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HomeMy WebLinkAboutMiscellaneous - 131 DUNCAN DRIVE 4/30/2018 Ill DUNCAN DRIVE / 210/104.B-0185-0000.0 1 i I I I i a Date.'-tl?.��1............ ` LJ4J of NOwrry,� TOWN OF NORTH ANDOVER ° n PERMIT FOR PLUMBING �,gsgC14Us�t4 z This certifies that.�LA A Le- �� has permission to perform....'Y.-e...ft'\a c�.0..... "(A!b4 2 �jM+ ........ ..... plumbing in the buildings of... 2^'S . ............................................................... at........I.� .I......... e. '........k':2,d.Q.-............ North Andover, Mass. -I M A Fee4l.." ......Lic. No. ID` LP1... .M. ................................................................. ����� PLUMBING INSPECTOR Check# 6P c,-1t) -- 14 � 111-t e MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY I NORTH ANDOVER MA DATE 4-30-14 PERMIT# I JOBSITE ADDRESS 1131DUNCM,DRIVE OWNER'S NAMEJ LINDA BURNS POWNER ADDRESS I SAME TEL FAX �1 TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIALE] PRINT CLEARLY NEW:® RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES[:] NO FIXTURES-1 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 3 DEDICATED SPECIAL WASTE SYSTEM EE DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM _ DISHWASHER DRINKING FOUNTAIN '— FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY _ 2 - — ROOF DRAIN SHOWER STALL SERVICE I MOP SINK — TOILET 1 _ URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER ._ .' F- =F _ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES E] 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 F] 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 Q AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance withUPertint provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. . PLUMBER'S NAME JAMES BURKE _ __ LICENSE# 10469 SIGNATURE MP[D JP® CORPORATION[Z] 27270 PARTNERSHIPD# LLC # COMPANY NAME I BURKE&SONS PLG&HTG INC ADDRESS I PO BOX 102 CITY GROVELAND STATE MA ZIP 101834 TEL 978-374-7837 FAX 978-373-6615 CELL 1 978-360-4453 EMAIL I JIM@BURKEANDSONSPLUMBING.COM ell -1W ti t� j r >:c*::COMMONWEALTH OF MAS5ACHl3SETTS - e • • Nu ril a mi 6-1 jai "FLUMBER ; ASF I TTERS, ISSUES TF1' F 0 L L OW IN G;;,;(~;I G E NS E LICENSEb AS A MASTER PLUMBEf w: �4 JAMES; A BURKE W I L L.-JI... w .: 7 3 F ;..: .NAV RN] LL _. :..MA 01832-3041 10469;:.:: ::: %ot/16 :;...: 223330 1 . The Commonwealth of;Massachusetts , - Department of Industrial Accidents Office oflnvestagations 600 Washington.Street .Boston,MA 02111 www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Cont°actors/.Electr iclans/Plumbers Applicant Information Please Prim Legibly Name(Business/Organization&dividual): C S tz� / Address: P 0 1 1 - - City/State/Zip: C�R-Oy c I�(1Y Phone#• Ar 011 a" employer?Check the appropriate box: Type of project(required): L 7I am a employer with _ 4. ❑I am a general contractor and I 6. ]]New construction, employees(full and/or part-time).* have hiredthe sub-contractors 2.[] I am a sola proprietor or partner- listed on the attached sheet. 7• El Remodeling ship aad'hava no.employees These sub-contractors have 8. []Demolition working forme in any capacity. workers'comp.insurance. 9. Building addition [No workers' comp.insurance 5. ❑We area corporation and its 10.❑Electrical repairs or additions required.] officers have exercised.their 3.[] I am a homeowner doing all work right of exemption per MGL I L[]Plumbing repairs or additions Myself [NOworkers' comp. c.152,§1(4),and we have no 12.❑Roofrepairs insurancerequired.]; employees.[No workers' I3.❑Other comp.insurance required.] ,!Any applicaat that checks box#1 must also fill out the section below showingtheir workers'compensation policy information. t-Homeowners who submit this affidavit indicatingthey&doing allwork and then hire outside contractors must submit a new affidavit indicating such. TContractors that checkthis box must attached an additional sheet showingthe name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for fny employees Below is the policy and joh site information. Insurance Company Name: ✓L Ali b q Policy#or Self-ins.i ic.#: - I C) l Expiration Date: Job Site Address: l 1� Y` pity/State/Zip: Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage.as re V1IM dander Section 25A ofMGL o.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 statementmay be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. X do hereby certify under filepains andpena ties ofperjury that the information provided above is true and correct. - Si ature• Date: ��_5 � Phone#• official use only. Do not write N this area,to be completed by city or town official. City or Town: PermitlLicense# 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 9: 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 ofbire,- express orimplied,oral orwritten:, An employes is defined as"an individual,partnership,association,corporation or other legal entity,or anytwo or moxe of the foxeg9ing engaged in a joint enterprise,and including the legal representatives of a•deceased employer,or the receiver ox 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 ofthe dwelling house of another who employs persons to do maintenance,constriction,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 employar." 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 fox 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 fbr the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have beenpresentedta 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),addresses)and phone number(s)along with their certiftcate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are notrequired to carry workers'compensation insurance• If an LLC or LLP does have employees,apolicyisrequired. Be advised that this affidavit maybe submitted tothe Department ofIndustrial Accidents fox 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 thepemut 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*orkers' 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 andprinted 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 inthe permit/license number which will be used as a reference number, In addition,an applicant that must submit multiple p ermit/licoma 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 avalid affdavitis on filefor future permits orlicenses. Anew affidavit mu* be,Med 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 orpermit to burn leaves etc.)said person is NOT required to complete this affidavit. The Offico 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 aid fax number: Tho emmonwealth ofylouachwetEs Department o£Zudu5xzal,A.ccidouls Office 0:C1Aveaisga-0o. q 60 Was gtm Silcet Boston 0.21.11 TQJ,9 QM27-4900 0A 406 or 1-877-MASSAF� Devised 5-26-05 `ay,0 617"727'7749 w�vc�xua�s,gcv�di� 0152 - 2z - // Date.tal................................. � �10R71� TOWN OF NORTH ANDOVER o p PERMIT FOR WIRING �SS,qcfaus� This certifies that .............. ..5.............................................................. has permission to perform ......w.�..:` ......... �v.......<Xj .° .... wiring in the building of ' '�v� '�.... ......................... .................................. at.... � North Andover,M'j�Q a Fee... S. ...... Lic.No�j / 7..... ...... ............ ...... ..... EICALNSPECTOR Check v i nI Commoruueal ol/I/a�sac�Zuself� Official Use Only c� Permit No. 2c7epartment W ire Services Occupancy and Fee Checked r BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: 6 E `!Z_L/ City or Town of: A Ia P y\old X4 To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to pelf the electrical work described below. Location(Street&Number) & (' (h Owner or Tenant L Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building , ► eh C e • Utility Authorization No. Existing Service Amps r / 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: jq/C P , dr, F C Co letion of the followingtable may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans TransTotal Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- El o.o Emergency Lighting rnd. rnd. BatteEy Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gers No.of Detection and Initiating TotDevices J No.of Ranges No.of Air Cond. / Tons No.of Alerting Devices S No.of Waste Disposers Heat Pum Tons W No.of Self-Contained Totals: �umber Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local[:] Municipal [:1Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water Kms, No.of No.of Data Wiring: r 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: 5© (When required by municipal policy.) Work to Start: �bh"et<&XT- 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 issu g office. CHECK ONE: INSURANCE Dr,BOND ❑ OTHER ❑ (Specify:) �k,tI G[J 5►,(/o n C . I certify,under the painssaand nalties ofperjury,that the information on thu apph ation is true and completes FIRM NAME: q rn _� Q q LIC.NO.: 7 Licensee: Signature 1.t -Q LIC.NO.: (Ifapplicable,ente <. empt"in a license u ber li 8'S�L� / Bus.Tel.No.: 1 Z Address: � V► //"(4' Li-�A- y ; G Alt.Tel.No.: � T_ *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 PERMfT FEE: $ ZS Signature Telephone No. Date a..�..... ............ 1 OF NORTH,h TOWN OF NORTH ANDOVER A * PERMIT FOR WIRING US� This certifies that 6 has permission to perforinP,nn�?..... °1 cv-� 5 wiring in the building of................. U� �+ S P -3\at ..... .�......I�.w Q O t% v Q"..... ... North Andover,M ss. 'J Fee.. ..........Lic.No��!.,q ....... ........ ........ ................... � v ELECTRICAL INSPECTOR f Check# ' A', % J • Official Use Only Commonwealth of Massachusetts y .4 Nsam' Permit No. - Department of Fire Services Occupancy and Fee Checked s 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(IvIEC),527 CW 12.00 (PLEASE PRINT INMK OR TYPE ALL INFORMATION) Date: 13 -6- City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intent*Dr- Owner to perform the electrical work described below. Location(Street&Number) V co n or Tenant U (n Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building j I^I g M . iN %qe) Utility Authorization No. - Existing Service a06 Amps ['20 / Z DVolts Overhead ❑ Undgrd W No.of Meters 1 New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Pewode, Comp e ion of the following table may be waived by the Inspector of Wires. } No.of Recessed Luminaires 3 No.of Cell:Susp.(Paddle)Fans No.of Total " Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA _ Above In- o.o mergency Lighting No,of Luminaires Swimming Pool rnd. ❑ grnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiatin Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons C- 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 p OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 1500 . (When required by municipal policy.) t Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) X certify,under tlze�inns a enalties o 'ury,t1ia tthi mforuzation on this application is true tzntl complete. FIRM NAME: . Iti((( �,w (a J LIC.NO.: 2 I 1= Licensee: Signature LIC.NO.: (If applicab� er " empt"in the i nse nz er line.) Bus.Tel.No.: Address: � Alt.Tel.No.•*Per17 c. 147,s.57-61,securi work requires epartment of ublic Sa "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 ignatur b w,I re waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/AgentPERMIT FEE. $ Signature Telephone No. 0Zt� ❑ 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 r J 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 4 n tification of completion of the work as required in M.G.L.c.143,§3L. P units 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 oAhe 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 r uest 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 pciipose 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. C7 Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ q Permit Extension Act—Permit/Date Closed: Trench Inspection Pass(] Failed IN Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE I INSPECTION: Pass0 I Failed (] Re-Inspection Required($.)❑ i Inspectors Comments: t Inspectors Signature: Date: PARTIAL`ROUGH INSPECTION: Pass[ N Failed Re-Inspection Required($.)❑ i Inspectors'Comments: l� Inspectors Signature. Date: ROUGH6SP)ECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors'Comme Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Co ent . J Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department oflndustriglAccidents Office of Investigations 600 Washington Street Boston,MA.02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le0bly Name(Business/Organizationffndividual): e"U J� b, Address: d �J l City/State/Zip: � Lt qD _1�s6 Z C, Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(fall and/or part-time).* have liiredthe sub-contractors 2.'�] lam 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, [i Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.E1 Electrical repairs or additions 3.❑ I am a homeowner,doing allwork right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.Q Roof repairs insurance required.]t 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. T Homeowners who submit this affidavit indicating they ire 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 isproviding workerscompensation 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 requiredunder Section 25A ofMGL 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 lof 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 painerjury that the information provided above is true and correct. - Si ature: MW Date: " l L4 Phone#: 0 �0 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person:—, Phone#: l Information and Instruction's PMassachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. rsuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire, ress 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 complianceWith the insurance coverage required" .46ditionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall e i er into any contract for the performance of public work until acceptable evidence of compliance with the insurance r quirements of this chapter have been presented to the contracting authority." iplicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to our situation and,if necessary, Ppy y ary,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 i 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 A��cidents for confirmation of insurance coverage. Also be sure to sign and date*the affidavit. The affidavit should b 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' 4pensation policy,please call the Department at the number listed below. Self-insured companies should enter their serif-insurance license number on the appropriate line. ClIay or Town Officials P1-,ase 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. Phase be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant th 't must submit multiple permit/license applications in any given year,need only-'submit one affidavit indicating current poicy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or toif Wn)"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 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 GoMMORMalth ofMomach etis Dapaxt�ant ofJadusWal Accidents M (office ofInmestigations 600Wasbin&a Street Boston,MA 02111 Teel,#617-727,4900 eX.t 406 or 1-877:MASSAUF, Fax 0 617-727;7749 Revised 5-26-05 11 vAVW.mace anzz/,iia COMMONWEALTH OF MASSACHUSETTS { ;.r B©AI�>d QF ELEGTR I Cl ANS I ISSUES THE FOLLOWING LICENSE AS A> 12 G JOURNEYMAN :>ELECTR"I C I AN MATTHEW J STROBEL P 0 B..,0 X 514 J HA4 ii D N.H 03841-051 # 24984....E 07/31/16 31296 /NORTH ' r r cry... .... HORTM ' TOWNDOVER FO P • . PERMIT FOR GAS INSTALLATION �,SSACHUSES This certifies that . . . —�. . . . . . . . . . . . . . has permission for gas installation.,* !�. .':. . . ..... . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at North Andover, Mass. Fee-fi . . . . . Lic. No.. • : .�.` . . . . . . . . GAS INSPECTOR' Check# %Z 5722 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) M(�_ d��.r Mass. Date_ q ha /0& - City, Town Permit # Building ((�� Owner 's AT: Location /31 Otjn DCJ LrC Name rrt1J Type of Occupancy: ASC n cf- GNew Renovation ❑ Replacement Plans Submitted Yes ❑ No N N Y W N Vl fn 0 ZW N (� M O 0 0 = a .j 0 W h U m z o w h < * = z 0 h oe Win N O W 4 nI z H N > 4 O W W W Vl J 4 fL It W jr W ►- „°, h x Ix Y 4 W � a W F- N Y N O > 0 h W 0 H W 4 W > OC W z 4 < z 0 W O W x oc x O 0 x �. 3 o c� s0� s > o °a o SUB—RSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH F - -]E1 LOOR 8TH FL.00R JEM (Print or Type) ' I j Check One: (� Certificate b Installing Company Name Po I d(>,n nl I nry 21 Corp. CO2"/ Address C11 I -( n o f I e � Tfn e+ ❑ Partnership P 0 ❑ Firm/Company Business Telephone 1' g q Name of Licensed Plumber o Gasfitter 01 I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signature of Owner/Agent I have a current liability insurance policy to include completed operations coverage. ❑ By TYPE LICENSE: Title Plumber ASignae of ZLicensed Plumber or Gasfitter City/Town Gasfitter 4X Q APPROVED (OFFICE USE ONLY) Master l v� ❑ License Number Journeyman FORM 1243 A.M.SULKIN CO. 1989 u 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): -140 L DCAI ®14. /j,/C. >_Address: 91 1_y.vA1r'-1 L t_.b QTR e e7 City/State/Zip: ""P(F 1 La c),L)y .4 01719 o l Phone Are you an employer? Check the-appropriate box: Type of project(required): 1." I am a employer with q5 4. ❑ I am a general contractor and I 6. ❑ New construction YU employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet $ EJ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑ Electrical repairs or additions required.] 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 repass insurance required.]t employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information: t Homeowners who submit this affidavit indicating they are doing all work and then hire outside 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 inforniation. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Nol ss slR�—T,�rL �e�p,Dc,�Gs CcM-,ia �7 Policy#or Self-ins.Lic. #: talcs. 000,314 c/— Expiration Date: Or o o /moo�► Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: 0,1Z411'4431r•C.v-- Date: Phone#: Q7k- 5-81- 3,9 Y-Y Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermittLicense# 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 Date.. .............. t NORTI{ TOWN OF NORTH ANDOVER i. p PERMIT FOR WIRING CHUS s e�., lice-•i This certifies that ... .................................................................... has permission to perform U. , `.............................................. wiring in the building of... ............................................ at../2/. ........... �2� ...........�s : .::.... ............. .North Andover,Mass. ......... . Fee�§..'............ Lic.No34..2?S........... ...... c,. ..`-' ........... .y ELECTRICAL INSPE� .. Check # �/ rr- , Commonwealth of Massachusetts Permit N`0. Department of Fire Services Occupancy and Fee CheckedBOARD OF FIRE PREVENTION REGULATIONS [Rev. 9 051 (leme blank) A�m APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK ' U1 •.%ork to lie pertlirnied in accor&"Ice with the Massachusetts F[Wric,Ll Cotic(\iEC) 51-CAIR 12.00 PLL INE PRI,\T IN IN OR T1.PE.IL1.\=ORHITIOX) Date: 4 A iii� - City or Town of: &D, I TO 111C IJITSIh(!L!101' 0 I By this ;rpplication the undersigned dives Ilo I e of his or her intention to l)erforrn the electrical work described below. Location(Street& Number) 171A Owner or Tenant n . Telephone No. Owner's Address SuI.,�W-- Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service AnIps Volts Overhead ❑ U ndgrd❑ No. of Meters New Service Amps Volts OverhcadEl Undgrd F-1 No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: '11.1,00hk IPIOr he It J11 L 11 1"V;the 11isl't."t')r 0/ If', No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.oTotal Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA above In- -Noolt Em ergency Lighting No.of Luminaires Swimming Pool 21-nd2 El Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No. of Switches No.of Gas Burners iNo.of Detection and Total Initiating Devices No.of Ranges No. of Air Cond. g Devices Tons Heat Pump] Number Toils No. of Waste Disposers Tot. I No.of Self-Contained Totals: Detection/alerting Devices No.of Dishwashers Space/Area Heating KW Local E] Municipal F-1 Other Connection No. of Dryers Heating Appliances KW Security S;stems:* No.of Water No. of No.of No.of Devices or Equivalent Heaters KW SiBallasts Data Wiring: igns No.of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No.of Devices or EquiN alent OTHER: 1V,j10J*L./1-1.1 lift' F-,,tirnatvd VJuc of Electrical Work: CNMID (V�lien required by municipal p(,,Iic\,.) \k ork to 5Cirt: hispitions to be rcqLICStCd in accordance with \IEC RLIlt: 10, and Upon COITIPICtion. INSURANCE COVERAGE: 1--nIvss waived by the owner. no permit for the Perlorniancc of electrical work imty P.Ale L111le,- IIIv licell:;ec provides proul'Of liability ill'AWMICC illCkldirw-,--onlpIctcd operation-co�ervje or its st&slalltial tII;It '(ICII Co %�/!',e I.. III 1(:rcc. mid has Ilibitc-d proof tA ;,1111C to Ille permit I, uill..: olticc, YJR (4111 ww.s -i t; )b iris ppth.-Ildial J'Ife 0,11d C0 j 4 I-ictilsee: ta Ire Tel. 3us. 'o- Address: Alt. Ti.-I. N . `SCCLII-ity Sy:,Iejll Contractor 1,ick:n.,;c re,Iuti-L:d for this-,vurk; if applicable,ClItCI'the IiCVWX R111113-Cr 110-L: OWNFR'S INSURANCE 14AIVER: I mll;m;kre that III,: no/17cl."the liabilit" T I"C MT11MIK IU(iLlired by law. 13N' III) : :-1'MItUrL below, I hereby •.vaivc this 1-cquirt.111,11t. 1 ;1111 tile(Lllcck(,lie)0 o��nt.:r 0 0 1 !ILI-*:, 1, Owner,'Agent r. Commonwealth of Massachusetts I P No, Department of Fire Services Permit 5 0CCLIranc\ and Fce Cliccked/ D [Rev. 9 051 BOARD OF FIRE PREVENTION REGULATIONS APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WOF All cork to he rert-ornied in accordance will'the N11:1,,sildlUsetts Hcctrical Code i\Il:(') 51-(AIR 1".u0 il)LLISE PRLN T LN [NK OR TYPE.lLk LVCOR.11.ITION) Date: 4 A il0� City or Town of: TO dle 117-VIV001' 0/ 4'71T.Y.' BY INS qpliLtion the undersigned gives Ilut, U VI it's ol,her intention t0 PC 1, I-l"H-111 the%:Icctrical \%ork described below. Location (Street& Number) Owner or Tenant Telephone No. Owner's Add ress Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Ltility Authorization No, Existing Service Amps Volts d)verhcad El UndgrdE] No.of Meters New Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of P6p'oised'E1ectrical Work: lahlV1110t he It Lill L I0V the b0;11V,.'bX 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 No.of Emergency Lighting d. iBatteo 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 I — __1 I-nitiatine Devices No. of Ranges No.of Air Cond. TotalTons I:No.of Alerting Devices No.of Waste Disposers I eatP ump Number ro.n.s., . KW INo.of Self-,Contained rotals: Detection/,k lerting Devices No. of Dishwashers 0 Municipall Space/Area Heating KW Local 0 Other Connection No. of Dryers Heating Appliances KW Security,SVstems:* No.of Water NO.0 No.of Devices or Equivalen "caters KW _Signs Ballasts Data Wiring:-ices or Equiv. No.of De,, Equivalent No. Hydromassage Bathtubs No. of.Motors Total HP 'f clecommunications Wiring: No.of Devices or EquiN alent OTHER: ....Umona", F-Iiinated Value of Electrical Work: app ( k lien required by municipal policy.) 1� ork to Mart: In:;pecttuns to be in accordance with EIEC Rule 10, and Upon completion. INSLRANCE CON ERAC'E: L-nicss waived by the okvncr. no permit for the PCH01_111IMICC Of CICUI_iLid work Ilia) 111C licensee rrcides prooforliabilitv insurance includinu-1-, mnpIvtcd i)per;ttion­c0verl,,,c()I,its "I.117"'lantial rqtli%alcllt. 1:1 ILI vl-:.i.jled certirle" rli;tt.(!cll c I:. ill lf:rcc, ;IIl%I �:,.Ilihitccl proof 1:f tc the permit 1._-Alill.: officv. �Vl - I I E: K il"I.S1 !�AXCL* Lvj I JZ 1.� (Sp.cify:) _wrf�/J% i.vder ilt Va.viA qts "PlArC11611W 11 Iq N.VN I E: XDIP4_�� Address: Aft. T�-3u.s. Tel. 0 1. Nn SCC LI I-i ty Sy,-,(C 111 Contractor license I-ctl Ll I rc a' for this �v rk if applicable.inter dic license 11LIInbel-1%R; NV'N I-R'S I NS UR,V\C E bN,k I VE R: I %Y;11-c that 111 i,,'cllfee J( n-1 lir;vc the Iiab;I; I lII1.StII';IIlCQ ncl-111 icquired by 11M. (3y my [Ili:, requirement. I ;tin the(check cnO 0WIlLI'*:, . Owner,A,aent �. �� � �� a- �_� 2 �� Date. .l . .Z. :. No 4. 65 ;. �' TOWN OF NORTH ANDOVER 3' °°� ° Milllidftp PERMIT FOR PLUMBING �SSACMUSE� This certifies that . . .,r . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . .R.�:!Q " .f . . . . . . . . . . . . . . . . . . . . . • at . . . . . . . . . . . . . . . . . North Andover, Mass. Fee. �. . . . . . .Lic. No... `. .-.?. . . . . . . . . . . . PLUMBING INSPECTOR f Check # ,. 7 WHITE: Applicant CANARY: Building Dept. PINK:Treasurer go MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) 196�� 6 e,21" Mass. Date permit # Building Location :J >14 of a" ,Z))"- Owner's Na.l l f ak , 16A Type of Occupancy E 1i r-1 L_ New ❑ Renovation ❑ Replacement P" Plan ubmitted: Yes ❑ No ❑ FIXTURES PZ y y Z Y < F- y y y OX y W Y J y V y O (Q Q y 2y < Cr _ = O 2 y G J y WW~ W y ~ V ¢ Y C) s Q W y _ a _ V z go 4A O 7 < W Q < W D < 0 Z R a D: 0 W CC LLIW o J y c s J c s c W W Y W = y � 2 o O y Z = W f" O V S J J H N a < O < C < ¢ = a < o < f- 3 (A W O O < S C in O SUB—BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR r 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name (rmA_ -rAi_-0 Check one: Certificate Address CoACHmaA) y.p j ❑ Corporation /)I !:%N i 'F_ A), fil A o ❑ Partnership Business Telephone -�7 -ig7 firm-/Co. Name of Licensed Plumber ,( ,%3 r=;�?T fry SA,�ylrylr4 TrCI�c" INSURANCE COVERAGE: I have a current Ability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes [a' No ❑ If you have checked ves, please x. /indicate the type coverage by checking the appropriate bo A liability insurance policy ld 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 [3 Agent C3 I hereby certify that all of the details and information 1 have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations narformed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plu"ge and apter of the eras Laws. Title re o LicensedIum r City/Town Type of License: Master % Joumeymah C3 APPI104M(OFFICE USE ONLY) License Number !33`� BELOW FOR OFFICE USE ONLY FINAL INSPECTIONS SKETCHES PROGRESS INSPECTIONS FEE NO. APPLICATION FOR PERMIT TO DO PLUMBING NAME A TYPE OF BUILDING LOCATION OF BUILDING PLUMBER PERMIT GRANTED DATE 19 PLUMBING INSPECTOR r