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HomeMy WebLinkAboutMiscellaneous - 26 MAIN STREET 4/30/2018LaMarche Associates 5 North Road, P.O. Box 250 Chelmsford, MA 01824 800-349-1525 Fax: 978-256-8590 May 14, 2015 Building Commissioner/Inspector of Buildings NORTH ANDOVER, MA 01845 Board of Health/Board of Selectmen NORTH ANDOVER, MA 01845 NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B Claim has been made involving loss, damage or destruction of the property captioned below, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss, cause of loss and LA file number. Insured: PONDVIEW CONDOMINIUM TRUST Loss Location: 26 MAIN STREET NORTH ANDOVER, MA 01845 Policy Number: BO111866 Date of Loss: 02/28/2015 Cause of Loss: Water LA File Number: MA -2-29289 On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. John Anderson Adjuster LaMarche Associates, [nc. - 800-349-1525 Page 1 of 1 This certifies that .. )..... `1 (...:Q._.F...0..-{�,.... . t� Sw P5 tU / ry Prco S has permission for gas installation in the buildings of. at ...�Q .M.rNPP. h�5 (.. , North Andover, Mass. `1.. ►`1 . %. -� .. .. .................. ... Fee Lic. No..1.2. GASINSPECTOR Check # 8760 V •` — - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK f Ion CITY - MA DATE 7~ , 7 Lf71 PERMIT # LD I �6 JOBSITE ADDRESS _?_ OWNER'S NAME GOWNERADDRESS F TYPE OR OCCUPANCYTYPE COMMERCIALEDUCATIONAL Ll RESIDENTIAL' PRINT CLEARLY NEW: RENOVATION: E1 REPLACEMENT: PLANS SUBMITTED: YESE] No APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 1 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE- . a ---J] DIRECT VENT HEATER DRYER 1 _r i I I-- _. mt FIREPLACE FRYOLATOR FURNACEGENERATOR GRILLE_- INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT I _=1 I__ _ __ -_ i-__ 1, r _-1 OVEN POOL HEATER _ T ROOM / SPACE HEATER ROOF TOP UNIT C ST __.-J UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER �_ - 1 Y�. I INSURANCE COVERAGE the MGL. Ch.142 YES INAO E have a current liability insurance policy or its substantial equivalent which meets requirements of IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER .0 AGENT El 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 compjiame with all Perti provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME LICENSE #E SIGNATURE MP MGF JP JGF LPGI CORPORATION _J # PARTNERSHIP 0#il LLC 1# COMPANY NAME: ,1 ADDRESS rQ(h1V1 CITY --_--_11 STATE �ZIP - TEL FAX ...__ CELL—EMAIL �I H O z 0 H U W A4 rA W o El Z O HEl W � � ~ W [Oi CL Z U w 3 a F- w CO wCO 5 O w a �+ w d w N a 0 a a a U J H a a a � � w x w F- w L H O z o � H U a � O ' CODW c7 - a 0 9 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kvi 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Address: J/ 6LnWn /i f (( � d J J City/State/Zip: /%('J S6,1 Nk 63&(( Phone #: 603 1 Fi� %6 -0 Are you an employer? Check the appropriate box: 2 LID 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 11Plumbing 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. #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. %� /F/ Insurance Company Name:. d / �/ f Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address:2 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. I do hereby certip under the spins andpenalties ofperjury that the information provided aabove is true and correct. Signature: , Date: 1�2 7-0�7 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Person: Phone #• 4A q N Information and Instructions - Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The, Com- monwealthofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston} MA. 02111 Tel, # 617-727-4900 ext 406 or 1-877rMASSA.FF Revised 5-26-05 Fax # 61.7-727.7749 www.m,ass.govfdia � w w ,,This certifies that ... l .\Aryl -..O- Qi e ..... . . . . ........ . . . has permission for gas installation ..... ... O ►Vu-i in the buildings of. . p�r', at ....�.--�yp.. "I a., -I- .�3N e... , , .. , , Nort Andover ass. Fee. ) 0 Lic. No.-Q-741. .... GAS INSPECTOR Check #_4br58 0565 N .4a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 1,4 —d—(5 .__� MA DATE Z(7 PERMIT# C10%K q'1 5 OWNER'S NAME JOBSITE ADDRESSZ Ml GOWNER ADDRESS TEL i z Q FAX I TYPEOROCCUPANCY TYPE COMMERCIALE] EDUCATIONAL ] RESIDENTIAL c CLEARLY NEW: [ RENOVATION: �I REPLACEMENT: E � , g PLANS SUBMITTED: YES []-_I No E-11 APPLIANCES -1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1- _ BOOSTER1- CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE i _ I z I I { �- —. GENERATOR - - - - GRILLE IBJ i =.- INFRARED HEATER . - I-�f (' I= I _ - -j L LABORATORY COCKS MAKEUP AIR UNIT OVEN __ _-_ t I �� - L I v POOL HEATER ROOM / SPACE HEATER= -1 - _._ ROOF TOP UNIT TEST UNIT HEATER _ UNVENTED ROOM HEATER WATER HEATER - _. i i� __,i I__ J i__ L �_� I'l _ .J OTHER - --- -- - - _ J lm- L = —f L_s.! _I INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 1((NO E] i 11` YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L OTHER TYPE INDEMNITY D BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER F-11 AGENT �1 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 com ' ith all Pertinenn vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / PLUMBER-GASFITTER NAMELICENSE #y, 7 _ SIGNATURE NPP MGF- JP [ i( JGF LPGI 1 CORPORATION# PARTNERSHIP# ' LLC COMPANY NAME: t#=11ADDRESS CITY STATE _ - 11%} _ II L�`!LI�JZIP ©_3 ITEC O - 6-- FAX CELLL- _ _ _ EMAIL 11aa117-5 1 AVz' -cam tnfi l -P- I 11K171`I+1 %111` 1117 '1 0in.-Y Q 11011 j F- LU IL 4 I' N r 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 Name (Business/Organization/Individual): City/State/Zip: ( (Phone #: �� &0 U Are you an employer? Check the appropriate box: Type of project (required): 1. T, I am a employer with 7— 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. # F1 Remodeling ship and'have no employees These sub -contractors have 8. E]Demolition working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its 9. 0 Building addition [No workers' comp. insurance required.] officers have exercised their 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. ['lumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance ] ired. re q ut employees. [No workers' 13.0 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 aie doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: 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. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: w 0: 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 ofhire,- 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. t 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 ofIndustrial Accidents Office of Investigations 604 Washington Street Boston, MA 02111 Tel, # 617-727-4900 ext 406 or 1-877,7MASSAFB Revised 5-26-05 Fax # 617-727-7749 wwwanass,gov%dia This certifies that ... ........6 . I- ...................... has permission to perform .. (C) �r�!tJY1Ov.�PS- plumbing in the bulli ngs of. -1Z .Q............ . ... . at...... , .4a-t" .... N • • •-�, t�•� • • • • .. North Andover ass. Fee 2 Lic. No. 27'K.. —/ .... .. . PLUMBING INSPECTOR Check # -P. 101 -01 -I1 -D %&.1*7VnVG&--CA_ m Il )Fo;jlt11 ��1��I�7i L^- C—G.-P 101t I�7 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY 0" © _ _ �I MA DATE -7 7 -Z�tnRMIT # JOBSITE ADDRESS Vq OWNER'S NAME POWNER ADDRESS' O s TEL TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL$ PRINT CLEARLY NEW: 0 RENOVATION: Q REPLACEMENT: Q U,,CZ C44a,54 LANS SU PITTED: YES © NO®ICr� FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _[ _ (. _ ! I [ __-- f __.----- CROSS CONNECTION DEVICE (.__._ E I _ I �._, ( __. _._ .__-1 _.____I _...__..f .___.__I ._____f_ ( _I DEDICATED SPECIAL WASTE SYSTEM M_el ._._.._._1 _ _I _.__.__.I ___J _..____I _____._� ._.___1 __j ---j- DEDICATED GASIOILISAND SYSTEM (_.__ r DEDICATED GREASE SYSTEM ( I { f _ [ —_f I ------- _.___1 ___J DEDICATED GRAY WATER SYSTEM ! [ I .-_ ------ I __ _ I _ ! I _._._- DEDICATED WATER RECYCLE SYSTEM DISHWASHER__._� DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN �?1 ..__ - I f 1 (—_.._J 1 ...__! _1 ..-.___ ..__.-.._( INTERCEPTOR (INTERIOR) KITCHEN SINK ---j ------ ----.__ LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION m t 1 ! -- -_.I _ A i _ .. ' _ . (_ WATER HEATER ALL TYPES WATER PIPING d ! —__1 ...._.....! _i i _I _ i ........._; I i OTHER iF INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Df BOND Q OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the lassachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT ID, SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application willbe'pliance all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME[,/ -- _._ LICENSE # f SIGNATURE MP _4 JP CORPORATION F # PARTNERSHIPO# _ ! LLC COMPANY NAME _ 0 ADDRESS L CITY__..__..._.........._f STAT ZIP TEL % FAX CELL EMAIL f 101 -01 -I1 -D %&.1*7VnVG&--CA_ m Il )Fo;jlt11 ��1��I�7i L^- C—G.-P 101t I�7 I El z N ❑ W iui W LL o The Commonwealth of Massachusetts Department of Industrial Accitlents Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual):, yanization/lndividual): Address: 7 N( City/State/Zip: S©(��I i fl 3�� Phone 4:& 7 Are you an employer? Check the appropriate box: Type of project (required): L& I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. E] Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its g• ❑ Building addition [No workers' comp. insurance required.] officers have exercised their 10.❑Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 1 ITY Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13. ❑ 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 aie doing all work and then hire outside contractors must submit anew 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:. J 1 P 1 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. 1 do hereby certify under dlpains and Phone #: that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: w Information and. Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -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: Tho Commonwealth of Massachusetts Department of Industrial .Accidents Office of Investigations 600 Washington Street Boston, MA, 02111 Tel, # 617-72.7-4900 ext 406 or 1-877rMASSAFE Revised 5-26-05 Fax # 617-727-7749 wwwanass,gov#dia f h 7iF F i f PERMIT FOR WIRING This certifies that ..... ..... ... , .... , .. . has permission to erform . wiring in the building of .�� `2- ........................... at .... 2k .. �� , . , . , , , . , rth Andover, Mass. Fee .`�ca . Lic. No.(.r:..... .. ELECTRICAL INSPECTOR Check # It P /t>3 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS (Please add zip codes & electrician's cell #,- contract # & bid permit # if applicable.) Official Use Only Permit No. ]1�& Occupancy and Fee Checked :ev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 1i3 City or Town of: /0. %'�/er To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work de.,crihnri hP1r)w Location (Street & Number) a� j J Owner or Tenanta�a� 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 New Service Amps / Volts um er o ee ers and Ampacity Location and Nature of Proposed EIectrical Work: Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ Qs No. of Meters No. of Meters cIs —IC,r-yl No. of Recessed Luminaires �•-t ur, �.J ane.10 0!!� No. of Ceil.-Susp. (Paddle) Fans ruule may oe waived by the inspector of Wires. 1140. 01 Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ o. o mergency ig i ng rnd. grnd. Batter 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 of Ranges Totallo. No. of Air Cond. Tonslo. of Alerting Devices No. of Waste Disposers Heat Pump Number """"' Tons ."""."""."" . of Self -Contained Totals: 7qD tection/Alertin Devices No. of Dishwashers Space/Area Heating ICW cal❑ Municipal ❑Other Connection No. of Dryers Heating Appliances Its, Security Systems:* No. of WaterNo. of No. No. of Devices or Equivalent Heaters KW of Signs Ballasts Data Wiring: ---TNo. No. of Devices or Ei uivalent No. Hydromassage Bathtubs of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: SAttach additional detail if desired, or as required by the Inspector of ll,`ires. Estimated Value o Electrical Work: 3o�.�j (When required by municipal policy.) Work to Start: 54W Inspections to be requested in accordance with NEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER X (Specify:) Self Insured I certify, under the pains and penalties ofperjury, that the infgr.�natior on this application is true and complete.FIRM NAME: ADT LLC DBA ADT Security LIC. NO.: C-172 L' Licensee: Thomas J. Lee ignature ' LIC. NO.: C-172 (If applicable. enter "exempt" in the l' ense number line.) ~" - Address: i C• i r� m 'i r . �� \\is, N \ O �O �1 Bus. Tel. No.:�o V3 t� `S�iaB *Security System Comraetor J icense required for this work; if applicable, enter the license number here: No.:,*001779 OWNER'S INSURANCE WAIVER: I am aware that the Licensee sloes 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. PEdZMIT FEE. $ - / fes- °eX�. 41 /2-0/3 /97-3&s-90 - ` - ------ � - COMMONWEALTH OF MASSACHUSETTS ELECTRICIANS * uEEuuyu/Exoco TRAcTO ` ~~.E..E.~.,E LICENSE TO: . ~ SECURITY . ` / uoA ADT -- -Nil -VERS ^.. AVE � �E,..,,, "* 0209v-231 � 172 C 07/31/13 2019341 _'hcn ___h'_~~~~~ . . Date ..� 2 ..........(Q�✓ l ..................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .....: �...... ..... � � 0. ............ ��......... has permission to perform .. _ P. w ............................................................................... wiring in the building of..... .P . „ ...... • at .....Z. ..... 0(,(\, ............. . rth Andover, Mass: ..................�. Fee,3 D.......... Lic. No.114Y, A.Z.................... . ..... ......... ... ... ........ 01 ELECTRICAL INSPECTOR Check # 1 r- Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. �1 4 Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL MFORMATIOA9 Date: —j 3 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives noticeorhis or her irate tion to perform the e ctrical work described below. Location (Street & Number) (o vi/�Gc I t) Y Owner or Tenant lg� O Telephone No. Owner's Address ,Q "id ZAlvevel, 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 Serviced Amps 1 / Z YaVolts Overhead 0 Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: , IA /?� n e iv -7-y k1A 011,5-42, Completion ofthe following table may be waived by the Inspector of Wires. S No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- Elo. rnd. rnd. o mergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number ..................................................... Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coveXe is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE V BOND ❑ OTHER ❑ (Specify:) I certify, under tlteptiins anter penalties ofperjur�, that the inorma{ion on this application is true and complete. FH2M NAMFyL /Xi{.� r r � 4 JL'�''t/r C L�g 0.: l q6 t W Licensee: ro p_r7- Gh �(�i�,Y/�% Signature t LIC. NO.: ` (If applicable, rater "exempt i the 1F� e yber lipe.) l e� ®3� Bus. Tel. No. - `Z 7-6 " `1(p Address:, di7 i f e� J4k / Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. � OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the IT permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed ❑' Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass F X Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL Ilei PECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Co ments: r `4*r` Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com N s' M w The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information M6171-1-11 Please Print Le iblNaMe (Business/Organization/Individual): � L / �CCY, Address: City/Stip: 5a1fi-14- Vv Y i9 -O Phone #: Are ou an employer? Check the appropriate box: Type of project (required): 1. M I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. t 7• ❑ Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition workingfor me in an capacity. Y p tY• workers' comp. insurance. 5. ❑ We are a corporation and its 9. E] Building addition [No workers' comp. insurance required.] officers have exercised their 10.0 Electrical repairs or additions 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.❑ Roofrepairs insurance required.] t employees. [No workers' 13.[i 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 aie doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:, Policy # or Self -ins. 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. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Signature: %� Date: Z 2- (o 5 —/ 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 Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to 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 Mossachusetts Department of Industrial Accidents Office o£Iavestigations 600 Washington Street Boston, MA, 0211.1 Tel, # 617-727_4900 ext 406 or 1-877rMASSAFB Revised 5-26-05 Fax ## 617-727-7749 www-mass,gov/dia I� �.a'. AIA° m ''zr• �1V,�a�B N .y', p • y i m �✓ ° _y PAZ. M q D m m [.°W W W > �. C` C O W ' �.,N � o ? • o O Q Q � LO O •a i 'a O Q � i� This certifies that..V1I.�'��..L��.�'.A� ��{2v•...... �. 40 has permission to perform . ..... �'15:� ............ .� . wiring in the buildin of at ... 2.(,:. NA,— V.(,-! .1.... Z:..... ,rth Andover, Mass. Fee x;�L ." .. Lic. No 2.�`+(.ov.. ..... . ELECTRICAL INSPECTO Check,q,. 10(I 4 111 YW Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. M2q l 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 (NEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL MFORW TIOA9 Date: -) --LI City or Town of: NORTH .ANDOVER To the Inspector of Wires: By this application the undersigned gives notic of his or her intention to perform the el c ical work described below. Location (Street & Number) -A 1A%� !J�'l / - Owner or Tenant -ZT-L° r-� O i ^ Telephone No. Owner's Address �O , �� X 'g0 2f A DVel�i Is this permit in conjunction with a building permit? Yes 2' 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: re n&,✓ -/-0 Lv/Z do IvS (!�i r'mmnlotinn nftho fnllnwina tnhlo mm) ha wnivad by thv %n.cnector of Wires. No. of Recessed Luminaires No. of Cell: Susp. (Paddle) Fans V No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- E] rnd. grnd. No. o Emergency Lighting BatterV 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 g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Dis posers p Heat Pump Totals: Number Tons I.KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Securitio o Devin s or Equivalent No. of WaterKW Beaters No. of No. 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 E uivalent OTHER: Attach additional detail if -desired, or as required by the Inspector oJ 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 c9""'BONDE1 ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OTHER ❑ (Specify:) Icertify, under the nips an j enalties ofperjury that the information on his application is true and complete. FIRM NAME:. ' %i°G v' r LIC. NO.:��� Licensee: e�j'/e/'- Signature Z LIC. NO.: % 1 1l6 (Ifapplicable, X enter "exempt" in the license number l line.) Bus. Tel. No.• �� "-79"��,� Address: pDr RO1rS 7� .5fte_!M 6210 Alt. Alt. Tel. No.: *Per M.G.L c. 147,-s. 57-61, security work requires Department of Public Safety "S" License: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, they permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: h Inspectors Signature: U Date: ROUGH INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: f Inspectors Signature: Date: FINAL IN CTION: Pass Failed ❑' Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: / Date: DEB WEINHOLD ... TOWN OF MER MAC, MA. .......dweinhold@townofinerrimac.com r J s 10 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 - UV. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plum-bers Applicant Information Please Print Legibly Name (Business/Organization/Individual):"' Address: City/State/Zip: ; �� (�� % ®��Yhone #: �� -7,? ``L Are u 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. shop and have no employees These sub -contractors have working for mein any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and.their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site information. f Insurance Company Name: Policy # or Self -ins. Lic. #:_ Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under 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 da hereby certify under the pains and penalties of perjury that the information provided above is true an �dact. Signature: 2— Date: / -- Li -7 � -I/Z Official use only. Do not write in tins area, to be 6ompleted 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 6. Other 4. Electrical Inspector 5. Plumbing Inspector f w z V) m .s Oiz Pte+ Et PAZ • M cu p O m(Y m W W N c CO p .._m Q Jiz y Lo (n W U O Co 0c) CD i � U f PC This certifies that C N41' K ................................. Date............................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING has permission to perform ...@.Q: J .............................................................................. ................................................................................ wiring in the building off..j.��... k..!'Y.�.cjo........ �--/0-............................................... at . — �—}l ✓p e `J �` �' 1-.... , North Andover, Mass. ..................................................................................... Fee ` ......... Lic. N072VA A ' " � ELECm cAL INSPECTOR Check4t 11 b4 K, q Commonwealth of Massachusetts Official U ly Department of Fire 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 W INK OR TYPE ALL )NFORMATION) Date: 3 -- 6 1 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. C Location (Street & Number) %f Owner or Tenant "fGD Owner's Address f �, �e� Is this permit in conjunction with a building permit? Yes ❑ No ❑ Purpose of Building - Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: W Telephone No. (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters 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 KVA No. of Luminaires Swimming Pool Above ❑ In- Elo. rnd. rnd. o mergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. TotalTons No. of Alerting Devices No. of Waste Dis posers p Heat Pump Totals: Number - Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers y Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of DataWiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent 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 L� BOND ❑ OTHER ❑ (Specify:) I certify, under th aims d penaltiesf per'ury, that the in ntation�on this application is true and complete. FIRMNAMP/11.// G LIC. NO.: % g� Licensee: Signature NO.: (If applicable, nter "ex pt" in the license number line.) Bus. Tel. No.: Address: o -0 7 Alt. Tel. No.• // *Per M.G.L c. 147, s. 57-617, security work requires Department o Public Safety "S" License: Lic. No. • OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ 3ecl Signature Telephone No. I. ❑ 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 of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass EN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL GH INSPECTION: Pass V Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: a Date: 3 7--'� ROUGH INS CTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: " A Inspectors Signature: Date: — 7— / FINAL INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comment Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com r 7 The Commonwealth of Massachusetts Department of IndustrialAccidents 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. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 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 K ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. 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. am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site :formation. asurance Company Name: olicy # or Self -ins. Lic. #: :)b Site Address: Expiration Date: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 Cup to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. ignature: 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 #: r �1 4 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 of 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 .evised 5-26-05 Fax # 617-727-7749 www.mass,gov/dia r • •fir! m '/ i p 47 L�Bji O 4. • .9 Qf_ 3 W�. r • •fir! m '/ L� 43l A0 . Ln . 31.V p 47 L�Bji O Qf_ 3 W�. O _co O 0 4 Q o q Lo iA W 86 'm e t Z • .• .. to ' N J L I J i % f r This certifies that ... 0,.k. .� LIQ � e.., P e, has permission to perform l P.�,�l ? N �n ........... wiring in the building of "T! 4-3-r , s�.. -�--�` 0 at .' . .. �..t.. i An. V �; �- . � `? , , North Andover, Mass. .... Lic. No.7`71 k,k '� .. �.. . ELECTRICAL INSPE TOR Check # a 0 111 11398 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Onjy Permit No. 1 Occupancy and Fee Checked [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: A —LA — 13 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perfo the ele trical work described below. Location Street & Numbe Owner or Tenant d Owner's Address pl') Jqo x Telephone No. Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service New Service Amps / Volts Overhead ❑ Undgrd ❑ Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 'j✓l re j'l (,(,J 7-0 % 0 U S Completion of the following table maybe waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: (Paddle) Fans Total TransSusp. Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ o. o-TEmergency Lighting rnd. grnd. BatterV 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 o. 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 r Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: �J Attach additional detail if desired, or as reptired by the Inspector of Wtres.� Estimated Value of Electrical Work: (When required by municipal policy.) r �� 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 e is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ND ❑ OTHER ❑ (Specify:) Icertify, under the sins a penalties ofp rju7,1ha the i formation on this application is true and complete. FIRM N r 1 Chi ('rvIt _, es LIC. NO.: � Z,1 L%6 Licensee: �� Signature s . NO.: ZI q69 (If applicable ter "e empt" 'n the license number li(�e.) A Bus. Tel. No.: Address: 1 E(J 0 - 2- (ewL tai/ p D 7F Alt. Tel. No.: *Per M.G.L c. 147,–S. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass IN Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass EN Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: 1 r Inspectors Signature: Date: ROUG SPECTION: Pass - Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass 04 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia !1Vorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print L-eeibly 5 Name (Business/Organization/Individual):' �)� ���//7 �1 C lj 2rtz Address: City/State/Zip: f A�?al�hone ._..!K'7 Are u an employer? Check the appropriate box: 1. fam a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 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.❑ 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. 7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors ttiat 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 informatio. z. Insurance Company Name: Policy # or Self -ins. Lic. #: 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 v correctILI//,; Sienature: Date: �3 � - Li -7 � --I/Z Official use only. Do not write in'dils 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 C'nntart PPrcnn• Phnna it- Date..." 151 ... l..5 .............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...........�� , ............................................. has permission to perform . (9Uf,' — G�,!,%............ %@uvi,fbvl�'" a .— t firing m the building of.....�P'/\.K/........................................ at ......... --`�✓ H. 1 ..!. ^...--?.!r�Q� ................... /...... , North Andover, Mass. .............I Fed 765. ... Lic. No .................. ............... ......... J ECMCI AL INSPECTOR V Check # �� 15 WWI 11, Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only /� Permit No. I 1 Ll 7,2— Occupancy ZOccupancy and Fee Checked [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 IN)NK OR TYPE ALL INFORMATIOA9 Date: .2 o1 -s- — ) J City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Num Owner or Tenant --��, Owner's Address V, INS" , Telephone No. Is this permit in conjunction with a building permit? Yes N No ❑ (Check Approprix . Purpose of Building Utility Authorization No.13-760 - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ o. of Meters New Service ��� Amps `o7P /NOVolts Overhead ❑ Undgrd [ No. of Meters IT Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: /7 P(i✓ Completion ofthe 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 KVA No. of Luminaires Swimming Pool Above ❑ In- Elo. o mergency Lighting 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 Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices Nos of Waste Disposers Heat Pump Totals: I Number ....................._"' Tons KW No. of Self -Contained Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local ❑Municipal El Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under th pdins d penalti of erjurp, that he ' forntatfon on this application is true and complete. FIRM NA ff -eb LIC. NO.: 02 Licensee: Signature IC. NO.: (If applicable, t r "ex mpt" i the icen numberlin) /' A , Bus. Tel. No. -q')6-q2%- Address: - " Address: ppo. 6 Z f 0 1 2- �ci.�- rk"-. [� v � Alt. Tel. No.: *Per M.G.L. c. i47, -r57-61, security work requires Department of Public Safety "S" License: Lic. No. • OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner [:]owner's agent. Owner/Agent PERMIT FEE. $ 7 Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pas ? Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass EN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Y Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n Failed 0 Re- Inspection Required ($.) ❑ r" Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass F?] Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ..'.TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts 07 Department of IndustrialAccidints Office of Investigations IN 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name Address: F , Q f r I ( cct ( jet✓��C' S d Phone #: Z ? i� — 7 � `' / ( t 16 Aye)6u an employer? Check the appropriate box: Type of project (required): 1.M I am a employer with 4. ❑ I am a general contractor and I 6. FJ New construction . employees (full and/or part-time).* have hired the sub -contractors 7• ❑ Remodeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet.1 ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions " required.] 3. I am a homeowner doing all work officers have exercised their right of exemption per MGL 11. ❑ Plumbing repairs or additions y myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roofrepairs insurance required.]r employees. [No workers' 13.❑Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insura4ce Company Polic # 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 DIA for insurance coverage verification. Ido hereby cert' under thepains andpenalties ofperjury that the information provided above is true and correct Signature: Date: 2 2,5--13 ,5-- ? zr-7 � — f6t` Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person Phone #: Information and. Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have ' employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.' Please be sure to fill in the permittlicense 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 TO, # 617-727-4900 ext 406 or 1-877-MASSAFB Revised 5-26-05 Fax # 617-727-7749 wwwanass.govldia FEB -21-2013 13:01 PAUL DAUIES ASSOCIATES 1,.. ur 1 4., xr"0,c r February 14, 2013 Mr. Gerald Brown, Inspector of Buildings 1600 Osgood St. - North Andover, MA 01845 10% Re: Project 3127 Jeffco, Inc Eight Unit Condominium 26 Main St. North Andover, MA Dear Mr. Brown; 978 654 5135 P.01i01 The developer of the above referenced project would like to relocate the second means of egress of each unit from the second level deck to a rear 2'-8" door. This complies with the 8th Edition of the Massachusetts State Building Code, Section R311 Means of Egress. If you have any questions please call All. PnrYPrc V I Init A I nwPI1. MA 01852 978-459-2154 TOTAL P.01 FEB -21-2013 13:01 PAUL DAVIES ASSOCIATES L, February 14, 2013 Mr. Gerald Brown, Inspector of Buildings 1600 Osgood St. - North Andover, MA 01845 Re: Project 3127 Jeffco; Inc Eight Unit Condominium 26 Main St. North Andover, MA 978 654 5135 Dear Mr. Brown; j. The developer of the above referenced project would like to relocate the second means of egress of each unit from the second level deck to a rear 2'-8" door. This complies with the 81h Edition of the Massachusetts State Building Code, Section R311 Means of Egress. If you have any questions please call L g!'A"sasaaw Amw- --� d �40 k H66- �.� a flow �. �T z P.01/01 A.15 Pnnpm .Cf I lnif A l owPll. MA 01852 978-459-2154 TOTAL P.01 err This certifies that... .. . has permission for gas installation av in .. �.IJ L ....... in the buildinrgs, of JSP �� a at . .. .,............. .... ,North Andover, Mass. Fee h...... Lic. No.�qg,4.... .A .................. ... GASINSPECTOR Check # M109 8547 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .- GOWNER TYPE OR PRINT CLEARLY CITY 1. NORTH ANDOVER I MA DATE JANUARY_ 10, 2013- PERMIT # I JOBSITE ADDRESS 1,26 MAIN ST. OWNER'S NAME I JEFFCO INC. (STAN) ADDRESS JEFFCO INC. (STAN) TE 978-609-3762 FAX OCCUPANCY TYPE COMMERCIAL EDUCATIONAL E] RESIDENTIALE] NEW: RENOVATION: El REPLACEMENT: 0 PLANS SUBMITTED: YES® NO® APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 12 13 14 BOILERBOOSTER a0i CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE - ! - _ ---- FRYOLATOR FURNACE GENERATOR 1_ GRILLE INFRARED HEATER . LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ! ROOM / SPACE HEATER ROOF TOP UNIT I TEST _- - UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSTALL AN UNDERGROUND 1 GAS LINE AND CONNECT TO A PLUMBERS INSPECTED LINE INSURANCE COVERAGE I 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 0 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• Wr E714GINT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application re ue d acr e t th est o y knowledge and that all plumbing work and installations performed under the permit issued for this application will be in p' n ' all P rtin nt p ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME JOHN COOMBS LICENSE # 3 SIGNATUkE MP F--1 MGF ® JP ® JGF LPGI E] CORPORATION E]# P TNERSHIPF-1# LLC ®# COMPANY NAME: EASTERN PROPANE GAS I ADDRESS 131 WATER ST. CITY I DANVERS STATE MA ; ZIP 01923 TEL 800-322-6628 FAX CELL EMAIL i �---_ The CommorwcaZth oj_/�ccssucrvwseryr Jcparrmen: o, Industria%_tic^iQunZ JJfzcoJlnvesilcgZions ZLZL�E i 00 C, jor - yv x w _ maS s o v%aia - , F ��._-�i�a�s yUn 1 5,� mb \7,1 �' rnmr��n 3C10Z_.1Z�iL�aIl�_-_IT1Ct8� Z /C _ rr rtr � lila — - - -- — '' "_:=S=RIv PP,'OPF�IJ= & 'OlL N2-IT't Eusmtss/Jrpnizan0n%jndTvldualj ddTt-QS City / S-Lat--/'Zr VV k. 1� P'T rR E I DANV=P.', MA D1923 978-75C-0300 Are you an employer? ChEch the appropriate boii: ",5 7' ' am a general conte aotio- and I 1.2I T am a tmQloYEr with employees (cull and/or par-=---) � have fired the sur,-coIlaactors art, a sole prooriator o: partner- listed on the attached sheet. ThesE sub coma i ors have ship and have no employees employees and have workers' w0r-I=E for int in any capacity. COMP. iLS1Lr3IlGE. PJO worker' COMP. insurance required �. � -We are a Cor potation.and its officers have e}.ercised tizEir 3. 1 am s homeovmem doing z1] wort: right of e�.empnon per hSGL ro�5e1T No workers' comp. mp" c. 152 01(4;, and wE have no i-msumnct required.] t V�-s" j��io workers' employ comp. ins=anct requ-imdl Type of project (required) I�Aw conSu-uC-DOIl 7. ❑ Y_..mode]ing I DEmolitl07l I g. Building addition ] U.❑ Blecu icai repairs or additions 11.[� Plumbing repaz s a additions 12.[:] P oof repairs G>L.5 F—1i I IJ G 1--ny, appIicent thz chemo box tl MTs also a out the sacrior brlou shower tn� warmer c,�mDAnsanon polite n,ir rr tzriOIl. c Ilw� 74a1'Li lIlQ1Q8tm= sll L. Eiom_.owners whn mirrm = amdnl: mdica=6' the; are mmg aD wow and Zhu ] ou*sici carr Mrs semi' - i- - a==and an atldm.� Stun'- ShOwl21� tht IIE.In"t 0 tU -nZh 3Ontra" LD;, and matt whefa%= ❑-n0i TIlQSe �LL77.:5 233V� .OIIIi"3CL� ttLa:.:.hsCL '[II.� DO:: mus-, nploy=s. Z the sut-conra.^wrr have nnioyaes. tae}' Mrs provide the wok ---s' cow. poii--y nuuibW- arr_ an EMDLayer that is providing -workers' corzpvc'atiar insurance for my emplo7��s _BELOW is the poii^1' ¢nd job sib zforanv�.ar� ssurancE Company N=.- iB� I�UiUf:L IIJSURtiIJ�� COI�/IP.ANY olicy t or SELF -ins. Lic. �: 1NC7-X41-'35806-052 7- i. auo -Date: 03/15/2013 Ob Sit. Address:�� V�q S+ 7sl�-Acr-O ^a �..L C- y/State/Zip: 17p��}� Antsier tach a co of the worker compensation pohcy� declaration page (showing the poli=;' number and eypiration date). P� P Osition Of Criminal naltes o a ailure to secure coverage as required under Section 25� of I GL c. 1�2 can load iO the imp P� DE up to S1,300.00 and/or one -yea imprison_Tnen� as well as civil ptnalaes in tae folzn Of a STOP'WOR OPDEP- an6 a E f up to T230.00 a day against the violator' BE advised that a copy ofthis statement may be f O -J,' d to the Once of rvesugat- ons of the DIA for insu-ante coverage ve irication. do h_ereo7 cerLif - under the pairs and penaZiies of periun- the rite znfo; matilor_ provided above s z Le and Corte`` II ����-� 03/ i3/20"ice 978-750-6500 GfiiciQl use only. Do -Loi WT- f it it LS Qr°a, to De=OmpLe!�Q bV _z _y DT ioYVrc of�zciQ Cir --v or To -?'n: Pe=I-L."T icenst ssunc l� uthtTmL_�_ L J LJ -._ _ - L 1 - "- t _.. _nS;J�" r. 1. Boer L' of H, eal h ? _ 6. 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