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Miscellaneous - 120 MILK STREET 4/30/2018
EEZ = y 120 M\�K A5zoo0. 0 � 2101060. I 9454 Date.�l ' °1-1� NORT1y TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SA HUS This certifies thatOV�'' �,C`(� .; (2t_ �c. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform 4. . . . . . . . . . . . . . . . . plumbing in the buildings of . Pe-4-C_.r. . .-o.. (!`w`G.... . . . . . . . . at . . . .1.20. .M��V,. . rte( . . . . . . . . . ., North Andover, Mass. Fee.Ll ZQk-�-1 .Lic. No.. (S-0.6 6. . . . . .`!mac . . . . . . -g PLUMBING INSPECTOR Check #33 JUI. lb IUI I IIM iNo. JIUb f'. i MASSACHUSETTS UNIFORM APPLICATION FOR pERMITTO b0 PtUMBfNG city/to wn: TA A/J�� MA. Date: ;L:55 fi Permit# Building Location: - f Owners Name: ` Type of Occupancy: Commercial❑ Educational❑ industrial❑ institut(onai ❑ Residential` ' New: Alteration; Renovation; ' ❑ Replacement:❑ pians Submitted: Yes❑ No El FIXTURES DEotcATrn SYSTEMS VA m M y °o a o ° o SUB OSMT. d BASEMENT 1S FLOOR 2 FLOOR a% FLOOR f FLOOR 5 FLOOR d FLOOR 7 FLOOR 8 FLOOR f installing Con�pany Wattle: ow F '-M 9 P[..M13� Ali a //,� CheClc Orae Only Certikicate it ---�—� I'�t<� , Address;Bax 3qa orporation OWTown: stater Rasinessl'eL-5'09Fax:.3 1 d Partnership S� So���I L1�� . Q Finn/Company Name of Licensed plumber: Q L,Cg C iINSURANCE COvtRAGC; lbay8acurrentiLibiLitonsurantepoilcy or Its substantiai equivalent which meets the requirements of MGL. If you have checked YeE,please indicate the type of coverage by checking the appropriate box below, Ch'942 Y�No❑ A liability insurance policy.DZ Other type of indemnity ❑ Bond OWNER'S INSURANCE;WAIVER:I am aware that the licensee y d4ea no hie the Insurance coverage required b Chapter 942 of the Massaohusette General Laws,and that signature on thle permit application r�i a thin requirement. Check One Only S' nature of Owner or Owners A ant Owner [3 Agent ❑ f hereby certify at al of t e detalls end Infomnallon t have 11 su6mltled(or enw Khowledge and that all plumbing work and installations performed under regarding rfile application are true andaccurateto the best of my Pertinent provlelon of OW Maseachusatts State Plumbing Code and chapter 14of the General�h►sapplteaBon will he in campuance With all By �` S 7yrpe of License: � Plumber One, re of likensod Plumber "W own aster �pPROVEp pFp tJ8E ONL ❑Journeyman License Number; b UNIFORM APPLICATIONFOR PERMIT.TO DO CiASFITTINQ (Print or Type) NORTH ANDOVER , Mass, Building Permit #� 3 6 } Location��Q l`"— Owner's a ;" Name C New Renovation ❑ Replacement Pians Submitted: Yea ❑ No E „ au z le 0 � v p �' y z h a x c p h t r z z 0 �, ac d M F- sc w 0 C x w IK _ h !„1 p r1 ~ s O = w A H i tIL ��.. tt yy MM w at 'z 0 tl 06 5 I!. �o .1 V 19 y Sus—RSMT. • IIASHMSHT 1ST FLOOR 1110.FLOOR n 3RDFLOOR 4TH FLOOR STH FLOOR E LOORLOORLOOR Check one: CertHicate Installing Company Name rp Address El Partnership ❑ Firm/Co. Business Telephone Name of Licensed Plumber or Gas Filter 10, INSURANCE COVERAGE: Check one I have a cement liability Insurance poll cyor Its substantial equivalent. Yes V3`— No ❑ It you have checked yes, please indicate the type coverage by checking the appropriate box. A Ilabli ty Insurance policy ��. Other type of kxiemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: nature of Owner of Owners Agent Owner ❑ Agent 11 I hereby certify that an 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 an plumbing work and installations performed under the permd Is for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 01 the al Laws, �' T of Ucense: Title �ber na O nse Number or as er ,� Master License Number J ` ❑Joumeyman 3W� /IPPT)OWD (OFFICE USE ONLY) :S Say State Gas Company GAS INSTALLATION AUTHORIZATION Date Issued to tv's G Address L 41D For Installation of: C BTU Input CV-0 Restrictions BSG Representativ PERMIT ISSUED _ BY INSPECTOR 2365 Date ........ NORT#1 TOWN OF NORTH ANDOVER R 32 °• • O PERMIT FOR GAS INSTALLATION_ A # i s SSACMUSE _ - ko This certifies that .��65t,� i �.� . . . . f . . . . . . . . . . . g has permission for gas installation in the buildings of . 5C!3 (".-S: . . . . . . . . . . . . . . . . . :-7. . at JA 0 .01/'// . .5.4 . . . . . . . . . . N Andover, Mass. Fee.,�te Lic. No..-7!H.`'. . . . . . .. . . . . . .. '1 . . . . . . . . AS INSPECTOR fJ WHITE:Applicant~ CANARY: Building Dept. PINK:Treasurer GOLD:File I ocation /,a Kz- AF F No. 1 d Date N° .o TOWN OF NORTH ANDOVER , 16 Certificate of Occupancy $ Building/Frame Permit Fee $ *-Too � �ssACMUSE� Foundation P r it Fee $ "—�— CSJ Other P rmi ee $ a U Alf Sewer Connection Fee $ Water Connection Fee $ TOTAL $ l t� Building Inspector 7151 Div. Public Works r PERMIT NO._ APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. AGE 1 a !1►MtO. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK ;PAGE ZONE I SUB DIV. LOT NO. �I i LOCATION PURPOSE OF BUILDING Jp OWNER'S NAME NO. OF STORIES SIZE OWNER'S ADDRESS ®�, 0 BASEMENT OR SLAB -- ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME 'r1 SPAN DISTANCE TO NEAREST BUILDING Y DIMENSIONSOFSILLS DISTANCE FROM STREET '" POSTS DISTANCE FROM LOT LINES—SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING x IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST �A PAGE I FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. _ ot PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED BOARD OF HEALTH S@jAkATURE OF OWNER AUTHO ED AGENT FEE �. PLANNING BOARD PERMIT GRANTED OWNER TEL.# CONTR.TEL.#ij t9 CONTR.LIC.#,O-j? 1 BOARD OF SELECTMEN �`J f BUILDI INSPECTOR r i BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS I RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE a t 2 13 CONCRETE SL K. PINE BRICK OR STONE HARDWD PIERS PLASTER _ DRY WALL UNFIN. 3 BASEMENT AREA FULL FIN. 8 M AREA _ 1/1 '/, '/, FIN. ATTIC AREA _ NO B M T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE ��— WOOD SHINGLES EARTH ASPHALT SIDING HARD"✓D _ ASBESTOS SIDING COMMON VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY _ STUCCO ON FRAME BRICK ON MASONRY ATTIC STIRS. & FIOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIORPOOR I� POOR — ADNONE 5 ROOF 10 PLUMBING GABLEHIP BATH 13 FIX.) GAMBREL MANSARD TOILET RM. (2 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I) _I 1 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st 13rd I NO HEATING �1 'A ORTH ovm of �o over 0 No. 112 _ p L ANort N dover, Mass., /�`/�ir1 ze /� 19v�/ coc"IcMlwlCK �A0"�'ATE1) BOARD OF HEALTH 30 PERMIT T ILD Food/Kitchen Septic System • BUILDING INSPECTOR THIS CERTIFIES THAT......... .. � ��..... .. ...................................... Foundation has permission to erect..A.1.11t/.. X.h�..... buildings on ...� I. .r..*e!................................ Rough • to be occupied as..IJ04S.r ... .00�49�.....A.OV.W� 6.�........................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough ......... ................... Service BUILDI G INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner PLANNING FINAL CONSERVATION FINAL Street No. Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT Date. . . . ,NORTH - 3 TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION 9 h ��SSAf HUSEtA This certifies that j . . . . . . . . . .a. . . has permission for gas/in stallatio.�',. . ! !. in the buildings f? /fie �1 f at . . . . . . . . . ., North Andover, Mass. Fee.Z& Lic. N( • �� GAS INSPECTOR Check# 4752 MA55AL;HUatt lb UNIt-UIiM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) _(JO RTH 1-1�bV E 32- , Mass. Date 6 -�(�`i 6� _ Permit # 1 BuildingLocation..QD M I L IL S T /Owner's Name liJi;P_tJkIL S6KUEPIUS AN06UER /'1,4 Type of Occupancy PESIRENTIAL New ❑ Renovation ❑ Replaceme it Plans Submitted: Yes❑ No ❑ N Cr N, N N U Jz Q O z N t- �C N cc (n a x 1- W W a O VCC 30- m H x am �' a ¢ x a z a r W Cw d FOa- N C a W o N a w z v W x N W a a °' a ' W r- N x 0 t- z j i- Z W W0 0 > W }- (J _j ��+ W Z Q W Q C >. N M Z O Z W O I= '2 O tl Y U. M � G tl J V 0 y D a F O SUB—BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR _ 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name BAY STATE GAS COMPANY Check one: Certificate # Address 55 MARSTON STREET XJ Corporation 1862 LAWRENCE . MA 01840 ❑ Partnership Business Telephone .687=1105 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery _ INSURANCE COVERAGE: I have acu renntt liability insoura❑nce policy or its substantial equivalent which meets the requirements of MGL Ch. 142. ,Af you have checked yes, please Indicate the type coverage by checking the appropriate box. liability Insurance policy P< Other type of indemnity❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent owner[] Agent [I hereby certify that all of the details and information I have submitted(or entered)in abo plication are true and accugte to the best of my knowiedge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the G. e s. T of License: Plumber Signature of Licensed Plumber or Gas Title Gasfitter ty/Town Master License Number 3-14.5 Ci . Journeyman APPROVE (OFFICE SE ONLY i. BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO,DO GASFITTING c, NAME TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIG NO. PERMIT GRANTED DATE _.19 GAS INSPECTOR 7760 Date.. NORTH 0 °p TOWN OF NORTH ANDOVER • - PERMIT FOR GAS INSTALLATION SSACNUSE This certifies that . . S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . .l`-Q�=C' '.B Q M.L. . . . . . . . . in the buildings of . . . �7o u.. . . at . . . .� T . . . . . North Andover Mass. Fee.l�C?�•?. Lic. No.. 5(� �. C. . GAS IN ECTOH Check# j�3 I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town://684 AAld*Q Vi£ , MA. Date: Permit# Building Location: /0,0 M ( L L� SA Owners Name: jp2jej ZOL/ ' 4 `f Type of Occupancy: Commercial ❑ Educational❑ Industrial ❑ Institutional ❑ Residential Q New: Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES cc � co W Lu coz ~ V) co L) = a m Z 0 W w 0 N H 0 = W W z H z 0 W W W 0 w WLLJUJI W > � 0WWWz9 Xv, o 91-- a > W } z N P H 0 z -j 0 u- F = W H w of w O a a w w m w 0 a z O y 2 > z x v 0 0 u. 0 0 x = -j O Oa 9 0WFW- > > > 100 SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR 4 FLOOR 5TH FLOOR 6 FLOOR 7 FLOORqffff— — . . -1 t 8 FLOOR Check One Only Certificate# Installing Company Name:_bo'6 1. Re—r,�aT PA 9 r ruC z)yS . Corporation Address: City/Town: NAtuTV-W", State: M a' ❑Partnership Business Tel: Sag-��S-S��y Fax: "-,6 00 /y13 ❑Firm/Company Name of Licensed Plumber/Gas Fitter: Da�6 L-EC�cz�G INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YesXNo❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy` Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner 1:1 Agent ❑ By checking this box❑;I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. p,J Type of License: By �l Plumber Title �f ElGas Fitter Signifture of Licensed Plumber/Gas Fitter Master Cit /Town ❑Journeyman /S®L6 License Number: APPROVED OFFICE USE ONLY E]LP Installer [ 1 ra�r 1 0327 Date..../........................ � NORTH TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,SSACMUSEt This certifies that .. e . �' ................................. .................. has permission to perform �V A' °v .�'L''"-' v— .................... . ... .............. ............................... wiring in the building of. .GG�� .,North Andover, ass. Fee-�' Lic.Not (.. /! ...... ........ 1vLECTRICAL INSP Check # ��� / ;4 Of Commonwealth of Massachusetts ficial Use Only " Department of Fire Services Permit No. f G 3 Z_1 Ck, Occupancy and Fee Checked l Wt BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK {�Yf 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 ention to perform the electrical work described below. Location(Street&Numbfer) Owner or Tenant /S=+'f r L�c��ll2Telephone No. r Owner's Addresse— `�`` Is this permit in conjunction withha building permit? Yes No ❑ (Check Appropriate Box) 'N, Purpose of Building in 6 W� p . gn i,-, 4 Ffit, y � l�` Utility Authorization No. Existing Serviceli/ Amps Volts OverheadET 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 of the ollowing table may be waived by the Inspector o 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 Swimming Pool Above ❑ In- 1:1o.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I 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 No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: G // Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the +e 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 Ind penalties orjury„that the information on this application is true and complete. S FIRM NAME: �— i' rt.► LIC.NO.: �C Licensee: Signature—LIC.NO.: (If applicable, enter "e pt”in the licenseatynber line.) Bus.Tel.No.: llel Address: /1, 61le t � Alt.Tel.No.: *Per M.G.L c. 147,s.5-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑ owner ❑owner's Owner/Agent Signature Telephone No. PERMIT FEE: $ ��� 2. 9 � � ��d v `° � r ,� JJ� (� �/ c � � � �-� �` ��� �c S �, t .� . � ,�.. r .�. �. . � y , e n 9 , � d r The Commonwealth of Massachusetts 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 Applicant Information �{ Please Print Legibly Name (Business/Organization/Individual): C / Sr 47 1- Address: j/� City/State/Zip: Phone#: 4�e7/ Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. E�New construction ,,,employees(full and/or part-time).* have hired the sub-contractors E]Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet. 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.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 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 rtundder the pains andpenalties ofperjury that the information provided above is true and correct. Signatur6;;✓yu9 L Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 10252 Date....... NOR71� ' "° TOWN OF NORTH ANDOVER �? a .......e °L PERMIT FOR WIRING �43ACHUS� This certifies that ........ I ......................................... has permission to perform C= L o u lll; wiring in the building of................ ............................................................... at...�. -0..M.�.�.:...��.........?..�.............................. h Andover, s. �" l�4�tL (i Fee...... Lic.No.............. �?................. .............. ........... ...... ,�.... ELECTRICALINSPECTR Check # 1 S 03 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked 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 Cod (MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 6 g q 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) �' ,1 MtL4 4 S To Owner or Tenant Telephone No. Owner's Address 6 A Gt 4.. A4,+ Is this permit in conjunction with building permit? Yes EK No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd ❑ No.of Meters New Service "Zo Amps l Zy/ 1-44oVolts Overhead Undgrd.❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ,� 51 jL ct�li,r.G Ory ��W �hotJSv Completion of the following table may be waived by the Inspector o 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 Swimming Pool Above In- o.o Emergency Lighting rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMSNo.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tonal No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: ') pp(q„ `*' (When required by municipal policy.) Work to Start: 5jA t-1 1 L ( 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=13 has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: n t A--C- eL, { t� LIC.NO.: -( Licensee: M1CA-64,e l— J-kAc A -tet ignatureLIC.NO.: 2;:) sk-p (If applicable, eVr "exempt"in the license number line)� Bus.Tel.NO.: Address: � t'� �bJ 4 AA 'S� , �1 ��dd,,�,�5� 1 Alt.Tel.No.: *Per M.G.L c. 147,s. 57-61,s curity work requires Department of Public Safety"S"'License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑ owner ❑owner's Owner/Agent Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts 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 Applicant Information Please Print Legibly Name(Business/Organization/Individual): ,•t-CLQ �� Address: City/State/Zip: UC�b S'�N , N� U3�`t Phone #: 1 7 Y Are yan employer?Check the appropriate box: Type of project(required): 1. ` a employer with�2 4. ❑ I am a general contractor and I 6. ew construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition 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.F1 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp. insurance required.] 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 1-0 City/State/Zip: )Jb;, ;,c���W4n,t`.v1.4 01,?'Y i 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 cerfifii under the pains andpenalties ofperjury that the information provided above is true and correct. Siiznature: Date: Sr 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#: 10589 TOWN OF NORTH ANDOVER _ 03?�� .,, •. ooh p PERMIT FOR PLUMBING $8'�CMUg� This certifies that.................�.� . �f ................. has permission to perform. ...r.. ..... c-...: .?,.....{�a,a t: - - plumbing in the buildings of.... .. > ..................................................... • at...... a. ,�r..`../ �f North Andover Mass. ��5 Fee.�/. Lic, No.............. .............'�. �/.�................................... ............................ v PLUMBING INSPECTOR Check# -2 q 9 =i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY ' Uef MA DATE ; 1_.I,,M-IJ( PERMIT# JOBSITE ADDRESS /� ;/(� _ OWNER'S NAME__! �, �✓ pOWNER ADDRESS I2(2 1121"M S% r TEL 36 f� FAX TYPE OR OCCUPANCYTYPE COMMERCIAL EDUCATIONAL © RESIDENTIALP' PRINT n��k CLEARLY NEW: [9 RENOVATION:El REPLACEMENT:Q PLANS SUBMITTED: YES Q NOP FIXTURES Z FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE ! DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM ! DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEMC- DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN ____,f .__-j { .__-__( .__._I [__.__.._I __,...__( ,____.1 .__....__.I ....__..( -------j ___..__I -_-�J= FOOD DISPOSER FLOOR/AREA DRAIN I __.._1 _._ [ __.._.] INTERCEPTOR(INTERIOR) _ E -____[ ..___._I ____i __....-__f i __._._i ._.-_J T-_i KITCHEN SINK I _� —_-� _--_� 1 _._ ( i l I ___( LAVATORY ROOF DRAIN SHOWER STALL ( .__. f l .i .__.! _I _._ ( I J _.__1 ___ I _.__. C I I ,$ERVICE/MOP SINK TOILET I _I _-_-__( ___f____-. —___ 1JRINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _f i ( ___.__} WATER PIPING _ f __I --A OTHER .._._..._____.-_____ ( __.._._.( INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO t IF`YOU CHECKED YES,PLEASE INDICATE TH YPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITYf BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER _f AGENT 10 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pe ' lent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME /_0 AJC / _- _ f LICENSE# L;S 11 SIGNATURE MP 01"'-JP[]f CORPORATION ..'#=PARTNERSHIP F# LLC COMPANY NAME 7 cco "/f - ADDRESS i s: CITY ----_.._ _ _)STATE ZIP I.�/1 �____ �i TEL 1 FAX CELL i EMAIL V2 I ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION O S Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ IF I FEE: PERMIT it PLAN REVIEW NOTES z The Commonwealth of Massachusetts - Department oflndustriglAccidents Office of Investigations 600 Washington Street Boston,MA.02111 U9V www.massgov/dia Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Auplicant Information Please Print Legibly Name(Business/Organization/Individual): tif � -- Address: `3 l — S-7;_ - K36ArCity/State/Zip: 1V7)c_U 1414- Phone#• 27& - K36 - Are e you an employer?Check the appropriate box: Type of project(required): 1.[a!�am a employer with 3 4. ❑ I am a general contractor and I 6. 0-5e-w construction employees(fall and/or part-time).' have lured the sub-contractors 2.❑ I am a sole,proprietor or partner- listed on the attached sheet. �• ❑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 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing allwork right of exemption per MGL 11.E]Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and wehave no 12.❑Roofrepairs insurance required.] employees.[No workers' q � � 13.[1 Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they tie 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the,policy and job site information. Insurance Company Name: LZ Policy#or Self-ins.Lie. 0 S 14-0 Q E Expiration Date: 5 �// ,y 7 Job Site Address: Zoo ('it� City/State/Zip: 'v` 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do laereby certify under the pains and penalties ofperjury that the information provided above is true anti correct. - Signature Date: Phone# Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit(License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - C''nnfnrf PPrcnn- Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,- express or implied,oral or.written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance With the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only.submit one affidavit indicating current Policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew 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 Gommoawoalt�of Mossac?�vsPtts Depafteat offndustdal Accidents • ()face ofIu�estigat�ion� 6.04'4 Engtou Street Boston?MA 02111 Tel,#61.7-727-4900 ext 406 or 1.-877rMASSAFF, Revised 5-26-05 Fax#61.7-727-7749 aiCOMMONWEALTH OF MASSACHUSETTS 0 0 0 o o lLt7t .II1 DUBOARD EtE unt t PLUMBERS ND G`�1SF 1 TT;ERS ! !j X. Department of Inspection Services ISSUES THE FOLLOWI NG LICENSE j Rf:G 1 STERED AS A PLUMB I NG -CORP �p r I JOSEPH A. ROZZI z , PLUMBING AND GAS INSPECTOR MARK ;MAGN I F I CO MAGN I F I!CO BRO5 PLBr;HGT,GAS, F I TT11 lZ 31 FORE-S Iv J ttF _ 4 otwoburn.com Ktbbi ETON MA 01949 201`5". 3266` 05%O1/16.:: 204666 _ COMMONWEALTH OF MASSACHUSETTS. 0 0 o • o o BOARDOF I' 1 TER S ' SF: T i I Town of Wakefield UM EK :AND GA ISSUES THE FOLLOWING <LiCENSE LIC1_NSED AS A MASTER PLUMB-ER F`FfELD C/w / , rK-18 MAGN I F 10: Paul J. Donohoe CTl Z Plumbing&Gas Inspector31 FOREST SIRE ET J Tel:(781)246-63883 380 Fax:(781)224-5020 M 1:0:0 L ET O N M.A 01949-201:5, 13559 05'%0.1/16 204667 Il :::.,1V3;,,COMMONWEALTH OF MASSACHUSETTS - - - -' -- Tel:978-983-8625 BOARD;OF Fax:978-946-1573 PLUMBERS AND GASF I:TTEFS' jmquinlan@ci.methuen.ma.usISSUES THE FOLLOWI N.G L I CENSE LI CENSE[1„ A5 A JOURNEYMAN;PLUMBEfa James M. Quinlan :. Plumbing&Gas Inspector MARK 8 MAGN I F I CO i w 31 FOREST ices OFFICE HOURS FOREST::-ST; 1 Monday-Thursday I ;. MA 01949-201 NLDOLETON uite 313 8:00-10:00 a.m.,1-2 m 5 8 44 Friday: 8:00-10:00 a.m. 250 ,2. 20466 r Date...i.i.. ..�..��. ............... i d NORTry °� '4� TOWN OF NORTH ANDOVER 9 PERMIT FOR WIRING • i ,: s �`QACIIUS� This certifies that ... C..... 1 — ................... ........................................................................... has permission to perform ..A L— A-X wiring in the building of......0 J� {.L...uti!+r�G. ....................... at ..........�. `` .............�..,`�North Andover,Mass. Fee.$ .. ........Lic.No22h!..... . ...........................................'Idl........ ...... ELECTRICAL IwEcrmo Check# © ' 12 018 44c�— 4 %113 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. ly Occupancy and Fee Checked 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) / f` j Owner or Tenatit --r-� Telephone No. 5pi�-(V!W-c Owner's Address i Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 6,&Y1r.Q 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: ' j IC t c Completion o thefollowingtable may be waive the Ins ector o Wires. No.of Recessed Luminaires 1� No.of Ceil:Sus addle Fans No.of Total P (Paddle) Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA AboveIn- o.o Emergency Lighting N No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ 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 Initiatin Devices Total No.of Ranges f No.of Air Cond. Tons No.of Alerting Devices No.of Waste Dis osers Heat Pump Number Tons KW No.of Self-Contained P Totals: Detection/Alerting Devices Municipal No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑ Other Dryers I Heating Appliances KW Security Systems:* No.of D ry No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Si ns Ballasts No.of Devices or Equivalent Bathtubs No.of Motors Total HP Telecommunications Equivalent No.Hydromassage No.of Devices or E uivalent 1 OTHER: r' Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) 1 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 j the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The .. undersigned certifies that such coy age is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [V�BOND ❑ OTHER ❑ (Specify:) I certify,under the pains andpenalties of erjury,that the information on this application is true and complete. FIRM NAME: ' LIC.NO.: Licensee: � N f &AW Signature LIC.NO.: (If applicable,enter "exempt"in the lice se number�ine.) Bus.Tel.No.,• 9i'-�" Address: Alt.Tel.No.: *Per M.G.L c. 147,s. 57-61,scYarity work requires Department of Public Safety"S"License: Lic.No OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally waive this requirement. I am the check one 1:1 owner ❑owner's agent. required by law. By my signature below,I hereby q Owner/Agent PERMIT FEE: $ -- Signature Telephone No. sA `, 1 r w �� t l� z2_� 31� � /� �/� �. . 1 -' The Commonwealth of Massachusetts07 - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 UF www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly Name(Business/Organization/Individual): Address: IQ AToff',-4 kin(kna �c JYl City/State/Zip: /j 91 r)n _�(,� Phone#: Are ou an employer?Check the appropriate box: Type of project(required): .1.1 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.El am a sole proprietor or partner- listed on the attached sheet. 7• E]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. El We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roofrepairs ,00 insurance ]ired.re q ut employees.[No workers' 13.[i Other comp.insurance required.] *luny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they 2te 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: iM (D. Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: / / .City/State/Zip:��®/'�� � �y_ Att: h 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 ' to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. X do Izereby ce and the 'ts-a td penal ' -of perjury that the information provided above is true and correct. - Signature: Date: Pho #: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express orimplied,oral or written." An em to er is defined as"an individual a P .Y ,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a-deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be,an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking tfie boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate he. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Co onwoalthofMossachusetts Department of Industrial.Accidents Office ofInvestigatlous 600 Washington.Street Boston,MA 02111 TO,#617-7-27-4900 at 406 or 1-877-MA.SSAFE Revised 5-26-05 Fax#617-727-7749 www-mass,govaa COMMONWEALTH OF M ►SSACHUSETTS ® oa wilsig • ISSUES THE FOLLOW.-Ru ..1_f CENSE AS A SEG JOURNEYMAN ;ELECTRO CSI AN ,Q r JARED` EATON 1 If �t • + y �� !� h Lu t� ROwi 1003 BADWAY ,� F #Z i H ► R�i I LL MA VC01832 1 257Jf2 a7/3]/tb 32661 :