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HomeMy WebLinkAboutMiscellaneous - 21 HIGH STREET 4/30/2018 (13)I '� Date.... ..................... ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING \ (yam This certifies that ........:.....v...�. 1 �= has permission to perform .:............ ............ai ........................ wiring in the building of ................ iC.��'.......................................................... � at .......................... .. .. .............. . North Andover, Mass. Fee... .................... Lic. No.................. ! `' � ................................................... �'"'� ....... _ . ELECTRICAL INSPECTOR Check # D 1L% 7U ��? r Commonwealth of Massachusetts official Use only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK 2 All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 10/14/15 `: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) 21 High St suite 202 Owner or Tenant Owner's Address RCG Is this permit in conjunction with a building permit? Telephone No. Yes ® No ❑ (Check Appropriate Box) Purpose of Building Commercial Utility Authorization No. Existing Service Amps / Volts New Service Amps / Volts Number; of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Fit up Completion of the followingtable may be waived by the Inspector of Wires. Attach additional detail ij desired, or as requirea ay me inspector oj w ares. Estimated Value of Electrical Work:,, (When required by municipal policy.) Work to"Start: 10/10/15 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 ❑ OTHER ❑ (Specify:) I certify,.`under the pains and penalties of perjury, that the informatio this application is true and complete. FIRM NAME: Young and Son Electric LIC. NO.:Al3847 Licensee: Miroslav Mlady Signature _ LIC. NO.: (Ifapplicable, enter "exempt" in the license number line) Bus. Tel. No.- 8779284T77 Address: 2 Blossom St Woburn, MA 01801 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department blic 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. No. of Total No. o ecessed Luminaires No. of Ceil: Susp. (Paddle) Fans Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires AboveIn- Swimming Pool rnd. E]rnd. E]Batte o. o Emergency Lighting Units No. of Receptacle Outlets 12 No. of Oil Burners FIRE ALARMS I No. of Zones 6 No. of and No. of Switches No. of Gas Burners IDetection Initiating Devices No. of Ranges No. of Air Cond. Tonsl No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained No. of Waste Disposers p Totals: Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal ❑ Other Connection No. ofD Dryers ►'Y Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: 15 Heaters Signs Ballasts No. of Devices or Equivalent Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or Equivalent OTM Attach additional detail ij desired, or as requirea ay me inspector oj w ares. Estimated Value of Electrical Work:,, (When required by municipal policy.) Work to"Start: 10/10/15 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 ❑ OTHER ❑ (Specify:) I certify,.`under the pains and penalties of perjury, that the informatio this application is true and complete. FIRM NAME: Young and Son Electric LIC. NO.:Al3847 Licensee: Miroslav Mlady Signature _ LIC. NO.: (Ifapplicable, enter "exempt" in the license number line) Bus. Tel. No.- 8779284T77 Address: 2 Blossom St Woburn, MA 01801 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department blic 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. N Date./O�Z*/" TOWN OF NORTH ANDOVER PERMIT FOR WIRING f Thiscertifies that ..................................................... . ............................................... -A'f-0) / �6 ),F,3 Re U4 Al has permission to perform-'/-—K****/**.— wiringin the building of...... ................................................. * ......... ** ....... — ....... at c'--2 / 5 �2,,�— .................................. �b. 1� I I NqrTb Andover, Mass. .......................................................... Fee, .. Lic. N,2j..�.�� ... .. . .... ELECTRI AL INSPECTOR rn Check # COmmonwea& o f Maniac"tb Official Use Only cc�� cc�/ Permit Na ..UePartmeref o/..tire Swvices AM Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: October 23, 2014 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) 21 High Street Owner or Tenant e= -,A Telephone No. Owner's Address 21 High Street Is this permit in conjunction with a building permit? Yes ❑ No 0 (Check Appropriate Box) Purpose of Building Offices Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity,. Location and Nature of Proposed Electrical Work: Install two - 15 HP Variable Frequency Drives & two 15 HP Marathon Motors for tower loop pumps Install two - 5 HP Variable Frequency Drives on Hot Water Loop Pumps, Install temp control panel Comple4" Of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. grnd. o. of Emergency Lighting 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 Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pum Number Tons KW *" '' No. of Self -Contained Totals I ]­ Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of WaterKW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: fAS6-16q V FI s t Z (0; -hp) mo4ors '7-- U Attach additional detail if desired, or as required by the Inspector of Wires. _.,1—Estimated Value of Electrical Work: $ 29,218.00 (When required by municipal policy.) T Work to Start: Oct 27, 2014 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 ❑x BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Horizon Solutions, LLC 1 _ LIC. NO.: 21853A Licensee: David F. Perron Signature � LIC. NO.: (Ifapplicable, enter "exempt" in the license number line.) Bus. Tel. No.: (508) 837-6549 Address: 705 Myles Standish Blvd., Taunton MA 02780 Alt. Tel. No.: 774-328-2935 *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 Signature Telephone No. PERMIT FEE: $ �j� M The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations _ 1 Congress Street, Suite 100 �- Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Horizon Solutions, LLC HSC Corp. Address: 2005 Brighton-Henrieretta Town Line Road P __L__1__ \1\/AA^^^ /cnc% A/' /State/Gro: UNUU1 IUa«I ° IN 1 IYVLJ Yrione 4: `aJVaJ1 `t. Are you an employer? Check the appropriate box: 1. ® I am a employer with '200 <300 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ TI a sole proprietor or partner- listed on the attached sheet. ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have employees and have workers' comp. insurance.+ ❑ 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 *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. fi 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: Zurich American Insurance Co. Policy # or Self -ins. Lic. #: WC6800179-21 Job Site Address: 21 High Street Expiration Date: 01 /01 /15 City/State/Zip: North Andover, MA. 01845 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. Ido hereby yrder the paw and penalties of perjury that the information provided above is true and correct. October 23, 2014 Phone #: (508) 837-6549 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 #: Please visit our web site at http://www.mass.gov/dpl/boards/EL HORIZON SOLUTIONS LLC DAVID F PERRON 705 MYLES STANDISH BLVD SUITE 2 IST FLOOR TAUNTON MA 02780-7300 (E L) Fold, Then Detach Along All Perforations CONTROL # IMPORTANT If your license is lost, damaged or destroyed; is inaccurate; or needs to be corrected, visit our web site at mass.gov/dpl for instructions to ensure the proper mailing of your Renewal Application and any other correspondence. This license is subject to Massachusetts General laws and regulations. Your license is a privilege, and cannot be lent or assigned to any person or entity under penalty of law. Keep this license on your person or posted as required by law and/or regulations. ® A� o CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) ,0,24/20,4 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER MARSH USA, INC. ONE TOWNE SQUARE, SUITE 1100 CONTACT NAME: N FAX (A/C. No. Ext): AIC No): E-MAIL ADDRESS: SOUTHFIELD, MI 48076 Attn: EDIC Team - F: 313-393-6505 INSURERS AFFORDING COVERAGE NAIC # INSURER A : Zurich American Insurance Company 16535 06297 -00060-14-15 INSURED HORIZON SOLUTIONS, LLC INSURER 8: N/A N/A EACH OCCURRENCE $ 1'000'000 HSC Corp INSURER C: INSURER D: 2005 Brighton -Henrietta Town Line Road ROCHESTER, NY 14623 GL06800181-21 01/01/2014 INSURER E: INSURER F: MED EXP (Any one person) $ 10,000 rnVFRAr.FS CERTIFICATE NUMBER: CHI -005048896-01 REVISION NUMBER:2 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF P Ll YIY X LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1'000'000 MMERCIAL GENERAL LIABILITY GL06800181-21 01/01/2014 01/01/2015 DAMAGE TO RENTED 500,000 PREMISES Ea occurrence $ MED EXP (Any one person) $ 10,000 CLAIMS -MADE M OCCUR PERSONAL & ADV INJURY $ 1,000,000 2GGEINTLAG GENERAL AGGREGATE $ 2,000,000 GREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 $ ICY PROJFQT LOC AUTOMOBILE LIABILITY COEaMBINED accidentSINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ A X ANY AUTO BAP6800180-21 01/0112014 01/01/2015 BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS PROPERTY DAMAGE $ Per accident NON -OWNED HIRED AUTOS AUTOS UMBRELLA LIAB HCLAIMS-MADE OCCUR ACH OCCURRENCE $ $ EXCESS LIAB DED RETENTION $ [AGGREGATE $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N OFFICER/MEMBER EXCLUDED? ❑N (Mandatory in NH) N / A WC6800170-21 01/01/2014 01101/2015 WC STATU- OTH- T RY LIMITS ERA L. EACH ACCIDENT $ 1'000'000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 1,000,000 E.L. DISEASE - POLICY LIMIT 1 $ If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) 21 HIGH STREET IS/ARE INCLUDED AS ADDITIONAL INSURED (EXCEPT WORKERS' COMPENSATION) WHERE REQUIRED BY WRITTEN CONTRACT. A WAIVER OF SUBROGATION APPLIES FOR WORKERS COMPENSATION, AUTOMOBILE LIABILITY, AND GENERAL LIABILITY IN FAVOR OF THE CERTIFICATE HOLDER. WORKERS' COMPENSATION DOES NOT APPLY TO THE MONOPOLISTIC STATES (ND, OH, WA, AND WY), PUERTO RICO, OR THE VIRGIN ISLANDS. CERTIFICATE HOLnFR CANCELLATION 21 HIGH STREET SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 21 HIGH STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER, MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. John C Hurley ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD .1n296 Date..............................f TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... ..vv '?.. .......f`.....�... OIL--. .................................. has permission to perform .... ST f kv ........................... t.........%�.. wiring in the building of ............................................................ at ....Z.%. ... �T ,c, North Andover,,PAass. FeeZ....l...... Lic. No"'- ... _ ELECTRICALINSPE OR Check #�-- Commonwealth of Massachusetts Department of Fire Services + , BOARD OF FIRE PREVENTION REGULATIONS Official Use Only / Permit No. la � % (' 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 (MEC) 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 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) 14/ ?Ve/� /I—. . Owner or Tenant Owner's Address 1>400 09- /7 /v4Loo LL -e Telephone No. Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building k-1hQ r -U Ar- Utility Authorization No. Existing Service 17-v a Amps Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters _ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: P� Completion of the following table may be waived by the Inspector of Wires. Nay. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans TransTotal Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. rnd. o. o Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches / No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons KW ..... ... No. of Self -Contained Detection/Alertinjl Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water Kms, Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsWiring: No. of Devices or E uivalent OTHER: Attach additional detail ifdesired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE K BOND ❑ OTHER ❑ (Specify:) I rertify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: ��/ /3-lz e. LIC. NO.: Licensee: �ol�i�r� Signature LIC. NO.: (If applicable, enter " xemp " in the license n ber Bus. Tel. No.: 41e;7 -W77 S Address: /��i/�r%f2d�'` G �-/�/3,m/ �� Alt. Tel. No.: dT *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 Owner/Agent Signature Telephone No. PERMIT FEE: $ / Z--> /,,;,/ 5/'G, -7 .G % ^ 2-3'/"/ Ivy 040 ot)4- /k-) -jj, a. ro -f IK " 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 Name (Business/Organization/Individual): Address: 4 +�i /UAP_-1r_l1G� City/State/Zip: MAX �hone #: �✓ % / 170, Are you an employer? Check the appropriate box: 1. K I am a employer with 2— 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 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.] 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 *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and 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. �T� Insurance Company Name: Policy # or Self -ins. Lic. #: �i ,/� Expiration Date: Job Site Address: Z� y� ��`� t/v City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under th ains and penalties of perjury that the information provided above is true and correct. F/zo Phone #: 0�1 epo�, 17�� 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 #: 11 '102,,2 Date..... ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............... .................................... has permission to perform ....... Vn� . VO r ..................................................... wiring in the building of ..... P6�'... . ... )<,. e 5; ...... at ... C9./ �y N/ .. 57 ..................o .... No h Andover, Mass. ..... ....................... . ...... Fee ..3357..... Lic. No. ...1 .. 39017 AIC ECr c I WSPE MiR Check # 90% ' Common -wealth of Massachusetts of1c;al Use Only ®epartment of Fire Services Perrrut No. 1 D r Z BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked _ N'PPLICATION [Rev. 1/07] (leave blank FOR PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code E ®�� (PLEASE PRINT. W AW OR TYPE ML INFO ( ), s27 CMR 12.00 City or Town of NORTH ANDOVERTI011� Date: & f �� BY this application the undersi edTo .the Inspector of Wires: gn give notic� his or er, ' tention trfotm the ele cal work described below. Location (Street & Number) Owner or Tenant Owner's Address Telephone Is this permit in conjunction with a building'pernut? ' esvG v Purpose of Building 4!b rG NO El (Check Appropriate Box) /,�� Utility Authorization No. Existing Service Amps L—ow eVolts Overhead ❑ Undgrd ❑ No. of Meters Nw— Service Amps_Volts Overhead El Undgrd Number of Feeders and-Ampacity ❑ No. of Meters Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches O No. of Ranges No. of Waste Disposers No. of Dishwashers / No. of Dryers No. of Water Heaters KW No. Hydromassage Bathtubs OTHER: Lcuw[ aJ zn No. of Ceil. Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool Above ❑ Ir_. d. No. of Oil Burners No. of Gas Burners No. of Air Cond. Total Heat Pump Number Tons ns 1 Totals: -----._._...... _... Space/Area Heating KW Heating Appliances KW No. of No, of Signs Ballasts No. of Motors Total HP KIng table may be waived by the Ins est No. of Total Transformers KVA Generators KVA ❑livo. of Emergency ig g il..�.i...__ TT_... '1 FE .Aj A.RMS No.' of Wines No..of Detection and Initiatin Devices No. of Alerting Devices No. of Self. -Contained Deteefion/Alertin Devices Local ❑ Municipal Connection ❑Other Security Systems:* No. of Devices or Equivalent Data Wiring: No. of Devices or Equivalent Telecommunicafiom Wiring: No. of Devices or Eanivnh.»+ Estimated Value of Electrical Work: Attach additional detail ifdesired, or as required by the Inspector of Wires. Work to Start: (When required by municipal policy.) 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 ❑ OTHER I certify, under the pains and enalties o er'u that the i�orSpaecify.) " FMM NAME- P l ry, f n this application is true and complete. O��A' Licensee: LIC. NO.: Wapplicable, enter "exempt " '2 th a e eu Signature LIC. NO.: Address: r li . Bus. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires De Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware thaticens a dolc Safety es not have 1 Licen lei 1 required by Iaw. B m Sig Lic. No. Y Y gnature below, I hereby waive this requirement. I am the check one msurance coverage normally Owner/Agent ( ) ❑ owner El owner's agent Signature Telephone No. EPERMIT FEE: $ ELECTRICAL PERNI[T NO. INSPECTZONREPORT: Eg,ECTRICALINSPECTOR - DOUG SMALL I. ROUGH INSPECTION: Passed — Failed — f 7 1 Re inspection required ($50 00) [ ] Inspectors' comments no in Z. FINAL INSPECTION; — Passed – Failed – Inspectors' comments: �.�unk,ct:wA,- .signature - no 3. UNDER GROUND INSPECTION: Passed — [ ] Failed Inspectors' comments: -no R,4SPE—SERVICE:•ANE C C��TION LD NATIONAL G110: Passed — [ ] Failed — [ ] Inspectors' comments: (Inspectors' Signature -)10 5. INSPECTION - OTHER: Passed — [ ] Failed — [ ] inspectors' comments: - no initials) NAYME: ection 0)_ Date Date Date Date Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF TBE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 TS TO BE CHARGED. r 'a I The Commonwealth of Massachusetts Department of Industrial Accidents Office of rnvestigations 600 Washington Street .. UV. Boston, MA 021.71 www mrass gov/dia Workers' Compensation Insurance Affidavit: BuRders/Contractors/Electricians/Plumbers Applicant Information ,� / Please Print Le 'bi, Name (Business/Organization/Individual): Address: City/Stat Are you an employer? Check the appropriate box: 1. I am a employer with 7i 4. ❑ I am a general 2. ❑employees (full and/or part time) * I am a sole proprietor or contractor and I have hired the sub -contractors listed partner- ship and have no employees on the attached sheet. I These subcontractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation 3. ❑required.] I am a homeowner doing all and its officers have exercised their work myself. [No workers, comp. right of exemption per MGL c. 152§ 1(4), W'd the have illsi Bance re uired. fi q ] no emp IoY ees. [No vporkers' comp, insuranc 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 e required.] 13.❑ Other *'my applicant that checks box til must also ]Ltt eat the section beloe, s _ _ t Homeowners who submit this affidavit indicating they are doing all work and then hire outsicc de contractors must submit a new affidavit indicating such. y....°......n tlJ....J ...YC.:.^.atrCn. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers comp. policy information. I /b an. employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. '�^` Insurance Company Name: ✓ G— Policy # or Self -ins. Lie. M xpiraiion Date: Job Site Address: ity/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 fine up to $1,500.00 and/or one-year imprisonment, as of criminal penalties of a 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 statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under t pains an penal ' s Signature- at the information provided above is •tie and correct � . �/`- P}rnnr if• 7 is a, // / - Date: Official use only. write in this area, to be completed by city or tow n offWat City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical in 5. Plumbing 6. Other b Inspector Contact Person: Phone #: P 0 9976 This certifies that 3 -t7-11 Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING P06 -h-7- 7w—,o,,,,,-5 a A �}) , ........................ .............. has permission to perform .......... wiring in the building of ........... .- / 5 ;o, at ........................................ ................ -, North Andover, Mass. Fee ................. Lic. No. ..... 5S/ 8 ELECTRICAL INSPECi�R Check # N lugCommonwealth of -Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. � 7 C Occupancy and Fee Checked APPLICATION qq PERMIT [R�epv. 1/07] leave blank APPLICATION F®R PERMIT TO PERFORM ELECTRICAL, WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASEPRINTMINKORTYPEALLINFO TION) Date: City or Town o£ To the Inspector of Wires: By this application the undersi ed gives not' e of hifthher mtenntfioWnAtoerform the electrical work described below. Location (Street & Number) Owner or Tenant �'� " ` J, Owner's Address /O vi Telephone No. Is this permit in conjunction with a building permit? Yes No ❑ BLDG PERMIT # Purpose of Building Utility Authorization No. Existing Service Amps _ / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: lo. of Recessed Luminaires lo. of Luminaire Outlets fo. of Luminaires "o. of Receptacle Outlets o. of Switches No. of Ranges r aste Disposersshwashers yers No. of Water KW Heaters No. Hydromassage Bathtubs Completion oft .e No. of Ceil.-Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool Above ❑ In- grud grn No. of Oil Burners No. of Gas Burners No. of Air Cond. Total Tons rea Heating KW Appliances KW No. of s Ballasts of Motors Total HP No. of Meters No. of Meters 6?A11-,-('_ a",Vol Ss 10 table may be waived by the Generators KVA o. ALARMS JNo. of Zones of Alerting Devices tion/Alerting Devices ❑Municipal C'nnnPrfinn ❑Other No. of Devices or Data Wiring: No. of Devices or Telecommunications No. of Devices or Wires. Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: _ (When required by municipal policy.) Work to Start:.277/Z_// 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 ❑ OTHER ❑ (Specify:) P �y:) Icert�, under thepains andpenalties ofperjury, that the information on this application is true and commtpleta FIRM NAME: Licensee: / 1 Ci� P�" LIC. NO.: / y� T %�itdr Signature_ (Ifapplicable, enter "exem t" in the license numb r� l.it? e.) r LIC' NO.: Address: /�j�/�/ f' ��� d� Bus. Tel. No. �2f �— *Per M.G.L.c.147, s. 57-61, security work requires Department of Public Safety "S" Licen Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liabili ` cov required b law. $ m signature qu. h' ism coverage ormally q y y y gnaiure below, I hereby waive this requirement. ement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL 1. KUUli i MSYM11UN: rassea — Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date L. JUINAL INSF CTION: Passed — [ Cr 3. UNDER GROUND INSPECTION: Passed — [ ] Failed— [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 4. INSPECTION —SERVICE: DATE CALLED NATIONAL GRID: NAME; Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (lnspectors- bignature - no initials) Date r 5. INSPECTION - OTHER: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. The Commonwealth of Massachusetts Department of Industrial.Accidents Office of f -Investigations 600 Washington Street Boston, MA 02111 www mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A pplicaut Information j� ]Please Print Legibly Name (Business/Organization/Individual): / ✓Q� ��.�� Address: /a4 City/State/Zip:f Lr lac t -z ql lt�eA �l �`� #: J'� 0 —eP-6'� �� �✓� Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I "'loyees (full and/or part-time).* "amp have hired the sub -contractors 2. 0-Ia 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.] i 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. El Plumbing repairs or additions 12. F1 Roofrepairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. -Tam an employer that isproviding workers' compensation insurance for my employees Below is the policy andjob site information. Insurance Company N, Policy # or SeIf-ins. Lic. #: Expiration Date: rob Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be. advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby certify under the pains andpenalties ofperjuiy that the information provided above is true and correct. Signature: Date: Offzcial 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 CIerk 4. Electrical Inspector S. Plumbing Inspector 6. Other 1 Contact Person: Phone #: 11 99 6 Date....-.... ... ............ 1 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... /./..u!.!!. ` }:... S� ^' /�...................................................... has permission to perf.................e ...'` ......... .�✓...h.T:7-............ wiring in the building of ....... Z �....... ��i �.... 5- ......................... at ................ I�e_ S .......................................... , North Andover Mass. Fee.k�.`...... Lic. Nola Y. 7 .... . ••••• .... ................... . 7MICAL INSPE R Check # 3 i Commonwealth of Massachusetts Official Use Only AI Department ®fFire Services PermitNo.- �9f� BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERF®R,M ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (AMC), 527 CMR 12.00 (PLEASE PRINTWINK OR TYPEALL INFO TION) Date: �-//V' /W City or Town of: To the Inspector of Wires: By this application the undersi ed gives no ' e of his or her int tion to erform the electrical work described below. c& Location (Street Number) / In t? ►1 Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes V No ❑ BLDG PERMITBuilding ��%��,�j�-� # - `��/ Purpose of Utility Authorization No. Existing Service Amps / _Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undrd Number of Feeders and Ampacity g ❑ No. of Meters Location and Nature of Proposed Electrical Work: % No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets 5 No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers No. of Water KW No. Hydromassage Bathtubs tNo.f Ceil.-Susp. (Paddle) Fans f Hot Tubs ming Pool Above ❑ Tn_ ❑ rnd. rnd. 60 INO. of Oil Burners No. of Gas Burners No. of Air Cond. Total Tons Heat Pump 1�Tumber Tons KW Totals: ................................................... Space/Area Heating KW Heating Appliances KW No. of No. of Signs Ballasts No. of Motors Total HP table maybe waived by the Inspecto, No. of Total. Transformers KVA Generators KVA ME ALARMS INo. of Zones fo. of Detection and Initiating Devices .o. of Alerting Devices o. of Self -Contained etection/Alerting Devices )cal ❑ Municipal ❑ Other Connection :curity Systems- of ystems*of Devices or Equivalent ita Wiring: 11 No. of Deviceor Equiv salent L iecommuntcations Wiring: No. of nOvinpa nr Attach additional detail ifdesired, or as required by the Inspector of Wires. Estimated Value of ,lectrical Work: (When required by municipal policy.) Work to Start: 141011 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO 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 ❑ BOND ❑ OTHER ❑ (Specify:) I cert, under the pains an pen 1d" of er , ,that the i anon on this a Zication is true and completes FIRM NAME: p�o/�� ,� PP Licensee: `sLTC. NO.: Signature LIC. NO.: (Ifapplicable, e�Ilexempt a license nu ber lin Address: Bus. Tel. No.:1 �3 *Per M.G.L. c.147, s. 57-61, security work requires Departure of Public SafetyS Licen Alt. Tel. : OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability oI required by law. 13y my signature below, I hereby waive this requirement. I am the (check ane) ❑ ownerco ❑ coverage normally Owner/Agent Signature Telephone No. PERMIT FEE: G ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL 3. UNDER GROUND INSPECTION: Passed — [ ] Failed — [ ] - Re -inspection required ($50.00) - ( ] Inspectors' comments: (Inspectors' Signature - no initials) Date 4. INSPECTION — SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: y (Inspectors' Signature - no initials) Date 5. INSPECTION - OTHER: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. The Commonwealth ofH'assachusetts Department of Xndustrial,Accidents Office oflnvestigations 600 Washington Street Boston, MA. 02111 UqF www.mass.gov/dia Workers' CompensationlnsuranveAff'idavit: )3udders/Coniractorrs/JEleci:ricianBfPlumbeirs Applicant Information )Please Print Leatbly Name (Business/Organization/Individual): City/State/Zip:. Phone #: Are you an employer? Check the appropriate box: 'I - ❑ 1 am a employer with 4. ❑ I am a general contractor and I employees (full and/orpait tim.e).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner listed on the attached sheet. x 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.] 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.❑ Roofrepairs 13.❑ Other 'Any applicant 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. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that isproviding workers' compensation insurance for my employees Below is thepolicy andjob site information. Insurance Company Policy # or Self -ins. Lic. #: I- fob Site Address: Expiration Date: City/State/Zip.- Attach ity/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ti 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 ofup to $250.00 a day against the violator. Be advised that a copy ofthis statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: _ _ Permit/License -Issuing Authority (circle one): I. Board ofHealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other c` �'ontactPerson: Phone 8814 This certifies that Date �` Y �� . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 67. �c� -� has permission to perform ... IC- } �: G.':.'4. ................. plumbing in the buildings of ... Al 1 .C. G......�,- .f /.......... . at .. ./... ��! .S..�.... S. F ........ .. _North Andover, Mass. Fee. . Lic. No. �. .�J. 1.. .... I�... .... ........ . PLUMBING IOR Check k Ix /`N", MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS J 1 Date 45)t/ Building Location ( ) < Owners Name C Cr- L C Permit # P7S° 1Amount V / + 1 Type of Occupanc r q M ! r.1 a f New Renovation Replacement 0 Plans Submitted Yes ❑ No ❑ FIXTURFR (Print or type) Installing Company Name Th Me, 5 (' („f C' F4 H Check one: Certificate ElCorp. ElPartner. ® Firm/Co. Name of Licensed Plumber: w is Insurance Coverage: Indicate the type of msur` ance coverage by checking the appropriate box: Liability insurance policy M Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑a Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State PI u bin Code and Chapter 142 of the General Laws. By.'SigIJULUM 01&y Eicenseaer Title Typd,6f Plumbing License City/Town APPROVED (OFFICE USE ONLYiceuse NumDer Master Journeyman ❑ jr The Commarrweatfh of Massachusetts Department of Industrial Accidents tt� Office of Investigations 600 Washington Street �.: Briton, MA 82111 r ; www_mass gov/dia . Workers, Compensation insitranee Affidavit: Baiiders/C Ar Piicant nformation ontras%rs/Eieciricians/Piumbers I Name Address: Citylstate/Zip: Ale • ., Phone #.-. Are you an employer? C mk.the appropriate box: I. ❑ I am a employer with 4. ❑ 1 am a general contractor and I employ= (full and/or pa _time).* have hired the sub -contractors 2. I am .a.sole proprietor or partner- listed on the attached sheet. _ ship and have noemployees These suit -contractors have working for me in any capacity, workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its y required.) officers have exercised their 3. ❑ 1 ain a homeowner doing all work right Of exemption per MOL myself. [No•workers' comp, a 152, § I(4),'and we have no insurance- equired.) t .employes. [No workers' come. insurance uired.I n Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. ❑ Demoiition 9. ❑ Building addition 10.❑ Eiaetrical repairs -or additions 1 I .❑ Plumbing repairs or additions 12.❑ Roof repairs req 13 -❑ .Other 'Any applicant that checks hoz' #I must also fill out the section below sbovnng their workers' boropensatimi pansy mformatioa 1Ccntt I zruszwners who submit this at davit indicating they ars doing all work and then has outside conuacton; must submit Anew aitidavit indi ractors that check this box must strecbed an additiocal sheet show sating such trig• the name of the sub-contntators and their workrrts' corm- I sat ar. a 14er drat % ••,,,••:•r Fti� ir,`,nrmetion. Per s�M...�a�:;i nFfiers cnntpensarian insrcrMcefor M employees: Below is the o1i atfarmafion. P cJ andjob site . Insurance Company Name: ' Policy # or Self -ins. LAC. #: Expiration Date: Sob Site Address: . Attach a copy of the workers' comCILYI, Failure to ate/Zip: pensation policy declaration page (showing the policy number and expiration date] secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal fine up to $1,550.00.00 and/or one -yew, as well s z civil penalties in the form of a STOP WORK ORDER sial a fine in a to tions 0 a day against the an tor. 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 certijy�der the pains and penalties gf'Perjrcr�, mat thein nrmatioR ra ' l f P vuled o6nve is due and ronrd Y OJT,IC al ase only. Do not write in this area, m he compkxvd b or town off y cih'c+a� City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town 6. Other Clerk 4. Electrical Inspector S. Plumbing inspector Contact Person: Phone #: Information a nd Instructions Massachusetts General Laws chapter 152 requires all emp Ioyers 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, assodiation, corporation or other legal entity, or any two or MOM of tine foregoing engaged in a joint enterprise, and includirig the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, associatio-in or other legal entity, employing employees: 'However the owner of a dwelling house having not more than three apm rtments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maiTuteruaruce, 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, 525C(6) also states that "every state os local licensing agency shag withhold the issuance or renewal of 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 eater into any contract for the performance of public wort-_ tmil-acceptable evidence of compliance with the insurance requiremcnis of this chapter have been presmrtad to the coaltractmg authority." . Applicants Please fill out the workers' compensation• affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sob-coniractor(s) name(s), addresses) aTd phone numbers) along with their certificates) of ' insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the membrrrs or partners, arc 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.. Ain 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, nota he 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 numberlisted below. Self +*rst�*ed crmps: a(nn�iri e.rr tFr self insurances 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 your to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the pmmitliicense number which w-iII be used as a mference number. In addition, an applicant that must submit multiple pormittlicensc applications in any given year, need only submit one affidavit indicating -current policy;infonnation (if necessary) and under ".lob Site Address" the applicant should write "all locations in (city or town)." A copy of -the affidavit that has been ,officially stmmped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for fuivae permits or licenses. A new affidavit must be filled out each year. When 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 bice 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 Depattrncnt of Industrial Accidents Office of Iavestibations 600 Washington Str;--et Boston, MA 02111 TeL 9 617-727-4900 6=t 406 or 1-977-MASSAFE Revised 5-26-05 Fax 4 617-727-7749 www-mass.gov/dia , 9796 Date .... a- )- g - /e)- . ..... —.1 ............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............... ........ I ..... lf�L... . .................. has permission to perform ........... I ............. F.-.; ................................................... 5 wiring in the building of at .......c . ......................................... North Andover, Mass. ........... .. ....... Fee.. Lic. I ELECMCALINSPBCr�Iy Check # Z -3 Commonwealth of Massachusetts 1!7 wa7zw Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. q '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 (MEC), 527 CMR 12.00 (PLEA SE PRINT IN INK OR TYPE ALL INFO TIDN) Date: %/`z 3 I/© City or Town of: �� �' To the Inspector of Wires: By this application the undersi ed gives not' e 9f his or her intention to perform the electrical work described below. -/) ra . � ti er--• Location (Street & Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes Purpose of Building M Oz— Existing Service New Service Amps / Volts Amps Number of Feeders and Ampacity Volts Telephone No. No ❑ BLDG PERMIT # Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ Location and Nature of Proposed Electrical Work: • "F/ % `f,,2> No. of Meters No. of Meters ritcucn aaauaonai aetau if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE El BOND ❑ OTHER El (Specify:) I cert, under the pains and penaldes o rjury, that the '' rmation on this a plication is true and complete - FIRM NAME: LIC. -AnA� 77 Licensee: Signature LIC. NO.: (Ifable, en _hexer i th e u bg reez) � Bus. Tel. No.: O Address: !� /(�(/ �'ii/ Alt. Tel. No.: l *Per M.G.L. c. 147, s. 57-61, security work requires Department o Public Safety "S" Licen 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 Signature Telephone No. PERMIT FEE. $ ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL 1. O INSPECTION: Passed — Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: 0 - no initials 2. FINAL INSPECTION: Passed — Failed — [ ] Inspectors' comments: (Inspectors' Signature - no initials) 3. UNDER GROUND INSPECTION: Passed — [ ] Failed — [ ] Inspectors' comments: (Inspectors' Signature - no initials) 4. INSPECTION — SERVICE: DATE CALLED NATIONAL GRID: Passed — [ ] Failed — [ ] Inspectors' comments: Date Date / -' ^f 7 — Date (Inspectors' Signature - no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. The Commonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibl NaMe,(B.usiness/Organization/Individual): Address: City/Sime/Zip:/ Jt%�� Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2.41 am a sole or have hired the sub -contractors listed on the attached sheet. proprietor partner- 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. ❑ 1 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.] 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 12.0 Roof repairs 13.❑ Other *Any applicant that checks box #1 must also Ell 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 anew 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. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: 11Pl-7- I-1, Policy # or Self -ins. Lic. #: Expiration Date: Sob Site Address: � i 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 ofthis statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the andpenalf erjury that the information provided aboove is true and correct. Signature: ,&� Date: Official use only. Do not write in this area, to he 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. EIectrical Inspector 5. PIumbing Inspector 6. Other Contact Person: Phone #: .-S 9706 Date ... M.— rF— /61 ........................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................ yo— (2.� lne/....................................................... has permission to perform ............... wiring in the building of ................ .. .... ................................... at ... 01 11?.9.F4pr.............. 777", ,North Andover, Mass. ........ .. . .. Fee.� ................... Lic. No. ......... . . ........ RIC� �I�Si�r! Ed I Check # �.. q,Urnrr,►creoVVW affUff aan a�sws�saa,oaaa��a6s 9 �� r' Permit No. Department of Fire Services Occupancy and Fee Checked a„ BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Cod 2 �,C MR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: z To the Inspector o Wires: City or Town of: I�®R`ICIH[ ANDOVER p By this application the undersigned gives notice of. is or her intention toper the��ca� k described below. Location (Street & Number) / v y— 1 Telephone No. Owner or Tenant Owner's Address Is this permit in conjunction with a bu'lding errmiit? Y No E] (Check Appropriate Box) Purpose of Building ZNO v Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work /T gJz> No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers No. of Water KW Heaters No. of Ceil: Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool Abovegrnd. El No. of Oil Burners No. of Gas Burners No. of Air Cond. Tons Heat Pump Number Tons Totals Space/Area Heating KW Heating Appliances KW No. of No. of Q.— Ballasts table may be waived by the Inspector of Wires. No. of Total Transformers KVA Generators KVA PIFFI. of Emergency tagn Ling REALARTZ�NoofZones Battery Units Initiating Devices o. of Alerting Devices o. off- Co Self; etection/Alerting Devices Municipal ocal E] Other ❑ !'nnnarfinn No. of Dei Data Wiring: No. of Dei or Equivalent or P No. Hydromassage Bathtubs No. of Motors Total HP of Devices or E uivalent OTHER: .Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in'force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE P( BOND ❑ OTHER ❑ (Specify:) I certify, under the pat t S dpenalties o erju yh at the in o Cation on tli s application is true and complete. FIRM NAME: �G LIC. NO.: Licensee: Signature LIC. NO.: 17 (If applicable, enter " e pt" i g� e e_�I er I' Bus. Tel. No.: ? Address: (/ ��IIJJ �'�� It. Tel. No.•weft *Per M.G.L c. 147, s. 57-61, security work requires Department ublic Safety "S" License: Lie. No.• OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's Owner/Agent Telephone No. PERMIT FEE.--$ Signature (�,�L"�� G'� /lam /��1��� i y The Commonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston, MA 02II1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Dl..., _ ID—"+ T .nrrihl, Name (Business/Organization/Individual): ` eo Address: �4Lj����/�Y Ci /State/Zi ���%%?&MK "©� � Phone #: City/State/Zip: p �-9___— --�— ou an employer? Check the appropriate box: AX114. ❑ 1 am a general contractor and I 1 am a employer with 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. 5. ❑ We are a corporation and its [No workers' comp. insurance officers have exercised their required.] 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 employees. [No workers' insurance required.] t 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, *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and 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. eTz ` to � F�W Insurance Company Name: /v Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: �j '/ /fo " i City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day. against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License #, Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone Date.: ©- . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...Tllll�-I&.5 has permission to perform ................... plumbing in the buildings of9lr.l'r�•,.1ra2� ..,57amw6 .l�je�,��S at,5;1/. ,G//�,c�.-I/ ....................... North Andover, Mass. Fee .5'?q .4�. Lic. No./-5­**/*J- ............................. �7 PLUMBING INSPECTOR J Check x 7 itL✓ll FIXTURES MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: IVA r -Pi MA. Date: 0� % Peerrmit# bf Building Location: 1 lqf CS 6, to M' Owners Name: /? C Type of Occupancy: Commercial [ Educational ❑ Industrial ❑ Institutional ❑ Residential ❑ New: Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes jib No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Qd Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Sianature of Owner or Owner's Anent (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title ® Plumber Sign re of Licensed Plumber City/Town ®Master License Number: 1; d APPROVED OFFICE USE ONLY)❑Journeyman �1 DEDICATED SYSTEMS LU Z zH D: 4A Z F' Y LU z Ce LU z Z 3 H °0 Z `^ W Z ~ z ¢ W W Z a bd u d �( a IIQ Q = fa/1 = W F- 3 Q 3 at O J n x W a w s G o a W 3 0 O a Q W 3 Z a W Y `' z Z :r W 1= W 0 l W W a = Q Q a fA v, 'c o o>> Z g 5 o o= o Q a a a c At m m o �. x oc v� v� 15 0 3 3 3 0 a tD W (D 3 SUB BSMT. BASEMENT JIT FLOOR 2ND FLOOR 3"D FLOOR 4T" FLOOR 5 FLOOR 6T" FLOOR FLOOR 8m FLOOR Check One Only Certificate # Installing Company Name: �./i�/Ip � C T� P_eE/$ D� � El Corporation - v / ,J %I C[ '� J � Address: / y City/Town: State: E] Partnership Q t a j` _ Business Tel:4?6 ✓ / — Fax: X Firm/Company Name of Licensed Plumber: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes jib No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Qd Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Sianature of Owner or Owner's Anent (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title ® Plumber Sign re of Licensed Plumber City/Town ®Master License Number: 1; d APPROVED OFFICE USE ONLY)❑Journeyman �1 9595 Date...,?—/e,- :...122 TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that .........YW-ux.. ...'--4i .� .............................. has permission to perform........... > � ........................................................................... wiring in the building of ...6m. &� ��'F.. err:! .... .... at....�/ ...... /-/ If. 41 ....... .............��.............. . North Andover, Mass. Fee .12.41-- Lic. No.. �..�� / . 7/Y ....... ,! �j��� . &Ici� INSPECT(ft Check #J—_ x-11 a,urr►rr►u►►wcan.0 v► ►-ia��aw►u�c«.P---�-{- --�y- De artment of Fire Services Permit No. ' p Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank) M APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (WC), 5 7 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: City 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) X Owner or Tenant m m g o% n a Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building AMA A�if�,/�' � Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table maybe waived by the In ector 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- ❑ rnd. grnd. o. o cy Lighting Battery Units Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection andInitiating Devices No. of Ran es g No. of Air Cond. Total Tons 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 Heating Appliances KW Security o Devils s or Equivalent No. of Water Heaters KW No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent Hydromassage Bathtubs No. of Motors Total HP WirinNo. Telecommunications No. of Devices or Equivalent OTHER: Attach additional detail ifdesired, or as required by the Inspector of Wires. Estimated Value of El ctric I Work: (When required by municipal policy.) St-, Work to St / Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO E GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains an peva/ttes of perjury, that the infor anon on t/iis ication is true and compleNFIRM NAME: LIC. NO.: Licensee: /� Signature _ _ LIC. NO.: _ (If applicable, ent exe t" i the licen um ) Bus. Tel. No.• ✓ �a ,� Address: //� Alt. Tel. No.: *Per M.G.L c. 1,T7, s. 57-61, security work requires Department ub is 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 Owner/Agent PERMIT FEE. $ Signature Telephone No. Jf m ` The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 5 • www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /, n Please Print Legibly Name (Business/Organization/Individual): 1W_ Address: e��z X/d)&. ro L�' p p Phone #: Are you an employer? Check the appropriate box: L ❑ 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.'§dI 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. [:1 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.] i 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 *Any applicant that checks box #E1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and 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: 972, h4,,I-6W Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: L% 7/ r City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under t ai and penalties of perjury that the information provided above is true and correct. Signature: Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector• 5. Plumbing Inspector 6. Other Contact Person: Phone #: Date.. i,110. ter+ "OftT : ti TOWN OF NORTH A DOVER ° PERMIT FOR PLUM. �I G sACH„5� aS � �� This certifies that .. ��''.......�....................... .. . has permission to pe form ...... /.!. , f .................... plumbing in the bu`ildings.of .`.(1....tJ.!`�/�................. at. �..../!/.. -S ...!...!A No h Andover, Mass. 0 /S/< Fee.,�..... Lu. No......J �. ...... �:' .. �`Y��!!"`�...... PLUMBING INSPECTOR Check ++ 35 if -2- 8391 FIXTURES MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: IV o r N All V e)C MA. Date: !d Permit# Building Location: a,1 ti Z6 h A I , 6/ 04 ? Owners Name: gc & " 4 LC.. Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential ❑ New: ❑ Alteration: [jfl Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes [A No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy 'r-" Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Cinnofi irc of (lumcr nr rlumcPe Annn4 I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: J Title Pt Plumber Signatuof Licensed Plumber aster City/Town License Number: APPRnvt:n inFFif_F I ICF nim v► []journeyman OF DEDICATED SYSTEMS W z O N W Q:me Z N } Qa` D U yr W 0 W GC Z Z 3 H z = H H W 12 Z r W to Z FJ iA ca c yl j d_i Z Q y O: Q W Q 0 m W ie 1 ~ a 3 z cc 2 O O W Z H W .J Q z _ U d �y °� =1 o W 3 LU a bU.e p` f W u x I. - F- o 0 O X IL~ x z > Q > U. O 3 O d; O Z s Q W Q W W Q a y f - Q I= m m v► in a c z H Y 3 5 cc I rA SLI BSMT. BASEMENT 15T FLOOR % Z'1D FLOOR 3"D FLOOR ,C FLOOR 5T" FLOOR 6T" FLOOR r FLOOR 8T" FLOOR Check One Only Certificate # Installing Company Name: (TA C7rr ry El Corporation Address: ?y 4r),r✓ �r^ c5f City/Town: JQ i /ems State: ❑ Partnership C9'7 6 ) P-1 3 ` 7C 9 V Business TeI Fax: ❑Firm/Company Name of Licensed Plumber: J-1 M 6 re-, INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes [A No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy 'r-" Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Cinnofi irc of (lumcr nr rlumcPe Annn4 I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: J Title Pt Plumber Signatuof Licensed Plumber aster City/Town License Number: APPRnvt:n inFFif_F I ICF nim v► []journeyman OF 956; Date ..... .... �P TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............. .. . .... ......... !!.!�& ...... . .............................. YA / 15 has permission to perform ......%,2.7.1.... ..... r("b. ea ................................ C �g wiringin the building of ................................................................................... at 5. ............... 1g, . 1,1? ........ . n. North Andover, Mass. Fee ..(.T15..—... Lic. No..3.1a/..24 ............ Check # • m Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code MEC), 527 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: D City or Town of: NORTH ANDOVER To the InSP - ktor of Wires: By this application the undersigned gives otice of his or her intention to perform the electrical work described below Location (Street & Number) X "well O 7 , �#QJJ, g) Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes 3 No ❑ (Check Appropriate Box) Purpose of Building eo �.�7/7Lr�Qil4 t� Utility Authorization No. Existing Service Amps Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters up Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o Units Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiatin Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number ...................................................... Tons KW No. of Self-Contained Totals: Detection/AlertingDevices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal El Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. l Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. / INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless / the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains an penalties of erjury, that the i ormation o s application is true and complete. FIRM NAME: �C9 � -� LIC. NO.: Licensee: f Signator LIC. NO.: i ` �r (If applicable, ent xemP.���;; in the license nu b ine.) Bus. Tel. No.' �42—�-!sAddress: /2�✓T2� t,�Alt. Tel. No.:*Per M.G.L c. 147, s. 57-61, security work requires Departm Pu lic Safety "S" License: Lic. No. < `' OWNER'S INSURANCE WAIVER: I am aware that the icensee 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 Owner/Agent Signature Telephone No. PERMIT FEE: $ 9,/, b -K 8- C(� I !' 1 d 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): Address:- City/State/Zip: ddress:City/State/Zip:�%�L�G Phone #: f//�z���1 Are ou an employer? Check the appropriate box: 1 I am a employer with 4. ❑ I am a general contractor and I .employees (full and/or part-time).* have hired the sub -contractors 2. ( 1 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.] 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 *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and 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:,/ �1//D� City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and enalties ofperjury that the information provided above is true and correct. Signature: Date: t/ / //0 T _// to 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 #: W Date..................... ....U.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......... ...... `..:.ev ' r ? ..:................................... has permission to perform .-- �.:.--�*�-� ............................................................... wiring in the building of .......... at ...c:..........................................................,. ... , North Andovei:,-Mass. Fee.: 7?x..� .... Lic. No' .Z,� ,/,7........... .. ...... -� LECTRICAI INSPE �l Check # 14'\Commonwealth of Massachusetts Official Use Only Department of Fire Services Pemut No. I ._3 9 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked _Z = [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK 0�/�641 All work to be performed in accordance with the Massachusetts EIectrical Code (MEC), 527 CMR 12.00 (PLEASE PM7 EV INK OR TYPE ALL INFOR L4T10N) Date: `j City or Town of: NORTH ANDOVER By this application the undersi ed To .the Inspector of Wires: gn gives notice of his or her intention to perform the electrical work described below. Location (Street &Number) Owner or Tenant a v Owner's Address Telephone No. Is this permit in conjunction with a building permit? q, ,� � Yes No (Check Appropriate Bog) Purpose of Building Co J4I Utility Authorization No. Existing Service Amps / Volts Overhead Undgrd No. of Meters New Service s / �P Volts Overhead. Undgrd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: f/ l 4(P Com letion o the ollowin table may be waived b the Inspector of Wires. No. of Recessed Luminaires No, of Ceil.-Sus No. of I� (Paddle) Fans Transformers Total No. of Luminaire Outlets No. of Hot Tubs KVA Generators KVA No. of Luminaires Swimming Pool Above Ia o. o mergency —, No. of Receptacle Outlets / d Batte Units 2- No. of oil Burners F" ALARMS . RlidS No, of Zones No. of Switches No. of Gas Burners 0. of etection an No, of Ranges Initis • Devices No. of Air Cond. °� No. of Waste Disposers Tons No. of Alerting Devices Z eatp Number ons .' KW o. of elf -Contained Totals: .-"`. Detection/Ale No. of Dishwashers Space/Area Heating KW Devices �� uaicipal No. of Dryers Heating A Connection Other K Appliances ms' Security Systems: o. of Water o. of No. of Devices or E uivalent Heaters' No. of Data W' o, No. Hydromassage Bathtubs Si s Ballasts. No, of Devices or E uivalent �Y g No. of Motors Total HP Telecommunications Wiring: OTHER No, of Devices or E uivalent % Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. Work to Start: (When required by municipal policy.) INSURANCE COVERAGE: —Unlessections to be requested in waivedby the owner, no permit fo the performance of ce with MEC Rule electrical upon completion the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equ may uTnhless undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE M BOND ❑ OTHER ED a I certify, under the pains a (Specify:) . P penalties a� perjury, that a fo on on this a FIRM NAME: p[Ica on is true and complete. Licensee: Signature LIC. NO.: --�ir (If applicabl1_ LIC. NO.:e, ente, exem t to the license nu line.) Address: �/ �p�J ��—Bus. Tel. No.:�igmz ? *Per M.G. c. 147, s. 57-61, security work requires D Alt: Tel. No.: OWNER'S INSURANCE W q epartment of Public Safety "S" License: Lic. No. RIVER: 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 (c Owner/Agent heck one) owner ❑owner's agent Signature Telephone No. PERMIT � �' Ra,cz- yA The Commonrc ea&k of Massachusetts Department of Industrial Accidents Dice of Investigations 600 Nlaslzington Street Boston, MA 02.111 wwnzussgovldia . Workers' w Compensation Inskrance Affidavit. B,adders/Contractors/Eiectriciaus/Plumbers Aicant Information Name (Business/organization/individual Address: City/State/Zip: Phone 4.. Lam% y a i ? — Are you an employer? Cheek.the appropriate box: I . ❑ I am a employer with 4. ❑ I am a general contractor and I 2.21 employees (full and/or part-time).* I am have hired the sub -contractors .a.sole proprietor or partner- ship and have no employees Iisted on the attached sheet. t These su&contractors have working for me .m any capacity, [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL n7Yself. [No -workers' comp. c. kS2, § 1(4), and we have no insurance acquired, t � •employees. [No workers' Type of project (requiref: 6. New construction 7. ❑ Remodeling S. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs. or additions 12. ❑ Roof r apairs I3.❑ Other ' applicant that checks bo'# 1 must also fill out the section beiow showing their workers' oompensstion policy infomtation a ;Any who submit this affidavit indicating they ars doing an work and then hhe outside contractors fComraaton: than check this box must anached'an additional sheet showing. the trEme of the sub.. must submit a new afridavit indicating such. I am an entPloyer that ispro ' '`�,;i, intnmcaiion. �► . vidutg:workers compensmdon 1nsuraaeefor vp e in, formation, mP Oyem, Below is the policy and job site . Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: - Job Site Address: City/Stste/Zip. Attach a copy of the workers' eoue Failure to sepeasation policy decfaratiou page (showing the policy number and expiration date). cure coverage as required. under Section 25A of MGL C. 152 can lead to the imposition of criminal fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORp £shies of a Of up to $250.00and a fine 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 l/te pabu and enaltles o ii P iPerj fiat the infor»wtion provided obove is trueandcorretx Si titre; l r /� Date: /Y Phone #: �✓ %�i� � l [I-Board al use rudy. Do not write in this area, be co 1 mp eted by .city or town offir r Town: Permit/License # g Autborify (elide ooe): I. of Health 2. Building Department 3. OWTown Clerk 4. Electrical Inspector S. Plumbing I 6r g nspectort Person: Phone #: Date..?/ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .... hl...... .../...... , `, , , , .... , , , , has permission to perform ... (`..- �`'..... :.:........ . plumbing in the buildings of .... +...I ............... at .. I .... Q.4 :................ . North Andover, Mass. Fee. .... Lic. No../.) .0 .. .... ........ . -t PLUMBING INSPECTOR Check # 3 S O % A MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS `n (-,LC— Building Location o� I 4 t, �� Owners Name �� � L� Date # � j- 3 L Amount �p Type of Occupancy Com M -e- rC t A New Renovation Replacement Plans Submitted Yes ❑ No ❑ (Print or type) Installing Company Name J Q M,*t A 1z'-C!r tJ � Pi Check one: Certificate Corp. Partner. Firm/Co. Name of Licensed Plumber: -,),11-7e- .5 r,n, 5�Q'. Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner 1:1 Agent rl I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac efts State Plumbi ode and Chapter 142 of the -General Laws. By: igna ur icense um er TA e f Plumbing License Title City/Town Master n Journeyman ❑ APPROVED (OFFICE USE ONLY .J I ' ` .: Gam` I --�-----------�--�------- `9 B MMM WN MMMMM 1 • • ' ---------------.-MM -- MMW WN WMM (Print or type) Installing Company Name J Q M,*t A 1z'-C!r tJ � Pi Check one: Certificate Corp. Partner. Firm/Co. Name of Licensed Plumber: -,),11-7e- .5 r,n, 5�Q'. Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner 1:1 Agent rl I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac efts State Plumbi ode and Chapter 142 of the -General Laws. By: igna ur icense um er TA e f Plumbing License Title City/Town Master n Journeyman ❑ APPROVED (OFFICE USE ONLY Attach a copy of the workers' 'compensafion policy declaration page (showing /e policy Failur�oamber and expiration date Failure, to secure coverage as required under Section 25A of MGL C. 152 can lead to the imposition of criminalfine up to $1,500.00 and/or one-year imprisonment, as well res civil penalties in the farm of a STOP WORK ORDpenalties and a fine of up to 5250.00 a day against the violator. Be advised that a copy of th investigations of the DIA for insurance coverage verification. is statement may be forwarded to the Office of I do hereby certify under the erjtcr�' that the utfor»iation pro vided above is true and rorreat Sierratarre� � �. . Date: Phone #: f 9 7b i"c� � LjI EAuth, onfy. Do not write in this area, m be cnmplr'[ee+b or town. o J' cy ffi da( n: Permii/l.icense # horify (circle ooe):Health 2 Building Department 3. City/Tov-uClerk 4. Electrical Inspector -5Pinmbing inspector son: Phone#: The Commonwealth of Massachusetts Department of Industrial Accidents Office Investigations of i 600 Nrashington Street Via& _ Boston, MA 62111 "ww massgov/dia , Workers' Compensation insurance Affidavit: Builders/C ontractors/Eiectricisas/pfnmbers I ,kppficant nformation Please Print Lem Mame (Business/Qrganiration/individual): AdCm35:/�/ d 52 City/state/Zig: Phone #:. . 3 - i6 9.y Are you an employer? Check the appropriate box: roject (required). I. ❑ F am a employer with 4. ❑ I am a general contractor and IF[:3. employees (foil and/or part-time).* 2. I am .a.sole proprietor or have hired the sub -contractors construction listed partner- ship and hate no employees on the attached sheet S odeling These soli -contractors have working forme in any capacity, [No wonders' comp. insurance workers' comp. insurance. olition 5. ❑ we are; acorporationanditsding addition 3. ❑required.) 1 ain a homeowner doing officers have exercised their trical repairs or additions all work myseI£ [No workers' comp. right orf exemption per MOL bing repairs or additions c. 1.52, § 1(4), and we have no ti insurance required.] t employees [Nowarkors' 12.0 Roofttpairs comp. insurance requked..3 I3.❑.ether `AnY appi� that checks boi #I must &iso illi out the section beiow showing their wonders' oompensatien policy information _. t Homeowners who submit this s�davit indicuuing they sic loin an g work end then hie outside conmaetors mu&t'submit kConmacton; that cheek this box must arae a new affidavit mdi alztd an additiaasi sheet showitg• the name of the sub- aatioE each conmacton; an their workers' comp. F r• paFim• irfortnadon. . am an -IMP/* P im th Es M r%difng:worie' cor informado/L iisrrare{or IM =Floye= Be%pw is tJte Of1CJr Q7!(IjDl7 site Insurance Company Name: Policy # or Self -ins. Lie. #: Expirdion Date: Job Site Address: Attach a copy of the workers' 'compensafion policy declaration page (showing /e policy Failur�oamber and expiration date Failure, to secure coverage as required under Section 25A of MGL C. 152 can lead to the imposition of criminalfine up to $1,500.00 and/or one-year imprisonment, as well res civil penalties in the farm of a STOP WORK ORDpenalties and a fine of up to 5250.00 a day against the violator. Be advised that a copy of th investigations of the DIA for insurance coverage verification. is statement may be forwarded to the Office of I do hereby certify under the erjtcr�' that the utfor»iation pro vided above is true and rorreat Sierratarre� � �. . Date: Phone #: f 9 7b i"c� � LjI EAuth, onfy. Do not write in this area, m be cnmplr'[ee+b or town. o J' cy ffi da( n: Permii/l.icense # horify (circle ooe):Health 2 Building Department 3. City/Tov-uClerk 4. Electrical Inspector -5Pinmbing inspector son: Phone#: Information a. nd Instructions. Massachusetts General Laws chapter 152 requires all emp Soy- = 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 ofhire:, express or implied, oral or written.^ Ii An employer is defined as "an individual, partnership, mc:)diation, corporation or other legal entity, or any two or mom of the'foregoing engaged in a joint enterprise, and includir-ig the legal representatives of a decxased employer, or the receiver ortrvstm of an individual, partnership, associatiori 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." MOL chapter 152, §25C(6) also states that "every state o;- local licensing agency shalt withhold the issuance or renewal of a license or permit to operate a business or its construct buildings in the commonwealth for any applicant who has not produced ameptable evidence.o'F compliance with the insurance 'covera�ge required" Additionally, MOL chapter 152, §25C(7) states "Neither t3be commonwealth nor any of its political subdivisions shall enter into any contract for the perfonnance of public work- until accept able evidence of compliance with the insurence requirements of this chapter have been presm-ftd 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-corftctor(s) name(s), address(es) aund phone numbers) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, arc not requ red;to carry workers' compensation insurance. Van 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 loot sure to sign and -date the affidavit The affidavit should be returned to the city or fawn that the application foT.the permit or license is being requested, notthe Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers, oompamtion policy, please -call the Department at the nurnber. listed below. Self insured companies should ente th= - self insurance -license number on the*appr opriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Departmew hes provided a space at the bottom of the affidavit for you to fill out in the event the Office of' has to contact you regarding the applicant. Please be sure to fill in the pormit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permittlicense 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 mown)." A copy ofthe affidavit that has bean .officially stamped or marked by the city or town may be provided to the applicant as proof thea valid affidavit is on file for fume 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 per mitto bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance foryour 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 b3dustrW Accidents Office of Investigation 600 Washington Street Boston, MA 02111 TeL # 617-727-4900 6ct 406 or 1-877-MASSAFE R►-vised s-26-115 Fax # 617-727-7744 www.mass.gov/dia M. Date.. �-:::.. M z .: -z. ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .................................. .............................. has permission to perform ..... ..................7�= . z6 ........................ .......... �.21-�"A' wiring in the building of `.............................................. at ..c ........... . . . ........ ....... . ...... 0- North Andover, Mass. Lic.Nd�,�.2 . ........... ... ... Fee'� .. ....... ......... ELECTRICAL INSPECTOR Check # a2: It Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No- 5�21R-� BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked_ [Rev. 1/071 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINTININK OR TYPE ALL INFORALMON) Date: City or Town of: NORTH ANDOVER To the By this application the undersigned gives notice of h' r er in ntion to perform the el� electrical wk dector of escribed below. Location (Street &Number) �� ��� �' �t Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes Z No ❑ (Check Appropriate Bog) Purpose of Building— C Ol)2A Ce ply— Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires Fof minaire Outlets minaires ceptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers Heaters KW Hydromassage Bathtubs Completion of the No. of CeiL-Sasp. (Paddle) Fans No. of Hot Tubs Swimming pool Above❑ in - d. grIc 3 No. of Oil Burners q. of Gas Burners . of Air Cond. Totalat pump Number Tons ns ] Totals: — X' '- --- Space/Area Heating KW O. Appliances KW f// j " le maybe waived b the Ins ector of Wi o. of Total ansformers KVA jGenerators KVA o mergency rg tte UnitsRE- g ALARrriS INo. of dunes No. of Detection and Initiatin ry Devices No. of Alerting Devices tion/Alerting Devices ❑Municipal Connection ❑ Other ity Systems: * _ i. of Devicec nr IP— ... —1--4- Ballasts Data Wir No. of of Motors Total HP Telecommunications No. of Devices or Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: Work to Stark(When required by municipal policy.) Inspections to be requested in accordance with MEC Rule 10, an d upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER tify ❑ I cer(Specify:) under the pains an penalties of pr , that the in rm¢don on is application is true and complete. FIRM NAME: Licensee: tr Q Si LIC. NO.: Signature LIC. NO.: (If applicable, enter "exempt " in the license number line) 44W Address: Bus. Tel. No.:DW7 *Per M.G.L. c. 147, s. 57-61, security work requires D Alt Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Department a does not have the liability Lic. No. required by law. B m signature Y q ty insurance coverage normally Y Y Mature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent - Signature' Owner/Aent Telephone No. FE:"771T:FE:E:-7S�_ ,y V 11 0 1 The Commonwealth of Massachusetts Department of Industrial Accidents igl ! Dice of Investigations 600 W-ashing ton Street Boston, MA 02111 www.massgov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Eiectriciaas/Piumbers Applicant Information Please Print LeQlbly Name (Business/Organization/individual): Address: City/.state/Zip Phone #: . ---------------------- Are you an employer? Check -the. appropriate box: • I —] I . ❑ I am a employer with 4 Type of project (required): ❑ I am a general contractor and I employees (full and/or puss -time).* have hired the suircontractors 6 ❑Nom' construction 2. ❑ I am .a.sole proprietor or partner- listed on the attached sheet. = 7. ❑Remodeling ship and have no employees These sub -contractors have 8. [] Demolition working for me in any capacity, workers' .comp. insurance. [No workers com . insurance 5. 9.. ❑Building addition P ❑ We are a corporation and its 3. ❑required.] officers have exercised their 10-0 Electrical repairs or additions I am a homeowner doing all worts right of exemption per MGL I l.❑ Plumbing repairs or additions rgysel£ [No -workers' comp. C. L52, § 1(4), and we have no insurance required.] •employees. [No workers' 12.7 Roof repairs rN 1 13.❑ mer comp. inst�r-ance.required..] "Any appitcarti that checks bo> !Ff must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they ate doing all work end then hire outside contractors must submit a new aiitdavit indicating such ;Contractors that check this box must am an additional sheet showing the "_*me of the su a tt._i, b-` t a" •.,•r,N. foliey inmrmaiion. I am an employer that is protdding:workerscompensation insurance for nv employees; Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. 4: Expiration Date: Job Site Address: . City/state/zip:Attach a copy of the workers' compenseflon policy declaratiion 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 conem Si acre:. Date: Phone k Official use only. Do not write in this area, to be completed by .city or town official City or Town: Permit/License # Issuing Authority (circle one): I. Board of health 2. Building Department 3. City/Town Cierk 4. Electrical Inspector S. plum bing inspector Contact Person: Phone #: r C+ Z z F� A a O v U O w a u v Cl) a z z z A Cq C OC G O u. x:to O a5 C U G x a o Z tio,��tko p w' G w x a u w p w' v y cn G LL. a a bo p w G w d A w a W b as o z cn i a' v O c/) a 2i H L H Q 0 h C O O cm .E- CD O cm c .05 CDc N m Z O Z O z O U Cf) �911-' G� 4 CD Z O D I y h CD CDC co m CL CO2 0 V ts H C O C..3 O 3� �co o cm L 16. CL cnQ c +-+ C 9cc O O Z m O. COD C W 0 W CO) c o C2 0 C HO C � 'ate CL= ev eo o c := o c ea N = Ea m c `mom �t v COL Vl S'T � D o •- m C = N W CO 0 0 3 cm -p C m � = c y.O ANN"1�7� Sm W— C.C3 i fA ®' w � o �coOQ o cma _� CM -1 yZ 11EC2o m n .. mG = o w 3 o : ao10 W •+ N m �+ O � o t= W E at E +' •N v"fl v p► V2 _ 1— !O C i O •O.. • d •... m 2i H L H Q 0 h C O O cm .E- CD O cm c .05 CDc N m Z O Z O z O U Cf) �911-' G� 4 CD Z O D I y h CD CDC co m CL CO2 0 V ts H C O C..3 O 3� �co o cm L 16. CL cnQ c +-+ C 9cc O O Z m O. COD C W 0 W CO) 14 Date ...... 1,9 ....................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......... ........1..'. 7.7.-/-= ...................... has permission to perform ........ .. .... ..... T.A? . .......................... wiring in the building of .................. /�c . . ........................................ at ..... ......S./................................. . North Andover, Mass. Fee ... Lic. No...... .............. t A - =1 Check # LE�CMiCAL il' 9279 1 Commonwealth of Massachusetts Official Use Only Department of Fire Services Per=mit No. 7 07 BOARD OF FIRE PREVENTION REGULATIONSOccupancy 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 (MEC), 527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATIOI9 Date:_ la City or Town of: To .the Inspector oWires: NORTH ANDOVER f By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) R Owner or Tenant a.I gree "ON aw eil' Telephone No. Owner's Address ��vo. I �,� .� S6Mr-ryi 1(r �A C 6� Is this permit in conjunction with a building permit? Yes ` No ❑ (Check Appropriate Bog) Purpose of Building V& t ( `e / J a -%-k Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und d ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �) S•f-� e . votc� ao. wi✓ l ►i Com letion of the ollowin table may be waived b the Iris ector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) FansTotal Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above in-, o. o mergency ig g d. ❑ d. ❑ Batte Units -- , No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detecfion and Iniiiatin Devices No, of Ranges No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers eat PSP Number Tons KW No. i::Self-Contained Totals: . _..�..__. Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local ❑ Mumcipal Connection ❑ Other No. of Dryers Heating Appliances KW Security Systems:* No. of WaterNo. No. of Devices or Equivalent Heaters I o. oof fs Ballasts . Data Wiring: No. of Devices or, Equivalent No. Hydromassage Bathtubs No. of Motors Total HPTelecommunications Wiring: OTHER: No. of Devices or E uivalent Estimated Value of Electrical Work: 3,00o Attach additional detail if desired, or as required by the Inspector of Wires. Work to Start 3 ID �b CO (When required by municipal policy.) 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 cov ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 91 BOND ❑ OTHER ❑(S ify, p ' ec P' ) I cert ,under the sins and enalties o perjury, that the information on this application is true and complete. FIRM NAME: e-�ev' Sru jy� ,' �.�. � LIC. NO.: Licensee: Signature (Ifapplicable, enter "exempt"' in the license number line.) LIC. NO.: ! Address: ckLvj�Lo�uj ✓`t'V-10e 0 � O `144U Bus. Tel. No.: l7- -ZI- 3 (� *Per M.G.L c 147, s. 57-61, security wor requires Dty Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that thre Lecens a does not have the liability Lic. No. required by law. By my signature below, I hereby waive this requirement. I am the check one insurance coverage normally Owner/Agent ( ) ❑owner ❑ owner's agent. Signature Telephone No. PERMIT FEE: S %Z' ` dr* -J�,OA- 141le/I - '9 6 - / o r t: The Commonwealth of Massachusetts Department of Industrial Accidents c` ! Dee of Investigations I I V 600 Ida-ashington Street \•:' � i" Boston, MA 02111 c ;v www mass govldia . .'Workers' Compensation I hranee Affidavit: Builders/Contractors/Eiectricians/Plambers ApDliicant rnfhrmutinn Name (Business/Organization/Individual)� "1 `— & �t/t City/State/ZiP Insurance Company Policy # or Self -ins. Lie. #: h,V40 C r 4 t G� Expiration Date: Job Site Address: al Atu SFr,c4 N 6 i'Ch Ain of- fAk City/state/zip: Norte A-t14jvR✓'/ MA Attach a copy of the workers' eompensatioo 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 fine up to $4500.00 and/or one-year imprisonment, as well Ms civil penalties in the famn oa STOP WORK ORDER and a fine f of up to $250.00 a day against the violator. Be advised that a copy of this statement may f forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains til % tt RA %I %I— and penalties of perjury that the iRfarmation Pro true vrded above is and cowM161 .. - Officio! use only. Do not write in this area, to he completed by city or town ociaL M161 City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6.Other Contact Person: Phone #: .ore yoy an employer? Cheek.the appropriate box: l . `�'/I am a em to eT with 4, P y_ ❑ 1 am a general contractor and I Tf project (regained): employees (full and/or part-time).* 2. Q I am .a.sole proprietor have hired the sub -contractors listed 6.7[M; New construction 7. or partner- on the attached sheet t ❑ Remodeling ship and have no employees These soli -contractors have 8• Q Demolition working for mei' an y capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9 ❑Building addition required.] 3. ❑ 1 am a homeowner doing officers have exercised their 10•❑ Electrical repairs or additions all work n7yself. [No•workem, comp. right of exemption per MGL c. 152, § 1(4),'and we have no 11.❑ Plumbing repairs or additions insurance required.] t -employees. poye:es. [No workers' 12 Q Ro f repairs comp. insurance.required_) 13 other �m re /d a w 1 ✓' 1 ;Any applicant that checks bob # I must also lilt out the section below showing their workers' oornpensation policy information 1' wncrs who submit this affidavit indicating they are dying ontrac all work and then hire outside contractors must submit a new affidavit indica* such, ZContractons that check this box mustamcbed an additional sheet showing the name of the sub-acrtrr_ractor -4 �a.p. puticy inibrnsaiion. I am an emtployer that is providing:workers' compensation insurance for ►ay en3PLoyees: Below is the policy, and job site information Insurance Company Policy # or Self -ins. Lie. #: h,V40 C r 4 t G� Expiration Date: Job Site Address: al Atu SFr,c4 N 6 i'Ch Ain of- fAk City/state/zip: Norte A-t14jvR✓'/ MA Attach a copy of the workers' eompensatioo 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 fine up to $4500.00 and/or one-year imprisonment, as well Ms civil penalties in the famn oa STOP WORK ORDER and a fine f of up to $250.00 a day against the violator. Be advised that a copy of this statement may f forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains til % tt RA %I %I— and penalties of perjury that the iRfarmation Pro true vrded above is and cowM161 .. - Officio! use only. Do not write in this area, to he completed by city or town ociaL M161 City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6.Other Contact Person: Phone #: 03/04/2010 16:49 9786833147 PAGE 01/01 DATE (PAMlDDIYYYY) ACC)R r CERTIFICATE OF LIABILITY INSURANCE 3/4/10 THIS CEwIFIcATE IS ISSUED AS A MATTER OF INFORMATION PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE M.B. Roberts :Insurance AgenCY HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1060 Osgood street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. North Andover, MA 01945 INSURERS AFFORDING COVERAGENAIC # -- --._.. 1IGURED 1NSURERA Merchants Mutual Insurance ..._..._. •___-.. _ AFFINITY L & 8 COMPANY, THE LNSURERB: ---. -- C/o SCOTT MIT LETTE INSURER G _— --- --- 67 FPJU4KLIN ;5,VENUE INSVRER1> SWAIMSCOTT, I -JA 01907 IP(gU�RE: COVERAGES THE POUCIESOF IN:3URANCE LISTED BELOW HAVE BEEN ISSUEDTO THE NSURED NAMED ABOVE POIJCY PEfiidb INQCATEb. N0TWt1 HSTAUED NDING MAY PERTH THE ItT15RM OR CONDITION OF VSURANCE AFFORDED Sy THE POLICIES OESCRIBECT OR D HEREIN IS USUBJFCT TO LUMENT WITH CL THEOTERMSS,EXC USTHIS K)NSFAND CONDITIONS hPA OF SUCH POLICIES. AGGREGkTE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAA�13. _--. -• -• _--- ---•- — ' --- - �— POLICY NUABER SFE '*" RA LIMrrS EACHOCCUAREN.CE $-1,0001OgD GENEiALLIAIRSIT GEST EI3ftiA A X coMME:R-.IAL GENERALLIAOILITY CCP1038583 2/21/10 2121/11 tceaccumenca) .. S 10-- ..1 CIRiP� MADE40CUR MED E1lP (Any Dna per) $ 5,000 - — PERSONAL&lS7VIPUURY R 1100.0—F000-- D GENERALAGcAae TE $ 2.000,000 GEN'LAWAEaATELMTAPPUESPER PRODUCrs_cDMPiOPAGG s 2,000,_990..-- POLICY --- PRD- LOC AUTOMMILEUAINU Y C"INED SINGLE LIMIT g 1,000,000 (Ea ecclaerx) ANYAUTJ —�--... _.._..- A ALLOWPEDAUTOS 7AM0277014523 2/21/10 2/21/11 SODILYINJURY (Par pardon} SCHEDU[EDAUr03 -- --- X HIREDAIITOs WDII.YINJURY $ (Per acdderj) X NON -O NEDAUTOS _...__..___......—...._._ PROPERLY DAMAGE 3 ---- - ---- (Pm atjdantl GARAGELWEIILi1'Y AUTOONLY-F.AACCLDENT S_---•-•--•_ -.., A14YAU110 OTHERTHAhI -FAhCC -5-- ---• AUTOONLY: Arae $ EXCESS IUMilRELLA41AmIUTY EACH OCCUMENCE 3 1_, 000 _,o00__ X] Occm CLAIMSMADE AGGREGATE.. -_--- s 1,000,040- A DEDUCTIBLE CUP9139349 2/21/10 2/21/11• _._....... s._._--._..-- REYENTION $. S YtlDRKEitS C4euPEF61TION X 'i WC STATU- OTH. AND EMPI.OYERS'I.IAEEILITY _ TORYLIMPIS _ --- ANYPROPIRIE1ORMARTNIME%ECUTIV6 YIN EL EACH gpE $ SDO,OOO OFFnERAENBER EXCLUDED? A (MandatoyInNH) ';�CA9095IS4 2/21/10 21'11/11 El.DISP�•EAEMP EE 500,000 Nyea,d SPEgeacALPROR"09ueVIS(0VSbtilelEL. DIS ICYLIMIT's 500,000 f OTHER DEsc/aPnON OF OPERXIONS I LOCATIM 1 VER CLU 1 OCCLUMMS ADDED BY ENDoRsEMENT I SPIrC1AL PROYMIM RE: BRADM!D MEDICAL ASSOCT.ATZS 21 HIGH STREET NORTH ANDOVER, M14, IF -775-402-47:4 I F%=0"= nAIM un1 n=o r-AN@FI 1 ATIntJ AGQRD 25 (ZU091U1) () 19BB-2009 ACgRD CORPORATION. All rights reserved. The ACORO name and logo 2m rtegistomd marks of ACORA SHOULD ANYOFTFIE A80VEDEWRIIRIMPOUCIP.S W CANCELLEDREFORE TNEE)MRATION DATE THIDiEOF, THE 19SWO INSUReR WILL W01SAVOR TO MAIL —i-0 DAYS WRIrrEN RCG NOTICE TO TRP CE RTIFICATE? HOLDER NAMED TO THP LEFT, BUT FAILURE TD DO SO SHALL NORTH ANDOVER MILLS LLC IMPOSE NO OBLIGATION OR UAAIUTY OF ANY KIND UPON THE INSURER, rM AGENTS OR 17 ]VALOO STREET REPRESMITATNES. SOME,RVTLLE , MA 02143 AUtEEORIzED REPRESE:NTA7M /V #? '/ 0 AGQRD 25 (ZU091U1) () 19BB-2009 ACgRD CORPORATION. All rights reserved. The ACORO name and logo 2m rtegistomd marks of ACORA Date.. &--raj TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......................................................................................... has permission to perform A, ;� ................... j wiring in the building of .... "Z ... C, ............................................................. at �:Z .... 7 IZ . ...................................... . North Andover, Mass. Fee -.'.-.�? ............ Lic. No.,- ....... . . . ...... . .. .. . i�S�E=' ELECTRICAL INSPE Check # 14' —2 6 Commonwealth of Massachusetts Oflicial Use Only Department of Fire Services I r'em'it No. Occupancy and Fee Checkedc��Isr � BOARD OF FIRE PREVENTION REGULATIONS (Rcv. 11;99] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All �Nork to he perlonned m accordance mth the M;tsstuhusetts 1'Icctncal Code (IM lit.'). 527 CMR 12.00 (PLEA( E PR1JVT IN INK OR 117 E, .4LL, IM-ORA1,9770N) Date: _ 1 {h 405 City or Town of: Nor-}\ Ar\JOVC-r- Tn 1he Inspector of wires: By this application the undersigned Elves notice of his or her intention to perfor n the electrical work described below. Location (Street & Number) Z I 14iry1N S�ree+ Owner or Tenant Re Telephone No. Owner's Address LI 14 r q11 is VI-ee. v Is this permit in conjunction with a building permit? )`es ❑ No jQj y`" (Check Appropriate Box) Purpose of Building CO tMMeT'LI`G� \ Utility AuthoriT.ation Nn. Existing Service Amps / Volts Overhead ❑ Undgr•d ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: --1 hr�h r` INo. of Recessed Fixtures lVo. of Lighting Outlets J No. of Lighting Fixtures 17-5- No. ZSNo. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers PNd Dishwashers No.Dryers lit Heaters KW romassage BathtubsR: k um itvtrun n n/ //re lull rin luhle /114111 he ti -aired by the /its wtYo No. ofCeil: Susp. (Paddle) Fans No• of Total Transformers KVA No. of plot Tubs Generators KVA Swimming Pool Above ❑In- 11o. o _mergency ig mg rnd. rnd. Batte knits No. of Oil Burners FIRE ALARMSNo. of Zones No. of Gas Burners No. o Detection and No. of Air Cond. Dotal Tons Heat Pump Number 'Pons KW Totals: Space/Area Heating KW Heating Appliances KW No. K11 Si Wns No. of Ballastslr�3(p No. of Alerting Devices' No. of Self -Contained Detection/Alertin Devices Local ❑ Municipalo Connectin ❑Other Security Systems: No. of•Devices or Equivalent Data Wiring: No. of Devices nr Fw....... I - No. of Motors "Total HP Telecomm No. of INSURANCE COVERAGE: Unless waived by the owner, no permirtifor tilerpe ibrinancerofelectricalred bwortkjmay issue unless pecn,rr of (ti'ires. the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in limce. and has exhibited proofofsame to the permit issuing office. CHECK ONE: INSURANCE, BOND ❑ OTHER ❑ (Speedy:) Estimated Value of Electrical Work: $L/0,000- by (IixpirationDate) •O00• (When required b� municipal policy.) Work to Start: Inspections to be requested in accordance with N1Fl(' Rule IO, and upon completion. 1 certify, under the pubis and penalties q/'perjurp, that Clue infortttatimt nn this applicrttiott is trite and complete. FIRM NAME:m EI��r; Cruet Licensee: LIC. NO.: lal M2 11/'applivahle, enter-exenrpl - in the lircn.cr nrlmhc•r /h7t.. r Signature LIC. NO.: Address: IZ� Ncc.) ( {ph St Sic �e ZVO�jU,� Bus. TO. No.L 35-aa7- by6o OWNER'S INSURANCE WAIVER I ani aware that the Licensee does notGha►c- tEhe liiaabllity insurance coverage normally Alt. Tel. No.: required by law. By my signature below, I hereby waive this requirement. 1 am the (check one) ❑ owner Owner/Agent 11 owner's agent. Signature Telephone No PERMIT FEE: $aSo. 0p The Commonwealth of Massachusetts 11�jj 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 Name (Business/Organization/Individual): PA -111 C.._ EC_ M1 C4LSUN 5U� 1%N� c7l,% I/ 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 't 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 Office of Investigations 640 Washington Street Boston, MA 02111 Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov{dia Date............... <"`° '• "� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING S.4c"Us This certifies that ..........:...... 1.11d, ........................................... has permission to perform ......................... ....... ..................................... wiring in the building of ...../�.. � .......'............................................................ at �:/.........,,................................. ... . North Andover, Mass. I73 Feed........... Lic. No?�? ................ .........; ELECTRICAL INSPECTOR Check # O 8951 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only [Permit No. 0 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 ( C), 52 CMR 12.00 (PLEASE PRINTININK OR TYPE ALL INFORMATION) Date: �l City or Town of. NORTH ANDOVER To the Inspecto of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) V46—" Owner or Tenant Owner's Address / 7 Telephone Is this permit in conjunction with a building permit? Yes 9 No t�/�/��� [:](Check Appropriate Bog) Purpose of Building /// Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: - No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers Heaters Ili Hydromassage Bathtubs completion o the o. of Ceil.-Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool Above ❑ d. No. of Oil Burners No. of Gas Burners No. of Air Cond. is ollowing table may be waived by the Insoectnr nr wi—, irangiormers KVA Generators KVA o. o mergency >$ g 2., L ❑ Batte Units FIRE ALARMS INC. of Trines INC. of Alerting Devices u Totals: __._._ _._. - �� •. GNU. of acu-t., Detection/Ali Space/Area Heating KOV Local ❑ Mu Cox Heating Appliances ICS' Security Syyst No. of No. of Dei No. of Data Wiring: Si s Ballasts No. of Dei No. of Motors Total HP Telecommuni No. of De-. ! .Devices P,❑Other n 0 or Equivalent or Eanivalent Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ;K BOND ❑ OTHER ❑ (Specify:) P �1':) I certify, under the pains dpenalties ofper'ury, that t information on this application is true and complete. FIRM NAME:y�� Licensee: LIC. NO.: �l (If applicable, enter "exempt'�� lice e numbe line. &-- Signature LIC. NO.: Address: B�us. Tel. No.: 7 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. L cl No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ .E — ��� �� f,� i2 `zo-o ff �.' �� o� a-z�-i � �,� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Ararhington Street Boston, MA 02111 t www n ass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Nan a (Business/Organization/Individual):_ Address: City/State/Zip:/✓�, Are yo an employer? Check.the appropriate box: rkets' 1. I am a employer with 4, ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ i am a:sole proprietor or have hired the sub -contractors listed x partner- ship and have no employees on the attached sheet These subcontractors have working for me .in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.) 3. ❑ I am a homeowner doing officers have exercised their all work right of exemption per MGL myself [No•work=' ' comp, c. 1.52, § 1(4), and we have no insurance required.].t .employees. [No workers' comp. insurance required_] •Any applicant that checks bo)C #I must also fill out the section below show: th ' Type of pra}ect (required):6. ❑ New construction 7. ❑ Remodeling 8. Q Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I I.❑ Plumbing repairs or additions 12.E] Roof repairs 13.❑ Other ng err wo compensation policy mtormation. Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such. 3Canttactors that check this box m„srarraehed an addition! sheet showing the name of the sub -contractors and their workers' camp. policy iniosma@on. I am an employer that fs.providing:workers' compensation ursuraace for my employees: Below is the. policy acrd job site Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Hate: Job Site Address:_ ,,G ��� City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal -penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerfiiry under the pains pe es of p rj that the information provided above is a and correct Signature: Of, j`Icial 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): L Board of Health 2. Building Department 3. Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all emp11oyers 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 t3he 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 toyour situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificates) 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. 1f.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 perit or license is being requested, notthe 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 numberlisted below. Self-insured comvanies 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 permitAieernse 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 offthe 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 Bice 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. # 617-7274900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7744 www.mass.gov/dia Date .... .3=Z,�— /J 9� ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... ....................................................................... has permission to perform �EC t` �/�1'9 wiring in the building of ..................................................... ...... ....: 4....-c..................'./..1'.t�...�� , North Andover, Mass. Fee...f �s ........ Lic. No...? Y,1A ... ... ........ . I i1cMICAL INSPE*R Check 'I i 866 _(603) 898-1069Cell (603) 493-7007 Tim VISTtms S,rAco Inst'llmtioo novNo ~_."M,030___-- ti II Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Offi`cciial Use Only FPermit.!y and Fee Checked [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT LV JAW OR TYPE ALL INFORMATION Date: l City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives otice of his or her intention to perform the electrical work described below. Location (Street & Number)-r— Owner or Tenant nit , /..,:. i /I Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes NO Purpose of Building ❑ (Check Appropriate Box) Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps 1 Volts Overhead ❑ Undgrd ❑ Number of Feeders and. Ampacity Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers Heaters KW o. Hydromassage Bathtubs OTHER: e. •— C,'om�etion of the followin No. of Ceil: Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool Above �_ P-rnd. ❑ rnd. ❑ No. of Oil Burners No. of Gas Burners No. of Air Cond. Total Tons Heat PumpNumber Tons KW Totals: ._..._ _..___.. Space/Area Heating KW Heating Appliances KW No. of No. of Signs Ballasts . No. of Motors Total HP kd,c,�P— No. of Meters No. of Meters table may be waived by the Inspect INo. of Total Transformers "7 A6 Generators KVA ALARMS No. o. of Alerting Devices tion/Alerting Devices ❑Municipal Connprfinn ❑ Other No. of Devices or to Wiring: No. of Devices or ecommunications No. of Devices or Wires. Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to StartInspections 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 ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete FIRM NAME: `� ° Si LIC. NO.: Licensee: Signature (If applicable, enter "exempt " in the license number line.) LIC. NO.: Address: Bus. Tel. No.: rl?3 -74-k9 Z *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. L cl. No OWNER'S INSURANCE WAVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ 3,f�—©ct Ap A The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 NTashingion Street Boston, MA 02111 c : www.mass.gov/dia Workers' Compensation Insbrance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Pr>tnt LeQlbly /' Name (Business/Organirafion/Individual): City/State/Zip: Z_ Phone #: . FM Type of project (required): 6. ❑ New construction 7. ;� Remodeling 8. Q Demolition 9. ❑ Building addition 10. Q Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.E Other homeowners who submit this affidavit indicating they are daring all work an0 V- On Poi icy InTormation, d then hire outside c ntnutots must submit new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing. the name of the sub -contractors and their worts' cam ,Folic; i ;w rattan. I am an employer than isproviding.workers' compensation insurance for my. employees. Below information. is the policy andjob site Insurance Company Name: Policy 9 or Self -ins, Lic. 4: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the Workers' .compensation policy declaration page (showing -the policy number and expiration date Failure to secure coverage as required. under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the farm 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 I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct 1� Signature: Date v 0 ri Phone 9: 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): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Are you an employer? Cheek.the appropriate box: I. ❑ 1 aro a employer with 4. E I am a general contractor and I employees (full and/or part-time).* 21MO, I am .a:sole proprietor or have lured the sub -contractors _ listed partner_ on the attached sheet. ship and have no employees These sub -contractors have working for mei' any capacity, workers' comp. insurance. [No workers' comp. insurance 5. [1 We are a corporation and its required.] 3. ❑ I am a homeowner doing officers have txercised their 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..] *Any applicant that checks bc,)e# l must also fill out the section below showin their workers' oom FM Type of project (required): 6. ❑ New construction 7. ;� Remodeling 8. Q Demolition 9. ❑ Building addition 10. Q Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.E Other homeowners who submit this affidavit indicating they are daring all work an0 V- On Poi icy InTormation, d then hire outside c ntnutots must submit new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing. the name of the sub -contractors and their worts' cam ,Folic; i ;w rattan. I am an employer than isproviding.workers' compensation insurance for my. employees. Below information. is the policy andjob site Insurance Company Name: Policy 9 or Self -ins, Lic. 4: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the Workers' .compensation policy declaration page (showing -the policy number and expiration date Failure to secure coverage as required. under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the farm 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 I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct 1� Signature: Date v 0 ri Phone 9: 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): L 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,,asscniation, 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, MOL 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 cityor town that the application for the permit or license is being requested, notibe 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 numberlisted 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/iicense number which vvilI 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, pie= 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, 1\4A 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MA.SSAFE Fax # 617-727-77451 Revised 5-26-05 www.mass.gov/dia A I Date.":....... Z ........ ....... 0*,- TOWN OF NORTH ANDOVER 10 PERMIT FOR WIRING 'Vow '5bhis certifies that ................................................................. has permission to Perform- .................................................................... wiring in the building Of ..... ................................................. at ...... ............. 4�2�North Andover, Mass. Fee ........... Lc. Nofl�l/-?`/ �........ jc , ... E JNsiE Check # rb 5 (1, )� Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. o Y,9 Occupancy and Fee Checked010 / � [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice his or eerrriinntenttiiionntto perform the electrical work described below. Location (Street & Number) Owner or Tenant P/7f Owner's Address ,/77 , Telephone No. b/%�"I-r/I- Is this permit in conjunction with a building permit? Yes NO E] ❑ (Check Appropriate Box) Purpose of Building_ �//,�/� `�f Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters New Service Amps / Volts Overhead ❑ Und rd g ❑ No, of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers _ Completion o"' No. of Ceil.-Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool Above ❑ �_ : rnd Sri No. of Oil Burners No. of Gas Burners No. of Air Cond. Total Tons No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Appliances KW No. of Water KW No. of o. of Heaters Signs Ballasts Hydromassage Bathtubs INo. of Motors Total HP LN table may he waivad h„ tha T. -- LN . -- No. of Total Transformers KVA Generators KVA 0.0 mergency Ig g Batte Units hFIRE ALARMS No. of Zones VNo. f Detection and nitiatin Devices f Alerting Devices f Self -Contained Detection/Alerting Devices Local❑ Municipal Connection ❑ Other Security Systems: * No. of Devices or Equivalent Data Wiring: No. of Devices or E uivalent Telecommunications Wiring: No. of Devices or E uivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Elec 'ca Work: _ d (When required by municipal policy.) Work to Stark � � OY 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 ❑ OTHER ❑ (Specify:) I certify, under the pains and p Wallies o perju , that the informa ' on this application is true and complete FIRM NAME: LIC. NO.: Licensee: C - �� �� Signature (Ifapplicable, ente "exempt in the license number 1' LIC. NO.: Address: Z GiiQd� G1-`jo.�j� Le Bus. Tel. No.: 1 D 7 *Per M.G. c. 147, s. 57-61, security work requires Department of Public Safety ""S" License: �t L cl. No.�7 3 OWNER'S INSURANCE WAVER: I am aware that the Licensee does not have the liability insurance covee o m lly required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ Y w. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Nrashington Street Boston, MA 02111 r = www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plambers Auulicant Information Please Print Legibly Name Addre,, City/State/Zip:_ /�'/,��✓ Phone #:. Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ 1 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. ❑ 1 am a homeowner doing all work myself. [No•workers' comp. insurance required.) t .A_..___.• have hired the sub -contractors listed on the attached sheet. # These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 1.52, § 1(4), and we have no employees. [No workers' camp. insurance required..] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. [] Building addition 10.❑ Electrical repairs or additions f 1 - Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other -•-1 "" .. ... Lo, w'c xD vox u 1 mus[ also tail out the section below showing their workers' compensation policy information. T Homeowner¢ 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' camp, prlic� i ; madon. I am an employer that is providing workers' compensation insurance for my employees: Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. LIC. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date Phone #: a F only. Do not write in this area, to be completed by city or town official 1r Permit/License # hority (circle one):Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector son 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 tnrstee 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 cant' 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, note Department of Industrial Accidents. Should 'you have any questions regar-ding 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 sell= -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 Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia h .14 L Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SS US � This certifies that ............. . has permission to perform ..... `a ..... ...................... . plumbing in the buildings of .. f, `..... �................ . Y ............. .North Andover, Mass. Fee. Lic. No...)�(�..1.. LIVIBING INSPECTOR Check # h MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Buildin Location /� Date - g - �� y7 Owners Name �� �I& S Permit # a T an Type of Occu c d-oAU/z'iR Amount New Renovation Replacement Plans Submitted Yes ❑ No Tt M"rYTD imo trnnt or type) Installing Company Name Address Name of Licensed Plumber: Insurance Coverage: Indicate the Liability insurance policy El -ance coverage by checking the Other type of indemnity ❑ Check one: Certificate Corp. Partner. Firm/Co. box: Bond ❑ Insurance Waiver. I, the undersigned, have been made aware that the license three insurance e of this application does not have any one of the above Signature Owner ❑ ❑ Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State lu inQ Code miter 142 of the General Laws. By. Signa ure p Lrce s rum er-c Title Type of Plumbing License City/ own - 7 rcense um er Master journeyman APPROVED (o tcs usE oNLy ❑ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that...... 1: ........ 11.. .................... has permission to perform ...... ...... .. .... ....................................................... wiring in the building of ............................................ at.::: ... ........... 1: .... .................. North Andover, Mass. Fee :: ........ Lic. Noll,', 4f�- ................ ........ .. ELECTRICAL "i=4 R... Check # D i Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 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 (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /Q -�)"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) �2 / N t ��l -) _ () �„�,✓ Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes Q No ❑ (Check Appropriate Box) Purpose of Building f j.; �/e Utility Authorization No. Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters No. of Recessed Luminaires J ••- No. of Ceil: Susp. (Paddle) Fans uune n�uy ue waived D the Jl ector o wires. o. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above El- ❑ 2rnd rnd. o. o mergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection and Initiatin Devices No. of Ranges No. of Air Cond. TotaTons l No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons o. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers No. of Water aeaters KW Heating Appliances KW No. of No. of Signs Ballasts . Securityj Devices or Equivalent 1 Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivaleut OTHER: Auacn additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: / 0 ;)r-0$ 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 cov rage is in force, and has exhibited proof of same to th eimit issuing office. CHECK ONE: INSURANCE [ BOND ❑ OTHER ❑ (Specify:) /t�]`t'► —r 0—CR I certify, under the pains and penal ' s of perj uryythat the in ormation his applica ' is true atld complete. l�^ FIRM NAME: LIC. NO.: Licensee: ✓MAI 4e. re LIC. NO.: L Qj (If applicable, enter " m t " in e lic �e numb 1' Bus. Tel. No.4 %r� O�//q.)Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security wor requirnt 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 Signature Telephone No. PERMIT FEE: $— `�- j491e- 3_1�-D4 4� i 1'� The Commonwealth of Massachusetts Department of Industrial Accidents Off ce of Investigations 600 Washington Street Boston, MA 02111 f `r www.muss.gov/dia . Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organizationtindividuat): Address: City/State/Zip: Phone #:. 7 7e-0 _,�)'1lq) Are you an employer? Check the appropriate box: Type of project (required): I. ❑ 1 am a employer with 4. ❑ 1 am a general contractor and I 6. New construction employees (full and/or part-time).' 2. ❑ 1 am a.sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. Remodeling ship and have no employees s ese sub -contractors have e S. Q Demolition working forme .in any capacity, m' comp. insurance. in 9 Building addition [No workers' comp. insurance 5. , are a and its l0.[�Eleo'bical repairs required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MOL P or additions 11.0 Plumbing repairs or additions myself. [No workers' comp, c. 1.52, § 1(4), and we have no 12.E] Roof repairs insurance required.] t employees. [No workers' 13.[].Other comp. insurance required..] nny appircam mar enecxs box # I must also fill out the section below showing their workers' compensation policy information, t Homeowners who submit this affidavit indicating they are doing an work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this boa mustauachad an additional sheet showing the name orthe sub -contractors and their wotkers' camp. policy information. l am.an employer that. is providing workers' compensation insurance for my employees: Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MOL 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 again"e e violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA i urance coverage verification. I do hereby certify and penalties of perjury that the information provided above is true and correct t I� Offxhd use only. Do not write in this area, to be completed by city or town of ciaL City or Town: Permit/License # Issuing Authority (circle one): I. 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 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 peimit 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 v<<ilI 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 3 Department of Industrial Accidents Offiee of Investi rations =� 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 Ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7744 www.mass.gov/dia M Date ... f .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING RC Thiscertifies that................................/....................................................... has permission to perform ....4pA9 ....... wiring in the building of ...... l...0.................................................................... at ......— Nor ..............................th Andover, Mass. Fee l Z�.7 ... Lic. No. L �a y .V .............1. ,,.Gf ...G � .. ..;•�.......... _..... EI )CTRICAL INSPECTOR Check # 8467 V "I Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC),,527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /G' %&; 1*140 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) f'/41 Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes Q Purpose of Building &JO 1 awl Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Telephone No. No ❑ (Check Appropriate Boz) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Cmmnletinn nfthv fnll—ino tnhlo ,,, , ho -a A— R.,, T rar.. 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- ❑ o. o mergency ig g rnd. rnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of SwitchesNo. of Gas Burners No. of Detection and InitiatingDevices No. of Ranges t No. of Air Cond. Total No. of Alerting Devices No. of Waste Disposers Heat Pump Number _Tons KW No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances Imo' Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Data Wiring: Si s Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uiv'LR OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains andpens ofperjury, that the information on this application is true and complete. FIRM NAME: ��% f� �-' �r� LIC. NO.: 4-4:2;I1 '7 Licensee: � I Signature « LIC. NO.: (If applicable, enter "exempt " in t e license fnumoer Address:Bus. Tel. No. 7C��G 1% "%St'�//'�/v- Alt. Tel. No. V - X✓ 717W *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 Signature Telephone No. PERMIT FEE: $ "' iq u t ." I 1 tl �IX, i s" www.niass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridians/Plumbers Applicant Information Please Print LegibIy Name (Business/Organization/Individual): Address: City/State/Zip: e 0,A/ R �Z/�� �e Phone i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Are you an employer? Check the appropriate box: 1. [9 I am a employer with 4 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 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. 1.52, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] *Any applicant that checks box ## 1 m— l fll th 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-ElRoofrepairs 13.❑ Other us .so r out a section below showing their workers' compensation policy information. t art .0 11 atl work and then hire outside contraciors must submit a new affidavit indicating such. Homeowners who suUmit.fliis affidavit indicating they lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_ TL Policy # or Self -.ins. Lic. #: Expiration Date: Job Site Address: ) �i� , 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. / do hereby certify under theme ains and _ naides ofperjury that the information provided above is true and correct Sirrtature: �-'1 �. - j r, .. &A;"/ #: IS 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 w insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to cavy 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 t 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. 4 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax 4 617-727-77449 www.mass.gov/dia Datee�U/Z /* G* TOWN OF NORTH A DOVER PERMITi FOR PLUM I G This certifies that .:/Cf.%,�L �.... � �-. 4-.�t�....�... .......... . has permission to perform ... S ....................... plumbing in the buildings of .. Rc(r.......................... at. ./.. Fir 1 S ! f orth Andover, Mass. Fee .9-U ... Lic. No. ......? . ...... `�. .. �.!� y . . 'PLUMBING INSPICTOR Check # � U i� I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Date U t < A A -- Permit Permit # 7Ft r Amount New Renovation Replacement ' Plans Submitted Yes ❑ ❑ No FT 'TT TD tMo (Print or type) InstaIling.Company Name Name of Licensed Plumber. Insurance Coverage: Indic; Liability insurance policy ance coverage by checking the Other type of indemnity M Check one: Certificate 11 Corp. Partner. Firm/Co. box: Bond ❑ Insurance Waiver. I, the undersigned, have been made aware that the lic three insurance ensee of this application does not have any one of the above Signature Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachuset4"ns &22-04 and Ch 4 e General Laws. By: igna ure Title Type of Plumbing License City/ own f $ 7 License um er '�� Master 0 ---Journeyman ❑ APPROVED comics vsE ONLY r' M Date... /07/' .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........... \A0tv.-q.... r... kvs........ ,-, C .............. has permission to perform ..... v. 7.7' .......... wiring in the building of ...................................................................... LS at ........ .... r�.'���....�.L.............,_. .......... T' ......... ,North Andover, Mass. Fee . �........ `-" ... Lic. No. % ...... ......... ............ .....,r,Wa..� .......... ELECTRICAL INSPER Check # Q4u4 A cl�N, Commonwealth of Massachusetts Official Use Only Now, Department of Fire Services Permit No.'/j C/ BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/073 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC) 527 1 MR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFOP1lIAT70N) Date: 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)C11 jL/l(tj #Ir Owner or Tenant Owner's Address Is this permit in conjunction with a buildin permit? Yes Purpose of Building Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: j�ewd 4-VOIJ OF 'Plyo5 11,zlw Telephone N No ❑ (Check Appropriate Bog) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters / Estimated Value of Electrical Work: 0� Attach additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the Iicensee 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 Al BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that th information on this application is true and complete. FIRM NAME: � C� LIC. NO.: 64 Licensee: 71in�,,;2: SLIC. NO.: 7 14717 7/ (If applicable, en er "exe pt" i�� is use numbeAddress: (� � � Bus. Tel. No.: / 7l% ,4 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt Lec. 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 o Owner/Agent !1_e_)0 owner El owner's agent Signature Telephone No. PERMIT FEE: $ .... 1.,..UW..1 - le may oe wazvea oy 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 3 Swimming Pool Above ❑ in- ❑ o. o mergency Eigg rnd. grnd. t Battery Units No. of Re^�-tacle Outlets �"r N` f `t=' B v. v vu yiiruerS FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and linitiatin Devices No. of Ranges No. of Air Cond. To Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW No. of Self -Contained Totals: - _ Detection/Alertin- Devices No. of Dishwashers Space/Area Heating KWMunicipal I'O� ❑ ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Water No. of Devices or Equivalent No. of Heaters Si s Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: / Estimated Value of Electrical Work: 0� Attach additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the Iicensee 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 Al BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that th information on this application is true and complete. FIRM NAME: � C� LIC. NO.: 64 Licensee: 71in�,,;2: SLIC. NO.: 7 14717 7/ (If applicable, en er "exe pt" i�� is use numbeAddress: (� � � Bus. Tel. No.: / 7l% ,4 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt Lec. 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 o Owner/Agent !1_e_)0 owner El owner's agent Signature Telephone No. PERMIT FEE: $ r 11 k 1 wy�� i• 1 �? i L �� F t•Tf r tl�rpr"�� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, jVL4 02111 t -" www_mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrieians/Plumhers Applicant Information /,% p Please Print Legibly MName (Business/Organization/Individual): "Y /fi -";V/A Address: City/State/Zip: 4PIM �WVPhone #: 0`V � qz� � y Are you an employer? Check th appropriate box: I T I am a employer with .1 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I have hired the sub -contractors 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. 1.52, § 1(4), and we have no insurance required.] t '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 11.0 Plumbing repairs or additions. 12.❑ Roof repairs 1.3.7 Other --.+-rr••--••• ••••-• •••••'�••� w^ ^ • I-- aWU LID ULLL LDc section De10w snowing their workers' compensation policy information, t homeowners who subi»it.this affidavit indicating they ate u'oing ail weak $tLel Chen.hire outside contra "tors must submii.a new affidavit indicating such. 'Contractors that check this boa must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I an employer that is providing workers' compensation insurance for my emp�gyees. Below is the policy and job site information.�/ Insurance Company Name:_ • y Policy # or Self -.ins. Lic. #: Expiration Date: ' Job Site Address: � //C l�}y City/State/Zip:_",_� Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). .Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Si -em ature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone # Information %nd Instructions -e ,, 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 Piease fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contactor(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 afficlavit 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 nuumber.listed below. Self-insured companies should enter their self-insurance license number on the appropriate tine. 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 pennit/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. 4 617-727-4900 ext 406 or 1-877-MASSAFE Fax 4 617-727-7749 Revised 5-26-05, wvm,.inass.gov/dia Date.... t NORTH '1 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... ........ ...... has permission to perform .............. wiring in the building of ............. ec.c .... ...................................................... ....... at ................. jc�Llo.�2;W .. : T ............... North Andover, Mass. i .Fee/54-, Z.... Lic. Nol.—S.? .. ......... . �C................ ELECTRICAL S )t Check, 76s-iq 840 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. r BOARD OF FIRE PREVENTION REGULATIONS 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 (MEC), 527 C4R 12.00 (PLEASE PRINT IN INK OR .TYPE ALL INFORMATION) Date: 14- e v' City or Town of. NORTH ANDOVER To the Inspector of ices: By this application the undersigned gives notice of his or her intention to perform th Oectrical workdescribedb Location (Street & Number) 2� �%� %�, ��� �/''' zz .ice✓ Owner or Tenant _ Owner's Address A/ Telephone No. Is this permit in conjunctio with a building permit? Yes ® No ❑ (Check Appropriate Boz) Purpose of $wilding Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity fi Location and Nature of Proposed Electrical Work: No. of Meters No. of Meters i'mm�lotinn No. of Recessed Luminaires — •••E ,...•. No. of Ceil: Susp. (Paddle) Fans —1- --y tie wutveu by the ins ecror of wires. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above in- ❑ o. o mergency ig , g rnd. rnd. t 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 Initiating Di'vices No. of.Ranges Total No. of Air Cond. Tons No. 'of Alerting Devices No. of Waste Disposers Heat Pump Number Tons _- KW _ No. of Self -Contained Totals: Detection/Alertim Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW SecuritySystems:* No. of Water No. of No. of or Equivalent Heaters KW s Ballasts Sivices Da No. f De or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Arracn additional detail ff desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE K BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and nal'tie//�� o per u th the in non th' pplication is true and complete FIRM NAME: 7��/l/ LIC. NO.: Licensee: Q Signature LIC. NO.. (If applicable, entt r"exempt e li en e u :n / / /J / Bus. Tel. No.: Address: _ ��i/L{p� i� "U /� / !p� Alt Tel. No.: �Q�O *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 Signature Telephone No. [PE" -[T FEE: $ Rl� to/ -c The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 _ www. 17zMs,gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legnbly NaMe (Business/Organization/individual): Q / �Z Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 114 I am a employer with _90 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I have hired the sub -contractors 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.] 3. ❑ I am a homeowner doing all work officers have exercised.their right of exemption per MGL myself. [No. workers' comp. c. 1.52, § 1(4), and we have no insurance required.] t 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 11.7 Plumbing repairs or additions 12.0 Roof repairs 1.3.7 Other - - - --•• ��•• •• • ••• • u .� • �u< <��_ bccnon ociow snowing their workers' compensation policy information. t Homeowners who submit.'ihis affidavit indicating they arc doing aei work aticl thenhire outside contraciors must submit.a new arndavir indicating such. +Contractors that check this boa must attached an additional sheet showing the name of the subcontractors 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: l�� f�j` �(j I'� City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). .Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under t a and penalties of perjury that the information provided above is true and correct Sic -nature: Date: Phone #: (— Official use only. Do not write in this area, to be completed by city or town offciaL City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information %nd Instructions Y 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 permit16 operate a business or to construct building 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 comps etely, 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 cavy workers' compensation insurance. If an LLC or LLP does have _ employees, a policy is required. Be advised that this afficlavit 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 workcms' compensation policy, please call the Department at the namber.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 pennit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/iicense 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 # 617-727-77449 www.mass.gov/dia Date.../P" /$ :�'. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......... P4,7 ............ ....:.................................................... has permission to perform ��!�%Tl—'/� ..................................................................... wiring in the building of .............. /..�. .. ��.................................................... at ...!.�9..y :......'-.. `�'���L , North Andover, Mass. ............................. . �= Fee.......'............ Lic. No../y......ah ..... i# ........ ..:.................................. % ELECTRICAL INSP CTOR Check #l'7 9� IJ ., Commonwealth of Massachusetts Of Use Only Department of Fire Services Permit No. l3 UV BOARD OF FIRE PREVENTION REGULATIONS occupancyv 9 1and Fee Checked leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be perfortned in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPEALL INFORMATION Date: q - a5 -o '6 City or Town of: A r --J d of e r- To the Inspector of Wires: o`" By this application the undersigned gives notice of his or her intention to perform the electrical work d bed below. Location (Street & Number) 9.1 14; oO) -S NOW K Owner or Tenant RCG H 0 c+h Arvcloy e; Ivt ; I 1 S LLC C>-2-1143 Telephone No. Co iy S9 I -g (o c6 a Owner's Address P 1vAL-00 51 Su;.}& LAUQ gor�ec�v; Il Q �/i Is this permit in conjunction with a building permit? Yes a No ❑ (Check Appropriate Box) Purpose of Building O Vit^ kC2 SPA -Q-0- Utility Authorization No. t ---J/,4 Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / _Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity t C /o G A - 12 0 / ZO S 1 G Pp -N o-� Location and Nature of Proposed Electrical Work: p F F k C e C-, P . L , ,� h Po �N O - Q N6 N ew P P" e l 'f Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires Lo No. of Ceil.-Susp. (Paddle) Fans o. of Transformers ota KVA No.. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool 7KbOVe ❑ In -El rnd. emd. No. ot Emergency Lighting Battery Units ,J No. of Receptacle Outlets I No. of Oil Burners FIRE ALARMS I No. of Zones No. of SwitchesNo. 1 of Gas Burners o. of Detection an Initiating Devices No. of Ranges No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers eat Pump Totals: Ium er ITons I KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal Connection ❑ Other No. of Dryers Heating Appliances KW Security ems: No. of Devices or Equivalent No. of Water, Heaters o. o o. o Signs Ballasts ::INo. Data Wiring: No. of Devices or nuivalent Hydromassage Bathtubs No. of Motors Total HP a ecommunrcahons No. of Devices or Equivalent irmgg• (OTHER: (ooA 30 DlScaNNec+- Attach additional detail if desired or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: q I 2 (0 16 `,S 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, andhas exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE M BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Page Electrical C. NO.: A14091 Licensee: Kenneth A. Page Signature ;i'C , :: r LIC. NO.:_ E27010 afapplicable, enter `exempt" in the license number line.) t Bus. Tel. No.:( 978) 537-8437 Address: _60 Elm Hill Avenue Leominst ihLA 01453 Alt. Tel. No.: *Security System Contractor License required for this work; if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent Owner/Agent Signature Telephone No. PERMIT FEE. $ 4q-8-� C a-5 a 0 `4 V 8280 sq F" 1, 25. o i I 1-60 � r� � u° jLW 0 69.f 1-04 41 10/31/2008 FRI 8:40 FAX 9785371837 Page Electrical Corp. • R ni Om 69 Og n r m � �1 N m W s,.— do D 5- ` 14 O Z . m m • R ni 69 r W s,.— w 0002/002 Date ....... ....... TOWN OF N6R;rH' ANDOVER PERMIT FOR GAS INSTALLATION . . This certifies that . .,/. o/..... . . . . . . . .' has permission for gas installation ... ............ in the buildings of ...... .......................... . at . Z-!... North Andover, Mass. Fee". .r ©. roti Lic. No.. -,� . ........ ./ ................... GAS INSPECTOR Check# 12�") 6501 MASSACHUSETTS UNIFORM APPUCATON FOR PERNIlT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations/ S -f" SL�e �P Owner's Name New Renovation ❑ Replacement ❑ C� SU B-BASEM ENT BASEMENT 1ST. FLOOR 2ND. 3RD. 4TH. FLOOR FLOOR FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. 8TH. FLOOR FLOOR (Print Name Addre Date Plans Submitted ❑ Permit # Amount $ w vi o zrA 0 c o° z a� c a > w W I- F y+ or typW� Check one: Certificate Installing Compan ❑ Corp. y ss�- ❑ Partner. :ss Telephone Q , �y ? _ ❑ Firm/Co. Name of Licensed Plumber'or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance, policy or it's substantial equivalent. Yes If you have checked es please indicate the type coverage by checking the appropriate box. No[ --] insurance of , P icy � Other type of indemnity 13Bond13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent 13t hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Stage Gas Code and Chapter the General Laws. Title y City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber --�J- 7 ❑ Gas Fitter (cense NumDer ffl aster ❑ Journeyman Z p, aa 0.' W W x C7 s F w Z > F Z z W W C7 = d Permit # Amount $ w vi o zrA 0 c o° z a� c a > w W I- F y+ or typW� Check one: Certificate Installing Compan ❑ Corp. y ss�- ❑ Partner. :ss Telephone Q , �y ? _ ❑ Firm/Co. Name of Licensed Plumber'or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance, policy or it's substantial equivalent. Yes If you have checked es please indicate the type coverage by checking the appropriate box. No[ --] insurance of , P icy � Other type of indemnity 13Bond13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent 13t hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Stage Gas Code and Chapter the General Laws. Title y City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber --�J- 7 ❑ Gas Fitter (cense NumDer ffl aster ❑ Journeyman z �/' This certifies that Z:e .. ... ......."....../ ........... has permission for gas installation .......... in the buildings of ....... :............/..................... . .at ................. I .................... North Andover, Mass. Fee....'.:..'. Lic. No.. .......... GAS INSPECTOR Check # J 6500 Date....:.%' NORTH TOWN OF NORTH ANDOV • PERMIT FOR GAS IN LATIO z �/' This certifies that Z:e .. ... ......."....../ ........... has permission for gas installation .......... in the buildings of ....... :............/..................... . .at ................. I .................... North Andover, Mass. Fee....'.:..'. Lic. No.. .......... GAS INSPECTOR Check # J 6500 4 it MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FMING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Logations _/I! .�li 1i,2 W.-� Owner's Name New U Renovation D Replacement Date ■ Permit # Z2.'rfr Amount $ Plans Submitted (Print or type)/ Check one: Certificate Installing Company Name / � Corp. Address � Partner. O Busy essTelephone — (o - Firm/Co. Name of Licensed Plumber'or Gas Fitter A" o /J INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. YesNo13 If you have checked yes, please i cate the type coverage by checking the appropriate bo13 x. Liability insurance policy Other type of indemnity D Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent 13 I hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code an� Cha r/t4f the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber /J -a 7 Gas Fitter License Number u Master 0 Journeyman w �vi w a x C w Z � E� F w Q rant O vyO O w F CO) F ¢ W a w "' W O W F Z W > cael a .F. Z F d h Z O Z w p m o x 3 0 a o> o a SU B -BASEM ENT BASEMENT 1ST. FLOOR 2N D. FLOG R 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 5TH. FLOOR 1T H. FLOOR. IT H. FLOOR (Print or type)/ Check one: Certificate Installing Company Name / � Corp. Address � Partner. O Busy essTelephone — (o - Firm/Co. Name of Licensed Plumber'or Gas Fitter A" o /J INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. YesNo13 If you have checked yes, please i cate the type coverage by checking the appropriate bo13 x. Liability insurance policy Other type of indemnity D Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent 13 I hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code an� Cha r/t4f the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber /J -a 7 Gas Fitter License Number u Master 0 Journeyman Date. w a'.".��� TOWN OF NORTH ANDIO ;ER ° p PERMIT FOR�'PLUM$1NG NSS� This certifies that ....... has permission to perform .. .............. ................ plumbing in the buildings of ................................ . at %... .. .1! o `r�th Andover, Mass. o! Fey..... L'c. No.......... ....... PLUM INSPECTOR ' Check .742 d V Date. TOWN OF NORTH ANDOVER PERMIT FORPLUMBING This certifies that .......... ............................... has permission to perform Plumbing in the buildings of ........ at ........... orth Andover, Mass. Fe -e-3!-.-. Ul/c. No .......... '.-PLUMB�-1Z. . .... 'INSPECT 0 R Check 2 8186 ; , MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location a 1 n l+ � A 5 �. an G 6— Date U/,;� , Permit # / Amount T pe of Occupancy Cbmm p rr_ + e t New Renovation Replacement 0 Plans Submitted Yes No ❑ (Print or type) p Check one: Certificate Installing Company Name ❑ Corp. Partner. Firm/Co. Name of Licensed Plumber: ,Tg M0 S to j<'r f Ayr Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ® Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner 1:1 Agent 11 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Pe ued for this application will be in compliance with all pertinent provisions of the Mas sAeTsetts n Chapter 142 of the General Laws. By' ign e 01 LicenseCI iriumoer pe of Plumbing License Title j Jr o APPROVED L'ticense um er Master Journeyman 11APPROVED (oFFtcs USE ONLY / / .J -�-----�--�---------®----■ .!�.----------.----- --MMM -----■ NM= -.-------.-m ---� W-11juFF970MMMMMMM--.------------.. ---- (Print or type) p Check one: Certificate Installing Company Name ❑ Corp. Partner. Firm/Co. Name of Licensed Plumber: ,Tg M0 S to j<'r f Ayr Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ® Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner 1:1 Agent 11 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Pe ued for this application will be in compliance with all pertinent provisions of the Mas sAeTsetts n Chapter 142 of the General Laws. By' ign e 01 LicenseCI iriumoer pe of Plumbing License Title j Jr o APPROVED L'ticense um er Master Journeyman 11APPROVED (oFFtcs USE ONLY M t 0 Date...`..~.. /�^p v %``° '• "� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that ..........D.(/.w�....................................... Y-1.has permission to perform ...Ig 41 S �i�i/lilAl, .iCri% ......................... wiring in the building of ��G f1r��ts L ................................................................ .....:: S %...�/ �! $7`........ , N rth Andover, Mass. Fee'//. / .:..... Lic. No... t .M�7t."A.'.............................................� .... % , ELECTRICAL INSPECTOR Check N 8302 ra U Commonwealth!' of Massachusetts Official Use Only Department of Fire Services Permit No. �3�Z Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (M 52p7 R 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspe for of Wires: By this application the undersigned gives notice of his or her inten ion to perform he electrical work described b -l`ow.w. _ Location (Street & Number) ,.- (j�V. ( 1 Yl( (�Fl �D� r4o5l Owner or Tenant H (4 Telephone No. Owner's Address `7 /`"�JO® At /0,0 e, 0 A'45 0/0/z Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building D�%�1-- 4# 1111r_f � -/ Utility Authorization No. Existing Service P_ Amps / !e7 Volts Overhead ❑ Undgrd g No. of Meters _ New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity. Location and Nature of Proposed Electrical Work: W/0/04 7-1V'jtJ Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Z Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o mergency ig ng Battery Units No. of Receptacle Outlets �3C7 No. of Oil Burners FIRE ALARMS I No. of Zones No. of SwitchesNo. �o of Gas Burners No. of Detection and Initiating Devices No. of RangesQ No. of Air Cond. TotTons No. of Alerting Devices 410el No. of Waste Disposers/ / 0 Heat Pump Totals: Number Tons KW ...................... No. of Self -Contained Detection/Alerting Devices 214r - No. of Dishwashers /Q Space/Area Heating KW Local ❑ Municipal ®- Other Connection No. of Dryers /0 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 Equivalent v 4 No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Estimated Value of Electrical Work /�O k Attach additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 0 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that th rmation on this application is true and complete. FIRM NAME: O e X/4 f LIC*NO *- Licensee: y04/A .) 4 Signature LIC. NO.. (If applicable, enter "exempt" in the licens number line. Bus. Tel. No.: Address: �y A,10 par -7- � � %Z. �i�� i Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Llc. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $� ,or - q;_" Se7� !-�d�� 9 V 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 uplicant Information Please Print Leeibl, Name (Business%Organization/Individual): 4e� -2 Address: City/State/Zip: �i��P0/YPhone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors ?. ❑ I am a sole proprietor or partner- listed on the attached sheet. # ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] f These sub -contractors have workers' comp. insurance. ❑ 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 10.0 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: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address:_ _ Z/ � City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. ` Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 6VP /9- 5rg Date ........Sl..... .................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............ ...... ** 0'W " has permission to perform.................................... wiring in the building of ............ ... 41KAY1 :K../4c at ....... M14 ............................ North Andover, Mass. 2 Fee Lic. No.. 1-3R'V'A ..... -/I -; * ELECTRICALINSPECTORP Check # 8300 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. p 3 ay 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( EC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: d�I� e 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/ � T�oGAi 9lk �i�'- Owner or Tenant Owner's Address Telephone No. OW E7 Is this permit in conjunction with a building permit? Yes [ No ❑ (Check Appropriate Box) Purpose of Building �D, 1A5:>�A2�1 Utility Authorization No. Existing Service 919,0 Amps G' l Volts Overhead ❑ Undgrd [0 No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters _ Number of Feeders and Ampacity //4 Location and Nature of Proposed Electrical Work: Az / Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires t` Above In- Swimming Pool rnd. ❑ rnd. ❑ o. o mergency ig ing Batte Units No. of Receptacle Outlets %/7 No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches 5 No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number I TonsJ. KWNo. ........... of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal rg Other Connection No. of Dryers Heating Appliances g pp Kms' Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: n No. of Devices or E uivalent C• No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of per ury, that the infor on on this application is true and complete. FIRM NAME: vLvvs LIC. NO.: Licensee: Signature LIC. NO.: /// 4 0' 7 ;1 (If applicable, entyxexe nthe linum er line �� Bus. Tel. No.:*12509;71 7 Address: �� Q� Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. P ERMIT FEE: $ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 mss. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Z�W%76 i�,/0aoi5,7 Phone #: ar/ Are you an employer? Check the appropriate box: / 1. ®, I am a employer with �p 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- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t listed on the attached sheet. These sub -contractors have workers' comp. insurance. 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. 15TNew construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F-1 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. t :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: 2 1 Job Site Address: :% // U /� City/State/Zip:-_ _/P®497/_� 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 zs and enalties ofperjury that the information provided above is true and correct. Signature: Date: �`��/�v ��i `� /_Z/1 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 4-10 �P /0/ /67? ,0, , !, Date...!! ,ORT : Oti OOL TOWN OF NORTH ANDOVER d �?: t��•o ' PERMIT FOR PLUMBING 'SA LIS This certifies that .....A/. A/ ..�a �/�....... . f l.`7........ . has permission to perform ..... ....fQ........... . plumbing in the buildings of ._ ...' .................... . .... {<< ........ , North Andover, Mass. Fee .,If Lic. No.. .f S. 5 ... < ILUMBING K /P�eeiOR Check # 7807 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS // 1 Building Location (-9/�,r S��aeT Owners Name M -a -r615. -( Date �� permit # O Amount Type of Occupancy New Ey Renovation Replacement Plans Submitted YesElNo F1XT1JR F.c (Print or type) Check one: Certificate Installing Company Name 1-1 Corp. Addre s —. , n Partner. A ' usmess elephone p g F1 Firm/Co. Name of Licensed Plumber: 9/l t', - k ( i/P 0-7, Insurance Coveraee: Indicate the typt of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I the undersigned, have be three insurance en made aware that the licensee of this application does not have any one of the above Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Stat Plum 'fti 2Ce and C 2 of the General Laws. By: 19114ure o 1 ense um er Title Type of Plumbing License City/Town 7 L cense um er Master Journeyman ❑ APPROVED (OFFICE USE ONLY N -.-- Date .....7 ... 7 7 . U17 ..........ag..... TOWN OF NORTH P DOVER PERMIT FOR WIRING This certifies that ............. ............................ has permission to pe..,,....�6, 7 5�51'-101 ................... wiring in the building of .......... at .................. C.2 .... / ..... or ....... 4�. roo ...... S. . ;P ..................... . North Andover, Mass. Fee .7FR.. f.. Lic. No. ................. ........ ..... P E�EiCrR�IcA�L IN�NSP�TO Check # /0 -7 ?, L( 812 5%. y; r 'W-1% LOMmonwealth of Massachusetts official Use Only Permit No. ,� 5 7 Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.1/07] (leave blank) APPLICATION FOR PERMIT TO All work to be performed in accordance with the MasPERFORMCode ELECTRICAL0WORK (PLEASE PRINT W INK OR TYPE ALL INFORMATION) . Date: . 7 1--1 f p By this City or Town of. NORTH ANDOVER To the Inspector of Wires: application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & �C 5T. Number) & W ter' �i Owner or Tenant Telephone No. 1 90-.6730 Owner s Address `� ��% sYt,vp �j `� � v t � / �n G�vc M A Is this permit in conjunction with a building permit? Yes 1 ( Z/ y Purpose of Building ❑ NO ❑ (Check Appropriate Box) p b d t� Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No, of Meters New ServiceAmps / Volts Overhead ❑ Undgrd ❑ No, of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: -5l ,tl No. of Recessed Luminaires No. of Luminaire Outlets No, of Luminaires F Receptacle Outlets Switches Ranges i' No. of Waste Disposers No. of Dishwashers No. of Dryers No. of Water KW Heaters No. Hydromassage Bathtubs Lei :1 Do Completion of the No. of Cet1.-Susp. (Paddle) Fans No. of Hot Tubs ----------------- Swimmingpool Above ❑ In_ d. No. of Oil Burners No. of Gas Burners No. of Air Cond. Total Tons Beat Pump Number Tons 1 Totals: Space/Area Heating KW Heating Appliances KW No. of No. of Signs Ballasts . No. of Motors Total HP (06.-7 K—( -V vin table /nay be waived by No. of nsformers the Inspector of Wires. Total KVA _ KVA JGenerators o mergency UnitsE lg ger ALA.,RM_S ,.No. of Zones o. of Alerting Devices ❑ municc C=,Pinnipal ❑ Other o. of Del wiring: No. of Estimated Value oElectrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start 77 'Lc p Qtr Inspections to be requested in accordance with MEC Rule 10, and upon completion. p INSURANCE C 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 cove is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER tify El (Specify.-) cer under the pains and penalties of perjury, that the information on this application is true and complete FIRM NAME: �,.,►•�L ��1,L� S1Z:�c LIC. Licensee: t—U&AA }� /V1 � � Signature °�--� (If applicable enter "exempt " in the license number tine.) LIC. NO.: Address: o c s 63, � ,®i ce �� KS1i7v �u / Bus. TeL No.: 3 3 o. *Per M.G.L c 147, s 57-61, sec ty work requu es Department of Public Safe "S" License Alt Tel.No.. 32 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurancLic.e coverage normally required by law. By my signature below, I hereby waive this requirement I am Owner/Agent the (check one) ❑owner El owner's agent Signature Telephone No. PERMIT FEE. $ A6 7 7l0 - ?'S3o ��� . •-w w � Z�w O U z z LL U 0. 0. 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TOWN OF NORTH ANDOVER PERMIT FOR WIRING -4 Thiscertifies that ................................ .......................................................... has permission to per,44 ... �?(!tel..... ................................... wiring in the building ov .. . ...... .............. ........ .... . ..... c�� ...... ............... 0 ass. at Fee 4n.?,? �Lic...Nofi 411 JELECTRICALINSPECTOR Check # 716-8 8,1 9 3 •.•• •' • • v r erSSe3ChLlSeffS . Official Use Only Department of Fire Services Permit N°. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked v. " 77) 3 (leave blank) C1 APPLICATION FOR PERMIT TO PERFORM ELE AU work to be performed in accordance with the Massachusetts E3e,cal Code CTRICAL WORK (PLEASE PRINTW INK OR TYPE ALL INFOR-A"TI0 (MECj, 527 CMR 12. o City or Town o£ NORTH ANDOVER By this application the undersignDate: �� ed c gives notie of his or her ..To the Inspector of Wires: Location (Street & Number) p!�/�ylt � perform e electrical work descnbb beloyv. Owner or Tenant Owner's Address t 1jAtZ,0 r//✓, Telephone Is this permit in conjunction with a building permit? v s Purpose of Building Yes 12No ❑ (Check Appropriate Boz) Eats . gUtility Authorization No. Service !4/Q Amps %% / Volts Overhead ❑ Undgi d� No. of Meters New_ Service `gimps / Volts Number of Feeders and Ampacity Overhead ❑ Undgrd ❑ No. of Meters Location and Nature of Proposed Electrical Work: Na, of Recessed Luminaires Co letion of the ollowin table may be waived thel ector of Wires. No. of Cert -Sus No. p• (Paddle No. of Luminaire Outlets No. of Hot Tubs of Tota! T�nsformers KVA No. of Luminaires Swimming Pool Above ❑ �- Generators KyA o. o mergency No. of Receptacle Outlets n - /3 d. No. of Oil Bixrners ❑ Q ong Batte Units 3 No. of Switches / 'f lr/ J . No. of Gas Bruer, FIRE ALARMS No. ofZunes Na. of Ranges No. of Air Cond. otal o. of _+__tion and Devices No. of Waste Disposerseat Tons oP Tlumber Tons No. of Alerting Devices �2 No. of DishwashersS Totals: "" ,t o. of Self: ontained Detection/Alertina Devices pacelArea Hea�g KW Local [] Municipal r No. of Dryers Heating Appliances Connection ❑ Other No. of ater KR' Security Systems:* Heaters KW y� a of o. of No. of Devices or E uivalent Data No. Hydromassage Bathtubs Gr Si Ballasts No. of Motors Wiring: No. of Devices or E aivalent OTHER: . Total HP Telecommunications firing: No. of Devices or Ec uivalent f Estimated Value of El t1 ical y(�ork: Attach additional detail if desired, or as required by the Inspector of Wires. Work to Start:' (p (When required by municipal policy Inspections to be requested in accordance with MBC Rule 1 Q, and upon .completion INSURANCE COVERAGE: Unless waived by the owner, no the licensee provides proof of liability insurance incl udin perm t for the performance of electrical work may issue unless undersigned certifies that sucb coverage is in force, and g completed operation" coverage or its substantial equivalent The CIMCK ONE: INSURANCE has exhibited proof of same to the permit issuing office., I certify, under the airs ❑ BOND ❑ OTHER ❑ (specify. P penalties of perjury, that formn on this FIRM NAME: O�%U� �rJfl app&atfon is true and complete Licensee: _ ���G�y� LIC. NO.: applicable, en r .1 Signature pt " in the a number line.) LIC. NO.: . Address: Bus. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work es D Alt TeL No.: V,7 OWNER'S INSURAN requires eP� +mem of Public Safety "S" License: CE WAIVER: I am aware that the Licensee does not have the liabilityLic. No. required by law. By my signature below, I hereby waive this re insurance coverage normally Owner/Agent quu'emnent I am the (check one) ❑ owner Signature ❑ owner's agent Telephone No. PERMIT F h �; s L4 li r r , — 41i! umpwyer zkw.is - __ — OOMP. policy infDrumijon. infOrMadoiL aompawadixa iftswwScefo?. '""ItFloye= Bel" is. fhePaU4Yandji;6 site Insurance Company Name.: 7(-1— Policy # Or Self -ins. Lic. #. Expiration DatL-: Job Site Addres . ks: 1P Attach a COPY of the .workers' coon PeMMtiDR Failure to 9"0= coverage as required I under Secp*k7 dcc'�Mration pap (showing the Nlir-Y number and expiratiom te� fine- up to 6on 25A of MOL a. 152 can lead da $1,50000 and/or one-year imprisonment, as to the impasiticin of edminal penalfim of a Of up to $2.50.00 a day against the Violator. Be d,i,;r, Well as civil pezialtics in 6e form of a STOP WC) Investigatibris of t6' DIA for ingyzance coveragc� verification. that a copy of this statement may be fe WORK C)P-DER ltn� a fine rwarxied to the Office of lAn 16-1— "JY Knaer the pains andpenaWas ofp ariAe.7 .01V VW io0r..d"', provided Si ture. 460vc is male and co,,,4 Phone Date: offi-cia ase Do not write h% . .this area to be CvnW,,ejed city or town City or Town: Issuing Authority (circle one): Perntit/License 6. othe-t 3 fie'jtb 2- Ru"Ea Rg DePzrbnen. City/Town I. Board of Outer Clerk 4. -Electrical Inspector S. Plumbing Inspector Contact Person: Phone The comnwnwe, of Marsachrrset c Department Of Industriat Accidents Office HN of lnvesWgadons 600 Wasizinton ,.streetU Boston, MA 6.2.111, Workers' atiOu insurance Wn."=Lr0V/dia orker"I C0nPeRs Alicant rnform2600 Aff"Vit:,Ruilders/Ce nhuftaraMectriciRR/Plumbers NaMi. eSV0 . rPnizationAntr Please P Print Lm-'biv Address: City/State/Zip Are you an euRPIRYer? Check the appmpr- te,bo= R mnPl0Ycr with 3 4. am IL general a 7ype-of Project ("quio: Ontractor MPIOY= (fun and/67p_.;�__tim�).. .2. arn'asole Proprietor. or and 1. have hired the MA>_0MTftcbDrs 6. 0 New construction Partner- ship and have no employees - I listed cm the attached sheet 7. [3 Remodeling . , . Theft sub_cOim=tM have working for me -M any capacity, [No workers, cOm * "e P. Msuranc' S. 0 workers, comp. i Demolition. Insurance, , 5. ❑ We are a corporafion 9. M Building addition required.) 3 1 am a homeowner eowner doing all work and its . Officc:zm have exercised tj� 0.0 Electrical rePairs or additions right Of exemption myself.. [No -workirs, calfip. insurance C Pw MOL Plurn bing repaim or adtiffions LS2� § 1(41'and we have required.] 1, no 12.[j Roof .employees. [Nowork=! repairs *Any appamth' chcomp. instiranccrcquhj]: 13.:.Oheecke l#m= also . Homeownen who submit this ffffWvft. fill out the section Wow showing their workers' b6mpcn2wio� . iftdicUting Pei* in they am loin i famle, OtL 9 Oil wO* and then hire -outside coeulfto nluo submra new affidavit r -addi.1-0— _'�Z wwwmg the UMUM e�utb--c� a_,. id lL , — 41i! umpwyer zkw.is - __ — OOMP. policy infDrumijon. infOrMadoiL aompawadixa iftswwScefo?. '""ItFloye= Bel" is. fhePaU4Yandji;6 site Insurance Company Name.: 7(-1— Policy # Or Self -ins. Lic. #. Expiration DatL-: Job Site Addres . ks: 1P Attach a COPY of the .workers' coon PeMMtiDR Failure to 9"0= coverage as required I under Secp*k7 dcc'�Mration pap (showing the Nlir-Y number and expiratiom te� fine- up to 6on 25A of MOL a. 152 can lead da $1,50000 and/or one-year imprisonment, as to the impasiticin of edminal penalfim of a Of up to $2.50.00 a day against the Violator. Be d,i,;r, Well as civil pezialtics in 6e form of a STOP WC) Investigatibris of t6' DIA for ingyzance coveragc� verification. that a copy of this statement may be fe WORK C)P-DER ltn� a fine rwarxied to the Office of lAn 16-1— "JY Knaer the pains andpenaWas ofp ariAe.7 .01V VW io0r..d"', provided Si ture. 460vc is male and co,,,4 Phone Date: offi-cia ase Do not write h% . .this area to be CvnW,,ejed city or town City or Town: Issuing Authority (circle one): Perntit/License 6. othe-t 3 fie'jtb 2- Ru"Ea Rg DePzrbnen. City/Town I. Board of Outer Clerk 4. -Electrical Inspector S. Plumbing Inspector Contact Person: Phone Information aL nd Instructions ` Massachusetts General Laws chapter 152 requires all emp Ioyers 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 ofhim, express or implied, oral or written." An emploper is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more ofth t1bregoing engaged in a;joint enterprise, and including the legal representatives of a dm=a=d employer, or the receiver ortrustoe•of an individual, partnership, association or other legal entity, employing employees. 'Howeverthe owner -of a dwelling house having not more than throe apartments and who resides therein, or the occupant of the dwelling house of another who employs persons. to do maisrtenanee, construction ori wci k 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 as- local licensing aggency 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, MOL, chapter 152, §251C(7) states "Neither the commonwealth nor any of its -political subdivisions shall enter into any contract for the perforirtarrce of public wore umtr7-acceptablc evidence of compliance with the insurance requn-ements of this chapter have been presented to the carrtrading authority." Applicants Please fill out the workers' compensation• affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contsd r(s) name(s), addrms(es) amd phone number(s) along with thoir certificates) 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' cnznpensation insurance. If an LLC. or LLP does have employees, a policy is required Be advi:sed.thaz this afiidavit.may be su'omitied to the Department of industrial Accidents for confirmation of insurance coverage. Also Esc 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 .arc required to obtain a workers'. compensation potiey,:please-call the Department at thcmrrnber.listed below. Self insured compaaie should enter their self irrscaar►ce :license mrmoer on tine appropriate iirre. City or Town Officials 1 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 save to fill in the pcmit/Iicense number which wiII be used as a rcfsrance number.. In addition, an applicant thar.m.ustsubmit multiple permit/license applications in mny given year, need only submit oneaffidavit indicating•curmnt policy 'informafion (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy ofihe affidavit that has beeh 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. e. dog license or permit to bum leaves etc.) said persost, is NOT required t.D- complete this affidavit The Office of lnve 6lMiiions would liime 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, teiephone and fax nwnb= The Commonwealth of Massachusetts DcparEtuent of Indnstial Accidents Office-of-Imeatigaflons 600 Washington Street Boston, MA 0211.1 Tel- 4 617-7274900 ext 406 or 1-977-MASSAFE Revised 5-26-05 Fax 4 617-727-7744 wwwmam.gov/dia AP 1.0 Date .... / ... / ......... 9-... G.7... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... ...... r.............. has permission to perforjd�..C�... ..................................................... wiring in the build )ng of ..................................................... North Andover,- Mass. ......... ... ... cro Ilee/ No.A ELEcTi Rl��ZANS�ECI�R:l Check# 7786 A Commonwealth of Massachusetts Official�UJse Only Department of Fire Services permit No. ` ��J p Occupancy and Fee Checked `— �{ y` BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires.- By ires:By this application the undersigned give notice of his or her i tention to perform the electrical work described below. Location (Street &Number) , 11�, m „ Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service New Service Amps / Volts Amps / Volts Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity /l Location and Nature of Proposed Electrical Work: No. of Meters No. of Meters Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans o. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires `� Swimming Pool Above ❑In- ❑ rnd. rnd. o. Batto Emergency tg mg e Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. In eteng D and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices Heat Pump Tons o. oSelf-Contained No. of Waste Dis posers p Totals: J.Number 1.W Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local[E] unicipal ❑ Other Connection No. of Dryers Heating Appliances KW Sectio. of Devices or Equivalent No. of Water KW No. of o. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications firing: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. c �J CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) 413 0 �( I certify, under the pains a penalties of per' , th t t e info r r n this application is true and complete. FIRM NAME: LIC. NO.: 4 V& Licensee: Signature LIC. NO.: (If applicable, ent -ex em �se nu er li e Bus. Tel. NO.: ;h7 t�wffo Address:Alt. Tel. No.: � *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: 1 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. 1 am the (check one) ❑ owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ rt4,�,j oic II-(Y-07 per/ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ADDlicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: ��`Phone #:� Are you an employer? Check the appropriate t I . ❑ I am a employer with 4. ❑ 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 5. ❑ required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t I am a general contractor and I have hired the sub -contractors listed on the attached sheet. $ These sub -contractors have workers' comp. insurance. 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. f4 Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I l.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: ICity/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. Ido hereby certify under th ain' andallies of perjury that the information provided above is true and correct. Signature: Date: I;e Z410 17 Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Date.1.4. z/`. -12 7.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ �U� f has permission to perform . �.-.Z ..:. 3.... Y.S.......................... ...... ' ingrain the building of................................................................................... at Q. �f � '� sT /�13 5!3 �.North Andover, Mass. od Fee Lic. No3A'�%................1 �.l-A-!lE: ELECTRICAL INSPECTOR Check # 6 87 7 i� 0 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. ) 24? 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 (MEC), 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspect r of ires: By this application the undersign�eed give notice of his or her intention to perform the electrical -work described below. Location (Street & Number) 1743 ///a// AF, /. &111�1/f/10 1717 14 x; Owner or Tenant Owner's Address 17 Is this permit in conjunction with a building permit? Yes 10 Purpose of Building �/lrwew,� Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Telephone No. No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No, of Meters No. of Meters Cmmn1PtifA nfthe fnllnwino tnhlo -, ho ,. 0 1 ] ­ fh- 7.,...,,,,.t,... ,.f AR 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 ��Vt7� Swimming Pool Above ❑ In- ❑ rnd. rnd. o, o cy ►g ng BatteryUnits Units No. of Receptacle Outlets 5- No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Devices No. of Ranges ToFInitiatin No. of Air Cond. Tons o. of Alerting Devices 5— No. of Waste Disposers Heat Pum Totals: Number Tons KW Zr o. of Self -Contained [Detection/AlertingDevices No. of Dishwashers Space/Area Heating KW cal ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water Heaters KW No. 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 Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: e�� (When required by municipal policy.) Work to Start: �? �� Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO E: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains an penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: Signature ae�LIC. NO.: l (If applicable ep4er "exem t" to a lice a nu e.) �� Bus. Tel. No.: x ' Address: - 2e-Aw%�i Alt. Tel. No.: /f4D *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 Signature Telephone No. PERMIT FEE: $ 1Z_2,?-rD-7/ l J, 7--�- " �lq , ,,-w The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 c z www.ntass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #:_ Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 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. t 7• ❑ Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition working for mein any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9, ❑ Building addition 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. 1.52, § 1(4), and we have no 12.❑ Roof repairs insurance required.) t employees. [No workers' 1317 Other comp. insurance required_] -Any appueant mat encs box t# I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractors that check this box must attached an additional sheet showingthe name of the sub -contractors and their workers' comp. policy inibmration. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip- Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Sip -nature.- Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): I. 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 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 cant' 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 Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Fax # 617-727-7744 Revised 5-26-05 www.mass.gov/dia Date .....1Z:...... - — -7-0 -7 ................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .................. ....... -' So has permission to perform... ............Irl Tv /' — ........................................................... wiring in the building of ............. � ... C ...... r� .............................................. .... ...... at .......... ................................... . North Andover, Mass. .4 . ..... Fee.... Lic. No. ...... ..... ........... ELECTRICAL INS;E R Check# 7558 %ww#iusiwiwCaiun Or Massachusetts Official Use Only '• ,. Department of Fire Services Permit No.Mo WrF -S BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT INDNW OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to erform the electrical wo d scribed below. Location (Street & Number) 7 2 � Owner or Tenant Telephone No. Owner's Address %% 171111� /%J�. Is this permit in conjunction with a building permit? Yes Purpose of Building �� ��� No [J(Check Appropriate Boz) Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters _ New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ..�.uuus1wraa[ aeiau iiaes:rea, or as required by the Inspector of Wires. Estimated Value of Electrical Work: Q (When required by municipal policy.) Work to Start: ` ,0� Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE 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 J9 BOND ❑ OTHER ❑ (Specify.) I certify, under the pains aid penaltie f erjury, that a information on this application u true and complete. FIRM NAME. ® LIC. NO.: Licensee:,OT/j Signature LIC. NO.: (If applicable, �a Fer .1exempt " in the lice e u ber l�i+ e.� '� Address: _/� �< /1�'O.L®r L�l/%� ��' Bus. Tel. No.• %%� �� Alt Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am -the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: S . I ,cOk 1( 70 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 t " www mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Ar P icant Information Please Print Legibly Naive (Business/Organization/individual): Address: City/.State/Zip: Phone #: . Are you an employer? Check the appropriate box: 1. ❑ i' am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have 7 hired the sub -contractors �shipam .a.sole proprietor or partner- listed on the attached sheet and have no employees These suit -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.[] 1 an 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.] ' "Any applicant that checks boil # I must also Ml out the section below shuwia the' Type of project (required): 6. ❑ Now construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ .Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 1.3J7 other g rr wo a compensation policy mtormahotL liomeownets who submit this affidavit indicating they ace doing all work and then hire outside oontracton; 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 ant an employer that is providing:workers' compensation insurance for niy enrplayees Below is -the information. policy job site Insurance Company Name: ' Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State2ip: Attach a copy of the workers' compensation policy declaration page (showing the policy Dumber 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 rip 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 maybe 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 eat Signature: D Phone # LTown: only. Do not write in this area, to be completed by city or town official n: Permit/License # hority (circle one):Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector son: 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 bmstee-of an individual, partnership, association or other legal entity, employing employees. 'However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence.of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation• affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), addresses) and phone number(s) along with their catificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with' no employees other than the members or partners, are not mquired.to carr workers' compensation insurance. If an LLC or LLP does have Jr employees, a policy is required. Be advised that this affidavit -may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Aiso .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' eompensation.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 permitllicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/licanse applications in any given year, need only submit one affidavit indicating,eurrent policy information (if necessary) and under ss "Job Site Address" the applicant should write "all locations in (city or 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 fut= 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 of permit to bum leaves etc.) said person is'NOT required to- complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not, hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations 600 Washington Street Boston, MA 42111 Tel. # 617-727-4900 ext 406 or 1-977-MASSAFE Fax # 617-727-7744 Revised 5-26-05 www.mass.gov/dia Date...................... d . ... HORTM TOWN OF NORTH ANDOVER p PERMIT FOR WIRING 41 _ This certifies that .............. �1 oaxe-- f- J ©�11 T..... ....... ............... .............................. has permission to perform .....!.1 � O CL �� SCC ............. ...............f.... . ........................... wiring in the building of.....................................................C--� .................... .!... at ...............�t..�....1`t . !ta%... 5i..................... .... ,North Andover, Mass. ]Fee j';?:F ........ Lic. No/.3I .t-/ ')P ....... :....v..t: 4f ELECTRICAL INSPEEMR Check# �F`� 7551 -C-\ Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORT{ All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or h r intention to erform the electrical work described below. Location (Street & Number) W; Owner or Tenant R&(9 Telephone No. t7G Owner's Address 17 /"" Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 1'-D/'4;11n �� Utility Authorization No. Existing Service/�_ Amps / olts Overhead ❑ Undgrd,8 No. of Meters i New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:l�!%/� Completion of the follnwino tahlo 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 l/ Swimming Pool Above ❑In- El rnd. rnd. o Emergency Lighting 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 2 Initiatin Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number. .. . .................... Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ MunicipalElOther Connection No. of Dryers No. of Water Heaters KW Heating Appliances Kms, No. of No. of Si ns Ballasts Secu of Device s or Equivalent Data Wiring: / r� No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail i/'desired, or as required by the Inspector of Wires. Estimated ValVofectrica Work: (When required by municipal policy.) Work to Start:3 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of erjury, that the inf r ton on t s'appl{'cation is true and complete. FIRM NAME: T %/Jlia � �� � � —1 Licensee: LIC. NO.: Signature LIC. NO.: (Ifapplicable, ent r -e`xetn" pt inthe jnse numb line A.) �� us. Tel. No.: Address: �! V Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ 0s 7 52-F gg0o7 .W 7-f-0-7 The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers onlicant infnrmatinn Name (Business/Organization/Individual): City/State/Zip: G /���li� Phone.#: 117 Are ou an 1 J mp oyer? Check the appropriate b DX: 1. ❑ I am a employer with 4. 0 I am a general contractor and I employees (full and/or part-time).• AT I am a sole proprietor or have hired the sub -contractors listed partner_ on the attached sheet ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp, insurance comp. insurance.$ required.] 5. We are a corporation and its 3.0 I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t C. 152, § 1(4), and we have no employees. [No workers' comp, insurance required.] Any applicant that checks box #i moat also 511 out the section below showin thei Type of project (required):. 6. 0 New construction 7. 0 Remodeling 8. 0 Demolition 9. 0 Building addition 10g -Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other Homeowners who submit this affidavit indicating they are doing ap work and then hire ou�tstde contractors mustsation information. 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 co mp. policy number. I am an employer that is providing workersCompensation insurance for my employees. Below is the o information. p lacy and job site Insurance Company Name: P 1' o icy Or or Self -ms. LIC. M Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coveraoe I do hereby certify un#pains use only. Do not write in this area, to ofperjury that the information provided or town official correct 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 #: 1 2 A M G a= Nv 0 G 000 000 3'-4" C9 ALIGN WITH 0 WALL ABOVE ®0 ON THIRD 0'-J ' T - 4" V- 0" 8 SOFFIT ABOVE FOR B ° FLOOR MIN. 6 EXHAUST RISER. COORDINATE LOCATION WITH OWNER. 5 I 4 4 0 S4 1 BUILDING 44, SECOND fOOR PLAN NOTES: . 1. REFER TO DRAWINGS A001-AO04 FOR GENERAL NOTES, KEYNOTES AND SYMBOLS. C 2. REFER TO DRAWING A501 FOR ADDITIONAL DIMENSIONS. 3. NEW PARTITIONS TO BE 2-1/2" STEEL STUDS WITH 5/8" GWB ON EACH SIDE OF STUD. WHERE ��S�DARCH/� PARTITIONS ENCLOSE UNOCCUPIED SPACE, PROVIDE 5/8" GWB ON OCCUPIED SIDE ONLY. s Sti1/��`FC►J 4. PROVIDE FIRE SAFING AROUND ANY PIPING THAT PENETRATES FLOOR. No. 10080 5. PROVIDE A FIRE DAMPER IN ANY DUCTWORK THAT PENETRATES FLOOR. C111 NEWBURYPORT y �MASS. 6. PROVIDE 1'-0" CLEAR SPACE (AS INDICATED) ON PUSH SIDE OF ALL DOORS AND V-6" CLEAR ON q c V THE PULL SIDE. F S B U R T H I 1, L, Sheet Issued Drawing Number EASTMIL L Project Issued 10/18/07 A202 N O R T H A N B O V E R June 29, ARCHITECTURE ENGINEERING INTERIOR DESIGN LANDSCAPE MASTERPLANNING Scale 2007 303 Congress Street 6th Floor Boston MA 02210 9 Project No. RCG LLC TEL: 617 423 4252 FAX: 617 423 4333 1/8"= V-0" 07804.00 ©BURT HILL INC. vs 2.1 a 1 2 tu-,+v rA �� to-- Y 1 r1 �1 r1 �l r1 r1 C� UNISEX BATHROOM Z O d FUTURE BATHROOM LL - 00 0 LLI MECH. ROOM Q 0' - 4"FT-" 1' - 0" MIN. w 6'-0" M 000 000 O 0 H ALIGN WITH `' ® 9 ® N of o WALL BELOW El8 ON SECOND L) Z FLOOR 6 B 5 4 4 v v — in 0 n BUILDING 44, THIRD FLOOR PLAN 1/8" = 1'-0" NOTES: 1. REFER TO DRAWINGS A001-AO04 FOR GENERAL NOTES, KEYNOTES AND SYMBOLS. 2. CONFIRM BEFORE BUILDING THAT MECH. ROOM SIZE IS ADEQUATE FOR EQUIPMENT. C 3. NEW PARTITIONS TO BE 2-1/2" STEEL STUDS WITH 5/8" GWB ON EACH SIDE OF STUD. WHERE PARTITIONS ENCLOSE UNOCCUPIED SPACE, PROVIDE 5/8" GWB ON OCCUPIED SIDE AED A RP^ G�S�S ONLY. Q�, �\aQNs. 4. PROVIDE FIRE SAFING AROUND ANY PIPING THAT PENETRATES FLOOR. - No. i008DMAS ORT 5. PROVIDE A FIRE DAMPER IN ANY DUCTWORK THAT PENETRATES FLOOR.RYP$ 6. PROVIDE 1'-0" CLEAR SPACE (AS INDICATED) ON PUSH SIDE OF ALL DOORS AND V-6- CLEAR ON THE PULL SIDE. B U R T H I L L Sheet Issued Drawing Number EASTMILL Project Issued 10/18/07 A203 N O R T H A N D O V E R June 29, ARCHITECTURE ENGINEERING INTERIOR DESIGN LANDSCAPE MASTERPLANNING Scale 2007 303 Congress Street 6th Floor Boston, MA 02210 Project No. RCG LLC TEL: 617 423 4252 FAX: 617 423 433307804.00 1/8" = 11-0", ©BURT HILL INC. VS 2.1 10750 Date ... f�.�.... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that.........7/a.....4............. has permission to perform plumbing in the buildings of........ ... ... .....................at ...4r 4144. Fee43)c0vuc. No./ ,W...... Check # ............` ......... Arty Andover, Mass .......... ( �y..... ........................I...... PrUMBING INPPECTOR C4 Date ..... 7h yj ...... -4�- J. L` TOWN OF NORTH ANDOVER // Pj, - � C. --, This certifies that...... .......................... .................. -Lr h*,*0i--11k;II--*--- has permission to perform ...60 ��Q-, ... . . ........... PERMIT FOR PLUMBING plumbingin the buildings ............................................................................................. . ............................... . ....... North Andover, Mass. .................................. ..... Lic. No. /6>20./ . ...... ... UMBING,I SPECTOR Check # "7 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY I North Andover MA DATE 09/23/2014 PERMIT # JOBSITE ADDRESS 125 High Street OWNER'S NAME Jamie's Restaurant POWNER ADDRESS 25 High Street TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: ® RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES NOE] FIXTURES 7 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM _=== DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR INTERIOR _ KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL _ WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 WATER PIPING OTHER I Replacement Boiler INSURANCE COVERAGE: I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E] OTHER TYPE OF INDEMNITY ® BOND El 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 NE ON • OW R A NT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I.have submitted or entered regarding thisNqpplication are tr a a ur to f est o y knowledge and that all plumbing work and installations performed under the permit issued for this applicatio ill be a ith Perti ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Timothy A Giard __ LICENSE # 10301 -' GNATURE MPE] JP® CORPORATION Ej#F3-44-3---1PARTNERSHIP[J#E�= LLC ®# COMPANY NAME Timoth A Giard Plumbing &Heating ADDRESS 27 North Main St CITY North Andover I STATE MA ZIP 101845 TEL 978 689-8336 FAX _ CELL 978-490-7108 EMAIL TGiardplb@ ahoo.com 4L c ,k MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK b CITY North Andover MA DATE09/23/2014 j PERMIT # JOBSITE ADDRESSI 25 High Street OWNER'S NAME Jamies Restaurant GOWNER ADDRESS 25 Hi h Street TEC —JFAXI TYPE OR OCCUPANCY TYPE COMMERCIALQ EDUCATIONAL ® RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NOQ 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 GENERATOR _ GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT _ TESTAll UNIT HEATER I UNVENTED ROOM HEATER WATER HEATER 1 OTHER 77 -- _ I 111 1111 111 INSURANCE COVERAGE I have a current liabili 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 0 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. HECK ON ONLY: NER ® ❑ SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true d a u t o the b s of no ledge and that all plumbing work and installations performed under the permit issued for this applicatio will be in compl' ce it .Perti nt pr si n of e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME I Timothy A Giard LICENSE # 103-M — SIG URE MP El MGF ® JP F-1JGF [jLPGI [� CORPORATION L]#3443 PARTNERSHIP #� LLC ®# COMPANY NAME: Timothy A. Gia rd Plumbing &Heating Inc ADDRESS P.0 Box 782 CITY I North Andover I STATE Ma ZIP 01845 TEL 978 689 8336 FAX 1978 689 8300 CELL 978 490 7108 EMAIL tgiard Ib@yahoo.com w F 0 z z 0 H U W 0, z d z w . . . . . . . . .. . .. . . . . . . . a Z o d❑ w � O w O E- a 4t z z W N i z a W a a W Q w N .a o a a x J F a a LU = w W F O z z 0 F U W CL z x x 0 a