HomeMy WebLinkAboutMiscellaneous - 261 CARLTON LANE 4/30/2018 (2)K)
This certifies that .... 4. MAC.
has permission to perform . .6�5. .147,0��&R7-
......................
wiring in the building of ... C �0. - 5. F � 0 ...................
af . J. 4 -1. - . ......... North Andove , Mass.
Lie. No.
Check #
I I 13 y
ELECTRICAL 4�PE R
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF kE PREVENTION REGULATIONS
Official Use Only
Permit No. 11-S-21
Occupancy and Fee Checked
[Rev. 1/07) (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be perfornied in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLF-4SEPRflVT IN INK OR TYPE ALL LNFORMATION) Date: / --22 ---13
City or Town of- NORTH ANDOV"ER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to verforin the electrical work described below.
Location (Street &
Owner or Tenant
Owner's Address
Is this permit in conjunction with a.building permit? Yes F] No (Check Appropriate Box)
Pu rpose of Building Utility Authorization No.
Existing Servicel*� Amps 1A2.1ib—Volts Overheadt Undgrd [] No. of Meterr-;Z
New Service Amps volts OverbeadF] UndgrdE] No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
QY4 -07- 6 OU7Za-7-
&aL� ZEZ
7.
CnmvL�tinn nfthp fnllnwina tahlo mav hp wnivpd hv tho Inchoemr nfWirov
No. of Recessed Luminaires
No. ofj�eil.-Susp. (Pjd�e) Fans A
No. of
Transformers
Total
KVA
No. of Luminaire Outlets
No. of 4ot Tubs I
�enerators
KVA
No. of Luminaires
Sw+�g pool Aqove
emd. lgnrnd.
INV. of Emerge
B*tery Units
No. of Receptacle Outlets
No. 4 Oi Burners
F11* ALARMS JINo.
okZones
No. of Switches
No. + Gak Burne4
No. Detection Ond
%itiating Dovices
No. of Ranges
No. f Air �ond. I T I
No. AAlerting Oevices
No. of Waste Disposers
Hea Pump �.Npmber
I ...........
Totals:
JKW
No. of Vielf-Con e
Detectfon/Alert 2 Devices
No. of Dishwashers
Sp+/Area ea g KW
Local a Muni t ippi n �her
Conit ction
No. of Dryers
He ting App es 1�v
Securi ste s:
No. o e ces; or
* E:;u::iv:aJ1t
No. of Water
Heaters KW
N 0 \J No. of
Signs Ballastsl�
Data Wi ng V
N f tices or Equivalent
No. Hydromassage Bathtubs
Nfo of Motors Total Hp`
elecommunicanons Win"n
No. of Devices or Ea ent
uivaj:
OTHER:
6V Attach additional detail ij desired, or as required by the Inspector of Wires.
Estimated Value offlect calWork-d-m (When required by municipal policy.)
Work to Start:
,/ �3 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE.tOVE(RAGE: 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 A BONDE] OTTIERE] (Specify:)
I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete.
FIRM NAME.��, , A4fC�l 4 LIC. NO.
Licensee: A1,41- LIC. NO.:
, _/AA//� Signature 2!5&-/
(Ifapplicable,,pter "exempt "in the license number line.) 1L.", - Bus. Tel. No.
Address: 0/9��57
,�,V IVIJ 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 arn 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) 0 owner Elowner's t
Owner/Agent IT FEE. S
Signature Telephone No. PERU
This certifies that ...
.
has permission for gas installation. 2
......................
in the buildings of.
...............
at. .;7
............. North Andover, Mass.
Lic. No ..........
....... ...
GAS INSPECTORP
Check # S -2 L/ -2-
6 5 0" 3
0
orl
M
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY MA DATE JJPERMIT#
JOBSITE ADDRESS IOWNER'S NAME
G
OWNER ADDRESS TELL FAX
TYPE OR
PRINT
OCCUPAN E COMMERCIAL EDUCATIONAL RESIDENTIAL
�RENOVATION:
CLEARLY
I NEW: ;� REPLACEMENT: [I &I 10to - I I I PLANS SUBMITTED: YES [31 NO
APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE --J, J
GENERATOR �l --J1 --J1L=
GRILLE
INFRARED HEATER
LABORATORY COCKS
[MAKEUP AIR UNIT L—J
OVEN F—I
POOL HEATER
ROOM / SPACE HEATER
�AOOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
--dT—HER
F—
INSPF NCEh�OVERAGE
__tw 1
equl��
1 have a current liability insurance policy or its substantial lch meets the requirements of MOL. Ch. 142 YES No F- 3
I IFYOU CHECKED YES, PLEASE INDICATE THE TYPE OF COV E BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY � OTHER TYPE INDEMNITY [j 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 E] AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision ofthe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER NAME LICENSE SIGNATURE
IMP 7-GASFITTER
M U
FEI JP D JGF LPGI DJ CORPORATION[]#[- PARTNERSHIP El#= LLC [—i#=
C 0 M P A N Y N A M E: ADDRESS
CITY (r. G'1'— STATE � ZIP TEL 11-12
FAxL CELL �EMAIL
/�-f ?s- -<s,3 4- Z oF -3
orl
M
i ED
; ED
14 The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, M4 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Buflders/Contractors/Electricians/Plumbers
Avvlicant Information Please Print Le0bly
Name (Business/Organizati6n/Individual):_ �A AG -A) , E,L�
f�l
Address: 4)\,
City/State/Zip:
Phone#: 3
Are yo n employer? Check the appropriate box:
1. �Z ana a employer with "4
4. El I am a general contractor and I
P 'mployees (full and/or parf--time).*
have hired the sub -contractors
2. El I am a sole proprietor or partner-
listed on the attached sheet. I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. El We are a corporation and its
require j
officers have exercised their
3. 1 am a homeowner doing all work
E]
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 oJect (required):
6. � �New construction
7. El Remodeling
8. [] Demolition
9. E] Building addition
10.0 Electrical repairs or additions
ME] Plumbing repairs or additions
12.F1 Roof repairs
13.n Other
kny 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'
'ontractors 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 isproviding workers' compensation insurancefor my employees. Below is thepolicy andj*o'b site
!formation. N A
isurance Company N
olicy # or Self -ins, Lic. #:
_? 6)
Expiration Date:
)bSiteAddress: s6i caf[6, Le, __ City/State/Zip:
Itach 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
C.
L up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Lvestigations of the DIA for insurance coverage verification.
do hereby certify under the pains andpenalfles ofperjuiy that the information provided above is trite and correct.
I nature: Date: 3
�/ — -Z e,5
Official itse 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 ajoint 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 (LLQ 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 Be.
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 homeowner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1,877-MASSAFE
Fax # 617-727-7749
.evised 5-26-05 www.mass,gov/dia
Date.k
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that . . .............................
has permission to perform C /4A
....... �4. -. 77. 1 ........
wiring in the building of . (,( )-�- :ON e.q ......................
at - -c2 1/1 ......... Npjh Andover, Mass.
Fee\36��... Lic.No.�*-?Q'/-?/. ..... ..
-. 0
.. . . . . . . . . . . . . . .
ELECTRICAL INSPECTOR
Check# h)
I 12 6 9
Commonwealth of Massachusetts Official Use Only
Permit No. I I *Z— 6
Department of Fire Services Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS L[Rev.9/051 (leaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT 17V 17VK OR TYPE ALL INFORMA TIOA9 Date: 11/30/12
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 & Number) 261 Carlton Lane
Owner or Tenant Robert Costanz;o
Telephone No. 978-852-2349
Owner's Address same
Is this permit in conjunction with a building permit? Yes F] No 0 (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service_ Amps I Volts Overhead [J UndgrdF] No. of Meters
New Service — Amps —Volts Overhead [:] Undgrd [:] No. of Meters
umber of Feeders and Ampacity
� o
cation and Nature of Proposed Electrical Work:
Outside Outlets
ComDletion 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
Above Ei In-
Swimming Pool grnd. grnd.
0 .0- Emergency Lighting
AgtLealjnits
No. of Receptacle Outlets 2
No. of Oil Burners
FIRE ALARMS I
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection aiFd
Initiating Devices
No. of Ranges
Total
No. of Air Cond. Tons
No. of Alerting Devices
Heat Pump
K.W
No. of Self -Contained
No. of Waste Disposers
Totals:
1
..... .....
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
7 Municipal [:1 Other
L0calE1 Connection
No. of Dryers
Heating Appliances KW
Secur' Systems:*
Ity
No. of Devices or Equivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
1,No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
FoTHER:
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: 12/03/12 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANC OVERAGE: 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 Z BOND F] OTHERF� (Specify:)
I certify, under lite pains andpenallies ofperjury, that the information on il, * application is true and complete
FIRM NAME: Folsetter Electric, Inc. .11 7 LIC. NO.: 20421 A
Licensee: Robert Folster
Signature
LIC. NO.:
(Ifapplicable, enter "exempt" in the license number line) Bus. Tel. No.: 978-658-9975
Address: 30 Parker Avenue, Tewksbury, MA 0 1876 Alt. Tel. No.
*Security System Contractor License required, for this work; if applicable, enter the license number here:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
requiredbylaw. By my signature below, I hereby waive this requirement I amthe (check one) Downer El owner's agent.
Owner/Agent
Si nature Telephone No._ FEE: $ 55.00
/2—/-3g
.C\.
The Commonwealth of Massachusetts P I rint
Department ofIndustrial Accidents
Of
.fice ofInvestigations
600 Washington Street
Boston, MA 02111
www.mass.gov1dia
orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
i . cant Information Please Print Legibly
I Folsetter Electric, Inc.
ae (Business/Organization/Individual):
J
—d,ress: 30 Parker Avenue
) I
EJ
ip: Tewksbury, MA 01876
Phone#: 978-658-9975
you an employer? Check the appropriate box:
I am a employer with 2 4. E] I am a general contractor and I
employees (full and/or part-tirne).* have hired the sub -contractors
I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub -contractors have
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.:
reQuired.1 5. F1 We are a corporation and its
I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
officers have exercised their
right of exemption per MGL
c. 152, § 1 (4), and we have no
employees. [No workers'
insurance
Type of project (required):
6. F� New construction
7. R Remodeling
8. E] Demolition.
9. R Building addition
10.R] Electrical repairs or additions
11. n Plumbing repairs or additions
12.Fl Roof repairs
13TJ 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 state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that isproviding workers' compensation insurancefor my employees. Below is thepolicy andjob site
information.
Insurance Company Name: Peerless Insurance, Co.
Polic�#orSelf-ins.Lic.#: WC1235167
Expiration Date:
08/07/12
Job Sie Address:All Loacitons In... City/State/Zip: North Andover, MA
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 undeAtlifpains andpenalties ofperjury that the information provided above is true and correct.
Phone #: 978-658-6975
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#:
This certifies that. f. i / 1) ... L .0— 1 tu . ...........
has perinission to perforin ... .................
wiring in the building of s -A ......................
at ....... 2. -.(,, -� ..... C P��- .1 --6- �� ' , Noqh Andover, Mass.
Lic. No.92.,� ..... .. Hb..
... ... .... .
ELEC /RICAL INSPECTO
Check
'110978
Commonwealth of Massachusetts Official Use Only
Permit No.
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00
(PLEA SE PRINT IN JXK OR TYPE ALL INFORAM TION) Date:
City or Town oh NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her mitention to ncrform. the plectrical. work d below.
� 4 r4a MAAe- I
Location (Street & Number), � b, r-�
N%
Owner or Tenant COPIS-7—If A) 1,0 TelpinhnnilNo.
Owner's Address - 1-4
Is this permit in conjunction with a building permit? Yes No (Check Appropriate Box)
Purpose of Building R4 ICAVA� Utility Authorization No.
Existing Service Amps Volts
New Service Amps Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
OverheadEl Undgrd D
Overhead [] Undgrd [I
L'V I
120
No. of Meters
No. of Meters
Completion of the following
.f llowing
.f llowing ble may be waived by the Inspector of WiAs.
No. of Recessed Luminaires /0
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 n In-
grnd. grnd.
Ao. o Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
iTtok- �Ie
No. of Ranges 6?.Ar.
Total
No. of Air Cond. Tons
lNo. of Alerting Devices
No. of Waste Disposers
Heat pump
Totals:
J.Nq �K]J�R�
J.KW ...........
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local [I MunicippI El 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
rNo. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
W Attach additional detail i(desired, or as required by the Inspector of Wres.
Estimated Value of Electrical Work: 1:AK00 - (When required by municipal policy.)
Work to Start: 2/J5'/")-L_Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVI(RAgE: 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 operatioe' coverage or its substantial equivalent. The
undersigned certifies that such coyerage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE 9 BOND [I OTHER [I (Specify:)
I certify, tinder thepains andpenalties ofperjury, that the information on this application is true and complete.
FIRM NAME:. i� XV g6&X
,;�,/ �C LIC. NO.:
Licensee: og&,�4ezo t 'rliel& Signature LIC. NO.:
(Ifapplicable, enter "exempt" in the 1�cense number line.) BUS. Tel. No
Address: 12,:,7 '5(lervic 160 60 GO A4�- 03 ZY Alt. Tel. No oj)
*Per M.G.L c. - 147,7s. 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)EI owner El owner's agent.
Owner/Agent
Signature Telephone No. LPERMIT FEE.- $
olloq I
(fuppectoril Siguatao -xo Mials) Pate
2UNAMNSPACtION;
3?lqsseaLv .
ji�qplpltor �Cowm�ewgi-
Date
MDAR GRODND INSROCTION.-
awactors, comments.
cing Bofors" slgna�lre - -110 faluals)
VAM CAU-I"r-Urb WATXOXM�
,ctbrsl cwnwep:fs:
:ed—F I
octoxe . cwl�me.-ats:
Pate
The Commonwealth of Massachusetts
Department of Industrial Accidents
Off ice of Investigations
600 Washington Street
Boston, AM 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 4;,le
Address:_- S cesIv 0
�p COA41 A /I/
City/State/Zip: Phone#: 603
Are you an employer? Check the appropriate box:
LEI I am a employer with
4. El 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-
.0
listed on the attached sheet. t
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. El We are a corporation and its
required.]
officers have exercised their
3. 1 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.] f
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. El New construction
7. E] Remodeling
8. E] Demolition
9. E] Building addition
10. El Electrical repairs or additions
11. El Plumbing repairs or additions
12.r-1 Roof repairs
13T] Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers I compensation insurancefor my employees. Below is the policy andJo'b site
information.
Insurance Company
Policy # or Self -ins. Lic. #:
Expiration
Job Site Adress: City/State/Zip:
Attach Wcopy 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
fmc 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.
f do hereby cert?ry under thepains andpenalties offierjury that the information provided above is true and correct.
Sip -nature: Date:
JA I _?X/-
11 Official use only. Do not write in this area, to be completed by city or town official 11
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 defitied 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 ajoint 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 (LLQ 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 � 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 infori-nation (if necessary) and under "Job Site Address" the applicant should write "all locations in city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www,mass,gov/dia
1 Mull M 1111
L
1fiWanwi-mil
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary AssesE
261 Carlton Lane
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
MA 01845
State Zip Code
M C EIVED
OCT 2 0 2009
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
8/17/2009
Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Neil J. Bateson
Name of Inspector
Bateson Enterprises Inc.
Company Name
111 Arailla Road
Company Address
Andover
Cityrrown
978-475-4786
Telephone Number
B. Certification
Ma 01810
State Zip Code
S115
License Number
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
M Passes El Conditionally Passes F-1 Fails
El Needs Further Evaluatio y the Local Approving Authority
M,1,44 8/17/2009
Inspettor's Signature �/ Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17
Property Address
James Bryant
Owner
Owners Name
information is
required for
North Andover
every page.
Cityfrown
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
MA 01845
State Zip Code
M C EIVED
OCT 2 0 2009
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
8/17/2009
Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Neil J. Bateson
Name of Inspector
Bateson Enterprises Inc.
Company Name
111 Arailla Road
Company Address
Andover
Cityrrown
978-475-4786
Telephone Number
B. Certification
Ma 01810
State Zip Code
S115
License Number
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
M Passes El Conditionally Passes F-1 Fails
El Needs Further Evaluatio y the Local Approving Authority
M,1,44 8/17/2009
Inspettor's Signature �/ Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
261 Carlton Lane
Property Address
James Bryant
Owner's Name
North Andover MA 01845 8/17/2009
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
After permit from Board of Health, pump septic tank & install outlet tee in septic tank, inspection from
Board of Health , septic system now passes Title 5 Inspection
13) System Conditionally Passes:
Ej One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
El Y El N n ND (Explain below):
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
Date
TOWN OF NORTH ANDO�VIER
PERMIT FOR PLUMBING
This certifies that . "�Y.Csj ........................
has permission to perform ...........................
plumbing in the buildings of ............
at t . ......... North Andover, Mass.
Fee /5—. Lic. No..,/ Y?� ( .. ..... ...........
PLUMBING IN4PECTOR
Check #
7 5 B 9
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING k'-
0117 "-j.
(Print or Type)
/V Date 2007 Permit#
Building Location zin . Owner's Name -v
Owner's Tel #
7 ;YType of Occupency
I -N
New 1:1 Renovation El Replacement M
Plan Submitted: Yes No
Installing Company Name Addario's Plumbing & Heating LLC. Check one: Certificate
Address 20CooperStreet Corporation 2720
Lynn, MA. 01905 Partnership
Business Telephone 339-440-8100 Firm/Co.
Name of Licensed Plumber or Gas Fitter Steven J. Addario Jr.
Insurance Coverage :
I have a current liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes MX No ri
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy nx Other type of indemnity [:] Bond
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.
General Laws, and that my signature on this permit application waives this requirement.
. Check One:
Signature of Owner or Owner's Agent Owner El Agent
I hearby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By Type of License:
Title X Plumber
City/Town Gasfitter Signature of Licensed Plumber or b1i's Fitter
,Approved (OFFICE USE ONLY) X Master
Journeyman License Number 13106
n
Installing Company Name Addario's Plumbing & Heating LLC. Check one: Certificate
Address 20CooperStreet Corporation 2720
Lynn, MA. 01905 Partnership
Business Telephone 339-440-8100 Firm/Co.
Name of Licensed Plumber or Gas Fitter Steven J. Addario Jr.
Insurance Coverage :
I have a current liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes MX No ri
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy nx Other type of indemnity [:] Bond
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.
General Laws, and that my signature on this permit application waives this requirement.
. Check One:
Signature of Owner or Owner's Agent Owner El Agent
I hearby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By Type of License:
Title X Plumber
City/Town Gasfitter Signature of Licensed Plumber or b1i's Fitter
,Approved (OFFICE USE ONLY) X Master
Journeyman License Number 13106
z
0
LU
CO)
LL
0
w
0
LL
0
-j
LU
m
(1)
z
0
LU
z
U)
U)
LU
w
CD
0
w
0.
U)
LU
LU
cn
z
0
F-
L)
w
(L
0)
z
z
M
LLI
ul
U.
0
z
LL
0
uj
a.
uj
z
0
z
M
im
LL
0
z
0
0
-j
w
uj
IL
a
uj
u
z
LU
IL
0
F -
w
a.
z
CD
Z
ca
2
A
D / I/
ate.
TOWN OF NORTH ANDOVER
q r_iw
PERMIT FOR GAS INSTALLATION
SAC HU
This certifies that ... ..................
has permission for gas installation 17 ....................
in the buildings of .... / ........................
at ........... I North Andover, Mass.
Q—
Fee.b.-. "-.. Lic. No./;�� ... .... I., ..........
AAS INSPECTOR
Check 4
5 2- F -,o
11�
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING 4
(Print or Type)
All dr�-W,� , Mass. Date 7
Building Location
Owner's Tel #
New Renovation Replacement
1:1 1:1
2007 Permit#
Owner's Name
Type of Occupency
Plan Submitted: Yes No
Installing Company Name Addario's Plumbing & Heating LLC. Check one : Certificate
Address 20 Cooper Street X Corporation 2720
Lynn, MA. 01905 Partnership
Business Telephone 339-440-8100 Firm/Co.
Name of Licensed Plumber or Gas Fitter Steven J. Addario Jr.
Insurance Coverage:
I have a current liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes MX No M
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy E] Other type of indemnity [:] Bond E]
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.
General Laws, and that my signature on this permit application waives this requirement.
Check One:
Owner Agent
Signature of Owner or Owner's Agent
I hearby certify that all of the details and information I have submitted (or entered) in above 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 injqoMpliagnce pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By Type of License:
Title X Plumber
City/Town Gasfifter Signature of Licensed Plumber or Gas Fitter
,Approved (OFFICE USE ONLY) X Master
L—j Journeyman License Number 13106
r
Installing Company Name Addario's Plumbing & Heating LLC. Check one : Certificate
Address 20 Cooper Street X Corporation 2720
Lynn, MA. 01905 Partnership
Business Telephone 339-440-8100 Firm/Co.
Name of Licensed Plumber or Gas Fitter Steven J. Addario Jr.
Insurance Coverage:
I have a current liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes MX No M
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy E] Other type of indemnity [:] Bond E]
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.
General Laws, and that my signature on this permit application waives this requirement.
Check One:
Owner Agent
Signature of Owner or Owner's Agent
I hearby certify that all of the details and information I have submitted (or entered) in above 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 injqoMpliagnce pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By Type of License:
Title X Plumber
City/Town Gasfifter Signature of Licensed Plumber or Gas Fitter
,Approved (OFFICE USE ONLY) X Master
L—j Journeyman License Number 13106
(1)
z
0
F-
L)
LU
CL
U)
z
U)
uj
0�
0
Od0�
cn
w
LU
U)
z
0
LLI
CL
U)
z
z
LL
0
z
w
w
LL
c!)
z
U-
0
LU
0.
ca
uj
2
z
0
z
D
m
U.
0
z
0
0
—i
w
LLI
m
a.
0
LU
z
9
0
LLI
fL
uj
w
0
L)
w
(L
V)
z
I