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Home My WebLink AboutMiscellaneous - 20 LITTLE ROAD 4/30/2018amu. a a r 00 8 41 Date ....... L/4,7zz ....... e TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......................... ........... .. ............ fir has permission to perform ..... /-� onL��A ......... wiring in the building of ............. e �........... h .............................................. orth Andover, Mass. ..... ................. Fee ... ......... Lic. No. .......... NSPECI�;/ Check # U 2012 Massachusetts Electrical Code Amendments 527 CMR12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, §, 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. GL c. 166, § 32, an y electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shalt be responsible for the notification of completion of the work Ps required in M.G.L. c. 143, § 3L. Permits shallbe limited as to the time of ongoing construction. activity, and maybe deemed by-t1je .Insp.ectv-of-Wires abandoned.and.in .alid-ifhe—.. 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 Secttons.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 certaispermits and licenses concerning the use or development of real properly. With limited exceptions, the Act automatically extends, for four years beyond its otherwis a applicable expiration date, any pemmit or approval that was "in effect or existence" during the qualifying period beginnin�on August 15, 2008.and extending"through August 15, 2012. f beg" 8—Permit/Date Closed: ❑ Permit Extension Act—PermitA)ate ** Note: Reapply for new perm Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. /ae tI Occupancy and Fee Checked [Rev. 1/071 nPA„P t .-t.N 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 WINK OR TYPE ALL INFORMATION) Date: .- �, City or Town of: NORTH ANDOVER To the Inspector o Wires: By this application the undersigned gives notice of his or er intention to perform the electrical work described below. Location (Street & Number) % 6) t1 i 4; P ^ A4*N Owner or Tenant Owner's Address Is this permit in conjunction withuildingTrmit? Yes F-1 Purpose of Building Telephone No. No M (Check Appropriate Box) Utility Authorization No. Existing Service Amps / Volts Overhead ❑ New Service Amps / Volts Overhead ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ON Undgrd ❑ No. of Meters Undgrd ❑ No. of Meters -uu.,4 uetuct y aeszrea, or as required by the Inspector of Wires. Estimated ValWofEleGqcad Work: ®(When required by municipal policy..)Work to Start:Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCEGE: 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 overage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCEBOND F71OTHER [3(Specify:) I certify, under the pai s and eniddesAf perju t ei ormadon on this application is true and complete. FIRM NAME: ��i (j LIC. NO.: Licensee: U6S,-u t. Signature LIC. NO.: (If applicable, ter " p " ' e 1' ease tuber line.)/�'f1J Address: ,ti J, us. Tel. No.: 0_22? - 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 b hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/ Signatur elephone No. PERMIT FEE. $ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 t' l www.mass.gov/dia . Workers' Compensation Insetrance Affidavit: Builders/Contractors/Electricianc/Phv>„l,P,.. City/State/Zip: r i ,6()L4�, Phone Are you an employer? Check -the appropriate box: al LEI I am a employer with 4. ❑ I Mn a general contractor and I employees (full and/or part-time).* 2. [] 1 am.a.sole proprietor or partner= have Hired the sub -contractors listed on the attached sheet i ship and have no employees These su&contractors have working for mein any capacity, orkers' comp. insurance. [No workers' comp. insurance 5.e are a corporation and its Nficers required.] have exercised their 3. ❑ I im a homeowner doing all work right of exemption per MOL myself. [Nonworkers' comp. c, 152, § 1(4),'and we have no insurance required.]"t employees. [No workers' comp. insurance required..] ' 'Any applicant that checks bolt # t m t fill I ' Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. [] Demolition 9. [] Building addition I OXEiectrical repairs or additions I IU Plumbing repairs or additions 12.E] Roof repairs 1.3.[] Other us so out me section below showing their workors 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 mustattached an additional sheashowing• the name of the sub -contractors and their workers' comp. policy infomuadon. I am.an employer that is protnding:workers.I compensation insurance for my employees: Below is the policy and job site information. Insurance Company Name:_' j) T e- �p Policy # or Self -ins. Lie. #: 'C- PP 01 (ad -51— 2S _7? LF Expiration Date: Job Site Address 7-0 L, Et e 62CIA City/State/Zip: nl *k d c, u.r Attach a copy of the workers' compensation policy declaration page (showing the policy numberand 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.violawn 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 enperjurythat the information provided above is true' and correct Signature: Date: 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 S. 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 -contractors) name(s), addresses) 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 permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, needonly 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 flog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not, hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7744 www.mass.gov/dia 76 i 8 Date. !l • %.A/ .......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...... qU�..................... has permission for gas installation .... .:IeA ................ in the buildings of , ....,�1... ................................ at.... �. . . ............. North Andover, Mass FeB. , Q.. Lic. No. 31 %.h ... . . Y9 GAS INSPECTOR Check # %1_9 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) %V�J_ bL' )Q Mass. Date 3i( 20 / I Permit # Building Location,40 L[tT� 6- P-12 Owner's Name Owner Tel# Type of Occupancy R 7 E New ❑ Renovation ❑ Replacement. Plan Submitted: Yes ❑ No ❑ FIXTURES Installing Company Name_ �- C1sI,,P— Check one: Certificate Address 10 S L T ❑ Corporation Uyj Q/� d( P—(4'q ❑ Partnership Business Telephone # ?� � ` O f ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter dA„_[ �F C INSURANCE COVERAGE: I have a curre t 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 coverage by checking the appropriate box. A liability insurance policy ,4 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information 1 have submitted (or entered) in above 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 By Title CitylTown APPROVED (OFFICE USE ONLY) Is State Gas Code and Chapter 142 of the General L 7 Type of License: • -Plumber Sign• tura of Livens Plumber or Gas Fitter y'Gas filter (Waster License Number 7��t • -Journeyman 8 �95 Date.. F TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .. J.M...0: ! �!t ..... �} ... .. . has permission to perform plumbing in the buildings oii�... ��7(�"? C,t� ..................... at ... �'�.... ! � (.k.... l�A..........., North Andover, Mass. Fee.SS..G..Lic. No...v .(.titV4a..:. j/..... } PLUMBING INSPECTOR Check # �K a P MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING N y� (Print or Type) ,fU� ) �J U V I, U(:�L,Mass. Date 20jt Permit # Building Location60 ( [ l t f- I? J, Owner's Name C-3- Owner Tel# (?70 — Type of Occupancy New ❑ Renovation ❑ Replacement IV—__ Plan Submitted: Yes ❑ No ❑ FIXTURES Installing Company Name [ 1-1 h['�( L. �`'f Check one: Certificate Address 0 S S ( ❑ Corporation 9-) `i '"1 ❑ Partnership Business Telephone # 1 3 a I o ❑ Firm/Co. Name of Licensed Plumber ` K e -o%? � 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 have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy �,— 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: Owner ❑ Agent ❑ i nereoy cernry mar an or me aetaus ana mrormanon t nave submitted (or entered) in above 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 provisions of City/Town APPROVED (OFFICE USE ONLY) Chapter�rn, w . Sum 'r Type of License: Master 13 Journeyman r License Number J 1) S% • IM Installing Company Name [ 1-1 h['�( L. �`'f Check one: Certificate Address 0 S S ( ❑ Corporation 9-) `i '"1 ❑ Partnership Business Telephone # 1 3 a I o ❑ Firm/Co. Name of Licensed Plumber ` K e -o%? � 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 have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy �,— 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: Owner ❑ Agent ❑ i nereoy cernry mar an or me aetaus ana mrormanon t nave submitted (or entered) in above 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 provisions of City/Town APPROVED (OFFICE USE ONLY) Chapter�rn, w . Sum 'r Type of License: Master 13 Journeyman r License Number J 1) S% i ACORD,M CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 02/25/2011 PRODUCER v THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION - Matthews Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 182 Parker St HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lawrence, MA 01843 INSURED Michael Capeless 105 Tyler St Methuen, MA 01844 COVERAGES INSURERS AFFORDING COVERAGE INSURER A: Atlantic Casualty INSURER B: Arbella INSURER C: NAIC # 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID.CLAIMS. /NSRADD'L T POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS EACH OCCURRENCE S 1,000,000 GENERAL LIABILITY COMMERCIAL GENERAL LIABILITYDAAr-To � L143000684 08/07/2010 08/07/2011 T RENTED PREMISES Ea occurence $ 100,000 MED EXP (Any one person) $ 1.000 CLAIMS MADE OCCUR PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000000 POLICY PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO HC357357 1 08/30/2010 08/30/2011 (Ea accident) ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per person) $ 300,000 HIRED AUTOS NON -OWNED AUTOS BODILY INJURY (Per accident) $ 300,000 PROPERTY DAMAGE $ 300 .000 (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ $ AUTO ONLY: AGG EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ 1,000,000 7X OCCUR D CLAIMS MADE AGGREGATE _ $ 1,000000 XL111463 02/22/2011 02/22/2012 $ DEDUCTIBLE RETENTION $ $ X WORKERS COMPENSATION AND WC STATU- OTH- EMPLOYERS' LIABILITY MILS E.L. EACH ACCIDENT $ 100.000 ANY PROPRIETOWPARTNERIEXECUTIVE 890911-0937696 11/17/2010 11/17/2011 E.L. DISEASE - EA EMPLOYEE $ 100,000 OFFICERIMEMBER EXCLUDED? If yes, describe under E.L. DISEASE - POLICY LIMIT $ 500,000 SPECIAL PROVISIONS below OTHER 1 orcwAL rNuviaium, Heating or combined heating and air conditioning systems or equpipment, installation, servicing or repair Plumbing 20 Little Rd North Andover, MA town of north andover north andover, ma ACORD 25 (2001/08) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL REPRESENTATIVE OF ANY KIND UPON THE INSURER, ITS AGENTS OR Oc TION 1988 Ba stake Gas 1y Bay A NiSource Company June 28, 2007 Mabis Robinson Account Number: 1265140018 20 Little Rd North Andover, MA 01845 Dear Mabis Robinson: This follow-up letter is to inform you that your gas Oven & HE located at 20 Little Rd has been tagged due to a violation of state safety regulations. It is unsafe to use until the following condition has been corrected. Bad oven, control or hot surface & bad leaking HE control valve The Masachusetts code pertaining to the installation of gas appliances and gas piping, established under Chapter 737 Acts of 1960, requires that the condition be remedied. If you have questions or would like to discuss this issue, please call 978-687-1105 and ask for the Service supervisor. Please disregard this notice if the condition has been corrected. Sincerely, Service or Meter Department Bay State Gas Company CRR:CRR# CAcisupdatedletters\236 06/28/07 55 Marston Street P.O. Box 869 Lawrence, MA 01841-2312 978-687-1105 Fax: 978-688-1875