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Miscellaneous - 279 WINTER STREET 4/30/2018
a Date. ��v ............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......../J. ./......%.....:y.A Vis ......................... has permission to perform .................... ........... .......... .......}............................................... .f....... wiring in the building of.......................... 9 ................................................................................. 07 % I � J�2- �� , North Andover ass. .at........................................................................................... Fee..-5?..� �/%oZ / Lic. No .................. ..................... S fi CTRIC EC Check # � ��J ' Con tmon wealth of Massachusetts fficial Use Only a Department of Fire Services Permit No. 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 (MEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATIOA9 Date: 3 ),Ti71 / 5— City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of ' or here tion to perform the electrical work described below. Location (Street & Number) 7-.7 Q W j,/'1 Owner or Tenant r Qln Telephone No.( 7 7F) 07 — ASV g Owner's Address 2 3 Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) . Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature f Proposed Electrical World: ,. Lv t�j�,y EA / ri/✓t'_ S°y A &W 069AS hw I "Vel i� Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above El ❑ o. o mergency Ug ting rnd. rnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS 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 77— No. of Waste Disposers Heat Pump Totals: Number Tons ."'......."".. KW ...."""............. No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Mres. Pstimated Value of Electrical Work: Z Z Z , (When required by municipal policy.) Work to Start: 14SAA 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the gins and penalties !f. erjury, that the inforn2ation on this application is true and complete. FIRM NAME: D'd` _,&C NO.: C-1-7 Z Licensee: L Signature LIC. NO.: _�rp (If applicable, enter "e empt in the li ns number li ) Bus. Tel. N Address: ; , -Vg lz V Alt. Tel. No.: *Per M.G. 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) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ -`g0 Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the , t 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 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 ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass ❑' Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Dater ROUGH INSPECTION: Pass R Failed r Re- Inspection Required ($.) ❑ Inspectors Comments: t Inspectors Signature: Date: FINAL INSPECTION: Pass 0K - Failed Re- Inspection Required ($.) ❑ Inspectors Comments: r� Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwea m of 1Y1ass0crzrA6secz,) Department of Industrial Accidents office ofInvestigations d 600 Washington Street t Boston, KA 02111 www.mass.gov/dica WorIcers' tCor1ripensatio>n insurance Affidavit: Bail ders/CORtractors 4 Pectracians/Fiumbers Alf��pll��TG1� Ilflli®Il10[A�iCfl®AA please Print ILegal�l� • NaMe (Business/organization/Indiyidiial)y_ UKr 4 Address: City/State/Zip: Phone #: j Are you an employer? Check the appropriate box: 1. ' I am a employer with \0 (7rt`. 4. ❑ 1 am a general contractor and 1 employees (full and/or pa )ne).Y have hired the sub -contractors listed on the attached sheet. 2. ❑ 1 am a sole proprietor or/ ner- These sub -contractors have ship and have no emplr s working forme in any )acity. workers' comp. insurance. [No workers' comp. insurance 5• ❑ We are a corporation and its officers have exercised their required.] 3. ❑ T am a homeowner doing all work right of exemption per MOL myself. [No workers' comp. c. 152, § 1(4), and we have no employees. [No workers' insurance required.] t comp. insurance required.] Type of project (required): 6. ❑ New construction. 7. ❑ Remodeling S. ❑ Demolition 9. [] Building addition 10. F1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.0_Other L-�7��r Ll o\��'=iL 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i HoreoiNmers 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 must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. ,T arn.an erraployer• that isproViding wopkers, coinperasation znscca•atnce for rr<y employees. Below is alae policy rind jaffi sire in, f ohil-ation. { "'� � „ t�>>•��- J`���� ,C,� �•� e•;j`-.� w';3��x:;:E.:.�°.eszzC—;.u.�--. K.r�'r`sv'w`ap�yi-�,. Insurance Company Name: Policy # or Self -ins. Lic. #: j'y ` =ST 4 4k 0 21- � �c�Lo��.Dotq t Job Site Address: �—� 1 ��V ' City/State/Zip: � � cp� Attach a copy of the workers' cornpensation 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 acid/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 veri- :' ation. I do 1%er•ehy cedijy aunder• the that tlae iraf0rrraatiora provided aboopeisj trace and correct. Tlat, � 12- �1 , 0ffacial 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 Cler4. Electrical k Inspector 5. Plumbing inspector 6. Other Contact Person, _ Phone #: X A� " CERTIFICATE OF LIABILITY INSURANCE DATEIYYYY) 10108//20142014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Marsh USA Inc. 1560 Sawgrass Corporate Pkwy, Suite 300 CONTACT NAME: FAX AICONo Ext): (A/C, No): E-MAIL ADDRESS: Sunrise, FL 33323 Attn: FtLauderdale.Certs@marsh.com 10101/2014 10/01/2015 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Zurich American Insurance Company 16535 048953-ADT-GAW-14-15 INSURED ADT LLC INSURER B: American Zurich Insurance Company 40142 INSURER C 18 Clinton Drive Hollis, NH 03049 INSURER D: INSURER E: AUTOMOBILE X INSURER F: COVERAGES CERTIFICATE NUMBER: ATL -003303542-01 REVISION NUMBER:2 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL IN SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE M OCCUR GLO 5095899 02 10101/2014 10/01/2015 EACH OCCURRENCE s 2,000,000 DAMAGE TO RENTED 1,000,000 PREMISES Ea occurrence $ MED EXP (Anyone person) $ 10,000 PERSONAL &ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PRO- JECT LOC PRODUCTS - COMP/OP AGG S 4,000,000 $ B It AUTOMOBILE X LIABILITY ANYAUTO ALL OWNED SCHEDULED AUTOS AUTOUTOS NON-0WNED HIREDAUTOS AS i I BAP 5095900 02 10/01/2014 10/01/2015 COMBINED SINGLE LIMIT 1,000,000 Ea accident) S _ _ BODILY INJURY (Per person) S BODILY INJURY (Per accident) S PROPERTY DAMAGE S $ UMBRELLA LIAR EXCESS LIAB r OCCUR CLAIMS -MADE EACH OCCURRENCE s AGGREGATE S DED RETENTION$ S B A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED' � (Mandatory in NH) f yes, describe under DESCRIPTION OF OPERATIONS below N / A WC 5095897 02 (AOS) WC 5095898 02 (MA, W) 10/01/2014 10101/2014 10/01/2015 1010112015 X I WC STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT ; $ 2,000,000 E.L. DISEASE - EA EMPLOYEE $ 2,000,000 E.L. DISEASE - POLICY LIMIT 1$ 2,000,000 I DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Town of North Andover is included as additional insured (except workers' compensation) where required by written contract. i CERTIFICATE HOLDER CANCELLATION Town of North Andover ATTN: Electrical Inspector 124 Main St. North Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee "1�� @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Application for Standard Permit FP -006 0 Return completed application to: (Rev. 04/12) Permit Number: DIG SAFE NUMBER City or Town: Start Date: Date: In accordance with the provisions of M.G.k. Chapter 148, as provided in Section application is hereby made by S�cC s—�• (Phone Number) (Full Nam o Person, Firm or Corporation) Of \,.` �. Is"t l (Address: Street or P.O. Box, City or Town, Zip Code) for permission to (state clearly purpose for which permit is requested) V, 2 —�" _50N a -4'\ e", d Name of Competent Operator (if applicable) Cert. No. Date Issued -rejected By (Signature of Applicant) Date of expiration Fee Amount Paid $ Q----------------------- ------ 07-7 FP -006 (Rev. 04/12) PERMIT City or Town: [DIG S:Date: NUMBER Date: tart ' Permit Number (if applicable): this permit is granted In accordance with the provisions of M.G.L. Chapter 148, as provided in to (Full Name of Person, Firm or Corporation) for Restrictions: at (Street and # or Describe Location for Adequate Identification) Fee Paid $ This permit will expire on Signature of Official Granting Permit: Title This permit must be conspicuously posted upon the premises 01z—rn 9 CC4S ��� `b -*A Date ..... .......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies thaA D1.L 1........... . ................................ .............. has permission to perform A e3e C (-t + 1-k 'firing in the building of .................... ........................................................................................... t.................................. ................ Nodh Andover, Mass., ..... Zan —A ................ -1 Fee L ... (It ....... Lic. No. ............ .................................................................. I . . .............. ELECTRICAL INSPECTOR Check# Ovq 4 �r�vc�rsv ur r�tt t tcCVLI+! HlU1 tct(�UTl{ t 1�1�1� I j p1( l - Occupmcy and Fee- Checked / � .. ELOL se ar chfa cotes & arldctlfftan , s cellCRev. 1f071 (IeaveblanL) • ` co,��t•�cc�&bl�'�emai#�i�'aa�,�taa,��� APPLICATION FOR PERMIT TO PgRFORM EL CAL WORK ��il orlt fo be performDd iu accordance tete l fagsachuseftsEIeetrical Code (IAC), 577 Cn21 2.00 (M�u�,PPI. V.1'M)PYOR TYPEALLV-F0L,1,&TrnNI Tl L: CRY or Tor, oats.��� To the Inspecfor of Ores: By this applica-um t' o undesired m es nonce ofnrs or eriufenizaD io perform the electrical vrork descrxbzd be±okY, LOC2 OXL (, `r eei c N'izmcer) � K S� . �rFz,� Os �`ortan.� _ � \ . ��> �S.�µ— —• _ TCIe�31i0Ji@ �r6• � � ���^ � :J(� One eeg address % this, pez€,'tirtcortprireamaTd&al}ttildingpermit? yes [- o (C.DeckAppropridteDox) kurpaseo u dYug [7%iiiy (�udiorizatlorWo: E�-z'sti ?g e�`Face �! ps t 'oljs overhead uni rd r ' g � 1�0, aRYf'eters New Serti?ce 1€rnps f �iblis OV-Arhead [J Inclgrd [ i rc. of it eters Xw1bet ofFeed rsand.�.ns paeiip Location and Datura of> xoposed ElectricalViror:lt. Te »afped N0.0��ieC6S58C��,FtiTtxilaires ilL'.0��`eir.-�iSp.�2.C�C�e�.�'allS e.:� J�rO,O:E yflE;}� Tramboxmers ls�4r Nfa: ofY;umrxiafre Ouflas lro. of cl'Tnbs ' freneramrs -m7A 14�3.4i gnmiraxxes 9 riir�a73ingp001 ri-boye �"� In ar�zcl. L1 krT. ((. i0. 0 .Nmbigelicy t n� t� a;atce U1U $s No. ox RaceptaclL barudst N0, of Off Bzrmas 1- A7�A1�,S-No, of Zone, I�'o, of Sr,rIties IT4: Oa iras d3rzrrzers �;�io. aEetee€zozr and - 7ni£iathtl)zviees NO o•" Ranges Total N-0- of Air cwad. Tom iNo. ofAIeFUug DBvfces o: o£ aste Bzsposers Hmt. =ump AN=be Tors ► .t\io. of self^Coxttaiued - Eolals: pefectiort/A1eunaDaldces Zoo, oxo E3is �*as e? 5 f SpaW rea �3eating KW �IA�I� _ M cil . Cher " o€I7ry,,xs r eatingapplisDees K��t; ontzectioa �Scctiriip ysfertrs - '" 2 �,7 .LSE}e 03'x. � Heat RM RM .No. Of r4. 01 P tto.ofDe�dcesox �� aTeuf_ )Tata Heaters Siazzs r'aTI'aStS 1kT0.08'FiG pdoniassage atht r s 1�Y4. of ;€ours o, a L[p elecommunieationng: Own orFalefii OT.t� RE si zch adciztio lot a'z<eit f desired nr a. requiredby tliArzrpec;.01, of fires. Esti nated Vain,, Q071ecf ral -Votk Q - -j (4rJ7�en regulzed b53 znuDicipal policy.) Fork, to Sta i S xuspzctio n be re �nicsted in accordance vrith MEC.1 1a I0, and ttp oxt completron. WRWANCECOYARAGE. Unless -waived by th6 o-�ier jao permit for tLaperformaalce ofelertdrat-,0 may zssue ruless -:. .... . ihelieeDseeprovzdesproof ofliabWfyinsncc inclndutg"completed.o zrai7on coveragzor' its subs'iantialeqi&aierxt,.11ae uuderslg d car ti$as that such coveraga is iu fQmc and has c�hibitedpzoof ofsane to tho permit issuing ofCfee: MCK OhT-- )W90TU TCs -0 BO-�3 E] OTMI� X (Speolj r:) Self- ammo -- - I cer f ; fncTer &e pehy arzd pe za &t ofper, j zq, tlaicf thain formation on ihIs eppl cado c a's true ¢7d complet, FIRMTI MM ADTILC M ADT Secuut ,�- �� C-172 L"Cezxsee. Thomas I .Lea Sigfnaba e _ r� �r �i.GC�- I �� bra.: C-17-7 �r�• pp7icabl� eater ' exempt"in Brie Iicer�ca n�nnbeY�?'in.�) �--• ' Gf I-Ie�s. . (•'• LIZ) 5c", ./' tY 3 s`hu'Licen erzqusecxoz flus work; ifapplicable, eztier;uelicensenrimber. h•.ere: 001779 GTO r1N INSfi' 'CEWAMR: lam aware -that theLicensee does saotTiuve the IizbiliLy insurance coveragenonnally -11N*edbplaty: Epmyszonaurebelow, bzraby� aivwtlifsrecluixemenz Ian�fhe(clteckofie}Qo���aer ❑rnwbes.agenx C�ei/Age3a-� � Sigrtaiv�a _ Te1en1?o o o> Ppiily- ��s j s r`LLc�i'Ati¢�Ay:�#.�S''��,' �,- �•���'�:V.�C-•:71=•u�.N�.:E:?a`..1 - w ' ON :SIjE'S\;,1:I4ft {;p;L(]+aNG::.:_ s r5 f•fJ,�: .,.:. ,l is _ 1S, ` G.o'I�1T3�7�CT.15�.: ^�''.�` �'� • • fir- � - i r[ G` YB.A'•:Aa ::��'1'':(;Cx;�'�.�::::�` i,_:t: _ • � N`s;[ is �:7�;i::: `� ;713: lv �<';�y:.. 3�j�.;: • _=_rY ,1.:,a: � °:�,' _ �aj��°1�Jo s9il-:��:4��s�R,.� S9.y J1Y11`•. ... _ , .:.._ � - --- __ r,m ��� ��-\. _yam;___—•--Ys�• f. - i cornmonwealiof 9assachus2i s - k ` [ (Department of Puhlla Safety Szcuri[; Spstems-4 Ljr2nve j« t License: SS -009779 [fill1 A liar a5 �-. �km�ILl1C:i51'ey':t�V r�:ri-'=`��_, .t " • _i , ry CommissioneC5/�6f?0�6 - f a. -•.re -. w ..• r• -n r •' ®0/ � C/V d�'� - •y n rr -• r •.• F .-r ./ p i i . i . i • 1 • E a 40 AC"R L>®DATE CERTIFICATE OF LIABILITY INSURANCE IYYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 10/0812014/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Marsh USA Inc. AX 1560 Sawgrass Corporate Pkwy, Suite 300 IF �NNo Ext : AIC No): A/E E-MAIL Sunrise, FL 33323 Attn: FiLauderdale.Certs@marsh.com ADDRESS: X COMMERCIAL GENERAL LIABILITY INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Zurich American Insurance Company 16535 048953-ADT-GAW-14-15 INSURED INSURER B: American Zurich Insurance Company 40142 ADT LLC INSURER C: 18 Clinton Drive INSURER D: Hollis, NH 03049 INSURER E INSURER F PERSONAL &ADV INJURY $ 2,000,000 COVERAGES CERTIFICATE NUMBER: ATL -003303542-01 REVISION NUMBER:2 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN RI LTR TYPE OF INSURANCE ADDL INSR SUER WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY GLO 5095899 02 10/01/2014 10/01/2015 EACH OCCURRENCE S 2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 1,000,000 PREMISES Ea occurrence $ CLAIMS -MADE M OCCUR MED EXP (Any one person) 5 10,000 PERSONAL &ADV INJURY $ 2,000,000 GENERAL AGGREGATE S 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG S 4,000,000 X POLICY PRO- JECT LOC $ B AUTOMOBILE LIABILITY BAP 5095900 02 10101/2014 10/01/2015 COMBINED SINGLE LIMIT 1,000,000 Ea accidert $ BODILY INJURY (Per person) $ X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) S PROPERTY DAMAGE $ Per acddent HIRED AUTOS NON -OWNED AUTOS $ UMBRELLA LAB OCCUR EACH OCCURRENCE $ 'EXCESS LIAB ICLAIMS-MADE AGGREGATE S DED RETENTION$ S B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/ N OFFICER/MEMBER EXCLUDED? � (Mandatory in NH) WC 5095897 02 (AOS) WC 509589802 (MA, W i N / A 10/01/2014 10/01/2014 10/01/2015 I X I STATU- OTH- TORY LIMIT ER 10101/2015 i E.L. EACH ACCIDENT $ 2,000,000 E.L. DISEASE - EA EMPLOYE_ S 2,000,000 If yes, desc be under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT S 2,000,000 I I DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Town of North Andover is included as additional insured (except workers' compensation) where required by written contract. lya;1111II2N/_\IM;Lai 051;4 9:6Lha11/_ULei 9 Town of North Andover ATTN: Electrical Inspector 124 Main St. North Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee SCauvrociv' .S�nu.a-c.t @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD T The Commonwealth ofMcassachusetts Department of Industrial Accidents w ®ffice ofInvestigcations + d 640 Washington Street Boston, ISA 02II1 s�v�a www.mass.gov/dia Wolricerrs' CorlQpensatuon insurance Affidavit: Builders/�C®nIlt>r� cto>rs/Electricaans/Plumbers AAppllicint Information please Print Lean NaMe (Business/Orgaiiization/Ind�idugll 4ti 7, t Address: City/State/Zip:�a ��� Phone Are you an erraployer? Check the appropriate box: 1.5kl am a employer with \C (1�'r 4. ❑ 1 am a general contractor and I employees (full and/or part-time)."' have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its [No workers' comp. insurance officers have exercised their required.] 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance. required.] Type of project (required): 6. ❑ New construction. 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. [1 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13.E Other � t *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy intormation. i 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 must attached an additional sheet showirig the name of the sub -contractors and their workers' comp. policy information. X ata an employer that isproviding workers' compensation insurance fox rq employees. Belolp is the policy and job site information. `'' `-au.n."vaef'•a5�t�"'Fi Insurance Company Name: Policy # or Self -ins. Lie. #: v`y C, q Y, 0 Job Site Address: �C City/State/Zip: ` �—� V�1 �r� '' 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 line 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 verifi-ation. I do hereby certify -tinder the tlaert the illfoYrriation provided above is true and correct. nate- \J 2\, I ��5 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 Cleric 4. electrical Inspector 5. plumbing Inspector 6. Other Contact Person, Phone M Date..�bL° ..��............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING I — — Q-/ "- --Z V., -J This certifies that . ....................... Lia �7 jjff has permission t perform,,/ ' M'N p rvd �r-or-f /C; t/C L^j ........................................... wiring in the building of... `...u.,iT ......P'e- ............................................................................... at 2 7 % t�J,,. ��2 S rth Andover, Mass. FeP „ Lic. No... J��........ v...........: ELEC ICALINSPECTOR Check # V Check # l.0 Commonwealth of Massachusetts Official Use Onl Permit No. iz1�` Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS up [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 1_0/07/207[4 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intentiori to perform the electrical work described below. Location (Street & Number) 279 Winter Street OwnerorTenant Diane Huster Telephone No. 617-372-1862 Owner's Address Same as above Is this permit in conjunction with a building permit? Yes ❑X No ❑ (Check Appropriate Box) Purpose of Building one Family Dwel 1 i n�j Utility Authorization No. 18078250 Existing Service 10 0 Amps 120/240 Volts Overhead ® Undgrd ❑ No. of Meters 1 New Service 200 Amps 120 /240 Volts Overhead ® Undgrd ❑ No. of Meters 1 Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Kitchen, dining room, living room, bath. renovations Main service upgrade Completion of the following table may be waived by the Insnector of Wires No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans 1 No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. grnd. o. of Emergency Lighting Battery Units No. of Receptacle Outlets 20 No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiatin Devices No. of Ranges No. of Air Cond. Total Tons 3/4 No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number 1 Tons KW 3.,...5.... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers 1 Space/Area Heating KW Local ❑ Municipal El Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of WaterKW Heaters No. o No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors 2 Total HP 1/6 Telecommunications Wiring: No. of Devices or E uivalent OTHER: M Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: $15000.00 (When required by municipal policy.) Work to Start: a -10/07/2014 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 [3 BOND ❑ OTHER ❑ (Specify:) 1 certify, under the pains and penalties of perjury, that the information on this applicat' is true and complete. FIRMNAME: JTech Electric Inc LIC. NO.: Al 5 3 5 5 Licensee: John W Thompson Signature LIC. NO.: E27036 (If applicable, enter "exempt" in the license number line) Bus. Tel. No - 8 8 9 -1709 Address: 14 Murray Street Chelsea, Ma V2150 Alt. Tel.4cov��en�ormallyly : 6 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ �j I 0 CJ a The Commonwealth of Massachusetts L !ffE� Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): JTech Electric Inc Address: 14 Murray Street City/State/Zip: Chelsea, Ma. 02150 Phone #: 617-889-1709 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑✓ I am a employer with 1 4. ❑ I am a general contractor and I 6. F] New construction employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. E] Building addition [No workers' comp. insurance required.] comp. insurance. $ 5. ❑ We are a corporation and its 10. 2] Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions myself. ' y �o workerscomp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no 13. ❑ Other employees. [No workers' comp. insurance reauired.l "Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: National Grange Mutual Policy # or Self -ins. Lic. #: WCS31425 Expiration Date: 09/26/2015 Job Site Address: 279 Winter Street City/State/Zip:N. Andover, Ma.01845 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify undeUhe pains ajlg4/penalties of perjury 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 #: t i, i Date ... V y//Y........... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING -�„„� This certifies that .....N,.-hv:!= ���.1,4.u'��-t has permission to perform. .,..fi (i;.hn,,fjP(1 -L V;1� A i plumbing in the buildings of:: -v:`.' ...................................................... at .. �.......t�� �.� North Andover Mass. ......... ...... Fee.'�...... Lic. No. ..MD ..MD ..........................:........... ............................ 2 PLUMBING INSPECTOR Check # 2 Y4' Zb�-I� vh 117zliq URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTi'. INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESX NOEII IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY © BOND�]__i OWNER'S INSURANCE WAIVER: I 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 AGENT IEJI 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 Laws. i7 A L A A A ---A l PLUMBER'S NAME I LICENSE # r� ( ~SIGNATURE MID JP D CORPORATION PARTNERSHIPP# _ f LLC _.[]t#.[ I /-Am MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK N�low POWNER TYPE OR PRINT CLEARLY a CITY MA DATE T PERMIT# JOBSITE ADDRESS Z W l OWNER'S NAME U tori ADDRESS f TEL iFAX OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL UL NEW: RENOVATIONS REPLACEMENT: n[ PLANS SUBMITTED: YESEQ NOSY FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM l .—..j .___.._i ___,_{ -------1 1 � [ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM [ , ..__ { 1 f (_�-. ► __ (-_ I ___I f { DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _ _) ( 1 .____ { _[ _____.1...... ___.._.1 ._...._ FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR(INTERIOR) I _- [ _.__. __....__{ _._._ ( _yf _.._._i _____i ___._. KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/ MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTi'. INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESX NOEII IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY © BOND�]__i OWNER'S INSURANCE WAIVER: I 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 AGENT IEJI 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 Laws. i7 A L A A A ---A l PLUMBER'S NAME I LICENSE # r� ( ~SIGNATURE MID JP D CORPORATION PARTNERSHIPP# _ f LLC _.[]t#.[ I /-Am 0 ❑ Z H .w W U- z a a } f H .w W U- z a a 1 t } 1 t The Commonwealth of Massachusetts - Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeAly Name (Business/organization/Individual): Address: Po &d -)C ?2,q City/State/Zip: IV ne #: 929 • Y20, 174 Are ou an employer? Check the appropriate box: Are 1. I am a employer with _Z_ 4. ❑ I am a general contractor and I (fall and/or part-time).* have hired the sub -contractors 2. ❑ 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. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New contraction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1r.Roof lumbing repairs or additions 1repairs 13. ❑ Other *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. 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 is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. 6w Q Policy # or Self -ins. Lic. 42 o UPS Expiration Date: Job Site Address: �1 L-rtM Z. � City/State/Zip: NO •IQ IXt.Vi. 0AOl B�S� Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requireclunder 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 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 hereby cert under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: 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. PIumbing Inspector 6. Other - - - Contact Person: Phone #: i 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 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 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 -contractors) 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 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 be sure to fill in the petmit/license number which will be used as a reference number.e In -addition, an applicant -that must submit multiple permit/license applications in any given year, need only submit onaffidavit 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 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 Goxnx Onw0a. ofMassa�hv.,setts Department of fj dustrial Accidents Office offuvestigations 600 Washington Sire. et Boston} MA 0.2111 TeX, # 617-727-4900 at. 406 or 1-877.MASS.AFE Revised 5-26-05 Fax # 617-727-7749 wWW=ss,govfdia Date....%..0...... .. (V .................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION T s certifies that QC -'6'..,e.4 .... ...... has permission for gas in I tallation ... . ...... in the buildings of :=j .... m . ...................... ....................................... at ......... P*) ... 7.9 ......... . ...... ............. North Andover, Mass. Fee1p.p .......... Lic. No..... .................................................... GAS INSPECTOR Check# :�21 r !7 7 n •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE �• a• PERMIT # .� JOBSITE ADDRESS 1.Z W 1 40. OWNER'S NAME GOWNER ADDRESS S pM TE I �FAX TYPEbR PRINT OCCUPANCY TYPE COMMERCIAL F-] EDUCATIONAL ® RESIDENTIAL CLEARLY NEW: RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES NO APPLIANCES 1 F DORS—► 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 � I_ I. , FURNACE GENERATORszi r GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER�- OTHER ~— INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES XNO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY y OTHER TYPE 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 ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT 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 cc fiance with all Pertinent provision Massachusetts State Plumbing Code and Chapter 142 of the General Laws. • PLUMBER-GASFITTER NAME LICENSE # ( SIGNATURE MP MGF [A JP JGF © LPGI ® CORPORATION)4# PARTNERSHIP®#= LLC Df#= COMPANY NAME: _ . DRESS �� pp����_�2 CITY _ _ STATE F�ZIP STEL FAX CELL&EMAIL ! -- 0 H U W e � o Z O N� } W � ~ W OF a Z W � � co Q w O w a w w co a o E. D- c 0 i0 w E w F -I w H O z H U ; W C7 � J L�� Date ... P1 ................ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION M; certifies that. .................. ....................................................................... has permission for as installatione- in the buildings of ......... c --,a .. ..... ... ........... ... at ...... ............ Q . ................. I ......................... ... 4.: ................. . North Ando'ver, Mass. Fee.0�� ..... Lic. No -1922 . .... N.0 .. . ................... GAS INSPECTOR Check# r ", - i. r It, v. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY _ _ _ 0 _ _ (�U-p �'� MA DATE MIT # l lJ JOBSITE ADDRESS c % Pr Si OWNER'S NAMEP II I V-190 OE GOWNER — ADDRESS TEC 5P0- FAX TYPE OR PRINT OCCUPAN PE COMMERCIAL ® EDUCATIONAL RESIDENTIAL [' CLEARLY NEW: I RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES 7 NOE] APPLIANCES 7 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 _1 _ FURNACE GENERATOR^ GRILLE -- -- --- = -- -� (, ------ - -- INFRARED HEATERL— - . -- - - - LABORATORY COCKS MAKEUPAIR UNIT _-� - OVEN _ _ --�- POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT _ TEST v n UNIT HEATER UNVENTED ROOM HEATER I_ _ - WATER HEATER OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES _ NO [j 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF CHECKING THE APPROPRIATE BOX BELOW Cr_. LIABILITY INSURANCE POLICY OTHER TYPE 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 ONLY: OWNER © AGENT 0 SIGNATURE OF OWNER OR AGENT 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 nce with allP inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME % _5 _ LICENSE # 0� _J SIGNATURE MP ® MGF 0 JP ® JGF LPGI CORPORATION PARTNERSHIP 0# LLC COMPANY NAME:fADDRESS A,.X�/A)S i�c lam✓.^._^ _ CITY �v%en( _ P STATE ZIP TEL 7 - -Z7 FAX �_ CELL 7�'` I_o D EMAIL (06c) H O z 0 H U W A4 w • p+ O ❑ z O Nrl W O� a Z U w f - w CO) wco W a Waj O w w w C o a U J i Ei a a a x w LL r4 N H O z 0 F U W Pi C7 The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations quo 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. # �• El Remodeling ship and' have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] 3. ❑ 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.❑ Roof repairs insurance required.] t employees. [No workers' 13. ❑ Other comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. i 'Homeowners who submit this affidavit indicating they a"re doing all work and then hire outside contractors must submit anew 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 is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:, Policy # or Self --ins. Lic. #: Expiration Date: Job Site Address: City/Statelip: 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 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 certtfy under the pains and penalties ofperjury that the information provided above is true and correct Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, • express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in 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 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 -contractors) 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 maybe 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 be sure to fill in the permithicense 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 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 ofMassarahwetts Department of ladustrial Accidents Office of luvestigatiom 600 Washington Street Boston., MA, 02111 TO, # 61.7-727-4900 ext 406 or 1.-877:,MASSAFB Revised 5-26-05 Fax # 617-727-7749 www.rnass,govfdia PIRATION UP =a .. �Wlmw ~Location No. Date----�ta L 7 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ _ Foundation Permit Fee Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ m TOTAL $ i r �. Building Inspector W V Q a a z aC U W N ce A z w � Q x A H z ce .k .a A 0 O O a ow g O O F+1 C7 W `n F W ° W z a F z ; 0 A o o z p w xp ttt8zu6uu O O o w ° O z z z o c� N O z u, O O O t w W¢ Q z t oz ZA oz z w C W ry nw Z m z z z Z n �I 0 � M�1 ^� z w d o LLI o w Cd V¢ LU u, Cm O m z z F z w z LLjN 2 w Q z w U ¢ [..i z o Z z o o z z a z zC� �n Fp. 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