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HomeMy WebLinkAboutMiscellaneous - 21 PERRY STREET 4/30/2018North Andover Board of Assessors Public Access NORTH OE ii�ae �a't4O � s 9 t i'7 AOR+no ''A4`� SSwtMUS c(� Click Seal To Return Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial Page 1 of 1 Sroperty Record Card Location: 21 PERRY STREET Owner Name: HAMEL, RICHARD C MARCELLE HAMEL Owner Address: 21 PERRY STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 5 - 5 Land Area: 0.16 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 1180 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 248,100 248,100 Building Value: 93,400 93,400 Land Value: 154,700 154,700 Market Land Value: 154,700 Chapter Land Value: http://csc-ma.us/PROPAPP/display.do?linkld=1887352&town=NandoverPubAcc 5/17/2012 N O N } LL F W W H fNY IL w CL N U � -00 U Q UJU a) � 0 Q CL a .@ O � O � O Of J LO O Y U 0 m O LO O O Q i 00 O O 7 ::Q V)U) ..'o ac CO �(( o JJ A_ z "�.. r `�j co OO � ZLOLO ~ LL Q '� . 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" -_ °° ab N m "aVr - tE,E: 0+0)�7f0 Ci(0 xco to z �m HIma,2[w m�YrW m"Q '^ �`�=Z,f 1-A E {3 f °aLQja;;Q TZ a,fL� °`_ ��� n" U w aO O Xn�E0" `a) a) `p Y cn°cn,a Wit LL =ILL LL;U m w U) _ Date./f'//............ 10680 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...... e le ... 5.......:/1'x/ ............................................................. has permission to perform .... �j.�. /.................j...........:.........................:......... plumbing in the buildings of /.../.'7'`�� /"✓��� e4 � . z�r N...orth..Andove..r M..ass. Fed50 ,? .............. Lic. No.'.�7.7e.. IF 3;1 PLUMBING INSPECTOR Check # °`' /r7 , C MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY - oALC F- _r( MA DATE L ( PERMIT # Ap JOBSITE ADDRESS e OWNER'S NAME Rp POWNER ADDRESS A19 a TEL b_ 3-3 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Of EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ® REPLACEMENT: OK PLANS SUBMITTED: YES FQ N00 FIXTURES -1 FLOOR -4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB =2 E=1 `s CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM IL_ { _._._J _._._ ___! ___ f _ (_._____.{ _.___�' ____► ._._..__J _{ ..______f _—I __I DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTEf KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOIIET URINAL WWA RING MACHINE CONNECTION WA-kR HEATER ALL TYPES WATER PIPING OTHER F INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [n'NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY _, BOND M 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 0 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli nce ment provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ©.f. 0!2i n! ( LICENSE # � SIGNATURE MP M JP 0 CORPORATION 0#©PARTNERSHIPO# LLCQ COMPANY NAME o �S _ _; ADDRESS CITY _ _ �- ISM _STATE ZIPI o� p �� �� TEL D 3 FAX CELL ...�._... EMAIL —_ -- -3— 'k T a o o z N El W CL w W LL 0 e//(//-/ Date................................................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Thiscertifies that ................................. ..................... ................................. ......................... V :::�- has permission for gas installation ........ . ......... 4k/& ...................................... All, /-/j in the buildings of ............ n 0 C>� .............................................................. at............................. R ..... ........................................................ , North Andover, Mass. Fee ...... Lic. No...// 7.7....../..r"" GAS INSPECTOR Check # 9465 -bI-1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY() ve kL— , 5— JOBSITE ADDRESS OWNER'S NAME OWNER ADDRESS C_ _NiL?_�_ _lbl l'V TEL FAX TPY� OR © e? OCCUPANCY TYPE COMMERCIAL ( EDUCATIONAL Q RESIDENTIAL CLEARLY NEW:RENOVATION: REPLACEMENT: [Zr' PLANS SUBMITTED: YESF---] NO E3 APPLIANCES Z FLOORS--► BSM' 1 2 3 4 5 6 7 8 9 10 11 12 '1 3 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR j �} _ - FURNACE GENERATOR - --TI - - ( a _ I J- GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT - OVEN POOL HEATER ROOM/ SPACE HEATER ROOF TOP UNIT _ -_ _ -- L- _-- . :- TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER ...INSURANCE COVERAGE___-- 1 have liability insurance a current policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 1[�J'NO 0 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF CrY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY E] BOND F 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 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliatace with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME ot�p ►Zi �1 LICENSE # J SIGNATURE MP [0/MGF Ell JP ® JGF Q LPG[ © CORPORATION ©# =PARTNERSHIP 0#-__jj LLC [f #� COMPANY NAME: _-__ ae&� ADDRESS C)_ z_ CITY �I STATE W ZIP]TEL FAX ICELLEMAIL _ -bI-1 The Commonwealth of. Massachusetts " Deparbu ntoflnd4s€riglAccidiints Office of Invesfigaflons 600 Washington. Street Boston, MA 02111 www.mass govIdia '9 orkexs' Compensation bsurance Affidavit: Budder s/Cont°actors/Electriciansl.,'Zumberrs Apuliean Znforination Please Print Legibly Name (Businessiorgadzaiionlfndividual); Address: CAY/State/Zip: © 3 "JPhone M tot 3 -,135-- �) ft 95' n. employer? Check the appropriate box: A=a, Type of project (required): with er emp to 1. � y _ 4. ❑ I am .a general contractor and I ' 6• Now cbnstntction employees (full and/ox part time). � 2. [ 1 I am a sole proprietor or partner have Hired the sub -contractors listed on the attached sheet. 7� Remodeling ship and1aveno employees These sub -contractors have 8. i] Demolition working for me in any capacity, workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑ Building addition [No workers' comp. insurance required.] officers have exexcised.theix 10.[] Electrical repairs or additions 3.E1 I am a homeowner doing all work right of exemption per MGL ME] Plumbing repairs or additions myself. LEO workers' comp. c.152, §1(4), and we have no 12,x] Roofrepairs �red. a insurancere fi7 employees. [No workers' 13.❑ Other comp. insurance required.] 'Any applicautthat checks box#1 must also filloutthe section below showingtheir workers' compensation policy information. 'Homeowners who submit this affidavit indicatingthey tie doing allworK and then hire outside contractors must submit a new affidavit indicating such. rContractors that cheek 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 pYoviding workers' cornpensadon insurance for my employees Below is the policy ani'job site information. r t - Insurance Company Policy # or Self -ins. Lic. #: Expiration Date: lob Site Address: �� rz �S ICity%State/tip: Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,50 0.00 and/or one=year imprisonment, as well .as civil penalties in tha 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 Iuvestigations of the DIAD for insurance coverage verification. X do Hereby certify Mde �andpenalties ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official City or Town: PermitlLicense 0 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electricallnspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone N. Information and Ims4ructions 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 ofhire,• 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 tforegoing engaged in a joint enterprise, and including the legal representatives of a•deceased employex, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having notmore than three apartments and who resides therein, or the occupant ofthe 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 beenpresented to the contracting authority." Applicants Please fll 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 certiflcate(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, apolicyisrequired. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for condrmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retained to the city or town that the application for thepermit or license is being requested, not the Department of Iudustrial 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 soli insurance license number on the appropriate line. City or Town Officials Please. be sure that the affidavit is complete andprinted legibly. The, Departmenthas 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 bo -sure to fill in the permit/Iicense 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 stamp ed 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 orpermit 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 aird fax number: The Ca onwealth ofMas�achv.:sP s Dep rbeut QfZ dust al cc dents of oe a juvestigaA013a 6QQ WAiugm Street Bostw, MA021ZX TeA. # 617-7-2' -4.9QQ e 4QC ox x•-87--7 MASSARE Revised 5-26-05 Fax 0 617"727-7749 w�c%c�.x�ass,g¢vfcti� r r 10340 DateAlYlA ........... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING -,, --- �A t>ri �,j . This certifies that .......... Rao�-y . . .................................. has permission to perform ..... / c l� ... M. R plumbing in the buildings of ...... T .. ........................ ,--) at .............. I K- --r ..................... ....... North Andover, Mass. Fee.�'10 .... Lic. No. . . . ............................................................... PLUMBING INSPECTOR Check # li P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE � 7 7 - PERMIT # P JOBSITE ADDRESS t n OWNER'S NAME ,4 OWNER ADDRESS rl TEL _ FAX OCCUPANCYTYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL NEW: 0 RENOVATION: REPLACEMENT: Q FIXTURES Z FLOOR- BSM 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 C - LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL V1'F,',SHING MACHINE CONNECTION WATER HEATER ALL TYPES ' VATER PIPIN OTHER L-MNjt v/ IV�e PLANS SUBMITTED: YES ® NOR 10 1 11 1 12 1 13 1 14 IIINSURANCE COVERAGE: E,have current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO Q YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY DI BOND 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT 10 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of a General Laws. PLUMBER'S NA oc I LICENSE # 7 f I SIGNATURE VIP K JP R CORPORATION n#PART NERSHIP# ® LLC COMPANY NAMEor % ADDRESS O e ,t c CITY r0._ _ _ _� STATE ® ZIP 0,3 a '�� TEL FAXCELL EMAIL AFS .. -% :,- I iii LLJ LL The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations k4jr 600 Washington Street Boston, MA 02111 www.massgov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly NaMe (Business/Organization/Individual): V Address: ?� �0 X CP z 0 y City/State/Zip: s ra- L. M l)/ 83079 Phone #: &a 3 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with �— 4. El am a general contractor and I 6. Q New construction ' employees (full and/or part-time). � have hired the sub -contractors 7. [�Wemodehng 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. - ship and'have no employees These sub -contractors have S. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑Building addition [No workers' comp. insurance 5. El We are a corporation and its 10.E1 Electrical repairs or additions required.] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' 13. ❑ Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they ere doing all work and then hire outside contractors must submit anew affidavit indicating such. $Contractors that check this box must attached anadditional 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-. h :Ara • Ph Policy # or Self -ins. Lie. #: Expiration Date:. Job Site Address: A A_�4 .�� City/State/Zip: /(o A P/ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA- for insurance coverage verification. Xdo hereby certify under t1 pains andpenalties ofperjury that the information provided above is true and correct. Phone #: 3 oZ 3s- - 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 Pers Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who. has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), 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 anLLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe 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 aff? davit 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 ofMassarliusPtts Department of Industdal Accidents Office of Iavestigattons 604 Washington Street Boston, 1\!1.A, 42111 Tel # 617-727-4900 ext 406 or 1-877,7MASSAFB Revised 5-26-05 Fax # 617-727-•7749 wwaxxass,goV/dia DatAA ............. 'TOWN OF NORTH ANDOVER PERMIT FOR WIRING 1—.— 0 1 This certifies that ..�366,�,) U4— .................. . ...... L..nt.P.0 .......... has permission to perform .............................. AVA4A,-' .......................................... yang in the building of .......................... ............. ................ . .................... ...... . Nrth Andover, Mass. Fee ...................... Lic. No. M ..... .. .......................... ............. ........... ELEc rRicAL INsPEcToR Check* 12017 Commonwealth of Massachusetts Department of Fire Services a BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. I -Td CI 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 Electrica*Insecto"r C) 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: 3 - City or Town of: NORTH ANDOVER To the of Wires: By this application the undersigned gives ce of his or her intention to perform the electrical work described below. Location (Street & Number�. Owner or Tenant vA i� dL 1 �S Telephone No. �,3 q Owner's Address Is this permit in conjunction with a building permit? Purpose of Building - Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Yes ❑ No (Check Appror . iate Box) Utility Authorization No._ Overhead ❑ Overhead ❑ Location and Nature of Proposed Electrical Work: P-bu Undgrd ❑ P7,). of Meters Undgrd ❑ No. of Meters ofthe following table may be waived by the Insnector of Wires No. of Recessed Luminaires No. of Cell.-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. No. 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 4 sy -b�- No. of Waste Disposers Heat Pump Totals: I Number ' ' """"""""""... Tons KW ' " No. of Self -Contained 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 Water KW Heaters 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 BOTHER: S Attach additional detail if desired, or as required by the Inspector of Wires. —�- Estimated Value of Electrical Work:,:95Z `y0 (When required by municipal policy.) — Work to Start: 6� 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 ,�]C BOND ❑ OTHER ❑ (Specify:) X certify, tinder the pains and penalties of per uty, t7tat the infoYntation on this implication is true and complete. FIRM NAME: YLvs�.i. S�U% �� S7/ c -T� LIC. NO.: Licensee: Signature LTC. NO.: (If applicable, enter "ex tt" in the l)'cens npi ber Bus. Tel. No. • v Address: QCT die -,(� ev-, fs� �� Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. 3 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. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed r on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: / Inspectors Signature: Date: FINAL INSPECAON. Pass Aln Failed Re- Inspection Required ($.) ❑ Inspectors Comm nts IN r-14A, Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com i The Commonwealth of Massachusetts Department ofIndustriglAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name (Business/Organization/Individual): � Address: ?d 96�1 l �� City/State/Zip:t0f`d 6S;() I 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).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑ Remodeling ship and'haveno employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9. E] Building addition required.] officers have exercised their 10-ElElectricalrepairs or additions 3. E] I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] i employees. [No workers' 13. ❑ Other comp. insurance required.] ,Any appmant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they aid doing all work and then hire outside contractors must submit a new affidavit indicating such. t6,ontractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. I yam 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:, � �� vl Job Site Address; ' City/State/Zip: p(� > Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine o0p 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 DTA for insurance coverage verification. X do hereby cern y un r t e aloes ofperjury that the information provided above is true and correct~ Si 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. PIumbing Inspector 6. Other - - - Contact Person: Phone r - 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 producedacceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' �. compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. Ij 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 1 (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 Mo ss achij seutts Department of Industrial .Accidents Office of Investigations 600 Washington Street Boston, MA, 02111 TQJ, # 617-727-4900 at 406 or 1-877:MASS.AFB Revised 5-26-05 Fax # 617-727-7749 ' WW-mas%goV'1Ch'a N I Location C21&-tk No. 7 Date 0 TOWN OF NORTH ANDOVER .. 9 Certificate of Occupancy $ '� s"•••° tt�' Building/Frame Permit Fee $ tCMUs Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # ) 3O v "-- 18-479 ,"Building Inspector �= TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO. CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING t .a „ ,d ,y.., .«x�,.. "kS _ix ..w;."�-. ... ..q s��S'7i'TC -.,, •{.�-,l��f 4'�_.`7.1G. .� '�?in'sy'S l; i+ .i^+K'+tz+a^ �` d °Y BUILDING PERMIT NUMBER: / DATE ISSUED: 0 / SIGNATURE: Building Commissioner/Inspeofor of buildings Date SECTION 1- SITE INFORMATION 1.1 Pr ed Address: 1.2 Assessors Map and Parcel Number: err, Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area (so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReqWred Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Reecorr/d� /7y/�1 4 /ry�q� 7/1/� w �/J // /�r s7/— Name (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print A'daress for Service: V— x Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ _ ®t % Conp*ny Name Registration Number Address `(�(�7—CEJ Can- &,at�ure Expiration Date Telephone r SECTION 4 - WORKERS COMPENSATION (NLG.L. C 152 6 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction 0 Existing Building ❑ Repair(s) ❑ Alterations(s) 0 77ddition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 7`u d ii i c rel Je SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be.OF'ICIAI Completed bypermit applicant USE f#NLY 1. Building a� (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee tel X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, , as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name C Si at e of Owner/A t Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINIBERS 1 ST2 ND3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 1� 1 ne t-urnmur[weutiri Vf IYlUJJIdI /dllJGIIJ Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ° _ ,5 3vww.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Orgarrization/Individual): Address: City/State/Zip: Phone #:dt Ue 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).* 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. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. These sub -contractors have 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. EJ 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: t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 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. n Insurance Company Name: Policy # or Self -ins. Lic. #:� f�1� ,9.��� Expiration Date: Job Site Address: City/State/Zip: Z( Attacb a copy of the worker's' 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. 1 do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct. s Phone #: 46—, /,ez� Oficial 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 #: ,. . I ntormation ana 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 legalentity, 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 reauirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees, other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of. Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ., • ,;, Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE :•tiIS'^ g; Fax # 617-727-7749 ::j,° Zevised 5-26-05 vvww.mass.gov/dia ;. y m x m m y m y m y C CA O az y Q.O C� = Ej c ?O CLS. y a� -w C.) o v C° CDCL O Q d 0 CD 0 C CD y� �. CD CL 0 y CO' C S v Cos O 'v CD z o • CD a CSD W. o = a� o,� m ° _ y Z EL 0 msm m m I O p a O O N m Z Erm � 3 N f�1 °.��' = y w O N p W n. cp Wit.a O Cn �o (n z b7 '?f p �. C) R O g. r po O C° OV EL O S. O 5 W n. cp p� S a b � � Omi 0 0 c REPAIRS CASTRICONE CONSTRUCTION LLC FREE ESTIMATES CASTRICONE ROOFING & SIDING CO. Telephone: (978) 682-4266 • Fax: (978) 794-0910 MARIO CASTRICONE • DAVID MICAL P.O. Box 441, North Andover, Mass. 01845 I/we, the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms, and conditions, on premises elow described: Owner's Name. / ... ..(,% .. ......... Job Address. ,,% ... l' ... .:............. City ��. /1� StateQ III SPECIFICATIONS Mee. -f -w Oe� ...................................................... . . . . . . . . . . . . . . . . . . . . . . . . . . , Materials and labor to cost $ ...... Payable .. n . . . . . . . . . . . and balance in ... ... . monthly installments of $ ........... each, payab eon ....... , day of each and every month thereafter until paid in full (. . . . . . % charge per year is to be added to above cost of labor and materials and is included in monthly payments.) Contractor will do all of said work in a good workmanlike manner. Workmanship is warranted for one year. Upon completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation and a completion as requested by the contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid immediately due and payable. It is agreed that if permitted by law, contractor shall be paid by the owner(s), all reasonable costs, attorney fees and expenses, in addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of this contract and/or any lien in connection therewith. It is further agreed that this contract may be assigned by contractor; and also that the obligations hereof shall bind and apply to their heirs, successors or estates of the parties. The undersigned warrant(s) that he is (they are) the owner(s) of the above mentioned premises and that legal title thereto stands of record in his (their) name(s). PROVISO: This contract shall be void and of no effort if credit approved of owner(s) is refused. There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is this contract dependent upon or subject to any conditions not herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties. Cover attic storage cleaning not included. Not responsible for ice back up, Not responsible for broken plants or rip-offs. Receipt of a copy of this contract is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and understandings of said parties are contained herein. Owner or Owners are not responsible for Property Damage or Liability while job is in operation. IN WITNESS WHEREOF, the parties have hereunto signed their names this , . . . . 4.. . . . . day of 20 .4:;tS. r, Accepted: Signed .� : ... .... . . Owner (OWNER HAS 3 DAYS IN WHICH TO CANCEL CONTRACT) Per.. ..... :��M:;: Signed............. Owner ............. Signed.............................. -I ��Date. . A ^ I�OR;Th U tii IM 16 0 TOWN/OF' NORTH ANDOVER PERMIT -FOR GAS INSTALLATION This certifies that S �1'aOZ4 I-rl� le 01—............................ has permission for, gas installation ................... in the buildings of ........................... at ........ North Andover, Mass Fee. GAS INSPECTOR Check# 7320 1I MASSACHUSETTS UNIFORMAPPUCATONFORPERMITTODO GAS FTMNG (Type or print) NORTH ANDOVER, MASSACHUSETTS Date�3 Building Locations Permit # 3 Z, v Amount $ 2 c> Owner's Name New ❑ Renovation Replacement Plans Submitted ❑ v� U z C4 W (Print or type) �f / Name ! ` .II 1 Address -•% U --y► d Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company ❑ Corp. Partner. �irm%Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 0-- No O If you have checked ,es, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity � Bond M 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 Agent - --�--.1 -•=-y .-- Cil- V- Lug. U� LLD aLLLL LLLLn1LL'GUVLL i nave suormaea for entereti) m above application are true and accurate to the best of my knowledge and that all plumbing work and installati-iIns perfolmed undFChter 't Issue or this a plication will be in compliance with all pertinent provisions of the Massach tts tate G Co e and 142 o the G al Laws. City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber 0 Gas Fitter LicenseNumber taster 0 Journeyman r.4) O x O V H x x z c x W z° z o z o ° 0 0 V) SUB-BASEM ENT a N o BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLO 0 R 4TH. FLOOR 5TH. FLOOR 6TH. F L 0 O R 18 7TH. FLOOR # -T -H . •FLO0RI -- I I 1 .1 — (Print or type) �f / Name ! ` .II 1 Address -•% U --y► d Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company ❑ Corp. Partner. �irm%Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 0-- No O If you have checked ,es, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity � Bond M 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 Agent - --�--.1 -•=-y .-- Cil- V- Lug. U� LLD aLLLL LLLLn1LL'GUVLL i nave suormaea for entereti) m above application are true and accurate to the best of my knowledge and that all plumbing work and installati-iIns perfolmed undFChter 't Issue or this a plication will be in compliance with all pertinent provisions of the Massach tts tate G Co e and 142 o the G al Laws. City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber 0 Gas Fitter LicenseNumber taster 0 Journeyman ♦ •k The Commonwealth of Massachusetts Department o f Industrial Accidents Office of Investigations ..600 Washington Street . qV Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibl, Name (Business/Organiza6on/Individual): Address: City/State/Zip: Phone #: ox:L❑Are you an employer? Check the appropriate box- LEI 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. E1 I am a sole proprietor or partner- listed on the attached sheet I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp, c. 152, § 1(4), and we have no insurance required.] t 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 13.0 Other ;Any applicant that checkz box #1 must also I'M out the section belong shovz b =ham workers' com^enation Poi:cy nfo: a ion 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 their workers' comp, policy information. I am ann employer that is providing workers' compensation insurance for my employees. Below is the p informaolicy and job site tion. 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 #: F ficial use only. Do not write in this area, to be completed by city or town of -ciaL City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person: Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone #: Information as d 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 orother legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to .do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter .152, §25C(6) also states that "every state or local licensing'agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with.no employees other than the members or partners,. are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial- Accidents ndustrialAccidents for confirmation of insurance coverage. Also be se re to sign and date the affidavit. The affidavit should be retuned to the city or town that the application for the pernaitor 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 Investibations 600 Washington Street Boston, MA 0.2111 Tel. # 617-72.7-4900.ext406 or 1-877-MAS.SAFE Revised 5-26-05 Fax # 617-727-7749 wvrv,.mass._gov/dia