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Miscellaneous - 24 GILMAN LANE 4/30/2018
1 V/ UU Date ?�./o ..... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that.,... ............. ��.'5.� / ................ has permission to perform ...... plumbing in the uildings of at ........ - ................. ............... ............................ North Andover, Mass. Fee740 ..7..... Lic. No. Ig;)TI ..... ................................................................................. PLUMBING INSPECTOR Check # il�D � L ---T `fro- 2-o\yvv, 31zZ`iy� �1�- + d MASSACHUSETTS UNIf-U ?M APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY MA DATE PERMIT # JOBSITE ADDRESSZ L OWNER'S NAME C en. p P �y U— OWNER ADDRESS 9A -IK PL i _ TEL 5 - C �� �{ FAX l TYPE OR OCCUPANCY TYPE /COMMERCIAL © EDUCATIONAL ETI RESIDENTIAL PRINT CLEARLY ' NEW: I RENOVATION: W. REPLACEMENT: Ell PLANS SUBMITTED: YES ® NOP FIXTURES -1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 .BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM _ { 1 _ j --JI ( DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM I I (_ = DEDICATED WATER RECYCLE SYSTEM . 1==== I _ w_f _ I . __j DISHWASHER I __ J DRINKING FOUNTAINVEFOOD DISPOSERFLOOR / AREA DRAIN 1 1 I i 1 1 I J _INTERCEPTOR (INTERIOR f _ I j ____j ___.__ I ___.____I _-_ __I ._.�I ._.___w..1 SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER _.---- _ i INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES IN NOEIJ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 54 OTHER TYPE OF INDEMNITY © BOND DI 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 0 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information 1 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 co fiance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. // _ 1,y /, PLUMBER'S NAME :T60 n �n/ cwn f�ellZ�3 I LICENSE # % 5 $ (( SIGNATU/ MP JP Q CORPORATION Q# '� (o PARTNERSHIP 0#®LLC COMPANY NAME �,J�t, gu,�,,, e ®ey,,JADDRESS A -M g QLue CITYt �.trtc.iZ n- (STATE ZIP TEL I C7cx� 1 FAX—� CELL��EMAIL v UI j� - - \y W H °z z 0 u w P4 az- w o� z N ❑ W Ix ui W U- t The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 "t www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: f-(5 V �,S44,lrc ow awl j o - City/State/Zip:_ c L R.n�C /mac)( x'21 Phone Are you an employer? Check the appiopriaie box: Type of project (required): l.di am.a. employer with employees (full and/or part-time).* 7. ❑ New construction 2. ❑ I am a sole proprietor or partnership and have no employees working for me in 8. Wemodeling any capacity. [No workers' comp. insurance required.] 9. ❑ Demolition 3. ❑ I!am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 10 ❑ Building addition 11. ❑ Electrical repairs or additions proprietors with no employees. 12. ❑ Plumbing repairs or additions 5. I am a general contractor and I have hired the sub -contractors listed on the attached sheet. ❑ � 13. F-1 Roof repairs These sub -contractors have employees and have workers' comp. insurance.t 6. ❑ We are a corporation and its officers -have exercised their right of exemption per MGL c. 14. E] Other 152, § 1(4), and Nye have no. employees. [No workers' comp, insurance required.] .,;. . . *Any i policy information. T Homeowners who subriiif 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-corilzactiors have employees, 'they must provide their workers' comp. policy number. I am anemployer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. p Insurance Company Name: (n! r �/ (_ c KKyny- -y,5 . Policy # or Self -ins. Lic. #: 6? W h- C /lc ' tet/ '7- Expiration Date: Job Site Address: '2'1 M P , &v ny o 1-4 City/State/Zip _A-) /moi () b V it- et_ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. I do hereby certify under the pains andd/penalties of pefjury that the information provided above is true and correct .Qianai,tra• % / .� /(�P_ A/r.e�. w, hate- / 2 2. / '%�s l 0 - 6 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 #: . . , j 'P. 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 oliire, express or implied, oral or written." An employer is defried 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 foi• 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 bum leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 1-ASSACIY7SE,'I T - DRfVER'. OF Mgrs .�.`?. Ira, 9a ENb 1d MT�ER . NONE 50997561 006 !8 tM 31•"19`l3 M 4 7 6-Q71 SNE . k . .URY r�... . e 45 0SSA10EGIlHN RD BILLERICA, IVIA 01821-$A18 5-DDM9.2010007-152009- . Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS -073226 TODD D WOOMMY 45 OSSAMEQUJN RDS BUXERICA MA18211 r� n2d., Expiration Commissioner 12/31/2015 . F a. ~' 7/1.. rt1 /i._tl flee ..�.r�f/r e/ Mll_lfeellle, le` ' Office of Consumer Affairs & Business Regulation, NOME IMPROVEMENT CONTRACTOR 4 -'registration 181877 Type: Expiration x/612017 LLC M-;�� •yr 1. WOODBURY HOME SOLA fI.ON5., LSC. 1k� TODD WOODBURY� 45 OSSAMEQUIN RD BILLERICA, MA 01821 Undersecretary SHEET METAL WORitERS _ ISSUES. THE FQELOWIRG}`ILENS' Fr Date..... `..l. `;.i.� .................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that......!..' A .......................................................................................... has permission for gas in. tallation7 . .�.... ... � .. ......................... in the buildings s o S L.!`:.................... North Andover, Mass. at ..... ................1..+M G., .�............ t�,� Fee.:.:.K ........ Lic. No. �%.�.. I ...................................................... GAS INSPECTOR Check #% 00 907 -` �I - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,t CITY O n t/L MA DATE y y PERMIT# JOBSITE ADDRESS /T 1 �'►� �r�+ ^ �~�OWNER'S NAME - OWNER ADDRESS TE2�� FAX -- TYPE OR OCCUPANCY TYPE COMMERCIAL ( EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:.,�._[�'!l RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NOQ APPLIANCES'l FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1::J _ ..- Zzi E. --L - I Fj1 . BOOSTER CONVERSION BURNER ==== COOK STOVE - : _ ... _ . . DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUPAIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE thave a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES fj NO [j IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E3' OTHER TYPE INDEMNITY [I 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 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and 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 Pertpf t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /,% I / PLUMBER-GASFITTER NAME LICENSE # L,? I RE MP 0 MGF Ej JP [D JGF Q LPGI © CORPORATION [J# PARTNERSHIP ©#= LLC [J# COMPANY NAME:1-0- ¢ _ ADDRESS L� i ✓e _ _ ___� CITY H STATE/h 9- ZIP O� _I TEL FAX CELL _7EMAILL_ z ps i H O z O H U W W � o Z O y� W � W � ~ W LU O U w n z W I-- --C I-- CO a w ui w u w C a 0 a a a U J F, a IL a � iii x w F- LL H °z 0 H U W Pi C7 �1 sk 9 r The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): t(3 6 Address: zc�� City/State/Zip: 1i vet. 0%94 Phone 4:_9 > 6 V Are you an employer? Check the appropriate box: 1. ❑ I am a employer with - 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. D- am a sole proprietor or partner- listed on the attached sheet. I ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' I comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ['Plumbing repairs or additions 12.❑ Roof repairs 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 2te 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 is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address;-s`�—� �,-� L�^--R L v, City/State/Zip:_,,J v/ 4 - Attach 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. Ido hereby certify zinc he painsan' d penalties ofperjury that the information provided above is true and correct. Signature:� Date: 1� use only. Do not write in this area, to be completed by city or town official. City or Town: PermitUeense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 6. Other - 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone #: r Information and instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit 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 ofMassachusPtts Department ofladustrlal ,Accidents 4fAce of Investigations 600 Washington Street Boston., MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 wwv.mass,govfdla COMMONWEALTH OF MASSACMUC s PLUMBERS ANp.GASFITTERS LICENSED AS A JOU,RNEYMAN: PLUMBER ISSUES THE AE C&t LICENSE i O xx CRAIG �- G WH ITE 4AVE s 44E�THUEN ,. MAj01844x; G234 26318 05/O1lI4�`, �. ,;Z83r�73 ' Safety Insurance _ PO Box 55098 Boston,lVlA 02205 _- �— Form of Notice of Casualtv Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings City Hall NORTH ANDOVER, MA 01845 RE: Insured:'- Property nsured:`-Property Address: Policy Number: Claim Number: Date of Loss: Company: Board of Health or Board of Selectman City Hall NORTH ANDOVER, MA 01845 GEORGE J-GIKAS and CHERYL J GIKAS 24 GILMAN LANE, NORTH ANDOVER, MA HMA 0080555 BOS00067511 2/15/2016 Safety Indemnity Insurance Company Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Maria Rivas Claim Examiner Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3324 Fax: (617) 502-2846 Email: MariaRivas@Safetylnsurance.com 2/17/2016 PO Box 55088 Boston, MA 02205-5098 617-951-0600 Form of Notice of CasualtX Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 RE: Insured: GEORGE°J GIKAS and CHERYL J GIKAS Property Address: 24 GILMAN LANE, NORTH ANDOVER, MA Policy Number: HMA 0080555 Claim Number: BOS00052555 Date of Loss: 3/2/2015 Company: Safety Indemnity Insurance Company Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000.00 or. cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. ,If any notices under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it'to" he attention of the writer and include a reference to the captioned insured, location, policy number; date of loss and claim number. Allan' Leavitt Claim Examiner 3/3/2015 Safety Insurance Company Homeowners Claims Unit P. 0. Box 55098 Boston, MA 02205-5098 Phone: (617.) 951-0600.EXT 32.13 Fax: (61'7) 53178891... Email AllanLeavitt@SafetyInsurance.com - Date. C�',l �! . 7... . NORTH r OF Bio 1ti6 TOWN OF NORTH � OVER 9 f • PERMIT FOR AS STALLATION This certifies that ....�.. t . ).... �'o /.f 1 .................... has permission for gas installation .. ? ; . /-/// . _ ...... . in the buildings of ... '1. S ............................ at In. 4-7 ..1.k ......... , North Andover, Mass. Fee..Lic. No. Z f ?.e . g. �� ! ':.... . GAS INSPECTOR Check # 2 C r/ c/ MASSACHUSETTS UNIFORM APPUCA'PON FOR PERNIlT TO DO GAS FITTING (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations JL1 b dm ( /1 G :/i e Permit # / Amount $ 3 1, )� Owner's Name Lei orl i t' C:,'► New ® Renovation ❑ Replacement ❑ Plans Submitted ❑ Name of Licensed Plumber or Gas Fitter l 5 .! u 1,67n CAQgk one: Certificate Installing Company Corp. ❑ Partner. ❑ Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ©--' No ❑ If you have checked Les, please indic the type coverage by checking the appropriate box. 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 El I herebv certify that all of the details and information I have submitted (or entered) in abnve annlicatinn are tn,e and acmrnte 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 Massachusetts State Gas Code,and Chapter 142 of the General Laws. (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber ❑ Gas Fittertcense um er ❑��er ❑ Journeyman a w rp v� v, a U o 9 a I+ x W z a F OF z z F a � ° w d � a OF w w z U w x m w a W x S� z F z F d x 1-Z w d W L7 p cc w w o E z v a a o a w x w> a e °a > a N o _ T BA SEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. F L 0 0 R 8TH. FLOOR Name of Licensed Plumber or Gas Fitter l 5 .! u 1,67n CAQgk one: Certificate Installing Company Corp. ❑ Partner. ❑ Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ©--' No ❑ If you have checked Les, please indic the type coverage by checking the appropriate box. 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 El I herebv certify that all of the details and information I have submitted (or entered) in abnve annlicatinn are tn,e and acmrnte 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 Massachusetts State Gas Code,and Chapter 142 of the General Laws. (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber ❑ Gas Fittertcense um er ❑��er ❑ Journeyman 10 ei Date/V `1 ........................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING 1"/z This certifies that.� ......... . .................................. has permission to perform ..........AA -Z . ....... x .. . ........... wiring in the buiKlding of ... ...... ....................... at ........ "!.%, -51�7 ..... . 141 .......................... . North Andover, Mass. ............w. Lic.No.,2� ..................................................... ELECTRICAL INSPECTOR Check # 7359 fi C'ommonwea& o` Mamac"tfa Official Use Only 2epa,t.d of -%. Permit No. c� Occupancy and Fee Checked BOARD OF FIRE,PREVENTION REGULATIONS [Rev. 1/07] leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00_ (PLEASE PRINT IN INK OR TYPE ALL INFO NATION) Date: City or Town of: rl leer' To the Inspector of Wires, By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 4� G I L/MA,v 44), Owner or Tenant 45,p;,- — /kis Telephone No. Owner's Address .Mime,. Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 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: N� -�Aelb/ 601 o -O yGfiMiL? 4I-oX Completion ofthe followine table may be waived by the Inspector of Wires. No. of Recessed Luminaires : No, of CeilSusp. (Paddle) Fans No. of Tota Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners o. of Detection an Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No, of Waste Disposers Heat Pump Totals: . -umber Tons ..... " .....1..." KW No. -o-T-5elf-Contained Detection/Alertin2 Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑Other Connection No. of Dryers Heating Appliances KW SecuritySystems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: _ , — (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: 4 Licensee: �i4tit 5rlrZ,Signa tu LIC. NO.: Q (If applicable, en r ' e in the license numb line.) Bus. Tel. N.'1 Address: / = . /LSA numb , A)_41 iMO94-2 Alt. Tel. No.: *Per M.G.L: c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic, No, OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby, waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ OK .Ss,az �,1 ex y.af,o1/Jy 14 f N I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 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): 1 JA v { 4 Address:_�%i`6,�,� City/State/Zip:Phone Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I e. ployees (full and/or part-time).* 2. I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. I These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other_t '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. 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. #: Job Site Address Expiration Date: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and 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 #: