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Home My WebLink AboutMiscellaneous - 274 CHESTNUT STREET 4/30/2018 (2)N) IM, .4 z C/) 0 m Lieb��y Mutual. INSURANCE November 13, 2015 Town of North Andover Attn: Building Inspector 120 Main Street North Andover, MA 01845 Liberty Mutual Insurance New England Region Central Property Unit 75 Sylvan Street Danvers, MA 01923 Tel: (800)566-0323 Re: Property Address: 274 Chestnut St, North Andover, Ma 01845 Policy Number: H3221813682222 Underwriting Company: Liberty Mutual Fire Insurance Company Claim Number: 031497330-0001 Date of Loss: 2/7/2015 Attn: Town/City Official Pursuant to M.G.L. c. 139, § 3B, please be aware that a homeowners insurance claim has been made involving loss, damage or destruction of the above captioned property, wl-�ich may either exceed $1,000.00 or causes the condition of a building or other structure to render Mass. General Laws, Ch. 143, § 6 applicable. You are required to notify Liberty Mutual by certified mail in accordance with Mass. General Laws Ch. 175, §99, if you intend to initiate proceedings designed to perfect a hen pursuant to Mass. General Laws, Ch. 139, § 3A & B, or Mass. General Laws, Ch. 143, § 9, or Mass. General Laws, Ch. 111, 5 127B. This letter should not be construed as a waiver or estoppel of any of the terms, conditions or defenses afforded by the policy or applicable law. Please direct your notice to the attention of the undersigned and include a reference to the above captioned property address, policy number, claim number, and date of loss. Sincerely, Liberty Mutual Support Liberty Mutual Insurance New England Region Central Property Unit 1-800-566-0323 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 forin. 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, § 3L. - Permits shall -be limited ap to the time ofongoing construction activity; and may be -deemed -by. the Jnspector-of-Wires abandoned-and-invalid-ifhe--- 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. n The Permit Extension Act was created by Lection 173 of Chapter 240 of the Act.- 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 farthers 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. 8 — Permit/Date Closed: El Permit Extension Act — Permit/Date Closed: !V ***Note: Reap' ply for new permlu-v Date ... . ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING C� Thiscertifies that ............................................................................................. has permission to perform ......... &9-- �-/-/ ................................................ wiring in the building of ........ 1�v4:pe .. ................................................... at.... -2.7 Z11 ........................ ... ... 7 ...................... /-,)North Andover, Mass. ........ ...... Fee-A�..::7= ..... Lic. No. .............. k .... .. Check # EdEcTRICAL INSPECTOR (/* y . 10824 (fommonwvalg ol Majjaclwatb Official Use Only PermitNo.— BOARD OFF'IRE PREVENTION REGULATIONS Occupancy and Fee Checked kv [Rev. 1/07] (leaveblank) I APPLICATION'FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code WC), 527 CMR 12.00 (PLEA SE PRINT IN INK OR TYPE ALL INFORM4 TION) Date: 51-7 // 2— City or Town of: A&A 4,0�-,�Xz 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) 2-'7 q dbtS,41,j7- 5 Owner or Tenant Ai?khu )=VcJ4�� Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yesef=— No El (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Yolts Overhead Undgrd [] No. of Meters New Service Amps Yolts Overhead Undgrd F -I No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: '14�11� Completion of the following table may be waived by the InSDector of Wires. No. of Recessed LtJimlnalres6� No. of Cefl.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminarres Above [] gn- Swimming Pool grnd. rnd. IV57-6TY—m ergency Lighting Battery Units No. of Receptacle Outlets No, of Oil Burners FIRE ALARMS. I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: J.Nyjp.��r I .......... JKW ........................ No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local [j Municippi 0 Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water Heaters KW No. -of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP tal ecommunications NVirin ; No. of Devices or Equivint OTHER: A flach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy,) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [91 BOND 0 OTHERE] (Specify:) I certify, under the pains and penalties ofperjury, that the information on toqpplica ,Aon is true and complete. FIRM NAME: PAV112 ELECTRICAL 0wr9Ac,-r1W41A�L,&1 LIC. NO.: Licensee: DAV ID 14A66AP,— Signature LIC. NO.: I A (If applicable enter "exempt " in the license number line.) 47, Bus. Tel. No.:418- 6-92 - 047 - Address: 61 IDELWwr ST- N Rill ANDOV �/4 OAT - Alt. Tel. No.,q 79-37 5*- 573Lf *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER., I am aware that the Licensee does not have the liability insurance coverage non-nally required by law. By my signature below, I hereby waive this requirement. I am the (chec one) E] owner El owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: S The Commonwealth ofMassachusetts Print For Department ofIndintrialAccidents Office of Invesdgadons 1 Congress Slree4 Suite 100 Boston, H4 02114-2017 www.nzassgov1d1a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): DAVID ELECTRICAL CONTRACTING LLC Address: 87 BELMONT ST 1-4%jr-, I r-1 M1-4LJVvr_rW, w1m. U I 01+Z) Phone #: UIUAWZ_�Uzt)z Are you an employer? Check the appropriate box: Type of project (required): 1. Q I am a employer with 7 4. [] I am a generdl contractor and 1 6. E] New construction employees (fidl and/or part-time).* have hired the sub -contractors 2- C1 I am a sole proprietor or partner- listed on the attached sheet. 7. [] Remodeling ship and have no employees These sub -contractors have 8. E] Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp. insurance required.) comp. insuranc Z.+ 5. E] We are a corporation and its 10.0 Electrical repairs or additions 3. 1 am a homeowner doing all work officers have exercised their ILE] Plumbing repairs or additions myself [No workers'comp. right of exemption per MGL 12.E] Roof repairs insurance required.] t c. 152, § 1 (4), and we have no 13.El Other employees. [No workers' comp. insurance required.] *Any applicant that checks box# 1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. I *Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurancefor my employees. Below is the policy andjob site information. Insurance Company Name: THE HARTFORD Policy# orSelf-ins. Lic. #: OBWECC18293 Expiration Date: MARCH 1, 2013 -.v / d*512W7— 4�7— Job Site Address: City/State/Ziv: A"y 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 ins 9 ,pr�nce covera e verification. I do herebV c"fV under 978-682-6262 that tke wmadon provided above is true and correct. Official use only. Do not wrfte in Otis area, to be completed by city or lawn officiaL City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Date ....... 7 ....... ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................... .............. 11�' ............................................................ has permission to perform ..... ...... ....................................................... wiring in the building of ........... ............................................. at...................................................... ................ . North Andover, Mass. Fee...., ............... Lic. No/.'..Z.-::.:�� .................................... ..................... ;e... ELECTRICAL INSPECTOR6" z Check # /6 9 Cl 31 Commonwealth of Massachusetts Official Use Onlv Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS Rev. 1 /071 (1ca,e h1ank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK M1 work to he perforniLd in accordance with the Massachusetts Electrical Code'(�MEC), 527 CMR 12,00 WLEASL'1)R[W'1N INK OR �YPE ALL INFORMA TION) Date: City or Town of: NORTH ANDOVER To the Inspector of WireT: By this application the undeN- gned gives notice of his or he-rTtnte-n-Ti—onto perform the electrical work described below. Location (Street & Number) Owner orTenant Owner's,Address /9 --, 4 r- - - C', - / Z Telephone No. -C Is this permit in conjunction with a building permit? Yes Purpose of Builoing / I- I �N, 0 17 (Check Appropriate Box) Utility Authorization No. Existing Service p/-4, Amp/s/ /Z' / Z '7'C Vo ts OverheadE] Undgrd No. of Meters .New —Service J- e- 0 Amps ZL� / e Y --/ Volts Overhead [� UndgrdE] No. of Meters Number of Feeders and Ampacity 1, 1 IZ/— Location and Nature of Proposed Electrical Work: Comnlptinn ,ffh, L No. of Recessed Luminaires 14 - - ...!:! "' - ' - No. of Ceil.-Susp. (Paddle) F ans -11 ' "'." "' (�i, ine inspector OJ Y1,1ri"y. No. of ' — ------T-O-taT Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above mergency L-igh-ffn—g rnd, rnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Switches No. of Gas Burners No. of Deter and 4 'rotai Initiatinu Devices No. of Ranges No. of Air Cond. Tons No. of Alerting Devices No. of SeIU-Contained No. of Waste Disposers Heat ump T otals: Number ons Detection/Alerti Devices No. of Dishwashers I Space/Area Heating KW um apal Other Local E] C onnection No. of Dryers Heating Appliances KW 4-- security -S-v—stems-* ' R-0.or ater No. of No. No. of bevice; or Equivalent Heaters KW S*ryns Ballasts Data Wiring: No. of Devices or E uivalent --mm No. Ilydromassage Bathtubs No. of Motors Total Te-leco u ; Maio n -- s Wiring: No. of Devices or Equivalent OTHER: Allach addiiional dewil �f desirecl, or as reqefired by 1he Itispecior ofgirc.,�. Estimated Value ofElectrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10. and upon completion. INSURANCE COVER—AGE: 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 [9--156ND 0 OTHER F1 (Specify:) I cerfift, under the pains andpenalties ofperiuoy, that the information on this OPPficalioliiv true and complete. FIRM NAME: /1;1 LIC. NO.: 13L 91,5�, -7 Licensee: J�l Signature LIC. NO.: ie"Ip/ it? Me license trurnher hote.) 13us- f�o.: 7 Address: Bus. lei. Eig -�It, L Alt. Tel. No.: of I Per M. 6. 1. c. 147.1 s, 51-6 1, security work requires Departm of Public'Safety "S" License: Lic. No. OWN ER'S INSURANCE WAIVER: I am aware that the Licenseedoes n-, "t have the liability insurance coverage normally C, - tequired by law. By my signature below, I hereby waive this requirement. I am the (check one) 11 owner [] owner's a gent, Tclephone No. " 0 kz- ci .0 /(- `7 o6 A,,, 7- Date—' .............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... ��s'f (A c- .............................. ............................................ r"j 'PA ...... has permission to perform wiring in the building of ............. U-...!��L) ................................................................... 2-14 Ck,,o:zA,,,-A at........................................................... I ............................... 1 ...... K. ,forth Andover, Mass. &e .... !�� ......... Lic. No.1--51�_5 ........ 1.) .......... ELEBUCA�!L �P�E�CrO�R Check # wl� Official Use Only Commonwealth of Massachusetts Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. iw] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEQ, 527 CMR 12.00 (PLEA SE PMT IN HK OR TYPE A LL ) NFORAM TION) Date: M4!j 26 , ZO 13 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) 27 4- c. q EST)i v T- sTzc- c- T - Owner or Tenant 13 &yA Aj Ro LD S Telephone No. Owner's Address 2--il C-Hestiju-t &15tfitE -F Is this permit in"conjunction with a building permit? Yes No (Check Appropriate 13ox) Purpose of Building Utility Authorization No. Existing Service Amps Volts OverheadF] UndgrdF] No. of Meters New Service Amps volts OverheadE] Undgrd [I No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 2wPFj(),0ye I�A(LW6�- Completionofthefollowin table mav be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers -KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above Ei In- Swimming Pool grnd. grnd. El No—. -5TEme ing BatterV Units No. of Receptacle Outlets 4. No. of Oil Burners FIRE ALARMS JN'o. of Zones No. of Detection ond No. of Switches 3 No. of Gas Burners Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices Heat Pump I Number I ToA§ No. of Self -Contained No. of Waste Disposers Totals: ........................... I ......... .......... JKW ....................... Detection/Alerting De ces No. of Dishwashers Space/Area Heating KW -1 Municipal LocalEl Connection ElOther No. of Dryers Heating Appliances KVV Security Systems:* No. of Devices or Eguivalent - No. of Water -- KW No. of No. of Data Wiring: Heaters Signs - Ballasts No. of Devices or Equivalent - No. Hydromassage Bathtubs --TNo. of Motors Total HP Telecommunications Wiring: No. of Devices or Eguivalent - OTHER: Attach additional tail i(destred, orasrequireavyineinspecroruj yrlrey. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 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 un ess 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: INSURANCEEI BOND [I OTHEREI (Specify:) Icertify, underthepains andpenalties ofperjury, thattheinforniation on this application is trueandcom plete. FIERAINAME: . 66oizoc J"� HASSAMPlE, Rk 6XII Gt6C--1!,C)C- LIC. NO.: A 134� Licensee: (5 eo p-&& j-, cA re D lir Signature LTC. NO.: - & Z 0 .9 3: (Ifapplicable, ent "exempt in the license number line) Bus. Tel. No.--.(2�03- Address: QeiP6 0"Dowy o14-inzot�Z Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I 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 E] owner's agent. Owner/Agent PERMIT FEE.- $ Signature Telephone No. �ij 4�- \Zl< NIS K) C) #1 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, § 3L. 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 Act,; 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, E00 Ru:le 8 — Permit/Date Closed: Note: Reapply for new permit 0 u '—P o p m Pe rmit Extension Act — Permit/Date Closed: rench I S Trench Inspection ec eio Pass n? Pass [ mt Inspectors Co Inspectors Comments: m n t s Failed Re- Inspection Required D Inspectors Signature: - Date: Cn E R SERVICE INSPECTION: IN5SPE1ON- 7 T a 5,CE Pass S rInspectors Comments: sp ctors Comm ts. Failed Re- Inspection Required 0 n n Inspectors Signature: Date: PARTL4,L ROUGH INSPECTION: Pass M Inspectors Comments: Failed Re- Inspection Required El Inspectors Signature: Date: ROUGH INSPECTION: Pass M Inspectors Comments: Failed Re- Inspection Required ($.) El Inspectors Signature: n pe gnat re: S ctors Si u Date: 27-17 L i IINAL INSPECTION A INSPE TION C Pass M a ss EE nspectors Comments: F Failed Re- Inspection Required El Inspectors Signature: Date: I :BWEINHOLD ...TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com The Commonwealth ofMassachusetts Department of Industrial Accidints Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/FIectricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrganizatiorAndividual): GT14 G-LECI-A)c Z6,6012C.C-J_ L,�S_56ta-lrt- I Address: Ut-__ City/State/Zip: � A 0 Do /i )J q (93 6) ? 3 Phone #:, Go -2- 3,5"- 0 -34 8 Are you an employer? Check the appropriate box: 1. F1 I am a employer with 4. El I am a general contractor and I employees (fall and/or part-time).* have hired the sub -contractors 2. 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. E] We are a corporation and its required.] officers have exercised their 3. 1 am a homeowner doing all work E] right of exemption per MGL myself. [No workers' comp. c. 152, § 1 (4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. El New construction 7.-Aff Remodeling 8. Demolition 9. F1 Building addition 10. Electrical repairs or additions 11. Plumbing repairs or additions 12. Roof repairs 13.[__1 Other VAny applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractorsthatcheckthis 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 isthepolicy andjoh, site information. Insurance Company Name: Policy # or Self -ins. Lic. M 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 requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a Rhe 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 the paiM andpenalties ofperjury that the information provided above is true and correct. Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit0cense # 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 Instruction' -s - Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an em ployee is defined as ". ... every person in the service of another under any contract of hire, express or implied, oral or written." An employerIs 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 ffie 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 requ-ired." Additionally, MGL chapter 152', §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic 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. SeY-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 provided a space at the bottom 0 f 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 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 loc*ations 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 p* ermit 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 CommoRwealth of Mossachusetts Department of Industrial Accidents Office of Investigations 600 Washington Strec,-t Boston., MA 02111 Tel, # 617-727-4900 ext 406 or- 1-877,7MASSAFE Revised 5-26-05 Fax # 617-727-7749 __WWW.Mass.9ov1dia Dates.: 9 ORT" TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING 40 ,tSA US This certifies that i ................. has permission to perform .... ..A.. plumbing in the buildings of ... ......... h 0Aer, Mass. _;SFee..Z/3�—. Lic. No.. ........ Check # PLUMBIN SPECTO R POWNER TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA. DATE PERMIT # JOBSITE ADDRESS 3-2 C k' OWNER'S NAME A ADDRESS TEL FAX OCCUPANCY TYPE: COMMERCIAL El EDUCATIONAL El RESIDENTIAL NEW: D RENOVATION:ig REPLACEMENT: PLANS SUBMITTED: YES E] NO E] FIXTURES I FLOOR— BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIL1SAND SYS DEDICATED GREASE SYS DEDICATI) GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL 40 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which, meets the requirements of MGL Ch. 142. Yes ER No 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE BOX 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 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 Laws. PLUMBER NAME ')rk'( J9 U V19 f C -f . .. SIGNATURE LIC# 4� MP [A JP El CORPORATION # ')- 9 9- PARTNERSHIP [I # LLC M # 1,4 :t%c C/ COMPANY NAME P Y V_3 e 5 S eju 3 A 0) ADDRESS: 16 11C41 h�k 11 A CITY—T Yo -3sdo V0 —STATE JA-; ZIP EMAIL TEL 0 CELL 9' 2 FAX V1 412 Z 41 L, 7. 4W.Ifz 11r0�x"111_'51'At11'1'z_ The Commonwealth ofMassachusetts Department of1ndusNdAccWnts Office Of InVESAP&M 600 Washington Street Boston., MA 02111 kvi www.massgovIdla Workers' Compensation Insurance Affidavit: BuUders/ContractorsfElectiticiansfPlumbers Applicant Mormation Please Print Legib Name (Business/orgarhationandividuaD: 19 U r e S C Address: clot Ke,,d City/State/Zip: 7)?'�i J S;e & v- o Y), Phone#: Are you an employer? Check the appropriate box: Type of project (required): 1. El I am a employer with 4. El I am a general contractor and 1 6. [1 New construction employees (M andlorpart-time).* 2.0 1 am a sole proprietor or partner- have hired the sub -Contractors listed on the attached sheet : 7. []Remodeling ship and*have no employees These sub -contractors have 8. El Demolition working for me in any capacity. workers' comp. insurance. 9. [] Building addition [No workers' comp. insurance 5. We are acotporation and its 10F1 Electrical repairs or additions required.] 3. D I am a homeowner doing all work officers have exercised their right of exemption per MGL 11. n Plumbing repairs or additions myself [Noworkers'comp. c. 152, § 1(4), and we have no 12.E] Roofrepairs insurance required.] t employees. [No workers' 131i Other comp. fimmoe required.] ?Any applicant that checks box Of must also fill out the section bdow showiftg their workers' compensation policy information. T Homeowners who submit this affidavit indicating they sie doing a work and then hire outside contractors must submit a new affidavit indicating such. t0ontractors that check this box must attached an additional sheet showing the name ofthe sub -contractors and their workers' comp. policy information. .1 am an employer that 1sproviding workers' compensation insurancefor my enployees. Below is fliepollcy andjoh site information. Insurance Company Name% 0 V- F. A h d ne Policy # or Self -ins. Lic. #: LU e c to 0 A EvirationDate: /Z Job Site Address-, *17 Y - .,.-( 4 _ H, -V C, f Pity/State/Zip: A' -Ac�dt,-f v - Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o. 152 can lead to the imposition 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert& urider thepains andpenaliles ofterfury that the Information provided above is true and correct, Signature: X42� Date: Phonefi: �) g- - 4, y � - 'a,,/ / o Official use only. Do not write in this area, to be completedly chy or town official City or Town: - Permit[Licenseg Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CltyTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other ContactPerson: Phone#. 100 k Z�� 09 Date ............. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... /I r ................. ............ has permission to perform-_ ......................... plumbing in the buildings of ... ];;"I ............... at....... ................ 11 ...... North.Andover, Mass. 4 Fee. .... Lic. No .......... ..... ............ z - PLUM'B'1N'4 INSPECTOR Check 41 2? 7'/'/ 0 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOvER, MASSACHUSETrS Building Location -7 Y 04,&f orrs Name k� Type of Occuppcy New Renovation ET"' Replacement Plans Sul r. Date ?.b '0 F - L L2 -b. , -,/-, 0 —F Permit # 7/a y Amount /F- t5- mifed Yes. No (Print or type) Check one: Certificate Instilling Company Name ri Corp. Address -... AZ TJ 0 k rd A, <--T- Partner. '),V 0 ( Q 0�eill -11 U 4. 0 / El . Business Telephone -Q "Z' 0 Finn/Co. Name of Licensed Plumber: jj 3 � -'? WV -e:� Insurance CoveErME Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy a Other type of indenulity n Bond F1 Insurance Waiver: L the undersigned, have been made aware that the licensee of this applicatiori does not have any one of the above three insurance Signature Owner rl Agent ri I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massphui2ts St�V- Plumbing Code an 14�4f the General Laws. // By: I SigrTaL Title Type of Plumbing License City/Town - a s 6,-7 1APPROVED (OMCE USE ONLY se 'NumDer — Master Journeyman ky) -W 1- "o 0 05 5 0 M M M M M M M 1. _7 - g- MMM mmm L*1481—ra-c'MMMUMMOMOMM MM MMIMMMMMM IFT-1-10-6-6 �OMMMMMMMMMM MMMOMMMMM 91-1p, Orgill, MMMMMMMMMW = mmmmmmw 0W1*'121r#-6NMMMMMMMM M mmmmmmm M M N W-3111me-18"MMMMMMMMMM MM MMMMM (Print or type) Check one: Certificate Instilling Company Name ri Corp. Address -... AZ TJ 0 k rd A, <--T- Partner. '),V 0 ( Q 0�eill -11 U 4. 0 / El . Business Telephone -Q "Z' 0 Finn/Co. Name of Licensed Plumber: jj 3 � -'? WV -e:� Insurance CoveErME Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy a Other type of indenulity n Bond F1 Insurance Waiver: L the undersigned, have been made aware that the licensee of this applicatiori does not have any one of the above three insurance Signature Owner rl Agent ri I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massphui2ts St�V- Plumbing Code an 14�4f the General Laws. // By: I SigrTaL Title Type of Plumbing License City/Town - a s 6,-7 1APPROVED (OMCE USE ONLY se 'NumDer — Master Journeyman Date. .7 TOWN OF NORT4 ANDOVER PERMIT FOR GAS INSTALLATION This certifies that has permission for gas installation ..... ...................... in the buildings of ... I�Q. ***** at ... .7.L/ .... C4.e I North Andover, Mass. .... .. .... . . Fee..) P.... Lic. GASINSPt CTOR Check # MASSACHUSETrS UNIFORM APPUCATON FOR PERNUr TO DO GAS FITrING (Type or print) Date NORTH ANDOVER, MASSACHUSETTS —A Building Loqations Permit # Amount $ Owner's Name -,r—o Ll New 0 Renovation 0 Replacement [3— �lans Submitted (Print or type) Check one: Name— /OL I T -4-11 e 1-71 El Corp. t -7) 111 I Name of Licensed Plumber'or Gas Fitter Certificate Installing Company LjPartner. " I 137irm/Co. I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts GWCode an*haptVI 42 olDhe General Laws. 10 By: Title City/Town 1APPROV, ED (OFFICE USE ONLY) Signature of Plumber Gas Fitter 13--M aster [3 Joumeyman sec F r Gas Fitter P��-O U cPse INUMDer Ed W U z Z Z i - U < rg z W > z z rA I 12 in L > i- U > It 0 z W TU B-BASEM ENT U > BASEMENT IST. IF L 0 0 R - 2N D. F L 0 0 R 3 R D F L 0 0 R 4 T H F L 0 0 R F- 5 T H F L 0 0 R 6 T H F L 0 0 R 7 T H IF L 0 0 R ........ .. PT H F L 0 0 R HLLEIETI��' (Print or type) Check one: Name— /OL I T -4-11 e 1-71 El Corp. t -7) 111 I Name of Licensed Plumber'or Gas Fitter Certificate Installing Company LjPartner. " I 137irm/Co. I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts GWCode an*haptVI 42 olDhe General Laws. 10 By: Title City/Town 1APPROV, ED (OFFICE USE ONLY) Signature of Plumber Gas Fitter 13--M aster [3 Joumeyman sec F r Gas Fitter P��-O U cPse INUMDer TH jq,,j.paV'.F JOB 7� C94:5 T- COLLOPY I)l 1 1.2 ENGINEERING CONSULTANTS SHEET NO. OF -- 65 Ayer Street CALCULATED BY DATE — 6/7- 0/,=18 METHUEN, MASSACHUSETTS 01844 TEL/FAX (978) 685-8069 CHECKED BY DATE