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Miscellaneous - 166 HIGH STREET 4/30/2018
-166 HIGH STREET 210/053.0-0017-0000.0 Date TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . &V. ( . . . . .'. .( .�'!�!.'`'"' . . . . . . . . . . . . . . . . . has permission for gas ins�talllation/ . . . . G?�. 5 �-e– in the buildings of. . . . . � at . .Ap.(,a . ` I` . .J( . . . . . . . . North Andover, Mass. F � Fee �— . . Lic. No. " . . . . . . . . . . GASINSPECTOR E Check# 8566 Insured MA Lic#21195 PAUL E. MARTIN Plumbing & Heating Gas Piping (978)794-8041 Free Estimates (603)893-6954 f MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK MA DATE .../ �'4..� -/�PERMIT# CITY ..... . .... n _ ,� JOBSITE ADDRESS.��j.� OWNER'S NAME ►_LQ. TEL FAX; OWNERADDRESS �. .:.. .,.. . .. TYPE OROCCUPANCY TYPE COMMERCIAL EDUCATIONAL . RESIDENTIAL PRINT CLEARLY' NEW: RENOVATION: REPLACEMENT: :✓ PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS— BOILER LOORS BSM 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 COCKS MAKEUP AIR UNIT OVEN _ ^... ... POOLHEATER ROOM 1 SPACE HEATER ROOF TOP UNIT TEST r UNIT HEATER UNVENTED ROOM HEATER WATER HEATER. OTNFR r- INSURANCE OVERAGE 7 I have a current liabilit, insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES _ NO . E IF 1 OU CHECKED YES,PLEASE INDICATE THE T'Y'PE OF COVE BY CWECIJNG THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY .,,,,.,,': OTHER TYPE INDEMNITY ^, BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts C:eneral Lass,and that my signature on this permit application waives this requirement. CHFCK ONE ONLY: OWNER ; _ AGENT Or SIGNATUIE OF OWNER OR AGENT I hereby certify tt,�t all of th 'Tj ils and information I have submitted or ente d fo gar inglthit:anpw'illabor are truliance rate ate ertine be pro Smy knowledge der the permit issued pp and that all plumbing work and installations perfomned un Pe co Massachusetts State Plumbing Code and Chapter'142 of the General Laws. n LICENSE#/oZ.3SO; SIGNATURE PLUMBE -GASFITTER NAME MP MGF,... JP JGF; ; LPGI CORPORATION � . ;PARTNERSHIP # LLC #, p ,tJ ;ADDRESS (�fER�b i A N QR COMPANY NAME l Rt�L- AjI l p . . . STATE ZIP CITY �,© 9 TEL FAX,.S /YJ� CELL &AIL w _ II Jnr i CVVY fpZC�jj `3 y �� �� �� U�� I r� �� � / �,.�� `�� �� �, e. f The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesfigations 600 Washington Street Boston,MA 02111 M sY www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): H Address: City/State/Zip: _z)QZ41,c 0-3079 Phone#: �J''g 9 3_e 9,-l krey6u an employer?Check the appropriate box: Type of project(required): I am a employer with e�, 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors FJI am a sole proprietor or partner- listed on the attached sheet.# ? Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. E]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.n Electrical repairs or additions ❑ I am a homeowner doing all work right of exemption per MGL I L VIumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]uit employees.[No workers' q ] 13.n Other comp,insurance required.] iy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. m an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site brmation. urance Company Name: icy#or Self-ins.Lid.#: Expiration Date: Site Address: City/State/Zip: :ach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 tp to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of estigations of the DIA for insurance coverage verification. hereby rte snler the pains and penaltie rjluy that the information provided above is true and correct. na Date: ine#: ?fficial itse only. Do not write in this area,to be completed by city or town official. �ity or Town: Permit/License# ssuing Authority(circle one): .Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector �.Other 'nntarf Aarenn• Phnna#- � J f. CQMMONWEALTH OF MASSACHUSETTS j • PLUMBERS AND GA ,P ITTERS LICENSED AS A-MASTER PLUMBER ISSUES THE ABOVE LICENSE TO: } ` l PAUL` E ::MARTIN 3 b MEF 1DTAN DR i SALEM NH 030.75 41`-12 ` 1'2380 05/01/14 170529 i COMMONWEALTH OF MASSACHUSETTS 4 PLUMBERS AND GASFITTERS - REGISTERED AS.A PLUMBING CORP ' j v ISSUES THE ABOVE LICENSE TO: ' I PAUL =E MARTIN 4 ` ° PAUL 'F "MARTIN PLUMBING & .NEA'T 11 I b' MERIDIAN DR { ��4LFM. NN %0307.9 4112 I 2961 05/01/.14 170527 I COMMONWEALTH OF MASSACHUSETTS77 E x ,ok • • • ••• i PLUME ERS AND GASFITTERS LICENSED Sa A,JOURNEYMAN PLUMB .ISSUES THE ABOVE LICENSE TO: PAUL E MA';TIN r1, 6. MERIDIAI! DR ? SALEM NH 03079 411.2 i 21195 05/01/'.4 170528 1 1 i t 09771 Date . Vq IM. . '' .. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . . . . :/ . .'. /. . . T? has permission to perform . ?. . .���J.J.. .4�_. plumbing in the buildings of. . . �.+� /;1 . . . . . . . . . . . . . . . . at . . . . ( ro . . . . . . . .North Andover, Mass. Fee . . . . . Lic. No. . ,/�kO. /`.A . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check# J f " MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM FLUftIBING WORK CITY E��a� — / PERMIT O _ /l cd —� MA. DATA JOBSITE ADDRESS fp / OWNER'S NAME / OWNER ADDRESS: TEL: FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT _._.__. .._.. _.. . .._. CLEARLY NEIN: [' RENOVATION: X REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ FIXUTRES 1 FLOORS- _Bsmt 1 2 3 4 5 6 7 8 9 10 11 1 12 13 14 BATHTUB CROSS CONN DEVICE DEDICATED SPECIAL WASTE SYS I I I I DEDICATED GASIOIUSAND SYS I DEDICATED GREASE SYSTEM DEDICATED GRAY(NATER SYS DEDICATED WATER REUSE SYS DISHWASHER I I I DRINKING FOUNTAIN I i FOOD WASTE GRINDER UNIT I FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY I ROOF DRAIN SHOWER STALL SERVICE 1 MOP SINK i TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING _ I I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES W/NO ❑ If you have checked YES,please indicate-`,he type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted(or entered)regarding this applicatio ue and accurate to the best of my Knowledge and that all plumbing work and insialiations performed under the permit issued for this ap ' ation wi e in compliainju with all Perti provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER NAME: L) L _ / 1 LICENSE# gQ SIGNATURE l COMPANY NAME: IVAVL E _1y7f)PT IAtl } jj ::] ADDRESS: 1*),4*R I A AU OR I CITY: LE/179 STATE: ZIP: Q FAX: i TEL: 9)$-79yso - y/ CELL: 3 Qj_y_ S06 EMAIL: RT I A) m S/rly. " 7' f MASTER ?" JOURNEYMAN ❑ CORPORATION 21®PARTNERSHIP❑#E� LLC❑#E Zf 1 P �< �//zz/� o�t� ��� �//�z/� �� ����' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 UT. . www mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information p,, nPlease Print Legibly Name(Business/Organization/Individual): 1 ( •(.lL r�� + H Address:_ lyzlg� z City/State/Zip:Sad /y-11 0-?079 Phone#: Areru an employer?Check the appropriate box: Type of project(required): LI I am a employer with 4. ❑ I am a general contractor and I 6. F1 New construction employees(full and/or part-time).* have hired the sub-contractors ❑ I am a sole proprietor or partner- listed on the attached sheet.# ?•. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers'comp.insurance. 9 y p ty. F]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions ❑ I am a homeowner doing all work right of exemption per MGL 11.Vlumbing 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 my applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. iomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. rm an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation. surance Company Name: dicy#or Self-ins.Lid.#: Expiration Date: b Site Address: City/State/Zip: :tach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a te 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of the DIA for insurance coverage verification. 'o her rtify curler the sins and penaltieux3ztlint the information provided above is true and correct. ,Hato Date: one#: 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#: ti Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to 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.#617-727-4900 ext 406 or 1-877-MASSAFE vised5=26:05 Fax# 617-727-7749 COMMONWEALTH OF MASSACHUSETTS � -LUMND.BERS AGA3P ITTERS LICENSED AS A-MASTER PLUMB R ISSUES THE ABOVE LICENSE TO PAUL E :MARTIN 6 MERIDIAN, DR L � }SALEM `NH X03075 4112 `- 1'2380 05/01/14 1',74529 F `COMMONWEALTH OF MASSACHUSETTSI 1 t PLUMBERS AND GASFITTERS J REGISTERED AS.A_PLUMBING CORP , ..- : I r iS$UES;THE ABOVE 'LICENSE TO: F PAUL E MARTIN A � . PAUL `F MARTIN TLUMBING' & HEAT' ' ! b MER=IDIAN 'DR I v� 34LFM -NH3 4112 r p2961 05/01/14 _ 170527 ! ;� r _ r COMMONWEALTH OF MASSACHUSETTS + PLUME+RS A 401 LIGASFITTERS CENSED AS A JOURNEYMAN PLUMB [ ISSUES THE ABOVE LICENSE TO =1 + � i f ij PAUL E ^MATIN d` r � . 6. MERIDIAII DR 'i 1 1 'r SALEM NH 6307:9 41.12 i 21`-1'95 05/0li .4 17,0528 t Date h � TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . . . . . . . . . . . . . . . . . . . . . has permission to perform . .('�fi� . . tJ.�/I c/I.a,.. . . . . . . . . . wiring in the building of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . ./('?6z " .��o cP . .` -. .�?7?��- '. , orth Andover, Mass. DW Fee d. . . . Lic. No-7.6./. . . . . . . . . . . . . . . . . .. . . . . . . . . ELECTRICAL INSPECTO Check 11312 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 1 I Iy p Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CYR 12,P1 (PLEASE PRINT IN INK OR TYPE ALL)NFORMATION) Date: /.,-)// City or Town of: NORTH ANDOVER To the Inspector of Wir s: 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 Telephone No. Owner's Address Is this permit in conjunctio with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building (Jp�Se"Yi Utility Authorization No. 4F6 99( T Existing Servicea?LVC Amps / /;Volts Overhead Ej Undgrd❑ No.of Meters New Service _ Amps J Volts Overhead Undgrd ❑ No.of M t rs Number of Feeders and Ampacity 60, ^ Location and Nature of Proposed Electrical Work: v � M Completion of the following table may be waived by the Inspector of Wires. ry No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of TotalTransformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- [j No.o ting Emergency rg k rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones S) No.of Switches No.of Gas Burners No.of Detection and Initiating Devices V. Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices Heat Pump Number Tons KW No.of Self-Contained ' No.of Waste Disposers Totals: ""'""""" "" ' "" Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection No.of Dryers Heating Appliances KW Security_Systems:Y y No.of Devices or Equivalent � No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications No.of Devices or E uivalent y OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of El ctri 1 Work: ?OC) (When required by municipal policy.) Work to Start: / 1 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO E: 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 �j BOND ❑ OTHER ❑ (Specify:) I certify,acnder the pains and penalties of perjury,that the information on this application is tr a and complete. FIRM NAME: . / LIC.NO.: Licensee: pr���,��.,C ature LIC.NO.: 510,3 F (Ifapplicable,enter"exempt"in the license number line.) Bus.Tel.No.:l/7 J- -Q0S— Address: Alt.Tel.No.• *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. � OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not 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. r ❑ 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 M 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 M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass❑' Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: t ROUGH INSPECTION: Pass EN Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL P TION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Com ts: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 s� www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Abulicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: 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. F1 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• ❑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 10.❑Electrical repairs or additions required.] officers have exercised their K❑ I am a homeowner doing all work right of exemption per MGL 11.El Plumbing repairs or additions myself[No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]f 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. 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. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site zformation. isurance Company Name: olicy#or Self-ins.Lic.#: Expiration Date: 3b Site Address: City/State/Zip: ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. ignature: Date: zone#: 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 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. 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. #617.727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 evised 5-26-OS .,n _ --,,IA:- Page 1 of 1 Division of Professional Licensure: License Search I The Official Website of the office of Consumer Affairs and Business Regulation(OCABR) I Division of Professional Licensure Mass.Gov Mass.GovHome State Agencies A-ZTopics ONLINE SERVICES ;,Home>Division of Professional Licensure> ................_........................._.:._....._............. .......... ....... ................................._.........._......._........................................ Check a License Locate a Licensed Check A Professional License Professional j Online Address Change I By the Division of Professional Licensure Contact the Agency More... I SEARCH CRITERIA REFERENCES& Profession:Electrician RELATED INFO License Number:51031 Disclaimer Regarding NEW SEARCHWebsite License Searches - - - - — --------"` LIC. _ LIC' NAME CITY/STATE STATUS Enforcement Process LIC. LIC.TYPE NUMBER BOARD Glossary Journeyman ARTHUR J. NORTH ANDOVER, Current Electrician Glossary of License Status Electricians I l e ciass E 51031 GUTHRIE MA Codes Your search has resulted in 1 licenses ` More... ^. . The page above has been generated by the Division of Professional Licensure web server on Thursday,January 24,2013 at 8:14:38 AM. Site Policies Contact Us ©2007-2011 Commonwealth of Massachusetts I I „,/r„1,1;t,gni ihT.;r,R ange.asp?profession=Electrician&licenseNo=... 1/24/2013 1 O 2 Date. . . . .1. .! .... .. .. y T �ti TOWN OF NORTH ANDOVERRM o= .o s PERMIT FOR MECHANICAL INSTALLATION f P # f ► h �'ISS AC'NUSEAll This certifies that ul . . . . . . . . . . h `��� . . . . . . . . . . I . . has permission for mechanical installation'R '+??- .:/P.,.—�. . . . . . . . I I in the buildings of c��,:1. .`' . . . . . . . . . . . . . . . . . at ?)SAP.:'. ? . : :.�^^. � . . . . . , North Andover, Mass. Fee ..t). . . . . Lic. No��f. (.�. . . !.1. . . . . . . . . . . . . . . . . . . . . . GASINSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer i Commonwealth of Massachusetts Sheet Metal Permit Date: 1 3f ) Permit# 1/ Estimated Job Cost: $ 1,00V D!7 Permit Fee: $ 3y-°O Plans Submitted: YES NO Plans Reviewed: YES NO Business License# Applicant License# Business Information: Property O,imer/Job Location Information: Name: �oaw.c.c� �s Name: l�ob-\ 14' �jj LIAAC4 Street: Street:�k City/Town:�.,yN%j�ao rn V\Nr City/Town: 1-9. I Telephone: 'QU Y (t� c( 516 Telephone: Photo I.D.required/Copy of Photo I.D.attached: YES NO Staff Initial J-1 I M-1-unrestricted license J-2/M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq.ft./2-stories or less Residential: 1 2 family Multi-family,/ Condo/Townhouses Other Commercial: Office Retail Industrial Educational Institutional Other c Square Footage: under 10,000 sq.fL-,,k over 10,000 sq.ft. Number of Stories: Sheet metal work to be completed: New Work: Renovation: HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents .Air Balancing Provide detailed description of work to be done: 4 e r Commonwealth of Massachusetts Sheet Metal Permit Date: Permit# Estimated Job Cost: $ Permit Fee: $ Plans Submitted: YES NO Plans Reviewed: YES NO Business License# Applicant License# Business Information: Property Owner/Job Location Information: Name: Name: Street: Street: City/Town: City/Town: Telephone: Telephone: Photo I.D.required/Copy of Photo I.D.attached: YES NO Staff Initial J-1 /M-1-unrestricted license J-2/M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft./2-stories or less Residential: 1-2 family Multi-family Condo/Townhouses Other Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work: Renovation: HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: INSURANCE COVERAGE: I I have a current liability insurance policy or its equivalent which meets the r irements of M.G.L.Ch.112 Yes/No If you have checked Yes,indicate the type of coverage by checking the appropriate box below: A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this boxl],I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation:YES NO Progress Inspections Date Comments Final Inspection Date Comments Type of License: By ❑Master Title ❑Master-Restricted Cityrrown ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: Fee$ ❑ Check at www.mass.qov/dpl Inspector Signature of Permit Approval CbMMON.WEALTH OF MASSACHUSETTS f� w AS_A MASTER-UNRESTRIG.TED t ISSUES,THE'ABOVE LICENSE TO GHR I:S-TOPHER R HARTS013 Y lD ,BEL KN�A,P '; RU Y J' f� HUEiU�J �FJHr 05D51 s = I 0�%�8%13 =-. 9778ri8 Y The Continonwealth of,llassachusetts r Department of Industrial Accidents Office of lit vestigations 600 Washington Street ' Boston, MA 02111 www.inass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information Please Print Legibly t Name(Business/Organization/Individual): 1 Address:— 4 CU rn m i cl City/State/Zip: 1 s b �v 06 F7'/ Phone#: Are you an employer?Check the appropriate box: 4. general contractor and I Type of project(required): I am a 1. I am a employer with ❑ g employees(full and/or part-time).* have hired the sub-contractors 6. ❑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' [No workers' comp. insurance comp,insurance.x 9• ❑Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doingall 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. lContractors 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,theymust provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below information. is the policy and job site Insurance Company Name: �"�/ir�- /G �j� +✓e TnGie4o _ad 41 �. Policy#or Self-ins. Lic. Expiration Date: 31 Q Job Site Address: City/State/Zip: / C,d,}Ltz Attach a copy of the worke ' 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 under the pa' and penalties of perjury that the information provided above is true and correct: Si nature: - Date: l" Phone ----------------------- #: Offlcial use only. Do not write in this area,to be completed by city or town offrciar: City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. PlumbingInspectorector6. Other Contact Person: Phone#: r ,:R x fit^ �Nr`,,�1prr T. < :x s r WORKERSr COMPENS�ATIONND�EMPLt01(ERS�LIABILITY I,NSUR�NCP_OLtCY� 5 � Infos atioriPa((��e P Lw f . Independence Casualty Insurance Company NCCI Co. No.:36835 Policy Number: WC100096901 1. INSURED: Prior Policy Number: WC100096900 Lamco Systems, Inc. Producer: 4 Cummings Road The Rowley Agency, Inc. Tyngsboro, MA 01879 Federal ID Number:042437642 PO Box 511 Risk ID Number: Concord, NH 03302 Business Type: Corporation SIC:999999 NONCLASSIFIABLE ESTABLISHMENTS Other Named Insured: Other Work Places: 2. POLICY PERIOD: The Policy Period Is From: 4/1/2012 To 4/1/2013 12:01 A.M. Standard Time at The Insured Mailing Address 3. COVERAGES: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insured: Part Three of the policy applies to the states, if any, listed here: All states except Monopolistic State Fund States D. This policy includes these endorsements and schedules: See WCE105 4. COVERAGES: The premium for this policy will be determined by our Manual of Rules, Classifications, Rates& Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate Per Estimated Classifications No 'Estimated Annual $100 of Annual Remuneration Remuneration Premium See WC 00 00 01 Minimum Premium: Deposit Premium: $550 $6,488 Interim Adjustment: Annually Servicing Office: Total Estimated Premium $24,980 25 New Chardon Street Surcharge(s) . 7,575 Boston, MA 02114-4721 Total Premium ind Surcharge(s) $32,555 Issue Date 04/04/2012 Countersigned By: Date - Copyright 1987 National Council on.Compensation Insurance Form:100m Date � 4r�ctan�vr TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . ca ` ' . P. . . . . . . . . . . . . . . . has permission to perform . ° l< . .L . . wiring in the building of . . . . . . . . . . . . . . . . . . . . . . . . - . , Orth Andover, Mass. Fee ."() . . . . . Lic. No.15 W. . . ELECTRICAL INSPECT t Check# �I ! 11378 Commonwealth of Massachusetts Official Use only is Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRI AL WORK All work to be performed in accordance with the Massachusetts Electrical Code(ME ,527 C 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: 1,9o 13 City or Town of: NORTH ANDOVER To the Inspect r of res: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) L Q(A k k(ei( Owner or Tenant t } p�nc..�. ` L ,t� Telephone No. Owner's Address vv u_ oe 1 C Is this permit in conjunction with a b ding permit? Yes No ❑ (Check Appropriate Box) Purpose of Building k' Utility Authorization No. Existing Service O9 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 Wor J Vcl_.,Lw V17u1cAl, 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- ❑ o.o mergency Lighting ��� rnd. rnd. Batter 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 g Tons No.of Ranges No.of Air Cond. Total No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: ........... " " Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local ElMunicipal 171 Other p g Connection No.of Dryers Heating Appliances gay Security Systems:* Y No.of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices ox Equivalent Bathtubs No.of Motors Total HP Telecommunications Wiring: No.Hydromassage No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of lectr' al Work: pd(). (When required by municipal policy.) Work to Start: 1 Q Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provi es pro f 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 thepains andpenalties ofperjury,that the information on this application is true and complete. FIRM NAME: . R,.— LIC.NO.: — (�3 Licensee: nature � LTC.NO.: (If applicable,enter "exempt"in the license number line) Bus.Tel.No.• Address: Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. � OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not 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. ❑ 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 Re-Inspection Required($,) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors C ments: 3 Inspectors Signature: Date: ROUGH INSPECTION: - Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: 3 Z ` �a Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations uv� 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): - 1.❑ I am a employer with 4. ElI am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction 2. ] I am a sole proprietor or partner- listed on the attached sheet.$ 7• ❑Remodeling - ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. [:1 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.]I 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 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. 7' Insurance Company Name: P014#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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: J Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as ....every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to 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. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www,mass.gov/dia Location "/l / "J --2t No. Date 23 i NORTIy TOWN OF NORTH ANDOVER 3? • OL � 9 ' Certificate of Occupancy $ CHUS t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # /3 7� , 16161 "-�Building Inspector Pk OCT. '$2 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: 0"2 ,� DATE ISSUED: SIGNATURE: Building Commissioner/I for of Buildings Date Z SECTION 1-SITE INFORMATION 0 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number ParceNumber v 1.3 Zoning Information: 1.4 Property Dimensions: v Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Repired Provided Re red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private ❑ Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M { 2.1 Owner of Record Name rint) Address for Service O Signature Telephone '7'17,5-- 7/17,5— ®aQl/ Q 2.2 Owner of Record: Name Print Address for Service: z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ t Licensed Construction Supervisor: O �Y o /� O�ObV License Number Mn E.ddress h /9lrlf D 41 /V/// Expire' n bdte Signa Telephone egistered Home Improve nt Contractor Not Applicable ❑ v Company Name Registration Number Address 36,2— W Expir tion 6ate ^� Si a Telephone v• SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition Other ❑ Specify C Brief Description of Proposed/Work: 604 give 22r(4 f /7Ui 7 �� 40i�/C SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be oFI ICI4,L-, - E ONLY Completed by permit applicant 1. Building (a) Building Permit Fee Ste, J Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 PlumbinE Building Permit fee(a)X(b) �4 D 4 Mechanical HVAC 5 Fire Protection 6 Total (1+2+3+4+52 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. r -Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION f I, /'0n as 9wfter/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief .%Ohm Print Na iz a, Signat fir/A ent Dat NO.OF STORIES / SIZE (oaC/aAlly 6 BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST 2 ND 3 SPAN (o DIMENSIONS OF SII LS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIlVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUMDING CONNECTED TO NATURAL GAS LINE FORM U - SLOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *********************/********APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT �O�n PI rp hD PHONE -f31 LOCATION: Assessor's Map Number �.3 PARCEL /7 SUBDIVISION LOT(S) STREET /-"�%/? S��C�" ST. NUMBER i ************************************OFFICIAL USE ONLY*********************************** REC MENDATIONS OF TOW. AGENTS: C SERVATION ADMINIST TOR DATE APPROVED / a DATE REJECTED COMMENTS 3 TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 im �� �� � �'��� �� Cgs ��6 �07)E47E4%Yf(M.2Gl/L O��l.[7ddCtC✓LU4CCrd II = BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR _ I -77 Number: CS 040824 { > r Birthdate: 08/03/1956 Expires:08/03/2003 Tr. no: 9205 I - Restricted: 00 IIII JOHN W PROKOP t 9 JASMINE DR TATKINSON, NH 03811 Administrator r North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant 60 C�oZ Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector _ The Commonwealth of Massachusetts ` = Department of Industrial Accidents Office of Investigations �R Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name Address 3,0 City 2 1 S o o �, t'� 0 306 Phone#: 3 rS d Insurance Co. /'/�f 6Pre2J �l��L/s9A41 Policy# �� /� Company name: Address City: Phone#: Insurance Co. Policy# Failure to secure coverage as required.under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to$1,500.00 and/or one years'imprisonment_as-vrell_as_civii-penaltiesin thetnrm..cfa STOP WORK.ORDERand..a fine_of .si-oom,)-adw. against_m.e. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby certify under a pain and nalties of perjury that the information provided above is true and correct. i Signature Date /0 O Print name -- Oh Phone (V)3(d- Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing EJ Building Dept ❑Check if immediate response is required E] Licensing Board p Selectman's Office Contact person: Phone#: E] Health Department Ei Other II NORTH Town E of ....:,;.` Andover 0 No. o� �o� LA � dover, Mass., 30 04R 4 0RATE D P .(5 S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT......... +t ............................. Foundation 4 / has permission to erect....Y.X .................. buildings on . .f'............. ................. ........ Rough to be occupied as.... � �...��I►�'�.... �. � �! ���. ..... ..� .�r... NI ..g� himney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. taor,3 —, )f4lo PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR 'bRough ........... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. MORTGAGE INSPECTION PLAN The certification on this plan is made for financial purposes only. The undersigned will not be responsible if this Plan is used for boundaries, fences, plantings, additions, special permits or variances. LaT 97 I 99, 5 � LoT 6A AG �L g -- � Lo ` M.4 tC•@ smz,i ,rc kr _0 5 77E,2 2:- P(A,,. 3c4tt P0?'\C k S ` 01 K9 /D /&k S' T. THIS IS A MORTGAGE LOAN INSPECTION FOR FINANCIAL PURPOSES ONLY -— - Location NORTH ANDOVER MASSACHUSETTS CITY OR TOWN STATE Date July 19, 1990 20 Scale: 1 inch= feet 9. -" Deed and Plan Reference: Essex North Registry of Deeds Deed Book 1956 Page 45 Plan Book 126 Page 600 Cert.of Title No. �+ Certification is hereby made to: John M. Kaleigh & Young J. Lee & First NH Mortgage Corp. 4> Br.1."-_-r'tVV0 j cf yr_ lllue pv-e(i_ that the existing structures as shown are situated on the lot designated in com. K* - pliance with the applicable Zoning By-laws for setback, re- quirements of the municipality when con area and frontage P constructed. cted. `�►�*,�N ��E ,.'..IF Certification is hereby made that the structures shown on this plan IS NOT ARG located within a Special Flood Hazard Area as delineated on the FIRM map of i k. tw Community Number 250098 00058 Date June 15, 1983 u IOHNSiQN This plan was prepared to conform to the regulations of the Commonwealth of No. 27291 ) . Massachusetts 250 CMR 6.05. ♦ 5S\0 ♦ Lp LAND SURVEYORS COLLABORATIVE, INC. By. PO BOX 136 uNo wRvEroR ARLINGTON, MA 02174 278 MAKEPEACE HORrh Zoning Bylaw Denial Town Of North Andover Building Department Y 4 p9A'.p..*•��g 27 Charles St. North Andover, MA. 01845 �ssACHUS�'K Phone 979=688-9545 Fax 978-688-9542 . .Street:— Map/Lot: .Street:Ma /Lot: 53 – / Applicant: ,To /V m ! • /: U 0 _- +ems Re uest• rern0 b E_ 4-. ge P(Ac e Date: -/, ,c/ > Please be advised that after review of your;Application and.,Plans that your Application is DENIED for the:following Zoning Bylaw-reasons: Zoning x Y� Item Notes Item Notes A Lot Area F .Frontage 1 Lot area Insufficient1 Frontage Jnsufficient 2 Lot Area Preezi"sting qe,5 2 Frontage Complies 3 Lot Area Complies 3 Preexisting frontage 4 Insufficient Information 4 Insufficient Information B Use 5 No access over Frontage 1 Allowed G Contiguous Building Area q 2 Not Allowed 1 Insufficient Area 3 Use Preexisting 2 Complies 4 Special Permit Required Ll r-S 3 Preexisting CBA 5 Insufficient Information 4 Insufficient Information C Setback H Building Height 1 All setbacks comply 1 Height Exceeds Maximum 2 Front Insufficient re. 2 Complies 3 Left Side Insufficient 3 Preexisting Height 4 Right Side Insufficient Tq t_' S, 4 Insufficient Information 5 Rear Insufficient I Building Coverage JV 6 Preexisting setback(s) ,F { S 1 _ Coverage exceeds maximum 7 Insufficient Information 2 Coverage Complies D Watershed 3 Coverage Preexisting 1 Not in Watershed L4'e-S 4 Insufficient Information 2 In Watershed j Sign 3 Lot prior to 10/24/94 1 Sign not allowed 4 Zone to be Determined 2 Sign Complies 5 Insufficient Information. 3 Insufficient Information E Historic District K Parking JAV) 1 In District review required 1 More Parking Required 2 Not in district `( PS 2 Parking Complies 3 Insufficient Information 3 Insufficient Information 4 Pre-existing Parking Remedy for the above is checked below. Item # Special Permits Planning Board Item # Variance Site Plan Review Special Permit Setback Variance Access other than Frontage Special Permit Parking Variance Frontage Exception Lot Special Permit Lot Area Variance Common Drivewav Special Permit Height Variance Congregate Housing Special Permit Variance for Sign Continuing Care Retirement Special Permit Special Permits Zoning Board Inde endent Elders Hou sin S ecial Permit —Special Permit Non-Conforming Use ZBA Large Estate Condo Special Permit Earth Removal Special Permit ZBA Planned Development District Special Permit Special Permit Use not Listed but Similar Planned Residential S ecial Permit Special Permit for Si n R-6 Density Special Permit S IP reexistin nonconformin Watershed Special Permit 5 ry s tr The above review and attached explanation of such is based on the plans and information submitted. No definitive review and or advice shall be based on verbal explanations by the applicant nor shall such verbal explanations . the applicant serve to provide definitive answers to the above reasons for DENIAL. Any inaccuracies,misleading information, a other subsequent changes to the information submitted by the applicant shall be grounds for this review to be voided at the discretion of the Building Department.The attached document titled"Plan Review Narrative"shall be attached hereto and incorporated herein by reference. The building department will retain all plans and documentation for the above file.You must file a new building permit application form and begin the permitting process. .8-6ilding Department Official Signature Application Received Application Denied Denial Sent: If Faxed Phone Number/Date: Plan Review Narrative The following narrative is provided to further explain the reasons for denial for the application/ permit for the property indicated on the reverse side: yPj '1.i- y>,;,2 fay .'•'l ','�J°fir 1 r�'tr r �'� 17/3 � .?!!e.�r f �Vy ..�`;yA�� �}7�� -m su �f"{f' +.ap+�`2; '�,�y�ys��,.t �'A� ��:�'ae yt�.i?t3`�y��;Et� f�,*t � }f,!t S�,t r -:r �2S 4 h.t ,�x�,4r�A;S$ ✓.. "a ,i '�xt.Q,;yt LN}'!dw�,,� oau��n�ir.S'iA�' zti;/ •�i .��v�d�'�"� - 't�y«.c� y ape�.t--rt.y� �h�7�`?�' 4 {.�SsY cn��,«r.�`.4�. Mrd �.laFtA t't 4 };� � L �,�.�n�� �j';�s�`�.xiB�r 4lAh�;�'o 'ta������i"��1�'t.. �t`�e°e 4"u+^• i lr`-�''.a��'1�ru q� �85�t{r r��''`j�.7r h{I.S�7 uv'atl �,1�p`, S51t ?�� :�.�i h <<. "j •�. Ni,�PS' ..., ir}���k'e, {S#;,', ,�t'�.�� �f*h '' °y{ht4�df�Y�'�� 0 N a q, �e � 1�I� Referred To: Fire Health Police Zoning Board Conservation De artment of Public Works Planning Other Historical Commission BUILDING DEPT i MORTGAGE INSPECTION PLAN The certification on this plan is made for financial purposes only.The undersigned will not be responsible if this plan is used for boundaries, fences, plantings, additions, special permits or variances. LoT 9� 99, �s 23 - - -- - IJARAG t� 40 7' �� + N Zi/2 5T/• .. � d o� , , /�• N N�� or S TEfZ `` ff,,-- (Z�p l f1 Com- Bbl Po rc k p S I ' H / GH ST } � THIS IS A MORTGAGE LOAN INSPECTION FOR FINANCIAL PURPOSES ONLY Location NORTH ANDOVER MASSACHUSETTS CITY OA TOWN STATE Date July 19, 1990 Scale: t inch= 20 feet 4 5 Deed and Plan Reference: Essex North �. Registry of Deeds : t Deed Book 1956 page 45 Plan Book—121600 600 Cert. of Title No. Certification is hereby made to: John M. Kaleigh & Young J. Lee & First NH Mortgage Corp. Br Ler wood t�(✓'_ 41L)c ou-e(�_ D�8f0 dd °- that the existing structures as shown are situated on the lot designated in com- - - -` pliance with the applicable Zoning By-laws for setback, area and frontage re- quirements of the municipality when constructed. ►4��11� <<t ::.•, •Y� Certification is hereby made that the structures shown on this plan IS NOT ��• located within a Special Flood Hazard Area as delineated on the FIRM map of MAL(C'.i✓ N: t Community Number 250098 0005E Date June 15, 1983 1O NSi0N This plan was prepared to conform to the regulations of the Commonwealth of N0. 21291 3 9 Massachusetts 250 CMR 6.05. ♦ LO LAND SURVEYORS COLLABORATIVE, INC. B ����� PO BOX 136 By uNo SURVEYOR ARLINGTON, MA 02174 278 MAKEPEACE