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This certifies that ...1., C.
.
has permission for ga4ins allation .............
in the buildin s of .. h+ rjs ..........................
at ...... .! ..,5. e.tl--� v\ P, ,�, c.� .... , No h Andov -,Mass.
Fee A,5 .. Lic. No..7_G3A.%. M ... .
GASINSPECTOR
Check #
8400
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY _ r�- , _ . I MA DATE & PERMIT #
.. F-.
JOBSITE ADDRESS _ J- •�►. -' f.J T_ OWNER'S NAME U U�,l (Q•-� �.
GOWNER
_.. ,.,_..-_�__
ADDRESS TEL[: _ r�_�FAx
TYPE OR
PRINT
OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL RESIDENTIAL
CLEARLY
NEW: E1 RENOVATION: F REPLACEMENT: F--j' PLANS SUBMITTED: YES 0-( NO D
APPLIANCES Z FLOORS- BSM 1 2 3 4 5
6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE �? ._ I �.,..�
DIRECT VENT HEATER
DRYER -T I - L- I�.m1 I._.:.I
FIREPLACE
FRYOLATOR _J
FURNACE
GENERATOR
GRILLE=-
INFRARED HEATER
LABORATORY COCKS_
�.
MAKEUP AIR UNIT _ _ ![[--I . __._ I r _.. � _. h_ . (� —� .- .JI --_--_I
OVEN(-_-
POOL HEATER —j J -1 n (—m- _ _ I _=1 T- - LY._
ROOM / SPACE HEATER
ROOF TOP UNIT _.
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER _
__ _ J
--_.. v--- -. -.- -'-- - - -- --- -_ -- - _ -� -
INSURANCE COVERAGE
have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch.142 YES _�NOD__I.
1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY _ OTHER TYPE INDEMNITY E] BOND 7
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 ED] AGENTE]
SIGNATURE OF OWNER OR AGENT
1 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 complia , ' - U Pertine9t'provision of the
Massachusetts State Plumbing Code and Chapter 142 the General Laws. r
of
PLUMBER-GASFITTER NAME /� �, ,,., LICENSE # " _ SIGNATURE
MP ED MGF A JP [ . F[] LPGI E] CORPORATION Q# j PARTNERSHIP ��](, #= LLC [j-1 #F8'%�
COMPANY NAME:[—
AME: ADDRESS
CITYSTATE ZIP �J/ TEL
FAX CELL -EMAIL
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
kvi. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/OrganizaVon/lidividual):
Address: / ri (10^11, �C
City/State/Zip:�OPhone #: �1 )�� �')d"d
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
e oyees (full and/or part-time).*
have hired the sub -contractors
2. I am a sole proprietor or partner-
listed on the attached sheet. $
ship and have no employees
These sub -contractors have
working for mein any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I 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'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
I I.�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.
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:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address:—
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
Df 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.
1 do hereby certify undertains and penalti of perjury that the information provided above is true and correct.
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
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass,gov/dia
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Date...... ...
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that . .
has permission for gas in
in the buil fngs of : ! e/
at4.-6r . �....
Fee�6't� . Lic. No.`,/J33
' ISl
G�heck #
li�36
IIG110,1, 20
stallation �.J��.:-J ..........
�:1..... ......... .
North Andover, Mass.
GAS INSPECTOR
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IASSACHUSETTS; UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or ''Type)
- 4-4 ` , Mass. Date Zr j Permit
BuildingLo
do vers Nam
1
r Type of Occupanry�l
New ❑ Renovation ❑
Plans Submitted: Yes[] No ❑
Installing Company Name . - 0 Check one: Certificate
Address7 COA C M ,h A, j L l ❑ Corporation
F 7 H U a✓ fj Al A � j! ?q ❑ Partnership
Business Telephone_ &92 -(7 (7-7 f 2-firm/co.
Name of Licensed Plumber or Gas Fitter AQ & f` T � . 5 A m m t9 Tr4 r
INSURANCE COVERAGE:
I have a curregnt I}'abiifty insurance poifcy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes her No ❑
If you have checked Yes, please indicate the type coverage by checking the appropriate box
A liability insurance policy '
Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner❑ Agent ❑
1 hereby certify that all of the details and information I have submitted (or entered) in above
knowledge and that all plumbing work and installations performed under the application are true and accurate to the best of my
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 Ofphure
for this application be in compliance with all
Laws.
vy
T of License:
Plumber
Title tter n u _ or fitter
d&(-'eBo
myman License Number V3�___
Y
■■■■■■■■■■■■■■■■■■■�■■■■■i
'
■■■■■■■■■■■■■■■■■■■■■■■■■i
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Rol
..
■■■■■■■■■■■■■■■■■MIKE
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■■■■■■■■■■■■■■■■■■■■■■■■■I
WAAANT..
■■■■■■■■■■■■■■■■■■■■■■■■■I
Installing Company Name . - 0 Check one: Certificate
Address7 COA C M ,h A, j L l ❑ Corporation
F 7 H U a✓ fj Al A � j! ?q ❑ Partnership
Business Telephone_ &92 -(7 (7-7 f 2-firm/co.
Name of Licensed Plumber or Gas Fitter AQ & f` T � . 5 A m m t9 Tr4 r
INSURANCE COVERAGE:
I have a curregnt I}'abiifty insurance poifcy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes her No ❑
If you have checked Yes, please indicate the type coverage by checking the appropriate box
A liability insurance policy '
Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner❑ Agent ❑
1 hereby certify that all of the details and information I have submitted (or entered) in above
knowledge and that all plumbing work and installations performed under the application are true and accurate to the best of my
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 Ofphure
for this application be in compliance with all
Laws.
vy
T of License:
Plumber
Title tter n u _ or fitter
d&(-'eBo
myman License Number V3�___
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10316
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Date,Cf. .2..:.' �....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that f ✓ '' r / c X , �;
has permission to performK.
...�..... .................................................
,I� rr
wiring in the b ilding of .....
P�. .f'..t !�
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at .tip...... Z 5... ( ................................. . North AndSver,
Fee ..3 S .... Lic. No.72v .. 'ry... Y
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EucmiCAL R
Check # U
N, Commonwealth of Massachusetts
m Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. TG3 Z (J
Occupancy and Fee Checked
[Rev. 1/07] (leave blank
i APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEP, 527 C R 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:Cl
City or Town of: NORTH ANDOVER To the Inspe or oj'ires:
By this application the undersigned gives noif his or her intention to perform the electrical work described below.
Location (Street & Number) dat"Ce-
r j.-`CrL g -o rs
Owner or Tenant
Owner's Address
Telephone No.
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
Lo ation and Nature of Proposed
lr 0 -
Completion of the ollowing table may be waived by the In ector 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
No. of Luminaires
Swimming Pool Above In-
rnd. [Irnd. ❑
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
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
Heat Pump
Totals:
I.Npp4er
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
Heaters KW
No. of No. of
Si ns Ballasts
Data Wiring:
No. of No. or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
``��.1v Attach additional detail if desired, or as required by the Inspector of Wires.
Es�mated Value of ctric 1 Work: V (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE VE G : 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 pain a d penalties o perjury, that the information on this application is true and complete.
FIRM NAME: LIC. NO.: cJ
Licensee: Signature LIC. NO.:
(If applicable, enter " e " iryth license umber a e.) —Bus. Tel. No.•� 4/7- LiQ�
Address: rd u w 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
Owner/Agent
Signature Telephone No. PERMIT FEE: $
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibl,
Name (Business/Organization/Individual):
Address:
City/State/Zip:
-6\2 L
ff Phone #: �r— 4�2 - �IM 6,
Are you an employer? Check the appropriate box:
1.CS-I am a employer with 2,
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. +
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. ❑ I 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'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. El 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.
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:
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.
Sienature: Date:
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
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