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Miscellaneous - 20 EMPIRE DRIVE 4/30/2018
� _ _� S� S P .`I i Date.S. .-.L. . . .lz. 9423 TOWN OF NORTH ANDOVER 3: .�� - '•°oma ° PERMIT FOR PLUMBING ctmw This certifies that Gq.�^S .. . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . . . . . . . . .4 plumbing in the buildings of . . . . . . . . _ m .i at . . . . ... . . . . . . . . . . . ?. .CZ. . . . . . . . . . ., North Andover, ass. Fee. . .Lic. No.. �.3`t. . . . . . . . . PLUMBING INSOR Check # -7,5Z-0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY Mo>1. w JNAU't - n MA. DATE Jam" 2-3 %L PERMIT# / JOBSITE ADDRESS OWNER'S NAME ©f ulu POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIACEP PRINT CLEARLY NEW. RENOVATION:El REPLACEMENT ❑ PLANS SUBMITTED: YES ElNO ❑ FIXTURES Z FLOOR- BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIUSAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ] 3 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET ( 2 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['No❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY jr OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE BOX ONLY: OWNER ❑ AGENT ❑ Signature of Owner or Owner's Agent 1 hereby certify that all of the details and information 1 have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Cha ter 142 o e General Laws. �3 C PLUMBER NAME STEM+E1GALJ OSKY SIGNATURE LIC# 1 034 S MP 0' JP❑ CORPORATION [P(# 3191- PARTNERSHIP ❑# C ❑# COMPANYNAME 66140SW( PLUMPIMb ItRVAT110Ca ADDRESS: P.0• Gex 1701 CITY N�AVERFtIt,t STATE m•A- ZIP 01'93( EMAIL WWW. mrpIymbefe)Re Coves TEL g0V-37y- 1?'t 3 CELL •SOB-509-590`•1 FAX q76-5,2t-1413i ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No If le7 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ zj4t1z u FEE: $ PERMIT# PLAN REVIEW NOTES t Date. -Z 7-�-.1.? . .. .. . AORT#4 14,0 TOWN OF NORTH ANDOVER p S • PERMIT FOR GAS INSTALLATION �,SSACNUSESS This certifies that .C`! ��. . . . . . . . . . . . . . . . . . . . . e `A- has permission for gas installation . . . . . . . . . . . . . . . . . . in the buildings of . .P.% c� .. . . . . . . . . . . . . . . . ` at No Andover, Mass. Fee/00? ov, . Lic. No.�03�(�. . f� . . . . . . . . . . k GAS IN PECTOR Check#7,5 ZO r; 8163 A � b MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: 4A')q W MA. DATE: S L PERMIT# JOBSITEADDRESS:_ aOWNER'SNAME: OfiX-0✓ Nasoy�l_L AcC u c GOWNER ADDRESS: TEL: FAX.- TYPE AX:TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL ` PRINT CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCESZ FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER L EPLACE OLATOR NACENERATOR LLE %INFRAREDD HEATER TORY COCK AIR UNIT ATER PACE HEATER P UNIT TERD ROOM HEATER WATER HEATER 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 have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. I CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I 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 wi be in com 'ance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER/GAS FITTER NAME: ST E Ph EN C. G A L Z 1JS KY LICENSE# 10 3 LI8 I SIGNATI�- COMPANY NAME.- QAL143Kq PLurA610(, fi )4rAl- & ADDRESS: P.O- NOX 1701 CITY: 0AVE7p-HILL STATE: rn-A- ZIP: OiS31 FAX: q79- 5a1-14131 TEL: '179-3714- 1743 CELL: w4- 5"03- 5go4 EMAIL.- wW'w• mr iuw%be of yv\ MASTER[� JOURNEYMAN 0 LP INSTALLER❑ CORPORATION/t 319G PARTNERSHIP❑# LLC 0# ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ o/i `�3� �Z. FEE; $ PERMIT# PLAN REVIEW NOTES LAWRENCE H. OGDEN,P.E. 198 EAST MAIN STREET 978-3524318 fax 978 352-2858 cell: 978-502-5921 June 7,2012 Mr. Robert Messina Orchard Village LLC. 277 Washington Street Groveland,Ma 01834 RE: THE WILLOW GB#6213 Lot 2,20 Empire Drive,North Andover,Ma. 01845 Dear Mr. Messina As you requested I visited the site 6/7/12 to review the installation of the Engineered Materials consisting of LVLs and Engineered Joist utilized in the framing of the aboveproject. These are shown on plans prepared by G.J. Bruno and Associates A- 1 to A-5 Dated 7/30/09 with the framing sheets certified by me 6/15/10, and sketch SK-1 dated 2/15/11. Based on the above site visit and based on what I could visibly see I can certify that to the best of my knowledge the LVLs members and Engineered Joist utilized in the framing as shown on the drawings are installed properly and meet the loading conditions of the7th Edition of the Massachusetts State Building Code for 1&2 Family Residences. All other framing requirements of the drawings and code, including but not limited to materials nailing schedules blocking,connections ections and other details are the responsibility of the licensed construction supervisor responsible for the project. Should you have any questions please do not hesitate to call. Yours truly, L ence H. Ogden P.E. Structural 27765 i g � o 4/1/17- ca 0 ocoM Cc:Mr. Gerry Bruno Mr. Jeff Horne �,s� 27763 o ca Copy mailed to Mr. Robert Messina `ST E i I r M i Date...... �Z ' �-S ................................... F r►ORTh, ; TOWN OF NORTH ANDOVER s PERMIT FOR WIRING s`SACHuS� This certifies that ...... .. ......... 9.SG........................................................... has permission to perform .../,A .... 5�'� !..f................................... n _ .. �il. .... (s. �f.!5—.......................................... wiring mt��he building of......�,.,�};�,..... �(�.,.'�(,/... .:. at ... .f�....�,411,214.........S.j ......................... .,..c..,..., orth ndover,Mass. � p Fee�....................Lic.No. 1.�..v�....1��1.�.........JN... ....................................................... ELECTRICAL INSPECTOR Check# 12579---1 h a Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/o5] teaveblank 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 PR 7VT IN INK OR TYPE ALL INFORMATION).Abr6 Date: S-- - City or Town of: 3JUirgio JW Aidlo ue r 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) o<� pi l-p lye, Owner or Tenant e Telephone No. -18 1 9 7- Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) P Purpose of Building Utility Authorization No. Existing Service 20G Amps jzo 1 2 yp Volts Overhead❑ Undgrd No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity 3/600 Location and Nature of Proposed Electrical Work: Com letion o the ollowin table maybe waived by the Ins ctor 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 KVA No.of Luminaires SwimmingPool Above n- o.o Units ng d. d. Batte Units No.of Receptacle Outlets -- G No.of Oil Burners FIRE ALARMS No.of Zones No.of SwitchesNo.of Gas Burners No.o Detection and Initiating Devices No.of Ranges No.of Air Cond. To l No,of Alerting Devices ns No.of Waste Dis posers Heat Pump um er on . s KW No.of a ontained P Totals. ......�.`._........_.�..... ...........-.- Detection/Allerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other P g Connection ' Heating Appliances ecun ystems: No.of Dryers KW No.of Devices or E uivalent No.of ater KW No.o No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Tota!HP Telecommunications el of Devicesoor E uwalent 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:62---//—/f Inspections to be requested in accordance with NEC 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 permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties ofperjury,that the information on this application is true and comWleta. FIRM NAME: LIC.NO.: Licensee: t1 r�&n4rr �r is JPr Signature � LIC.NO.: k&4-2e4q (Ifoppllcable enter"exenipt"in the lice se numbgr line) Bus.Tel.No.: Address: /9/9 ,sa-,7% .5z• Z12 OIJ.0 Alt.Tel.No.:-35d-—Z62—07,P' *Security System Contractor License required for this work;if applicable,enter the license number here: 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. lam the(check one El owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ � j I li R �i G t The Commonwealth ofMassgchusetts Department of IndustrialAccidents d X Congress Street,Suite 100 - == Boston,MA 021.14-2017 www.massgov/dia Workers,Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers— TO BE FILED WITH THE PERMITTING AUTHORITY- Applicant UTHORITY.A licant Information / — Please Print Le6b Name(Business/Organization/Individual): / `/�J Address: `9SOC)7 A City/State/Zip:, - /� Phone Are you an employer?Check the appropriate box: Type of project(required' 1.❑I am a employer with .. : employees(full and/or part-time).* 7. ❑New construction 2.V I am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.[No workers'comp.insurance required.] • 9. El Demolition 3.0 lam a homeowner doing all work myself-[No workers'comp.insurance required.]t 10 E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12..Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.* 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submif 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-coniracfors fiave employees,they must provide their workers'comp.policy number. am an employer that is providing workerscompensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: 14 _ xee4 Policy#or Self-ins.Lic.#: L/r`8.00/ Expiration Date: /,a Job Site Address: A//"G Gtr- City/State/Zip:07 /��I�i/C✓' s Attach a copy of the workers' c nupensation•policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer i der th pains andpenalties ofperjury that the information provided above is true and correct Signature- "" Date: la ^457 Phone#- U 9oe/ 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#: f 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 Iocal 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 checkingle'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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.# 617-727-4900 ext. 7406 or 1-877-MA.SSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia .r3:;COMMONWEALTH OF MASSACHUSETTS.: , • • BOARQ OF ELECTR'I C V ANS ISUES THE F0LL0WING NSF w AS A REG JOURNEYMAN ELEC i?I=C i Ate FRA�ER. t t T�0 P HER � •I S: R - 33 JAK LEAN""'DR' :SAL I`SBURY MA o 19 52 433 �.> 128g8 :B,. 07/3�1.�.:6 8ozgz Date...2�......... ........ � NCRY» 3:;r;,`'".;`���o� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �sswcMUS� This certifies that ..... .. ..... !°"!.f........................................................ has permission to perform ... ..... '.... . g ..... I! '... . ....... wiring in the building of....,&:.�...........��-5.,� �.. .................... �.........,,1 ._.............. orth Andover,Mass. Fe 73.2.<. . Lic.No. . ... r ELECTRICAL INSPECTOR - Check # 10887 i I A Commonwealth of Massachusetts Official Use Only Permit No. /, F 7 Department of Fire Services 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(NEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: LO - /-Z- — /Z_, City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant ,Q Telephone No,j7.C-' r�r 7 Owner's Address Z77 e- Xr 4/0-- Is this permit in conjunction with a building permi . Yes [A—Wo- ❑ (Check Appropriate Box) Purpose of Building , /r- its,-7,/% a Utility Authorization No. 2� Existing Service Ams / Volts Overhead ❑ Undgrd ❑ No.of Meters New Service 71 Amps 1.,2-1/ 2-,Y"-'Volts Overhead❑ Undgrd �No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: v Completion of the following 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 KVA No.of Luminaires Swimming Pool Above ❑ In- El o Emergency Lighting rnd. rnd. BatteryUnits Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Dis osers Heat Pump Number Tons KW No.of Self-Contained p Totals: "...............'"'............................ Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Connection No.of Dryers Heating Appliances KW SecuriNotof Devic s or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total 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: 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 coverae' orce,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under thepains andpenalties ofperjury,that the infor7 i on this application is true and complete. FIRM NAME: . /� �` �i-:k 11 LIC.NO.: ,� Licensee: Signatur LIC.NO.: (Ifapplica6le, ter "exempt"in the license numb r 1' .) Bus. o•��7 Address: Alt.Tel.No.: *Per M.G.L c. 147, s. 57-61,sec ity work requires Depa of Public Safety"S"License: Lic.No. OWNER'S INSURANCE IVER: 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. i .1�1JL/MMCF'�'-(P^E�0-•lY•J TJ.�L®•. �'�sset�-,j - �'a31eft-�j ] �e-xnspeet�o�t xequzz'ec7[$�O.OQ)�j � 3nsectvxs'copxzueAts; ' Olusp ectore sigaRture-.a Tnztia s) Pate :.1YINALI rIRIXIONON; 3Cusp_ctoxs'co------------------ mments; (fxis�adoz's'gignata re 4o Wilals) Pate ' kassec�—j j �'azIecT—j � �teinsp►ectio�xec�nixet�($�O.OQ)�j ] inspectors'Comments: (lnspectozs', ignataze��o?niffaTs) Date '�, �Cf �—YfY��l�7C1� rY � X71 - P,[�,1 ri,Cr-s,.�.r'r`-0 J.4.t3.��l.+'15iJ..l.K; 11 ; NAME:. assed-- �+'aiie�.-j � �e-�nspectzou.xequixet�($50.OD)�j � Ispeeto 'e mepfs; !(Cuspectozs',�zguatuxe� znitiaxs) Data yseo��-j � �`ailec�•,j ). 'ate cusp ectzon xeOuTx'e0($50.OQ)•-j � - vectors,eotameds: ' S • �l iso actors'minatuxe-no initials) w date ' r)'Q TA 6--,q APP: O ITT_AT"T.VFT OTT MITH-W THE APXA TOM INSPECTED Xg NOT The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kvi. 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.[ 1 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' 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 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: i 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 penalties ofperjury 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 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 permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26-05 www.mass.gov/dia 3 Date. . . . . .. .... .... NORTH TOWN OF NORTH ANDOVER PERMIT FOR MECHANICAL INSTALLATION • Oq ..rr i SA US I This certifies that . ... . . . . . .�. .. . V�.' j . . . . . . . . has permission for mechanical insta lation in the buildings of . . .�-��� � S:^ I... . . . . . . . . . . . . . . . . at ' c,?. �...:. rn,.. .? . _ �.. . V�. . , North Andover, Mass. Fee/ Lic. N������. . . GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer p. t Commonwealth of Massachusetts .Sheet Metal Permit Date: Estimated Job Cost. $ 7 rao Permit Fee: $ Plans submitted: YES NO Plans Reviewers: YES NO Business License # Applicant 1 icense Business Information: Property Owricr/Job Lccation Jnformation: G o`J ��l SS•i� Name: _ .1/ ��j�i G � � name: Street: �l �a�►A/ �a��� Street: 20 r,A,Di;et Gor` Z CitylTown, /V, /051Clo Teiephore:_rl�,7� G 7/ Tetephane. �7� �7 7 3 Photo ID,required r Copy of Pho-�c I-V.atta;.hed: YES NO Stsft initis! J-� r -1-:tnrestricted license J-2/-M-2-restricted to dweilings ?-stories or;oss and commercial up to 10,0U�,) seg. µ,12-stone,or less Residential: 1-2 family Multi-family _— Condo!Townhouses Other Coir.rnercial: 0ftice Retail Industrial Educational Instirational. t;ther Square Footage: under 10,000 sq. ft. LI o,er 10;000 sq t"t. r umber of Stories: Sheet metal work to be completed: New 1Wcrk: � a e _ / ravat:oa: HVAC V Metal Watershed Roofing Kitchen Exhaust System Instal Chimney I Vents Air Balancing P.rov,,de detailed description of tivorc to he done: 10-01 1 f p. 2 INSURANCE COVERAGE: ----�� I have a currentliablllhj insurance pcticy 0r ito equlva;ant Nhtch meets the roqulremente of M.3.L.Ch.112 Yes;Z Nv 7 If you have checked Yes,:ndicste the type of Coverage by chocking the appropriate bo:below: I A ilabllity insurance pcticy Other type of inrderrinity ❑ Bond O'NNER'S INSURAN�E WAIVER:1 am aware that the I1"nsoe does not.have the Insurance coverage requirsd by Chapter 112 of the Massachuaetts Ceneral Laws,and that my signature on this pormit application waives th's recuirament, Chick One Gnly owner ❑ Agent 5iynataro cf Owrer or Owner's Agent i Sy chocking thm bozC,I hereby oartify that all of the de(a'le and Information I neve submitted tot entered)regarding this applicatlon are true and eccurato to the beat of my knowledge and that all shoot metal work and Instailations pertormed under the permit Issued for this app'leetion will to In compliance with all pertinent provision of th.hlasaachusot.:Building Code and CI?apter 112 of the General Laws. / Duct Inspecticn required prior to Insulation installation: YES Na !/ ProjEress);nspections Date "Mmcnts ----- Fina]Inst:ection ---- - Date 0irrit •en•s r— I ype of License � I3y -- ❑Master /''� Title 6A3stQr-Restricted :lJoirneyperec-n i Permitfi I Signature of Licensee ` JoOneyperson-Re6-rlcter Lice^se Nuni [[ 1 Pee$ —_ _ ❑ �'-- Check a'www.rn v!d I mss.no >, � 1 _ Inspector 31pnaturs of Permi,approval --_= MASSACHUSETTS' —� _ --:._. _ DRIVER'S.. `=- LICENSE duu p OF 9e END 4d NUMBER -......... i• 1H HONE NIM a _t. E -36 . yFr — q t 'tis izTTE e 657 MAMMOTH RD DRACUT,MA 01826.4349 � 5 DD 09.03.2010 R v 07-152009 4• ' COMMONWEALTH OF MASSACHUSETTS'` "` LUMU SHEET METAL WORKERS AS A MASTER-UNRESTRICTED • F r> ISSUES THE ABOVE LICENSE TO: DONALD J OUELLETTE ; 657 MAMMOTH RD DRACUT 'j MA 01826-4349 4688 07/28/12 947069 4 i, Sheet 1 S�iP,O�y Nx it N QVA �1,I st flccr CO 3-82 c'm � � n 1 711 f2miIy u /7 4 I S y�`Elm .fob #: RA MECHANICAL INC Scale: 1 : 74 Performed for. Page 1 16 LOMAR PARK Right-Surte'ID Universal PEPPERELL, MA 01463 7.1.17 RSU11207 Phone:9784338671 Fax 9784334900 2010-Oct-1411:21:08 t ramedlanical@aol.cnm C!.Cocuments and SettingslALAM... +�Irl i x 2:.0 door r, x l f , 2115 cfrn4-1 ;. �f 'cfm t 2nd floor cfm ]fir 2 D5 cfm ; it i 1V cfm 7 Il 1 c'm � k _'i;`. s =T. .Job#: A'i P rformeq for: RA MECHANICAL INC Scale: 1 : 74 •:� 16 LQMAR PARK Rl'gtTt -Suite®Universal PEPPERELL, MA 01463 7.1.17 R5 1207 Phone: Fa 978433490 2010-Oct-1411:21.08'y,+ 0 ramechanical(Qaol.COM C100cuments adSetnp _ �,4. "t:•.c�.. � �++•����, aye The Commonwealth of Massachusetts Department of Industrial Accidents w 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):�r� Address:/ 1_nYY1Cn10 I �/G `�,�TcN - / City/State/ZiPhone#: Are you an employer. eheck the appropriate box: Type of project(required): 1.Q 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. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ 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 11.0 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.❑ Other comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. � Insurance Company Name: /C oa(Cii L n Policy#or Self-ins.Lic.#: 1 (h L(�� "��� , 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 u der the pains a penalties ofperjury that the information provided above is true and correct Si atwe: Date: �' G Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitJLicense# 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#: . ,a►coRD® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYn FO3/26/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: NORTH ANDOVER INSURANCE AGENCY, INC. (A/CN No, Ed): (978) 686-2266 jalc, No):(978) 686-6410 M.J. FOSTER INSURANCE SERVICES ADDRESS: cfernandez@nafins.com wSTOMER .A . Mechanical 163 MAIN STREET CUSTOMER ID ae� r Inc. _ NORTH ANDOVER MA 01845-2508 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A :PEERLESS INSURANCE CO R.A. . Mechani cal, Inc. INSURER B :GUARD INSURANCE 16 Lomar Park INSURER C Suite 1 INSURER D INSURER E Pepperell MA 01463- 1INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS ' LTR INSR VJ1/D � POLICY NUMBER (MMIDDIYYYY) (MM/OD/YYY1� A GENERAL LIABILITY Y ICBP5337500 1/01/2012 01/01/2013 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY I / / / / PREMISES Ea occurrence) $ 100,000 CLAIMS-MADE x I OCCUR / / / / MED EXP(Any one person) $ 15,000 PERSONAL 8 ADV INJURY I$ 1,000,000 GENERAL AGGREGATE $ 2,000,000 I GELIMIT APPLIES PERJECT : PRODUCTS-COMP/OP AGG $ 2,000,000 N'L AGGREGATE X] POLICY I-1 PRO LOC / / / / EBLIA $ A AUTOMOBILE LIABILITY BA8832363 01/01/2012 01/01/2013 COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS j / / / / PROPERTY DAMAGE $ X HIRED AUTOS / / / / (Per accident) X NON-OWNED AUTOS / / / / $ i ��$ A X UMBRELLA LIAB X OCCUR iCO8825678 01/01/2012 ?01/01/2013 EACH OCCURRENCE Is 1,000,000 EXCESS LAB CLAIMS-MADE / / / / AGGREGATES$ 1,000,000 DEDUCTIBLE / / / / i$ RETENTION $ / / / / 1$ B WORKERS COMPENSATION RAWC231923 01/01/2012 01/01/2013 1 WC STATU- OTH AND EMPLOYERS' LIABILITYORY LIMITS I ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N I / / / / OFFICER/MEMBER EXCLUDED? ❑ NIA E.L.EACH ACCIDENT $ 500,00 0 (Mandatory In NH) / / / / E� L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under I� DESCRIPTION OF OPERATIONS below I / / / / E.L.DISEASE-POLICY LIMIT 1$ 500,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it rnom 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 ACCORDANCE WITH THE POLICY PROVISIONS. R.A. MECHANCIAL, INC. 16 LOMAR PARK AUTHORIZED REPRESENTATIVE SUITE 1 ,. - PEPPERELL MA 01463- ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD Sheet Metal Residential Guidelines/Inspection Checklist Yes/ No N/A Detailed description and sketch of sheet metal system to be installed has / been provided V All workers performing sheet metal work onsite has valid Massachusetts / sheet metal license All sheet metal work being performed with proper joumeyperson-to- apprentice ratios 1/ Equipment sized per heating/cooling load calculations ✓ Duct work sized per manual "D"calculations 1/ Bath/shower rooms contain mechanical exhaust fan vented outdoors V Electric dryer exhaust properly installed maximum total run 35'-0" maximum flexible run 8'-0" V Flexible duct runs installed l4'-0" maximum length / g V/ Volume dampers installed for each supply air branch duct V Ductwork installed using properers au es and hangers g g g Ductwork/plenum connections sealed substantially airtight Ductwork insulated b means of external covering / y o enng or internal lining New/clean -properly sized filter installed (final inspection) V/ Testing and Balancing report complete (final sign-off)