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HomeMy WebLinkAboutMiscellaneous - 224 FRENCH FARM ROAD 4/30/2018 224 FRENCH FARM ROAD 210/062.0-0067-0000.0 p n� 4U Date. . TOWN OF NORTH ANDOVER �: •` 1- . PERMIT FOR PLUMBING SA US This certifies that . . '! . . ��f?? . �`? . . /� CS . . . . . . . . . has permission to perform plumbing in the buil/dings of . . . .A!QCfj�!��j . . . . . . . . . . . at . . .,:, North Andover.Mass. Fee.t.O../.-P. .Lic. No.. / . . . . . . . PLUMBING INSPECTOR Check x 8411 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK U ON- 11 CITY �N d/` _— _,I MA DATE PERMIT# 1W JOBSITE ADDRESS OWNER'S NAME P OWNER ADDRESS. c�� a�� _C TEL _jy Q_ FAX k TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: 0 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 { ► _ I ! f i ! ___� ! _____[ _! - __..! ! —y_k CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM I DEDICATED GREASE SYSTEM -__- ------.{ DEDICATED GRAY WATER SYSTEM ! _ ! ! ! ! I ( ! 7 DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER L FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) I .._.__ ! ___..._i ( i I 1 —__-f ( l .._____ =1 KITCHEN SINK __-- LAVATORY ROOF DRAIN 1 _A_.__.J _-_I SHOWER STALL SERVICE/MOP SINK _.__I TOILET � ( -__-, f -_- _� �.� � _ _I ! J URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES -- -- - — WATER PIPING OTHER ____��__ __--__ �_.___ I ► _! .__....__.c ._...____i I _____l .__-__� .-_____i - ! _._-_-.___t ___! _` ------ —___i INSURANCE COVERAGE: 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 0 BOND P OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT 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 ccurate the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com ' c ith all rtinent p ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. d PLUMBER'S NAME , _ LICENSE# SIGNATUR MP Er JP Q CORPORATION .. l# /-Z PARTNERSHIP[-]# LLC COMPANY NAME - t y DDRESS CITY _ . ..h_..._.i STATE ZIP ��/(Jf.� -�j TEL ; CELL 6RMAIL -- --�I1ir 4�►'3-� - -- ._.. ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES as .I THIS APPLICATION SERVES AS THE PERMIT El ❑ 7-7 ivy FEE:-$ PERMIT# PLAN REVIEW NOTES w 'a The Commonwealth of Massachusetts Depaament of£,zdustrial Accidents Office of Investigations ..600 Washington Street Boston, AM 02.711 www-mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /3 Please Print Legibly• ' Name(Business/Organization/Individual):– Address- City/State/Zip: Business/Organization/Individual):Address:City/State/Zip: j /40-Phone#: liorpartner- employer?Check appropriate box: employer with 4. Type of project(required):' ❑ I ama general contractor and Iees(full and/or part-time).*' have hired the sub-contractors 6. ❑New construction sole proprietor or partner- listed on fhe attached sheet.t 7• ❑Remodelingd have no employees These sub=contractors have 8. ❑Demolition g for me in any capacity. workers'comp,insurance.rkers'com .insurance 5. 9. []Building addition p ❑ We aze a corporation and its d.] officers have exercised their 10.❑Electrical repairs or additions 3.❑.I am a homeowner doing all work right of exemption per MGL 11.[]dumbing repairs or additions myself.[No workers'comp. c. 152,§44),and we have no insurance required.] t em to des. 12•❑Roof repairs P Y• [No workers' comp.insurance required.] 13.❑Other THHo apa t t`at cLec:W box�1 ns`-t also fill out the section below ^ovir. _ __ _ omeownernrs as who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: �- Polio y#or Self-ins.Lie.#: 1- 7—"F, ' � Expiration Date: Z� Job Site Address: z City/State/Zip: .17 - 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 ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,504.00 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 IA for insurance coverage verification. I do hereby n th pains d penalties of perjwy that the information provided above is true and correct Sitmature: - // Date: Phone#: Official use only. Do not write in this area, to be completed by city or town offzciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.plum in,:,Inspector 6.Other Contact Person: Phone#: n 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 6r 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* another who-employs persons to do-maintenance,.construction or-repair-work-on such dwelling-houseor on the grounds 6r building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152;§25C(6)als�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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,.are not required to carry workers'compensation insurance. If an LLC or.LLP does have employees,a policy is required. Beedvised 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 epsu - nybe rye aed to the c?sy or t7CT H=thIlicPs?St iR hYP9t'g re u@Bred;not the Dnpartm.e71t Of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be-used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business.or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would'like to thank you in advance f6r your cooperation and should you have any questions, please do not-hesitate to give T a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts. Department ofF.ndustdal Accidents Office ofInvestigations 600 Washington Street Boston,MA 02111 Tel. # 617-72.7-4900 ext 406 or 1-8.77-M.AS-SAFE Fax#6.17-727-7749 Revised 5-26-OS S7PF'f7Pnn Tn Aov "^n hT, Date... '"�Q.� .... NOR7M O�t,�ac i•11' TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that ........ �.......... l..yld Q ,l........................ has permission to perform ........L.....� �{�W............................................ wiring in the building of C /111.LilJ ........... . ............ .................................................... at............... ........................y. .....�. ...... ............ ,North Andover,Mass. Fee..., ............. Lic.No�....� ...... ELECrRI1......................... CALI PECTOR Check # 3 Y 8927 t�. Commonwealth of Massachusetts Official Use Only Department of Fire Services FPerrmnilNo. �� � BOARD OF FIRE PREVENTION REGULATIONS pancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) � mTy"�'►�t ��,Q�4� Owner or Tenant Owner's Address Y /\ Telephone No. Is this permit in conjunction with a building permit? Yes I No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work. --------- Completion of the followin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of CeiL-Susp. (Paddle)Fans No.of Total . Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming pool Above In- o.o mergency ig g I• d. Batte Units - No.of Receptacle Outlets No.of on Burners FIRE AiARNrS No.of hones No.of Switches No.of Gas Burners No.of Detection and No.of Ranges No.of Air Cond. Total Initiating Devices Tons No.of Alerting Devices No.of Waste Disposers Heat pump Number Tons KW o,of Self-Contained Totals: -_..._._-!" -'� Do.of on/Ale tinSelf-Contained n,Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal No.of Dryers Heatin A Connection ❑ Other g ppIiances , Security Systems: No.of WaterNo.ofo.oNo.of Devices or Equivalent Heaters KW Si as Ballasts Data Wiring: 1 No.of Devices 2LLquivalent No.Hydromassage Bathtubs No.of Motors Total Hp Telecommunications Wiring: OTHER: No.of Devices or Equivalent Attach additional detail tf desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage 's in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Spec I certify,under the pains and enaldes o ) t P f perjury,that the information on this application is true and complete. FIRM NAME:�T kl LO LIC.NO.: Licensee: Signa (If applicable, enter"exempt"in the license number line.) C.NO.0° Address: F ,� �. Bus.TeL No.: (j *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Alt.L cl.No.• 3 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ '� .t,. ��' ' � cp.e, � � .3�` �� 4; . k 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 ff ashington Street Boston, M4 02111 www nwss gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers Apylicant Information Please Print LeQlbly a Name (Business/Orgmiration/Individual): 1 SL Address: i City/State/Zip: Phone#: . Are you an employer?Check.the appropriate box: 77. al�e_m_od ject(required): l.❑ i a employer with 4, [] l am a general contractor and I employees(fill]and/or part-time).* have tired the sub-contractors construction 2. I am.a:sole proprietor.or partner- listed on the attached sheet.x eling ship and have no employees These sub-contractors have . ❑Demolition " working for me.in any capacity, workers' comp.insurance. [No workers'comp,insurance 5. ❑ We are a corporation and its 9 ❑Building addition • required.] officers have exercised their 10. Electrical repairs ts 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. 1.52, §1(4),and we have no 12.[]Roof repairs insurance required.]t .employees. [No workers' comp. insurance require&] 13•❑.Other *Anyapplicant that checks bo>rtl t must also fill out the section below showing their workers'compensation policy information, Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their work ers,ca mp_roEicy i„firma on I am an employer thal is.prgvi i g:workers'compensation insurance for n7 employees: Below is the policy artdjob site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip. ” Attach a copy of the workers'.compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment;as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert under the poi and penaides of perjury that the information provided above is is true and correct Si tut r(� Date: V Phone 23-1 U Offici a 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 a nd Instructions Massachusetts General Laws chapter 152 requires all emp1loyers 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 nurnber(s)along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the ° members or partners,are not required to cavy workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this 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 nurciber_listed below. Self-insured companies should enter their self=insurance license number on the appropriate tine. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the 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 i year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bush leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, pie=do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts ti Department of Industrial Accidents Office of Investigations 600 Washington Sheet Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Fax#617-727-7744 Revised 5-26-05 www.mass.gov(dia Date/..0 .. ... t HORTM 3?O�tn•�`�-+°'I,e�Op` TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �Ss�cHusE� This certifies that ,� �. ...........�i✓i<? f LO`�....................1..... has permission to perform . / .............. ..... wiring in the building of.......a a.... ..Y....r'L�� . ........................................................ at. -.r!f.���� -....................................... orth Andover,Mass. . ................ 4�Lic.No....JS ............... .'. ..... ELECTRICAL INSPECTOR Check # _ 902 (fommonweallh o f MaJJachu.Jelle Official Use Only —'7 Permit No. 2 cc�� eCJeParlmenl o/..tire Occupancy and Fee Checked y(> BOARD OF FIRE PREVENTION REGULATIONS Rev. 1/07 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK ORINFORMATION) Date: / ' I TYPE L City or Town of: ' To the Inspector of Wires: By this application the undersigned lives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant �� Telephone No. Owner's Address Vn Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. 7,6-77-7e) Existing Service( 0 Amps 0 1240Volts Overhead� Undgrd❑ No.of Meters J New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters r Number of Feeders and Ampacity X l tA N 15"Te-lzz, 5,004e t- iV 13 Location and Nature of Proposed Electrical Work: Completion o 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 AboveIn- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battea 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 Ran es No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of D ers Heating Appliances KW Security Systems:* �' No.of Devices or Equivalent No.ofWater KWNo.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 4 OTHER: Attach additional detail if desired, or as required by the Inspector of WirtI Estimated Value of Electrical WoJlaL�V-- (When required by municipal policy.) ! Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE �BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: td� o i ( � Licensee: St -� Signatur o � LIC.NO.: (If applicable, nter "exe t"in the license numb line.) - Bus.Tel.No.: 07 Address: 4 ,N vw , ,ear��t N / v ��� Alt.Tel.No.: 6O " L733 *Per M.G.L.c.47,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 oneeEl owner ❑ owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE. $ a The Commonwealth of Massachusetts k- ! Department of Industrial Accidents Office of Investigations fl., 600 Washington Street ilt,r, , Vasa ,i Boston, MA 02111 c; www.rnass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le_aibly Name (Business/Organization/individual); Address: City/State/Zip:�/�~ �1 /U Phone#: �(2 Z3 �l�( Are you an employer?Check the appropriate box: l ❑ Type of project:(reequ7i,:re*d):am a employer with 4. ❑ 1 am a general contractor and Iemployees(full and/or part-time)* have hired the sub-contractors 6' ❑New cons 2. I am a:sole proprietor or partner. listed on the attached sheet.x �• ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me.in any capacity, workers' comp.insurance. 9. ❑Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical �mred] officers have exercised their repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I Plumbing repairs or additions myself. [ o-workers'comp. c. 1.52, §1(4),and we have no 12.[]insurance.required.]t employees. [No workers' Roofrepairs comp. insurance required.] 13.❑.Other •Any applicant that checks ba#t must also fill out the section below showing their workers''compensation poiicy information. 7 Homeowners who submit this affidavit indicating they are doing all work and then hive outside contractors trust submit anew affidavit indicating such. $Contractors that check this box mustattached an additional sheet showing•the r�±ms of the sub-conttactn�and tkeir u it a n'comp.affidavit icy in indicating lam an employer that is providing workers'compensation insurance for my employees: Below is the policy mid job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$4500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORT{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 Y investigations of the DIA for insurance coverage verification. I do hereby c ify under the p and penalties of perjury that the information provided above is true and correct 5t tore: /� „q Date: V" \ � Phone# +fj`Ic• e only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector S. Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the'foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. 'However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence.of compliance with the insurance'coverage required." Additionally, MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation.affidavit completely,by checking the boxes that apply to your situation and,if r necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,notthe Department of Industrial Accidents. Should you have any.questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the n---..b-.r list~d 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 pernit/license number which vvill 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 marred by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. r 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#617-7.27-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-7744 vvww.mass.gov/dia GeoAmbient Consultants Inc. 101 Pine Island Roar Newbury,MA 01951 July 30,2009 L MacMillannch Farm Road Andover, MA RE: Framing Inspection 224 French Farm Road,North Andover,MA Dear Allison, On July 27, 2009 we performed an inspection of the recent framing work at the above referenced address. Upon review we believe the work completed meets the intent of the plan prepared by this office titled"Wall Modifications and Associated Structural Design..." bperformed in a workmanlike manner and in compliance with 780 All remaining work to e p p CMR and local building codes. If you have any questions or if I can be of further assistance please contact me @ 978-502-5197. yo John W. Hargreaves,Jr.,PE GeoAmbient Consultants Inc. 1N OF N4 E No.42426 ►OVAL n Date.. . ..�`�....... HORTM Of ,.•o ,°,�O o? TOWN OF NORTH ANDOV. R PERMIT FOR GAS INS ►LLATION ACMUSEt This certifies that . . . . � -�. . . . . . . . . . . has permission for gas installation . . . . . .... . . . . . . . . . . . . . in the buildings o at .IF! . . . . . . . . ';�orth Andover, Mass. Fee.; . . . . . Lic. NoA'4J.Z . � _ :. . . . . . . . . GAS IN OR Check# /,Pa 9 6864 r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS d / �'�?.2IZ' � ^ I C�G v ( DateBuilding Location �hatOwners Name Permit# 044Y- Amount 2 �. Type of Occupancy New Renovation Replacement ri Plans Submitted YesF-1No ❑ FIXTURES F � W a x a a W x w U W C7 pro U SMI MC BASE"M IR HDCR MHOCR I T- M MOM 4M FLI)Cl2 5M MOM 6M FIDM - 7M HBM gm HDD h (Print or type) j Check one: Certificate Installing Company Name �L�`S' ❑ Corp. ! RI�fS/� Address f`rW� ❑ Partner. r A r -V-V—Or -: Yl d Business Telep one C ep.. y0q- S-7Firm/Co. Name of Licensed Plumber: q Insurance Coverage: Indicate the ty of insuranqjcoverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent I hereby certify that all of the details and information I �,av ub}�itted(or entered a �Zpplication are true and accurate to the best of my knowledge and that all plumbing work and inla'6ns performed u er e t Issued for this application will be in compliance with all pertinent provisions of the Massac e State Plumbing d hapter 142 of the General Laws. By: SignaRreTT L7cense um er Ty e aumlr PIbing License Title �?� City/Town cense Master Journeyman ❑ APPROVED(OFFICE USE ONLY I R ,s The Commonwealth ofMassachusetts In k j }� Department of industrial Accidents _t 1 Office of Investigations 600 Ffrashinoton Street ti a Boston, MA 02111 Www mass.gov/dia . Workers' Compensation Insurance Affidavit: guilders/Contractors/Eiectricians/Piambers A licant Information. Please Print Legibly Name (Business/Organization/individual): Address: CityLState/Zip:`�ers�.o1.�1.�: th � 3, Phone#: . Fhomeowner n employer?Check.the appropriate box:a employer with 4, Type of pro1�(required): ❑ l am agenera)contractor and Iyees(fu(1 and/or paetrm .* have iced the sub-contractors d ❑New constructiona.sole proprietor.or partner- listed on the attached sheet$ 1. ❑ Remodeling nd have no employeesThese sub-conttaetors haveng for me.in act workers' comp.insurance. g' ❑DemoimontY• 9. Btii)diorkers'comp.insurance 5. ❑ We are a corporation and ifs ❑ ng addition ed j officers have exercised their l 0❑Electrical repairs or additions homeowner rising all work right of exemption per MOL I I.[] Plumbing repairs or additions myself.[No�warkers'comp, c, t52, §I(4),and we have no insurance re ired. .t 12.❑Roof repairs -required.] .employees. [No workers' 13.❑Other comp. ismsurance required.] `Any BPPliceownarrt fIcflt checks bor#t must also fiQ out the—tion below showing theirworkew oompensatiori policy mfommtion. t homeowners who submit this affidavit indicating they lim doing 111 work and then hire outside contractors mustsubmtt a new affidavit indicating such 4C-n' actors that check this box must attacb�an additional sheat shown.the aunts of the sub-co , trttactors and their work= cern.. _inforniati I ann an enrrpioyer that is providW9':w0rkers'compensation tnsttrance or information: f m1'eMloyem Below is dw Policy and job site . Insurance Company Name: x Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/statrzip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration dated . Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DIA-fQr insurance coverage verification. ]IdO hereby certify oder the pains and penalties a erj that the infornzatfoR provided above ' true rowed Date: Phone#: 78— P o c ® n� Fof useonly. Do not write in this area,to be comfpletea'by city or town official Town: Permit/License ig ority(circle one): Kmith 2 Suiidi , Department 3.City/Town Clerk 4. Eiectrica!Inspector 5. Plumbing Ipspector son• Phone#: •"A Information a nd Instructions ' Massachusetts General Laws chapter 152 requires all emp 3 oyers 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 ormore of the'foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver w trustee of an individual,partnership,association or other legal entity,employing employees. 'However the owner.of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or-local licensing agency shall withhold the issuance or renewal of license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence.of compliance with the insurance coverage required" Additionally, MGL chapter 152,§25C(7)states"Neither tiie 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•afidavit 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 fiheir certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required*to cavy workers'co-rnpensation 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 Aaaideri s 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,nofthe Department of industrial Accidents. Shotild 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-inattre.d emm� ;f-.c Anmrt Pntmrfne"r self-insurance-license number on the'appropi iate•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 s 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 permittliceme number which w-iIl 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 i policy information(if necessary)and under"Job Site Address"the applicant should write"ail 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 firtum permits or licenses. A new affidavit must be filled out each year. When:a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permitt3o 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 Depamnent's address,telephone and fax number. The Commonwealth of Massachusetts Department of 13ndustrial Accidents Office of Investigations 600 Washington Street Bosfon, MA 02111 TeL# 617-72.74900 ext 406 or 1-9.77-MASSAFE Revised 5-26-05 Fax#617-727-774 www.mass.gov/dia Date. b ` 01 -1 •�;.-1�aoL TOWN OF N H ANDOVER p PERMIT FOR PLUMBING is CHUS This certifies that . . . . . . . . . . . . . . . . . . . has permission to perform ',.'! t:- ,.;.. ._?.. . . . . . . plumbing in the buildings of . . . . . . . . . . . at . . . �!- r�r-!. . \, , North Andover, Mass. Fee. 1 .Lic. No& 5 . . . . . . . . . . . . QQ �� PLUMBI G �SPECTOR Check 8'158 N 7SE'I'IS UNEFORM APPUCA,70N FOR PERMIT'Tp Dp GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date r//.2`I166F Building Logations oZ . A Permit Amount Owner s NameA (/�yL p New Renovation Replacement ❑ Plans Submitted ❑ y w 947 ; co 14 Z10 za F z e z a z o a > < d w F. w C7 w u C Z a 4 p z SUB-BASEM ENT U > G a C BASEMENT ` IST. FLOOR I 1N D , FLOOR 3RD . FLOOR 4TH . FLOOR TH . FLOOR 6TH . FLOOR 7TH . FLOOR. 8TH. FLOOR. (Print ortype) Name e` Cneck one: Certificate Installing Company Address Corp. (� Partner. usmess a ep one7 aFirm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE I have a current liability insurance,policy or it's substantial equivalent, Check one• � If you have checked yes,please indicate the type coverage by checking the appropriate es No Liabiiity insurance policy �i�" Other type of indemnity v� ❑ Bond 13 Owner's Insurance Waiver lam aware that the licensee does n_ of have the Insurance coverage required by Chapter 142 of th Mass. General Laws,and that my signature on this permit application waives this requirement e Signature of Owner or Owner's Agent Check one: I hereby certify that alOwner l of the details and information 1 have submitted(or en d)in 0 PPlec�ion�e best of my knowledge and that all plumbing work and installations per u der Permit Issue compliance with all pertinent provisions of the Massachusetts State G d accurate to the th' tion will be in od d Chapter 14 Laws. B y: Signature of Licensed Plumber Or Gas Fitter Plumber ff Gas Fitter LAL,ense Number M- Master 0 Journeyman i ,I n- trn OJMassachusetts Department of Adustr' �a1.,4ccidents VV Vice Of jr""S�6e llti0 6.00 W asFii naton Street ., Boston, MA 0.2111 r , ov/dia WorkersCoensation Insurance-Affidavit-'Fidavit-' ganders/Contractors/Ele A I Iicanf nformamption ctracis.ns/PiumMrrs Name (Bus;ness/or Mease Print Leaibf�, ganizati on/in div i dua(): Address: Qty/31ate/Zjp: • .tr r. Are you an employer?Check the appropriate box, 1.❑ I an a employer with 4. Type of project u�red ❑ )ash a g�neral contractor and I (required): employees(frill and/or part )emtr .* have hired the sub-contractors .b. ❑ New con 2• i am a sole proprietor or partner- Iisted oni the structian ship and have no employees Theses` ruched sheet,x 7• Q Remodeiing working for me in any capacity. workers b-cOn�ctors have 8. D DernoIition [No workers'comp. insurance 5. ❑ We e a comp. insurance. regtured_] corporation and its 9. ❑ Building addition oftic� have ex 10: 3.❑ [am a homeowner doing all work right of a ercised.their ❑Electrical repairs or additions myself. [No workers' comp, c 2, Xemption per MGL 11.0 Piumbing repairs or additions insurance require[.) t e 1(. and we have no errtplayee . [No we 12'❑ Roof repairs cheeks box appfi�n *Anromp. insurance required.) 13.E]Other i! t.that #I.must also fill out the section boiov showing t i-lomcowuers who sabtnit•ihis a udavh indicating they cue duinr `:��owing their workers'compensation poii�,iniorntation. 'Cona$ctom that chcc}:this box. must attached an additional sheet showi "`Eh='nir--Gutside contmiurs 111tw submit a nen, f Qltt e....,j�.� tt2 the netne.of.f?e c;.�actota and their wor atrtaavn tno: ng scah. all. . er that is prov a k='comp.policy iniotmation. �ewor�e�s z,,.pep�c�,,, : .. ¢r,jormadom -b_'sri"a"ce for ng,emPloYem Below cs the policy and job site Insurance Company Name: a Policy#or Self-.ins. Lic.#: Job-Sit:Address: ExPiration Date: Attach s copy of the workers' compensation tic decia Ctty/sip- .Failure to secure covers P y ratEion page(showing the poiicy Dumber and expiration date coverage as required under Section 25A of MGL c. 152 can nne up to 31,500.00 and/or one-year imprisonment as well i to the imPosition of Of up to.S250.00 a day against the violator. Be advised that a co criminal penalties of a as civil penalties in the form of a STOP WpRK OBER and a fine Investigations of.the DI r 'nstvance coverage verifica' 1�of this statement may be forward°,d io the Office of I do herebj)certifj, roarer a Pains , P o er�ur3'that the information Sirmature: Provided above cs true and correct ® Date: 'Phone#: 97� — Official use onip. Dv not write in this area, to be corrrpletad.bj,city or town o ccial City or Town: ff FssuinQ Autho ' , Per�nit/L,icease e rrtj (circle ones: I. Board of H ealtb 2. SuiidiRg Department 3. City/Tc wn fi. Other Clerk 4. Electrical Inspector S. P turbine Inspector Contact Person• Phone# i 1111V1 LuaLIVU i:wi u tustj ucTions p Massachusetts General.Laws chapter 152 requires all em-;Dloyers to provide workers' compensation for their employees. Pursuant to this statute;an employee is defined.as"..--� person v�r-y in the service of another under any contract of hire, express or implied;oral or written." An employer is defined as`pan individual,parinership;association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and inclutii ng the legal representatives of a deceased employer,or the receives or trustee of an individual,partnership,associati on orother legal entity,employing employees. However the owner of a dwelling house.having not more than.three ap artments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maa_intnance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall.not because of such employment be d,-emed to be an employer." MGL chapter 152 §25C(6)also states that"every state cb-r 10ca1 licensing agency shall withhold the issuance or renewal of a limnse or permit,to operate a bnsumss or to construct buildings in the commonwealth for-Ray applicant who has not produced acceptabie evidence cb�T comphance with tine insurance coverage required" Additionally, MGL chapter 152, 925C(7) states"Neither 7_he eommanwealth nor any of its political subdivisions shall enter into any contract for the performance of public worl< 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 compl-etely,by checking the boxes that apply to your,situation and,if necessary,supply sub-cbntra.ctor(s)name(s),addresses) and phone number(s)along with their c.-rtificate(s)of instmmm. Limited Liability Companies (LLC)or Limited Liability Partnerships LLP with no em o ee o � (LLP) Ply s then than the members or.partners,are not required to carry workers compensation insurance. if an LL A C or LLP do s have.. employees, a policy as re oared Be advised.that this af5 - - P cY . 4 cl-avit may submitted to the Department of. Industrial Accidents for confirmation of insurance coverage. Also ]be sure to sign and date the.affidavit. The,a.ffidavitshouid be returned to the city or town that the application for the permit or license is being requested,not the'Departmmt of Industrial Accidents. Should you.have any questions MI-Mv--ding the-Lam,or if you am mquimd to obt2in a workers' compensation policy,please call the Department at the n0_nb-_Tiis+_-d below. Self insu-cd companies should enter their self=insurance license number on the atspropri—a— line. City or Town Officials Please be sure fi at the affidavit is complete and printed Ieonbly. 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 i Please be sure to fill in the pesmitAicense number which%kill be used as a reference number. In addition, an applicant -that must submit multiple permit/license applications in arty given year,need.only submit one affidavit indicating cwTmrrt policy information(if necessary)and under"Job Site Address"the apphrantshouid write"all locations in (city or town)." A copy of the affidavit that has been official},stamped or marked.by the city or town may be provided to the appiicartt as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Nhrhere a home owner or citiz-n is obtaining a licens- or pert not related to any business or commercial venture (i.e. a.dog license or permit to burn leaves etc.) said p--norn is NOT required to complete this affidavit. The Office of investigations would like t6 thank you in advance for your cooperation and should you have any questions, . please do not hesitate to give us a call. The Departm ant's address,telephone and fax number. The Comnsonwea ltb of MassachuSett ac.pattent ofLmdustrial Accidents Offim of Lavestigations 600 Wash (:)n Street BQSton; MA G2111 TeL 4 617-727-4900 ert 406 or 1-877-14ASSAFE Revised 5-2645 Fay,4 617-72.7-774-9 W`"W-Mom.c ov/dia Date. .. .. .... NpRT1y Of °,tip 3r �` 0 0 TOWN OF NORTH ANDOVER ' PERMIT FOR GAS-INSTALLATION This certifies that . � . . . . . . . . . . . has permission for gas installation . . . ! .< .Z./-i.e. -:-. . . . . . . . in the buildings of .lw"ee_. ./2? .. . . . . . . . . . . . . . . . . . . . . at . .2 L.`r In e-,,.c.�. . 1=d/7 ~. . . . , North Andover, Mass. Fee. .3 ..' . Lic. No../:7.J j.?. . . . . . . GASINSPECTOR Check# 5384 MASSACHUSETTS UNIFORM APPUCATON FOR PERNIlT TO DO GAS F rrnNG (Type or print) Date -'pl—06 NORTH ANDOVER,MASSACHUSETTS Building Locations ��`r —�`��� arm � Permit# 6 3oP-y Amount$ Owner's Name UAVLl 1714 a,( 19,7 �� L New❑ Renovation Replacement Plans Submitted El U F a z � o m zCl p GW W y � d 0 04 73 C� D 3 A 3 2 0 g aa.. N o SUB -BASEM ENT B A S E M ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type) cc __ Che_Qk one: Certificate Installing Company Name ?— AA- Corp. Address S 1jP- Tc;, 7-- Partner. usineessss Te ep one 9 7�_ 3/6' 7$ ,;� Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE• Check one: 1 have a current liability Insurance policy or it's substantial equivalent. Yes ® NoO If you have checked yes,please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity � Bond 13 Own Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the VI s G neral La s a t my lure n this permit application waives this requirement. Check one: Signature of Owgr or wner's Agent Owner Ea Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Nlassalhusetts State Gas Code and C - r 142 of the General Laws. By: Signature of Licensed Plumber Or Gas Fitter Title Plumber / A 7 i 7 City/Town 1:1 Gas FittericL�Number 0-1viaster APPROVED(OFFICE USE ONLY) Journeyman NUMBER DRIVER'S LICENSE 031661381 DATE OF BIRTH CLASS REST HEIGHT SEX 11-30-1982 D 5.08 M j EX%AES 11-30-2008 Mu CCAULEY T SCOTT J I� 46 FRIENDSHIP ST BILLERICA,MA 01821-3627"k',', COMMONWEALTH OF MASSACHUSETTS IN PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMBER ISSUES THIS LICENSE TO SCOTT J MCCAUI_EY 58 SARATOGA ST LOWELL MA 01852=x.561 13787 05/01/06 111728 1S' WA A NUMBER DRIVER'S LICENSE 031661381 DATE OF BIRTH CLASS REST HEIGHT SEX 11-30-1982 D °B M EXPIRES A 11-30-2008 r..} 'MCCAULEY SCOTT J I 48 FRIENDSHIP ST n.ats a BILLERICA,MA 01821-3627 v i i f p r COMMONWEALTH OF MASSACHUSETTS . vga IN PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMBER ISSUES THIS LICENSE TO SCOTT J MCCAULEY - V 5-8 SA_RATOGA ST in LOWELL MA 018525618 13787 05/01/06 111728 1751maalf- mo SCA Class-D:Small vehicle less than 26,001 lbs,except School Bus. 11-30.1982 www.mass.gov/rmv MA 01-162004 + t t t II'IIIII III II'll�lll'IIIIIIIIIIIIIIII'II F440 M M21MM1 Place change of address label here •Mel Aq pannbaa ste P,"' mo% uo 8su8011 SWI daa�{ •umad aaglo /,ue O; I,,, paueol aq jou�snut pue'a6allnud leuosaad e s,It p iGua+ 1 snne_l leaauaO ag1 10 suoIslnoid agi 1 toa(gns G. ` 1P.011aagwnu asuaop JnoA of Ja19j sAenAld }xau 10 6wlieul aadoid einsul of ssa'ppp pleoq jnoA.410u 'pa6uag3 si"Ot4s ssaapp4 _11' 'bLILZo VV4'uoisog �g �tennasneO 6£Z 'ainsuaoi, leuolssajWd W :aql le paeog inOA �(}llou 'pa4(0jlsap ao 1g' sl as, 1NVIMOdVil 96TZZ03#,Q �.�G� ��o�I �— � 7g 3 �s 7s3 � N2 3 4 1 Date....<.:..� �. AORTH "o°� TOWN OF NORTH ANDOVER o PERMIT FOR WIRING o . � �SSACHUS — � This certifies that ........ .. .. :...........c ................... ..Y..?........................... has permission to perform / f/ wiring in the building of.........�f.f.....!�.......L.�//.. ....�.................................. North Andover Mass �w at.......... ....`t.......... ... �}/ ,, ,, Fee..�.....:........... LIc.No.....`......... ......................... .............................. /ELECTRICAL INSPECTOR Check # �' ' 1-1 WHITE:Applicant CANARY: Building Dept. PINK:Treasurer 1 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 111991 (leave blank 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 INK OR TYPE ALL9"Y) ORMATION) Date: City or Town of t0 , dOV'Cr To the Inspector of Wires: By this application the undersigned yes notice of his or her igLention to perform the electrical work described below. Location(Street& mber) Owner or Tenant 6(cidrd Macmillan Telephone No. 911 `• Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps I 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: LkAq Lt Com letion ofthefollowing table may be waived by the Inspector of Wires. tr No.of Recessed Fixtures No.of CeiL-Susp.(Paddle)Fans Tal ransformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool bove ❑ n- ❑ o.of Emergency Lighting rnd. 2rnd. 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 Initiatin Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pumper Tons KW No.of Self-Contained Numb Totals: �� Detection/Alerting Devices " No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW SecuritySystems: No.of Water o.o No.of Devices or Equivalent o.o Heaters KW 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 ❑ ND ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical Work: S (When required by municipal policy.) Work to Start: tQ_13 "Q Inspections to be requested in accordance with NEC Rule 10,and upon completion. I certify, under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: ADT Security Services 111 Morse Street,No voo ,MA 02062 LIC.NO.: 1533C Licensee: John S.Bassett Signature LIC.NO.: 1533C (If applicable,enter"exempt"in the license number line.) Bus.Tel. No.: 781-278-1169 Address: Alt.Tel.No.: 781-278-1131 OWNER'S INSURANCE WAIVER: I am aware that the Li nsee 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: $35-06