HomeMy WebLinkAboutMiscellaneous - 272 BEAR HILL ROAD 4/30/2018Is,
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4,
C HUS
Date.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ... 5/45�10 ..................
has permission to perform .... ...............
plumbing in the buildings of . . ....................
at i'. North Andover, Mass.
Fee. . Lic. No.. .......
Check # L BING INSPECTOR
8 5 c, 9
Date . ... ..
.. q ..........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
t4
has permission to perform ..........................................
wiring in the building of ..... ....... t. .....................
....... ... . . ..
at.<.JI.JJ.JC,.,5 . . ...... j. 44 . .. 7 ........ . North,� �dov Mass.
Fee..[J.� ........... Lic. No.,Va6..;� ........
L.g.�
", i;�;�A
Check #
9373
I
Commonwealth Of Massachusetts - urnmaj Use Only
Department of Fire Services Permit No. -7
rm'
[Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] 0eaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (M C), 5 7 CMR 12.00
(PLE,4SEPR8TflVTNK OR YYPEILL NFORMATION)
Date: 10
City or Town of. NORTH ANDOVER To the Innspe tor Wires:
By this application the unders,gned gives no ce of hi perform the electrical work described below.
Location (Street & Number)—.,2 '7 a 1
Owner or Tenant aLa--C_�
I / e,
Owner's Address Telephone NO.
Z
Is this permit in conjunction with a building permit? Yes No
Purpose of Building (Check Appropriate Box)
Utility Authorization No.
Existing Service Amps Volts Overhead 0 Undgrd No. of Meters
New Service Amps —volts Overhead D Undgrd No. of Meters
Number of Feeders and Arnpacity
Location and Nature of Proposed Electrical Work: Y' __L
No. of Recessed Luminaires
No. of Luminaire Outlets
No. of Luminaires
No. of Receptacle Outlets
FNo. of Switches
No. of RanHges
No. Of Waste Disposers
Completion ofthe
of CeL-Susp. (Paddle) Fans
INo. of Hot Tubs
__ - —AAbove.
Swimming P 01
"—n LJ
No. of oil Burners
No. of Gas Burners
No. of Air Cond.
N N
o. of Dishwashers Space/Area Heating KW
No. of Dryers Heating Appliances
W KW
No. of W ater No. WX
Heaters . KW Si4ens Ao. of
I Ballasts
No. Hydromassage Bathtubs No. of Motors Total HP
1071
�f �blebe �waiwd �bthe �hmecto, of
iLransiormers KVA
Generators KVA
ALARMS No. of Zoness
Of Alerting Devices
tecti � 'Al rft D -
OIL e evices
M
umcipal
.8111 Connection Other
urity S stems.*
11evices or quivalent
:a Wiring:
No. of Devices or j� valen�t
ecommunications Wiring.,
�jO_-Of Devices or Eanivalehf
Attach additio etail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: t�"' r) (When required by municipal policy.)
Work to Start -0
hispections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE CA�G_EUnless waived by the owner, no Permit for the performance of electrical work may issue unless
11
the licenseeprovides 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 IR BONDE] OTHER [] (Specify:)
I certify, under the pains andpenaldes ofperjury, that the information on this
FIRM NAME: aPPlication is true and complete -
Licensee: LIC. NO.:
(If applicable, enter Signature LIC. NO. -
"exempt " in the T�ic_enjn_,-_mbehm.) natur 2-1 _jfS
Address: _2 S /3 IV,
& Bus. Tel. No.:
0 Z'90.<
t P Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work reqihres- 2a�rtrnent o Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) 0 owner owner's a-ent.
Owner/Aa�nt —
Signature" Telephone No.
Ll
,f, /Z -,/a d,
of —
The Commonwealth of Massachusetts
Department of Lndustrial Accidents
Office of 1nvestigations
.600 Washington Street
Boston, AL4 02111
www-mass.gorldia
Workers' Compensation Insurance Affidavit: BuBders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): E -s Se, 1-1
Address: 14-b CJ51��14
City/State/Zip:_ '54 L)d 0 (Y�OL 0 ) 90 Phon I e #:
Are you an employer? Check the appropriate box. -
I - f�rI am a employer with — /
4. D I am a general contractor and I
employees (full and/or part-time).*
2. D
have hired the sub -contractors
I am a sole proprietor or partner-
listed on the attached sheet
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. El We are a corporation and its
required.]
3. 0 1 am a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself. [No workers' comp.
C. 152, § 1(4), and we have no
insurance required.] t
employees - [No workers I
-A
comp. insurance required.]
79
Type of project (required):
6. F� New construction
7. El Remodeling
8. Demolition
9. Building addition
10.7 Electrical repairs or additions
11 - 11 Plumbing repairs or additions
12.0 Roof repairs
13.7 Other
A" 1w out Lae sect'M- bei 'A' showinng their worlers! compensation policy information.
t Homem-mers who submh this affidavit indicating they are doing'all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the riame of the sub -c
Outractors and their workers' GOTUP. Policy information.
I am an employer that is providing workers I compensation insiurancefor my employees. Below is the policy andjoh site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: ��3 3 Expiration Date: SA/,Jc>
Job Site Address: -7 /2 -
City/State /Zip;o_�- CV,2 L/ c� 446t
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 A
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 11
Investigations of the DIA for insurance coverage verification.
I do hereby ceytf&.under the pains andpenallies ofperjury that the information provided above is true and correct
3
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):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
501
Contact Person:
Phone#:
iw�l
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartrnents 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 coimpliance 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 7 -
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Departmen of Industrial
Accidents for confirmation of insurance coverage. Also he sure to sign and date the affidavit. The affidavit should
be returned to the citty or town that the application ffor the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permittlicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
tojwn)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
yelar. Where a home owner or citizen is obtaining a license or permit not related to any business. or commercial venture
(i. be. 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 VV.1VM7.mas&.gov/dia
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLLMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location Date
Permit 9
Owner Y -L LT Amount
New Renovation 0__� Replacement 0 PlansSubmitted Yes r-1 No
(Print or type) Check one: Certificate
Installing Company Name Q.Ae iS P+ Corp.
Address "e('j4'26"ZT --Y)L Partner.
Business Telephone Firm/Co.
Name of Licensed Plumber: _M(LkAC�
Insurance Coverage: InctIcate the type of insurance� coverage -by checking�ffie appropriate box -
Liability i nsurance policy El Other type of in�ity Bond
rl El
ffismnr,e Waiver: L the undersigned, have been made aware that the licensee of this aPPhcat10n does lot have any one of the above
three insurance
Signature Owner
I hereby certify that all of the details and information I have submitted (or Eno
best Of my knowledge and that all Plumbing work and installations p
compliance with all Pertinent Provisions of the MwsachusettsAS�
By:
SipauMiree I Lie-MUTTu-m-rm-
Title of Plumb* License
Citv/Town eV7,
Agent F1
m
,0bove application are trw and accurate to the
rPermit Issued for this application will be in
and Chapter 142 of the General Laws.
e lNumt)--r — Master r%';Pl
APPROVED (omcF usF, oNLy Journeyman F1
4L The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
.600 9"ashinclon Street
Boston.- AL4 02111
kvi www-massgov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information T"
Name (Business/organization/Individual): S—rJA_C_�S
(0th,
Address:
City/State/Zip: kC>tJ1*T M& Phone 4 &q(4 -77.3o
I _Z7
Are you an employer? Check the appropriate bov
a employer with
4. 1 am a ge3aeral contractor and I
employees (full and/or part-time).*
2.7 1 am a sole or
have hired the sub -contractors
listed
proprietor partner-
on flae attached sheet. I
ship and have no employees
These. sub- contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5.7 We are a corporation and its
required.]
3.7 1 am a homeowner doing all work
Officers have exercised their
right Of exemption MGL
myself. [No workers' comp.
per
c. 152, § 1 (4), and we have no
insurance required.] t
employees. [No workers'
Comp. msuran= required]
:Any appheant that ch-ecks box !�! mu-stalsO fill out Cat st.tion beiaiv .06_;_W�,�
Type of project (required):
6. New construction
7. Remodeling
8. Demolition
9. Building addition
10T� Electrical repairs or additions
11 - 11 Plumbing repairs or additions
12-F� Roof repairs
13 -El Other
Home -owners. who submit this affidavit indicating they are doing all -- = _'mP---uQu poncy miormation.
�0011t-ctors that check this box must attached an additio work and then hire outside contractors must submit a new affidavit indicating such.
nal sheet showing the name of the sub -contractors and their workers, comp. Policy information.
am an employer that is providing workers, compensation insurancefor my employees. Below is thepolicy andjoh site
information.
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Job Site Address:
Expiration Date: I
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 M'GL c. 152 can lead to the imposition of c . riminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the fbim 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 for . warded to the Office of
Investigations of the DIA for ce coverage verification.
I do hereby cerWjy
and penalties ofperjury thizt the informagon provided above is true and correct
0
Phone #: f
11 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):
L Board of Health 2. Buildin.
, Department 3- City/Town Clerk 4. Electrical Inspector 5. Plumbin.,
6. Other Inspector
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 e mployee is defined as "...every person in the service of another under any contract of hire,
express or unplied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing -engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
.receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of coinpliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the common alth 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) narne(s), address(es) and phone nuniber(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other tim 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
I or license is being requested, not the D--partmen, of
be retumed to the city or tovm that, the application for the pernait
Industrial Accidents. Should you have any questions regardirig the law or if you are required to obtain a workers'
compensation policy, please call the Department at the numbc-,r listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would I&e to ffiank 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 Qf Ma&sachusetts
Department of Industrial Accidents
Office of Investigations
600 WashingtonSt7eet
.Boston, MA 02111
Tel. # 617-727-4900 ext 4,06 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05 www.mass-gov/dia