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Home My WebLink AboutMiscellaneous - 28 STAGE COACH ROAD 4/30/201811 Ul > GI m 0 C') Ln C� 0 ;a p ol C:) > x Town of North Andover, MA F Sea-rch- 21131 *Plumbing Permit - In Conjunction with a Building Permit (Commercial or Residential) TwEtINE Submission received Your request Is in progress Aug 16,2016 at 11 ,Sam We'll letyou know ofany updates via email. Feel free to checkthe —L-- status at any time by coming back to this page. Plumbing Permit Review In Prog— Permit F Ridge Pd V_. Pr— Pvymc,, PCrfflit Issuance ApcOlkant L-1- kevin brolzan 28 STAGE COACH ROAD. NORTH 2Z SAinr�06,c)JI-1, 9T � - 2-C) (-I 4 5D I bz-.3-0 0-bs+c �C-:�)- 1'�Lhf, CUJI -- Tuesday, Aug 16, 2016 11:18 AM Yhe Commonwealth ofMass�chusefts Department ofIndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov1dia 'Workers, Compensation Insurance Affidavit: Buffders/ContractorsfEl�,etricians/Pl=bers. TO BE' FMED WITH TBE PERMITTING AUTECOR-ITY Name (Business/organization&di-vidual): Address: Y LQ CA -V<_ Q� '.'Q \A City/State/Zip one Areyou an employer? Cherkt& appirlopriaidbox; am a employer v&h_L_,L.�oY60S (full and/or Palt-time)-* Lql 1 I am a sol? proprietor�or Partnership and have no employees VDA&g for mein \any capacity. [No woricers' comP. insurance required-] I n I'lim a homeowner doing all work myselE [No workers' comp. -insurance required.] t 4.FJ I am a homeownDr and wi1l be hiring contractors to conduct ad woik on my Property. I will ensure that aU contactors either have Workers' compensation insuraace or are sole pr6Frietors withno Gii�IOYGBS. 5.FJ I am a general contractor and I have hired the sub -contractors listed on the attached sheet 'hiasle s�b- conflar-toris �a, , " oyq,� andh�,- wc�kers' -�P. insw.; . ie, P* . 6.F] We are a corporaii9n. pd #q pfficers have exercised their right of lexemption per MGL c. 152, § 1 (4), an� wp hEivp r1o. es. pTp wor�ersl comp. insurance requiredJ T�T e of project (T�cjuirtd) 7. - []New coristaction 8. Remodelffig Demolition 10 F1 Building addition I LQ Electrical repairs or additions 1 , 12. F1 Plumbing repairs or additions ij.-E1Ro6fr'ePafrs 14. n Othbr *Any applicaut that che cks b 6x 41 mu st als offl out the se otion below showing their Workers' COMP CUS3110n P Olicy i0fOrmati— indicating such. T Homeowners who uaEif t1w affidavit mdic.atmg they are doing all work and then hire outside contractors mast s4bmit a now affidavit TContractois That checkthis box nmstq!taqbed an additional sheet showing t119 name of the sab-contractors and state whether or not those entities have employees. - Ifthe sub-c&AL6*s&�� Pl6iee's,&ymuft providetheir workers' comp. policy munber. yees,'Belov is-t7iepolicy andjob site I ain an employer tfz at is1rovidij7g -work�rs' compensation iflSUrancafor 7ny emplb iqfbi-mation. Insurance Company Name: ExpirationDate: date). 0.00 ai Mandafine.ofnpto $250.00 a and/or one-year imprisonment, as well as civilponalties inthe form of a STOPWORIK day against the, violator. A copy of this statement may be forwarded to the Office ofluvestigati6ns of theDIA for insurance coverage verification. anapenaldes ofpeiyury diat the informadonprovided above is i–eue and correct. I do A ereby ! er Phone -10 L( 61 OfJ7cialuseonly. _Do not -write in th& area, to he completed by city or town official. City or Town: PermibLicense # issuing Authority (circle one): i 1. Board ofIlealth 2.)3uffding Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: — Phone 'ei J': pAof'ss-ear-AvAm I)OST"Q-a 6VLL-LZL-LI9 # X'eJ 9,qVSSVN-LL8-1 -70 90tLlx-9 006V-LZL-LI9 # aoz-vuzo vw'aolsoff OOT olInS cloo:4S mi2mD I sluoploovivi4supuigo luouaixedba S44QSnT73SSI?WJ0 URj'eQAAU0U=0D QU :xoqmuu mj pue ouo-qcTbjoj 'ssuppe sjuguo4sedo (I @U -jjAepDp sr -Bol umq qpmoclzo, osuovq2op -e -wj) q� opplaroo ol pospbu ION si uosiod plBs �0�o snA oz4uoApjos@-mmoo,To ssourgnq Lm qpo42j@xjou4jmQdjo osuea.q-e �lu=jqo si =Mososovio omo-q -e osQ-q&,XBQS ipaea Ino poITg oq:pnia jjm3ppp A,-gu V *sosuooi I ;rg ST IIA:BPDP PHBA 13 j13tRjO0:rd sB ;mo-.qcicT-e .1so sipu ocl om xqj 4)lg uo . oig ol poplAosd oq �vui mAAol so f4jo oiR fq pwpmso podwels SIpIqUo vooq suq ImR lWpDp Gqljo f-doo V,,-(u,,Ao; u Bmso �?T cl o4 Im . _[o ;,ao:rxno.'JUD:eOrPUIIIA:BPDTeouo;lTaq-ns.�raopog,a'nosu@AT2,�u-ems-ao4to,.qcTd-eosuoor Fa Is -M 4 ppmodoldIllnurl qns n p I jueoi .Icicl-e ue 'uopipp-e uj --Toqumu oo-aoxqjox-e s -e pos-a eq M,�A rfoTqas@qmuu osuooi eins eq oseol(I Wpmgcl oq� rq ITg ol quBOT'Idd-0 OIR 2UTjB2gx -nos jo-eJU00 ol SBTI SUO.4'0.'Jl GIR Ul 4nO RU O� UOS J:Oj TIA'epg 0 JO jSQAUjJO 00DJ0 GIRTUGAG p T ucro4oqc)iR�eoo-eclst!pc)plAoid,s-e-q;aou4nclo(lo-qI -,�jqoolpgliD�adpueo�oldmoosilIA-epgpc)ia�eqloms-oqosLolcT SIBIZ)BIO UKOX.10,�41D --gaig zo�uo.prnci4s somclmoo pqxn�u�j-jjoS 'mopq po;sil soqmna oT Te quou4miloc( c)-ql Mo osn lcl'90110d VORBS-agcTmOO ,sm3fig . &-eumTqc)olpoiffibo:roxe.Tto4jTxoA&eloTOuTpxe�?o.Tsuo4sonb,�moA-e-qnoSpino"qS sTu-qpjooVpi .4snpaj JO Tuouqndoci GIR IOU �o;s�n�osgupq si osunif so TjEasocl oT xqj uo4uor -e oig:prj mAol id f4j� o- ; ol pausr4ox oq fcicl q pjno-qsjjA-ep�jeoU -IIAEPMUGUIlo'l-gppuuaisolgxnsoqosff -of'mAoogormmmjouoT iuoppoV pungffoo 4qj s, pT.4supu ,I-jo pouqwd�C( oiR ol po4lzaps oq AUU4&-BPDP STU TeT p0q&P-e @a -ponnbo:rsr.KolToffe,sggxoldurc; oA-e-q spop cyjqs� DIj ue jj -oommm -ampsuoduaw sse:qso& �imo q poxinbol jou am 'saou�md so mqurgm oiR u -ma imao. sob,�ojclbs@ ou iRFA (&I -f) Or .quou4su&�jiF qej-1 pogaq-f so (DT]) somvduioDEjTq'ejj polpigf jo(s)o;,aoUpxoo-uo qlyASaoIB(s).ioqmnu-ouoqd.pue(sc))ssojpp-e'(s)oumii(s)�o;oL,4uoo- IR ps �Iddus 'Xmss000ir JI'Pug ITOTPr4is snoS ol -�Iddv 4:eia soxoq-oTR.9uM@-qo Xq'-�14)�ojduac.p qjAepDje uo-gusuoduioo m3fma o-qj-:jxLo.ff.g oseojj sju-ea-.qddV ,,,,�4110TRm 2up'e-4Troo -OTR 01 polugsaid uooq QA'eTI solclep syq�jo sjuguag--pbax OOTMMSUT GTR TI& gomiT,dwoo To oomplAo ojqejdGoo-u F 31xo& oi .fqudg:o oommuopod o-qj zoj p-e4uoo �Te oli:q io;Tro -rpqg suoisTATpqns pem ;rlod slljo Sueso-a Tgpomuo=oo QTR jgTion, SQTRTS (L)DgZ§ ZgT soldep -1-DW 'Slpuo4rppV o3mxagm oip, Idugo3 So o;)uopj&a ajquj&;);)u pa-aupoad jork su-q o" -Invaijddu SUB x'6j qIjuakaoraTaw a-qTi aT s2m sycoj olao ssamsnq u a�uaqdo ol Ilmx-aclxo osuazi .plm . q puxi .1 -ujo yemauax jo 93massy o-qj ploffqlp& lluqs lmafu fuuug3-q lezolao TuR sojels osp (9)DgZ§ 'ZcTiqd-eT -I-DW ,jaS-olcluia ue c)q ol p9moop qq luous-Soldum -qo-nsjo esneoaq jou ITqs ojQ:r@,q; �uuuqiaddi3 fulplm cc . qso spanoj2 erg uo so osno-q 2uffpap -qons -ao 3[:roA& apdosao uo-pri4suoo loomuolufem op ol suossod sZoldwo oijasoiRoaajo os -no -q Ouqp&p GTRJO 4uedn000 GIR 10 lulaigig SOPISO.1 01[a pue quoummclp, oojq; mig ojoua jou �iujA-eq estio-q 2uffiw&p -epxamwo GIR J9AQ,'AOH TOO-901duUg 2UTSOT(IMO cf44ug fe201 ZQTRO JO U04BIOOSS-e cdRSlGU�Md'rRn.PjAr.p-Eq WJP OPISn-4 10. JeAT000.1 QIR 10 '19.�Ojd= POSUGOOP -B SO SQA'.WluQso.Tdos I-effol oiR 2u.Tnjoiq pue cosyclx%ug lrqoFB m pogt2uo 2uTo2oxqj otRjo Q.T0WJO OAA4 SUB 10 'f44ug It'.391 JQI�O .10 uo-piocT.Too 'do-plo om 'dfqssouged 'NiLpjArprq ue,, si3 paugop sl jadoldwa nV 4c,trogya so reso 'po-qduiT:ro ssoxclxo ,oxrqjq jqv4aoo Xue xopunsoigouejo oop�sos oiR ug uos:racl AsoAo---,, m pougop spodoldiva uR 'ojs4-ejs sr qj ol �mnsmj .Soakofd&�ko sojuo-gesndmoo, It, 4-asnupesnN . TR slgq.IOM QPIA0Jcl 01 sJQXOld-cdQ �u Sgxmbg-T Z91 JglcleT sA&la'I Ic)ugD S - TJ I)ate ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... x, ................. ............ . . ........................................................................ has permission to perform ..... ke'l 1"'e .... .. .......................... wiring in the building .. ..... ............. ........................................ at ..... 2 .............. North Andover, Mass. ..................... & Fee ....... .............. Lic. ................. ... .................................. LEcnuc�L INSPECFOR ,Check# 1549 .A% M Wd: C001.1�iotuvea& ol 2eparttnetd ol Jire SIrviced BOARD OF FIRE PREVENTION REGULATIONS F_ r )fI-16,fl J�(. Perin t NO. Occupancy and Fee Checked [Rev. 1/071 (1.... blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Flectrical Code MECJ, 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 5 t 2-1 /3 City or Town of: Pb(H.-,_ PA+,-)0Q)Ub'Q To the Inspector of Wires: By this application the, undersig�e_d —gives notice of his or her intention to perform the electrical work described below. Location (Street & Number.) M C, e: aoml Owner or Tenant �:D\, Ij � 4; U Telephone No. Owner'sAddress 15c -.--Q - Is this ermit in conjunction with a building permit? Yes No (Check Appropriate Box) jr Purpose of Building %IC014,4& Vt-X� tArOVK�-�@ "'tt' (et ty Authorization No. Existing Serviceq C�U Amps I Z C.) 2-40VORS OverheadF] Undgrd Ej" New Service — Amps Volts Overhead n Undgrd [ ] Number of Feeders a6d Ampacity Location and Nature of Proposed Electrical Work: v fic, "A No. of Meters No. of Meters Completion of the following able m be waived by the In ector 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 Swimming Poc F1_ d. rn No. f Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS jNo. of Zones No. of Detection and No. of Switches No. of Gas Burners Initiating Devices No. of Ranges Total No. of Air Cond. Tons No. of Alerting Devices Heat Pump No. of Self -Contained No. of Waste Disposers Totals- .......... Detection/Alerting Devices No. . of Dishwashers Space/Area Heating KW Local [j Municipal 0 Odier Connection No. of Dryers Heating Appliances W ty System Securi s: No. of DeVices or Egulyalent No. of Water KW No. of No. of Data Wiring: Heaters Si ns Ballasts No. of Devices or Equivalent No.. Hydromassage Bathtubs. No. of Motors Total HP I elecommunications Wiring: No. of Devices or Equivalent. 60 Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 9G60 ' (When required by municipal policy.) Work to Start: �& 5 AO . inspections to be requested in accordance with MEC Rule.. 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no perrnit 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 oWifies that such coverage is in force, and has exhibited proof of same to the pennit issu.ing offiQe. CHECK ONE: INSURANCEE] BONDE] OTHER 0 (Specify:) I certify, under the pains andpenalties.ofperjury, that the information. oil this application is true and complete. FIRM NAME: LTC. NO.: e ?So �6 ,N,vc k Licensee: I/ tj Signature LTC. NO.: (If applicable, enter "exempt " in the license nu+er line.) Tel. No.:-,?-) 9 —p—p) f2 r- Bus Address: L -L)-) (f c�, a Alt, Tel. No.: *Per M.G.L. c. 147, s. 57-6 1, security work requires Department of Public 9afety "S" Licens'e: Lie. No. OWNER'S INSURANCE WAIVER: I ain aware that (lie LiMISCT does r;o(hove the liability insurance coverage nonnally required by law.. By my signature below, I hereby waive this requirement. I arn the (chec one) [I owner 0 owner'sagent. Owner/Agent Signature __ I PERMIT FEE: $ tl.,i 1,47 /-Zf 2- I iv� . �t Department Of Industrial Accidents Office of Investigations 600 Washington Street Boston, AM 02111 klip www.mas.&gov1dia Workers' Compensation Insurance Affidavit: Builders/ContractorsiElectricianv?I umbers AnNicant I Inforniation— Please Print Legibi Name (Business/OrSaWzation/kWividual): ok) Address: L%-.) e a ty/state/zip: K LX:, M I 14tA 0 [7�O Phone M Are you an employer? Check the appropriate box: I - Q4 am a employer with 4. 111 am a general contractor and I employees (full and/o4i�;4* have hired the sub-contractcn-s 2.0 1 am a sole proprietor or partner- listed on the attached sheet. I ship and have no employe= These SUb-Contractors have working for me in any capacity. workers' comp. insurance. (No workers' comp. insurance 5. 0 We are a corporation and its required.] 3. 1 am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers, conip. c. 152, § 1 (4), and we have no insurance required.] t employees. [No workers' COMP. insurance required.] Type Of Project (required): 6. [1 New construction 7. El Remodeling 8. F] Demolition 9. E] Building addition I O-VElectrical repairs or additions I I - El Plumbing repairs or additions' 12.0 Roof repairs 13.[:] Other rr A 6-04 GLJ*V Lill uut tat section oetow showing their worken'90MICUsation policy infow, �tlon: Meowners who sutntit this t Ho affidavit indicating they am doing all work and Own hire outside contracton mu 8 t a new affidavit indicating such. -contmetors and dwir workem, c4nV. policy infornution. tcontracton that chock this box nwst attached an additional sheet showing the naTne of The sub st ubnzi I am an employer that is providing worker$' compensation insurancefor my employee& -- Below is thepolky an. djob site informAtion. Insurance Company Name: Policy # or Self -ins. Lic. M. `E Lt '2, 0 Job Site �- r+ d - Expiration Date: t U 13 City/State/Zfn: 0 ft� ANN) I C(,v HI)f Attach a copy of the workers' compensation policy declaration page (Showing the policy number and explrat,,Dn date). Failure. to secure coverage as required under Section 25A of MGL c. 152 can lead I to the finPositiOu Of criminal Penalfies of a fine up to $1,500.00 and/or one-year imprisonment, as well as civ7d penalties in the form of a STOP WORK QRDER and a fine of up to $250.00 a day against the violator. Be advised that a COPY Of this staternent may be forwarded to the�ofr7lce of investigations of the DIA for insurance coverage verification. I do hereb y cenY r epa!ns andpenaMa 00edJury that the Information provided a .fy unde th tMe and correcr. —siz-03 tur&�� Da Phone#: Sq 7— Official use only. Do not wrke in this area, to be completed by city or town ojftcld City or Town: Permit/Ucense # Issuing Authority (circle one): I . Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing IlksPector 6. Other Contact Person: Phone#: J . Iii S I I CD m Yl!j 2gqp al q p'i OM "i UIVIII re i i Date../.? ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... ......... ..... .... . ..... has permission to perform .... 171 *, v Z" I I , 11 7 ............................................. 7**'***'**'***'* ... , wiring in the building of .... 2—... -/ . .......... ...... at ............... - 0 -.t ....... .. .................................. . North Andoveri-Mas Fee.r-,.3 ....... Lic. NoZ2,.,?.�.7A'- .......... CAL INSPECTdIR Check# /// 9-145 94 9_� Commonwealth of Massachusetts Offi ial Use Only Department of Fire Services P e rMmu I No. F Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Re. 1/07] (leave b] ik) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK � All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEA SE PR L VT IN INK OR YYPE ALL flVFORMA TION) Dai�: 11 City or Town ofi, NORTH ANDOVER To . the 7Inspector of Wires: By this. application the undersigned gives notice f his or Location (Stre-et & Number) intenpon to p brm the electrical work dmribed below. .2 Owner or Tenant Owner's Address U2.,s Telephone NO. .Is this permit in conjunction with a building permit? Yes No Lj (Check Appropriate Box) Purpose of Buff ding L Utility Authorization No. Existing Service �2 JU Arnp�sj/�,�2�_a�:22volts ---------------- New Service Amps Overhead El Undgrd [D— No. of Meters Number of Feeders and Ampacity —volts Overhead D Undgrd No. of Meters Location and Natur,e of Proposed Electrical Work: rthe ollov�in table maybe waivedb th I No. of Recessed Lumin No. of Ceil.-Susp. (Paddle) Fans 0. of ow Trans" No. of Lun3dnaire Outlets,, No. of Hot Tubs KVA No. of Luminaires Swimming Pool Above [] In- Generators KVA ,m 0. of mergency ig grnd. d. L -J Battery Units 9 /0 No. of on Burners FIRE ALARM No. of Zones No. of Switches No. of Gas Burners N...ujL Delecuon and No. of Ranges No. of Air Cond. Total Tnif-infina Devices No. of Waste Disposers eat Pump _. T us No. of Alerting Devices Totals: -.-.-.-her -Tons 0. of Self -Contained Detectiorr/Alertin a, Devices No. of Dishwashers Space/Area Heating KW Local Municipal F� other Connection No. of Dryers Heating Appliances T -1 - KW ecurity Systems-: 0. of Water 0. of No. of Devices or E nivalent Heaters No. of Data Wiring: No. Hydromassage Bathtubs Si s Ballasts No. of Devices or E uiv ent No. of Motors Total HP Telecommunications Wiring- nTr-rrD. No. of Devices or Enuivafe.nt Attach additio Estimated Value of Electrical Work: .2 5-2/0 nal aetazl tt desired, or as required by the Inspector of Wires. 0aen required by municipal policy.) Work to Stam 6 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE 6�VEGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licenseeprovides proof of liability insurance including "Completed operation" coverage or its substantial equivalent The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE P--90ND 0 OTHER 0 (Specify:) I cerWfy, under the pains andpenalties ofperjury, that the inforInation on this applicagion is true and completa FIRM NAME: Licensee: LIC. NO. A Sigmature (If applicable, enter -exempt in the licynse number lineL. LIC. NO.:;Z4S-'�.zz/c- Address: C5� Bus. TeL No.: ei27��y !W, 4 / Alt. Tel. No.: *Per M.G.L c. 147, s. 57 61, security work requires Department of Public Safety "S" License: Lic. No. OV*MRIS INSURANCE WAIVER: I am aware that the Licensee does not have the liability insul'ance coverage normally required by law. BY my signature below, I hereby waive this requirement I am the (check one) 0 owner 0 owner's agent Owner/Agent SignatuW Telephone No. PERMIT FEE. $ �� - l Z ��`� The Commonwealth of Mas sachusetts Department Of Lndusfrial Accidents QJf1ce of In vestigalions 600 Washington Street' Boston M4_02111 www.mass-gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrici . ans/Plumbers Applicant Information Please Print Leffibly Name (Busines�/organization/individual): Address: City/Stat � e/zip. 4�6 1AJ Phone -2 Arre, y!o5jw-employer? Check the appropriate box: I. O'lam a employer with -2- 4. El I am a general contractor and I . I employees (full and/or part-time).* have hired the sub -contractors 2-E] I am a sole proprietor or partner- listed On the attached sheet ship and have no employees These sub -contractors have working for me 'many capacity. workers' comp. insurance. [No workers' comp. insurance 5. El We are a corporation and its requii6d.] officers have exercised their 3. El 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. msurance required.] Type of project (required): 6. F] New construction 7. E] Remodeling 8. Demolition 9. 0 Building addition 10. 11 Electrical repairs or additions I 1 -0 Plumbing r epairs or additions 12-F-1 Roof repairs 13-0 other t --.y Oux i�! ll—K—so –,U, outtaesecuonbelow showing their workers' compensation policy infortnition. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name Ofthe sub -contractors and their workers' comp. policy information. I am an enWloyer that isproviding workers'compensadon insurancefor my employees. Below is thepolicy andjob site information. Insurance Company Name: Policy # or Self4ns. Lic. #: 1V C q 0 Expiration Date: 2,7 Job Site Address: 5�� e Z2/ Z9 — City/State/Zip-l�� 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 - I do hereby cei# ,fy u pains ��Ye ,�5 �Pa"'ff ofteriury that the infi01M-d0- PrOlided above is true and correct. Official use only. Do not write in this area, to be completed by city or town offw ial City or Town: Permit/License # !-01 Issuing Authority (circle one): L Board of Health 2. Building Department 3. Cit:3VTown Clerk 4. Electrical Inspecto . r 5. Plumbing Inspector 6. Other el Contact Person: Phone 4: 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 contact of hire, express or implied, oral or written." An , employer is defined as "an individual, partnership, assoc-- iation, corporation or other legal entityj or any two or more of the foregoing engaged, in a joint enterprise, andincluding 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 dd 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 chap�ter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contact 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 completdly, 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 art 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 Officie of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit,one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for 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 Eke to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us � a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Amidents Office of Inves6ptions ,600 Washington, Street Boston, MA 0.2111 Tel. # 617-7274-900 ext 4,06 or 1-977-M-ASSAFE Revised 5-26-05 Fax 4 617-727-7749 1"r"r"7.Mas&.L-oV/c1ia Date ..... I..K 2, - /1!9 ...................... -7-w, TOWN,,OF NORTH AN -ROVER ��o - eT;p 7 / PIC ' ER�fT FOR WIRI��G/' This certifies that ................. ....... ma.. jev-/ ...................................... has permission to perform .......... A.,.!Pt,7—W .................................................. wiring in the building of ... ............ 0 ........................................... ce at ... Z2K .... . ...... North Andover, Mass. Fee....3-5�*.. Lic. No. ............. '. REC'MICALIMPECMIt Check , �.o -r� NMI Commonwealth of -Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only 1—f / [Permmit No. 17, Occup 11cy Occupawicy and Fee Checked [Rev. 1/07] (leave blank) I APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NMC), 527 CMR 12.00 (PLEASE PRINTEVINK OR TYPE ALLWfORWTION) —d -10 M �-- - .6 _ , .Date: / / �'� City or own of - By this application the undersi Location (Street & Number) Owner or Tenant Owner's Address WBdff To the Inspector of Wires: or her intention to Ve6orm, the electrical work described below e Telephone No. Is this permit in conjunction ith a building permit? Yes Purpose of Building_ Rle-5 '- cka-.4 � -A- Existing Service. Amps Volts New Service Amps Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No n BLDG PERMIT #_ Utility AuthorizatiouN.o. Overhead Undgrd El No. of Meters Overhead UndgrdE] No. of Meters r,J.0— Estimated Value of Electrical Work: "uattlurtut aeiau u aesirea, or as required by the Inspector of Wires. (When required by municipal policy.) WorktoStart: 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 operatioW' coverage or its §ubstantial equi v*alent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE.: INSURANCE 0 BOND 0 OTBER 0 (Specify:) I cerij&, under thep * s andpenaldes qfper jury, that the information on this application is true and compLete. FIRMNAME: LAI- e K, �, LIC. NO.: Licensee: - , Signature LIC. NO.: (If applicable, e e t " in the li�ense n— MP UM�er line.) ai� Address: yJ4 a 0 2 S B u s. Tel. No— —7e�l f �-V!v �6 r^-4- t'P- 'rZ0( _j�r4edP6y,,,4 Alt. Tel. No.: *Per M. G.L. c. 147, s— 57-61, security work requires Department of Public Safety "S" Licen LIC. NO.: OWNER'S INSURAN E WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally _f required by law. By signature belo hereby waive this requirement. I aim. the (check one El owner El owner's agent. Owner/Agent t Signature 7 _ Telephone No.' EPER"MIT FEE. $ ELECTRICAL PERMIT NO. - INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL 3. UNDER GROUND INSPECTION: iassed — [ I Failed — Inspectors' comments: Re -inspection required ($50.00) - I (Inspectors' Signature - no initials) Date L�- _INSPECTION — SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed — f ] Failed — Re -inspection required ($50.00) - Inspectors' comments: I (fnspectors' Signature - no initials) Date 5. INSPECTION - OTIIER: Passed — f I Failed — Re -inspection required ($50.00) - f Inspectors' comments: (Inspectors' Signature - no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. The Commonwealth ofHassachusetts Department ofIndustrialAccidents f t@V Office ofInvestigations 600 Washington Street Boston, MA 02111 www.mass.gov1dia Workers' Compensation Insuranee Affidavit: ]3uilders/ContractorsYElectriciansjplumbers ADDlicant Information Please Print Leziblv Nalne (B.usiness/Organization/Individual): Address: /\J City/State/Zip: y7?0 Phone#: P74 0 Are you an employer? Check the appropriate box: LEI I am a employer with 4.0 1 am a general contractor and I I es (fall and/or part-time).* Oayseole, have hired the sub -contractors I .2��aimp proprietor or partner- + t listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. El We are a corporation and its required.] officers have exercised their 3 -El, I am a homeowner doing all -work right of exemption per MGL myselE [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. 0 Now construction 7. E] Remodeling 8. 0 Demolition 9. E] Building addition 10. n Electrical repairs or additions ILE] Plumbing repairs or additions 12.E] Roof repairs 13.n Other !Any applicant that checks box #1 must also fil. 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 newaffidavitindicatffig such. lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that isproviding workers'compensalion insuranceformy employee�. Below is thepollcy andjob site itz0ormation. Insurance Company Name: Policy # or Self -ins. Lie. Expiration Date: 4S "' C Job Site Address: City/Stat A,) Aro�oJAJ__ 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 ioaposition. of criminal penalties of a flue up to $1,500.00 and/or one-year finprisonment, as well as civil penalties in the form of a STOP WORK ORDBR and a fine of up to $250.00 a day againstthe 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 ceril nderthep andpenaltles ofpaqury that I.he informadonprovided above is true and correct. —2, 9 Signatur Date: Phone#: Official use on,�V. Do not write in this area, to be completed by city or town official City or Town: Permit(License 9. Lsuing Authority (circle one): \ \" 1. Board of Health 2.13uilding Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact hone 8769 Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING� 'S'4C14US This certifies that ... F�� ...... P.) ................ has permission to perform ... fl.C.& P. ................... plumbing in the buildings of . ................. at.,2, 1 7. Z ............... North Andover, Mass. Fee. Lic. No. ...... ...... �iPLU.IiD. WING INSPECTOR Check # I/ -� ? �Qx MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING IV IV Permit# City/Town: / -1 MA. Date: Building Location: c;? -6 -, —IX -Zi- <a -,Ac t4 iq t> Owners Name: 44- P 1 Type of Occupancy: CommerciaIF] EducationalEl IndustriaIR InstitutionalF] Residentiel� New: Alteration: F] Renovatiop�6 Replacement: F] Plans Submitted: Yes F] Nge! 01 FIXTURES INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 y7K No El If you have checked Yes, pleas i icate the type of coverage by checking the appropriate box below. C, A liability insurance poli YZ Other type of indemnity El Bond t, 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 Signature of Owner or Own&s Agent Owner El 4 Agent El I hereby certify that all of the details and information I have submitted (or entered) -6g- #ding this ap Knowledge and that all plumbing work and installations performed undex4116-- plicfition are true and accurate to the best of my permit,Wsued for t�)r; apolication will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Cliapter 142 ofAe Gene%Kaws./ By Title City/Town APPROVED (OFFICE USE ONLY) of License: Plumber Sig Master lburneyman e of Licensed Plumber Number: 47" DEDICATED SYSTEMS LU 2i z 1-- z fA 0 Ln > 1.1 'n LA M z 9 Ln LA LA U 1A 0 0 z z 0. cc Uj z z 0 Z 0 Z LU UJ 0 Ln LU In z 0 = Z Ln z -j — X L, 3: -J LL �Id 0 0 CL 0 W = Z 2 ui W z F: Ln = LU t— Uj = Uj 0 1 LU LA < Uj I -- (A LU -uj 0 0 00zr= -n U LAW < cc < ca 79 L Sl 1 01 1 1 1 0 W 0 SUB BSMT. BASEMENT 1 ST FLOOR 2 ND FLOOR 3 RD FLOOR 4 TH FLOOR 5 TH FLOOR 6 TH FLOOR 7 TH FLOOR +4 8 T" FLOOR Check One Only Certificate # Installing Company Name: Q Address-V?y/AA'/0(g- /,�A k" IiA El Corporation CitylTo.n: State: Ej Partnership Business Tel: Fax: El Firm/Company Name of Licensed Plumber: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 y7K No El If you have checked Yes, pleas i icate the type of coverage by checking the appropriate box below. C, A liability insurance poli YZ Other type of indemnity El Bond t, 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 Signature of Owner or Own&s Agent Owner El 4 Agent El I hereby certify that all of the details and information I have submitted (or entered) -6g- #ding this ap Knowledge and that all plumbing work and installations performed undex4116-- plicfition are true and accurate to the best of my permit,Wsued for t�)r; apolication will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Cliapter 142 ofAe Gene%Kaws./ By Title City/Town APPROVED (OFFICE USE ONLY) of License: Plumber Sig Master lburneyman e of Licensed Plumber Number: 47" 3123 3 Date ................... ,,V&ORTN TOWN OF NORTH ANDOVER 0 PERMIT FOR GAS INSTALLATION SSACHU ION LD This certifies that. ...... // ................. has permission for gas installation /-./ ................... in the buildings of /-x ............................. at Z North Andover, Mass. Fee.. Lic. No.. f�/S� GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MAS!�ACHUSETTSI,UNIFORM-�APPLICATlOt4 FOP, PERMIT TO DO SFITT F:17 ING (Print or Type) NORTH ANDOVER Mass. Date 51AI16 �uilding Local tion' Permit Owners Name Plans Submitted 0 New -7 Renovation Replacement FIXTUR=1z wl� -1,10" (Print or Type) Check one: Certificate Installing Com Name ANDOVER PLBG. & HTG. CO., INCM Corp. 2122 P Address 5731" 'SO. UNION STREET Partner. LAWRENCE, MA. 01843 Firm/Co. Business Telephone: 978 685-8383 Name�;*f - Ll er�.:or Gas Fitter GFOgGE LAgUSF n rlEnc.- cdvei4aitie�' '�"I'ndlcate the type of insurance coverage b '�Ched.king the Y, ajap, vpr a te box: Liability insurance policy [Z�Other type of indemnity = Bond Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application s not have any one of the above three insurance coverages. Signature of own.er/agent of property . Owner 17 Agent El I hereby certify that a1l of (he deuils and information I have submitted (of entered) in sbove application ace trucand accuzate to the bcst o(my kno-ictlCe. and that &U plumbing work and instALLations pctrormed under rermit issued tax this application wW-be In compliance with all p=ttncnt Provisions OCLhe Massachusetts StateCas Cade and Maptes 142 of the General I.Aws. By TYPE LICENSE: - Plumber Title Gasfitter- SigArture of Licensed r Gasfitter CitY/Town: Master Plumber o Journeyman. 9983 APP116VED (OFFICE USE ONLY) License Number MENNEN MEN IMEMEM 0 .......... IM"D ml- 0 0; MENOMONEE MMEM MM FEE EMERMINE W21,1161MIJI 0 0 MKNMMO1V1 NEENOMEMENEE=EE� MOM MEMO MUMMEMMENEMMENEEMEM 011M=10ONMEMN MOMMINNUMMEEMEMEM -1,10" (Print or Type) Check one: Certificate Installing Com Name ANDOVER PLBG. & HTG. CO., INCM Corp. 2122 P Address 5731" 'SO. UNION STREET Partner. LAWRENCE, MA. 01843 Firm/Co. Business Telephone: 978 685-8383 Name�;*f - Ll er�.:or Gas Fitter GFOgGE LAgUSF n rlEnc.- cdvei4aitie�' '�"I'ndlcate the type of insurance coverage b '�Ched.king the Y, ajap, vpr a te box: Liability insurance policy [Z�Other type of indemnity = Bond Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application s not have any one of the above three insurance coverages. Signature of own.er/agent of property . Owner 17 Agent El I hereby certify that a1l of (he deuils and information I have submitted (of entered) in sbove application ace trucand accuzate to the bcst o(my kno-ictlCe. and that &U plumbing work and instALLations pctrormed under rermit issued tax this application wW-be In compliance with all p=ttncnt Provisions OCLhe Massachusetts StateCas Cade and Maptes 142 of the General I.Aws. By TYPE LICENSE: - Plumber Title Gasfitter- SigArture of Licensed r Gasfitter CitY/Town: Master Plumber o Journeyman. 9983 APP116VED (OFFICE USE ONLY) License Number 14� 3965 DateY-1:- TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING j This certifies that .... Ok e�y .... .......... has permission to perform ..... ........... plumbing in the buildings of at. . 1. 5/10� i-. North Andover, Mass. Fee Lic. Nd9'�.V. 3 ... ... PLUMBING INSPECTOR 03/16/9q 12:31 25100 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer to E v%j %jisig—lim tArru%-or%4&%jiv g-%jea r"alillosal (PtInt or Typel NORTH ANDOVER, Mass. c)aie Bulidlng Location dw&/A New 0 nenovallon 0 Fleplacement FIXTURE9 permit# - AREM .3 7- o"er ' a NAMG Plans Submitted: YesC1 41 Check one: CartNic-Ale Installing Compiny Name ANDOVER PLG. 8 HEATING CO. N C . 2 12 2 Address 573 112 50- UNION ST- 0 Partnership LAWRENCE, MA. 01843 0 Firm/Co. Ou5lnesl Telephone 508 685-8383 Name of Licensed Plumber GEORGE LAROSE INSURANCE COVEnAGE: Checx one I have It cuirent 11ablifty insurance policy or Its substantial equWenL Yes C1 No C1 It you have checked y&j. please Indicate the type coverage by checking the appropriate box - A Itablilly Insurance p<Alcy . Other type o( Indemnity 0 Bond 0 OWNER'S imsunAfICE WAIVER: I am aware that the licensee d2jj rxA hjM the Insurance coverage fequited by Chapter 142 c4 the Mass. General I-Avve. and that my signalixe on No permA application waives this requirement.. Check one: owner 0 Ager -A El ggnstuls of oymel og (Nmel 1 Agent I heisby c*01N that &M of the detaAs &M infoirriallon I have subenitted kw sntoi" in abo" appikation we bue and sc=ste to the bait o'! MY know4dge and that al plumbing *rvqk and 1nstJ&ttonsW(xm*d undtit th*p*m-A1"U*d Sm I &PP#c&tJon*11 b-19 In cofftpRancit with 0 'I�M pw0nani proviOonv of the Matuchuiatit State Piumbirq Code aM Cheater 114'=M V'w ai Cfty[Town MI'K-?-TD ( NFX-E USE SigKAture of Ucensed PVumb*t uc,antemimbee 9983 Type of Pkimbing Lksnse: Mailet Jouinsyman F-1 Z 0 11 Is W A 0 N, 1- Ul x 16 X UX 10 L '41 I- "Z U pr .' 's 46 as 0 44 :Ira me IL N K 01 .4 t a U a 0 $US —114 IdT. BAS414KHT A— I IST FLOOR 2010 FLOOR 3AD FLOOP 4TH FILOOM ITH FLOOR OTH FLOOR YTH FLOOR OTH FLOOR Check one: CartNic-Ale Installing Compiny Name ANDOVER PLG. 8 HEATING CO. N C . 2 12 2 Address 573 112 50- UNION ST- 0 Partnership LAWRENCE, MA. 01843 0 Firm/Co. Ou5lnesl Telephone 508 685-8383 Name of Licensed Plumber GEORGE LAROSE INSURANCE COVEnAGE: Checx one I have It cuirent 11ablifty insurance policy or Its substantial equWenL Yes C1 No C1 It you have checked y&j. please Indicate the type coverage by checking the appropriate box - A Itablilly Insurance p<Alcy . Other type o( Indemnity 0 Bond 0 OWNER'S imsunAfICE WAIVER: I am aware that the licensee d2jj rxA hjM the Insurance coverage fequited by Chapter 142 c4 the Mass. General I-Avve. and that my signalixe on No permA application waives this requirement.. Check one: owner 0 Ager -A El ggnstuls of oymel og (Nmel 1 Agent I heisby c*01N that &M of the detaAs &M infoirriallon I have subenitted kw sntoi" in abo" appikation we bue and sc=ste to the bait o'! MY know4dge and that al plumbing *rvqk and 1nstJ&ttonsW(xm*d undtit th*p*m-A1"U*d Sm I &PP#c&tJon*11 b-19 In cofftpRancit with 0 'I�M pw0nani proviOonv of the Matuchuiatit State Piumbirq Code aM Cheater 114'=M V'w ai Cfty[Town MI'K-?-TD ( NFX-E USE SigKAture of Ucensed PVumb*t uc,antemimbee 9983 Type of Pkimbing Lksnse: Mailet Jouinsyman F-1