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Miscellaneous - 165 MASSACHUSETTS AVENUE 4/30/2018 (2)
r 165 MASSACHUSETTS AVENUE 210/006.0-0045-0000 0 I North Andover Board;f Assessors Public Access Page 1 of 1 NORTk North Andover Board of Assessors OEt«ae,�t7'O Il44�property Record Card Click Seal To Return Parcel 1D :210/006.0-0045-0000.0 FY:2014 Community : North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge Search for Parcels Search for Sales ' Summary Residence r Detached Structure Condo 165 MASSACHUSETTS AVENUE Commercial Location: 165 MASSACHUSETTS AVENUE Owner Name: KORALISHN,ANDREW C/O MASSKEY DEVELOPMENT CORP Owner Address: 165 MASSACHUSETTS AVENUE City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood:5-5 Land Area: 0.11 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 1405 sgft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 269,800 269,800 Building Value: 124,600 124,600 Land Value: 145,200 145,200 Market Land Value: 145,200 Chapter Land Value: LATEST SALE Sale Price: 0 Sale Date: 12/31/1976 Arms Length Sale Code: N-NO-OTHER Grantor: Cert Doc: Book: 01289 Page: 0347 http://csc-ma.us/PROPAPP/display.do?linkld=2431587&town=NandoverPubAcc 6/13/2014 10147 q � Date . . / .�l.'. . . . S�Rpt TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . has permission to perform . . . . . . . .. . .�. . . ` plumbing in the buildings of. . . .! .,/01�,�. , /10 �tov-' at . . . �! ta.�� . . 7. SL--. . . . . , North Andover, Mas4. Fee . %.,9 . Lic. No. .?F'*?r2.,. . 10(L� . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check# 7 n 3 .� MASS!RCHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - CITY �!,ovC� _I MA DATE _f PERMIT# JOBSITE ADDRESS rl eJ- 1%e 5 ve OWNER'S NAME POWNERADDRESS amu/ S _/�� { TEL FAX l TYPE OR OCCUPANCY TYPE COMMERCIAL DI EDUCATIONAL © RESIDENTIAL Le PRINT CLEARLY NEW: 0 RENOVATION:V REPLACEMENT: 0 PLANS SUBMITTED: YES 01 NOD FIXTURES 7 FLOOR- BSM 1 2 1 3 4 5 6 7 8 9 10 11 12 13 14 3 BATHTUB i !L___1 F771 CROSS CONNECTION DEVICE _.._.__.l DEDICATED SPECIAL WASTE SYSTEM f ._..-__l _ f ._.._.__.,( ! ....___._! 1 ._____...J DEDICATEDGASIOIL/SAND SYSTEM DEDICATED GREASE SYSTEM _---....._f DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER -J] _.I I I= ...._._J FLOOR/AREA DRAIN _..__J € _-___.J -_---._1 ..___......._ _-----_.J .._...__ _......_( ....._..__! _{ __..._. JF INTERCEPTOR(INTERIOR) �€ __I . ...... KITCHEN SINKE±1E . _ . _____ _LAVATORY _ --i ,- __1 _..___._I _.._._....J ____-----I J ...._..._.E J -_...I _.__..I ! _ I ROOF DRAIN ----( - - I --! ..___._.J .--- --- ! --I ----- J -J .....-_ ! - -� .._..__( .... I ..._..! SHOWER STALL TOILET ._ ._.._ -� - _ _ URI!44L WASHING MACHINE CONNECTION WATER HEATER ALL TYPES -77 j i _ + ! I } , E. - ----' --- - WATER PIPING ! ! - _.. - OTHER —I F -1 .__.._._.l X INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142, YES R'NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY IM/ OTHER TYPE OF INDEMNITY Q BOND 0 " OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the M Massachusetts General Laws,and that my signature on this permit application waives this requirement. ! —_T CHECK ONE ONLY: OWNER 0 AGENT �0 �% SIGNATURE OF OWNER OR AGENT _--- E 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 �1 and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertine rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Ali% -T�L01� ,�J T�Q.LICENSE# ly�_ SIGNATURE MP JP 0 CORPORATION 0# _ PARTNERSHIP 0# i LLC COMPANY NAME ADDRESS CITY �i/`/"its,! .....__..... !STATE rf I ZIPI TEL FAX € CELL L EMAIL --/''0 o. ..�r) 1z \�I ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL-INSPECTION NOTES 9—C8�� ✓ � u�I, �G� Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES ti Ol d • � w The Commonwealth of Massachusetts - Department of IndustriglAccidents 07 Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/El please Print Le ibl _Apnhrm cant Infoation - Name(Business/Organization/Individual): , C' Address: �/fv�`/� �N'U Z' City/State/Zip: ,Ua RIZ6rZC,4 �� 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 I 6. [-]New construction � mployees(fall and/or part-time).* have hired the sub-contractors 7. Remodeling 2.Ltd I am a sole proprietor or partner- listed on the attached sheet.t 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 10.0 Electrical repairs or additions required.] officers have exercised their of exemption per MGL 11.[�lumbing repairs or additions 3.Elriht I am a homeowner doing all work g p p12,❑Roof repairs myself. [No workers' comp. c. 152,§1(4),and we have no insurance required.]t 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 6e 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:. �� ���� ��X/ �NS' Policy#or Self-ins.Lic.#: Expiration Date:,/ J 7,¢$S Avc City/State/Zip: Job Site Address: f G / Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP.WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true an/d correc Signature: / t. " Date: — _ ,3 Q Phone It: /' 7 9 7 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#: r ! , 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 the self-insurance license number on the appropriate line. ir 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 Gonrn?Onwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA,02111 TeX,#61.7-727-4900 ext 406 ox 1.-877,7MASSAFF,, Revised 5-26-05 Fax#617-727-7749 www.rnass,gov/dia `'''COMMONWEALTH OF MASSACHUSETTS " � . •• • :.•-. . PLUMBERS AND GASFITTERS LICEN SSD ASEABoMAScER PoLUMBER EN RALPH C FLODIH JR 4 LAURIE ,ANN LN N BILLERICA MA 01862-1752 9822 05/01/14 176495 Date........cj. ....�/3.................. r10RT/� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION '•`t<s 88�c„usE This certifies that ..........Re......t.Icd4. ........l... /' ......................I�l........... ._ has permission for gas installatio ...c7.?�!.✓e....., .... P ,;..... in the//buildings of.. .. ...�.....................4.5.-�...S....1..o........>.✓............................. at...../.. .r� �.�� ..... .........@.............................Lth Andover, Mass. Fee.. —L...... Lic. No. ... .G?�e...... yN�F ............... . .............................. ' GAS INSPECTOR Check# n n ! r r •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �I CITY � (��cJ_�-_.cls_- _ MA DATE 1���7�.�.�PERMIT# -- • JOBSITE ADDRESS OWNER'S NAMEGIV OWNER ADDRESS I f �4JV.S• IY� TEL _ ___�_�_IIF (L TYPE OR OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL [JI RESIDENTIAL PRI CLEARLY NEW: RENOVATION:@/ REPLACEMENT:- PLANS SUBMITTED: YES-J N 0 0-1 APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER ? 3 CONVERSION BURNER -- _.-- .- ( _- J �I _ I .J -J T._ --1 �I .--1 ____ I __ J. COOK STOVE �-J� ...� . lT -� _ ..�_T1 _ J __,�J �.L.�,�1..__-i i,--.i -,--._.�. 11P. DIRECT VENT HEATER r _( J . �J ..: .rJ Y _. _J _ (�- ,_.��f _._([_—,I I DRYER TA - _- FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS J 'a MAKEUP AIR UNIT ( _- 1 ---!. ,._.�I,�. ^:� _--. _- _ - I ._--_ - =.�..I _..__._1 _. I P OL HEATER R OM/SPACE HEATER R OF TOP UNIT ( ( .._..J -.TLLj= TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER --11-- OTHER — ....... .I :. _.. I _ ....... . . _ . . I } INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 'NO 01 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ���I OTHER TYPE INDEMNITY EJj BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER �__,_I! AGENJ [J1 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 Pe ' pnt provision ofthe Massachusetts State Plumbing Code and Chapter 142 of the General Laws. o PLUM BER-GASFITTER NAME /�L/' ..,_. y -_ ._L4040A) LICENSE# SIGNATURE - - MP GF ] JP j JGF[]__I LPGI�I CORPORATION[]# � __-_PARTNERSHIP LLC[ ]# -__._r_.__.___._II � COMPANY NAME: /ti.../ / - qADDRESS CITY /..-�'/'�C'.�- - - - ._..r..... ._....__I STATE ._. . (ZIP I / G -_]TEL FAX CELLLEMAIL •!'� O .� A!V-:_2-0(04 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES .•��—=� Yes No t D THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ ` FEE: $ PERMIT# PLAN REVIEW NOTES 12,0 1uv w may. Clearance - General List of Minimum Requirements Page 1 of 2 GEAppliances.com Clearance - General List of Minimum Requirements For proper air circulation and correct installation, some appliances must have air clearances around the product. Installations can vary, so checking the installation instructions to determine space requirements for your specific model is recommended. The following are minimum clearances required by product lines in general: Chest Freezers: 3 inches of clearance on all sides. 3 inch of clearance at the back. Upright Freezers (less than 9 cubic feet): 4 inches of clearance on top. 4 inches of clearance at the back. 1/2 inch of clearance on each side. Upright Freezers (9 cubic feet and larger): 3 inches of clearance on top. 3 inches of clearance at the back. 3 inches of clearance on each side. Refrigerators: 3/4 to 1 inch of clearance on each side. 1 inch on the top (this is above the case). 1 inch in the back. Note: After the above requirements have been met, there are no other restrictions or limitations concerning location when installing a refrigerator. (i.e.) They can be installed by a dishwasher, range or a wall-oven. Dryers (In an Alcove or Closet installation): 0 inches on side. 4 inches front and rear(allows adequate space for venting). 52 inch minimum space from floor to ceiling or overhead cabinets. Countertop Microwaves: 3 inches on each side. 3 inches on the top. 1 inch in the rear. http://www.geappliances.com/search/fast/infobase/10011571.htm 6/16/2014 Clearance - General List of Minimum Requirements Page 2 of 2 Note: In cabinet installation for countertop microwaves is not recommended without the use of a built in kit. Built in kits will be listed for specific models in their specifications. If a built in kit is not available, the above air clearances are necessary. Ir i Note: If the microwave is located near a range, 2 feet of clearance on the side adjacent to the range will be necessary. Microwaves cannot be mounted over a range unless they are specifically made to be an over-the-range model, with a vent included. Hanging Microwaves (mounted under a cabinet, not over the range): 2 inches on each side. 2 inches underneath. Over the Range Microwaves and Advantiums: Over the range microwaves require a minimum 66" mounting height from floor to top of the micro. The 66" from the floor dimension will allow approximately 13"-16" between the cooktop and the bottom front of the microwave. All current over the range microwaves can be installed over gas cooking products up to and including 5 burner stoves. As long as the 66" minimum from the floor to the top of the microwave is followed there will be no performance or warranty problem. This includes Advantium ovens and convection microwaves. Note: Over the range microwaves and Advantiums are not recommended for use above any range or cooktop that has a combined btu rating over 68,000 btu's, including the oven/broiler btu's. Ranges: 1 '/2 inches to nearest adjacent sidewall above the cooktop on both sides. 30 inches between the cooktop and the bottom of a cabinet. 0 inches for sides below the cooktop. http://www.geappliances.com/search/fast/infobase/10011571.htm 6/16/2014 � 3 l/3 Date............ d ............................... CF poarM,� g o�; X09 TOWN OF NORTH ANDOVER * ' , PERMIT FOR WIRING $B�cHug� This certifies that ....,v................ ! e,e-- ..........................................................0L...................... has permission to perform40Amd--:N �-t" rz� S4— . ... .................................... wiring ' the building of....��...��........ CfSS � ................................................................................ at ............. -zq." /..q':` q....................................................... North Andover,Mass. lee.... N..: Lic.No. .Jr- .. ......... !��,��. ELECTRICAL INSP CTOR t Check# oo ! !I b . . t C `t } Commonwealth of Massachusetts Official Use Only Permit No. 117S-1 Department of Fire Services j Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (1m eblank 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 WINK OR TYPE ALL)NFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) (/� Owner or Tenant R.A.410 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building n _ Utility Authorization No. - Existing Service ! O Amps / / fb 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: Completion of the following table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA s No.of LuminairesSwimming Pool Above ❑ In- El o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No. of Switches No.of Gas Burgers No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons 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: Attach additional detail if desired,or as required by the Inspector of WYres. 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 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: INSURANC T BOND ❑ OTHER ❑ (Specify:) Xcertify,underthepains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: . r.:—L, LIC.NO.: Licensee: :11 ,7- ` 2a C IA/r x Signature LIC.NO.: (If applicable,enter "exempt"in the license number line) Bus.Tel.No.: u Address: IV�A 7'z2 t Gi'f�—�o--17—m 1, j� Q JlMf SS Alt.Tel.No.: ? *Per M.G.L c. 147, 57-61,security work requires Department of Public Safety"§"Licence 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 PERMIT FEE:$ Signature Telephone No. L � Q ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass Failed M Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed M Re-Inspection Required($.) ❑ Inspectors Comments: . R V f Inspectors Signature: Date: ' PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTI N: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: / rV Inspectors Signature: FINAL INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com J 0 The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations QU 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): , ��` �_ /1) , Address: _ t City/State/Zip:__4_�=� ,j ZJC Tl } S,!� dl7,^one#: Q'�`� �j o? 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. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. �• F1 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.❑Electrical repairs or additions 3.❑ I 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.] 1 !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. i $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-. �r�� 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. do herebyc der e=ndes of perjury that the information provided abov is true and correct.T - Simature: Date: �3 D ZI Phone#: 9 elf z V / 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 employeiis defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current Policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. t 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 CommojjwoaIthofMqSSaVhv.,setts Department of Industrial Accidents Office of Iu-Vestigations 600 Washington Street Boston,MA,02111 Tel,#617-72.7-4900 ext 406 or 1-877rMASSAFE Revised 5-26-05 Fax#617727-7749 www.mass,goV1dia 2 . x � 7 Date. .. ./ � 4 HQRT►, TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACHUSES � l — This certifies that . . G �. L has permission to perform ........,...................................................................... wiring in the building of .I(, A- f - ..... ,North Andover,Mass. Fee./5.-.-..O')..... Lic.No �.% .......... !... : 1�'......... 7 ELECICAL INSPECTOR Check # TR WHITE: Applicant CANARY: Building Dept. PINK:Treasurer OfficiallUUsCe`�onllyy Permit No. p�iG G' ��e67�21xdzrlri�,�,��0�n2�ss��s��1s D04T r 4;P.R&S4,ft Occupancy&Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 C RR 1W- Town :00 (Please Print in ink or type all information) Date 3U/ of North Andover To the Insp Wires: The undersigned applies for a permit to perform the electrical w rk described be ow. Location(Street&Number / &3- Fi41sS Owner or Tenant Owner's Address � �p Is this permit in conjunction with a building permit Yes ❑ NoCheck / 1,� ( Appropriate Box) Purpose of Building ��'�l /Z Utility Authorization No. +E)isting Service Amps Voits Overhead ❑ Undgrnd ❑ No.of Meters New Service Amps Voits Overhead .!� Undgrnd ❑ No.of Meters 1 Number of Feeders and Ampacity UU � Location and Nature of Proposed Electrical Work_ No.of Lighting Outlets Total No.of Hot fuse No.of Transformers KVA Above ❑ In ❑ No.of Lighting Fixtures Swimming Pool grnd ❑ grnd ❑ Generators KVA No.of Receptacles OutletsNo.of Emergency Lighting No.of Oil Burners Batte Units No.of Switch Outlets No of Gas Burners FIRE ALARMS No.of Zone Total No.of Detection and No.of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No.of Di osal No. Pum s Tons KW No.of Sounding Devices No./of Self Contained No.of Dishwashers Space/Area Heating KW Detection/Sounding Devices No.of D rs ❑ Municipal ❑ Other Heating Devices KW Local Connection No.of No.of Low Volta e W,in No.of Water Heaters KW Signs Bailases g No.Hydro Massage Tuds No.of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES= NO = have submitted valid proof of same to the Office YES= NO = If you have checked ESase i icate the INSURANCE = BOND = OTHER = (Please Specify) Zp type of coverage bM'hecthe appro Estimated Value of Electrical Work$ If (Expiration Date) 64 Work to Start Inspection Date Resquested Rough under the Pe Finalfpr > FIRM NAME UM zo ��3 �' '' LIC.NO. Licensee_ J F2 1It✓� \ J�� Signature � // y LIC.NO. Address C!,rC/ l h Bus.Tel No. U��J7 4O 3 / Alt Tel.No. OWNER'S INSURANCE WAIVER: I am aware that t icenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) (Signature of Owner or Agent) Telephone No. PERMITfEE $ [ `d) HOME ENERGY, INC. Bill for _ Robert Scarano MK Realty Trust j 14 EDGEHILL, RD. Address: 17 Lee St._ j HAVERHILL, MA 01830 --.City/Town _-ITewksbury, MA 018.76 { 978-374-6256 Date: _1. 9/5/13 - - Job address: 165 Mass.Ave., No.Andover MA door kits _ -- $45.51 _ $_0.00 door swee �� �P , $15751 $0.00 attic kneewall floor R-38 5281 $1.47, _ $776.16 attic air sealing _ 2 $75.00 j� ( $150.00 attic cap R-30 { 3001 .$1.37-1-- _ { $411.00 attic slope 13-4-12 res. 1 1001 $1.30 { _ $130.00 attic knee II R- �__ _ 550 $1.31 _ {_� $720.50 wall ins ation/vinyl { 1320 $1.79 $2,362.80 garageceiling cellulose 267 $2.10 $560.70 Sill fo _ _ 60 _ $2.20 _ _� $132.00 { the ax 2"foam �_ �� $2Z.50 _ $0.00 fiberglass R-11/13 ��_ $1.31 -! �_ $0.00 glass replacement { $44.00 $0.00 rigid foam board 1"4x8 j $62.74 I �1 $0.001 duct insulation R-5 $3.10 $0.0_0 roof vent Lomanco_ 135 5 _$105.00 _ L__$525.00 bath fan vent _ 1 �^ $135.00 6.601- _j $135.00 power vent _�� 1 $400.00_` $4.00.00 blower door _ $45.001 $0.00 attic hatch 2 pc/w/hinges $150.001_ $0.00 attic access holes $105.001 _ _$0.00 R-5 ductwrap door f 4$51.00� _I_ $0.00 attic hatch repair { T $60.00 _$0.00 basement outside door/jambs _ $435.5.7 _ $0.00 -- ,'Total due $6,303.16 Blower door I before after Miscellaneous: