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Miscellaneous - 14 BAY STATE ROAD 4/30/2018 (2)
14 BAY STATE ROAD 210/058.6-0028.0000.0 9639 Date. . �!791a, N- { , f, TOWN OF NORTH ANDOVER t PERMIT FOR PLUMBING CM S ( �t f VfJI �...J . .. , This certifies that . . . . . . . . .. . . . has permission to perform . 7?� !��... . . . plumbing in the b ildings of . . .. . . . . ..... . . . . . . . . . . . . . . . . . at. . . . . . . . . . ` . . . . ... . ., N rth Andover, Mass. g Fee. � �.Lic. No.M. p . . H1�. . . PLUMBING IN ECTOR Check # WHITE:Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DTE 111f ( PERMIT# 1(-P171 JOBSITE ADDRESS L JCOWNER'S NAME POWNER ADDRESS -JI TEL TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCAT NAL ® RESIDENTIAIZ' PRINT CLEARLY NEW: 0 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES� NO©f FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE ( DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIL/SAND SYSTEM DEDICATED GREASE SYSTEM -.._.I —J1 I _._..-A �1 _! DEDICATED GRAY WATER SYSTEM I f I ._. 1 __. _J I _ . ._ 1 1 _._ _.._ I - ---J _f DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER __I -_-___.! I -.-___- I FLOOR IAREA DRAIN ____! INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY _—__1 ROOF DRAIN ( ----._-J SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION _1 WATER HEATER ALL TYPES WATER PIPING I € OTHER INSURANCE COVERAGE: I have a current liabilily insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE TH PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY DI BOND Q 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 0i AGENT SIGNATURE OF OWNER OR AGENT 1-1 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 nyknowledge and that all plumbing work and Installations performed under the permit issued for this application will be in compliant it all Pe ' nt pr on of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S ME S. (LICENSE# /S3J SIG URE MR JP© CORPORATION # _ iPARTNERSHIPP#� _ILLC COMPANY NAME r� I ADDRESS CITY �ZiLe_ C i STATE �ZIP I�l6 - TEL FAX CELL��EMAIL j 01 i 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 L The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):. � � Address: & A n & A. City/State/Zip: /y t-g t`RlCt( A4 Q/ .hone#: O Are f an employer?Check the appropriate box: Type of project(required): 1. I a employer with C 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.$ 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' 74– comp.insurance required.] 13.❑Other C"P C *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: p Expiration Date: Job Site Address: l q 5 .711__ l ` City/State/Zip• O T—, 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 JJKe p ins an e ies of perjury that the information provided abo/�e is trc and correct. Si nature: Date: e; Phone#: – C( 7-0 Official use only. Do not write in this area,to he 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 M 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 l 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-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 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.govldia l Fold,Then Detach Along All Perforations COMMONWEALTH OF MASSACHUSETTS • • • • "' • ' IMPORTANT NOTICE - BOARD PL LICENSED AS A MASTER PLUMBER INSTALLAl IIONS ONBSTATE OWNED OR USED ISSUES THE ABOVE LICENSE TO: OFACILITIES OFT ES TATEFILEDBE B3 AAT THE RD, TYPE CHRI.STO:PHER M SWIFT -M \ �a P:0 BOX 284 ��r N. ;BI LL.ERICA MA 01862-0284 191223 15364 05/01/14 1.91223 Um Fold,Then Detach Along All Perforations I Date . �. .�.t . • 'YlLRby ,abYE�✓ �¢ �+TOWN OF NORTH ANDOVER ID , LAPERMIT FOR GAS INSTALLATION R This certifies that . . 2.t;IA k,/ 5U-4-�. . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . l� in the buildings of. . . .('G:rrJ at . . . . . . � . . . ,-� �.e_. . . � ... . . , INorth Andover, Mass. GAS INSPECTOROR Check# 8404 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY _ _ _ M DATE �J� PERMIT# JOBSITE ADDRESS -, j �t OWNER'S NAME GOWNER ADDRESS TE FAX TYPE OR OCCUPANCY TYPE COMMERCIAL��_-I-I EDUCA ONAL ® RESIDENTIAL _ PRINT CLEARLY NEW:R RENOVATION:[j REPLACEMENT: PLANS SUBMITTED: YES❑—I NOR APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _I G�.._. .. .. :j _ 1 I====I BOOSTER CONVERSION BURNER COOK STOVE _ __ I_ I-- —J J DIRECT VENT HEATERI DRYER FIREPLACE ---� ,._ .� _ _ .I I FRYOLATOR f FURNACE GENERATOR GRILLE .! INFRARED HEATER LABORATORY COCKS _ �( l --. .s �_� J -- 1 MAKEUP AIR UNIT OVEN _.-.t- — - I-- 1—j I J POOL HEATER ROOM/SPACE HEATER — ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER ..._...._._......._......._.. ......._.... ........... ......._ E-73A=___ I ----1 ----�--F--]=. I INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equ' ent which meets the requirements of MGL.Ch.142 YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY __, OTHER TYPE INDEMNITY D BOND f--jl 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 E] AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true an acc¢urate to the est o my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia a wifh all Pe ' nt inion of the Massachusetts State Plumbing Code and Chapter 142of the General Laws. PLUM GASFITTER NAME ] r„!I_ LICENSE# /s SIG TURE -- — � � - MP MGF aid JP JGF C�( LPGI CORPORATION[[�)# PARTNERSHIP[j4[ LLC R#= COMPANY NAME: t�1._�_.-r _ ADDRESS CITY _ t_ � 1�"_ .._.___.._.__. _ i STATEAK ZIP I�� TEL X 0 9 - --_ 11 FAX -- --— --� CELL.�J( 11.Q--EMAIL --- i Vi (/V- 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 0060,7 ,r The Commonwealth of Massachusetts fu Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 kvi. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information p Please Print Legibly Name(Business/Organization/Individual): Address: E LK �utl City/State/Zip: NC 6 , VP q A4 Phone#: 4 7F4 I jq 767 AVyan employer?Check the appropriate box: Type of project(required): 1. 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.E] I am a sole proprietor or partner- listed on the attached sheet.$ E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.❑Other KePj4ce�h comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: I Expiration Date: d Job Site Address:_Iy TRS /V c /City/State/Zip: 11 d o o ef Cf 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. l do hereby certify under the pai aitd penalties o erju that lite information provided above i true an correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Y 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 adch-ess,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 a_ Fold,Then Detach Along All Perforations . COMMONWEALTH OF MASSACHUSETTS • • ''• `• • IMPORTANT NOTICE PRIOR Y`fER 8 BOARD LICENSED AS A MASTER RLUMBER ,. PERMITS FOR PLUMBING AND GAS FITTING PL INSTALLATIONS ON STATE OWNED OR USED 'ISSUES THE ABOVE LICENSE TO`. FACILITIES MUST BE FILED AT THE OFFICE OF THE STATE BOARD. TYPE CHRISTOPHER M SWIFT —M PO BO:X ..2g4 �jco' N BIL.LERICA MA 01862::-02$:4 6. 191223 15364 05/01/14 193223- Fold,Then Detach Along All Perforations _ • � Date....... 3 � 9 �...................... NORTN TOWN OF NORTH ANDOVER PERMIT FOR WIRING �ss1% HusE� This certifies that .....( w.1.�. ........................................................�EC%"Zi L has permission to perform ...... wiring in the building of........... 14.N .. ���. S T/. ..� North Andover Mass. at............. .�.......................... , Fee... :s �.. Lic.No.M. S..L�...... �� .�� !j.�� z t� • d : ELECTRICAL INSPECTOR y Check # 8579 k . Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/991 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CKrR 12'00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: No `rh G Al cf dV el'- To the,l6pector of Wires: By this application the undersigned gives notice of his or her intention to perform the e'I 6rical work described below. Location(Street&Number) /Z/ ac4-y Owner or Tenant W a L 'TQ r— C a rN e Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Re 6,/de6/ee Utility uthorization No. Existing Service Gd Amps 120L2 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: �f1 rt, I f e 0 1 o2 /X /z f rkd l rloN/ Completion o the followin table may be waived by the Inspector of Wires. No.of Recessed FixturesNo.of Ceil.-Sus . addle Fans No.of Total p ) Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above ❑ In- -lVE:1o.o Emergency Lighting rnd. rnd. Batten Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners o.of Detection an Initiating Devices No.of Manges No.of Air Cond. TotalTons No.of Alerting Devices No.of Waste Disposers Heat Pump Number To 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 WaterKW No.o No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,oras required by the Inspector of Wires. 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 cove a is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical Work: 0 U Q (When required by municipal policy.) Work to Start:7 "2 —.2-(fA9Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify,under the pains andpenalties of perjury,that the information on this application is true and complete. FIRM NAME: Q(le 0 I`T-- CSE'C/ C LIC.NO.: /c 5Z-,r Licensee: E%�r 10a Je�JPO/"TSignature LIC.NO.: /o Fr (If applicable/ente exemto the license number line.) Bus.Tel.No.- Address:` / 6,4 rL S T RO a&IJ!g /L(6 p/ 76� Alt.Tel.No.: OWNER'S INSURANCE WAIVER: 1 am aware that the L16ensee 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. Alt ok r The Common wealth of Massachuse& De artment o P f Industrial Accidents Office ofinvestigations vj � I r �i it 600 K ashineaton Street Boston 02111 t �" ww>K�-rrzass.gov/did Workers' Compensation Insurance.Affday.jt; Builders/Contractors/Eleetricians/pftcmbers Anpficant Information Please Print Lembiv Name (Business/Organization/individual): (1��✓ 2G Address: 7 Afe rL s7- city/State/zip: 17e4 r� t Ncj Ni Phone#: Vyoupioyer?Check the appropriate box: ployer with 4. ❑ I am a o Type of project(required);general contactor and 1 s(fu]]and/or part-iime).'� have hired the sub contractors b ❑ New construction ,LL� am a sole proprietor or partner- Iisted on, the att�h�sheet x I [] Remodeling ship and have no employees These stab-contractors have 8. 0 Demolition working for me in any capacity, workers' comp. insurance. [No workers' comp. insurance 5. Q We are a corporation and its 9' Building ao.dib.on 3.❑ required.] officers have exercised.thcir 10-0 Electrical repairs or additions i am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp, c. 152, §1(4), and we have no insurance required.] t empioyees. [No.workers' 11❑ Roof repairs comp, insurance required.] 1.3•7 Other t*Any applicant,that checks box 91 must aiso'fil;out the section below showing tfrir workers'compensation ii .. Homeowners whe submit.titis rsiide.vit iltdieat4':b uiey are uuiF.__E t::;:rk po c7 iniormation. Biu inch hire cutsiae conuaoiurb must submit a ncvw amriavit indicating such. iConuactors that enc k this bo must attached an additional sh w showing the name o.,h_sub ccn�a tars and their workers`coin viE i ff o !am an employer that is providing workers'compensation p p rs iniatmatior,. ttsurance for my employees. Below is the policy and joh site informatio2 Insurance Company Name: Policy;or Self-.ins. Lic.#: Expiration Date: Job Site Address: City/State/zip: Attach a appy of the workers' compensation policy deciaration page(showing the policy number and expiration date). ' raiiure 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 herebq)cee�r�''jo)underthepains andpenatiies ofperjury that the information provided above is True and correel Signature: (/ OC/ Date: 3 4 Phone#, Of use onlp. Do not write in this area,to be completed by city or town of ciaL City or Town; Permit/License Issuing Authority(circle one): 1. Board of Healtb 2. Building Department 3.City/Tovvn Clerk 4. Electrical I 6. Other nspector 5. Piumbirzg Inspector Contact Person: Phone�: Information and Instructions Massachusetts General Laws chapter IS2 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 empinper 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 includiti.g the legal representatives of a deceased employer,or the receiver or tntst,e 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 nit because of such employment be deemed to be an employer." MGL chapter lit,§25C(6)also states that"every state o►r local licensing agency shall withhold the issuance or renewal of a license or permitto operate a business or to construct buildings in the commonwealth for any appiicant who has not produced acceptable evidence o►f 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 worts until acceptable evidence of compliance with the insurance requirements ofthis chapter have been presented to the corntra.cting authority.". Applicants � Please fill out the workers'compensation affidavit compj*-etely,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 Dr 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 re_map_rdirg the lava Or if you are requi ed to obtain a worker' .Compensation noiicv,please call the Department at the mL1nl r,l.---e�,a�l�` mel-insi;�.d Cvi�t`unniRS S70llid Bi1.tEr 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 but in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permiMicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/hoense applications in arry given year,need only submit one affidavit indicatin;current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or , town)."A copy of the af.davit 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. 'Arh=-- 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,teiephone and fax numb-- Tine ColnmOnwealth of Mac azhusetts Department of Lndustnal Accidents. Office of Investigations 600 'WaslE.ington Street Boston; MA 02111 Tel. 4 617-727-4900 ea.•-t 406 or 1-877 7-MASSAFE Revised 5-26-05 Fax#617-727-7749 WWW-uiass.gov/dia Date. . Q o &ORTq •�"o TOWN O1F_NO TH ANDOVER 3r .t� -�•.'. pL PERMIT FOR PLUMBING sSACMUS� Z r This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . r . . � -�. . . . . . . . . . . . plumbing in the buildings of . . . . -y*-� . . . . . . . . . . . . . . . . . at �j-� . .. .., . . . . .,. . . .� . . . . . North Andover, Mass. f RLUMB N.G NSPECTOR Check ,H A'I (f 8146 ,yrs MA%AQJUSETTS UNIbiORMAPPUCATONFOR PUMTODOGAS f j,ING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Laqations /[r L7 S�ct T r Permit# Owner's N eJ , ) Amount S Nyl New (/ Renovation � Replacement Plans Submitted ❑ rA U w 0U Z 114, CC Zc Z S OGwIt 7 L' c e o SU B-BASEM ENT c7 V > c a B A S E M ENT iST. FLOOR 2ND, FLOOR 3RD . FLOOR 4TH . FLOOR T , FLOOR 6TH . FLOOR 7TH . FLOOR BTH. FLOOR (P.;at ore Name �'P , sue �f— r N neck ore: Certificate Installing Compan Address '� Corp. y e( /� ❑ Partner. us mess a ep one irro/Co. Name of Licensed Plumbei or Gas Fitter INSURANCE COVERAGE I have a current liability Insurance oficy or it's substantial equivalent. Check If you have checked es pl ndicate the type coverage by checkin the Yes No� Liability insurance policy g appropriate box. Other type of indemnity jut Bond 13 Maser's Insurance Waiver 1 am aware that the licensee does not__ the insurance coverage required by Chaps 142 of Mass.Genera)Laws,and that my signature on this.permit application waives this requirement the Signature of Owner or,Ckwner's Agent Check one: t hereby certify that all of the details and information I kava submitted 0 Agent D best li nc knowledge and that all plumbing work and installations (or entered)in above application are true and accurate to the compliance with all pertinent provisions of the Massachuse �Om'ed and r P CQ rmif Issued for this application will be in ° e and apter.142 of the General Laws, By' Signature of Li ed Plu Title ED Plumber r Gas Fitter City/Town: Gas FitterI icense umber Master APPROVED(OFFICE USE ONLY) Journeyman Depart p °j 1rtMWhrrsetir Jr, ' i ? i,, '�d6 merzr f Adxcctrial Accidents. Office Of jr""fi. ns 600 W ¢shh2von Street r, Boston, MA 02111 Workers' e Com asation I>Qsuranee w"7K'-rns,-aov1a dn Pdavit: Bui}ders/Contractors/Electricians/Pinmbers A Dficant InforMafion Name (BusinesslOr C P}ease Print L ibill granizaiion/individual): (1 � � Address: 1 f� City/State/Zip: f( 'In ,r Phone Are you an empioyer?Check the appropriate box: 1•❑ I an a employer with 4. Type of projecf(required): l am a caner$1 contractor and I M s(null and/or part- emtt * have hired the sub-contractors 6 ❑New construction ? yam a sole praprietar or partner. listed nai ship and have no em lovee the attached sheet 7.XZModeiing. worlang for me in any capacity, workers' 8.have 8, ❑ DernoIition [No workers'eomp. insurance 5. ❑ We are comp.insurance.. 9 required,] corporation corporation and its ❑Building addition ofnc ercised.their 3•❑ I am a homeowner doing all work right of have er. 10:[f Electrical repairs or additions myself. zemption per MGL i 1. [No workers'comp, c. 152 ❑Plumbing repairs or additions insurancerequired.] t 1(4),and wehaveno employees. (No workers' l2°�Roof repairs comp. insurance required] 13.0 Other '�Anuappiicant.thw checks box#1.must aiso nil outttteseotion below showing+ilomeownert whu submit.this a"davit indicarin.6 they ars doing a 1,wog2r . ,t it workers'corn tConmmtots that Pensation paiic� intormatioa. eireal:fits box.must AnAr,h��,additional Sheet showinggra��him outside the n tAntraetuf6ltra$l"'''Mit n new atnrinvit indipng ami of Ei c;Y�ca„mctots and their woti,ers'comp,policy itriotmation. I am an erttpleyer xhX t;Provirfi�ao worir�'cter„serasatio� ' ir'Yormatiore umurance for ng,earP(nye= Below is the o Insurance Company Name: P Rz Iandjob site Policy#or Self-ins.Lid.#: ' Expiration Date: Job Sit--Address: Attach a copy of the workers' compensation file City/Stite/Zip: ' Po Y decla ration page(showiQp .Failure to secure coverage as required under Section 25A of MGL Poli cy number and expirtion adate), ear fine up to 51,500.00 and/or one- im P c. i 52 can lead ttheo the im osition of Y prisonm nt as well as civil penalties in the form of a STOP WOR Cnal ORDER aned a fine of up to. 250.00 a day against the violator. Be advised that a eo Investigations ofthe DIA for insurance covers P pY of this statement mai be forwarded fp the g.,verification, Office of 1 do herebJ�certffj,u � e ' P and cr oJPerjurf�=hat the informa/inn provided abo a is t Signature: -�� e correct Phone#: A II or Official use nn1P. Dn not write in this area, to be cnninleted by c or town offtcia1 Cit,or Town: Issuing Antho ' PermittLicense# it} n (circle one): 1. Board of Health 2. Bulletin-Department 3. C' iTo 6. Other wn.Cierk 4. Electrical Inspector E. Plumbing b Inspector Contact Person;: Phone## lIu1V! 111a LlVll ea nu :Last ucTionS Massachusetts General Laws chapter 152 rewires 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 contiad of hire, express or implied;oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or an)'two or more- of the foregoing engaged in a joint enterprise,andmcluci-ink the legal representatives of a deceased-employer,or the receiver or trustee of an individual,partnership,associati on or other legal entity,employing employees. However the owner of a dwelling house.having not more than three ap;;rtments and who'resides therein,or the occupant of the dwelling house of another who employs persons to do ma..intsnance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall.not because of such employment be dam-nrd to be an empioyer." MGL chapter 152,§25C(6)also states that"every state ar local licensing agenq shah withhold the issuanmor renewal of a license or permitto operate a bnsinessOr- to construct bubdin s in the commortweatth for-any applicant who has not produced acceptable evidence sf.compliance with the insurance coverage required." Additionally, MGL chapter 152,g25C(7)states'Neither *he commonwealth nor any of its political subdivisions shall eater into any contract for the performance of public worms until acceptable evidence_ of compliance with the irusiaance requirements of this chapter, have been presented to the cont aeting authority,-, Applicants Please fill out the workers'compensation affidavit comptZ-etely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es) and phone numbers)along with their c.-.rt 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 affic1a.vif may,b--submitted to the Departrnent of Industrial Accidents for confirmation of insurance coverage. Also ]be sure to sign and date the.afndaviL Theaffidavit6ouid be returned to tht city or town that the application for the permit or license is being requested,not the Departiomt of industrial Accidents. Should vou.have any questions MI--a-0-ding the or if you are required to obtain a work=' comaensabOn policy,please call the D--Pw trcent at the nta�azber.lisFwd below. Self-insW�-ed coin a<ries Should enter their self-irsuran=Ii-ne rse number on+.he appropriate line. City or Town Officials Please be sure fat the affidavit is complete and printed lebly. The Department has provided a space at the bottom of the affidavit foryou to fill out in the event the Office of Investigations has to contact you regarding the applicant: Please be supe to fill in.the permMicrose number which will be used as a reference number. In addition an applicant that must submit multiple permitliicense applications in arty,given year,need only submit one affidavit indinating current policy infarrnation(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 ar Iicenses. A new affidavit must be filled out each year. V it — a home owner or citiz-n is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn haves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank youin 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 far,number. The Commonwealth of Massachusetts Department of Lmal Accidents Qfsee of 11avestigations 600 wash-an Stmt Boston; SLA G21 I I Tel. # 617-727-4900 W-t 406 or 1-977 rv1A.SSAFE Revised 5-2645 Fax 4 617-7-7-7749 bt`UW'-M ss.DOV/d a Date.. . / b ....... V ORTH TOWN OF NORTH ANDOVER • - PERMIT FOR GAS INSTALLATION sy S^CMUSEt �. c This certifies that . ..y. .� f . . . . . has permission for gas installation ..... . . . . . . . . . . . . .. . .. . . in the buildings of . . . . . . . ..-!. . . . . . . . . . . . . . . . . . . . . . . . . . at North Andover, Mass. G S fi1SPECTOR G' Check# 6857 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS / 7 Q ) /� /� ate Building Location IV 5���C ��Owners Name JV dV �G( d f I tpermit# Amount Type of Occupancy Newri . Renovation ri, Replaceme et� Plans Submitted Yes No FIXTURES a .a W sisiM RASffvIIvr M FLOCR MIffm M ELOCR 41H ILOOR 51HK slHHJOCR - 7MH-OOR sin Iivootz .-PF+17-F (Print or type) �^ 1 /� Check one: Certificate Installing Company Name ' 04— ❑ Corp. Address Partner. d 6/'Firm/Co.Business Telephone f) G Name of Licensed Plumber: Insurance Coverage: IndicateLe ty insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installa' j perfo ed under P 't Issued for this application will be in compliance with all pertinent provisions of the Massach S Ping and Chapter 142 of the General Laws. By: Signature 01 LicensEciu er Title Type of Plumbing License �? City/Town icense MmDer Master ❑ Journeyman APPROVED(OFFICE USE ONLY 'LJ tl The Commonwealth o.f Massachusetts 44 1 `1 Department of Industria!Accidents E� ! Office of Investigations 600 Flrrashington Street Boston, MA 02111 Workers' Cwww_massgov/dia . ompensation Insurance Affidavit- Bailders/Contractors/Electricisns/piumber Anuli-ant Information Please Print Lm-* Na,6e(Business/0gMization/Individnl): 1 Address: city/stat/zip: j 40 Phone#. . 7-asoleproPrietoror mployer?Check-the appropriate box: m la et-with 4, I ject(requires: P Y 0 1 am a general contractor and I es(foil and/orpart-tirne).'� have bred the sub-cortisac orsnstruc40 partner- listed on the attached sheet.1 odeling ship and have no employees These sub-contractors have lition working for mein arty capacity. workers' comp.insurance.[No workers tom .insurance 5. ing additionP 0 We are a corporation and itsrequired] officers have exercised#heir cal repairs or additions1 am a homeowner doing all work right of exemption per MGL ing repairs or additions myself.[No-workers'comp, c, 152, §1(4),and we have no insurance re ired t 12TI Roof t epa- -required.] .employees. [No workers' h irs COMP, insurance required..] 13.0.Other 'Any epplictutt that mbms#I moat also fill outthe section bolow showing their workers'bompensation policy information. t liotneownt s who submit this affidavit Indic i ting rhoy are doing all wmtc and than hire outside contractors most-submit a new affidavit indica*such. tontractnrs that check this box in'&at>adlr-14 an additional sheershowing Etre name oftfie sub-contractors and tieeir workers I eery^. ri r ea•"• infannalton. !am,an ebr kpar thin is'prow&ng:workers'compensation insurance or a to information. 1'eee Below is the Policy and jot site Insurance Company Name: Policy#or Self-ins. Lie.#: Expiration Date: Job Site Address: e City/state/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration da*4 . Failure to secure coverage as required under Section 25A of MOL 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 investigations of the DIA for insurance coverage verification. Office of !do hereby certify u er a pains a perjury that the information provided alio is tru and coned Si tore: Date: Phone#: q (� 09'cia!ase only. Do not write i>z this area to he 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 a nd Instructions Massachusetts General Laws chapter 152 requires all emp Ioyers 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,par mership,association,corporation or other legal entity,or any two Or MOM of the'foreping engaged in a joint enterprise,and includir-kg the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,associatioin 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 dwellinghouse or on the grounds or building appurtEnam 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 r4deuce,of compliance with the insurance'coverage required" Additionally,MOIL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the pmTormance 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),addresses)aired phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Usability Partnerships(LLP)with no employees other than the members or partners,are not required to cavy 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 rewmed 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' oampermtion policy,please-call the Department at the nurnber.listr~d below. Self-a-cured companies should enter their self-insurance license number on the'approprim line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottorn , 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 I 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 futrae 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 Deparunent's address,telephone and fax number. The Commonwealth of Massachusetts Department of Indlzst W Accidents Office of Lnveatiations 600 Washington Street Boston, MA 02111 TeL#617-727-4900 Ext 406 or 1-8.77-MASSAFE Revised 5-26-.05 Fax#617-727-7749 wwwmem.gov/dia Date.!. , -D�. . ,aORTH , 3 TOWN O NORTH ANDOVER 4 o • PERMIT FOR-GAS INSTALLATION SA HUS This certifies that .Aev rY-0. . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation A".4. . ti � .Jk.c y�—'. . in the buildings of y at'VV&? SZPZF. . .t?4. . . . . . . . . . .. North Andover, Mass. Fee.a9�S'U. Lic. No..q.�./. . . . . . . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR Check.4. 6659 MASSACHUSETTS UNIFORM APPUCATON FOR PERM TO DO GAS FITTING (Type or print) ` NORTH ANDOVER, 1]ate ` MASSACHUSETTS —� Building Locations Permit# Owner's Name Amount �-.. cc, Y New Renovation Replacement D Plans Submitted w c . a F a F W w z Q a y z `y9 p w �� z d % !- F w O > a s p R z C ¢ p o z w 0 m x a SUB -BASEM ENT 3 -2 U p BASEM ENT IST. FLOOR 2ND. FLOOR 3RD• FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH. FLOOR. (Print or type) / 4 Name �,�-({/J-- fC Check one: Certificate Installing Company Address D Corp. 1 Partner, Business a ep one Firm/co. Name of Licensed Plumber or Gas Fitter ��'� SURANCE COVERAGE I have a current liability Insurance•policy or it's substantial equivalent. Check on If. Yes you have checked es lease in ' e the a cove b checking the appropriate box. No[ �P type rage Y Liability insurance policy Other type of indemnity n Bond Owner's Insurance Waiver Lam aware that the licensee does nit have the Insurance coverage required by Chapter 142 of the Mass. General Laws,and that my signature on this permit application waives this requirement Signature of Owner or Owner's Agent Check one: er t hereby certify that all of the details and information 1 have submitted(or entered)in D Agent 1 best of my knowledge and that all plumbing work and installations performed under Permit Issued for this applicatioon me and n cw I be in the compliance with all pertinent provisions of the Massachusetts S C�oa�e and jhaPt42 General Laws. BY : ignature of Licensed Plumber Or Gas Fitter Title Plumber City/Town: Fitter icense Umber Master _ APPROVED(oFMCEUSEONLY) Journeyman Date..........C;3..:.d� TA Th TOWN OF NORTH ANDOVER PERMIT FOR WIRING ♦ o ��f AC US This certifies that .:-.Z` - ............—�� has permission to perforin---, .-.. �1 ...::........................................... wiring in the building of.............—��.......u::.- . .................................. . .... ,North Andover,(Mass. t Fee........... Lic.Nott G p................( * ELECTRICAL turt ? Check N SA46 ' N Commonwealth of Massachusetts Official Use Only Services Department of Fire Permit No. ��14 V1WJBOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked_ [Rev. l/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: 2 3 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned Zives notice of his or her intention to perform the electrical work described below. Location(Street&Number) ca e R cc Owner or Tenant J—U c.(y ca�y Telephone NogW6 Owner's Address lG Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Boz) Purpose of Building Res I a -.1 Utility Authorization No. Existing Service lG l7 Amps jRd/ ovolts Overhead ❑-�Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Und rd g ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion o the follom' table may be waived the Ins ector o Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans o.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires l Swimming Pool Above ❑ In- 1-1o.o mergency ig g d• rnd. Batte 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 No.of es Ran Total lmtiahn Devices Ranges No.of Air Cond, Tons No.of Alerting Devices No.of Waste Disposers Hest Pump Number _Tons KW No.of Self-Contained Totals: ' �� '- - Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local Municipal ❑ Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No.of WaterNo.oNo.of Devices or Equivalent Heaters Imo' f Na.of Si rns Ballasts. Data Wiring: No.of Devices or Equivalent No.Hydromassage Bathtubs No,of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent l OTHER: / Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: l O (When required by municipal policy.) Work to Start: 6 ,U Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Vniess 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 cove a is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) ` I certify,under theTains andpenalties of peryu ,that the information on this application is true and complete. FIRM NAME: LIC.NO.: l a YJ- Licensee: e�' t f 1�% Signature LIC.NO.: /O?2j (Ifapplicable, enter"exe in the license number `�/ Address: 9' 1 ci r i- S T ett te(1 a (l g�� Bus.TeL No.: Alt.Tel.No.: -U 3d,7 *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�B ice" T 1. P _� (�� � ��� ��� tS 1 r , ` 1 J -� The Commonwealth of Massachusetts j I Inir Department of Industrial Accidents Office of Investigations 600 Washington Street • i Boston, MA 02111 {'1 www.n2assgov1diaa . Workers' Compensation Insurance Affidavit. Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeQtbly Name(Business/organization/individual): Address: ! zot—,., City/State/Zip: � l � C/ ( neG � v Are you an employer?Cheek.the appropriate box: I.❑ I aro a employer with 4. ❑ 1 am a general contractor and I Type of project(required): *rMloyees(full and/or part-time).* have hired the sub-contractors 6• ❑New construction 2. I am.a sole proprietor or partner_ listed on the attached sheet t 7. ❑Remodeling ship and have no employees These suis-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 Electrical❑ required-] officers have exercised their 10. repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11. Plumbing repairs or additions myself,[No•wockers'comp. c. 1.52, §1(4),and we have no 12. Roof repairsinsurance required.]f employees. [No workers' I3.❑.Other comp. insurance required.] *Any applicant that checks boX#I must also fill out the section below showing their workers'oom g Pensation policy information I Homeowners who sabmit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Conkactots that check this box mus±a±rae. an additional sheat showing the name of the sub-contractors and their workers'comp.policy information. [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 decfaration page(showing the policy cumber and expiration date). Failure tosecure 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 WORE{ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cerfl' ,under the pains and penalties of perjury that the information provided above is true and correct Si tare: �!G DateG—,2 -' : Phone#: official ase 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 f erson: 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,Eicensing agency shall withhold the issuance or renewal of a.license or permit to operate a business or to contruct building's in the commonwealth for any applicant who has not produced acceptable evidence.olt 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),addresses)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' w compensation policy,please call the Department at the numberlisted 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%,ill 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 it 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 of Industrial Accidents Office of Investigations f 600 Washington Street Boston, MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7744 www.mass.gov/dia Date. zl ..C.7. ..... Of NORTH o� 2` TOWN OF NORTH ANDOVER tD PERMIT FOR GAS INSTALLATION ` h .1 SACH 5E�A `r This certifies that . . h.s��. 7 4% . . . . . . . . . . . . . . . . . . . has permission for gas installation . ..P'. in the buildings of ..... . . . . . . . . . . . . . . . . . .. . . . . . . . at . . ./. !!. . l��`'� .T !f�� ,?4�. . . . . K North Andover, Mass. Fee,)j .. . . . . Lic. No.:`! 7. . . . �� - : . . . .. . i/GAS INSPECTOR Check# ) b`/I U 4196 MASSACHUSETTS UNHDRMAPPUCATONFORPIIMr TO DO GAS FITTING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations 14 RNJ, StO:Le- Permit# ylcf Amount$ a.) Owner's Name New❑ Renovation Replacement Plans Submitted " z a a � � a F a w w o v p H a PQ w wz w a H w U �, a a ° N o SUR-BA SEM ENT BASEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type) I ^ Chec one: Certificate Installing Company Name 1�111d�JPa P� t W• Tne. Corp. 2122 Address Zd Pemenjn T)r. t),;-t-4-I Partner. UP-y) MAD i Business Ib ephone (qj a-) 1�gy-65 8 3 E] Firm/Co. Name of Licensed Plumber or Gas Fitter Ggeg4 CaR ose INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ® No If you have checked yes,please indicate the type coverage by checking the appropriate box. 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: Signature of Owner or Owner's Agent Owner 13 Agent El 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. Signature of Licensed Plumber Or Gas Fitter By. d Plumber �9 gj t Title City/Town Gas Fitter License Number Master APPROVED(OFFICE USE ONLY) Journeyman DatezU. / ... TOWN OF NORTH ANDOVER pe FPERMIT FOR PLUMBING . S SSACNUS� This certifies that . . . . . . . !". . . . . . . . . . . . . . . has permission to perform plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . at .. . . . North Andover, Mass. Fee C) . . . .I. No.. . PLUMBNSPECTOR Check It (JJ 5397 -\ tYunt of [Wel ^— NORTH ANDOVER, - Mass. Dale Building Permit -S-2 9I Location P4 ?4,n,u Lo,� onrl a ` / Ownel',s _.. None fid Ae New O Renovation O Replacement 11/ Pians Submitted: Yes O No.Q FIXTURE$ ..... .... » : K dc x ~ p s Y s M • at s# t ell s M 16 Z10 � F' V M • x sIL s M x no �. to r N 0 O J ; s N M sus—elfMT. eAslY�14T IST FLOOR 1140 FLOOR ORD FLOOR 41H FLOOR eTH.FL00R GT" FLOOR. xi TTH FLOOR EITH FL00R Check one: Certwicate Instailing Company Name Andover P1bg. & Ht.g. Co. , Inc. 4a Corp, 2122 Addre3a_20 Aegean Dr. Unit 11 10 :DPartnership Metbi inn, r14 0.1.AP-A O Firm/Co. Buslness Telephone (978) 685-8383 .Narve of Licensed Plumber_George LaRose INSURANCE COVERAGE: ac pne I have a current liability Insurance policy or As substantial equivalent. Yes ® No D It you have checked yam, please Indicate the type coverage by checking the appropriate box A IlablAy insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the ilcens'es does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this perl application waives this requirement. Check one: Owner O Agent O UjiMiffe 01 Ownef or Owns s Agent I r I Mreby certify that&I of the details and Information i hays surbmitted for entered)h above appllcaUon me bus and accurate to the best of my knov+tedgo and that a0 plumbing work and installations performed unda the permit Iuu*d for thls appilcaUon will be In compliance with aA pertinent provisions of the Massachusetts Slate Fkrmbkan dA Code d Chaplet 142 of the t3enarel By rice 1ri{e ,se Number 9983 Oty/Town Type of Plumbing Uconso:Master NTflOWD (off10E USE ONLY) Journeyman 0 r-� Date...A.. . .. ...... ....... . %ORTH pf , '. '.. 411 o� '` TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION M1+ �9SSACMUSEt This certifies that . . . . °.: . . . ...... . . . . .:`... . . . . . . . . . . . has permission for gas installation . . . . . . . . . in the buildings of at .. . . . . . . .� . . J. " ? , North Andover, Mass. Fee. .?. . . . . . . Lic. No.:l:.� . . .. . . . . . ✓GAS INSPE"GTO. Check# 4157 AD IMASSAl APP CATON FOR PE, LIT TO DO FITTING TPARCEL ype or print) Date F I NORTH ANDD S �T= / Building Locations Permit 9 Amount S of Owner's Name JtJ� l O•t'12�t New❑ Renovation ❑ Replacement 1z Plans Submitted ❑ In ri cn M Z — n L _ ;Ij Z r C z F rn ` .� � W Z Y3_ W _ Z t W !f Z iIn Z C 7_ '� C In t W i C W Z SUa-13ASEVl ENT BA SEM EST IST. FLOOR 2V D . FLOGR 3RD . FLOOR 4'r 11 FLOOR 5'r If FLOG R ` 6'T 11 FLOG R 7T It . FLOOR 3'rn FLOG R (Print or type) Chec•one: Certificate Installing Company Name AndoUP-s- 21L `g f MtQ- l�n•� T�.a . Corp. 211L Address 10 IAecter,, ''Dv- I )A;t Partner. Luekht_w,e n , Mo- ©IS3U4 Business Telephone 1478 k95_P36 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter GeorA La f�c INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked ves,please m tcate the type coverage by checking the appropriate box. Liability;nsurance policy 9 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: Sienature of Owner or Owner's Agent Owner ❑ Agent ❑ i hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued For this application will be in compliance with all pertinent provisions of the Massachusetts State G- Cade and Chapte 42 General Laws. 2 By: Signature o icensed Plumber Or Gas Fitter Title Plumber CMA3 CityrTuwn ❑ Gas Fitter License iNumoer Master -i'vi APPROVED(OFFICE.USE ONLY) ❑ Joumeyman !r Date.. . .�.,1 `..' ... ..... NORTH TOWN OF NORTH ANDOVER 0 PERM 1r2 q^ ,-G7�S'INSTALLATION " NJflRTH s o 9SSACMUSES MAY IX 99 ' This certifies that . . . . . .." :? !._: ".1( � . . . . . . . . . . . . .. . 111� qq � �• has permission for gas installation in the buildings of .. r. (. .f.f. �t E f . . . . . . . . . . . . . . . . . . . . . . at ./:!. . ".., � �J{:�� :'-. . . �'. ., North Andover, Mass. �. Fee/: .J..U:. Lic. Nf .-. . . . . . . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR WHITE:Applicant CANARY:Building Ddpt. PINK:Treasurer GOLD:File IAASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 GASFITTIN( (Print or Type) NORTH ANDOVER Mass. / Date kuilding Location S 7e cG Permit Owners Name "rue/,/ ey New '� Renovation r] Replacement Plans Submitted FIXTURES N >t x cc w rn as v a r rr frl Q N 'r- .O O U1 =LIS w o v w r x ai m . � 0: z a t•- w Z w 02 W w FO- as a cc 4 W O V S a N K Q O 1 D W w W cf z d W d C. W ~ W v x t7 yWU.. to m z 0 2 ¢ O N z Q •m > C: W O 2 Q E d d O O W — O W l+ ¢ z O 0 Y u. A O .1 U W y a a F- O SUFI—BSidT. BASEMENT IST FLOOR 2140 FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR TTH FLOOR STH FLOOR (Print or Type) /' Checc ne: Certificate Installing Company Name davtT Corp. Address Partner. ,LaZ.) re cam Q IdIa- ��,� 1__1 Firm/Co. Business Telephone: (� V,5— KVZ g Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy UTOther type of indemnity Q Bond Insurance Waiver: . I , the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. ElSignature of owner/agent of property Owner Agent i hereby certify that all of the details and infotmation I have rubroitted(or entered)In above application are true and accurate to the best of mY knowledge and that aU ptvmbing work and InitaUalions petfomted under Petmit issued for this spptication wiUfiein mmpunce with all pertinent provisions of the Massachusetts Slate Car Code and Gupta 142 of the general Laws. TYPE LICENSE: By Plumber Title Gasfitter Signature of Licensed Master Plumber or Gasfitter City/Town: Journeyman � 73 9 APPROVED (OFFICE USE ONLY) License Iltunber