Loading...
HomeMy WebLinkAboutMiscellaneous - 191 MASSACHUSETTS AVENUE 4/30/2018 191 MASSACHUSETTS AVENUE 210/010.0-0055-0000.0 Date-51-LP1.1.4.............. NORTH 0* TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............................................... has permission to perform ..... .....C-e ............ —................ ......... .... .......... .......................... OL wiring in the building of......S ...... ....... at ........................................................................................................ orthh Andover,Mass. R14 Fee..........................Lic.No. ................... .......... ....... ............ ....... ELECTRICAL Li c LEcTrFRUicAL SPECTOR 4 Check,# 12339 r C Official Use Only Commonwealth of Massachusetts Y Permit No. � Department of Fire Services r(a BOARD OF FIRE PREVENTION REGULATIO APPLICATION FOR PERMIT TO PER All work to be performed in accordance with the Massachusetts (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) City or Town of: NORTH ANDOVER By this application the undersigned gives notice of his or her intention to Location(Street&Number) S„Sei,c� -C,,4s kL2Owner or Tenant C Z Owner's Address I /-I evs> C Is this permit in conjunction with a building permit? Yes ❑ �tk I Purpose of Building U{ 1 Existing Service 2000Amps / Volts Overhead v ' �., New Service Amps / Volts Overhead Cl Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: (, , Completion o the follo 12-0 t� No.of Recessed Luminaires No.of Ceil:Suisp.(Paddle)Fans No.of Luminaire Outlets `Z No.of Hot Tubs No.of Luminaires 3 Swimming Pool Above ❑ Ingrnd. - "C No.of Receptacle Outlets Z No.of Oil Burners No.of Switches No.of Gas Burners No.of Ranges No.of Air Cond. Total Tons No.of Waste Disposers Heat Pump Number Tons I KW Totals: No.of Dishwashers Space/Area Heating KW No.of Dryers Heating Appliances. KW No.of Water No.of No.of Heaters KW Signs Ballasts _ No.Hydromassage Bathtubs No.of Motors Total HP - _l eiecommunications irmg: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 5-()0 (When required by municipal policy.) Work to Start-M. �S ca Inspections to be requested in accordance with MEC Rule 10,and upon completion. "T INSURANCE C,_VERAGE: 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 0 BOND ❑ OTHER ❑ (Specify:) I certify,under the pains andpenalties ofperjury,that the information on this application is true and complete. FIRM NAME:?10111C eq zv LIC.NO.: 13(,)1.1 13 Licensee: R,41J, Signature LIC.NO.: (Ifapph bl ,enter"exempt"in the license number line. Bus.Tel.No.:! (7U--76&--7 Y13 Address: 5 C��-tem �t �c�v�rcc { A O lrl 2 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 El owner ❑owner's a ent. Owner/Agent PERMIT FEE: $ Signature Telephone No. 1 ♦�� H k. � � Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked y BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] 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: Q_ j 201 City or Town of: NORTH ANDOVER To the Inspector ofWires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) ci ( !✓1 S S G��c�,�� �w-�_ Owner or Tenant C r,S Telephone No. (t 1-1 Owner's Address S;� g C��� ��- Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service 200 Amps / Volts Overhead F!�f Undgrd❑ No.of Meters L New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ` Ujk Completion o the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil: No.of Total Susp.(Paddle)Fans -.y Transformers KVA No.of Luminaire Outlets `Z No.of Hot Tubs v Generators KVA No.of Luminaires Swimming Pool Above ❑ In • ❑ o.o Emergency ig ing rnd. rnd: Batte Units No.of Receptacle Outlets Z No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiatin Devices Tonnsso.oAlerting No.of Ranges No.of Air Cond. TotalNo. Alin Devices No.of Waste Disposers Heat Pump I Number I TonsKW No.of Self-Contained g Totals: Detection/Alerting Devices n l li No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Connection No.of Dryers Heating AppliancesSecurity tY S ystems: No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Data No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Te ecommunications 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: SZ)b (When required by municipal policy.) Work to Start-M i Inspections to be requested in accordance with MEC Rule 10,and upon completion. "3 INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 0 BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME:R4,JC -a . - LIC.NO.: 13(,1 ll 3 Licensee: Signature LIC.NO.: (If applicabl ,enter"exempt"in the license number line. Bus.Tel.No.-,!217P--766-703 Address: G Ke ��� tc�r. V-,,,4 p 0 Z-3 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 Signature qq Telephone No. PERMIT FEE: $ =r. . � �. �. � �w� o�� z,-�1 �, ... yy ' pMM�NWEALTH OF MASSACNI�SETTs 0 ll! o - oE:BOARR OF ELECTR'1 C TANS , ISSUESvTHE FOLLOWINGICNSE , LE AS "A REG' JOURNEYMANCTRI C'I AN4 , ES / N PaTRI CCK TAYLOR - �, w �W M N ` 49 GREEN ST Ott , DANVE.RS MA 01923 1336 \ ; 888 6 1'4 B- o Y. d I The Commonwealth of Massachusetts - ~� Department of Inclustirig1 Accid&ts Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/clza Workers,Compensation Insurance Affidavit:Builders/Cont°actors/Electricitans/Pliimbers Applicant Information Please Print Ledbiy Name(Business/Organization/Tu(Uvidual): �er•" r,Ac• --T��,f I o r Address: 91 Gee.,City/State/Zip: b��,,j<E S , V^A_ 0 tai 23 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 luredthe sub-contractors 1 am a sole proprietor or partner- listed on the attached sheet. 7• El Remodeling ship and•have no.employees These sub-contractors have 8. ❑Demolition worldng forme in any capacity. workers'comp.insurance, y. E]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their I . umbmi re 3.❑ I am homeowner doing all work right of exemption per MGL 11.[]Pl g pairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12,❑Roofrepairs insurancere edemployees.[No workers' �' .] 13.❑Oilier comp,insurance required.] xAny applicant that checks box Of must also fill out the section below showingtheir workers'compensation policy information. i Homeowners who submit this affidavit indicatingthey tie doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is die policy and job site information. Insurance Company Name, Policy#or Set£ins,Lic.#: Expiration Date: lob 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 requiredunder Section 25A of MGL o.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or onie-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine ofup 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 cer n e pa• and penalties of perjury that the information provided above is true and correct, Sip-nature: Date: G Phone 4: lid- 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.EIectrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: Information and Instruction's 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 f6regoing engaged is a joint enterprise,and including the legal representatives of a:deceased employe, or the redeiver or trustee of an individual,partnership,association or other legal entity,employing employees. TXowever 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 h6ce9sary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation.insurance. If au LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe 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 maybe provided to the ; applicant as proof that a valid affidavitis on file for future permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e.a dog license orpermit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance fox 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: Tho Coumoat�wealt� 0fMassachvsDM9 Doparbout ofZudwWal.A,ccideuta Office ofJAVestigaft%% 6.00 Washiagtou Street Boston,,MA 02111 Td,#617-72.`x_4900 QA 406 ox 1;-8777 MASS•AFE Revised 5-26-05 NY,0 617-727-7749 WWW.ME ss,g 'a Date ..1.��l..... 10536 T TOWN OF NORTH ANDOVER ° 9 PERMIT FOR PLUMBING gsACMUS� This certifies that...........'..:.... : : .............. .11.......... 1L ;t Chas permission to perform....... ..........................................................�...�....... :.....!.-: ............... plumbing in the buildings of.....5.!!l �- .. ............... f: at....6A.. .............5?...... North Andover, Mass. Fee�.. .. me ..... .Lic. No. �'� ..... _ PLUMBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE ( PERMIT# JOBSITE ADDRESS SS OWNER'S NAME SApc., f OWNER ADDRESS TEL y/y - '�y3 7 �IFAx j TYPE OR OCCUPANCY TYPE COMME ® EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES Ell NODI FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 1 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE I __.__.k _I _.. _ _._1 ._.__� ..,•__._...f _.. _i ..�__.! M .___, ,_ __. I DEDICATED SPECIAL WASTE SYSTEM �.! 1 I .._.. _ 1 .__ l ._ __ f ________I ___1 __ _.._..._I _ ! I DEDICATED GAS/OILISAND SYSTEM ! _ _ I k I I —_ __.__.-_1 _._._ -iI--I1 I DEDICATED GREASE SYSTEM .1 _...__._k _ S I I I � _-1' ._.--JI] I I - - - l DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) _ I ._._..___._I KITCHEN SINK —__- LAVATORY ROOF DRAIN. _,._..,-,4 —_1 SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION 1 _-_•._� _. I .—._.-_G ___1 _____._j _ _ I _ ,_ __..__ _._. _-.:___( ._-_.. --i ____.! WATER HEATER ALL TYPES � I ) I _ I _ —� j __j f _ } WATER PIPING UQ71 _.� I _.__.. _j _ _f — ! ._._.._ _... I __..._.__I _ I � _I I OTHER --j I INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES dNO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY `S OTHER TYPE OF INDEMNITY L- 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-11 AGENT JR .J OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME (LICENSE# �3 sS S I SIGNATURE I MP[-1""'JP Q w CORPORATION ...i#PARTNERSHIP Q# _ LLC j COMPANY NAME f c4) dl,71" e ADDRESS CITY Ce �rsr STATE ®ZIP r�17�. TEL FAX —� . CELL EMAIL l I ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No Imur CA THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT PLAN REVIEW NOTES I M � J } I _ i 1 ....................... Rr 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies thattbMPNr-I f,C. ..................................../.............A� Vic................................. has permission for gas installation .............................................. in the buildings of............ .................. at....I.:)A......tj&�A�r ........................... North Andover, Mass. Fee ....... Lic. No. ...................................................... ............. GASINSPECTOR Check# '1 9286 011- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE / PERMIT# JOBSITE ADDRESS17� OWNER'S NAME Tz I�q OWNER ADDRESS 1 SS TE / - 7Y� _ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL 2---- PRINT CLEARLY NEW:� RENOVATION:( REPLACEMENT:® PLANS SUBMITTED: YES D N021— APPLIANCES 7 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 1 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER J -._ _ . —.. . . I—u - --J DRYER FIREPLACE FRYOLATOR _ FURNACE _ ( _► ._ -a [-- — :_ l v_ GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS ( [ ___(- 1 MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER _.. ROOFTOP 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 NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COERAG Y CHECKING THE APPROPRIATE BOX BELOW LP 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. 10 CHECK ONE ONLY: OWNER F_] 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMEC- �'f/laC,�t d e r LICENSE# f3.S�S SIGNATURE MP[M"'MGF 0 JP 0 JGF[] LPGI©J CORPORATION�# �C PARTNERSHIP 0#=LLC E]#= COMPANY NAME: t�C� ]F1 Cc i3ro "Gc.-S ADDRESS CITY / ( STATE�ZIR� TEL 1 FAX CELLEMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTO R USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PEI MIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NO rES y a The Commonwealth of Massachusetts Department of IndustrialAccWnts Office of Investigations 600 Washington Street Boston,MA 02111 UV www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):/%r'/�%�T�(r�U� �' /r�✓L ,$ Address: 3 7 City/State/ZiPhone#: j b'' Are y employer?Check the appropriate box: Type of project(required): 1.81 am a employer with. ? 4. EJI am a general contractor and I 6. ❑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.F1 Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. Wo workers' coin-P. c. 152,§1(4),and we have no 1211 Roof repairs insurance required.]t 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. i Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam 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.#: ��$ 5 (,) ?� C� Expiration Date: Job Site Address: (7f &4:55— 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 requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Pt!5Date: lY 2c/ Phone#: 22 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#: e 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-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance, Ifan LI C er r LP dens 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 bum 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: Tho Conu onwealth of Massachusetts Department ofIndustrial Accidents WOW of Investigatiions 600 Washington Street Boston}MA,02111 Tel,#617-727-4900 ext 406 or 1-877,71ASSAFB Revised 5-26-05 Fax#617-727-7749 www-mass,govldia Division of Professional Licensure: License Search Page 1 of 1 The aif I V*bsr,-a of ft ee Offxm of consumer Aflays and Btmess Re bon t R1 Division of Professional Licensure Mass.Gov Q{ Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES ........................................................................................................................................................................................................................................................................................ Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency LICENSEE More... Name:MARK B. MAGNIFICO REFERENCES& MIDDLETON,MA RELATED INFO Disclaimer Regarding *This Licensee has additional Licenses,click here to view them.** Website License Searches Glossary of License Status Codes Licensing Board: PLUMBERS Et GASFITTERS License Type: MASTER PLUMBER More... License Number: 13559 Status: CURRENT Expiration Date: 5/1/2016 Issue Date: 9/30/2003 Exam Date: 9/6/2003 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. t €I f The page above has been generated by the Diva of Professional.Licensure web server on Wednesday,May 14,2014 at 11:34:20 AM. 02007-2011 Commonwealth of Massachusetts Site Follraes Corgi Us htt :/ li � r / cense.reg.st.ate.ma.us/public/PubLicenseQ.asp.board_code=PL&type_class— _M&li... 5/14/2014 Date. . ` V HORTM > `w of TOWN OF N� ORS ANDOVER 41 - PERMIT FOR GAS INSTALLATION SAC MUSESt This certifies that . . has permission for gas installation . . in the buildings of_. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . .. .. , North Andover, Mass. Lic. No . . . . . . . . . GASI NEPEC O v Check# / '1' � l3 MASSACHUSETTS L�N:IF©RM ARPLtCAT1ON F R PERMIT TO DO GASF1TTii�3GI. r (Pant or Type) �Q77�4�u� 2 Mass Date 1� Pe�mtt #` , 1. ~' Building Cocatlori._ � � �/ Owner s Name .. : ., _- , 2mType;of Occupancj+ New [ '. flenovatlan [p Feplacement (] Plans Submitted Yesj] No N tC IA'. W N '' �L r Y tr H O U K 1- a N tt N � O' a �. X } W w nc t� U rh �' z n 1. v -� `�. w t cc z a u: t a 1.o P' } w i }. to w z U W y' ar !( x or -- > w w =� r -. iz w F� 11.11w _ :Wt iz * d -t Y ;tC w Z'..- '( K �[ .�( Q O id Q .:let !- - ..;S O. c7 3' ti. �;_ 3: p,::_ a J i� fL - 'ct. ,a F� Q SUS SS MT 8i15EMEKT 1ST FL O O fit,;: 21tD t✓LOOR - Rd FLOOR {TH FLOOR .11 SETH FLOOR aTHFLooR:ti , = TTH FLaaR'. 8T1t FLOOR` Installing Company Narne �} ���} 1/t,r �, C f Check�-7-711one Certificate : Address �..: - 1. Gfi Coparativn L r /�+ J - 1. p Pa nershlp 13ustr`ess Tej —.,6e � �- ; q / �' t� Ftr !Ca h Nannie of t_Icenseri'Plurnbet or Gas Fitter 0 e�fL. iNSt1RANCE Cb1/ERAGE I have n current Ilabliriy insurance pallcy ar iEs substantialequivalent which meets the requirements of MGI,Ch iq2 F Yes No C3 It you have checked yes;Please Indicate the type coverage by checking the approprtale 6ax z A tlablltt s a c . Y In ur n e policy Other#ype of Ind.emnity,Cl Bandli� Q OWNER S iNStI ANC-BI (AIYER !am awaie tha# the ileensee does hat have the lrrsurance caverage.tequired by Chapter 14,2 of the Mass: General Laws and:that my signature on this permtt`application wratves< his requiremen# t III Check ane Ownerl� Agent p Signature of Owner or Owner s Agent ' I hertby certlfythat ail of the details and Information l;have submitted,for enteredl(n above ap"pliratloi are frua sad accurate to the bail al my ._ knowledge aril that alt plumbing work and installations eriormed under f1�e.:pp"ermit Jsued lot Ihts nppticatloo°;villi tia;tn compllarics wrath all ;. perttrent provisrons of the Massachusetts State Gas Coe and t caplet t42 of:the Genie a)taws ;. , > HY - e of license Title ; Plumber i ti e o c ase um er or Gas ,fttt r astFtlet �11 aster license Number City/7own = Jota neyman lU'III 11 f DSO TTG p Date. . !" TOWN OF N RTH DOVER WL 0 PERMIT F LUMBING SSACMUS� / This certifies that . . . . . .G4 "e . . . . . . . . has permission to perform . . .. . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of ��.-.�. . . . . . . . . . . . . . . . . . . . . . . .g at . .91. . . . . . . . . . . . . . . . . . . . . North Andover, Mass. 1 f Fee_ 7. . . . . .Lic. N6:�l��,. . . ! . , . . . . . . . . . . . , p {� P.L-UMB'NG fASPECTOR Check # l/rdY i 7118 MASSACHUSETTS UNIFORM APPLICATION .FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location Date Owners Name '[-�—� Permit# Amount A Type of Occupzncy kG New Renovation Replacement E31-- Plans Submitted Yes ❑ ❑ No FIXTURES z w c zr r z 1 O 3 z A w > �i�l>c a as BA99V Nr IST.FLOOR M FLOOR FLS s1H MOM bpi FLOOR 7M FLOCK SIH FLOOR I (Print or type) Check one: Installing Company Name (% j C Certificate -� � Corp. Address n L V uS � _ � S � Partner. Business Telephone 7 � Firm/Co. Name of Licensed Plumber: L F1' NU Insurance Covera ge• Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ®'f Other type of indemnity ❑ Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance ignattue Owner ❑ Agent I hereby certify that all of the details and information 1 have submitted(or entered)in above;application are true andaccurate to the i_)cst of my knowledge and that 211 plumbing work and in, ' ti s rforna• u der Permit Issued fir this application will he in compliance w%ith;dl pertinent Provisions of the Massac ase S ; Plaam - Chapter 1112 of the Gencral Laws. � By: agna ur Title T, e f tip bing License City/Town cL'�cnse um er LasterT a APPROVED((.)FFcr I;sE ONLY � of rneman cam/