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Miscellaneous - 2001 SALEM STREET 4/30/2018
.jp IN (D0 -0 0 E cc 06 (D " 0 0 O'D a= CL N =3 (D .8 7-1 <1 5 o UJ E -0 j3 cu C: V5 0 2e 00 0 E 3: E C.) 0 o C 42 7-1 <1 15 f • Date... d`... �... . NORTH 1TOWN OF NORTH ANDOVER pf ti „.o PERMIT FOR MECHANICAL INSTALLATION P Q _ s This certifies that 7 )q ........ ......... . !i '_,, 1 has permission for mechanical installation ..T . ¢ . ........... in the buildings of —. Z �(.V1t. uw .4".r .. I;) P.P:............. . r at .....Q`�..:i.....'...., North Andover, Mass. Fee.�%Z ..... Lic. ... ...................:1?s� GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. IPINK: Treasurer Y� 6 I Commonwealth of Massachusetts Sheet Metal Permit Date: Estimated Job Cost: $ %� Plans Submitted: YES NO Business License # Business Information: /7 Name: S� 6,,4,a1 cL � ���>n� cl�14L"Ida,ch Street: 33 &n 14 G.Q Vic.! City/Town: UC('rq N4 Telephone: X03- q 3Q 3503 Permit # Permit Fee: $ Plans Reviewed: YES NO Applicant License # a y `LD�� a 8 -14 Property Owner / Job Location Information: Name: Crc:rS Street: g )OT4 City/Town: Telephone: Photo I.D. required / Copy of Photo I.D. attached: YES NO Staff Initial J-1 / M -1 -unrestricted license J-2 / M -2 -restricted to dwellings 3 -stories or less and commercial up to 10,000 sq. ft. / 2 -stories or less Residential: 1-2 family Multi -family Condo / Townhouses Other Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft. over J0,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work: t/ Renovation: HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney / Vents Air Balancing Provide detailed description of work to Abe donde: / —I`�54Q11 � IC n��v kert!�1Q A1d,CC4L4c��� �►1c sYS�°►1-� INSURANCE COVERAGE: policyor its equivalent which meets the requirements of M.G.L. Ch. 112 Yes No I have a current liability insurance ❑ If you have checked Yes, indicat the type of coverage by checking the appropriate box below: of indemnity El Bond El liability insurance policy Other type OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Ch k One Only Owner Agent ❑ Signature of Owner or Owner's Agent By checking this box[], I hereby certify that all of the details and information I have submitted (or entered) regarding this application true will d accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Date Date By Title Cityrrown Permit# _ Fee $ _ Inspector Signature of Permit Approval Prog -ess Inspections Comments Final Inspection Type of License: ❑ Master ❑ Master -Restricted ❑Journeyperson ❑J ou rneyperso n -Restricted El Comments Signature of Licensee License Number: Check at www.mass.govldpl L�7 Sheet Metal Residential Guidelines / Inspection Checklist Yes No N/A Detailed description and sketch of sheet metal system to be installed has been provided 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 Equipment sized per heating / cooling load calculations Duct work sized per manual "D" calculations Bath / shower rooms contain mechanical exhaust fan vented outdoors Electric dryer exhaust properly installed maximum total run 35'-0", maximum flexible run 8'-0" Flexible duct runs installed 19'-0" maximum length Volume dampers installed for each supply air branch duct Ductwork installed using proper gauges and hangers Ductwork / plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining New/clean - properly sized filter installed (final inspection) Testing and Balancing report complete (final sign -off) Ad in _ w co Q o to M C/)Ix F U W Q f3 ❑ M o a Q w U' Z GY LL a w z co 0 LD _• 0c!) Q Q Z 2 ro J ti w , ,w • t) w Q F-q _ Q u m toIZ 3 . � 1 (/) }' 7 L'4 U,-,-Li rn W . To: Page 2 _f:3 20'12-07-31 '15:12:28 (GMT) 16035903229 From: Obr y Insu m- Agency Inc CERTIFICATE OF LIABILITY INSURANCE °ATE`MM`DD/YWY, 1..... VA112012 PRoqucER. THIS. CERTIFICATE. 1S. ISSUED. ASA MATTER OF INFORMATION. Obreylnsurance:Agency,.lnc. ONLY AND.:CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS. CERTIFICATE DOES N.OT -AMEND, .,EXTEND: OR 1E Commons DriveUnit 27 . ALTER. THE COVERAGE AFFORDED BY THE POLICIES BELOW. Londonderry NH. 03053 INSURERSAFFO..RDING COVERAGE., ..." NAIC #- " 1NsURED.. ....5.E C.atdtdl :. .. INSURERS "RIVCrjI.O.ft.In.SUfdnC.e.'C.O, . P ;O X. 158 , De.rry,.NH,Q.qq58 I1JSt1RER D: 'INStJf2ER'E , , COVERAGES THE POLIGjES:OFINSURANCE.LfSTEDBE.LOW.HAVEBEENISSUEDTOTHEINSUREDNA„IVIEDPBOVEFORTNEPOLIGYPERIODINDICATED N6 * THSTANDING. " ANY REQU.IREMENT,.TERM OR. :CONDITION OF: ANY CON RACT QR OTHER "DOCUMENT WITH. RESPECT TO WHICH THIS CERTIFICATE.MAY BE:ISSUED OR' . MAY'PERTAIN, THE. INSURANCEAFFORDED BY'THE:POLICIES; DESCRIBED HEREIN' IS,SUBJE&TT0AL'LTHE TERMS, EXCLUSIONSANDCONDITbNS ..OFSUCN " ... .O P..OLICLES. AGGREGATE.LIMITS.SHOWN.MAY'HAVE-BEEN REDUCED:"BY.PAID.CLALfYIS: INSR, DD'L ICYNMBER " ".P.OLU P.OLICYEFFECTIVE. POLICYEXRIRATION LIMITS ' .. GENERAL.LIAB Lrry .. '.. "„ " • .. .EAGH'0 ;CURRENCE. ....� C_ MMEF(C AL GENEFAL"LIABILIT.Y. .... ...". •' .. .. . GL PR MIS 40 aE Cc �3nC . . ...... CLAIIvFSN1ADt OCCUR ...... . `- ... ..' ....... - .. '..niED EXF IA'n one ..erson.. . PERSONAL.& ADy" II�IJURY:... GENERAREGATE: ` ... , GEN'L:AGGRCGATG.LLMIT.APF.LLCS FEP.: ' PRODUCT $.-. COtvIPl6P ACG' $ " . . P:OLICY.. PRO--IJECT.. LdC " AUTOM091LE'.LIASILRY:.. •. .... ANW AUTO ... .. .. ... `...., .". � ..: .. .. .. �. aBcdd D:P) SINGLE LIMIT' .. " - � ILY�IN;IURY . :BOD .. - ALLO]VVNED,AUTQS; " . '•• SCHEDULEPAUTO5 " ' .. .. .. .. � ��".. .... .. .. ... �BODILY INJURY '. $ HIRED:AUf08 .... NON-C?WNEO.AUTOS ` .. ... �. PPQPERT'+:DAMAGE ..".,....dt) ' `... er cc.' $ (P?en _. GARAGE LIABILITY "" '• ', •' ... ..AUTO"ONLV.: EA•ACCIPENT hHEk�7 H2JV... . - - .., .. �. •. .. ANY AUT!? , ... •, ... .... ... ,... .. ...P,IJ .. ...., ACG'". $ _ ..... EXCESS:! UMBRELLA LIABILITY '• ', .. .EACH OCCURRENCE.$ " _ ©.CCUR CLAIMS MADE. AGGREGATE: $ $ RETENTION. :$ ` " WORKERS COMPENSATION '... .. .. ..- . '.. .. :WC.STATU-" -.Q7H= X A AND EMPLOYERS LIABILITY .YIN AyYPRUPCIETURrPAR71VER/EREGUTIYE WC2843002713 09/2512011 09124!2012 - tt-LACHAQ.(;RjEN". $ 1001000 '. uF.FII:ER/MEMBER EX4LUDED? •.. ,(MmdatoryinNH). - '" ' ' •„ . ,.... " "E.L•, DISEASE.— BAtMPLOYIEE $ 100,000 ffAes, describe. llrtder... .. S• ECIAL PFOVISIGNS below, `". E.L. UFStSSt - H.ULI(Y LIM. I I 500 OOO • : ,OTHER ..... � .... � "_ ' � .. - :DES6RIPTIONOFIOPERATIONS.i.L6CATIONS/:VE)4ICLESiEXCLUSIDNS:ADDEO BY: ENDORSEMENT /'SPECIAL P.ROVISIONS+ LIAA I.1%^CI 1 ATI/11.1 .. .. , .. SHOULDANY:O.F..THE ABOVED.ESCRIBED POLICIES:BE:CANCELLED BEF.ORE.THEEXPIRATION. . T.QWN•OF NORTH ANDOVER . ` DATE THEREOF, :THE ISSUING•INSURER WILL ENDEAVOR TO.MAIL. 30 DAYS WRITTEN 223 CHESTNUT, STREET - :NOTICE TO THE,CER7IFICATE.HOLDER,NAMED TO.THE LEFT, BUT.FAILURE TO Dq SO SHALL " „•".. ;IMROSE,"NO-OBLIGATION:OR.CIA BILITY..OF'ANY:KIND .UPON THE:INSURER; ITS..AGENTS`G!R NORTH ANDOVER;.MA.REPRESENTATIVES. ......................... . RI AUTHORIZED REPRESENTATIVE ;` ,/R� d >. 7. ACORD 25 (2009101). 19882009.ACO.RDCOR:PO ..ION. A:II rights reserved.. The. ACQR.D !name: and logo: are:.registered marks:of.ACORD:.... _................... _... _.......... _.. To: Peg- 3 of 3 2?Ol 07-31 'IS:I 2:28 (GMT) 16035903229 From: C>k—y Insurance Ag—y Inc 07/31/2012 06:57 p T0:+1 (978) 6889542 FROM:6034324732 Page: 2 ACORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MMDD/YYYY) ��. 07/31/2012 THIS CERTIFICATE IS ISSUED ASA 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(les) 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 UUNIAIA NAME: Caleb Kirby Caleb Kirby PHONE 603-432-2944 603-432-4732 AIC No Ext): (A/C, No): ADDRESS: ckirby@derryinsurance.com American Family Financial Group LLC 43B Birch Street - Unit 3C INSURER(S) AFFORDING COVERAGE NAIC N INSURERA: Farm Family Casualty Insurance Company Derry NH 03038 INSURED INSURER B: Scott Cataldi INSURER C: SE Cataldi Heating & Air Conditioning LLC INSURER D: 33 English Range Road INSURER E: Derry NH 03038 INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OFANY CONTRACTOR OTHER DOCUMENT W ITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TOALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MWDDIYYYY) (MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 PREMISES (Ea occurrence) $ COMMERCIAL GENERAL LIABILITYTOFE1 CLAIMS -MADE 1;71 OCCUR MED EXP (Any one person) $ 5,000 A V Contractors Advantage 2801 X 0441 09/27/2011 09/27/2012 PERSONAL & ADV INJURY $ 1,000,000 Fire Legal Liability $50,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATELIMITAPPLIES PER: PRODUCTS -COMP/OPAGG $ 1,000,000 POLICY PEC LOC $ AUTOMOBILE LIABILITY (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ ANYAUTO A AAUTOS LL OSWAUTOS NED SCHEDULED : 2808 C 0852 09/27/2011 09/27/2012 BODILY INJURY (Per accident) $ NON -OWNED HIREDAUTOS AUTOS AMA (Per accident) $ UMBRELLA 11 HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y/ N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N / A TORY LIMITS ER E.L.EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ (Mandatary In NH) If yyes describe under DESG�RIPTION OF OPERATIONS below F.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS r LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) Heating & Air Conditioning Fax: 978-688-9542 CERTIFICATE HOLDER CANCELLATIC)N Ak;VML) 20 (ZU1 U/U5) U 1988.2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover, MA THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Caleb Kirby Ak;VML) 20 (ZU1 U/U5) U 1988.2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD To: Pages 2 of 3 20'12-07-31 1S:OS: 4S (GMT) 1603S90322S From: Obray 1—uranoa Aoanoy Ino DATE,(MMlDp/YYYY, CERTIFICATE F. LIABILITY .INSURANCE �...� 01/3112012 PRQQPCER:. THIS. CERTIFICATE.. IS, ISSUED.:AS:A MATTER: OF,.1NF.ORMATION. 04irvy Insurance; Agency,:Inc. '... ' ONLY AND.:CONFERS NO" RIGHTS. UPON THE CERTIFICATE: HOLDER, THIS.-'CERTIFICATE ODES NOT AMEND, EXTEND OR.' 1E Commons Drive Unit 27" . ALTER. THE 'COVE:RAGE AFFORQED. BY THE "POLICIES BELOW, Londonderry NH.0.3Q53 INS..URERS'AFFQ.RQING C.O.VERAGE::.... NAIL INSURED.. SE Cataldi .. NSURER k: RIV.Qrj107t InsUranc.e'CO3 ;0 60X.158.3 • D: De ry.. N H.. 0.3038wSURER , I NSURER.E _ ..... COVERAGES THEPOLICI> S;OFINSUi?ANCE.LISTEDB.ELOW.HAVEBEE.N.I$SUEDT* THE.INSUR:EDNAMEDABOVEFORTHEPOLICYPERIODINDICATED.NOTVUITH$TANDi.* ANY REQUIREMENT, .TERM O"R .CONDITION OF ANY CONTRACT QR QTHER DOCUMENT W,..ITH. RESPECT TO'WHICH THIS CERTIFICATE. MAY BE'.I$SUED :OR` MAY PERTAIN, THE.INSI)RANCEAFFORDED BY THEPOLICIES DESCRIBEDHERFINIS,SUB.IECTTOALLTHE TERMS EXCLUSIONS'ANDCONDITIONS:OFSUCH P..OLICIES. AGGREGATE:.LIMITS.SHOWN.MAY HAVE BEEN REDUCED. BY.PAID'-CLAIMS: INSR. DD'L .POLI,GYNUMBER. POLICY EFFECTIVE'. POLICY EXPIRATION . , ' '�LIMIT5 `. . - .GENERAL.LIABILIT.Y .. �, �. �� '' '... . • ". � � � .. _..� �EAcH'.UL'aURRENCE .. " LUMMEac AL UEIVEFA� BLIT.Y. .. O C. DAMAGE.T REi1TE . PR .. .'• CLA.!..SDE MA.... OCG.UR .. .. '..MED"D(P+An one".'ersoin ". $ ... .. PERSONAL..&:.A.DV IN,IURY:... $ .. �• . - "i;ENEKAL.AVGkEGATE:: .. _ ... .. ..... � '.. " GCN'LAGGRO..GATLLIMIT,6P.PLICS:PCR.: �FRODUCTu-CO.Iv1P/bPflGG:' $ • ,. � � ". .. ... :... (,..OL'.CY. ...: PRO. LOC ... _ _ _ ..... .. - '" . . AUTO moSILE.LIABILITY:.. "'. .. .... .. _.. `" COMBINED :5INGLE:LIMIT' Design Conditions for Residence: Name of Residence: Number of Rooms: Summer Design Temperature: Winter Design Temperature: Room -by -Room Heat Gain (Loss) Data: Cataldi Greenscape 9 90 -10 3 Name Area (Sq. Ft.) Heat Gain Heat Loss KITCHEN 152.0 5301.66 7689.88 DINETTE 102.0 5999.76 8712.44 DINING 170.0 3486.6 5869.6 FAMILY 248.0 5692.44 7225.68 FOYER 58.0 3042.39 3821.62 POWDER 18.0 710.84 1411.96 LANDING 70.0 569.4 425.48 LAUNDRY 98.0 2784.99 4119.06 HALLWAY 72.0 461.76 234.08 Total Residence Heat Loss: Total Residence Heat Gain: Model Number Recommended: 39509.8 28049.84 (2.5 Ton) y- 0 Ta --V) -re, rA, I�. I MP Design Conditions for Residence: Name of Residence: Number of Rooms: Summer Design Temperature: Winter Design Temperature: Cataldi Greenscape Flr 2 8 90 -10 Room -by -Room Heat Gain (Loss) Data: Name Area (Sq.Ft.) Heat Gain Heat Loss BR # 1 146.0 4191.72 5676.44 BR # 2 144.0 3986.58 5305.96 MASTER BEDROOM 244.0 5244.33 8569.66 MASTER BATH 154.0 2799.03 3410.66 BATH 66.0 976.82 1871.76 LANDING 96.0 627.12 436.48 HALL 74.0 492.18 190.96 WIC 44.0 457.08 124.96 Total Residence Heat Loss: 25586.88 Total Residence Heat Gain: 18774.86 Model Number Recommended: (2 Ton) G' 9528 Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .. .': !t-- n .................... . has permission to perform .. �P ^-1.. vl'''t-�-- ............ ........ plumbing in the bu{illdin s of at ...0z 0c)1.. — ... i�... �c% . , orth Andover, Mass. Fee.,VS� 0&. Lie. No�L/5y/� _,y R ........ . n// PLUMBING INSPECTOR Check T MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY V I� _ N ov e✓L MA DATE PERMIT # - -- JOBSITE ADDRESSgQ4� _ OWNER'S NAME �j P OWNER ADDRESS 1 TEL ,FAX TYPE OR OCCUPANCY TYPE COMMERCIAL © EDUCATIONAL Q RESIDENTIAL UJ PRINT d CLEARLY NEW: RENOVATION: El REPLACEMENT: ® PLANS SUBMITTED: YES , NOQ FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 1 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICEi DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM RAI ___......___ �f ._._ f _ 1 _.,I I _ _—_ I DEDICATED GREASE SYSTEM —.i _..._____f DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER _ I LEI .___J ----J= ------ __.-DRINKING DRINKINGFOUNTAIN —._f _..__._.( .__.-_-; _.___-- _.-_-._ _)(f ) _f FOOD DISPOSER FLOOR !AREA DRAIN f _.__ __.__l . _ I _..__s ___._J .____( __.___ ► .____� INTERCEPTOR(INTERIOR)I_I __-.___i ._._._.J f KITCHEN SINK —.___f LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET I_ _1 _z-� _- [ __.._i URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES i WATER PIPING OTHER I a_ I ill INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO E]f IF YOU CHECKED YES, PLEASE INDICAT7TPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY0 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 Gener Laws, d that y signature on this permit application waives this requirement. "'AGENT CHECK ONE ONLY: OWNER [O 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 jo the Wst of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in c pli a w' h all ertineA provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME i LICENSE # SIGN ATUR MP JP Q CORPORATION 0#=PARTNERSHIP 3 LLC f PARTNERSHIP P# - _i _ COMPANY NAMELv�2-c�b �1�,,,,,1��.�,+��,, DDRESS L (�.p, CITY STATE Nk ZIPTEL FAX g CELL -- — _..____.. EMAIL_ a.& _LF_-- o rl z W CL Iii w LL At N The Commonwealth of Massachusetts Department of IndustrialAccidints 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 Leizibly Name (Business/Organization/Individual): �� � I-0 �O k: -t I E L f -. 6 Z_ Address: Q n. 9 n,,- Z L— City/State/Zip: UYLe le ..,,c�r � ►ti0- u ops'-% Phone #: (e b � - 3 (o " /v 3 Are you an employer? Check the appropriate box: a employer with 1. ❑71am 4. El am a general contractor and I loyees (full and/or part-time).* have hired the sub -contractors 2. a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] 704q, -, LLC Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they aie 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: 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 requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert that the information provided above is true and correct. 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 local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' - permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Cmx monweaith of Massac-usetts Department of Industrial .Accidents Office of Investigations 604 Washington Street Boston, MA 02111 Tel, # 617-727-4900 ext 406 or 1-8777MASSAFE Revised 5-26-05 Fax # 617-727-'7749 www mass,govfdia 109 Date .... F-/7! :. 2-.... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...11(e .:. "" ... Z �tQ A L' ............ . has permission for gas /installation1ve....... �'''��'Q- ....... in the buildings of ..C�. '� `t7:4.?�......... at ..P?.d v 1.. 747..' North Andover, Mass. Fee.A�ffll.. Lic. NoeL/ 7W:7*"9 . � GASINSPECTOR Check # Q 1 N - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK s r� CITY �yZ-1-j-F _rte Cl cl J �L I� MA DATE I_!j- _1Z. JI PERMIT # JOBSITE ADDRESS;.._ _ OWNER'S NAME ��4?� 3�t GOWNER ADDRESS TE FAX TYPE OR PRINT OCCUPAN TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW: _. RENOVATION: El REPLACEMENT: PLANS SUBMITTED: YES �_I NOE] APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER! COOK STOVE___(L_._ L-A DIRECT VENT HEATER DRYER FIREPLACE 3=J I 1 -�)J -_a�-J _-_- (IV_ I 1 I --i hj-- -- ---I — FRYOLATOR FURNACE+L _--- -- -- - -- -- - 1 -- GENERATOR I__�— i I _ L �� _ I� _-_I r- GRILLE INFRARED HEATER T,. E-71-77] LABORATORY COCKSI_,_— I. MAKEUP AIR UNIT I --1 -. I OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT L TEST UNIT HEATER UNVENTED ROOM HEATER _ i i� __ I I !_ _ 1.__-_ ' _ _ WATER HEATER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES O__I NO [�( IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE 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 h11%ssachusetts General Laws, an that y signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER .__ AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance vyith all Pertinent pr isio f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1z 'LL PLUMBS ASFITTER NAME _� G 1 1-� �j,2Z i =LICENSE # �j _ ��g SIGNA RE MP __ MGF �_I JP ___ I JGF 1 LPG CORP ' G [m I [� 0 ORATION ®# PARTNERSHIP �#�� LLC 04 COMPANY NAME:.__..__rL`t-l------�-� I'_1_rFtr 'ADDRESS[ CITY STATE ZIP d d TEL Q FAX CELL i� _._ . -. - --1iEMAIL k on z N ❑ w CL w w LL The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ° www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legiblv Name (Business/Organization/Individual): Address: P. 0, Q -6 , 2 Z City/State/Zip: /? R!L , m v4- C Ic N - It . i 1; `'hone #: 663 - 3 6 Are you an employer? Check the appropriate box: 1. ❑ I a a employer with 4. ❑ I am a general contractor and I ployees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1111 Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. 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. #: fob Site Address: Expiration Date: City/State/Zip: kttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a "me up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine if up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certify ugtder yie pains and peva#ies 91perjury that the information provided above is true and correct. I I - 03— __�(o-5-- 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 Revised 5-26-05 Fax # 617-727-7749 www,mass.gov/dia c This certifies that . l>....1...... . ...ti ...... _ ... . has permission to perform ..Re51A . :.. ki r� 4.- .... _ . wiring in the building of ti .2 .-} ........... . at .. Q U. O...... , dover, Mass. Fee. 74/• �..� Lic. No.... a . 1P ELECTRICAL INSPECTO Check,# .r 'i ,10 0 0 .1" Commonwealth of Massachusetts --S Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. I I ccl Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code EC 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: / �), City or Town of. NORTH ANDOVER To the In pe ' of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) I a.0(2 ir Sct k s7'/ e4 Owner or Tenant Telephone Owner's Address Is this permit in conjunction/ with a building permit? Yes JR1 No ❑ (Check Appropriate Box) Purpose of Building /NG'v✓ /Xv145e _ Utility Authorization No. f j�5-7 o-3-5-161 Existing Service Amps / Volts New Service Amps / D /QM Volts Number of Feed e nd Ampacity Location and Nature of Proposed Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd P" �� SLaUC)�i,✓� No, of Meters No. of Meters Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires SusFans v No. of Ceil: p (Paddle) s Total Trsformers KVA Tran No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- E]o. rnd. grnd. of Emergency Ligliting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches O No. of Gas BurnersNo. of Detection and Initiatin Devices No. of Ranges i �� S No. of Air Cond. Tons 3 No. of Alerting Devices 6 No. of Waste Dis osers p Heat Pump Totals: Number Tons J.KW .......... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal ❑ Other Connection No. of Dryers Gr~ Heating Appliances KW SecNo. urito De is s or Equivalent No. of Water Kw,,/No. Heaters f! 5 of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E Equivalent OTHER: _ Attach additional detail if desired, or as required by the Inspector oJ Wires. Estimated Value of Ele trical Work: 10,:360. (When required by municipal policy.) Work to Start: Inspect—ions to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE O RAGE: 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 X, BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. d FIRM NAME:. rY/� Z5LGCl/i" . tic : LIC. NO.:. Licensee: AA j ,, rO- (If applicable, enter "exempt" in the cense n tuber li e.) Bus. Tel. No. �a 5� Address: r ✓► � Q 3 Fta% Alt. Tel. No. 7 - 96 D *Per M.G.L c. 147, s. 57-61, security work requires Department o Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: s g i Signature Telephone No. • �► X+��L�y�'j.(,A■('.�[�j{�3��► 3�I���•C'�" �T��' ��yQ`�.' 'rry�Q�{,{���y1�■'( 3��P�+ ���@�T�'�?�.'�'. � � _ - � JJJ.-/.LJ�•ll J�..1 �iL i+�. V J'. ®� � • • • • - r l , � ' • . ."ov,x�rs�ec�co . P�ssei�- �'aiiefl-j ] ate-xnspset#oxt z'ec�uiz'eti{��O.OQ) � X � .14 �speetpXs' �apzme�fs; , (JCnspee$oxs zea -oto ultials) Pate 2. MAL WSPAOMON'. �ias�ecto $' co7mm.eJxfs; spect�mw. ' 'fiats) Pate �. TMDAR GRODND ))WRA 7CZON. 'asseci--j j �'ailec�--j � �.Ze-�ns�eefZo�aec�ui�re[�(��0.00)�j � asioectoXs' cotum.e�.ts; , {-Inspecfoxs" uignafuxe-�OLo iuluais) Pate ' � TPil eAlAllinP I,vecfbxs' eo (.ittspectoxs',�ignafuze � 7a+ - actoxs' coxamenfs; _ � . .. ��s� ecfoxa' �zgnairzre � no initials) �'iafe . a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Lj �1, AName (Business/Organization/Individual): Zoc Address: �57_ 6—//e-5 1401, City/State/Zip: COW 74✓I /f/#, Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. R; I am a employer with / 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. $ E] Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 101-1 Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicdnt that checks box # 1 must also fill 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. $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: !/1Gl ' d _40 5wa.,i M '%wG Jy%Policy # or Self -ins. Lic. Expiration Date: Job Site Address: MSMZiell ki AA"t1"'M4 City/State/Zip: Attach a coy 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,,300.00 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 cert i nder th s and enalties o .4 rr&at the information provided abov is tri e and correct. Signature: Date: Phone #: 0 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 w 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 Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia Date.. M4? -/"z ......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION a o .Sy This certifies that ... ieff,4...�!vv/q ,?.......�.j. ........ has permission for gas installation 4Z.Xr !a -C-. STin the buildings of /. Ts?`....... at .....Z°'Pt/ . �/ ��!�?... .......... North �Andoverr,-Mass. Fee:..,IP,, G:;�. Lic. No..4-�. .%7` .. r.A . . GAS INSPECTOR Check # LO 5-�S I— PAIf . vJ C-� (C)'" - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - CITY I NORTH ANDOVER MA DATE SEPT. 7 2012 PERMIT # JOBSITE ADDRESS 12001 SALEM ST. OWNER'S NAME 12001 SALEM ST. REALTY TRUST GOWNER ADDRESS 2001 SALEM ST. REALTY TRUST I TE 508-335-3932 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[j EDUCATIONAL ® RESIDENTIALE] PRINT CLEARLY NEW:E] RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES® NO[j APPLIANCES 7 FLOORS— BSM 1 2 1 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 =j POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER I RUN AN UNDERGROUND GAS LINE TO A PLUMBERS INSPECTED LINE --t- - III- - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E] 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 Ej AGENT Ej 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 o h ce with all nen vi ' of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME JOHN MARSHALL LICENSE # 778 SIGNATURE MP ® MGF ® JP ® JGF ® LPGI CORPORATION M# PARTNERSHIP®# LLC ®# COMPANY NAME: EASTERN PROPANE GAS ADDRESS 1131 WATER ST. CITY DANVERS STATE =ZIPI 01923 TEL 800-322-6628 FAX CELL EMAIL