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Miscellaneous - 230 SOUTH BRADFORD STREET 4/30/2018
/ 230 SO BRADFORD STREET 210/104.C-0102-0000.0 Date....w....1f. ........... ... I C �►ORT/� OF .�tio TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING a�►cHU This certifies that.l.!!�.1 �? ... .......� ...9� ........................................... 1 ! f has permission to perform..f� �''....../'....-eh, .............................................. plumbingin the buildings 4f............................................................................................ �� .,.. 1.....-�..�.....1............!North Andover, Mass. at Fee .......Lic. NoP /./*........ ........ . ....................................... l PLUMBINGANSPECTOR Check#,611,& \J r Date......�. .� ..................... t � OF p10RTH,� TOWN OF NORTH ANDOVER ►- � 9 r', i e f PERMIT FOR GAS INSTALLATION a t')r a. s3 CMU$( ti r. ' This certifies that fiG �Jla GK.....(/! � ....�!.................. .......................... has permission for gas installation .... vq�....`. .... ..................... in the buildings of........... �.............../...... .......................................................................... .... .... .......9 N rth Andover, Mass. Fee;.a.!w... Lic. No���4............... ... ................................. GASINSPEC OR Check# 6 P� `� �. C ! L / � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK x CITY NA/1A 4,, ICuc r- MA DATE /s. PERMIT# JOBSITE ADDRESS ;�3G'3ovH�t�rf.d4of-J(S-k-' OWNER'S NAME ZZ c.)c- t'l�-a` ) POWNER ADDRESS 5A^A Jp— TEL k 6d0Y y/3/ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:©� PLANS SUBMITTED: YES❑ NO FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER r FLOOR I AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES l WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES® NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [K] OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ 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 tru nd 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 compli ce with all Pert'nent pr ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Peter G.Viens LICENSE#12116 SIGNATURE MP® JP❑ CORPORATION[fl#3631C PARTNERSHIP❑# LLC❑# COMPANY NAME Merrimack Valley Corp ADDRESS 15 Aegean Drive Unit#3 CITY Methuen STATE Ma ZIP 01844 TEL 978 689-0224 FAX CELL EMAIL pyiensfirrIvalleycorp.corn ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECRON NOTES Yes No l�3 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY Ju/E/A Idn c✓vE✓ MA DATE TAf'— PERMIT# JOBSITEADDRESS ;230 Sou F\, a ddeo%Js-t OWNER'SNAME 'T;1-0c. ISVA.%J GOWNER ADDRESS s5A,21Z TEL YAP-Ycl<//31 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[�] PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT: (�� PLANS SUBMITTED: YES❑ NO ' APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YESX❑ NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ 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 a d a curate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli ce 'th all Pertipenpprovisi of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Peter G.Viens LICENSE# 12116 SIGNATURE MP® MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATION ©#3631C PARTNERSHIP❑# LLC❑# COMPANY NAME Merrimack Valley Corp ADDRESS 15 Aegean Drive Unit#3 CITY Methuen STATE MA ZIP 01844 TEL 978 689-0224 FAX CELL EMAIL pviens(@mvalleycorp.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION YOTES Yes No dl THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ 17 FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts -- Department of Intlaastriarl Accialents Office of Investigations 600 Washington Street Boston, MA 02111 www.m ass.gov1dia Workers, Compensation Insurance Affidavit. Builde)rs/Ccn traerors/E@ect ricia>ns/Piumbe>rs p�ica>��gnfo��atio;>a Please FriYll>t TL e ibi l A _ Name (Business/OrganizatioMndividual): Address:_' -� % tit:�>`. 1._/=`a'z' P City/State/Zip: >,,% J��'j� ';'/ � � Phone #: Are you an employer?Check the appropriate box: Type of project (required): 1.0 1 am a employer with 4. ❑ I am a general contractor and J employees(full and/or part-time)." have hued the sub-contractors 6. New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.; b required.] 5. ❑ We are a corporation and its 10.D Electrical repairs or additions 3.❑ 1 am a homeowner doing all wort: officers have exercised their l l.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL l2 ❑Roof repairs insurance required.] T C. 152, §1(4),and we have no 13 theyf G(.��zi, c employees. [No workers' comp. insurance required] 'Any applicant that checks box 01 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. (Contractors that check this box must attached an additional sheet showing the naive of the sub-contractors and state whether or not those entities have employees If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. _ Insurance Company Name:_y/moi Policy# or Self-ins. Lic. #: /A& Expiration Date: d'3 fav Job Site Address: v2,50 de'r 4A_13Md P-1-d 0+ City/State/Zip: Ale/l-A .4"_/c vt- olio, Attach a cop} of the workers' compensation policy declaration page(showing the policy¢cumber and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to theunposition of criminal penalties of a fine up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WOR7< ORDER and a fine of tip to 5250.00 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 here 8 eriify under the paires and penallies of perjuly that the information provided above is true and correct. Sienature: _ ��l�i,-✓— i�KncTl�i (ai� Date: Phone#: 74�� F cial use only, Do not write in this area, ro be completed by city or town official.or Town: --- — -- ----Permit/L,icense#— - lssuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector- 5. Plumbing Inspector- 6. Of her Contact Person: Phone#: IN1502 71 2:jffe • BOARD OF OP PLUMBERS AND GASFITTE.',RS- i PLUMBERS AND GASf.ITTERS:;-: ISSUES THE FOLLOWUM LICENSE ISSUES THE FOLLOWING OCENS L I CIRS-f!) AS A JOURNEYMAN PLUMBER 'U N-S ED AS A MASTER PLUMB-Elt:�.- PETER G VIENS PETER G VI ENS 9 BLUE91:RD' LANE z LU 25 9 BLUEBIRD LANE Af I s -2U ATK I'NSON.. 03811-2362 -0 1-H 03811 H N ON N 02 216-3---� -6-- 213586 121--,16 O�&-viL 213515 .5 05/Q)/]:. Commonwealth of Massachusetts Department of Public Safety Commonwealth of Massachusetts Hoisting Engineer Department of Public Safety '0' j R License: HE-110323 Pipefitter Journeyman ,e\45 IIlk License: PJ-028388 PETER G VIENS� 9 BLUEBIRDLN PETER GVIENS N ATKINSON NIT 0391 9 BLUEBMD Lr< ATKINSON NH;:03811 !zz— Expiration: Commissioner 11/1312015 Expiration: Commissioner 1111312015 State of Ne' w- Hampshire GAS FITTERS 'k STATE OF NEW HAMPSHIRE LICENSE BUREAU OF BUILDING SAFETY&CONSTRUCTION NAME: PETER VIENS, PLUMBING SAFETY SECTION ENDORSEMENTS: S T-N, STP NAME: PETER G VIENS rJ DATE ISSUED: 10/15/2013 DATE EXPIRES: 11/30/2015 LIC #:3249 M LICENSE#:GFE0700587 EXPIRES: 11/30/2014 ► -U FE FZ f; I certify that I have examined 0 in accordance with the Feder5M.�T.r-.�,.'Safety and with knowledge of the driving duties,I find this person is qualified:and,if applicable,only when: 0 wearing corrective lenses ❑driving within an exempt intracity zone(49 CFR 391.62) t. El wearing hearing aid 0 accompanied by a Skill Performance Evaluation Certificate(SPE) El accompanied by a [I qualified by operation of 49 CFR 391.64 .,, �T waiver/exemption ii The information I have provided regarding this physical examination is true and complete.A complete examination form with any attachment embodies my findings completely and correctly,and is on file in my office. if SIGNATURE OF MEDICAL EXAMINER T EP Peter Viens V MDATE Cert# 1023121001-12 ErExpires: 10123/2015 AL NAME(PRINT) ❑MID ❑Chiropractor eek, [I DO Advanced Certification MEDICAL EXAMINER'S LICENSE OR CERTIFICATE NO. ISSUING STATE Practice Nurse N.F.P.A.99-2012 ed. 0 Physician E]Other ASSE 6010 Installer&ASME IX Brazer Assistant Practitioner NATIONAL REGISTRY NO. 1VER OSHA NATUR OF7INTRASTATE CDL 600316337 ONLY II 0 YES 0 YES NO U.S.Department of Labor Z� �Q 00— Occupational Safety and Health Administration DRIVER'S LICENSE NO. STATE IN# Peter Viens ADDRESS OF DRIVER has successfully completed a 30-hour Occupational Safety and Health Trd-jrWV Course in 9 a41�kjA:d t MEDICAL CERTIFICATION EXPIRATION DATE Construction Safety&Health Xw—e 66813 711-6 Mir) PLY 1 DRIVER PLY 2 MOT'R CARRIER 26520(5/13) ` Client#: 79303 MERRIMACKV17 ACORDTM CERTIFICATE OF LIABILITY INSURANCE [76/1112014y' TE(MM/DDY) 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 'RESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. m! i..,r'ORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS W IVED,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). ODUCER CONTACT NAME: UB International New England PHONE 978 657.5100 FAX 8 AIC,No Ext): AIC,No): 66-475-7959 19 Ballardvale St ADIESS: nee.certificates Qehubinternational.co`I71 'ilmingtongton, MA 01887 DRINSURER(S)AFFORDING COVERAGE NAIC# '8 657-5100 INSURER A:Travelers Casualty Insurance Co 19046 'URED INSURER 6: Merrimack Valley Corp etal 15 Agean Dr#3 INSURER C: Methuen, MA 01844 INSURER D: INSURER E: INSURER F: )VERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD NDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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. R TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS INSR WVD POLICY NUMBER MMIDDIYYYY MMIDDIYYW GENERAL LIABILITY X X CO1A653551TIL14 6/13/2014 06/13/2015 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occu ence $30O OOO CLAIMS-MADE 51OCCUR MED EXP(Any one person) s5,000 X PD Ded:2,500 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG _s2,000,000 POLICY X PRO JECT F LOC $ WTOMOBILE LIABILITY X X 8102A91436000F14 6/13/2014 06/13/201 (CEO,aBc;deSINGLE LIMIT n, $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident X UMBRELLA LIAB X OCCUR X X ZUPl OP714314NF 611312014 0611312015 EACH OCCURRENCE s6,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE s6,000,000 DED X RETENTION$10000 $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X DTAUB1 A64521314 6/13/2014 06/13/201 X TORY LIMITS ER WC STATU- OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? a N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEEI$1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 Install floater C01A653551TIL14 6/13/2014 06/13/201 $500,000 Transit Limit $250,0001$500,000 $1,000 deductible SCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) anket Additional Insured, Blanket Waiver of Subrogation, Per Project Aggregate&Primary/NonContributory Drding applies as per written contract; Named Insured includes Matz-Rightway, Berkshire Heating &Air Dnditioning and Sanders Heating &Air Conditioning RTIFICATE HOLDER CANCELLATION Evidence of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. +non oc rfn�ninc� • Tom_ nnnon..............�i,,,.,, re..;c♦nrdrl mer4c of ARr1Rn Date.....1...��.�—�..�.1`+................... 3��NowrM,hOOL TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ,88�CHUgE This certifies that ... .... ............................�.. . . �, r............................ has permission for gas installation ...:% �,�-to't-�,, in the buildings of � S • North Andover, Mass. Fee...��..�.... Lic. No. 1Z 11 ..... . .. .. ........................................................ GAS INSPECTOR Check# n�1 � Jr � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK A CITY/J,A,-n Z MA DATE /�)� PERMIT# t JOBSITE ADDRESS,�W OWNER'S NAME 5;4e GOWNER ADDRESS TEM/0�" 121 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NOX APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT ° TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND i r j 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. T C SIGNATURE OF OWNER OR AGENT HECK ONE ONLY: OWNER 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 compliIcwith all Pertinen rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Peter G.Viens LICENSE# 12116 SIGNATUR MPX MGF JP JGF LPG[ CORPORATION X# 3631 C PARTNERSHIP # LLC # COMPANY NAME: Merrimack Valley Corporation ADDRESS 15 Aegean Drive,Unit#3 CITY Methuen STATE MA ZIP 01844 TEL 978-689-0224 FAX 978-689-2206 CELL 978-807-2819 EMAIL pviens@mvalleycorp.com �1 f The Commonwealth of Massachusetts i r Department of IndustrialAccidents f' Office of Investigations 600 Washington Street Boston, AM 02111 www.mass.gov/ilia Workers' Compensation Insurance Affidavit: Builders/Cons)racy`o>rs/Elec>tricians/Plurnbe>rs Applicant Information please Print lJbly c: Name(Business/Organization/Individual): Address:---z ul City/State/ZiP Phone #: � 61 9 Are you an employer?Check the appropriate box: Type of project(required): 1.%1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(firll and/or part-time).' have hired the sub-contractors 2.❑ I am a sole proprietor-or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g• ❑Demolition working for mein any capacity. employees and have workers' 9 ❑Building addition [No workers' comp. insurance comp. insurance.! required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or-additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑ Roof repa' insurance required.]1 c. 152, §1(4),and we have no employees. [No workers' 13(.Other comp. insurance required.] *Any applicant that checks box Ill must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy Tann'job site information. / �� � Insurance Company Name: � L,l Policy#or Self-ins.Lie. #: --;W/ 31 el Expiration Date: /I-//. Job Site Address: ' Li'�C�.�lCity/State/Zip:A�/', AQPY1 141(9- e91,:411? 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 ce r-u filer tlapa' and p In of perj w that the information provided ave i,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 S.Plumbing Inspector 6. Other Contact Person: Phone#: Man "M �l►r�H7lr��El�1s61:1�iv�al�I�]LIFJ 15151�9i\C►1� i.� BARD ' BOARDflF PLUMBEAS: AM CASF ITTER.S PLUMBERS AND GASF ITTERS: `y ISSUES THE FOLLOWING LICENSE ! ISSUES THE FOLLOWI`N'G LICENS L 10EN:S:ED, As. A JOURNEYMAN PLUMBER i LIfNLE'D AS A MASTER PLUMBER ) < 1 j PETER G VIENS 1 w. PETER G VIENS � 9 6LUEEl.lRfi3 LANE 9 BLUEBI'R`D LANE J ATX INSON NH 03811-2302 ATK1NSON NH 03811-2362 216.. 05/01/1:6 21 586 121'1.6.:. 05/01:/16 21A585 - a Colt9rtonmcn1 QI VcsstSltr s Qbpe�at2 of Pubft st=y Co W� o9 Mc s hzmlza s Hoisting Engineer Q��of Pant Stir License:HE-110323 1006 Pipefitter Journeyman Luse:PJ-028388 PETER G VIENS-` I t'` to 9 BLUEBIRD LN I PETER G MENS I ATKINSON NIf 03811 :/'.' _ _ _.__� 9 BLUEBIRD LN,,' 1 j ATKINSON NH-,03811. 6 Commissioner Expiration: \�� 11/13/2015 -�-'�-^ � ` �a tae i Commissioner Expiration: 11/13/2015 State of Neer Hampshire �- ------ - - ----- - -- --- ------------� p STATE OF NEW HAMPSHIRE GAS FITTERS1,1ttNSE BUREAU OF BUILDING SAFETY&CONSTRUCTION Q NAME: PETER V1tj PLUMBING SAFETY SECTION `;N, ENDORSEMENTS-STN;STP I NAME: PETER G MENS DATE ISSUED: 10/15/2013 LIC #:3249 M DATE EXPIRES: 11/30/2015 11/30/2014 LICENSE#:GFE0700587 EXPIRES: I certify that I have examined in accordance with the Fed era oor arrier Safety ul ions(49 391.41-391.49)and with knowledge of the driving duties,I find this person is qualified;and,N applicable,only when: ❑wearing corrective lenses ❑driving within an exempt intracity zone(49 CFR 391.62) + Y b1 C1 wearing hearing aid ❑accompanied by a Skill Performance Evaluation Ceificate(SPE) � � ❑accompanied by a ❑qualified by operation of 49 CFR 391.64 f waiver/exemption > The information I have provided regarding this h m Icomplete. Fr 9 9 p Y pl a ly and orr iS true and nfilinA complete examination loan with any attachment embodies my findings completely and correctly,and is on file in my office. �fF( I .�.•-.• - SIGNATURE OF MEDICAL EXAMINER T EPH E 7 Peter Viens DATE` Cert # 1023121001-12) ®jTd1d c, MEWCAL EXAMINER'S NAME(PRINT) Expires: 10/23/2015 E-1MID E]Chiropractor � U ❑DO Advanced Certification j MEDICAL EXAMINER'S LICENSE OR CERTIFICATE NO. ISSUING STATE Practice Nurse ' N.F.P.A.99-2012 ed. ❑Physician ❑Other ASSE 6010 Installer&ASME IX Brazer Assistant Practitioner I NATIONAL REGISTRY NO. i SIGNATUR OF IVER INTRASTATE CDL ' ONLY it ❑YES NO ❑YES NO WS' ft14=t= DRIVER'S LICENSE NO. STATE �^ I'".8L"�l1.1TYV'R8Lf1 /! V-S `IP/ 1 / N 171 ADDRESS OF DRIVER Peter Viens MEDICAL CERTIFICATION EXPIRATION DAT A, r zcc _ 12 -- PLY 1 DRIVER PLY 2 MOT R CARRIER 26520(5/13 ) J�/!. r) Date.4p/ ....... "OR TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,gSACtHqu NP This certifies that ....C ..... ........ ..... ... .................... ............. ............................................... has permission to perform...1-f-A.le-4� plumbing in the buildings of..... at.!;�................................................................J....../I...47e....-.74 North Andover, Mass. Ilk Fee.:,..?,O ......Lic. No. /5 35 ��...........' PLUMBING INSPECTOR Check# m _ w MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY ,�, ................-,�.,....... ... __._ .w_._� MA DATE 5 �PER�M--IT—# �— JOBSITE ADDRESS 0 C - OWNER'S NAME P OWNER ADDRESS .. Gi/tet TEL 2g -" 5--d FAX - ..� TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:® REPLACEMENT: PLANS SUBMITTED: YES NO[] FIXTURES-1 FLOOR— BSM 1 2 3 4 5 6 1 7 1 8 1 9 1 10 1 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY �., OTHER TYPE OF INDEMNITY ® BOND Ej 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 [ 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 i mpli ce itRrtinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I Richard Bymes.Jr. LICENSE# 15435 SI ATURE MPE] JP( CORPORATIONQ# 3498 PARTNERSHIP®# LLC[J# COMPANY NAME Nurotoco 1 of MA d.b.a Roto-Rooter ADDRESS 175 Ma le Street CITY I Stoughton STATE MA ZIP 102072 TEL 781-297-7049 FAX 781-341,8817 CELL 617-212-4589 EMAIL Richard:Bymes@rrsc.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL IN5PECTAONOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES a k The Commonwealth of Massachusetts Department of Industrial Accidents i Office of Investigations I Congress Street, Suite 100 h Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Nurotoco of MA d.b.a. Roto-Rooter Address: 175 Maple Street City/State/Zip:Stoughton,MA 02072 Phone#: 1-781-297-7049 Are you an employer?Check the appropriate box: Type of project(required): 1. MRI am a employer with 66 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.: 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.■❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. /am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Old Republic Insurance Co Policy#or Self-ins. Lic.#:MWC 11826400 Expiration Date:4/1/2016 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 ce uMrt �ndpenalties of perjury that the information provided ab veistr and correctSi ature: Date: � �� rC Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership, association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractors)name(s), address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information (if necessary) and under"Job Site Address"the applicant should write"all locations in__(city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 0211.4-2017 Tel. #617-727-4900 ext 7406 or 1-877-MASSAFE Revised 7-2013 Fax# 617-727-7749 www.mass.gov/dia OMMONWEALTH OF MASOHl#SET'F.'':. <>: • • - • • A►Rp-:QF PLUMBEk"SAt'i3 G4SF1TTERS ISSUES THE FOLLOWI LICENSEr , ::` LI GEI+IS U k5 A JOURNEYMAN.-PCi A fi-- RICigARD P BYRNES JR , x } 0368 SPR:i NG 'ST DGEWATER:.:MA 02379-11 276.? 05/ : . 207905 01 �W,..COMMONWEALTH OF MA AC" l#SETT BOARID.-W , `PLUMBE#?S A.NU GASFlTT. f;S ISSUES THE FOLLOWING IEEN'S E: L i CE�3SE11 AS A MASTER RtUhil E r ,y�.__=.. •lam z� RII:IIARD P BYRNES JR I °� 368 SPR1:. G ST W 8R I DGEWATEt MA 02379-11 t}7 27 go .. :COMMO WEALTH OF ME#S�ACHIfSE'tTS BOA RDW.... PLUMBER AAfii3 GASF 1 ISSUES THE FOLLOW1klG LItEUS RI:G St`I:i2 D AS A:.,.PtUMB 1 f�4i ~ CGRP f1;1GFtAftD BYRNES1=�� r v N�1ROtoco GF MASSACHUSETTS, I 368 SPRI:ifG 'Sfi f ` : • fs 1 N t W S U i T.E 2 R 1 `� Y�`: B#'tlGEWATER MA 02379-110 . 3g ... . 0 1011:: 6 2075o6 I AG URO` - CERTIFICATE OF.LIABILITY INSURAN�� DATE(MftDNM)i. -- -- 03/1712014 -' THIS' ICATECATE IS ISSUED AS,:Aa.�IRATTER;OF.iNFDfiMAT10N-ON Y AND CQNFER$ NO."RIGHTS;iJPON.'THE CERTIFICATE HOLDER.THIS ;. . BELOW- THIS CERTIFICATE IFIL AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFlCATE•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 polky(lea)must be endorsed N SUBROGATION IS WAIVED,subject to the terns and conditions of the policy,,certain policies may require an endorsement. A statement for rights to the certificate holder In lieu of such endorseme s on this certificate does not can PRODUCER MARSH USA INC. E. 525 VINE STREET,SUITE 1600 ' PHONE FAX CINCINNATI,OH 45202 �1aL Attn:d.nclnnW-ce<trequu*mamfi.com 400408- GAU& 4.15 INSURER 8 AFFORDING COVERAGE N N 00015 INSURER A:Old RepubllC Irsilran(*Co 24147 ACOR X15-ROTOADOTER SERVICES COMPANY u1suRER s:N1A NIA 175 MAPLE STREET INSURER c:MkImst�y Casualty Company STOUGHTON,IM 02072 � 23612 INSURER D: INSURER E-- COVERAGESREa CERTIFICATE NUMBER:' CLE-003892293-04 REVISION NUMBER-0 THIS 1S TO CERTIFY THAT THE POLICIES OF INSURANCE.LISTED BELOW HAVE BEEN ISSUED TO THE INSURED ED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO Vi1HICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE'AFFORDED BY THE.POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. In I TYPE OF INSURANCE o. EFF POLICY EXP A - GENF AL uABIUTY MWZY80132Pou"NUMBER M uMrs X04/01/2014 0 M1:115 EACkioccuRRENCE $j 2,000,000 jfiMERCVLL GENERAL LIAB1UTY ELAIMS=MAGE a OCCUR. S 750,000 EXP ane ffi 5A00 PEasoNaLa ADV INJURr $ 2,0001000 ENT.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE : 6,000,000 X7POLICY PR POLICYPRODUCTS-COMP/OP AGG i 6,000,000 A . AUTOMosiLE uABArTY MWIB21957 $ 0410112014+ • 0410101015 L I 5A00,000 X ANY AUTO ALL OWNED SCHEDULED BODLYINJURY(Par peraw) $ X AUT09 X NON-OWNED BODILY INJURY(Per accidu t) s . HIRED AUTOS AUTOS P � RTY UMBRELLA 1rA6 ' OCCUR S EXCESS LIAS CLARE EACH OCCURRENCE i DED R A-.GREGATE s ION A WORKERS COMPENSATIONS AND EMPLOYERS'LkAEIUTY S) WC STATU-. OTH- C ANY PROPRIETORrPARTNERIEXEcurnE YM=301934 00(TX) 04/0112014 0410112015 C' OFFICERAAEMBER EXCLUDED? N. N/A EL EACH ACCIDENT s 1.000, MAY NN) 3808. OH1 04/01/2014 04/0112015 EL DISEASE-EA EMPLO sSLOW 1�,000 N deadibswder. DES PTK)N OF OPERATION E.L DISEASE-POUCY LIMIT y 110001000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(Agxh ACORD 101,Addillonal Remarks SehedWe,H noon EVIDENCE OF INSURANCE awes 10 neHlred) CERTIFICATE HOLDER CANCELLATION ROTO-ROOTER SERVICES COMPANY 175 MAPLE STREET SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE STOUGHTON,W 02072 THE EXPIRATION DATE. THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashl Mukherjee -11�'LaAw.ab>t.: ACORD 25(2010/05) ®1988.21110 ACORD CORPORATION. All rights reserved. .:" The ACORD name and logo are registered inarks of ACORD e Date.�� ?.,!�t..... .. N°QTM c °f TOWN OF NORTH ANDOVER ,> X -PERMIT FOR GAS INSTALLATION SACHUSEt�� ij , f This certifies that . . .�1. . . . . . . . . . . . . . has permission for gas installation . . ! !v j�./.�. . . . . . . . in the buildings of . .Q.c-k . . . . . . . . . . . . . . . . . . . . . . . . at Po :S v4.'!// . .� . . . . . .S�. , Nort ve S. Fee. T�'. Lic. No..l 'f��°. . /!.'c�.✓. lj. . . . . . . . . . . GASINSPECTOR Check#/0--To 7960 ,a w MASSACHUSEr]SUNNIFORMAFIPUCATONFORPERM frTODO GASFfrDNG (Type or print) Date 2. NORTH ANDOVER,MASSACHUSETTS . Building Locations x30 Permit# •S &,SSownees Amount$ /V Or 4-6 Art- Qdr Name New Renovation ❑ Replacement ❑ Plans Submitted ❑ � w � ��a w o U H x O H C O a p x w � \ z W�W WW zz z� a e as 0 o° w °o w o A ]C O x ir. P a t7 U x > a a F i SUB -BASEM ENT B A S E M ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR f 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR STH . FLOOR runt ortYPe) SAVAGE h one: Certificate Installing Company Name E193 H334 __Corp. Address R0 a BOX 34 1 SAla m 03 79 ❑ Partner. Business Telephone - — ® Firm/Co. Name of Licensed Plumber or Gas Fitter R(WA W SAV A 6E INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes IM No❑ If you have checked yes,please indicate the type coverage by checking the appropriate box. Liability insurance policy MA Other type of indemnity ❑ Bond ❑. Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my 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 Massachude.and, Qh2ayter 142 of the General Laws, By: Signature of Licensed Plumber Or Gas terr Title ❑ Plumber M t 3 4 9-7 City/Town ❑ Gas Fitter License Rum6er Master APPROVED(OFFICE USE ONLY) Journeyman The Commonwealth of Massachusetts Department oflndustrial Accidents Office oflnvestigations 600 Washington Street Boston,MA 0211.1 s� www.massgovldia Workers' Compensation Insurance Affidavit:Builders/Contractors/EIectricians/Plumbers Avy icant Information please Prmt Legibly Name(Business/Organizationgridividual):_ SAV A c c— Address: Q l�oX City/State/Zip: Go,.tp .� . Phone#: Q 7S -•0 Are you an employer?Check the appropriate box: ---- 1.❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required): 2.Kemployees(full and/or part-time).* have hired the sub-contractors 6 El construction I am a sole proprietor or partner- listed on the attached sheget. t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. []Demolition working for mein 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 or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.[❑Plumbing repairs or additions Myself. [No workers'comp. c. 152, §1(4),and we have no insurance required.]t employees. 12•❑Roofrepairs [No workers comp,insurance required.] 13.❑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 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. Iain an employer that is providing workers'compensation insurance for information. my employees Below is the policy and job site Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: , City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' der the ams andpen ties ofperjury that the information provided above is true and correct. Si nature: Date: 2 2, 'hone#: r If FOfficialonly. Do not write in this area,to be completed by city or town official n: Permit/Licenseuse (circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more ` of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartinents and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or,permit to operate a"business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the,commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers;compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. 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 Iicense 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 O01-14onM-alfla oflNfassacl��setts Department of zudustrzal Accidents Offloe of Investigations 600 Washington Street Boston;M-A,02111, Tel.#617-727-4900 ext 4406 or 1-877-M SSAFE Revised 5-26-05 Fax#617-727-7749 WWW.mass.gavMa Y C,QMM©NWEALTH OF MASSACHUSETTS LCfIV"SED AS A MASTER PW MBE. . ISSUES THE ABOVE LICENSE TO: RONALD` K SAVAGE JR 10.':HENDERSON CIRCLE >� SALEM NH 03079-=26:3 1. ' .. N 134:87 05/01/12 79593 N Y f =ti �a c ,k V s. 'Y G:. 'w S. i r �i Date..... .Z:...... ........... :N 3?;•`:�`` "�,� TOWN OF NORTH ANDOVER PERMIT FOR WIRING !� ��SSACNUS� y` This certifies that ,1.7m — 44KTE v i has permission to perform ......... ..R............................ wiringin the building of............. ...... ...................................................... at....... 3-0..... ',�� .:.. . f ee,6...6CTRIiCAL North Andover,Mass. EL INSPECTOR Check # F �— `► 0522 kA Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 10-5-' 2 . 2 . Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank r APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK b All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 v (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: [2- City 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) 2-3 O v�L, l�c 4�4-,4- S�- Owner or Tenant .J �,� �,.� Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building tv�z Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd ❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: C�x.tr Completion of the ollowing table may be waived by the Inspector o 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 "1 No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I 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 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: i Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring.. No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: o-o v• e� (When required by municipal policy.) Work to Start: t L_ 7 - I k 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 R BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: A,0(-0%r_ LIC.NO.: d),5F 2- Licensee: Rxc�l.a l p cc�w Signature (�o.A LIC.NO.: �I15`t Z`i (If applicable, enter ` empt"i the license ber line. Bus.Tel.No.: S^ `!S 2^ .Sr("� Address: �s .c\� - 4 W C130? 6Qf Alt.Tel.No.: �3-L3 >P 3 h 7 (IJ *Per M.G.L c. 147,s. 57-61, security work requires Department of Public Safety"S"License: Lic.No. LS f 2 S 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 Owner/Agent FPERMIT FEE: $ Signature Telephone No. The Commonwealth of Massachusetts Department of Industrial Accidents ,.. Office of Investigations ky 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/Organiz^ation/Individual): Apl,�, t L Qr r Address: `7 ��,J_Q S� . City/State/Zip: Q4C,-, , 11 63x, Phone Are you an employer?Check the appropriate box: Type of project(required): 1.�1 I am a employer with 3 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 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 required.] officers have exercised their 10.❑Electrical repairs or additions ' 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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: SSc>U4 ,L (.yc C-A.1 chi Policy#or Self-ins.Lic.#: 0 C L 6 Ct o 3 c-,1 2_43 Expiration Date: 12— Job ZJob Site Address: 2—?>0 City/State/Zip: a uv , — O I9''4I 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 cer 'y under the pains and penalties of perjury that the information provided above is true and correct. Si nature: Date: 12--?-11 Phone#: - 2';�3 - -?1r 14,S- Official {SOfficial 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#: Location No. 3 Date R MORTh TOWN OF NORTH ANDOVER 3?O•t�� o .�,tiOt Certificate of Occupancy $ * ; ; Building/Frame Permit Fee $ zo .dv Foundation Permit Fee $ 1ACMus Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL Building inspector W11/98 12:33 180.40 PAID 1 17 :J J Div. Public Works Location No. Date NORTh TOWN OF NORTH ANDOVER O9 Certificate of Occupancy $ "or 4W Building/Frame Permit Fee $C Foundation Permit Fee $ s^ MUSE Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ ' Building Inspector Div. Public Works PERMIT NO. 33 -7 " APPLICATION FOR PERMIT TO 13UIL1)********NOR"T11 ANDOVER, MA AI\Y NO. / O LOLNO. 2. RlCORI)OFON'NLRSIIIY DATE ROOK PAGE 7/)hE SUD1)t\'. LOT NO. /� J PURPOSE ISE(M=Mill DING /(/!�7-e7-eJC'S)drNe,e LOt11tUN 30 c.>g+ SZ. slzr NO.OFSCtN21L'S (AVNER'S NAME OWNER'S ADDRESS / -S7� BASEMENT(NL SI.AI) '6'r)sRD � 3c7 .Sd 1 I z 3 SIZE OF FLOOR I IMBERS .4R1 111 l EC1'S NA/.IE BI III DER'S N.4b1E iz�we �`1 L1�S C-v SPAN DIMENSIONS OF SILTS DISI ANC E TONEAREST DUILDI NG �67 i DIMENSIONS OF 1Y1s1 S DIS FANCE FROM STREET' DIS FANCE FROM LOT LINES-SIDES REAR S � � Z- 8S� � 3�� DIMENSIONS OF GIRDERS v /S� I IEIGi rr OF FOUNDAT I(NI 5S" -�G THICKNESS A{tfAOFLOT FR(NIl'AGE SIiLO-MMIM, IS BUILDRAi NEW /1/(� MAiER1A).OF Cl IILINEY pl. ADDITI(NI /./b IS BUILDING(N�t SOLID OR FII LED LAND ALTERATIONS y24,S' witINGCONFCXtMTORE(-XIIREMENIS OF CODE IS BI IILDINGCtNNL'CIED 1OTOWN WA1ER APPEALS ACTION, IF ANY IS DUILDING CONNEC 1 EI)1't)1 OWN Sli WI:R ISBUILDI NG CONNECTED TO NA it)RAI.GAS LINE LAND COS] INs'1lI('TIONS 3. PROPERTY INFORNIATION EsI BI Ixi. COsf l / EST. Bi I)(;.C(>ST I'ER SQ. 1 i. PAGE I FII.I.OIff SECTIONS I-3 ESI. Dl.lxi. COSI 1'L'KKt1(N.1 ELECTRIC METERS MUST BE ON OUTSIDE OF 0011 DING SEPI IC PERMI I NO. AFI ACI IEDGARAGESMUST C(NJFORMTOSfATEFIRLREGII1.AlIONS 4. .-\1'1'ItO\'kl) Ul': ^ MIMI (.INSFECTOlt PLANS MUST BE FILED ANT)APPROVED DY BI)II DING INSPECT- Mt OWNERS'IE:LN 4' DAIEFit I:D bp- � 'J2 � / v� CtN IRAE1.N 77/' 933—G�Z�a t� ► i� L�vIS �L�. . J1f�TiS ✓�'✓� C(Nr)R.I.101 U� O SIGNAItIRtiOFOWNF:Rt1R f IORIZEDAGL•Ni FIA: � .e)- � PI:RAIIT GRANTED 19 ,µ \ 'fie�amimwnuiea/,�l o�✓�aaaacfivaelta I, . fT r j� % DEPART ENT OF PUBLIC SAFETY CO TR _ ,. ._UPERVISOR LICENSE i ,Expires: Birthdate: ��+ j31 ji999 19 j31 j1951 r 6 LINDA. WAY NIODLETON, NA 11949 _ -------------- ROME IMPROVEMENT CONTRACTOR Registration 104724 ;Type PRIVATE CORPORATION Expiration 07/15/00 CRO,CKER SALES CO., INC. Louis M. Klipper AD wS1RA��A 9 igh Street Woburn MA 01801 ... FR FZASFi1NC t OURA-LDAP .. 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'Zd/`Nz -RAA•E 'r.7el�:ON .fie ON O�} yE ; A _!z s°i.�Nc;WrMON `r?� �w„•'��"�y a•B Orr �tAYE aI Psr yS LL LAS7�a"G +a:r ^•o°�c•�oac�a PSF yA>< SNpN � ��r�.C�• r I DETAIL REFER a,.CEDENCE NOTE J/a-oAsSCALE' N T S ISOMETRIC AR �t C-12 UNlI n.Lc o a-WAIL OMRV FtOY tiD5 a_O-O.C. DATE; ELaEDYFNr ' OL7`TN O RECAPP URS BOE a1AMl g-,.REFERE,yCE ' 1, MArE AITt; P,ACf; I M SECTS of —� _ oRARrIC NIA�t 14 /0 b6 —66 ILI ST I Ntl C-r Vbo D F� L .6- ——---------- 3/4 r, {>� � AC- 31� < �.h=�j �'r7L�>. G L v -7Xlo Len.-y' c�(f R� �roq (L��1.�4➢ plST / �jtJ(j�� p�51s i b`► lo, . lo 12'' S "Q� AN 31S a R3�Rvo- EX15TINV -�" STRUCTURE 6 X10 E DOVSleb Zx/67 )STS lQ �,�„ �-i6 D q Ex 5-TI r4 v FovNv<aT rant a v d v 7 p Ti GRpu�b '> 14 D f, — 5/4" PLYII ORIENT IN HORIZONTAL DIRECTION 5TAf5GER JOINTS 9 MULLION � 2x6 BLOGKInG ®PLYYVOOD t-tt EDGES, NOTGH ON SITE 1 11 4" RIGID FAGED INSULATION _ CENTER 2x6 � 8' OVER MULLION! 4, tt� k UPPER HIULLIOM DOUBLE.2x6 I 4" 0 ENDINALLS 8" 1" DEEP (� 1x6 CEDAR V ' LINER �" p�vltTON II V' rn� I it MUNTIN BLOCK ti �1 L4 � c G'0 1..Gtt� CGt..L'-.'� /�1Lj'GL'�)�•yc�i f72Gl�tC:�,f,f ,r�CLs�ttG� DRpTSMk J THIS DRAWINJO IS CONSIDERED PROPR►E7ARY. R IS NOT T6 j ORDER MJMSER DAA, ),. Linda¶ SunmjWMs H REPRODUCED.O. kOR IS (� ll ll IILFiIEL THE INFORMATION THEREON TO UE USED TO PRCOUCE PRgDUNLESS Y7RITftN CONSU14L S WRIT O ;�OM� l ALindal ` Lindal Btjildsng Products SunRopms & Windows 1156 W4ter Tank Road Burlington, Washington 98233 T; (360) 757-6616 F: (360) 757-4036 u:www.lindol.com ' : ...... ... ..... ....... : .. VERTICAL ANALYSls Roof Vertical Loading: Live Load LL 40 psf vertically on horiz. proj- Dead Load DL 7.7 psf verdcally on actual prof, Duration of Load Stress Increase = 1.15 Roof Fitch 4112 — 3 1$.43 degrees Live toad Normal to Roof = (LL)(coo—2 ) = 36.0 psf Dead Load Normal to Roof = (OL)(cos o) = 7.30 psf Total Normal Load, TL = 43.30 psf Contributory Width = Bay Width = 3 ft ————} w 130 Iblft 4 x S Section Properties: Select Western Red Cedar Species Properties: Width b 3.6 Depth d 7.26 Fb 1100 psi Area A 25.38 in"2 Fv 76 psi Section Modulus S 30-66 in-3 E 1.10E+06 psi Moment of Inertia I 111.15 in-4 Max Span in Shear = (Fv)(D uration)(2)(2)(A)/(3)(vv) = 22.46 ft Max Span in Bending = [(Fb)(Duration)(8)(S)/(v }(12')]—(1 12) = 14.11 ft Max Span in TL Deflection = [(384)(E)(1)/(B)(w)(180)(144)]"(1/3) = 14.08 ft Max Span in LL Defl = [(364)(E){I)/(b)(v�&LfrL)(24q'(144)j"-(1/3) — 13.6o ft ——— Max Allowable Span measured Horizontally= (Max Span)(cos(') = 12.90 ft Actual Maximum Span = (12'-8.26) -- (2.5n + 2.26") = 1229 ft 12.90 ft OK 3033 ® Printed on Focyclnd ppp9.. 2 f 2 = CU.�Cr r*iersT a C 6,09,1 , FSD /0 e A�lr ,S'7eY.0 /N 72 r L - �r1vv-7� 6F s ' N f,,;, �, e , 1p L85 F(-)c; t(:�D 1 A� IIoGXlx3. / 67 'a x I . � ) off cgs/s��sr Ia- 46-T k i-3 3 , 14 67 = IS -757.'7 /6 F6 i I i I i PLAN OF LAND - ------ I NN0RTHA 0WNDOVERI` MASS, NED BY J•F SHAW III SCALE 40 FEET To INCH_AP RIL 26,19184 ROBERT E. ANDERSON REG. PROFESSIONAL ENGINEER R REG. LAND SURVEYOR 178 PARK STREET PO BOX NORTH READI177 NO 2 N G, MASS. • F,p r O •pp \ O O O L9 LeFT si cv c9 2Cy'TO / O / / a / a W LOT 1 a 2 55, 618 SQ.FT. \ O 19.64 2 � 19.50 61.6 6 Lp N v rn \ a 1 \ O t , a 1 \ t ` \ t Z t 1 , 0 t - ��� `. 19.40 ,.-- 1"50..00 . ,• _ o SOUTH , BRADFORD' .. STREET • I CER�TLFY' HAt\��S FOUNDATION IS LOCATED 0 LO,T AS WN. SHQ N T r1ORTy 0 over Tomm 4r 19 *Vr _ dover, Mass., A O LAKE yY COCNICME WICK A�qA E D I" 1 S BOARD OF HEALTH { Food/Kitchen 1 Septic System PERMIT TBUILDING INSPECTOR THISCERTIFIES THAT...............7 ........... ,...kft.1W................................................:...........;.................. Foundation has permission to erect.....S"AC.Q. . buildings on ......... ........ >v ........ Rough . .........W... �. to be occupied as............a.i�!!�.. .........�� �I •• Chimney . . ... . ........................ . .. provided that the person accepting this permit shall iv respect conform to the terms of the application on file Final this office, 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 INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ST TS Rough ................................. ... .............. ........... . ............................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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 C4,t a Street No. "Y I a73� Smoke Det. N2 V Date../...�:...�.............. NOR7M TOWN OF NORTH ANDOVER p PERMIT FOR WIRING cMus�� This certifies that �`' �"�` ` I/ ........................................................................................... has permission to perform ........:.....-ra r, %!... -. %<�: tom....................... wiring in the building of...-.-;, .:.. . ............444 ........................... � G at.... . -�.�'....... .-..!......Q :1:`...... North Andover Mass. rte/... r�.1` Fee r:.!O....." Lic.NoA;:�..7<!14............................................................. ELECTRICAL INSPECTOR 11/09/98 09:57 25.00 PAID WHITE:Applicant CANARY: Building Dept. PINK:Treasurer • R Mice use only The rrIZ7IOnII1P- th Uj i`✓lassnchusetLs , Permit No. Depo, t nJ Public Safety occupancy S fee Clicked BOARD OF FIRE PREVENTION REGULATIONS S27 CZAR 12:W 3/90 Otave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance with the Maesachusetu Electrical Code, 527 CMR 12:90 (� (PLEASE PRINT IN INR OR TYPE M-ORMTION) Date I I "I % 6 City or Town of NA'� fl ?2" To the Inspector of Wires: The undersigned applies for a permit to pe((r��formt e el rica work described below. Location (Street & Number) Owner or Tenant Jq C�j Owner's Address 177 E Is this permit in conjunction with a buil in�gi Yes No ❑ (Check Appropriate Box) Purpose of Building. v45� �� �'< /°!i� Utility Authorization N0. Existing Service Amps / Volts Ove-"tad ❑ Undgrd❑ No. of Meters New Service Amps- __ _ / Volts Overhead ❑ Undgrd ❑ No. of Xeters Number of Feeders and Ampacity I- A , �� Locationl., ^and Hatur of Proposed Electrical Work �1�I� �h h—a 5, °f No. of Lighting Outlets Total. 8 8 No. of Hot Tubs No. of Transformers KVA No, of Lighting Fixtures Swimming Pool Above ((-'�El In- grnd. grnd. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting -- Battery Units No. o: Switch Outlets No. of Gas Burners FIRE ALARIMS No. of Zone3 No. of Ranges No. of Air Cond. Total No. of Detection and .3 —�-- tons Initiating Devices No. of Disposals No. of Ileat Total Total No. of Sounding Devi(,es Pumps Tons KW No. of Dishwashers Space/Area Heating KW No. of Self Contained Detection/Sounding Devices No. of Dryers Heating Devices K13W Local Municipal ❑Other Connection No. of Water Heaters Ku No,nof Ballasts Low Voltage -jjZs No. Hydro Massage Tubs No. of hotors Total IIP OTHER: -- INSUF,,kNCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I haveia current L biltty Insurance Policy including Completed Operations Coverage or s substantial equivalent. YES NO E] I have submitted valid proof of same to this office. YES V NO I.f you have checked YES, please indicate the type of coverage by checking the appropriate bo . INSURANCE d BOND ❑ OTRER ❑ (Please Specify) Estimated Value of Electrical Work $ Ex iration ate Work to Start Inspection Date Required: Rough Final Signed under the p�nallt�i�es�f perjuurry: a FIRM NAME-���.� C. NO —��( L+ Licensee (6-44 I Signature_ NO. Address_ rs Lr ^/-'� Bus. TYRIC- . I n sem.-Alt. Tel. No. OW'NER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- scantial equivalent as required by Ptassachusetcs Ceneral Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) T�!nnhnnp No. PERMIT FEE S )