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HomeMy WebLinkAboutMiscellaneous - 1650 TURNPIKE STREET 4/30/2018N o I Date ./ 3 // .r r � TOWN OF NO TH ANDOVER 3? °� PERT IT OR PLUMBING This certifies that -.!g �.� n ............................ . has permission to perform ... fr^ plumbing in the buildings of ..Cr ? �. (! , G ...................... at.. /r ll..L!? H�. / .......... , North Andover, Mass. Fee. 43) .-Lic. No.. I.s.i."Y. � ......... ..... PLUMBING INSPECTOR Check # f 7260 MASSACHUSETTS UNIFORM APPLICATION FOR -PERMIT TO DO PLUMBING (Print or Type) Mass. Date /—:C7 20 per it # CG Building Location_ Owner's Name �ild'1 /� Q J� C f'PC10 Qe r CION Type of O cupancy New ❑ Renovation It/ Replacement t Plans Submitted: Yes ❑ No ❑ B.P. # ' CG1it1�D FIXTURES Installing Company Name4,i Addres Business Telephone Name of Licensed Plumber or Gas Fitter ❑ Corporation ❑ Partnership INSURANCE COVE GE: I have a curre5fliability insurance policy or its substantial equivalent, which meets the requirements of MGLCh. 142. Yes iV No . ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURNACE 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. Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or enter- ) I4tiG my knowledge and that all plumbing work and installations performed under the p rall pertinent provisions of the Massachusetts State Plumbing Code and Char 14 o By Title City/Town APPROVED (OFFICE USE ONLY) Check one: Owner ❑ Agent 0 rcat n are true and accurate to the best of >r tjf/s application will be in compliance with I L s. Signature of Licensed Plugnier Type of License:--ETU-aster / License Number 1a 2? tS ).Journeyman /Fl/) to I' Z Z z Y < >- O U ¢ ~ > � W � W X j b LO Z v7 w to �ri z to U w to Z Lo O u_ z z a th z a z U z 0 O m LU< w r¢< L z o a Ln z a o i- W U¢ _ W 0= >¢ Cn a z to >¢> W � � + a 0~ z z W• u- Y w ¢ ¢ Ln Ln D ¢ O Q OJ OJ Q �Q O U 0 LU _ SUB-BSMT LL BASEMENT 1ST FLOOR oZ 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name4,i Addres Business Telephone Name of Licensed Plumber or Gas Fitter ❑ Corporation ❑ Partnership INSURANCE COVE GE: I have a curre5fliability insurance policy or its substantial equivalent, which meets the requirements of MGLCh. 142. Yes iV No . ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURNACE 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. Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or enter- ) I4tiG my knowledge and that all plumbing work and installations performed under the p rall pertinent provisions of the Massachusetts State Plumbing Code and Char 14 o By Title City/Town APPROVED (OFFICE USE ONLY) Check one: Owner ❑ Agent 0 rcat n are true and accurate to the best of >r tjf/s application will be in compliance with I L s. Signature of Licensed Plugnier Type of License:--ETU-aster / License Number 1a 2? tS ).Journeyman l� r�f n C, 9 -leo, k.", Da 17 .... 13 .... q3— TOWN OF NORTH ANDOVER PERMIT FOR WIRING ......................................... This certifies that 1.1'.Iz ...... 4�.� has permission to perform 6-"Ppa.ru.. . ef ............... wiring in the building of ..lore d—o 71117AoP) t- < 4 4 C— ................... ............................................................ F. at/6.0 ...... .............. ...................................... North Andover, Mass. . - ........ .. / U - Fee .SP ........... Lic. No . ............. ........ ......................... (LEMICAL INSPE R Check it YOI 7525 Date............................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Thiscertifies thattl.................................................................................................. has permission for gas installation 'c7- �....:........................... in the buildings of ...... 75Q....... ..•.............................. .............................................:. at .......g...�%...1��........ :. u.c. .... , North Andover, Mass. Fee t). `-`... ..... Lic. No. ...1.....5...3........-'........:.......................................... GASINSPECTOR Check # 9239 O GOWNERADDRESS: TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: NORTH ANDOVER MA. DATE: 01/16/2014 PERMIT # q)�7? JOBSITE ADDRESS: 1650 TURNPIKE ST OWNER'S NAME: TO RENTAL LLC I O ._I.►,c - TEL: 978-794-1400 FAX: OCCUPANCY TYPE: COMMERCIAL I' EDUCATIONAL ❑ RESIDENTIAL ❑ NEW: [ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCES FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER Aznep INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Q NC) ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY M OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted (or entered) regarding this permit application is true and accurate to the best of my Knowledge. I certify that all plumbing work and installations performed under the permit issued, will be in compliance with all Pertinent provisions of the Massachusetts Uniform State Plumbing Code, and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME/�%f154 - ✓��SG� LICENSE #_ SIGNATURE COMPANY NAME: OSTERMAN PROPANE LLC ADDRESS: 321A Merrimack St CITY: Methuen STATE: MA ZIP: 01844 FAX: 978-738-0118 TEL: 800-368-9956 CELL: EMAIL: INFO@OSTERMANGAS.COM MASTER El JOURNEYMAN ❑LP INSTALLER ZeO—RPORATION ❑# PARTNERSHIP E]#L LLC Q The Commonwealth of Massachusetts -' Department of IndustrialAccidints Office of Investigations It 600 Washington Street Boston, HA 02111 www.mass.gov/dia Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeAly Name (Business/Organization/Individual): �� 03 Address:S%— City/State/Zip:%%E7�i, /tel D/%l Phone#: 3 (o a--���� A=yon employer? Check the appropriate box: 1. a employer with 4. ❑ I am a general contractor and I employees (full and/ox part-time) have hired the sub -contractors 2. ElI am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F1 Electrical repairs or additions 11. E] Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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: ��i- T Policy # or Self -ins. Lie. #: 132�� 77 Ste' Expiration Date: D Job Site Address%Q 9& LA3 R 2! L S2 City/State/Zip: /I�4jjDliiJ 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 DIA for insurance coverage verification. I do hereby certo under theXaIns andpenaldes ofperjury that the Information provided above is true and correct 0 Phone #: / — Ro 0— 3 6 9-- /9-576 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 'ASS' MUSETTS' _ yr , ' COMMERCIAL - " DRIVER'S'LICENSE oko up`.aEND DdS09256764_:. ` x 413 t is T?" is set,M illloT 508'; ONE 9' r� I� E A� (� 9'8 ARBOR CT LYNN; MA" 019D2.1110 G' S DD it-062D1]Rev07.1S2DD9 PLU LI t'JfBERS AND CENSED AS AND GASPITTEP,e LP GAS INSTALLEF; ISSUES THE AsovC ucen;SE rd; hITCHAEL A BRYSON SR i a ARBOR CTLYNN .' . L, NA o190'�-1'I.i�� 3 93" 0.,/pY/14 0 AC40 " CERTIFICATE OF LIABILITY INSURANCE ATE D06/26/2013IDDIY3 06/26 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 1-630-773-3800 Arthur J. Gallagher Risk Management Services, Inc. CONTACT Allison S adaro NAME: P PHONE 630-285-4456 FAX 6 A/C No Ext: AIC No: 30-285-4006 E-MAIL allison s adaro@a Com ADDRESS: P Jg• Two Pierce Place INSURERS AFFORDING COVERAGE NAIC# Itasca , IL 60143-3141 INSURERA: INSURANCE CO OF THE STATE OF PA 19429 Mary Beaver INSURED INSURER B: Osterman Propane, LLC COMMERCIAL GENERAL LIABILITY C: -INSURER INSURER D: 6120 S. Yale Ave. Ste 805 Tulsa, OK 74136 INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: 34415543 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE(RENTED PREMISESS Ea occurrence $ CLAIMS -MADE 1-1OCCURMED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ $ POLICY jECO- LOCI AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ A A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YINNIA OFFICER/MEMBER EXCLUDED? 15883775 79331530 06/30/1 06/30/1 06/30/14 06/30/14 X WCSTATU- OTH- E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEd $ 1, 000, 000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) 978-688-9542 GtK 11HL:A I t HULUtK LANL;LLLA I IUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Mary 146 Main St AUTHORIZED REPRESENTATIVE North Andover, MA 01845 , n D I USA m �• P>� ACORD 25 (2010/05) ankurita 34415543 ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD GENERATOR APPLICATION ,,m LOCATION: OWNERS NAME: GENERATOR kw NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: ` PHONE NUMBER: ELECTRICAL RESIDENTIAL GAS OM MERCIAL LOCATION OF GENERATOR: *ZONING DISTRICT: cjvv 0 , -" *PLANNING APPROVAL (IF IN WATERSHED) *CONSERVATION APPROV TEMPORARY Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No. Occupancy and Fee Checked c 34 BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Z J ( , d -7 City or Town of. NORTH ANDOVER To the Inspector Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 145-0 %u r n p et ST 4' Y) Owner or Tenant 1 * LLC Telephone No.77 61 y ,3 Owner's Address V f apt e $ Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. A 1-12 4 $ 4 y Existing ServicecQ00 Amps I.Zc /246 Volts Overhead ❑ Undgrd $� No. of Meters C New Service Q00 Amps 1.2cr / Q (/6 Volts Overhead ❑ Undgrd © No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: a" L hcl 49(_ C T 3 Q er -t-crm Otcj Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. rnd. o. oEmergency Lighting Batte ry 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 Tons No. of Alerting Devices No. of Waste Disposers Heat Pum Totals Number Tons KW No. of Self -Contained 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 Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent p( OTHER: 14d —tw D o vs Jlo � S U Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: T01!J,07 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO RAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited'proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Elrec+wc LIC. NO.:—9 0!2 fc 1¢ Licensee: 4awrene� r= Dr4�1 Signature LIC. NO.: (If applicable, enter "exempt" in the license number line.) Bus, Tel. No.:97%P"07 0.7' Address: I Sc nSe.a.C-I' (24 140iduer% N 4 Tel. No.5172--"V-/Q 9.Tr4l *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 agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. ..4 Date ...'? -../-.....7 ........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that.............................?.................................. ................ . has permission to performl��'-.r 750 7 wiring in the building of at ... ............ . North Andover, Mass. ......... Fee. Ak: ........... Lic. L``'........ ELECTRIFAL 01;�1P­ECT0 Check # 7552 a Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. �_Z Occupancy and Fee Checked [Rev. 1/071 leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Auce 20017 City or Town of: NORTH ANDOVER To the InspeciTr of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) GS'O 7-6 rnn i Kr S 4&-& + Owner or Tenant 14-51d Tv mh ne' e- S)�- LLC n i7 Telephone No. Owner's Address /4SZ7 TGrnni'IZC S-1 Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building tokaii e. 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: G-ac_�l QT %3U t' U I.n A Com letion o th 4-71 bl Attach additional detail iJ desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: J14og 1 G % Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ,% BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: I= lea LIC. NO.: Licensee: i• *W C -C bad Signature LIC. NO. OT (If applicable, enter "exempt' in the license number line.) us. Tel. No.. -97P 7 Yq Address: I SonSc}- 120 `L � t ��C6LffV- }(J+ Olig a `�0---� Alt. Tel. No.:97fr fila? 03A8' *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 agent. Owner/Agent / Signature Telephone No. PERMIT FEE: $ /�' e o owtn to a may be waived by the inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- El. o mergency tg ng rnd. rnd. BatteryUnits 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. Tonal No. of Alerting Devices 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 ElOther Connection No. of Dryers Heating Appliances KW Security Systems:* No. of WaterHeaters No. of No. of No. of Devices or E uivalent KW Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications iring: No. of Devices or Equivalent OTHER: C, UC. ; • Z`,� Attach additional detail iJ desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: J14og 1 G % Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ,% BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: I= lea LIC. NO.: Licensee: i• *W C -C bad Signature LIC. NO. OT (If applicable, enter "exempt' in the license number line.) us. Tel. No.. -97P 7 Yq Address: I SonSc}- 120 `L � t ��C6LffV- }(J+ Olig a `�0---� Alt. Tel. No.:97fr fila? 03A8' *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 agent. Owner/Agent / Signature Telephone No. PERMIT FEE: $ /�' A wt`, ­1fl �; The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 iw www.rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Naive (Business/Organization/Individual): Address: % S City/State/Zip:_ (�_-1 /19- Phone #: Ql 7 �- -2 y'z 'z S c e/ Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. [ I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.4 Electrical repairs or additions 1 1.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.0 Other ISI tJ� *Any applicant that checks boz #I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. 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. #: Job Site Expiration Date: City/State/Zip: v /vc 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 he�eb certify under the pains and p5palties o�rjury that the information provided above is true and correct. Phone #: T7 9— % V F% 9 Z 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 k Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. d Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or.more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-NIASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia Date z .. ...................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... .................................................................... .......... I, has permission to perform l .................................. M'-4 ............................ wiringin the building of.................................................................................. fir at ................. ...................... . North Andover, Mass. Fee/6 ................ Lic. No. . ................. ...... ELECTRICAL -SP E CTO R Check # 7178 A 4 C:4OJ�W�//"/itZfLl Official Use Only Permit No. _ 1� 1/ 79 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 7'lq N 200-7 City or Town of: Nook K) K Joy e r 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)- 116S0 "Twr n pl' kc S4r ee-i Owner or Tenant .kevt'k - Lam, AKn Cr r Paco Telephone No. 79/ 334/ 2"S -- Owner's Address 14 wy #b%6 aJ k� Is this permit in conjunction with a building permit? Yes Q& tt JJ �� Purpose of Building V/7 aewTC G7��T;ICe"s Overhead ❑ Existing Service Amps / Volts New Service Amps / Volts No ❑ (Check Appropriate Box) SD Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: O gre 14 r• 14 t <.✓a.r t: 6thye . Com letion of the followingtable maybe waived by the Inspector of Wires. No. of Recessed Luminaires .2 No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires 120 Swimming pool Above ❑ In- ❑ g rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets .20 No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches /0 No. of Gas Burners3 «i. `tN No. of nd IniDtInitiatingDevi es No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons ............ W ....................... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW SecuriNo of y Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: ( 0 y 3 Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: „2S', Ci (When required by municipal policy.) Work to Start:7ppj 0-7 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit. for the performance of electrical work may'issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: D (=1 LIC. NO.: 1490 9 iF Licensee: k14L j IreilC ! le o AV Signature LIC. NO.: (If applicable, enter "exemp " in the license num er line) us. Tel. No.: 976r 7y 9 9 Sb rj/ Address: 1 5w ns 20 c J e R d. 14ptclloy er 14 04 G t F/6 Alt. Tel. No.: 971r SO 7 a98'P *Security System Contractor License required for this work; if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ RIJ�- OA4a 6i -A, Vv-tsTuu IN -2--D? PAI Dianne Meyers Architectural Services 159 Wakefield Street Reading, Massachusetts 01867 781-944-2309 Construction Affidavit Date: 07-10-06 Project: Lou -Anne & Charlie Greco 1650 Turnpike Street North Andover, MA 01845 Scope: Interior fit up and renovation of existing building I, Dianne Meyers, Registration No. 10067 have been retained by Lou -Anne and Charlie Greco to act as architect of record for the interior fit up and renovation within the existing building at the above address. I went though the design process with the Greco's, completed construction drawings, and have done some site inspection during construction. I did my final walk through on Wednesday, June 27, 2007. To the best of my knowledge, information, and belief the work was, in general, completed in accordance with the documents approved for the building permit as per Section 116.2.2 of the Massachusetts State Building Code. Signature: Dianne A. Meyers \\D:\My Work\Greco\Affidavit-2.Doc Design Professional Seal tEti No 10067 BASTn , 9 Date ..//— � . 3 i //! .7 ....... o? °� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION °y . 9 �9SSACMUSEA This certifies that ..... t.'. l �..�............ . has permission for gas installation in the buildings of .'.l.U�.` : �` :. C C C at ... �. v ..!'.`:/':.............. North Andover, Mass. Fee../?.... Lic. No. ....... .... ........ GAS INSPECTOR Check # 4 C- i Installing Company Address Business Telephone MASSACHUSETTS UNIFORM APPLICATION FOR' PERMIT TO DO GASFITTING % (Print or Type) Mass. Date—/-- � 2o-27/Permit N Building Location �j Q (C, fy1 j owners Name t Type of Occupancy New Renovation V Replacement❑ Pians Submitted: Yes ❑ No 0 /esrt�� Name of Licensed Plumber or Cas Fitter WE Check one: Certificate ❑ Corporation ❑ Partnership 7 il - 0 Firm/Co. INSURANCE COVE E: I have a curren iabllity Insurance policy or its substantial equivalent, Which meets the requirements of MCL Ch, 142. Yes No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability Insurance policy ❑ Other type of indemnity 0 Band ❑ OWNER'S INSURNACE WAIVER: 1 am aware that the licensee does not have the insurance coverage'r9quired by Chapter 142 of the Mass. General Laws, and that my signature on this perm application waives this requirement Signature o Owner or Owners Agent Check one: Owner ❑ A Agent ❑ I hereby certify that all of the details and Information I have submitted (or entered) In above applicati ar u d ur to to the best of my knowledge and that all plumbing work and installations performed under the permit Issued For thi ap a on t e n compliance with all pertinent provisions of the Massachusetts state Cas Code and Chapter 142 of the General La of License: BY �pe lumber Signature ofl tensed Plumper Gas Fitter Title `La G as A tte r Qity/7own ❑Master License Number APPROVED (OFFICE USE ONLY) p Journeyman s s • • • ' MM 5MM1 mmmmmmm MM /esrt�� Name of Licensed Plumber or Cas Fitter WE Check one: Certificate ❑ Corporation ❑ Partnership 7 il - 0 Firm/Co. INSURANCE COVE E: I have a curren iabllity Insurance policy or its substantial equivalent, Which meets the requirements of MCL Ch, 142. Yes No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability Insurance policy ❑ Other type of indemnity 0 Band ❑ OWNER'S INSURNACE WAIVER: 1 am aware that the licensee does not have the insurance coverage'r9quired by Chapter 142 of the Mass. General Laws, and that my signature on this perm application waives this requirement Signature o Owner or Owners Agent Check one: Owner ❑ A Agent ❑ I hereby certify that all of the details and Information I have submitted (or entered) In above applicati ar u d ur to to the best of my knowledge and that all plumbing work and installations performed under the permit Issued For thi ap a on t e n compliance with all pertinent provisions of the Massachusetts state Cas Code and Chapter 142 of the General La of License: BY �pe lumber Signature ofl tensed Plumper Gas Fitter Title `La G as A tte r Qity/7own ❑Master License Number APPROVED (OFFICE USE ONLY) p Journeyman