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HomeMy WebLinkAboutMiscellaneous - 17 EMPIRE DRIVE 4/30/2018 �i9i 9�l1a19f9� - ` G l 72 Date . --- - - --- -. o r HORTI, TOWN OF NORTH ANDOVER � 4„t e,��G PERMIT FOR MECHANICAL INSTALLATION t o s i a i a a 'a �9SS4CMUSEt k This certifies that . . . has permission for mechanical installation in the buildings of . �._ "� R r' ., �? . . . . . . . . . . . . . . . . . . . . . . at .6. . . 'F^ s?.�: .. . r k,.. . . . . . . . . .. Nor- Andover, Mass. Fee.'X),�D. Lic. N&w. . . . . GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer Commonwealth of yIassachusetts Sheet yIetal Permit Date: ?•_rmit *—I � L Esticiated Job Cost' e �✓ y Permit Fee. Plans Submitted: YES No Plans Rcviewe,,i: YES �t0 Business License # -.pclicant License Business Infornttitior.: Properc.' 0%%ner/ Jou Lccatioc lnfcrmation: name: Street 'T'2 /�G` Strxt 7 � �� ,�,Z9) own. Teiephor-e: ;94�71 i Tetep'..a e: 7 7 qFk 3 Photo I.D, required/Coe; oC Pho-c I.D.attached: YE-5 Slarr Initial J-Y -1-anresirictcd livens J-2 /M-2-restricted to dwellings ?-stcries or:css and catnmercial up to !0,600 se. =,!2-storie3 er less Residential: t-2 fatTliiy_ - �fuiti fs,-ti!y Condo'Townhouses Other Commercial: Oftice Retail E,jueat;enal I stividor.al t;thcr Sgaare Footage: ur.dc: 10,000 ,c. ft. `t/ over 10.0,00 sq. ft. Number of Stories: S;ter metal work too tompleted: Ntw IW crk: HVAC ✓ Meta! Water3hed Rcofina � _em _ Kitchen L:«asst ,.v;tem Metal Chimney / Vents Air 5ala;,ci tg ?rovide detai'.ed descrirtion e-'%vork to be done: INSURANCE COVERAGE: I have a current liability Insurance policy or its equivalent,which meets the requirements of M.G.L.Ch.112 Yes �/ No If you have checked Yes,indicate the type of coverage by checking the appropriate box below: 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 b Chapter 112 of the � Y P Massachusetts General sand that my signature on this permit application waives this requirement Si natu of Owner or Owner's Agent Owner ❑ Agent 9 9 By checking this box 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 installation performed under this 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 instailation:Yes No Progress Inspections Date Comments Final Inspection Date Comments Type of License By: Master Titre: ❑ Master-Restricted ❑ Joumeyperson Permit#7. ❑ Joume erson-restricted Fee S: ❑ Inspector Signature of Permit Approval Signature of Licensee License#: SHEET METAL PERMIT 02.19.11 AC0' DAT! (MMIODIYTYT, . CERTIFICATE OF LIABILITY INSURANCE 03/26/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terns and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: _ NORTH ANDOVER INSURANCE AGENCY, INC. PHONE (AIG, No, EAtI: (978) 686-2266-SAX No):(978) 686-6410 M.J. FOSTER INSURANCE SERVICES n DRESS: c£ernandez@na£ins.cam PRODUCER 163 MAIN STREET CUSTOMER 10 D•A Mechanical, Inc. F" NORTH ANDOVER MA 01845-2508 - INSU_RER(SIAFFORDING COVERAGE _ N_A_IC_9_ _ INSURED INSURER A :PEERLESS INSURANCE. CO R.A. . Mecham cal, Inc. INSURER a :GUARD INSURANCE 16 Lomar Park INSURER C Suite 1 INSURER D INSURER E Pepperell MA 01463- INSURER F COVERAGES CERTIFICATE NUMBER: 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 ; ODC-SLBR POLICY EFF"-POLICY EXP LTR TYPE OF INSURANCE INSR WVO POLICY NUMBER (MMIoDIYYYY) (MM/OONYYY) LIMITS A GENERAL LIABILITY Y CBP5337500 01/01/2012 01/01/2013 EACH OCCURRENCE S 1,000,000 DAMA E TO RE_NTE_D X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence).___S 100,000 CLAIMS-MADE X OCCUR / / / / MED EXP(Any one person) S_ _ 15,000 PERSONAL 8 ADV INJURY S 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE A R ATE U E MIT APPLES PER: / / / / PRODUCTS-COMPIOP AGG S 2,000,000 _ PRO X POLICY - 5- ---- ! LOC EBUR A AUTOMOBILE LIABILITY BA8832363 01/01/2012 01/01/2013 COMBINED SINGLE LIMIT S 1,000,000 (Ea aCCIdern) ANY AUTO - BODILY INJURY(Per person) S ( P 1 ALL OWNED AUTOS BODILY INJURY(Per accident) S X SCHEDULED AUTOS / / / / PROPERTY DAMAGE X HIRED AUTOS (Per accldern) S - . X NON-OWNED AUTOS / / / / '--- ----------g---------- A X UMBRELLA LIAR X OCCUR CU8825678 01/01/2012 01/01/2013 EACH OCCURRENCE S 1,000,000 EXCESS LIAB CLAIMS-MADE: / / / / AGGREGATE S 1,000,000 DEDUCTIBLE / / / / _ $ RETENTION S B 1WORKERS COMPENSATION RAWC231923 01/01/2012 01/01/2013 WC STATU- OTH- ANO EMPLOYERS' LIABILITY YIN TORY LIMIT___-ER---------- ANY PROPRIETOR/PARTNER/EXECUTiVE / / / / E.L.EACH ACCIDENT S 50O_ OOO OFFICERIMEMBER EXCLUDED? ❑ NIA -- ------------- -- ---0 (Mandatory in NH) - / / / / E.L.DISEASE-EA EMPLOYEE S _500 000 Ifyyes.descnbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (AV..h ACORD 101, Additi—I R—rka Schedul., it mon spat. i. ,squired) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. R.A. MECHANCIAL, INC. 16 LOMAR PARK AUITHORI= REPRESENTATIVE SUITE 1 PEPPEREIM MA 01463- ACORD 25(2009109) ©1988-2009 ACORD CORPORATION. All rights reserved. ! INS025(2oogog) The ACORD name and logo are registered marks of ACORD .t- u. — Sr.-- r3..a3:�:.•=��;:>l -.gym'^ {l::y: - :t.:i:.._i^:•'..:;ia. iz• • MASySACHU�ETT' DRIVERS_ _ LICENS ,usA 1 - OF M.1ss ,..... 9,eie <d :4T_to- 9$4 .. E- t9 snc"M.— ............ . , MOTH RD f =t`` DRACUT,MA 01826.4349 'I--� C/�/7��V �5OD 09.07.1010 My0T•11M09 COMMONWEALTH OF MASSACHUSETTS • • •^0.'1.`1• M7it, i w mover.invol:2 METAL AS A MASTER-UNRESTRICTED ISSUES THE ABOVE LICENSE TO: DONALD i DUELLETTE 657 MAMMOTH RD 's DRACUT MA 01826-4349 4688 07/28/14 223139 i ,.�..� The Commonwealth of Massachusetts Department of Industrial Accidents ft46ROffice of Investigations. I _ 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):--P.A.1 A f�}�eM�il_a i oaa lack Address:l kOffl,!2 r 12,c/< City/State/Zip: 13e/�v),o(ej/ 1�24 0/� 3 Phone #: Are you an employer. Check the appropriate box: Type of project(required): 1.Eft i am a employer with 4. I am a general contractor and I 6. ew construction employees (full and/or part-time).* have hired the sub-contractors attached sheet. 7. Remodeling 2. I am a dole proprietor or partner- These on thea ❑ ❑ P P P ship and have no employees These sub-contractors have g, Demolition P , workingfor me in an capacity. employees and have workers Y p tY• ._ 9. ❑ Building addition [No workers' comp. insurance comp. insurance.* required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11. Plumbin re airs or additions 3.❑ I am a homeowner doing all work g rep right[No workers' comp. right of exemption per MGL 12.7 Roof repairs t c. 152, §1(4), and we have no insurance required.] 13.❑ Other employees. [No workers' comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. '-Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the palicy and job site information. Insurance Company Name: Lo�.(c� Policy#or Self-ins. Lic.#:�/I(' �l 7,> j Expiration Date: Job Site Address: 17 0irst44�t, City/State/Zip.- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify der the antenauldes of perjury that the information provided above is ue and correct. Si ature Date: �� d i 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#: Sheet 1 zj CE C", X r r. CTM _ =first -.ccr I til 225 f r I ;\00 I _ UN iii in x '�✓� 7 oz i S I r A ik IVt I a� Job#: Scale: 1 :64 Performed for. RA MECHANICAL INC Paye 1 BOB MESSINA 16 LOMAR PARK Right-Suite®Universal EMPIRE DRIVE PEPPEREL—MA 01463 7.125 RSU11207 N.ANDOVER,MA. Phone:9784338671 Fax 9784334900 2011-Feb-24 08:12:59 cJa 4v-1v ...arty orchard village 2-23-11.rup T!� ..^I'�• III 2nd floor r 2rie i1ccr Ct " C h C s ���✓�,C �y v 1yN t� v` /Qo ern rl Gs er LES, O 4/ cim c�rrl S Job #: Performed for. RA MECHANICAL INC Scale: 1 :64 BOB MESSINA Page 2 EMPIRE DRIVE16 LOMAR PARK Right-Suite®Universal N.ANDOVER,MA PEPPERS I MA 01463 7,1.25 RSU11207 Phone:9784338871 Fere 9784334900 2011-Feb-24 08:13:59 7/;e ,, r LtH ramechanical®aol.com ...arty orchard village 2-23-11.rup c HusE� CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 152-13 on 8/23/2012 Date: December 5, 2012 THIS CERTIFIES THAT THE BUILDING LOCATED ON 17 Empire Drive MAY BE OCCUPIED AS a single family home IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Orchard Village LLC 277 Washington Street Groveland,MA 01834 Building Inspector Fee: PrePaid Receipt: 25643 Check : 3153 %%ORT1i q ~ APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION �9SSACHUSBUILDING PERMIT # 15cZ"1-3 ADDRESS/LOCATION OF PROPERTY: 7eM,�/�C'- Map q X Parcel '9-W , Lot Number ' SUBDIVISION: c =r V i L L A C C DATE REQUESTED FILED/READY FOR INSPECTION: '7 CLOSING DATE ON PROPERTY: 2_11e FIVE (5)DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN-OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLLARS ($20.00)WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. APPLICANT SIGNATURE Permit Issued to: e�9 gcz1a � e-,,(-,- 4L C Addressa'2 7 UJ RS I (�T A) e 7� G40064MY0—e14 19 61&3V ROUTING TOWN ENGINEER, SITE PLAN-DRIVE-WAY REVIEW ©C✓ i f-Z -I Z CONSERVATION PLANNING DPW-WATER METER SEWER CONNECTION L DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCYANSPECTION REQUEST DPWJ�. K� �- SIGNATURE File:Application for OC form revised Jan 2007/2011 r NORry O��•C{,EC ry6�+ 3 J. t O Bt:;{�- 6 0 } L APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION �Z'c 1 h 5 R«�„TEo�P���S* BUILDING PERMIT # SACHU`S ADDRESS/LOCATION OF PROPERTY MapIP-0) ,21� � Parcel Lot Number # SUBDIVISION: K'CA C_0 I �-�- (f C- DATE REQUESTED FILED/READY FOR INSPECTION: `T CLOSING DATE ON PROPERTY: 2_ � b 2-,- FIVE 5 CLOSING DATE IS RE UIRED DAYS NOTICE PRIOR TO L ( 1 ALL WORK AND SIGN-OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLLARS ($20.00)WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. APPLICANT SIGNATURE Permit Issued to: Address•X V-7 UJ AS f-I l 1J q D AJ C C-;�Co 61 44, 13 61 ROUTING TOWN ENGINEER, SITE PLAN—DRIVE-WAY REVIEW 141 aE= c {T w j j_z� _jz CONSERVATION LCI PLANNING DPW-WATER METER SEWER CONNECTION [� DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPW, ( �''��J­6f`- �- SIGNATURE File:Application for OC form revised Jan 2007/2011 r 1NORTH . : .: . E .1, c . . ve' . O - C% ti ver, Mass, 2s�� . COCNICNIWICK �1• . �d A�4ATED PC S U BOARD OF HEALTH Food/Kitchen PERM. IT T D Septic System THIS CERTIFIES THAT ......... `.��: �' �!./G 6..h. .fa..c................ 4 ��..................... BUILDING INSPECTOR Foundation has permission to erect..........................:buildings on ...1 . Ir. l�`....... .l'.1.. !f....................... Ruh (� Ale IL tobe occupied as ...... / .............................................................................. cn� neq= SGS provided that the person acceptin6his permit shall i every respect conform to the terms of the application Final on file in 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. PLUMBW�INS.,ECTORough S rL VIOLATION of the Zoning or Building Regulations Voids this Permit. Final41,10 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSP CTOR UNLESS CONSTRUCTI STARTS /'6-1om--f '2-Pz ........ . y ... ...................... Service ....... .......... ��. //_ BUILDING INSPECTOR in Z&._/ Z GAS INSPECTOR Occupancv Permit Required to Occupy Buildin4.41 Display in a Conspicuous Place on the Premises — Do Not Remove Final fo /Z No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner • Street No. ��1�L Jl-22-I SEE REVERSE SIDE Smoke De. �:�_z �d �vFrn ''^--- r 1NoRTM - 1c . . ve' . No. t k4-th r� 2.s"�f�-ver, Mass, COCHIC//l WICK y1. �L1,9 AOR�TEO ►.PP�gS S U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT ............................................. BUILDING INSPECTOR ....�4.�a......................6.�....... Foundation has permission to erect..........................:buildings on a5. l.`. ... .l'.<. ! ....................... �� R ugh � to be occupied as �¢ /...' <�✓i .............................................................................. cn� ney�-rrs �'�� �f ....................... ......... provided that the person acceptin this permit shall ifi every respect conform to the terms of the application on file in 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. PLUMBING INS ECTO aough 3 �� 2 VIOLATION of the Zoningor Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSP CTOR UNLESS CONSTRUCTI STARTS Service ............... .:�:-�, ... .............................................. BUILDING INSPECTOR in //- Z-9-/ Z GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz ,`�n� � Display in a Conspicuous Place on the Premises — Do Not Remove Final /��,; f� a� fZ No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner A 'Street No. . lrf� Smoke D.e IV _ SEE REVERSE SIDE NORTH w. .. : : _ c . . ve' 'Q. . 0 No. ® T �o h ver, Mass, Se 1b Poe coc KICMt WICK y1. TIE o S U BOARD OF HEALTH PERMIT LDFood/Kitchen S System THIS CERTIFIES THAT �. .......... ..L. .. ... 4,,,,,,,,,,,,, ILDI G INSP CT ......... .......... Ol V has permission to erect, .............. buildings on ..• • ............... ..��.}..... .........� ---Rough to be occupied as .......... .....idl.�/,-�1=l�:1�7olowo..... .... .... ...R�...................:.......... Chimney provided that the person accepting this permit shall in eve re ect conform to the terms of the application e p p p g p every p pp Final on file in 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. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES I ONT . S ELECTRICAL INSPECTOR IDO UNLESS CONSTRU T ST Rough Service ........... . ...............................................•rr.--�;... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz 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. Smoke Det. SEE REVERSE SIDE N2 9587 Date. .._ao-12 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACHU This certifies that . . . . . . . . . . . . .� . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . .. ..�. .�```.'��". . . . . . . . . . . . . . . plumbing in the buildings of . . .�.�"�. . . . .. . . . . V'l.(.4.. .. . . . at. . �.... . .... . ...itic D 2`VL'. , North A dover, Mass. Fee.y l�:c�� Lic. No..!"3 Y.� . . . . . . . . . . . . . _ PLUMBING INSPECTOR Check # y Y WHITE: Applicant CANARY: Building Dept. PINK:Treasurer i � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK i CITY uc�tti n,cY 3 MA. DATE Ct F Z PERMIT# JOBSITE ADDRESS , OWNER'S NAME O A.G l� alp l)t -fii�Az�CC. POWNER ADDRESS k"J `a_,F TEL FAX 1 TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[� PRINT CLEARLY NEW: RENOVATION:El REPLACEMENT ElPLANS SUBMITTED: YES E] NO ❑ FIXTURES I FLOOR— BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GASIOIUSAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY J 3 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET + Z URINAL WASHING MACHINE CONNECTION +. WATER HEATER ALL TYPES WATER PIPING OTHER 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which,meets the requirements of MGL Ch. 142. Yes& No❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 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 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement- i CHECK ONE BOX ONLY: OWNER ❑ AGENT ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information l have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapt 1 2 e eneral Laws. PLUMBER NAME STEP+60 C GAu0sKV SIGNATURE LIC# I034 S MP Lr' JP❑ CORPORATION X# 31 C1b PARTNERSHIP ❑# LLC ❑# COMPANYNAME 6+9WOSKY PLUMOItjjs> *- {feApAj ADDRESS: P.D. GGX 1701 CITY HAV61zItILL STATE M•A- ZIP 0I$31 EMAIL www• m�p�V +ber�a�OaOI � Com TEL 4'7V-32q_ 0143 CELL 50$-50CI-5909' FAX 97$- yli-41 i Owl ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES kS THE PERMIT ❑ ❑ FEE: $ PERMIT :� 9 fF— PLAN REVIEW NO`f ES Date �,oti�Llip'7�' TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that t � 1 j%l'1'f Vt'GJ '� �,.f '�'t•�'J�`�.�{ice_. .�.�.C',ci:1.1 . has permission for gas installation . E . . —l • • , • , , . , , . in the buildings of. . . . f;•L •c• ; . . . . . . at . . j.-I . . ,- .��.i •\4 .. . . . . . . . North Andover, Mass. Fee k,gcu� . Lic. No. 3�.�. ,. GAS)NSPECTO Check# 8333 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: MA. DATE: `�—C�L PERMIT# JOBSITE ADDRESS: (_7 &Wp i�cIDCOWNER'S NAME: 60ghd n4 LAU ofCs f LL,C_ GOWNER ADDRESS: ( J `0 -1, 6 p TEL: FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[� PRINT CLEARLY NEW.-[f RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES? FLOOR, l3smt 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 s_ TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES M NO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER E] AGENT E]SIGNATURE OF OWNER OR AGENT F certify that all ofi the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my ge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws, PLUMBER/GASFITTER NAME: ST is PN EN C G A L S NS KY LICENSE# 1 O 3 y IS SIGNATURE COMPANYNAME: QAC?oS3Kq Pt-WA611. 6 + O-�4tIO& ADDRESS: P.O. Nox 1,701 CITY: OAVEP—HILL, STATE: M-A. ZIP: 01831 FAX: 979-1521-4131 TEL: 978-3714— 17143 CELL: Avg— 60q— 59014 EMAIL: W VV W. m 1 u mbe 01 yv� MASTER[;?� JOURNEYMAN❑ LP INSTALLER❑ CORPORATION[J)# -319t. PARTNERSHIP❑# LLC 0# \� ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES q-e Date t TOWN OF NORTH ANDOVER +� PERMIT FOR WIRING i 6 This certifies that . . . /,�: . S .f . � has permission to perform . . .... . . . . . . . e. . . . wiring in the building of . /�� . . . . .,l?1 r���p.i7. . . . . . . . . . . . 4AU ,- l 4 at :?k--. /�7. :/. ..y North Andover, Mass. Feeic. No. ,� j���. i � . . . .�!�✓✓�. . ��. ELECTRICAL INSPECTOR �^ Check# l3 1 Commonwealth of Massachusetts Official Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /G — f —/Z— City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical wordescribed below. Location(Street&Number) 7 10/ Owner or Tenant A?I /C Telephone No. Owner's Address 277 A- d��"` h Is this permit in conjunct with a buildi g permit? Yes No ❑ (Check AppropriateBox)� . Purpose of Building /i'rr � Utility Authorization No./3 �� 7 - Existing Service AIMPS / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps/z v /�`/G Volts Overhead❑ Undgrd No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the followin table maybe waived by the Inspect of Wires. No.of Total No.of Recessed Luminaires No.of Ceii.Susp.(Paddle)Fans Transformers KVA k� No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o mergency ig mg No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices Total No.of AlertingDevices No.of Ranges No.of Air Cond. Tons Heat Pump Nu%b.!T...Tons KW..,.,,,,,. No.of Self-Contained No. of Waste Disposers Totals: Detection/Alerting Devices Municipal Other No.of Dishwashers Space/Area Heating KW Local❑ Connection Heating Appliances KW Security Systems:* No.of Dryers No.of Devices or E uivalent f No.of Data Wiring: No.of Water No.o g Heaters KW Signs Ballasts No.of Devices or Equivalent ' Telecommunications Wiring: Total No.Hydromassage Bathtubs No.of Motors Tot HP No.of Devices or Equivalent OTHER: 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: Inspections to be requested in accordance with MEC Rule 10,and upon completion. ed b the owner,no permit for the performance of electrical work may issue unless INSURANCE COVERAGE: Unless waived y p the licensee provides proof of liability insurance including"completed o eration"coveragee or its substantial equivalent. The undersigned certifies that such covera s m 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 iti ormation on this application is true and complete. FIRM NAME: � vv ��f /� �`r y LIC.NO.: Licensee: /c fNi Signatur LIC�'O.: 3� (Ifapplicable, er "exempt"in the license numbe line.) Address: /- -G Alt.Tel.No.: *Per M.G.L . 147,s.57-61,se rity or requires Department of Public Sa ety"S"License: Lic.No. � OWNER'S INSURANCE AIVER: 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 I PERMIT FEE. $ Signature Telephone No. • t ' .1�1J'-lJ6Jll..r.RJ.�-4•l�rt'ff�'(l.L.A=1�L'�-•t��J�Jj.�dl�®•�� •.y�`y�t^�y /'� ��J.+.,L!'L.iJ+..RV'.i.`�J191�J.®J•+.1.� '� .f1_D/I�.�j Jl.l`�.•.�s,�.lL\�.L.�fV��.l�� • r . ..�• + ��sseu�-� _ �+'ai1eQ-�j � �e-xuspectiox��•ec�ui�red'($�'0.00)-•X � ox �:izspectQxs . 7�e�ats; - speetoxs' igua •e•3� &nfiaYs) Pate MAL 'arse aflec� -r Rib-hl Betio.�xe �tspeetoxs'comm�enfs; (fAs&doxs'gignatuz •-3zo Walk Pate •ter - C. 'assed-j +ailec7- l xze-fnspectiop,xequirea($90.00)-[ aspectoxs'co3nnzents: • �lnspectoxs� ignatuxe-�o�sv`fiaTs) ))ate ' -M,CAI�-IQRVD WATIONM�OR 11 ssec�-- �+'aiie�.--[ � �e-xnspectzottxequire�(�50.OD)••( � , pectbxs'eomm.eph. • • rte - �- (�spectoxigu2tuxe 3io jnitials) - bate Re1LSP ectiottrf,gvirea($50.00)-•[ ectoxs'coxa eats; _ . sp ectoxs',signature azo initials) date ' i I A The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.F, I am a sole proprietor or partner- listed on the attached sheet.$ ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]i employees. [No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach,a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as 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 cert under the pains and penalties of perjury that the information provided above is trite 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): I.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 ted 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;# f 17-777-774.9