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HomeMy WebLinkAboutMiscellaneous - 15 BRADSTREET ROAD 4/30/2018 J �DSTREE?ROAD 2101043000��__� � �_ i I I 1 THENORFOLK EDHAMGROUN August 24, 2011 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B Building Commissioner, or Inspector of Buildings c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Board of Health or Board of Selectmen c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Fire Department or Arson Squad c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1127982 Insured: PATRICIA HENDERSON Address: 15 BRADSTREET ROAD, NORTH ANDOVER, MA Policy No.: H1048941A Loss Date: 08/22/2011 Loss Type: Building or Other Structure Damage A claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be applicable. If any notice under Mass. Gen. Laws; Ch. 139, Sec. 3B is appropriate, please direct it to my attention and include a reference to the captioned insured, location, policy number, loss date and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property, and the claim will be paid in our customary manner. Sincerely,Michelle M. Roust Sr. Property Claims Examiner 1-800-688-1825 x1171 NORFOLK&DEDHAM MUTUAL FIRE INSURANCE CO. 222 Ames Street,P.O.Box 9109,Dedham,MA 02027-9109 DORCHESTER MUTUAL INSURANCE CO. Telephone:(800)688-1825 FITCHBURG MUTUAL INSURANCE CO. p Fax:(781)329-1818 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings City Hall JAN 0 4 2005 North Andover, MA 01845 TOWN OF NO RTH HEALTH Q PAR7.MEON7'E� To: Board of Health or Board of Selectmen City Hall North Andover, MA 01845 RE: Insured: Patricia Henderson Property Address: 15 Bradstreet North Andover, MA 01845 Policy Number: F0110665 Cause/Date of Loss: Fire Damage Loss of 11/1/2005 File or Claim Number: BOSO43481 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Don Winslow On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Signature Date New England Claims Service,Inc 100 Conifer Hill Drive Suite 308 Danvers, MA 01923 (978) 777-9900 (978) 774-9296 NEW ENGLAND CLAIMS SERVICE, INC. Incorporated 1985 ❑ Reply To Reply To ❑ P.O.BOX 345 100 CONIFER HILL DRIVE,SUITE 308 MANSFIELD,MA 02048 ^,�,L„ap; DANVERS,MA 01923 Na TEL.(508)337-8058 NUNSTE4 TEL.(978)777-9900 FAX(508)339-5835 FAX(978)774-9296 wrandall@newenglandclaims.com Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec 3B To: Building Commissioner or PREC IVIII Inspector of Buildings , City Hall i r North Andover, MA 01845 TOWN OF NORTH ANDOVER RE: Insured: Patricia Henderson L HEALTH DEPARTMENT Property Address: 15 Bradstreet Road,North Andover, MA 01845 Cause of Loss/Date: Property Damage Loss of 2/25/2010 File or Claim No: BOSO47853 Claim has been made involvm* g loss damage or destruction of the above' p captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 313 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Mark Randall Adjuster On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Signature Date �y.............. Date.................... 0* TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ....................................j. ................................... This certifies that ("� ....... has permission for gas installation ... ....................leA— ........................................... in the buildings of 6�Ae vv*N c,—j at ...... North- "-Andover, FeeNo. ........ .6! ........................................... GASINSPECTOR Check# 9148 •`' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY �= , MA DATE PERMIT# JOBSITE ADDRESS T3 r JqA -f �OWNER'S NAME r i4 r I (-le- Ft4 t-e tft p .� GOWNER ADDRESS TEL =FAX f TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL RESIDENTIAL" PRINT CLEARLY NEW: RENOVATION:[ REPLACEMENT: PLANS SUBMITTED: YES01 NO E] APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER ` En- CONVERSION BURNER ` COOK STOVE I DIRECT VENT HEATERy DRYER - - -- - — ._ FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER �- ROOF TOP UNIT TEST UN,T HEATER j UNVENTED ROOM HEATER WATER HEATER _ -- OTHER ..._INSURANCE COVERAGE --- -- ~=- � - ---�- I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ]NO r I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY © 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: 0 I WNER � AGENT 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 ccurate to the best of my know)edge and that all plumbing work and installations performed under the permit issued for this application will be in comp' nc with all Pertinent PP p nen provision of e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �%" PLUMBER-GASFITTER NAME r vi LICENSE# SI E MP El MGF Ej JP JGF LPGI© CORPORATION©# PARTNERSHIP®#=LLC®#Ic � COMPANY NAME: _ v'^- ADDRESS �_J !.c- �ri✓v/C (,;ZQ CITY STATE ZIP TEL -zlg FAX CELL EMAIL NVA ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINALINSPECTION NOTES Yes No . THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES v ( `s The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations UV 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /' Please Print Legibly Name(Business/Organization/individual): 4 cl_g4 ✓i G t , Address: Lj c /L City/State/Zip: �� �j 63 c�i Phone#: F2 9- 2— Are Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with S.- i i^ 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.# E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. F1 Building addition [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL ILEIPlumbing 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.[i Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they aie 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 thepolicy and job site information. Insurance Company Name:. Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as 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 certlfpmder the pains andpenalties ofperjury that the information provided above is true and correct. - Si ature: Date: 3 Phone#: , r2- Official 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#• J ' G j; 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 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 ladustrial Accidents Offiiee of Investigations 604 Washington Street Boston,MA 02111 Tel#617-727-4900 ext 406 or 1-877,7MASS.A.FB Revised 5-26-05 Bax#617-727.7749 www.mass,govldia COMMONWEALTH OF MASSACHUSETTS 5 PLUMBERS AND GASFITTERS LIGEN' ED AS A.MASTER PLUMBER ISSUES THE ABOVE LICENSE TO: GAFFNY 45 WINBROOK :AVE SALEM . NH 03D79=4469 X� 19.9158723 i Date��•->��...... 14410 OF NORT/�,� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ss ° 45 CMU r - This certifies that..7 ..::.. ...........: . . .. Lk...... .............................................. has permission to perform .. ee ....... F..................................... plumbing in the buildings of:......................:.................................................................... .......... ....... North Andover, Mass. Feeff�€./o.:..Lic. No./4?..i�6/r-' ....... ...1:..... PLUMBING NSPECTOR.................... Check# r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY _ --I MA DATE PERMIT# JOBSITE ADDRESS /J' !_�_ S, iZr�x+r1 ?�Q I OWNER'S NAME ` °_.— POWNER ADDRESS TEL --- FAX TYPE OR OCCUPANCY TYPE COMMERCIAL� EDUCATIONAL Q RESIDENTIAL DI PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES® NO FIXTURES 7 FLOOR- BSM 1 1 2 3 ..4 5 6 7 8 9 10 11 12 13 14 BATHTUB _ ! 1 ____ ! ._. I=1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM —Al ! �. f DEDICATED GREASE SYSTEM _ __._.1 _____$ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER ..j FLOOR/AREA DRAIN .__..__ -._.__..! —A INTERCEPTOR(INTERIOR) KITCHEN SINK I .__.� t 1 _.._—� ---____[ I ._._.....__! LAVATORY ROOF DRAIN SHOWER STALL SERVICE 1 MOP SINK TOILET i _. . _I __._.! URINAL WASHING MACHINE CONNECTION _[ i __.--.. t _ __. ---J L_j _-_.-..4 WATER HEATER ALL TYPESI WATER PIPING E _i _.. f _ ! _ ! OTHER � � _ ►. I f [ _ij ____.I (� INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES, . NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY®-- OTHER TYPE OF INDEMNITY El BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does no#have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT SIGNATURE OF OWNER OR AGENT 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. I _ ; PLUMBER'S NAME _ J LICENSE# 6 I SIGNATURE MP�&— JP0 CORPORATION#U333_1PARTNERSHIPP-M LLC ._.,U COMPANY NAME r DDRESS r CITY STATE ZIP TELFAX CELL _ EMAIL ZZL 1/5/7Y ROUGH PLUMBING INSPEC ION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES S Ill/W Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ �� FEE: $ PERMIT PLAN REVIEW NOTES t ,y The Commonwealth of Massachusetts Department of IndustrlalAccidints Office of Investigations Uf 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): �-- Address: S — City/State/Zip: u e Phone#:J,?' 77A� Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I ' 6. F1 New construction employees(fall and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7 modeling 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 3.01 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.[i Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they 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 I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. S' Insurance Company Name:. Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as 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 ofup 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 DTA.for insurance coverage verification. Ido hereby ert under the in and penalties of perjury that the information provided ab ve is tr a and correct, Si a re: - 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#: - c Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire,• 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-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 lndusWal.Accidents Office of Investigations 600 Washington Stroct Boston.,MA,02111 TO,#617-727-4900 oxt 406 or 1-877r"S.AFE Revised 5-26-05 Fax##617-727-7749 �vww.rz�ass,govfctia Date .�. . . .�.�1 Z. . . b�,�TL°itria�s TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION { This certifies that �Q. . . . ` +�. . . . . . . . . . . . . . . . . . has permission for gas i stallation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..w in the buildings .of . . . e i . . . . . . . . . . . . . . . . . . . . n . . . . . . . at . . 1 5 .�✓�'�c�S --�'. . .� �. . . . , orth 4Vdoor, Mass. F . Lic. N l",- Mb Fee . . . . •. . . . . . . . . . . . . . . GASINSPECTOR Check# �+�3 8362 i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK F" CITY. ��r /� B j MA. DATE: PERMIT# q� - r / � � JOBSITE ADDRESS: �� �dt S Y- OWNER'S NAME:_'RA 7�- OWNER ADDRESS: WGLt� TEL: �12Y� .FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ - EDUCATIONAL ❑ - : RESIDENTIAL-� _ PRINT.. _.. CLEARLY ,NEW ----RENOVATION:❑ - __REPLACEMENT:_ -- • _. ._. PLANS SUBMITTED:'YES❑ N0,(�} - APPLIANCES-1 FLOOR: Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 .BOILER . _.. ;BOOSTER _ -CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER .. LABORATORY COCK_ MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOFTOP UNIT - TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES WNO ❑ If you have checked YES,please indi.ate the type of coverage by checking the appropriate box below. LIABILITY IN: URANCEPOLICY OTHER TYPE INDEMNITY ❑ 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 thai my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ 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 and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application 'I be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERIGASFITTEER NAME:��O��_ �/l t2-{�,�,� LICENSE#11119!iSIGNATURE COMPANY NAME: 9,,,?d .&ost. �NN ' nL_ ADDRESS: ek- Sr CITY STATE: 111131.- ZIP: ���f„cdv FAX: TEL: � I�I o `d�� CELL:6,7 l JW 5a • EMAIL: � l� MASTER❑ JOURNEYMAN ❑ i-P INSTALLER❑ CORPORATION �6 7 PARTNERSHIP❑# LLC❑# o Y-e lc� r i - 1 t MEN 6ZO2'��e`��' \ rYc�h§It5 r� rM1 d s COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMBER - ISSUES THE ABOVE LICENSE TO: JOHN M.. MACONE 21 MELBA LN u) STONEHAM MA 02180- 1338 I 11495 05/01/14 178512 Fold,Then Delarh Along All Perforations QOMMONWEALTH OF^MASSACHUSETTS� 7! min Ill 11 PLUMBERS AND 'GASFIT.TERS REGISTERED AS A PLUMBING CORP ISSUES THE ABOVE LICENSE TO: JOHN M MACONE ; POWDER HOUSE PLB M11495 76 89 HANCOCK STN STONEHAM MA 02180-2626 2267 05/01/14 178528 4, Fold,Then Detach Along SII Potions til Y The Commonwealth of Massachusetts Department of Industrial Accidents - Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information (( Please Print Legibly Name (Business/Organization/Individual): Address: V 4 City/State/Zip: 17/1641.1 AW 4Vz20Phone#: Are you an employer?Check the appropriate box: Type of project.;(required): 1.Vi am a employer with�_ 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Rernodelinb ship and have no employees These sub-contractors have g. ❑Demolition working for mein any capacity. employees and have workers' 9. E]Building addition [No workers' comp. insurance comp,insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11�'i-umbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.E] Roof repairs insurance required.]t c. 152, §1(4);and we have no employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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 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: 4 ®'✓6-u Sao_ - c •a._ Policy# or Self-ins.Lic.#: �� G� �(o 7,7 Expiration Date: /�/ Job Site Address: City/State/Zip:_44 Adv�l 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 c ify snder t ail s and penalties of peijuty that the information provided above is true and correct. SiLynature: Date: Phon 17J 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#' S F Date. C;45 - C° 0ORT" <.�•°;.'tio TOWN OF NORTH ANDOVER o40 PERMIT FOR PLUMBING sSACMUS� .�.. This certifies that . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . - . . . . . . . . . . . . . . . . . . . . . plumbing in the buildingsof `'`-" : . . . . . . . . . . at . . . . . . .f�. . . . . . . . North Andover, Mass. FeP .: Lic. No.. . '` . . . . . . . . . ... PLUMB.NG INSPECTOR Check # �� _ 7767 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS ` Building Locationl,5 BLA r t2T L / f Date cS i Owners Namedevqt1'Sp�/y Permit# Z Type of Occupanc Amount New Renovation ri Replacement '�/ Plans Submitted Yes El No ❑ FIXTURES F � O U O � a A a. Lf) Co O v� A ca &�5i+1VII�II' 1ST FUJCit 1 2N.1 Fif.�t 3MFLOM 4.IHK-OM SM FROOM 6MFLOM _ ME II)CR (Print or type) ii f � � r Check one: Installing Company Name_c_ , P�q t 1(�1c� Certificate ❑ Corp. Address o is Partner. a ' usmess elephone .7C7 Firm/Co. n Name of Licensed Plumber: Insurance Covera ee Indicate ane of 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 three insurance of this application does not have any one of the above ignature Owner 1:1Agent A n . I I hereby certify that all of the details and information I have subtted(or entered)in above true and accurate to best of my knowledge and that all plumbing work and installations performed under Permit Issued forothisrapplication will be in the compliance with all pertinent provisions of the Massachusetts State Plumbing Code Chapter 142 o�the eneral Laws. By. igna ure ol T7ceTs-uUTTu—m-Te—r Title Type of Plumbing License City/Town 4 APPROVED(omm USE ONLY icense um er MasterJo urneyman ❑ F r, Date............ ...... r�^ ! i �aORTry o0 _ TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,SSACHUS� '�. This certifies that " " �� T G................................... a S� has permission to perform ........�:�........ .��.,�.�1....�:'....................... wiring in the building of.................C � 't'��!/..................................... at 1-� � � 'E ,North Andover,Mass. �= Fee. ... '�'.�Lic.No.Jr^/.- :.3. ...... . ' .C�!�I ......... ELEmicAL INSPE MR Check # fD �- F 7276 o., Commonwealth of Massachusetts Official Use Only Permit No. y7 2—-7L Departmento f Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(M fC), IR 12.00 (PLEASE PRINT IN INK OR TYPE LL FO ATION) Date: 307y�' Cityor Town of: 0 To the Insp ctor of fres: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street &Number) Owner or Tenant i /� �t/jS Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (ClieckAppropriate Boz) Purpose of Building Utilit Authorization No. 2-7-101V / Existing Service � 0 Amps Z'J/ 240 Volts Overhead Undgrd [I No. of Meters (� New Service 2 Amps J / QLo Volts OverheadEl Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be ri,aived b_v the Inspector of 6Vires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KV A No. of Luminaire Outlets No. of Hot Tubs Generators KVA Above In- o. o EmergencyLighting ` No. of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battery Units .i No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total No. of Alerting Devices Tons g No. of Waste Disposers Heat Pump Number Tons KW No. of Self-Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No._Hydromassage.Bathtubs No. of Motors . Total HP Telecommunications Wiring: . No.of Devices or Equivalent OTHER: a Attach additional detail if desired,oras required by the Inspector of 6Vires. Estimated Value of Ylectrical Work: (When required by municipal policy.) Work to Start: Z Inspections to be requested in accordance with MEC Rule 10, and upon completion. ' INSURANCE CO ERAGE: 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- e is in force, and has exhibited proof of sar to the aetnnt issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) J/�.Vve<r� I certify, under the pains andpenalties of-perrjury,tha 'ie inf ation on this application is true and complete. FIRM NAME: 1 4 7���G 11/Zl( n ��' LIC.NO.: 45M Licensee: St'no aid V bI A Signature LIC.NO.: (If applicable, enter -ezeJ�lp� t 'u7 th license naunbe 1 ie.) � Bus.Tel.N Address: v��S�l 0 tt;101W7 Alt.Tel.No.: *Security System Contractor License required for this work; if applicable, enter the license number here: 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: $ Generators Residential& c) each additional meter ..$10.00 TOWN OF ANDOVER Commercial: Sewer Ejection Pump:. $25.00 ° ELECTRICAL PERMIT FEES a) including photovoltaic-&- Signs: $25.00 each ballast (Effective March 12, 2003) generating Equip Per KVA $1.00 Smoke &Heat Detectors & MINIMUIYI PERMIT FEhS b)un-interruptible power systems, Initiatin Devices: g RESIDENTIAT; $25:00 per KVA $1.00 Residential: $1.00 each COMMERCIAL $S0,0, c) batteries over 100 amp. hours, per Commercial: $60.00 up to 10 NO SE CABLE ON cell $1.00 devices over 10 - $1.00 each OUTSIDE OF BUILDING Heat Devices: $1.00 each Space Heaters: Air Conditioners: $40.00 each Heat Pumps: $40.00 each area heating$1.00 each Alarm Systems Security: (for fire Hydro-Massage Bathtubs/Hot Sub-Panel: $25.00 i i 00 each Swimming systems see smoke/heat detectors) Tubs: $20. g Pools: Residential: $40.00 Lighting Fixtures $,1.00 each, -r Residential: Commercial: up to 10 Devices Lighting Outlets`'$1'.00,each'- Above Ground: $25.00 $60.00 additional devices over 10- Major Appliances:`(nr,t l`ffed) Inground: $50.00 $1.00 each $20 each Commercial Pool: $100.00 Carnival Equipment: $50.00 each Motors: (per hp or fractional part Switches: $1.00 each Ceiling Fans: $1.00 each thereof) $2.00 Temporary Service: Oil/Gas Burners: !�l:nsr have Utility Authorization Number Commercial New Construction or Residential$20.00 each Residential$25.00 Alterations: Alteratper 1,000 Sq. Ft. of Commercial$20.00 each Commercial $100.00 Construction Space Office Furnishings: per circuit$10 Transformers: Commercial Service Change/ (Relocatable Partitions/Cubicles) a)capacitors, Per KVA $1.00 Repair: Outlets & Fixture: $1.00 each b) ducts,conduit &conductors M iisi have Utility Artthorization Number Ovens Built in/Counter Top Units: (Associated w/Padmount Transformers)$415 $100 (first 100 amperes or fraction,one $10.00 each c)each manhole$10.00 meter) Panel Change/Circuit Breaker: d)each handhold$5.00 a) each additional 100 amperes Residential: $20.00 e)per KVA$1.00 capacity or fraction. $30.00 Commercial: $25.00 0 primary feeders, $25.00 each(over b) each additional meter$25.00 Phone Jacks: See 600 volts,non-utility owned) j g)vaults and equip. $25.00 each Commercial Temporary Service: data/telecommunications Washers: $15.00 each $100.00 Ran �es $15.00 each ikiust have Utility Authorization NumberWaste Disposals: $5.00 each Receptacle Outlets: $1.00 each Water Heaters: $30.00 each r w _ : l Repaird/ and/or Lonime ciaRecessed Fixtures: $1.00 each Maintenance Permit: (Blanket yl NSC Re-inspection Fee: $25.00 Permit)up to 2 Electricians$150.00er pair of Electricians over 2$50.00 or lIN'jQllti-Fa>i> itv, & Repair to Service Residential: .- $20.00 serge Commercial Project Data/Telecommunication: Residential New Construction Residential: $1.00 per port :SQL Wiring Inspector for (Dwelling): $220.00 Commercial: $30.00 up to 10 pricing: (with service_up to 200 amps) devices over 10-$1.00 each Nhist have Utilita-Antlwization Number pawl Kennedy (978) 623-83016 . Dishwashers & Disposals: for services over 200 amps.see below (Office fours 8 ani to. 1.0 am) $5.00 Each a) for each 100 amps capacity or Dryer : $15.00 Each fraction add$20.00e. Emergency Lighting (Battery Units) b) each additional meter$10.00 Inspection .yt hedul. $ 1.00 each unit c) each additional panel/sub panel 1 ROUGH t Feeders or Sub-feeders: $25.00 1 FI=NAL � each 100 amp capacity of fraction Residential Additions/Alterations: 1 TRENCH (if applicable) thereof Residential: $5.00 each $220.00 maximum Commercial: $15.00 each Residential Service Change or ADDITIONAL Gas/Oil Burners: Underground Service:$40.00 INSPEC TIO S ''$25 00 or Residential: $20.00 each Must have Utility Authorization Number applicable) Commercial$20.00 each a) one meter,up to 100 amp capacity $40.00 (revised 07/05) b) each additional 100 amp capacity or fraction$20.00