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HomeMy WebLinkAboutMiscellaneous - 14 WALKER ROAD 4/30/2018 (2)c� o N clU o U- m Q c � U co clN U N ry C N rn 0 N V Y N w a) o U 'w E z N O a 70ZU 0 0 _ � U � .o Q Li > O L co O LL z F 0 0 co U- 0 O O .E T Z w a.1 M o U L °Ocu W O �Q T� 2 U) Z C Q c W L co UO 6U Z E o 0 `t (n m .0 a N 0) Q . ; U 0co a� 0 Lo UL U O -0W d N Y J M cu m Q <C: O O Ln CN co DC7 LL 3 co 0 J f T 0 N M m w 16000sgood Street Building 20, 2035 North Andover MA 01845 Tel: 978-688-9545 Fax: 978-688-9542 COMPLAINT FOR INVESTIGATION DATE: FROM: ADDRESS: ELECTRICAL: PLUMBING: GAS: Tel #: Complaint Against: BUILDING CONTRACTOR: PROPERTY OWNER: OTHER: �ejewr- Signed: ul, p"4ev-A be- �J" 0 North Andover Board of Assessors Public Access 4 i 0 c ecctrTtf oFt�cd `•��'o .f Click Seal To Retum Search for Panels Search for Sales Summary Residence Detached Structure Condo Commercial Page 1 of 1 North Andover Board of Assessors am lroperty Record Card Parcel ID :210/083.0-0214-0006.0 FY:201.4 Community: North Andover SKETCH PHOTO Location: 14 WALKER ROAD Owner Name: WEBB, LUCILLE Owner Address: 14 WALKER ROAD #6 City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 0 Land Area: 0.00 acres Use Code: 1.02 -CONDOMINIUM Total Finished Area: 787 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 88,100 98,400 Building Value: 88,100 98,400 Land Value: 0 0 Market Land Value: 0 Chapter Land Value: http://csc-ma.us/PROPAPP/display.do?linkld=2437286&town=NandoverPubAcc 9/17/2014 101 N TOWN OF NORTH ANDOVER Office of the Building Department Community Development and Services 1600 Osgood Street North Andover, Massachusetts 01845 RE: 13 Walker Road North Andover MA 01845 Telephone (978) 688-9545 FAX (978) 688-942 September 17, 2014 At the recent visit to 13 Walker Road Unit 6 several Building and Electrical Violations were observed. This Building is a commercial Multi -family and falls under the 2009 International Building Code, 780 CMR , Section 105.1 Required. Any owner or authorized agent who intends to construct, enlarge, alter, repair, move, demolish or change the occupancy of a building or structure, or to erect, install, enlarge, alter, repair, remove, convert or replace any electrical, gas, mechanical, or plumbing system, the installation of which is regulated by this code, or to cause any such work to be done, shall first make application to the building official and obtain the required permit. Thank you for your attention to this matter. If you have any questions, please call the office of the Building Department at 978-688-9545. Sincerely Yours, Brian Leathe Building. Inspector This certifies that. �V..wt.? e .................... has permission to perform .. ................ plumbing in the buildings of. . ............... . at ....%. <��..Q./finfP .. C�. /...... , North Andover, Mass. Fee 2�� .. Lic. No.�3k7/ ... . 1, ................ ... PLUMBING INSPECTOR Check 4 3o,3/11-7?" �jr_�J, s o MASSACHUSETTS UNIFORM APPLICATION FOR!A' PERMIT TO PERFORM PLUMBING WORK CITY [4(j\0i7). _•tel Vim.._ -. - MA DATE -1.l" PERMIT # _ F' - JOBSITE ADDRESS lA NN&1(,�a( OWNER'S NAME n P OWNER ADDRESS TEL[_11 cj1 __71`AX TYPE OR OCCUPANCY TYPE COMMERCIAL] EDUCATIONAL [] RESIDENTIAL PRINT CLEARLY NEW: Ej RENOVATION: REPLACEMENT: Tr PLANS SUBMITTED: YES -0 NO[E FIXTURES Z FLOOR— BSM 1 1 2 3 4 5 1 6 7 8 1 9 10 11 12 13 14 BATHTUB i CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM _ DEDICATED GASIOILISAND.SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER Lj DRINKING FOUNTAIN - FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR (INTERIOR) -f KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL ., I . .... ... - - - �' _ . _; •. _. SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION JI ai WATER HEATER ALL TYPES _.._ ; I WATER PIPING+ s OTHER INSURANCE COVERAGE: , I have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER E] 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 a best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliafice • h all P e t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Michael Porter LICENSE # .13671 SIGNATURE MPM JP [J CORPORATION(# 3516._ PARTNERSHIPLLCO#� COMPANY NAME 124 HRS INC ADDRESS 1134 Gold St CITY Worcester r STATE MA ZIP 01608 TEL 508-798-9955 FAX508713-9556 CELL 413 668 6544 EMAIL dispatch@m0mb,com �jr_�J, s o w H O z z 0 F w a m z a d z w ' o� Z o � w Oz w LU ILLU wC0w 5 O Q a a W a O > z wIt 3 U) a O z a a o w a � U J a CL vs � w = w f- LL W H O z O E� U W � � a z z as a a, x a 0 cue lk k The Commonwealth of Massachusetts JF77Tint Form Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 24 HRS INC Address: 134 Gold St City/State/Zip:Worcester MA 01608 Phone #:508-798-9955 Are you an employer? Check the appropriate box: 1. ❑✓ I am a employer with 50 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t employees and have workers' comp. insurance.1 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions I L ❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Liberty Mutual Insurance Company Policy # or Self -ins. Lic. #: WC531 S387893012 Expiration Date: 10/12/2013 Job Site Address: ALL JOBS City/State/Zip: ALL 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 cfrtify under the pams andpenalties ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official: City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express 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 beenTresented-to the -contracting -authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department. of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 7-2010 www.mass.gov/dia --~�-^--^``-�-- ~'-^ ----- '_~~~—~~°-- ~.- --^-^~�- � -- - --------'----------7 ll:��MONWEALT TTS' PLUMBERS mAsTER. PLUM. VE LICENSE TO: MICHA' 1 OP TL 11 po 251 1,67632 . 10273 Date.... 4 .. ......... ..... ......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .......... ............ ................................... has permission to perform..'Z�SA ..... .. . ...................................................................... plumbing in the buildings of.., ................ ............................................................ at ....... .............. Z ........ . ........ No A;over, Mass. .................. Fee4LP Lic'.*4 No.3!YIVI � � N PL BING INS TOR Check # O -A !a-�' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK oler J MA DATE _� 9 f ?,_11 PERMIT# U'rCITY JOBSITE ADDRESS , f%,`a OWNER'S NAME /—G C, POWNER ADDRESS TEL `7`D7 4/56, FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW: El RENOVATION: EQ REPLACEMENT: 0 PLANS SUBMITTED: YESE11 NO FIXTURES 1 FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM (= J ,__ I _.___..(_( DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER i -__ _! L—j FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR). KITCHEN SINK LAVATORY ROOF DRAIN 1 SHOWER STALL (. SERVICE / MOP SINK rr--- TOILET — URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER t,�__ _._� ( _._..__-�_1 ! --_--_.I ..._ A .....__...._( 4 - _P INSURANCE COVERAGE: 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 D OTHER TYPE OF INDEMNITY Q BOND 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNEREI AGENT 10 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE # SIGNATURE (VIP d JP D CORPORATION F]# PARTNERSHIP _I # LLC COMPANY NAME ncul(-r¢�, ADDRESS %r�r rlc e cfv4"eL4 Z ZI I CITY IN An cove. _ _ � STATE / ZIP al !fS' TEL JE�0© 30 4OS' o FAX^� CELL ��� EMAIL W H °z 0 H U W W o o z N O H w Q IL Z u w F= O Q w co a W w co p a z W� J IL CL CO w z w LL H O z O H U W a �7 a a G� p 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 Lelribly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3.01 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 1011 Electrical repairs or additions 1 l.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they Lire doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and 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 #: Information and Instruction's \ 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 employeiis 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 loeal 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 theappropriate line. i City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to 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 1-877,7MASSA.BB Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/data. MAN euvJo ut. Kj co 0 — ck Guo v� Date./—. e�4 .. G .1 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...... �/��y���L.�f"� .G ............. has permission to perform ....J .. ...................... . plumbing in the buildings of ./../ ."'. ......................... North Andover, Mass. Fee .)l1; r... Lic. No..rz .71?.. ........ ? .... . P UMBING INSPECTOR Check # 5"169 MASSACHUSETTS UNIFORM APPLICATION (Print or Type) • n A f/0"` , Mass. Date LN Building New ❑ FOR PERMIT TO DO PLUMBING do — Renovation ❑ Replacement FIXTURES Z4 ate- Permit #�} Owner's Name -/)I/"-5 1'rll ra,' Type of Occupancy �t S 1 D E IJ -rl A Plans Submitted: Yes ❑ No ❑ r Installing. Company Name � DO f keT • 'r' W M t4 7 A ?- -Q Check one: Certificate Address 7-)(-) C0 A C 4 01 rT n) A �j ❑ Corporation /Y) C Ti -4 Ti -4o F_ n YYi A ❑ Partnership Business Telephone 3F 2 - i17 7 P 2--J!5i-rm-/co. Name of Licensed Plumber _& 6 Fee 7- 15Aejv►mA INSURANCE COVERAGE: I have aY usrrent lability ins 13ce policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. L�' If you have checkedrimes, please /Indicate the type coverage by checking the appropriate box. A liability insurance policy Ad Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ 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 nerformed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum 'ng a andre?l of the eral laws. By Title re of Ucensed Plumber Type of license: Master % Journeyman ❑ Qty/Town APPROVED OFFICE USE ONL License Number_ • • Y • • • • Installing. Company Name � DO f keT • 'r' W M t4 7 A ?- -Q Check one: Certificate Address 7-)(-) C0 A C 4 01 rT n) A �j ❑ Corporation /Y) C Ti -4 Ti -4o F_ n YYi A ❑ Partnership Business Telephone 3F 2 - i17 7 P 2--J!5i-rm-/co. Name of Licensed Plumber _& 6 Fee 7- 15Aejv►mA INSURANCE COVERAGE: I have aY usrrent lability ins 13ce policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. L�' If you have checkedrimes, please /Indicate the type coverage by checking the appropriate box. A liability insurance policy Ad Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ 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 nerformed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum 'ng a andre?l of the eral laws. By Title re of Ucensed Plumber Type of license: Master % Journeyman ❑ Qty/Town APPROVED OFFICE USE ONL License Number_ V m v r C W m z 0 ' m A D o m O r z � In O In 7D O m p O z m =� v m -a c 0 N o m 0 0 'o Z r r C �! ao Y c� r Date./'I.V. ate .I � �",� . �". ...... . 3j6NOTOWN OF NORTH ANDOVER a ; PERMIT ,FOR GAS INSTALLATION This certifies that . fir. !.. ? A . �.... ?? ...................... . has permission for gas installation il .................... in the buildings of ..141.:! :A .................... . at . �. �� . U.: t?-.... J ....... • ((.��, North Andover, Mass. Fee.3A .-... Lic. No./.v ?.c/ ... ....`!, ...lJ. .�.,.�� ..... . 6ASINSPECTOR Check # 5529 ,LvIASSACUSEM L'NTFORNI APFUCATON FOR PERMIT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations FAF Owner's Name New ❑ Renovation ❑ Replacement Date 4 —11�-6 & Permit # S F 0 An t 30- to r Plans Submitted ❑ (Print or Nan>&---� usiness J d`J Name of Licensed Plumber or Gas Fitter// / lie 4 C one: Certificate Installing Company eL Corp. ❑ Partner. ffFiffn/Co. `v 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 ❑ Agent ❑ t 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 .cork and installations performed under Permit Issued for this application will be in .,cmpliance with all pertinent provisions of the Massachusetts State Gas Code japter I42 of the General Laws. tle IAPPROVED iGFICE USE ONLY) Ignature of ol-spliumber -9Gas Fitter Master Journeyman tcense IST. FLOOR (Print or Nan>&---� usiness J d`J Name of Licensed Plumber or Gas Fitter// / lie 4 C one: Certificate Installing Company eL Corp. ❑ Partner. ffFiffn/Co. `v 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 ❑ Agent ❑ t 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 .cork and installations performed under Permit Issued for this application will be in .,cmpliance with all pertinent provisions of the Massachusetts State Gas Code japter I42 of the General Laws. tle IAPPROVED iGFICE USE ONLY) Ignature of ol-spliumber -9Gas Fitter Master Journeyman tcense 9560 Date ! Z:1 -d A4- TOWN OF NORTH ANDOVER a PERMIT FOR PLUMBING This certifies that�l A 4d,'%' ►....4AII70', ./-j ............. has permission to perform plumbing in the buildings of .'9J4!1 -n.. G 1e, at. � .. �1,!6i G/ r'iy . -)Q:K .....eoGr.th Andover, Ma,/.s. Fee�Or �o. Lic. No...f161,4d.....?*/ % /NINSPECTOR Check „" �'�/// vPuvnuvu rUUIN IAIN FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTEF KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER ED ---------- - -- INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES VO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BONDI r 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 ❑ AGENT 10SIGNATURE 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 comp lance with all Pertinent provision of the K/lassachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME °y�//— LICENSE # i -S G ATURE MP _J JP W CORPORATION .. I # -_- _-.i PARTNERSHIP Ell LLC EkF COMPANY NAME L ADDRESS i IT - CITY __-.. _.._.___._......._..__ i STATE %!_i ZIPS/ _- TEL FAX EMAIL v MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY I AAr a/J,,J�/,��, % MA DATE���( PERMIT# JOBSITE ADDRESS .R � d__Jl OWNER'S NAME P OWNER ADDRESS TEL /� ,s',,� "S "K611FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ® NO❑ FIXTURES"I FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB { ( ,.�, ._..-[ ..____J v__.._.( __.__l ❑ .-_-._._i i CROSS CONNECTION DEVICE ....__.I -__.__I ._.,,_._E _.______f ____,_--_t �....i ._.._ DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEMS [ ( _! -..- I„{ - ._ _ _. _J DEDICATED GREASE SYSTEM . . DEDICATED GRAY WATER SYSTEM L.J ___! I ___ ___( DEDICATED WATER RECYCLE SYSTEM DISHWASHER ._..___-.J ........ vPuvnuvu rUUIN IAIN FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTEF KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER ED ---------- - -- INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES VO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BONDI r 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 ❑ AGENT 10SIGNATURE 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 comp lance with all Pertinent provision of the K/lassachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME °y�//— LICENSE # i -S G ATURE MP _J JP W CORPORATION .. I # -_- _-.i PARTNERSHIP Ell LLC EkF COMPANY NAME L ADDRESS i IT - CITY __-.. _.._.___._......._..__ i STATE %!_i ZIPS/ _- TEL FAX EMAIL v .m r M ❑ Lia w �. LL. The Commonwealth of Massachusetts Department of Industrial Accidents 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/Organization/Individual):jr�C�c`/✓(,J Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑Xam employer with 4. El am a general contractor and I yees (full and/or part-time).* have hired the sub -contractors 2. sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] E] I am a homeowner doing all work myself. [No workers' comp. insurance required.] i officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. .r am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site nformation. assurance Company Name: 'olicy # or Self -ins. Lic. #: Expiration Date: ob Site Address:7�� ",/A ,��G ee 7 6,(,City/State/Zip: Utach 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 ine 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 C up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of avestigations of the DIA for insurance coverage verification. do hereby certify it r the pains nalties of perjury that the information provided above is true and correct. i nature• Date: _ F/Lilo /ib, Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 'I'd 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 thy+"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 021.11 Tel. # 617-727-4900 ext 406 or. 1-877-MASSAFE evised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia This certifies that Date ....... -/ / TOWN OF NORTH ANDOVER PERMIT FOR WIRING ... . ............. . ........................... has permission to perform ....... .. ... .. .............. wiring in the building of ............... 11-. wle ....... ( ................................... at .......... ...... .................. North Andover, M Fee.. . -6-,- Fee fg— . Lic. No. . 7 ...... . .. ............ 'Ei&RICAL' INSPECTOR • Check# 7 10492 Ifommonweat°tlz o f MaeSachujetb Official Use Only c� Permit No. � 2epartment o f Jire Serviced Occupancy and Fee Checked y` BOARD OF FIRE PREVENTION REGULATIONS [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 IN INK OR TYPE ALL INFORMATION) Date: November 15, 20.11 City or Town of: North Andover To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 14 Walker Road Unit 3 Owner or Tenant Kevin Campbell Telephone No. 781-953-3741 Owner's Address 14 Walker Road Unit 3 North Andover, MA 01845 Is this permit in conjunction with a building permit? Yes ❑ No ❑x (Check Appropriate Box) Purpose of Building Condo Unit- Residential Utility Authorization No. Existing Service Amps _ / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Rework Kitchen Outlets, replace existing Panel as needed and Replace existing Electric Heat as needed. Completion of the folloivinQ table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires 3 Above ❑ In ❑ Swimming Pool rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets 5 No. of Oil Burners FIRE ALARMS No. of Zones No. of SwitchesNo. 4 of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alertin Devices g No. of Waste Disposers Heat Pump I 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 ecurity Systems:* No. of Devices or Equivalent No. of Water K`,�, o. o o. o Data Wiring: Heaters Signs Ballasts I No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunuahons Wiring: No. of Devices or E uivalent OTHER: 3 - 4ft Baseboard Heaters and 1 - 8ft. Baseboard Heater. 30 Circuit 120/240V Load Center Attach additional detail if desired, or as required by the Inspector of ' [Vires. Estimated Value of Electrical Work: $ 1.018.00 (When required by municipal policy.) Work to Start: 11/12/2011 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:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: The Electricians & Co.. Inc. LIC. NO.: A10737 Licensee: Wayne Morganti Signaturo%e ��, LIC. NO.: MtA07 (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 781-322-9344 Address: 50 Branch Street Malden, MA 02148 Alt. Tel. No.: 781-322-3100 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. SS CO 001021 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 a ent. Owner/Agent Signature Telephone No. PERMIT FEE. $ 125.00 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street ;E Boston, MA 02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): The Electricians & CO Inc Address: 50 Branch Street Phone #: Are you an employer? Check the appropriate box: 1. ❑1 I am a employer with 15 4. ❑ I am a general contractor and 1 employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comm insurance required.] 81) 322-9344 Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ .Building addition 10.21 Electrical repairs or additions 11. E] Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Hanover Insurance Company Policy # or Self -ins. Lic. #: WH N 6055762 02 Expiration Date: 09/0112012 Job Site Address: 14 Walker Road Unit 3 city/State/Zip: N. Andover, MA 01845 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 andpenalties of'perjury that the information provided above is true and correct. Signature: �L r"�'�� Date: November 15, 2011 Phone #• (781) 322-9344 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 #: