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HomeMy WebLinkAboutMiscellaneous - 22 PUTNAM ROAD 4/30/2018 22 PUTNAM ROAD~� 210/021.0-0008-0000.0 i L I it Date... OF tAORTH L TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING ,sSACHU This certifies that ................ ... ..... 7—........012 c ........................ ................................... has permission to perforin ................ ..... ......................................................... .......................................................... wiring in the building of....D.................... ..L .... . at ....... ....................................................."North Andover,Mass. av Oe Lic. No. .;�TYIT4 44AL�INSPEcrOR Gieck# Commonwealth of Massachusetts Official Use Only —a o Department of Fire Services Permit No. 6 �i-�7Z, Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank M 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 IN HK OR TYPE ALL INFORMATION) Date: 9- 3 o — j a I LI 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) 4&I a o p/ Owner or Tenant J2 A Vib P lip1' Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes Rr No ❑ (Check Appropriate Box) Purpose of Building �lj/p' Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table 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- ❑ Ao.of Emergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and a` Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: -" '....."'"'"............."""".'""""' Detection/Ale ting Devices No.of Dishwashers 7 Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: d No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 7V c— 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: INSURA-NNE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this ap I' tion is true and complete. FIRM NAME: _ LIC.NO.: /Z Licensee: ��,8iy s S �' .S�2 (2�' Signature LIC.NO.: (If applicable,aqnter "exempt"in the license number line.) f,/Bus.Tel.No.- _ v- 0 d Address: d� �i(///V7' S /yJ7/�J7j(�(j �i-r/� Q�-j �s 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 IT 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 L' 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 conceming 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 n Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INPECTION: Pass Failed Re-Inspection Required($.) ❑ , Inspectors Co m nts: Inspectors Signature: Date: FINAL INSPECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: sff © LL� ZI Inspectors Signature: U Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com �- The Commonwealth of Massachusetts - Department of bidifstriglAccMiks Office oflnvestigations 640 Washington.Street Boston,MA 02111 -www.mass:gov/clia Workers' Compensation Insurance Affidavit:Builders/Cont°actorsWlect i.cians/Plonbers Applicant Information Please.Print Lealb 'Name(Business/Organi'zatlon/ludividual): "I Address: 1&14 L71/ /Z E7 Yz Y 4 T!_ City/State/Zip:�/'Q /-a(ZO•�� o �. S Phone#: 6/:7 ASCI Are you an employer?Check the appropriate box: Type of project(required): 1.N I am a employer with 4• ❑I am a general contractor and I 6• New construction f employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner listed on the attached sheet 7. Remodeling ship and•have no employees These sub-contractors have S. []Demolition working for mem any capacity, workers'comp.insurance, g• F1 Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised.their 10.[1 Electrical repairs or additions 3111 1 1 am a homeowner doing all work right of exemption per MGL MEI Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and wehaveno 12•[]Roofrepairs insurancere ed. t employees.[No workers' a 13.❑Other comp.insurance required.] xAny 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 Are'doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that checkthis box must attached m 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 ift policy and'f ob site information. Insurance Company Namel Zf Policy#or Self ius.U0. �V' CZ-�' s Expiration Date: Job Site Address: � y TAA 0--? Aep� Pity/.State/Zip: Am RVV-,d M0 o L,4 (1.- Attach LAttach a copy of the workers'compensatlowp ollcy declaration page(showing the policy number and expiration date). Failme to secure coverage as requireduuder Section 25A ofMGL 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 of up to$250.00 a day against the violator. Be advised that a copy of thus statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby cerci un er t/ ins enalties of perjury that the information provided above is true and correct. - Si afore• Date: Phone#: 7 _ O ^ O U 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 - Coatact 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 coriiract of hire,. express ox implied,oral or written." An employes 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. Awever the owner of a dwelling house having notmore 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 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 fox 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 beenpresentedto 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 notrequired to carry workers'compensation insurance. If an LLC ox LLP does have em ployees,a policy is.required. Be advised thatthisaffidavit maybe.submitted tothe 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' compeusationpolicy,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"J'ob 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 b e filled out each year.Where a homeowner or citizen is obtaining a license ox 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 aiidfax number: The CQ onw-aaM ofM-assac by,5etiS - Depax`�ie�.l of�dus�ral.E`�ecxdez�ts oxce o m wtigatio= 6.9G Washh-g(an Roel: Boston,MA02111 TQL 617-7-27,4900 W 406 or 1-8,77,MA.SSAM - Revised 5-26-05 Fax 0 617-727"7749 I i ....Aqw.comm OF MAS1kCH'ISETTS s s - • • ISSUES THE FOLLOWING LICENSE .AS A; REGIOURN EYMAN :.ELECT_R I C'f.•A i� iF JAMES J SARTOR I,. 2; WINTER hl: b b RD > Ma 02 155-43f-7: 5 . .: . .. 07/3 ::6..:.<: X06524 • I ' OP ID:SS ACORO° DATE(MMDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 09/29/2014 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(les)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 CONTACT Sartori Insurance Agency,Inc. NAME: Stephen Sartori 76 Bedford St.Suite 37 PHONE N Ext;781-861-6900 AX No):781-862-8831 Lexington,MA 02420 E-MAIL steve@sartori-insurance.com Sartori Insurance Agency Inc. ADDRESS: PRODUCER SOSEL-1 CUSTOMER ID#: INSURERS AFFORDING COVERAGE NAIC# INSURED James Sartori Electric Co INSURER A:The Travelers 25674 27 Winter St Medford,MA 02155 INSURER B:The Hartford Ins Co 19682 INSURER C: INSURER D: INSURER E: INSURER F; COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. INADLICY LTR TYPE OF INSURANCE 2M&MaL DL UBR POLICY NUMBER POLICY EFF MM DDI EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY 680-1880951A 1210312013 12/03/2014 PREMISES Ea occurrence $ 56 NEN FED 0,00 CLAIMS-MADE I OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICYX PRO - LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ALL OWNED AUTOS ANY AUTO (Ea accident) BODILY INJURY(Per person) $ SCHEDULED AUTOS BODILY INJURY(Per accident) $ PROPERTY DAMAGE $ HIRED AUTOS (PER ACCIDENT) NON-OWNED AUTOS $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,00 EXCESS LIAB CLAIMS-MADE A CUP 0048871638 1210312013 12/0312014 AGGREGATE $ 5,000,00 DEDUCTIBLE $ X RETENTION $ 0 $ WORKERS COMPENSATION WC STATU- 0H- AND EMPLOYERS'LIABILITY Y/N X TORY LIMITS ER B ANY PROPRIETORIPARTNER/EXECUTIVE 08WECLC5879 10/05/2013 10/05/2014 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) 10/05/2014 10/05/2015 E.L.DISEASE-EA EMPLOYE $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Andover ACCORDANCE WITH THE POLICY PROVISIONS. 36 Bartlet St Andover,MA 01810 AUTHORIZED REPRESENTATIVE Sartori Insurance Agency Inc. ©1988.2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD Date.A.I.X21ig............ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING a D 'It. This certifies that..... ........ .. ...... ......rp.................................. has permission to perform.. .....134J .................................................................. plumbinthe buildings of............................................................................................. at.j�.h 1.4, .. .....................................................A.1......North Andover, Mass. Fee��.O)...Lic. No. ... w ...... ...... ................................................... PLUMBING INSPECTOR Check# 3 S' MASSACHUSETTS UNIFORM APPLICATION FOR A PERI'AIT TO PERFORM PLUMBING WORK IC'_ , tV Z` CITY/W � #/74/d 11C«.. MA DATE Gr'.3!J-�L( PERMIT# ItIll JOBSITE ADDRESS �0� � / OWNER'S NAME�rf+Gi.1L Pre), POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Ei--" PRINT �,,/ CLEARLY NEW:EI RENOVATION:L7 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES Z FLOOR— BSM 1 2 3 4 5 6 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 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 ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER F-1AGENT ElSIGNATURE 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 complian e wit"'ll ine ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME PAUL FLAHERTY LICENSE# 9059 SIGNATURE MP❑X JP❑ CORPORATION®# 1752 PARTNERSHIP❑# LLC❑# COMPANY NAME PAUL FLAHERTY PLUMBING&HEATING CO. INC ADDRESS 186 FOUNTAIN STREET CITY FRAMINGHAM STATE MA ZIP 01702 TEL 508-653-1775 FAX 508-620-1775 CELL EMAIL CONTACTUS@FLAHERTYPLUMBING.COM ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No ��.� d 33lf THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES DATE ACoORVCERTIFICATE OF LIABILITY INSURANCE 8/29M20 4 Y' 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 CONTACT NAME: Tina TOiCh10 W.T. Phelan & Co. , Insurance Agency Inc. PHONE (761)611-7200 FAX No):(781)646-2410 645R Massachusetts Avenue AIL ADDRESS:tina.torchio@wtphelan.com INSURER(S)AFFORDING COVERAGE NAIC# Arlington MA 02476 INSURERA:Travelers INSURED INSURER B AmGuard 21873 Paul Flaherty Plumbing & Heating Co. , Inc. INSURERC: 186 Fountain Street INSURER D: INSURER E: Framingham MA 01701 INSURER F: COVERAGES CERTIFICATE NUMBER:2014-2015 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBRPOLICY EFF LTR TYPE OF INSURANCES POLICY NUMBER MMIDD/YYYY MM DDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED �OCCUR 680-009E182725 PREMISES Ea occurrence $ 300,000 A CLAIMS-MADE 9/1/2014 9/1/2015 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 A ANY AUTO BODILY INJURY(Per person) $ ALL AUTOS OWNED X SCHEDULED -9E183457 9/1/2014 9/1/2015 BODILY INJURY(Per accident) $ X HIRED AUTOS X AUTOS NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 3,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 3,000,000 DED RETENTIONS UP-009E197044 9/1/2014 9/1/2015 $ B WORKERS COMPENSATION WC STATU- I OTH- AND EMPLOYERS'LIABILITY YINCRY L'M ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N I A E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in NH) AWC557165 9/1/2014 9/1/2015 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. Inspectional Services 1600 Osgood Street AUTHORIZED REPRESENTATIVE North Andover, MA 01845 R Ramsey, Jr./TORCTD ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INSn25 i9ninnsi m Tha Af:r1Rr1 noma onrl Innn ora ranicfararl mnrlrc of&rr1Rr1 The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Paul Flaherty Plumbing& Heating Co., Inc Address:186 Fountain Street City/State/Zip:Framingham, MA 01702 Phone #:508-653-1775 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 employees(full and/or part-time).* have hired the sub-contractors 6. E] New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance. T required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no 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 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: Guard Insurance(Amguard) Policy#or Self-ins. Lic.#:PAWC557165 Expiration Date:09/01/2015 Job Site Address:22 Putnam Road' City/State/Zip:N.Andover,MA 01840 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby!c _, nder th _pffl*qndpenqities o perjurythat the in ormation 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#: 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 conunonwealth 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 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 7-2010 www.mass.gov/dia —MBERKSHIRE HATHAWAY Worker's Compensation and Employer's Liability Policy GUARD INSURANCE AmGUARD Insurance Company - A Stock Company — COMPANIES Policy Number PAWC557165 Renewal of PAWC447270 NCCI No. [21873] Policy Information Page [1]Named Insured and Mailing Address Agency Paul Flaherty Plumbing & Heating Co., Inc W.T. PHELAN &COMPANY 186 Fountain Street INSURANCE AGENCY, INC. Framingham, MA 01702 645R Massachusetts Ave Arlington, MA 02476 Agency Code: MAWTPH10 Federal Employer's ID 04-3008950 Insured is Corporation [2] Policy Period From September 1, 2014 to September 1, 2015, 12:01 AM, standard time at the insured's mailing address. [3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Massachusetts B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident - each accident $1,000,000 "t Bodily Injury by Disease - each employee $1,000,000 Bodily Injury by Disease - policy limit $1,000,000 C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming. D. This policy includes these endorsements and schedules: See Extension of Information Page - Schedule of Forms [4] Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page) Total Estimated Policy Premium $ 21,657 Total Surcharges/Assessments $ 1,676.00 Total Estimated Cost $ 23,333.00 INTERNAL USE XX Page - 1 - MGA Information Page : PAWC557165 9 Date : 08/27/2014 WC 000001A MANOTE Issuing Office: P.O. Box A-H, 16 S. River Street,Wilkes-Barre, PA 18703-0020 •www.guard.com a>COMMONWEILTH OF Mi?#551HUSETT&:;; :<< D 0 0 O O F P L UMB E `>: 1' G`A S.F..I TT,ER;S€: ISSUES,. THE FOLLOWING` L'I`CENSE..::::::;:::::`:°' R>EI<SERED AS A;:;;:,P:.LUMB I NG CORP' P:A:U:LJT FLAHERTY.. PAUL FLAHERTY` t'LB HTG I.NC M905 � s� PO Bo 629 %J NRTICK' MA 01760-00OJ- 175 t 7 >:; o5/o;:a>/a: ; >` 2 t 885 t . CONTROL# J 21 6- 1 IMPORTANT If your license is lost,damaged or destroyed; is inaccurate; or needs to be corrected,visit our web site at mass.gov/dpl for instructions to ensure the proper mailing of your Renewal Application and any other correspondence. This license is subject to Massachusetts General Laws and regulations.Your license is a privilege,and cannot be lent or assigned to any person or entity under penalty of law. Keep this license on your person or posted as required by law and/or regulations. Date...... .I .�.�....................... OF &ORTh�h - °3,�' TOWN OF NORTH ANDOVER Q PERMIT FOR GAS INSTALLATION ti gs�c►+uss This certifies tha `P ...... `''te.................. has permission for gas installation .....�$+PA- in the buildings-9f.. ..! .. ' - .....................................:.............................. at...... Z............ i�.... ..� ..................... North Andover, Mass. �' I3 2 Fee...........�'....... Lic. No. .I-;- ..................................................................... GASINSPECTOR Check# 'V� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE / PERMIT#— JOBSITE ADDRESSF-9 A tI{OWNER'S NAME r/#1Ae,Mw GOWNER ADDRESS SM e, FAX TYPE OR OCCUPANCY TYPE COMMERCIAL R EDUCATIONAL I RESIDENTIAIA PRINT CLEARLY NEW: Az RENOVATION:El REPLACEMENT:® PLANS SUBMITTED: YES R Nd l APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I 1 ( - [- -, 1 BOOSTER _ J CONVERSION BURNER COOK STOVE _. . .�- —A.. __ --j- .__ ji DIRECT VENT HEATER DRYER FIREPLACE (G, I __.[ I►-. j __ _ I _ FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKSI(�[� [._ MAKEUP AIR UNIT OVENI- POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER I j^ —( -Q UNVENTED ROOM HEATER 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 ® -' I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW �y LIABILITY INSURANCE POLICY 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. V CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and ac urate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli e 'h erti t provi ' n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (7 PLUM BER-GASFITTER NAME 616nel N ceL LICENSE# 3 SI NATURE MPXj MGF 0 JP D JGF rj-� LPGI© CORPORATION©# PARTNERSHIP©#�( LLC[I# S6)i J COMPANY NAME: ,I��-C',4ee Flu _�n6� n6 ADDRESS I c�2 F,4et 121 CITY �P6�2 _ _ _ I STATE ZIP d 3ITEL FAX CELLE � EMAIL _ ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INPECTIOT OTES Yes No fly THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES O' The Commonwealth ofMassachusetts Department oflndustdalAccidents Office of Investigations VV 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): � i�/J�i /�Ir?t � Address: e City/State/Zip: � � Phone#: "e-2 Are you an employer?Check the appropriate box: Typo of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2 I am a sole proprietor or partner- listed on the attached sheet. �• Remodeling "''�'4" 111111 ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9• EJ Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner,doing all work right of exemption per MGL I LE]Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.❑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. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. p Y Policy#or Self-ins.Lie. E irationDate: 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 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 cert' n the 'ns onalt's ofperjury that the information provided above is u and correct. Sivanature: Date: �7 l 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 - - C'nntart Persnn: Phone#: b 1 D Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or.written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance With the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are notrequired 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 lavestigations has to contact you regarding the applicant. Please be sure to fill in the pennit/license number which will be.used as a reference number. In addition,an applicant that must submit multiple pennit/license applications in any given year,need only.submit one affidavit indicating current Policy infonnation(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 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 Commonwoalth of Massachvsetts Departmeut ofZvdustdal.A,coldevts Office ofInvestigatiom 600 Washingtoa Slioa Roston?MA 0 111 Tel,#617-727-4900 at 406 or 1-877-MASSAFF, Revised 5-26-05 FaY W 617-727-7749 �r V 3 COMMONWEALTH OF MASSACHUSETTS .>; o • e • • o BOARD t!F s PLUMBERS :::AND GASFITTERS ISSUES THE FOLLOW(NC LICENSE s LI.CENSE'D AS ;;A MASTER PLUMBEF �Z GLENN M MCCAB.EN 1 POORPARM ROAD Iv t Ir w �J S DERRY N.H 03038-4209 05/n1 tQRQ ��i«a�r.7a.ntrQ:�a.�+yt��lf�1►1' Date.12—.. ............ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... ... .........................0..... &C..................................................... has permission to perform .. ... .. ......... ............ .... . e- ............................ wiring in the building of..............P: ......................................................................... at .....2. /!:w' . . ...................................................................................... Andover,Mass. -Fee...55�—^........Lic.No. ELE CAL INSPECTOR Check.. -)P Y 1���� , 1� U � �� ,tet �_� --- �_-- i 0 Commonwealth of Massachusetts Official Use Only a Permit No. Department of Fire Services Occupancy and Fee Checked y 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(ME5),527 CYR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: �� 2 City or Town of. NORTH ANDOVER To the Inspector o Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 7 1?01 Owner or Tenant `V P,Q,� Telephone No. Owner's Address Is this permit in conjunctio with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building $l(Gey{�j�ci Utility Authorization No. Existing Service /4�70 Amps /20/ Z O Volts Overhead ❑---Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 647m1,z Completion o the followingtable ma be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:SusNo.o Total p.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above Ei In- Emergency Lighting rnd. rnd. Baoo 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 No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number I Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of Water , No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of El ctric I Work: (When required by municipal policy.) Work to Start: 12 �2 13 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: v1C� (�G LIC.NO.: 11,153Z Licensee: Signature ,�, C.NO.: _ (If applicable,enter "exempt/to the lice a numbgr line.) ��Jl �l MI_ Bus.Tel No.:��}-1 �5 Address: �� G!'/a�i Sk /y� -1-1 1 �� 02y'� Alt.Tel.No.: 25/ *Per M.G.L c. 147,s.57-61,security work requires Department of&blic Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's a ent. Owner/Agent PERMIT FEE. $ l Signature Telephone No. The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 UV www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansfPlumbers Applicant Information PIease Print UAW 01 / . Name(Business/Organization/Individual):_P� ��yZ,P C_ Address: 13 Cl2G , S� City/State/Zip: /y�W/0!1 O2Y5-Y Phone Are ygixa employer?Check the appropriate box: Type of project(required): 1.E�,I am a employer with 4. ❑ I am a general contractor and I 6. ❑New bnstruction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.$ �• modeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. F1 Building addition [No workers' comp.insurance 5. El 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 box41 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis 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.Lie.#: ! D 4�3 5_ZU7 U6 Expiration Date: 7 Job Site Address: Z 2 �y�7'/G AL1- tel City/State/Zip: A//P Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fip e 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 Ifnvestigations 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 Si ature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: - r Information and Instructions ' Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not 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 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 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. I 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: Tho COMM011wealthofMassavhu.setts Department of lxadustdal Accidents Office of Investigations 600 Wasbingtan Street Boston}M,02111 Tel,#617-727-4900 ort 406 or 1.-877,7MASS.AF.F Revised 5-26-05 Bay#617-727;7749 WW-Mass,govfdza lool �` • COMMONWEALTH OF MASSACHUSETTS • • - • [010 FA No ki j BOARD OF 1 ELECTRICIANS ISSUES THE; FOLLOWING C:1 CENSE AS .A I REGISTERED MASTER ELECTR17 IAN Q CEDRONE ELECTRIC INC +, t ALFREDO CEDRON,E i 13 CHAPEL STREET ``s . lu NEWTON :::MA 02458-10 11556. A 7/3 / o 1 16 41260 4 rj -: n - Date.1 / . R °`..".01FI T"�ti TOWN OF NORTH ANDOVER ° p PERMIT FOR PLUMBING HUS tt " This certifies that ...-!.:....1c. � e �0 e- ........................... has permission to perform...... - a plumbing in the buildings of....... CP. .►............ `` ....................................................... at....... ,,........�tti�...J.f3::''�1.......1............................. North Andover, Mass. Fee... 1 t..... PLUMBING INSPECTOR Check# i MASSACHUSETTS UNIFORM APPLICATION FOR A PERI'AIT TO PERFORM PLUMBING WORK r if..... .. -. MA DATE l� 'l3 CITY G G PERMIT# JOBSITE ADDRESS 4&&- U fid OWNER'S NAME GG�I OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ PRINT EDUCATIONAL ElRESIDENTIAL - CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 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 ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® OTHER TYPE OF INDEMNITY ❑ BOND ❑ e 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. 4 CHECK ONE ONLY: OWNER F1 AGENT ElSIGNATURE OF OWNER OR AGENT �V I hereby certify that all of the details and information I have submitted or entered regarding this application are tr&e-and accurate to the best of my knowledge �q and that all plumbing work and installations performed under the permit issued for this application will be in complian a wit 11 Pe 41 Z sion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME PAUL FLAHERTY � v�►�• LICENSE# 9059 SIGNATURE MP❑x JP❑ CORPORATION®# 1752 PARTNERSHIP❑# LLC❑# I COMPANY NAME PAUL FLAHERTY PLUMBING&HEATING CO.,INC ADDRESS 186 FOUNTAIN STREET CITY FRAMINGHAM STATE MA ZIP 01702 TEL 508-653-1775 FAX 508-620-1775 CELL EMAIL CONTACTUS@FLAHERTYPLUMBING.COM Vl'` !A I i � I �, . ,fir • 4. ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES I Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ t FEE: $ PERMIT# PLAN REVIEW NOTES