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Miscellaneous - 26 DARTMOUTH STREET 4/30/2018 (3)
Vi ty c�7 Date.. 4 & ............... v TOWN OF NORTH ANDOVER PERMIT FOR WIRING l / (>l� ./ �1�D�/�� � 4,1, This certifies that!..? .......................1° ........................................................... 1 has permission to perform :,%...Jv �,U �� 2(5 (Ieed) �, f1f5 �AJ ..................................................................................... wiring in the building of ......... f'. �1...:`�"'................................................................... 2(,o ..................................................................................................... .North Andover, Mass. Fee........rx7� �....... Lic. No%3�°...............��V........... .......... ,..,.. --,7 ELECTRICAL INSPECTOR Check, 773 7 72, r�� �e ,� q6 /6 e• J )a\ Comutoaweat�!' o�!/%a�.�at�uavtls U¢ ! . .URparlmalrl o�.tirv.SR!'fnr.R� BOARD OF FiRE PREVENTION REGULATIONS kk �r Print Form Official Use Only i'ermit No. �m Occupancy and Fee Checked Rev- I/071 {liavc blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK %11 work to hr pesfornied in accordance with tilt: Mumachu%cill t:Iectsicul ('ode (MIX). 527 CMR 13.(10 iPLEASE PRJAY IN INK OR TYP ALL IAT-01111ATI0Nj Date:: /() r (0 -lq City or Town of: A)rj�-+ find6o{i To the Insperta r nJ'i41hv.v: -- By this apphc•:tuvn 111c mulct signed gives entice of his or herinte:ntioa to perl'unn lite electrical work described below. Location (Sireel 6c Number) 2 —PY-0— --01W44) S� Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Purpose of Building w/ Solar - PV Fitisting Service Amps / Volts New Service Amps / Volts Number of feeders and Anipacily Telephone No.D7 _20 - , / Z Yes n Nit U (Check Appropriate Box) V 11111ily Authorization No. nta Overhead L] Overhead Lj Undgrd ❑ tindgrd ❑ No. of Meters No. of Meters Location and nature of Proposed Electrical Work: Install Solar Electric - Photovoltaic (PV) system 17,7 panelsj rated(,,,, %_ C kW -DC @ S.T.C. Grid Tied. In conjunction with a Budding Permit. Conjollefiml f.t ll..• 9o1.1. ua.... /... .0-u.r.l lu. dr.. l.r......_d_..-..f'llt:..... _.�..... No. of Recessed Luminaires -- ------------- --• -" ------ No. of Geil.-Susp. (Paddle) Fans ....-.. ...... ... ....r., .. .. rr_.., ..... raa r[.r No. o otul Transformers KVA No. of Luminaire Outlets No. of [lot Tubs generators KVA No. of Luminaires Swimming Pool say r ❑ n- ❑ No. of Emergency -7, g ng Lornd. ernd. Ilallerl• Units I• IRF At %101-ls INil. of 7.one% •'rt -111 I)eteclioll and No. of Receptacle Outlets No. of Oil Burners No. of Switches No. of Cas Burners (nstiatingllrrire� ___ \u. ul Alt -Hite; Deice+ � _ b. avel - ontainrd DMecliati/Alerlilig No. of Ranges No. of Air Cond. .uta 'i'ons No. of Waste Disposers [eatPump- I 'unit) Pons 1" 'Totals: �� _ � 11mirm No. of Dishwashers Space/Ares ileatint; KW Local ❑ NltlMictltal I other Connection_ No. of Dryers heating Appliances KW Security ty a ystems:�� No. of Devices or Equivalent i, t�0 Heaters KWDam . 0. to �.. _. No. (of— ._.. Wiring: Signs Ballasts Nit. of 1leviccs or 1Juivalrnt No. Ilydromassage Balhlubs No. of Motors 'Total IIP a ecotnatu s catiuiis' Wiring: No. of Devices or H'uiv:aleul OTHER: :�:d '41ta h additional detail i/ thwirt.d. ar u.t t•t•ytli!•t'd 6r the hi,in•c•lrt!• .,J lyfrev. Iistimnled Value tri'Flectrical Work: 00-0- -- (When required by municipal policy.) Work to Start: A.S.A.P. Euspcctirnts to be requcrlcd in auorclance with MF 'limb 111, and spun rt+nlplcUnn INSURANCE (-( VERAGE: thiless a aived by the owner, no permit for the perkinnance of electrical wort, imly uukss the licensee pray ides pruul alt liablln}" itsstttaMcr including "%unlplctcd upcialitm- coverage or its substaimal equi%alc•m. 'I lic undersigned ctrl ilies that such coverage is iti force, and has exhibited prooful•satnc to lite permit issuing office. ('Fili('K ONE: iNSURANCE ❑✓ BOND ❑ I)TIIFi( ❑ (Sperify:) I rert0y. under lite pains and penalties ajpc rjury. float !be injaratatiou nn this application is trite and rainplete. FIRM NAME: SOLARCITY CORPORATION l.it'. N(1,; 1136 MR Licensee: Matthew T. Markham_- Signature Z'.W411 LiC. NO.; 1136 MR - (it rryrplirYoble. rata•#- -nempt - in the fivence #-!anther fiue'1 Bus. 'fel, No.: 774-258-8180 Address: 24 St. Martin Drive (Buitdinq 2/ Unit 11). Marlborough, MA. 01752 All. Tel. No.: 774-258-8505 "Per M.G.L. c. 147, s. 57-6I, security work requires Department of public Safety "S" Licensc: Lic. No. OWNER'S INSURANCE WAIVER: I ant aware that the Licesisec does not have the liability insutaoce coverage 11orntally required by law, lay lily signature below, I hereby waive this requirement. I ata the (check enc) ownc:r c►wnu's a ocnt. Owner/Agent Signature 'Telephone No. PrsRA1IT Fr: E: S��it—� YMrt of Consumer Affairs & Ileriness Regutrlion I ! IOME IMPROVEMENT CONTRACTOR , )' Rogrstrauon 168572 Type Expiration 31812015 Supplement SOLARCITY CORPORATION MATTHEW MARKHAM 24 ST MARTIN STREET BLb 2UN1 IUALBOROUGH, MA 01752 Undersrertlary 0MM0NWFALTH P"ASSpC1{USF1JS � , ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS A• REGISTERED MASTER ELECTRICIAN r SOLARC I TY CORPORATION °i`► MATTHEW T 14ARKHA14 &4 SAINT MARTIN OR BLDG 2 UNIT 11 MARLBOROUGH MA 01752-3060' j J .q 1 j J ' The Commonwealth of Massachusetts RA -6. i Department of Industrial Accidents Office of Investigations ' l I Congress Street, Suite 100 ' Boston, MA 02114-2017 * - ` www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Analicant Information _ Please Print Legibly Name (Business/Organization/Individual):_SOLARC[TY CORP Address: 3055 CLEARVIEW WAY • COMN MH 1 CL, kaf% tR14VA Phone #: o00 -r00 -440t! Are you an employer? Check the appropriate box: Type of project (required): I . © I am a employer with 5000 4. E]l am a general contractor and 1 6 El 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. 7. ❑ Remodeling ship and have no employees These sub -contractors have g, ❑ Demolition workingfor me in an capacity. Y9. employees and have workers' [�] Building addition [No workers' comp. insurance required.] comp, insurance.t 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑ hoof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' S 13.E Other OLAR ! _ LA PV comp. insurance required.] *Arty applicant that checks box #t must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside conlracxots must submit a new aMdavit indicating such. ,)Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. Al am an employer that is providing workers' compensation hisarance for my employees. Below is lite policy and job site information. Insurance Company Name:_LIBERTY MUTUAL INSURANCE COMPANY_— Policy tt or Self -ins. Lic. It: WA7-66D-066265-024 Fxpiration Date: 09/01/2015 Job 5itc Address:_ Q, )+h_._,_ City/State/lip:_A)_ oL&r _ 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. do hereby certify under the pains and penalties of perjury tool the hiformallon provided above is true and correct. Sk t t arc^�.� � - _ IL � - - - 1 Ml Phone H: Official use only. Do not write in this area, to be completed by city or sown official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone #: ACORD® CERTIFICATE OF LIABILITY INSURANCE ;r— DATE (AMID 014YY) oa119,�,4 DOCUMENT WITH RESPECT TO , , THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER MARSH RISK B INSURANCE SERVICES CONTACT PHONE I FAX 345 CALIFORNIA STREET, SUITE 1300L A Ext); _ _ _ i (AIC, No): CALIFORNIA LICENSE NO. 0437153 ADDRESS:lLo- SAN FRANCISCO, CA 94104 - # MED EXP (Any ora person) i f INSLIRER(S) AFFORDING COVERAOIE +I NAIC a 998301-STND-GAWUE-14-15 INSURER A . Liberty Mutual Fire Insurance Company 116586 INSUREDPh INSURER 6: Liberty Insurance Corporation 42404 (650)963.5100 NIA NIA SdarCity Corporation INSURER C : 3055 Cieanriew Way INSURER 0: San Mateo. CA 94402 25.000 A AUTOMOBILE LIABILITY AS?-NI.066265.044 09.10112014 090111015 INSURER E 1,000,000 INSURER F: CA1UFRAr2FC CFRTIFICATF M"MRFR- SFA -002440269-02 REVISION NUMBER:4 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IL SR TYPE OF INSURANCE ADDL,SUBR POLICY EFF ' POLICY EXP POLICY NUMBER MMIDD MMIDDIYYYY LIMITS A GENERAL LIABILITY l T62 661-066265-014 09/0112014 09!0112015 EACH OCCURRENCE f 1.000 MO X 1 COMMERCIAL GENERAL I,IABII ITY DAMAGE TO RENTED PREMISES (Ea ocT:yrrew) I f 100.000 CtAIMS•MADE X I OCCUR # MED EXP (Any ora person) i f 10,000 1 PERSONAL ti ADV INJURY f _ 1.000-000 - GENERAL AGGREGATEf 2,000.000 GENL AGGREGATE LIMIT APPLIES PER. I I PRODUCTS - COMP/OP AGG f 2.000.000 X POLICY I X jr-c7 I PRO- 1 : LOC Deductible f 25.000 A AUTOMOBILE LIABILITY AS?-NI.066265.044 09.10112014 090111015 COMBINED SINGLe LIMIT (Ea a .&1i 1,000,000 X I ANY AUTO i 80011 Y INJURY (Per person) : f ALL OWNED j SCHEDULED + BODILY INJURY We accdenq i AUTOS !AUTOS X I141REOAUTOS X VMED AUTOS I i PROPERTYDAMAGES X )Phys.Damape ; j COMPICOLLDED: f f1.0()OIS1,000 UMBRELLA UAB 1 OCCUR } EACH OCCURRENCE S '1 EXCESS UAB L ,CLAIMS MADE' I I AGGREGATE S OED RETENTIONS If g TYORKErtSCOMPENSATION WA7.66D-066265.024 09-10112014 10910111015 1 X ' WC STATU- OTH- AND EMPLOYERS' LIA91UtY YIN (WI) .09-10112014 109:'0112015 g I TORY LIMITS . . ER i ( 1p00,000 ANY PROPRIETORIPARTNFRIExECUl1VE �WC7.661-066265.034 OFFICERNEMBEREXCLUDED N N/A E l EACH ACCIDENT S f B (Mandatory In NH► WC DEDUCTIBLE: $350.000' 1 I E 1,DISEASE • EA EMPLOYEE f i.000,000 r yes desenee under DESCRIPTION OF OPERATIONS Wow E l DISEASE POLICY LIMIT IS 1.000AW DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, It more space Is required) tvicl3imof Insurance SotarCdy CorparatXXi 3055 Clearview Way San Mateo. CA 94407 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh Risk & Insurance Services Char4es Marmolejo C! -2e7- 10�---�� 01988.2010 ACORD CORPORATION. All rights reserved. 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E:P: . . . . . a q Ol u JT cu c'o o�v E 0: 0: L 0 E E CO 0 ix O:. . . . . . . . . CC 3: 0 x m E 75 , c 0E 2 X: .2 E0 m c 0 c4 oi, �d' E CL 0 . . . . . . CL. Z 6: .0. . :O: CL I Zi i Z: B - z': '-: - a::L cr > CL CL C? Cm 0E -0 = -0 LO co W< CL a) CC 7 CD yeacl LA cc c.c Eimmi 0 t: E. E' E cn 75: . E. . . E:P: . . . . . . . . . Ol u JT cu c'o E - E E CO 0 ix O:. . . . . . . . . CC 3: 0 x m E 75 , c 0E 2 X: E0 m c 0 oxd CL Z 6: .0. . :O: CL I Zi i Z: B - z': '-: - a::L cr > x IL LA cc c.c gi,i i -,i pi o z i i zi Ei i-! Z Z 2 0 o 2j'i j 'j Ej E: in o: 1E, 'E' E: E E .- i fl Z� Z -�� w >: o cc x A u E- Z- > 5: mx: x: O 2:2 o -o Ol u JT cu c'o E - E E 4) 4. to E 0 3: 0 x m E 75 , c 0E 2 t E0 m c 0 CL > D CL I A40 m 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the { 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 ofongoing construction activity, and may be.deemed.by.thelnspector_of_Wires abandoned.and.invalid,ifhe—__.. _ 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 puipose 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. 8 — Permit/Date Closed: Permit Extension Act — Permit/Date Closed: *** Note: Reapply for new permi Date . 1.?.-'.1.�►' .�- TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................. s-! . .... , .......... , ... . has permission to perform. wiring in the building of .. ���? .. ,,,�7?�L �� .. . ...... . .... . at ............. • `-7-98Y ............. North Andover, Mass. Fee Lic. No.. (-7 1.7? . ..... �., ...... . ELECTRICAL INSPECTOR 1 Check # — if 11317 f Commonwealth of Massachusetts Department of fire Services BOARD OF FIRE PREVENTION REGULATIONS (Please addzip codes & electrician's cell contract # & bid permit # if applicable.) Official Use Only Permit No. 1 l,`5 –7 Occupancy and Fee Checked ,ev.1/071 (leave blank) APPLICATION POGO PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PR.INT.ININK OR TYPE ALL NF TION) Date.--- ! O$t3' or Town of: //// To the Inspector of Wires: By this application the undersigtte gives notice of fiii or, her interaipn t�grform the electrical work described below. Location (Street & 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 I+Tnzrn–Ioea o " eeclei s a id"Xmpacity Locations and Nature of Proposed EIectrical Work: Completion of the following table may be waived by the Inspector of 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 XVA No. of Luminaires Swimming Pool Above Ej In- rnd. nd. 0' o. Emergency tg t ng Batteo r 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 Aleirtin Devices 11 g No. of Waste Disposers Heat Pump Totals: Number .. Tons ................................... IOW No. of Self -Contained Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW LocaI Municipal ❑Other - emmec ' No. of Dryers rj�ecurity Heating Appliances KWNo. Systems:' ofDevices o uivalent No. of Wafer R, Heaters No. of No. of Signs Ballasts g: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTBER. (36 5q4 Attach additional detail if desired, or as required by the Inspector of lflires. Estimated Value of Electrical Work: _ (When required by municipal policy.) WorIc to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVET; AGE: Unless waived by the owner, no permit for the performance of electrical work map 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. CI.IECKONE: INSURANCE ❑ BOND ❑ OTHER Y (Specify:) Self Insured X certify, under thepains anripenalties oflmrjury, that the infQrinatix on this application is true and complete. (FIRM NAME: ADT LLC DBA ADT Security , LIC. NO.: C-172 Licensee: Thomas f. Lee i nature 1 4� ,e LIC. NO.: C-172 g ,�� t �_, (If applicably. enter "exempt" in the license number line.) "" J fit' �� Bus. Tel No.: �e tJ� 5 c� � ���� Address: �' C� t r1 _i '+ � . 1�is, N \ (-),So�cn Alt. Tel. No. •_ "Security System Contractor License required for this work; if applicable,'enter the license number here: 001779 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) [I owner [I owner's agent. Owner/Agent , Signature Telephone No •.-E.PdmITFEE. s Li�— d 12111 a r" �� vwA.1- `j dd : 0V9,PACIA;VEE LT1.10F ftRA.`a ,, (1,$ I.1 J-SETp 8... ; i �:IT�lflh;!l�ol� IJl_o_o"lil_, j�iJpJif�'.'�! i9fl:.l=1i�'r;_OL'`•i==_��_ �'hL��91F ELECTRICIANS A° PECIS.TERED SYSTEM CONTRACT6)� ? ISS UES.I•HEABQVE LICENSE 7-0: • v i` `':AD'T-:`•L;LC. DBA ADT SECURITY,' I.H0144s •J LEE. om � 41D :LRIVERSITY• AVE.�`,�, �v. . ST•WOOD MA 02090-231 \3, 17.2 C 07/31/13 _ 201§344 tJtrly_!f_y ry_0, Fold, 7hr-n Dench A?nng All Perbrdlonc — 134 Date. f " f li :.� ..... . TOWN OF NORTH ANDOVER PERMIT FOR MECHANICAL INSTALLATION This certifies that has permission for mechanical installation.!!N.�l--�. in the buildings ofn �. t=... .......................... . at ... .��' ... n .. ....�r. , North Andover, Mass. Fee .' .. Lic. No... z.�? ............... Li�'Yt GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Commonwealth of Massachusetts Date: ll Estimated Job Cost: $ 17 O-0 Plans Submitted: YES NO Business License # 69 Sheet Metal Permit Permit # Permit Fee: $ Plans Reviewed: YES NO Applicant License # 37 31 Business ii Inlformation: I, Property Owner / Job Location Information: Name: 4`���` S ei fl/� `1 aR� hkcaln� Name: Street: STS S W Atm v\ Street: C '6 00- + Ww �— 5�' City/Town: w s v.r City/Town: .%mc L /4-j4Vt4i Telephone: _(�1� 4; S (-- `-(�( (73 Telephone: Photo I.D. required / Copy of Photo I.D. attached: YES NO Staff Initial J-1 / M -1 -unrestricted licensee J-2 / M -2 -restricted to dwellings 3 -stories or less and commercial up to 10,000 sq. ft. / 2 -stories or less Residential: 1-2 family Multi -family Condo / Townhouses Other Commercial: Office Retail — Industrial Educational Institutional Other + Square Footage: under 10,000 sq. ft. t� over 10,000 sq, ft. Number of Stories: Sheet metal work to be completed: ' New Work: 1 HVAC �- Metal Watershed Roofing _ Metal Chimney/ Vents Provide detailed description of work to be done: a- 41-T . r— c., Y Renovation: Kitchen Exhaust System Air Balancing L� -o'L Al L -r,- 6 "'e- r.� � c4V-- \ ad s v AL4-<A w o r k'-. a,,, Ak , k INSURANCE COVERAGE: I have a current liability Insurance policy or Its equivalent which meets the requirements of M.G.L. Ch. 112 Yes dNo ❑ If you have checked Yes, Indicate the type of coverage by checking the appropriate box below: A liability insurance policy [y", Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this boxg, 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 sheet metal work and installations performed under the permit Issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Date Date Duct inspection required prior to insulation installation: YES NO Proaress Inspections Comments Final Inspection Inspector Signature of Permit Approval Comments SignatureofLicensee License Number: _ , )� , � ) Check at www.mass.gov/dpi Type of License: By ❑ Master Title ❑ Master -Restricted City/Town ou—meyperson Permit # Elio urneyperson-Restricted Fee '$ ❑ Inspector Signature of Permit Approval Comments SignatureofLicensee License Number: _ , )� , � ) Check at www.mass.gov/dpi «/\, _ z � © p .LL, CD @ 7. cc\ 1 CN«\ \ tn�( m .��Uj 2 i .6 . ^ \7I 00 e "�:(n 0 \ /�. LU w ._ui «.-, ul �2 2w ®�® O : u a � ®Z} . \ . �� , 0 in �0 ¥ 0.}°LU tl- 0 No -,g w fY N \ cr) LL) M Oo d' N LU i N V ,q /> G .a 6�s W Y (n N goy..rri..iq %.IIIMtI'yb�i0.R.a!`.Ia1j.9M.pWWFi.R.Mfil b!.m+Wa.w�� 1 t- M f \ n AAC cD u alwrlar. .mc�werwnA' r�arraa.ameryy, \ . 00 h ! r 0 � W ui '00 D r ronroa� way terct:e� 'WIW. .n a� 110-.0L CV The Cs`9mnwonswr?alih d f I�cC)'Sflt'Y�d7,�� e'yh' Depm,lmeiyY of Indiistrinlofceident.> Office of Investigations 600 Wcr.5hington Sireet u ~ 6 Boston, MA 02111 -._�•,j www. mass.govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/F+,lectricians/Plumbers Applicant Information 1_ — I Please Print Legibly Name (Business/Organization/Individual): �'� �' l S t (p `Or ,ti. `� S 14 { cJ Address: S 5 _S City/St.ate/Zip:'' - w k/S h, , r ti , AAA M � � Phone #: Are you an employer? Check the appropriate box: 1.� I am a employer with _S 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. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § ] (4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I I.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. Other hJ L *Any applicant that checks box ft 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 coniractors roust submit anew affidavit indicating sucl I. tContractors that check this box must atbaehed an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. lam apt eri t)loyer tlattt is providing worker s' conipenstation insurance for my employees. Below is the policy and job site inforinaction. Insurance Company Name: A '] 1 ti v_,- L Policy # or Self -ins. Lic. #: U �% ;S j y , tv� !_ Expiration Date: - u I I 0. Job Site Address: d'V D&_f + v --city/State/zip: Atta.r.'h 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 $250.00 a day against the violator. Be advised that a copy, of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify arnde ins and penal ies of perjury drat the information provided ahove is trite and correct. IJ_ 9_l% <�S (-`( ()3 Official use only. Do not write in this area, to he completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector 5. Plumbing Inspector 6. Other LContact Person: Phone #: 378 Date. .?�X0Z.. . <: •:'� TOWN OF NORTH ANDOVER ' PERMIT FOR PLUMBING This certifies that . �..�Q�!. . has permission to perform . . plumbing in the buil ings of . !-�! ��!/.Qe.17 ........... at ... � .. �C/i�!'�'4?�!.? . � ......... , Orth A over, Mass. 7 ' / ... Fee. .li. f. ! �Lic. No..S�Qi�GS . . �1�. � ........ PLUMBING INSPECTOR Check # A/ � MASSACHUSETTS UNIFORM APPLICATION FOR A PJERMIt TO PERFORM PLUMBING WORK j -CITY ►� E � '� Ado v I MA DATE] C/ 111 11-1 I PERMIT H JOBSITEADDRESS C -A6 0o A- ,14 OWNER`SNAMEJ Pct, 4g6f,Ztt., TIM OWNERA,DDROs TELT IFAXI I TYPE -011 OCCUPANCYTYPE COMMERCIAL( j EDUCATIONAL I RESIDENTIALj:, PRINT CLEARLY NEW,..I I RENQVATION:(>1 REPLACEMENT:( ( PLANS SUBMITTED: YES NOj j FIXTURES FLOOR—' BSM 1 2 3 4 5 s 7 u 9 10' 11 12 13 14 BATHTUB _I........ _ . GROSS CbNNECTIONDEVICE :.. _.....':......._ .. ___. !; DEDICATED SP0IALWASTESY$TEb1 .:.., .. _.:; .; .,i._...:.._.._' __._ _.I�:a...._..;...... ; .._.. ,, .._ ..; ......_; ..�.:.. _..... DEDICATED GASIOIUSAND SYSTEM •. •- .i DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM ` DISHWASHER :.. .. DRINKING FOUNTAIN _ .. � ... :. .. . FOOD DISPOSER FLOOR !AREA DRAIN !. i INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY - ROOF DRAIN I I SHOWER STALL I ! ! . . SEMACEIMOP SINK TOILET -,... �.......... URINAL i I -- 1 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES, WATER PIPING, 7; INSURANCE COVERAGE: have a ctirront.liabilit iitsivailce policy.or its sulWantlal equivalent which meets the requirements of MGLCh.142. YES ( I NO j IF YOU CHECKED YES, PLEASE INDICATEHE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY I I BOND I. OWNER'S INSURANCE WAIVER: I ant aware that the licensee.does nt have the insurance coverage required by Chapier•142 of the Massachusetts General Laws, and that lny signature on tiiis permit application �ygves this ret jtdre(nent. CHECK-ONEONLY:_ OWNER ( AGENT. SIGNATURE OF OWNER-Oit AGENT I hereby certify ilial all of the details and irifonnalion I haVe subin$Iled of dnlered regarding:this application ate true and accurate to the best of my knowlddge, and that all plumbing work and installations performed under the permit issued for this application Wit be in cro i Bance wth all Perk ent provision of the Mas$achusells State Plumbing Code andChapter 142 of the General Lays.- iw PLUMBER'S NAME[.' ,� ���- 0. It Gib ILICENSE fI 17,096'� 1 SIGNATURE —�- MPI I JPIG� CORPORATION) .IIIA 1PARTNER81ilp, III! ILLCI. I;ij COMPANY NAME+ let, P i . -ft-m L -4R I ADDRESS I j S ly /GA, I f4 4 I CITYI i7!!s11,5 ice ISTATE I..0.ITdj ZIP I I TELL FAX ICEILI S4w.� IEMAIL r14 2 OD ;,o Er* F L � v a. u to P, 9 R Date ...... �:.� �... �.Z.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING r This certifies that..........................................vM ......(..................................:........ has permission to perform� `' &,V c r M L—T- d 17 ........................................................ .................. C p ,L -u <— wiring in the building of................................................................................... at y`? L)!ZrW . �1.... 12j),North Andover Mass. a Fee..................... Lic. No.............. ............l�-''i. �ELECTRICALINS PE�eTOR Check # i � r � 110768 The Commonwealth of Massachusetts - - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrganizatiorAndividual): 5't -e, U-& (4 P t N T• ,]7i��, Address:— Sir City/State/Zip: 6 s' Phone #• 6'0 - 4 65 7 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 Pemployees (fall and/orW-lime).* have Hired the sub -contractors 7. ❑ Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g, ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10. F1 Electrical repairs or additions required.) officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] i 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. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lie. 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 may be forwarded to the Office of Investigations of the Dl for insurance coverage verification. I do hereby cert under the pains andpenalties ofperjury that the information provided above is true and correct. Phone #: `U 3 Sli C -� 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): I. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Pers 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 j oint 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. Iran 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 permittlicense 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 De- .artbaent of Industrial .Accidents Office of Investigations 6.04 Washingtoa Street Boston} MA. 02111 Tel, # 617-727,4900 ext 406 or 1.-877, NMASS.AFB Revised 5-26-05 Fax # 617"727-7749 ww.mass,gov/dia Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. p -7 �,?F BOARD OF FIRE PREVENTION REGULATIONS[ Occ p �yandFeeChecked leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: q —// / 1 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersignedgives notice of his or her inte ion to perform the electrical work described below. Location (Street & Number) oC. , 1)n 1,_) AA ri, L Owner or Tenant—e f 11, 41 Owner's Address - x. 0 2 - Is Is this permit in conjunction with a building permit? Telephone No. Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No.? S O 3 Existing Service /'% Amps 64:e olts Overhead Undgrd ❑ No. of Meters New Service J—&—O Amps 02f1/ Z olts Overhead Undgrd ❑ No:%- Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: % � F' Y'V G[a 1. ►/ Attach additional detail if desired or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cove ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the sins an enaltiesfperj !ry,.thn-t the infor anon tOn this application is true and complete.FIRM NAME:C /" LIC. NO.: Z t Licensee: Y_t"'Signaturej C. NO.: (IfappZicable, ente em pt" i he i nse member line.) ®g � Bus. Tel. No. � �– !�6 Address: (,P- � •,� / 'Per M.G.L c. 47,s. 7-61, security work requires Department of Public Safety "S" License: Alt. Lie. No.l. / OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ UOin lett-- o the ollowin table Ynav be waived by the Inspector 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 Above11In- E]o. o mergency ig i n g rnd. rnd. 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 Initiatin Devices No. of Ranges No. of Air Cond. TotaTons No. of Alerting Devices No. of Waste Disposers Heat Pump ...... Number .Tons ........................................._ KW No. of Self -Contained Totals: Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances RW Security Systems:X No. of water No. of Devices or Equivalent No. I Heaters Si ns Ballasts Si BalNo. as Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cove ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the sins an enaltiesfperj !ry,.thn-t the infor anon tOn this application is true and complete.FIRM NAME:C /" LIC. NO.: Z t Licensee: Y_t"'Signaturej C. NO.: (IfappZicable, ente em pt" i he i nse member line.) ®g � Bus. Tel. No. � �– !�6 Address: (,P- � •,� / 'Per M.G.L c. 47,s. 7-61, security work requires Department of Public Safety "S" License: Alt. Lie. No.l. / OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ r FMECTRiM PERMT EEECTMCAL INSPECTOR - s ' M�[J' Failed--[ ] Re -inspection requ ired($50.00) - e y h•• ffugectore Signaiare -no iuiizals) � Date Z. S�7N lC�7 PEC ION: Passed' Failed--[ j Re -inspection req&ed ($50.00) - [ Impectors' comments: on (Ri4ectors' Signatur - no ' ials) Date S. IMER GRODM IMPACTION: Passed — [ ] Failed -- [) Vw4usp ection required ($50.00) - [ ] Inspectors' comments; (Inspectors' Signature •- no initials) Date 5. WSPECTION -OTHER-' leassed — f wiled -- [ )- Re-insp ection required ($50.00) - [ ) Inspectors' conameuts: �1, asp ectors' Signaiure no initials) Date D OOR TA.O5 ARE TO BE MLED OUT.AND EEFT ON SITE -W TSE .APES. TO 3E INSTECTED IS NOT ACCESSIBLE AND A. RE WSPECTION OF $50.0 0 Is TO DE CHARGED. The Commonwealth ofMassachusetts - 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 Legibly Name (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. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 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 12.0 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. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. 9; Job Site Expiration Date; City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required -under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 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 #: Il 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 producedacceptable 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 retumed 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. # 617-7274900 ext 406 or 1-877,MASSAFE Revised 5-26-05 Fax ## 617-727-7749 www.mass.govldia Date..... . ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......... ......... ... OA�� ........................................... has permission to perform ........... ......... 4�9�-v ................................................... ....... -'-6 f, — �-- d 7� wiring in the building of ....... .-r-k . ............................................................... at ... D9A7W.0kPY. 1245 ............ . North Andover, Mass. Fee... 35� Lic. No. q .............. EL CTRICAL INSPEcm Check # 0770 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. /0_71P Occupancy and Fee Checked [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: L/ /) —12-- City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of hi or her intenti94 perform the electrical work described below. Location (Street & Number) Uart Y%^a)'" Owner or Tenant ~' e ' L Telephone No. Owner's Address d Ve-el Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �/, (-��Oe yo i fJ No. of Recessed Luminaires eae unuwln No. of Ceil: Susp. (Paddle) Fans ranee may oe waived by the Inspector oj Wires. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ o. of Emergency Lighting rnd. rnd. Aj#Lry 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. Tonal No. of Alerting Devices No. of Waste Disposers Heat Pump Number_ .Tons KW. No. of Self -Contained Totals: Detection/Alerting Devices No, of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑Other Connection No. of Dryers Heating Appliances KW Security Systems:*. No. of WaterNo. of No. No. of Devices or E uivalent Heaters' of Signs Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail fdesired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov age is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under thepains a �enalties ofpe� jury, that(he the information on trs application is true and tori pt'ete. FIRM NAM C� r/�✓tLIC. NO.: 2 I % . Licensee: Signature �- ZC, NO.: (Ifapplicable,�gnter " empt" in the licensg numb r leve.) Address: f, ©, �; S( (Fj j l �° �-� ,i{,y� i'- p 4� Bus. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. Lie. No. e 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 check one requirement. I am the Owner/Agent ( ) El owner ❑ owner's agent. Signature Telephone No. PERMIT FEE: $ ` f ._. E�JIlCd.L�-LC[�.�Cj��-��( i/.''���1%�.C�iJ(U:L%�•�J.�'l�®��.�y�y�j �j'� •� ,�.1.'I13J1 .L:1't�J4J.��Jl9.L1J1. L��� ._. • _ Jlv r•••LJ.JI'�.II.V.C3.J-!Ji\NJ�..71:1CJ, ®JIO.� .. � — • ♦�_ . �017,7N_ SP CTIO_N_ Pissed--• +'ailed--[ 1 Re-iuspeetionrequzzecT($50A0)-( 1. Inspectors' contmepts: ' s y 'a•• 7 (Inspecto Signa a »uo ijals) Date Passed -K Failed-[ ] T2e 3�uspection rec�uixeci ($50.00} •- [ � InSliectors' comments: - -AZZ (tnsliectors' BtnaturVno ixutials) Slate r 3• UNDER CROIM WgRYCTION'': Passed - [) Sailed— [ Re -inspection, required ($50.00) -• [ Inspectors' comments: (Inspectors' Signature -• no initials) Date �S S IMNS'ECTION -• OTBERf Passed -• [ 1 I+ailed - [ )- 'Re -Inspection. required ($50.00) •- [ j Inspectors' co)]►Ments: (La-spectors' Winatare •- no ii Mals) Date 1300)?, TA G,9 ARE TO BE FEUD OUT A" LEFT ON SITE IF TM AREA TO BE INSPECTED 18 NOT .ACUSSIBLE AND .ARE INSPECTION OF _S50.00 JS TO BE CHARGED. i,• The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations IN 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: 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 12.0 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: r Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required. under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: ;i Information and Instructionsr'1 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 producedacceptable 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. A 617-727-4900 ext 406 or 1-877,MASSAFB Revised 5-26-05 Fax ## 617-727-7749 www.mass.gov/dia Date .... 11=J.y--zl TOWN OF NORTH ANDOVER PERMIT 'FOR WIRING This certifies that .........`.. � �r21tG- �/ .... c.... ./ has permission to perform . G{...`t!TL��G/5�h/r1� ...����T wiring in the building of ....................f `Lo .......1... C-..................... a at ... .er5?67?'! ?. 5 7" , North Andover, Mass. ......................./.............$ELEcrR1c Fee.16 .. Lic. No. 21 �l4 ? �.....��r� :. ............ 1 IN CMR.. Check # �6 _ 10471 a P Commonwealth of Massachusetts Official Use Only Department of Fere Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: %� % L% ^ // City or Town oh. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her inte tion to perform the electrical work described below. Location (Street & Number) Ate V` Jed 'T ! ' Owner or Tenant Owner's Address � ffco 90 X h'v L Is this permit in conjunction with a building permit? Yes Telephone No. No ❑ (Check Appropriate Box) Purpose of Building 7�, Utility Authorization No. Existing Service /6(9 Amps 120 /G Volts Overhead [3'- Undgrd New Service Amps Number of Feeders and.Ampacity No. of Meters Volts Overhead ❑ Undgrd ❑ No. of Meters Location and Nature of Proposed Electrical Work: W I Completion of the followin3ftable may be waived by the Inspector 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- ❑ nd. rnd. o, o Emergency ig ng Battery Units No. of Receptacle Outlets No. of Oil BIR -Mees FERE ALARMS No. of ?ones 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 ICS' Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters of No. of Si ns Ballasts . Signs Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov rage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND F! OTHER ❑ (Specify:) I certify, under the pains ajMdpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: C � kr e r , (:C e rv; (es LIC. NO.:"11116 Licensee: 4( " �Gt 1e%- Signature o� Z, LIC. NO.: ,G. % q6 (Ifapplicable, enter exempt"in the lic n* number line`) Bus. Tel. No.• `� % "`�7�%'%/f,+ Address: C 1/(" Jq 116J -1Z& 0.�ro T �? Alt. Tel. No.: Ver M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAVER: 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: S The Commonwealth of Massachusetts I Department of Industrial Accidents . Office of Investigations 600 Washington Street it lin ; g Boston, MA 02111 {� l www ,owss.gov/dia . Workers' Compensation Inshra.nee Affidavit: Builders/ContractorsXleetricians/Plumbers Applicant Information Please Print Legibly Nanle (Business/Organization/individual): Address: City/State/Zip: Phone #: . Are you an employer? Cheek.the appropriate box: - 1. ❑ I' am' a employer with 4. ❑ I am a general contractor and f employees (full and/or part-time).* 2. ❑ I am.a.sole have hired the sub -contractors listed t proprietor. or partner- on the attached sheet ship and have no employees 'These sub -contractors have working for main any capacity, workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ 1 din a homeowner doing all work officers have exercised their right of exemption per MGL myself, [No•workers' comp. c. 1.52, § 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. ❑-Electricai repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.[].Other --Y -PPucnm roar cnecKs ooX I l must also flit out the section below showing their workers' bompensation 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 musteltaehed an additional shoe t shoving- the name of the subcontractor and their workers' ten p. policy infor, adoa. I aril aft employer that isprgvlding:wo herr' corn infarl`raatiom pevt�eaa r� srasurapace j`or try employees. fed®w is tlae policy grid job site ' Insurance Company Policy 4 or Self -ins. Lie. Expiration Date: Job Site Address: City/Stale/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 MOL c. 152 can lead to the imposition of criminal penalties of a• tine 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 of perjury that the information provided above is true and correct. Sienature: • Date: Phone 4: Official use only. Do not write %n f*is ar ea, to be completed by cu`,y or taws Official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 6. Other Contact Person; 4. Electrical Inspector 5. Plumbing Inspector Phone #: AN G t, Date .g/.%,l�.. .. . 9517 ��. TOWN OF NORTH ANDOVER .- .'• °oma PERMIT FOR PLUMBING This certifies that ........... L.O.. .. .... . has permission to perform ..... ......:. plumbing in the bui dings of ........ a ............. at .... ..y L"/.... .............. , N rth Andpver, Mass. Fee .at0?.. Lic. No../. ZIW . , ...... . PLUMBING 1 ��TOR Check " �Sli I �I S'N_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _ MA DATE �'�� 7 ' ZDI 'PERMIT # - JOBSITE ADDRESS Z ._ OWNER'S NAME POWNER ADDRESS TEL— FAX { TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW:�M RENOVATION: El REPLACEMENT: © PLANS SUBMITTED: YES © NO M-1 FIXTURES'l FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE _ € ,4. _•_( ! __..,._ ' __._. ( I DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM-_......... ... € DEDICATED GRAY WATER SYSTEM I _...__._I f ____-__{ _.__.....•_€ __.__._€ € ____.._f ____ 1 _.__ __I _..__._. I ! _____1 f .. t DEDICATED WATER RECYCLE SYSTEM DISHWASHER l ...___..._! ( .._.-._..€ .__._..._€ .---._-_{ _.__.._._1 ._.____( -_.__..J _._.. DRINKING FOUNTAIN FOOD DISPOSER _J ___1 __I _ _-__f t _._ _ _______ ( ___._. _ € _--_-._—( .___. _J .__. _....� € _`l ..•.-,__...I FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) _€--_----_€ .._...._....€ s` i _ t I -____-_1 KITCHEN SINK —_) _ __._...t ..._..._ _._._1 � ___-- i E !--_-__! I __.._._I —_-_-� .-_--_-_.1 _ I A ..__._.._.._� LAVATORY .__..._._Al...__.-._( I_.-----.-( .._.____i __..-_._1 __-- ___.€ .-__.__J :_...._._! E'_'. 71 .I ROOF DRAIN-_.-.-_. j .__..__.1 -.____f --____.l _._._.___l _..._._'J I ..-__.. I SHOWER STALL SERVICE / MOP SINK TOILET URINAL-...€ .... I WASHING MACHINE CONNECTION _ ( _€ i I _ _ . ( ! _I i 1 ; .... WATER HEATER ALL TYPES +, ; WATER PIPING _I _-- I € .. _._..! € _ ► I i .____..€ €F ----._� OTHER T€ ___1 ___j I _J INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES FV NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY r$ OTHER TYPE OF INDEMNITY Q BOND P, 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 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 co 4iance wit all P t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ # . I Z , _ ._..f SIGNATURE MP t� JP Q CORPORATION F# i PARTNERSHIP PA LLC COMPANY NAME DDRESS ZIP TEL CITY ;STATEiAy FAX i CELL I EMAIL I P NF . W a LLi LU LL The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 s. www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. [!o 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.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. [1 Electrical repairs or additions 11:J;/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. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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. — _1 1 f— I , Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: 26 �Q(r rn(' 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 un to pair d p e ofperjury that the information provided above is true and correct. Si nature: /' Date- —,7—,7 7 ^7C /> 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 #• ti 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-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 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 Date. . 71 & ........ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that Z/,?Z"./`*.................. . has permission for gas installation ............... in the buildin s of ............................................ at Z( .. .. . . AW. . - - �. ( . ....... North A d , Mass. :11,4V ji over, Fee 3� Lic. No:�� Ifor4e;rZay�. /P*- GASINSPECTOR Check# 1-5-6 8226 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY cvrr MA DATE PERMIT # JOBSITE ADDRESS G `x411 v : _ _ _ _ OWNER'S NAME � (I,L GOWNER ADDRESS TEL����FAX PST OCCUPAN Y TYPE COMMERCIAL EDUCATIONAL [J RESIDENTIAL d CLEARLY NEW: RENOVATION: REPLACEMENT: 0 PLANS SUBMITTED: YES [�!('NOQ APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER ��J TRI I _ I I -_I. _.. _ .- ---1. �-1 COOK STOVE .......... DIRECT VENT HEATER _11(—J� DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER— LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM /SPACE HEATER _.-�._- _ -_^ :�.. L_ _ _ ,.- T J ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATERI^___ WATER HEATER Il .J �-J i -.f -- i OTHER (.-1 _ _.�J INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 1&0[j NO.�I 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COV 'RAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY E] BOND [j OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER El AGENT EJ 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 compli nee with all a inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t % + / i PLUM BER-GASFITTER NAM� j�E%+�G 1 _ _ ( LICENSE#3c,� SIGNATURE MP0_I_I MGF [:J1JP__,-1 J G F LPGIJ CORPORATION Q#—� PARTNERSHIP ©# w ! f LLC [J]# COMPANY NAME: HT �)�,� ADDRESS 5 -- __j& CITY STATE� 4. ZIPt� 3,�j'� TEL ��� 56t 173 (� FAX�CELL 14_3 �,L-C?3 EMAIL A H °z 0 H U W a w .w O N� w � W = v, a w W5 a W Oco � w w N a o a a a � U • �y J H a a a � w x w F- w W H O z 0 H V W a C7 L7 The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations qu . 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/fndividual): N t t,161 Address:_ � S 4 e_k I � f -t 5'l G� City/State/Zip: f ) 6 S''a vi OJ J ` 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 1011 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 hire 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cerci under thepyins aVpenalties ofperjury that the information pro videdabove is true andcorrect Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License .2/1,9 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 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 ext 406 or 1-877. MASSAFE Revised 5-26-05 Fax # 617-727-7749 wWW-mass,8oV1d is 9368 Date .. wy....k- TOWN OF NORTH ANDOVER ., CL p PERMIT FOR PLUMBING T This certifies that ... f /' �� .. ........... has permission to perform .. /%!/ ..,/. ......... plumbing in the uildings of ......... ................. �...Ar '�'� at ... -7.................. .............. , North Andover, Mass. Fee. �'? . Lic. No. .. ... ............ // , 5/ PLUMBING INSPECTOR Check # O Date ...���z ........ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... 7/ 0. .. &vzc ............. . has permission for gas installation e COr� • in the buildings of ..`' ....................... . at ......................... .. �.�Nqi ver; ass. All Fee... ... Lic. No./ Z ...... GAS INSPECTOR Check # s ` f MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town:- A O rAllt`/jCV wMA. Date: &17— Permit# Building Location: 2-6 6-3 Y rn� �%'�'� Owners Name: Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New:`q Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES 1 3 4 6 6 FLOOR 8" FLOOR �laInstalling Company Name: Address. �I e(� City/Town: State: Business Tel: ��`��Q �f �g Fax: Name as Fitter: Check One Only Certificate ❑ Corporation ❑ Partnership Firm/Company INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yid No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only .Sign re of Owner or Owner's Agent Owner ❑ Agent ❑ By checking this box ❑; 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By,Z . 7G Type of License: ,Z� El Plumber Title El Gas Fitter Signature of !� U Master Journeyman ❑ LP Installer License Nu S Licensed Plumber/Gas Fitter ber: % %yT co Q: Lu Q co co C) x p=p = Ix O W W UO W l'-- 0= W W zi P -~O L z J W Z w W re 0 ~ a a F. 0 00 a �C a W ~ W Q W W W � g z W O QW u� I- ❑ Z w Z 0 Q J I— h O M co Z W .-t O C7 Z u- O = H> W H W f' W 4 0 iY w w_ cn Z 2 SUB BSMT. 1 3 4 6 6 FLOOR 8" FLOOR �laInstalling Company Name: Address. �I e(� City/Town: State: Business Tel: ��`��Q �f �g Fax: Name as Fitter: Check One Only Certificate ❑ Corporation ❑ Partnership Firm/Company INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yid No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only .Sign re of Owner or Owner's Agent Owner ❑ Agent ❑ By checking this box ❑; 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By,Z . 7G Type of License: ,Z� El Plumber Title El Gas Fitter Signature of !� U Master Journeyman ❑ LP Installer License Nu S Licensed Plumber/Gas Fitter ber: % %yT The Commonwealth of Massachusetts Department of r ndush ial Accidents Office ofinvestigations ..600 Washington Street Boston, AM 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Dolicant fnfnrmn;;nn Name (Business/Organization/Individual):—]Z 'I (it/41/`Z it/`1/ /. - - Address: Lf -- City/State/Zip; ,�,� �6138( / Phone #:6z93' :6z93' o t/v& O Are you an employer? Check the appropriate boa: 1 • I am a employer with �� 4. E]I am a general contractor and I employees (full and/orpart time).*' 2. ❑ I am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheet t ship and have no employees These sub -:contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing officers have exercised their all work Myself. [No workers' comp, right of exemption per MGL c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' • *A11 -y Eppticant th at ehec: s box #1 must also fill out the T tr comp. insurance required.] section b oa el , sho , ;,,,� ;xe , Type of project (required): 6. ❑ New construction 7. [] Remodeling 8. [1 Demolition 9. [] Building addition 10. ❑ Blectrical repairs or additions .11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other omeowners 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. lam an employer that is providing workers' com F enation insTQ ante for my employees Below is the policy and job site information. 3& ,' Insurance Company Name: Policy # or Self -ins. Lir. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be Investigations of the DIA for insurance coverage verification forwarded to the Office a I do hereby certafy tiler the ins penalties ofperi"'iy that the information provided above is true and correct -JJ'ciac use only. Do not write in this area, to be completed by city or town official City or Town: # PermitlLicense Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other :_x / 2- Contact Person: Phone M K 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 coinpliance 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 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 Bo -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; r n— t 1. 't r.. 1_..s 65, li t Y, f L r �yei: v e Yi n 4P' F' n n t f ett=E _ to t_e 9r6y 4a' town tua� cax a�uavuCa�r� or the pe_adt 0� li 5 i . b ing regaested., n . the D �?artmonv 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 f6r 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 Sleet Boston, MA 02111 Tel. #: 617-727-4900 ext 406 or 1-8.77 M- hSSAEE Revised 5-26-05 Fax # 617-727-7749 MASSAC"USETTS UNIFORM APPLICATION FOR A PERMIt TO PERVORM PLUMBING WORIt V!' CITY PQy h /f 14 j01V'Q r MA DATE] ���''Zo I PERMIT# ":' Aei m 0u�r ` JOBSITEADDRESS C llri • i OWNER`S NAME P OWNERADDRESS �� �� TEL IFAXI 1 TYPIE-09 OCOUPANCYTYPE COpJMERGIALI I EDUCATIONAL (I RESIDENTIAL PRINT CLEARLY NEW: A RENOVATION:I I REPLACEMENT: j ( PLANS SUBMITTED: 'SES I I NO] I FIXTURES T FLOOR-* BSM 1 1 2 3 4 5 6 7 a 9 10' 11 12 13 14 BATHTUB I .. _..I ... CROSS CONNECTION DEVICE _... _ .... ......._.........., . DEDICATED 8RE61ALWASTE` OTEM 1. . i. ..�.� .....•., .._:..., DEDICATED GAS/OIUSAND SYSTEM • .. I ..._ i I ...,.....{ , :.._-.� DEDICATED GREASE SYSTEM ' DEDICATED GRAY WATER SYSTEM _I ...:.........._...._.... -..._....:..., :.. ....... DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER I'. i. . FLOORIAREADRAIN i i INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY I' ROOF DRAW SHOWER STALL ...--,�.•_._1—_....+. j_ 1,, ..... i SER=E/MOP SINK TOILET -- - -- - URINAL i --' WASHING MACHINE CONNECTION -- - -- — WATER HEATER ALL TYPES. WATER PIPING + rr , INSURANCE COVERAGE: —. __ I have a ctirrent.hsttratice po11gy.gr its stilistantial equiValent vrhich meets the requireniefits of MGL'Ch, 942. YES I X NO I I IF YOU CHECKED YES, PLEASE INDICATE THE TY.eE OF COV FRAGE .BY C14ECKING THE APPROPRIATE BOX BELOW LIABILITY 1148URANCE POL(CY'�, I OTHER TYPE OF INDEMNITY I ( BOND I, OWNER'S INSURANCE :WAIVER: I ani aware that the licensee.does not have the"insurance coverage required by Chapid'142 of the Massachusetts General Laws, and that-n)y signature on this Permit applieatioli v+aives this regttiretitent. . CHECK-ONEONLY: OWNER I I AGENT -1-1 SIGNATURE OF OWNER 0k AGENT I hereby certify that ali of the details and kfonnalion I havesubmltled of dntered regarding;this application and true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the permit issued for this application twill be in co ipliance W th Pdrlinent prevision of the -Plumbing Massachusetts Stale Code and Chapter 142 of the General Lags. PLUMBER'S NAME ]LICENSE ttl I Z 7 y SIGNATURE MPTP JPI 1 CORPORATION] .I11! jPARTNERSNIPI I1Ij LLC 1' I#' COMPANY N/A�ME1TMdo�(Q®lvn Il _1 �ADDRESSI V �f e j ! rL1/�r'� CITY] �fK f'I.S k STATZIP I 0 TEL (p03 f• d l 6 - 1 FAX CELL I .. I EMAIL I k o \ q U � k � . #/ , � R U 7 / 2 M m ® § k / � 0 § A U � A � � . m # LLI k k k� / k � % 0 M . 1 i..1* 1, � .#r,)vjrq a' 0, ws Am AO 11. � Sirdr. .ot M fin't tido lqr to. six p fbillw*4 (0 file-Ofaie-Or '4410, - , "j! iwi aprhoi qr,dVtA44Ycr (7r(Ce� pa nat I IrrhL, hk 61 lk area, 1-0 k, C'mumela 00"bruA*z 2. Ruilding DellaKrutolit 3. c-IfOW"t Ockh 4. C10 A Pla 11.0 W it Z. t= ftlntltelil�ib¢rt�itfi- .. ri.�A111R�Q1inCA�C�lllr(tClOiAltt Ef listed &flioat(aFlje(t 41061.4 S111pitit(HImilocalptoos� YD coilva6laghm Porwo fa ppy0j)(t6tv w111*10,11sill-alleo, P reacb. . wqvLl q! (.7--callf �flnlf it (..I., -ir Sirdr. .ot M fin't tido lqr to. six p fbillw*4 (0 file-Ofaie-Or '4410, - , "j! iwi aprhoi qr,dVtA44Ycr (7r(Ce� pa nat I IrrhL, hk 61 lk area, 1-0 k, C'mumela 00"bruA*z 2. Ruilding DellaKrutolit 3. c-IfOW"t Ockh 4. C10 A Pla 11.0 W it Z. 0 0 0 Rod Whim. of,rdpa'i r-Whirk oil N9911 (TIV61irugg 110rifu'. NOP 641,Por 152�gSC{6) also'sjqto t1lafseyer., , milloc . 01111pillyeafthrolralky H IiubdfytsI onis4vift ip ce EleaseftlLouf v61fipTdtdIv,,b k To& 110,111111UN-tt) aloi6b, m -11h n. IOUrance. If a ILC Or'LL*P does bino is Afs*Q rjp fox 110 sholild yo . . -a P-011fAdA1110111jolicy, please call kes ON or Tqji<ii 6irmaTs ICitat7itisPoti lePeaittprI4 I've Please be SlIrd to fill in the POVITIMicenswumiliar fvItIcl) %vil Lbaiisicd-asm- roreqO1111 nib.n. &d(fil'Lon, -.In applicanta f inu s f: s tibib it 11W lcfplf,-. P em I Rd& e I I se. Ipp) le a 601611111 arelV6 I yl� a q Tied -0111), t . fbililt (C!W-IDr K�Vii)2'A c9py of (lie., a ff i(TaVit thathasbeen OfflWallyshuppad 01- m afkdd by ifla.014, or to' 11 s ffhafa vaf[d s pron, 6j*M6-fbrAaureL' erml6pffice.nsps A p Ifelygt1daviflijusf filledplifeac co himercial V6qtuko a (Tog Rc-cilso Oriefauk to burn heaves etc) said V. 03-s011 I's XO)7rgqu Ired to c0ijActo tfds a. f f idlliif. (10. not jlesffdfa to-givim ft'cRIL MiJadment of IltdilsIefitlAccuiettts Olkew qfiftvovwfoll� 600,1vash hipil-&-tept Boston, AI&OUI) Date ..tp 17- ]).-1 ...... . TOWN OF NORTH ANDOVER ,2 PERMIT FOR GAS INSTALLATION f This certifies that .. .......`.... � .............. . has permission for gas installati........... in the buildings of .. J.P.�c .0.7. � �....................... at ..... �7p . �!4 VY1 �'�'� } �- ..... No h o er, Fee..3 d.7 . Lic. No..� t ... Ho . A ... . GAS IN Check # Vo 82) 3 �A0.0D e�4r490(A 16 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK — s CITY I NORTH ANDOVER MA DATEJ UNE 21, 2012 PERMIT # v' 1 JOBSITE ADDRESS DARTMOUTH ST. OWNER'S NAME JEFFCO INC. GOWNER ADDRESS JEFFCO INC. TEd 978-886-8408 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:Q RENOVATION:E] REPLACEMENT: E] PLANS SUBMITTED: YES® NO® APPLIANCES 7 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 ROOF TOP UNIT TEST - UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER CONNECT TO A PLUMBERS INSPECTED LINE INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E] OTHER TYPE INDEMNITY E] 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: 0 EN SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are rue a ccur a best y know!jpd§e and that all plumbing work and installations performed under the permit issued for this application will be in co Iia all rtin r ision of e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I JOHN COOMBS LICENSE # 30 SIGNATURE MP F-1 MGF Q JP E] JGF E] LPGI El CORPORATION E]# TNERSHIP ®# LLC ®# COMPANY NAME:j EASTERN PROPANE GAS ADDRESS 131 WATER ST. CITY I DANVERS _ STATE = ZIP 01923 TEL 800-322 6628 FAX CELL EMAIL 16 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston; M.4 02114-2017 ,.Print, Form www. mass.gov/dia Workers' Compensation Insurance gffidavit: builders/C0utrraCtOrS ler- ricians/Plumbers — - -- ��plicant Ic er-m Qn - Please Print Leaibly Name (Business/OrQanizationllndavidua]): EASTERN PROPANE & OIL Address: 131 WATER STREET City/State/Zip: DANVERS, MA 01923 Phone #: 978-750-6500 Are you an employer? Check the appropriate boa: 17/ I am a employer with 45 4_ E]I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 5. ❑ 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance. We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling b. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.7 Roof repairs 13 ❑ Other GAS FITTING *Any applicant that checks box "1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check: this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees; they must provide their workers' comp. policy number. i I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: LIBERTY MUTUAL INSURANCE COMPANY Policy # or Self -ins. Lic. #: WC7-641-435806-052 Expiration Date: 03/15/2013 Job Site Address: 9 (A Z$ c -i ✓•, o%. 4% ';1 , City/State/Zip4)04k JlA c4cyup , I o1c . 01f q(— 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 S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certifi) under the pains and penalties of perjury that the information provided above is true and correct. 03/13/2013 978-750-6500 Official use only. Do not write in this area, to be completed by cit)) or town official City or Town: Permit/License r Issuing_ Authority (circle one) I. Board of Health 2. 4. Electfical Inspector 5. Plumbing, Inspector 6. Other Contact Person: Phone r: I �` m . ,� C3 '° m fi7 • Tom:;,zZ ._ Mm aN u rn-n Al 7, 9'Load Short Form 0 °�'a. .- Entire House HEATING SERVICE Frank's Heating Service 555 Woburn Street, Tewksbury, MA 01876 Phone: 978-851-4403 Fax: 978-851-0398 Web: www.franksheating.com For/` 26 DARTMOUTH ST N. ANDC)VER, MA Job: Date: Apr 10, 2012 By: Htg Clg Infiltration Outside db (°F) 1 88 Method Simplified Inside db (°F) 70 75 Construction quality Tight Design TD (°F) 69 13 Fireplaces 0 Daily range - M Inside humidity (%) 50 50 Moisture difference (gr/Ib) 50 28 HEATING EQUIPMENT Make Trade Model AHRI ref no. Efficiency Heating input Heating output Temperature rise Actual air flow Air flow factor Static pressure Space thermostat 95 AFUE 0 Btuh 0 Btuh 0 OF 939 cfm 0.037 cfm/Btuh 0 in H2O COOLING EQUIPMENT Make Trade Cond Coil AHRI ref no. Efficiency Sensible cooling Latent cooling Total cooling Actual air flow Air flow factor Static pressure Load sensible heat ratio 13 SEER 0 Btuh 0 Btuh 0 Btuh 939 cfm 0.047 cfm/Btuh 0 in H2O 0.93 308 ROOM NAME Area (ft2) Htg load (Btuh) Clg load (Btuh) Htg AVF (cfm) Clg AVF (cfm) LAV 36 1020 646 38 30 KIT/DIN 308 4695 4154 175 194 LIVING 294 4310 3606 160 168 FOYER 112 1271 1177 47 55 MASTER BED 252 3955 3658 147 171 WIC 50 1445 885 54 41 MASTER BATH 90 1152 887 43 41 BATH 80 1065 862 40 40 LAUNDRY 54 1454 891 54 42 BED 3 168 2609 1797 97 84 WIC2 24 442 97 16 5 ALA i47C IA%S2 1 AA / F G Dr—LJ L Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. wrightsoft" Right -Suite® Universal 8.0.22 RSU10062 ACCP. F:\Wrightsoft HVAC2\Project\26 DARTMOUTH ST N. ANDOVER, MA.rup Calc = MJ8 Front Door faces: S 2012 -Apr -10 11:14:48 Page 1 Entire House d 1622 25241 20140 939 939 Other equip loads 0 0 Equip. @ 0.93 RSM 18730 Latent cooling 1630 T AI n Ar_nn nLnAA nnoCn non non LI■ LSJ Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. r� wrightSOW Right -Suite® Universal 8.0.22 RSU10062 ACCP, F:\Wrightsoft HVAC2\Project\26 DARTMOUTH ST N. ANDOVER, MA.rup Calc = MJ8 Front Door faces: S 2012 -Apr -10 11:14:48 Page 2 Sheet Metal Residential Guidelines / Inspection Checklist YesNo N/A " Detailed description and sketch of sheet metal system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license ✓ All sheet metal work being performed with proper journeyperson-to- apprentice ratios Equipment sized per heating / cooling load calculations Duct work sized per manual "6" calculations Bath / shower rooms contain mechanical exhaust fan vented outdoors Electric dryer exhaust properly installed maximum total run 35'-0", maximum flexible run 8'-0" Flexible duct installed runs 14'-0" maximum length Volume dampers installed for each supply air branch duct Ductwork installed using proper gauges and hangers Ductwork / plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining New/clean - properly sized filter installed (final inspection) Testing and Balancing report complete (final sign -off) Li T INI \YZM\ z cr) O WW \ QCO� \ �\ Cff171' N\ � za_ \ 0 o \ 444 ao-i LLI w ` CL Q� \ 3,0000 IZ.S�.- '00,00 l Z z O OJ \0 W(03) � Do LLJ MY ,b2 W -7 m O � U Iin LLJ( �Of af LO CJ �i!f p Y I I tt .. O r N CL Y U x Q a w o� � 09 LLI N O, I M riga—LL Q aCNN I Of _ Io a o 66 w + 8Z a z � J N9m In Q ' Y �+ 2 N �1 N � � - to > M Z to x 00 y 1 x I I Q Z 1 f I I w WD ry ,00'00 l 1 ' M„00,12,5 IN ! a mEco 4974 GUY PPJ c- REMOVE EXISTING CAP 6" 90* BEND 6" GATE VALVE 6" DI PIPE 6" SOLID SLEEVE COUPLING HYDRANT WORK ON DARTMOUTH STREET (ALTERNATE N0. SCALE: 1"=40' m cc Z o cp 0 E 0 0 U) .0CD cd cO E C C 0 cq to co N 674 11 CL m . Town of North Andover ZONING BOARD OF APPEALS Albert P.1\-lanzi III, Esq. Chairman Ellen P. McIntyre; 1-ke-Chairna11 Richard J. Byers, Esq. Clerk Richard M. Vaillancoutt Associate Alevrbers i -fichael P. Liporto D. Paul Koch ir. Any appeal shall be filed within (20) days after the date of filing of this notice in the office of the Town Clerk, —AA.— — (10„ T rh AOA R17 Notice of Decision Year 2011 Town Clerk Time Stamp Prnnertv at: 26 Dartmouth Street North Andover, MA 01845 NAME: Doug Ahern (JeffCo, Inc) HEARING(S): 8 November 2011 and 13 December 2011 ADDRESS: 26 Dartmouth Street (Map 23 Parcel 55), PETITION: 2010-009A North Andover, MA 01845 The North Andover Board of Appeals held a public hearing at Town Hall, at 120 Main Street, North Andover, MA on Tuesday, 13 December 2011 at 7:30 PM on the application of Doug Ahern (JeffCo Inc) located at 26 Dartmouth Street (Map 23 Parcel 55), North Andover, MA 01845. Petitioner is requesting a Special Permit from Sections 4.122 and 4.122.14.13 and 4.122.14 and Section 10.3 and Table 2 of the Zoning bylaws for an existing single family home, to be converted and constructed into a two family within the R-4 District. Legal notices for the Special Permit were sent to all the certified abutters provided by the Town of North Andover, Assessors Office, and were published in the Eagle -Tribune, a newspaper of general circulation in the Town of North'Andover, on October 25, 2011 and November 1, 2011. The following voting members were present: Albert P. Manzi III, Ellen P. McIntyre, Richard J. Byers, Richard M. Vaillancourt and D. Paul Koch Jr. The following Associate member was present Michael Liporto. The Chairman Albert P. Manzi III recused himself from the vote and Deliberation Vaillancourt made a motion to Grant the Special Permit from Sections 4.122 and 4.122.14.B and 4.122.14 and Section 10.3 and Table 2 for an existing single family home, to be converted and constructed into a two family. Vaillancourt referenced all the plans in front of him along with the dates. With the following conditions: I. -That the gutters are maintained in good working order per manufacture's specifications for the life of the Condex Units. 2. -Infiltration system maintained per manufacture's specifications for the life of the Condex Units. 3.-Maintanance on these items as designed should be written into documentation of the Condex Units. Byers second the motion All were in favor to approve the Special Permit: Ellen McIntyre, Richard Byers, Richard Vaillancourt, D. Paul Koch Jr., and Michael Liporto. 5-0 Pagel of 2 The -Board finds that this use, as developed by the building & site plans, is an appropriate location for such a use and will not adversely affect the rieighborhood. There will be no nuisance or serious hazard to vehicles or pedestrians, since there are provisions for the required off-street parking. Adequate and appropriate facilities will be provided to construct a second family dwelling *'on this properly. The Board finds that the additional second dwelling will not be substantially more detrimental than the existing dwelling to the neighborhood and that this use, is in harmony with the neighborhood and general rnirnnea a„rl infanf nffh; 7]s.1-, Site: ILALJ L LCLYV. 26 Dartmouth Street (Map 23 Parcel 55), North Andover, MA 01845 Section 4.122 and 4.122.14.B and 4.122.14 and Section 10.3 and Table 2 for an existing single family home, to be converted and constructed into a two family within the R-4 District. Plan(s) Title: 1) "Plot Plan of Land" Dated November 18th 2011, containing one (1) sheet. Prepared by Merrimack Engineering 66 Park Street, Andover MA 01810 2)"Proposed and existing Plans" Dated Sept 12, 2011 containing four (4) Sheets. Front Elevation of proposed and existing, Front Elevation of Existing House outline, First Floor Plan and second Floor Pian,. Prepared by Gerard E. Welch INC, P.O BOX 248 North Andover, MA, 01845. Voting in favor: Ellen P. McIntyre, Richard J. Byers, Richard M. Vaillancourt, Michael P. Li orto and D. Paul .Koch Jr. Voting in the Negative: N/A The Board finds that the applicant has satisfied the provisions of Sections 4.122 and 4.122.14.B and 4.122.14 and Section 10.3 and Table 2 for an existing single family home, to be converted and constructed into a two family for property located on 26 Dartmouth Street (Map 23 Parcel 55) in an R-4 District. Notes: I . This decision shall not be in effect until a copy of this decision is recorded at the Essex County Registry of Deeds, Northern pistrict at the applicant's expense. 2. The granting of the Special Permits) as requested by the applicant does not necessarily ensure the granting of a building perrnif as the applicant must abide by all applicable local, state, and federal building codes and regulations, prior to the issuance of a building permit as required by the Inspector of Buildings. 3. If the rights authorized by the Special Permit are not exercised within two (2) years of the date of the grant, it shall lapse, and may be re-established only after notice, and a new hearing. oi-th Andover Anin Bo d of Appeals Albert P. Manzi III, Esq., Chairman Ellen P. McIntyre, Acting Chairman Richard J. Byers, Esq., Clerk Richard M. Vaillancourt D. Paul Koch Jr. Michael P. Liporto Decision 2010-009A Page 2 of 2