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Home My WebLink AboutMiscellaneous - 262 SOUTH BRADFORD STREET 4/30/2018 (3)ca 0 6 0 -n 0 IlUo 0 U) 0 9 ;u 0 M m f C evi /.,,, , / /-o C&-LC-M#A1l-'l elt, 69M L-Ae TOWN OF NORTH ANDOVER Office of the Building Department Community Development and Services 1600 Osgood Street, Bldg. 20, Suite 2035 North Andover, MA 01845 978-688-9545 Donald Belanger, Inspector of Buildings July 12, 2016 To: Mr. Brian Marshall Fr: Donald Belanger Re: 262 South Bradford Street, Lot A-1-1, North Andover, MA 01845 Dear Mr. Marshall, Lot A-1-1 was established pursuant to a subdivision plan dated August 8, 2000 and approved by the North Andover Planning Board on November 3, 2000. The structures on Lot A-1-1 consist of a garage, main house, and carriage house. My finding is: the main house is a single family dwelling, the carriage house is a single family dwelling and detached garage are legal non -conforming structures within Lot A-1-1. The Planning Board required a subdivision and approved a subdivision establishing two lots; Lot A-1-1 as aforementioned and lot A-1-2 upon which a single family dwelling was built on shortly thereafter. Sincerely, Donald Belanger Cc: Christopher Coreman Pamela Marcinkewich %b ?A, TOWN OF NORTH ANDOVER Office of the Building Department Community Development and Services 1600 Osgood Street, Bldg. 20, Suite 2035 North Andover, MA 01845 978-688-9545 Donald Belanger, Inspector of Buildings July 12, 2016 To: Mr. Brian Marshall Fr: Donald Belanger Re: 262 South Bradford Street, Lot A-1-1, North Andover, MA 01845 Dear Mr. Marshall, Lot A-1-1 was established pursuant to a subdivision plan dated August 8, 2000 and approved by the North Andover Planning Board on November 3, 2000. The structures on Lot A-1-1 consist of a garage, main house, and carriage house. My finding is: the main house is a single family dwelling, the carriage house is a single family dwelling and detached garage are legal non -conforming structures within Lot A-1-1. The Planning Board required a subdivision and approved a subdivision establishing two lots; Lot A-1-1 as aforementioned and lot A-1-2 upon which a single family dwelling was built on shortly thereafter. Cc: Christopher Coreman 248 Main Street Reading, MA 01867 Cc: Pamela Marcinkewich Sincerely, Donald Belanger L�Tg 49 6i f �;-rwgz- 1-�/ Z -op P-A2r LZ 2! 14'e-111 k, A I C Cc 1�gil D t -J v �L ', , , C- I /V I")/ C, N d9 C: LU 0) 0 'o 0- -0 N 0 M 00 0 '00 "Ol r) m 0) cu. 20 X (D %D Ln @ ro OL o,6 m E 00 Ei 0 r, , T (a U) .0 m 00 00 0. 0 N .. F, w N 0 E :!:! -0 a) CD 0) C: fo m (1) CL cr- C, c 0 q- 1�->� a' u b" 0-4 This certifies that & ........... z ........ has permission to perform wiring in the building of Cti&, at ...... 11-5.-. r< C,! f�C 4. ,,Nprth And 0"4/vass. - "J '6D 19'. - Fee Lic. No ... N ..... ........ . r�0,1,q ... .... ... ELECTRICAL INSPECTOR Check 4 10 5 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 ackpted by dn 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. Pennits shall -be limited as to the time of.ongoing construction activity, and may be.deemed -bytheTnspector-of -Wires abandoned-and-inv.alid-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. El 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 23 8 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 qualii(ying period beginning on August 15, 2008 and extending'through August 15, 2012. W -Rule 8 — Permit/Date Closed: Note: Reapply for new permit 1< 0 Permit Extension Act — Permit/Date Closed: Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 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 IN INK OR TYPE ALL NFORAM TION) Date: 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.�,®r described below. Location (Street & Number) �64 s7keel Owner or Tenant -- C4 ZQ Telephone No. Owner's Address r- L4Av Is this permit in conjunction with a building permit? Yes Ja No (Check Appropriate Box) Purpose of Building Existing Service 100 Amps 1.20 Volts New Service �ZOO AMPS /9,:;7 1,10V Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Utility Authorization No. Overhead 2' Undgrd [J No. of Meters Overhead F1 Undgrd Dr No. of Meters I Completion ofthe followine table mav be waived bv the InsDector 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 o In- grnd. grnd. El No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS INo. 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 Punip Totals: I Number I * ** *** I Tons ** '] FK—W ** * No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW LocalEl Mun'c'Pfil 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 No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent [OTHER, Attach additional detail ifdesired, or as required by the Inspector of THres. Estimated Value of Electrical Work: (When required by municipal policy.) WorktoStart:9-y-/a _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 covera e is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANG OBONDE] OTHERE] (Specify:) Icertify, under th e pains andpenalties ofperjury, thatthe information on this application is true and complete. FIRM NAME: . Cl XIA171707 /I 7-�� LIC. NO.: Licensee: Signature NO.: (Ifapplicable, enter X In in the license number lin Bus. Tel. No.: e.) Address: -j- go /&". f ; � � F/ ! 1,2 -,4 0/, Alt. Tel. No.:f *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) El owner F1 owner's agent. Owner/Agent Signature Telephone No._ PERMIT FEE. $ FILE ASP Betors, COMMON: m-matue - no -Traltials) Pate Vfis�pctorsl gignature -.vo inifials) Pate MDrP, GROM MOCTION'. CwB.p ectors" Sjgna�axa - nobiffals) A V, CAL I&I -Tb NIAT-f 0 NA I , ON DO - issell — F I rane 11 — F spactbW cowMe3its: NSTACTION - OMR:' 0 . co)D�Ments. Date Pate �ORTAQOAU TOMMAXI) 9 -UT" IMTOX81TEW TMAPXATO BEINSTECTEMS NOT I 'tV .7 �. r papex L Ad&e= q SrrA S hw4- afAAb IF" mme Animma4fta Cbmkdo PF I "IbM 1.9"ImaampiuDwv* 4.13 Imagmadcoosclorwdi MPIWM(WMffWPwWM)o�O hmmMmdgw 2.011inambromple'- or ddpmdbmwaopioym modbg form itaw mpg WO Db cmqL iwmmm nqdm&l 3.[1 lmn&bomwmwdoiugslwo& mynx pb cmqL bm=wreqdm&jt Porlqy#QrsdNo&ljm*. S.OW*macoqwmdmmdits dbwhmewciwdbw lWatumv"Porma r- UX il(4), md vie have= map, poft mmibm mum Tnestpr*d(nqdn* 6. ONewommonfim 7- E3Rmm*ft 0 DamoMm 9. E3DaBftadmn IL[3Pbmftnp,fmQradmm 12.0 Ridxqmim job'so CAVIsbftTm AtewhaaWstdo pdkydodm"pmvObmlogdkepdkymmbwmdafbm*sdft* Faamwo- covawuv,q',Iuxlwsecfin ofM(]Lc. fmapibSI,SKW mdfbr="wbWdwmmmL aswaUss dyfimuffim b6c fm ofa SIM WMKORDERwd a fim hwesdgdkm offie DU for hwunme CuVaWVgdb=dOiL mma#. r IQI r— rls�� %17 ojwmwdwbL DvAWWd&bAkAv% AFkemwr"d&y4*drANm da I I CkyarTown: LB, , I*fH=M I.BWUbgB 1 3. CUyfllnm Ck* 4. Bedded.hwpodw & PI g hqwder codw cenftdp�� Ph Date ... . . . ................. ...... ..... . ..... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ................................. �4 ........ ...... ......... ..................... has permission for gal installation .. .... 9..0 �,k) tN)2- ........................... ... ............ I ...... in the buildings of C ' IA -P ........................................................... at ... 2-6 2- So. -4North Andover, Mass. ..... ........................................ i).Y ............ I .................. Fee...3t.�� .... Lic. No . .......................... 1�� ........................................................ Check,, 411 �/ GASINSPECMR 0-7 i� ."030 00 - c)O �4 512-11ij v-�( �2 1 iyv-6 L V I- M�l M K) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I- NORTH ANDOVER J MA DATE I -MAY 30,2014 PERMIT # JOBSITE ADDRESS 1_262 SO. BRADFORD ST. OWNER'S NAME I BRIAN MARSHALL GOWNERADDRESS LBRI�N_MARSHALL TE 603-674-8789 IFAX TYPE OR PRINT OCCUPANCYTYPE COMMERCIALE] EDUCATIONAL RESIDENTIAL ED CLEARLY I NEW:E] RENOVATION: REPLACEMENT: PLANSSUBMITTED: YES[:] NO[j APPLIANCES -1 FLOORS- BSM 1 2 3 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE J GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER F-- F-- F-� UNVENTED ROOM HEATER ANATER HEATER OTHER I INSTALL A GAS LINE RIEPLACING THE EXISTING GAS—LINE F- 1-7 177 1 - 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 [:] OTHER TYPE INDEMNITY [3 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 [j AGENTE] SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are truemd accura wledde and that all plumbing work and installations performed under the permit issued for this application will be in -,—o?�f I' nde with alltePetortitneenbtest visio e the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. I (All A r'e . PLUMBER-GASATTER NAME I JOHN MARSHALL LICENSE # SIGNATURE MP Ej MGF [I JP 0 JGF LPGI E] CORPORATIONE]# PARTNE IP[:]# LLC [:]# COMPANY NAMEI EASTERN PROPANE GAS ADDRESS F1 31 WATER ST. CITY FDA STATE =ZIPI-01923--- - ::]TEL 11 -800 -322 -6628 - FAX I CELLI--.- ]EMAIL A&A V 512-11ij v-�( �2 1 iyv-6 L V I- M�l M K) The Commonwealth of Massachusetts Department ofIndustrialAccidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 wwwmass.govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le2ibl Name (Business/Organization/Individual): Eastern Propane Gas, Inc Address: 131 Water St City/State/Zim Danvers, MA 01923 Phone #: 978-750-6500 Are you an employer? Check the appropriate box: 1. 9 1 am a emnlover with 45 4. E] I am a general contractor and I employees (full and/or part-time).* 2. 0 1 am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 1 am a homeowner doing all work myself [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.1 5. FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 15 2, § 1(4), and we have no employees. [No workers' insurance Type of project (required): 6. E] New construction 7. E] Remodeling 8. E] Demolition 9. F1 Building addition 10.[] Electrical repairs or additions 11. F] Plumbing repairs or additions 12.F� Roof repairs DAN Other Gas Fitting & Fuel Supply *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 is providing workers' compensation insurancefor my employees. Below is the policy andjob site information. Insurance Company Name: Safehold Special Risk, Inc Policy # or Self -ins. Lic. #: EWGCDO00080614 Expiration Date: 03 / 15 / 2015 Job Site Address: L City/State/Zip: 0 r\ c�cy'U,9-11 MQ. a (1345' 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 thepains andpenalties ofperjury thayte information provided above is true and correct. W 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 #: Fold, Then Detach Along All Perforations NH477156 I* ACOORLY CERTIFICATE OF LIABILITY INSURANCE 11%� ATE (MMIDDNYYY) 3/13/2014 r - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Commercial Lines - 800-990-7465 (CA DOI # OG13561) Safehold Special Risk, Inc. 230 Commerce Way, Suite 230 Portsmouth, NH 03801 CONTACT -NAME: Donna Desharnais H �N E., FAX, (A N Ell: 603-559-1361 P IC (A/C No): 855-529-7684 E-MAIL -ADDRESS: donna.desharnais@safehold.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: HDI -Gerling America Insurance Company 41343 INSURED Eastern Propane Gas, Inc. P.O. Box 1800 -INSURERB: -INSURERC: -INSURER D: INSURER E: A AGE To RENTED 'P RE' MISES (E. $ 250000 Rochester, NH 03866 INSURER F: CUVERAILiF-S ClIFIRTIFICATIF Nt)MRFR* (44]�Jb4 RFVI_qInN11JIIMRF:R- RPPhf-_Inw THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP IMMIDD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY F _V� CLAIMS -MADE OCCUR EGGCDO00080614 3/15/2014 3/15/2015 EACH OCCURRENCE $ 2000000 A AGE To RENTED 'P RE' MISES (E. $ 250000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 7 PRO- JECT [:] LOC GENERAL AGGREGATE $ 2000000 PRODUCTS - COMPIOP AGG $ 2000000 $ OTHER: A AUTOMOBILE LIABILITY EAGCDO00092214 3/15/2014 3/15/2015 MBINED INGLE LIMIT (CEO, .d.rits $ 2,000,000 BODILY INJURY (Per person) $ X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPER DAMAGE (P.r..Z I) $ UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? FNI NIA EWGCDO00080614 03/15/2014 03/15/2015 OTH_ X ISTEARTUTE I ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT � $ 1,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Evidence of coverage CIFIRTIFICATIF HOLDER e'AMf'gl I ATIr%kI Any city/town in Massachusetts SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MA AUTHORIZED REPRESENTATIVE The AGORD name and logo are registered marks of ACORD ACORD 25 (2014/01) (This w6fieste mplawsosgifiesta# 7441310 issuedm 311312014) (9) 1988-2014 ACORD CORPORATION. All rights reserved. k e 0 CD cn z 0 m cn k e Ma m m -4 30 z 00 ;a m" C) Z 0 z p, Z X0 r r 0 ):0 < j m 0 z A CD 0 Ma m m -4 30 z 00 ;a m" C) Z 0 z p, Z X0 r r 0 ):0 < j m 0 z A CD VWL- �194, 4V, Its e - 05b Lkb-Te:54- q or) A4 -1 ")3 V "M (0 NJ 7'S� k\v of MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I NORTH ANDOVER MA DATE [�OV. 8,2012 PERMIT# JOBSITE ADDRESSI 262_q9UTH BRADFORD ST. OWNER'S NAME [BRIAN MARSHALL GOWNER ADDRESS I BRIAN MARSHALL � TEIT9-78-984-5058 , "____IFAXF TYPE OR PRINT CLEARLY OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL RESIDENTIALE] NEW:E] RENOVATION: [I REPLACEMENT:E] PLANS SUBMITTED: YESE] NOE] APPLIANCES -1 FLOORS— BSM 1 2 3 4 5 6 7 8 1 9 1 10 11 12 13 14 BOILER 1- A BOOSTER CONVERSION BURNER . . . . . . COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE . . . . . . GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT ------- OVEN POOL HEATER ROOM / SPACE HEATER 17 ROOF TOP UNIT TEST UNIT HEATER ---- -- -- LINVENTED ROOM HEATER WATER HEATER OTHER KSTALLA GAS LINE AND CONNECT A RANGE AND A DIRECT VENT HEATER I INSURANCE COVERAGE YES E] NO [:1 I have a current liabili!Y insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D OTHER TYPE INDEMNITYE] 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 [] 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 perfon-ned under the permit issued for this application will be in co nce with all Perti t pr ..n Massachusetts State Plumbing Code and Chapter 142 of the General Laws. .13�p: PLUMBER-GASIFITTER NAME I JOHN MARSHALL LICENSE # SIGNATURE MP [D MGF [:] JP [:] JGF [:] LPGI [Z] CORPORATIONE]# PARTNERSHIPEJ# LLC []# COMPANY NAME:j_EASTERN PROPANE GAS ADDRESS I 131WATER'§T. CITY I DANVERS STATE � ZIP TEL E800 —322-6628 FAX CELLI_ EMAILj'__ NJ 7'S� k\v of > < m C) C/) > cn > n �7 Cl) > Ln V)cn m m > > zz Lrl m T— In m r— < m > M> M >cn > z cn U) m U) > 0 W Enm LM c En m s, m L14 ti) S�lgnature 4 f 'Ib ---------- The CommonwealM Of Mass LLch LLS gr-� _DfDarrrngtzz of lndv-s�Trial-Accidmzs 4-- - 7 Con,07-:�,SS Srrgf�. SU -Zg 00 www. mass. crow&Lz S 11ild r Zia �TiL V�T PROPANE &- OIL 2M -- rBUS1ntSS/C)TgamzabD11/hdjv dual' AdCiTtss Cirv/sla--/ I , -D 7 1,�j VVk-711-7-P, E;7R7-:: T DANVEP—S, NAA 01923 Phon,� 'IT.- 97B -75D-6500 -A-re you am tmDloyrerl Che�ch the appropriate box: Id 1 45 4� 71 1, airi a orcnt�ral -oi1c-azTo. a, 1.7 1 am a tM-�)10,VtT With have; har-d tht sub-comraclors 11sted on the attached sheet. ,�=pjoytts aiad/oT parl-lhnt-)- 2.7 1 a= a. sole propn'5101- o7'Da7Me1- Thest sub-conlractors have ship an6l have no employeEs =S' Inploytts and have worh W o rhin 2 fo T- M t iD aD y C a -D a -=Y No workers, comp. insurance comp. insurauc�t-4 5. wt ar-- a corporaticm.and its of53trs ]aaye --Kerclsed thelT i am a hLom5ovmer doing all wOrl, right of cxemp'- non PtT 1\407L e �rs I COMP. =yself. [No work c. 152, § a (4), =6 wt- h-av- no insurance reqIr ed -j einployees. [No worhers' cora-p. insu:ranct rtqUjr5A Type of Pro) ct (.required) --V? consu T—j Deinoliti011 Ei B ndiDo additiOD U1 Electrical Tepar, 01' adch-ra o as r, - tions plumbinlc epar, or addi 1,).[] poof repairs GAS F171-ING 13 21 pClim, mfocTmau0n. 2�Amy 2pp1i==rtba! ch--c-1-sbox-xi mL�st also -FV1 DIrL thLe se -mm below Sh Sutml,, z j,.Z,, zfEjdavit indimm-a S= - r Homtow= vAio subirut tais affidaVit Mdimtiag ti�-y an clom. aD wofh alLd theen biTr- D=iCL -CMTm=n Mu5 OT lot thost; --tj�-s nave ShLowimE: tht n=z- of tbL-. suh-o==073 =1d s=� Conm-&=rs thwL chtck, this bm: mug! Er. add'-donal 1=` -mployets. Lfth-. sdL-conuz.-tan ha- =32PI'Yt��': t11--Y1nust -Droyi&e thedr -ark-rs, colap. Policy numob=. ncEfo7_ 7?g fnPj0VCF,, thgpoZica, andjob site _T a?r P -Z - an CMDLoyer that jEp;-CvjLLj�,G1 WDrk-CrS' C10?n CnSaf'On Szzra infoTmatio7L LIBERTY )\ALTI-U AL INSURANCE COMPANY Insurance Company J,�ame: 03 115 / 2013 1, WC7-641-4"5806-052 jratDn, "Policy 4, or Self-ims LIC. F: txp Job Sim Address: �)told S6..A C3 City/Statt/z1P:1(,)QjA &kC n, 13UMberand expiratioii date)- e]aSatiol, policy, declaration pa -e (showing the poli If the -yvorjer-S' CDMP F J inal Iles of a Attach a copy o CtiDD 25A o'ilVjGL c. 152 lead lo the i1nPOEIZIDD 01 C -nM Penal " F;9iljjrt 7 lir -V,70RY,_ 0FDEF- and a flD� o stcuTt coveragut as Ttqi ed UndfT S' of a STOP fIlle Up to S1,500.00 aDd/OT onc-vEaT imprisOnmen-L 2-s well as civil penalties iD the form p -jrDrwa - f � . lator. Be advised that a copy oftbLis statement inay b_. -7ded to the OfficP- 01 of up to S2SO-00 a day against the v10 v * cation UTanac c trifi ID-vemiggatjions of the DIA foT mis ovtT?-,,ce — - - zd of perjLLm, tha� the information provided above is true and Corr!�ICL Ido hereb cert�ft under Zhg NZZnS a) 20-13 03/ 978-750-65DO r'D 0 Of' no,- Wr-�, j) -L thk'ZZT912�. to bE C0MDZeZfd k11 T WWR o 11cial zi-se only. Do L - - - CiTy or To-wn: Ftrmit./Liceusf --I,' T - - ----- -Pj-aEabJ-n= Lnsptc-LOT -SDtclor T -r -)W-33 -7ie74L ec�l 1. B o2 r d of H ealth -Bru-iidlag --Dep 6. Other- CO]at-aCt Pel -SOD: 395C ,AORTH AV' Dat6� ............ TOWN.OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...... has permission to erform plumbing in f thS)2uildings of .. ......... ..................... A . . North A�,dqyer, Mass. Lic. 0 02/23/99 10:55 PLUMBING INSPECTOR 27-00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer As A - 0�r 00 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT DO PL;UMB:ING (Print or Type) it # A0tjW0,r Mass. Date 1VPermit # Building Location Owner's N ame Za Type of Occupancy Residential New 0 Renovation 11 Replacement N Plans Submitted: Yes F-1 No 11 FIXTURES Installing Company Name Heritage Htg.&Plg- Co. Inc. Check one: Certificate Address 35 pleasant Street EX Corporation 714 Stoneham, Ma 02180 [] Partnership Business Telephone 781 —43 8-77 76 F] Firm/Co. Name of Licensed Plumber Gordon Switzer , INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 91 No 0 If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability Insurance policy IX Other type of indemnity El Bond 11 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 0 Agent 0 I hereby 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 Plumbipq Code and Chapter 142 of the General Laws. By_ 'e'Wa7d �J� -) ignature cl License -d Plumber 0 Title Type of License� Master [X Journeyman E] City/Town -T-F---GS— APPROVED 0 FICE E ONLY) LicenseNumber 8322 Z 0 Z �4 Z 'rod W �d J 0 U In 0 Z 0 -j .4 W cc . X 0 U. Z Z -P 'm �4 W cc >. U "t " Z . 0 q Ll Cr 0 X rd M M U cr Z W 0 CC U, W 0 = I < W - a < Z U. M X A W X 3: o �d 0. 0 W U- Y. W �4 < > 0 0. 0 Z 0 0 Z Z W H 0 a) 41 C( 0 0 -P SUB-BSMT. BASEMENT 1ST FLOOR 1W 2ND FLOOR N A 3RD FLOOR D T_ 4TH FLOOR I T STH FLOOR R S 6TH FLOOR E 7TH FLOOR C 9 8TK FLOOR T + D Installing Company Name Heritage Htg.&Plg- Co. Inc. Check one: Certificate Address 35 pleasant Street EX Corporation 714 Stoneham, Ma 02180 [] Partnership Business Telephone 781 —43 8-77 76 F] Firm/Co. Name of Licensed Plumber Gordon Switzer , INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 91 No 0 If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability Insurance policy IX Other type of indemnity El Bond 11 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 0 Agent 0 I hereby 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 Plumbipq Code and Chapter 142 of the General Laws. By_ 'e'Wa7d �J� -) ignature cl License -d Plumber 0 Title Type of License� Master [X Journeyman E] City/Town -T-F---GS— APPROVED 0 FICE E ONLY) LicenseNumber 8322 J z 0 w w u iz L6 0 m 0 U. �r 0 -i LU C3 0 z 0 p u w z w cc 0 0 w ul U. 0 w 0 z 0 P u w .j 4 wi 6 z 0 z 0 a 0 t I CC w M cc 0 LL z 0 P 4 u m U. 0 w 0 z LL 0 z 0 0 -2 it LU m :E M .j IL %k I I Date ... In TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . . . . . . . . . . . . . . .. . . . . . . . . . L has permission for gas installation in the buildings of ................... at ................... Andover, Mass. Fee;A) Lic. NO. .. .... Al��' GAS IN��iC'�OR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer I* A* -'<�'. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) A Date G 1[13�00— R=Wpt#_ Psrmh#—, M Building LocatIom;-)6'.';- OwneesNany;!J o h n kol Lko Map: Lot: Zone:_ Type of Occupancy New Renovation U Replacement U Plans Submitted>Yewa-�No (3 Installing Company Name EASI-fr Address KA I - 5XIOVErs . 123 r�r 0 1 EstimateValueof Work: Business Telephone I - Y 40 Q - Kl.-fl i�ncMPIurnher or Gas Fitter OV\ Checkone: Certificate Of corporation — U Partnership L1 Firm I Co. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 9 No U If you have checked X@.s please indicate the type coverage by checking the appropriate box. A liability insurance Policy 5( Other type of indemnity 13 Bond U 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. Checkone: Owner Q Agent L3 Signature of Owner or ownees Agent I hereby 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 permitissued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the G erall-aws Ty e of Ucense: By Plumber Signature of Licensed Plumber or Ua�s itter i CD 9 Tide Gasfitter Master License Number 7 City/Town Journeyman APPROVED (OFFICE USE ONLY) MONO MEN 5 T H F L 0 0 R I - MMMM Installing Company Name EASI-fr Address KA I - 5XIOVErs . 123 r�r 0 1 EstimateValueof Work: Business Telephone I - Y 40 Q - Kl.-fl i�ncMPIurnher or Gas Fitter OV\ Checkone: Certificate Of corporation — U Partnership L1 Firm I Co. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 9 No U If you have checked X@.s please indicate the type coverage by checking the appropriate box. A liability insurance Policy 5( Other type of indemnity 13 Bond U 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. Checkone: Owner Q Agent L3 Signature of Owner or ownees Agent I hereby 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 permitissued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the G erall-aws Ty e of Ucense: By Plumber Signature of Licensed Plumber or Ua�s itter i CD 9 Tide Gasfitter Master License Number 7 City/Town Journeyman APPROVED (OFFICE USE ONLY) 10 V V m rm (A VI. I Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: John Zahoruiko Property Address: 262A South Bradford Street Policy Number: H017007035 Date/Cause of Loss: 10/29/2011, Storm Damage/Electrical File or Claim Number: 25661 -W Claim has been made involving loss, damage or destruction of the above captioned property, 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 and claim or file number. Wade Anderson On this date, I caused copies of this Notice to be sent the persons named above at the addresses indicated above by First Class Mail. 11-17-11 Si , nature and Date 9 ANDERSON ADJUSTMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053 7 5 L� 5' Date. . ......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION FU I Lk/ I- (--I- %This certifies that ...................... has permission for gas installation .. I ... ........... in the buildings of Toq,�,, I a R ....................... at ........ North. Andover, Mass, Fee. 2 F.—. Lic. No. .'[. ". '. GASINSPECTOR Check # /6' WiASSA— IUSE77-S UNIFORIV APPLICATION FOR PERIVI17T& DD PLURABING 4eAC-ity/Tow r, 10,�- Drate: h Permitv Building- Lazaticir: Dwner� Narn� A -o r a (,rt o l'-') --ia' i no 11 T� 1 t I cm-' a J�tpS kj e Vc 7 a t 10 e 3 11; 7- 0 p :3 i a C e 7! e:7 -5- L 10 7 1 F", DEDICATE SYSTEMS LLJ I V, V) LL! LL; ;� V1 < I W " -1 W LU LLI < LL LLI u-, C) < vj < cl zj M < I C� < 5' CL < W Lj > L < < < < <1 < < LV 01 u) SUB BSI\AT. BASEMENT i ST I FLOOR i 2N FLOOR 3; FLOOR 4": FLOOR STI. FLOOR 6T��'*FLOOR TH 7 FLOOR ST11 FLOOP, . Checl, One Only CertificatE� instaffing Company Name: 17 Corporation Address: City/ -I own: '4 ye, State Partnership Business Tel: 4 7JV7'7 F, a L7 Firm/Company Name of Licensed Plumber: INSURANCE- COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 1142 Yes)gNc, If you have checked Yes, please indicate the type of coverage by checking the appropriate boy below. A liability insurance poficV Other type of indemnity 17 Bond OWNIEP'S INSUPANCE WAIVEP: I arn 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 Drily Owner L-1 Agent Sionature of Owner or Dwner's Agent I hereby certify that all of the details and information I have submitted (or entereclt reciarding this appitcation are true ant ac -curate w tnc oest m rn�' Knowledge and thal, all plumbing worV and installations performed unaer the Permi, issued tar this application will be in comtiiian--6� with ail Pertinent Provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. A/ By Type of License: I —1-Ve/ Signature of Licensed Plumber Title "$?Iumber 1 7 Master City/ -I Own man 2—J I ,Rj o u rn ey I i-ense Numbe,--. APPROVED (OFFIC-E USE ONLY) i 1 88�7 Date. + TOWN OF NORTH ANDOVER PERMIT FOR PLUMBW� This certifies that ...... Y/. 10V �� . 1. 1� . . X1.' e� :r ............... has permission to perform ..... U. . �K ......... ............................ plumbing in the buildings of . .71v. /I t 14 /' , at. . North Andover, Mass. Fee. . —Lic. No..� ? (J. 5.1 . ....... .... PLUMBING INSPECTO Check # I I:IYTIlPr:Q U) X I= Lu Lu MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING 0 City/Town:WO 4JO.Ile MA. Date:_ Permit# Building Location:20/2 �0((lk �r4-464,�' Owners Name: J04 -1t- llt� 0 r-44 U) Type of Occupancy: Commercial F] Educational E] Industrial [I Institutional E] ResidentialK New: [] Alteration: F� Renovation: F-1 Replacement: [�, Plans Submitted: Yes [] No E] I:IYTIlPr:Q U) X I= Lu Lu U) Ui IX F- . cn Z 0: =) Uj 0 IX 0 U) 0: L) 0 U) 0 CO z LU F- < z Lu U U) 0: U) 0 0 0: 0 w Lu ul lz D 0 z LU > U) LU w LLI CO 0 F- 16- 4 D a. LLJ < Uj 0 0: W X U) LLJ 1-- w L) L) < Z U) X U, Uj W 0 UJ (n = U) LU 0 U) Lu F- Z 0 Lu = W 0� > III z W 5- z BE -j F- (1) ::� < F- < 0 Z co LU 0-j z LL F- 0 U) LLI > F- z III LLI F- = 0W—X=)<0:LULLI<>0<0WzzW<�- 0 LL 0 0 0 IX W F- D D > 0 SUB BSMT. BASEMENT -T' FLOOR 2 NuFLOOR 3"u FLOOR 4' FLOOR 5' FLOOR 6' FLOOR FLOOR FLOOR Installing Company Name: ek L,_) vV 'T-�- ff Check One Only Certificate # f4o- AddressA City/TownAL,(�Je(- Statell�,� I E] Corporation f Ej Partnership Business Tel: "I -?'L�' '7 -7 7 S-RS� Fax: J�L- El Firm/Company Name of Licensed Plumber/Gas Fitter: tA--j LAI INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes'X No El If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy W Other type of indemnity E] Bond 0 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 Agent Signature of Owner or Owner's Agent Bv checkinci this box F1 I herebv certifv that all of the details and information I have submitted for enteredl reoardina this annfication are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbinq Code and Chapter 142 of the General Laws. By Title City/Town APPROVED (OFFICE USE ONL Type of License: Plumber .11� -k- Gas Fitter Signature of Licensed Plumber/Gas Fitter Master N.Journeyman License Number: 0 LP Installer The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 4 600 Washington Street Boston, YM 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contrac.tors/Electricians/Plumbers Applicant Information Please PrintLegib NaMe (Business/Organization/Individual):. H Address: , / f� 4'e" (— / * L,1,4- r I - City/State/zip: A&, &ItrflU 6 rqz,3 Phone#: q7ur 77 7 S-? :k -S Are you an employer? Check the appropriate box: 1. F1 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.$4-1 am a sole proprietor or partner- Jisted 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. F1 We are a corporation and its required.] officers have exercised their 3. Ll 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.] employees. [No workers' comp. i.n�urance required.] Type of project (required): 6. F1 New construction 7. Remodeling 8. Demolition 9. E] Building addition 10.E] Electrical repairs or additions I LD 9 Plumbing repairs or additions 12.F1 Roof repairs 13T] Other *AnyApplica�tthat 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 afld their workers' comp. policy information. lam an employer thatisproviding workers' compensation insurancefor my employees. Below is the policy andjob site information. Insurance Company Name: Policy # or Self -ins. Lie. #:. Expiration Date: Job Site Address: - City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Se6tion 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 cerfifyoder the palnsandpeodltles ofpeijuiy that the information provided abVe is true and con*ect.' Phone#: 7 7&- 7 -?'7 kCIA' I 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 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 deerned to be an employer." MOL 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 insura'nce. If an LLC or LLP does have employe' es, 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 pen -nit 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 pen-nit/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 4ficially 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 pen -nits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or pen -nit 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 Indus -trial Accidents Office of Investiptions 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 N I 001, NWE�LTH OF MAEISSACHUSE'TTS E m MMO mp. - . I I USET, I �; :� 0 c IG E F41 7 Ll ENS LICE: SED AS A JOURNEYMAN PL 'MBER issuts THE ABOVE UICENSE TO: tAWN C WHITE c 00 BOX 1186 I.P MIDDLETON MA 01949-3186 25491 05/01/12 788605 ,l Date. N2 4. '- 3, -' ��'z 2.1% TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that �.. ............ ................... has permission to perform ;-:-�'S\. ................... plumbing in the buildings of . . . . . . . . . at rth Andover, Mass. Fee Lic. NoZl,-?. �el ... ............. . I . ..... ....... PLUMBING'INSPECTOR Check WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location 6226 So. ?MJ4 New EEI---' Renovation M of Replacement El FIXTURES -v 7/'-,vc Plans Submitted Yes Date Peimit# Amount NO F1 (Print or type) Check one: Certificate Installing Company Name 's c 10c [I Corp. Address/-� E] Partner. Business Tele phone (0 6 3 3,ga ;7 942 jp Firm/Co. Name of Licensed Plumber —f—, z q, W-0 Insurance C�yerqge: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy rQ/ Other type of indemnity Bond Insurance Waiver L the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner n Agent n I hereby certify that 0 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 Permit Issued for this application will be in compliance with all pertinent provisions of th M usetts State bing Codc: and C �'% bgpter 142 f the Gen' I Laws. Title City/TovIrn APPROVED (OFFICE USE ONLY Type of Plumbing License /.S- V7 -License Number Master all" Journeyman FI Date...'-:� - _/_ - _" .................. TOWN OF NORTH ANDOVER X.1;7 PERMIT FOR GAS INSTALLATION This certifies that ........ has permission for gas installation in the buildings of ...................... at-. lz� ........ ............. North Andover, Mass. -�.< ............ Feeg� ....... Lic. No-//-.) GAS INSPECTOR Check # /LASS.ACj-jLTSETrS LTNTFORM APPUCATON FOR PE, RNUT TO DO G.AS PTIMC or print.) Date r.MnX1r A QQ A f-TJTjr,17TTq 0 k -j M I rl t,% A,%� r? -1 r - I , ,,- I Building Locations (I &C Permit 9 -V Owner's Name Amount S -r~ (e ji4 �� t, New Renovation Replacement F� Plans Submirte! [] (Print.or �,z C., Le— Nam4 Check one: Certificate InsEalling, Company 11 Corp. Address �j Partner. A J S, L-'-) -TV --j Business Telephone 46.3 3 F R 72-;z F-1 ' Firm/Co. Name of Licensed Plumber or Gas Firte., Bc-- K.,,v L INSUR,-kNiCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No M if you have checked ves, please indi te the type cove-,a!ze bv checkin,-, the appropriate box. LiabIlin, insurance policy Other type of indemnity Bond Owner:s Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Nlass. General Laws. and that my signature on this permit application waives this requirement. Check one: S lanarure of Owner or Owner's Agent Owner F-1 A2ent El i hereby cl-,-,TiN that all of the details and intormation I have submitted (orentereo) in aooveapplicaLlUH best ot'my knowledge and that all plumbing work and installations pertbi-med under Permit Issued For this application will be in comphanc,- with all pertinent provisions oFthe Massac s State Gas Codeil Chagr 142 of L�e Gene -a[ Laws. luo 11 By: Title City/Town APPROVED i0vi.-ici- us�!)NLY) ignature ol'Lic" P b 2?piumber F7Gas Fitter [�-11 lasier F7 Joumeyman FA— MON 11111111 11111111 M=91119�� ONION NO 1111011111 (Print.or �,z C., Le— Nam4 Check one: Certificate InsEalling, Company 11 Corp. Address �j Partner. A J S, L-'-) -TV --j Business Telephone 46.3 3 F R 72-;z F-1 ' Firm/Co. Name of Licensed Plumber or Gas Firte., Bc-- K.,,v L INSUR,-kNiCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No M if you have checked ves, please indi te the type cove-,a!ze bv checkin,-, the appropriate box. LiabIlin, insurance policy Other type of indemnity Bond Owner:s Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Nlass. General Laws. and that my signature on this permit application waives this requirement. Check one: S lanarure of Owner or Owner's Agent Owner F-1 A2ent El i hereby cl-,-,TiN that all of the details and intormation I have submitted (orentereo) in aooveapplicaLlUH best ot'my knowledge and that all plumbing work and installations pertbi-med under Permit Issued For this application will be in comphanc,- with all pertinent provisions oFthe Massac s State Gas Codeil Chagr 142 of L�e Gene -a[ Laws. luo 11 By: Title City/Town APPROVED i0vi.-ici- us�!)NLY) ignature ol'Lic" P b 2?piumber F7Gas Fitter [�-11 lasier F7 Joumeyman FA— Date..7.-J..-.�'. -� ..... 0'.""o '... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that IrA �i ....... has permission for gas installation A 7. in the buildings of .................................... at . ). !� .� . . �� . ?� ........ North Andover, Mass. Fee. Lic. No.. .".S .'. . . . ... (� . .'T�-. ..... 7�AS INSPECTOR Check# 7? `� V 4779 MASSACHUSETTS UNIFORM APPLICATION FOR PE' (Print or Type) RMIT TO DO GASFITTING North Andover Mass. Date c 04 permit 8uilding Location Xowner'sNam, J, Pr9at ZPhoruiko Map: Lot% Zone.: - New Renovation LJ I Re Fee. $25-00 S U a SUE-8SMT. S M T A S E BASEMENT M E N T 1 1ST S T F L FLOOR 0 0 R 2 2ND N 0 F L 0 FLOOR 0 R 3 3RO R 0 F L 0 FLOOR C R JFL 4TH F L 0 0 R S 11 TH FLOOR 6 T TH F Loo F L 0 0 R T 7TH Loo 0 0 R a T STH Loo F L 0 0 R Type of Occupancy 01 V 1 LU (n z :n M _j W X cn z 0 0 = I < . 0 M l'- < I cm z o: LLI < M ID LU i- LIJ LLJ 0 0 0. 0 LIJ V) M Uj < X Z M LU W W 0 z C.) LU (n U, U3 > LLI z Z W LU 0 �-:--tnmzo 6�-LLI LU < = < M U7 0 0 - 0 W �-> 'a -C , residential Plans Submitted: yes El No elclligts e o a e Installing Company, Nam6 11,� Addr . ess . ._ 11 Ili INC'. Check one: Certificate 131 W -,','TER ST DAT�EERS 11,1 01 q --- Estimate Value of Work: X Corporation --------- Business Telephone---a��.. Z] Partnership --------- Firm / Co. Name of Ucensed Plumber or Gas Filter .......... ................ ..... . 7INSURANCE COVERAGE: c rrr have a u I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. _ i If you Yesv No If You have checked ygs _, please indicate the type coverage by checking the appropriate box. A liability insurance policy X Other typ . e of indemnity :1 Bond Ej OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapt . er 142 of the Mass. General Laws, and that my signature On this '�errmWitCapPlication waives this requirement. Ignatura of Owner or Owner's Agent Owner 0 A . gent El I hereby certify that all of the details and information I have submitted (or entered) in above application are true and acc . urate to the best of my knowledoe and that all plumbing work and installations Performed under the permit iss -dfo IN all pertinent provisions of the Massachusetts State Gas (-,, Ye r in's aPplicabon will be in m ii C�ttv / -own APPROVED NLY) le and �-napter 1.42 of their al vs, Type of License: Pfumber of Gastitter ;Si na�rweL,�.en.,d P�Ilmber or Gas Fi�-,te, Master License Number -'aurneyman . -#993