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Miscellaneous - 23 PHILLIPS COURT 4/30/2018
23 PHILLIPS COURT j' 210/095.0-0041-0000.0 L] Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS4) 36" . SCOTT M]PHMU)ftT 17 Morrison Roar s o Raymond NH 03im = r � r F Expiration s Commissioner 06113=16 t � i i Date....?/./S�!�_ 1063.5 F"SRT"� o TOWN OF NORTH ANDOVER ..� ,, do ° p PERMIT FOR PLUMBING �• 8s.+cMUS� 10, This certifies that ................ ... .. ..... !...L.+ .. ........................ has'permission to perform ...... ,F-� . � .. . ,fid r.:....... ..:...... . ........ ' plumbing in the buildings of............................................................................................. at: i...A41.mr...C.r..................:..........................,, North Andover, Mass. Feef3.%P...Lic. No. .l . ' .. ........... .�..;................... ..:.................. ............. PLUMBING INSPECTOR Check# if I �GQ r MASSACHUSETTS UNIFOR APPLICATION F1011 A PERMIT TO PEAFORM PLUMBING WORK CITY D'Ge�/1 __-_f MA DATE / ( PERMIT# IM :J JOBSITE ADDRESS OWNER'S NAM jr OWNER ADDRESS TEL _ =FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:REPLACEMENT: Ell PLANS SUBMITTED: YES Q N0E-1 FIXTURES"I 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 ! . ! ._ - _ III_ DEDICATED GREASE SYSTEM = ( ____...Ji DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER [ . _._ J 1 f f ._—.._( J ( _J ._—[ _._...I DRINKING FOUNTAIN __I ..___._.J ._.--_ f .______f .__._[ _ f ..____.-J _____._[ _.____.1 ..___.__1 ..,.._--J ._..__F __.._ �__f .__._. '• FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK _—I _ _._I LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING .-__J _ _f __( ! OTHER J . I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES PI-'N0 DI IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICYOTHER TYPE OF INDEMNITY i BOND M OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER R AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the iMassachusetts State Plumbing Code and Chapter 142 of the General Laws. 04 4 PLUMBER'S NAME� >� - sILICENSE# I SIGNATURE i VIP 0,---JP© CORPORATION FJj# PARTNERSHIP E# b LLC COMPANY NAME ADDRESS C CITY M STATE ZIP TEL FAX —�CELL��EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES lcx The Commonwealth of Massachusetts - Department oflndustriglAccidents Office of Investigations 600 Washington Street Boston,MA.02111 www.massgov/ilia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name(Business/Organization/Individual): Address:- �c - City/State/Zip: one 4 Are you an employer?Check the appropriate box; Type of project(required): 1.Q I am a employer with 4. Q I am a general contractor and I 6. Q New construction ployees(fall and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. �• E]Remodeling ship and'have no employees These sub-contractors have 8. Q Demolition working for me in any capacity. workers'comp.insurance. g, Q Building addition [No workers' comp.insurance 5. Q We are a corporation and its officers have exercised their 10.❑Electrical repairs or additions required.] o 3.El I am a homeowner doing all work right of exemption per MGL l Ln Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.Q Roof repairs insurance required.] employees.[No workers' q 1 13.❑Other comp.insurance required.] '%ny applicant that checks box#1 must also fill out the section below showingtheir workers'compensation policy information. i Homeowners who submit this affidavit indicating they&ie 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. lam an employer that 1s providing workers'compensation insurance for my employees. Below is the,policy and job site information. Insurance Company Name:. Policy#or S elf-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do h ereby certify under the pains an dp enalties ofp arjury that the information provided above is true and correct. Signature:RN&_4 Date: �7 z /�T Phone#: Official use only. Do not write in this area,to be completed by city or town official. jCity or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire, express or implied,oral or.written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a j oint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer" MGL chapter 152,§25C(6)also states.that"every state or local lic-ensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants .� Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. ,A.new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license oz ermit not e . g related to an business o p y r commercial venture (i.e.a do license or permit to bum urn lea e p 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: Tho GoMoawealth of Ma ssa chvSe,#s Department ofZnduMat A.celdonts Qface ofI1westigation,s 600 Washington Street Boston}MAL 421 X X Tel,#61.7-727-4900 ext 406 or 1;-877,MA.SSA.F.F Revised 5-26-05 Bax#617-727-7749 i 'cucvct€.maee ansrlrT;a COMMONIAIEaLTH OF MASSACHUSETTS: ® . >,:BOARD.OF • PLUMBERS GAS,F 1 S S UEfS,:-.>TH E FOL - - - -- LOWI�}G�`'L'iCENSE:<>=;: �::::�>` >, . tt ASER PLUMBER _,'k1ARK' BOUCHERll 37 ACADEMY AVEJ 03811-22.0 rJ r I f NORTH own of ,, Andover O 0 No. 91 S. oh ver, Mass, COc N1C Kt WICK Z1,9 Areo 10Q�,��(y S U BOARD OF,,HEALTH Food/Kitchen ... PERMIT T L D Septic System kopTHIS CERTIFIES THAT ............. �........�!i.�.. BUILDING INSPECTOR Foundation has permission to erect .......................... buildings on ......a.z........P.1%.4.t.4 ........ ....... _ • Rough__ .• to be occupied as .116 .. . ... . .. ...... ...... ... ,� . p �. Ye i... Chimney ��' 'provided that the person accepting this permit shall In every respec conform to the terms ofapplication '- a :on file in thi7roffice, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING SPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final CIL PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR: sloe CONSTRUCTI S R S o7-1-4 ..................... Fin BUILDING INSPECTOR GAS INSPECTOR , Occupancy Permit Required to Occupy Buildin,:; Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. mss:•°r; �'�I i j + a � `4�e LAWRENCE RENCE .OGDEN 'P.E. 198 EAST MAS STREET GEORGETOWN,MA 01833 978-3524318 fax 978 352-2858 cell;978-502-592 :August 5.2014 Mr-Fred Deherardins 220 Main Street Plasto*Iii.113865 RE: Renovation 23 Phillips Court,North Andover.)l845 Dear Mr.Deberardins As you requested I conducted a site visit 8'5114 to review the installation of the Engineered Materials consisting of LVLs-.beams utilized in the framing n4 the drive project.. The Lvls are shown SKA. S1 -2 dated 4130/14 certified by me 4/30/14. Based on the above site visit and based on what I could,% slbly see. I can certify that to the best ofazY knowledge ledge the LVLs members and details utilized in the framing as sho�vri on the drawings are installed properly and meet the loading conditions of the 8th Edition of the Massachusetts State Building Code for 1&2 Family Residences, proAded the following work is performed. All other framing requirements of the drawings and code,including but not limned to materials,nailing schedules,blocking,connections.manufacturers installation requirements and other details are the responsibility of the licensed construction . supervisor responsible for the project. Should you have any questions please do.not hesitate to call. Yours truly, Of At LFrence H. Ogden P.E. Structural 27765 �,o�� - ��or�xt het To:John&Diane Donovan April 4, 2014 rt Phillips Court (z.i') NQrth.Andover.,.Ma_ From: Fred De Berardinis 220 Main St. .Plaistow,.N,H,.,.038.65_ .Subject:.W.ork.to_be_done_on.flrst_floor.. Insulate all exterior walls with craft faced insulation with the most R value that fits in 2x4 walls. Move,install or change all water and drain lines for new kitchen,half bath on first floor.All other water and.-drain,lines_to.be..rem.oved_as_needed,_Take out partial,walt in:ktchera,side_.entrance,.entrance_ to dining room from kitchen and wall from dining room to living room. Beams to be installed where needed for second floor support.Take out and install (3)new interior hollow core 6-panel doors in apartment.These_will_.replace one in.living„room to front.entrance_hall,.front-room.closet.and.basernent_ door.All will have new passage knobs installed.A light will be installed at top of basement stairs with light switch. Flooring to be patched where needed from removing of walls.Wiring on first floor to be } installed.where..n-eeded,tocode.witb.ceili.ng_Iight.cans.:and..ceiing_.fan.brackets,. YVblue.boar..d.and- plaster to be installed on all ceilings and walls of entire first floor apartment.All doors,windows,base board trim to be installed.Crown molding to be installed where needed on ceiling. Pine floors to be sanded-and-refinished.in..clear coat-urethane-First-floor to.be_painted...Color to be_pickedby owners._ Side door entrance to be devided by a wall with door.A toilet,sink.faucet with all water and drain lines to be installed for Y2 bath.Side entrance door to be changed to a steel entrance door approx.36x80. !, Door has to be reframed and.raised: Entrance and.bath.floor areas to.be-raised to match.kitchen.floor level.These floors to have same tile as kitchen floor. Bath room to be finished and painted. Install kitchen cabinets,faucet and dish washer.Take out front entrance door to apartment and replace with new.94ight steel.entrance.door with..new dead_bolt_.and.entrance_lockset-Replace-decking,.stringers,, risers and step treads.Contractor to take away all debris from work he is to do. Home owner to pay for any permits for work being done. .Note.:.Owners.to,buy.cabirnets,..counters tops,_si.nks,.faucets,.toilet:a.nd..electdcal,.fJxtures.,such.as ceiling. fans or lighting other recessed lighting and trim for cans. Total...materia.ls_and_.labor.s_uppiied_by,contractor---$.2.4,_764..00 Jp 7Ta k u { J , 1 { rf Payment schedule y e e for work to be done at first floor 23 Philips Ct. North Andover,Ma.: lune 2, 2014 Job to start within one week of deposit and to be completed in approx.6 weeks. A deposit for contract of$5,500.00 required to start work. $5,000.00 when rough wiring and plumbing completed. $5,000.00 when insulated,blue board and plaster. $5,000.00 when finish electrical,plumbing,doors and trim installed. $4,264.00 when cabinets,installed,floors sanded and refinished, painted and job completed. T, i i i Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 303793.00 m $ - $ 369.52 Plumbing Fee $ 46.19 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 46.19 Total fees collected $ 561.90 23 Phillips Court 918-14 on 6/14/2014 Kitchen and 1/2 bath remodel I y The Commonwealth of Massachusetts , - Department of IndustriqlAceldints Office oflnvestigations 600 Washington Street Boston,MA 02111 www.mass.gov1dia Workers'Compensation Insurance Affidavit:Builders/Cont°actors/EIectricians/Pluinbers Applicant Information Please Print Legibk Name(Busyness/Organi'zationftdividual): S C a f"�" �h r��� e s -Address: - City/State/Zip: ga_ymo,7,1 X1, 030 77 Phone#: G 03 - 9yy A�7 3. 5- Are you an employer?Check the appropriate box: Type of project(required): er with to 1.0 I am a em 4. ❑ I am a general contractor and I ' employer 6. ❑New construction _Jmployees(full and/or part time)* have Hired the sub-contractorss/'" , 2. am a sole proprietor or partner- listed on the attached sheet. 7. emodeltng ship and'have no employees These sub-contractors have 8. ❑Demolition working forme in any capacity. workers'comp.insurance. 9, Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its To quired.] officers have exercised.theix 10.❑Electrical repairs or additions 3. 1 1 am a homeowner doing all work right of exemption per MGL 1111 Plumbingrepairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance,required.] employees.[No workers' 13.E]Other comp.insurance required.] xAny applicantthat checks box#1 must also fill out the section below showingtheir workers'compensWonpolicy information. i'Homeowners who submit this affidavit indicating they t re doing all work and then hire outside contractors must submit anew affidavit indicating such, tContractors that cherdcthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X 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.Lia#: Expiration Date: rob Site Address: City/StatelZip: Attach a copy of the workers'compensation-polley 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 fmo 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 fmo 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 pains and penalties of perjury that the information provided above is true and correct. Signature, Date: Phone##: o.3A a k7 6 0 q zyy A 73 9 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 instruction Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire,- express or implied,oral orwritten." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two ox moxe of the foregoing engaged in a joint enterprise,and including the Iegal representatives of a-deceased employer,.or the receiver ox trustee of an individual,partnership,association or other legal entity,employing employees. )Nwever 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 theaffidavit. The affidavit should be retumed 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 roust submitmultiple 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 asproof that a valid affidavit is on file for future permits or licenses. .A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license orpermit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Tho Caxr_>mom.ealthof Massachvsotts - Dopartmout of Industdal AAceldouts Office QUAVOStigatiom 600 Washbg m Strod Boston,NA 02111 Te4, 61.7 7274900 OA 406 or-1-877�MMSAFB Revised 5-26-05 Fax 0 617-727-7749 . �.x>2�ass,gov�c�ia ACOIRL> CERTIFICATE OF LIABILITY INSURANCE 4AT$E(M201D4YYY) 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: ---Cynthia St. Amand Insurance Solutions Corporation PHO'dCNE (603]382-4600 FAXAIC No (603)382-2034 60 Westville Rd EMAIL .cstamand@isc-insurance.com INSURERS AFFORDING COVERAGE NAIC# Plaistow NH 03865 INSURERA:Merchants 23329 INSURED INSURER B Fred DeBerardini s INSURER C: 220 Main St INSURER D: INSURER E: Plaistow NH 03865 INSURER F: COVERAGES CERTIFICATE NUMBER:CL144816022 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. NOTVVITHSTANDING 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 SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY 500�000 PREMISES Ea 0..".".) ccurrence $ A CLAIMS-MADE ❑X OCCUR BOP1042942 9/30/2013 9/30/2014 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ Included 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 $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- JOT - AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I 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 John & Diane Donovan ACCORDANCE WITH THE POLICY PROVISIONS. 23 Phillips CT North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Keith Maglia/KLMACORD 25 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD CoastaD Kitchens and Math4 LLC COASTAL KITCHENS and BATH,LLC [Estimate P.O.Box 156 Seabrook,NH 03874 @W==G24b (603)814-1132 03/24/2014 1043 brenda@,ckbvh.com waw.ckb-nh.com am 04/24/2014 John and Diane Donovan 23 Phillips Ct. 42 Horace Greeley Rd. N.Andover,Ma.01845 Amherst.NH •Forevermark Cabinetry in the"K"series Honey tone,std drawer,w/fascia and crown drawings sent via ! 3,966A0 gmail,no island j f •Granite counters and 4"backsplash does NOT include pass through @ dining area (This is a mid-grade 2,381.00 fEf granite for pricing only)no sink no faucet C •Pricing policy:add 4°/a to this quote for CC or DC ($6497)+40/o j -Deduct 5%for pd in full upon ordering cash or ck shown below I i I F .'N,. Please look over your estimate and if you have any questions,concerns,or are in need of further _ SubToW $6,347.001 intonvation in regards to this matter, feel free to contact us at the above phone number or a-mail. Thank you for considering us.Brenda&Mark Discount(S%) $-317.35 _-- ---- Total $6,029.65 Y _._ Accepted B.Ni Accepted Date J I Date . ..4. ..� ................. '40ATH TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING CHU f tG This certifies that _7 0-6 ........................ ....................... .............. ..................... ............................... has permission to perform �Q...1-4........ wiring in the building;of......N. ...rZo....Aj ........ ... ................................................................................... orth Andover,Mass at N 41 Fee.�P ..Lic.Nol�5 ......... �sp ........ ............ ... ... ..... PCT�RICA I L�IiNSPECTO*R* Check# zi 5 3 S4 Commonwealth of Massachusetts official Use Only Permit No. Department of Fire Services I � Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] peaveblank 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 MK OR TYPE ALL) FORMATION) Date: 7-16—e y 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) 23 + Z S' pL&� [L /J S G-z—. Owner or Tenant ct%A.C-- ft. e✓C4- "X . Telephone No. 6 °3 _67 3- 6'{g Owner's Address %-L Z -Q • --t �- ,-%T N Is this permit in conjunction with a building permit? Yes ❑ No � (Check Appropriate Box) Purpose of Building z Fp—� L, \A---<, Utility Authorization No. 1-7 Lf 36 3 Z I - Existing Service t 010 Amps a to/ --e.o Volts Overhead[9�Undgrd❑ No.of Meters New Service 200 Amps t / 4b Volts Overhead 9' Undgrd ❑ No.of Meters Z Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: e- Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.;of Cell:Susp.(Paddle)Fans No.of Total A Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA r Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. rnd. 11 Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones It 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 I Number I Tons J.KW.......... of Self-Contained r�, Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* Ballasts No.of Devices or Equivalent No.of Water KW No.of BNo.al as Data Wiring: I Heaters Signs No.of Devices or Equivalent ` No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent nTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: /Sd . "a (When required by municipal policy.) Work to Start: 7-t S 1`'1 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such covera e ism force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE '0 BON ❑ OTHER ❑ (Specify:) Icertify,cinder thepain and penalties ofperjury,that the information on this application is true anti complete. FIRM NAME: . «-� �� << G L C_ LIC.NO.: /4 /�Y 7 C Licensee: r„ . vw Signature LIC.NO.: (If applicable,enter "exeet"in the license number line.) Bus.Tel.No.- 6*3 41?-6 41"Z Address: -t-c:50" `A3,.-Y LC% --r Ste-. N N 3$"`-C�r Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires epartment of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE:$ Signature- Telephone No. i ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the 0 permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: , 4 Trench Inspection Pass 0 Failed Re-Inspection Required.($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed ❑' Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass 0 '• Failed 0 Re-Inspection Required•($.) ❑ Inspectors CommKent . Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations Ut 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):_ � �. .� ..� 0-1—a , Address: 2— City/State/Zip; City/State/Zip: fieV'�c sem- Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I ' * have hired the sub-contractors 6. F1 New construction employees(full and/or part-time). 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their. 10.❑Electrical repairs or additions 3.F11 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.E]Roof repairs r insurance required.]t employees. [No workers' comp.insurance required.] 13.0 Other 'Any applicant that checks box#1 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 anew affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. - I do hereby certo under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: Information and Instruction's 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 g Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line.. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. 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 ladusidal Accidents Office ofInvestigatiom 6.00 Washington Sixeet Boston}MA 02111 Tel#61.7-727,4900 ext 406 or 1-87TMASSABE Revised 5-26-05 Fax#61.7-727-7749 �w.z�ass,govfclia .� MI1lIONWEALT.HOFFM�kSSAHISETfS <T" v xs E LE CTR ISSUES THE E`:OLLOWI NG rL#GENS 'ASh:A MASTER EL'<ECZR f G�`i C „c BRIAN J'. TOTO : 44., , w 20,0RDWAY 'LN ', #NGSTON � �N#�A o�3848r 354 '.` } 478 .R:lo .< :.s 07r/3� 1$ 10.1060. ?h i Date....... ............Z......... . { NORTh � TOWN OF NORTH ANDOVER O ' PERMIT FOR WIRING s`SACH 11 �I This certifies that ...... n'Z'�............l...�?J.� 4— P { -� �2� � ................. has permission to perform .........................�...................-.. ..................... wiring in the building of............... .C? 1. ?. a................................................. at ..... LL � .......... .............. ................. ... ...>North Andover,Mass. Fee.... .. ......Lic.No. .�..���. *..�........ . � - - x.�........... ELECTRICAL INSPECTO�t V Check# 1249 ? �j,P I►��► X118 L� (.e Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked „ BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07j (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL)NFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of lus or her intention t per the electrical work described below. Location(Street&Number) Z 3 ,t4a Owner or Tenant r �C 1, bo vo cSo Telephone No. 4-0 3.- 0 3—�q T Owner's Address Is this permit in conjunct1ionw a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building L. /a w• ` l; Utility Authorization No. - Existing Service 1 0 U, Amps 2 cco Volts Overhead A-- Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed iElectrical Work: Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans 1 No.of Total Transformers KVA ti. No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.of4 mergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets Z No.of Oil Burners FIRE ALARMS No, of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges 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/Alerting Devices t� No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Ballasts Si ns No.of Devices or Equivalent ' i a No.Hydromassage Bathtubs No.of Motors Total HTelecommunications tions Wiren g. No.of Devices or Equivalent OTHER: fS Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value oflectrical Work: 3 O (When required by municipal policy.) Work to Start: 7 Ie /`l 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=NCE BOND ❑ OTHER ❑ (Specify:) I certify,under the pat and pen o perjury at thein orniation on this application is true and com lete. / PP P FIRM NAME: _ !�e+, c� c- r LIC. NO.• 3 � Licensee: u Signature LIC.NO.: (If applicable,enter "exempt"in the h'nse number e.) Bus.Tel.No.• Q 3—�"t R G`( Address: �� �n l� i ..i 9,ta-i �j 64 v S%Cg�" Alt.Tel.No.• *Per M.G.L c. 147,s.57-61,security work requires partment of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ i ❑ 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 Mfr' electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑ Permit Extension Act—Permit/Date Closed: Trench Inspection Pass F?] Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: yti .J Inspectors Signature: Date: y PARTIAL ROUGH INSPECTION: Pass Failed ❑' Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: a ROUGH INSPECTION: Pass IN Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Ir -/6 Inspectors Signature: Date: FINAL INSPECTION: Pass F71 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comment J Z Inspectors Signat e: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustriqlAccidihts Office of Investigations 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print Legibly Name(Business/Organization/Individual): � o � Address: City/State/Zip: S Tn--\ N [4 0 984a- Phone#: a Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.[I,I�a sole proprietor or partner- listed on the attached sheet. E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑Electrical repairs or additions required.] 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]i employees. [No workers' 13.[i Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they Are doing all work and then hire outside contractors must submit anew affidavit indicating such. $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:. P Y Policy#or Self-ins.Lie.#: 11 Expiration Date: /� Job Site Address:_ 3 1_�`• ' l S � T City/State/Zip;&)A,-Qd,, Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certo under the pains and penalties of perjury that the information provided above is true and correct. Simature: Date: Phone#: Offccial 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#: Inform- ati®n 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 ofpublic 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 coinpletely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone numbers along with their certificate(s)of insurance. Limited Liability Companies( LC or Limited Liability Partnership s(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 M 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 r 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 CommonmanofMassachusetts Department opzndust rial Accidents Office of Investigations 600 Washington Street Boston,MA.02111 TO,#617-727-4900 ext 406 or-1-877:MASSAk'B Revised 5-26-OS Faz,#617-727-7749 v ww.mass,govldia Date. 1. 1 . . .. .... r' WORTh OF ��•o ,61'YO o? TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION o•�• .Ch SA US , This certifies that . . f—Qar?? . . . . . . . . . . . . . . . . . . . has permission for gas installation in the buildings of . ;. . �/. . . . . . . . . . . . . . . . . . . . . .at . . �' �.`�!9S North Andover, M'ms. Fee. . ' Lic. No.-��?P j- . . . GASINSPECTOR Check# SZ.S' �- 828 - ; MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITT`ING (Print or Type) .vJOM A>fDo& . Mass. Date � �Z1�1� Permit # Building Locatlon;?_�—Zs fttups cl-, Owner's Name J- 6M " -&A AN�0UE-, PIA, Type of Occupancy Z EMILY New ❑ Renovation ❑ Replacement ❑ Plansu miffed: Yes[] No ❑ GI N �2 1 i T--a N W N Z c � Q N U) Mo y U W W a O U = f- 2 F- �j N m 2 n ° W M o =' °c r W m W Q W �0. in a C > 4 W z V W 2 N Z Q O 0 > W 0 tW- z H i r W w tl o > ►~i H W � h w z Q W — < a r c� m z a z , c ui W > 2 W O 2, Q rL Q Q O O W a O r 1- 1P+�G� O t� x u. a o tl U tl > n a F- O SUB--8SMT. 1. BASEMENT ' 7STFLOOR 2ND FLOOR 3RD FLOOR (v 4TH FLOOR STH FLOOR )� 6TH FLOOR i oo 7TH FLOOR BTNFLOOR Installing Company Name COLUMBIA SAS OF MASSACHUSETTS Check one: Certificate # Address 55 MARSTON STREET DC7 Corporation 1862 LAWRENCE, MA 01841 - � (2 El partnership Business Telephone 7 691- 640 6 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: 1 have a current,liability insoura❑nce policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes If you have checked Yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy Other type of Indemnity❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in abo pplication are true and accur,4te to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application will n c,Ompliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S. T e of License: Title Plumber Signature of Licensed Plumber or Gas Gasfitter City/Town Master Ucense Number_3745 APPR OVED OF ICE SF ONLY) Journeyman BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION F E E NO. APPLICATION FOR PERMIT TO AO GASFITTING J � • - �" NAME & TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIG NO. PERMIT GRANTED DATE .19 GAS INSPECTOR