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I :: „ � ,.:., r M�a:p. 4 «;a:: I:�p rhwdA 7',.u�TMI s-�':'PYa •Ir ;w'ii 'li4 h ;:w�:4� I+::`� r r q L'. w'X;,•a n � t ir:r: I I'.: d� M aW"a4,::; 1 `uX• hfnq h w' hr„� A F 4 w� P" {Xq ml r'°m I .'J�•N:I ++ I• n a, I" Ifu n,N 1�'n k 11*' a r J d ,k.« F h• - FY 4� 4 I X 5 rx d � �r�� ��Yi p y 5' t nI r w1 u . x` , j X Dat. ............ �? NORTh F TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION CHUS� ` I This certifies that ` ............!....................................... ................... has permission for gas installation in the buildings of... c W. at....... . 1........��.... ..... . �..........., North Andover, Mass. Fee W J GASINSPECTOR Check# 10375 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY "�CtZ,�-'e rC- __j MA DATE I //S PERMIT# .v JOBSITE ADDRESS e,,4-S:i .sV OWNER'S NAME L ^` OWNER ADDRESS I TEC�L=__ JFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:[RENOVATION: ] REPLACEMENT:® PLANS SUBMITTED: YES NO® APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER - (� '.I_. ..._ BOOSTER CONVERSION BURNER COOK STOVE (u- . �~ DIRECT VENT HEATER ( � -.. I . DRYER - FIREPLACE FRYOLATOR �-^ _ I - _ �- _ I _ FURNACE - _- ! ._ ...._ I �-- _ L_ - ---J - - 1 GENERATOR GRILLE _ ._.. =-1 -- - -- -- -_tl _ - INFRARED HEATER LABORATORY COCKSCom- MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER _ --.-- - - ROOF TOP UNIT - TEST UNIT HEATER - UNVENTED ROOM HEATER ._ WADER HEATER - OT'i R . - - --- INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY F--11 OTHER TYPE INDEMNITY ®f BOND 0 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 Ell SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in corAfance with alla ine t pr ' ion of�te Massachusetts State Plumbing Code.and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME��4H9� l�grWW LICENSE# /f^ SIGNATURE MP P�'MGF El JP 0 JGF Q LPGI CORPORATION©#=1 PARTNERSHIP 0#=LLC # COMPANY NAME: C'. _f_ � - ADDRESS CITY _ _ _� STATEJ�':l ZIP 6a_ TEL D FAX CELL� EMAIL -- - - - - - - - - - UGH GAS WSPECTIODW NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES -� Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES r � The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information _( {1 Please Print 2gibly Name(Business/Organization/Individual): �t) 1� � y I , ��''� P Address: /�- �-�A) Le Low City/State/Zip:,()eW'7—Ds(J /JJ4•d37ffPhone#: &6-3 *7 X02 9 Are you an employer?Check the appropriate box: Type of project(required): 1.FJ I am a employer withemployees(full and/or part 7. ❑New construction am'a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.E:1 Electrical repairs or additions proprietors with no employees. 12.[j� 'lumbing repairs oe or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[]Roof repairs These sub-contractors fiade employees and have workers'comp.insurance.$ 14.[]Other 6.❑We area corporation and its,officers have exercised their right of'exemption per MGL c. 152,§1(4),and we have no.employees.[No workers'compinsurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub contractors and state whether or not,those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name- Policy#or Self ins.Lie. . �r, Expiration Date: 1 1 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration age(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi nder thepai ndpenalti ofPperjury that the information provided above is true and correct. Date: a-a t— Si ature: q Phone#: e �'3 `3 9a 7/ 02 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): LOther ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector on: Phone#: 1 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. 6 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 yoursituation 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 cavy 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 youare re ui e g g y r d to obtain a workers q . compensatioti'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 do license or permit( g p to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext.7406 or 1-877-NlASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia �a- USETS COMMONWEALTH OF Mi4SSACH PLUMBERS AiJD GASF ITT ;RS ISSUES THE F0LLOWINGtLICENSE: LIE�IPC� AS A MASTER,PLUMBER` NOR?MANDP BERUBE 12 L IN C*GL N:"' RD NE4fTON NH 03858-310 l ;t ' i Plpk 1—e—1-4 k I I� Date................................... of R T#j TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that.................� C ... .......... ...................... has permission to perform... ........ ................. ................... plumbin n the buildings of....... ........................................................ q at ....................... r, . ... ........ .................... North Andover, Mass. Fe .......Lic. No. 115M.. ................................................................................. ........... .ARP PLUMBING INSPECTOR Check# 2-c MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY 0• _ Ycie- MA DATE /02 -02 -5'� PERMIT# JOBSITE ADDRESS I ��? �T�i c.�s ^ OWNER'S NAME POWNER ADDRESS TEL a6a.1 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL p EDUCATIONAL Q RESIDENTIAL PRINTPLANS SUBMITTED: YES® NODI NEW: � RENOVATION:© REPLACEMENT: FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM i w-• J -- ) ---�- - - -- ---,) --- --t I DEDICATED GAS/OIL/SAND SYSTEM .____1 .--=j ..! - . DEDICATED GREASE SYSTEM ( _..._._.1 J __._.� _.__! __._._1 _ 1 ___( ___1 _.._.-G —E DEDICATED GRAY WATER SYSTEM i - ..__ ( ( _f DEDICATED WATER RECYCLE SYSTEM DISHWASHER _-1 ._T_-! -____J _____) .__..._� _..-._J _.,.1 _.__._._ __ j I ___,___( DRINKING FOUNTAIN _.__{ FOODDISPOSER i ._E:._.1 _-_.-._-L ..__.-,-.( ___1._ __I .____..i ___...._._1 .__..____.I ._.___� --.___! ._.___) FLOOR/AREA DRAIN �i ____-__� __-- _--..__( _ __..._.1 __-__� . _.___( _..__1 ..w.._f _-..._.- -__.__1 ( ._______! INTERCEPTOR(INTERIOR) ! _. _.-! ____-_ 1—.-J,[-.-,j.. f _. . [ __.._._i KITCHEN SINK .l _f._....I _vl __ _I I_.__ l __ J __---_...( -____I .._-... I I _Y_.{ LAVATORY _I _ __I .-___ __._.._1 __ ( __.____1 _._.__.__f __.- __J ._.__J' ROOF DRAIN __ l _J _____._6 ___( _ E __._.1 _ _.! .._.___ J 1__j SHOWER STALL SERVICE/MOP SINK TOILET I __ --• J . - ( _ ( __ J _ ! .___-J __J .—I ------J _.._._ ( ____( UR NALLML WASHING MACHINE CONNECTION _._lf --_..__ ` WATER HEATER ALL TYPES WATER PIPING ( OTHER ! ( -- I ( ----------- ..J _.__... f -- -! f -I --...J __j _..._.__J - INSURANCE COVERAGE: 1 have a current liabilt insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES J NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY d OTHER TYPE OF INDEMNITY L] BOND 0 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 F-I AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in c liance with rtinent vision of the 106 (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME,���'�! e-w,j LICENSE# SIGNATURE �� MPH/ JP CORPORATION 1# PARTNERSHIP®# LLC COMPANY NAME JL 1f1 ADDRESSAz �- CITY ,�-L JT6 - � � 9 ZIP TEL I /v � �STATE �" `.-., -- v �S FAX CELL EMAIL - ROUGH PLUMBING INSPECTION-NOTE.S BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES ¢� Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: PERMIT# PLAN REVIEW NOTES A Date...0-1z (.t..'. a �NORT�y, O .�ao ra 'VQ o?' °p TOWN OF NORTH ANDOVER PERMIT FOR O GAS INSTALLATION CHU�tt� y` �,......`� R This certifies that ............ .�`�::..'�..,...................::.tr-...-�'^..........................:.............. has permission for gas installation'.-.......................................... Q w .. ..,........................... inthe buildings of ......................................................................... ......................................................................... at....... � J. ."tet ...S 1lU 1 , .� , North Andover,Mass. ................................. ........... .:. FeeA.W.......... Lic. No. ... ...51!. a ..................................................................... GAS INSPECTOR Check# ) ° 037 . •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 0 UVCITY le AAA& V-P—'ep MA DATE /� o?/` J PERMIT# It 51q ' JOBSITE ADDRESS s WNER'S NAME GOWNER ADDRESS _ TEL 7 3�i b©�a FAX _ TYPE OR OCCUPANCY TYPE COMMERCIAL[ EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:[RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES NO R APPLIANCES 7 FLOORS- I3SM'j 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER -. I . _... ....... I BOOSTER --� - _�.- - - — _ CONVERSION BURNER COOK STOVE _ .- DIRECT VENT HEATER DRYER FIREPLACE 1( � . . . FRYOLATOR FURNACE GENERATOR _. . GRILLE _.. _�.�1[-_ -- -- - ----------- INFRARED . ._-_.INFRARED HEATER _- LABORATORY COCKS MAKEUP AIR UNIT ._. OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER -- UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1[3 NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA E BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY BOND 0 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 EI AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true a d 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 co ce with all P !!e, n of the Massachusetts State Plumbing Code,and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME AVL J LICENSE# SIGNATURE _- � - — --- MP 0doo`MGF�].1 JP 0"�JGF LPGI© CORPORATION J# PARTNERSHIP El#=LLC E#= COMPANY NAME: y_Lt7 f. ADDRESS CITY _ _ STATE ZIP 5 (TEL FAX CELL1 .�� IEMAIL ..�� — - - --- - ROUGH GAS INSP TON NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES t The Commonwealth of Massachusetts f Department of IndustrialAccidents M 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. _Applicant Information �, a Please Print Legibly Name ©1 (Business/Organization/Individual): /6 1��0)Q Address: L,>/v 4,6 � ���� �° �b3 Phone#: � �"z 1 o6 City/State/Zip: 9 Areyou an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. [J New construction 2.®I am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.F1 I am a homeowner doing all work myself,[No workers'comp.insurance required.]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.[Kumbing repairs or additions 5.F]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13,0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 14.❑Other 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no.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. i Homeowners who submif this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have theircomp.policy number. employees. If the sub contractors have employees,they must provide � I am an employer that is providing workers'compensation insurance for my employees.' below is the policy and job site information. Insurance Company Name- �' u4� nn t�-S C&mip Policy#or Self-ins.Lic.A 0 �2 r 2 0kS('C Expiration Date: t 1 w City/State/Zip: Job Site Address: Attach a copy of the workers' compensation policy declaration age(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi nder thepai ndpenalti ofperjury that the information provided above is true and correct. Si afore: Date: �� Phone Offzcial use only. Do not write in this area,to be completed by city or town official.. City or Town: PermitJLicense# Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: , f • kv COMMONWEALTH OF MASSA&AUSETT'S :� s • 9 a , lalt BOARD of i. PLUMBERS AJD GASEITTE`RS ISSUES THE FOLLOWING LICENSE, W ; LLCENSECl AS A MASTER PLUM NOR:MAND P BERUB.,E 12 L I NCGL N' RD r�EWroN ISH 03858-3to3 8 O c�2 IV- Date.. Z-1-.-?—% �I< .............I. 54 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING �sACHU Thiscertifies that............................................................................. ........................................ has permission to perform.......*, .!!w......7�� ...... . ....... ..t .............3................ plumbing in the buildings of... ........................ ............................................................... at M&_Kf.�.2............ . ......................... North Andover, Mass. Fde3q�.........Lic. No. .11%6. ................................................................................. PLUMBING INSPECTOR Check# 2,61 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY - w Q�e MA DATE / 'oP/ Sr( PERMIT#. I � JOBSITE ADDRESS ! ii -heLos __ OWNER'S NAME 5 jam. S 'Jd�l¢ kl POWNER ADDRESS TELL7 ��aB4a�FAXE----� I TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL D RESIDENTIAL PRINT CLEARLY NEW: e RENOVATION:Q REPLACEMENT:Q PLANS SUBMITTED: YES Q NOD. FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 1 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM [ ._._. ) _.__ _�� I _-._ ---_-1 - -) ----( •-----• - t f { DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM _._.-.._..1 .._._.._._{ ___..l ._.._ _.._.._.I --.__ DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER .___.._I ._.L._1 FLOOR I AREA DRAIN ------ INTERCEPTOR(INTERIOR) _.__INTERCEPTOR(INTERIOR) KITCHEN SINK _^I . .._1= -------I LAVATORY ROOF DRAIN I JL—j SHOWER STALL I _W._J . J ___-.t ___..__f ___.__ _._ 1 _..____1 _.__f __.J _t _.__ 1 _— -- t SERVICE/MOP SINK ) ___—f _.___( ____t _1 _._ l _.._w_J ___._. __J _..-_i L--j _.__J ._.__._(' _---A TOILET URINAL l ._.__ __? _._._ ___ ( _f ___.f ___.....J ____:I _ri ___._J __ t .__. t ---__I WASHING MACHINE CONNECTION WATER HEATER ALL TYPES LdU f __ t E ! __ t _v.___) ---- WATER PIPING __ E f f _.___._ OTHER —_� _-_ __._ _ _ ._ { __ ( _ _.- f --- f --! ..�: �. -..- _.��__ .6 ___._.I ( _.__.__f _._.._I ..___..� ► ..______I n__...J .-_._._.f _..__J _._. _I __.__I _.___.J _ ( t � INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ....; NO Q IF YOU CHECKED YES,PLEASE INDICATE THE PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY _� OTHER TYPE OF INDEMNITY Q BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNERF-11 AGENT JQ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accur to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in c lance wi all�nt pr ision of t A/lassachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME !f' _ (fl2a ICENSE# //-��.,. I SIGNATURE tVIP JP Q CORPORATION�.!#=PARTNERSHIP D# _T-- 1 LLC[! i COMPANY NAME ADDRESS cae`V CITY /L/E.�/� _._....---..._._...._I STATE ice„ v ZIP p TEL God 3 FAX � � CELL �l�EMAIL __. _.-•------.____.__..__._..._...---------._.__.._--.------....__._._......_.__...._.__..----------_._---- - ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES Date. ....o�...................... i r►ORTH TOWN OF NORTH ANDOVER PERMIT FOR 0 GAS INSTALLATION tss�CHuss This certifies that C�l2 `tea-X.t Sic. ............................................. .................... ..................:...................... has permission for gas installation ,�. .... n _.. rr in the buildings of.................. .�t�.......................................................... at � '—t °-:`�... , North Andover, Mass. Fee,P .......*.�(. Lic. No. .� ....... . GAS INSPECTOR Check# I C4E: Date......��':...�.�.t* ..f�!4........... F NORTH o TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION l., g It pThis certifies that.,>� ...................................................................I.............................................. ` has permission for gas installation Q, ►••,••_.l& S?...•••,••••••.••••••.•.••. in the buildings of.............. t •••••••••••••• .................................................. at':�4............................................................................. ........... North Andover, Mass. Fee .:.....:....... Lic. No.�..� .. 3......... ..................................................................... Cq GAS INSPECTOR Check# -i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: .._N(1fR k1100A-" MA. DATE: , ' 17+ f 6 PERMIT# JOBSITE ADDRESS: i 7 �- V9 04 --" OWNER'S NAME: SSV__(_ A COW � G OWNER ADDRESS: TEL: FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL' PRINT CLEARLY NEW:' RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCESI FLOOR-+ Bsmt 1 2 3 4 5 6 7 8 9 10 1 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 I SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE 1-have a current liabilq insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [ NO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY 9 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 hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application w i i ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERIGASFITTERNAME: STEPHEN C. GALINSKY LICENSE# 103WS COMPANYNAME: 6Ai.1133K%1 PLtIG'►'t010C + I4C*t14& ADDRESS: P.0- ROX 1701 CITY:— M AV EkH I L L, STATE: 1'n•V ZIP: 01231 FAX: 971 - 5-al-1f 131 TEL: q78-3714- 1743 CELL: 9Cq- Slq- 5gOq EMAIL: W W'W, m�` i c1+^�►�ae o� ,M MASTER V JOURNEYMAN❑ LP INSTALLER❑ CORPORATION/k- 319G PARTNERSHIP❑# LLC 0#-�-- r1 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTIONIVOTIES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE, $ PERMIT# PLAN REVIEW NOTES Date... L.�.�. .�;k�...... 11627 i TOWN OF NORTH ANDOVER O aD � .1rO• Off• p PERMIT FOR PLUMBING sswCHUs� This certifies that.... !.'. �f- .�.. has permission to perform��'-.-, \Ao, -�-- .................................................................................. plumbing in the buildings of... k�1 (._................................. at.............� ........�i6 .e-�--S til� ..............., North Andover, Mass. Fee r�d'.............Lic. No.'�J.I(z..... ................................................................................ ( � PLUMBING INSPECTOR Check# VcV ot2- gl��s ' Date.ZIN.%,aAl ....... 11- 628 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING -ACHU This certifies that. ........ .......................................... has perrv.ion to perform....... .......................................... L� I f plumbing; the buildings o ............................................................................................. at.................. ..............gw� .A.............................. North Andover, Mass. Fee. Lic. No. .. ....................P:LU.M.BI.N.G..IN.S.P.E.C.T.0.R..................... Check I CukA . C i 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Cil Y MA. DATE 0 i1` r7 PERMIT# I JOB,ITE ADDRESS�� L.� ��✓�l�C,t.1� OWNER'S NAME 1— l�"�'. �►�'`�C If POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT NEW: RENOVATION: CLEARLY ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ElNO El FIXTURES Z 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 GAS/OIUSAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER FOOD DISPOSER Z FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ZLfZ ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 1 2 Z Z URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: %jhave a current liability insurance policy or its substantial equivalent which,meets the requirements of MGL Ch-142. Yes F No❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [+/( OTHER TYPE OF INDEMN ❑ BOND ❑ OWNER'S INSURANCE WAIVER:1 am aware that the licensee does not hav insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE BOX ONLY: OWNER ❑ AGENT ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information 1 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 pe it issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter the General Laws. PLUM13ERNAME STIEW6 J C. GAL-10SKY SIGNATURE LIC# I O3y S MP[r JP❑ CORPORATION M# -3194,- PARTNERSHIP ❑# LLC ❑# COMPANYNAME 6AW#JSK1( Pt.QM0IA)b *- I4VATt1.3G- ADDRESS: P-o- GGX 1701 CITY HAVER tiLL STATE 11A-A- ZIP 01131 EMAIL WWW• rnf` IVrAber- 1 , co r T 7t-3,2'1'- 17+fi 3 CELL 50-50q-Tg0J1 FAX C17,5-5;N-14131 ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY �cF,INAL NpS�PE TIO NO ES Yes No d THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTE'S R Date.l. ...........Z........... TOWN OF NORTH ANDOVER o PERMIT FOR WIRING ssgCHUs�t 1 This certifies that ..................... .............................................................. has permission to perform ............................ ..... ................................................................. /"�'G✓ f'f GM e . wiring in the building of..... ., ..,,.... .....,�--L�'' J ...................................................... at .....�... (..q....... .. : � w� f ............................. :..:................North Andover,Mass. Fek 7..............Lic.No. ..�........: A Nt� � .... ........................................................... C ELECTRICAL INSPECTOR Check# 3 12979 —/ s � Commonwealth of Massachusetts Official Use Only 4� Department of Fire Services Permit No. Occupancy and Fee Checked aw BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C),.27 CMR 12.00 (PLEASE PRINT INNK OR TYPE ALL INFORMATION) Date: 1` 2,2. t City or Town oh NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 1 7 -11 � Owner or Tenant V N N TJ—` Telephone No. Owner's Address 1 v4r Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building CLC-S (5 A.)-I-% * (. Utility Authorization No. 2,I V 1 3 919 - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service '7,oc2 Amps 110 /`Z`tO Volts Overhead❑ Undgrd No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: (,tJc&tc, Dopwg� Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cel Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ Ino.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 No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained p Totals: .. .""""........................ ............ Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection No.of Dryers Heating Appliances KW SecuritNo.o Systems:* ev is s or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total IlP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: , C0 (When required by municipal policy.) Work to Start: Z z-L 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 provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cover is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE R BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of penury,that the information on this application is true and complete. FIRM NAME: .&&CL-&C�Nle-- LIC.NO.:ZI Licensee: f� ( C.l('� �1 q L��„�,d.�f) Signature LTC.NO.: Z7�'0,� (If applicable enter "exempt"in the license number lute1 Bus. rel.No.: 33152-- Zti9 y Address: Pc 0_. 6 O X <,,,o61, ��4� 1, c.��C-t A.t-4 hf5'K.� Alt.Tel.No.:!J-)k3 )L7e-L-6-' L *Per M.G. 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 r 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 Inspe on Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: i SERVICE IN CTION: Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass F?1 Faile M Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: l Inspectors Signature: Date: FINAL INSPEC ON: Pass Faile Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature. Date. DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com IA The Commonwealth of Massachusetts Department of Industrial Accidents ✓ _ �� I Congress Street,Suite 100 02114-2017 Boston,MA. o�r www mass.gov/dia ODM SJ�ti Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/klumbers. TO BE FILED WITH THE PERMITTING AUTHORT7 'Y. please Print Le •bl A ••licant Information Qn Name(Business/Oigariizationitndividual): Address: 6z) -L— v� vl A e#: C 7 IVI196-y Phon City/State/Zip: • :. .:. ,. : ...,x.<; �. . r Are you an employer?Check ttie appropriate box: Type oftpro" ct(required): 1. am a employer with__ ___employees(full and/or part-time).' '7, ew'construction 2.❑i am a sole proprietor or partnership and have no employees vVorking forme in $. Remodellrig any capacity.(No workers'comp.insurance required.] 9. ❑Demoliti0T1 3.❑I am a homeowner doing all work myself[No workers' comp.insurance required.]t 10E]Building addition 4.F1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole 12T"`Prbg repairs or additions �m Proprietors with no employees. 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13�.[ IRo6freliairs These sub-contractors have employees and have workers'comp.insurance 14 0 Other 6.❑We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and•wehavetrio empldydes.[No workers'comp.insurance required.] applicant that checks bbx#1 must also fill out the section below showing their workers'compensation policy information: davit *Any PP all work and i Homeowners who submit this affid att indicating an additional do gshowing the name of the sub-contractors and state wheth rs must submit a r or,ew not thoseentiges•have 1; A tContractors that check this b6i m employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. X am an employer that is providingworkers'compensation insurance for my employees. Below is the policy and job site information. c Insurance Company Name: ✓✓®l�C�"k ^� Expiration Date' Policy#or Self-ins.Lic.#: fob Site Address: Z l�,dJr� lJ< City/State/Zip: `� Dem Attach a copy of the workers'compensation policy declar4f ion page incl(showing np�habl by a fine up to$1500 00 U mber and expiration . Failure to secure coverage as required under MGL e.152, §25A is a criminal p rm of a STOP and/or one-year imprisonment,as well as civil penalties in the a�ded to the ffle o IroveesWORK sttigations of the DIA for insd a fine of up to ?uranco a day against the violator.A copy of this statement may be forty coverage verification. X do hereb certi under the pains and enaldes of perjury that the information provided ab ve is true and,correct. Date: L SiMature: Phone#: Official use only. Do not write in this area,to be completed by city or town official Permit/License# City or Town: Issuing Authority(circle one): ' X.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#• Contact Person• r 1 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'6k 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 b6 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('1)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractors)name(s),address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If 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-Accidenis. 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-A ASSAFE Fax#617.727-7749 Revised 02-23-15 wwwmass.gov/dia