���_S -� tib— Telephone No. Owner's Address r Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Q Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) FansNo. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑o. rnd. grnd. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total 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 Signs 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, or as required by the Inspector of Wires. Estimated Value of Electrical Work: v 3G 6 (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, icnrler tla ains and enalties of erjuty, th the information on this application is true and complete. FIRM NAME:. f c, LIC. NO.: Licensee: Signature LIC. NO.: 06 7St (If applicable, enter "exempt" in the license numbyr line) Bus. Tel. No.•�%O 175' Address: Alt. Tel. No.: *Per M.G.L c. 14W7-61, 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 El 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 P PP� P g � PP� r,- 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 r {' 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 M 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 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed (] Re- Inspection Required ($.) ❑ y Inspectors Comments: r Inspectors Signature: Date: FINAL INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: i Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts -' Deparbu ntoflndustriglAcc/dints Office of Invesfigations 6170 Washington. ,Street Ll- FY Boston, MA 02111 www.mass:gov/dia of . Workers' Compensation Insurance Affidavit: Builders/Cont°actors/Electr icianslPlii nbers Applieant Worm.ation Please Print LedbN ' Name(Businessiorganiyaiion/.tn,dividual): Address: J14 HiGc,` ✓e- City/State/Zip:S4 ac�� (V CIT"27 PhonaM 9 360 1 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4• ❑ I am a general contractor and I 6. ❑ New cOnstraction - /employees (full and/or part-time).* have nod the sub -contractors on the attached sheet. `%• E] Remodeling 2. I am a sole proprietor or partner -listed ship and`have no employees These sub -contractors have 8. E] Demolition working forme in any capacity. workers' comp, insurance. 9• [1 Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] 3. ❑ 1 am a homeowner doing all work officers have exercised.theix right of exemption per MGL 11. F1 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roofrepairs insurancerequixed.] ; employees. [Nb workers' 1311 Other comp. insurance required.] 'Any applicant that checks box must also fill out the section bel6w showingtheir workers' compensation policy information. i Homeowners who submitthis affidavit indicatingthey kdoing all work and then hire outside contractors must submit anew affidavit indicating such. TContractors that cheekthis box must attached as additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Policy ## or Sel£ ins. Lic. ExpirationDate Job Site Address: City/State/Zip: Attach a copy o#the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a $axe up to $1,500.00 and/or one-year imadsopm ent, as well.as civil penalties in the form of a STOP WORK ORDER and a fine ofup to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage ver cation. I do Hereby �(pt u tl pains andpenalties ofperjury that the information provided above is true and correct. Official use oRy..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 Pers Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract ofhire,- express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation ox 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 redeiver 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 employes." 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 op erate 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) andphonenumber(s) along withtheir certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are notrequired to carryworkers' compensation insurance. If au LLC or LLP does have employees, a policy is required. B e advised that flus affidavit maybe submitted to the Department of Iudustrial Accidents fox confi oration 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 xeq*od to obtain a *orkers' 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 fox 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 thatmust submitmultiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (ifnecessmy) and under "Job Site Address" the applicant should write "all locations in. (city or tow.il). " 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 ox permit not related to any business or commercial -venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance fox your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone aird fax number: The CmmonwoaXt z ol, assachvsPtt - Depaxtmnt d1ndustxial A,ccldonta (.Tee ofIRVestfgaam f OQ Wu*gtm stxe t Boston, 021 It TOL # 61.7-7.2.7 4QQ e 4Qf� Qx Z• -8.77,L Revised 5-26-05 Fax # 617-72 7- 7749 WWW -M,15% - a 1 Of VkORTH O Date 4 ..... .... , . 2 ........... C) ....... . TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............................... ...... ........ ............... ............................ I,! :� e has permission to perform .... n .............................................. wiring in the buildingof--)" ............ 1 .. f ............... at North Andover, ass. ... ................ ....... ............... FW�—........... Lic. No. .............. X ELEcrRICAL INSPEC70 Check# 8165 1 1Je�ar�snait o��tu¢ s�� BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 6 /6�5— Occupancy and Fee Checked -! ev.'1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 {PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 5 /?"110W City or Town of: Q p{.I-h dOff 4 - 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)yin�y _ fad A-noye_y-, hc;i f`a2q Owner or Tenant S®LllY2^ p SkA4-' Sitmq�e_ loo _ Telephone No.`71(o-(p�- 1 BSO Owner's Addressee' Is this permit in conjunction with a building permit? Yes C1 No ® (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No, of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work. Lnt) VO14-0Ue. 60M O(LaS r"jp7 nr- Completion of the following 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 Tabs Generators KVA No. of Luminaires Swimming Pool Above E]In-❑ rnd. grud. o. o Emergency ng Patter—v Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Tonal No. of Alerting Devices No. of Waste Disposers rnT taLP umber Tons xw No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ElOther Connection No. of Dryers Y Heating Appliances KW Security Systems-.* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: I Attach additional detail ifdesire4 or as required by the Inspector of Wires. Estimated Value of Electrical Work: 1 4$00. (When required by municipal policy.) Work to Start: 5 LIL nspections 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 a pains and penalties of perjury, that the information on this application is true and complete FIRM NAME: (- j LIC. NO.: q p (i G Licensee: Ci -C4,10 Ct 1� Signature Y __ LIC. NO.: 01a (Ifapplicable, enter` t" " the license er ' e.) Bus. Tel. No.; Address: Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. SS ( p 00 J- Off& 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 aizent. Owner/AgentturaTelephone No. Signature PERMIT FEE. $ QSZO 3 TYPE SECURITY DESIGN INC CRAIG M HALLORAN -C 13 DEPOT ST S GRAFTON MA 01560-130 286756 7011 C 07/31/10 286756tI Feld. Thea Detach Along All Perforations BOARD FA TYPE —0 286771 Fad, Then Detach Alaig All Perforations COMMONWEALTH OF MASSACHUSETTS �OF'ECECClTRiC1ANS • i REGISTERED SYSTEM TECHNICIAN ISSUES THIS LICENSE TO CRAIG M HALLORAN 6 BRADISH FARM RD AI UPTON MA 01568-10 226 D 07/31/10 286771 Feld. Then Delach Along All Pe dorataris Department of Public Safety One Ashburton Place, Rm 1301 Boston, Ma 02108-1618 License: S -LICENSE Number: SS CO 001028 Expires: 05/08/2009 - CRAIG M HALLORAN 13 DEPOT ST S GRAFTON, MA 01560 DPS-CA1 %+ 50M-05./06•PC8490 e y*� - ✓fe "(J4:Yi73zOs7.C!!n.C�( Of�✓!f(.lJ4JQGltUJG'd..d DEPARTMENT OF PUBLIC SAFETY �'•� S - LICENSE Number: SS. CO 001028 Birthdate: 09/05/1955 Expires: 05/08/2009 Tr. no: 311.0 ..P S -License: SECURITY DESIGN INC CRAIG M HALLORAN, 13 DEPOT ST S GRAFTON, MA M60 Birthdate: 09/05/1955 Restricted To: 00 Tr. no: 311.0 Keep top for receipt and change of address notification. USM V1 � M � 00 if 00ca a c3 .� 0 00kn ° W4CD .2 GOo �r :. ..,. _ .�... .mom .: ,y. ..._. �rm�.« T. �s;�•.. .".�. Date................................. r TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that ........' SL''�T'eiG �k. G ............................_.............................................. ��l2v�cE' r7U . ITity has permission to perform '� Lf lJs1iG,C=/. - sort wiring in the building of.....................,>.........n. ................ �.... T.....t at ..... //..71,..1.. ... ,��!P!vP ! .;P ........ .�=..... , North Andover, Mass. A? 7 Fee ... ...........777— Lic. No............. ................ 4�!-; .... � 4� .... S LECTRICAL INSPECTOR / Check # ' 7042 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 2a Z, Occupancy and Fee Checked [Rev. 9/051 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /D -Z �-06 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) //I/ ✓ c/R,iP/ gJ-C 5� j Owner or Tenant f f j ICt r= A$0& 'SC -Z -F -,5:-I�,eA 6,C Telephone No. Owner's Address 64(p? /14A1AJ S%: 13WF')rA-GO Alf Is this permit in conjunction with a building permit? Yes P No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. % 01 b 6 / Existing Service CSO Amps 20� / JZO Volts Overhead ❑ Undgrd [E< No. of Meters % New Service Vvb Amps S'D 17-77 Volts Overhead ❑ Undgrd EP/"No. of Meters Number of Feeders and Ampacity y x �UOmGybt Location and Nature of Proposed Electrical Work: 06—�= n JAIL 2C' Iq 14 y,4C U'Alf>S jti19 '4/Ey7S 7'O i O �c�c� Fw itGy Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of otal�� Transformers No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. rnd. o. o Emergency Lighting Batter Units No. of Receptacle Outlets '1 No. of Oil Burners, FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o Detection and o. Initiating Devices No. of Ranges No. of Air Cond. Ton l 32 No. of Alerting Devices No. of Waste Disposers Heat Pum Number Tons I 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 Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start:/© -3 /-O G Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cover is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 0 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: /� S EfEGi72/ LrL LIC. NO.: Licensee: 0S"7- f 7— Signature- LIC. NO.: If 1206L11 (Ifapplicable, enter `exempt" in the license number line.) 1/��^ Bus. Tel. No.: Address: �i 7 �/ />e�sou.E2 �QI J� L/Z/l,�?o�. (� Alt. Tel. No.: V01-25 4 ? *Security System Contractor License required for this work; if applicable, enter the license number here: 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 --7 Signature Telephone No. PERMIT FEE: $ 5-pE-- -4k-- ? d qS t 3 X TOWN OF ANDOVER O P • - PERMIT FOR GAS INSTALLATION 10 .� �9SS�CHUSEt Y This certifies that ............ ........ ....... ,/y! ..���• _z has permission for gas installation in the buildings of . ' .../r2 !� - .: O z ui am c c o C2 C y O C r O vV CL C M e0 m C O CD CD N c m ` o ry E c CD CD c Ilk. 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Jo; s6w;oo; d!J;s snonu;uo0 �c bxZ ilnd snonu!;uo0 :SON1100d •Ieu!d 'uol;elnsul 'aweJd 'uol;epunod '6ul;ooj ` uogeneox3 (wnw!uiw) :SNO1103dSN1 suo!>toedsu! ou JO"010 J1d00) lIINU3d (INV 'SS31J(3aV,SU3ev4nN 10l TIV 1SOd } M0138 SIN311 OI a311W11 ION -1SM03H0/S310N JNIa-iina lVa3NM) i C!1 L MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT 7%& EiO GASFI I TING (Print or Type) )9,/jP9j/&y. , Mass. Date 1 p 20 c Permit # S r�5_ Building Location 14_ wner's Name j/�Ll� i3 fl� f j�jj g Telephone Type of Occupancy New Renovation ® Replacement Plans Submitted: Yes 11 No❑ Installing Company Name EnergyUSA Propane, Inc. Check one: Certificate Address 900 Myles Standish Blvd., Suite 101 X❑ Corporation 132 C Taunton, MA 02780 Partnership Business Telephone (800) 822-1300 Manager -Bob Olander X8055 11 Firm/Co. +� Name of Licensed Plumber or Gasfitter William. Kent Corson (800) 822-1300 X8051 Cell (508) 294-6660 ISURANCE COVERAGE: EnergyUSA Propane; -Inc. ; is a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch. 142. Yes XD No you have checked vs, please indicate the type of coverage by checking the appropriate box. liability insurance policyX❑ Other type of indemnity Bond .•, «:. NNER'S INSURANCE WAIVER: 1 am aware that th"e:'licensee does not have the insurance coverage required by iapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Code and Chapter 142 of the General Laws. Type of License: By .EPlumber Title Q Gasfitter City/Town X Master APPROVED (OFFICE USE ONLY) �Jo- urn eyman Signature of Licensed Plumber or Gasfitter License Number 3707 J z O w Cl) w U LL U- 0 w O LL O J W m z O F- U W IL U) z_ J Q z LL w W LL O z 0 z 0 J m LL O W 0. 06 LU Q z 0 z 0 J_ m LL O z O a U O J w r LL U Q c� O w m D J CL 0 LU z (� W F_- Q � o W a fq.4,� Date -0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... (2— ............................. .............. ............................................ has permission to perform ......................... wiringin the building of ................ ................................................................... at ..... ...... �.* ....... il ................ I North Andover, Mass. -Zc.� 6-tl f 10-3 1 -�7,�) Feel.. ............. Lic. No. ............. ............................. ...... ELEc-rwcALECTOR Check # 4745 THE COMMONWEALMOFMA,SSACHUSE77S DEPARTA1 EW 0FPUBL1CS4FETY BOARD OFFIREPREVE MONREGULA77ONS527CAIR 12:010 Office ^Use �only Permit No. VX -A V' Gam, cv� Occupancy & Fees Checked APPLICATTONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wire; The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Owner or Tenant S6 Owner's Address Is this permit in conjunction with a building permit: Yes M No F-1 (Check Appropriate Box) Purpose of Building Existing Service Amp Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work /4o-vt Utility Authorization No. _ Overhead Underground No. of Meters Overhead Underground No. of Meters No. of Lighting Outlets No. of Hot Tubs Rough Final Signed u ndeM anah es of perjury: No. of Transformers Total FIRMNAME 7Q%� e -4 44 -f r IiomseNo. Liege Sig>Thue KVA No. of Lighting Fixtures Swimming Pool Above Below BUSinessTel Nb. `- `r 1 /j Generators a _ KVA Addt�, ��' round ground AIL Tel. No. OWNER'S WSURANCEWAIVFR Iamawatetfiatdrl-immdoesnothavetheitwanoeoowraWaitsstttantialequivalultaswquaedbyMa%achusemGffiedLaws and that my signatt m on this petint application waives this tequitemal No. of Receptacle Outlets No. of Oil Burners (Please check one) Owner Agent Telephone No. No. of Emergency Lighting Battery Units Signature o . wner or gets No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHERS kwanceCovetaga PtmatgtDdrmgmm-ottsofNlwmdm .sCenaallaws Ibav abiiliedvaanddpudofsametodrOlfioeYES' I r INSURANCE rj K BOND OTHER alert YES " NO Ifyouhavec rdodYES,pbmindicanthetypeofooNuageby ( SPXfy) F�m-aliorlDate EtmA2dValueofEbc1dcalWotk $ WodctoStatt hpecfionDateRequested Rough Final Signed u ndeM anah es of perjury: FIRMNAME 7Q%� e -4 44 -f r IiomseNo. Liege Sig>Thue LieNo BUSinessTel Nb. `- `r 1 /j �0ZOt�� �f i/�t�Gtc.a�PF-SLt a C � Addt�, ��' AIL Tel. No. OWNER'S WSURANCEWAIVFR Iamawatetfiatdrl-immdoesnothavetheitwanoeoowraWaitsstttantialequivalultaswquaedbyMa%achusemGffiedLaws and that my signatt m on this petint application waives this tequitemal (Please check one) Owner Agent Telephone No. �},v PERMIT FEE �, f Signature o . wner or gets The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print - Name: Location: gly Phone # I am a homeowner performing all work myself. 0 I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: -- Address citc. Phone #: Insurance. Co. Policv # Company name: -- - Address City Phone #: Insurance Co. Policv # 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' imprisonmentas wtX-as_civil_penaltiesinlheinan-faSTOP.W—ORK-ORDFR,,nd_a.fine-f_($1110-oo)-ajdm against.mc;. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. ii ! do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Pbone.# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing. Building Dept []Check if immediate response is required Licensing Board E] Selectman's Office Contact person: Phone #.• Health Departmen Other TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ................ has permission for gas installation ........ in the buildings of - at "�1 ........ .. ................. North Andover, Mass. Fee :�-�' Lic. ............ GAS INSPECTOR Check # IVD. <-- 4286 '-I MASSAC1T$ETTS,UN0-0RM APPUCATON FOR PERMIT TO'66 GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date /- 3 d - Q 3 Building Locations // 7 / y Q # n, A/p b f ' 0 • 0(j a . 14f A Permit # 1/,) Y& Owner's Name Amount $ 2,0 New ❑ Renovation ❑ Replacement Er Plans Submitted ❑ - (Printor C one: Certificate Installing Company Name _ C �a 1` a 4 / c fiPQ fCorp. Address �J»+a } S� �o �u �%� ❑ Partner. Business Telephone g 7 —6 A,F- 5.2 3 ❑ Finn/Co. Name of Licensed Plumber or Gas Fitter �o Se_ o h 3,l INSURANCE COVERAGE Check on I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑ Ifyou have checked yew, please indicate the tyre coverage by checking the appropriate box. Liability insurance policy , v' Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner —]Agent ❑ nereoy cermy utas an or me oemus ana mrormanon r nave sumninea (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac>;iusetts Status Code pd Chapter 142 of the General Laws. (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber M 3 V4 o Gas Fitter License Number Journeyman FLOOR - (Printor C one: Certificate Installing Company Name _ C �a 1` a 4 / c fiPQ fCorp. Address �J»+a } S� �o �u �%� ❑ Partner. Business Telephone g 7 —6 A,F- 5.2 3 ❑ Finn/Co. Name of Licensed Plumber or Gas Fitter �o Se_ o h 3,l INSURANCE COVERAGE Check on I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑ Ifyou have checked yew, please indicate the tyre coverage by checking the appropriate box. Liability insurance policy , v' Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner —]Agent ❑ nereoy cermy utas an or me oemus ana mrormanon r nave sumninea (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac>;iusetts Status Code pd Chapter 142 of the General Laws. (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber M 3 V4 o Gas Fitter License Number Journeyman Commonwealth of Massachusetts official Use on/ly` Permit No• Department Fire Services Occupancy and Fee Checked O BOARD OF FIRE PR ENTION. REGULATIONS r Rev. 11/99j leave blank APPLICATION fOR PERMIT TO PERFORM ELECTRICAL WORK All work to bF'Ofr�A in accordance with the Massachusem Electrical Code (MEC). 527 CMR 12.00 (PLEASE PRINT IN INK R L INFORMATION) Date: S'- /0 City or Town of.��- To the Inspector of Wires: a By this application the undersi Ives noticeof his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction ivitL a building perhii t'I Ye �❑ 'k No (Check A:ppppriate Box) gl Purpose of Building Uti>aty Authorization No:} i � g/9 ; "+ `` >- Existing Service �0 Amps )� O / 2 , t) Volts Overhead ❑ Undgrd (1 No. of Meters r New Service Ampsr" , / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and jAinpacity Location and Nature of Proposed Electrical Work: �i p�;`_ un �rC,-t ovnj C'ondc, t >' to U�tli�` 6l� f 0,0 eglgte `©04nl,�Mtte� SpLICe�` L✓.l`� �t:!t`��So�4t� c..i7`fn �i�% iSS Completion of the jollomng table tri be dui ved by the Fnspector of Wires_ No. of Recessed Fixtures' — No. of CeiL-Susp. (Paddle) Fans No. of Total Transformers" 1}CVA No. of Lighting Outlets No. of Hot Tubs Generators KVA of Lighting Fixtures AboveIn- Swimming Pool rrud. ❑ rad. o mergency hg ngNo. ro. atte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Tot l No. of Alerting Devices No. of Waste Disposers HeatPuN°tuber Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ M nnn�hou El Other No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW Heaters o. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring. No. of Devices or Equivalent OTHER AMM addravnal dew) rf dcium. or as required by the lmpmixw oJlPvrs 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 operatioif' ooverage 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 [i BOND 11 OTHER [I (Specify.) (Expiration Date) Estimated Value of Electrical Work -(When required by municipal policy.) Work to Start 5-/0 -U 5 Inspections to be requested in accordance with MEC Rule 10, and upon completion. I cetYify, under the pains and penalties of perjury, that the information on this trpplication is true and complete FIRM NAME: TerVIn't S- /17' l.0 1Tn 4 --/et i n LIC. NO.: 3ri7tt 3 C Licensee: ` erom /�%tl,Set„ T�. Signature ` LIG NO.: ;fills. TeL No.. tS,17 33541115'v Address: Alt TeL No.: 506 )2g -9G1( OWNER'S IIVSURANCE 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 a ent. Owner/Agent eP Signature Telephone No. PERMIT FEE: S Receipt 11 �2ew< <- f - 0 t -e-, - 5&2ve-C e O k 6 - z- -s mm m EO