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Home My WebLink AboutMiscellaneous - 20 COACHMANS LANE 4/30/2018 (2) / 20 COACHMAN'S LANE 210/037.A-0017-0000 0 �I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY U�� t OU MA DATE � -�-�PERMIT# a b-L41 JOBSITE ADDRESS 0 OWNER'S NAME-r �r9� P OWNER ADDRESS S TEL TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:El RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES NO[] FIXTURES 1 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 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER _ . INSURANCE COVERAGE: _ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[j] NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature.on tl;l3 pa,•mit appllcatlon•,sive;this requirement. CHECK ONE ONLY: OWNER 0 AGENT 0 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 an rate to the best oApy knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com ce e 'nent p o Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME IDAVID SILVA LICENSE# 10965 SIGNA RE MP JP 0 CORPORATION 0# PARTNERSHIPO# LLC 0# ,COMPANY NAME D.A.SILVA PLUMBING&HEATING ADDRESS 1124 SEQUOIA DR. CITY TYNGSBORO STATE MA ZIP 101879 TEL 978-649-1588 ^� FAX 978-226-1211 CELL 508-517-6234 EMAIL DA.SILVA.PLUMBING.HEATING GMAIL.COM -L01 n V UZe C L9 I vnnva(�L Fold,Then Detach Along All Perforations CIM VIO M 'LTx.0 1111 THUS x l • ILOI a • • F-11 MIR WRINIUM tUWI� RS-ANp�ASP(T�'�1�5 'P�4111D/��SIL1/A-JFt �. 12' si b . '. TYNG�BQR�3'11�A�01'.$T921fi4 \ .; •,,�Y�t }Z. :3 10965 t5%01/2U18: 38980 t — — ----------------------- - E G' 6I s;f t,atli 'Err.Enrsma.�riamaicdd'acsYmm.�"srsd�ira=2�'Ai.,hx:r /-1417/4052 '---------- ---- - �3 -cam pW�,wm. Town of Noah Andwer,MA 4 Sema.. �- 20417 •Fk. F..&- r or., �acwo.rsar TIMfUNE - �6LYf. Sim v to d Ma.1•s.�s.rz23i'•am '� .,^`E+k-;atx:,t itd;... mPlumbing REVIeW AsSa�.as S�hitiy3�T�. oPerna,Pee oPerm l=Si1d1Y.2 r v,. Thursday,May 19,2016 02:38 PM Date. ...... 1, ,-- A, ------i?/. RT#f TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING x This certifies that......./..: ... ......... ................................. ................................... has permission to perform... ......... 4.......... plumbing vi the buildings of... ............ at.........../.....IcAe�.................................................... North Andover, Mass. Fee., Lic. N(0-15...... ......................................................... 4"1- PLUMBING INSPECTOR Check# Zlf 7 �f-k' f� I '2-0 i� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY, MA DATE /�l ( PERMIT# JOBSITE ADDRESS L / 4A/ OWNER'S NAME POWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: E0 RENOVATION:LEr REPLACEMENT: © PLANS SUBMITTED: YES[I NOD 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 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER _ m�[ { �._. J DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN _l ..__1 - r -._-_) � f 1 __--J INTERCEPTOR(INTERIOR) f _I _.__. ._1 _ _._.-1 I i I _--____1 KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTIONi WATER HEATER ALL TYPES _! I ...__I I I WATER PIPING I - JI ( - - I i OTHER _�_ _-__- _..�__._I ( ►. 1 ._.._... -( ! ' --- - ( - --._ _ ( ._._...__I _( i INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ...i' NO __ IF Y(A)CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY M OTHER TYPE OF INDEMNITY ' BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ® 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 tp4q 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 pl! nce hal !Hent vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ 41 �LICENSE# �- NATURE MP D JP CORPORATION M# PARTNERSHIPQ# !LLC U COMPANY NAME D 10, i Qv' r`TC-i P ADDRESS sol trl_ J �.,��---,- __ IISTATE- ZIP TEL 3 ---- FAX �— CELL��EMAIL ROUGH PLUMB INSPECTION NO BELOW FOR OFFICE USE ONLY INAL INSP CTIOS �& --,�L d,&e& K� Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES M The Commonwealth of Massachusetts , - Department of Indtfstrlgl Accidents Office oflnvestigations 600 Washington.Sheet Foston,MA 02111 -www.mass gov/ciza Wprkexs'Compensation Insurance Affidavit:Buffders/Cony°actorsfFIectricianstpliimbers Applicant Xnformaon — Please Print LePitbly Name(Business/Oxgani'zation/fndividual): V l t) �I( VU'S' Address: City/State/Zip: )f-C �11� dy Z�� Phone ik 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 c6nstruction f f employees(full and/or part-time).* have Hired the sub-contractors 2.0 I am a sole proprietor or partner listed on the attached sheet. 7• El Remodeling ship and`kave no employees These sub-contractors have 8. ❑Demolition woridng forme in any capacity. workers'comp.insurance. 9, E]Building addition [Nb workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exerclsed.their 3.❑ I am a homeowner doing all work right of exemption per MGI. 11.❑Plumbing repairs or additions c.152 1 4 and we have no myself.[No workers comp. �§ ( )� 12.❑Roofrepairs insurancerequired.]? employees.[No workers' 13F]Other comp.insurance required.] 'Any applicantthat checks box#1 must also fill outthe section below showingtheir workers'compensationpolicy information. T Homeowners who submit this affidavit indicating they Are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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-ias.Lic.#: Expiration.Date: Job Site Address: City/State0p: Attach a copy o#the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requlredunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a flue up to$1,500.00 and/or 'one-year imprisonment,as well.as civil penalties in the form of a STOR WORK ORDER and a fine ofup to$250.00 a day against the violator. Be advised that a copy of this statementmay be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. X do Hereby c under t ae pains and alties ofperjury that the information provided above tsiqwe and correc4 - Si ature• Date: 02 Phone#• 3 ( Q ° " official use only. Do not write in this area,to be completed by city or town official. City or Town: Permif/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 hi the service of another under any contract of hire,• express orimplied,oral or•written." An employdis defiued 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 xdeceased empleyex,or the receiver or trdstee 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 onthe grounds orbuilding appurtenant thereto shallnot because of such employmentbe deemedto be an employe'." MGL chapter 152,§25C(6)also states that"every state or local lie-easing 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 chapterhave been presented to.the contracting authority.." Applicants Please fiil out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if a6cessary,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 notrequired to carry workers'compensation insurance. If au LLC or LLP does have employees,a policy is required. BE)advised thatthis affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance ceverage. 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 andprinted 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 whichwill be used as a reference number. In addition,an applicant thatxnust submit multiple permit/license applications in any given year,meed only submit one affidavit indicating current policy information(ifnecessary)and under"Yob Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamp ed or marked by the city or town may be provided to the applicant as proof that a valid affidavit-lion.file for future permits or licenses. Anew 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 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 for your cooperation and should you,have any questions, pleasa do not hesitate to give us a call. The Department's address,telephone and fax number: Tho Com-monwcalth ofMhssachu&eutts - Mpart eat QfIndustrlal.A,cca donts Qfce ofJAVestip on'a 6bG Wakiugt�n G7re t Boston,MA 021 It Tel#617-727,4900 OA4Q6 Qx 1-877-MASSAFE Revised 5-26-05 Fax#617"727"7749 www-mass,govldia • COMMONWEALTH OF MASSACHUSETTS, s • 11912:1:513Mlrolorl oil BOARD OF i PLUMBERS..AND -GAS F.ITTERS ISSUES THE FOLLOWING LICENSE ¢' LICENSED'AS: A JOURNEYMAN PLUMBER, F DAVID ;R CARLETON 142 SOUTH MAIN ST �' z ` NEWTON' NH 03858-3709 207.31: . 05/01.116:; 208797 • Date.. ............ 3r; ooL TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,gsACHU This certies that �44 0as pernus ............................................................. wiring in the building of................../e............... aO�,?4 Z". .............................................................................................. ..Prth Andover,Mass. Fee.R62..........Lic.No,.21,0? ..... ........ 4 -4(J ................. ELE TRIC*A*L*IN'SPECT0Rj Check# —3 on C) i Commonwealth of Massachusetts Official Use Only a Department of Fire Services Permit No. 11 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.1/071 (leave blank 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 W INK OR TYPE ALL RWORMATI019 Date: , /p /s 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) _a0 C()r,cA M[zn f Z q . U Owner or Tenant —Fo m Me c lrct w Telephone No. 3' Owner's Address )-tb Cor cti n.,q n r Is this permit in conjunction with a building permit? Yes R No ❑ (Check Appropriate Box) Purpose of Building ,QA,Gk,71-" y ,,-tf tel ) Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Und rd \ g ❑ 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 5 No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets �' (� No.of Hot Tubs Generators KVA rgp Above In- o.o Emergency Lighting No.of Luminaires ef+ Swimming Pool rnd. grnd. Battery Units l No.of Receptacle Outlets y No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices -S. Heat Pump Number Tons KW No.of Self-Contained �- No. of Waste Disposers .. . ....................................................... Totals: Detection/Alerting Devices ! s No.of Dishwashers Space/Area Heating KW Local El municipal Connection [I Other .� No. of Dryers Heating Appliances KW Security Systems:' \ No.of Devices or Equivalent No.of Water KW No.of No.of -)Rai a Wiring: Heaters Signs Ballasts \. 0.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Tel communications Wiring: No.of Devices or Equivalent OTHER: (Ia.k 1: °n ii L.28U C r - Qta n e, K/�e R Ik f4 a Attach additional detail f desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: o�l d Q(/< dTJ (When required by municipal policy.) Work to Start: _9Z19115 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VE GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless' the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I"certify,under thepains and penalties o perjury,that the information on ai applic ' n is true and complete. FIRM NAME: . Q p vJq C1Q �4-C LIC.NO.: ;7/5 Y,3 4 Licensee: 114iirWcfe.5 Signature LIC.NO.: (If applicable,enter "exe pt"in the li ense number line.) Bus.Tel.No.-JIT 60 Y�1�Y Address: _ �6 Lov,,,0l/ Uni'l SY13 G�Ji ��►.►i na km , ^4r p/c?ff 7 Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of ublic 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:$ 1� _"" I Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the r permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed rte. 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 p j electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the �J 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—Pcrmit/Date Closed: Trench Inspection Pass 0 Failed 1fl Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ m Inspectors Comments: 57— 2—Zo-1 2tib Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com 3 r The Commonwealth of Massachusetts - Department ofIndusfr1g1 Accidents Office oflnvestigations 600 Washington.,S'h'eet Boston,MA.02111 www.mass govIdia Workers'Compensation Insurance Affidavit:Buffders/Cony°acforo/Electicians/Plri n6 ers Applieant Information Please Print Legibly Name(Business/Organizatioafndividuat): L) V, P,/ Address: Q (a Le11 5V (/rl i � 613 , - City/State/Zip:—No 'yh t`h Phone#: 7� Are Vu an employer?Check the appropriate box: Type of project(required): 1.HI am a employer with e9- 4. ❑ I am a general contractor and I 6. []New construction employees(full and/or part time)* have lured the sub-contractors 2.El 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 .forme in any capacity. workers'comp.insurance, g- Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its MEII 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 Iwo workers'comp. c.152,§1(4),and we have no UPRoof repa'us iusurancereT*ed.]; employees.[No workers' 13.❑Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out thesection below showingtheir workers'compensationpolicy information. ,T-Homeowners who submit Phis affidavit indicatingthl 2're doing allworlc and then hire outside contractors must submit anew affidavit indicating such, tContractors that checkthis box must attached as additional sheet showing the name of the sub-contractors and their workers'camp.policy information. I am an employer that is proYiding workers'compensation insurance for my erdlployees. Below is the policy and job site information. T f Insurance Company Name; / I+C, y�( Policy#or Sol£ins.UG.#: 76 w t G-0 6 Expiration Date: 01 3 / Job Site Address; 0 Q as c N Pta K 1- Z-0. 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 ofMGL o.152 can lead to the imposition of criminal penalties of a fine up to$1,50 0.00 and/or one-year imprisonment,as-well-as civil penalties in the form of a STOP WORD ORDER and a fine of tip to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the AIA.fo ance coverage verification. _i X do Hereby cert uride ie ains d penalties ofperjury that the information provided above is true and correct. - Si ature: Date: Thone#• �7 F &0 Y Coat Y V 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#: _ o• r. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an em ,ployee is defined as"...every person in the service of another under any contract of hire, express orimplied,oral or written." An employee 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 legalrepresentatives 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 notmore 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 employes." 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 beenpresentedta the contracting authority." Applicants Please 1111 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)andphone number(s)along with their cextifxcate(s)of iusuxance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other thaia the members or partners,are notrequiredto carry workers'compensation insurance. If an LLC orLLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents fox 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 lino. ` City or Town Officials Please be sure thatthe 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:M in the permit/license number which will be used as a reference number. In addition,an applicant tha6aust submit multiple permit/license applications is any given year,need only submit one affidavit indicating current policy information(ifnecessmy)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 affidavitis 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 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 for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone aiid fax number: ho Caxoxr�ox�woatz o Eassafihvsotls Dapartment o.£XuduaWa-1,A,coldents Ofte ofTnvestzga-&ij,% 60 wasb�Qa sttea Boston,:MA.421 It tel.#GM21-'_49QQ OA 406 or 1-•877-MMSAFE Revised 5-26-05 Fa 9 617-727-7749 • Wt�STir'.1X1,sSS,go��clia . i c i COMMONWEALTH OF MA55AOHUSETTS I EI.ECTR�I C I ANS � �{ I:SSUES THE FOLLOWING LJ CENSE ASA RE61STERU MASTER E.L R"►C N lz i MD#3EN ELECTRIC, INC i I'3ANNY RESINDS 1 1 R GAdVE f NGTpN MA 01887 372a I !� 215$3 0 /31. 6 50450 i I I v Q U �-�1Z1M� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY i ? MA DATE'/ PERMIT# JOBSITE ADDRESS Q Q OWNER'S NAME y_C_ OWNER ADDRESS SD. ,C�2h�9rt ._ . � TE �' � FAX` . t TYPE OR OR OCCUPANCY TYPE COMMERCIALI EDUCATIONAL � RESIDENTIAL PRT CLEARLY NEW:I� RENOVATION: REPLACEMENT, PLANS SUBMITTED: YES NOF-2 APPLIANCES I FLOORS-' BSM 1 2 3 4 J 5 1 6 7 S 9 10 11 12 13 14 BOILER BOOSTER i CONVERSION BURNER =- COOK STOVE DIRECT VENT HEATER - DRYER FIREPLACE -- _ FRYOLATOR ,..��.I...�..,,.. ._�t ..e.�...�.. ... �. _.. _._ _ FURNACE GENERATOR GRILLE ' INFRARED HEATER --. ,. .. _ � ,. ._,•�_�..—,L�_Y�.,....�._. _ _ .n_. LABORATORY COCKS MAKEUP AIR UNIT OVEN 1,. . _ . . � -_ " •� � --- -� , - - -_ POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER — OTHER ' - . :. .-. . _ _ - `. .. I ;� INSURANCE COVERAGE / I have a current liabil' insurance policy or its substantial equivalent which meets the requirements of MGL,Ch.142 'YES �0 _F I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ( AGENT ..; SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this 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 provisiop of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (af �3� r✓/ PLUMBER-GASFITTER NAME ENSE X3,&,, SIGNATURE MP MGF Tom` JP[-I JGF i5XPGI E2 CORPORATION�# `PARTNERSHIP Imo„ # LLC -# COMPANY NAME:L1 `1i{ �. . Y'`13r� ADDRESS CITY . Y►r� : E �--7'ZIP p _ f 4 STAT IP TEL FAX! CEL �.� t�� 'EMAILn � _ . f �� L1 -- GENERATOR APPLICATION DATE: 12- �( �jr� LOCATION: OWNERS NAME: I�j A-CC014 ) GENERATOR kw it vyu) NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: me- Llec�-, PHONE NUMBERW ELECTRICAL GAS RESIDENTIAL COMMERCIAL TEMPORARY ---� LOCATION OF GENERATOR: *ZONING DISTRICT: *PLANNING APPROVAL (IF IN WATERSHED) *CONSERVATION APPROVALS I � 3 • � HUS� �, , MENARD 52 gxN�py I I i AC� DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 11/13/2014 ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. ' IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endors(bment. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Patricia Blai.s NAME: Financial Insurance Services Inc PHJC_ttoONE . (603)432-6414 AIC No: (603)432-3852 PO BADox 950 E-MDRAILS:P blais@fisins.com INSURERS AFFORDING COVERAGE NAIC# Derry NH 03038 INSURERA:National Grange Insurance Co 14788 INSURED INSURER B Jus-Piping LLC INSURER C: 18 Clark Road INSURER D: INSURER E Londonderry NH 03053 INSURER F COVERAGES CERTIFICATE NUMBER:14-15 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE JUM XyJL POLICY NUMBER MMIDDIYYYY MM/DDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 500,000 A CLAIMS-MADE OCCUR b4PT2279G 1/17/2014 1/17/2015 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,000 A ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BlT2279G 11/17/201411/17/2015 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident Medical payments $ 5,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 4,000,000 DED I I RETENTION$ CUT2279G 11/17/2014 11/17/2015 $ A WORKERS COMPENSATION I WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? ❑ N I A (Mandatory in NH) CT2279G 10/28/2014 10/28/2015 E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Sam Fragala/PAT ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD North Andover MIMAP December 8, 2014 �aAL 11 fc ' �. & r.w� 0'GR yt "M �a • v .4 02D 405 R• T P© D 0 --FI N LN kw °��',•�, 0 4-0009 Interstates —I SR Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, Roads Meters Data Sources:The data for this map was produced by Merrimack MORTIS Valley Planning Commission(MVPC)using data provided by the Town of [r Easements Of ,tette ,� North Andover.Additional data provided by the Executive Office of ❑MVPC Boundary j �� *�00 Environmental Affairs/MassGIS.The information depicted on this map is I I Parcels 3 _ L for planning purposes ony.It may not be adequate for legal boundary H L definition orregulatory Interpretation.THE TOWN NORTH ANDOVER MAKES NOOWARRANTIES,EXPRESSED OR IMPLIED,CONCERNING # * THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY R i ^ # OF THESE DATA,THE TOWN OF NORTH ANDOVER DOES NOT ASSUMEANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF q�'S+•trEn THIS INFORMATION wCHUS 1"=124ft ��• North Andover MIMAP December 8, 2014 r 06419,10137 , 4a • 440GRg T^PON ARD) i + a 03 A-¢t101' 4�� 06#O,-'O 9• sa 465�Gf��l�T�PANb)2D r 03�?A-0055] ��.10 4h41_�QgN�TRY0LII Cit 03J;+xA`-0t102s `'� 037?A-U016' �• \ 83658' 425jG12EAT T D f2d1� a i • o64�aots 03.71A;0017J s a , r •. ...•.. ,.�..,...,. ......... ,, *•� �� Q3,7!A'-0018 03,7!N-,MO, ..•' 405)GREAiT'F"Q RD; - `y_ s')r� •.• 03� �*0029r 1 033 A-0019,: 03T2A-0_021' co� 40-OA --HNIANSJLNj i� 037�0015� ?7/CpA`CFiMAN`S�LW1 ` so Q3,7 03.7 A-0009 c--- ager, .= Rail Line C:Exempt Lands Interstates O WSP_ZoneA Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, I t:WSP_ZoneB Meters Data Sources:The data for this map was produced by Merrimack SR Roads WSP_ZoneC NORT1f Valley Planning Commission(MVPC)using data provided by theTown of North Andover.Additional data provided by the Executive Office of [Easements j �� 00 Environmental Affairs/MassGIS.The information depicted on this map is ❑MVPC Boundary 3 L for planning purposes only.It may not be adequate for legal boundary O A definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER O Municipal Boundary ►' - v MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING OWalershed } THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY f i + # OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT "–,Watershed Sub-basin #o i ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF O Parcels .��'bTHIS INFORMATION L:;Hydrographic Features 's`�•�C14 —Streams -..Wetlands 1"=124 ft iC Public Parks , North Andover MIMAP December 8, 2014 0 4.0-037 r 064.0-oa7 440-GREAT POND'RD 037,:A-000l/ ¢� 064:0-0029 465 GREAT POND RD O� 037A=0055 / �l�� 44 COUIV KLUB CIR f, -64.0-0075 037.A=0002 37.A-0016 425-GREAT PONDNater Protection 201COACHMANS,LN Rl o3/A:OOla/ /-41 064:0-0152 037.A-0007 037:A'0018 �03 .A-0020 j// / 30,COACHMANS�LN . . •-•, • 405.GREAT'PON D,RD 37.A-0019 037.A-0 15 27/OAC/�/��LN 401COACHMANS LN 37 A-0 22 Rail Lina 7�Wetlands Zoning Interstates C:Exempt Lands Y'Busine s 1 Dist _I O Busine s 2 District Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, SR ®Busine s 3 District Meters Data Sources:The data for this map was produced by Merrimack Busine s 4 District HORT1y Valley Planning Commission(MVPC)using data provided by the Town of RoadsGenera Business District Of c q� North Andover.Additional data provided by the Executive Office of r Easements O Planne Commercial Dev = �� 00 Environmental Attairs/MassGIS.The information depicted on this map is C:Corrido Development Dist 3 L for planning purposes only.It may not be adequate for legal boundary Q MVPC Boundary O Corrido Development Dist O —. in definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER 0 Municipal Boundary D I orrido Development Dist F 9 MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING Induslri 11 District THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY Zoning Oveday t - • 01 ndustn 12 DisMct B Adult Entertainment • t OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT D Indust6 13 District *o t f ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF 0 Downtown Overlay District 0 Industri I S District �� E3 Historic District o+ns.o `�j THIS INFORMATION ®Water Protection Reside ce 1 District �,� Reside ce 2 District SSACMUs�t E3 Parcels C1 Ra=ode ce 3 District t.:Hydrographic Features de ce 4 District —Streams 1"=124 ft ^ .de ce 5 Dislncl FFF de ce 6 District �a a a, ential District Date... z,...21 lf.. ' �p►ORTIy r;` :�tioo om TOWN OF NORTH ANDOVER ' PERMIT FOR WIRING This certifies that ........... .1./. ......... �.... ........................................ has permission to perform ......2..-2kca,>......� �A75 . wiring in the building of.................:... ...�.f................................................................ at ...................... P.. �2..f .........4Az...................North Andover,Mass. FeeA ,.?'`�..................Lic.No. �...�.1.Z,9�..................-: �.... ....................:..,'��.fl./..'..... ��L�TRICAL INSPECTOR / Check# 7 r A-ej VYN— I-z- I 2A m �61e-�, 4D 6-�-, - - Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. ,}y �36,1 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev-1/071 (leaveblank) APPLICATION FOR PERMIT TO PERFORM .ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: (Z- t -1 tf 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) 2cv C.oAd-swcj-3, Lolnl— Owner or Tenant -4yV4-1 ML C„r Telephone No. (o o3--?I'f -9 2(--7 Owner's Address Is this permit in conjunctio 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: � �I 2-2 V Completion of the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators l KVA 2 2— No. No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Bane Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiatin Devices No.of Ranges No,of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number .Tons KW No.of Self-Contained Totals: _"""'""'.""""' Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Sectio.ofysteDevices or Equivalent No.of WaterNo.KW No.of No.of Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent , OTHER: Attach additional detail if desired or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 1 2-b -)`t Inspections to be requested in accordance with MEC Rule 10,and upon completion. if 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 N BOND ❑ OTHER ❑ (Specify:) I certify,under the sins and penalties of perjpry,that the information on this application is true and corijleie. FIRM NAME: ' .;t, 0 car` LIC.NO.: 419q2-9 Licensee: I Signature LIC.NO.: 1415'i2- (Ifapplicable, ter"exemp " n the liFense.number Address: K�c9��, e_� c..-�`..�Z S �►J 1} Bus.Tel.No.: 3-4Y? 4rG Alt.Tel.No.: "3- 2-73- 7S7(J- *Per M.G.L c. 141,s.57-61,security work requires Department of Public Safety"S"License: Lie.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 Telephone No. PERMIT FEE:$ �P _. ELECMCAL PERMT NO, _ �LEC`T.�]fCAL�1'►�'l'E-►�`T®Jl��.' � � � -- x.ROU 'I M8 cT or: PAssed-�C ] +'ailed--[ ] Re-inspection requires s-moo) C j ?�uspectors'Comments: - (Inspectors'Signature-no initials) Pate 2.MAL XNSPXPUOX,- Passed-[ J Faded.J 7 Re-Inspectim required($50.00)--j Inspectors'comm.enfs: ft4ectors'Si afar no Wfials) Date 3.U ;—[ RODM XNSPECTZON- PasseI+'ailed"[ ) Re-inspection requi ed W0.00)Inspew3 m.ents: (kspectors'Signature•-no initials) Date 4.INSPECTION—SER�Sr[J CE: DA! F,C.LT ED NAd►ONA-1,C� : NAMM. Passed—C ] Naffed_[ Re inspection required( 50A0) [ 7 Inspectors'ea7mm.ep�fs: (Inspectors'Signature-io initials) Date 5.MSPECTION-OTHER:' i Passed—j ) I+.ailed--j ] ?fie inspection xeciuixed($50.OD) j ) .Inspectors'comments: '(fusp ectors'Signature-no initials) Pate 1�O OR TAGS.APX TO BE FILLED-OUT AND LEFT ON SHE IF THE APXA TO DE WSPECTED IS NOT A.CCESSOLE AND ARE wspECTioN OF X50.00 is TO m cmROED. The Commonwealth of Massachusetts - Department o,f dostriglAecMiks Office of Investigations 600 Washington Street Boston,MA 02111 kvi www massgov/dia Workers' Compensation Insurance"Affidavit:BuffdersfConlractors/El PX�� Prinlans]Plumb it A pp]7ly [cant Wo natio Name(Business/Organizaaon&dividuat): �— Address: City/Sfafe/Zip: � �-� , �3e7 9 Phone Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 2— _ 4• E] I am a general contractor and I 6. []New construction F ( part-time).*ees emp to full and/ox have Hired the sub-contractors ylisted on the attached sheet.r 7• ❑Remodeling 2.❑ I am a sole proprietor or partner These sub-contractors have S. E]Demolition ship and'have no employees working .forme in any capacity. workers'comp.insurance. g, E]Building addition [No workers, comp.insurance 5• ❑We are a corporation and its 10.[]Electrical repairs or additions required.] officers have exercised their light of exemption per MGL 11.[(Plumbingrepairs or additions 3.[� 1 am a homeowner doing all work myself.[No workers' comp. c. 152 § (1(4), ,and we have no 12.Q goof repairs insurance required.]t employees.Ego workers' ISE Other comp.insurance required.] -Any applicant that checks box41 mustalso fill out the section below showingtheir workers'compensation policy information. t'Homeowners who submit this affidavit indicating they Re doing all work and then hire outside contractors must submit a new affidavit indicating such. ub contractors and their workers'comp.policy information. TContractors that checkthis box must attached an additional sheet showing the name of the s X am an employer that is providing worlters'compensation insurance for my employees: Below is the policy and job site information. Insurance Company Name. �'r�''�``"'3 3 2 ExpixationDate: Policy#or Self ins.Lie'.#: ��`o G ��11 Job Site Address: AA City/Statelzip: Attach a copy of the workers'compensation Tolicy declaration page(showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A of MGL o.152 can lead to the imposition of criminal penalties of a fine upjto$1,500.00 and/or one-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. De advised that a copy of thus statement maybe forwarded to the Office-of Investigations of the DIA for insurance coverage verification. X do Hereby c unit e pains and penalties ofperjury that the information provided alcove is true and correct. Si afore• Date: Phone#: 3 �2-•F S Co 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(3ne): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbinglnspector 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 employei is defined as"an individual,partnership,association,corporation or other legal entity,or any two ormore of the foregoing engaged in a joint enterprise,and including the legal representatives of aAc ceased 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 lobal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings iu 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),addxess(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. De advised that this affidavit maybe submitted to the Department of Industrial Accidents fox confirmation of insurance coverage. Also be sure to sign and date the affidavit. 'the affidavit should be returned to the city or town thatthe 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 obtainn,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 Departnenthas 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 submitmultiple 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 shouldwrite"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may b e provided—to the applicant as proof that a valid affidavit is 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 or permit to bura 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 shQuId you have any questions, " please do not hesitate to give us a call. ' The Department's address,telephone and fax number: Tho CQWyAQRWf,,ajtjL of M.sj hv.:sPtEa Department o£ZndwWal. ooldmita . Q�ce o�Inve�t�,��i�x�s• 60 a. . . aa Sft�t DoStQnF .a�X X� TQJ, 617-7.27_4900 0A 40,6 Qx 1-877-MASS FF, Revised 5-26-05 Fal,#617-727-7749 �4v.l�la�s,gav�c��a Date.6/ `. ............... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,gsACHUs�t This certifies that V6kx o r...... P.c .. ............................................... has permission to perform .......:/ � .�`+ :e.... ...r , . .......................... wiring in the building of... `(? .f�. ...................................................................... .....?4� .....................North Andover,Mass. ......... ................... . iFee....I ......Lic.No.—M.I.9.7 �....................................................................... ELECTRICAL INSPECTOR check# �d � i> Commonuweakk o f Mamachueeffj Official UAOnly Permit No. alJepartment o13ir¢�eruices • Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C),527 CMR 12.00 (PLEASE PRINT IN INK OR TYwe,#7 ALL INFORMATIONS Date: 02 9 /G City or Town of: 1;�)dadPr To the Inspector of Wires: By this application the undersigned gives notice of his for her intention to perform the electrical work described below. Location(Street&Number_ 6 04"A) art 6 �h 1°- Owner or Tenant �'Q1��/�/��fly !�G(.;t-q�. Telephone No. Owner's Address yvt p7�=(,,ss 'go f _ Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building h-,ido,2 e 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: � S �u t�o�cc�p c;7— Completion ;7—Com letion of the followingtable may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total KVA + P No.of Luminaire Outlets No.of Hot Tubs Generators KVA �. k No.of Luminaires Swimming Pool Above ❑ ❑ o.of Emergency Lighting rnd. Q rnd. Batte Units �I No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches NoGas Burne �' No.of Detection and .of Initiating Devices No.of Ranges No.of Air Cond. Tonal %5\ No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained > Totals: ...............""'. Detection/Alerting Devices 3 No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Connection �-- No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of Water K`,,, No.of No.of Data Wiring: Heaters Si ns Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired or as required by the Inspector of Wires. Estimated Value of Electrical Work: (� (When required by municipal policy.) Work to Start: (10,',, f.��X 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 coverage is in force,and has exhibited proof of same to the ennit issuing office. CHECK ONE: INSURANCE 9 BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the informs 'on on this application is true and complete PP r FIRM NAME: im esLy l2� LIC.NO.:,� Licensee: Signature LIC.NO.: (If applicable,enter " mpt"'ip the license number line.) Bus.Tel No.: 9 7t e-5',7 Address: f /Cr l'1 �+ 6�� 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 a%zent. Owner/Agent PERMIT FEE: $ tP Signature Telephone No. The Commonwealth of Massachusetts Department of IndustrialAccidents i Office of Investigations kvi 1 Congress Street,Suite 100 Boston,MA 02114-2017 elf www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): CI I Y�( Address: D1 ,14'/"( Is fr)e �� c City/State/Zip: / "le (Jde_ f4 Nq Q�h n#: f,7,f-FS 7- 7.5 3 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 employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.211 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. EJ Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp. insurance. $ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: _ Policy#or Self-ins.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 and he pains and penalties f perjury that the information provided above is true and correct. Signature: Date: —S'a 'Z/- Phone /Phone#: �s 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#: * 4 ISSu�SLC1`RiC1Q �C- OURN��' iQl�. FC1� xNS L , EQNgR� r,. ,oc. . , '54:r { a Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: Thomas & Michelle McCraw Property Address: 20 Coachmans Lane Policy Number: HP3061137 Date/Cause of Loss: 9/6/2014, Windstorm File or Claim Number: 30168-R Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 36 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Ryan Werner On this date, I caused copies of this Notice to be sent to the per ons named above at the addresses indicated above by First Class Mail. Signafur and Date ANDERSON ADJU ` MENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NHI 03053 Date... .�P.�.�.`li.......... o� 4.0Rr"'ti TOWN OF NORTH ANDOVER ` ° 9 PERMIT FOR PLUMBING IThis certifies that.................................... ! QNS e�1�................... ......................................... ............... has permission to perform-ki.14.....�.(........ plumbing in the buildings of......M a�� at....2-0......�'..Uf�c�.`'�!�.✓�--s...�.n+.............. North Andover, Mass. Fee...�h......Lic. No. 1 Z 11 lP.. M ............................................................... PLUMBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ...._ CITY L Qr _ .._ _�� DATE� PERMIT# JOBSITE ADDRESS �� OWNER'S'NAME POWNER ADDRESS — TE al� FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL } RESIDENTIAL(_ PRINT CLEARLY NEWT ii RENOVATION:0 REPLACEMENT:� PLANS SUBMITTED: YES[i N0 FIXTURES-1 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 DEDICATED GREASE SYSTEM - _ - _-- --- DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER [ DRINKING FOUNTAIN FOOD DISPOSER # 1 I 3! FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL �-� SERVICE/MOP SINK TOILET - URINAL WASHING MACHINE CONNECTION , WATER HEATER ALL TYPES - ( I WATER PIPING OTHER __- - - - -- - r INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESX NO F IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY i .i BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER D AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true accurate to the best of y knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compl' n with all Pertine provis n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LPeter G.Viens __ _ _ _____jLICENSE#L 12116 Y j SIGNATURE MP JPLI CORPORATION #i 3631 C PARTNERSHIP(,#; {LLC COMPANY NAME; Merrimack Valley Corporation ADDRESS 15 Aegean Drive,Unit#3 — CITY[Methuen STATEMA ZIP 01844 - TEL978 689 0224 FAX [978-689-2,206 i CELL!978-807-2819 ;EMAILpviens@mvalleycorp.com _ �� ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ i G. ;1( FEE: $ PERMIT# l✓�C T PLAN REVIEW NOTES Date ... ... ..W-. ..................... OF NOR7ly�h TOWN OF NORTH ANDOVER r- law. 9 ¢ PERMIT FOR GAS INSTALLATION This certifies that ....'T...12..t..e.`........... `S./.. ........ .t .. ....... . has permission for gas installation ./..+�.��..... ............. . c 1 in the buildingsnof.�.........0-.�-�-�u�v ........................................................................................... at....... P.......C O U c ✓� - 1—�` ; North Andover, Mass. Fee 3�...... Lic. No. `.�. ......... M ' .................................................................... GASINSPECTOR Check# � 27� • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK + CITY /\/Oy Adole s' eMA DATE OkYl PERMIT# V JOBSITE ADDRESS,?O �D Q�� s �� OWNER'S NAME � /nc��-�, , ) 1 G w OWNER ADDRESS TEL 5�5- /�- FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:. RENOVATION: REPLACEMENT:x PLANS SUBMITTED: YES 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 I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER I I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES XNO 1e I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY )� OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. C SIGNATURE OF OWNER OR AGENT HECK ONE ONLY: OWNER AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and a rate to the best of my nowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance,wi all Pertinent p visii':� iL� of e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Peter G.Viens LICENSE# 12116 SIGNATURE MP K MGF JP JGF LPGI CORPORATION # 3631 C PARTNERSHIP # LLC # COMPANY NAME: Merrimack Valley Corporation ADDRESS 15 Aegean Drive,Unit#3 CITY Methuen STATE MA ZIP 01844 TEL 978-689-0224 FAX 978-689-2206 CELL 978-807-2819 EMAIL pviens@mvalleycorp.com � SIU ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPE TI NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street lug 4 Boston,Mass 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeiblv Name(Business/Organization/Individual): i Address: City/State/Zip: v/ tJ��it J �/ �� Phone#: Are,you an employer?Check the appropriate box: 1.XI am an employer with '�" Type of project(required): 4. 0 I am a general contractor and I 6. El New construction employees(full and/or part time).* have hired the sub-contractors 2. 0 I am a sole proprietor or partner- listed on the attached sheet. 7• C Remodeling ship and have no employees These sub-contractors have working for me in any capacity. employees and have workers' g Demolition [No workers'comp,insurance comp.insurance.$ 9. 0 Building addition required] 5.0 We are a corporation and its 10. 0 Electrical repairs or additions 3. 1] 1 am a homeowner doing all work officers have exercised their myself [No workers'comp. right of exemption perm MGL 11 Plumbing repairs or additions insurance required]t c. 152,§ 1(4),and we have no 12. 1-!Roof repairs employees. [no workers' comp.insurance required.] 13. l I Other *Any applicant that checks box#t must also till out the section below showing their workers'compensation policy information. }Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contactors that check this box must attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,-they must provide their workers'comP.Awlicy number. I am an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#:-922? --� 3 Expiration Date: Job Site Address: d/j 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 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 $250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby cerci nd t e!a7indpe !ties of perjury that the informati n p ovtded above is true and correct Si nature: ` Date: Print Name: 5/ ti edPhone Official use only Do not write in this area to be completed by city or town official City or Town: Permit/license#: Issuing Authority(circle one): I.Board of Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#• COMMONWEALTH OF MASSACHUSETTSSTATE OF NEW HAMPSHIRE BUREAU OF BUILDING SAFETY&CONSTRUCTION PLUMBERS AND GASFITTERS PLUMBING SAFETY SECTION LICENSED AS A JOURNEYMAN PLUMBER ISSUES THE ABOVE LICENSE TO: i ' NAME: PETER G VIENS ' a ET.ER G` VIENS I LIC#:3249 M V` BLUEB'IRD LANE EXPIRES: 11/30/2014 AT1C1480'N NH 038112*v •` 2163:5 05/01/14 •-r F. :. ....... 5.1 x,18.. LICEN SE NO. EXPIRATION DATE SERIAL NO. oH Fold,Then Detach Along All Perforations State f ampshire� GAS FITTER NAME: PETER u COMMONWEALTH OF MASSACHIJSETTS ENDORSEMENTS . TM ^ P ilEWABEkS ANDGASFITTEf7S DATE ISSUED: 10/1 2013 LIGE tSED AS A MASTER PLtfMBra ISSUES THE ABOVE LICENSE Ta DATE EXPIRES: 11/30/2015 PEER VIEn'3 LICENSE#:GFE0700587 ``BLUEi' RD LE VE ..:..:............. .. ... ATICINS`0''ty NH 03811` 30 . 12,1 1.6 05"01/14 151719; LICENSE • EXPIRATION DATE SERIAL NO. Fold,Then Detach Along All Perforations Peter Viens Cert# 1023121001-12 Expires: 10/23/2015 EDIC MI R'S CERTIFICATE I certify that I have examined � ! C Certification in accordance with the Fede 1 A or artier Safety ul 'ons 4§'d 391.41-391.49)and with knowledge N.F.P.A.99-2012 ed. of the driving duties,1 find this person is qualified;and,if applicable,only when: ASSE 6010 Installer&ASME IX Brazel ❑wearing corrective lenses ❑driving within an exempt intracity zone(49 CFR 391.62) ❑wearing hearing aid ❑accompanied by a Skill Performance Evaluation Certificate(SPE) ❑accompanied bya ❑qualified byoperation of49CFR 391.64 Commonwealth of Massachusetts waiver/exemption f The information I have provided regarding this physical examination is true and complete.A complete examination Department of Public Safety I form with any attachment embodies my findings completely and correctly,and is on file In my office. SIGNATURE OF MEDICAL EXAMINER EPH E Pipefitter Journeyman 7 C¢7J License: PJ-028388 / DATE/ `\�l.I-I\ U♦ I V!♦L /'CJC� PETER G VIENS= �, ME AL EXAMINER'S NAME(PRINT) ❑MD ❑Chiropractor 9 BLUEBIRD Lrf L ATKINSON NH: 38>~1 j J1t ❑DO ,yp/Advanced Ii MEDICAL EXAMINER'S LICENSE OR CERTIFICATE NO. ISSUING STATE "'Practice Nurse [I Physician [I Other -r♦ /34//& if Assistant Practitioner I Expiration:NATIONAL REGISTRY NO. •�iw+• •` f Commissioner 11/13/2015 SIGNATOR OF IVER INTRASTATE CDL ONLY Commonwealth of Massachusetts []YES NO ❑YES NO Department of Public Safety DRIVER'S LICENSE NO. STATE Hoisting Engineer I ✓S /0 � / / License: HE-110323 1:tr� ADDRESS OF DRIVER P /,�~ , PETER G VIENS` { 9 BLUEBIRD LIQ MEDICAL CERTIFICATION EXPIRATION DA ATKINSON NH 03 PLY 1 DRIVER PLY 2 MOTOR CARRIER 26520(5/13) t Expiration: , Commissioner 11/13/2015 Location C`'6 C/1 H'A v S 1A ti No. 3 /? 0 Date -J$ MORTol TOWN OF NORTH ANDOVER 0� .•o r•,ti 0 • • Op ♦ i f7C� ; Certificate of Occupancy $ �'�s'•'•"'��' Building/Frame Permit Fee $ � ` JACMUSE Foundation Permit Fee $ Other Permit Fee $ _ TOTAL $ �s ` Check # qq,;20 (jell, 15 r` � �r- r Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING M BUILDING PERMIT NUMBER: 0 DATE ISSUED: 3� 70 SIGNATURE: CC Building Commissioner/I for of Buildings Date Z SECTION I-SITE INFORMATION I o1.1 Property Address: 1.2 Assessors Map and Parcel Number: G C( tkw�Aw S t4v-- Map Number Parcel Number 6 J 1.3 Zoning Information: 1.4 Property Dimensions: O Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ J SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record -V/VV RAP- A 1M 6-G L-W C�A C-T TT- 3 o Coa e, \wct w 5 Name(Print) Address for Service: � 1 Si f h UMAXAI 2.2 Owner of Record: PAA llcZ A-. - C _3o Pri ^ Address for Service: Z . -, -A— z8 3 M -Signature Tele hone SECTION 3-CONSTRUCTION SE CES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Uy i 5 SetrviT-Q S orf c. Licensed C struction Supervisor: `L 9-3 / 7 O Addre "N`� j�Jp vl j License Number M ss �L,J 111661 > f178 G ? ? 30 >xptra tin—Dat � Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v IJ i.5 s Toe-- / a d C� Company N me m Registration Number r Address 63 oa- 2003 Z. © Expiratio6 Dated ^ Signature Tele hon Y, SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work(check ali a ticable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: Re'yoxjt� Ba-t )FO-n M SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee 003 Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee tel X(b) 4 Mechanical HVAC L J 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR`` APPLIES FOR BUILDING PERMIT I, C t�t ocb i as Owner/Authorized Agent of subject property Her y a rite U �e� to aci on My a i tte r t to or o i ing pennit application. Z Si hue of Owner Date SECTION 7b OWNERJAUTHOR&ED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Signature of Owner/A ent Date ! NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS 1 2ND 3 RD SPAN DIMENSIONS OF SILLS DIN ENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE i - i # The Commonwealth of Massachusetts ti Department of Industrial Accidents ., Office of investigations Boston, Mass. 02111 ' Workers'Compensation Insurance Affidavit Please Print Name: Location: City Phone = am a homeowner performing all work myself. �I am a sole proprietor and have no one working in any capacity JI am an employer providing workers'compensation for my employees working on this job. Company name: -DV p u% Se ��c e S Ivc Address t 1 f City: M ffln • U� f� - 618 y46 Phone# ,FZZ 6 87 7-9 3 y Insurance.Co. Policy# Comony name: Address City: Phone# Insurance Co. Policv# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties .d a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine d($100.(70)a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and penalties of perjury that the information provided above is true and correct Signature QAMI i►v; Date ;2 Print name Phone# 36$7 7�36 Official use only do not write in this area to be completed by city or town official' C] Building Dept C]Check if immediate response is required Building Dept [] Licensing Board El Selectman's Office Contact person: Phone#: I] Health Department ©fher XV WORKMAN'S COMPENSATION North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: /'fJL/(�if1/ (Location of Fa lity) Signatur of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector '• E Town of Andover 0 No. j7c; 4 7�it-7-4�. J, _W7 701 Od :Z COCHIC E CK dover, Mass., V RATED PPG`�5 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System 0 THIS CERTIFIES THAT...A&4- . ........... BUILDING INSPECTOR./1.�a��r.��..+�..4'..�.r��.�.................................................. Foundation has permission to seer.. '` O A ...... buildings on ....a.0:...Cm.....C....... N.i..... .' Rough to be occupied as..........1...� .. " ..re O iM 1 N S N �� mit iM. /��S/�to" Chimney ..................................................... .... ..............I......... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. 1`7 ;e ys— PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough Is ..... �.C............................... ....... ... Service BUILDING INSPECTOR Final Occupancy Permit Required t0 Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner -r Street No. SEE REVERSE SIDE Smoke Det. Location �-d ` ✓�.�— No. 2 n 9 Date �Z G MORTN TOWN OF NORTH ANDOVER Of' `1O ,a,�•G O? • a Op h 9 ' Certificate of Occupancy $ +�•�s',.a EA Building/Frame Permit Fee $ s�cHUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # r 5 L 3 9 Building Inspector / v TOWN OF NORTH ANDOVER BUILDING DEPARTMENT PPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING XMORMONaZ .e. ,--'...,.- :: ar'^ €3 f.,.i.a. r. ::: UILDING PERMIT NUMBER: D DATE ISSUED. -GNATURE: C Building Commissioner/IpRworff Buildings Date ICTION I-SITE INFORMATION 1.1 Property Address: 1.2. Assessors Map and Parcel Number: Map Number Parcel NumWber ' 1.3. Zoning Information: 1.4 Property Dimensions: , ^ ning District Proposed Use Lot Area Frontage 11 V( i BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided Water Supply M.G L.C.40.1 54) •1.5. Flood Zone Information: - 1.8 Sewerage Disposal System: - 'lic 0 Private 0 Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ :CTION 2-PROPERTY OWNERSIIIP/AUTHORIZED AGENT i! Owner of Record me(Print) U Address for Service: 1 nature Telephone O Owner of Record: ame Print Address for Service: z nature Telephone CTION 3-CONSTRUCTION SERVICES Licensed Construction Supervisor: Not Applicable ❑ 0,0v l S C-v U G ce-9 e Q :nsed gtructioivis 6& �� ^ �JU License Number ress bl/1 xp Da e ature Telephone j Zegistered Home Improvement Contractor Not Applicable ❑ `5 SO (e pany Na e Registration Number ess j Explraf on Date ; tture Telephone i •� i f • SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building unit. Signed affidavit Attached Yes.......0 No.......0 SECTION 5 Description of Proposed Work check all a ucabie New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ N � t•. 'ti l l' Accessory Bldg. ❑ Demolition ' !❑` Other ❑ Specify Brief Description of Proposed Work: �r 1 Clo��xd 4- 6TIed roc v Zoo . _SECTION 6-ESTIMATEb CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be Completed by permit applicant �_ hl 1. Building (a) Building Permit Fee 0�0 Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)x(b) 4 Mechanical HVAC 2 • 5 Fire Protection # 6 Total (1+2+3+4+5) Check Number I SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN •OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 4 Las Owner/Authorized Agent of subject property He y a tho ' C'C S !V C - to act on ' 11 i e t6''i au ed this building permit application. 11161161 i Signa a of Owner ate SECTION 7b OWNER/ THORIZED AGENT DECLARATION I, I)�yt — ,as Owner/Authorized Agent of subject ; property Hereby declare that the stateme is and information on the foregoing application are true.and accurate,to the best of my knowledge and belief Print Na Si ature Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 RD 3 SPAN ` DIMENSIONS OF SILLS j DM ENSIONS OF POSTS DEVIENSIONS OF GIRDERS ' HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE i 1 t F j r ✓/ze �omrrw�eusea�i �`i�aacrfu�� BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number. CS 058317 f Birthdate: 11/08/1963 .:Expires: 11/08/2001 Tr:no: 8658 Restricted To: 00 DOMINIC F DUPUIS _ 720 LOWELL ST METHUEN, MA 01844 ! Administrator • ✓fie i9arnirito�2tue¢� %`/�� -Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 112176 Expiration- 03/02/2003 Type: Private Corporation DUPUIS SERVICES,INC. DOMINIC-DUPUIS i ..716 LONELL.ST. METHUEh,1jA:.01844 `• - AdniiriistYatar 1 t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Please Print Name: Location: CityPhone F-1am a homeowner performing all work myself. �I am a sole proprietor and have no one working in any capacity 1 am an employer providing workers' compensation for my employees working on this job. Company name: u (e S :00e Address L' f S-7" ` City, M A - 019W Phone# 6�a 6 er�a Insurance Co, rnDS7�E fPolicv# Company name: Address City: Phone#: Insurance Co. Policy# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of($100.00)a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. ` 1 do herby certify under the pa i and penalties of perjury that the information provided above is true and correct. c Signature DateT a 216-�_ Print name A]:k ID S Phone# �27 86$ 7 Official use only do not write in this area to be completed by city or town official' F, Building Dept ❑Check if immediate response is required Building Dept [] Licensing Board m Selectman's Office Contact person: Phone#: r-1 Health Department ❑ Other FORM WORKMAN'S COMPENSATION NORTH E Town of And No. AIL 3 d o� co� L ' � dover, Mass., A ,•• D/?ATE D PPa Cl BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System PA- /// D C // c BUILDING INSPECTOR THIS CERTIFIES THAT..... A ................................. !4.`��.4...............�! .......... ..................../.................. Foundation has permission to erect...s. .. �os'�" rr".. buildings on .c;?0...... ......�,A!✓. Rough to be occupied as................... Nl, .�7..... Vic{ i,v�....../�mo�rl......m ae f- ....6a r,a y -�... chimney provided that the person accepting this permit shall in every respect conform to the terms of the applicationt,00n file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. 2 9 A //7 � as _ PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough ............................................ Service BUILDING INSPECTOR Final ' Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Date....... ../N) + HORTq TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING This certifies that ......... 5.............. has permission to perform ........ .......... .............. wiring in the building of....... S.A.ffn�fq......tA.mh.... at...10.... ......L4V........... North Andover,Mass. "< Ke� -'Fee.... Lic.No. ��.t� ........ ........................ CAL IN EcrOR 7)')'7)a/-20/99 14:43 35.00 PAID WHITE: Applicant CANARY: Building Dept. PINK:Treasurer �L\ /r Offbe Use Only Ile (lommonwealtll of MUSUC411atts Permit No. 43, Etparttntut of Public %ftta / Occupancy3 Fee Checked BOARD OF FIRt PREVENTION REGULATIONS 527 CMR 12:00 L 3190 Peeve blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 4/13/99 City or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) 20 COACHMAN T ANE Owner or Tenant NANCY tic SIDNEY LAMB Owner's Address f 9781 683-0568 Is this permit In conjunction with it building permit: Yes ❑ No ® (Check Appropriate Boz) Purpose of Building Utility Authorization No. w Existing Service .Amps__1 Volts Overheat#'❑ Undgmd ❑ No. of Meters New Service Amps_I Volts Overhead ❑ Undgmd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No.of lighting Outlets No.of Hot Tuba No.of ltansformers Tbtai KVA No,of Lighting Fixtures Swimming Fool Above In- gmd. ❑ gmd. ❑ Generators • KVA No.of Emergency Lighting No. of Receptacle Outlets No. of ON Sumer$ Battery Units No.of Switch Outlets No.of Gas Rumen FIRE ALARMS No.of zones No. of Ranges No.of Air Cond. Total No.of Detection and tons Initiating Devices No.of Disposals No.ol Pumps Tons KW No.of Sounding Devices No.of Self Contained No. of Dishwashers Space/Area Heating KW OetectkxVSounding Devices No. of Dryers Heating Devices KWLocal Mu icipal [3 Other No.of No.of Vbitage No.of Water Healers KW 819rt4 Ballasts wiring BUR AT No. Hydro Massage Tubs No.of Motors Tbtai HP , OTHER: INSURANCE COVERAGE:Pursuant to the requkernents of Massachusetts general Laws 1 have a current Liability Insurance Policy kroludkV Completed Operations Coverage or Its substantial equivalent. YES G NO O 1 have submitted valid proof of same to the Office.YES O NO O If you have checked YES,please indicate the type of coverage by checldng the appropriate box. INSURANCE O BOND, O OTHER O (Please Specify) Estimated VaIw470.00 (Expiration Oats) 4/8 99 _ Work to Start tropectlon Date Requested: Rough Final 4/12/99 Signed under the Penalties of perfury: ,• FIRM NAME LIC. NO. 12310 Licensee ilnnar 1 d A_ Rrnetka nature LIC. NO. . 123 Ir Address 111 Morse Street. Norwood. MA Bus.Til.No. (203) 741-4008 Alt.Tel.No. (281) 978-1131 OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the Insurance coverage or Its substantial equivalent as re- quired by Massachusetts General Laws, and thnt my signature on this permit application welves this requirement. Owner Agent (Please chock one) ...Telephone No._, PERMIT FEE S.35-00 (Signature of Owner or Agent) ..rc�a No J �; Date......~. ...'� '.... s HOR7►, °f<��`°;•�"o TOWN OF NORTH ANDOVER 10« « PERMIT FOR WIRING SACMUS� 1 This certifies that has permission to perform y r '............................................................. wiring in the building of................................................................................... at............................................................................. —North Andover,Mass. Fee.. 1............... Lic.No.............._.................... ........................... ELECTRICAL INSPECTOR Check # WHITE:Applicant CANARY: Building Dept. PINK:Treasurer Official Use Only Permit No. Occupancy&Fee Checked - BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all information) Date z-&-Q To the Inspector of Wires: Town of North Andover The undersigned applies for a permit to perform the electricalwork de{scpbbed below]. Num (l / Location(Street&Nu �`�/f(fl I 1 J /I 1 � e Owner or Tenant Owner's Address Is this permit in conjunction with a building permit Yes Id/ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service 00 Amps /ZQ -Z fl Voits Overhead ❑ Undgmd X No.of Meters New Service Amps Voits Overhead ❑ Undgmd ❑ No.of Meters Number of Feeders and Ampacity i Location and Nature of Proposed Electrical Work 6 • � r Total No.of Li htin utlets No.of Hot fuse No.of Transformers KVA Above ❑ In ❑ No.of Lighting Fixtures Swimming Pool grnd ❑ grnd ❑ Generators KVA No.of Emergency Lighting No.of Receptacles Outlets No.of Oil Burners Battery Units No.of Switch Outlets No of Gas Burners FIRE ALARMS No.of Zone ' Total No.of Detection and No.of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No.of Di sal No. Pumps Tons KW No.of Sounding Devices No./of Self Contained No.of Dishwashers SpaceJArea Heating KW Detection/Sounding Devices ❑ Municipal ❑ Other No.of Dryers Heating Devices KW Local Connection No.of No.of Low Voltage No.of Water Heaters KW Signs Bailases Wiring No.Hydro Massage Tuds / No.of Motors Total HHP,��,� OTHER r INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have 4x.Lqent Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES= NO = ha valid proof of same to the Office YES= NO = If you have checked YES please indito the type of coverage by checking the appropriate box RAN SUCE BOND = OTHER = (Please Specify) �� l k (E51piration Date) Value of I ctri I Work$ 200 Work to Start Inspection Date Resquested Rough Final Signed under the Pehiftiek of perjury- .,,««�� FIRM NAME U LIC.NO. V� Licensee t/r/t� Signature 17 ��/ 2 --7LIC.NO. . C.94.Tel No. �2 x`23 -2170 %p 9 / U n Address Alt Tel.No. —- OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMITTEE $ (Signature of Owner or Agent) Date 0� ,. 'b HORTM TOWN OF NORTH ANDOVER �? �� .• OL ap p PERMIT FOR PLUMBING TRW ,SSACHUSE� This certifies that . . . .� . . . . . . . . . . . . . . . . has permission to perform . . . . �.".r.� `}�i` plumbing in the buildings of . . . . //I!/ c7.�.'�. `.�. t�! .. . . . . . . . . at. ..... . . . . . . . . . . . . . . North Andover, Mass. Fee. Lic. No.. c. 1. t. . . . . . . ..(. 'L -.` . . . . . . . . . . PLUMBING INSPECTOR Check # 5111 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS f Date Building Location 2v �V GL Owners Name Permit# Amount Type of Occupancy New Renovation ©� Replacement Plans Submitted Yes No FIXTURES z � cn w x a sz o Cn ww x z z Cn a x Cr a d Cn x a a o o D w w Z A a A a x ARIA RASEv>avr c MHA001Z Zu MOOR �m11fm 4MHIM 5M>1CM 6MHDM 7MHj" sMIWI (Print or type) / / 4i �P Check one: Certificate Installing Company Name + S ►a I e /94- rl Corp. Address �U 13v X PU It.c► 1;� � Partner. Business Telephone n e Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy [a 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 Signature Owner Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and in st tion erformed un er Permit Iss d for this lication will be in compliance with all pertinent provisions of the Massa tts to P mbing de and Ch r 142 e General Laws. By Signature Of +cense u riper j Type of Plumbing License Title City/Town icen um er Master Journeyman ❑ APPROVED(OFFICE USE ONLY