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Miscellaneous - 12 RICHARDSON AVENUE 4/30/2018
12 RICHARDSON AVENU 210/031.0-0011_D = 000.0 I I II 1 0 Date....... ........ . -0 7 f NORTH 1 TOWN OF NORTH ANDOVER p PERMIT FOR WIRING • i �: i �,SSACMUSE� This certifies that ........4-: ...... 6LQ......... has permission to perform ......../' /T<</E� ...................................................................... wiring in the building of........ .................... at........1 .. Q-.11...... E .... ,North Andover,Mass. 17 Fee.. . ......... � Lic.No. �.�Y 9. .................... ..... ....... ..............:....... ELECTRICAL INSPECTOR Check # �z 7825 Commonwealth of Massachusetts Official Use Only " 7---r>'r Department of FMm ire Services Pemut No. ` IFBOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked 1W [Rev. 1/07J (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 W INK OR TYPE ALL INFORMATION) Date: , 1 �j r City or Town of: NORTH ANDOVER To the I pec or of Wires: By this application the undersigned gives noti,e=orintention to perform the electrical work described ow. (!:W4 Location(Street&Number) q�1t' 77 9 / 9: / Owner or Tenant1 � ��Mc 1'�nq, Telephone No. Owner's Address Is this permit in conjunction with a building ermit? Yes No ❑ (Check Appropriate Boz) Purpose of Building , Utility Authorization No. Existing Service_LOQ Amps `Volts Overhead Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters R Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: C.t a 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 No.of Luminaires SwimmingPool Above In- o.o mergency Lighting nd. rnd. ❑ Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection an Initiatin Devices No.of Ranges i No.of Air Cond. Tonsotal No.of Alerting Devices No.of Waste Disposers eat Pump - umber..Tons.-. .. _ No.of a -Contained Totals: Detection/AlertingDevices No.of Dishwashers Space/Area Heating KW Local Municipal El❑ Connection �� No.of Dryers Heating Appliances KW Security Systems:* + o.of Water KW No.of Devices or E uivalent Heaters o.of No.of Data Wiring: Signs Ballasts . No.of Devices or E uivalent No.Hydromassage Bathtubs No.of MotorsTotat HP elecommunications Wiring: OTHER: No.of Devices or Equivalent Lt-1 Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: A6C" (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 is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under th!.q painsand penalties of peri. at the information on this application is true and complete. FIRM NAME. L� LIC.NO.: License Signator txi�LIC.NO.: (If applicable nter ` mpt"in the license u Iz .) f/p Address: as.Tel. 70 *Per M.G.L c. 147,s.57-61,security work requires Departentf c oPublic Safety"S"License: t.L l m .No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$ The Commonwealth of Massachusetts nil Department of Industrial Accidents Office of Investigations }}_#; 600 Washington Street Boston, MA 02111 www mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant Information Please Print Legibly Name (Business/Organization/individual): Address: fie. City/State/Zip: 5,bone —a33: Are you an employer?Check the appropriate box: Type of project(required):1. I aun a employer with 4. ❑ 1 am a general contractor and I 6 ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.[] I am.e.sole proprietor.or partner- Listed on the attached sheet i 7. Remodeling ' ship and have no employees These sub-contractors have 11. ❑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.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exxemption per MGL 11.❑ Plumbing repairs or additions myself,[No•workers'comp. c. 1.52, §1(4),and we have no 12.❑Roof repairs insurance required.]-t .employees. [No workers' comp. insurance required..] 1,3:❑Other *Any applicant that checks host*I must also fill out the section below showing their workers'compensation policy information. P Homeowners who submit this affidavit indicating they are doing all work and then We outside contractors must submit a new affidavit indicating such. ;Contractors that check this box mustattached an additional sheet showing the as=of the sub-contractors and their workers'comp.policy information, I am an employer that is providingwworkers'compensation insurancefor my employees: Below is-the policy and job site information. Insurance Company Name: ' Policy#or Self-ins. Liicc�.#: Expiration Date: Job Site Address: `c^zt- �hQ � 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 edminal penalties of a fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and coned Si tore Date; ~d� Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical inspector S. Plumbing Inspector 6.Other Contact Person: Phone#: DIVISION OF PROFESSIONAL LICENSURE OFFICE OF INVESTIGATIONS Application for Complaint 617-727-7406 www.mass.gov/dpl Date Received(stamp): Entered into the Database(Date): / / Docket#: - - Acknowledgement letter sent(Date): / / Signature: --------------------------------------------------------- Please complete this form as fully as possible.(PLEASE DO NOT WRITE ABOVE LINE.)Please type or print legibly in ink. SUBMITTED BY: Name: /q`l Ug Last Name First Name MMI. Address: lboo9S�S�78 Number Street Daytime Phon City r- V— gz{'7 7.� State Zip Code Evening Phone Best way to reach you: ❑Evening Phone XDaytime Phone ❑E-mail: 112MtlRA16e LICENSEE SEEKING COMPLAINT AGAINST(use separate form for each licensed individual/business):,. Name: 69,0 P,&/Z W e L.c i oe4 --�. Last Name n First Name M.I. Address: 133 0irVEC2C—s7- /f ® [}663 qZq 133 Number Street DaytimePh7—)-- �Tc4r-f Zr� D 3 cam 2 ?yR q.?3 City State Zip Code License Number/ ype Class C tAWtte/wy Lnit✓` Business Name ` Business Address Daytime Phone 59"/%V,P_ City State Zip Code Business License#/Type Class Please check the trade or profession that this application for complaint pertains to Accountant Funeral Director Optometrist Aesthetician Gas Fitter Physical Therapist Architect Hair Salon Physical Therapist Assistant Athletic Trainer Hair Stylist Plumber Audiologist/Speech Language Health Officer Podiatrist Pathologist Hearing Aid/Instrument Psychologist Barber Home Inspector Radio/TV Tech. Barber Shop Real Estate Agent/ Chiropractor Land Surveyor P Broker/Salesperson Dietitian/Nutritionist Landscape Architect Real Estate Appraiser Dispensing Optician Manicure Salon Rehab.Counselor Drinking Water Manicurist Sanitarian Ed. Psychologist Marriage&Family Therapist Social Worker Electrician Mental Health Counselor Veterinarian Electrologist Occupational Therapist Engineer Occupational Therapist Fire or Burglar Alarm Assistant Page 1 of 2 Description of the incident(s): Briefly describe the incident(s) that led to your application for complaint and note the times and dates that • events occurred.List the names of all individuals involved.Please attach additional pages if needed. Me ���Pe2 �s;?,G�n T� /�vzy'�� /�Er�rr% �.v �v•v� �;- z�no7 QA42 A Mos S 6414152-,2 !M 3 31— CT `TNS m,a� r24 r 2 f?t cA-IA41?L<zp t: Avg /Vo"2 T±;Z"Olt 97 /978 3/7 8953 M R 640,Pc 2 jo 7_YACn S �t Lt sy5 7'0 J 411aGL C��1��15 6aA7—en, Oytyvr FTC f CODILOfs /- —a i eh> r L-07 &di /-- /\ AA-t,�I AM,kv lS'����� — �% r ix'f ere d 7� (Please use a separate sheet if necessary.Do not write in the margins.) Additional information or materials attached kes ❑No To speed up the application for complaint process,submit legible copies(not the originals)of all relative documents supporting your application(e.g.contracts,medical records,cancelled checks,etc.).You will receive an acknowledgement letter notifying you if a complaint is issued based on your application.If a complaint is not issued, you will receive information on additional resources that may be available to you. AUTHORIZATION FOR RELEASE OF RECORDS AND FORM REFERRAL My signature to this form,or a photocopy thereof,authorizes the Division of Professional Licensure to: (1)receive copies of all medical,dental and mental health records relating to my application for complaint,and(2)to refer my application for complaint to other appropriate law enforcement authorities to investigate and/or prosecute. Please note that all applications for complaints are examined to determine their factual basis. The act of filing an application for complaint does not assure or imply that disciplinary action will be taken against the licensee. I attest that the information provided is true,correct and complete to the best of my knowledge. Signature Date O27—,-/ Mail this form to: � << Division of Professional Licensure,Office of Investigations �vr�s/JTarz 239 Causeway St.,Suite 500 Boston,MA 02114 Page 2 of 2 —.r iii �p ;!:an a.t)U avl/Vhtf.$1�Q U7Y ' SC 22��° esalon CORMPRI"IllURT OUS190'COURT ADMFSSMp (3DE/1iY0 1 Msit # 3NEY(ilany) FF'SA�'r(�i RAfi3 ;> x "'. itfidress `� Dti"NP5i111A`Ilif . r 94IJD Narne- AWje :'. �,. . . PLf . bLAfik th" e'defierat ant v #scouff-costs#arty r:,_ a .. w ; @��tfi�!# SOT3'S. A " - t 1 I r :'.16: A T#IF3E UF�4A#1Q7�FF Ua Z Jae�rr '.. arfiesagra�etsctirssrr�atter.vta � wr�✓ Tner#reiori a deeridar#t .� .: c # slf�'11F 'DA The 2t1#ailff tfin :, t17 . P} states:under : e r#s and Penalties ofierJury that the: above ndant(s)is s the _{�not serrit�g - rnititary at present iive(,S) or .above deter#da s is ars' servin an at the abov®address. The rr#l# � � �,Serving .in # i 1C,x+9A �lEi►hIDi�D pg�iQ3F�ipURt IM TWI �A eM SLEWia ' u .fika0-A b ! I? stx �ittfi '4 ia#ntiedated #r:al ##t#Ts Fe�2ta Jadiaea�ter,- O cl a xaoted old It #+�#s i to Bettie his ctanr#' W76the#r#ai date,your � err e¢ :. 411 .. . _ rAr►�r � xaarENb. aHrErrFtziAi BEE aftffley- ADMMNAL.INIS=RtICI cot Rr MCE ®NS'fl f'SHE BACK taF T#Iis 1= �d�wE. 12/3/2607 i�A O TT�omSS Ai, CicsazERtsyCaEE ----- ---_' l3 aQ aim€ BrenII -DATE '. — SFECIFIEt) �.- Toz1� rin�E � eomr+aaca. eDCI'i0A1S FOR fILiNG 2 A SMftL CLAjM —, you vDU rr###St complete Parts 1-6 of Chic f:,..., .WrGo.t.. v. viLuisi use unty Department of Fire Services Permit No. /zqZ-s� 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 PRINT W INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives no ce of his or hAr intention to perform the electrical work described below. Location(Street&Number) s c L Owner or Tenanti Telephone No. Owner's AddressG✓Y`Y�C` Is this permit in conjunction with a budding Permit? Yes No ❑ (Check Appropriate Boa) Purpose of Building , ray Utility Authorization No. Existing Service Ams F p l ) / Volts Overhgad KN Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No,of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: (,� • Completion o folloit4nz table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Tota Transformers KVA No.of Luminaire Outlets f No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ - o.o mergency tg g d. d. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No. of Gas Burners No.of etection an Initiatine Devices No.of Ranges No. of Air Cond. Tonal No.of Alerting Devices No.of Waste Disposerseat PSP Numbe....._.r ons o. ofSelf-Contained ......_.............. Detection/Alertine Devices No.of Dishwashers Space/Area Heatin KW Municipal g Locsl❑ Connection R Other No.of Dryers Heating AppliancesKW Security No.of Water o.oNo.of Systems:* No.of Devices or Equivalent f Heaters KW Ba Data Wiring: Signs Ballasts No.of Devices or E nivalent No.Hydromassage Bathtubs No.of Motors Total HP elecommunications Wiring: No.of Devices or Equivalent OTHER: L 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 is in force,and has exhibited proof of same to the permit issuing office. ; CHECK ONE:-INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under 4thheains and penalties of perj, at the information on this application is true and complete. FIRM NAME: L •w LIC.NO.• License • Signatur _ .�hIC.NO.: (If applicable nter ` mpt"in the license' u II .) r us.Tel. 01 Address: _ t Tei. *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lin.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement I am the(check one) ❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ MIN- Commonwealth of Massachusetts official Use Only } Permit No. / �� WWIDepartment of Fire Services Occupancy and Fee Checked r BOARD OF FIRE PREVENTION REGULATIONS [Rev. 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: 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) Owner or Tenant s«�4� G�j[�,�S Telephone No. 5'J Owner's Address . 7 -7 �ZC J Is this permit in conjunction with a building permit? Yes ❑ No 19-� (Check Appropriate Box) Purpose of BuildingUtility Authorization No. Existing Service LD Amps 11.0 /210 Volts ' Overhead Undgrd ❑ No.of Meters _L New Service j Amps 1201 /D4D Volts Overhead Undgrd ❑ No. of Meters 1 Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Loln G A✓\G v�l:t,.l Completion of the followingtable may be waived b the Ins ector of Wires. No. of Recessed Luminaires No.of Ceil:Susp.(.Paddle)Fans o.of Total Transformers KVA No.of Luminaire Outlets No. of Hot Tubs Generators KVA A ove n- o.o Emergency Lighting No. of Luminaires Swimming Pool ; rnd. El In- Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Bur ri rs' o.o etection an InitiatingDevices p No.of Ranges No.of Air Cond. TonsTiTt—al No.of Alerting Devices No. of Waste Disposers eat Pump Number Tons.. K .. o.oSelf-Contained Totals: .... _. Detection/Alerting Devices icippi No.of Dishwashers Space/Area Heating KW Local 0 un'ectio ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW o.o No.o Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP elecommunications iring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: lem,ctr - (When required by municipal policy.) Work to Start: 11_F,_ V1 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ OTHER ❑ (Specify:) /certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: Signature �- LIC. NO.: (If applicable, enter "exempt"in he License num er line.) Bus.Tel. No.•Qi�-�4"11-5F)gZ_ Address: -IahIG� - = i Alt. Tel. No.:io&l-361—y 8� *Per M.G.L c. 147,s. 57-61, security w rk 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. 1 am the(check one)❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $,in, M.G.L. - Chapter 143, Section 31 Page 1 of 1 tT e General Laws Of Massac usetts „ Search the Laws.- Go To: Next Section [Chapter revious Section PART I. ADMINISTRATION OF THE GOVERNMENT Table of ContentGL Search Page neral Court Home TITLE XX. PUBLIC SAFETY AND GOOD ORDER Mass.go -- CHAPTER 143. INSPECTION AND REGULATION OF,AND LICENSES FOR, BUILDINGS, ELEVATORS AND CINEMATOGRAPHS INSPECTION OF BUILDINGS Chapter 143: Section 3L. Regulations relative to electrical wiring and fixtures; notice of electrical installation Section 3L. The board of fire prevention regulations shall make and promulgate,and from time to time may alter, amend and repeal, rules and regulations relative to the installation, repair and maintenance of electrical wiring and electrical fixtures used for light, heat and power purposes in buildings and structures subject to the provisions of sections three to sixty, inclusive, and the state building code. Such regulations shall be in accordance with generally accepted standards of engineering practice, and shall be designed to provide reasonable uniform requirements of safety in relation to life, fire and explosion. Upon the making of such rules and regulations and prior to their promulgation,the board shall hold a public hearing thereon, notice of which shall be given by advertising in at least one newspaper in each of the cities of Boston, Worcester, Springfield, Fall River, Lowell and Lynn, at least ten days before said hearing. If, subsequent to their being deposited with the state secretary, as provided herein, the board on its own initiative contemplates changes in said rules and regulations, or if a petition is filed by any other person for changes therein, like notice and a hearing shall be given and held before the adoption thereof. Such rules and regulations, and any alterations, amendments or repeals thereof shall be deposited with the state secretary, and the same shall become effective when so deposited. No person shall install for hire any electrical wiring or fixtures subject to this section without first or within five days after commencing the work giving notice to the inspector of wires appointed pursuant to the provisions of section thirty-two of chapter one hundred and sixty-six. Said notice shall be given by mailing or delivering a permit application form prepared by the board, to said inspector. Any person failing to give such notice shall be punished by a fine not exceeding five hundred dollars. This section shall be enforced by the inspector of wires within his jurisdiction and the state examiners of electricians. Any person installing for hire electrical wiring or fixtures subject to this section shall notify the inspector of wires in writing upon the completion of the work. The inspector of wires shall, within five days of such notification, give written notice of his approval or disapproval of said work. A notice of disapproval shall contain specifications of the part of the work disapproved, together with a reference to the rule or regulation of the board of fire prevention regulations which has been violated. http://www.mass.gov/legis/laws/mgl/143-31.htm 11/20/2007 COMMONWEALTH OF MASSACHUSET I S OF ELECTRICIANS k AS A REG JOURNEYMAN ELECTRICIAN j ISSUES THIS LICENSE TO RBF WILLIAM L COOPER III o moy 133 PINECREST RD MIX oo,m LITCHFIELD NH 03052-2338 T 7: s 483JR 07/31/10 344232 -� f n t I COMMONWEALTH OF MASSACHUSETTS Ings t� OF ELECTRICIANS Q , ,•- ,O , REGISTERED MASTER ELECTRICIAN ru 2a0'Zei 4 v ISSUES THIS LICENSE TO Z F , WILLIAM L COOPER III ' i3 •r ;; `w"'`� .�A r 133 PINECREST RD LITCHFIELD NH 03052-2338 C) O ':ri ", ,�" p� 424MR 07/31/10 344231 o y ` r , Date.......�..�..-.. : .- ..7 NORTN TOWN OF NORTH ANDOVER PERMIT FOR WIRING SS�CHUS� a This certifies that lam '"C //..''..... ...... ...........� ..................... has permission to perform ........A -/ Z-/- ..../............................................... wiring in the building of........ �`f .....4r<l.��- .f.1t,1.S.................... at ........1.z-....1 (..��. ,P ......�E.... ,North Andover,Mass. Fee..................... Lic. No. .rYl.�t'. �.y.................... ..... .... ..... ELECTRICAL INSPECTOR , Check # — ,[G2 Z.:- 7825 CERTIFICATE OF INSURANCE n,Illinois This certifies that STATE FARM FIRE AND CASUALTY COMPANY,Bloomingtoilois STATE FARM GENERAL INSURANCE COMPANY,Bloomington, ❑ STATE FARM FIRE AND CASUALTY COMPANY,Scnrbo terHsvenOntario STATE FARM FLORIDA INSURANCE COMPANY, ❑ STATE FARM LLOYDS,Dallas,Tetras insures the following policyholder for the coverages indicated below. Policyholder CW WIRING INC Address of policyholder C/0 WILLIAM COOPER 133 PINE CREST RD, LITCHFIELD, 14H 03052 Location of operations Description of operations ELECTRICAL The policies listed below have been issued to the poficyho lder for the policy periods shown. The insurance described in these policies is subjed t0 all the terms,otocclusionc,and conditions of those policies.The limits of liability shown may have been reduced by any paid claims. POLICY PERIOD LIMITS OF LIABILITY (at beginning of policy period) POLICY NUMBER TYPE OF INSURANCE Effective Own •ration DOW BODILY INJURY AND Comprehensive 07/2 5/07 17/2 6/O t3 PROPERTY DAMAGE 94->aT-leez-� Comp 1 Business Liability --------------•--- This insurance includes. Products Completed Ope one Each Occurrence S.1 cin n n n n ®Contractual LiaUllily ®personal Injury General Aggregate $2000000 ®Advertising Injury Products-Completed $2000000 Operations Aa ate POLICY PERIOD BODILY INJURY A(Combined Single Li� DAMAGE EXCESS LIABILITY Effective Date ER*mf n Date (]UmDmla Each Ooaurrencc Y 0 OtherAggregate $ POLICY PERIOD Part I-Workers Cornpensa§011 - Statutory Effective Date : Ex iradion Date Workers'Campensslion Part II-Employers Liability and Ernploy�Liability Fsrh Acaddent $ D S9ase-ELmh Employee $ Disease-Policy Limit $ POLICY PERIOD LIMITS OF LIABILITY POLICY NUMBER TYPE OF INSURANCE Effective Date ; Expiration 0a* (at beginrrirtg of policy period) THE CERTIFICATE OF INSURANCE IS NOT A CONTRACT OF INSURANCE AND NEITHER AFFIRMATIVELY NUfR NEGATIVELY AMENDS,EXTENDS OR ALTERS THE COVERAGE APPROVED BY ANY POLICY DESCRIBED HEREIN. Name and Address of Certificate Holder If any of the described policies are canceled before Billing Dept. N. Andover, MA their expiration date,State Farm will try to mail a soo Osgood ai . written notice to the certificate holder 3o days belbre t. 3. Andover., MA 01895 cancellation. If however,we fail to mail such notice, N. no obligation or li ill 11 be imposed on State Attn: Peter Murphy Fane or its agt> r nt4#ves. FX' 978-680-9542 (:.• mit Signature of Aut orized Representative 11/29/01 1/, /07 AC2NT Title Date RON BECHARD Agent NernO Telephone Number 603-434-0400 Agent's Code Stamp Agwel cuutt 29-3042 AFO Code F976 5$8.994 8.5 Rev.11-06-2001 PIWL-d in U-SA JN Date. ... Cf kORoT#1 TOWN OF NORTH ANDOVER f p PERMIT FOR WIRING 'MACMUS� This certifies that ....?.�'. '. ..G�.. .�� .�..... ...!.RC ......' Gf has permission to perform ....',t ..l�t!i� � . ............................................. wiring in the building of t.�.eo ..... . ........................................ at... ...t.6wt A......&. ....................AorthAndover,Mass. �� �' Fee... .c. .... Lic.No. ...... .. ................... .�* '"'*'i . .. ..... ....BLE L INSPECTOR Check # 10858 0 - Commonwealth of Massachusetts Official Use Only - Department of Fire Services PemutNo. BOARD OF FIRE PREVENTION REGULATIONS [Rev. j and Fee Checked (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C),527 CMR 12.00 (PLEASE PAWT.W INK OR TYPE ALL INFORMATION) Date: ZQ I I 2.. City or Town of: NORTH ANDOVER To the Inspe for ol Wires: By this application the undersigned gives notice of his or her inten'on to perform the electrical work described below. Location(Street&Number) TIC Owner or Tenant Telephone No. Owner's Address Is this permit in conj tion 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: Completion offhefiollowing table may be waived by theles ector o Wires. No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No.of Total Transformers RVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ JNo.olEmergencyughting red. Lyrnd. Battery Units No.of Receptacle OutletsjNo. f Oil Burners FIRE ALARMS No.of Zones No,of Switches f Gas Burners No.of Detection and Initiatin Devices No.of Ranges f Air Cond. Tons l No.of Alerting Devices No.of Waste Disposers Heat Pump Number .Tons . KW No.o Self-Contained Totals: Detection/AlertingDevices No.of Dishwashers Space/Area Heating KW Local❑Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:x• No.of Watero. No.of Devices orEquivalent Heaters KW No.Si Bal as Data Wiring: Signs Ballasts No.of Devices orE uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or E uivalent Attach additional detail ifdesired,,or as required by the Inspector of Wires. Estimated Value o Electr cal Work: d (When required by municipal policy.) Work to Start: �ay 1 I Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the per it issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) j"7 �,Z ��z�� Fcertify,under t e p ittnilptiPs of erjy.that he in f rmatior.on this application is true and cor•:p�e FIRM N �� "� �' S• . Licensee: J. �h Signature LIC.NO.: of (Ifapplicab ,e e `lx eliicense iW*er lin us.Tel.No.: Address: -4— JT Gupv � t.Tel.No.: 'Per M.G.L c.147,s.57-61,security work requires Department of Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensed s not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this re reMent. I am the(check one ❑owner ❑owner's a ent. Owner/Agent Signature Telephone No. - - Y PERMIT FEE:$ The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/ilia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print L_e�i'bl�, Name(Business/Organization/Individual): Address: - City/State/Zip: Phone#: 6 n -S 4, — Are you an employer?Check the appropriate box: Type of project(required): 1.© 1 am a employer with 11-- 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have Hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9, E]Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their ME]Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I LJA Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs insurance required.]i employees.[No workers' comp.insurance required.] 13.[i Other 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is pYoviding workers'compensation Insurance for my employees. Below is thepolicy and job site information. Insurance CompanyName:. __i)�,AeA\pa_ h Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address:t aRz( � C- A n.�f, City/State/Zip: Attach a copy of the workers'coin enation olicy declaration age(showing the olio number and ex iration date). P P p ( g policy p ) Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. IT do hereby, ti ndenTrdpenalties ofperjury that the information provided abo a zs true nil correct. Si afore: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other - - - Contact Person: Phone#: I Date.. ....... ..! ..................... NORTF�,� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION -y 834cMus� This certifies that ........ ..� U 1 �1 ............................................................................................ has permission for ga\s/�'nstallation .... !..P ,............................................. in the buildings of...........(AI...0 c'.Kv.... . ............................................................. at.......1. ... ..� 1 Lf7,p.r.>1....................(....... .., North Andover, Mass. Fee...��..-. Lic. No.%A'AL .�......V - 1..!. ............................................................. GASINSPECTOR Check# � i � U _414 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK *IV CITY N44PI/7'��,01a MA DATE �v'13"2013 PERMIT#��__ JOBS ITE ADDRESS I Z�/�AC#I-Y�Al OWNER'S NAME U/g k I L' t-D GOWNER ADDRESS 5/919W, TEL _FAX _ TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑/ PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO APPLIANCES 7 FLOORS— BSM 1 2 3 1 4 5 6 7 8 9 10 1 11 1 12 13 1 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE ,.;'have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑ i JF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ' 4 LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT El I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the est of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia a ith i t provision of the Massachusetts State Plumbing Code and Chapter 1422 off�the General Laws. flqt)&:l`PLUMBER-GASFITTER NAME /7 LICENSE# ATURE MP[9-' MGF❑ JP❑ JGF❑ LPGI❑ // CORPORATION X15-2 Z2 PARTNERSHIP❑# LLC❑# COMPANY NAME—I `'IM5 / �-1-7Y.� � ADDRESS 9�/I6 6E L 41 h� CITY '(f)IL M/�7 T�/� STATE ZIP n TEL 47,9-e�5L 2710 FAX �d 1� CELL ���y0.7'67729?� EMAIL +�I^ (//�I C !Z9/�� rt The Commonwealth of Massachusetts 07 Department ofIndustrial Accidents Office of Investigations IN 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information l/ Please Print Leaffily Name(Business/Organization/Individual). I IN Address: City/State/Zip: (.c) Phone#: 47 7 -(fo 7 7G'j6' Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I employer with 4. ❑ I am a general contractor and I 6. ❑New construction ployees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. �• E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. El Building addition [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.2�1.�ecal epairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11. epairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 1311Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'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 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 requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cert nder.the mains andpenalties ofperjury that the information pro videdabove is true and correct. Si afore: y Date: Phone#: 41A 2`6,�0 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#: COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMBER ISSUES THE ABOVE LICENSE TO: PAUL J RAFFI 8 BRIDGE LN . WILMINGTON MA 01887-2672 9898 05/01/14 168471 r 66mMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS REGISTERED AS A PLUMBING CORP- ISSUES THE ABOVE LICENSE TO: PA'jL J RAFFI P RAFFI PLB & HTG INC M 989 8 B,�TDGL LN WILM.*NGTON MA 01887-267 1552 05/01/14 168472 '= COMMONWEALTH OF MASSACHUSETTS . . PLUMBERS AND GASFITTERS. LICENSED AS A JOURNEYMAN PLUMBER ISSUES THE ABOVE LICENSE TO: PAUL J RAFF! 8 • BRIDGE LN MINGTON MA 01887-267 19347 05/01/14 168473 � . Date .�.�`�� ...... TOWN OF NORTH ANDOVER i ��i -`� •• OCL ° 9 PERMIT FOR PLUMBING 83ncMua� This certifies that.........�. . � T ..... .............................................................................................. has permission to perform... ....... ..... ..P....P:Q—................... plumbing - the buildings of.............A-2..., ►.S..�.�................................... at..Z..... .. X..`w�,1... �-�`✓e-........ North Andover, Mass. FeZ.O'N.......Lic. No. 0 .. .��......................................................... .......... PLUMBING INSPECTOR Check# MA�S�SACHUSETTSS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • CITY MA DATE /YO/�.�3�Z�/� PERMIT# �/� JOBSITE ADDRESS-1 z- f)GAVDI Soly �i� OWNER'S NAME PAY iloleI"'CIle POWNER ADDRESS '54-141& TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUC AL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NOEr FIXTURES 7 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE D DEDICATED SPECIAL WASTE SYM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM 3 DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL �N WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING cJ OTHER INSURANCE COVERAGE: ,/ I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 2--'NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. i CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge {� and that all plumbing work and installations performed under the permit issued for this application will be in complian "th all P , nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ��I V ^Jr IFF� LICENSE#q gjg / ATURE .. • MP [❑' JP❑ CORPORATION 21 1552-C—PARTN/EER,SpH,IIP►❑# LLC❑# COMPANY NAME tel. 1�,/moi FF/ )24# TwC ADDRESS c�F�YL�y L7 GL/re CITY W�L�� 'r STATE 1M. ZIP TEL %17d�'—4 777/0 FAX �7 �� ��? 7�® CELL 97�.�� y � EMAIL �" �D DEVAL L. PATRICK 'S GOVERNOR DANIEL C. CRANE TIMOTHY P.MURRAY Commonwealth of Massachusetts DIRECTOR,OFFICE OF AFFAIRS& LIEUTENANT GOVERNOR Division of Professional Licensure CONSUMER REGULA ONBUSINESS DANIEL O'CONNELL Office of Investigation GEORGE K.WEBER SECRETARY OF HOUSING DIRECTOR,DIVISION OF AND ECONOMIC DEVELOPMENT 239 Causeway Street - Boston - Massachusetts - 02114 PROFESSIONAL LICENSURE January 3, 2008 Peter Murphy 1600 Osgood Street North Andover, MA 01845 CASE NAME: Peter Murphy vs William Cooper DOCKET NO: EL-08-100 INVESTIGATOR: Richard Paris Dear Peter Murphy: This is to acknowledge receipt of your complaints. They have been assigned to the investigator noted above. Your cases are important to us, and they will be completed as expeditiously as possible. The investigator may contact you for additional information if needed. Once the investigations are completed, the case files are forwarded to the licensing board for a decision. Most of the boards only meet once per month. You will be notified in writing of the decision by the board. The Office of Investigations administrative staff can assist you with any procedural questions you may have. They can be reached at 617-727-7408. If you need to speak with the investigator, he can be reached at 617-727-6090. incerely, — lama—ntha McBean Administrative Assistant I iA TELEPHONE: 617-727-7408 FAX: 617-727-1944 TTY/TDD: 617.727.2099 http://www.mass.gov/dpi 60[4p,. 5 2- R I C-/Ae D -�:01V DIVISION OF PROFESSIONAL LICENSURE OFFICE OF INVESTIGATIONS Application for Complaint 617-727-7406 www.mass.gov/dpl Date Received (stamp): Entered into the Database(Date): / / Docket#: - - Acknowledgement letter sent(Date): / / Signature: Please complete this form as fully as possible.(PLEASE DO NOT WRITE ABOVE LINE.)Please type or print legibly in ink SUBMITTED BY: q e Name: /q V a Last Name First Name MI. lb®d ©Sy Address: �ce6 Sl g7�i' 69$ s47837S-eZFy Number Street Daytime Phona® City �L�cc ' gZ/7 7d State Zip Code Evening Phone 11lD�fw /��bc�vr2 rG9�- AsZ 0< Best way to reach you: ❑Evening Phone Xbaytime Phone ❑E-mail: �/l'l t�/PP/,/� �Tow��,G/�acTNl�esc E/t• �B LICENSEE SEEKING COMPLAINT AGAINST(use separate form for each licensed individual/business):�, a Name: L c LL i 4,4 L Last Name First Name M.I. Address: 133 PIAVE-C2C-s'/' 2L) 663 g2-il ?333 Number Street Daytime Phon rcczr� � 3 c��Z M2 't 2�/ �-R `1h'3 City State Zip Code License Number/ ype Class C c f2/w y LAIC_ Business Name Business Address Daytime Phone City State Zip Code Business License#/Type Class Please check the trade or profession that this application for complaint pertains to Accountant Funeral Director Optometrist ist Aesthetician Gas Fitter Physical Therapist Architect Hair Salon Physical Therapist Assistant Athletic Trainer Hair Stylist Plumber Audiologist/Speech Language Health Officer Podiatrist Pathologist Hearing Aid/Instrument Psychologist Barber Radio/TV Tech. Barber ShopHome Inspector Land Surveyor Real Estate Agent/ Chiropractor Broker/Salesperson Dietitian/Nutritionist Landscape Architect Real Estate Appraiser Dispensing Optician Manicure Salon Rehab.Counselor Drinking Water Manicurist Sanitarian Ed. Psychologist Marriage&Family Therapist Social Worker Electrician Mental Health Counselor Veterinarian Electrologist Occupational Therapist Engineer Occupational Therapist Fire or Burglar Alarm Assistant Pagel of 2 Description of the incident(s): Briefly describe the incident(s) that led to your application for complaint and note the times and dates that events occurred.List the names of all individuals involved.Please attach additional pages if needed. 4=L44EA M45-5 I-Au--, ��r�J/�"�2 1213 3/- CcT buy&i-e,,,,9 e/--- 0/ r'm/ei,s- 22 AA 97x627 '1 Z gz8 3/7 8998 /ti'IR Gom p�t2 j� % s ac4nV5 /o S MAzz, l�a��! 6647—onv 2 7 " A4v/LlFslu�l' l�e��sJl�ir��—��2GLo� 7715 cTc r al c. 66 �/ rs a oX; (AP- C&0Pe1z ,P A — �f�U Wa2eV_1 � ^ c a rra D� ryoi /9/ i L£t7q�;tcal�i2/•- /1 A�tziAM,ky (Please use a separate sKeet if necessary.Do not write in the margins.) Additional information or materials attached kes ❑No To speed up the application for complaint process,submit legible copies(not the originals)of all relative documents supporting your application(e.g.contracts,medical records,cancelled checks,etc.).You will receive an acknowledgement letter notifying you if a complaint is issued based on your application.If a complaint is not issued, you will receive information on additional resources that may be available to you. AUTHORIZATION FOR RELEASE OF RECORDS AND FORM REFERRAL My signature to this form,or a photocopy thereof,authorizes the Division of Professional Licensure to: (1)receive copies of all medical,dental and mental health records relating to my application for complaint,and(2)to refer my application for complaint to other appropriate law enforcement authorities to investigate and/or prosecute. Please note that all applications for complaints are examined to determine their factual basis. The act of filing an application for complaint does not assure or imply that disciplinary action will be taken against the licensee. I attest that the information provided is true,correct and complete to the best of my knowledge. Signature Date �d27—i�// fi64lZ Mail this form to: �LCPy�r� Division of Professional Licensure,Office of Investigations 239 Causeway St.,Suite 500 Boston,MA 02114 Page 2 of 2 AND NOME.OF � ..,�, �+► �t��� u��f a.�,. b 714 sC 2272° 5�#t s:. t 1 d AWIR, g a}� .//��j - fir. ��\Q o rcotIm, • a. ' oI'.: It'IlllaE,AonrrEss. coo-AND IORNEY#ferny) 1ViS1+Dl� �uaar. •• 1011 Addril lie All 7 ORM 2 N.A Name. Add :':. PHQNE1tIt" ... - .,. LAINiPioN> rriai C.tA111ii +e defendant ojwes� iGtvete`� '' tus fag _ co�costsfar#tae nxt ovang reasons+. r , - ,.4 Y .A} t n S r77 i - 77 77" a - - AT1aREtTF +LA1N7iFF yr` ' ®OT " parb. nFIe 104, SGl3SS Je' Z_ derrifet#1a edee�darat rattl# : .�srfitstra ti3a :: stedlatttra�rrre.#rl�t9 da# r a #i3eo1 # nrti 1i3AyIA' r t� The tairttf#.hates undert ire:. (pins and penalties of Aer above $ jury:tura#the: t( a �otse ,; - � !►aW at present ti osj dr about✓ r at the above address: , fs t e.serving In n e r MP{ FIA MA ... uag st WAMEAN) i1�tD 43�i�jl i3A n��•� t'�.� arae ary tae atbve fie» Dr ct2t1.rr� aea� b matf oris "yent ova Ws sp a ►g r ee :. Ora #aould Y aura be t the#r;�date,Y�:; #, ea ;EE NAi!N a ccasgr �/� :ncE SIAUCt�(t�NS.flNEiCK TH >= aw 12/3/200,7err o ct Ea1c-MA GISTPAMOR Th DESIGNEE oma PS. �raeE -_- 143 2 Brea OA • A.- TOI'l8 TIME SP�ECfRffl 13GI(3A�13�(3. t1C'�10NS FOR f1Z UNG A SMALL CLAt11l1-- You must � (06M) ATFWNnw. p)8te 'Nos 1-6 of this-I",— c__ :_ vv��uuv���rcoio�/ v� i-icy„off,/1L15C[L5 wuluini vsevnry Department of Fire Services Permit No. Z� 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 PRINT WINK OR TYPE ALL INFORIII4TI0M Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives noof his or h intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant d-�, ,�� i\1c1 , Telephone No. Owner's Address Is this permit in conjunction with a building ermit7% Yes No ❑ (Check Appropriate Boz) Purpose of Building Utility Authorization No. Existr r. ing Service ^Ams / Volts P ` Over 1s��� head� Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion o the rollowing table may be waived b the Ins ector o Wires. No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans o•of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No,of Luminaires Swimmin Pool Above In- o. o mergency ig g g d. ❑ d. ❑ Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of SwitchesNo.of Gas Burners o.of etection an --i4t4ating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers eat PSP Number ons o. ofSelf-Contained Totals: `..... Roils -- --- Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ unicipal Connection F-1 other No.of Dryers Heating Appliances KW Security Systems.:* No.of WaterNo.of Devices or Equivalent Heaters KW Si s Ballasts . Data Wiring; No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: ` O � Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: A/.;,.- (When required by municipal policy.) Work to Start Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof 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 ains and penalties of perj. at the information on this application is true and complete FIRM NAME: r LIC.NO.: License • �1' �� Signatur 611 IC.NO.: (Ifapplicable nter ' mpt"in the licenser u h .) � Address: us.TeL *Per M.G.L c. 147,s.57-61,security work requires.Department of Public Safety"S"License: L Licl No, OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the Iiability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am.the(check one) El owner E]owner's agent Owner/Agent Signature Telephone No. PERMIT FEE:$ lk'\ Commonwealth of Massachusetts Official Use Only Permit No. 77 Department of Fire Services Occupancy and Fee Checked �� �f� BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]/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 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 to perform the electrical work described below. Location (Street&Number) Owner or Tenant -Ii r, -A k�,�S Telephone No. ql Owner's Address . ' -7C f 2-C Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Buildings Utility Authorization No. A Existing Service im Amps I'LL) /2_4o Volts Overhead Undgrd❑ No. of Meters New Service jam_ Amps 17-0 17-40 Volts ..Overhead. Undgrd ❑ No.of Meters l Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: rac F Q`1-1 ��Vxe �. Completion of the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.-of Ceil.-Susp.(.Paddle)Fans o. ot Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No. of Luminaires Swimming Pool 'Above ❑ n- ❑ o.o mergency,Lighting rnd. rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS INo.of Zones o..o Detection an No.of Switches No.of Gas Burners` Initiating Devices p No. of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No. of Waste Disposers eat Pump umber . ons o.of Self-Contained Totals: Detection/Alerting Devices cippi No.of Dishwashers Space/Area Heating KW Local 11Conneectiun� ction ❑ Other No.of Dryers Heating Appliances Kir Security Systems:* No.of Devices or Equivalent No.o atero.o o,o Heaters KW 'Signs Ballasts Data Wiring: . No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP elecommunicationsWiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: lcocy),w (When required by municipal policy.) Work to Start: 1 i._ �,_ 01 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ©BOND ❑ OTHER ❑ (Specify:) /certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: Signature � LIC. NO.: l>Lti.p'S El. (If applicable, enter "exempt"in he license number line.) Bus.Tel. No.:114-4-74-S&4 Address: 8 i RAlt.Tel. No.:ioL:5-382,y1 *Per M.G.L c. 147,s. 57-61, security w rk requires Department of Public Safety"S" License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $,:b,� M.G.L. - Chapter 143, Section 31 Page 1 of 1 • The General Laves of Massachuset, '��Sear LaM►s �;� Go To: Next Section Previous Section PART I.ADMINISTRATION OF THE GOVERNMENT Chapter Table of Contents MGL Search Page General Court Home TITLE XX. PUBLIC SAFETY AND GOOD ORDER Mass. ov CHAPTER 143.INSPECTION AND REGULATION OF AND LICENSES FOR, BUILDINGS ELEVATORS AND CINEMATOGRAPHS INSPECTION OF BUILDINGS Chapter 143: Section 3L.Regulations relative to electrical wiring and fixtures; notice of electrical installation Section 3L. The board of fire prevention regulations shall make and promulgate, and from time to time may alter, amend and repeal, rules and regulations relative to the installation, repair and maintenance of electrical wiring and electrical fixtures used for light, heat and power purposes in buildings and structures subject to the provisions of sections three to sixty, inclusive, and the state building code. Such regulations shall be in accordance with generally accepted standards of engineering practice, and shall be designed to provide reasonable uniform requirements of safety in relation to life, fire and explosion. Upon the making of such rules and regulations and prior to their promulgation, the board shall hold a public hearing thereon, notice of which shall be given by advertising in at least one newspaper in each of the cities of Boston, Worcester, Springfield, Fall River, Lowell and Lynn, at least ten days before said hearing. If, subsequent to their being deposited with the state secretary, as provided herein, the board on its own initiative contemplates changes in said rules and regulations, or if a petition is filed by any other person for changes therein, like notice and a hearing shall be given and held before the adoption thereof. Such rules and regulations, and any alterations, amendments or repeals thereof shall be deposited with the state secretary, and the same shall become effective when so deposited. No person shall install forhire any electrical wiring or fixtures subject to this section without first or within five days after commencing the work giving notice to the inspector of wires appointed pursuant to the provisions of section thirty-two of chapter one hundred and sixty-six. Said notice shall be given by mailing or delivering a permit application form prepared by the board, to said inspector. Any YPerson failing to give such notice shall be punished by a fine not exceeding five hundred dollars. This section shall be enforced by the inspector of wires within his jurisdiction and the state examiners of electricians. Any person installing for hire electrical wiring or fixtures subject to this section shall notify the inspector of wires in writing upon the completion of the work. The inspector of wires shall, within five days of such notification, give written notice of his approval or disapproval of said work. A notice of disapproval shall contain specifications of the part of the work disapproved, together with a reference to the rule or regulation of the board of fire prevention regulations which has been violated. http://www.mass.gov/legis/laws/mgl/143-31.htm 11/20/2007 COMMONWEALTH OF MASSACHUSETTS OF ELECTRICIANS AS A REG JOURNEYMAN ELECTRICIAN ISSUES THIS LICENSE TO WILLIAM L COOPER III 133 PINECREST RD , m;x MIM.. LITCHFIELD NH 03052-2338 483JR 07/31/10 344232 ❑ �� k �` F �7�L�+ I COMMONWEALTH OF MASSACHUSETTS � Z eTT1` 'id` s . m OF ELECTRICIANS ❑ ';a0 REGISTERED .MASTER ELECTRICIAN ri =PF+ 3 `k" ° o Z .x ' ISSUES THIS LICENSE TO 9h z �dOPER I.II ■■ ,•� QR � ,i t�r�fn•��7f� � WILLIAM L CO � a c Y � 133 PINECREST RD LITCHFIELD NH 03052-2338 424MR 07/31/10 344231 ❑ �. F�' CIS¢� ��4r } Er_ �"' +' e 14 i � .v • ® e Date.......�..�..�.. .'a..7 rn. TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,..o CHUS This certifies that has permission to perform .........k .............../............................................... wiring in the building of........ f!' ... ......4-1G.l. I.S.................... at........1.z.... !.. 2.D. .4 ...... E' ,North Andover,Mass. Fee.. .....p.. . Lic. No. . 'j. .y.................... (=.�L EJ[?L/11,ED ELECTRICAL INSPECTOR Check # �_ 7825 • CERTIFICATE OF INSURANCE • is Thia certifies that STATE FARM GENERAL INSURANCE COMPATATE FARM FIRE AND CASUALTY COMF NY B Scarborough, th,Illinois li ario ` STATE FARM FIRE AND CASUALTY COMPANY,Scarborough,Ontario STATE FARM FLORIDA INSURANCE COMPANY,Winter Haven,Florida ❑ STATE FARM LLOYDS,Dallas,Texas insures the following policyholder for the coverages indicated below. Policyholder CW WIRING INC Address of policyholder C/o WILLIAM COOPER 133 PINE CREST RD, LSTCHI'IELD, )AH 03052 Location of operations Description of operations ETjr.CTRICAL older for the policy periods shown. The insurance described in these policies is The policies listed below have been issued to the policyholder subject to all the terms,exclusions,and conditions of those policies.The limits of liability shown may have LIMITS O�by any paid ciaimg. POLICY PERIOD POLICY NUMBER TYPE OF INSURANCE Effeotive Date ration Data (at beginning of policy period) 07/26/07 07/26/08 BODILY INJURY AND 94-ST 4682--� jCornprehenaive PROPERTY DAMAGE si2sLiability ................ ••........ ....... -•-•a insurance includes: Products-CompetepEach oocur.encet+ nbnnnn Contractual Lial,rility ersonall U 00 Advertising Injury ®P nl ry I Aggregate $20000 Genera Products—Completed $2000000 13 D Operations Aa ate POLICY PERIOD 90DILY INJURY AND PROPERTY DAMAGE EXCESS LIABILITY EfteiMve Date ExpirdAW Dale (Combined Single Limn) C3 Umtxetia Each Occurrence nce $ ❑Other Aggregate $ POLICYPERIOD Part I-Workers Compensation - Statutory Effective Date ; Ex !radon Date Part II-Employers Liability and Employer*Liability Djse Anrsdent iserss-Each E!ngl4ytae $ Disease-Policy Limit $ POLICY PERIOD LIMITS OF LIABILITY P OUCY NUMBER TYPE OF INSURANCE EtTective Data ; Expirat an Date (at beginrding of policy period) THE CERTIFICATE OF INSURANCE IS NOT A CONTRACT OF INSURANCE AND NEITHER AFFIRIMATIYELY NOFt NEGATIVELY AMENDS,EXTENDS OR ALTERS THE COVERAGE APPROVED BY ANY POLICY DESCRIBED HEREIN. If an of the described policies are Canceled before BilAName and Address of Certificate Holder their any date,State Farm win try to mail a J-600 Os Dept. N. Andover, Mwritten notice to the cert�icate holder 3o days before N... A Osgood 2L'. Andover, MA 01845 cancellation,If howelmr,we fain t0 mall SUCK notice, no obligation or n il! U be imposed on State Attn' Peter Murphy Farm or its agntOwes. FX' 978-68B-9542 v•=�� Signature of AutKorized Representative ACEVIT Twe Date RON BECHARD Agent Nemo Telephone Number 603-434-0400 Agent's Code Stamp Aguni Curie 29-3042 AFO Code F876 558994 a,5 Rev.11-08.2004 Printed in U-SA IA-N c,OmmonlwedlEn or 771l Wllflmo- Department of Fire Services Permit No. ? Occupancy and Fee Checked 3 34- BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 �y (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Y- 7— C� (® 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) Owner or Tenant �. ',-.l �,� Telephone No. -?,i-1 elggq 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 IM2- Amps I'LL) /2-�-iO Volts Overhead 'Undgrd ❑ No.of Meters New Service iCpI Amps i7 u /2-qQ Volts Overhead Undgrd ❑ No.of Meters Number of Feeders and Ampacity „ ,.. Location and Nature of Proposed Electrical Work: r-\ r n z_- ing table maybe waived by the Ins ector of Wires. No.of Total �� � 2 Date.................................. Transformers KVA'� Generators KVA &ORT11 No.of Emergency Lighting TOWN OF NORTH ANDOVER ❑ Batter Units p PERMIT FOR WIRING FIRE ALARMS I No.of Zones No. ofUetection an Initiating Devices ,SSACMUS� . No. of Alerting Devices / o.o e -Contained This certifies that Detection/Alerting Devices ..................................... r.... .......�rrw Ew i unlclpa has permission to perform e Local Connection El Other S cNo ySystems:* wiring in the building of.....::: - •- - .o �.- .......... .. ........................................................ Data Wiring Devices or Equivalent ��,/ : .- ` No.of Devices or Equivalent at.... .:..c - � -� -w• �ELiE�C�MGICAL North Andover,Mass. elecommunications iring: .............. .Fee......'.............. Lic.No` .�ftNo.of Devices or E uivalent ........... "INSP oR Check # runicipal sired, or as required by the Inspector of Wires. policy.) 778 1 ;erformance th MEC Rule 10,and upon completion. of electrical work may issue unless the licensee provides proof of liability insurance inc u ing comp e e o` " n"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.: N `i Licensee: ,"Q-A Q_1��-A A SignatureQ. LIC. NO.: j,:,S q (If applicable, enter "exempt"in the Jicense num er line.) Bus.Tel. No.:'-1J-I'i-X1-77- Address: ' '1 A L-i 6, Alt.Tel. No.:ie�- *Per M.G.L c. 147, s. 57-61, security w rk 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. 1 am the(check one)❑ owner ❑ owner's agent. t� Owner/Agent PF.R1l1IT FEE: $ Signature TPiPnhnna Nn f - Date.//........7....1�...2... r NORTH ar .. TOWN OF NORTH ANDOVER aalisim. p PERMIT FOR WIRING SACMUSE� This certifies that 1 ` f !„ has permission to perform ..,....... !...........................'..`..... ....................... wiring in the building of.... ................................................. �f at..../Q.....j. .: - y^ ................. .. ,North Andover,Mass. i FeF"e..f............ Lic.No/`S.`/"�4;�........... ELECTRICL SP INR % A Check # 7 7 L \ Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services 7 71l � BOARD OF FIRE PREVENTION REGULATIONS Rev.Occupancy and Fee lank)Checked � � (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: //- 7- 07 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) i2 ICj C'-J1\A.0 A4,i)n Qv� Owner or Tenant �casA,�. � 7� �nS Telephone No. glQ_31?- 84q$ Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No 0-- (Check Appropriate Box) Purpose of Building \mss i'AC,C G Utility Authorization No. Existing Service ILO Amps I'LL) /2_40 Volts Overhead Undgrd ❑ No.of Meters J— New Service 1Lg� Amps 120 /Zuy Volts Overhead Undgrd ❑ No.of Meters Number of Feeders and Ampacity ` Location and Nature of Proposed Electrical Work: plr,c L- 4`��. 1JA�G— 1,k j ~L�N ✓k r--AA 1 Completion of the following table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans o.of Tota Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ n- ❑ o.ot Emergency Lighting rnd. grnd. 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 No. of Alerting Devices Tons g No.of Waste Disposers Heat Pum Number Tons K No. ofSelf-Contained Totals ..... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municippi ❑ Other Connection pp No.of Dryers HeatingAppliances KW Security Systems:* No.of Devices or Equivalent No. of Water Kms, No.of No.of Data Wiring: Heaters 'Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications firing: i No.of Devices or Equivalent OTHER: + Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 1l0U)?Cr-> (When required by municipal policy.) Work to Start: 11_Q,_ o-1 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ©MOND ❑ 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.: Licensee: Signature a LIC. NO.: I'SLliOS Q (If applicable, enter "exempt"in he License nun berline.) Bus.Tel. No.•'i14-L11I-SFq D� Address: Alt.Tel. No.:ioo3-7z.61—9 801 *Per M.G.L c. 147,s. 57-61, security w rk 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 b law. B m signature below, I hereby waive this requirement. I am the check one owner q y y y g y q ( )❑ Downer's agent. N Owner/Agent � NJ Signature FEE: $� Signature Telephone No. , The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street : Boston, MA 02111 y� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information g (� Please Print Leibly Name (Business/Organization/Individual): �L,� c,1/NA Q_J Rez osA Aw % Address: (a'1 A C.,:�X_�J-zjG2.s &d or City/State/Zip: v,Jr llr✓, l� ©S61 9 Phone #: �51?)4 14 -;-aq ati�toc�,�1,82.-y6v 1 Are you an employer? Check the appropriate box: Type of project(required): LEI❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.©1 am a sole proprietor or partner- listed on the attached sheet. $ EJ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.[ �trical repairs or additions right of exemption per MGL 1 l.❑ Plumbing repairs or additions 3.❑ I am a homeowner doing all work myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] fi employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#l must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: (( g d 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Si yznature: Date: I Phone#: Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Date./60.//A IU.?. ... .. f ,,ORTM 1 TOWN OF NO TH ANDOVER • PERMIT FOR GAS INSTALLATION • o� - s h �9SSACHUSE'( This certifies that . . . .P/. r. . . �.�?�.c:(. ' . . . .��'�. . . . . . . has permission for gas installation in the buildings of . . 1 .Ej. . . . . . . . . . . . . . . . . . . . . . . . . . . . at . ./. -. ...�!A40.^.�f.G.--. . . . . . . . . . . . .. Nortth_�Andover, Mass. Fee. 20.' Lic. No.?. ."1. "' . .`�/✓c�,.-,,. . . . GAS INSPECTOR r Check# 6201 MASSACHUSETTS LUMMRM APPLUCATON FOR PERNIIT TO DO GAS FITTING (Type or print) Date /4 4a s f NORTH ANDOVER, MASSACHUSETTS Building Locations i a / �.�/p<D n/ ST Permit# �l Amount$ ?y✓ S V S', Cri 11N S Owner's Name New D Renovation Replacement D Plans Submitted D a eq v� F W 4 O O O z F. W W d ? a C W C W W E" x C z Q W Q C F I., vi CA z O F ee z o y m a O x kz 3 D CQ7 OU O0.' > D a F O s SU B -BASEM ENT BASEM ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type) Check one: Certificate Installing Company Name CnA ?1 V M f Corp. Address L) C S t Partner. Business Telephonerm/Co. Name of Licensed Plumber�or Gas Fitter f I INSURANCE COVERAGE Check one: I have a current liability Insurance,policy or it's substantial equivalent. Yes �� No� If you have checked ves,please in the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 0 Bond 13 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 13 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Cod and Chapter 14 of the General Laws. By: gnature of Licensed Plu „b r Or Gas Fitter Title Plumber City/Town,. Gas Fitter License Nurnoer Master _ APPROVED(OFFICE USE ONLY) �sumeyman e Zh . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING • ,SSACHUS� This certifies that . . . t .� : . . .�.�. .�?`. . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . C A? o ..tg i . . . . . . . . . . . . . . plumbing in the buildings of . . . at . . .1. -)-L. . . IR-1. 1't�." f v ` . . . . . ., North Andover, Mass. 0 Fee. 6r . .Lic. No. 2.r?I.! . . . . . . . . . -. . . . . ., . . . . POUMBING INSPECT Check # 17 36 7556 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS / p j Date Building Location !z" &Owners Name _5115AX)c/ I C15 Permit# Amount Type of Occupancy New Renovation Replacement 1:1 Plans Submitted Yes ❑ No ❑ FIXTURES z d cc ° a w Z w a w m �, z z z w w � Z 04 F w � W A x x ax w 4 U d d � a � ° A A a 3 H O SLR» j RASEME yr 1n l zrnHJOCIR • 3MHAOM aMHfm 5M MOOR sM HjOOR - 71H MOOR 91H MOOR (Print or type) ) �,/ � �? Z G G Check Corp. Certificate Installing CompanyName �/ Address 04-1t)U, l r2 IU, ��. �.�XIGi El Partner. Business Telephone Z 3 y._ 2 E] Firm/Co. t Name of Licensed Plumber: Insurance Coverage: Indicate the typ6of 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 sub ' d(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and ins ati performed under PerIs ed for this application will be in compliance with all pertinent provisions of the Massa State Plu i ode g ter 142 of the General Laws. By ig ure i nse er Title � �% Type of Plumbing License City/Town ict um er Master 13/' Journeyman ❑ APPROVED(OFFICE USE ONLY Date. � ��. .�w. ... . . OF NO DIM 1ti 3� TOWN OF NORTH ANDOVER O 4 PERMIT FOR GAS INSTAL SACHUsf'SS .� 1 This certifies that . . . 1�:P . . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation -t.. . . . . . . . . . . . P in the buildings of . . . -. . .0. . . . . . . . . . . . . . . . . . . . . . . . . at J 2 . . ./7!.< . . . . . . . . . . .. North Andover, Mass. Fee. . U. . . . Lic. No../1.9rf . . . . . . . �.}... . GAS INSPECTOR f� Check# 6203 MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations Permit# Z d Amount$ 3 6 Owner's Name New❑ Renovation Replacement ❑ Plans Submitted ❑ � a w Ci rA F+ w �r O O O z F. a v u w a �, w a p o > w w v, c7 F z F z x w a w F w x a z y w c7 p > 0 Z a w az w > a z a d Q o o Q C x x o x 3 c .� u a > SUB-BASEMENT BASEM ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or ty Check one: Certificate Installing Company Name v rYi �ili�� ❑ Corp. Address rn 1, R,4 ( !V 1J ❑ Partner. Business Telephone o 2G& ❑ Firm/Co. Name of Licensed Plumber'or Gas Fitter .�,y�m„) 11 y,,q b lat INSURANCE COVERAGE Chec�ff� I have a current liability Insurance"policy or it's substantial equivalent. Yes No❑ Ifyou have checked Yes,please indicate the type coverage by checking the appropriate box. Liability insurance policy EDOther type of indemnity 13Bond 13 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 ❑ t 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 instans (e ormed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac to Gas C deh r 42 of the General Laws. By: gna ure of Licensed umber Or Gas Fitter Title ❑ Plumber City/Town, ❑ itter License Number Master APPROVED(OFFICE USE ONLY) 0 Journeyman Date. ,,ORTp o?o�<�`•o"•,M��.. TOWN ('OF N RTH ANDOVER PERMIT FOR PLUMBING ,SSACNUSEt This certifies that �. .n�.`f!` '.r.`'. . . . . . . . . . . . . . . . . . . . has permission to perform . . . .R.C: I.... ... . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . at. . . . . .1.I . . .I'.'.I /.1.1-. )./ �--:- . . . . . . . .. North Andover, Mass. Fee. G �.."".Lic. No..?S. . . . . . . . . . . t! �,.-� . . . . . . . . i' PLUMBING INSPECTOR Check # ��� � � r 7554 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date f Building Location �� s Qyv Owners Name S V!5 A h/ CO l/11y C Permit# T� Amount�>�' !� Type of Occupancy 'Re S New Renovation Replacement Plans Submitted Yes No ❑ FIXTURES z � U H w a x o w w F U w x a 3 a H W W a A z A A w H �" x a �, Z a F Z W w O U a -< F SU�-Bga BASE"M bT INIDM 2-,D FLOCJR �M)HIIM 4M HDOR 5M HDOR 6M HDOR 7M FLOCIR SIH HDOR (Print or type) Check one: Certificate Installing Company Name ❑ Corp. Address FlPartner. Business Te ep one Firm/Co. Name of Licensed Plumber: �--4 ('t"'e 00 IGJ Insurance Coverage: Indicate the t e of insurance coAveifage by checking the appropriate box: Liability insurance policy 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 ❑ 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts StM-- 71-9naLUre bi]Qg ode d Chapter 1 of the General Laws. BY o icense m er Title Type of Plumbing License � City/ y Me um er Master ❑ Journeyman APPROVED(OFFICE USE ONLY