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HomeMy WebLinkAboutMiscellaneous - 25 MATHEWS WAY 4/30/2018E Date ........................ � # (.1 ....................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �n �his certifies that ..................................................... .......... has perinission for gas installation .......- *.�^-:. ....... in the buildin s o ...... .�i�... � �.......:......................... U.I. :............................ at ...... !� ..................:............... `........................................ North Andover, Mass. Fee....t0C.... .... Lic. No........................... ..................................................................... GASINSPECTOR Check # 9, 1 , 10252 �(Y r�jj MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 11, CITY AQaV A16, MA DATE2��-/-SJP ERMIT# - JOBSITE ADDRESS !IOWNER'SNAME r se-Irre !:'r L 41�. GOWNER ADDRESS TE ]FAXI TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL E] RESIDENTIAL CLEARLY NEW: d RENOVATION: D REPLACEMENT: PLANS SUBMITTED: YES D NORJ APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER L::J '= BOOSTER CONVERSION BURNER COOK STOVEA -- _j I DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR I FURNACE GENERATOR A L LALLD-1— L:AL�JLrJL�L�E.11 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ED ED =1 J= —j ROOM /SPACE HEATER ROOFTOP UNIT__ L—j L--- L TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER . . . . . . .. . .............. ...... ... ..... . ...... .. .... .... ... . ... .... . ..... INSURANCE COVERAGE I haqe a current liabilit y insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES JE] NO El ,d I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ' OTHER TYPE INDEMNITY [] BOND Ell 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 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 c m I nce with Pertinent pr vision f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME fem o'cid e ICENSE# SIGNATURE IVIP ZGF 0 JP JGF LPGI CORPORATION []# PARTNERSHIP E]#= LLC E]# COMPANY NAME: ADDRESS at CITY STATE ZIP TEL Co 83 3 Rte. 7 /k V FAX CCS The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 =: F Boston, MA 02114-2017 www.mass.gov/dia d'M SJ. Y9 Wolkere Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers. FILED vffTTY THE PERMITTING AUTHORITY. TO BE Please Print Le 'bl A ' licant Information Name (Business/Oiganization/Individual): oud it to OA! Qt Address: ) c L j '� l2 l City/State/Zip: e r7Z W A)/1 Whone #: Are you an employer? Check the approprlafe box: If] [] I am a employer with employees (full and/or part-time).* 2. W am a sole proprietor or partnership and have no employees Working for me m any capacity. [No workers' comp. insurance required.] 3.Q I am a homeowner doing all workmysel£ [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 proprietors with no employees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6.0 We are a corporation and its'office rshave exercised their right of exemption per MGL c. 152 § 1(4), and'we have no employees. [No workers' comp. insurance required.] i,9-,) Type of project (required): 7. [] NeVd0"nstruct1on 8. kemodeliiig 9. ❑ Demolition 10 ❑ Building addition 11.[] Electrical Tppairs or additions 12. pptm- bing repairs or additions 131] Ro6£repairs 14.n Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this,affdavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and state whether or not (hose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providingworkers' compensation insurance for my employees. Below is the policy and jolt site information. Insurance Company Name: ' Expiration Date: Policy # or Self -ins. Lic. #: ���� � C� City/State/zip:'� Job Site Address: 2 the workers' compensation policy decl ation page (showing the policy number and expiration date). Attach atopy of Failure to secure the workers' rage ars required under MGL c.152, §25A is a criminal violation punishable by a fnib 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. Ido hereby cer%/y,/. under the p ' and /nena/ll ttJies of perj/u/]ry that the information provided above is^true and cojrr�ec�t. Z10 J A4 J'� _ Y A T�AfP.' / CSS (. J ' official use only. Do not write in this area, to he completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: r 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 receivef 6r, 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 xequiired:' 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 numbers) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. 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' compensatioii 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 luvestigations 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 thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "fob 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 idled 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-MASS.AFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia F 11444 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This ,certifies that .W.. 6e- ..... ... ...... . .... ... has permission to perform ....... ....... ....................... plumbing in the bui dings of......................................................................... . . ............ .... North Andover, Mass. ....... I ...... ........... .—) ........................................... No at ...... FeAd.W .... Lic. No. vvib.6 .. .................................................................................. Chec'N12 PLUMBING INSPECTOR k# — 000 144-5 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY D_ 6'° �� _ 1 MA DATE f® G `� / PERMIT V. JOBSITE ADDRESS o2 �- eIj-c z !A'41 OWNER'S NAME OWNER ADDRESS TE ,� d D 1 ��FAX —1 TYPE OR OCCUPANCY TYPE COMMERCIAL ED EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY �/ NEW: I:✓J RENOVATION: REPLACEMENT: Q PLANS SUBMITTED: YES Ell NO[: FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM �1 _..__. _! _-__._! DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _ f ..___._1 -.-. i .I _ _.__i _ l _.__._� __-...__i FOOD DISPOSER FLOOR/AREADRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK I_ .. _J _^ __f _...__._1 _.__� __._.__..i _.__i .__..__I ____ ---j LAVATORY.._.._J ROOF DRAINff-2 SHOWER STALLSERVICE/MOP SINKTOILET (.._, _ __.6 ___.-- J _.-_ __—..1 __--__I _ _-_ iURINAL i ( i ___1 __.-___i __..._.� __.-- _.-_...._I .._..__1 ___. WASHING MACHINE CONNECTION I 1 I .______.; 4 ._-______J _ __ _- ._ .-� WATER HEATER ALL TYPES WATERPIHVG OTHER _ -I COC V ; INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ..-_ NO IF YOU CHECKED YES, PLEASE INDICAT7TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICOTHER TYPE OF INDEMNITY DI BOND Q OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q • AGENT 10 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in pliance wit ertinent rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBE 'S NAME �Yt� c_ ENSE # //.5� i SIGNATURE MP JP CORPORATION �J # =PARTNERSHIP __i # s LLC COMPANY NAME��?t�. / L ���%� ADDRESS CITY P�-Z _..___.. _ _... I STATES �I ZIP i 0.�� —fl TEL (vjs 3 t�z 2 FAX CE 76S'/s?._.�MAIL L o El z N ❑ } w W LL Date ...... ............ TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that .................. ........ A-6 . . ............................................................. has permission to perform ........... o A ........................................................... .. . "*wiring nthe building .......... .......... ..................."................. at . .......... q , Andover, dover, Mass. . ........... Lic. No . . ...................................... Fee to 7 ............................................ ELECTRICAL INSPECTOR Check # 1278.9-/ Official Use Only Commonwealth of Massachusetts Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: /,0) -Z,1 / 5" - City or Town of: NORTH ANDOVER To the Inspectorf Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 2 � -�'7 ,r��} t�� <, Owner or Tenant 7,fEK;5L9I FQA J � j U C, Telephone No. Owner's Address 7� — j e 00 - Is ` 0 -Is this permit in conjunction with a building permit? Yes ❑'*'- No ❑ (Check Appropriate Box) Purpose of Building 5 t(�) A -C__ Utility Authorization No. - Existing Service aAmps / Volts New Service 7,00 Amps f �,y / �ycYolts Number of Feeders and Ampacity Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd No. of Meters Number --- Location and Nature of Proposed EIectrical Work: Completion ofthe following table may be waived by the Insvector of Wires. No. of Recessed Luminaires No. of Cell: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. grnd. o. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons KW ".......... ........... No. of Self -Contained 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 RW 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 Electr'cal Work: 1 ; dT �, `�3 (When required by municipal policy.) Work to Start: p 2j 1 In to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such covera is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) X certify, under the sins and penalties ofperury, that the information on this application is true and complete. FIRM NAME: , t1, L �i A-�_ LIC. NO.: t ' Licensee: i ignature LIC. NO.: 62-7 �VD-S:— AA (If applicable, ter "exempt" in the license number lin Bus. Tel. No.:-3Z—Z Address: � a , S -Ox �Sb(,7— 1—.4� cJ I�ze-t—t„e-t el ©! F- 3 Alt. Tel. No.: C, 37 i-' r6z-� *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 PERMIT FEE: ,$ � 1Z Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the .tl permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the ' notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall be limited as to the time of ongoing construction activity, and may be -deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Ins ction Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M ;✓ Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: ; G Date: i S' PARTIAL ROUGH INSPECTION: Pass F?] Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INS TION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSP TION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: i it/ l e)& Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com ne Commonwealth of Massachusetts _ Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia ' SRM 5J1"l Woi:kers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY - Name, (Business/Oigatizaiion/Tndividual): Address: City/State/Zip: Are yon an employer? Check Elie appropriate box: Phone #: 1.[] I am a employer with___... employees (frill and/or part-time)'* 2.I] I am a sole proprietor or partnership and have no employees working for me in any capacity. (No workers' comp. insurance required.] 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 proprietors with no employees. 5. ❑I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 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. 152 61(4), and We have no employees: [No workers' comp. insurance required.] Type of project (vequired): 7. ❑ Nevtw'constructlon 8. ❑ Remodeling 9. ❑ Demolition 10 [] Building addition 11.❑ Electrical repairs or additions 12 Q.Plumbing repairs or additions 13•. [] Ro6f repairs 14. Other *Any applicant that checks box #] must also fill out the section below showing their workers' compensation policy information. ers who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such IContractorHomeownmeown that check this box mu- .attached an additional sheet showing the name of the sub -contractors and state whether t or nothose,entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. ' compensation insurance for° my employees. Below is the policy and job site X am an employer that is providingworkers information. Insurance Company 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 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 AIA for insurance coverage verification. X do hereby certify under' thepains and penalties ofperjury that the information provided above is true and, correct. Date: Signature: Official use only. Do not write in this area, to be completed by city or town officiax City or Town: permit/License # issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone Contact Person: 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 deffiied as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enferprise, 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 b6 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 iequfred." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political sub"divisions 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 Pleasb fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub contractors) name(s), address(es) and phone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial -Accidents. Should you have any questions regarding the law or if you are required to obtain a wvorkers' 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 "fob 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 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-NMSSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia Date.....t.�.i TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies tha�t,.,M.,Z ....................................... has permission for gas installation V.-?..?.-*��. in the buildings of ... .. C.—- ............................... at ...... 7..�'�........ �. '� � r..........., North Andover, Mass. Fee .... UQ�...... Lic. No. � .?. ..... ..................................................................... GASINSPECTOR Check # 1, 102b1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY A,10 - ;VAI CCO le- MA DATE Ji4 PERMIT #A V�l lT JOBSITE ADDRESS T_tc-Is OWNER'S NAME OWNER ADDRESS - TEI�FAXf TYPE OR PST EDUCATIONAL OCCUPANCYTYPE COMMERCIAL [ D] RESIDENTIAL CLEARLY NEW: LTJ RENOVATION: E] REPLACEMENT: ® PLANS SUBMITTED: YES F NO F 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/ SPACE HEATER ROOFTOP UNIT�— TEST UNIT HEATER UNVENTED ROOM HEATER j WATER HEATER 0 L, --- -- —111-- - I - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E OTHER TYPE INDEMNITY ® BOND F 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 nI 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 comp . ce with a ertinent pr"on 'on oft e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME ICENSE# //3_ SIGNATURE MP EO"/MGF EjI JP D JGF [ LPGI F] CORPORATION E]# = PARTNERSHIP 0#= LLC E -j]# COMPANY NAME] metre` cO��L�i- ADDRESS /� 2 i�IG6Lt1 �2e1 -----� -�� — - -- ---.II +=- �--- CITY ���,�' atJ STATEZIP TEL C�ls3 3��79� FAX EMAIL H O z H U W w z O N� W O w O E� a 4 z w 5 W a a W U)R� w O � w w w to a 0 a con w a 5 U J F, a CL a s w 1— LL cn H Oz 0 H U W W Lin C7 The Commonwealth of Massachusetts .Department of jndustrialACcidents I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia ODM sV1Vl Workers' Compensationxnsurance Affidavit: Builders/Contxactors/Electricians/Plumbers. TO BE FILED WITH THE PERMCTtVG AUTHORITY. A Jucani lturvx aua....,.x Name (Business/(jrgariization/Individual): Address: % -Z L % Iel "1`4/ lz C" City/State/Zip:- Are you an employer? the appropriate box: 1. F] I am a employer with employees (fill and/or part-time)'* 2. W, a sole proprietor or partnership and have no employees Working for me in any capacity. jNoworkers, comp_ insurance required.] 3.L] 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 proprietors with no. employees. S.❑ I am a general contractor. and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance # 6. Q We are a corporation and its, off cern have exercised their right of exemption per MGL c. 152 § 1(4), and'we have no empldy4s. [No workers' comp. insurance required.] Type of project (tegdired) 7. ❑ N6Vd6nstr66tion 8. [] R.emodeliiig 9. ❑ Demolition 10 ❑ Building addition 11.[] Elec4ical repaixs or additions j2. ,y Lambing repairs or additions 11 [] Roof repairs 14.[] Other *Any applicant that checks box#1 must also fill. out the section below showing their workers' compensation policy information: 1 Homeowners who submit•this af$davrt indicating they are doing all work and then hire outside contractors must submit a new afffdavit indicating such tContractors that check ibis box must attached an additional sheet showing the name of the sub -contractors and state whether or pot those entities, have employees. If the sub contractors have employees, they must provide their workers' comp. policy number. X am an employer that is providingworkers' compensation insurancefor my employees. Below is the policy and job site information. Insurance Company Name: Expiration Date. Policy # or Self -ins. Lic. #: City/State/Zip: lob Site Address: 1ST Attach a copy of the workers' compensation policy declaration page bowing the policy number and expiration date). s a criminal violation punishable by a foie up to Failure to secure coverage as required under MGL c.152, §25A iand a fine of up o $25 0.00 0 a and/or one-year imprisonment, as well as civil penalties in the formrof a d to the Office e O K Oe RDERdtins of the DIA for insurance day against the violator. A copy of this statement may b fo coverage verification. X do Hereby c/e/r under the p an/d�/T ena//lJ/tJ�ies ofperjury that the information provided Jabq�ave is trope and co(r�relct. F' a Official use only. Do not write in this area, to he completed by city or town officiaL City or Town: Permit/License ## Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3.. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone #: Contact Person: • cc I �w 11445 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING te ............. This certifies that... . .. .... ............. has permission to perforM�3&1-� ...... ... ) 0 .. . ... .................................................... plumbing in the buildings of .... zu .... ... at .../�� ........... .............. North Andover, Mass. Feei' ................ ........................................................ ' g;�&.. Lic. No. ...... ........ 2D60 - PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY , �!�.__ MA DATEla` 1 PERMIT # �I l JOBSITE ADDRESS o"?�%�i �.u.! s OfWNER'SNAME- c? U S POWNER ADDRESS TEL V7 3640-11 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: D PLANS SUBMITTED: YES 0 NO,�.`s. FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB = =>_( ===== I _._ ==== _ .4 i CROSS CONNECTION DEVICE _ _(__,_, # = = -_._. __: = = _j = = ___ I = = DEDICATED SPECIAL WASTE SYSTEM= _ (__ _) .._.__ 6 .__ ...1 = _.._._.) __ _ J===== DEDICATED GASIOILISAND SYSTEM ,_._l -�� __._-.1( _. DEDICATED GREASE SYSTEM ( _,..__ ___f __ (.___._..1' - ___._( ___! _( .__..._._f I —[ _ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHERJ ____j DRINKING FOUNTAIN _ I l -----i I ( 1 ._..__.__) I � .__..__) � __.._j .___.J ._.__j FOOD DISPOSER —..i FLOOR/AREA DRAIN _.___..__I INTERCEPTOR (INTERIOR) KITCHEN SINK i .. I w_J ! � __.'__.I l ! { -------I ._1 -- ------ _I ____j LAVATORY _I. _ tJ 1 _ ROOF DRAIN 1 1 --___I ._—B _ _1 SHOWER STALL SERVICE /MOP SINK _ ___l ._.___._I ___._{ ___ (_.. s ._.___I ._.__,J _.-_.,-j TOILET ) .._ _ _ ( i .1 _._. URINAL WASHING MACHINE CONNECTION J _ _.___ � .___... J f ! - .___.1 __Y 1 __ WATER HEATER ALL TYPES ( I —1= WA ER PIPING INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES --. NO _! IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Q BOND 0 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 Ej 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 pliance wi II Pertinen rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Q PLUMBER'S NAME Jdl�c@�1�.��cl�LICENSE # SIGNATURE -_ iVIP JP Q CORPORATION #PARTNERSHIP_(# _ ; LLC _ _.II COMPANY NAME �, �2v %�L ®ar ' I ADDRESS C ANX_I l CITY -7-6 _ STATE �/ ZIP �s TEL FAX CEL4 3�MAIL o rl z N ❑ } iui w LL