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Miscellaneous - 2005 SALEM STREET 4/30/2018
N g �. Date ..! - 77," Z- toTOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............ .................... . has permission to perform ...... S EW4_7e c C5...... . wiring irk the bild'ng of .... ..S...................... . p�OQS `j jL� S7— ..... ... ©....... , North Andover, Mass. .SS�Q y V r72_ Fee ......... Lic. No... .... ELECTRICAL INSPECTO Check # I -7 11019 ea Commonwealth of Massachusetts lugDepartment of Fire Services BOARD OF FIRE PREVENTION REGULATIONS 4- Official Use Only Permit No. 110 7'� Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C), 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: �� City or Town of. NORTH ANDOVER To theInspec or of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) /7 5 f�a E g Owner or Tenant �- $G ' No. of Total Transformers KVA Telephone N . Owner's Address a G ° 5Ad L ehw Lighting Battery Units No. of Receptacle Outlets Is this permit in conjunction with a building permit? Yes , No ❑ (Check Appropriate Box) Purpose of Building MD --7 S`e/y1`C.� Utility Authorization No. / 35y0DO Z;, Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service /00 Amps /a VQVolts Overhead ❑ Undgrd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: IF Completion of the following table maybe 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- ❑WoK—oTEmergency rnd. grnd. Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices Heat Pump Number Tons No. of Self -Contained No. of Waste Dis posers p Totals: J.KW .......... Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Sectio. o ofDevicesor 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 No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of E ectrical Work: (When required by municipal policy.) Work to Start: g Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND El OTHER [I (Specify:) I certify, cinder the pains and enalties_o,perjury, that the information on this application is true and complete. FIRM NAME:. ri /[ C I'/ G L ° LIC. NO.: I �t SCS Licensee: 1( Signature L� LIC. NO.: 9 U�a (Ifapplicable, enter "exempt" int lice a number 'ne.)A Bus. Tel. No.: Address: -S c* i` a'� Alt. Tel. No.: �1'foC� *Per M.G.L c. 147, s. 57-61, security work requiresDepartment of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. WaRea—j I 3e -inspection required($-sOAD) j �nspectaxs' cap�trze�ts: • , Mon ectore iszanatao - Q Mtlals) Pate 2. VENA -*6)W X+C7CIUIai; �.'asse��-- j • �+`aiTe[��-•j �' � �e.�ns�ecttoxt�'e[�uixe�i (��0.00)-• j � . xnveetox c extts: r• fts�ectoxs signature- tza Pate 'asseci--j � �'ailec�-•j � ate-ins�ectzo�aec�uixec�{��0.00)�j � nspectoxs' comments. [tmspectoxs:,Fignatzu'e•-).oisIM) Pate . sseci-- j � �'aileci--j � ►fie-xnspectionxe�uire� (�50.OU) � j � ' �,�ect�xs' eoxnulepfs: . {%tspeetoxs',�zgnatuxe»azo initials) Data r ' ' erg •, [ � �`axXer� •-• [ )- ' ate �nsp eciion xe[�uiiCe[7 {��0.00) -• [) ectoxs' coximerits: _ . .'PEP eetOra, 8zgnature-.uoinitials) POO 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 Name (Business/Organization/Individual):%/G�O�CC'/'/^C �47(f_- Address: :�_ G1 'le __-� Ad , City/State/Zip: fi�g� �Sf�/t 111/t_Phone Are you an employer? Check the appropriate box: 1.6 I am a employer with % 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am 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.] 36�1 3 Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ 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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. *--- Insurance Company Name: Q N Fl L47 Policy # or Self -ins. Lic. #: Job Site Address: Expiration Date: 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. F do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. 5ip-nature: 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 5. Plumbing Inspector 6. Other if 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. .i 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 mace vnv/dia a This certifies that .... has permission for gas installation �,�..� J. . `,,�� , , .... , . . in the buildings of. -.-J Z.�........................ at ...... COX-,—, orth Andover, Mass. Fee. ��... Lic. No.'!%� .. ................. ... GASINSPECTOR Check # \�-2 t 8679 i MASSACHUSiETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY - _ t� • c.y2_ MA DATE L - (Q -1 iI PERMIT # ,IOBSITE ADDRESS _ C3_0 S_ l Q -�--_---]OWN ER'S NAME .Q J ... OWNER ADDRESS JTE FAX TYPE OR PRINTCLEARLY OCCU;'Y TYPE COMMERCIAL Q EDUCATIONAL © RESIDENTIAL VNO NEW: RENOVATION: ❑ REPLACEMENT: ® PLANS SUBMITTED: YES APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE -_ IhL_.a m_-. I r.�_1 , . _....... DIRECT VENT HEATER—I ❑ i J _� RJ T ._ _ _ _ _,_ I I _._T . _ _ -. I DRYER x .. -� 1 T11E. - . Ir { .T_T .. . . . . FIREPLACE�__ _-._ I J( �(� FRYOLATOR �I _ # FURNACE _ I L_..-=._( ---=3 GENERATOR - _ i-_�I (-f # -1 �� -J # J _J I_I [� .-11# GRILLE INFRARED HEATER LABORATORY COCKS f ,-:-,1 i-� . J-.-�.z( MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER __. —1 �._- I -_ ROOF TOP UNIT (_ J TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1.1-- J -_1 iT ! i _ _. L.� OTHER( J I _ :.. INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 1.._ NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY —. OTHER TYPE INDEMNITY © BOND i_J OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass c setts G era Laws, nd that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER LO/'AGENT ❑-I. 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 t the best of rpy knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance th all P inent P/Ovilon of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBS-GASFITTER NAME _ ..� EI'?"� _ _ t� -_(� LICENSE # -1. S ATA E MP ��I M-GFE- ( JP _-J JGF __( LPGI -__! CORPORATION _-._J# PARTNERSHIP(# ,LLC .-__## --� `� ❑ ❑ ❑ ❑ ___ J COMPANY NAME: J ADDRESS CITY _ -52_-e `-z--.._ __..-._._I STATE �4�� ZIP TEL FAX CELL #EMAILc' i F O z z 0 H U a w W � � W 3 aa W 5 w o ww w cn o a a a � U J a Q c ui FE w I--- LL UA H O z z � 0 F U W C7 - O V The Commonwealth of Massachusetts JD Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, PM 02111 www.massgovIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le;?ibly .VAMC (Business/Organization/Individual): C) Pr—L'o 1�I, �. 1-k- a—f-;��(� , kddress:Z "Z t �ity/State/Zip._ f ,,,� �L . �'ePone #: too 3 " 3C S-- 19, 3 � .re you an employer? Check the appropriate box: Type of project (required): ❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6 F1 Now construction mployees (full and/or part-thin' have hired the sub -contractors I am a sole proprietor or partner - listed on the attached sheet. # ? ❑Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g, E]Building addition [No workers' comp, insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions I am a homeowner doing all work right of exemption per MGL I L ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13F] other V applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. [tractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. 11 an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site 'rMation. trance Company cy # or Self -ins. Lid. #: Expiration Date: Site Address: City/State/Zip: ich a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). -ire to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of stigations of the DIA for insurance coverage verification. hereby certify under the pais anipenages ofperjury that the information provided above is true and correct. 5-( -t3 97cial use only. Do not write in this area, to be completed by city or town official. II ity or Town: Permit/License # suing Authority (circle one): Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Other w s� Commonwealth of Mashusetts Division of Registrati Board of Plumb' KEITH AI,� 35 CAMP$ J, MERRIMA� Master Plug, r PL15918-M 05/01/2014 004778 License No. Expiration Date. � Serial No. Date. (. .. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... f:\e-I. ' .. ".'yz� C' has permission to perform �- 1)... V 5" -e-- plumbing i^n� the buildings of . ��� �. � . . ............... .4-. ^'. . . �'C at ...... � (� `� ��.. vw .��.� yNorth Andover, Mass. Fee . 6Z,1 Lic. No.. R l�.. .. u` � ;-! ................. ... u� . PLUMBING INSPECTOR Check # j 2g Z .A MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - CITY MA DATE-� PERMIT # JOBSITE ADDRESS OWNER'S NAMEt7�^—' =J POWNER ADDRESS TEL FAX TYPE OR TYPE COMMERCIAL 0 EDUCATIONAL ® RESIDENTIAL OCCU7RENOVATION: PRINT ® CLEARLY NEW: REPLACEMENT: © PLANS SUBMITTED: YES R/'N0© FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM ( I k _-___._) DEDICATED GREASE SYSTEM ( _.....-..__( I __.._1 I -..1 _..__-_._.1 DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN i INTERCEPTOR (INTERIOR) k ..___.._._I .__.._._k J 1 _( I I I _.._._._._i ..__.._._1 ------- -.--_KITCHEN KITCHENSINK LAVATORY ______f -1--J .. __ 1 -------1 ROOF DRAIN SHOWER STALL �( _-_LA _._-.J &RVICE / MOP SINK TOILET \WRINAL k .--_-..! --_.___k .-__.__1 ------- WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER ._.......k- ( 1 __... _._.. _ INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES dNO MI IF YOU CHECKED YES, PLEASE INDICATE T ETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND Ell OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachus tts Gener I Law and at my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER : AGENT 10 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pe inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r PLUMBER'S NAME tT }— a HT1 LICENSE # 5 _ SIGNATURE MP W— JP [,],_I CORPORATION 0# PARTNERSHIP #=LLC COMPANY NAME ADDRESS t CITY Mp,VL_ % .............. STATE ZIP �n5 TEL FAX CELL �_� EMAIL AN. H O z 0 H U W m W o El z O W wO W a z _ 3 CO) w p 0 -5 LU LLJw U) O z a w a � U J 0 - IL a � LU EEJ w W z \ M o H U � a a 0' IL r .-A The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 J www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A mlicant Information Please Print Legibly LVa1ne Business/Oreanization/Individuall: L..© Address: Q_ o. V,d ,� Z - z-City/State/Zip: r-y1p ip ; �„` ,1L . 6S° hone #: (Q0 3(z S' r• .re you an employer? Cbeck the appropriate box: Type of project (required): ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction ployees (full and/or pari -time).* �m I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. # ? E] Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition workingfor me in an capacity. Y p tY• - [No workers' comp. insurance workers' comp. insurance. 5. ❑ We area corporation and its 9 [J Building addition required.] officers have exercised their 10.E] Electrical repairs or additions ❑ I am a homeowner doing all work right of exemption per MGL 1 l.❑ 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' 1311 Other comp. insurance required.] y applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. )meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. itractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. n an employer that is providing workers' compensation insurance for my employees. Below is the policy crud job site wrnation. xrance Company Name:. icy 4 or Self -ins. Lid. #: Expiration Date:, Site Address: City/State/Zip: ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 p to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of 'stigations of the DIA for insurance coverage verification. Iz ereby cert under the paiqs anipen ages ofperjuty that the information provided above is trite and correct. 5 -( -1 3 fficial use only. Do not write in this area, to be completed by city or town official. :ity or Town: Permit/License # ;suing Authority (circle one): Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector Other A,a, Itnf®r mats®n 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 )f the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. ?lease be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant hat must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current )olicy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or 'own)." 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 ,ear. Where a homeowner 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. he Office of Investigations would like to thank you in advatice for your cooperation and should you have any questions, Tease do not hesitate to give us a call. he Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 3 jr 4 PL15918-M License No. Commonwealth of Division of Registr, Board of Plumbiag KEITH AiLdFU 35 CAMP' �T MERRIMA� Master Plum�`'i 05/01/2014 Expiration Date. 004778 Serial No. Date .....V?A3 TOWN OF NORTH ANDOVER PERMIT FOR WIRING , �, Thiscertifies that.............................................................................................................. AJ 40 S / has permission to perform ................... ......................� �................................................ wiring in the building of.........��� P �../ ...............................:........................ .... at ...... ..... t ............................ o Andover, Mass. c.�/YS� ELE CAL INSPECTOR Check # �3 1? r 7 0 Iglo 6 7 5= 1,3 0,-- 'Yly!/.3 &I Commonwealth of Massachusetts Department of Fire Services s, BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. J �-10 Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASEPRINTWINKORTYPEALLINFORMATION) Date: ���/ S City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to.perform the electrical work described below. Location (Street & Number) —J. -O O 137eAl S Owner or Tenant 5ca e -m -i74y Aeq r&i.V- ZZC Telephone No 603 W5,— 3 - Owner's Address 6 6 4i IC—IW—. S /7t - Is this permit in conjunction with a puilding permit? Yes K No ❑ (Check Appropriate Box) Purpose of Building Mety kv '( Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service "�Q(9 Amps I--)-0 /P Volts Overhead ❑ Undgrd R No. of Meters Number of Feeders and Ampacity S1, Location and Nature of Proposed Electrical l w Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans v No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑o. rnd. grnd. of Emergency ig ting Battery 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 S InitiatingDevices No, of Ranges No. of Air Cond. C TonTots ),5 No. of Alerting Devices No. of Waste Dis posers p Heat Pump Totals: Number Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal E] Other Connection No. of Dryers Y Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: ' , No. of Devices or Eg uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: .ate Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 1'5-00, (When required by municipal policy.) Work to Start: � � / 73> Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVE GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSUIV NCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenalties of perjury, that the information on this application is true and complete. FIRM NAME:. rf/` A 417e-e-/'�� G TnC LIC. NO.: a/`J 5a Licensee: 4li/.4cC l Signature LIC. NO.: a 1'-/S,) �•� (If applicable, enter "exempt" in /the_ zcense number line�.i Bus. Tel. No.: 72162440 �1^3o 3 Obi $ Address: C 72' :2 � 7/i� /SOi�7` ,- /Ol �� 1 Alt. Tel. No.:1�" *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ � s Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed o i' on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shallbelimited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule R — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Co Im metits: Inspectors Signatu e: PARTIAL ROUGH INSPECTION: Date: Pass F?1 Failed M Re- Inspection Required ($.) ❑ Inspectors Comments: t i' Inspectors Signature: Date: ROUG IN ECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors ignature: Date: FINAL, INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: 2 - Inspectors Signature: Inspectors Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com 1 v Ift The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA 02111 Uf www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): cy Gr'`t P_,fG /YJ C- .-L n c— r Address: 67, 5_ . City/State/Zip: Nle tJ Mk 001al Phone #:(,'P?) 0 3 --Oa 5z - Are you an employer? Check the appropriate box: Type of project (required): 1.N I am a employer with c*:;)- 4. ❑ I am a general contractor and I 6. (New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. # �• ❑Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑ Building addition [No workers' comp. insurance required.] officers have exercised their 10.❑Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL I L ❑ 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 applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. r_,., :assurance Company C104W, Policy # or Self -ins. Lie. #: r�PPl��3 Expiration Date: Job Site Addressl905 �:+!%fM S� < ,City/State/Zip: Ni f44 d'C"'{� M 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 certify under the pains and penalties ofperjury that the information provided above is true and correct. e;O7 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 M 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 Commonwealth of Massachusetts Department of Industrial ,Accidents Mike of Investigations 600 Washington Street Boston., NIA 02111 Tel, # 617-72.7-4900 oxt. 406 or 1-877rMASSAFB Revised 5-26-05 Fax # 617-727-7749 www mass,govfdia Commonwealth of Mas etts Division of Registraii I Board of Electri PAICHAE iTl 5 GILES {Q M EAST KINGS r 7 Master Eleci .'a .m 21452-A 07/31/2013 'GSM —/v007 License No. Expiration Date. Sen .F l i� i PERMIT FOR• SSACHUS� r This certifies that r-'�S........ has permission for gas installation ........ ��.....,�_... . DD CJ_. in the buildings of .(.� .% .../1.il?� .. h.j„�............ at .r,2 ��Q .. JA -b .,-,V ........... , North Andover, Mass. Fe&39 .. Lic. No. 7 7.?" .. ............... ... A. GASINSPECTOR Check # o2 13 8710 It V`7 0 - 0 -�) ( I t'% `-1 7 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I NORTH ANDOVER MA DATE MAY 28 2013 PERMIT # JOBSITE ADDRESS 2005 SALEM ST. (GEORGE,HASELTINE) OWNER'S NAME 2009 REALTY TRUST GOWNER ADDRESS 12009 REALTY TRUST TE 603 785-8768 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[j EDUCATIONAL RESIDENTIALE] PRINT CLEARLY NEW: E] RENOVATION: El REPLACEMENT: ® PLANS SUBMITTED: YES® NO® APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER — _ ----- DRYER FIREPLACE FRYOLATOR FURNACE m GENERATOR GRILLE INFRARED HEATER 7-71 LABORATORY COCKS MAKEUP AIR UNIT OVEN -. _ -- - - POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER I INSTALL AN UNDERGROUND 1 GAS LINE AND CONNECT TO A - - - . --j--j- J1.1--- -- - — PLUMBERS INSPECTED LINE . - . _ - - _--_ __ _ _ -_ --- _.. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which'meets the requirements of MGL. Ch. 142 YES Q NO Ej I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co lianc�����the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I JOHN MARSHALL LICENSE # 778 Y I SIGNATURE MP ® MGF Ej JP ® JGF ® LPGI CORPORATION # PARTNERSHIP# LLC [:]# COMPANY NAME: EASTERN PROPANE GAS ADDRESS 131 WATER ST. CITY I DANVERS STATE MA ZIP 01923 TEL 1-800-322 6628 FAX CELL EMAIL �A o V.. a VA The Commonwealth of Massachusetts Department of Industrial Accidents ' Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applica-iit4nfor-mationPlease ft --int Legi-b1Y- Name (Business/Organization/Individual): EASTERN PROPANE & OIL .. Address: 131 WATER STREET Ci DANVERS, MA 01923 Phone #: 978-750-6500 Are you an employer? Check the appropriate box: ❑✓ I am a employer with 45 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity: [No workers' comp. insurance required.] 3. ❑ lam a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.1 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no 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 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑✓ Other GAS FITTING *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and 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: ENERGI Policy # or Self -ins. Lic. #: EWGCD000080613 Expiration Date: 03/15/2014 Job Site Address: 90IS SS I e, S3- . City/State/Zip: f 1ovA 0-aA,, e, V%, -.q, 084� 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 of perjury that the information provided above is true and correct. Phone #: 978-750-6500 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 #: c m�: aFn TJ = Q ID J D 70 U Dm fn C7 :: I m cn i IT > > 70 D > z G 1T1 r m r p < T- TO " C _ = J m D r, CD > �i L ' ^ �sEn . �� m YY+.F En CD LA Signature �