HomeMy WebLinkAboutMiscellaneous - 27 MARBLEHEAD STREET 4/30/2018 (2)-4
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MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston, Massachusetts 02108-1904
(617) 723-3800 Ma OnIv (800) 392-6108, FAX (800) 851-8424
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch. 139, Sec.3B
NORTH ANDOVER BUILDING COMMOSSIONER
NORTH ANDOVER TOWN HALL
NORTH ANDOVER MA 01845
Re: Insured: JOHN M & SHANNON NJOROGE
Property Address: 27-29 MARBLEHEAD ST, NORTH ANDOVER, MA 01845
Policy Number: 1225623
Type Loss:
Water Damage: Plumbing Systems
Date of Loss:
041121/2015
Claim Number:
337990
Claim has been made involving loss, damage or destruction of the above captioned property, which may either
exceed $1000.00 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.
MPIUA Claims Division
CMA00021
4/23/2015
MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston, Massachusetts 02108-1904
(617) 723-3800 Ma OnIv (800) 392-6108, FAX (800) 851-8424
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch. 139, Sec.313
NORTH ANDOVER BUILDING COMMOSSIONER
NORTH ANDOVER TOWN HALL
NORTH ANDOVER MA 01845
Re: Insured: JOHN M & SHANNON NJOROGE
Property Address: 27-29 MARBLEHEAD ST, NORTH ANDOVER, MA 01845
Policy Number: 1225623
Type Loss:
Water Damage: All Other Water Damage
Date of Loss:
04/01/2013
Claim Number:
313166
Claim has been made involving loss, damage or destruction of the above captioned propert, which may either
exceed $1000,00 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.
MPIUA Claims Division
CMA00021
4/3/2013
Date .....
TOWN OF NORTH ANDOVER
PERMITFOR WIRING
This certifies that .......... <j . ..........
has permission to perform ..... . ...... Aw.'.-ek 77.
wiring in the building of ............. . ................................
at ... 14.6.V 5 '�'
.. ........ North Andover, Mass.
0 Fee ... �5� ......... Lic. No..OA7
f .. IR ...... . .......
I AL INSPE
Check #
10459
Commonwealth of Massachusetts Official Use Only
PermitNo.
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. vv] (leaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), MR 12.00
(PLEASE P=INIATK OR TYPEALL INFORAfATION) Date: llle�/l
City or Town of.- NORTH ANDOVER To the Inspebtor of Wires:
By this application the undersigned gives notice of his or her intention to per-fofm the electrical work described below.
Location (Street & Number) a - &64-h 14 e4i
Telephone Nof� -? 3�0
Owner or Tenant Sj�/) Z�iurw
Owner's Address
Is this permit in conjunction with a building permit? Yes No ko (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service -,/ Amps /.�U 40 Volts Overhead Eg"' UndgrdF� No. of Meters
�0
New Service Amps Volts OverheadFj UndgrdF-1 No. of Meters
J Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work:
I
rnmnlptinn nfthp MlInwinp, table mav he waived hv the Insnector of Wires.
No. of Recessed Lumin"aires
No. of Ceff.-Susp. (Pauddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above El'bl- d. R
grnd. grn
IN0. of Emergency.Ligitting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
MX.ALAS.MS
JNo. of Zones
No. of Switches
No. of Gas Burimers
No -of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
I
J.KW
..........
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers r
Space/Area Heating KW
E] Mkinicip�l EjOther
L ocal Connection
No. of Dryers
Heating Appliances KW
Security Systems:* -
No. of Devices or Equivalent
No. of Water KW
I Heaters
No..of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
TNo. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
I I
00 Attach additional detail Y -desired, or as required by theInspector oJ Wires.
Estimated Value 9f 4lectrical Work: �f,)S-. (When required by municipal policy.)
Work to Start/M it 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 operation7 coverage or its substantial equivalent. The
undersigned certifies that such cove ge is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURAN( WBOND 0 OTHER'n (Specify:)
I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete.
FIRMN,kME: n LIC. NO.:
Licensee: Signatu�e LIC.NO.: 067 AIL
(1fapplicable, enter "exempt " in the license number line) Bus. Tel. No.:
Address: - Ix- 1, c., t, A A 4�- oletvi Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department of Pu51ic Safet� "S" License: Lie. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) [] owner El owner's agent
Owner/Agent
rr-1 --L -- - - &7- FPE"TT FEE.- S
The
ta\ CommarzWealth of Alassachuseas
Department of Industritil Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www..qwssgov1dia
Workers' Compensation Inshrance Affidavit: Builders/ContractOrsXlectricians/Plumbers
A�Pficant Information
P
Narr;e (13usiness/Organization'/Individual):
Address:
City/State/Zip: Phone #: .
Are you an employer? Check.the appropriate box:
1drn'a employer with
4. El I am a general contractor and f
emplOYMS (full and/or part-time).*
2. 1 arn.a.sole proprietor, or
have hired the sub -contractors
listed
partner-
ship and have no employees
on the attached sheet
nese su&contractors have
working for me.in' any capacity.
[No workers' comp. insurance
workers' cornp. insurance.
5. We are a corporation and its
re-quired.]
3. El I ain a homeowner aoinar all work
C,
officers have exercised their
right of 'exe - ption per MOL
in
myself, [No-worke'rs'comp.
c. 1.52, § 1 (4),* and we have no
insurance -required.] t
eMplOyees. [No workers'
comp. insumcc, require&]
*Any epplicant that checks bo)e-#1 MISt RISD [lout the
section "low
Type of project (required):
6. Niewconstructiot,
7. Remodeling
8. Demolition -
9. EJ Building addition
10. D -Electrical repairs or additions
I I EJ Plumbing repairs or additions
12.[] Roof reipairs
ME:1.0ther
theirworket ompensation policy infor7nation,
Mmeownirs who submit this affidavit indicating illey are do;ng all work and then hire owside contractors must submit anew affidavit in'
�Contmctors tilat che4c this box must E-ftachad an Pdditional sh�-�r show me ofthc: su dicating such.
in -h� p -contractors and the-,
g. L a b J. vm
and an CWkper fi2tV !Spr,?Vjd11_jg:W0j.,�epS Y co1MPCflSad0R lftSUM&Cefff My, er4,U10Y,1eS; BeJOW jS
inforynation. thepolicy-and-job site
Insurance Company
P0lieY 4 or Self -ins. Lie. #:
Expiration Date:
Job Site Address: City/State/Zip:
Att2ch a copy of the workers'.'compengation policy declaration page (showing the policy number and ex irstion date).
p
Faiture to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a -
fine UP to,$1,500.00 and/or one�year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against. the violator. Be advised that a copy of this statement maybe forwarded to the 0-ifice of
Investigations of thei DIA for insurance coverage verification.
--L-
1 do herehY cerdfY Undir the Pains andpnafflesqfpaj,,,X that the information provWd above is true and correct.
SiLmature: Date:
Phone 4:
City or Town:
Permit/License #
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector, 5. Plumbing Inspector
6. Oth6r
Contact Person: Phone
?x
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olito, Ma
From: DelleChiaie, Pamela
Sent: Monday, December 20, 2010 1:27 PM
To: Ippolito, Mary
Subject: Deleading Your Home - Mass.Gov
http://www.mass.gov/?pageID=mg2subtopic&L=5&LO=Home&LI=Resident&t2=Housing&L3=Home+Improvemen
t&L4=Deleading+Your+Home&sid=massgov2
Hi Mary,
Here is the link to the Deleading website regarding Massachusetts --P
Please note the Massachusetts Secretary of State's office has determined that most emails to
and from municipal offices and officials are public records. For more information please
refer to: http://www.sec.state.ma.us/pre/preidx.htm.
Please consider the environment before printing this email.
IV/
I
Location-�:2
No.
Date
AORTN
TOWN OF NORTH ANDOVER
0
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
17139
Building Inspecvr
-1
1.1 Property Address:
1.2 Assessors Map and Parcel
Map 11
Number:
Parcel Number
2.2 Owner of Record:
Name Print Address for Service:
1.3 Zoning Information:
Zoning DiArict Proposed Use
1.4 Property Dimensions.
Lot Area (sf)
Fronta&c (ft)
1.6 BUILDING SETBACKS (ft)
Not Applicable 0
Front Yard
Side Yard
3.2 Registered Home Improvement Contractor
Rear Yard
Required Provide
Required Provided
Required
Provided
11
Expiration Date
Signature Telephone
1.7 Water Supply M.G.L.C.40. 54 1.5. Flood Zone Information:
Public 0 Private D ' ) Zone Outside Flood Zone 0
1.8
Municipal
Sewerage Disposal System:
0 OnSiteDisposal System 0
SECTION 2 - PROPERTY OWNERSHM/AUTHORIZED AGENT
2..!,Owner of Record
j7t,
Nan�c (Print) ;�ddress for Service
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SEtTION 3 - CONSTRUCTION SERVICES
3-.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature Telephone
Not Applicable 0
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable 0
CQ�npany Name
Registration Number
Address
Expiration Date
Signature Telephone
Lim
SECTION 4 - WORKERS COMPENSATION (NL G.L C 152 § 25c(6) I
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
-in the denial of the issuance of the building permit.
-Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (check applicable)
New Construction 0 Existing Building 0 Repair(s) 11 erations(s) 0 _7�
Accessory Bldg. 0 Demolition 0 Other 0 Specify
Brief Description of Proposed Work: C
�_F6-'V-s <57ri 4.444', Ar /A/
d/V
h'sRCTION 6 - FSTYMATF.11 C0NqTR1TrTl0N rO.qT.q
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
56i
�:�' 77 MR I ,
I
Building
(a) Building Permit Fee
Multiplier
2
Electrical
Estimated Total Cost of
Construction
3
Plumbing
Building Permit fee (a) x (b)
4 Mechanical (HVAC)
5 Fire Protection
6
Total (1+2+3+4+5)
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMEPLETED WHEN
OWNERS- AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
mid belief
Print Name
Signature of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TEVIBERS IST 2 ND 3 RD
SPAN
DIMENSIONS OF SELLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHEVINEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
A
Town of North Andover
Building Department
27 Charles Street
North Andover, MA. 01845
D. Robert Nicetta
Building. Commissioner
(978) 688-9545
(978) 688-9542 Fax
HOMEOWNER LICENSE EXEMPTION
Please print.
DATE
jbBLOCATION �27 /'%,
Number Street Address Map / lot
` X- 7's- 2'T—
"HOMEOWNER
Name Home Phone Work Phone
PRESENT MAILING ADDRESS
City Town
State
The current exemption for "home6wners" was extended to include owner -occupied dwellings
of two units or less and to allow such homeowners to engage an individual for hire who does
not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5. 1)
DEFINITION OF HOMEWOWNER:
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
there is, or is intended to be, a one or two family dwelling, attached or detached structures ac-
cessory to such use and/or farm structures. A person who constructs more than one home in a
two-year period shall not be considered a homeowner.
The undersigned "homeowner" assumes responsibility forcompliance with the State Building Code and other
Applicable codes, by-laws, rules and regulations,
The undersigned "homeowner" certifies that he/she understands the Town of No. Andover
Building Department minimum inspection procedures and requirements and that he/she will
comply with said procedures and requirements.
HOMEOWNER's SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Zip Code -
a
4
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of IVIGL c 40 S 54, a condition of, Building Permit
Number —is'that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by IVIGL
c 11, S 150 A.
The debris will be disposed of in:
(Location of Facility)
Signature of Permit Applicant
Date
NOTE: Dernolit ion permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
ch
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Date'��.- 0? -
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBINd
CHUS
This certifies that�)o ...... Or .......................
has permission to perform A?i .1 ......
plumbing in the buildings of ..................
at..c)4.-01.5.A/Z4 AY4A7..!'��4�,North Andover, Mass.
Fee. ... Lic. No .......... ................. .........
Check # PLUMBING INSPECTOR
or -
.V
-�o
i
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLU . MMING
(Ilype or print)
NORTH ANDOVER, MASSACHUSETTS Date
Building Locpt!�6n -7 �-)- 1�- tA" W I Lk � owner- Name nR a 9,z; . Permi—#:
U Amount
Tvn'p. nf Occnna
New Renovation Replacement El Plans Submitted Yes NO
(Print- or -
InstallinE
Address
-nTV"r rTy)"V Q
Check one: Certificate
Corp.
FlPartner-
12 Fkm/Co.
Name ofLicens6d Plumber: " VS C) \L -AE C--p-
Insurance Coverage: Indicat of insurance coverage by checking the appropflate bom
Liability insurarice policy Other type of indemnity Fj Bond
Insiirance Waiver: 1, the undersignedy have been made aware that the licensee of this application does not . ha -ft any one ofthe iibove
three insurance
Signature Owner 10
I hereby certify that all ofthe details and information I have submitted ((
best of my knowledge and that all plumbing work and installations perfo
compliance -with all pertinent provisions of the Massachusetts State P u
6�=o 1 s
By: I a Icens
Agent n
ac,
,red) in above application are.true and curate to the
under Pegft-)ssued for this applicationwill. bem'
C ter 142 ofthe Gen6ral Laws.
A- -
Type ofPlumb* g cense
Title
- J.City/Town 173ens-3 NumDer Master
APPROVED (om.p USE ONLY
Journeyman
Ex-pirationDate:
Job Sit-- Address:_ (Z7
City/State/Zip-_W, &r
Attach a copy -of the workers' compensation Policy declarati..On pag, I e (shovOmg the policy n -
Failure to ScOUrecoverage as required un'der Section 25A of Mc3�L umberand expiration date).
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 theform
Of ap to S250-.00 a day again9t the violator. Be -advised that a c Vy of s sta. of a STOPWORK ORDER and a fine
Investigations of the for insurance coverage, verification. 0 thi . tement may be, forwarded to the Office of
-7 do here�hy cerafy
aria pen'uzzes PJPcrjU7J'th'zt Me infIrl"donProvidedabove-is Yrue and correct.
Official zese only. Do not wriic*izz this arej; to he completed h
J, cz
), or town official
City or Tovm:
-Elisulu,- Authori (circle one):
L Board of Health 2. Building, Department
6. Other
Contact Person:
a -
3- City/TqwM Clerk 4. Electrical Inspector S. Plumbing Inspector
Phone'#.
The CoM)1101zW_—jz Ith OfAfassachusetts
D6P'zrtm6,nf qf rndustrialAccidents
Office 0
600 Wavhin,.ton Str-eet
Bostoyz, M4 021,7_1
Workers' Compenga-don Insurance Affida-vit: Buffders/Co-ntractorsXlectri
n licant-Inform.nfinn
clans/Plumbers
tjiEt Legibly
NaMe (Business/Organization/Incli-�,idiial):
Addre�s- q� 7-,
City/State/Zip:
Phone #:_2 7k a ZE 3 2 f,
-Are you an employer? Check the appropriate box:,
1.0 lam a cpploy'er �Vith
T ype 0 r 0 e t re ed
4. E3 I am a gc�aeral contractor and I Type of project (required):
q
eral contractLr and.1
7,
employees (fall and/or part-time).*
2.01 an, a sole proprietor or
6 N ons t ,u
have hired the sub -contractors 6. D NeVv construction
1r:d c r ot,
-on tor
listed
partner-
)n t 7
on tbLe� attiched sheet 7. E] Remodeling
d I R
c S�mr 0 dec a g
ship and have no employees
DP
These sub-contractorsha:ve, Demolition
8 0
working for me in any capaci4,�
[No workers' comp. insurance
n
workers' COMP. insurance,
Buildin
5. 0 We are. a cc)rporation and its 9, Building addition
. Lo
g djt. �J
EOca
required.]
3. 0.1 am a homeowner doing
1 0. Elec�
offict-'rs -bL�5 exercised their 10-E]Elecirical repaim or add'itions
a a"
p Irs or
"g�t
all V�Ork
�11Y`SeIE [No workers' comp.
Of exegmPtion per MGL I I f�71 Plumbing reFfairs or additions
1 14 Plum m
- ' ICY b g Pam or a
c. 152, § 1 (4), and we have,
msurancD required-] t
no 1 0 0 f
12.M Roof repairs
emPlOYeas. [No *orkers, am
-----------------
13.[] Otber
SbMP insLlzmc%� required-] 06or
also M1 L -E the section beloll, :r, - —k = S' 0 0 M,-- - E z d 0 a P ol
I Em-neowners 1�ho submittlib affidavit indjeating thS, arn ;
doing all"'��'
�Contractorss o*and ihen him
that check this box must attached an additional sheet showing e alfi
-outside con=ctors 4L�_'t Snbk—uit new davit ir3dica�ng such.
th n,0 of the sub-contrwtors and th'eir workers, comp.
poHr
fam an eempkyer &at isproviding workers' compensazion ljr�vzrrancef , yinfornmfjon_
or My emPloyecs- Be1014'is thcPolicil andjob site
h1surance Compiny Name:
Policy # or Sel�fias. Lic. M
Ex-pirationDate:
Job Sit-- Address:_ (Z7
City/State/Zip-_W, &r
Attach a copy -of the workers' compensation Policy declarati..On pag, I e (shovOmg the policy n -
Failure to ScOUrecoverage as required un'der Section 25A of Mc3�L umberand expiration date).
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 theform
Of ap to S250-.00 a day again9t the violator. Be -advised that a c Vy of s sta. of a STOPWORK ORDER and a fine
Investigations of the for insurance coverage, verification. 0 thi . tement may be, forwarded to the Office of
-7 do here�hy cerafy
aria pen'uzzes PJPcrjU7J'th'zt Me infIrl"donProvidedabove-is Yrue and correct.
Official zese only. Do not wriic*izz this arej; to he completed h
J, cz
), or town official
City or Tovm:
-Elisulu,- Authori (circle one):
L Board of Health 2. Building, Department
6. Other
Contact Person:
a -
3- City/TqwM Clerk 4. Electrical Inspector S. Plumbing Inspector
Phone'#.
Information an- d Instructions
Massachusttfs General Laws chapter 152 requires all emplo_N��,--rs to piovide workers' compensation. for their employees -
Pursuant to thisstatute, an employee is defmed as "---CvCrYPe--rson in the service-ofanothcr under any coruract of hit,
F--);pT=s or implied, oral or written." I
An employer is defined as "an individual, partnefship,-associa�tion, corporation: or other'Itgal entity, or any two or more
of the forcgoirigg engaged in a joint eiitt-,rprise, and including t-lae legal representatives of a deceased employu-r, or the
receiver or trustee of an individual, partaerghip, association DM:7 other legal entity, employing employees. However the
owner of a dwelling house having not mom than -1hr= aPartroL ents and who resides therein, or the occupant. of the
clwelli�- housf-- of another who employs persons to do mainte--mance, construction or repftir work on such dwelling house
or on the: grounds or builc�ing, appurtenant thereto shall not be�4--ause of such. employment be. d --=ed to be. an cmpjoyer.-
MGL chapler 152, §25CR also states that "every state or I ' o.,cal licensing'aggency shall withhold -the 1§su" n ce or
renewal of a license or permit to operate a'business or to c-- an�struct buUdin,-,s in the com m*onwealth for any
applicant who has not produced acceptable evidence of counnpliance with the insurance cover*a.-e required."
Additionally, MGL chapter 152, §25C(7) states "Neither the c--ommonwealth nor any of its political subdivisions shall'
enter into any cohtra�t for thaiperfonnance of public work ilw-til acceptable e*rvidenca of compliance with thzinsurance
requirements of this c�aptc-r have been presented to the contrz-a-cting authority.
Ag�IiLants
'Please Effl- out the workers' compensation affidavit cqmPle�01::y,'by checIcing the b'ox-s that apply to your situation and, if
necessary, supply gub-contractor(s) name(S), address(es) and 1phono number(s) flong with their certificate(s) of
insiamme. Limited Liability Companies ' (LLC) or Limited Lizability Partnerships (LLP) -�*no employees other than the
members or pariners,. am not required to carry workers' comp ensation insurance. If an LLC or LLP does have�
employees, a policy is required- Be-, advised that this affidavit ma
y be submitted to the. Department of Industial
Accidents for confirmaiion of insurance coverag�. Also be rxtre to sign and date the affidavit. The afEid-avit should
be returned to the cd-ty or tovim that the C-�—�;Jhkafion 'LLT the perniait.
or license iq beinj .4'nat the r----naTt----nt of
Industrial Accidents. Should you. have. any * Tue-stions reg�rdir-:.., the lavv or if you are m4hirud To ob-tain. a workers'
compensation policy, please call the Department at the nil c�xlistedbulow. Self-insured companies should 6riter their
self-insurance license nu er on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibl3r. The Department hag provided i. space at the bottom
of the affidavit for you to fal out in the.5yq.it the Office of lim-estigations has to contact you regarding the applicant
Please be ' sure to M in the pmmit/license number which WM be -used as a mference nt�mbe�. In addition, an applicant
that mu t �ubmit multiple permit/license applications 'in any .1rx-ven year, need only submit.one affladavit indicating, current
policy information (if necessary) and under '.Job Site Address" the applicant should write "all loc'ations in _(city or
town).- A copy of the affidavit that has been. officially stampe-d or marked -by the-, city ort'own may be providc.d to the.
applicant as proof that a valid af Eidavit is on file' for future Prx-mit-s or licenses. A- new affidavit must be filled out Cwh
year. Where a home; owner or cifi2rn is obtaining a license or :pennft not related to any business. or commercial -,�Cntur
(Le. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidivit.
The Office ofimestigations would li1cf- to tban you in advanc�e f6r co
your operation and should you have any questions,
please do not hesitate to give us a call.
The Depa rtment's address, telephoritzrid.,fammumber.—
The Commanweolh af N.fa&3azhusett,,-,
Department of E adu&trial Accidents
Oflice of
6.010 wit�sr-� stre-et'.
Ro.-StOJ3, MA 02111
Teil. 0 617-727-4900 ext 406 ar 1-8 77-N6AS.SAFE
Revised 5-26-05 Fw: # 6.17-7'-77-7749
VrWiArxiam-gov/dia
7344
DateJ- ?--I - /(.)
.................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that . L. / ... an7t� '01 ............... , * * * , , * ,
has permission for gas installation ..... 46-0 1 4("e'C'. . Ree. � —
in the buildings of IV .....................
at C�. -;.I� ..... North i"dover, Mass.
Fee. —50 ... Lic. No..,;)4?0� . ........................
Check# ) )kv- GASINSPECTOR
NIA-SSACHUSMS LNUDRIVI APPUCATON FDR PERINTr To DO GAS FMING
(Type or print)
NORTH ANDOVER, -MASSACHUSETTS
Date �- —;, 3 � / o
Building Locations el
Permit
Amount $
Owner's Name (D bg- 5
LA
New Renovation Replacement El Plans SLibmitted El
("Print or type)
MTM
AME.
ess
Name of Licensed Plumber or Gas Fitter
Checkone: Certificate Installing Company
Corp.
Partner.
Firm/Co.
Lai
INSURANCE COVERAGE Check one:
I have a Current liability Insurance policy or it's substantial equivalent. Yes 0 No
If you have checked y��, please indicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity Bond
El 0 1:1
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 1,12 of [tic
Mass. General Laws. and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent
0
I 1CLUUy UMMY LIKIL itil U1 UIC UCLaUS anu iniormation i IMVC sL10mi
I.-,c,,t ofniN knowledge arid that all plumbing work and installations
compliance with all pertinent provisions Of [Ile NlaSSaChL1SCttSW' I(
By:
Title
CitviT6wn
APPROVED (OFFICE USE ONLY)
)r enteiva) in above application are true and accurate to the,
1-1-11cd linderyArinit Issued for this application will be in
�_4 _ �--Ka�tA- 142 ofthe General Laws.
Shyna6d-e of Licensed Plumber Or Gas Fitter
C] Pl'uniber a � qUl
C3Gas Fitter e IN umber
Master
JOUrneyrnan
A
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CA
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ENT
B A S E M E N T
1SUB-BASEM
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2 N D . F L 0 0 R
3R D. F L 0 0 R
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5 5 T L 0
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("Print or type)
MTM
AME.
ess
Name of Licensed Plumber or Gas Fitter
Checkone: Certificate Installing Company
Corp.
Partner.
Firm/Co.
Lai
INSURANCE COVERAGE Check one:
I have a Current liability Insurance policy or it's substantial equivalent. Yes 0 No
If you have checked y��, please indicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity Bond
El 0 1:1
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 1,12 of [tic
Mass. General Laws. and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent
0
I 1CLUUy UMMY LIKIL itil U1 UIC UCLaUS anu iniormation i IMVC sL10mi
I.-,c,,t ofniN knowledge arid that all plumbing work and installations
compliance with all pertinent provisions Of [Ile NlaSSaChL1SCttSW' I(
By:
Title
CitviT6wn
APPROVED (OFFICE USE ONLY)
)r enteiva) in above application are true and accurate to the,
1-1-11cd linderyArinit Issued for this application will be in
�_4 _ �--Ka�tA- 142 ofthe General Laws.
Shyna6d-e of Licensed Plumber Or Gas Fitter
C] Pl'uniber a � qUl
C3Gas Fitter e IN umber
Master
JOUrneyrnan
4LI, - -
CERTIFICATE OF. USE & OCCUPANCY
V TOWN OF NORTH ANDOVER
Building Permit Number Date
THIS CERTIFIE$ T
THE BUILDING LOCATED ON 6�? I IN-Rible r"T'd 's
MAY BE OCCUPIED AS c,2 —,*i 4�
IN ACCORDANCE WITH THE PROVISIONS. OF THE MASSACHUSETTS STATE BUILIC
CODE AND SUCH OTHER REGULATIONS AS MAY APPLY.
CERTIFICATE ISSUED TO 7'
o.21
Building Inspector