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HomeMy WebLinkAboutMiscellaneous - 25 HIGHLAND VIEW AVENUE 4/30/2018^~ - ---_'Dlo - '~| � -'-U4Ah;- H This certifies that J v.... .......sh c sk R has permission for gas installation .'I. r-,' A� 1.� ' `�' ..e., 1 in the buildings of P�'^`. �� '`: V-0 ................. • . at ..Z r�.--i 1� .-:'A-; �Q V! ?..x..61 ... • . , North An ov r, Mass. Fee �--�v: . Lic. NoT X. . 0C)..... ... . GASINSPECTOR Check # ) � 013 3360 Mfi G TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I NORTH ANDOVER I MA DATE OCT. 5, 2012 PERMIT # JOBSITE ADDRESS 25 HIGHLAND VIEW AVE. OWNER'S NAME TOM HORUIKO TARA LEIGH DEV. OWNER ADDRESS TOM KAHORUIKO TARA LEIGH DEV. TE 978-687-2635 FAX OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL NEW: [j RENOVATION: ❑ REPLACEMENT: APPLIANCES -1 FLOORS BSM 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 ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSTALL AN UNDE NECT TO A RESIDENTIAL El PLANS SUBMITTED: YES® N0[] MM0® w INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES E] NO 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY F1 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER [I 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 ir,Lcompltance with all Perlja�nyprgwsion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1 \ J /'1 / )/ / PLUMBER-GASFITTER NAME JOHN MARSHALL LICENSE # 778 SIGNATURE MP ® MGF JP ® JGF LPGI CORPORATION JPARTNERSHIP EI# LLC ®# COMPANY NAME: EASTERN PROPANE GAS ADDRESS 1131 WATER ST. CITY 12ANVERS I STATE MA ZIP 01923 TEL 800 322-6628 FAX CELL EMAIL c ant= ---.o UT! Tize Commonwealth of lllassachusezzs - Department of IrirZustriril Accidents Office of I nvesi'o aiions 1 Congress Street Suite 100 Bosion; AL4 02114-2017 h; www- ovidin 3L A c (-mmi3pingi1..U.ElL tiraDCC '-fflda i � er /�p_�,� �r;nrs,rF icians/l'lumbors Z��lica�L�on FT Drip , ; NGrl t Business/Jro-2ni72TioYnQivicival�: `P -S i ERN PROPANE &, OIL _Address City/Stag/ 15IV�-TERJTPEElI DANV=p.S, kJ , U 1025 Phone n: 978-75D-6600 Are you an employer" Checl: the appropriate boy: 1. ❑ l aLn a employer witl 4J 4. ❑ .l..am..a general contracto- and I emplo} ees (lull and/or pan-Lirnej." have hired the sut-conractors 2. D I am z sole proprietor or partner- Listed on the attached sheet. ship and have no employees These sub -contractors have employees and have workers' wonting for me in any capacity PNo workers' comp. insurance comp. insurance. - F G co oration d its o . ❑ W art a rp ; 3.� required. ] I am a nomeoumer doing al] wort: omcers have exercised their right of enemptlon per MGL myself. [No workers' comp. 1(,4 ), and wee have no insurance required.] t employees. [No workers' comp. irstaance required.] Type of project (required) 6. ❑ hl ew corsIIucv on 7. ❑] F,=odeiing S. ❑ Demolition . 9. ❑ Builaing addition U.❑ Electrical repairs or addition` 1 l.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. 271 Other GAS FFITING Any apnliazmr thAt ah -- s boy: rl —s, also a. oL*tthe secs= below' showing tam wofl= camoensanon policy in�on. Homeowl= who san this amdavit Md3i, tai tt1.'y are roma all wort and then hire o?usicL c r� *� miss submit a n -w a�davi? mbicarm� such. Comrac�or� that sect ins bot. IIIIS aBa=lied ar aciainonai slim_ shouting the =time of the. sVt-const. t= and smit "��= or not fnose C31=5 aave mpioyms. L th sub Gonna toy aave emnloym�, the} mnsL provide the workers' conn. poiic} nuni am an Enployer thZ Ls rovid *q- worl`ers' compensation insurance for 77U employees. below is Jz°p°Li-' and job si±- rzforrnaaon. assurance Company Name: LIBERTY M LTi UAL INSURANCE CDMP.ANY 'obey ;� or Seli-ins. Lic. #: WC7-6,41-4C5806-052 Et piration Date: 03/15/2D13 ob Site Address: City/State/Zip:�()014k ✓ti►S . (� 18 S ittach a cop} of the workers' compensation policy declaration page (showin.n the polio' n1:mber and expiration date). 'ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties ao.a lase up to 51,500.00 and/or ons -yea imprso_nznent zs well as civil penalties in the fozzri of a STOP WOF�Y OF.DER and a fine ,f up to 1250.00 a day atrainst the violator_ Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certifi- under the pains and penalties ojperiun- that the information provided above is true and corr:!�ct. 03/13/2013 978-75D-6500 Gffcial use only. Do not writ in Ibis area; to be completed by citj or Torun official Citi- or Town: Permit`License ------- -�-P�1�IlihinR �5 t: tUi 6. Other Phone -: "(-nntanr-P—Cnn- Ji 1 IN m L z = nO < = Z m -D m D �r •' U ;o t77 -nMC • O (n D rn m.�' Z m A 3 .. —I M U)> M ri (n Ln T U) U) = m D D -V A v 2 Ul m r c ZZ . m r < rD O D G3 D ~D X, o z D Cn U) m cn-n U) � D cf.) m = r iT.J. C Dom: U) IN r 171 m ' Signature 991 Date 3 �? '�'.�•:�+ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING -s , U" This certifies that.. l.' . . !4-7e.J,.Q. f:. has permission to perform ...Y.�C�t ................ plumbing in the buildings of ..�. �.Q.- ) ..L� -.0 .............."• . . at....�-�A. A...4�PL ,N ndo Mass. Fee . t �.. Lic. No. '1�0. . UMBING IN ECTOR Check p Imo- I I' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITYaTYE411 MA DATE PERMIT # JOBSITE ADDRESS ; vW 6' OWNER'S NAME, POWNER ADDRESS _ —ij TEL[__ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL D RESIDENTIAL PRINT CLEARLY NEW: E6ENOVATION: ® REPLACEMENT: El PLANS SUBMITTED: YES�]I NO 01 FIXTURES 7 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/OILISANDSYSTEM (_._._....._f __._► _._....__.I ._ ...._.._ __..J DEDICATED GREASE SYSTEM ...... _ DEDICATED GRAY WATER SYSTEM I ___I --I ( 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 �0 EI IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ef OTHER TYPE OF INDEMNITY © BOND I 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER [D AGENT JE E 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 4 Pertinent pr ov sj Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f� PLUMBER'S NAME r LICENSE.v' MP &�/ JP CORPORATION ©# #= PARTNERSHIP PARTNERSHIP (j# LLC U COMPANY NAME fi ADDRESS Ain CITY Q STATEZIP ¢ �— - I � � _Q__T___._ 91 TEL FAX �� CELL �J MAIL H O z z � o a, W a w t zz e o� z Olz F v1 ;D w O W °- tph z LU W F- W 5 o a WLU o L LU U) p z a a W Q U J a IL CO w EE w F- w F O z z 0 H U W a conz z a cx7 0 a ' 0 1.0 The Commonwealth of Massachusetts Department of IndustrialAccidints 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 Legibly Name (Business/Organization/Individual): Address: City/State/Zip; Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors 2. El 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. El We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3111 am a homeowner doing all work right of exemption per MGL ME] Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑Roofrepairs insurance required.] t employees. [No workers' 13.[J 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 aie 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. Lie. #: 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 DTA- for insurance coverage verification. I do hereby certlo under the pains andpenalties ofperjury that the information provided above is true and correct. Sip -nature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person Phone Information and 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 ou 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 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, 42111 Tel. # 617-727-4900 ext 406 or 1-877, MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.lnass,gov/dia Date.�.1�Z .... t TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that hasermission for gas installation.. p L L in the buildings of�. a......... ................... . at ...7.6 . t�, ?r� �. V �.... rth Idover, Fee.��??.... Lic. No. �5 t T. �... . GAS INSPECTOR Check# Vi --o 8255 G TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY /��--�(,o t,:�� MA DATEPERMIT # JOBSITE ADDRESS A.OWNER'S NAME OWNER ADDRESS ITE OCCUPANCY TYPE COMMERCIAL r�_ ) EDUCATIONAL NEW: 01'�RENOVATION: 0 REPLACEMENT: Fj RESIDENTIAL PLANS SUBMITTED: YES -1 NO Q FLOORS - —Wt FE- r n 1r iii�Fi—ir--Fr— i 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 ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch.142 YES JZ'NO 0 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY UZI," OTHER TYPE INDEMNITY 0 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 0-1 AGENT[-�_.I[ 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 Pertinent provi 'o o Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM NAME LICENSE # SIGNATU E - _� ---- j MP JP F I JGF LPGI � CORPORATION 0# L� !I PARTNERSHIP D#= LLC [# COMPANY NAME: ADDRESS CITY STATE [WZIP Q C:]TELEr O_CA��j'_ �4 FAX __ = CELL a .S_ AIL O z 0 H U a I w � z a W � � W OF a Z w � W � � 3 ~ W w 5 acn a O w w w Q co o a a a U k$y+ J F a a a � co w x w F- LL W F °z F U cr � a � C�7 O 1. • Y The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations UV 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Naive (Business/Organization/Individual): Address: 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 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. ❑ 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 ace 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 Policy # or Self -ins. Lic. #: Expiration Date; Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer -is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit 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 bum 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 oxt 406 or 1-877rMASSA.FB Revised 5-26-05 Fax # 617-727-•7749 vvwwanass.gov/dia Date ..... �— 7- 7 — / Z- ....................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....................... has permission to perform .... wiring in the building of .......... 7774,.1).........Z -Z. .c . .................................... at .... orth Andover, Mass. o Fee. Lic. No. M.Ml.b ............... — W.-.2 �A s E� EL ICTRICAL INS E R Check # 10809 I Commonwealth of Massachusetts Official Use Only Permit No. logo Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Lt 17,-2 City or Town of: NORTH ANDOVER To the Insp ctor of Wires: By this application the undersigned gives,.notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant L\ Owner's Address I/ Telephone No. bY7_ Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check A ropr'ate Box TGE, .� 17 8,3075 Purpose of Building j S ���w1�4-t-- Utility Authorization No.�� 1 Zg' z3) t c) - Existing Service Amps / Volts New Service Amps l Zd "?Volts Number of Feeders and Ampacity Overhead ❑ Undgrd ❑ No. of Meters Overhead D------Undgrd ❑ No. of Meters Location and Nature of Proposed Electrical Work: `Tj�p S!= h ✓ct� (,� t t,� Lt-0%/SC— Com letion of the followin table may be waived by the In ector of Wires. No. of Recessed Luminaires to No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets 1,0 No. of Hot Tubs Generators KVA No. of Luminaires to Swimming Pool Above ❑In- Elo. rnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets g No. of Oil Burners FIRE ALARMSNo. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges t No. of Air Cond. TonTots -1 No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained No, of Waste Disposers p Totals: ............ Detection/AlertingDevices No. of Dishwashers � S ace/Area Heating KW p g Local ❑ Municipal ❑Other Connection No. of Dryers Y Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: 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 gif Electrical Work: 7 moo" (When required by municipal policy.) Work to Start: �-L- Z. Inspe tions to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such covera e is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE E] BOND ❑ OTHER ❑ (Specify:) I certify, tinder thepains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME:. 1B %tLAIA c— 6;6.aff�- G--"r-ce LIC. NO.;,4�CIJL Licensee: Signature LIC. NO.: 6 7-*> b0 (If applicable, enler "exempt" in the lic nse number line.) Bus. Tel. No.: 31f 7-- Address: Y�u� 6� �' Alt. Tel. No.: &-t *Per M.G.L c. 147, s. 57-61, s urity 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. $ Signature Telephone No. . X'�sset�-^ �+'aiieK��' J �e-�speetzoz� x'equzxeri•(��'O.OQ) � � � �as,pectoxs' eopmxe�fs: - (xnspectoxsy rigaAme V40 iiiaYs) - Pate .'TN'l�T'C�CION; - ]?asse +aflec -,r e,Xnspectiox�xecXtxixe ($ 0.00)- [ �tt5�eci• S' c enfs: . . (Xns iectoxs° `ignature •-) o Wfiais) i Date 3, UNDER.GRODM E$g'E•CTXON. Passed-[ � �aziec�--[ � Xte-fnspeeiio�xec�uixe[�(��O.UO)�[ ] Xnspctoxs' comments: . [lnspectoxs�,�ignafuze- �o?iifas) ]ate fT' (.ixtspeetoxs',�igaatuxe��zo jnifzals? v.- ,� � rr / ' safe - — •� �s—ed .-.0 I X+'aiier���' ].'?�e�nspecizoxtxequixec�($50.00)[ � - pectoxs' co�tzacafs: - OR TAGS AM TO DYOMLED Q'UTAO XXFT OXINITE N .APM TO BE INSPEffED XS NOT CX The Commonwealth oflMassachusetts - Department oflndustriglAccidents Office oflnvestigations quo 600 Washington Street Boston, .MA 02.111 www.massgovIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):Li�(J� C� r Address: City/State/Zip:_-��-�-�5� �,�.t P 0)3 ti Mono #: —O 51, 'Z -- 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 (full and/or part-time) * 2. ❑ 1 am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. x 7. ❑ Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working forme in any capacity. workers' comp. insurance,g, Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its ME] Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their 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' -131:1 Other comm insurance reauired.l "Any applicant that checks box#f must also fill out the section below showir7g their workers' compensation policy information. I Homeowners who submit this affidavit indicating they tie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name% Vk s>; ,U Policy # or S elf -ins. Lic. #: Expiration Date: Job Site Address. City/State/Zip:_. . A.��1�C .�-( � Attach a copy of the workers' compensation policy $eclaration 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cert! under the pains andpenalties ofpei jury that the information provided(above is true and correct. - Signature: 17ate. LfI 7 _-77) t Z—. 7 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. PIumbing Inspector 6, Other - - - Contact Person• Phone #: Information and instructions Massachusetts General Laws chapter X52 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,• express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) andphone 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. Han 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' compensationpolicy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant, Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current Policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year. 'Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license orpermit to burn leaves etc.) said person is NOT xequired to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: Tho Comm onwoalthOfMa Mp.a invent of Industrial ,Accidents ON'.e of Westigatim 6.00 Washington, Street Boston., MA. 02111 TO— # 617-727,4900 ort 406 or 1-877� ASSAFjj Revised 5-26-05 Fay ,# 617^727-7749 '�.znass,g4vfd:�a