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Miscellaneous - 160 BRIDLE PATH 4/30/2018 (2)
/ 160 BRIDLE PATH \ 21O/1O4.0-0076-0000.0 IN I i Date...- ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... ....... 4y ........................... has permission to perform ......... ........................... wiring in the building Of........M'q 1?6A Aj............................................. at......... ........ ............................. North Andover,Mass. Fee ........... Lic.No-iTW4�.......... /? r- �,/f 2.P.... jEtecrxiCAL INSPEMi( Check # 8561 BO RDOFFEEP1EVENUONmom RBts A1i0NS aeit4at�e � �.T�E FOR PELT TO PER�+O Ci'R1�AtyMORK rt�r�ataaz �D NO Daft bdkm .riW■t m o r g 9 y) ' AdW e '_5ckAP, �e!•itaegodmolmumsbummal W a D Mb Ell a�e�■t� P �! _ �■�, ML seedea� AMP /,_its Oweiesi0 An" It w4ft a•.ie.iQ Odw- D lre..raTefe� wi�na i A9 777 oil )rc,, " ails 11is A XVA 13m!" - ',r MSCAI&rC=imL 11■es _ �tA1es �esies Geis� � 1AI D air Mks&= KwINS mels Z�eileis ! �1e1! 77 �iaiees�r � =7)m �14Ic � �' -� ill M IIiiass..i.�ibie�ar�==���0.�,�0e�E�ieeNie�two �s�saiees i�sss:i isiaSeoa�...iise■iiioa�., �;"�'�'ii4WD IN GOOL 13awe El owd C�1 n� u r-api c 42 4 20 n g �!!�°"�'sirws�■its�iee�� eele►d 'P� w1�s ol : _ � r neiw'i_s r W *1' a is(E.�MLi- i - . "---... r ��,- �- -- -� - 1 - • �,, / .. /� r o9� � _ � � ( ( ( r v . . Date i NORTH 3?oq";'*°'"*.. o` TOWN OF NORTH ANDOVER j '" PERMIT FOR PLUMBING 71 �r,D w 1SSACMUSf This certifies that . . . . A I ��`�"` . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . .�. . . . . . . . . . . . . . . . . . . . . . . . plumbing in the k buildings of . .�`�'`. d� �. . . . . . . . . . . . . . . . . . . . . at . .f�.d fi ! �t�l� �l . . . . . . . . ., North Andover, Mass. Fee.32 Lic. No..�. . . . . . . . . . . . . . .. . . . - . . . . . . . / PLUMBING INSPECTOR Check # I -� f 7959 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) LCIr4AS��1��Mass. OatePermit # �^ Building Location_ �r© 1' �F QL7 h Owners Nam _1- A —�— -7 _2 Type of Occupancy. Residential New ❑ Renovation ❑ Replacement Plans Submitted: Yes ❑ No ❑ FIXTURES I Zcn = r4 j n Z YP_ I rz 0 w ta- w N r 0 r4 o cr � Z n u z �' a tQ)j Sa x p w n — a_ 1 0 z Cr. m Q w } a r- cn z p a a s 0 N N W w w d rn o < w n a _ o 0 i z C 2 3 3 0 x i > X a ¢ a x w r U z a o = _ ( x P � � SI a r- > r o 0 (n t- x 0 0 mwf SUB—BSMT. f BASEMENT =kF p 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOORHIE 5TH FLOOR 6TH FLOOR 7TH FLOOR TT I 8TH FLOOR i Installing Company Name Heritage Htg. &Plg. Co. Inc Check one: Certificate Address_ 35 Pl aunt Street EXCorporation 714 Stoneham, Ma 02180 ❑ Partnership Business Telephone 781 —438-7776— n Firm/Co. Name of Licensed Plumber Gordon Switzer INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 2;1 No ❑ It you have checked_yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy L$ 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 El Agent❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of theGeneral Laws. By 4 Title Signature o1 er Licensed lum City/Town Type of License: Master[X Journeyman APPROVED(OFFICE USE ONLY) license Number 8322 %" Watts 9D Hp on water lisle to water boiler--- c� BELOW FOR OFFICE USE ONLY FINAL INSPECTIONS SKETC}{ES PROGRESS INSPECTIONS FEE NO.- APPLICATION O.___.APPLICATION FOR PERMIT TO DO PLUMBING NAME & TYPE OF BUILDING LOCATION OF BUILDING PLUMBER PERMIT GRANTED DATE 1g PLUMBING INSPECTOR sr it Date.... .. ... ..... . TOWN OF NORTH ANDOVER 0 $- PERMIT FOR WIRING 49 S CHUS EI This certifies that ......... ........................................................................... has permission to perform .... I ':� 4 k" .....A... .. .....S., -'-, z�...................... wiring in the building of....................1.191nfx�................................ at........./AQ...6!/tet.A ...... p1.. North Andover,Mass. Fee.:!�J—=. Lic.No . . ..................... . . G.. .... ...... . .d 2 ,fI06-7, -e6 3 ELI ICAL INSPE R Check # 8205 i ee II nV�/] / Official Use Only (//77rmgrc�mfornmonwaaltlr.o////a96acLe� Permit No. ��O ..(JeParfinerrf o�}ire�ervice� , Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 MR 120 �Q (PfEASE PRINT IN INK OR 7P ALL INFORMATION) Date: City or Town of: /'7� A)-I dV�°��.. To the Inspector of Wires: ' ( By this application the undersigned gives notice of hi or her intention erform the electrical work described below. Location (Street& Number) / --------p Owner or Tenant �� r�� T/17 C� ���1"fi� Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpese of Building Utility Authorization No. Fxting Service Amps / Volts Overhead ❑ Undgrd❑ Nv.of Meters NSW Service Amps / Volts Overhead❑ Undgrd,❑. No.of Meters Nu.—r)er of Feeders and Ampacity Location.and Nature of Proposed Electrical Work: IJ S�- I G'� 01= �c :L:.s t o t Completion of the followin cable m 5e iva sed by the Instie rdr bJ;'ricer �'� o.o Total -- FPo.Mir Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans 'Transformers �,'V.A — > l Y.of Luminaire Outlets No.of Hot Tubs Geueratot s K A _ — �� -- Above In- No.ot E Mxn rgccy ign-li —F - : No.'of L;!minaires Swimming Pool d. ❑ ornd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones C o.o etection and E--'r No.of Gas Burners Initiatin Devices No.of Switches Total No.of Alerting Devices No.of Ranges No.of Air Cond. Tons Heat Pump I Number I Tons o.of Self-Contained No.of Waste Disposers Totals:I Detection/Ale!:n Devices Local❑ Municipal ❑ Other No.of Dishwashers Space/Area Heating KW ion Appliances KW ecuri S ste evtces ' No.of Dryers Heating A pp or Equivalent iiA- o.of Water o.of No.o Data Wiring: Heaters ICW Si s Ballasts No.of Devices or Equivalent elecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent_ OTHER: QIP J �/o�=3 �p Attach additional detail cf desired,or as equired by the Inspector of Wires. Estimated Value of Electrical Work: - � ' (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless tiie 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 Q BOND ❑ OTHER ❑ (Specify:) I certify,under thepains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: St r S-c t' es LIC.NO.: -LI SC LIC.NO.: "HSC Lice {'�''�nsee: 1 1 1Qr Jhy Signator Bus.Tel.No.: S �a� (If applicable,enter "exempt"in the teen umber line.) O 3 0 L-� AIL Tel.No.: Address: 1 C,1,f n—k m i�1^• 1 t 5 iJ! Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License Lic.No: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement I am the(check one)❑owner owner's a ent. Owner/A ent PERMIT FEE: 3 'Signature Telephone No. DEPARTMII=NT OF PUBLIC SAFETY I; 't� v • S -LICENSE — ;�` Number. SS CO .000953 - �fr Birthdate: 02/07/1958 , Expires: 02!:712695 rr. no' io?.1) S-1_1censa: ADT SE0URITv SER%4'ICF MARK A BROPHY SR 111 MORSE ST NORWOOD, MA 02062 DIG SAFE CALL CENTER: (t Commissioner M TTS hWIER DRIVER'S LICENSE I S29197428 E I et7fOFtn11N Cuss REST MGM Ict F 02-07.1958 D 6.10 M -' ��� �'�-: �` !�� �4►�-7 I 02-07-2009 BROPHY MARK A 104 BOSTON ST MIDDLETON,MA — 01949.2119 yv�p�C- a ` t Fold,Then Delech Along All Pedorallons _) COMMONWEALTH OF MASSACHUSETTS D0ARD OC ELECTRICIANS FA REG'STER1;0 SYSTEM CONTRACTOR ISSUES THIS LICENSE TO I 1 TYPE AD-r SECURITY SERVICES , INC . MARK A '-BROPHY SR -C 111 'MORSE S I l NORWOOD MA 02062-4602 353795 45 C 07/31/10 • 353795 r , Fold,'rhen Delach Along AE Perforallons TONWR — .+....+�.....rwn Date l P ? NORTM "`° TOWN OF NORTH ANDOVER I * ; PERMIT FOR WIRING 8s.+c►n,s� This certifies that(f-4w ` ^ -0 AD u gni 10 Gam` f ..................J......... ....................................................................................... has permission to perform ........ ........................................................................ ' wiring in the building of...............�?.. .... ............................................................................ ��o at .................................................�........ /,)North Andover,Mass. ....................... Fee........... . .........Lic.No.13 Al ......................� ........ ..... ...:....... ` EL CAL INSPECTO� r Check# f ✓✓✓✓✓✓ t 14 .r L; U 17� Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No. q BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/99] 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:— I1z 67 /ol -3 City or Town of: lvoF-:4 e4vc(p6,1,^ 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) /(p(9 f3'`;y(`e i-3,otr�h Owner or Tenant 84.1- ", G tc MoTelephone No. Owner's Address Sjpm t"_ Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building j�(tfi�2GL Utility Authorization No. Existing Service act Amps 1912 / 6�,7 Volts Overhead ❑ Und rd I; ® No. of Meters / New Service Amps ! Volts Overhead ❑ Und rd g ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: � GeMcr I Completion of the followin table may be waived biv the Ins ector o Wires. of Recessed Fixtures No.o Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No. f Lighting Outlets No.of t Tubs Generators 'KVA a� - No.of .\ghting Fixtures Swimming ool Above ❑ In- o.o mergency ig mg rnd. rnd. ❑ BattUnits r No.of Receptacle Outlets No. of Oil Bu ers FFIRE�\�\ALARMS No. of Zones No.of Switches No. of Gas Burne No.of I ction and ,C Initiatt Devices No. of Ranges No.of Air Cond. TORI No.of Alertin�Devices Tons No.of Waste Dispb\ers H�Total P Number Tons__ KW No.of Setf-Contac ed Detection/Alertin vices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal Connections Other No.of Dryers Heating Appliances ICW Security Systems: No.of Devices or E u\lent No.of Water No.of No. of Heaters KW Si ns Ballasts Data Wiring: No.of Devices or E uival nt\ No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. 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:) 11 Estimated Value of Electrical Work: 1 3, ot9(> (Expiration Date) (When required by municipal policy.) Work to Start: 111 t r 0 Inspections to be requested in acco ance with MEC Rule 10,and upon completion. 7 certify, under t/ie pains and penalties of perjury,that theAOrman t ' app cationis true artd complete. FIRM NAME:ELECTRICAL DYNAMICS, INC. LIC.NO.:A13881Licensee:GARY R. LETOURNEAU SignaLIC. NO.:.A13 81 (Ifapplicable, enter "exempt"in the license number line.) Bus. Tel. No.:_ -664-1050 Address: 72B Concord Street North Reading, MA 01864 M OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the Iiability lnsu ance 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 T ephone No. PERMIT FEE. $ z D --Ttzwv 12 -6--1 -�r Pal J- `4 nil i 44 The Conntnonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 1 Co s:g rens Street Suite 100 Boston,AL4 02114-2017 wwminass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business'Oroanizationr'Ii,dividual). Electrical Dynamics, Inc./EDI Network Systems, Inc. Address: 72B Concord Street City/State/Zip: North Reading, MA 01864 phone #: 978-664-1050 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a empY to er with 109 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑Nle-,N, construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodelmg ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity.ca i employees and have workers' t5• 9. ❑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 hoineoNvner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑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. 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 isproviding trorkers'compensation insurance.for my employees. Belotn is the.policy and job site. information. Insurance Company Name: AMGuard Insurance Company Policy 4 or Self-iris. Lic. #: ELWC218391 Expiration Date: November 1, 2014 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisotuuent, as well as civil penalties in the forth 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 foi-xvarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi I r thelpains and penalties of perjury that the information provided above is true and correct. SiEnat re: Date: November 1, 2014 Phone#: 9M-664lbKo Official use,only. Do not write in this area,to be completer)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#: ` e I °� COMIIAONWE�LTBi OF M�S�ACliIDS�TT& ......: j r B. AFiZ7 OF E I�f CTR i C I A N S ISSUES THE FOLLOWING LICENSE ASA €.:. R -GISTfRtD MASTER fLECTRI'GIAN:.. a. EE ECTi�I CAL DYNAMIC 'I NC L 72B C0NGORD STREET iZ '. . f� KEADLNGMA: 01864=2607 �3881..:A 3281 I GENERATORTLITI DATE: LOCATION: f 6 OWNERS NAME: 1'12oria ll GENERATOR kw �Q 0 NO INSTALLATION OR GROUND DIS CONTRACTOR: BEFORE APPROVALS* CONTRACTOR: PHONE NUMBER: 27S' �-,6 Y- ELECTRICAL GAS RESIDENTIAL COMMERCIAL TEMPORARY LOCATION OF GENERATOR: er *ZONING DISTRICT: I *PLANNING APPROVAL IF IN WATERSHED) 11 i 13 *CONSERVATION APPRO AL 5� c P LaA {. t`�' ( 1�. I c k)l r/j 3 co, ii C(wr/V 0 =Grie Am t ail c: Alle �6 F .._ d shy I ! F 'K � y -"' SEWER LINE' F r •s' J 161.8 1 i •,, f �} � � }fila / 4T.,-CONC.BEI 1 ! t 1 - - 1156•.3 \ t ,. - BN'W // l T ivl1 a 4 S BVW t � D } 07 4 a. ! BVW r r 153'0 �3 AC. ' BVt?4# y Co 156.6 vL� i _,...:ea,...i,e�-,.w�st...-.v..rc.—r--_.,a,+aw.-.,aarx,..�::u>,�isz..:n:,r.�++x�,.:.Tss..•...�.w.-...,F.:.,:.....w.: -.-.-:....nsza...=*...s�:�us...M-.._:�axv�r�re_..r.:wr-:..,.<.w,-+�1:•=�.r.,..M+.+ca:--=R-��,.»•<:-.:........-..-:-.�-.< c • a a a { xm°1 sr1d�s Ci X.3 a of v '90 9, 0Q/ r h 0 I North Andover MIMAP November 1 2013 i r I P rte rc �ra iS I 31 1W4 i gar y interstates Interstate —Major Roads Horizontal Datum:MA Staleplane Coordinate System,Datum NAD83, Roads Meters Data Sources:The data for this map was produced by Merrimack Cf Easementsf pOR1M N Valley Planning Commission(MVPC)using data provided by the Town of C3 MVPC Boundary O 4t�ao ra'.trO North Andover.Additional data provided by the Executive Office of ? e� ♦ O Environmental Affairs/MassGIS.The information depicted on this map is [7 Parcels Cfor planning purposes only.It may not be adequate for legal boundary F a definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER "' MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING i ♦ THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY f s ^ 7 OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION �ITSACHUSe� 1"=150 ft �E North Andover MIMAP November 1, 2013 10 .0-0120 2 ; - 11)4.0-0017 t #2 ^ � ,�, '�''� �'.��°�'�",���;� •104: =0011 ✓ ;r '' 104:C-0072 r .. ., : a.• . :. 104:C-00 3 #124 �`..f" .:.:•.:-.� ..'.. •• - ..:•.. 104:0-0089 #136 -•' '' t _ 104:C=0086 Water Protection•= 104.0=0015•.:••.: •:•:-::�:: ..:'. I .....':•. - �'� ` V /#300 t ifl4.0=00 9 Rail Line _w Wetlands Zoning Interstates C7 Exempt Lands Busme s 1 District Interstate Busme s 2 Distract Hmixwovl Datum.MA ftwplane Coordmate Sys%m,D ahmi N AD83, ! —Major Roads 23 Mine!s 3 District Meters Data Seutmoc The data trthis map was prmiuc,d by F weimck E Busine s 4 Distract pORTN U'aaley FyRnnang Aoranea84W MVPCt}using data pmvWed 6y the Town of Roads N Genera Business District Of t�ao qr�. ''aft,+'*+;t"ww,Add`ikinte(data provseled by tEm Executive C>#tzce of O Planne Commercial Dev r• C r Easements ? •4 +a OQ Enuiroementaf A{6airstMas #S,T,"a e{`fornnat un dnpided on this map rs Comdo Develo ment Dist O MVPC Boundary P 3 L Ycrr pVanrr*g�raarpdse¢dnly;it may evrtt*e 3tlacs.+r`ate for 1pga46¢nsaetaey M Comid Development Dist Q __. 1a c'd.6nuit?n txr ragadadety rntea}ste4atlsn THE TOWN OF NORTH ANDOVER 0 Municipal Boundary la Corrid Development Dist I. A MAKES t ba WARRRANTMS EXPRESSED DR IMPLIE€t,CONCERNING Industn I 1 District THE ACCURACY,COMPLETENESS,RE Lpk9fUTY OR SUR ABIUTy Zoning Overlay Y C.:Industn 12 Distract ^ # Or THESE G#tA.THE TCJWd't OF PSC}ETTFi kxNC1LaG'ER.DQE:MCAT O Adult Entertainment i Q IndusN 13 District r — i 0 Di toric ri Overlay District * o oc;K:. s. ♦ ASSUME ANY EMIL&'ASSOCATED WITH TRE USE OR MISUSE OF Q Historic District G Indusm I S District �+ ®Water Protection Reside ce 1 District 71 °+.cr10.'"tqh 'IS€4FORiMAINON Reside ce 2 District �9SSA ❑Parcels n R—ide ce 3 District CNU 9e C`.Hydrographic FeaturesA de ce 4 District---Streams 1"=150 ft ^K Tc de ce 5 Distract YYY de ce 6 Distract o—ge esidential District N° 2615 t NORTH, 3r;.��`";•_�.."�o� TOWN OF NORTH ANDOVER PERMIT FOR WIRING �,SSACMU This certifies that .....6.1.... .................................................................... has permission to perform :: .:..I'.` ' r :.r.� ...........:..:..................... .. ................ wiring in the building of ' at............... ........................................................ ,North Andover,Mass. .......... -1/ ' �Fe� 5................ Lic.No.�`1: � � t�::. .. ...... .................... � �--`- ELECTRICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK:Treasurer 1� ! _ Commonwealth of Massachusetts Ol icial Use Only Department of Fire Services Permit No. ©gGAr BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checkeda5�� [Rev. 11/99) (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: 047— #-- jg1Lk'/�'Ue1k—' To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform die electrical work described below. Location(Street&Number) a L� Y04 T* Owner or Tenant S"� Cc_ ® �J Telephone No. Owner's Address Is this permit in conjunction with a building,permit? Yes ❑ No [ ] (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Sen�ice 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: 0 I^ ol-m 0- e /Z)� Completion of the followingtable may be waived by the Inspector of 11•ires. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No. of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above ❑ In ❑ o. o Emergency Lighting Lighting b b Md. ornd. Batten•Units No.of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No. of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No. of Alerting Devices Tons b No.of Waste Disposers Heat Pum rNumber Tons KW No. of elf- ontained Totals: ----•--• - Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other onnection No.of Dryers Heating Appliances KW ecunty System . es or Equivalent No.of Water KW o.o o.o Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Ifires. 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'd (Expiration Date) Estimated Value of E ctric 1 Work: f Q • (When required by municipal policy.) Work to Start: 9 Inspections to be requested in accordance with MEC Rule 10,and upon completion. I I certify,under the pains and penalties of perjure,that the information on this application is true and complete FIRM NAME: ADT Security Services 111 Morse Street,No voo.,MA 02062 LIC. NO.: 1533C Licensee: John S.Bassett Signature LIC. NO.: 1533C (If applicable,enter"exempt"in the license number line) Bus. Tel. No.•-7$127.8-1169 Address: Alt. Tel. No.603 594 5928 R.ESI ONLY OWNER'S INSURANCE WAIVER: I am aware that the LicYnsee 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: $3J� Date o.�. 1)... . NpRTry TOWN OF NORTH ANDOVER p� �.•o;�,gyp PERMIT FOR PLUMBING SSACMUS� This certifies that �. . . has permission to perform . . vn Q.Q. : `? plumbing in the buildings ofta�V.l?. . . . . . . . . . . . . . . . . . . . . at. �Q.�e, . . . . . . . . . f-North Andover Mass. Fee4'?.,.t. . . .Lic. No' ?t00© . Mom , - . . . . . PLUMBING INSPECTOR Check i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE Z ( PERMIT# JOBSITE ADDRESS (� © _ r,j a� OWNER'S NAME oeG✓i rl _ I POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL © RESIDENTIAL Rol'- PRINT oPRINT CLEARLY NEW: I RENOVATION:' REPLACEMENT: PLANS SUBMITTED: YES[] NO FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 � BATHTUB ( __._._1 [ i CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSANDSYSTEM i ,._ _ _! _ { I _- ,� _ I _1 .__ I { 1 I -1 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER _i 1 ___--.- ' -- .-.__.J J ._-_-J __J J _-...._! __J _-.__._I ...r._J I DRINKING FOUNTAIN FOOD DISPOSER PF=1 FLOOR/AREA DRAININTERCEPTOR INTERIOR I I J .-_-. I I __. 1 _.__.JKITCHEN SINKLAVATORYROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL -A ----- --- -- WASHING MACHINE CONNECTION _..... WATER HEATER ALL TYPES ( ! _ 1 1 J== WATER PIPING I _-► -�-�I _ ___.f i . ! _. __ _ ( ____ ! ! _I i OTHER _77- EJ _I INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 9-�O a IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ' OTHER TYPE OF INDEMNITY Q BOND DI 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 0 AGENT SIGNATURE OF OWNER OR AGENT 6 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate Whe best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com it a e ' t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ (LICENSE# _ ®_i SIGNATURE IVIP 01 JP R"" CORPORATION r-11# _ j PARTNERSHIP D# I LLC COMPANY NAME rt4 S-,De-Fro,, ADDRESS ( t CITY --- STATE G ZIP T� (tel g �_$ TEL FAX L= _ - CELL --..I EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No l THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 1 The Commonwealth of Massachusetts fu D2 Department ofIndustrialAccidents VM Office ofInvestigations 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/Organizatio0ndividual): ,r, O(L Address: l Cq q 4-2, p7 �:� ( � o�� J gip/ Ci /State/Zi : G p S Phone 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 1 6. QNzw construction _ eniployees(full and/or part-time).* have hired the sub-contractors 2. :+1 am a sole proprietor or partner- listed on the attached sheet.T odeling 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.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.[i 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. 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 cert fy and pai and penalties of perjury that the information provided ahoy e is t1rue correct - Signature: Date: 6 L� Phone#: op)) 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 j oint 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 numbers)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 anLLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel#61.7-727-4900 ext 406 or 1.-877,MASS.A.B& Revised 5-26-05 Fax#617-727-7749 v WW=ss,govfdia 1 Date..�....y. ................... �10RT1y 1 TOWN OF NORTH ANDOVER 9 PERMIT FOR WIRING s j This certifies that .............."�. has permission to perform ...�-i Vic.L.9.�1....�,e aM .. .. .... ..................... wiring in the building of.... .....�1^.............................................................................. at ........'. ....... �� ........... .................. .North Andover,Ma . ►� . 6-.1.... .......... ....... Fee.. Z. ......Lic.No. .....�.. �.. . .......... .......... E CAL INSPECTOR Check# -174 2 3 i, 5 �r : CoRlI onwealm of Maw-c ..I[S ! Oficial US`Only went of Fire •' Services � � �o. BOARD OF FIRE PREVE"ON REGULATIONS Occupancy and Fee Checked Rev. I1/99] heave blank) --- —_ APPLICATION FOR PERMIT TO PERFORM ELECTRIC All www to be performed in accordance with me?vF�sszcauseas Electrical Code : A.0 CORK (PLZ4SE PRINT'IN INK OR (mac);s2%cis z 2.00 14LIINFORM�4TI01VJDate: City or Town of: U By ft To the inspector --'-- app cadoathe of wires: gauss notice of s or her intention to perform The eiecn-ica:work described below. c &Number) Jl�(� 4r d le rva >Vlalm Int. Owner or Teaaat Teiephoae No. ��(1 Owner's AddressIs thb Permit ill c0lauctift Willi a bang , Yes i No ❑ Btilding Permit; PRMOse of Building Utility Authorization No. E'tt sft Service Amps ! Vohs Overhead D Undgrd❑ ?!o.of Meters New APs I Vohs Overhead ❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity L0102doa and Nature of Proposed Electrical'Work: Y Com Dellen of 1he follow' table be waived by the Istcpector of Wire No.of Recessed Pb tres No.of CeL-Susp.(Paddle)Fans No-of Total Transformers KVA No.of Iaghtmg Outlets No.of Hot Tabs Generators KVA a � N0.of LAOtag Fres swimming Pool Above D In- D o.o d. 1AMM Units N0.of Bemptacle Outlets No.of OR Burners FIRE ALARMS No.of Zones I No.of Swkdtes No.of Gas Barney No.of Detection and Devices N0.of ItaBges / No.of Air Cond. 1 Tons No.of Alerting Devices No.of Waste Disposers Hest Pomp Naotber I Tons KW No.of Self-Contaiaed Totals- R9t9fiWAJerbRg Devices N0.of DishwashersSpace/Area Heating KW Local D llgnaxxpa3 D Other COMectfon No.of DSryers Heating Appliances KWsecrif systems- o. v s or eivaleat 0.of ater KW No.of No.of Data Wirin . Heaters Signs No.of Devices or t No.HYdro> e Bathtubs No.of Motors Total HP ITelecommunications Wiring; No.of Devices or aiv�eat OTHIR-- ver ler S rErtaeh additional dewR 8rdesi7ed,or as required by the bzWccror ofW, INSURANCE COVERAGE: finless waived by the owner,no permit for time performance of electrical work may issue unless the licensee provides proof of liability iasmance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that s coverage is in force,and has eximtb' proof of same to the permit issuing off ce. � CHECK ONE: INSURANCE �! BOND D OTHER D (Specify:) � d Estimaud value'of Electrical Work (When required by municipal policy.) Date) work to Stats"16 ID inspections to be requested in accordance with MIEC Rule i 0,and noon completion. Icerdfy,Under fhePabw andPmahla ofperjury,that the hiformation on this application is true and corrrplete_ FntM NAMjjE:C1 r i s 2r: ti , LIC.NO.: '2 flfagplieable,ewer•�ernpl"b1 i�lieotse�aanber line. �c �.A sus-Tel.?iia: 1, '1� �idd►ress: (✓p,� � i t� . �('�Lr3C� Alt_Tel.10.: OWN 'S Il�iSliitANCE WAVER: I am aware that a Licensee,3aes not have the liabilSy insurarsce coverage normally required by 1 $y mq signalise below,I hereby waive this requirement I am the(check one)D owner D owner's ageat._ Owner/Agent PERMIT FEE. S '� Signature Telephone No. I t ®lz � 2e-- Al �i I I i I i :OMMO W IILTH.OF M �1�SWS � °i> €i .I-C:. jjSE "A I Cl AN :>ISSS THF,.-:-FOLLOWING S: A UE :.. : .«a. LECTRICIAN''=' ; a� t ELECTRI C .,}I"N C` 3955 .x ti A oig61-395'5 `07/ l #_. 45416 730:: ;A>: 1,� ..<. OMMONWE `LTH O.-IVAWiU `. • 9pusilaoue • Mas 14[4dq, I AN '.�`. I SSU HE FOLLOW111(:R" l'I CES. : ":' E 5 E::.::. OURNEY I �N 'ELECTR ICI1� No M D..I:N I fi UW Y' DATE(MM/DDIYY ) 11/ / 03CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terns and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights E holder in lieu of such endorsement(s). to the PRODUCER CONTACT NAME: Wally Valdez, CIC, CISR EA Stevens Company, Inc. PHONE wr, FAX 389 Main St. E-MAIL (781)322-2324 A/C No:(781)397-7672 P• 0. BOX 188 ADDRESS:wallyva@eastevenS.inS.COIII I Malden MA 02148 INSURERS)AFFORDING COVERAGE NAIC# INSURED INSURERA:PeerleSS Insurance Company Dinis Electric Inc INSUREReThe Netherlands Insurance 4171 PO Box 3955 INSURERC:Peerless Ins 4198 INSURER 0: Peabody MA 01960 INSURER E: COVERAGESINSURER F CERTIFICATE NUMBER?013-2014 THIS IS TO CERTIFY THAT THE POLON NUMBER: ICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMIEED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VVITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADDL SUER TYPE OF INSURANCE POLICY EFF POLICY EXP GENERAL LIABILITY POLICY NUMBER MM/DD MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE S 1,000,000 PREM SES Ea occu Dnce S 100,000 A CLAIMS MADE OCCUR SP3918373 IF/2/2013 8/2/2014 MED EXP(Any one person) S 15,000 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,00 X POLICY PRO- LOC PRODUCTS-COMP/OPAGG S 2,000,000 AUTOMOBILE LIABILITY S COMBINED SINGLE LIMIT B ANY AUTO Ea accident S 1 000 000 ALL OWNED X SCHEDULED BODILY INJURY(Per person) $ AUTOS AUTOS 3918368 /2/2013 8/2/2014 X HIRED AUTOS X NON-OWNED BODILY INJURY(Per accident) S AUTOS PROPERTY DAMAGE Per accident S X UMBRELLA LIABX OCCUR Underinsured motorist BI s lit S 100,000 C EXCESS LIAR CLAIMS-MADE EACH OCCURRENCE S 1,000,000 DED X RETENTIONS 10,008791524 8/2/2013 AGGREGATE S 1,000,000 (` WORKERS COMPENSATION 8/2/2014 S AND EMPLOYERS'LIABILITY WC STATU- 0TH- ANY PROPRIETOR/PARTNER/EXECUTIVE Y!N X T RY IMIT OFFICERIMEMBEREXCLUDED? IN NIA E.L.EACH ACCIDENT If ns,dtorybeund C3918369 /2/2013 8/2/2014 $ 500 000 Dyes,describe under E.L.DISEASE-EA EMPLOYE S DESCRIPTION OF OPERATIONS below $00 000 A BPP E.L.DISEASE-POLICY LIMIT S 500,000 BP3918373 8/2/2013 /2/2014 t $33,530 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Electrical Inspector 1600 Osgood St AUTHORIZED REPRESENTATIVE North Andover, MA 01845 /+ ACORD 25 Thomas Cares, Jr/WV ' (2010/05) / INS025 19mnn5t ni ©1988-2010 ACORD CORPORATION. All rightsreserved. Tho Ar nPn nmmo mnrt Innn aro ronietorori mmAce of Arr1Rr1 ' i 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): 0 0r Address: City/State/Zip: (p Phone #: S�V�• '�f Are you an employer? Check thea propriate box: 4. I am a general contractor Type of project(required): 1.Q'I am a employer with g and I e sub-contractors New con employees(full and/or part-ttme).• have hired the sub contractors ❑ construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g• ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.= 9• ❑ Building addition required.]. 5. [] We are a corporation and its 10.ZElectrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their l l.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 152 12.[:] Roof repairs c. insurance required.] �' , §1(4), and we have no employees. [No workers' 13•7 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. jHomeowners 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: .Policy#or Self-ins. Lic.#: 4(�,,, �j cj Expiration Date: 071) Job Site Address: City/State/Zip: _ Y, �- n 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. Ido hereby cern under the pains and penalties of perjury that the information provided above is true and correct Si ature: Date: �(p 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#:_ `J ..................... ° TOWN OF NORTH ANDOVER O p PERMIT FOR WIRING This certifies that ....\�. Ps ��"�e e/___ .................................................................................................... has permission to perform ......../)J,— ...................................... wiring in the building of.......�....:/..d .. ........................................................................:........ ///off 2,e//e . .at .........:..4.................�.................................................................. rth Andover,Mass. Fee...'.J........:. Lic.No3d'.. ...... ................. ELECTRICAL'�NSPECTOR. 1 7 Check# f 12 r: 3 C,ommonweakk o f kamacLeffj Official Use Only (�) Apa,&,d ol5ioe Semiced Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank _ 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 INFOR41ATION) Date: L2 7-/Z City or Town of: /10 rA AP a°dP� To the Inspector of Wires: By this application the undersigned gives noticeof his or her inten ion to pe form the electrical work described below. Location(Street&Number) /� Q �/t�, e , Owner or Tenant �q -tG n'Id��c,v) Telephone No. Owner's Address `jdj h7 ?/Yr48,- ya p Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building //e_S/leo Ce • Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd[J No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 24 Completion of the ollowin table may be waived by the Inspector o 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 1 No.of Luminaires Swimming Pool Above ❑ In- E:] No.of Emergency ig mg rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switcheso.o Gas Burne Z 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 PumpNumber Tons KW No.of Self-Contained Totals: "` Detection/Alerting Devices �-- No.of Dishwashers Space/Area Heating KW Local ElMunicipal ElOther Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water , No.of No.of Data Wiring: Heaters Si ns Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: ] Attach additional detail if desired,or as required by the Inspector of Wires. 77-- Estimated Value of Electrical Work: 3s© �- (When required by municipal policy.) Work to Start: C6 al Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COV GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless �J the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The o 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:) Afsl/z 1 cert,under the pains aid penalties of perjury,that the information on this application true and complete FIRM NAME: e LIC.NO.: Licensee: Signature LIC.NO.: (If applicable,enter "ex m t"int license number line) Bus.Tel.No.: �7 rt` Z f!J >>f Address: P X�_V, "g /-/]d"j IAJ 4-0 1-4-1-4114 Alt.Tel.No.: 17f_- e.S Z Z,S.?,1 *Per M.G.L.c. 14 ,s.57-61,security work re ire-be'epartment o Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent / Signature Telephone No. PERMIT FEE. $ �. — The Commonwealth of.iVlassachusetts Department of Industrigl Accidents Office of Invesfigations 600 Washington Street Boston,MA 02111 www.rnass gov1d1a Workers' Compensation Insurance Affidavit: Bunders/Contractors/Electriicians/Plumbers Applicant Information Please Print Le0bly Name(Business/Organization/Individual): Address:_ City/State/Zip: �P � DGfj Phone#: �(� �,� ,%S3 L Are you an employer?Check the appropriate box: Type of project.(required): J.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have Hired the sub-contractors 2 I am a sole proprietor or partner- listed on the attached sheet.� 7• El Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition ` working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its xequired.] officers have exercised their 10.F1 Electrical repairs or additions 3.01 am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] 'Any applicant that checks box A must also fill out the section below showing their workers'compensation policy information. i'Homeowners who submit this affidavit indicating they tie doing all work and then hire outside contractors must submit anew affidavit indicating such. }Contractors that check this box must attached an idditional sheet showing the name of the sub-contractors and their workers'comp.policy information. i X 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: s 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 xequiredunder 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 maybe forwarded to the Office sof Investigations of the DIA for insurance coverage verification. X do hereby cert&unler thepains and pen Ities ofpe&ry that the information provided above is true and correct. Signature: Date: 2-9-. Phone#: ` V =53 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 ortrustee 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 P construction or repair wank on such d or on the grounds or building appurtenant thereto shall o p welling house g pp not because of such employment ent be deemed to . p ym bean 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 ofpublic 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 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 au LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions 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 whichwill 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 oflnvestigations 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 Co oawealth,off-assa.,chv�sPtls Department of%dustrial.Accidents Office offaVestigalaoas 600 Washington,Street Boston,MA 021 It TQ1.#617-727-4900 oxt 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 wt .Mass,gov/dia r•' i �. . 1 I I Date.....................................(....... ' OF NORT#y,� oar TOWN OF NORTH ANDOVER 9 PERMIT FOR WIRING SSACFiuS� This certifies that ............... ....... .. .. . ........................................................ ...... ...... .... . has permission to perform .....09d,-V-Tr✓' Af— f�T/t!... ........................................... . wiringin the building of............... J..................................................... at ..... . .. .. L.f;.... /' ............. ..............North Andover,Mass. a 1 Fee....,57 --' Lic. No. ..�. 7. ..:. --��...AA�Gl. .... G� Check,, ELECTRICAL INSPECTORU 1 C J 1 y - (commonwealth of/I'lam"4i"eth Official Use Only 4 c7 I � 5 Permit No. � 2epartment of im Services 16 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMAT O1-N) Date: 2 ' Ci or Town of: CII !��V To the In pecto of Wires: By this application the undersigned Tues notice of his or her intention to perform the electrical work described below. Location(Street&Number) �j or(A P!cA Owner or Tenant Oajr 0 Telephone No. Owner's Address V 534 K e g Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building 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: E Ili ( .SL d h r �l7�— iJh1P Gr Completion of the followingtable maybe 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 1 No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting i rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total J No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons J.KW No.of Self-Contained Totals: I 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 Kms, 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: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electri1 Work: V (When required by municipal policy.) Work to Start: &. � tInspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VE GE: 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:) Go r I certify,under thepains andpenalties of perjury,that the information n this application is true and complete. FIRM NAME: LIC.NO.: 35217 Licensee: Signature LIC.NO.: (If applicable, enter "e t"in he license r�ber linp,� �P/' Q! �f� Bus.Tel.No.: Address: X -r (/i'f 1le Alt.Tel.No.: i *Per M.G.L.c. 1147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE. $ ____ _ � � � / r �. `� � 1 • �t 4 r 1 R. .- , , , , r The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations A ' d I Congress Street, Suite 100 w t Boston, MA 02114-2017 °�M S�•''•� www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Ef M L.e d,�a Address: �ree City/State/Zip: 1�eAveq ba Off 6 Phone#: 5) 7533 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 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. ❑Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. F1 Building addition [No workers' comp. insurance comp. insurance.1 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 1 I.F] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 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 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: _ 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 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 nder the pains and penalties of perjury that the information provided above/is true and correct. Si ature: Date: 2/ Phone#: 7 7J'CfS7- 7, Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermitJLicense# 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#: Date..n...1.7, fl TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that i ow c'............................................................. .................................. i L has permission to perform...... .........r.f A...... .................... plumbing in the buildings of ez-4"-1 y..... ........................................................ at..........�.�A()........�YtIIN �' .............................. .........., North Andover, Mass. a) FeeAZTn.....Lic. No. V.0................................................................... PLUMBING INSPECTOR Check, 9ol 2,P �. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE PERMIT# JOBSITE ADDRESS Q r`rr OWNER'S NAME o o wih. POWNER ADDRESS Sq /1-3- C� TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL-D EDUCATIONAL Ell RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION: REPLACEMENT:D PLANS SUBMITTED: YES® NOM-1 FIXTURES'l FLOOR--> BSM 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 v j BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM _f ( —JI ( 1.-1 DEDICATED GREASE SYSTEM _Tj _( i _1 DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM i __._--_J DISHWASHER i _-. ( --- DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREADRAIN -- INTERCEPTOR(INTERIOR) ( ._..—.( KITCHEN SINK I _ -__J __1 -- J i __—( J t _f _--- i --------( -----J LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET I -_i ___ (' URINAL WASHING MACHINE CONNECTION ( ► __.__ ` _____j ____ _ r __I _-J �_� - __J __..___j .._ _ __ _j —j WATER HEATER ALL TYPES WATER PIPING OTHER L _ — ( ( -__.__I .--j ( _.___.i jj INSURANCE COVERAGE: have a current liab_ ility insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ,__ NO IF YOU CHECKED YES,PLEASE INDICATE THE TY F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND M 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 ID 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 acc to to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in ce w I Pe ' rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ® CI E'_ =LICENSE# SIGNATURE MP 0I JP Er— CORPORATION 0#PARTNERSHIP 0# LLC COMPANY AME ADDRESS ADDRESS CITY ��— ... ...._..._.__7 STATE �� ZIP _ C --- TEL FAX ( CELL ��EMAIL _a 4�;Irp )jX1 ! l ROUGH PLUMBING INSPEC NOTES BELOW FOR OFFICE USE ONLY FINAL INS ECT. N OTES Sl S jq4Q49 Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of lndustriq[Accidents Office of Investigations 9 600 Washington.Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers AvOleant Information Please Print Legibly Name(Business/Organization/Individual): i'R q C Address: di 2� �� v iCA ff City/State/Zip: Q\ ' �, hone#: ? K ��3 '—�0 Z� Are you an employer?Check the appropriate box: Type of project(required): l.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2._ am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.[1 Electrical repairs or additions 3.❑ I am a homeowner,doing allwork right of exemption per MGL I LE]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' comp.insurance required.] 13.❑Other XAny 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 aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that 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 maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. I I do hereby certi z s a enaldes ofper'r lint-Oie4gyc b mation provided above' true and correct. - Sip-nature: Date: Phone#: 2-6 Official use only. Do not write in this area to be completed b ci or town official. Y P Y tY .ff City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: 1 . t 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 lie-ensing 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`Weither 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 LL C or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions 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(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that 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 orpermit 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: `I.'ho Coinmonwealt� ofMossarliusetts Department ofIndustrial Accidents OfRoe offavestigations 600 Washington.Street Boston MA 02111 `QL#617727-4900 at 406 or 1-877cMASSAFE Revised 5-26-05 Fax#617-727-7749 VV1W u-mace anid,445i h i i i r SASE h � .l CEt 11ES AJ E 1A ,''PL 1 i E CA 9J DE FRONZO , ; ; A 01,983-1 t Y I w 2012 Massachusetts Electrical Code Amendments 527 CMR12.00§Rule 8: in accordance-withtheprovisions 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.RL c. 166,§32,an electrical permit shall he 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 shalLbe limited as to the time of ongoing construction activity,and maybe deemed_by_theJuspector_of_Wires abandoned-and.in elid.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. N! �nde 8—Permit/Date Closed: ***Note:Reapply for new permi ❑Permit Extension Act—Permit/Date Closed: Date . . . . . . . . . . . . . � »M TOWN OF NORTH ANDOVER PERMIT FOR WIRING 'This certifies that .` .�. . . . . . . . has permission to perform . . f 'T�Y !r!(. . . . . . . . . . . . . . . . . wiring in the building of . . . . . . . . . , , , , , , , , , , , , , , , at . . . 6.©. 1. �fl . . ,1� , , No h Andover, Mass. �Fee :�. . . . . Lic. No. �7�D7.� . . . . . . . . .� ELECTRICAL INSPECTOf Check# 1.0902 Commonwealth of Massachusetts official Use only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked Vey.11/991 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MECO,527 CMR 1100 (PLEASE PRINT IN INK OR TYPE INFORMATIOA9 Date:_ Ce 02 City or Town Of: To the Inspector of fres. By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 1 n o 6n d_ a& j Map: Lot: I Owner or Tenant Q�l cl a 114an « Telephone No. — Owner's Address Ij Is this permit in conjunction with a building permit? Yes W No ❑ Building Permit# Purpose of Building Utility Authorization No. Existing Service Amps / Vohs 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: �yC � w` Co lesion of the ollowi table way be waived by the Inspector of Wires. tNo.of Recessed FixturesNo.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures 3 swi2t►ming Pool gr d. ❑ grd. Tinitigting Units�ry Lighting No.of Receptacle Outlets p� No.of Oil Burners ALARMS No.of Zones No.of Switches No.of Gas Burners Detection and Devices No.of Ranges No.of Air Cond. oil o.of Alerting Devices No.of Waste Heat Pump Number Tons KW No.of SeIPContained Disposers Totals: I I erting Devices Municipal No.of Dishwashers Space/Area Heating KW Logi ❑ Connection [I Other Heating Appliances KW Security Systems: ea No.of Dryers g pp No.of Devices or E uivAent No.of WaterKW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equhalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications EWWiring: y ge No,of Devices or E nipalent 1.4 OTHER: 29- Zurich additional detail if desired or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE lld BOND ❑ OTHER ❑ (Specify:) cR wa on mate) Estimated Value of EIectrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify,under the pains andpenalties ofperjury,that the information on this application is true and complete- FIRM NAME: n-,5 —[f_04-t ( LIG NO.: i 7319 Licensee: �.UC j n0 /�f n rS Signature IC.NO.: (Ifapplicable,enter"exempt"in the license number -Q line Bas.Tel.No. `S/•V Std/ Address: j1h6 i lotl�ch 1,Y74 0/91 e6 AIL Tel.No.: OWNER'S INSURANCE WAIVER: I am awarethat 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 rPERWTFEE.-$Signature Telephone No. - � l2 ' � � , o c-� �j ��� _ .. _ - . . . .. _ , �. i arm'- The Commonwealth ofMassachusetts Department of IndushialAccidenis Office of Investigations _ a 600 Washington Street = Boston,MA 02111 i S4 www.massgov/dia Workers' CompensationInsurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): {f j j S P ��fp : �r✓ Address: TDIZ-, sqss ss City/State/Zip: EULuAl IAA—LGILLPhone#: Are you an employer?Check the appropriate box: Type of project(required): 1.2 1 am a employer with 7 4. ❑ I am a general contractor and I employees(full and/or part-time)-* have hired the sub-contractors 6. New construction listed on the attached sheet. 7. ❑Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' ,. 9. Buildingaddition [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.❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.❑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. 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 provMi workers'compensation insurance for my employees Below is thepolicy and job site information. Insurance Company Name: PQ 7/e6S a��hn rte- . C � Policy#or Self-ins.Lic.#: (Oc 6-Is�j� � Expiration Date: � Job Site Address: I V `t City/StatelZip:VD. � (NP 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 dooereby cervi er the pains and penalties ofperjury that the information provided above is true and correct Si ature: Date: all, Phone#: / Official use only. Do not write in this area,to be completed by city or town ofciaL 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#: