Loading...
HomeMy WebLinkAboutMiscellaneous - 1929 SALEM STREET 4/30/2018 1929 SALEM STREET 210/106.6-0042-0000.0 i J' 1 I I I �� ]...� Date. ......�q .................. r►ORT/y °� "" '•�~ TOWN OF NORTH ANDOVER PERMIT FOR WIRING gs�CHUg� � � � Thiscertifies that ...............................................`............................................................................ has permission to perform .............. ................. .............. ..................................... wiring in the building of........� Isn e 2` ...... ....................................................... at ........�.ate ....... . ......................... North Andover,Mass. cSo Fee.. ..... ..-�: . o......Lic.No.wl... MD ELECTRICAL INSPECTOR Check# ' i commonwealth of Massachusetts O ficial Use On Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.l/07j (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts EIectrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IATMK OR TYPE ALL RWORM4TION) Date: & ,.2-I-,,,2o / /3 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 work described below. Location(Street&Number)/45�.Zcy S40fe.,-y 64 Owner or Tenant Sf p jr�� Q�Ssc-.fes r, Telephone No. Owner's Address S. PV -c Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No,of Total Transformers KVA o.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- El o mergency Lighting rnd. rnd. Battery Units _ No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No. of Switches No.of Gas Burgers No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. TotalTons No.of Alerting Devices -� Heat Pum Number Tons KW No.of Self-Contained No. of Waste Disposers P ..... . .. . ............... ..................................... Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of No.of No.of Devices or Equivalent Heaters KW Ballasts Data Wiring: Signs No.of Devices or Equivalent No, Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: N No.of Devices or Equivalent OTHER: ec,) c, nt- 1 r ca `- Attach additional detail if desired,or as required by the Inspector of 97res. Estimated Value of Electrical Work: (o cO (When required by municipal policy.) Work to Start:,2 2`1- o)_3 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove age is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) \ R I certify,under the pains and penalties ofperjury,that the information on this application is true and complete. �✓, FIRM NAME: . c r � 4 � s LIC.NO.: Licensee: I Signature LIC.NO.:l e S W/ (If applicable,enter"exempt"in the license number line.) Bus.Tel.No..• /7 15119 7 Address: _S2/0-1.0p � �� '13 •1 Alt.Tel.No. 5 *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. � OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE.$ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed it on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8–Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act–Permit/Date Closed: Trench Inspection Pass[N Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re-Inspection Required($.)❑ ' Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass EN Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ r Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Co ts: —2– Sp Z Inspectors Signature: a e: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com a ' The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston,MA 02111 Uf www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): ��cam/ �„�, ��� Vii-?c �/�6CGf��c L Address: S c c sfzfe -I,,- City/State/Zip: City/State/Zip: A Phone Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction mployees(full and/or part-time).* have hired the sub-contractors 7• 2. 1 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. Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.E].Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.n Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. #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: �/S `9 S /e City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure fro 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 of perjury that the information provided above is true and correct. - Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: 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 ofhire,- express or implied,oral or.written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each l 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigatitons 600 Washington Street Boston,MA.02111 Tel,#61.7-727-4900 ext 406 or 1-877:MASS.AFB Revised 5-26-05 Fax#617-727-7749 www.mass.goV1dia 9 COMMONWEALTH OF MASSACHUSETTS p..fi Rill '11111 OR OF ELECTRICIANS REGISTERED MASTER ELECTRICIAN ISSUES THE ABOVE LICENSE TO S} MICHAEL J . •CULLEN ELE:C.T 8 'HEATS{ k ;MICHAEL J CULLEN .` 5 BLAC:KSTONE STREET U� 1 PEAB'ODY MA 01.96.01-1010t. ' 16581 A 07/31/13 815845 _ 1 Fold,Then Detach Along All Perforations .a i i t Date . �. .�� . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifiesthat .r�/� :� . . �. '. . . . . . . . . . . . . . . . . . . . has permission for gas installation . . 1- . . . . . . . . . . . . . . . . . in the buildings of. . �� — . . . . . . . . . . . . . . . . . . . . . . . . . at . ./.Gt, Sea---A . . . . . . . . . . ,North And ver, Mass. Fe��l7 00. . . Lic. No. !1.� ?���,1, ce-�� \, GASINSPEC�TOR Check# 7 Yl 8674 •` WASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK J CITY __ Oh`�l4i� / .W nb dC_ .. MA DATE Q PERMIT# - - - y JOBSITE ADDRESS OWNER'S NAME S' _ GOWNER ADDRESS TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEWT-1 1 RENOVATION:Ej REPLACEMENT: f PLANS SUBMITTED: YES F---11 NO Q APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER �I _ - J. I f I I .._ I . I - 1 . I BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER L .1 J= .FIREPLACE - FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKSMAKEUP AIR UNITT OVEN J. POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER �—-- UNVENTED ROOM HEATER WATER HEATER OTHER _. INSURANCE COVERAGE 1 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 FV-1 OTHER TYPE INDEMNITY ® BOND D 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 AGENT 0 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 wi I Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAMEJ LICENSE#-.� SIGNAT RE MP El MGF[ f JP EjJGFLPGI[j CORPORATION[ #��➢PARTNERSHIP[3# _..___-.___�LLCM COMPANY NAME:_ / --___J ___._-___..._�IADDRESS� CITY STATE ZIP '�.��TEL FAX ___ __ CELL j�EMAIL 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 y The Commonwealth of Massachusetts Department of Industria[Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): f A.PA� 4* Address:_ b lrG k47° N ,n �Z City/State/Zip:_ M gjn p d Phone#: 2 Q ,S Q ® A Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.[M I am a sole proprietor or partner- listed on the attached sheet. �• F1 Remodeling t ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other *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. 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:. 1^A P V Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address:_1 �9' L,o .(''0�— 1,V D Ci /State/Zi : 9T�i--�r��l���� 'ri p 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 cero under the pains and penalties of perjury that the information provided above is true and correct. - Signafire: (t--- Date• Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: r 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 ofhire,. 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 monwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In.addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license or permit to 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: The Commonwealth of Massachwetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston.,MA 02111 Tel,#617-72.7-4900 ext 406 or 1-877:MASSAFB Revised 5-26-05 Fax#617-727-7749 www.m.ass.gov/dia 09849 Date 3 . . . b KrL I),�' TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . . . ,w,� . . . .9�?,�n!'/... . . ...�. . . . . . . . . . . . . has permission to perform . . . . . . . . . plumbing in the buildings of. . . .� ! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .North Andojver, Mass. r Lic. No. . . . . . . . . . PLUMBING INSPECTOR Check 19- U ItiIASSAtHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY �( MA DATEf ( PERMIT# JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS I TEL TYPE OR OCCUPANCY TYPE COMMERCIAL EI EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: Q RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES EQ NO FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN _I _._...___1 I _.. _( __— I __._.1 j .. __.__i '-I TERCEPTOR(INTERIOR) .___.._.._I KITCHEN SINK AVATORY I _.._-._._J ._._-_..-� ---._.-- 1 ----__._1 ..____1 __..-f --- ( __._- _f .---._._1 _:_-- -___._I __ I _ ► __.___f RkF DRAIN SHOWER STALL I ._..__� I ...__.__ I . f 1 .___f __—I SERVICE/MOP SINK TOILET E URINALI ___I WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER _ _ __. _ _� I ! _f 1 __ 1 I ! _____f _..._._..; ..._--..__I ! _.___i -____ _I Rims- INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES EJ NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY DI BOND D 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 Q 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 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 complice with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 2 &.4 PLUMBER'S NAME[_ 1,+-� _ - (LICENSE# i SIGNATURE Full MP� JP Q CORPORATION -. f# - _.i PARTNERSHIP P# ; LLC COMPANY NAME fr' ; ADDRESS CITY Je tp_1Af t4C _ f STATE ZIP — �ll TEL FAX �� d CELL _ ,� _.� EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# ��/dl� PLAN REVIEW NOTES x The Commonwealth of Massachusetts Department of Industrial Accidents 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): G4G4/� Z� /W Address: in 8 1 r e_ 9 � _ City/State/Zip: #3gpp p 1 1!4&e && Phone#: Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. am a sole proprietor or partner- listed on the attached sheet. 1 7• EJRemodeling ship and have no employees These sub-contractors have 8. ❑Demolition r 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.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152, §1(4),and we have no 12,❑Roof repairs insurance required.] t 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. t Homeowners who submit 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 their workers'comp.policy information. t am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ?olicy#or Self-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). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 if up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. i nature: C- ` Date: hone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments,and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house, or on the grounds or building appurtenant thereto shall not because of such employment'be deemed to bean employer." ` MGL chapter 152, §25C(6)also states thai"every state or local licensing agency shall-withhold ilie'issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance , requirements of this chapter have been presented to the contracting authority." ! Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary-,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. F The Department's address,telephone and fax number:, The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia Date . . bwrxti"rzn ao- TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . ,��.� . . . . .f?�.r; 11`+.t;. . . . . . . . . . . has permission for gas installation . in the buildings of. . . .IQ,.1.,,.S. �,Q,�(� �. . . . . . . . . . . . . . . . . . . . . jk at . . . .k .7 2 .15. . . .,S4. -1--�. . .S r��. . . . , North Andover, Mass. Fee .i-f0,S.° . Lic. No. .g J.7.0. . . . . . . . . . . . . . . . . . . . GASINSPECTOR Check# 3 8403 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITYY _ _- MA DATE 2 . PERMIT# JOBSITE ADDRESS g _ OWNER'S NAME � @ ��► �/' _ G OWNER ADDRESS 1. � (`e�x^ TEL ��FAX . TYPE OR OCCUPANCY TYPE COMMERCIAL F-I EDUCATIONAL E] RESIDENTIAL El PRINT CLEARLY NEW:[.j RENOVATION:[j REPLACEMENT: PLANS SUBMITTED: YES Q NO® APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE — GENERATOR - GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN ,- POOL HEATER ROOM/SPACE HEATER - ROOF TOP UNIT TEST ) UNIT HEATER - UNVENTED ROOM HEATER — L.._.__ ,!.W_ I ._i 1 I i i_ - l_ EQ WATER HEATER OTHER FI L INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES JEJ NO 0 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY P OTHER TYPE INDEMNITY Q BOND E] 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 0 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 NAME �W LICENSE#_ J SIGNATURE - MP[X MGF[I JP t---'t JGF LPG] CORPORATION _I#[=PARTNERSHIP[_ # __ LLC COMPANY NAME: _..---__.j ADDRESS jo Aif�' '� - CITY _ STATE ZIP L I^ TEL - - ®--- I FAX CELL. EMAIL 1� ROUGH GAS INSPECTION NOTES THIS PAGf—*r,OR-INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES X4,0 . 41/1 �i3 1 = r 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): A /Alz / Address:.`4 At IAC ty f 1'M f� l>�� City/State/Zip: `1, oy /!*)4 elI!!� A- ��k1-ione#: q?_9 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. I am a sole proprietor or partner- listed on the attached sheet. ? E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. [:1 We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 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. I 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: �;q r tq R fes, I L. Y 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 certify under the pains and pe lues of perjury that the information provided above is true and correct. Signature: c �--� Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: � N 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 1?herein,'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 employes." 5 MGL chapter 152, §25C(6)also states that"every state oelocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. _ I % The Department's address,telephone and fax number: , The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia i A, COMMONWEALTH OF MASSACHUSETTSTrLumtstm .\', LICENSED AS A MASTER,PLUMBER ISSUES THE ABOVE LICENSE TO: DAVID H BABINE , 30 BIRCH MEADOW RD MERRIMAC . MA 01860-1825 9820 142755 05/01/14 - Z I i 1 i CONTROL# H 3 3 8 9 0 7 IMPORTANT If this license is lost or destroyed, notify your Board at the:; Division of Professional Licensure, 1000 Washington St., Suite 710,Boston,MA 02118-6100, l If your name or address shown is changed, notify your board of correct name or address to insure proper mailing of next; Renewal Application. Always refer to your license number.' This license is subject to the provisions of the General Laws: as amended. It is a personal privilege,and must not be loaned or assigned to any other,person. Keep this license on your Person or posted as required by law. i Date.....��....�..1............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING NU ta AS Thiscertifies that ............................................................................................................ ..... b,as permission to perform .....� ..� "� ��t �l y`' wiring in the building of........................ .......--AP. .......................................................... .. ........... ....... w) e at ..................;��...... .........................................................North Andover,Mass. Fee..............................Lic.No. .........................I...... L E C M C A L � C'P'Eii" E Check 4t l Commonwealth of Massachusetts Official Use r}�y/ Department of Fire Services Permit No. U Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07] Oeaveblank 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 ININK OR TYPE ALL INFORMATION) Date: /,3 City or Town of. NORTH ANDOVER To the In ecto of Wires: a By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) ) J S411"w, S,+ CV Owner or Tenant �-f,,yr � J�er�e ig �c,<�l, � Telephone No. Owner's Address Sc4,. � Is this permit in conjunction with a building permit? Ys No ❑ (Check Appropriate Box) Purpose of Building 1)_ r/I P h a Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters - New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: /�,'�u�t rh (Z��•,�cl r a�� �/�✓cu o �S�rr /3c�► ' Completion of thefollowing table may be waived by the Inspector of Wires. No.of Total f No.of Recessed Luminaires 7�- No.of Cell:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA r No.of Luminaires Swimming Pool Above ❑ In- El o meLighting rnd. rnd. Battery Units No.of Receptacle Outlets 3C> No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burgers No.of Detection and Initiating Devices r No.of Range No.of Air Cond. Tons TotNo.of Alerting Devices No.of Waste Dis osers Heat Pump Number Tons KW No.of Self-Contained p Totals: - Detection/Alerting Devices r No.of Dishwashers Space/Area Heating KW Local❑ MunicipalConnection El Other No.of Dryers Heating Appliances KW SecuritNo.of Systems:* or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Bathtubs No.of Motors Total HP Telecommunications Wiring: No.Hydromassage No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. S{ Estimated Value of Electrical Work: Hood 6 (When required by municipal policy.) Work to Start: `/ ,?S- I3 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 unless1-2 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 [9 BOND ❑ OTHER ❑ (Specify:) I certify,under thepains and penalties ofperjury,that the information on this application is true and complete. FIRMNAW: �'J.cT P �a�yr '��c�rtc���► LIC.NO.: 11 SS—A—_ Licensee: ryl;c%��/ ,,�/G,,, Signature /ice :Q_- LIC.NO.;1,9 3y2 -13 t�J (If applicable,enter "exempt"in the license number I*ne.) Bus.Tel.No.(q 2y g-0 - Address: "l ///�/ rc (�e < 07� Alt.Tel.No.: *Per M.G. ,c. 147,1s.57-61,sdcurity 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:$ Siunature. Telephone No. 1, ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed Q on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass EN Failed Re-Inspection Required($.)❑ f Inspectors Comments: - Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass R1 Failed 0 Re-Inspection Required($.)❑ 7 Inspectors Comments: } Inspectors Signature: Date: ROUGH IN TION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: (/ ' FIN CTI Pas Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: f tis xi/- 71.7 ti Date: 3G — /,7 DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com Cr The Commonwealth of Massachusetts - Department of Industria.l Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers lease Print ibl Applicant Information // / �-l_ Name(Business/Organizatiorandividual):�iC 4 n! /jP Address: /3 Sp4 u 10h, rd City/State/Zip�OhGq, .Ulf 63076 Phone#:l Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6, []New construction ( art-time) employees full and/or .* have hired the sub-contractors p listed on the attached sheet.� 7. ❑Remodeling 2.91 am a sole proprietor or partner- ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, E]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.aElectrical repairs or additions required.] officers have exercised their ht of exemption per MGL 11.❑Plumbing repairs or additions right 3.❑ I am a homeowner doing all work g p p myself. [No workers comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]f employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit 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 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: C/4k)h c/' r4-4 c z: Policy#or Self-ins.Lic.#: Expiration Date: j Job Site Address: /9;,� City/State/Zip://. M4 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. Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Simature: Date: Phone Offccial 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#: t. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permittlicense 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�,MASS.AIiE Revised 5-26-05 Fax#617-727-7749 www.mass,govldia u Commonwealth of Mas uselts � Division of Registrati +R Board ofElectnc MICHEA, 7 WILLIE N o LOWELL, w b Master Dec ' 'a " 21199-A 07/31/2013 . License No. 006643 Expiration Date. serial No. L pS p f:EG JOURNEYMANLECTRIGAN t ISSUES ll J BOVE'LIC T'O F M.ZCHAEL RADAIR { t Z '!Y,,1 d • J '.J k= -MA, `01854;-•4117: 12342Bk 0]/3i/13 840452 • • Date.`"./x/� .... . °p TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION �1S SAC MUSEt This certifies that . .�. �. . . . . . . . . . . . . . . .. ... . . . . . . . . . . . . . has permission for gas,insta'llation Xb .�1�:�:l'.11 r7 �� m the buildings of .�,:� ,�._� . .-:1��/.��,0� . . . . . . . . . � l at /. .� (,. . . . . ... .. 4< . . . . . . . . . .. North Andover, Mass. Fee.?l).: Lic. No.�.. -. -1� . . . . . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR $ Check 4667 i MASS APPROVAL .# ,f MASSACHUSETTS UNIFORM APPLICATION FOR PE d�AIT O 00 GASFITTING (Print or Type) �' L j � A►nc�o�,a�— , Mass. Building Location /q,,j q O%m's Name Q.C\r%*AA g Ag1\NA • • �e✓\� t.J �� ev+ ' Typed Occupancy re—'(, rl- New p Renovation ❑ Re ce eM( Ptarts Submitted: Yap No[ o: Y Z G 4; y H tJ N rt N a: O ; in S !- yr W rt O V m t = 7! t1 J Q W F �, z C Z O ►' -Km Yl ►- y W O e. c • < w W w ' , Z S Q W Q Q W ~ W V S q rr J F W m 2 U. ~ W O a S •= O p = {L D O J 01 = > o d H O SUB—BSMT. BASEMENT I IST FLOOR I 2ND FLOOR ( 1 I o 3RD FLOOR I 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 6TH FLOOR Installing Company Name YANKEE GAS Check one: Certificate Address 140 SOUTH MAIN STREET [X Corporation 103C MIDDLETON, MA 01949 [. Partnership Business Telephone 978-774 ' 2760 C Firm/Co. Name of Licensed Plumber or.Gas Fitter WILLIAM R. HARRTS INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which mets the requirements of MGL Ch. 142. Yes M No O If you have checkedrimes, please lndicate the type coverage by checking the zpVopriate box t A liability Insurance policy 13 Other type of indemnity❑ Bond O OWNER'S INSURANCE WAIVER: I am aware that the licensee does nct have the Insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this permit&;plication waives this requirement. Check one: Ownerri— Agent p Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)in abare a�icaticn are true and accurate to the of my. knowledge and that all plumbing work and installations performed under the permit' for this appl' • 'll m all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Laws gy T of License: Plumber gnature muer ar mer Title Gasfitter Piaster License Numbs 3785 City/Town Journeyman ,, APPROVED( I NL