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Miscellaneous - 144 WAVERLY ROAD 4/30/2018
Date ............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that7om..A ..... c..J 6? 0 ............................................................................... has permission to perform ... M .................................... ........................................................... wiring in the building of ................ /N-R- .............................................................................................. at A;;.) .......... . ...... ed - ....... . NorAAndover, Mass. ................. Fee.b�? .. . ........... Lie. No. .. . ... ...... LFCTRICAL INSPECTOR Check # # I I I 12562-/' PY4 k h-, �- C, NO- Commonwealth of Massachusetts o Department of Fire Services �BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Z D 2' Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC 527 MR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: �0 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) f k✓� ���2L `� l� Owner or Tenant 422&.% 'W Telephone No. q 7 Owner's Address A/7 1–)14 Is this permit in conjunction with a building permit? Yes [V No ❑ (Check Appropriate Box) Purpose of Building !.J(,Utility Authorization No. -Existing Service 100 Amps %L// 2 UV Volts Overhead M Undgrd ❑ No. of Meters New Service _ U () Amps %ZU / Z VOVolts Overhead [4 Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:'3,/i/1 rmmnlatinn of the fallowing table may be waived by the Inspector of Wires. No. of Recessed Luminaires /0 No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. grnd. o. of Emergency Lighting Battery Units No. of Receptacle Outlets 30 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches LQ No. of Gas Burners % 1®10. of Detection and Initiating Devices No. of Ranges No. of Air Cond. / Tons Tot No. of Alerting Devices No. of Waste Dis osers P Heat Pump Totals: Number Tons KW .......... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal ❑ Other Connection No. of Dryers Y Heating Appliances KW Security Systems: No. of Devices or Equivalent.. No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail ij desired, or as required by the lnspecror ql rr Tres. Estimated Value of Electrical Work: O 7) () (When required by municipal policy.) Work to Start:y/ lj6 IrInspections 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 er ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: 1NSURANCE co[BOND ❑ OTHER ❑ (Specify:) I certify, tinder the pains and penalties of perjury, that the information on this application is true anti complete. FIRM NAME: 1_2A1 -,'V �' C1�%�� _ LIC. NO.: Z I Licensee:�1�J� L0R✓I' Signature (If applicable, enter "exempt" in the license numbe line.) Address:/-l��'r/1���� ff__i / �— LIC. NO. :1Q 6 0 r� Bus. Tel. No.: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not hove the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement.1 am the (check one) ❑ owner ❑ owner's agent. Owner/Agent I PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass N Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass N Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signa re: Date: ROUGH INSP CTION: Pass 0 V Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date:j��`� FINAL INSP CTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date:S'- DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com f 1 � v .. The Commonwealth of Massachusetts _ F Department of IndustrialAceldents M _.. ':��; X Congress Sheet, Suite 100 Boston, MA. 02114-2017 d< www mass.gov/dia • ' d'M sJs�� Workers' Compensation Insurance Affidavit: Builders/Contractors/Electritcians/Plumbers. TO BE FILED WITH THE PERMCTTING AUTHORI`�Y. A'licant tnxormauou Name (Business/Organ zation/Individual): a Address: % X1��nY0(f 5f, City/State/Zip:_ Are you an employer? the appropriate box: Phone #: 1. [] I a employer with __ ___ emPloyees (full and/or part-time).' 2- A am a sole proprietor or partnership and have no employees Working for me in ca acity [No workers' comp, insurance required.] any p Solt [No workers' comp. insurance required.] f In I am a homeowner doing all work my 4.[]I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.❑I am a general conhactor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance 6, ❑We are a corporation and its, officers have exercised their right of exemption per MGL c. 152 §1(4) andwe have no employees. [No workers' comp. insurance required] Type of project (xecluired); 7. [] New'construci[on g. Remodeling 9. ❑ Demolition 10 ❑ Building addition I l.Fo/Elecirical repairs or additions IZEJ Plumbing repairs or additions 110 Roof repairs 14.1] Other *Any cks box#1 must also fill out the section below showing their workers' compensation policy information. applicant that che i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this tiox must attachest provide their workers' comp. policy number. d jai additional sheet showing the name of the sub -contractors and state whether s or not those entities have employees. If the sub -contractors have employees, they mu compensation insurance for my employees. Below is the policy and job site X am an employes that is providingworkers' information. Insurance Company Policy # or Self -ins. Lic. #:, Expiration We, City/State/Zip: Job Site Address: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ation by a fuid up to $1,500-00 Failure to secure coverage as required undeM o. enaltieszin the form of criminal STOP ORK ORDER punishable nd a fine of up to $250.00 a and/or one-year imprisonment, as well ascivilp be forwarded to the Office of Investigations of the DIA for insurance day against the violator. A copy of this statement may coverage verification. X do hereby cern er the ains and enalties peYyary that the information provided above is tr a and correct. W99azure: � � �� / /� Phone #: C? T' Official use only. Do not write in this area, to be completed by city or town official permit/License # City or Town' Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone Contact Person: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of 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"ox trustee 6fan 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 whohas not produced acceptable evidence of compliance with the insurance coverage xequirred " Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the Workers, compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub=contractors) name(s), address(es) and phone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit 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 IndustrialAccidenis. 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 "alll, 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NUSSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia , A 112'78 Date.t�'P�111 ... V ........ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies. that ...... 2 ...... I .. 6.� ....... ......... i-r'N ........................ has permission to perform ..... ..... i�4 ....... ....................... plumbing in the buildings of ...... M ............................................................................... at .. ...... . . ......... North Andover, Mass. ................................ Fee... Lic. No.k.(P.Z-�.j .. ................................ ................................................ PLUMBING INSPECTOR Ched., Jr- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 7272 7 POWNER TYPE OR PRINT CLEARLY CITYD� h D✓ �_ __I MA DATE 31._..-,_..( PERMIT# JOBSITE ADDRESS % �V � OWNER'S NAME ADDRESS TEL JIFAX OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ® RESIDENTIAL NEW: 0 RENOVATION: REPLACEMENT: Q PLANS SUBMITTED: YES® NOM FIXTURES Z FLOOR--` BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 L 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 BATHTUB Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME o ( LICENSE # I SIGNATURE MP[�i] JP CORPORATION nJ #�PARTNERSHIP Q# #= LLC CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM �f _ I [ -._f . -_ -_� ( ► ., _ _.__ € _ ! ,.- _ _ FAX CELL�EMAIL 1 DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER _ f ....__1 _j FLOOR / AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN __,__.J __J _--i ._.. ..._ _I _....__I .--.--_- ___._ [ f -A SHOWER STALL SERVICE / MOP SINK TOILET URINAL WA AHING MACHINE CONNECTION YYH l CIC HEA i CPC HLL I T r'CJ ` P TER -- 7272 7 _ INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESP NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i OTHER TYPE OF INDEMNITY 0i BOND P 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 F AGENT 10 SIGNATURE OF OWNER OR AGENT L 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 o ( LICENSE # I SIGNATURE MP[�i] JP CORPORATION nJ #�PARTNERSHIP Q# #= LLC COMPANY NAMED�te�cf /✓,� Pte, /�cti�n� ; ADDRESS CITY STATE ZIP (� _ � _.. "'� ��� � ►I TEL _ l FAX CELL�EMAIL 1 H z z � o , U W v r., o F1 z N F] GOD W O IL z W � u = F= W H W p a w U) a w Ri GY c C) z a a � W a � . U J a O a z w E- LIL H z O H U W a as a a °a ' _0 The Commonwealth of Massachusetts Department oflndlustrialAccidents I Congress Street, Suite 100 _ - Boston, MA 02114-2017 �r www mass.gov/dia Workers, Compensation Insurance Affidavit: BuilderSlContxactors/Electricians/Plumbers. TO BE FILED WITH THE PERNHTT'NG AUTHORITY. — - - -- Nan1 , (Businessl(5iganization/Individual): /' / U' C / J • "' Address: 8 dY ACY City/State/Zip: 00-6'7 Phone #: 16-17 3 yIAYU Are you an employer? Check the appropriate box: 1.[AI am a employer with employees (full and/or part-time).* 20 I am a sole proprietor or partnership and have no employees 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 4. ❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1w I ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.F]I am a general contractorI and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance - 6. Q We are a corporation and its, officers have exercised their right of exemption per MGL c. 152 §1(4) andwe have no employees. [No workers' comp. insurance required.] Type of project (required): 7, [1 New'construction 8. [] Remodelitig 9. ❑ Demolition 10 [] Building addition l l.❑ Electrical repays or additions 12.,_I Qp mbing repairs or additions 11F! Rbef repairs 14.n Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit, this .1 affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such tContractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and state whether or not (hose. entities have ctors have employees, they must provide their workers' comp. policy number. employees. If the sub -Contra lam an employer that is providingworkers, compensation insurance for my employees. Pelow is the policy and job site information. Insurance Company Name: Mw " 'f w L C C K S q(p Expiration Date: l //XS Policy # or Self -ins. Lie. #: D n, o,//V l Al City/State/Zip: /Val rjn�p vie'" Job Site Address: 1 Attach a copy of the workers' compensation policy declaration page (showing the poexpiration date). licy number and lation by a fhib up to 0-00 Failure to secure coverage as required under penalties MGL c.152, §25 form criminal OP WORD ORDER and. a fine f up to $250.00 a and/or one-year imprisonment, as well day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cer r u er the pains and enalties of perjury that the information provided alio ej and correct. �� /YI/__17�' 1-1-4e. Phone #: �� 7 y� Official use only. Do not write in this area, to be completed by city or town offzcial. City or Town: Permit/License #. Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone Contact Person: Q. 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 receivef6r. 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 b6 deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or to cal 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(1) 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 ofthis 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 numbers) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit 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 -insura'nc'e 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 thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (ifnecessary) and under "fob 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia It f r �� Commonwealth of Mas usetts - Division of Registrati i Board of Plumbi STEPH 5 GLEN #202 STONEHA 4 Master Plu r o PL -16239-M 05/01/2016Srev005770 Lic6nse No. Expiration;Qate.Serial No. Date................... I ......... ......... TOWN OF NORTH ANDOVER PERMIT -FOR GAS INSTALLATION T his certifies that .......... �.j .... ey.�; inst ii f, has permission for aqa c)n 11.� ... I ... ..... .... . . ..... in the buildings of. A-cAPr.,r- . I ./� , - e . .............................................................. .......... ............ .... .. .............. .. , at �Ltl ..... .... ", .................... . North Andover, Mass. ............. F e e c!��On ..... Lic. No.j.(e��J ...... ...................................................................... GASINSPECTOR Ch,eck # � 1 U, 0- 6 C', i '•` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY Or ✓ _ MA DATE ��PERMIT# b� JOBSITE ADDRESS _.�_✓l OWNER'S NAMEG" OWNER ADDRESS ITE ___IFAX = ~Ii TYPE OR .-.; PR*T OCCUPANCY TYPE COM RCIAL EDUCATIONALEl RESIDENTIALM CLEARLY NEW: Zj RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES D NO APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER { f E DRYER FIREPLACE FRYOLATOR FURNACE L-A _ I GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE hale a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES IM NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY jr! OTHER TYPE INDEMNITY E] BOND 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-11 AGENT .01 SIGNATURE OF OWNER OR AGENT 1 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 complian wit all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 0 �% 'a PLUMBER-GASFITTER NAME Sn r� �li LICENSE # Lt3 j SIGNATURE MPI MGF 0 JP D JGF LPGI DI CORPORATION ©# © PARTNERSHIP©# LLC .3#= COMPANY NAME:Lh f9lilrnk,? �_ ADDRESS CITY STATE � ZIP /TEL FAX __]I CELL�EMAIL _ � _ The Commonwealth of Massachusetts M Department oflndustrialAecidents 1 Congress Street, Suite 100 t Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERATITTING AUTHORITY. Applicant Information p Please Print Legibly Name (Business/Organization/Individual): 010%14 S T ld lvl � l%a tw-roAr Address: a /0 jZGI' City/State/Zip: lFee?Af m4 6�S'�� Phone #: 76-1 yy-� 505(0 Are you an employer? Check the appropriate box: 1. I am a employer with employees (full and/or part-time).* 2. ` J I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6.FJ 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): 7. ❑ New construction 8. E] Remodeling 9. ❑ Demolition 10 E] Building addition 11. F1 Electrical repairs or additions 12.0 Plumbing repairs or additions 13.F] Roof repairs 14. ❑ 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 mustattached 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 pi'ovidiitg workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: 401AW © (S' f ( Expiration Date: &,/ WG d/ City/State/Zip: p: A0/'��J / 4CIOt/�- Y"19oa//y Job Site Address: ✓ ✓lr Ci /State/Zi Attach a copy of the workers' compens tion policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi nd r the pains and, peenalties of perjury that the information provided above is true and correct. c;..., ,+,,, a. . lu 4A -6z ' nate. 'elVd Phone#: 2�� �N2 YA910 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 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." i An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased elnployer, 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 -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 cityor 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 375 Date. . W-Wf -"; f VORTN TOWN OF NORTH ANDOVER 0 0 PERMIT FOR MECHANICAL INSTALLATION &I e.41'j This certifies that ........................... has pennission for mee anic I installation vy� ................. of . C. in the buildings of ....... at ... � �1-1 . U0 6--. 1 i C �? -�. I ... IP -1-4 ........... North Andover, Mass. Fee.�%(�.—. Lic. NA$.b0.A,,h'.F ... .......................... -2 GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer - I - -7 ��' t --A �r— `r • Commonwealth of Massachusetts Sheet Metal Permit Date 7 Estimated Job Cost: _ Plans Submitted: YES NO Business License # 2313 Business Information: Name: J ftn 40 ®� Street: J i96'2E/ City/Town:3--Q ' �& � /" Telephone: 7& / - %/ O — `f z116 Permit # 16" - Permit Fee: $—&A5- Plans Reviewed: YES NO t✓ Applicant License # Property Owner / Job Location Information: Name: Street: r l�e�+2�'% U� City/Town: •�� `k Telephone: %7 _ $ 33 — Photo I.D. required / Copy of Photo I.D. attached: YES NO Building Type: Residential: 1-2 family Multi -family Condo / Townhouses Commercial: Office Retail Industrial Educational Institutional Building Cubic Footage: under 35,000 cu. ft. L-- over 35,000 cu. ft. Sheet metal work to be completed: New Work: Renovation: �— HVAC Metal Roofing Kitchen -Exhaust System Chimney / Vents Provide brief description of work to be done: N S j LA. ,- G A,J ✓� +� i ✓L 1, cs w (� �9-���) i� L - w� I e -.-c S INSURANCE COVERAGE: 1 have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes ❑ No ❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy, Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner Agent ❑ eignature of Owner or Owner's Agent By checking this box[], 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 sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Date Progress Inspections Comments Final Inspection Date Comments Type of License: By ❑ Master Title ❑ Master -Restricted City/Town - ❑Journeyperson Signature of Licensee Permit # ❑Journeyperson-Restricted License Number: r -g 3 Fee $ El Check at www.mass.gov/dpi Inspector Signature of Permit Approval Sheet Metal Commercial Guidelines / Life Safety / Critical Systems Inspection Checklist Yes No N/A, Set of stamped engineering documents and detailed description of mechanical system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet -metal work being performed with proper journ.eyperson-to-apprentice ratios Fire dampers with access door properly installed and checked for operation Smoke and combination fire / smoke dampefs with access doors properly installed - actuator checked for proper operation (May also be verified by fire department during fire alarm testing) Duct smoke detectors with access doors properly located (May also be verified by fire department during fire alarm testing) Smoke / atrium exhaust systems installed and operation verified (May also be verified by fire department during fire alarm testing) Stair pressurization systems installed (where required) and operation verified (May also be verified by fire department during fire alarm testing) Grease / kitchen hood exhaust system installed with all seams and connections welded airtight with properly located cleanouts. Proper c1E`ances, fire rated enclosures and pressure testing required: t xes'.:arats instal'oin bgtiipment and d�=.:.-t:. •, 4 Duct penetrations in fire'rat& ivali:Y and floors sealed Metal roofing systems installed watertight using proper materials and fasteners Flexible duct runs installed 6'-0" maximum length Ductwork installed using proper hanger spacing, hanger stock, threaded rod and angle iron Ductwork / plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining Volume dampers installed for each supply air branch duct New/clean - properly sized filters installed (final inspection) Testing and Balancing report complete (final sign -of) . b t . Sheet Metal Residential Guidelines,/ Inspection Checklist Yes No N/A Detailed description and sketch of sheet metal system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper joumeyperson-to- apprentice ratios Equipment sized per heating/ cooling load calculations Duct work sized per manual "D" calculations Bath / shower rooms contain mechanical exhaust fan vented outdoors Electric dryer exhaust properly installed maximum total run 35'-0", maximum flexible run 8'-0" Flexible duct runs installed 14'-0" maximum length Volume dampers installed for each supply air branch duct Ductwork installed using proper gauges and hangers Ductwork / plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining New/clean - properly sized filter installed (final inspection) Testing and Balancing report complete (final sign -oft)