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Miscellaneous - 130 APPLETON STREET 4/30/2018 (2)
130APPLETON STREET 210/037.BA066-0000.0 tate ........ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,ssACHU Thiscertifies that..... ..................................................... .............................. has permission to perform..... ... J..I ...r. e . ,J plumbing in the buildings of................ ............................................................ aNorth Andover, Mass. t... ...... .......... Fee .......Lic. No32.17...�- ................................................................................. PLUMBING INSPECTOR Check# i � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING ORK . CITY _ MA DATE PERMIT# I _ JOBSITE ADDRESS ISO A�pI1��?NI. S OWNER'S NAME P OWNER ADDRESS N 1CTot l Sir TEL - (],) q0j;_0 UFAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL O RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:F-1 REPLACEMENT:Kr PLANS SUBMITTED: YES 0 N0go' FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ! _ _ .__._`s CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM =DEDICATED GAS/OILISANDSYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR IAREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK i l __-- F-77-1 LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET I _._:_ ______ URINAL i ..._._ _. _.._► ____l __J .__.____F __._.._. I __._._ f __.._._I ___ ..__.�. ____I __..._._I f WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER �C3, �/ LJ _: I f _....--E ---__! A! f I ! ._.__..[ .......-1 P 1--J I .-_—__-( ---._ -___-� I _____6 _..I .---...._ .. ¢ _ ( _.____I ._ I s 77 INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch,142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 01 BOND OWNER'S INSURANCE WAIVER:lam aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass h setts General Laws, that my s gnature on this permit application waives this requirement. 'r CHECK ONE ONLY: OWNER EdAGENT 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 beta-compliance w' all Pert' ent provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME (Z _C'&Q(-jft04N LICENSE# SIMATURE -MPE(1 JP Ff CORPORATION -i# PARTNERSHIP 0# f LLC r 4 COMPANY NAME Ir,044a ADDRESS CITY (.aWP.LL_ (STATE _t--lh ZIP TEL FAX CELL ��EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts _ Department of industrialAccidents M 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/die Workers,Compensation Insurance Affidavit:Builders/Contractors/l lectricians/Plumbers. TO BE FILED WITH THE PERWTT NG AUT""JT'Y• please print Le 'bl A licantlnfaormat�!Ilziadv j&ationu )Name(BusinesslOrg Address: T.�R•1�Q �� �t��-U`- �� 0�g54 Phone#: ��g- �S5 , 570S , City/State/Zip: y ' PP P 'Type of project(required): A.re ou an employer.Checkthe a ro riatebox: em to ees full and/or part-time).r` 7. ❑New'donstxuction L❑I aGn a employer with p y 2.�i I am a sole proprietor or partnership and have no employees working foz me in $• Remo deling any capacity.[No workers'comp.insurance required] 9, ❑Demolition 3.E]I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole re airs or additions proprietors with no empibyees. 12.L7 PX>lmblfig p $,❑I am a general coniractpiand T have hiredthe sub-contractors listed on the attached sheet. 13•.0 Ro6f repairs These sub contractors have einpioyees and have workers'comp.insurance .t 14 Comer 6.❑We are a corporation and its,officers have exercised their right of exemption per MGL G. 152,§1(4),and'we/rave no employees:[No workers'comp.insurance required.] applicant that checks box#i wrist also fill outthe section below showing theirworkers'compensationpolicy information: `Any app homeowners who k this li is Ad attachet indicating the d an addition sheegshdwing the yared all work name of the surb contractoos and state wrs-must hether t a new.or thoseentrnesnhave tContractors that employees. If the sub contractors have employees,they must provide their workers'comp.policy number. rs'compensation insurance for my employees. Below is the policy and job site X am an employer that is providing wor ke information. Insurance Company Name: ' Expiration Date: Policy#or Self-ins.Lic.#: • Kb�-v4 AN�E2 Job Site Address: '� Ape(� S 1 City/State/Zip' iration date Attach a copy of the workers'compensation policy declaration page(showing the policy number and exp . olation 0-00 Failure to secure coverage as required undevM penalties in the form of criminal25A is a TOP1WORK ORDER 1and a flue f up to $250.00 a and/or one-year imprisonment,as w P day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cert under thep ins andpenaltiec ofperjury that the information provided above b®, i tC a and,correct. Signature: P '' Date. !! Monet 7 - 55"5705 official use only. Do not write in this area,to be completed by city or town official Permit/License# City or Town- Issuing Authority(circle one): ' 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#• Contact Person 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 hii, 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 6f an individual,partnership,association or other legal entity,employing employees.-11 owevex 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 applica rt•who has not produced-acceptable evidence of compliance with the insurance coverage requbred" 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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. 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' compensatiori policy,please call the Department at the number listed below. Self-insured companies should enter their self insurance license number on the appropriate lino. -. 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 pefmit/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 homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: umber: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia i Division of Professional Licensure: License Search Page 1 of 1 ,. The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES .......................... ...........................................................__._..................._.........._....................................................................,._....................... ................................ Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency LICENSEE More... Name:RICHARD CUCINOTTA REFERENCES& LOWELL,MA RELATED INFO NEW SEARCH I Disclaimer Regarding **This Licensee has additional Licenses,click here to view them.** Website License Searches Glossary of License Status Codes Licensing Board: PLUMBERS i3 GASFITTERS License Type: JOURNEYMAN PLUMBER More... License Number: 32132 Status: CURRENT Expiration Date: 5/1/2016 Issue Date: 7/13/2010 Exam Date: 7/13/2010 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Wednesday,October 07,2015 at 11:23:18 AM. ©2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://Iicense.reg.state.ma.us/public/pubLicenseQ.asp?board_code=PL&type_class=_J&Iic... 10/7/2015 } Date..... .. . . . ......... NOR7'ly 3a ; �°oma TOWN OF NORTH ANDOVER y PERMIT FOR WIRING ss�CH (Z Thiscertifies that .....................(......................Q...._..........................`................................................ has permission to perform .. i ` U wiring in the building of..........r... ............................. { at ....:......t. ........... ... i. nJ......S1........................,North Andover,Mass. r Fee....9.5T .........Lic.No. .................................................................................... ELECTRICAL INSPECTOR Check# Commonwealth of Massachusetts Official Use Only i Department of Fire Services permit No. ��p Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank � M APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NOC),527 CMR 12.00 (PLEASE PRINT WINK 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' tention to perform the electrical work described below. Location(Street&Number) 130 IP-�Q 6 V41¢ Owner or Tenant M11V v r. 'e, i a'ra Telephone No. Owner's Address 3 e ■�ee 1�,� Q OC Is this permit in conjunction with a building permit? Yes'r 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 akZ�Iure of Proposed Electrical Work: G r r �r a�b(t1 �,c��4 G►rW i �')r' mvn Completion of the following table may be waived by the Inspector of Wires. ---Zll No.of Recessed Luminaires No.of Cell: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 tg tmg rnd. rnd. Battery Units Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat PumpNumber 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 IV Telecommunications Wiring: No.of Devices or E uivalent OTHER: :d Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: ,(a) (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: 1NSURANCE"g BOND ❑ OTHER ❑ (Specify:) I"certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: GleAnYln mete( Signature LIC.NO.:5Q 1715 E (If applicable enter"exemp "in the.4,cense number line) Bus.Tel.No.- Address: 1 �uo n r iv c La—C<tv-e, MA 0 19 43 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 normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE:$� / Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance 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 �1 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-terra 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—PermitMate Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 10 Failed Re-Inspection Required($.)❑ Inspectors Comments: 4 Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass EN Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPE ION: Pass 0 t.11 Failed '❑ Re-Inspection Required($.)❑ Inspectors Comments: 44 9 Inspectors Signature: Date: 70 DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com `The Commonwealth ofMassachusetts - Department of Industrial Accidents u 1 Congress Street,Suite 100 - Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/FIectricians/plunabers. TO BE FILED WITH TEE PERI/lITTING AUTHORITI'. ApWicant Information Please Print Le 'bl Name(Businessloiganization/Individual): Address: INAMN U e., City/State/Zip: Phone#: 9 Are you an employer?Check the appropriate box: Type of project(required); 1.❑I am a employer with employees(frill and/or part-time).' 7. ❑NEVd6nstruct1on 2.�I am a sole proprietor or partnership and have no employees working for me in $. Remo delifig any capacity.[Noworkers'comp.insurance required.] 9. ❑Demolition 3.E]I am a homeowner doing all work myself:[No workers'comp.insurance required.]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole ll.[M Electrical repairs or additions proprietors with no employees. 12�Q Plumbing repairs or additions 5.❑I am a general contractor and l have hired the sub-coutraotors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.Q We are a corporatigi and its,officers have exercised their right of exemption per MGL c. 14.El Other 152,§1(4),andtve have no employdes.[No workers'comp.insurance required.] *Any applicant that chdcks bok 41 must also fill out the section below showing their workers'compensation policy information. i Homeo-,vners who submit-this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such ur must attached an additional sheet showing the name of the sub-contractors and state whether or not those,entities have tContractors that check this liox employees. Ifthe sub-contractors have employees,they must provide their workers'comp.policy number. f 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). Failure to secure coverage as requited under MGL e-152,§25A is a criminal violation punishable by a fide 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. X do hereby certify under the s andpenalties ofperjury that the information provided above is true and correct Simature• � Date: Phone# X11 5 S d'5 33y EEms only. Do not write in this area,to be completed by city or town official. n: Permit/License# hority(circle one):Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: 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 hiz, express or implied,oral or written." I 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.-Howevex 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." I 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 lousiness or to construct buildings in the commonwealth for any applicaut•who.has notproduced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of IndustrialAccidents. 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 PIease 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number_ The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MA.SSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia i I, 3 i \ 101, fW3 :.. • HOARD OF ts_ECTR t C i At�� 1SSUE5 1HE FOLLOWING LICENSE AS k; REG J0URNEYMAN>'ELECTR Cl AN` " Is GLENNON M OBERMEIERr }w. w 6 WINSTON DRIVE ` '��t W ( AFIRENCE MA 01843 301 50125E 07/3;;/16 64416 .101 �yGeTy s. Gf�zicc E6�H� O A �R.EiEO+i! ��SS�cHus�t 16000sgood Street Building 20, 2035 North Andover MA 01845 Tel: 978-688-9545 Fax: 978-688-9542 COMPLAINT FOR INVESTIGATION DATE: \— `ZC�I Tel #: FROM: ADDREaS-- A-0, --�l� - � Complaint Against: • �E=- PLUMBING: GAS: UILDING CONTRACTOR: PROPERTY OWNER: f OTHER: 0 w S tee. Signed: ssc ss S7 /?A Ave- dAs d- 3e 9k-/ �J NORTy 0 F- At#i 8A 'f n� •^ ti k �tCH eFt49 SS�cHU50 16000sgood Street Building 20, 2035 North Andover MA 01845 Tel: 978-688-9545 Fax: 978-688-9542 COMPLAINT FOR INVESTIGATION DATE: `— `ZC�I Tel #: FROM: ADDRESS yU� Complaint Against • ELECTRICAL: PLUMEING: GAS: (! UI�LDING�CO�NTRA�CTO�R- PROPERTY OWNER: OTHER: Utib e w Ocu Signed: r� 83a 9�/ Date . i 9/2.VZ.. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . .T�V`\. ti S.( C. . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . )3.e s ' . . . . . . . . . . . . . . . . . . in the buildings of. . . Q. . . . . . . . . . . . I . . . . . . . . . . . . . . . at . . A LCA-ql .ST.. . . . . . . . . ,North Andover, Mass. Fee . 3.0s9 . Lic. No. A.P30j. . GASINSPECTOR Check# Z 0 830 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY _�`- ' .- ,_-.. __- --T-- MA DATE PERMIT# JOBSITE ADDRESSN � OWNER'S NAME _ 19 OWNER ADDRESS _ TEL _ ��FAX[ TYPE OR OCCUPANCY TYPE COMMERCIAL rJ EDUCATIONAL® RESIDENTIAL PRINT CLEARLY NEW RENOVATION:- REPLACEMENT:0 PLANS SUBMITTED: YES 0 N0[I APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER J i,._ ,J I I I I====I _r I BOOSTER r _ I _ I .__ �_ I I CONVERSION BURNER COOK STOVE J DIRECT VENT HEATER ! DRYER FIREPLACE _j I_Tj FRYOLATOR FURNACE - GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS I _ ) MAKEUP AIR UNIT OVEN -_- POOL HEATER ROOM/SPACE HEATER ROOF TOP UN ITl- J 1 --.._. h -- 1-=_ . _._ :- .:i..-:..:: I--I �.-1 . ....__{ TEST UNIT HEATERS __. _w_ UNVENTED ROOM HEATER C— _ zl I_. _J i_ _ I_._- I� i __. '�_. ! _J 1,:,. . I_-_J _ `i�, WATER HEATER _ !_—(_ ! _f`_-77 IT_-J THER I - I I I z- G�., ,_— h �- �_. -zI INAI INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES L NOD 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY �61 OTHER TYPE INDEMNITY 0 BOND 7 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. C LY: OWNER ENT E SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this ap ication are true an c ate t e b st knowledge and that all plumbing work and installations performed under the permit issued for this application will-brtm-emplii f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAM J f6f _ LICENSE#- 030 SI ATURE MP MGF JP _J JGFF ; LPGI CORPORATION __(# �( j ( PARTNERSHIP ._ # ]j LLC (]# COMPANY NAME: �I ___ 6 � ADDRESS ., -_- - - - - ----- CITY -CITY __ - _ _'_..._._.._„ ....,__ -__.-_- __.._ _-� STATE ZIP ( ,. _ . . TEL .12LrJ op CEL EMA f 4-1 kLb Q 0 --- - ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES n 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 ,13 Organization/Individual): 1 G Address. 6 �' City/State/Zip: Phone#:_ Are an employer?Chec 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.❑ 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 required.] officers have exercised their ME]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.]f employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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 i information. �y �� Insurance Company Name: / Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: l 0 � �t'! 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 V against the violator. Bea s d that a copy of this statement may be forwarded to the Office of Invest i ions of the DI r insu nce Covera ver' ation. F do herti and ie p ns it pe a i erjwy that the information provided (above is true and correct. 3i nota : Date: t'0 2 6 I Z- ?hone Official arse 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#: C 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 may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia N2 9628 .i�?/??/l.Z. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 'SSA HUS This certifies that Ct. 1�. . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . at. . .k3U . . . . . . . . . . . . . . . . , North Andover, Mass. Feej,.;a,V1 . .Lic. No..l.0.30.1. . . . . . PLUMBING INSPECTOR Check # 47 Del WHITE: Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK I L CITY IBJ • _ I� MA DATE " _ -Z6��( PERMIT# JOBSITE ADDRESS 0 a OWNER'S NAME e- POWNER ADDRESS - j TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL © RESIDENTIAI,ja'- PRINT CLEARLY NEW: 0 RENOVATION: REPLACEMENT:® PLANS SUBMITTED: YES® NO F-1 FIXTURES'l 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/OIL/SAND SYSTEM ( _1 _ ( _ i __ l .......__R __._! _! f ..._ .J I „ f ! DEDICATED GREASE SYSTEM —J ......_._..I I ...____J _.._�( ..___I ! _.._._... J _._f # I __! DEDICATED GRAY WATER SYSTEM I I f _ { -_...._-J ._( 1 _.,_. ._...___I --_J f _J ! f DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK ► .-------_1 LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET l ___.....J J .._T _J___. .., I ..-.-__ 1 ! _ �J ....__i i _-._..._! _J URINAL _._____.J -7 -1-1- .._._.J WASHING MACHINE CONNECTION _. _ f -_J -_- J i WATER HEATER ALL TYPES WATER PIPING OTHER ___ ._.._.E _------I ._.___I .......... INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch,142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY V OTHER TYPE OF INDEMNITY D BOND 0 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. HECK ONE LY: OWNER T El SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this appli ation are true and r to x e bes of y n wledge and that all plumbing work and installations performed under the permit issued for this application will in compliance vi rtinent pr isio o the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NA LICENSE# 6 I SIG URE MPZ JP Q CORPORATION .. i =PARTNERSHIPQ# LLCM�� � COMPANY NAM ADDRESSOff-- r�Z I CITY STATE �ZIP D(�'K - TEL - - I MAIL - _ J. - �� ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# x/'20 PLAN REVIEW NOTES �/2 ve,7 Z The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kvi. 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant InformationPlease Print Legibly 1-- Name (Business/Organization/Individual): i N O � 0;-,� Address: City/State/Zip: �1 Phone#: (�� ��—6-Y Are y an employer?Check the appropriate box: Type of project(required): 1 I am a employer with `7 4. ❑ I 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.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.El 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. r 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. tam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site Information. Insurance Company Name; 1 ?olicy#or Self-ins.Licii.#: Expiration Date: lob Site Address::l &Uzi City/State/Zip: kttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ?Filure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a the up to$1,500.00 and/or one-year' t,as well as civil penalties in the form of a STOP WORK ORDER and a fine if up to against t violator. a vised that a copy of this statement maybe forwarded to the Office of nest' ations of the DI for' rance coy rag verification. 'do h eby certify amd p 1 of perjury that the information providedabove is true and correct. .i nature: ( Date: 6 l 'hone#: 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#: l 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 may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia 56c, Date. .. ........ f ,AORTN pf „io ,°1ti0 TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION SSACMUSEt t This certifies that . . . . . >.f . . . . . . . . . .. . . . . . .. . . . .. . . has permission for gas installation . . . 19. !.f. .-c . . . . . . . . . . . . in the buildings of . . . . . . .0.! . . . . . . . . . . . . . . . . .. . . . . at . . �%. ., �' r./T. 4.- . . . . . . . . North Andover, Mass..-r Fee. .3 R -. Lic. No.. . . . . .. . . GAS INSPECTOR Check# `j i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER Mass. Date JAN.24, 2011 Permit> G Iy 130 APPLETON ST. EMILE GIARD Building Location Owner's Name Owner Ten, 978-682-0125 Type of Occupancy RESIDENTIAL New F-1 Renovation❑ Replacement Plan Submitted: Yes[]No[] FIXTURES Q rn Q m � N °' a 0 Z F z CY W Q W 0 C4 > Q W W U) w z Q x a a w w w F x a a O F- zJ �— z w w 0 0 9 w F v a w a z Q W Q R E" v� 0.1 z O z O Cn x W = 0 0 2 w 3 A BU Lu < U 004 > A a O w SUB-BSMT BASEMENT 1ST FLOOR 0 2N°FLOOR $ 3R0 FLOOR 4T"FLOOR 5T"FLOOR 6T"FLOOR 7T"FLOOR 8T"FLOOR Eastern Propane & Oil Inc Installing Company Name p � Check one: Certificate Address 131 Water Street Corporation Danvers, MA 01923 Partnership Business Telephone# 800-322-6628 Firm/Co. Name of Licensed Plumber or Gas Fitter JOHN MARSHALL INSURANCE COVERAGE: I have a cur liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YesNo ❑ If you have c ecked rimes,please indicate the type coverage by checking the appropriate box. 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 Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed underthe permit issu for this applic will in mpliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of th a ra Laws. By TyF�of License: •/Plumber Si ture of Licensed Plumber or Gas Fitter Title •Gas fitter r p •-Master Li nse Number U City/Town •-Journeyman APPROVED(OFFICE USE ONLY)