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Home My WebLink AboutMiscellaneous - 212 BRENTWOOD CIRCLE 4/30/2018 (2) W BRENTWOOD CIRCLE 2101064.0-0004-0000.0 c� i Date..............qv//j .............................. s AORT#j _4� TOWN OF NORTH ANDOVER n PERMIT FOR WIRING 'ls.� o+.rio O•tq ss�CHU5E This certifies Zat . 11?,!„!`7„ .. i F`v�Q............................................. �".c) has permission to perform + to�2�i�. x„22 �'1 vv,� 12aor” wiring in the building of...................... ,at ......... .................. z�x North Andover,r,Mass.C ..... . .. Fee. .................Lic.No. `. !P................. ..................................... 22 , ELECTRICAL INSPECT41Z •�� Check# 16 J1 v F' n - u Commonwealth of Massachusetts Offici aal Use Only Department of Fire Services Permit No. I / Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank C4) APPLICATION FOR PERMIT TO PERFORM .ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: Z) By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number)-2R)-,;1)— BREIV fWOGD CIA Owner or Tenant �phn Te r nu llo Telephone No. 6/7- ,775-3379 Owner's Address SA/Ae Is this permit in conjunction with a building permit? Yes a No ❑ (Check Appropriate Box) Purpose of Building RPMoDPI 13AA- 84rrmmi Utility Authorization No. ExistingAms 12-. /zyo Volts Overhead Service.�� P ❑ Undgrd Q' 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: Remo•DeL. 2" Floor i3A7H W 1RE �tiSEMPnf A'D-P (/2 BA+k in AsemeeN+ Avnb Y -re%rAfp NooK-UPS .� Completion o the following table may be waived by the Inspector of Wires. of No.of Recessed Luminaires I C No.of Ceil: TransSusp.(Paddle)Fans Total Trsformers KVA � No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires a. Swimming Pool Above rnd. ❑ d.In Batter Units ❑ o.o mergency Lighting No.of Receptacle Outlets 1O No.of Oil Burners FIRE ALARMS No.of Zones c� No.of Switches tO No.of Gas Burners No.of Detection and (`(\ Total Initiatin Devices �\ No.of Ranges No.of Air Cond. No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons No.of Self-Contained Totals: ""'-....................................... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers I Heating Appliances KW Security Systems;; No.of Devices or Equivalent No.of Water , No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or E uivalent 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: 39 00.- (When required by municipal policy.) Work to Start: 5-19- I S Inspections to be requested in accordance with MEC Rule 10,and upon completion. +E 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 age 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 ofperjury,that the information on this application is true and corililete. FIRM NAME: LIC.NO.: /a3&8 Licensee: ToMas L. J,i�'Pnso Signature LTC.NO.: (Ifapplicable,enter"exempt"in�the license number line.) Bus.Tel.No.:617- 1-/62-95/8 Address: a 16?w tJM& D2 S/OAiFAAM OR/80 Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public 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 agent. Owner/Agent Signature Telephone No. PERMIT FEE:$ )ELECTMAL PFInm NO. - ELEC7tMAL 3N•SPECTOP... kPassed'-, Failed--j ] Re-inspectzourequi ed($50.00)-jpectorss,copaaze'u1s: e y ••' L. (IGusp ectors"Sigratar no iu s) Date 2.FINAL 7N5P TION; Passed-j paned j ] - Re-Inspection required($50.00)-•j Inspectors'comments: ftspectors'Signature.-no Wfials) Date 2 Z' 3.TINDER GROUND INSPECTION: Passed-[ ] paired-j j • rte-inspection required($90.00)-j Inspectors'comments: (Inspectors"Signatare-no inifials) Date r 1MSPE�.'. CTION—SERWCR: - DATE Cisf1fITUD,WNT±03`ALC-301DI : Passed--f l Failed j ) Re-inspection required($50.00)-j ] Inspectors'commeits: (Zuspe.tors'Signature-tto initials) Date 5.INu}'ECT N••OMR: Passed—F4 X+ailed [ ] Re-inspection required($50.00)•-[ J Inspectors'comments: y �` 'Cbmpectors',signature-.no iiutials) Date D O OR TA.GN ARE TO BE FREED OUT AND LEFT ON WE 19 TIE LE AREA TO BE WSPECTED IS NO ACCESSIBLE AND A.RE]NSPECTION OF_850.0018 TO BE C3ARGED. F Ya� t IL The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 021192017 www.mass.gov/dia b�•` Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): TH o,v,A s Address: I DIARY?K —DR City/State/Zip: STorJeNAm, MA 02180 Phone#: 6 7L16 2 g�f Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.Y I am a sole proprietor or partnership and have no employees working for me in 8. EfRemodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no'employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14. Other 6.Q we are a corporation and its officershave exercised their right of'exemption per MGL c. 0 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 1 Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 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 MGL c. 152,§25A is a criminal violation punishable by 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.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#: 6/7 - Z-16 2- SES 1 g LEenonly. Do not write in this area,to be completed by city or town official. n: Permit/Licensehority(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 trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write•"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: i Y The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 t Tel.#617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Division of Professional Licensure: License Search Page 1 of 1 1 � The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES ..............................._......................_._....................................................,................................................................................................................................. Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency LICENSEE More... Name:THOMAS L. DICENSO REFERENCES& STONEHAM,MA RELATED INFO NEW SEARCH Disclaimer Regarding **This Licensee has additional Licenses,click here to view them.** Website License Searches Glossary of License Status Codes Licensing Board: ELECTRICIANS JOURNEYMAN ELECTRICIAN More..'. License Type: TYPE CLASS:B License Number: 12386 Status: CURRENT 7 Expiration Date: 7/31/2016 Issue Date: 7/20/2007 Exam Date: 7/20/2007 School: PETERSON SCHOOL This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Thursday,May 14,2015 at 11:35.21 AM. i 1 ©2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg.state.ma.us/public/pubLicenseQ.asp?board_code=EL&type class=_B&li... 5/14/2015 Date. q............... .......... to TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHU — Thiscertifies that ......................... .............................................I.................................... has permission to perform - wiring in the building of 4 L...................................................... at ........ North Andover,Mass. ........................ ... C Fee..6-.,.�.........Lic.No. ...... ... ......... �P�cT........ ........ .... ELECTRICAL '%E I ECTRICAL INSPECTOR Check# q r Commonwealth of Massachusetts Official us o y r Permit No. J`e Department of Fire Services 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(NIEC),527 CMR 12.00 (PLEASE PRINT IIV NK OR TYPE ALL INFORMATION) Date: I Zo 0 t) 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 ow. Location(Street&Number) eZ/a '3ReA14 tVV C P CI R Cell /I 1 Owner or Tenant �o�,r, ��,,,N..,�1b Telephone N 6 17- 2 75 r� Owner's Address e Is this permit in conjunction with a building permit? Yes ❑ No ❑✓ (Check Appropriat ox) Purpose of Building Utility Authorization No. - Existing Service Zoo Amps / Volts Overhead❑ Undgrd 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: 212 Srva4k oon yinfes/ 3 PVC j�a'„d,.;f g i� cK va,r� 'Fuibre Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA T7T7J No.of Luminaire Outlets No.of Hot Tubs No.of Luminaires Swimming Pool Arnd e ❑ Iii o.of Receptacle Outlets No.of Oil Burners ` No.of Switches No.of Gas Burners I U\,�{�-r- .., Total!, No.of Ranges No.of Air Cond. Tons I No.of Waste Disposers HeatPump Number .Tops Totals: Yo.of Dishwashers Space/Area Heating KW No.of Dryers Heating Appliances phi No.of Water KW No.of No.of Heaters Signs Ballasts No.Hydromassage Bathtubs No,of Motors Total HP OTHER: WWI • Attach additional t Q�Estimated Value of Electrical Work: $ &)p (When required by�uu��ya�puncy.7—�— VvCrk to Start: 7-29- IN 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 age ism force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE M BOND ❑ OTHER ❑ (Specify:) I certify,tinder the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: . LIC.NO.:-.1,7361 Licensee: L ;[phsQ Signature-52ALIC.NO.. (If applicable,enter `exempt"in the licensenaimberline. Bus.Tel.No.: Q7- %f2 Address: /4 1—f Z)l. S n'IPham, MA Palso Alt.Tel.No.: *Per M.G.L c. 147,s.57-6 ,se�ty work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE:$ 917 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 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 M / Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass❑7 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass F1 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass❑� ) Failed Re-Inspection Required($.)❑ Inspectors/om n s: Inspectors Signature. Date: FINAL INSPEC ON: Pass[E Failed❑' Re-Inspection Required($.)❑ Inspectors Comments: 12 Inspectors Signature: Date:�'��'�� DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com r Commonwealth of Massachusetts official us y a Permit No. Department of Fire Services IZ Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1107] 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 Inspector of Wires:fb � By this application the undersigned gives notice of his or her intention to perform the electrical work descri Location(Street&Number) f oZ 3 RCAI4tvOap C./lZ OwnerorTenant �� Q �lTelephone NOwner's Address vv.eIs this permit inconjunction with a building permit? Yes ❑ No ❑✓ (Check Appropr Purpose of Building Utility Authorization No. Existing Service 20o Amps / Volts Overhead❑ Undgrd B 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: 212 $rosltwoan r, ,R _ � ,U (3) p►/C Y. Boy-'K Yard FuLye FEW :Rrea L;j 9ZPrept Completion of thefollowing 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- ❑ o.o Emergency ig ting rnd. rnd. Batter Units' No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No,of Zones No.of Detection and No.of Swatches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.ofSelf-Contained Totals: " """"""'"'""' Detection/Alertin Devices o.of Dishwashers Space/Area Heating KW Local❑ Municipal ElOther Connection No.of Dryers Heating Appliances KW Security Systems:* Ballasts No.of Devices or Equivalent Heaters No.of Water KW No.of BNo.al as Data Wiring: Signs No.of Devices or Equivalent 00Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total 11P No.of Devices or Equivalent OTHER: �E Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: $ (When required by municipal policy.) Irk to Start: 7_29_ )� Inspections to be requested in accordance with MEC Rule 10,and upon completion. J�INS URANCE 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 age is in force,and has 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,drat the information on this application is true and complete. FIRM NAME: . LIC.NO.: 1238613 Licensee: " �Q, L 71ycensch Signature ` LTC.NO.: (If applicable,enter`exempt"in the license number line.) Bus.Tel.No.•417— 4162 Address: ,cS a tMAPal Bo Alt.Tel.No.: . 0- *Per M.G.L c. 147,1s57-6T,se�ty work requires Department of Public Safety"S"License: Lic.No. 0 1"1 D 1 0 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 FERWTFEE-$ 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 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: 3, ***'Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 i Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: f Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: . i Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass R Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass V ILI Failed Re-Inspection Required($.)❑ Inspector Cam n s: Inspectors Signature. Date: FINAL INSPEC ON: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date:---?, DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com i The Commonwealth of Massachusetts Department of IndustriqlAccidiks Office of Investigations 600 Washington Street j Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant InformationPlease Print Lmibly Name(Business/Organization/Individual): _5_ &Ma11 s 1...- 7iDi Ce ms G Address: r C 4on —D' City/State/Zip: JQm,,Vam( /SIA Phone#: (P/7 851& 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 mployees(fall and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. g ❑Building addition [No workers'comp.insurance 5. El We are a corporation and its 10. Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11. Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]I 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. X-Homeowners who submit this affidavit indicating theytie doing all work and then hire outside contractors must submit anew 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 is providing workers'compensation insurance for my employees. Below is the policy anti job site information. Insurance Company Name:- Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: ,City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby certify u d enalties ofperjury that the information provided above is true and correct. Simature: 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#: I Information and Instructions � ry Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,- express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who.has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial - Accidents for confirmation of insurance coverage. 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' 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(ifnecessary)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. D 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 Mlassachusetts Department of lzrdustrzal Accidents Office ofInvestigatiom 600 Washington Street Boston.,MA.02111 Tel,#617-727-4900 ext 406 or 1-877.7AMSSAFE Revised 5-26-05 Fax#617-727-7749 WWW.mass,govfdza i ► c ocl zco ods oCO.0pe �o rlodes o�t� o�orle iYos o� gaj o� E pro a daceas ori dtex �o c�tPloYePIoYe roPau y�,rt he oc $0 '�tb4d �oz sQlch to�; �w#h ,a �-,old coy� ��alto a�eo poj-tZCal gere�t7 ea�� bllaitcbdiv� d II1g�• tOYoor tZfc Sltga0 7roy0te<s)or d°os�a�o ex th ;COMMONWEALTH OF MASSAd-:: a I� BOA1 k� ep an s�t0 ELEI:TRI C I ANS } oft �df ISSUES THE FOLLOWING LICENSE : �Yor�ors� of AS A`t;EG JOURNEYMAN CLEGTR-IR ''�1N k ' Ido�ter \ LTFt(r'�AS L D I CENSO \ *W �Z 16 L-0WC.LCCT '1,o fit, hlED ORD MA 02155 2:83 °apt 12386'.>B _ 07/31;116:: . 05928 i j7eot 7tY or ` F r+ 9 �n 1 North Andover MIMAP .�� July 29,2014 p .Jm 34 BREN�'O�'OD�GIR 0 . 0 5. y�° 8 BRENTWOOD C R r 6 . -0052 rY >>S � '" "'� ��' � '� � `�` � 120 8 •ENTWOOD CiR w 2� BR•EN OOD -IR � � � - `�'' 3' :ase,.• g� xr .A BRENTW OD GIR aoB E o•oci Po 2 228�BR•EN OOD -IR ��- 0 Interstates '.R Hommntal Datum:MA Stateplane Coordinate System,Datum NAD83, Roads Meters Data Sources:The data for this map was produced by Merrimack t.r Easements f 40RT1y q Valley Planning Commission(MVPC)using data provided by the Town of O 4 ,So,e N North Andover.Additional data provided by the Executive Office of [3 MVPC Boundary = s4 s�O� Environmental AffairsWassGIS.The information depicted on this map is ❑Parcels F 9 for planning purposes only.It may not be adequate for legal boundary definition or regulatory interpretation_THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING • ; THE ACCURACY,COMPLETENESS.RELIABILITY,OR SUITABILITY •'s +; OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT o i AS ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION �SSACIN4 1'•=84 ft TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING gB,�CHUgE This certifies that �Tywc' ............................................................................................................................ has permission to perform ..Y?..V'--\Oa V%CQ--�L ........................................................................................ wiring in the building of.............. 0 At .......................................................................................... ....... N rth Andover, S. (TD �'7.5w Fee ..........Lic.No. ................ ....... ............. ... ......... . . .... .. ... ELECTRICAL INSPEC70 Check# 11970 (3p4: Commonwealth of Massachusetts OfficciialUseOnly o Department of Fire Services Permit No. Mo Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leave blank M 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 of his or her intention to perform the electrical work described below. Location(Street&Number) a I a IR E NTw o c t, C I R Owner or Tenant Sa r T ER Nut 10 Telephone No. 9)8'66�Z-X609 Owner's Address $A m Q Is this permit in conjunction with a building permit? Yes 9 No ❑ (Check Appropriate Box) Purpose of Building Rem obeL f rOAT W PI I I Utility Authorization No. Existing Service aoo Amps Izo / z.yo Volts Overhead❑ Undgrd Q' No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ala $rentwoon Ca - rK All ala) y" RecPss Lts l WIRE FAvj+ WAII lLecerl: 5wifCj1V5- =11s+All (2)I AFO CiR (Lf,/ Recepl. ) Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires12 No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA l No.of Luminaire Outlets No.of Hot Tubs Generators KVA S No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency ig ti t� rnd. grud. Battery Units N,4,.of Receptacle Outlets G 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. TotalTons No.of Alerting Devices a Heat Pump Number To KW No.of Self-Contained No.of Waste Disposers Totals: 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 Eq uivalent 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: M No.of Devices or Eci uivalent OTHER: _ Attach additional detail if desired,or as required by the Inspector of 97res. Estimated Value of Electrical Work: $00, (When required by municipal policy.) Work to Start: /0A, 13 Inspections to be requested in accordance with NEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cov ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) Icertify,under thepains and penalties ofperjury,flint the information on this application is true and complete. FIRM NAME: . oma s L. LIC.NO.: 19-38—08- Licensee: T6Q ,,,, L. L-Y Ce nso Signature LIC.NO.: (If applicable,enter"exempt"in the license number line) Bus.Tel.No.: &/7 Address: lG Lowell OT MEDroRb. 11A Q,?/SS Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE:$ 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 h permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shalt be filed F 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 M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed '❑ Re-Inspection Required($.)❑ Inspectors Comments: i Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass❑' Failed Re-Inspection Required($.) ❑ Inspectors Co ts: Inspectors Signature: Date: FINAL INSPECTION: Pass❑' Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department ofIndush ial Accidents Office ofInvestigations 600 Washington Street Boston,MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le;:ibly Name(Business/Organization/Individual): -- jynoks, Address: 16 La4e l I C7 City/State/Zip: M e-i,_)Fo R b, NA D,,-?/S5 Phone#: 617 Are you an employer?Check the appropriate boa: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction eI ployccs(full and/or part-time).* have hired the sub-contractors 2. m asole proprietor or partner- listed on the attached sheet. Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, E]Building addition (No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roofrepairs - insurance required.]i employees.[No workers' 13.0 other comp.insurance required.] 'Any applicant that checks box9l must also fill out the section below showing their workers'compensation policy information. t Horr'jowners who submit this affidavit indicating they 2ce 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL 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 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: • M U 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 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 Be. 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. d 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 Coxmmoawealtl Of Massachusetts Department oflndustdal Accidents Office of Investigations 600 Wasbington Street Boston,MA 02111 Tel,#617-7274900 east 406 or 1-877MASSAk'B Revised 5-26-05 Fax#61.7-727-7749 uw.mass,gov/dza COMMONWEALTH OF MACHOS S . . :'>. :>HOA..RD'O.f ELECTR ICIANS, f ISSUESTHE FOLLDWIk:G LICENSE t JOURNEYMAN iELEC-TIMI C 1`AN ` i I THOMA;5 L D I CENSO } FW 16 LOWS qqiw MEOFORD ; MA 02155 281 12386,1.,8 0PU: x6 65928 a Date,. /`3 ./..1 .......... OF r TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING 73 This certifies that ................................A.... �.................................................................................. has permission to perform .............6.......;...:.. ..................1?...j .............................................. wiring in the building of -2 at ..-.2/ 6<:P, �,kv 7....................................................................... ^orth Andover,Mass. Fee .......Lic.No.4?-��A. . .......................................... ELE cAL INSPECTOR Check# 12134 60 Commonwealth ref 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: 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) of b? S fe r►Tw oofl G I R Owner or Tenant �"r�,�h Te r r. it o Telephone No. Owner's Address ►• �� Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building lte"o'D e L MAS 1 e r $ATH Utility Authorization No. ---- Existing Service Zoo Amps I !py., Volts Overhead ❑ Undgrd[g- No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters �-- Number of Feeders and Ampacity•1%Jgt,-,g aJJR yy"d'a"o t t r Location and Nature of Proposed Electrical Work: Rew;Rr M65Ter S AT`t1 1) ZoA GFCI C1R C2) V" IC CANS (t) Phg&rmic FAN Completion of the followingtable may be waived by the Inspector of Wires. No.of Recessed Luminaires 2 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- ❑ o.o mergency Lighting ; rnd. d. BatteEy Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of SwitchesNo.of Gas Burners No.of Detection and 3 Total Initiating Devices Ranges No.of Air Cond. Tons T No.of Ran No.of Alerting Devices g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained p Totalsp: .. .... ... ........................................_..._.. Detection/Alerting Devices 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 No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent No.H dromassa a Bathtubs No.of Motors Total HP Telecommunications Wiring: Y g No.of Devices or E uivalent j OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. -ti Estimated Value of Electrical Work: /000. (When required by municipal policy.) Work to Start: a-3-/y 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 cove age is in force,and has exhibited proof of same to the permit issuing office. 4) CHECK ONE: INSURANCE [ BOND ❑ OTHER ❑ (Specify:) N I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: a A e o LIC.NO.:10?3&ep Licensee: -TtNov%o s L. Signature LIC.NO.: (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.: 6/7 " 4V 6 2 Address: J(s Lowell Cr MeD aM MA 10,21 S-5' Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"Liceh"se: Lic.No. 8518, 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 a ent. Owner/Agent Signature Telephone No. PERMIT FEE:$ M 4 � ,� t " ♦ � �` � - q: ... f ti'r � 1\ r �t. .v � .. r. F . . .. /'� (/ ! I J • i,. ! h • The Commonwealth of Massachusetts - Department of Industrial Accielents Office ofInvestigations 600 Workington Street Boston,MA 02111 www.mass gov1dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lelsibiy Name(Business/Organization4ndividual): :no-464$ L �;Ceps o Address: 16 Lowell CT City/State/Zip: M pTfo RD , MA da?13S Phone#: (a/7z16 2 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 lured the sub-contractors 2.91 am a sole proprietor or partner- listed on the attached sheet. �• [vrRemodeling ship and'have no employees These sub-contractors have S. E]Demolition worldng for me in any capacity. workers'comp.insurance. g. E]Building addition [No workers'comp.insurance 5. ❑ We area corporation and its xequired.] officers have exercised their 10.❑Electrical repairs or additions 3.El am a homeowner doing all work right of exemption per MGL 11.C1 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs wired. insurancere employees.[No workers' q � 13.E]Other comp.insurance required.] Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. Y-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 ddditional sheet showingthe name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o.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 bm 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. do Ieet eby cert gins 1 d penalties ofperjury that the information provided above is true and correct Signature: Data: a' 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 - - - ContactPerson: Phone#• Information and Instrn.ctions + 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 employSp6rsons to'do jhairiteiianee;&distraction 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 employes." MGL chapter-152;,§25.C(6)alsostates that"every state or locallic-easing age*ucy shall withhold theissuance or renewal of a license or periiiit to operate-'a'business or to constiii'i buildings in the&nJi anofioalMor 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have beenpresented 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 withtheir 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 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 he. 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 submitmultiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy ofthe 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 lion file for future permits or licenses. A new affidavit must be filled out each I 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 Deparbnent's addres',telephone and,fax number: `l`he Goraojawucaithofllassacl?usPttc - Depatiment dfadb&Wal.Accidents Of ttee of1AVeStiga-aong 600 Washia&n Sheet Bostw,MA 0211.1 TQJ,4 617-727-4900 ext 406 or 1-877-MASS.AFE Revised 5-26-05 Fax 4 617-727-7749 wwmMaSS,g¢Vfdid COMMONW ALTH OF MASSACHUSE`TT " BOAHC3 tP ELEOTRICIANS. i ISSUEWIN ,-S.-.THE FOLLOG' tICENSE:,. 1< AS A REG OURNFYMAN fLEUTFRz..0 1'�,1N� " $ THOMAS L D I CENSO F a j!If iz 16 LOWELL' CT- .... T J 21; :FORD h1A 02155 28.,E 3 r 12386:;;8 07/31/1:6 05928 i 11153 Date.. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING A,/ Thiscertifies that....................................................................................................................... .............. has permission to perform... k-,om .1 ............................... -..................................................... plumbing in the buildings of 7-P,<---,. Ay � ). .................................................................... at.....z�2 ........................................................................fie ................atC , North Andover, Mass. Fee.Y!..5 ...Lic. No. ................................................................................. PLUMBING INSPECTOR Check 13P �112 A i MASSACHUSET FS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �__�� MA DATE PERMIT CITY ----- _ JOBSITE ADDRESS �o?l a f� � . OWNER'S NAME E �v �. � TEL - 7_S'-33� ._ FAX POWNER ADDRESS TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 00 RESIDENTIAL a PRINT PLANS SUB CLEARLY MITTED: YES® N0� NEW: 0 RENOVATION:® REPLACEMENT: FIXTURES-1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10' 11 12 13 14 � BATHTUB _ J CROSS CONNECTION DEVICE � _I DEDICATED SPECIAL WASTE SYSTEM _) --•- 6 -- — I __1 ___( �I ____.� I DEDICATED GASIOILISAND SYSTEM S .. —_ l - _.— _._� _ I• I [ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM — DEDICATED WATER RECYCLE SYSTEM DISHWASHER I __.,� __ J _- { DRINKING FOUNTAIN FOOD DISPOSER ---- FLOOR 1 AREA DRAIN INTERCEPTOR(INTERIOR) ----I KITCHEN SINK LAVATORY ROOF DRAIN -- SHOWER STALL" I ____C __.._1 SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: 1 have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO �] IF YOU CHECKED YES,PLEASE INDICATE THE YPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLIC OTHER TYPE OF INDEMNITY 0I BOND Q i Y _� . OWNER'S INSURANCE WAIVER:I am aware that t the e licensee does not have the on in urance this coverequrage required by Chapter 142 of the Massachusetts General Laws,and that my sign permit CHECK ONE ONLY: OWNER [Ji, AGENT SIGNATURE OF OWNER OR AGENT accurate hereby certify that all of the details and t o'nso erfo'rmed under he submitted pe permit t issued for regal is applicationpwill abe In re and with all Pto Ane best vision of the and that all plumbing work and installs p Massachusetts State Plumbing Code and Chapter 142 of the General Laws. SIGNATURE PLUMBER'S NAME lC / -:11LICENSE# I CORPORATION# PARTNERSHIP©#=LLC MPS JP© l COMPANY NAME �}(/l ��/�� G64'�f ; ADDRESS � CITY FAX E -------�CEL ------ ._.i STATE ZIP O TEL . . MAIL .__��__1 __ .�-- �'1 ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ON LY FIN INSPE O NOTES THIS APPLICATIONYes No SERVES AS THE PERMIT ❑ ❑ �s-r 9�3'' �S FEE: $ PERMIT# PLAN REVIEW NOTES -t!. i .f The Commonwealth of Massachusetts Department of IndustrialAceldents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lezibly Name(Business/Organization/Individual): Address: 'Re, 9(P City/State/Zip: f M�°SZ�� , Phone#: ' 33dq'ioll7, - Are you an employer?Check 6c appropriaie box: Type of project(required): 1.D I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions proprietors with no employees. 12.�• Plumbing repairs or additions 5.❑I am a general contractor and I have hued the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no.eriiployees.Mo workers'comp.insurance required.] *Any applicant that checks box 41 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 hue 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 employee's,they,must provide their workers'comp.policy number. Iain an employer that is providing workers'compensation insurance for my employees.'Below is the policy and jab 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby c tify under the p s d penalties of perjury that the information provided above is true and correct Signature: j ,(.v Date: Phone#: 40 �W_ 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 C6ntact 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 permittto 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 Ihdustrial Accidents far confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the cityor town that the applieation 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised.02-23-15 www.mass.gov/dia s COMMONWEALTH-OF.NIAS ACHUSETTS: 1 t µ Ar :1 �AM PLUMBERS AND GASFITTERS ISSUES THE FOLLOW NG"LICENSE 3 6 AS A MASTER,PLU—A-8E } '.P I]c n D U Z.-0 f-'3' I MV HAMPSTEAD . 1�HfOs841 0 8G6tJ 3 97 10345 Date..l./g//V............ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that..n........................ WIe- .. has permission to perform........ plumbing in the buildings of................. .................................... at... North Andover, Mass. Fee�4.5......Lic. No. 6T... ..AAQ.................................................................. PLUMBING INSPECTOR Check# /60(p 5 All i r' y MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY � 'L— MA DATE I r -��PERMIT# JOBSITE ADDRESS 9AWai6//,� OWNER'S NAME POWNER ADDRESS 07l C -e" TEL �IS'�33 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:Q REPLACEMENT:Q PLANS SUBMITTED: YESEQ NOQ FIXTURES-4 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10, 11 12 13 14 BATHTUB I —1==== _-- 1--=== 1 _j _1 <S—' CROSS CONNECTION DEVICE j DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM _.! DEDICATED GREASE SYSTEM DEDICATED GRAY WATER — ---- ! ! ! �._ DEDICATED WATER RECYC ESTEM SYSTEM I _.___.._..1 ..__.. ! ! . J _ ! �'� —1 DISHWASHER DRINKING FOUNTAIN -._1 .__J FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) _.__ l KITCHEN SINK 1 I 1 1 { -----1 ._.-_..-_._l _-_-_( 1= LAVATORY ! _—_I ___..__1 ___._._( __I --------.1 __._._..! ROOF DRAIN. _ 1 — !_ _ __ SHOWER STALL i ! ! __._. [ _ _._ _._-_..1 ) SERVICE/MOP SINK TOILET -- ! ___. .! I t _ I I .^_.J URINAL ----_-. I __-- WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 WTER PIPING OTHER I I 1 i 1 1 ^__i INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[f NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ef OTHER TYPE OF INDEMNITY ®I BOND M OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the C Massachusetts General Laws,and that my signature on this permit application waives this requirement. S CHECK ONE ONLY: OWNERE] AGENT III S 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 cU742v�� vision of the. , Z Massachusetts State Plumbing Code and Chapter 142 of the General Laws. { PLUMBER'S NAME LICENSE# SIGNATURE MP d JP Q! CORPORATION FjI# j PARTNERSHIP Q# _ LLC COMPANY NAME ADDRESS ,r1, (. CITY �s ]STATE r ZIP Q3 / —� TEL FAX CELL ; MAILoox- ROUGH PLUMBING INSPECTION CTIO TES BELOW FOR OFFICE USE ONLY FINAL IN PECWION NOTES —/ —! Yes No ,116 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations , 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name(Business/OrganizatiorAndividual): A-tll-- ! ya rrc--- C��Wh/,/6- Address: ,/GAddress: d nl� City/State/Zip: in&Lej(-� : id 03 Phone#: d 3 -3 I- X6/7 � 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 7. 2.[gI am a sole proprietor or partner- listed on the attached sheet.Iodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill outthe section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce!rtlfv under t ze pains anI Penalties of perjury that the information provided above is true and correct Si ature: AllU��w�l Date: Phone#: &0 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: Information and Instructions ' Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract 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 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 requjred" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e,a dog license or permit to 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 Massachusotts Depaxtm.ent of Industdal,Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877rMASSAFB Revised 5-26-05 Fax#r`617-727-7749 wwwmass.gov/dia 1 I�LUMBERS�AN ArS ITTER .:,�-�"-�•". � ¢� LICENSED AS A MASTER PLUMBE ISSUES THE ABOVE LICENSE TO: 'PAUL E WH ITE, • w PO BOX 987 ' a HA14PSTEAD NH 0584'.1=.08 :11718 05/01/14 x.75068-' • •• , meq.},; � , Fold,Then Detach Along All Perforations •'_TM , 1_fCENSEE=0503500 " 101 55 DatA ! . . . . •• a ♦ gSLTp i • TOWN OF NORTH ANDOVER t PERMIT FOR PLUMBING • ` �� This certifies that . .��-V. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . i plumbing in the buildings of. . . .le. j at . . .� , , p ,`! '' �R. North Andover, Mass. Fee �a� . . Lic.No. . . . . M(I�r . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 11 CITY �� d � �� MA DATEPERMIT# JOBSITE ADDRESS L&I ,�¢X!f W C�X. jJ OWNER'S NAME POWNERADDRESS s' i� �11 TEL� r� 3�j� FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL ^ PRINT CLEARLY NEW: 011 RENOVATION: REPLACEMENT:El PLANS SUBMITTED: YES NO FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ( -----4 _ € -- € € --- CROSS CONNECTION DEVICE �.€ € i 4 _...__.._€ . ._._J _____ DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM - DEDICATEDGREASESYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM ,.1 E i _- -..J .__.._ ( ._... 1 _...._.._€ DISHWASHER _�.. I P _- .._! ..€ .. .._€ DRINKING FOUNTAIN 1 `� -' FOOD DISPOSER w,-I l FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) ..__---._J ----_..__€. _._ J _._. ... .___ 1 KITCHEN SINK - LAVATORY ROOF DRAIN ___... SHOWER STALL __€ _..._._._€ .....__ SERVICE I MOP SINK .�..( _..__J _._._..._€ ._.__€ _.._____I ____.._€ ._.__. TOILET I .i .._ I URI"ieAL _..___-( .—-_-' .___-. .._ . _ _€ ......_._ _1 ....__._. I .__J 1 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES d -__. __._ WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES -- NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW S LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY © BOND 0 Z 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 the'best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be llvgn-plian e with all in t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ✓e�: PLUMBER'S NAME LICENSE# _(l?l SIGNATURE mP V JP Q CORPORATION 0# ' � =PARTNERSHIPD# _ i LLC ^i COMPANY NAME11ADDRESS CITY L&ft/'V +L 1 STATE F-WW1 ZIPrU?l TEL FAX SIGH ( CELL ( .3 I AIL _� ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL MSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES i I I iI a V— The Commonwealth of Massachusetts - Department of IndustriqlAccidints 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 Ledbly r Name(Business/OrganizatiorAndividual): Address:_ V1 City/State/Zip: ko�51e-TO> A 4- Phone#: r!o l)3 �� 2- Are 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 )( art-time employees full and/or .* have hired the sub-contractors p listed on the attached sheet. [Remodeling 2. I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. E]Demolition working for me in any capacity. workers'comp.insurance. 9. Q Building addition [No workers' comp.insurance 5. ElWe are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their ht of exemption per MGL 11.❑Plumbing repairs or additions right 3.❑ 1 am a homeowner doing all work g p p myself.[No workers'comp. c. 152,§1(4),and we have no 12.Q Roof repairs insurance required.] 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 are doing all work and then hire outside contractors must submit anew 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. Jam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido Itereby certunder the paibo ns a 1 p(enaallties of perjury that the information provided above is true and correct. ` Date: ` `( —1 Signature: Phone#: 9673 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#: J' v 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 j oint 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 loeal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston,MA.02111 Tel,#617-727-4900 ext 406 or 1-877,MASSAFB Revised 5-26-05 Fax#617-727-7749 www.mass,govfdia -� PLMBEt SAND GASFITTERS LIC.eNSEQ AS A MASTER ALUMBE w ISSUES THE ABOVE LICENSE T0: �} i r Aq . P E WHITE Pp BOX 987 N HAMPSTEAD NH 03841-898 , 1.1718 05/01/14 175068 k Fold,Then Detach Along All Perforations "til - 87 ; Date,! NORTH •�;..�tioo� TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING • i � r f �.> TS US This certifies that . 4e,vi el . . ./S e!t Tr . . . . ✓`".'.� . has permission to perform . . . . . . . . . . . . . . . . plumbing in the buildings of . ��'!! ! . . .�1�� . . . . . . . . . . . . . at North Andover, Mass. Fee b. Lic. N3. .2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check # �� J .MASSACRUSETTS TTNOORM APPLICATION POR PE .7[T TO T}O PLUAO)NG (Type or print) NOR.THAND OVER,MASSACHUSETTS Date wners Name Permit# - BuildingLocatidn Amount LyLbofoccupancy New Replacezaent Plans Submitted Yes No Renovation ' FIXTURES rr rra rZ Cr Cr rr, O A w . Ho1 P� aQ Ha a A H A PiW a . r. x��1slr�a.. II IST No CR ZD-H—CCR ... /IMN-OCP- 5MR—om 7MROM Chec ne: Certificate (Prin-or type) ' ` � Corp 7ustalling CompanyName �M - Address I AAAm Firm/Co, Business elephone 01 Name of-Licensed Plumber: Insurance Coverage: 1•ndicate the e of insurance coverage by checking the appzopziate box: Uability insurance policy Other We of indemnity ,Tnsurance Waiver: I,the undersigned,have been}Wade aware that the licensee of this application does not have any one ofthe above three insurance ignature - - Owner Agent Ihereby certify that all of the details and information I have subutitted(or entexed)is above applitcation are iru0 and accurate to the best of my1mowledge and that all plumbing work and installations performed and I•'�htIss for se Genezal Lawsapplication l be in compliance with all pertinentprovisions o£theMassachusetts State Plumbing C By: lgna o kens um er iType of Plumbing License Title J - Joume an Ci&Towu icense um er Master II�� !! APPROVED(OF4CBUSE ONLY - ti The t;`omWonwerzlth of-Massachusetts Depaltmetzt af_ ndastE•iaj_4ccidents Office of�'�iuestigaiio�s 60.0 WasAinbgon Sheet $ostara, AM 021,7.1 Ttjrm. nrxssro�.�dia oxkexs' Compensation�t�zsYxz once A c a',rit:BO[Iers/Con racfors/+Iectric axrslP�tzmbex s .fin iicant•h;�arnaatJion� Pease Print Leaibi Nance(Business/Ora nization&gividu d): • Address: ' ' - City/5fatc Zip; Phone#: -A-re you an employer?Check the appropriate box: 1.Q I am a employer with 4. []I am a a. Type of project(required): beneral contractor and I employees(full andlorpart--lime) have hired the,sub-contractors 6. Q New construction •Q'I am a sole proprietor or partner- -listed on the attached sheet 7• ❑Remodaliug ship and have no employees These sub—contractors have working for me in any capacitlj, workers' comp,insurance, 8. ❑Demolifion [No warlcers'comp.in�7 nce �. Q We are a corporation and its 9, Q Building addition 3.Qrequired.] officers have exercised fheir Id•Q Blecirical repairs or additions ,I am a homeowner doing all work tight of e)fempfibn per MGL .11-El Plumbing repairs or additions myself.[No workers I comp. • a 152,§IN,and we.have no insurance required.]fi plc CCS- 12.0 Roofrepairs eta Y [No yvorkers' comp.Wince,required] 13,❑Other. w Fie *tom=ch;Usbox:=1 m• Ee?sC�,i� ceCeeee.^.ri^neeW Elozae owners who sumoiftliis ai�davit indicating thy,�dc;�a a3Iinformafim•w•c.$an r•-•-• Y""'..."•`:�"::�:`. +Coutczefon iL_ ,.h^i z: z ¢then bile outside cene•ac+c s 4 isE sa us2 a neW alaoavit indzc i cLt�.--^_?W,6Y u�c adtiirionai sheet showing thee'of the sub contractors and thafing such. a workers comp.policy o" .£urn an emptayer that is e ptovirlireg ruarkers'coirzpensauott insurance for my employees BeloH,is PFie padicy andjpb site- irtfgrmdtwn. Insurance Compiny Name: Policy#or Self-ins.Lin.A a-piration.Date: Job Site Address: City/statelzip: Attacl,a copy-of the workers'compensation policy declarai oII page(sbovdzrg thepolicy num oer•and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of c 'minaT penalties of a i3ne IT to$1,500.00 and/or one-year imprisonment,as welt as civil penalties in•Fhb form ora STOP WORK ORDER and a nue of up to 525100 a day zZain st the violator. Be advised that a copy of this statement ma Investigations of the DIA for insurance coverage vedfication y be forwarded tp the office of_ " I do here$y certify under the pains and pcizaltxes ofperjttr��ih,rzr}he informafiott.prarided'above'is tFzce unit correct Signature: _ Phone A — Official use ortly. Do not wri d in this area,to be completed•hj,city or tov7rz official City or Town- PertnitlLicease# hsuitta Authority(circle one). I.Board of Health 2.Building,Department 3. CIWTown Clerk 4.Electrical Inspector S.Plumbing Inspector 6-Other- Contact Per—sox Phone'i: Date........ ............. TOWN OF NORTH ANDOVER 09 PERMIT FOR GAS INSTALLATION This certifies that ....tC.L.W.4111c.................... has permission for gas installation ................ v ........................................ inthe buildings of.......................;..............4................ ................................................ at. .......... o h �4ndover,Mass. Fe4P:!�q...Lic. No. ZZI&.... ..... .. ... AS INSi4T,,0**,R,'***' V Check#-/,t'g�w 9419 •`'x- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE PERMIT# JOBSITE ADDRESS _ o�/�_ '�w �! OWNER'S NAME r��►t', yd—i=..e7 i GOWNER ADDRESS �/ ��w� C�i� C TEL ( 72 337 JFAX�� TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL E] RESIDENTIAL PRINT CLEARLY NEW:Y RENOVATION: REPLACEMENT:® PLANS SUBMITTED: YES F-] NO APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER _=1 ----- - CONVERSION BURNER COOK STOVE1 - DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE .- �.—.__-I�� -- - - -L-- J _► GENERATOR ( _ GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT _ OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER IVVENTED ROOM HEATER I I WATER HEATER OTHER — INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO [l I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Cff" OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER E] AGENT 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 and accurate to the est of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co iance wit all Pertin pr vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I�(/L (,tJ!_�/1�-f _ _ LICENSE# SIGNATURE MP[jj/MGF�I JP Q JGF LPGI© CORPORATION©#��PARTNERSHIP�I#� LLC[ # COMPANY NAME:&/C U/ �� s ?�_ ADDRESS CITY fu /y� _ STATE ZIP Q �--�]TEL FAX �? (,/ . _ CEL 3S1 EMAIL ��(/ ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES gA Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massach usetts Department of IndustrialAccidints Office of Investigations k9t) 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/tndividual): 4VL (,(10'45- /2L G F/A/f'y1o� Address: �•�_ &k City/State/Zip:_ Phone#: Are you an employer?Check the appropriate box: Typo of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction CMployees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑I am a homeowner,doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they Lire doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'camp.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 P or Self-ins.Lie.4: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation p olicy 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 maybe forwarded to the Office of 'Investigations of the DTA for insurance coverage verification. X do hereby ceoffy under the pains nd lties ofperjury that the information provided above is true and correct. Si ature: // 22 Date: L / Phone 4: (Oo/ 3 `/ j7 2- 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: i 16 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 j oint 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 orrepair work on such dwelling house or on the grounds or building appurtenant thereto shallnot 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have beenpresented 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 numbers)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 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 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. Anew 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 and fax number: 7'.he Commonwealth ofmassachlasoffs Departmezat of ladustnial Accidents Office of Investigatzom 600 Washirtp#oa St a Boston,MA 42111 Tel,-9 617-727,4.900 oyt 4Q6 ox l-877-MASS.Ak'1, Revised 5-26-05 Fax#r 617-727;7749 '6G�tu.ma.ce ant��rl;a 7402 Date./U.-. ... �.�... 1 ,ORTH o? �` f TOWN OF NORTH ANDOVER • 9 PERMIT FOR GAS INSTALLATION h + SSAC HUSE Y This certifies that 7. . 6e.V. :'� . . . .. has permission for gas installatiff. J . ... in the buildings of . . vi.!'t.T 7!t V)(Q . . . . .. . . . . . . ... ... . at . l ,.. . v aA. . . .4!A-, North Andover, Mass. Fee.1.n.17. Lic. . . . . . . . . . . . . .. . . . . .. .. . . GASINSPECTOR Check# a MASSACHGSMS LNMRl'1 APPUCATON FOR PERNJTr TO DO GAS FITTING (Type or print) Date h 0 NORTH ANDOVER,MASSACHUSETTS Building Locations C ' &&,A-k\h% �� Permit# � e �a b� Amount$Owner's Name� � ,y,�� New Rawvation ❑ Replacement �d� Plans Submitted ❑ v4-A.U9 w x1 W aU M z ° a V4 � a U z w ww O A Ci a U x 00 H 0 SUB-BASEM ENT B A S E M ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4T I3. FLOOR f 5TH . FLOOR 6TH. FLOOR 7TH. VLOOR t 8TH. FLOOR \ (Print or type) n Check ne: Certifica! s 1'ng Company Name � ' Corp. Address ❑ Partner.. 13usinesS Te ephone ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter 1� } INSURANCE COVERAGE Check one- If have a current liability Insurance policy or it's substantial equivalent. Yes No❑ If you have checked yes,please in ••ate the type coverage by checking the appropriate.box. Liability insurance policy Other type of indemnityWe& 13 ❑ Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of[tie Mass.General Laws.and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner p 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 mt knowledge and that all plumbing work and installations perrormed under Permit Issued for this application will be in compliance with all pertinent provisions of the MassachL1SL!ttS State Gas Code and Chapter 143 f the General Laws. Sv. Signature of Licensee unber . r Cas Fit r Title Plumber 1 zc�16P as Fitter City,Town tcense IN umber Master B :APPROVED(OFFiCF USE ONLY) ❑ Journeyman Date. .,77.-�rF: °,9 f NORTH, r� •� tia TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SS, use This certifies that . . . . . . . . . . . . . . . . .s has permission to perform �Y�'`.`'" plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . at. �� . . `�- ��°.-Y'2 . . . . . . . . North Andover, Mass. e---'�5—' L 1 c. N 6-- c2i �PCU�SPECT0R Check 9 / 8150 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS -7-22--07 2 rzrz (Z�T 0 eD G Date Building Location 6� w �wners Name Jb� �D� U Permit# /sT Amount C'I u Type of Occupancy New Renovation Replacement Plans Submitted Yes ❑ No ❑ FIXTURES H o CC � w o w w w Z U FCC W5C7 x a A z � w 9z -'11 W m ST.Sh'SlV1'C MSEV Nr St MOOR W MOOR 3M MOOR 4M Fly 51)fi ILOCR 6M NLOCIR 7M)HLOCIi 8M MOOR (Print or type) , r� Check one: Certificate Installing Company Name 4 ` ❑ Corp. Address a (0 5) L' A 1K C- ST• El Partner. Business Telephone Firm/Co. Name of Licensed Plumber: 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 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 Massett t:tgl bi g Code and Chapter 142 of the General Laws. By: W1amre or I lCenSea r um er Type of Plumbing License Title 19 k0'1-10 City/Town cense um er MasterElJourneyman APPROVED(OFFICE USE ONLY The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Workington Street Boston, MA 02111 e' www n urs gov/dia . Workers' Compensation Insurance Affidavit: Baitlders/Contractors/Electrician:s/pi Apambers Applicant form . r' Please Print Le�bly Name(Business/Organization/individual); Kit V GT Address: City/,State/Zip: g g Are You an employer?Cheek.the appropriate box: 1.❑ I am a employer with 4. ❑ I am a general contractor and T Type of project(required): employees(full and/or part-time)* have hired the sub-contractors 6• ❑New construction . am a.sole proprietor or partner- listed ori,the attached sheet= 7• ❑Remodeling ship and have no employees These sub..contzactors have S. [j Demolition working for me in any capacity, workers' comp.insurance. [No workers comp,insurance 5. 9. ❑Building addition p ❑ We arc a corporation and its required.] officers have exercised their 10-❑Electrical repairs or additions 3•0 r am a homeowner doing all work right of exemption per MOL 11.❑Plumbing myself, g repairs or additions Y [No•workers comp, c, 152, §1(4),and we have no insurance required.]t employees. [No workora' 12.❑Roof, repairs comp. insurance require&] 13-17 Other `Airy applicant tient checks bur#l must also fill out the section bekm showing their workers'compensation policy infomration t tiomeownets who submit this affidavit indicating they are doing all work and then hire outside contraetots must,suinn t a new affidavit indicating such xContractors that check this hoz must atracbed an add;tiaasl shoat showirrg•the name of the sub-connetons and their work=,cam1 ti; r Fo " trfomiatior..ar an Employer that is prourwg:worA= compensation insurancef or inforMwon my employees: Below is the policy and job site . 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 expiraEioo Failure to secure coverage as requited under Section 25A of MGL e. 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 tate fann 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 ofPerlrcry that the inf nrmatioa r» ' p untied above is hue and-correct Sr tures Date: Phone#: Ofj'iciat use only. Do not write in this area,to he completed by city or town ofjicidL City or Town: Permit/License;V Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Tovvn Clerk 4.Electrical;tor Plumbing lnspecEor 6.Othe'r Contact Person: Picone 4. Information and Instructions Massachusetts General Laws chapter 152 requires all emp I oyem to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the serviae of another under any contract of hire, express or implied,oral or written." l' An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or mom of the foregoing engaged in a joint enterprise,and includirag true legal representatives of a deceased employer,or the receiver or bmstc 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 as 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 busiess 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 t be commonwealth nor any of its political subdivisions shall enter into any contract for the pmTormence 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•a5udavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es).acid 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. 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 Depariment of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' comenation policy,please call the Department at the number.listed below. Self inaiireri coynnnnniPc ahnidti r..ntm their self insurance-Iicense number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department hes provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investiptians has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a n;ference number. in addition,an applicant that must submit multiple permiUlicense applications in any given year,need only submit one affidavit indicating-cmmt 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 affidaOt is an fele for future permits or licenses. A new affidavit must be filled out each t 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 Investigation 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 lmdustda[Accidents Office of Lnvesttinations 600 Washington Sttt.ct Boston, IIIA 02111 TeL 9 617-7274900 east 406 or 1-11.77-MA.SSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.govldia Date......... ...............� .............. {NonrN TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 88�cMus� r This certifies that 0hel '�Nk c ° .... .... has permission forgas in'-Pstallation .......... .... .:e:... ((AX�..................... in the buildings of... R� 0......................................................................... at......��.�:........ P ?.� ..��.! .�L-�., North Andover, Mass. Fee, . ...... Lic. No.1`'11.......... ....................................:.................. GASINSPECTOR Check# 9082 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I CITY r k ,�� MA DATE Lra Am.ea , PERMIT# + NER'S NAME d n Ajj f(f1JOBSITE ADDRESS o Z _ al OW6I,7 < OWNERADDRESS 1Z TE =FAX TYPE OR OCCUPANCY COMMERCIAL� EDUCATIONAL RESIDENTIAL®/ PRINT CLEARLY NEW: . RENOVATION:® REPLACEMENT:® PLANS SUBMITTED: YES 7 NO APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER LJ L.—_J _ _- . . I L:J( . ..1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR - j a1 -- FURNACE - _ �- _ — _—J — — - GENERATORGRILLE J-1 -- 1 _�_ C�- - . _- �-- - -- INFRARED HEATER �— LABORATORY COCKS `a- MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER E a7, ROOF TOP UNIT TEST UNIT HEATERS UNVENTED ROOM HEATERL.J,^ WATER HEATER ! OTHER .._.............. ...................._............ ..... _L:____E INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE NECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BONDE-1 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 D AGENT SIGNATURE OF OWNER OR AGENT �S 1 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 t 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. _ PLUMBER-GASFITTER NAME x l LICENSE# SIGNATURE MP�GF 0 JP D JGF D LPGI[j CORPORATION PARTNERSHIP©#=LLC D# COMPANY NAME; /4-(,-W/F!C v r)Ye ADDRESS !'— CITY STATE ZIP o/ y TEL FAX 3aY iso CELL Z �9,� ]I EMA ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES F 1 ( - The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 if 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: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.L3'1 am a employer with 3 4. ElI 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.t 7. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. E]Building addition [No workers'comp.insurance 5. ElWe are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 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.] employees.[No workers' comp.insurance required.] 13.[i Other *Any applicant that checks box#1 must also fill out the section below showingtheir workers'compensation policy information. I Homeowners who submit this affidavit indicating they Aire doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors 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 providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. �✓ Policy#or Self-ins.Lic.#: �°� S��U Expiration Date:_/ Job Site Address: Cy,�city/State/Zip:�NI / 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 certa under the pains and penalties ofperjury that the information provided above is true and correct Si ature: Date: 4, a ZO Phone#: �`S'�— C:E�( S ? 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 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 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. 1f an LLC 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 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 p* 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 CQMmonwealth ofMassachpsetts Dopattaent of Indwidal,A,ccxdeuts Offloe of Investigations 600 Washington St=t Boston}MA 02111 Tel,#617-727_4900 oxt 406 ox 1-877�,MASSAFE Revised 5-26-05 FaY,4 617-727-7749 wWW.Mass,goVNa Division of Professional Licensure:License Search Page 1 of l 41 The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics ONLINE SERVICES Check License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES&RELATED INFO Disclaimer Regarding Website License Searches Enforcement Process Glossary Glossary of License Status Codes More... Home>Division of Professional Licensure> Check A Professional License By the Division of Professional Licensure 1 � I f I �. NEW SEARCH LICENSING BOARD TYPE LIC. tt LICENSEE'S NAME CITY/STATE STATUS Sheet Metal Workers Master/unrestricted 13848 `MARK B MAGNIFICO MIDDLETON, MA Current Plumbers at Gasfitters Journeyman Plumber 25002 MARK B MAGNIFICO MIDDLETON, MA Current Plumbers Et Gasfitters Master Plumber 13559 MARK B MAGNIFICO MIDDLETON, MA Current Plumbers Et Gasfitters Plumbing Corporation 3266 MARK MAGNIFICO MIDDLETON, MA Current Plumbers Et Gasfitters Apprentice Plumber 20301 MARK B MAGNIFICO MIDDLETON, MA Expired The page above has been generated by the Division of Professional Licensure web server on Thursday, September 12,2013 at 8:59:28 AM. ©2007-2011 Commonwealth of Massachusetts Site Policies Contact Us h ://Iicense.re .state.ma.us/ ublic/ ubILiesn.as ?board code=PL& e class= M&license number-000013559&color—red 9/12/20)1 tfi g P P P _ h'P