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HomeMy WebLinkAboutMiscellaneous - 219 FRENCH FARM ROAD 4/30/2018 (2)a Date ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..................................................... .... .............................................................. has permission to perform ................... ......... wiring in the building of ............ ........... at C>? / 7 hcp lq�— --) ......................................................................................................... . North Andover, Mass. z>- —Yo �'/7� Fee -0 �,— ... Lic. No. ......................... ................. .................................................................................. ELECTRICAL INSPECTOR 7o Check # 12 7 C�lf71PCOa-Ow'rSe LIBG'cj'3MM s r •� D r �-T , ��� R��1�� 1 .. 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' ...':—.,,; �. - : s=i'wup �it� :olz:o'9 3: 8 :.::....::... . ,o��•..,1,:�..: Ilk Commonwealth of Massachusetts Department of Public Safety ' tiecurih-5_ stems- 5- license ��� - - _ ' License: SS -009779 �-- 4a0 T7niversity.Aver �ft N- NO '...: e5tfY00d� oaaSa 4:� .• ..air . - Expiration: Commissioner 051.1612096 - f Ilk r s • r • f , I . f I - I V PIE ARS CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 09/25/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Aon Risk Services Northeast, Inc. Morristown NJ Office CONTACT NAME: (AICO.NNo. Ext): (866) 283-7122 F No.): (800) 363-0105 44 Whippany Road, Suite 220 Morristown NJ 07960 USA E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # LIMITS INSURED INSURER A: Zurich American Ins Co 16535 ADT LLC ADT Security Services INSURER B: American Zurich Ins Co 40142 INSURER C: 1501 Yar11at0 Rd Boca Raton FL 33431-4408 USA INSURER D: EACH OCCURRENCE $2,000,000 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570051395419 REVISION NUMBER: d THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits shown are as requested I SR LTR TYPE OF INSURANCE ADDIL INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DD POLICY XP MM/DD/YYYY LIMITS A GENERAL LIABILITY 7-0 EACH OCCURRENCE $2,000,000 X COMMERCIAL GENERAL LIABILITY AMA TOR T $1,000,000 PREMISES Ea occurrence CLAIMS -MADE X❑ OCCUR MED EXP (Any one person) $10,000 PERSONAL B ADV INJURY $2,000,000 GENERAL AGGREGATE $4,000,000 � GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $4,000,000 X POLICY PRO- LOC o r - AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident BODILY INJURY ( Per person) ANY AUTO O Z BODILY INJURY (Per accident) ALL OWNED SCHEDULED y AUTOS AUTOS HIRED AUTOS NON -OWNED M PROPERTY DAMAGE AUTOS (Per accident) ;F _ d UMBRELLA LIAB OCCUR EACH OCCURRENCE V EXCESS LIAB CLAIMS -MADE AGGREGATE DED RETENTION B WORKERS ION AND WC509589701 10/01/2013 10/01/2014 X ORYLT T EORH A EMPLOYERS'LIABILITY Y/N wcS09589801 10/01/2013 10/01/2014 E.L. EACH ACCIDENT $2,000,000 ANY PROPRIETOR / PARTNER / EXECUTIVE OFFICER/MEMBER EXCLUDED? N/ A E.L. DISEASE -EA EMPLOYEE $2,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below — E.L. DISEASE -POLICY LIMIT $2,000,000 F_ �S i� DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) J � a -J �v CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Ej TOWN OF NORTH ANDOVER AUTHORIZED REPRESENTATIVE INSPECTOR OF WIRES _- 124 MAIN ST. � � NORTH ANDOVER MA 01845 USA -. /,j ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Alm v --s. .1 jamlivin, w, ROME Ae MIRIFIRImba ��Ifj NI -MET.' Alfliflilllfylavjllfl� g u, Affsecurky Addx 1. CH[gron Driva, pi -m, Rium nqnAq X W M -,� � @0 0. ROP - a A T�flgg :Lj-"gp gorm: U -ri-rawk.-I -,I ,Rrfj!. s al-c-n-j-pup.,wo -T,. -W-71th tr .- scmf-gr n r h&d"Ih'n Li ,'Rl W) yuses ifig-41,11 A-va IMAIIN,ba""m Ir T, 4N_ Iiog :ro lim o Wy-816 F n - 4-C g:n mt- -�Iiffenmdjll IR Um ON U yt- AL No, 5 and 1;m gir Ole g y -i jf o lr I xz, Voftage I offinla2n,— SecuritvSvs�Leffl &*DYVN5-l9ffl77CMirPIPM �a �t 'omi Mfm -I - 11 S -Y R! rso lqOik�, �j avol . k N w5if-.? ffl�,fqjlgg, '7tTrrrh ArnPr'(f'qninsurance cp� 1010112014 801 WC609589701JWC509589 ftl L -!C-f SEV? AP, lo"zin; un POUR ai. w" -Piv ahjl o -al 10 1! a fc, ME q azw i"T, e ROW ;4,2,tow Vow rvyg�&ICIT Tjov� S RIMS UK`$ -EP 0 10407 Date...., ..................... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that...&��P + lly6ao-e— ................... . ........................ has permission to perform ..... 12A '7A, ;VVA ......................................................... f �4 ...... plumbing in ui in �he b ildi 0 ........ I ................................................................................... ............ r4n 9 .............................. North,A�ndover, Mass. 3 Fee .................... �,.o. Iva ............................................. Check # P �iL B I NGINSPECTOR OP ID: SS ,a►166. r CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO 08/01/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Phone: 978-688-7000 Durso 81 Jankowski Ins Agcy LLC 198 Massachusetts Avenue Fax: 978-688-7001 North Andover, MA 01845 Durso & Jankowski Ins. Agcy. CONTACT PHONE AIC No Ext): FAX E-MAILNqL- ADDRESS: - PRODUCER KANNA-1 CUSTOMER ID #: INSURER(S) AFFORDING COVERAGE I NAIC # INSURERA:ZUrlch Small Business _ _ __ _____ __ __ INSURED Kannan PrICOne PlUmbing 81 Heating, Inc. 3 West Ayer Street Methuen, MA 01844 INSURER B : Main Street America Assurance .14788 -.. _ . INSURER C: NGM Insurance j14788 INSURER D : j INSURER E: B INSURER F; w T1.1.-- �IVIVI� 19VI�I�CR. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN R1 DL, UBRI LTR TYPE OF INSURANCE �INSRWVD j POLICY NUMBER POLICY EFF P - MMIDDIYYYY MMIDDIWYY LIMITS . GENERAL LIABILITY I j B X 1 COMMERCIAL GENERAL LIABILITY ! iMPK93787 EACH OCCURRENCE S 08/U4/2013: 0810412014 N ED 1,000,00 - i -- ! j CLAIMS -MADE X OCCUR PREMISES (Ea occurrence) i S I 500,00 I I MED EXP (Any one person) S 10,00 PERSONAL & ADV INJURY S 1,000,00 GENERAL AGGREGATE S 2,000,00 �GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG S2,000,000 POLICY PRO- ijECT i LOC I I j..S - AUTOMOBILE LIABILITY I � COMBINED SINGLE LIMIT j I j IANY AUTO M1T1021U (Eaacddent) S 104/01/2013 04/01/2014, 1,000,00 I BODILY INJURY (Per person) S C I X ALL OWNED AUTOS ! SCHEDULED AUTOS j BODILY INJURY (Per accident) S I C I X j HIRED AUTOS I PROPERTY DAMAGE I (Per accident) S C X NON -OWNED AUTOS ' - S j S j UMBRELLA LIAB OCCUR ' �—; ;Al EXCESS LIAB- I CLAIMS-MADEI EACH_ OCCURRENCE ; S 4,000,00 -- C :CUK93787 1 04/11/2013 04/11/2014 AGGREGATE S DEDUCTIBLE i X I RETENTION S 10000 I _ _ S- S WORKERS COMPENSATION I i AND EMPLOYERS' LIABILITY IWC STATU- ! OTH- A I Y / N ANY PROPRIETOR/PARTNER/EXECUTIVEI IWC05246121 OFFICER/MEMBER EXCLUDED? ❑N IN I A ,,_X ,TORY LIMITS ER 06/01/2013 06/01/2014 E.L. EACH ACCIDENT ' s _ 1,000,000j j (Mandatory in NH) j E.L. DISEASE - EA EMPLOYEE' S 1,000,000 If yes, descnbe under DESCRIPTION OF OPERATIONS below ! ! j I E.L. DISEASE - POLICY LIMIT S 1,000,00 I j DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Plumbing rY Heating NORTH13 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 384 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE 1 1 46-,Q- ___ - ____ v lavo-cuVV M%,Umu LUKII'UKAIIUN. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD Date.. �OA TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... cl(,� t�, -� �� z -e-4 ........... .......................................................................................................... -1 .......... has permission to perform ....... &4" . ................................. ................................... ....... wiring in the building of .......... ..................... V>2 0 r th A nd 0 at ...................................................................................................... orth Andover, Ma s. t#4% - Fe ....... ....... ;;i ... "I . ........... Lic. No. ..... .... ........ c 0 Check # 14112� /E=CAL �SR 12 2 6�2—ltl r ,j, 1/2 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only. Permit No. Z -' 14 Occupancy and Fee Checked [Rev. 1/071 (leave blank)S- APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASETRINTININKORTYPEALLINFORWTION) Date:- Mwc.& //, City or Town of: NORTH ANDOVER To the Inspector of Wiles: f-= By this application the undersigned gives notice of his or her intention to orm the electrical work described below. Location (Street & Number) 2 — Owner or Tenant ,Cj{��� Telephone No. Owner's Address ` Is this permit in conjunction with a building permit? Yes Eg-----No ❑ (Check Appropriate Box) Purpose of Building�Ej�/ /� EAZ AE— Utility Authorization No. N Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters f - New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion ofthe followink table may be waived by the Inspector of Wires. No. of Recessed Luminaires —.g 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- Elo. rnd. rnd. o mergency ig ting Battery Units No. of Receptacle Outlets / No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches .3 No. of Gas Burgers No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers p Heat Pump Totals: Number Tons . KW _ ............ No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Securityysteilces or Equivalent No. of Water Heaters KWSigns No. of No. of Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications No. of Devices or E u valent OTHER: i Attach additional detail if desired or as required by the Inspector of Wires. Estimated Value of Electrical Work: I ZOO- (When required by municipal policy.) } Work to Start: 5111 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 Covera es in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) c(, I certify, under the painsand�enalties of perjury, that the information on tis application is true and complete. FIRM NAME: _ G' G •Q✓1 C�� LIC. NO.: Licensee: vi Signature .:,; zk59 (If applicable, enter" empt" in the license number line.) Bus. Tel. No.: ��y�OZ �✓z� Address: /� A Z��z , ��, % dwN6, 214 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public afety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. 1 am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $,j'�a 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 r electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass F?1 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ a Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass n V Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: V 0��M:—rte f 54 Inspectors Signature: U Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com P .< The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual):. M-/ City/Stafe/Zip usn %/l'A� p A�j Phone #: eM -meq 7-56 5 Are you an employer? Check the appropriate box: L I am a employer with X_ 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. J>!m�deling 8. ❑ Demolition 9. ❑ Building addition 10. [J Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they kie 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. Yam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy # or Self ins. Lic. #:_ f rj�� 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 fine cf 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 PW for insurance coverage verification. of perjury that the information provided shove is true and correct. Phone #: q7�L — Jr,—�( % —,,59 5 :�5 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone Information and Instructi I .:COMMONWEALTH OF MXS"CHUSE' 10132 1)v ateA//2 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...... Z/ has permission to perform ................. plumbing in the buildings of.. AP .. at .... pq ., ........................ North Andover, Mass. Fee L i c. N o./. 25s I .. PLUMBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY- MA DATE PERMIT # li- JOBSITE ADDRESS OWNER'S NAME P OWNER ADDRESS TEL AX-- e TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Ej RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: E] REPLACEMENT: PLANS SUBMITTED: YES F NO KITCHEN SINK ' L4VATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK i TOILET _ URINAL ' WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER - l I 11— 3 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES _ 1 NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY [j 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 L] AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compi ce with ail Pertinent pro i In of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ ,, LICENSE #0 SIGNATURE MP JP[jPE1 CORPORATION;✓' Z:��PARTNERSHIP #= LLC[_`# COMPANY NAME DRESS Of 01f CITY = STATEJ47 ZIP TEL FAX CELL ;EMAIL ' 01 OP ID: SS CERTIFICATE OF LIABILITY INSURANCE DATE (M M/DD/YYYY) 08/01 /2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Phone: 978-688-7000 CONTACT Durso & Jankowski Ins Agcy LLC NAME PHONE 198 Massachusetts Avenue Fax: 978-688-7001 A/c No Ext): !FAX North Andover, MA 01845 EMAIL l -ASC Nod_ --� Durso & Jankowski Ins. Agcy. ADDRESS: PRODUCER KANNA-1 rel ICTf1MFR Ill N- INSURED mannan & vricone h Heating, Inc. 3 West Ayer Street Methuen, MA 01844 INSURER(S) AFFORDING COVERAGE ng & INSURERA:Zurlch Small Business INSURER 13: Main Street America Assurance INSURER C: NGM Insurance INSURER D: INSURER E: COVFRAGFS RFIZTIGICA TC All IMQCC• NAIC # 14788 14788 — -- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED `%G V 1.li V i9 IV U IYI Mt K: NAMED ABOVE FOR THE POLICY PERIOD INDICATED.. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. SR gDDL SUER; LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER POLICY EFF IMM/DDr(M POLICY EXP MM/DD/YYYY -"- -- ---- LIMITS i GENERAL LIABILITY X� COMMERCIAL GENERAL LIABILITY ,,MPK93787 1—�- ' 108/04/2013 108/04/2014. EACH OCCURRENCE $ 1,000,000 DAMA E Ems- -- CLAIMS -MADE `x OCCUR PREMISES Ea occurrence S 500,000 MED EXP (Any one person) I S 10,00 --- --- PERSONAL & ADV INJURY $ 1,000,000 ---"-- - — I I GENERAL AGGREGATE— S 2,000,000 I ----___-- r.�.-- GEVL AGGREGATE i LIMIT APPLIES PER' I-� r--) PRO- �— POLICY LOC i-- I PRODUCTS - COMP/OP AGG ; S 2,000,000 .-'—.i.S - ------ T AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident)S 1,000,000 ANY AUTO M1 T1021 U 04/01/2013 04/01/2014 I I ALL OWNED AUTOS BODILY INJURY (Per person) S i I C SCHEDULED AUTOS BODILY INJURY (Per accident) S C I X ;HIRED AUTOS , PROPERTY DAMAGE "-- (Per accident) S C X NON -OWNED AUTOS --"--`------ __... + S UMBRELLA LIAR !� I OCCUR _ 1 I I EACH OCCURRENCE S 4,000,000 EXCESS LIAB I MADE ("-- _ C - - CUK93787 104/11/2013 DEDUCTIBLE 04/11/2014 i_AGGREGATE I 1 X RETENTION $ 10000 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY_ Y / N A ANY PROPRIETOR/PARTNER/EXECUTIVE (_. 5 X 1 WC STATU- 1 iOTH- iTORY.LWITS j_LR�__ IWC05246121 OFFICER/MEMBER EXCLUDED? !N / A j 06101/2013! 06/01/2014 E.L. EACH ACCIDENT I S 1,000,000 (Mandatory in NH) 1 I If describe - ------------- E.L. DISEASE - EA EMPLOYEEI 1,000,000 yes, under DESCRIPTION OF OPERATIONS below S E.L. DISEASE i -POLICY LIMIT I 5 1,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Plumbing & Heating CERTIFICATE HOLDER CANCELLATION NORTH13 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 384 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... C4 7?-/- cle.0 has permission to perform .......... ...... A ........ ............................ --Ale wiringin the building of ............................. ................................................................................. .... 2.11 .............. t::? .... North Andover, Mass 72 -bN Fee j.2.' ... . ............. Lic. No . ................. ......... ....... ........ ....... ELD! Check 1102 1 ///S Commonwealth of Massachusetts OfficialU e Only Permit No. o Department of Fire Services Occupancy and Fee Checked , a BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07) (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL MFORMATIOl9 Date. City or Town of. NORTH ANDOVER To the Ins ctor of Wires: By this application the undersigned gives notice of his or her intention to perform the ctrical work described below. Location (Street & Number) .2 /9? �d Owner or Tenant Telephone No. Owner's Address z ==:54P( E _ Is this permit in conjunction with a building permit? Yes (.i No ❑ (Check Appropriate Box) Purpose of Building�jF-�j444rC: Utility Authorization No. - Existing Service Amps / Volts in New Service Amps / Volts Number of Feeders and Ampacity Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ Location and Nature of Proposed Electrical Work: e&/,QC5- ?w No. of Meters No. of Meters Completion of the_following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. grnd. o. of Emergency Lighting Battery Units No. of Receptacle Outlets Z 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 g No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Dis posers p Heat Pump Totals: Number Tons " KW ' """...'"....... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal E] other Connection No. of Dryers Heating Appliances KW SecNoto Devils : or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: 01- Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Vectrical Work: (When required by municipal policy.) Work to Start: ".A- 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 s in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 6 BOND ❑ OTHER ❑ (Specify:) X certify, tinder thepains andpenalties ofperjury, that the in ornzation o Z1 is app li do rs true and complete. FIRM NAME: .lj LIC. NO.: Licensee: Signature LTC. NO. 7 (If applicable, enter "exe pt" in the lice a number lin Bus. Tel. No.: Address: X el4f Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work r quires 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 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 auiomatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: ~• _.•' ***.Note:Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: a FINAL INSPECTION: Pass .. ., Failed ❑' ,` Re- Inspection Required ($.) ❑ Inspectors Com/men-1 ^J Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com t , The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 4 ,, Address: �U �� •%� �"Gwrl S �I City/State/Zip: ��� yf Phone #: ��7 ' '5rl 7 l0/7 Are you an employer? Check the appropriate box: 1, am a employer with �_ 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet t ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New onstruction 7. emodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. f Homeowners who submit this affidavit indicating they ace 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 thepolicy and job site information. Insurance Company N Policy # or Self -ins. Lic. #: Expiration Date: / Job Site 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby that the information provided above is true and correct / 11 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 #: O 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-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 retained 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 t6 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 oi`Industrial Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 Tel, # 617-727_4900 ext 406 or 1-877:MASS.AFE Revised 5-26-05 Fax # 617-727-7749 vwww.mass.gov/dia Division of Professional Licensure: License Search v The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Home State Agencies A -Z Topics Home > Division of Professional Licensure > Check A Professional License By the Division of Professional Licensure LICENSEE Name:CURT L. FORBES jjj TOWNSEN�D, ,MA **This Licensee has additional Licenses, click here to view them.** 1 Licensing Board: ELECTRICIANS License Type: JOURNEYMAN ELECTRICIAN TYPE CLASS: E License Number: 37854 Status: CURRENT Expiration Date: 7/31/2016 Issue Date: 12/27/1995 Exam Date: 12/2/1995 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, August 29, 2013 at 9:29:57 AM. © 2007-2011 Commonwealth of Massachusetts Page 1 of 1 Mass.Gov ONLINE SERVICES Check a 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 Site Policies Contact Us http://license.reg. state.ma.us/publiclpubLicenseQ.asp?board_code=EL&type_class=_E&li... 8/29/2013 t? G � OMMONWEALTH OF MASSACHUSET�T-- -�'T�ELECTRICIANS ` I �AS A REG JOURNEYMAN ELECTRICIA 6 ISSUES THE ABOVE LICENSE TO: d CURT L FORBES - it 0 NORTH END RD 'DWNSEND MA 01469-1125 37854 E 07/31/13 884.',8T CLkib OEM , COMMONWEALTH OF MASSACHUSETTS :;E:LECTRICIANS REGISTERED MASTER ELECTRICIAN I ISSUES THE ABOVE LICENSE TO: C L FORBES ELECTRIC CURT L FORBES b 10 NORTH END RDN TOWNSEND MA 01469- "2._ I 16744 A 07/31/13 88438 11 7, _ „ 16) - —�� el 7 Date............................ f ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING I This certifies that ....... ...... ....... /�?/� ......................... has permission to perform ....... ........ ............. wiring in the building of * .................. -20z'�7 North Andover, Mass. ............... Ole- ............ Lic. No. . .............. Check # 7756 r Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 2;� Occupancy and Fee Checked i [Rev. 1/07) n,.,_ 1,1_t, APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 27 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: %O% - n-7 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or hr intention to perform the el ctrical work described below. Location (Street & Number) r�) CT Finn r Z r' p- _ _ I Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes No Pb ❑ (Check Appropriate Boz) Purpose of Building G-��}rjn Utility Authorization No. Existing Service OeZ-1 Amps / Volts Overhead ❑ Undgrd)RI New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Meters No. of Meters 4 Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Elec cal Work: le . 6-j (When required by municipal policy.) Work to Start: >o2c'�7 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCFrN BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and pen ' s of perjury, that the information on his lication is true and complete. FIRM NAME: ,c. � IJ L�/eC'y� � LIC. NO.: Licensee: C f j f Signature LIC. NO.: (Ifapplicable, enter "exempt" in the license number line.) Address: 7 &J0V-t,-4/^ � MA Bus. TeL No.: St 1-2)oV `� ��� � Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: '� &j cl Completion of the followin table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of CeiL-Susp. (Paddle) Fans o. of Total 1l Transformers KVA No. of Luminaire Outlets No. of Hot Tubs '— Generators KVA No. of Luminaires Swimming Pool Above ❑In- 13o. o mergency tg g nd, rnd. Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones o. of Detection an No. of Switches No. of Gas Burners ✓ lnitiatinotal Devices No. of Ranges �- No. of Air Cond. .---Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons Totals: _._....................._. o. of Self -Contained Detection/Alertin i, Devices No. of Dishwashers Space/Area HeatingKW - —� unicipal Local ❑ Connection ❑ Other No. of Dryers Heating Appliances .. KW Security Systems:* No. of WaterNo. Heaters - - - KW No. of No . of of Devices or Equivalent Data Wiring: Signs Ballasts. No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors ..-- Total HP TelecommunicationsWiring: No. of Devices or Eouivalent 4 Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Elec cal Work: le . 6-j (When required by municipal policy.) Work to Start: >o2c'�7 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCFrN BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and pen ' s of perjury, that the information on his lication is true and complete. FIRM NAME: ,c. � IJ L�/eC'y� � LIC. NO.: Licensee: C f j f Signature LIC. NO.: (Ifapplicable, enter "exempt" in the license number line.) Address: 7 &J0V-t,-4/^ � MA Bus. TeL No.: St 1-2)oV `� ��� � Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: '� &j cl F� aj ®� 1 kr 1 j� `its 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 r I www.nzass.gov/dia . Workers' Compensation Insitrance Affidavit: Builders/Contractors/Electricians/Plnmbers APRUcant Information Please Print LeQibiv Name (Business/Organization/individual): Address: )�CwcJ1 City/State/Zip;_ , /'✓ 4 �o�rt� / Phone P 6Z'12 - c))(51 V *Any applicant that checks ho)f #1 must also fill out the section below showin their workers' 1 g pensetion Policy information. t homeowners who submit this affidavit Indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box mustattsched an additional sheershowing the mune of the sub -contractors and their workers' comp. policy information. I ant an employer that is providing workers' compensation insurance for my employees: Below is -Me information. policy and job site / % ,fInsurance Company Name:_ `i�t'�`7 AJo� sr c Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and eorred Signature: Dom, Phone #: Official use only. Do not write in this area, to be completed by city or town ofcia[ 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 #: Are you an employer? Check the appropriate box: l . ❑ I am a employer with 4. ❑ 1 am a general contractor and I Type of proj ect (required): employees (full and/or part-time).* 2.[] I am.a.sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. ! 6. ❑ Now construction 7._EJRemodeiing ship and have no employees These su&contractors have S. ❑ Demolition working for me .in any capacity, [No workers' comp, insurance workers' comp. insurance, 5. ❑ We are a corporation and its q, Building addition required.] 3. ❑ I am a homeowner doing officers have exercised their of MGL 10•❑ Electrical repairs or additions all work right exemption per 11.(] Plumbing repairs or additions myself. [No•workers' comp. .t c, 152, § 1(4),'and we have no Roof repairs 12.[]insurance required.] employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks ho)f #1 must also fill out the section below showin their workers' 1 g pensetion Policy information. t homeowners who submit this affidavit Indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box mustattsched an additional sheershowing the mune of the sub -contractors and their workers' comp. policy information. I ant an employer that is providing workers' compensation insurance for my employees: Below is -Me information. policy and job site / % ,fInsurance Company Name:_ `i�t'�`7 AJo� sr c Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and eorred Signature: Dom, Phone #: Official use only. Do not write in this area, to be completed by city or town ofcia[ City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building. Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: w� s� 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 t wstee-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 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 cavy 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, notthe Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, plemecall the Department at the numberlisted below. Self-insured companies should enter their self insurance License number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided'a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit(license number which wiII 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 l year. Where a. home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a flog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Fax # 617-727-7749 Revised 5 -26 -QS www.mass.gov/dia Date... TOWN O�,,,N.QIR VER PERMIT FOR GAS INSTALLATION �i-a -.4 This certifies that ................... ------ .. . . & has permission for gas installation . ................... in the buildings Of .'." ...... ................................ . ........ North Andover, Mass. Fed -36 ..... Lic. GASI SPE TOR 41 Check# 11140oh 6104 MASSACHUSETTS UNIFORM APPUCATON FORPERNll T TO DO GAS FITTING (Type or print) Datea l NORTH ANDOVER, MASSACHUSETTS Building Locations �l ` C�-NC� �GC +�� �Q Permit # Amount $ Owner's Name New D Renovation Replacement Plans Submitted 0 A: (Print or type Name ��� �a `� v � Address us ,A - Name of Licensed Plumber or Gas Fitter he k one: CertifLcate Installing Company Corp. Partner. Firm/Co. INSURANCE COVERAGE CAone: I have a current liability surance policy or it's substantial equivalent. Yes Nc If you have checked Les, plbqse indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner n Agent n I hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachuse State Gas Code and Chapter 142 of the General Laws. Title City/Town IAPPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber `V) IS Gas Fitter License Number Master Journeyman � w � � � O z H C a x cA v u F w t s �i z OC o o z a a a z > W z d w e a H w w I~ w E" x x x o a �' z o z a o x > co, o SU B-BASEM ENT BASEMENT ' 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type Name ��� �a `� v � Address us ,A - Name of Licensed Plumber or Gas Fitter he k one: CertifLcate Installing Company Corp. Partner. Firm/Co. INSURANCE COVERAGE CAone: I have a current liability surance policy or it's substantial equivalent. Yes Nc If you have checked Les, plbqse indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner n Agent n I hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachuse State Gas Code and Chapter 142 of the General Laws. Title City/Town IAPPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber `V) IS Gas Fitter License Number Master Journeyman �0 46 Date. . . . TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING This certifies that ........................ Z�11111'2 'V has permission to perfor plun-ibing in th�'building's of—, at.. Fee.�....Lic. No .......... ........ .......... ...... PLUMBING INSP rl�b It Check # �` 5 8 3 .2 F i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) rm AAj tj(/Ply Mass. Date &3 Permit # L�0 t 7r JIG Building LocationZ19 ,goj6A /—Q rm Owner's Name��. Type of Occupancy Residential New ❑ Renovation ❑ Replacement IN Plans Submitted: Yes ❑ No ❑ FIXTURES Installing Company,Name Hez`itage Htc . &Pig: Co. Inc: Check one; Certihcate F otation 714 Cor i Address 1 _.' � 35 Pleras3nt ' Street � lX p Stonehami.t'M� 02180 Partnership' .. _ ❑p. Business Telephone i• 781 4 3'13 7 7 7 6 171 Firm/Co.: ' Name of Licensed�pIumber . r ' i i Gordon Switzer r' INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142, ,Yes M No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. i 'A liability Insurance policy M Other type of Indemnity ❑ Bond ❑ , 1 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General taws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ I hereby certify that all bf 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 the permit issued for this application will be in compliance with all . pertinent provisions of the Massachusetts State Plumbing Code and Chapter 1 2 of the General Laws. rgi�Urecense um er j Title � � � • S ► type of. Ucense: Master [X Journeyman Lj t CN/town. t s Aim License Number 8322 y y u5 O z w W OJ Y _z 47 W J a N s Q �' V 47 = 7 o C7 N z a Uj R a �Ujf �1�1J7( (h QzMW O N N 1: w a 4) .+„ _ a C7 z '= a a a Q w= F- a w O> H a r s ►- W 3 o a 3 r° y o N a z x yr ►' O J �c z ( a o c o O K r- y J a Z Y z O Q w c o w a ►- o Q LL i4 Jr T� f� a Q m x ,n o c a J a 3 x a r J y J LL a¢ O o x o a a O 3¢ a m SUB—BSMT. BASEMENT IST FLOOR 2ND FLOOR 3RO FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR -H�+ BTNFLOORIII FE I + +H Installing Company,Name Hez`itage Htc . &Pig: Co. Inc: Check one; Certihcate F otation 714 Cor i Address 1 _.' � 35 Pleras3nt ' Street � lX p Stonehami.t'M� 02180 Partnership' .. _ ❑p. Business Telephone i• 781 4 3'13 7 7 7 6 171 Firm/Co.: ' Name of Licensed�pIumber . r ' i i Gordon Switzer r' INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142, ,Yes M No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. i 'A liability Insurance policy M Other type of Indemnity ❑ Bond ❑ , 1 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General taws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ I hereby certify that all bf 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 the permit issued for this application will be in compliance with all . pertinent provisions of the Massachusetts State Plumbing Code and Chapter 1 2 of the General Laws. rgi�Urecense um er j Title � � � • S ► type of. Ucense: Master [X Journeyman Lj t CN/town. t s Aim License Number 8322 0 Cl ti z z 0 0 z W cri z 4 LL. cc LL in 0 w w W CL 0 LL O 0 U. L6 0 0z .j 0 LU m P u :3 w W CL 2 UA IL -C 0 m Cl ti z 0 w z W z 4 LL. cc LL in 0 w w W CL 0 LL 0 U. L6 0 0z .j 0 LU m P u :3 w W CL 2 UA IL -C U. z m Cl ti z 0 w W z 4 LL m Cl ti w z 4 W CL m ti MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTiNG 7/ -� (Prinz or Type) J� A ,Mass. Date 19 Permit # 8611ding Location a) Owner's Names Type of Occupancy L(/WA New C/ Renovation ❑ Replacement [ . Pians Submitted: Yes[] No Installing Company NameN� u mfisim�t- mrFAMM —�., Address A GAS FITTING lit C. '.:60 Business Telephone 1 -68-- 14LV/y9 Name of Licensed Plumber or Gas Fitter Check one: Cdr orporatlon ❑ Partnership ❑ Flrm/Co. Certificate # INSURANCE COVERAGE: 1 have a current Ilablii�t l• insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes U--- No If you have checked -res, please Indicate the type coverage by checking the appropriate box. A liability insurance policy 01-� Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ 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 knowiedge and that all plumbing work and Installations performed under the permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 oft a General La —, _, T. a of Ucense: Title Plumber gna re o cense er or Gas filer Gast r Cit Off aster Ucense Number U/ APPP'n M —WC�F o i.. Journeyman lmmomms MENEM ME "Ramon ME mommommonsommomomm MR MEN OMEN MENNEN 0 mosommommommomimon ONE NOR iiiiiiiiiiiiiiiiiiiiiiiiii aa� Installing Company NameN� u mfisim�t- mrFAMM —�., Address A GAS FITTING lit C. '.:60 Business Telephone 1 -68-- 14LV/y9 Name of Licensed Plumber or Gas Fitter Check one: Cdr orporatlon ❑ Partnership ❑ Flrm/Co. Certificate # INSURANCE COVERAGE: 1 have a current Ilablii�t l• insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes U--- No If you have checked -res, please Indicate the type coverage by checking the appropriate box. A liability insurance policy 01-� Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ 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 knowiedge and that all plumbing work and Installations performed under the permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 oft a General La —, _, T. a of Ucense: Title Plumber gna re o cense er or Gas filer Gast r Cit Off aster Ucense Number U/ APPP'n M —WC�F o i.. Journeyman MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 GASFITTING (Print or Type)-' NORTH ANDOVER Mass. Date /fir ao j� r� u I uilding Location;-;) Owners New -7 Renovation D Replacement Plal F I XT[TCS DPermit i1 A701 Name s Submitted D (Print o- T �_' Installin Address Business Telephone: '��f- Name of Licensed Plumber or Gas Fitter Check one: Certificate Corp. Partner. Firm/Co. Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: � Liability insurance police/�I Other type of Insurance Waiver: I, the jundersigned, have this application does not have any one of the ignature of owner/agent of property indemnity F-1 Bond Ej been made aware that the licensee of above three insurance coverages. Owner U Agent M 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 worts and Installations perfomtcd under Permit iueed fo: this application will -be in compliance with aA pertinent provisions of the Mirsachusetts Slate Gas Code and chapter 142 of the Genual Laws. By TYPE LICENSE: Plumber Title asfi.tter Signa re of Licensed City/Town : � Master Plumber or Gasfitter Journeyman APPROVED (OFFICE USE ONLY) License Number - • Y • rrrrrrrrrrrrrr rrrrrrrrrr■ rrrrnrrrrrrrrrrrrrrrrrrr■ .. - rirrrrrrrrrrrrrrrrrrrr�rrrr W4"62 -se- rrrrrrrrrrrrNIENME rrrrrrr .... _ Ems SAME rrrrrrrrrrrrrrrrrrrr .. - ■rrrrrrrrrrrrrrrrrrirrrrrr ... rrrrrrllrrrrrrrrrrrrrrrrrrr' . ... ■rrrrrrrrrrrrrrrrrrrrrrrrr &Aljlj.. - SOMEONE SON Mrrrrrrrrrrr ... rrrrrrrrrrrrrrrrrrrrrrrr�r (Print o- T �_' Installin Address Business Telephone: '��f- Name of Licensed Plumber or Gas Fitter Check one: Certificate Corp. Partner. Firm/Co. Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: � Liability insurance police/�I Other type of Insurance Waiver: I, the jundersigned, have this application does not have any one of the ignature of owner/agent of property indemnity F-1 Bond Ej been made aware that the licensee of above three insurance coverages. Owner U Agent M 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 worts and Installations perfomtcd under Permit iueed fo: this application will -be in compliance with aA pertinent provisions of the Mirsachusetts Slate Gas Code and chapter 142 of the Genual Laws. By TYPE LICENSE: Plumber Title asfi.tter Signa re of Licensed City/Town : � Master Plumber or Gasfitter Journeyman APPROVED (OFFICE USE ONLY) License Number - Date. 40RTH TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ......... has permission for gas installation... .......... in the buildings of . .,��Irlx. /- ;.," . . . , North Andover, Mass. Lic. N .. .......................... GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File Date..................... 0* TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .... .................................. has permission for gas installation ........... ................... in the buildings of ..... .......... I—, ....................... at ................... ..... North Andover, Mass. Fee ....... :. Lic. No ............ .......................... GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File 3=7� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) Ajo Mass. Date d 19 Permit #---u q3 Building Locatlon „Z/9 /i,4A)Cll 94/11 A Owner's Name,el/GC cu. Type of Occupancy ICAC/ .JfiMe G 0 W --S / 1) 1-- NewX, Renovation ❑ Replacement ❑ Plans Submitted: Yes[] NoPf 1. Installing Company Name Yankpp (;ac r;, nil Check one: Certificate # Address 140 S0. Main Street [it Corporation 103c Middleton Ma. 01949 ❑ Partnership f Business Telephone SOg_774,.2760-- ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Wi 1 1 ; am R Harriq INSURANCE COVERAGE: ` I have a current liability Insurance policy or 4s substantial- equivalent which meets the requirements of MOL Ch. 142. Yes IR No ❑ If you have chicked yes, please indicate the type coverage by checking the appropriate box. A liability Insurance policy ® Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owner's 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 knowiedge and that all plumbing work and Installations performed under the permit Issued for this ap leation will •compliance with ali pertlnent provisions of the Massachusetts State Gas Code and Chapter 142 of the Go 1 Laws. , By T e of Ucense: "--- - Plumber Signatu�lJcenso um er or Gas fitter Title Gasfitter Master License Number 3785 Cit /Town Journeyman 0 . Soon 8 v m�NER s.0 .i .i.o.mom WAR" NENN MEN ONE 0 0 Elm MINION mom N No No OMENS 001000 loom No 100100010100 000100� Installing Company Name Yankpp (;ac r;, nil Check one: Certificate # Address 140 S0. Main Street [it Corporation 103c Middleton Ma. 01949 ❑ Partnership f Business Telephone SOg_774,.2760-- ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Wi 1 1 ; am R Harriq INSURANCE COVERAGE: ` I have a current liability Insurance policy or 4s substantial- equivalent which meets the requirements of MOL Ch. 142. Yes IR No ❑ If you have chicked yes, please indicate the type coverage by checking the appropriate box. A liability Insurance policy ® Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owner's 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 knowiedge and that all plumbing work and Installations performed under the permit Issued for this ap leation will •compliance with ali pertlnent provisions of the Massachusetts State Gas Code and Chapter 142 of the Go 1 Laws. , By T e of Ucense: "--- - Plumber Signatu�lJcenso um er or Gas fitter Title Gasfitter Master License Number 3785 Cit /Town Journeyman 0 . Date..................... I 0* TAORTN TOWN OF NORTH ANDOVER 4, 40 PERMIT FOR GAS INSTALLATION This certifies that ........................................... .. has permission for gas installation ............................ in the buildings of ........................................... at ............................. �..— , North Andover, Mass. Fee .......... Lic. No..' ......... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File Date ............ Aa 0.4 LORTH -1 TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING CHU This certifies that ............. .. ............................................... has permission to perform ........... ..................................... wiring in the building of .......... ......................................................................... & le 1; -1/ "), t at ....... ...... ................................. . North Andover, Mass.' Fee....��l ..... Lie. No . ............. ........... /,/ ........... / ....... ELECTRICAL 64SPECTOR Check # 456- ,d° r Commonwealth of Massachusetts Official Use Only Permit No. J Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/991 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CM 12.00 (PLEASE PRINT WINK OR TATE ALL INFO W ATION) Date: Q� City or Town of: To the Inspecto of Wires: By this application the undersigned g"ves once his or hernintention to perform thg,e)ectrical work described below. Location (Street & N Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No [M (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: Installation of Security system Completion of the followin table maybe waived by the Inspector of Wires. No. of Recessed Fixtures No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑In- ❑ rnd. rnd. o. ot Emergency Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal [I Other Connection No. of Dryers Heating Appliances Kit Security Systems: No. of Devices or Equivalent No. of Water KW Heaters No. of No. of I Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value of El ctrical Work: o�, (When required by municipal policy.) Work to Start:Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the ai s —and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: John S. Bassett Signature LIC. NO.: 1533C (If applicable, enter "exempt" in the license number line) Bus. Tel. No.- 60.1 594 9 $ Address: Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Li*see see 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: $ ' A AP Date ...... t4oRTPI 6 0 T WN OF NORTH ANDOVER i APPWIRW -: PERMIT FOR GAS INSTALLATION This certifies thi—t—)-.11�7� L. has permission for gas installation ......... in the buildings of at North Andover, Mass. Fe—e-Z. Lic. No. G A �S I �q §�:P 6(jC,,;Y�6j R Check # /6 J- ')7 5378 A MASSACHUSETTS UNIFORM APn ICATON FOR PERNIlTTO DO GAS FTIMG (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Permit # Building Locations Amount $ Owner's Name New Renovation Replacement Plans Submitted (Print orty ((�� /+ a one: Certif' t�Installing Company Name C��N�l1•N� GG,S ys�^ Corp'1 Address Partner. GN�acS ©\ a• Business Telep one �1 `l'1 1-3 Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE• k..nec one: I have a current liability Insurance policy or it's substantial equivalent. Yes No E-1 If you have checked yes, ple a indicate the type coverage by checking the appropriate box. ❑ Liability insurance policy M Other type of indemnity 13 Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent I hereby certify that allot the details ano mtormauon i nave suonuueu tur cuLcicu) III auvvc ZIYPncauvu MG LI UV dIS d%,UMIXL� .v t..� 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 Massachu to Gas C e and C er 14hif the General Laws. By: Title City/Town r�PPROVED (OFFICE USE ONLY) Signature of Licensed m r Or bas Fitter Plumber 1,-I 3 S Gas Fitter License Number Master Journeyman ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ (Print orty ((�� /+ a one: Certif' t�Installing Company Name C��N�l1•N� GG,S ys�^ Corp'1 Address Partner. GN�acS ©\ a• Business Telep one �1 `l'1 1-3 Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE• k..nec one: I have a current liability Insurance policy or it's substantial equivalent. Yes No E-1 If you have checked yes, ple a indicate the type coverage by checking the appropriate box. ❑ Liability insurance policy M Other type of indemnity 13 Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent I hereby certify that allot the details ano mtormauon i nave suonuueu tur cuLcicu) III auvvc ZIYPncauvu MG LI UV dIS d%,UMIXL� .v t..� 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 Massachu to Gas C e and C er 14hif the General Laws. By: Title City/Town r�PPROVED (OFFICE USE ONLY) Signature of Licensed m r Or bas Fitter Plumber 1,-I 3 S Gas Fitter License Number Master Journeyman