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HomeMy WebLinkAboutMiscellaneous - 119 OLD FARM ROAD 4/30/2018 119 OLD FARM ROAD 210/035.0-0035-0000_0 ® MAPFRE The Commerce Insurance Company"' Citation Insurance Companysm Commerce " Gore Road,Webster,Massachusetts 01570 INSURANCE- 508.949.15001 www.commerceinsurance.com February 03, 2015 BUILDING COMMISSIONER or Board of Health or INSPECTOR OF BUILDINGS Board of Selectmen TOWN/CITY HALL Town/City Hall NORTH ANDOVER MA 01845 RE: Our Insured: JEFFREY J BUXTON/ROSEMARIE C BUXTON Property Address: 119 OLD FARM ROAD Policy#: BCYDYP Date of Loss: 01/31/2015 File#: JWHJ87-HNMJ7 Claim has been made involving loss, damage, or destruction of the above captioned property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to my attention. Please reference the above captioned insured, location, policy number, date of loss, and file number on any correspondence. GREGORY'CRANNEY Telephone: (508)949-1500 Ext: 15857 Sr Claim Representative,Property Toll Free: 1-800-221-1605,Ext:15857 On this date, I cause copies of this notice to be sent to the persons indicated above, at the address above,by first class mail. February 03, 2015 CIC 254 (Rev.4/95) MAIL N34 Date. TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING s 7S SACMUS r✓�'+� ` This certifies that �. . . . . . . . . . has permission to perform . : . . . ... . . ..! . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . at. .//7 .�.�r�..` . !i.1). . . . . . . . . . . . . North Andover, Mass. Fee.3 7. . . .Lic. No.� � �- PL-UMBING INSPfCTOR Check N 8097 Date.... ... .°In........ t ,LORTN °f,"'° '• '"° TOWN OF NORTH ANDOVER . 1 FO P PERMIT FOR WIRING ` ,SSACHUSE� 1 F This certifies that ................................r '"�`? -`�", .............................. has permission to perf� ................................................... wiring in the building of....../..... ........ ..........................:...............:.................. at...A........................... l .. .. ............... . .. .North Andover,Mass. Fee` v . ..... Lic.No..� .. ....... ... i .............kE�Rl�;62SICTOi :. Check # C:;�L� r 8824 Commonwealth of Massachusetts Official Use Only y' glow Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS 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 Code(MEC),527 CMR 12.00 (PLEASE PRINTININK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER ~ By this application the undersigned gives notice of his or her intention to perform the Inspector electrical workWires: abed below. Location(Street&Number) 0w �, Owner or Tenant se , i1L/1 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No.of Meters New Service Amps / Volts Overhead❑ Und rd g ❑ No.of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: � At BAIN 2-h�(�� R� Completion of the followin 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 1 No.of Luminaires Swimming Pool AboveElIn- [0] o.o mergency ig g d. rnd. attea Units No.of Receptacle Outlets No.of OR Burners FIRE ALARMS No of Zones No.of Switches No,of Gas Burners No.of Detection and No.of Ranges InitiatingDevices / 11 No.of Air Cond. onTots No.of Alerting Devices No.of Waste Disposers Heat Pump Number..Tons KW _ No.of Self-Contained Totals: _.._........__.. Detectioi/4ertinun,Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Dryers Heating A Connection No.of D El Other ry g ppliances KW Security Systems: No.of Water No.of No.of Devices or Equivalent Heaters �' No.of Data Wiring: Si s Ballasts . No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Tom 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: (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 issueunless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent The • undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC.NO.: S50911-6— Licensee: Signature (If applicable, enter"exempt"in the license number li#e.) LIC.NO.: Address: t; 0381 Z Bus.Tel.No.: 607 *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Alt L cl.No. 62 7 3 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. ,$- ��' ' � � - �� � ` � -7_�, � �� �, f 1 CA The Commonwealth of Massachusetts Department of Industrial Accidents _ E,P .. Office of Investigations iisi 600 Washington Street Boston, MA 02111 { www.nuus.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plambers Applicant Information Please Print Legibiy Mame(Business/Organizadon/Individual): �-J 0 Lb Address: Va City/,State/Zig:_ V'K1/Vsil Phone#: . ' `�`� y�_ Are you an employer?Check.the appropriate box: I.❑ 1 am a employer with 4. ❑ 1 am a general contractor and I Type of project(required): loyees(full and/or part-time).* have lured the sub-contractors 6• ❑New construction 2.62"10 am a.sole proprietor or partner- listed on the attached sheet x 7• ❑Remodeling ship and have no employees These suit-contractors have 8. Demolition working for me.in any capacity, workers' comp.insurance. g, ❑Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself. [No•workers'comp. c. 152, §I(4),and we have no 12. Roof insurance required.]t employees. ❑ repairs � ] [No workers' I3.[]Other 1 comp. insurance required.] 'Any applicant that checks bo�fi I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contntctors must submit anew affidavit indicating such. ! 4Condactors that check this box must attached an additional sheet showing the name of the sub•comractm and their workers'comp.policy information. I am an employer that is providing:workerscompensation insurancefor my employees: information. 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. l do hereby c ify under the pains a penalties of perjury that the information provided above is true and correct Signatur Date: Phone _- U S 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): 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 �v 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 sucb 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 t 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 numberlisted below. Self-insured companies should enter their self-insurance license number on t1he'appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department hes provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current policy information(.if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that valid affidavit is on file for future permits or licenses. A new affidavit must be fitted 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 02111 Tel.#617-72.7-4900 ext 406 or 1-8.77-MASSAFE Fax#617-727-774 Revised 5-26-05 www.mass.gov/dia r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Dae Building Location �� '-0-W ftW LAI Owners Name �k— / �s rj, o Pe trmit# 9 97 .� Type of Occupancy /5- Pc Amount New ❑ Renovation �'� Replacement ri Plans Submitted Yes No ¢� FIXTURES H w x a oLn w o Z wZ w 3a Cn A a A w ARME RASEAvr in>JoaR —M HDr HjaR HIM M HDM sMH-OOR 7MHfM_[__ gmI (Print or type) r Check one: Certificate Installing Company Name ❑ Co Address 4- A-AW F7 ❑ Partner. Business Telephone Finn/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: 1,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance l4 signature Owner ❑ Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and instaEbiged u r Pe ssued for this application will be in compliance with all pertinent provisions of the Massac settsde _,Rfiapter 142 of;he General Laws. By: n icense um er Title ype of Plumbing License o � " City/Town ric—enseINUMDer Master MI—fo-urneyman APPROVED(OFFICE USE ONLY i The Commonwealth of Massachusetts kj )i Department of Industrial Accidents Office of Investigations rat 600 1�lirshinon Street Boston, MA 02111 ' www_massgov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleetricians/Plumbers Applicant Information. Please Print Legibly Name (Business/Organization/individual): Address: .S� City/state/Zip: d i��� //� ill i3 l Phone#: Are you an employer?Check the appropriate box: I am a employer with 4, Type of Project(required): ❑ I am a general contractor and I _ employees{foil and/or part-time).* have hired the sub-contractors b ❑New construction . 2. am.a:sole proprietor or partner_ listed on the attached sheet _ 7. ❑Remodeling ship and have no employees These subcontractors have 8. Q Demoiition working for me in any capacity, workers' comp.insurance. [No workers'comp.insurance 5. 9• Q Building addition p ❑ We are a corporation and its ! required. 1 p, ] officers h Electrical have exercised their ❑ airs or additions repairs tions 3.Q I am a homeowner doing all work right of exemption per MGL I LQ Plumbing TePairs or additions onsm self [ o•warkers comp, c, 152, §I(4),and we have no 12. Roof insurance required.]t employees. (No workers' ❑ repairs comp. insurance required.] 13.7.0ther *Any applicant that checks hod#I must also fUl out the section below showing their worked''compensation policy information. t Homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a rtav affidavit indicating such. ;Contractors that check this box roust attached an additionsi sheet showing.tthe name of the sub-contractors and their workers'temp•poli�'intnmaatien. I ant an employer that is promding:workers'compensation Insurance for my employe= Below is the informapolicy and job site . tion. Insurance Company Name: ' Policy#or Self-ins. Lic.#: Expiration Date: ------------ Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date), Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c un r t F m es of Perjury that the information provided above is true and carred Si Date: g' Phone ficial use only. Do not write in this area,to he completed by city or town o ciaL 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 11 oyers to provide workers' compensation for their employees. Pursuant to this statute,an empioyee 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 includirig 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 t3he commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation•affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),addmss(es).acid phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to can workers'compensation insurance. if an LLC or LLP does have r 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' OOtr.pensation policy,please call the Department at the number listed below. Self ingured E.o;P.c chm4A mrowfhf it self-insurance-license number on the*appropriate tine. 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 futr m 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 affidaviL 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 Investi rations 600 Washington Street Boston, MA 02111 TeL#617-727-4900 Ext 406 or 1-8.77-MA.SSAFE Revised 5-26-05 Fax#617-727-7749 wwwMass.gov/dia ".O R7:'ho TOWN OF NORTH ANDER �r .•. 0 Li o PERMIT FOR PLUMBING � SSACMUS� V � This certifies that r``o has permission to perform . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings . (... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _. . . . .. . . .,,North;Andover, Mass. Fee.-'�//. . . . .Lie. No.. 4?`/ g(o . .✓ «!. . . . . . . . . . . . . C/ PLUMB INSPECTOR Check # � / 8071 y• MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS J; Date L Building Location g (dr ha*m r o Owners Name �F Fiv &j Permit# C� ` / Amount Type of Occupancy �S New Renovation Replacement Plans Submitted Yes No FIXTURES rW x a s U O W W O z a Ux a �+ W `n QQa C�7 a 0 4 9z ~ A A w z z W 3 a as A A a 3 C6 C A a as SL]3-B%E BASEVENr —BEFIIOCIt —M HJOC[t 1 j -M FLOCIR 4M FLOCIR M FII : 6TH FIOOR 71H FLOUR SIH H-" F,44- (Print or type) y � C> ��1��� Check one: Certificate Installing Company Name `UM s' ❑ Corp. Addresses �� � Partner. •Business Telephone L v Firm/Co. Name of Licensed Plumber: r C� Insurance Coverage: Indicate t of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: 1,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and instal] erformed under Permit Issued for this application will be in compliance with all pertinent provisions of the Mass etts Swre P ng a apter 142 of the General Laws. BY igna u 1cense u r y�,/✓ Ty of Plum bing License Title ���. '-` / City/Town icense um er Master Journeyman APPROVED(OFFICE USE ONLY t ' The Commonwealth of Massachusetts k� Department of Industrial Accidents ; r ! Office of ti Invesations .,Ct, g is 600 IMashington Street i Boston, MA 02111 www_nzass gov/dia . Workers, Compensation Imiwance Affidavit. Builders/Contractors/Eleetricians/Plnmbers A licant Information. Please Print Legibly Name (Business/organization/Individual): E�',, !.",fl t�+� Address: City/State/Zip:_A f A . S' ©Phone#: . Are you an employer?Check the appropriate box: i.❑ I am a employer with 4, Type of Pref(required): enm ❑ I am a general contractor and I loyem(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. am.a:sole proprietor or partner. listed on the attached sheet,i 7. 0 Remodeling Remodel- ship and have no employees These sub-contractors have working for me n any aci�• workers' comp.insurance, g Q Demolition [No workers'comp.insurance 5. ❑ We are a corporation and its tion 9. ❑Building addi required.] officers have exercised their 10.[]Electrical repairs or•additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I!.❑ Plumbing repairs or additions myself. [No-workers'comp.. c. 152, §1(4),and we have no insurance required.]t 'em to ees. [No workers' 12.[ Roof repairs comp, insurance required_] 13-j].Other- *Any appiimm that checks bcd#t must also fill out the section below showing their worker;'compensation policy information. t homeowners who submit this affidavit indicating they are.8aing all work and then hire outside contractors must submit anew affidavit indicating each. ;Contractors that check this box must anaobed an aodhiaasl shwr showing.the name of the sub-contractors and their workers'won:C.pvii •iiedin such. t am an employer that is pro? i g:workers'compensation insurance or a to ees, Below is the information. -f �' y 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 e. 152 can Jead 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 cerci n er t ns andp of perjury that the information Provided above is true and rowed Si tare: 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): L Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Otber Contact Person: Phone#: I V 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'foreping engaged in a joint enterprise,and including the legal representatives of a dece=ased employer,or the receiver or tmstee of an individual,partnership,associatioin 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 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).a=nd phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. !fan 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 retwTied 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 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%vilI 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 futum 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 Iavesti rations 600 Washington Street Boston, MA 02111 TeL #617-727-4900 ext 406 or 1-8.77-MASSAFE Fax#617-727-7749 Revised 5-26-115 www.mass.gov/dia Date—. . "ORT" TOWN OF NORTH ANDOVER ° p PERMIT FOR PLUMBING TSACHUSE� / This certifies that . . . Q�t�. . . .. �� ly/�l9 /5?!� `. . . . . . . . has permission to perform . . . .�!.-./. . . . . . . . . . . . . . . . . . . . . • . • • plumbing in the buildings of . .Pe. ... .`.`. . . . . . . . . . . . . . . . . . . . . . . . at . /. .ax �. North Andover, Mass. Fee. 1.3 Lic. No.Gf.-33. . . . . . . . ! . J PLUMBING INSP CTOR Check # 7445 MASSACHUSETTS UNIFORM APPLICATION FOR-PERMIT TO DO PLUMBING :K�Mass. �- -\ Da ZO Per Bui ing L catio 7 ner's ame T Type of Occupancy New 0 Renovation❑ Replacement ge, Plans Submitted: Yes❑ No ❑ FIXTURES B•P•.# 'SEWER# SEPTIC# z YLn _j U >' .� Q to W LU o � to a W Z 0 Z cn w cn to F- U W cn u_ z .-, z a t tzil OLU z w LLJ E ¢ Ln Ln . Y a - cn C] g = cn u_ c7 D Q m D O SUB-BSMT BASEMENT 1ST FLOOR 2ND FLOOR K . 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR nstalling Company Name �,� � Check ong: Certificate 4d d ress A)lO Corporation 3usiness Telephone_- 1,669 ,Q' 17.q 0 Partnership dame of Licensed Plumber or Gas Fitter_ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGLCh. i42. Yes No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. ' A liability insurance policy P--*-, Other type of indemnity ❑ Bond 0 OWNER'S INSURNACE 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. Signature of Owner or Owner's Agent Check one: Owner ❑ Agent O hereby certify that all of the details and-information I have subm4rn ntered)In above-application are true and accurate to the best of y knowledge and that all plumbing work and installations perforthe permit iss for this application will be in compliance with i pertinent provisions of the Massachusetts State Plumbing Codek he eraI Laws.By Title ed lumber City/Town �.� APPROVED(OFFICE USE ONLY) Type of License: IYMaster OJourneyman License Number �j Date.........�U"..a,,3-..c)6...... ......... ...... NORTI/ TOWN OF NORTH ANDOVER FO 9 PERMIT FOR WIRING ,$SACMUS� 4 This certifies that --�-P l� ��- -�r� - /"� has permission toQ-........, ................. wiring in the building of..........� k, t -�-s ..v...................................... at.... 1Y..��........ /�.. ,North Andover,Mass. --„ r7� 1 F ..................... Lic.N030 .. Z .... ............. ` ELECfR��AL INSPEC�$R Check # 7013 Commonwealth of Massachusetts Official Use Only 4 Department of Fire Services Permit No. /01.3 R Occupancy and Fee Checked a BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] (leaveblank) 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: , City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention ttperform the electrical work described below. Location(Street&Number) ��� DId EQr P3 1/` 1 J Owner or Tenant t_ Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes �� No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: SE 450r Ebb VM &k 6C klwsc i- Completion of the following table may be waived by the Inspector of Wives. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets J12 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 I Number Tons K No.of Self-Contained Totals: .. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Mun'cipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems: No.o Water o.oNo.o No.of Devices or Equivalent +. Nf ' Heaters KW Ballasts Data Wiring: Signs 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: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage . in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the. and penalties of perjury,that the information on this application is true and complete FIRM NAME: �J )C- i l 1 LIC. NO.: Licensee: Signatur LIC. NO.:3�O 9 (If applicableenter "exem tt"}'n the license nwnber ine.) Bus.Tel No.: 97 � .J3-9 Address: Q- Alt.TeL No.:l03 362 ?73.3 *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 o� Signature Telephone No. PERMIT FEE. $ Ile- tk- vLta� .6y Date. L .� yc c TOWN OF NOATIH ANDOVER 41 o PERMIVOR PLUMBING r SSACNUS� This certifies that . . . . .�! . ! .?. . j(';.' . . . .f. . : . . . . . . . . . . . has permission to perform . . . .P.(�I) . t `. C . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at. . . . . . . . . . . . . . .. North Andover, Mass. Fee. a:1 . .r. .Lic. No.. . )' .�.? . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check 11 7215 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBIN (Type or print) NORTH ANDOVER,MASSACHUSETTS �/ `'1 UrA612RDateBuilding LocationOwners Name Permit-# / Amount Type of Occupancy ems! 4 New Renovation rj Replacement Plans Submitted Yes 0 No y. FIXTURES F cc 1z Cn cc 1-4 W C O a A SL1g13LS1VK B4SEMENr • M 1100<2 210 FIDOR �m FLO(;IEt 4M FIDOR 5M FLOOR 6M FLOOR 7M FLO(7I2 . gm)FLOOR (Print or type) l Chec one: ertificate Installing Company Name, JA 50,E �X�/Dwe orP. Address /&? &+e e Partner. r r!e e, Business Telephonef'ly Firm/Co. Narne of Licensed Plumber_ Insurance Coverage: Indicate,.th ype of insurance coverage by checking the appropriate box: Liability insurance policy U Other type of indemnity ® Bond Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner El 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 rformed and Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts St e umb' de d Cha 2 of the General Laws. By: igna ure o cense er Type o lumbing License Title /a©Qo2 City/Town License INumuer Master I'�I" Journeyman ❑ APPROVED(OFFICE USE ONLY LLL