HomeMy WebLinkAboutMiscellaneous - 270 MARBLERIDGE ROAD 4/30/2018 (3)b
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70
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Date...... .. ... ..........................
0' '
TOWN F NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies thatZ5�;5.��.. . .... 0A. -n." ... � ..... LAI,. �. 4;�
.. ............. .. . .
has pertnission for gas installation
in the building� of P
...... ..... . North Andover, Mass.
Fee.((X) ...... Lic. No. . ................................................
Check I # GASINSPECTOR
9446
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY I N. Andover MA DATE L 7/31/2014 PERMIT# 944-0 G--
JOBSITE ADDRESSI 270 Marble Ridge Rd OWNER'S NAME 6��
GOWNER ADDRESS I Same 1 TE�— !FAXI
TYPE OR OCCUPANCYTYPE COMMERCIALn EDUCATIONAL RESIDENTIALE]
PRINT
CLEARLY NEW:L] RENOVATION: El REPLACEMENT: PLANSSUBMITTED: YESE] NOE]
APPLIANCES FLOORS, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
LINVENTED ROOM HEATER
WATER HEATER
OTHERI
Replace f`d�asMeter(s)
.gnd _Associatft—dPiging
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 E] OTHER TYPE INDEMNITY Ej BONDE]
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER F-1 AGENT Ej
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 co liance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASIFITTER NAME I Jose_ph Marino
=LICENSE# 8 36D SIGNATURE
IPr_j
MP El MGF Ej JP [j JGF [j LPGI CORPORATION Ej# I 3285C 1PARTNE SHIP04F LLC []#
COMPANY NAME] RH White Construction Co ADDRESS 141 Central St
CITY I Auburn STATE=ZIP101501 =]TEL 1 (508) 832-3295
FAX 1508-926-4347 -1 CELLI 508-832- EMAIL RHWhite.com
ROUGH GAS INSPECTION NOTES
THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT E] F-1
FEE: $_ PERMIT #
PLAN REVIEW NOTES
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ACURV 7__
r DATE (MM;ONVYYI
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081
CERTIFICATE OF LIABILITY INSURANCEP... I of 1 08/29/2013
THI� OEI�TIFIeATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTACATE DOES NOT AFFIRMATIVELY OR NECATIVELY AMEND, EXTEND OR ALTER THE COVERAG� AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT SETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the poIicV(!es)murt be endorsed. If SU13ROGATION IS WAIVED, subject to
the terms and conditions of the Policy, certain policies may require an endorsement. A statement on this certificate does notconferrights to the
certificate holder In lieu of such endorsament(s),
willim Of MasuffeLueetts, Inc.
C/O 26 004tury Blvd.
P� 0. B05C 305191
Nhghville, TN 37230-N1§1
R. X- White Construction Company, rnc.
41 Central atreet
P. 0. Box 297
AUbUrA, M 01.501
INSURERA:The Cbartor Oak Fi=o TnaurancO Company — 25615-001
INSURERS. TrILVOIArLl Property Caqualt:y Coqpany oil Ain i3674 -001I
INSURER C: Nat i*n* l Union Piro Insuranco CQmpauy OE 19445-001
INSURERD; Travelers Ind=Ajty Company 256511-001
THIS IS TO CQRTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER OOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE IN$URANCE AFFORDED BY THE POLICIES DESCRI13ED HEREIN IS SU13JEOT TO ALL THE TERMS,
EXCWSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED By PAID CLAIMS.
_1 -
A I GENERAL LIABILITY
IMVROIAL GENERAL LIA911.1r(
CLAIMS-MADET OCCUR
AGGREGATM LIMITAPPLIES PER;
B I AUTOMOBILE LIABILITY
ANYAUTO
ALI.OWNED ISCHUDULED
AUT08 AUT08
HIREDAUTOS X NON -OWNED
X AUTOS
Co Ddd X CQ11 pea
,�;j
X __0 sndl)
CH umaRrULAALIAII OCCUR
X r
=XCEaq 411� E
a CLAJMS-MAOE
I D2D I V, [RETENTIONS lOrO0C
1) WORKERS COMPENSATION
D AND EMPLOYI2118'LIABILITY YIN
ANY PROPRIETORIPARTNERIEXECUTIVE N/A
OFFICERIMEMSER ZXCLUDED? Fl -q I
Mwideto In NN)
U ON UI- QP�.RATIONS halavo
L'vidonce of Inmurance
VTC2000 97799948-13
VT4TCAP 977K955z,-l3
9/3./2013
9/.1/20:L3
'.9/1/203.4
,9/1/2014
EACHOCOLIRRENCE
TO RENTPD
F_(
MED son
PERSONAL &ADVINJURY S 2 000
- 0 1-2-0–C
GUNERAL AGGREGATE S A nr%n
,000,000
PRODUCTS -COMPIOPAGG $ 0 0 0, 0 0 a
1 �11L' LIMIT S 2,00CI,000
BODILY INJURY(Perlwaon) S
130DILYINJURY(Peracaldeml)
BES766140 P/1/2013 19/1/2014
820SA185-13 9/1/2013 9/1/2014 x I WOSIAIU
To
[Ki . RKLI�.
8203A71A-13 9/1/2013 9/1/2014 [E-L-_WHACOIDFNT $ 11 00L 000
I F.L. 13105ASL- EA EMPI, QYF.rz S 1,000,000
FE. i7IDIWASr - POLICY LIMIT $ 1, O0Q,000
moreepeca
SHOULD ANY OF THr. ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THER50F, NOTICE WILL BE DE11VERED IN
ACCORDANCE WITH THE; POLICY PROVISIONS.
AUTHORIZED REPREEIENTATI'VE
C011:4197604 TPI:1694012 Cert:20267680 Q 1988-2010 ACORD CORPORATION. All rights
CORD25 , (2010105) The ACORD name and logo are registered marks of ACORD
-This certifies that ..... ......
Date..� ... v �. I (. -�-- >.
TOWN OF NORTH ANDOVER
has permission to perform ..... X- :f
PERMIT FOR WIRING
-e CJV*?-A ('J) I
.......................................................
wiringin the building of ................ ....................................................................
-Io
at ....... 2 ............................. 64—..'Ye� J Xe . . .................... . Morth Andover, Mass.
p,� ...... .................... Q
AL-I� Y
........ ........ . &SP 'r ....... .
Lic. No.
Check # ELEcI cAL ECTOR
11.670
\ iL\\ Commonwealth of Massachusetts Official Use Only
Man= m1itN Uwo
Department of Fire Services Pe 0'
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00
(PLEASE PRIWTHINK OR TYPEALL MFORAJATION) Date: 6 – k15- Q>
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) `Z.71 a YAAA3o(,
Owner or Tenant
Owner's Address
Telephone No.
Is this permit in conjunction with a building permit? Yes F] No (Check Appropriate 13ox)
Purpose of Building yko.4 — Utility Authorization No.
Existing Service — Amps Volts Overhead Undgrd 0 No. of Meters
New Service Amps Volts Overhead UndgrdF] No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Comvletion ofthe following table mav he waived hv thp fn.vnpctnr nf 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 Ei In- E]
grnd. grnd.
No. of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
IN'o. of Zones
No. of Switches
No. of G2s Burners
f Detection 2nd
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
JNo. of Alerting Devices
No. of Waste Disposers
HeatP mp
otals:
Numb.e.r
I.Tons
I .......................
I KW
I ......................
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KVV
Local D Municippi El Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water
Illeaters KW
No. of No. of
Signs Ballasts
Data Wiring:
. No. of Devices or Equivalent
No. Hydromassage Bathtubs
I
No. of Motors Total HP
Telecommunications Wiring:
No. of.Devices or Equivalent
[OTHER,
4t1ach additional detail ifelesired or as required by the Inspector of 97rey
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: '7 -V -k1 - Inspections to be requested in accordance with NIEC 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 operatioiP 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.
CBECK ONE: INSURANCE [A BOND [I OTBER El (Specify:)
I cerqy, tin der th epains andpenalties ofperjury, th at the information on th is application is true and complete.
FIRM NAME:.A1.&,, 61s, Z, A nk LIC.NO.: Aisi2_1
TAP— 0, _1\ - I
-9 �%. *,P� & "�io — oignature JLAC. NO.: 0 15 1 Z T
(Ifapplicable, eater "exempt" i . n the license nutpber line) Bus. Tel. No. J Y L - d4st
Address:
3J, AJ 14 030-)q
1 Alt. Tel. No.: (0 0 3 - Ill -5'6t !r
*Per M.G.L c. 147, s. 57-6 1, security work requires b6partment 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)EI owner El owner's agent.
Owner/Agent
Signature Telephone No. —[PERMIT FEE: $
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § K.
Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
• Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit 0_1
• Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass M
Failed
Re- Inspection Required
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass
Failed
Re- Inspection Required 0
Inspectors Comm ants:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass r?]
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass M I . I
Failed
Re- Inspection Required D
Inspectors CommentsNI,
�Inspectors Signature.
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
_CX The Commonwealth ofMassachusetts
Departmint ofIndustriqlAccidints
Office of Investigations
600 Washington Street
Boston, MA 02111
www'.mass.govIdia
Workers' Compensation Insurance Affidavit: Buflders/ContractorsfFle,etriciansIPlumbers
Applicant Information Please Print Leei
Name (Business/Organization/fndividual): ALP1111—
Address:_
CAY/State/Zip: �wl,, W4 03 t�- 7 5 Phone #: (A-03- 951-LISL�
Are you an employer? Check the appropriate box: -
Typo of project (required):
1. [M I am a employer with 2—
4. El I am a general contractor and 1
6. F1 Now construction
employees (M and/or part-timc).*
2.E1 I am a sole, proprietor or partner-
have hired the sub -contractors
listed on the attached shoot. t
7. EJ Remodeling
ship and'have no employees
These sub -contractors have
8. [1 Demolition
working for me in any capacity.
workers' comp. insurance.
9. El Building addition
I
[No workers' comp. Insurance
5. El We are a corporation and its
lo.E]Electrical repairs or additions
required.]
3. U I am a homeowner* doing all work
officers have exercised their
right of exemption per MGL
11.[] Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1 (4), and we have no
12.Q Roof repairs
insurance required.] t
employees. [No -workers'
nll other
comp. insurance required.] J
'Any applicantthat checks box#1 mustalsofill 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.
tContractors that check this box mustattached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that 1sprovNing workers'compensation insurancefor my employees. Below is thepollcy andjob site
infi,ormation.
Insurance Company Name:.
Poticy # or Self -ins. Lic. #: 0E 0 Expiration Date:
Job Site Address: "I"I Cn. I—&- City/State/Zip: �J
Attach a copy of the workers' compensation polic� declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A ofMGL c. 152 can lead to the impos ition of criminal penalties of a
fine up to $1,50 0.00 and/or one-year imprisonment, as well -as civil penalties in the form of a STOP. WORK ORDER and a fine
ofup 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 h ereby cer in un der tkp a ins an dp en alfles ofp erjury th at th e inform ation pro vided ah o ve is tru e an d correct
Phone4: G 0-3 - I f 2 - 14 5' (. (,
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit[License 0
G-17-1
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 ofhiro,.
express or implied, oral or written."
An employeiis 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 6r 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) als'o statesi that "every state or local licensing agency shall withhold the js�'su'ance 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, MOL chapter 152, §25C(7) states "Neither the commonwealthnor any ofits 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
necOssarY, 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 auLLC orLLP does have
employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents far confiraiationof 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 lice*lase 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 printedlegibly. The Department has provideda 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.
Pleas ' e be sure to fill in the perinit/lice'nse number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications *M* any given year, need onlysubmit one, affidavit indicating current
Policy information (ifnecessary) and under "Job Site Address" the applicant should write "all loo'ations in
town)." A co -(city or
py 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 ii on file for future permits or licenses. Anew affidavit must be filled. out each
year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial -venture
(i.e. a dog license or permit to bum leaves etc) said person is NOT required to complete this affidavit.
The Office of Investigations'would like to thank you in advance -for your cooperation and should you have any �questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
Tho ConmoRwalth of Musachusetts,
Depaftent of Industdal Accidonts
OfRoe of limstigatiolls , -_
600 Washingtau Stroet
BostonMA02111
Tol, # 617-72,.7,4900 (at 406 or 1-877-MASSAFF,
Revised 5-26-05 Fay,# 617-727-7749
DATE: tv - (13 - I ��
LOCATION: 2jo I-,- K
OWNERS NAME: Z\,o%.-ss
GENERATOR kw 24.7
llv-
.... ......
NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS*
CONTRACTOR:
PHONE NUMBER: "S- SEZ- 46 -LL
ELECTRIC GAS
RESIDENTIAL COMMERCIAL
LOCATION OF GENERATOR:
*ZONING DISTRICT:
*CONSERVATION APPROVAL
TEMPORARY
Vkloll
In-home survey
Automatic Standby Generator
Customer information 4zs- Zos -
__7T I
Name: --- 00-'!ng�A_ 14-M Phone: Number of rooms:
Address: Square footage:
City, State and Zip: ............... ..................
............................ . .. . . .... . . ........... . ... .................... . ................ .............................................................. . ........ . . . ...................................................................................
E-mail:
Basic Information ,
Generator Site Plan
BACK OF HOME
>
FRONT OF HOME
M
Site Plan Key VIX
n Generator
0 Transfer Switch
A Main Electrical Panel
0 Gas Meter
X Electric Motor
Installation Recommendations
Permits (if applicable)
Gas line installation
Gas line trenching
I I Additional wiring: Exterior I I I
Custom Electric
Interior
Electrical line trenching
Outdoor conduit
Additional sub -panel
Additional ATS
Additional disconnect switch
Other
C o n c r t e P` al�,
Additional Lands . -
Custom Work +ping
Equip
Additional Services
Option 1
ToTAL INSTALLED PRICE
Additional Services
Option 2 ' ToTAL INSTALLED PRICE
I I GENERAC"
Bulletin 01 81130SBY/ @2009 Generac Power Systems, Inc. All rights reserved.
neverfeel powerless. com
Wtsi-
WEALTH OF MASSA'CH
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Date
TOWN.OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certi fies that ... lt'�. .................
has permission for gas installation ... rc?.,j'tvI4 �. ..............
in the buildings of ... ..............................
at .... Pw'-W-e— eA 4-1- ..'01orth Andover, Mass.
Fee . 4t7-- . . Lic. No. . . ". ............... ...
GASINSPECTOR
Lheck #
8765
/11v.
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
clTy MA DATE PERMIT# 10
JOBSITE ADDRESS JOWNER'S NAME
GOWNER
ADDRESS TEL[�- �FAX
TYPE OR
OCCUPANCYTYP COMMERCIAL 01 EDUCATIONAL RESIDENTIAL
PRINT
CLEARILY
NEW 3ZVATION: Ej REPLACEMENT: Ej PLANS SUBMITTED: YES F--jI N o F--- 11
RENO
APPLIANCES -1 FLOORS- 13SM 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 L j I. —.J
FURNACE . . . . . . . .
GENERATOR JF
GRILLE
INFRARED HEATER
LABORATORY COCKS J —Ji -A
IMAKEUP AIR UNIT
OVEN
POOL HEATER J . . . . . . . . . . .
ROOM / SPACE HEATER Lm� , I - --------
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
-dT—HERF
I F-1
-j �'
� HH
INSURANCE COVERAGE
MGL. Ch. 142 YES19e0 D
I have a current liability insurance policy or its substantial equivalent which meets the requirements of
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICYE-9--� OTHER TYPE INDEMNITY [j BOND n-1
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142,of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER .0-1 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 of the
Massachusetts State Plumbing Code and Chapter 142 of the General V ws. 9W=f;te
PLUMBER-GASFITTER NAME I LICENSE # �� SIGNATURE
IMP El MGF D-1 JP EJ] JGF M'*: -PGI L] CORPORATION PARTNERSHIP F --I#= LLC ElP
A
COMPANY NAME:1-JM---qMr4 AD
ol DRESS ------
STATE
CITY ZIP[<2yl�� TEL[�
AA#
FAX CELL EWTI�L�
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The Commonwealth ofMassachusefts
Department of lndustriqlAccW�ts
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/ContractorsAElectricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): cei
Address:— /C�
city/state/zip: Loridan of 3
��� AS 0.10-3 Phone
Are y�n employer? Check the appropriate box:
1. 5XI a employer with 4. El I am a general contractor and I
am
- employees (fall and/or part-time).*
have hired the sub -contractors
2.0 1 am a sole proprietor or partner-
listed on the attached sheet
ship and'have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. 0 We are a corporation and its
required.]
officers have exercised their
3.0 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.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. E] New con struction
7. E] Remodeling
8. Demolition
9. Building addition
10. F1 Electrical repairs or additions
11. F1 Plumbing repairs or additions
12.EJ Roof repairs
1.311 other
*Any applicant that checks box 91 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that isproviding workers'compensation insurancefor my employees. Below is thepolicy andjoh site
information. - A I I
Insurance Company
A
Policy # or Self -ins. Lic. Expiration Date:
JobSiteAddress: am MnCbJ1er1 Pity/State/Zip: 4"&
Attach a copy of the workers' compensation pol ration 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 that the information provided above is true and correct
Phone#:
Official use only. Do not write in this area, to he completed by city or town official.
City or. Town:
Permit/1,1cense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
11 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 defmed 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
6iner 6f a dwelling. h,o,use 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 su& dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemi-ed to be an employer."
'k
MGL chapter 15.2, §25C(6) also states that "every state or local licensing agency shall vvithh6ld the issuance or
renewal of a license or Iiermit 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 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 besure to fill in the pem�it/license number which will be used as a reference number. In addition, an applicant
that must submit inultiple permit/license applications in any given year, need only su�bmit one, affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in -(City or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is'on file for future permits or licenses. A now affidavit must be 00 out each
year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Indusbial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel, # 617-727-4900 oxt 406 or 1-8777MASSAFE
Revised 5-26- 05 Fax # 617-727-7749
--www.mass,gov/dia
GENERATOR
DATE:
LOCATION:
OWNERS NAME:
GENERATOR kw 00 W(A i
NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS*
CONTRACTOR:
PHONE NUMB[
ELECTRICAL
RESIDENTIAL
CG 3A��
COMMERCIAL TEMPORARY
LOCATION OF GENERATOR:
*ZONING DISTRICT: 0 -
*PLANNING APPROVAL (IF IN WATERSHED)
*CONSERVATION APPROVA
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Date. 411,)
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
MThis certifies that .... ...................
has permission to perform .... .......
1 13 plumbing in the buildings of ..................................
at ...... North, AnAwover
Fee......... Lic. No.. ....... .....................
Pi itmwturz wzP;:rTnR
Check # /0/0
Installing Company Name: Check One Only —Certificate #
City/Town: El Corporation
Address: State:W/'/ El Partnership
Business Tel: 2 �-3 Fax: Firm/Company
Name of Licensed Plumber:
INSURANC
I have a current liab-
-iii-ty_insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes K No E]
If You have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy Othert I ype of indemnity F] Bond E]
OWNER'S INSURANCE WAIVER: I am aware that the licensee !Loes —not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application MLaLives this requirement.
est of my
all
By Type of License:
Title
El Plumber Signature of Licens d Plu ber
city/Town El Master
APPROV����� MJourneyman License Number: —ZZL75—
MASSACHUSETTS UNIFORM APPLICATION FOR
PERMIT TO DO PLUMBING
Cit /Town.j
City/Town A M Date: Permit#
M
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Building Location: M, Owners Name:
ye -4
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Type of Occupancy: CommercialEl EducationalEl IndustrialE] InstitutionalD Residential
Alteration:Ej Renovation: El Replacement:El Plans Submitted: YesEl NoEj
FIXTURES
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Installing Company Name: Check One Only —Certificate #
City/Town: El Corporation
Address: State:W/'/ El Partnership
Business Tel: 2 �-3 Fax: Firm/Company
Name of Licensed Plumber:
INSURANC
I have a current liab-
-iii-ty_insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes K No E]
If You have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy Othert I ype of indemnity F] Bond E]
OWNER'S INSURANCE WAIVER: I am aware that the licensee !Loes —not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application MLaLives this requirement.
est of my
all
By Type of License:
Title
El Plumber Signature of Licens d Plu ber
city/Town El Master
APPROV����� MJourneyman License Number: —ZZL75—
7 6 %51-7 Date. .
-0,
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies th at
...... ...................
has permission for gas installation ... !� 41�
.......................
in the buildings of ......... /,/?o. ............................
at 1) M ........ 4. lev, 7, North Andover,_M
a7l. ass.
j
FJ*30.Q0.. Lic. No.c;2.�,,aO ... /�. .....
GAS INSPECTOR
Check # A)
01VIr
LU W
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
co
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City/Town: A. Date: Permit#
Building Location: 9 ?o A, / IL I qr Owners Name: —go&v,,,
IJ
Type of Occupancy: Commercial[] Educationalo IndustrialEl InstitutionalEl Residentialo
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New: Ej Alteration: F-1 Renovation: Replacement: F] Plans Submitted: Yes [__1 No El
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Installing Company Name: 111c))
Check One Only Certificate #
Address:__11 City/Town:—Aki
i
State:
El Corporation
Business Tel: q3 g 1 5�1_
Fax:
[] Partnership
_6(7
El Firm/Company
Name of Licensed Plumber/Gas Fitter:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes DT No Fj
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy Z Other type of indemnit y E] Bond F�
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have theinsurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this pe—rmit application waives this requirement.
Check One Only
Signature of Owner or Owner's Agent owner El Agent [j
By checking this box E]; I hereby certify that all of the details and information I have submitted (or entered) regajoing this application are true and
accurate to the best of my Knowledge and that all plumbing work and installations performed under," permitWsued for this application will be in
compliance with all Pertinent provision of the Massachusetts State PlumbinOqOe 4d Chapter 1+2 of the G90ral Laws.
By Type of License:
El Plumber Te47", �,)
Title El Gas Fitter MOature 6f Licen'sed'Plumbei/Gas Fitter
0 Master
Cityrrown Siourneyman License Number: o5
APPROVED (OFFICE USE ONLY) 0 LP Installer
10054
4 rmmzlm�
YA
Date.3�.Z— 7 - //
.......................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
nis certifies that ........ ......
has permission to perform ... kiz ...
wiring in the building of ............ ...................................................
at ... t-
.. . .... . North Andover, Mass.
Fee6? .......... Lic. No ......
� - iLECMICAL INSP-E
Check,/,, '70Z
N
he Commonwealth of Massachusetts Office Use Only
Department of Fire Services Permit No.
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 CK# 3 7 0 2
Occupancy & Fee Checked
(Rev. 11 /99) (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 11�11 INK OR TYPE ALL INFORMATION) DATE April 15, 2011
City or Town of North Andover To the Inspector of Wires:
By this applicationthe undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street & Number) 270 Marbleridge Road
Owner or Tenant Brigit and Thomas Blass BUILDING CONTRACTOR Andover Renovation Solutions
Owner's Address 270 Marbleridge Road CONTRACTORS ADDRESS 11OWinnSt.
rth Andover. Ma 01845 Woburn, Ma 01801
Is this permit in conjunction with a building permit Yes FX—J No [-�
Purpose of Building
Existing Service
New Service
Residence
1 0 0 Amps 120/240 Volts single PHASE
2 0 0 Amps 120/240 Volts single PHASE
Building Permit no.
Utility Authorization no.
Overhead
Undgrd
No. of Recessed Fixtures
Mast Service
No. of Transformers
KVA
Syphone
Overhead
No. of Lighting Outlets
Undgrd
Generators
KVA
Mast Service
Swimming Pool Above In-
Syphone
No. of Meters one
No, of Meters one
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work Wire for new kitchen renovation with 200amp service upgrade
(1— 1�+;^, ^f +Kn fnlln ... inn +ohl= rn-i h= wni—ri hvi tho inQnpe-.tnr e)f wirF%q
OTHER:
Attach additional detail if desired, or as required by the Inspector of wires.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides
proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is
in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE E
Estimated Value of Electrical Work $
BOND [—] OTHER [--J (Specify:)
(When required by municipal policy. )
(Expiration Date)
Work to Start: April 15, 2011 Inspection to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME Leonard Electric, Inc. LIC.No. A10638
Licensee Signature LIC.NO.
Address 154 Fletcher Street, Lowell, Ma. 01854 Bus. Tel. No. ( 978 ) 937-8620
Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the licensee DOES NOT HAVE the insurance coverage or its substantial equivalent as required
by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner [:] Agent
(please check one)
Telephone No. PERMITFEE$ 104!r—
(Signature of Owner or Agent)
Total
No. of Recessed Fixtures
No. of Ceil.-Susp. (Paddle) Fans
No. of Transformers
KVA
Total
No. of Lighting Outlets
No. of Hot Tubs
Generators
KVA
No. of Lighting Fixtures
Swimming Pool Above In-
No. of Emergency Lighting Battery Units
grnc!F� gmd F-1
No. of Receptacle Outlets
No. of Oil Burners FHW FHA
FIRE ALARMS No. of Zones
No. of Switches
No. of Gas Burners FHW FHA
No. of Detection and Initiating Devices.
No. of Ranges
No. of Air Conditioners Total
No. of Alerting Devices.
Tons
Heat Pump
Number
Tons
KW
No. of Self Contained Detection Alerting
No. of Waste Disposers
Totals:
I .......................
.......................
I ...................
Devices.
No. of Dishwashers
Space / Area Heating KW
Local Municipal Other
Connection F� Connection Fj
Security Systems:
No. of Dryers KW
Heating Appliances KW
No. of Devices or Equivalent
No. of Water KW
No. of Signs No. of
Data Wiring:
Heaters
Ballast's
No. of Devices or Equivalent
Telecommunications Wiring:
No. Hydro Massage Tubs
No. of Motors Total HP
,No.of Devices or Equvalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of wires.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides
proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is
in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE E
Estimated Value of Electrical Work $
BOND [—] OTHER [--J (Specify:)
(When required by municipal policy. )
(Expiration Date)
Work to Start: April 15, 2011 Inspection to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME Leonard Electric, Inc. LIC.No. A10638
Licensee Signature LIC.NO.
Address 154 Fletcher Street, Lowell, Ma. 01854 Bus. Tel. No. ( 978 ) 937-8620
Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the licensee DOES NOT HAVE the insurance coverage or its substantial equivalent as required
by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner [:] Agent
(please check one)
Telephone No. PERMITFEE$ 104!r—
(Signature of Owner or Agent)
CQmW6hW9ALfHi OF MASSACI
Lo it
-hLhL; I KIL;IANZ:i
AS AREG JOURNEYMAW: CTIR!,
ISSUES THE ABOVE LICENSE TO:
C LIN T :R t'EIDNARD
25 P,ELHAM ST
-'NH 0 3.0.6 3
-10`10-8 4 B -07/31/13 8�
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or a ed. 11 is Yect to th tify
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ancf r'7 Mber
WAt?IV qu'rl-clb n- h -0q Laws,
P411 11146 ylaw. t/7is us' inOt be joarleor
's, � 12ut Icense On Your
A s
'rs
Date .... ......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....... 1.')4gxvll .... /8 e,. w. .. . . .... Z�
has permission to perform ......... —n/1 ..................................................
wiring in the building of ............ 6��455 ......................................................
at . ..... & ............... . North An, dover Mass
Fee ... 5 Lic. No. & Pf .........
Check # -32- 72� �7
Commonwealth of Massachusetts
Official Use Only
Department of Fire Services P111i1No--.
t
Occupancy and Fee Checked
. 1/0 ncy
BOARD OF FIRE PREVENTION REGULATIONS FER
P'V' 1/071 Cleave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code WC), 527 CMR 12.00
(PLEASE PMMM1NK OR TYPEALL INFORA41 TIOA9 Date:
City or Town of: F.
W�*Oe#atiojla to perform the electrical work described below.
13Y this application the undersified "givesno ' e of his or er To the Inspector of Wires:
her i
Location (Street& Number) a) C)
Owner or Tenant 1Z A-<;_ Telephone No.
Owner's Address r>,
Is this permit in conjunction with a building permit? Yes 1�f--No El BLDG PERNUT
Purpose of Building. ;S /1, 4i, ill I ji Utility Authorization No
Existing Service Amps volts Overhead UndgrdEj 'No. of Meters
New Service Amps volts Overhead UndgrdE] No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: F) -/3
No. of Recessed Luminaires ""thefollowing table may be wafv�e Lnspector of Wires.
. of Ceil.-Susp. (Paddle) Fans INO. ot Total
No. of Luminaire Outlets No. of Hot Tubs Transformers KVA
Generators KVA
No. of Luminaires wimming Pool Abov EJ in- 0. 0 mergency ig Ing
arud. Prrnfi- El R.++- IrT--"-
No. of Receptacle Outlets
NO. of Switches
of Ranges
jNo. of Waste Disposers
FNo. of Dishwashers
NO.of Dryers
No. of W-ater
Heaters KW
No. Hydromassage, Bathtubs
OTHER:
of Oil Burners
of Gas Burners
of Air Cond.
rea Heating KW
Appliances KW
No. of
S Ballasts
of Motors Total HP
IRE ALARMS jNo. of Zones
rO--Of Vetection and
Initiating Devices
0. of Alerting Devices
ii �1,; i 1-ned
etection/Alerting Devices
)cal [] unicit-al
- Connect on 0 Other
:CUr1tySystems:-
No. of Devices or Equivalent
ita Wiring:
No. of DeviceLi r Equ&alent
lecommunications wiring:
2 0. �of Devices or Eauivalent
-Y/ Attach additional detail ifaesired 3
Estimated Value of Electrical Work: , Ora required by the Inspector of Wires.
Work to Start: I I 1 21 60 - &0 (When required by municipal policy.)
-- ki 4) / 9�0 Inspections to be requested in accordance with NIEC 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 �ubstantial equj�alent- The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CIIECK ONE: INSURANCE 9?r J30ND E] OTHER E] (Specify:)
I cert��, under th e p ains an dp en alties ofp erjuTY, th at th e inform ation on th is app lication is true an d complete
FIRM NAM:. k7 '? 045 S 7-eQ el
Licensee: I I Signature LIC. NO.. -_Z .96 n
11 - LIC.NO..
(Yfapplicab enter -exempt in the license number line.) _L
Address: j - L - n) L11,- i Bus. Tel. No.
.57-61 ecurity work requires Department of Public Safety'��Licen� Alt. Tel. No.:
*Per M.G.. . c. 147, s
OWNER'S INSURANCE WANER: I am aware that the Licensee does not have the liability ins LTC. Nd-�
urance coverage normally
required by law. 13Y my signature below, I hereby waive this requirement. I am the (chec one)EI owner E] owner's agent.
Owner/Agent
Signature Telephone No. PERMT FEE. S
ELECTRICAL PERMIT NO. INSPECTION REPORT:
ELECTRICAL INSPECTOR - DOUG SMALL
Inspectors, —comments:
2. FINALIN5PECTION:
Passed — b1f, Failed — Re -inspection required ($50.00) - f
Inspectors' comments:
no il
(Inspectors Signatur no ini i IS) Date
3. UNDER ROUND INSPECTION:
Passed — Failed — Re -inspection required ($50.00) -
Inspectors' comments:
(Inspectors' Signature - no initials) Date
ION — SERVICE:
DATE CALLED NATIONAL GRID: NAME:
Passed — ( ] Failed — Re -inspection required ($50.00) -
Inspectors' comments:
(Inspectors' Signature - no initials) Date
5. INSPECTION - OTIJER:
SP
Pa7ssed — Failed — Re -inspection required ($50.00) -
I s.PeE
ctors, i
nspectors' comments:
(Inspectors' Signature - no initials) Date
DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT
ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED.
-t\l- I The Commonwealth ofHassuchusetts
Department ofIndustrialAccidents
Qfjlce of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov1dia
Workers' Compengation Insuranve Affidavit: Builders/Contractors[BlectriciansfPlumbers
Applicant Wormation Please Print Lezibly
NaMe (B.usiness/Organizatioivindividual):
Address:- 0 11"
C't-Y/State/ZiPU,L)1'-J/46)-A )VA- (3,362-2 Phone#:__7?)- 3Z
Axe you an employer? Check the appropriate box:
Type of project (required):
1 - EJ I am a employer with
4. 0 1 am a general contractor and I
11
6. New construction
f n
all and/orpart-th e).*
(proprietor
have hired the sub -contractors
2. fJJ4UaT.T0aY�seoe1sa or partner-
listed on the attac&d sheet. T
7. �modeling
ship and have no employees
These sub -contractors have
8. Demolition
working for me in any capacit:3�.
[No workers' comp. insurance
workers' comp. insurance.
5. El We are a corporation and its
9. FJ Building addition
required.]
officers have exercised their
10. F1 Electrical repairs or additions
3. El. I am a homeowner doing all work
right of exemption p or MGL
11. F1 Plumbing- repairs or additions
myself [No workers' comp.
c. 152, § 1(4), and we have no
12.E] Roofrepairs
insurance required.] t
employees. (No workers'
13. n Other
comp. insurance required.]
-."-ftny appiwant that chmks box #1 must also Jill outthe 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.
lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
-faman employer that isproviding workers' compensation insurancefor my emplqyee�. Below is thepolley andjoh site
infornzation.
Insurance Conapany
POEGY # or Self -ins. Lic.
lob Site Address:
Expiration Date;
City/State/Zip;
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimfnal 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. 0 0 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of
fuvestigations of the DIA for insurance covera go ver'ification.
I do 11 erehY c erffi ��n de r th a p ain s an dp en aldes ofp erju ry th at th e inform a don p ro vided ab o v e is tra e an d c o rre cz
/- 321-/-)
Offl'claluseonbl. Do not write in this area, to be completedby city or town official
City or Town: Permit/License
Issuing Authority (circle one):
1. 13oard ofHealth 2.ftilding Department 3. City/Town Clerk 4. Electrical bspector 5. Plumbing fnspector
6. Other
Contactrerson: hone
Date.
A
TOWN OF NORTH ANDOVE
PERMIT FOR PLUM61NG
This certifies that . . kAz j ............................
has permission to perform ..... /� 5-,. �� �.�% -w-/, '. .............
plumbing in the buildings of ... 1V !� .� y ........................
at ................ North Andover, Mass.
Fee.//7 Lic. No. ........... � V,
cu;. ......
BING INSPE&OR
Check #
CIYTIID=Q
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town:
MA. Date: Permit#
Building Location: 70 Haf Owners Name: b M ot n5 5
Type of Occupancy: Commercialo EducationaIF] Industrialo InstitutionaQ ResidentialM
New:Ej Alteration: Renovation: Replacement: F] Plans Submitted: Yes E] No 0
CIYTIID=Q
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes N' No El
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 0 Other type of indemnity [:] Bond F1
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 Owner's 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 oerformed under thaArmit kqnM fnr fhA)nnn1irnfindh �iu h�;n
Pertinent provision of the Massachusetts State Plumbing Code and
By Type of License:
Title El Plumber
Plumber
City/Town El Master
APPROVED (OFFICE USE ONLY1 IRriourneyman I License Number: 1 6(09
DEDICATED
SYSTEMS
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Check One Only
Certificate #
Installing Company Name:
E] Corporation
Address:
City/Town:
AO
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State:
El Partnership
Business Tel: 61 9 2-/
S-3 Fax:
Firm/Company
VC01-11
1
Name of Licensed Plumber:
05
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes N' No El
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 0 Other type of indemnity [:] Bond F1
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 Owner's 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 oerformed under thaArmit kqnM fnr fhA)nnn1irnfindh �iu h�;n
Pertinent provision of the Massachusetts State Plumbing Code and
By Type of License:
Title El Plumber
Plumber
City/Town El Master
APPROVED (OFFICE USE ONLY1 IRriourneyman I License Number: 1 6(09
IN eE A
LIPENP§Lo" G�A E
A SFTT PR S
S
A� AN LUmb
�VASJLIOS KAZAKIS
19 SCOTT RD
HOLBROOK
A 02343 -
.-108
L7
El
I
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Tl.
Boston, MA 02111
WWW.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contrac.tors/Electricians/Plumbers
Name
City/State/Zip:
Are you an employer? Check the appropriate box:
1. [1 1 am a employer with
4. r] I airi a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2.(S� I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. We are a corporation and its
required.]
officers have exercised their
3. 1 arn a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. New construction
7. Rem odeling
8. E] Demolition
9. 0 Building addition
10.0 Electrical repairs or additions
I I. Fj Plumbing repairs or additions
12.0 Roof repairs
13.n Other
"Anyppplicantthat checks box# I must also fill out the section below showing their workers' compensation policy information.
t Homeowner's 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 inust attached an additional sheet showing the name of the sub -contractors afid their workers' comp. policy information.
I am an employer that is providing 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 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*coveMge verification.
I do hereby
zo
that the information provided above is true and correct.'
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other---------- -
Contact Person: Phone#:
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 f6regoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or -on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfortnance 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) narne(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partner.ships (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 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 bottorn
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 pen-nit/license applications in. any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future pen -nits 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
Fax # 617-727-7749
Revised 5-26-05 www.mass.gov/dia
.... ..... X." -
Date.
No 4114
'�SACHUS
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that.
has permission to perform ..........
plumbing in the buildings of . e04!�.6:V'1*
.... ... ... .............
.... North Andover, Mass.
Lic. No. 7 . ............. ................
-4� Ij 0 z7u S. 40" PLUMBING INSPECTOR
14 0811 i 14:54 50.00 PAID
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MAP
PARCEL MASSACH SETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
k . Y F� — F. j
NORETANDOVER, NIASSAIC S T
T
- . �P/' I Date
Building Location 1:;'W 0 Owners Name Pern-iit4 -4it-l—
&L - - );f, -
Amount
Lue of OcEaancy--S-.-�74�/e,,�z,��m/
L, -
Replacement Plans Submitted Yes No
New ln� Renovation D
FIXTURES
(Print or type) Check.one: Certificate
Installing Company Name clorp
�7
Address -5-7Z Partner.
Ila
5�7,< []'-,Finn/.C.o
Business Telephon . /'..f _F
Name of Licensed Plumber -
Insurance Covera C� type. of insurance coverage, by checkinaith&-' pWpat-'b---'-
P.
ge: Indicate th ap
R;mity 7. Bond
Liability insurance policy Othertvve of iride
Ila"
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner - El 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.allplumbing work.and installations pedormedun plicatiori-will,.be in,.
��PenTiitlssued.fbrlthis ap i
compliance with all pertinent provisions of the ��haspg_§.��te.pjur
Vg C.�W&Chapj 142 of the GeneraEl-aw&.
�r 5ignafureoTLicenst1c1F1um0er
Type of Plumbing License
-::Ma er,
-st
APIRR&VED"FFICE USF ONLY -
Jol , M-y*�'
PERMIT NO.
I MAP NO
APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
PAGE, 1
INSTRUCTIONS
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS I - 3
PAGE 2 FILL OUT SECTIONS I - 12
ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATE FILED
PERMIT GRANTED
19
3 PROPERTY INFORMATION
LAND COST lgi(l
EST. BLDG. COST I Voco, "
EST.BLDG. COST PER dQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
BUILDING INSPECTOR
LOT NO.
2 RECORD OF OWNERSHIP DATE
BOOK
PAGE
ZONE
SUB DIV. LOT NO.
LOCATION 0
PURPOSE OF BUILDING
OWNER'S NAME
NO. OF STORIES SIZE -r
OWNER'S ADDRESS -
BASEMENT OR SLAB
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAM!,,,���� zxo-te- a�
SPAN
�±
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
DISTANCE FROM STREET
POSTS
DISTANCE FROM LOT LINES - SIDES REAR
GIRDERS
AREA OF LOT FRONTAGE
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE OF FOOTING x
IS BUILDING ADDITION
MATER;AL OF CHIMNEY
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND
Of
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS I - 3
PAGE 2 FILL OUT SECTIONS I - 12
ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATE FILED
PERMIT GRANTED
19
3 PROPERTY INFORMATION
LAND COST lgi(l
EST. BLDG. COST I Voco, "
EST.BLDG. COST PER dQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
BUILDING INSPECTOR
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