HomeMy WebLinkAboutMiscellaneous - 125 BRIDGES LANE 4/30/2018 125 BRIDGES LANE
210/104.D-0114-0000.0 ` -- -
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NOR=TH COVER BUR-DWG DEPARTMENT
/}A Cncrry tlt \V
TEn!�5��5 1600 Osgood Street .
North Andover .
r
Tel: 978-688-9545
Fax: 979-688.9542 .
BUSMSS-FORMFOR TOWN
NomAMMS& al�) -cy a4,--e-
: ` -� ,1�Y�
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®NDN-NGDl9TR--fC"l: .
T 3 M OF 3B-U8I EW-'
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BST. DINS`LAYOUT PROVIDED: YES � NO
I
ZONINGBYL WMACTE:_ YES NO
PUSM SS FORM Fox TM CLERK
2.40 Rome Oceupdion(1989132)
An accessory use conducted within a dwelling by a reka"wha resides in the dwelling as his principal ,
address, which is clearly secondary to the use'of'the building for living pinposes, glome occupations shall
:uiclude,"but iaot•limited to the following uses; personal services such as frunished by an artist or instructor,
but not occupation involved wift motor vehicle repairs, beaa4r parlors, animal kennels, or to conduct of
retail business,or the manufacturing o£goods,which impacts the residential nature ofthe neighborhood;
4, For use of a dwelling in any residential district or multi-family district for a Doane occupation,aIle
following conditions shall apply:
a. Not more than a total of three (3) people may be em lover ohome occupation, one of
whom shad benne owlzex of ttie home ociupatioiz and xesidig inaidr �elling;
b. `Site use is carried on stdctl3r-Mffikthe principal building;
o. There shalt be no exterior alterations, accessory buildings, or display which are not customary
with residential buildings; -
d. Not more than twenty-five(25)percent of the existing gross i1 oor area,of tho dwelling unit.
so used, not to exceed one thousand (1.000) square feet; is devoted to'such use. In
connectionwith
such use,there is to be kept no stock in.trade, commodities or products which occupy space
beyond these Jimits;
e. There will be no display ofgoods or wares visiblefromthe street;
f The building or premises occupied shall not be rendered objectionablbe or detrimental to the
xesidenVal character of the neigh-boyhood due to the exterior appearance, emission of odor,
gas, smoke, dust, noise, distr>rbaace, or in any other way become objectionable or
detrimental to any residential use within the neiglihoxhood;
g. Any such building shall include no features of desip-not cust6mary in.buildings for residential
• use:
Sigoatur Date
10821
".OpT"'ti TOWN OF NORTH ANDOVER
° a PERMIT FOR PLUMBING
This certifies that.... ... �J-S.:..... ..I. 'r-S.... �t3ct ac
has permission to perform...�^ :fi r'. ... � c 1...................
<: plumbing in the buildings of......�a... .fA-. S.�..0............................................
at.......0?.-�6......16A.4 " Q'....:...................North Andover, Mass.
x, Fee d. ........Lic. No. �!�Z,�. ...�. ..
PLUMBING INSPECTOR
Check# f�
� I
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY _—__-- _ MA DATE PERMIT#
JOBSITE ADDRESS A /a/. v OWNER'S NAME
OWNER ADDRESS
TYPE OR OCCUPANCY TYPE COMMERCIAL[ EDUCATIONAL ® RESIDENTIAL
PRINT
CLEARLY NEW.Z RENOVATION:1 REPLACEMENT: PLANS SUBMITTED: YESE-] NOD
FIXTURES Z FLOOR- BSM 1 __..._._..2_- 3—I 4 i 5 6_ I 7 8 _9_
f —1—0 1-_1-_ _...1.._2 1_.3-. --14
BATHTUB _ ----
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM _
;
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN _.._—
FOOD DISPOSER
FLOOR/AREA DRAIN --
INTERCEPTOR INTERIOR
KITCHEN SINK ____i -- —J _.....
_---1 _--
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE 1 MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
:x WATER HEATER ALL TYPESWATER PIPING
4_J
OTHER
I
INSURANCE COVERAGE: �'`�
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO t i
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW V)
LIABILITY INSURANCE POLICY By OTHER TYPE OF INDEMNITY EJ BONDEJ
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 n AGENT ]
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this appi!cation 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. Ap
PLUMBER'S NAME ' _ ''��° . _ LICENSE# _.- 'SIGN ATI IRS
MPV JP ._i CORPORATION EDWPARTNERSHIPS# _..._....._.....__ LLcD#E:=
COMPANY NAME ,S �1/'(, ADDRESS 1`
CITY STATE21P D/. �.... -- ....� TEL 1._2
FAX S�-r'�_ ._ .._ _. CELL ?d' IS" I MAIL I
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The Commonwealth of Massachusetts -
Department oflndustrialAccidents
Office of Investigations
600 Washington Street
.Boston,MA 02111
UV . www.mass.gov/ilia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: -
City/State/Zip:i /1n&Sd/ 2&. O/�T Phone#: ?;7 1--
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. El am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have Hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling
ship and'have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. kers'comp.insurance. 9. E]Building addition
[No workers'comp.insurance 5. We are a corporation and its
required.] officers have exercised their 1011 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.E Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.] employees.[No workers'
comp.insurance required.] 13.[i Other
*Any applicant that checks box#1 must also fill outthe section below showing their workers'compensation policy information.
T-Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors that checkthis box must attached an additional sheet showing the name ofthe 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. 1
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 maybe forwarded to the Office of
Investigations of the DTA for insurance coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
Si atuigi_re: Date: Iez�7,ZZ y
Phones
Offccial use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other - -
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not producedacceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retained 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(ifnecessary)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 oz permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
Tho Commonwealth of Moo machu.setts
Department ofJhdusWal A,ccxdonts
Office ofInvestigadom
600 Wasbingtoa Streot
Boston,MA 02111
Tel#617-727-4900 opt 406 or 1-8777- ASSAFE
Revised 5-26-05 Fax#617-727-7749
www-Mass,govfclaia
r
� 1
�MMONWEALTH OF MASSACHUSETTS
�" CO
� PLUMBE:R� �ASFITTE;f�S
ISSUES TH'E FOLLOWING L4'CENSE
L I CEN$;ED: S A JOURNEYMAN P,.L--UMBER Q
CHRIS PAPADOPOA05
~� c?
17,5 J O qle'
. DR�LCUT MA 01826-1503
223273
19026. . .
..:;.<:' 0 /01/16 .
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2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with theprovisions of M.G.L,c.143, e§,3L,the d
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall bfiled
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G1 c. 166,§ e an
firm or corporation stated on the permit application.Such entity shall be responsible for the
electrical permit shall be issued to the person,
notification of completion of the work as required in M.G.L.c.143,§3L.
Permits sharLbe limited as to the time of ongoing construction activity,and maybe.deemed_bythe.Jnspector-of_Wires abandoned-anddiwalid-if he—
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 23 8 of
the Acts of 2012.The purpose of this act is to promote job,growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain-permits-and licenses concerning the use or development ofreal property.With
limited exceptions,the Act automatically dxtends,for four years beyond its otherwis a applicable expiration date,any permit or approval that was
"in effect or existence"during the quarmfying period beginning on August 15,2608-and extending1hrough August 15,2012.
r
le&—Permit/Date Closed: --1�-� Note:Reapply for new permit,
ermitExtension Act—Permit/Date Closed:
Date.....7........................
NORTH
0
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
SSACHU
7- ......
This certifies that ............7..?..
has permission to perform ..................
Tring in the building of.... .......................................
;t... ......
....... ... .1,rNorth Andover,Mass.
7/3 Fee..... '��Lic.No.........;..� /'I�V, 'e", i.
......... . ................
I.Pi�N;SPiiCwT0-R4II---
Check
8896
f
(,ommonweahk o f I'Y/ailackudett6 Official Use Only
2ccyy
epartment o f Sire Service Permit No.
Occupancy and Fee Checked
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(ME ),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 1 -5
—2W6
City or Town of: MXJA,� 00dOVe-c To the Inspe for of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) / Z r d -ea l/.I
Owner or Tenant 2A� U �C.ebS� Telephone No.
Owner's Address J,9ry1-P—
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: tut�ir�c 2 S�so�n P �Q�,eit
i
Completion of the following table may be waived bv the Inspector of Wires.
3
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 mergency ig ng
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
Initiating Devices
Total
No.of Ranges No.of Air Cond. Tons f`D No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: .. ................ ... ................ DetectioniAlertinLy Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other
Connection
Heating Appliances Security Systems:,
`j No.of Dryers g pp Kms' No.of Devices or E uivalent
No.of Water No.of No.of
Heaters KWData Wiring:
c Si ns Ballasts No.of Devices or E uivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such covera force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE D BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME:
nn / d¢ -�' LIC.NO.:f 1 Y
Licensee: K p G- Signature LIC.NO.:
(If applicable,ente xempt"in he license number line.) c
Bus.Tel.No.: In//'r��'/—�l,/
Address: / 5�- l�'J 1Gl�iv /17,g e y Alt.Tel.No.: k/ E:yg- Y),'.Z.
`Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. ,By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent.
Owner/Agent -
Signature Telephone No. PERMIT FEE: $ n
00
,I
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule S: In accordance-with the provisions of M.G.L.c.143,§3L,the
Permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c.166,§32,an
electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c.143,§3L.
Permits shall-be limited as to the time ofongoing construction activity,and maybe_deemed_by theSnspector_of_Wires abandoned_and_invalid.ifhe—. ._
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or.the installing entity stated on the permit application.
The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property,With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending'through August 15,2012.
[7uPermHIDate Closed: ��—/ ***1aTote• eapply for new permi�xtension Act—Permit/Date Closed:S l�/�
Date. `
f NORTH 9 ;,
3:0��;�``°- TOWN OF NORTH ANDOVER
A PERMIT FOR WIRING
SACHUs�
This certifies that ......... � p .
` has permission to perform .......:...:..
wiring in the building of........... .!!SSS'?............:.........................
Zs' 2�
at ..................... �l orth Andover Mass.
Lf Es 1.
Fee...`..0..��Lic.No... �f Z
.................
!¢................ .., .. . . .. ..........
... ..���.
T ELECTRICAL INSPECTOR U 3
heck # !_ X2-2-
8826
Z2-826
Official Use Dnly
Co„ , oaGth o /aaeac�ivael�e 'Vy 2-
Permit No. 0
lug .1JePar�manl o�.�`irc �ervic¢e
Occupancy and Fee Checked
BOARD OF FIRB PRBVBM'ION REGUTA71ON5 [Rev. 1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be.performed in accordance with the Massachusetts Electrical Code 0 EC),527 CMR 1100
(PLEASE PRINT'IAT INY OR TYPE ALL IN.PORM4TJON) Date: 6/11/09
City or Town of: North Andover To the Inspector of Wires;
By thisapplication the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street&Number) 125 Bridges Ln
Owner or Tenant ' Fred Co arusso Telephone No. 978-685-3003
Owner's Address 125 Bridges Ln,North Andover,MA 01845-2220
Is this permit in conjunction,with a bulldin�permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building
esidenfial- 1 famt y
Utility Auorizatian No.
Existing Service Amps / Volts Overhead❑ Undgr'd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Comotetibn of the followin table mm)be waived by the Inwwor of Mires,
No. OfNo.of Recessed Luminaires Na.of CeiLsP• (Paddle) Tr-SuFans Trans
otal
sformers INA
No,of Luminaire Outlets, INa,afRot Tubs Generators KVA
t Above - o.o rgency ung
No.of Luminaires Swimming Pool ted. r7d, ❑ Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALAP.MS Ne. of Zones
No.of Switches MNe.of'Gas Burners a. o Detection
es
Initiatin
i
No.of Ranges No,of Air Cond. Ton l No. of Alerting Devices
No.of'tiVaste Disposers eat ump umber 'ans o. o = 'ontained
p Totals: IDetection/AlerfingDevices
No.of Dishwashers Space/Area Heating KW Lora ❑ Municipal ED Other
Connection
No. of Dryers Heating Appliances K'VV ecurity Systems:*
No.of bevies or Eouivalent
N o. o ater o.o' o.o Data w.
Wiri
t Heaters KW Siena Ballasts No.of Devices or Louivalent
No.Hydromassage Bathtubs Na.of Motors Total HP a No ofDeiiceio r trot : .
Na.of Devices or Equivalent
OTHER:
Attach additionaldetail tf desired, or ay required by the Inspector of Wires.
Estimated Value of Electrical Worlc: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
1 NST-TRANCE 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 coy a is in force,and has exhibited proof o Same to the permit issuing office,
CHECK ONE: IJ�'SURANC£ F7 BOND 71 O=R F7 (Specif},:) be Mutual
I certify, under the ins rid a{ er u the i formation on this application is true and complete.
I eySpan' o'me FhQy�e�ces�. LC LIC.NO.: 10128A
Fl RM NAME• n � �
Licensee: 6ignatur0l"�- G / LIC.NO.
(//'upplicabia, enter "e ¢C r �n fr{fp ,,MA 01803 l Bus.TeL No.: 781-359-2600
Address: g""' Alt.TeL No.:
"Ter M.G.L. c. )47,s. 57-61,security wort:requires Department ofPubiic Safety"S" License: Lic.No,
0 WN.ERIS INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by iew. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's as'ent,
Onvner/Agent PERMIT FEE: 40.0
Sienai.ure Telephone No.
�.P'F't-.C.1T+nff FAH E►-EGti"&a
Ti
Fifil"UT ti �ti5��cr�w of wujf4
Date..: ...............
1401%T#1
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
4re
This certifies thatK� 1 C.C4 t�, C, 4e CA10-It-J,
. ..............................................................................................................
has permission to perform ....P.A�4... ................................................
wiring in the building of...........,....6...\.......CA,(-.. V,S-5 0....................................................................................
at ............V2.5................................ Andover,Mass.
. ............... .....................N
Fee... ..............Lic.Nol.ji(4' j.........
Check 4
11496 :
-�4
>a
AL11\ Commonwealth of Massachusetts Official Use Only
Itclig
Department of Fire Services Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 1-1-2-13
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 aS -'brjc (,s 14 ,e
Owner or Tenant 'Fr rLi eotstr v5 S a Telephone No. (� 7e-99S--
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No E�' (Check Appropriate]Box)
Purpose of Building Utility Authorization No.
- Existing Service acro Amps 12(I / al-(6 Volts Overhead❑ Undgrd No.of Meters Z
New Service IAmps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Am pa city
Location and Nature of Proposed Electrical Work: I�e1�lAcc pts 'P
qh v n �.
Completion of the following tabl may be waived by the Inspector of Wires.
a No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Ge erators KVA
r
Above In- o.o mergency Lighting
No.of Luminaires Swimming Pool rnd. ❑ rnd. El Ba er Units
No.of Receptacle Outlets No.of Oil Burners F ALARMS No. of Zones
No.of Switches No.of Gas Burners No. of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices \�
Heat Pum Number Tons KW No.of Self-Contained
�\
P .....................r..j. ............. ...............
No. of Waste Disposers Totals: Det ction/Alerting Devices
No.of Dishwashers S ace/Area Heating KW Loc 1❑ Municipal F] Other
P g Connection
No.of Dryers Heating Appliances KW Sec o.of Dev Ices or E uivalent
` No.of Water KW No.of No.of Dat Wiring:
Heaters Signs Ballasts o.of Devices or Equivalent
a No.Hydromassage Bathtubs No.of Motors Total HP Tel co.of Devices or E u valent
OTHER:
Attach additional detail i desire or as re aired b the Inspector of Wires.
f 9 y p
Estimated Value of Electrical Work: (When required by municipal policy.)
e m actor ante w1 mule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,nb 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 cove e is in force,and has exhibited proof of same to the permit issuing office. N,
CHECK ONE: 1NSURA-NCE /❑BOND ❑ OTHER ❑ (Specify:)
X certify,acnder thepains andpenalties ofperjury,that the information on this application is true and complete. �
FIRM NAME: . LIC.NO.: any&4--A `1
Licensee: h �A5)L A, Signature LTC.NO.: a►yc,�(-�
(If applicable,enter "exempt"in the license number line.) Bus.Tel.No.--S
Address: � Sh-jay- /,,,, i)va d �,f I--F of 8a,, Alt.Tel.No.:
*Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage nonnOly
required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner .❑owner's agent.
Owner/AgentvV-
Signature Telephone No. PERMIT FEE:$
J
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§ 32,an .
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c.143,§3L.
Permits shall-be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012.
❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑
❑Permit Extension Act—Permit/Date Closed:
Trench Inspection
Pass M Failed Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION: M
Pass Failed 0 Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
PARTIAL,ROUGH INSPECTION:
Pass[ Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
i
ROUGH INSPECTION:
Pass Failed Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
FINAL,INSPECTION:
Pass 0 Failed Re-Inspection Required($.) ❑
Inspectors Comm Ants:
Inspectors Signature: Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
i
i
The Commonwealth of Massachusetts
07- Department of IndustrialAcclknis
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): P__40_07 V e-c-Fn" 5&-vices
Address:
City/State/Zip: Phone M X178fi V
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.�am a sole proprietor or partner- listed on the attached sheet. F1 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
v
required.] officers have exercised their 10.❑Electrical repairs or additions
g
3.❑ I am a homeowner doing all work right of exemption per MGL I L ]Plumbing repairs or additions
.
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs
w` 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.
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:.
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).
jFailure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP.WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certlo under the pains and penalties of perjury that the information provided above is true and correct.
Sip-nature: 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#:
i�
Information and Instructions N
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced-acceptable evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department ofzndustrial.Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
TeX,#61.7-727-4900 at 406 or 1-$77,7MA.SS.AFE
Revised 5-26-05 Fax#617-727-7749
wwwinass.gov/dia
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Insurance Adjusters and Appraisers
Samuel F.McCormack Co.,Inc.
ADJUSTERS AND APPRAISERS
January 28, 2013
Town of North Andover
Building Inspector
North Andover, MA 01845
RE ASSURED: Frederick& Roseanne Colarusso
LOSS LOCATION: 125 Bridges Ln, North Andover, MA 01845
POLICY NO: HO12338719
TYPE OF LOSS: Freeze Up
DATE OF LOSS: 01/27/2013
OUR FILE NO: 13-00417
Gentlemen:
Claim has been made involving loss, damage or destruction of the above-captioned property, which
may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to
be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3113 is
appropriate, please direct it to the attention of this writer and include a reference to the above-
captioned insured, location, policy number, date of loss and claim or file number.
Thank you for your.anticipated cooperation.
Very truly yours,
Peter Venie
Adjuster
pv@mccormackadjuster.com
cc: Board of Health , 4.
zf
42 Holbrook Avenue ■Braintree,MA 02184
(781)-843-1222 ■MA WATS 800-972-5399 sFax(781)-849-8191
Qj
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
• �� � (Print of 7yp e)
tU l�.v�c�u�.e✓ ---,Masi. Dale V ► A-J, j 197 Permit
l Building Location 1 J4,4 P S Ge Owner's Name__ �J e d (0
I4C
Map: Lot: Zone: Type of Oetvpancy_ -S:c�euN 7L Q
New A Renovation 0 Replacement G Plans Submitted: Yes:) No
Fee: I N
N t7
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< - ' ' O � u
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SUB—BSMT, I � I I I I I I I •I I I I. I
BASEMENT
" ET IIIIIIIIIIIIIIIIIIIIIIII ( !
IST FLOOR I I I I I I I I I I I I I I I >e-1
I I I I I I I
2ND FLOOR I I I I I I I I I 1 1 1 1 1 1 I I 1 1 1 1 1 1 FT l i
3RD FLOOR
4TH FLOOR I I I I I ( I I I I I I I I I I I I I I 71 I I
STH FLOOR I I I I I I I I I I I I I I I I I 1 1 1 1 F T-
1
6TH FLOOR I I I I I I I I I I I I I I I I I I I I I I I
7TH FLOOR
IIIIIIIII I
STH FLOOR 1 1 1 1 1 1 I I I I I I I I I I I I-1-1
1nsa11ing Ccmpany Na:r�e• EASTERN PROP Ali E GAS INC Gtieek one: Ce
rif
Address 131 WATER STREET D AVERS Ma 01923 f Cerporaticn
Estimate Valve of Work: Parl�ership
Business Telephone ( 508) 774-1930 Finn/Co•
: Name of Licensed Plumber cc Gas Fitter 1 )'e—y\
INSURANCE COVERAG E:
have a current liabilt'ty 1r.S;lance pct:cy er its s_bs:crt'ci eS a'alent which meets ih 2 ents f '
e reqr„ o MGL Ch, 1.2.
Ye3XX No Z)
If you have checked yes, please indicate the type coverage by checking the appr.-prate box.
A liability insurance policy N (rher type of indemnity ] Bond
_• OWNER'S INSURANCE WAIVES: I ant aware that L`e licensee rices not havziha
-" ' e
insurance coJ_tage required by
Chapter 142 of the Mass.General Laws, and that r,-,y signature on this pernit a?pGcatiorl waives this requirement.
Check one:
Owner O Agent O
Stgnature of Owner or Owners Agent
I hereby certify that ail of the details aid informa5on I have submired or entered)in above application are true and ar;rra:e tone best of
mY knowledge and that all plumbing work and installations performed under the permit issued for this application wm be in compliance wilt
23 pertinent provisions of the Nzssac'u:sers Save Gas Code and Chapter 142 of the General La„�
I =
T`e Plumber igna^;re of L'�oensed Plumber or Gas Firer
: Gasfi::er ..
Nas:et License Nur..ber
c'y/Town Jourr•tY::.an
GPPROVED {OFFICE USE ONLY)
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"CLOW ron orr1cE usE or1l_Y -
rtNAl itt;PECTIOIt SKETCIIpg
PROORESS INSPl:CT101t
FEE
110.
APPIICATiOII FOR PERMIT To DO OASFITT1110 ,
r
IIALtr A TYprnr nUllMlln
LOCATIOIt Or nU11.DI1ln
PILUmnrn On OArrIT71:n
LIC- 110,
--------------
PERMIT CnAuTED
DATE 19
OAS II(SPECTOn
r
• s
t +�J Date.4,
Il I * s t
TOWN OF N014TH ANDOVER.',
o? 0� PERMIT FOR GAS INSTALNSLATIOr..
SACH
.:
This certifies tMa .�. . , iz . ?Ct ;
has permission for gas ' tallattion r
in the buildings f . . . . . „.
at . �pZ-.� . . G'n�?� torfh Andover, Mass.
Fee•c90 Lic. No .. l
18L �6 GAS INSPECTOR` s
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WHITE:App icant CANIRY: Building Dept. PINK:Treasurer, GOLD:File