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Home My WebLink AboutMiscellaneous - 280 MARBLERIDGE ROAD 4/30/2018a) m C, G) rn 0 ;a Date...... .............. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 11-n C) / This certifies that ........ U.Joud.r.i.ev . ............................................ has permission for gas installation ..... *7 inthe buildings of ................................................................................................................... a— ... .... ........ NoA Andover, Mass. "IN . .. .. . ............................. Fee.��.J./&,Lic. No. .1,57.174.4 . ....... ... .... Check # INSPECTO 10160 TV -PTE OR CILE'RLY FIREPLACE FWAS'SACHUSETTS UNIFORM APPLICAT[ONT FOR A PERMIT TO PERFORM GAS FITTIMG IMORK CITY: N11A. DATE. Oy 'S NA 1,4A. DATE;. PERM IT JOBSITE ADDRESS:A OVINER'S NAME: sa O!'v*NER ADDRESS: Same as abov TEL: OCCUPANCY TYPE: COMMERCIALE] UCATIONAL RESIDENTIAL RENOVAATION:: REPLACENIEN N "V'Fl LFL 0 HEATER MAKEUP AIR UNIT OVEN POOL HffA—TER ROOh4/SPACE. �TER ROOF TOP UNIT TEST UNITHE�'tFR WATER HEATER I have a cu' INSURANCECOVERNG ---------------------------- rfent I Lab—r1tv insurance policy or i substantial equivalent " [is vvhich meets the reTirements of M -UL. Cb. 142 YPS 00 F-1 if you have checked Y,' :,S, please indicate' -the iype ol coverage by checking the appropriate box belotiv. LIABILITY INSURANCE P0LICYF-j 0 TH E R T�,,? E I N D E MI N 1 TY BOND OWNER'S INSURAiNICE WAIVER: I am avyare that the licensee does - ts General Laws, and that my signature on this permit aD lication �'Lfaivas this requirement. Massachuser ngt have the insurance coverage required by Chapter 142 of the I p — OF OWNER OR AGENT CHECK ONE ONLY: OWNER FIAGE111T r-� hereby certd�j thai all of 'Cie det its and information I have suimifted (0, 9."Itered) regarding this aPplica-don are true and ac;cura-I."-- to the best of mv ta Kf'01-111edge and thart ail plumbing work- and ir'stallatiOnS Perforrned under trip, perini- issued for this applicationyvill ban in complianGe wyli,'�'all Pertainen'. provision of the Massachusefts Stlate Plumbing Code and Chapter 142 of the Gene'ral Laws. PLUMBERiGASFITTER NAME: GEORGE A. POUDRIER L I C E N S E #. 15764 / SIGNATURE COMPANYNM,'jE: GAPS PLUMBING & MEATING 'ADDRESS: 15 EAGLE DRIVE CITV: DUDLEY S TAT MA Zip: 01571 FAX: 508-461-9349 iEL- 508-461-9382 GELI - 508-789-3486 15,11AIL GAPSPLUMB I NG@CHARTER. NET MIASTER1 /IJOURNEWAIANT-1i p jNSTAi P CoRpr 'R47 ------------ �1 TYPE OR - ID RUN TORY INA: TIER IWASSAGHUISET—IS jj;,jIF0RFt�, APPLICATION FoR A PEERMIT-TO P:-:R.--o�7aq akS EP jN,, WORK 'U PaRN.M1 D, --TE JOB IT Dop, 8'�- 01"IMER'S NINNAE: 1 014"NERAIDDRESS.- Same as abo TEL OCCUPANCY71YPE: COMiMERCIALEJ 'DUCATIONAL RE 'Ej TLAIL NE'iV- El r-71 RE1q01j,1,-1 10�,i: R&PLIACEbl@\IT� 11 IV I _LIF-LOOR— issm-, 3 8 4 4 6 1 7 1 8 10 10 12 3 4 LA - SC KOO 0 to -4; 11/ INSUR have a currentlLfab* MtV IPSUranCe n E Polic�y or it substantial equijj,=IC-ntt�jhj - MS. - the r=-'3 Lt;ref,- entS ONOG L. Ch. I A2 S ;F you have chacked _YES Please indicate the lype -.0 00 01 VM98 by ch=-c,1cj.rjg the 2PPI-00riate box belojij,. LIABILITY 1NISURAN i ICE POLICY OTHERTITPE ifjDEPZ1j%'-7fY 3 0 it D 0INNER'S INSURAMICE WAIVER- I am agrarc-& t licenseeAg El i Ls General Laurs, a _g§not have the insu fWassachuser' 11 nd that my signature on this oarr ra it applicatlon r,1r1ce cove ge req ired bY ChaPtar 142 offthe Waives Lhis requirement' z -5 if -G i, I A T U RRE .0nc 0 ipqr� 0 C CHECX DIME ONLY: -JAGENIT F --j 7 F" Neffa G. Lush Stever) W. Lush 280 Marbleridge Road Iyorth AT-dover, MA 01845-4715 "'L 129 53-13/110 MA 26660 Date M hRnco R E so TZ '08-461-9349 Merica.%1W8--. Dollai-S allARTER NET X 11--0 �11 �nh i -i �jq. :0 11 00 13al: 0000 1 ? S 3 3 PIP 100 12 �9 The Commonweauh of massachusetts Department of IndustrialAccidents Office of Invesagations I Congress Street, Suite 100 Boston, M,4 02114-2017 U.? UY U Y .114.— .'&M -30.6u Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/lindividual): Address: Type of project (required): 6. El New construction 7. [] Remodeling S. E] Demolition 9. 0 Building addition 10-n Electrical repairs or additions I I - [M Plumbing repairs or additions 12.E]Roof repairs 13.E] Other I I *Any applicant that checks box #I 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 5uch. �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. am an employer that isproviding workers' compensation insurancefor my information. employees. Below is thepolicy andjob site Insurance Company Name: Polity # or Self -ins. Lic. #: Expiration Date: Job Site Address: 01( ��n poli' 0 City/State/Zip - Attach a copy of the workers" 4com ensatio poli comp �eclaration ppage ((sh�o*ing 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 certyyunderthepainsandpena ofperjury that the information provided above is true and correct. Si-anature: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other PermittLicense # 3. CitY/Town Clerk 4. Electrical Inspector 5- Plumbing Inspector Contact Person: Phone #: Phone Are you an employer? Check the appropriate box: LEI I am a employer with 4. F] I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors M 42. 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.T required.] 5. E] We are a corporation and its 3. El I am a homeowner doing all work officers have exercised their myself [No workers' comp. right of exemption per MGL insurance required.] t C. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. El New construction 7. [] Remodeling S. E] Demolition 9. 0 Building addition 10-n Electrical repairs or additions I I - [M Plumbing repairs or additions 12.E]Roof repairs 13.E] Other I I *Any applicant that checks box #I 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 5uch. �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. am an employer that isproviding workers' compensation insurancefor my information. employees. Below is thepolicy andjob site Insurance Company Name: Polity # or Self -ins. Lic. #: Expiration Date: Job Site Address: 01( ��n poli' 0 City/State/Zip - Attach a copy of the workers" 4com ensatio poli comp �eclaration ppage ((sh�o*ing 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 certyyunderthepainsandpena ofperjury that the information provided above is true and correct. Si-anature: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other PermittLicense # 3. CitY/Town Clerk 4. Electrical Inspector 5- Plumbing Inspector Contact Person: Phone #: IS E HE FOUQW]t� -fj R, il JOURNEYM G-, 4 K S T TO'Li L S.L.1- s E a� AS A KASTER A,'PO Q 'T f MA C AA 0,15570 t 1"! ir L44OWWOR M. -��.V'jKfqt-YPERSON-UNRESe�T--R,'.rrC-T-E*�,b,r"''t., A P.OUDRI" E 5 E A G Y 15 .VE 01571- X 0 4 9 Check # 12A '� Date..W\ .......... TH ANDOVER PLUMBING ............................................... 3� 0,j ............................................... Drth Andover, Mass .............................................. PLUMBING INSPECTOR Date .... !1.44.64 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that.. t-'- 2W C44 - ............................................................ ..... .................... has pennission for g�s installation 6-3 ) IP -1, ............................................................................ inthe buildings of ...... .................................................................. X-"; North Andover, Mass. ........................................................ Ky ............... Fee.:�� . . ..... Lic. No. ..... ... M (�� .............................................. Check # Q-1 i; GASINSPECT . OR 97,09 [IF I F MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YE&ET-'N'O IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW CITY = K - e -MA DATE PERMIT Massachusetts General Laws, and that my signature on this permit application waives this requirement. JOBSITE ADDRESS c4. r OWNER'S NAME P OWNER ADDRESS h PLUMBER'S NAMEEM rQ Q 4, LICENSE # SIGN R TEL[ FAX TYPE OR OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: 01 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES Ell NOO' FIXTURES -1 FLOOR- BSM 1 2 3 4 5 6 7 8 1 9 10 11 12 13 14 BATHTUB j J L-11 CROSS CONNECTION DEVICE P7 DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM I DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER j ---i I FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR� KITCHEN SINK f LAVATORY j A L j ROOF DRAIN SHOWER STALL —1 F --j --- i —.—J. ERVICE / MOP SINK TOILET URINAL [IF I F INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YE&ET-'N'O IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLI CY [A-' OTHERTYPE OF INDEMNITY Dj BOND 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance cove rage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNERE-11 AGENT 1n -- 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 ac a E715—ffi—erbaskof my knowledge and that all plumbing work and installations performed under the permit issued for this applicatio i beinc lance wit 11 Pertinent largy1slon of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. h PLUMBER'S NAMEEM rQ Q 4, LICENSE # SIGN R MP ip 01 CORPORATIONFII# PARTNERSHIP 0# LLC COMPANY NAME ADDRESS CITY STATE ZIP TEL FAX EMAIL FIN LLI CL ,]Li Lij LL The Commonwealth of Massachusetts Department of Jndustria[Accid�nts Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le2ibly. Name (Business/Organization/Individual): Address: 0'A City/State/Zip:c(-ct�,,�,-f,�:,o ok!gt,3—k Phone#: Are you an employer? Check the appropriate box: 1. �am. a employer withc - 4. El I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2.0 1 am a sole proprietor or partner- listed on the attached sheet - ship and'haveno employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. 0 We are a corporation and its required.] officers have exercised their 3.0 1 am a homeowner doing'all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] employees. [No workers' comp. insurance required.] Type of project (required): 6. New con struction 7. Remodeling 8. E] Demolition 9. F1 Building addition 10. Electrical repairs or additions 11. Plumbing repairs or additions 12.EJ Roofrepairs 11d Other 'Any applicant that checks box4l 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. Iam an employer that isproviding workers'compensation insuranceformy employees. Below is thepolley andjob site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: , City/State/Zip:. Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one�year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do 11�wby-Gofy under MSjwh&-qWpena1Y1es ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to he completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone N: Information and Instruction -S. 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 ofhire, express or implied, oral or written." An employeils defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in ajoint enterprise, and including the legal representatives of a -deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction 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 lo'cal 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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the' application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate Eno. 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. Pleas ' e be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address"' the applicant should write "all 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 ii on file for future permits or licenses. A now 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 CQM M.oliwoalth of Mo ssachusetts Department ofladustrial Accidents Office of Investigations 600 Washington Sj=,t Boston, MA 02111 Tel. # 617-727-4900 ext. 406 or 1-877�,MASSAM Revised 5-26-05 Fax# 617-727-7749 __wwwmass,pv1dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE PERMIT# JOBSITE ADDRESS OWNER'S NAME iG, OWNER ADDRESS ---j ._____IFAX j TE TYPE OR PRINT OCCUPANCYTYPE COMMERCIAL EDUCATIONAL E] RESIDENTIAL CLEARLY I NEW:E1 RENOVATION: REPLACEMENT: [2' PLANS SUBMITTED: YES Ej NO APPLIANCES"I FLOORS -z.1 BSM' 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER I DRYER FIREPLACE I FRYOLATOR JL L FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER J ROOFTOP U NIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER . --6THER I ......... . .............. ........ j j INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YE I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF C�� CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 13OND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER E] AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to th es of m owledge � and that all plumbing work and installations performed under the permit issued for this application %vill b:,��Oance-Mtf-�all Pertin provisio the Massachusetts State Plumbing Code Chapter 142 General Laws. and of the PLUMBER ASFITTER NAMEE: 5 — 2;�� LICENSE#[�—j IVIP 7MGF EjI JP 0 JGF LPGI Dj CORPORATION D1# PARTNERSH I P E]#E.-�= LLC Ej# COMPANY NAME: DRESS L AD CITY STATE ZIP[_Q&— -7�j TEL FAXI CELL EMAIL El LU LU F - Cf) CO uj LLI co z 0 a. IL 6i LLI LL The Commonwealth ofMassachusetis Departmintoflndi!striqlAccidints Office of Investigations 6#0 Washington Street -Hoston., MA 02111 www.mass.gov1dia Workers' Comi)ensafion Insurance AffidaWt: Buffderg/Contractors)Electri.clans/Pliimber.8 Address: k i -i Zon n a CLQ_ Cityfftto/Zip: C Q A6^�,X o is Phone 4: (45 -2 4t3 i Are you an employer? Check the appropriate box: Type of project (required): 1. PrI am a employer with 4. F1 I am a general contractor and 1 6. [] New c6iistraGdon . employees (fall and/or patt-time).* 2.E1 I am a sole proprietor or partner- have hired the sub -contractors listed on the attached shoot. 1 7. El Remodeling ship and1ave, no employees These sub -contractors have 8. E] Demolition working formainaaycapacity. workers' comp. insurance I 9. E] Building addition [No workers' comp. insurance 5. E] We are a corporagon and its 10.E] Electrical repairs or additions r quired.] I am a homeowner fting all work 3.E1 0 officers have exercised.their right of exemption p or MGL 11.[] Phimbingrepairs or additions myself. EEO workers' comp. c. 152, §1(4), andwehavano 12.[.1 Roofrepairs iusurancareqaireO.] f employe6s. [No workers' 1311 . Other comp. insurance required.] 'Any applicant that diecks box#1 must also fill out the section bel6w showing their Workers' compensation policy information. f-Horneowners who submitthis affldavitindicatingtheYA7r�dgingallworKand then hire outside contractors must submit anew affidavitindicatifig such. TContractors that chookthis box. must attached a.n gdditional sheet showing the name of the sub -contractors and their workers' comp.policyinfonnatfon. I am an employer filatisproviding workers'com U rm t W is th 11 im 1 h site pensation ins rancefo y employees. Be o epo ey d o tnfarmation. Insurance Company Policy # or S elf-ias. Lic. ExpirationDate: lob Site Address: City/State/4): Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure ooverage.as requfredunder Section25A ofMGL o. 152 can leadto the, imposition of criminal penalties of a fine up to $1,50 0.0 0 and/or oneuyear im-prisomnent, as well -as civil penalties in the form of a STOP. WORY, ORDER and a fine of up to $250.00 a day against the -violator. Be advised that a copy of &is statement may be forwarded to the Office of - Investigations of the DIA for insurance coverage verification. .T do hereby cert6�.!qtder thepains anAgeuaMoy-itawrjury that Me informadon Provided above is trite and correct. kk- -;)Lk,l Phone 4: 0 pleted b fft-cial use anly. Do not vrite hz Mis area, to he com y cl(p or town offielal City or Town: Permit[License 0 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CltylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone Information and Instruction -_8 Massachusetts General Laws chapter 152 requires all employers to provide workers, compensation for their employees. Pursuant to this statute, an employee is defined as ".. ..every person in the service of another under any contract ofhiro,- express or imp.U4 oral or wxitten.11 An em ,ploydis defined as "an individual, partnership, association, corporation or other legal enfityp or any two or more of the _-T`o"re'g`Q'p-g' engaged in aj olut enterprise, and including the, legal representatives of a- deceased employ pr, or the receiver or trustee of an individual, partnership, askelation or other legal entity, employing employees. )Nwaver 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, constraction. or repair workon su�h 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 statte or lo�al licensing agency shall withhold the issuance or renewal of a license or p ermit to op erate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage requireV 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 a'cce, ptable evidence of compli�mca with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Pleas.e.fill out the workers' compensailon affidavit completely, by checking the boxes that apply to Your situation and, if necesisary, supply sub-contractor(s) name(s), address(es) andphono number(s) along with their cortif1cate(s) of insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees offier than the members or partners, are not required to carry workers, compensation insurance. If an LLIC orLLP does have employees, a policy is required. Ba advised thatthi� affidavit maybe submitted to 1he Department of Iudustdal Accidents for confirmation of insurance c overage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that thei application for the permit or license is being requested, not the Dep'artmont of Industrial Accidents. Should you have any questions regarding the law or ifyou are required to obtain a -�orkers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their selfriusuranco license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printedlegibly. The Department has provided a space at the, bottom ofthe, affidavit fox you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be -sure to M in the permit/11conse, number which will be used as a reference number, In addition, an applicant that �2ust submit multiple permfillicense applications in any given year, need only submit one, affidavit indicating curr6nt policy information (ifnecessaty) a -ad under "Yob Site Address; the applicant should write "all locations in (city or town)!) A: 66py ofthe affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that avalid affidavit -Is* onfilo�or faturePelmits orlicenses. A new affidavit m- a'st be filleLd out each year.'Whero ahoma owner or citizen is obtaining a license or -permit not related to any business or commercialventure (i.e. a dog license orliermit to bum leaves etG.) said -person is NOT required to complete, this affidavit. The Office of Investigations . would Eke to thankyou in advance foryour cooperation and shguldy9uhave any quesfions, please do not hesitito to give us a call. The Department's address, telephone, and fax number: Tho Commonw(mittt of yo�gqp-hv�c>tt_q Dc,'P.aftent of bffusWal Aciddelifs Office offAves-UgAtio"aa 6bG Wakiugton . . Sfteet B0*14 MA 021 It TO� 4 617-7274900 W 406 Qx 1-877-MASSM Revised 5-26-05 FaY, 0 617-727-7749 _Wwwaa�,s,govldla M.: i i: r �:M. C= Ln -n :C�' r7 m CD r,7. t7l M�ii� 0 CA Date......... b .... ................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION H. CtA � �j . / P-� \ � C - This certifies that-- ........ ..................... has permission for gas installation 6W\ -S V'f-1 k C A- P, .......................................... .................. in the buildings 9f.. . ...................... ..... ...... ....... Y North Andover, Mass. FeeA&�L ... Lic. No. C.33,�� ...... �10 ...... w ................................................ GASINSPECTOR Check# 9 115 9447 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I N. Andover MA DATEL 7/31/2014 PERMIT# C)01 6 JOBSITE ADDRESS[ 80 Ma�ble Ridge Rd L_ OWNER'S NAME GOWNER ADDRESS I Same TEC 1FAX TYPE OR OCCUPANCY TYPE COMMERCIALL] EDUCATIONAL L] RESIDENTIALL] PRINT CLEARLY NEW: RENOVATION: El REPLACEMENT: El PLANSSUBMITTED: YES[] NOE] APPLIANCES FLOORS--- BSM 1 2 3 4 5 6 7 8 9 10 1 11 12 13 14 BOILER I BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER 'UNVENTED ROOM HEATER .WATER HEATER OTHER[ .�Mlace 1 Gas Meter(E ----------- �;F —x -and —Associated Pir)ing INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 0 NO E] I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY F-,1 OTHER TYPE INDEMNITY Ej 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 [j AGENT F-1 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co liance with all Pertinent provision of the "a Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I Joseeh Marino LICENSE# 8736 SIGNATURE mp Fj MGF [j JP [] JGF [j LPGIE] CORPORATION L]# PARTN SHIP[FJ#F LLC []# COMPANY NAME] RH White Construction Co ADDRESS 141 Central St CITY I Auburn STATE L.UA JZIPJ 01501 ]TEL 1 (5018) 832-3295 FAX 1508-926-4347 j CELL ]EMAIL iite.com ROUGH GAS INSPECTION NOTES I THIS PAGE FOR INSPECTOR USE ONLY Yes No THIS APPLICATION SERVES AS THE PERMIT [I M FEE: $ PERMIT # PLAN REVIEW NOTES FINAL INSPECTION NOTES M COLU Lu <z R* LL o aS C!r L< 1-4 lz C� < LU LLJ-:4 w Z. �ATE (MMIDtaV CERTIFICATE OF LIABILITY INSURANCEP... F "J'." ZI Thl� CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLYAND 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 ceitificata holder is an ADDITIONAL INSURED, the poIioy(i@s)murt be endorsed. If SU13ROGATION IS WAIVED., subject to the terms and conditions of the policy, certain POlicies may require an endorsement. A statement on this certificate does notconferrights to the certificate holder in IIOU of such endorsoment(s), willim OL MasaffebLunotte, Inc. c/o 29 cont-ary Blvd. P. 0. Box 305191 Nftlhville, TH 37230-5101 ��W� �xww= INSURED INSURERA! The cbartor oak rine Ineurancq Company 25619-001 " a " " I R- El- White COnstruction Company, rnc. INSURERS: TrRvQlArs Properey Cagualtsy Coa�pany og AM 23674-00� 41 Central 5treet P. 0. Box 257 INSURER C: Nati=Al Union Firq 3:nqurand* �Q_P_ny _,E 1 001 CQMpany of 1.9445-001 AubUrA# MA 01501 INSURER D; Travelera Inda=jty CompIny 2 S69 a _ r)0:L 2S658 -D01 INSURER F; INSURER F; COVERAGES CERTIFICATE NUMBER: 20287680 REVISION NUMBER; THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW I-4AVE BEEN [$SUED TO THE INSURED NAMED ABOVE FOR THE POLICY iNDICA7ED. PERIOD 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 BYPAID INSR DD,[ SUB CLAIMS. I TP TYPROPINSURANCE vulm POLIGYNUMBrR FOLICYEPP POLICY EXP GENERAL LIAMILITY VTC2OCD 977X9940-13 LIMITS 9/1/2023 9/1/2014 EACH Or-P.VRRENCE 2 0 0 0 E 2 111, X CQMMPROIAL GENERAL LIARII.ITY D CLAIMS-MADEE] OCCUR 301 3 a-g'Qg0 EXP (Any one poison MED 000 1 PERSONAL &ADV INJURY $ 2 0 '000 �4JURY 0 _ 0 TE S 4 '00t GENERAL AGGREGATE 9 4,_000,000 GEN'L AGGREGATE LIMIT APPLIES PER; POLICY PRO- LOG PRODUCTS -COMPIOPA(go $ A(10 s 000,000 B AUTOMOBILE LIABILITY VT.TCAP 977K95SA-13 9/ LIMIT 9/1/2014 T • ANYAUTO ,,8,1rE,0,)9iNGLE LIS S 2,000,000 00(),0 ALI.OWNED SCHEDULED BODILY INJURY(Perverson) S AUTOS AUTOS • HIREDAUTOS X NON,OWNED 150DILY IWURY(Pigracoldent) '��,�AMAGE AUTOS Dad x CQm X C x Q11 Ded r�QP et(% UMBRrL C LA UAD OCCUR /l/20:L3 9/j/2014 �ACH OCCURRENCE Ls 5 000 Excgss LIAU CLAIMS-MAOE "000 AGGREGATE Is a, 000, 0 0 0 DED I X IRP-TENT[ONS :L0, 0 00 D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY VTRKUB 820SAISS-13 9/1/2013 -9/l/2014 X To -H- D ANY PROPRIETOR(PARTNER/FXECUTIVE VTC2xui3 A203A71A-13 OFFICERIMEMSER EXCLUDI!D? NxN N(A Ry L 9/1/2013 9/11/2014 E.L. EACH ACCIDENT 1 ' 000.000 MMandato InNH) 13 �rlbis Wflar L '101 E.L. DIqEASr=- EA EMPLOyp.rz S 1,000,000 e5bdas U K11- I ION UF QPk*RA'nONS below D18FASIE -POLICY LIMIT S 11000,000 V xvidonce of inx=Anca epeca SHOULD ANY 0; THr= ABOVE DESCRIBED F30LICIES BE CANCELLED BEFORE THE EXPIRATION DATE THERE -OF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVIsIONS. AUTHORIZE15 REPRESENTATIVEE C011:4297604 TPI:1694012 Cert:20287680 Q 1988-2010 ACORD CORPORATION. All rights reserved CORD25 , (2010/05) The ACORD name and logo are registered marks of ACORD , 3846 �L Date .... !�V&/ ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING C .................. r ............... ( ....... This certifies that ......................... ..... has permission to perform ....... ...... A�,!. Z ................ winng in the building of .......... ....... t ....... r C ......... .............. ...... ..... . North A over—M Fee.A.'.-.k. Lic. No. ......... ....... .... ELECTRICAL INSPECTOR Check # Official Use Only -2 C,- 4 1/, . Permit No. rME C091"095MIEALWOT 9I1,4SSACWVSEqTS Department of (public safety Occupancy & Fee Checked_ BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all Information) Towncif North Andover The undersigned applies for a permit to perform the electrical work described below. Lo6ion (Street & Owner or Tenant tn') 01. - �4-, L=I�f f � ( C,, I 0J �,- (,,- Owner's Is this permit in conjunction with a building permit Purpose of Building A -(—'Z) -i CL0,21 T -2,54 - Diate__CC.��Q& �� To the Inspector of Wires: Yes 0 No U//(Check Appropriate Box) EAsting Service -Amps--------Yofts New Service __,Amps voits il Number of Feeders and Ampacity_ Location and Nature of Proposed Electrical Overhead 0 Authorization No. Undgmd 0 No. of Meters Undgmd 0 No. of Meters OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy includi �Qpmpleted Operations Coverage or its substantial equivalent 0S) NO valid proof of same to the Office ES' NO - If you have checked YES please indicate the type 6-Mverage by checking the appropriate box. QNSURANC - BOND = OTHER = (Pleaseify) -3 — (-\ 7��> (Expiration Date) 1 m t, ated Value of Electrical Work$ Work to Start C-- -C, - c-, --I Inspection Date Resquested Rough Final Signed under the Penalties of pedury: FIRM N LIC. NO. NO. - -3713-�5 us. T� N o. q- y 9 Address _-:;S 0 1Q>&PJt T61. No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not havb the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Yelephone No PERMIT FEE $ cp� (Signature of Owner or Agent) Total No. of Lighting Outlets No. of Hot fuse No. of Transformers -KVA Above 0 In No. of Lighting Fixtures Swimming Pool gmd 0 gmd 0 Generators KVA No. of Emergency Lighting No. of Receptacles Outlets No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Burners FIREALARMS No.ofZone No. of Detection and Total No. of hanges No of Air Cond Tons Initiating Devices Heat Total Total No. of Diposal No. Pumps Tons KW No. of Sounding Devices NoJ of Self Contained I No. of Dishwashers SPace/Area Heating KW Deterftion/Sounding Devices 0 Municipal [] Other No. of Dryers Heating Devices KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wiring No. Hydro Massage Tuds No. of Motors Total HP I OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy includi �Qpmpleted Operations Coverage or its substantial equivalent 0S) NO valid proof of same to the Office ES' NO - If you have checked YES please indicate the type 6-Mverage by checking the appropriate box. QNSURANC - BOND = OTHER = (Pleaseify) -3 — (-\ 7��> (Expiration Date) 1 m t, ated Value of Electrical Work$ Work to Start C-- -C, - c-, --I Inspection Date Resquested Rough Final Signed under the Penalties of pedury: FIRM N LIC. NO. NO. - -3713-�5 us. T� N o. q- y 9 Address _-:;S 0 1Q>&PJt T61. No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not havb the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Yelephone No PERMIT FEE $ cp� (Signature of Owner or Agent) PAYMENT Date. .9 39 1 - 8 # , FEB 2 7 19" 01 N'o. And01fflO9&6F* NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that has permission for gas installation ................... in the buildings of ................ I ..................... at t,. . ........... I North Andover, Mass. Fee. Lic. No.1 �� ... ......... GAS I�SP`ECT'0*R*' WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File MA.SWAUHUSt"T'T"S' UNIFORM APPLICATION FOR PE Mint or Type) RM T TO DO GASFITTING -NORTH A14DOVE-R Mass. Date I g BuRdIng Permit Locatlon,,P�0 �\AA(U�k-EQ-,OuE QJ Eel Qo. AoDov-�,z - �tA - ot &-,i owner a Name q K�611i �-U&H New Renovation [I Replacemera Plans Submitted:, Yes [I No WPM Check one: Certificate Inslaning Company Name_,Z�60ifg P U M 43 jat,, p Corp. Address 11 Partnership .0-Virm/co. Business Telephone Name of Ucensed Plumber or Gas Fitter ei-c INSURANCE COVERAGE: Check one I have a current liability Insurance Policy oir Its substantial equivalent. Yes El No 0 It you have checked yes. please Indicate the type coverage by checking the appropriate box. I : I A liability Insurance policy 0 Other. type of Indemnity L? Bond 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee, dggs not have the Insurance coverage required by Chapter 142 of the Mass General Laws. and that my signature on this permit application waives this requirement. c4ec)C�ne: ftr�ature �f 0-w-n—et -o-t -0jW5-ei1 Au ent Owner a Agent 11 I certify that ag of the details and Information I have submitted (or entered) In above application are true and accurate to the best of my k=ge and that an bing work and Installations performed under the ad for this application will be In compliance with all portinent provisions of IVSUMMassachusetts State Gas Code and Chapter 142 �rff=',=Sua, Type pf License: mber Title M -A Ngnature of Lkensed Plumber or Gas FilFe—r /Town Master License Number .2 Joumeyman Ty 111OVED (OFFICE USE ONLY) WPM 111ITIM-7-77MM Mon NNO NNNN Mr=1NMNN ENNEM NNNNANNUMMMMM H., MM NNNN NNNNN NNNONNNNNNOM no A INAMMEMNARM NNNNARMAININNE101"Nom MOVERMANNAM am MAN NNAMEMENAM NNONNOMMON NNNENNNOMENNNNNON NERNMAN 0 NARAINNINNINNINNIN 0 0 Non moon ININININ moons NMI —man U."Wil IMIKINNOMMMMMME IN -on Check one: Certificate Inslaning Company Name_,Z�60ifg P U M 43 jat,, p Corp. Address 11 Partnership .0-Virm/co. Business Telephone Name of Ucensed Plumber or Gas Fitter ei-c INSURANCE COVERAGE: Check one I have a current liability Insurance Policy oir Its substantial equivalent. Yes El No 0 It you have checked yes. please Indicate the type coverage by checking the appropriate box. I : I A liability Insurance policy 0 Other. type of Indemnity L? Bond 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee, dggs not have the Insurance coverage required by Chapter 142 of the Mass General Laws. and that my signature on this permit application waives this requirement. c4ec)C�ne: ftr�ature �f 0-w-n—et -o-t -0jW5-ei1 Au ent Owner a Agent 11 I certify that ag of the details and Information I have submitted (or entered) In above application are true and accurate to the best of my k=ge and that an bing work and Installations performed under the ad for this application will be In compliance with all portinent provisions of IVSUMMassachusetts State Gas Code and Chapter 142 �rff=',=Sua, Type pf License: mber Title M -A Ngnature of Lkensed Plumber or Gas FilFe—r /Town Master License Number .2 Joumeyman Ty 111OVED (OFFICE USE ONLY) 0 C) )I. (A V rn 0 -A 0 0 31b m m 33 0 0 z rn 33 0 0 z 33 0 z rn I- 0 74 r" -4 c 0 (A a m 0 0 z r 33 0 Date. /�?.- ��. -. .0-?-. . . 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies thaf—:-�� ep If4 has permission for gas installation .................. in the buildings of ................. at North An!�qver, Mass. Fee,��...� Lic. No��Z-AS/7. GASINSPECTO Check # 4182 MASSACHUSEM uNIFORm AppucmoN FoR PERmrr To DO GAS FTrrING (Type or print) Date 3Q) (5�\ 0& NORTH ANI)OVER, MASSACHUSETTS Buildin Loc-ations Z, Z, 9 Permi # Owner's Name Amount $ New 0 Renovation 1:1 Replacement Plans Submitted (Printpr t?AXe Name- I Addriss 1-,D�Twq Q�0- S, 1-\� C)'\L'1112a Business Telephone Name of Licensed Plumber or Gas Fitter CJL%k one: Certificate Installing Company - bi Corp. ElPartner. 0 FirrrdCo. INSURANCE COVERAGE Checkbe: Y. I have a current liability his Ii or it's substantial equivalent. es Prance PO ICY N.0 Ifyou have checked M ple4e indicate the type coverage by checking the appropriate box. Liability insurance policy T�j Offiff type of indemnity 0 Bond Owner's Insurance Waiver I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this'requirement Check one. Signature of Owner or Owner's Agent , Owner Agent i hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations petformed under Permit Issued for this application will be in 1h compliance with all pertinent provisions ofthe Massachu State Codeand Q apitf 142 of the General Laws. C111sr lk�5 — I OVED (OFFICE USE ONLY) Signature ofl R-ensed Plumber Or Gas Fitter Plumber -Sc) -3 S Gas Fitter License Numberr Master Journeyman �2ND. FLOOR 13RD. FLOOR M ITH. FL4DOR 16 T A. FLOOR (Printpr t?AXe Name- I Addriss 1-,D�Twq Q�0- S, 1-\� C)'\L'1112a Business Telephone Name of Licensed Plumber or Gas Fitter CJL%k one: Certificate Installing Company - bi Corp. ElPartner. 0 FirrrdCo. INSURANCE COVERAGE Checkbe: Y. I have a current liability his Ii or it's substantial equivalent. es Prance PO ICY N.0 Ifyou have checked M ple4e indicate the type coverage by checking the appropriate box. Liability insurance policy T�j Offiff type of indemnity 0 Bond Owner's Insurance Waiver I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this'requirement Check one. Signature of Owner or Owner's Agent , Owner Agent i hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations petformed under Permit Issued for this application will be in 1h compliance with all pertinent provisions ofthe Massachu State Codeand Q apitf 142 of the General Laws. C111sr lk�5 — I OVED (OFFICE USE ONLY) Signature ofl R-ensed Plumber Or Gas Fitter Plumber -Sc) -3 S Gas Fitter License Numberr Master Journeyman Date. ....... TOWN OF NORTH ANDOVER i9p PERMIT FOR PLUMBING This certifies that ............... ....... ............. has permission to perform .... . ... �./ ......... plumbing in the buildings of"7?�'. .1� ................ North Andover, Mass. ............ Fe Lic. No.'. .2�. Check # PLUMBIN"I SPECTOR 5036 JVLA-SSACHUSEITS UNIFORMAPPLICATON FOR PE Rfvffr TO DO GAS FYPIING �T pe or print) Datt>x,0 DI NORTH ANDOVER, MASSACHUSETTS Building Locations asQ) 17,� *�', � Permit 9 C5Z& (61 Owner's Niame Ne4s Renovation Replacement F� - Amount S S >—' V Plans Submitted Ckleck one: Cert Insralling, Company (Print or GC IT -1 Niame Corp Address Partner. Firm/Co. Business Telephone Name of Liccnsed Plumber or Gas Fitter INSUR,ANCE COVERAGE .. Chec! I have a current liability Insurance policy or it's substantial equivalent. Yes If vou have checked ves, ple�§�indicate the type coverage bv checkin- the aDpropriate box - Liability insurance policV E9 Other type of indemni ry e: No ID Bond F7 Owner�s Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the tMass. General Laws, and that my signature on this permit application waives this requirement. Check one: Sianacure of Owner or Owner's Agent Owner Agent I herebv cL--,iif,/ that all of the details and information I have submitted (or entered) in above application are true and accurate to the best ot'my knowledge and that all plumbing work and installations pertbrmed under Permit Issued ror this application will be in comphanc�� with all pertinent provisions oftheMassachuserrs State Gas Code an hapt 142 of the General Laws. <z7—,> — � �� . - � By: Title CityiTown �kP P P )N1,Y) 0VED ((w�ic;, ()s�� T I SiQnature oFL1c,_�nsed19*Amber'0r Gas Firter Plumber 3a, 13—S Gas Fitter Tic_ -rise j\4umot--- ivlasi(f� Joumeyman F Ckleck one: Cert Insralling, Company (Print or GC IT -1 Niame Corp Address Partner. Firm/Co. Business Telephone Name of Liccnsed Plumber or Gas Fitter INSUR,ANCE COVERAGE .. Chec! I have a current liability Insurance policy or it's substantial equivalent. Yes If vou have checked ves, ple�§�indicate the type coverage bv checkin- the aDpropriate box - Liability insurance policV E9 Other type of indemni ry e: No ID Bond F7 Owner�s Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the tMass. General Laws, and that my signature on this permit application waives this requirement. Check one: Sianacure of Owner or Owner's Agent Owner Agent I herebv cL--,iif,/ that all of the details and information I have submitted (or entered) in above application are true and accurate to the best ot'my knowledge and that all plumbing work and installations pertbrmed under Permit Issued ror this application will be in comphanc�� with all pertinent provisions oftheMassachuserrs State Gas Code an hapt 142 of the General Laws. <z7—,> — � �� . - � By: Title CityiTown �kP P P )N1,Y) 0VED ((w�ic;, ()s�� T I SiQnature oFL1c,_�nsed19*Amber'0r Gas Firter Plumber 3a, 13—S Gas Fitter Tic_ -rise j\4umot--- ivlasi(f� Joumeyman IP TOWN OF NORTH ANDOVER PERMIT FOR WIRING "19 Thiscertifies that ............................................................................................. has permission to perform ........................................... wiring in the building of atr—P.Jb 4W Lic. No. Check # -6-,9 3AZi 5871 North Andover, Mass. ................ ELEcTRicAL INSPECTOR 0 Q Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. %6�0 7/ Occupancy and Fee Checked �"- 11/991 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (K), 5,7J2P 0�0 771�70X (PLEASE PRINT IN 17VK .R T AL qFORUI Date: City or Town of. &WA_�,o the Inspector of Wires: By this application the undersign fdgives notigA of hi or -her intention , perfioUn he electrical wg_�k described below. Location (Street & Nun,*er) A -d zip Owner or Tenan$—//0/o_p Telephone No.qyy- V�51,0015_ Owner's Address -7. Is this permit in -conjunction with a buil,din '.Yes E] No (Check Appropriate Box) g permit? Purpose of Building Utility A*Iuthorization No. Existing Service Amps i Volts Overhead Undgrd No. of Meters New Service Amps Volts OverheadEl UndgrdD No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Installation of Security system rt I- l`,17_-;- f -M, —, I- -_;-_,4 7— 1 - r_-_ _r No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of 7rofal Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool _Xb—ove EJ In- -1 grnd. grnd. F `370--.01 Emergenc3,17ighting Battery Units - No. of Receptacle Outlets — No. of Oil Burners FIRE ALARM o. of Zones No. of Switches No. of Gas Burners 75-751 Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump I.Number Tons KW No. of Self -Contained Totals: I Detection/Alertin2 Devices No. of Dishwashers Space/Area Heating KW Local El Mun'c'P�l 0 Other I Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equi alent No. of Water KW NO. —of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hvdromassage Bathtubs No. of Motors Total HP Telecommunications Wir�rlg: No. of Devices or Equivalent OTHER: Attach additional detail �/ desired, or as required b , y the Inspector oJ Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE El BOND F]" "OTHER F� (Specify) (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under thepains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: ADT Soc�lgity Sep�gicas 12 Cjif�+An nr� Hol I i NLU_ LIC. NO.: 1 1LU49 Licensee: John S. Bassett _ Signature LIC. No.: 1533C (Ifapplicable, enter "exempt" in the license number line) Bus. Tel. No.: 603 594 SU28 Address: Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that t�e Lidg.hsee 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) EJ owner 0 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ _n �11 Date.... ............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .. �:z.lj-. ............................................ has permission to perform ...... ........................................... wiring in the building of �/ ...... ... ............................................. at c ............................................... ..... e ... 1�- . . . X. �. North Andover, Mass. Fee6.6 .. Lic. No. /6 ......... .. ..... ................. ............................. ELECrRICAL INSPEcrOR Check # 4576 a Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked -115 [Rev. 11/991 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be perfonned in accordance with the Massachusetts Electrical Code (MEC), 52 CM7 12.00 (PLEASE PRINT IN 17VK OR IT ALLINFOPWATION) Date: 7� City or Town of. —tk TO the —Inspectb: of'Wires: By this application the undersigne ae,,,E�v.es n24MHs 0 er intention to per-form,!pe - rp , , J f lectrical work described below. Location (Street & Owner or Tenant Owner's Address Telephone Is this permit in conjunction with a building permit? Yes El No ff (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service - Amps Volts Overhead [I Undgrd Ej No. of Meters New Service Amps Volts Overhead El UndgrdE:l No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Installation of Security system Comnletion ofthe fn1lowinp, tahli, mnv hp wniwd hy the In —artne nt'W;,o, No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above Ei In- arnd. grnd. - ot Emergency Lighting Battery Units - No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS of Zones No. of Switches No. of Gas Burners No. of Dete Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pu p Totamls: [Number Tons I �KW I No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local F� Municipal r-1 Other Connection No. of Dryers Heating Appliances KW —f Security Systems: No. of Devices or Eguivalent No. of Water Heaters KW NT 0 No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent ydro .No. Hvd massa -e Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail ifdesired, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [-] BOND [:1 OTHEREI (Specify:) (Expiration Date) Estimated Value of Electrical Work: �42 *91 (When required by municipal policy.) Work to Start: " uj,� Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under Wpaing andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: Licensee: John S. Bassett _ Signature.JYL f (If applicable, enter "exempt "in the license number line) ff-7'� Address: OWNER'S INSURANCE WAIVER: I am aware that the Li*see does required by law. By my signature below, I hereby waive this requirement. Owner/Agent Signature Telephone No._ LIC. NO.: I r ,,I _I (�- LIC. NO.: 1533C Bus. Tel. No.. 603 594 5928 Alt. Tel. No.: not have the lia&ffiy insurance coverage normally I am the (check one) E] owner EJ owner's agent. F—ERMIT FEE. $ Location -2 Od No. S _;� Date Tpf TOWN OF NORTH ANDOVER 0 0 40 Certificate Occupancy 4L of $ ACH Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ CA � t-� Check # lVt,A ( 16593 --"Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERNUT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/IRT&tor of Auddings Date SECTION 1- SITE INFORMATION 1.1 Property Address: &e r2 9 - 1.2 Assessors Map and Parcel Number: 2 9 D/ - C;� ' Number Parcel Number U - I -P IVC) ia P 062 V R -,Z Adn -0(&Vr 1.3 Zoning Information: Zoning Didrkt Proposed Use 1.4 Property Dimensions: Lot Area (4) Fr-tage (ft) 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide Required Provided Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public 0 Private 0 Zone --- Outside Flood Zone 0 1.8 Sewerage Disposal System: municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT Historic District: Yes —.-,No r2. 0 er of Record �-/EtZA/ /- L)"w 2- Y -v Aq A, &,-,Ae Name (Print) Address for Service (? -?S-oot Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensedc-onstruction Supervisor: Licensed "truction Supervisor: Address Signature Telephone Not Applicable 0 License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable 0 Company Name Registration Number Address Expiration Date I Signature Telephone Ma M z 0 0 M 0 z M 90 0 mn M z G) I SECTION 4 - WORKERS COMPENSATION (MG.L. C 152 6 25c(6) I Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes ....... 0 . No ....... 0 SECTION 5 Description o ProRosed Work (check appUcable) New Construction 0 Existing Building 0 Repair(s) 0 f"'Ite rations(s) 0 tion 0 Accessory Bldg. 0 Demolition 0 Other 11 Specify Brief Description of Proposed Work: 4- Ee_,� Le L, i SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Colnpleteoy permit applicant -'�.0FFTCIAL1USE"" 1. Building V (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction L3 3 Plumbing Building Permit fee (a) x (b) -4 Mechanical (HVAC) -5 Fire Protection 6 Total -(1 +2+3+4+5) 14 Check Number 14 SECTION 7a OWNER AU' "�RIZATION TO BE COMPLETED WHEN OWNERS ENT OR C�;IORA!VTOR APPLIES FOR BUILDING PERMIT , 51�"Z__ , as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/A 4 ent Date -NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS I ST 2 ND 3 RD SPAN DINENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HE IGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHRANEY IS BUI1,DING ON SOLE) OR FILLED LAND IS BUUDING CONNECTED TO NATURAL GAS LINE Town of North Andover Building Department 27 Charles Street ACHUS North Andover MA 01845 Tel: 978-688-9545 HOMEOWNER LICENSE EXEMPTION Please print. DATE gZ rq lo 3 1 / -? 18 C) M'k R I A JOB LOCATION Number "HOMEOWNER S Number PRESENT MAILING ADDR City Town Address Home Phone State 8ection-of Town Work Phone Zip Code The current exemption for "homeowners* was extended to include owner -occupied dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 109.1. 1) DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one to six family dwelling, attached or detached structures ac- cessory to such use and and/or farm structures. A person who constnxts more than one home in a two-year period shall not be considered a homeowner. Such "homeowner* shall submit to the Building Official, a form acceptable to the Building Official,.that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned "homeowner' assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that he/she understands the Town/jf No. Andover Building Department minimum inspection procedures and requirements that he/she will comply with said procedures and requirements. Z7, )p HOMEOWNER'S SIGNA APPROVAL OF BUILDING OFFICIA Note: Three family dwelling 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127.0 Construction Control. NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM in accordance with the provision of MGL c 40 S 54, a condition of Building. Permit Number rom this work shall be disposed of in properly that the debris resulting f licensed solid waste disposal facility as defined by MGL Chapter I 11, S. 150 A. The debris will be disposed of in: 1,J ct"i -fe mi�i . (A a (Location of I Signature of Permit ant �,/, C,- (wt4 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector U) m m M m m m C/) m Cl) 0 m ce cr vi C3 CD = 3*098 im Co C-5 CL C.) m z Ir's. can CL CD CO2 CD ago 1-4 0 CD CO CO) C.) 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