HomeMy WebLinkAboutMiscellaneous - 281 MAIN STREET 4/30/2018/ �
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I I
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Thiscertifies that ........ ..................................... e . ....................................................
... ......... .. ..... ....
has permission to perform ......... d ..... t! .... 7 ...... n..
. .. ......
wiring in the building of ....... ...........................................................
0 2el 4�� . ................................... ......
at ... I .......... North Andover, Mass.
. ................................ ...........................................
-4e.AY.'_6 LIC.
.............. ................. ................. .. ... . .. Z . .. ........
AE 'INSPECT
Check # 5 D
1321 F.
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
- 7
PermitNo. 1 )7,4-, V
Occupancy and Fee Checked
tev- 1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00
(PLEASE PMNTINMK OR TYPEALL JNFORMATION) Date:
City or Town of.- NORTH ANDOVER, To the Inspector of Wires:
By this application the -undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 2-'91 MAHA) 6r
Owner or Tenant beteet- wessej Telephone No.
Owner's Address 2-91 MA410 57 -
Is this permit in conjunction with a building permit? Yes No (Check Appropriate 13ox)
Purpose of Building i6g, Utility Authorization No.
Existing Service 2�DO Amps 12-0 /2-qL) Volts Overhead 9 Undgrd [:1 No. of Meters
New Servic — Amps Volts OverheadF] UndgrdE] No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: WI&68 6A1z4q6 f pool A00AJ W0A- OU?WS
Comnletion ofthe following table ma -v be waived bv the InsDector of Wires.
No. of Recessed Luminaires
No. of Cefl.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above Ei In- El
grnd. grnd.
No. of Emergency Lighting
Battery Units
o. of Receptacle Outlets /5-
No. of Oil Burners
FIREALARMS
lNo. of Zones
No. of Switches
No. of Gas ]Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
A!yAl e r
I Tons
[ ..........
I KW
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local El Municlp�l El Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Eauivalent
JOTHER:
L—
Attach additional detail ifdesired, or as required by the Inspector of Wires.
Itimated Value of Electrical Work: c9W)'-- — (When required by municipal policy.)
WorktoStart: q-7- / Inspections to be requested in accordance with WC 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 operatioif '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.
CBECK ONE: INSURANCE [N BONDE] OTBER n (specify:)
I certify, under enalties ofterjury, that the information on this application is true and com lete.
th=dp P
FIRM NAME- LIC. NO.: iq At(43.5
Licensee: _JZWJ4 /Y)Lm1Z- Signature jQaA4L �M 09J� LIC. NO.: F--.32-20 1
ffapp7lcable, enter "exempt" in the license number line) Bus.Tel.No.:6017 (0A -7M
Address: 3S Omldmj ST !�0M-QJW&_ PAA- 02-14T- Alt. Tel. No.: & Q - W2 -5
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) D owner 0 owner's agent.
Owner/Agent CM
Signature Telephone No. PERMIT FEE: $ Y 4 — ]
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the -provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
El The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing An automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending -through August 15, 2012.
0 Rule 8 — Permit/Date Closed: Note: Reapply for new permit 0
0 Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass EN
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass [N
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
PARTLAL ROUGH INSPECTION:
Pass n?
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH JNSPE�TIQN:
Pass M <
Failed
Re- Inspection Required 0
Inspectors Compaepts:
1V__ A—
Inspectors Sign,ature:
Date:
FINAL W.'"ON:
Pass T -f tl,( Y
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
__14
The Commonwealth ofMassachusetts
Department of IndustrialAccidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERNUTTING AUTHORITY.
Applicant Information Please Print Legib
Name (Business/Organization/Individual): M002 -
Address: 33 RIOAL."111AJ 1�lr
City/State/Zip: A Wr 021W3- Phone#:
Are you an employer? Check the appropriate box:
LF] I am a employer with _-9, mployces (full and/or part-time).*
2Q I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.f_1 I am a homeowner doing all work myself [No workers' comp. insurance required.] t
4.FJ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5.F] I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have Workers' comp. insurance. t
6. F-1 We are a corporation and its officers have exercised their right of exemption per MGL c.
152, § 1(4), and we have no einployees. [No workers' comp. insurance required.]
Type of project (required):
7. F1 New construction
8. Remodeling
9. Demolition
10 Building addition
I I. E] Electrical repairs or additions
12. �J Plumbing repairs or additions
13. E] Roof repairs
14. R Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their 'workers' comp, policy number.
I am an employer that is providing workers' compensation insurancefor my employees. Below is thepolicy andjob site
in rmation.
Insurance Company Name: AggULI& qNsvr
Policy # or Self -ins. Lic. #: Expiration Date: /(—/S—
Job Site Address: 2-51MI4&j Sr /JY)14 /47&M e4 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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certTy under thepains andpenalties ofperjury that the information provided above is true and correct.
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
-S-15-
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perforinance 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 requ I ired to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
OF
02145-32
Date... .................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
has permission to performl/A P ... A�-f ..... . . .............
wiring in the building of
atO(P....... ... ... ........................ . X -o
V . . . .................... _�h Andover Mass.
Fet ... `� Lic. NO3-27.Q.�
hTRICAL INSPECTOR
L, E*'C'*'
Check#
12779
-4
10
1% <L
Commonwealth of Massachusetts OfficialUseOnly
Permit No,
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS
I[Rev- 1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code WC), 527 CMR 12.00
(TLF-4SEPNNT1NNK OR TYPE ALLMFORIMTION) Date: /0 —I—tq
City or Town of: NORTH ANDOVER To the Inspector of Wir�s:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
T 44 JD- Wr lk -701 M A i A I C'
xjua on kOLred Um el) I I /
Telephone No.
Owner or Tenant 199 9 /)7/ZS i
Owner's Address 2-T / MA11V �71
Is this permit in'conjunction with a building permit? Yes No N (Check Appropriate Box)
Purpose of Building 1--bu.�& Utility Authorization No.
Existing Service 200 Amps /AL) / ac4o Volts Overhead 21 Undgrd [j No. of Meters
New Servic Amps Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
ID. u d Qj & 6 TMA -74 11 2 17106
OverheadEl Undgrd F1 No. of Meters
1AJ
ofthefollowing table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. o Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
SwimmigP,.l Above Ei In-
grnd. grnd. El
-No. of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
JN'o. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat pump
Totals:
Number
...........................
I Tons
I .........................
I KW
I .......................
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
LocalEl Mun'c'PP' n Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water,
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
. No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
-7-
Attach additional detail i,,4,sire,7 or as re uIred h- the T—ector nf 97res.
Estimated Value of Electrical Work: #16bb _ (When required by municipal policy.)
Work to Start: lc-)-t-t4 — Inspections to be requested in accordance with NIEC Rule 10, and upon completion.
INSURANC 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 operation7' 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.
CBECK ONE: INSURANCE KI BOND 0 OTBER El (Specify:)
I certify, it n der th e p a ins an d p en a Ities ofp erjury, th at A e info rm ation on Ili is app fication is tru e an d com
,plete.
FIRMNAME: ()�OW2- LIC.NO.: AA/0,5-
Licensee: �JOSF,,Pg 1Y)L)tl 12,_ Signature qVLgCA AVIP!n8 LIC. NO.: E,3,Z,;LO
(Ifapplicable, enter "exempt'in the license number line.) Bus.Tel.No.:
Address: 33 tjjAJ J7 SoaLLjM)1,e A4 0,;214S' Alt. Tel. No. -617-,W2 C?
*PerM.G.Lc. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. -
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) [I owner [I owner's agent.
Owner/Agent I
Signature Telephone No. F� FEE.- $
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
0 Rule 8 — Permit/Date Closed: Note: Reapply for new permit 0
0 Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass
Failed
Re- Inspection Required 0
Inspectors Co�nments:
r )_ -
- . 1
-4
VMU�x
/0-7�/Y
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass
Failed
Re- Inspection Required 0
Inspectors Comments:
tp
Inspectors Signature:
Date:
PAP,TL4,L ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPF,�CTION:
Pass
Failed
Re- Inspection Required El
Inspectors CorpffTnts:
Inspector; Signature:� V
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
The Commonwealth ofMassachusefts
Departmintoflndustriql,4ccid�nts
Office ofifivesfigations
6#0 Washington Street
Boston., MA 02111
www.mass.gov1d1a
Workeys' Compensation bsurance Affidavit: BuUders/Contractors/FIectri.clansmliimbers
A Please. Pr Le
ppReant Information
'NaMe CBusin�ss/Organizationftdividual): QAJ 1,12
Address: 33 r*�/?/WV)/�J JT*
City/State/Zip: M4bZ145 PhoneM (_yt1-(P2_9—'7936
Are you an employer? Check the appropriate box.
Type of project (required):
1. 1 am a employer with V.-
4. El I am a general contractor and 1
J New cOnstraction
6, F
empl ces (fall and/or part-timc).*
OY
2.E1 I am a sole proprietor or Partner-
have lifted the sub-Gontractors
listed on the attached sheet.
Remodeling
ship and1ave no -employees.
These sub -contractors have
Demoliflon
-1
worling for me in any capacity.
workers 2 comp. insurance.
9. E] Building addition
[No workers' comp. insurance
5. El We area corpora�on and its
ME . I Electrical repairs or additions
required.]
3. El I am a hoineowner Aing all work
officers have exercised.their
right of exemption per MGL
1
11. [] Plwnbing repairs or additions
mys OM [No workers' comp.
c. 152, §1(4), andwehaveno
12,Q Roofrepairs
insurancereqaired.]
employe6s. LN6 worken'
13F] Other
conip, insurance required.]
xAnyapplicant that diecksboxfif must also fiU out the seegoaboldwsho-wingtheirwbrkers' compensation policyinfonnation.
T-HomeownerswIlo submitihis affida:vitiadlca>heyaiedgingallworMand then hire outside contractors mustsubmit anew affidavit indicatifigsuch.
tContractors that checkthis box must attached an 4dditionalsheetslowing the name of the sub -contractors and their workers' comp.policyinfonnation.
I am an employer that isprovidhig workers'comquensallon insuraneeformy employees. Below is thepolley andjoh site
infoimallon.
lusurance Company Name:. oa s u rum c-p—
Policy # or S elf -ins. Lir, ff: Expiration D ate;
Job Site Address, - 0 Z_13 t N 51- Pity/State/Zip: Pao, amJ00'ez
Attach a copy oftlie workers' compensation-polley declaration page (sliowing the policy number and expiration date).
Failure to secure coverage.as req� Aedunder Section 25A of`MGL o. 152 can lead to the imposition oferinikal penalties of a
Ae up to $ 1,50 0,0 0 and/or 0'ne�-Year implis onment, as wellas civil penalties itt the form of a STOP. WORK ORDER and a f1he
of up to $250.00 a day against the violator. Be advised ffiat a copy of this statement maybe forwarded to the Office -of
Investigations of the DIA for ibsurance, coverage verification.
I do hereby eerfljy under Alep'ains andpenaftles ofperjury tIzat Me information provided above is true and eorrec4
R40Mn-hirt-.. (^Yno OA" 0M Date: to ---� 1 —1(4 -
Phone#:
Off,7cial use oply. Do not write in 01S area, to he eoinp7eted by cliov or town official
City or Town:
Penult/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. Cllyffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contactrerson:
Phone 9:
Information and Instrnetions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursua�t to this statute, an employee is defined as every pers on k the service of another under any cojitract of him,
express or implied� oral or written."
An employdis defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the f6r6joiftj engaged in ajoint enteiprise, and including the legal representatives of a -deceased omp! y
receiver or tn'is'tc� of an individual, partnership, askciation or other legal entity, employing employees. 0 � g, or the
owner of a dwalIffig househaving notmore than three apartments and who resides therein, or the occupant of tha
dwelling house of another who employs persons to do maintenance, construction or repair workon 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 lie-enshig 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 tile insurance coverage required?'
Additionally, MGL cha�ter 15�, §25C(7) states'Neither the commonwealth nor any of its political sub6i'sions shall
enter into any contract for the performance ofp-ablic work until acceptable evidence of complianco with the insurance
requirements of this chapterhave beenpresentedta the cQntracting authority."
Applicants
Ploasro.fill out the workers, compensation affidavit completely, by cheoldng the, boxes that apply to your shation and,
if
jiecegsarY� supply sub-contractor(s).name(s), addross(es) andphono munber(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with -no employees other than the
members orpartners, arenotreqairedto canyworkers, compensation insurance. If auLLIC orLLP doeshavo
employees, a policy is required. Be advised thatthii affidavit maybe submitted to
theDepartmentof I
Accidents for confirmationofinsurance coverage. Also be sure to sign and date the affidavit. !he affidavit should
be returned to the city or town that th6 application for the permit or license is being requested, not the Dep'artment of
bdustrial Accidents. Should you have any questions regarding tho law or if you are required to obtain a *orkers,
col�pensatlonpolicy, 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 andpriated-legibly. Tho Department has provided a space at the bottom
of the affidavitforyou to fat out in the event the Offf cc of fuvestigations has to contact you regarding the applicant.
Pleas ' e be -sure to fill iu the, parmit/11censo number Whichwill be used as a reference number, InadditionanappEcant
that must subn-dtmultiplo permit/lica.me, applications in any given ye'ar, need only submit one, affidavit Indicating cun6.nt
policy information (ff necessary) and under "Sob Site Addrese'the applicant should write "A locations in (city or
toW�). A: 6py of th o affl d avit th at has b cen o ffl Gi ally s tamp a d or m arke d by Th a city or town m ay b a pro-�ded —to ihe'
applicant as proof that a valid affidavit -ii on file - for future permits or licenses. Anew affidavit m�st be, fuleLd out each
year. Vhere a home owner or citizen is obtaining a license or -permit not related to any business or commercial venture
(i.e. a dog license orpiermit to burn leaves eto.) said person is NOT required to complete this affidavit.
The office ofInvestigations'would like to thank you in advance for your cooperation and sh(?uldygu have any estjo�s,
please do not hesitate to give us a call.
The Department's address, telephone and. faxnumber:
The C=Aon-w. oaM of A4
_p s s 9� ( ,hv. � e,,t -
.tq
D_ eparbout Qf Indug
Val Acoldenta
Me 0:CJAYP-sffgatj()A,%
60 WAingtoe Stod
B oston, MA 02111
TO, 0 61M27,4900 QA 406 or 1-877,�UAS
Revised 5-26-05 Fax 0 617-727-7749
_WWm=.W.,gQV/(Ra
31 /1 Is
�9�
TH OF
Date.Qh.�/-/.6 ....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that..&,# 41 -3- L ---,l
.......................................... ..................................
has permission to perform .... &- .... V .
. .... .. 7 .......
wiring in the building of ......... Z?e.-
.......................................
at -4'241,oe2 h Andover, Mass.
................................................................ ....................................
CTRICAL IN S OR
Fee .... .............. Lic. No . ................. ....................... ELE
Check
13 11 '31 IP5
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use 0 1
Permit No. 1 _29- 11 �
Occupancy and Fee Checked
,[Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code WC), 527 CMR 12.00
(PLEASE PRINTININK OR YTTEALL INFORMATION) Date: � I 1 -7
City or Town of: NORTH ANDOVER To t0nspector 'of Wires:
By this application the undersigned ives notice of his or her intention to perform the electrical work described below.
Location (Street & Numbei _ 9 1 MAi tj .5 -�
Owner or Tenant
Owner's Address -> A 64
Telephone No.
Is this permit in"conj unction with a building permit? Yes R"_ No F1 (Check 'Appropriate Box)
Purpose of Building ,0Ujt_11j,/\Lj Utility Authorization No.
Existing Service 00 0 Amps 0 Volts Overhead [q Undgrd D No. of Meters
New Servic Amps Volts Overhead [] Undgrd [I No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: A CkA A:- flN ro o.,n ., _11V 13cooT, Ukk4v revek
_aA. SA4�) COC�
Comnletion ofthe following tahle mav he waived hv the InsDector of Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above Ei In-
Swimming Pool d. grnd. El
gry.
0-0 'Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gns Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
I Ny.!A�.tLFPM
I
I
.]m ...........
...........
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local Ei Municippl Ei other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs - Ballasts
Data Wiring:
No. of Devices or Equivalent
-No. Hydromassage Bathtubs
No. of Motors Total IP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
4 Attach additional detail ifdesired, or as required by the Inspector of 97res.
Estimated Value of Electrical Work: (When required by municipal poEcy.)
Work to Start: Inspections to be requested in accordance with NIEC Rule 10, and upon completion.
INSURANCE CbVERAGE: 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 operatioif' coverage or its substantial equivalent. The
undersigned certifies that such coveggelis in force, and has exhibited proof of same to the permit issuing office.
CBECK ONE: INSURANCE W BOND F1 OTBEREI (Specify:)
I certify, under th
,!�.pains andpenalfies ofperjury, thattheinformation on this application is true and complete.
FIRMNAME: M0(02 LIC. NO.:
Licensee: au � Te( C�%� 4 Signature_&,,��_ Xz- LIC. NO.: 112 9
(Ifapplicable, enter "exem t 11 1 - n the license number line) Bus. Tel. No
Address: ;3 04, S + Alt. Tel. No.:
*Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) [I owner El owner's agent.
Owner/Agent
Signature Telephone No. PPMHT FEE.-$ 1-07
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance-mith the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G1 c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of eithef the owner or the installing entity stated on the permit application.
El The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending*through August 15, 2012.
0 Rule 8 — Permit/Date Closed: Note: Reapply for new permit 0
0 Permit Extension Act — Permit/Date Closed:
Ar
Trench Inspection
Pass F?1
Failed M
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass n?
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
PassK
Failed
Re- Inspection Required 0 0
Inspectors Comments ------- �,
Z
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass IN K
Failed
Re- Inspection Required 11
Inspectors CommeyA-N
Inspectors Signature.
V W V VW
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
71
The Commonwealth ofMassachuseffs
-Departine-ntoflndusftiqlAccidi�ts
Office of Invesfigations
600 Washington Street
Boston., MA 02111
wvw.mass.gov1d1a
Workers' Compensation Imurance Affidavit: BuRders/ContractoroMi
AnDlicant Information
Name CBusiness/Oxganizationftdiyidtial)' - . . I - .
Address:
City/State-01): Phone
Are you an employer? Che& the appropriate box: Type of project (required):
El I am a employer with 4.El I an a general contractor and 1 6. E] Now construction
employees (fall and/or put -time).* have no d the, sub -contractors
2.E1 I am a solD proprietor or partner- listed on the attached sheet. 1 7. EJ Remodeling
ship and'lavano.employees These sub -contractors have 8. E] Demolition
workers' comp. insurance
worldng formoinanycapacity. 9. E] Building addition
[No workrors' comp. insuranco 5. F1 We are a corp ora�on and its ME] Electrical rep&s or addition . s
required.] officers have exercised.their
3. 1 am a homemmer ping all work right of exemption per MOL ll.E1 Plumbing rep&s or additions
MYS (Fowgrkers"Goinp., c. 152, §1(4), andwahaveno 12.Q Roof repairs
insurancereauired.1 employe6s. [No workers'
i3l] other
comp, insurance required.]
?Any applicant that che" box #I mustali0fill but the section bBldw showing their Workers' compensationpoliq infonnation.
I Homeowners who submitihig affidavit indicatingtfiqYk� doing allworMand then hire outside contractors mustsubmit a now affidavit indicatifig6hoh.
TContractorsthat check this box mustattached m,9dditional sheet showing the name of thosub-contractors and their workers' comp.polloyinforniation.
I am an employer that isproviding workers'compensation hisuranceformy employees. Below isthepolley andjoh site
infomation.
lasurance Comp my Name:
Policy # or Self -ins. Lic. ff: ExplratioiiDate:
lob Site Address Pity/State/Zip:.
At&ch a copy oft4e workers' compensation-polley declaration page (showing the policy number and expiration date).
Failure to secure coverage.as reqy1redunder Section 25A ofMGL o. 152 can lead to the imposition of criminal penalties of a
LV up to$ 1,500.00 and/or o'ne"year imprisonment, as well -as civil penalties in the fbim of a STOP. WORK ORDER and a fine
of up to $250.00 a day against the wolator. Be advised that a copy of this statement may be forwarded to the Offico -of.
Investigatio-w oftho DIA for insurance, coverage verification.
.1 do hereby ce rtl_fy wider & e F'alns andv en aftles of p erjury th at th e information pro vided ab o ve is true an d correct.
Signature: Date:
Official use oidy. Do not write in this area, to be com
,pleted by clo or town official
City or Town: PermiMicense
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S.Flumbing luspector
6. Other
ContactPerson: Phone 9:
Information and Instructions.
Massachusetts General Laws chapter 152 reqi*os all employers to provide workers, compensation for their employees.
Pursua�t to this statute, an eni
,ployee is dofmod as "...overy person In the service of another under any cmitract of hire,
express or impH4 oral or written."
An employeiis defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the tbr4o�ij engaged in ajohit enterprise, andincluding the legal representatives of xdeceased9Xplo!y
V, or the
receiver oi ii�& of"an individual, partnership, askciation or other legal entity, employing employ6es. 116weverib.6
owner of a dwelling house having notmore than three apartments and who resides therein, or the oc9upant of the
dwelling house of another who employs poisons to do maintenance, construction or repair workon su6h dwelling house
or on the grounds or building appurtemant thereto shall not because of such employment be deemed to bean 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 re.quired:'
Additionally, MOL chapter 15 -2, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofp-ablic work until acceptable evidence of complipce with the insurance
requirements of this chapter have beenpresented to. the cQntracting authority."
Applicants
Pleaslo:fill out the workers' compensailon affidavit completely, by checking the boxes that apply to your situation and, if
n6cossary'� supply sub-contractor(s)name(s), address(es) and phononumber(s) along with their cortillcate(s) of
iusurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) Yvithno proployees other that the)
members or partners, are not required to cany workers' compensation insurance. If anLLC orLLP does have
employees, a policy is required. Be advised thatflii� affidavit may be submitted to the Department of Industrial
Accidents for conffiniationof insurance coverage. Also be sure to sign and date the affidavit. he affidavit should
be returned to the city or town that th6 applicatign for the permit or license is being requested, not the Dep'artment of
Ind-astrialAccidents. Shouldyou. have any questions regardiag the law or if you are requiredto obtain a*orkers'
coippe.nsationpoliGy, please call the, Department at the number listed below. Self -loured companies should enter their
self-Irtsurarica license number on the appropriate Eno.
City or Town Officials
Please be sure that the affidavit is complete, andprintedlegibly. 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.
Ploas,a bo -sure to fill in the pormit/lIcenso, number which will be) used as a reference number, In addition, mapplicant
thatmust submit multiple pormit/liconse applications in any glyon ye . ar, need only submit one, affidavit indicaft cun6nt
P olicy information (if necess my) and under "Job Site Address" the applicant should write "all locations in (CitV or
town): I A: &py of' the affl d avit th at has b e on off Wally stamp o d or m arked by the city or town may b o'prov-1dpd to the'
a pro permits or licenses. A now afff davit m�st b a fffleLd out each
pplicantas
year. Where a home owner or offizon is obtaining a license, oi�ormit not related to any business or commercial venture
(i.e. a dog license or�ermit to bum leaves eto.) saidporson is NOTrequired to complete this affidayit.
The Office of Investigations . would like to thank you in advance for your cooperation and shQuld yqu have any.quostio�8
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
Tho CQmm-. ow-roafth of Mo.=
.,�eutts
Dapartmmt of Tafttrial Accidents
ofte Qf 13RVQNt%a#0=
13 oston, VA 02111
Tel, # 617-72,7-4900 W406 ar. 1-877,:MM
Revised 5-26-05 Fax 0 617-727-7749
-wwwmaagov1dja
*;A4� 02141- 1 9q,f"
12 8 7 1 7 7 3 10 3 8
110 9 9
Date .... qY�1.
................
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
AliThis certifies that 0,.� .. CAW .. . ....... I .. ........................................................................
has permission to perform ......
..........
............................. ........ I ......
plumbing in the buildings of .......
.. .... .......................................................................
at ... ....... ....... . —c�- ... .. ......................... North Andover, Mass.
Fee.k�.�� . ........ Lic. No.'�.�,.� . .............................
PLUMBING INSPECTOR
Check #
k --I
(61P. V)A-
TYPE OR
PRINT
CLEARLY
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY MA DATE PERMIT#
JOBSITE ADDRESS OWNER'S NAME
OWNER ADDRESS TEL FA
OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
NEW: RENOVATION: REPLACEMENT:,21.*,- PLANS SUBMITTED: YES Ell NOE]I
FIXTURES'l FLOOR-
BSM 1
2
3
4
5
6 7
8 9
10 11 12 13
14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER.SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
F—I
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR / AREA DRAI N
INTERCEPTOR (INTERIOR)
I --J
KITCHEN SINK
-j --J=
LAVATORY
J. I
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET
I==
—J =j
-.-J F --j
URINAL
F -J
MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I h&Na current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES B -IN -0-0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 2—' OTHER TYPE OF INDEMNITYE11 BOND El
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.
CHECKONEONLY: OWNER F-11 AGENT IR -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 ance with al ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 701 M
PLUMBER'S NAME --]LICENSE# —SIGIMATURE
MP D1 JP Q-- 1 CORPORATION Fjl# PARTNERSHIPOU LLCU�L—
COMPANY NAME 1AP ��UMIS'%OG ADDRESS 1 &6\ <YNK' n S -Y
CITY STATE ZIP TELE'7§��'�
FAX CELL EMAIL
�11
\r
o r -I
z
LLI
Ix
Lii
uj
U-
N
e
% b
I
, 1, '0J
The Commonwealth ofMassa.chusetts
Department ofIndustrialAccidents
1 Congress Street, Suite 100
Boston, AM 02114-2017
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: BuUders/Contractors/FIectricians/Plumbers.
TO BE FILED WITH THE PERAUTTING AUTHORITY.
NaMe Q3usiness/Organization/Individual):
Address: (, _,)� aAq-y\e_� U
City/State/Zip;
Are you an employer? Check &e appriopriate box:
n
GO 0 Phone #: _)t� a03)
I.El I ap-a employer with - ...: Suiployees (full and/or part-time).*
2. Wam a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.E] I am a homeowner doing all work myself [No workers' comp. insurance required.] t
4.FJ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. 1 am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have e n ployees and have workers' coinp. insuranceJ
6. We are a corporation ' and its officers have exercised their right of 'exemption per MGL c.
152, § 1(4), and Nye have no efnploye9s. [No workers' comp. insurance required.]
Type of project (Tequired):
7. R N construction
8. [c?Remodelitig
9. Demolition
10 F1 Building addition
11. F1 Electrical repairs or additions
12.E] Plumbing repairs or additions
13. E] Roof repairs
14.F] Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t davit indicating such.
I Homeowners who submif Us affidavit indicating they are doing all work and then hire outside contractors must submit a new afff
$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-cofilraciors have! !employees, ifiey must provide their workeis' comp. policy number.'
a m an employer th at is providing workers' compensation insurancefor my employees.' Below is th e polky and)ob site
information.
Insurance Company Name: Rek-rP6 mo�oa�
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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby 7t nder thep alties ofpeijuiy that the information provided above is true and correct.
T)ate. 3
Phone #: �?<Zk 6'95--f Q03 )
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
Issuing Authority (circle one): 'I
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
911A
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract'16f hire,
expres's or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall.
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Ple�se fill- out the workers' compensation affidavit completely, by checking - the'boxes that apply to your situation and, if
necessary, supply sub-contractoi(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 citypr 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 re'qu#ed to obtain a workers'
compensation'policy, please call the Department at the number listed below. Self-iiisur6d companies should'enter their
self-insurance license number on the appropriate -line. -
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
poll' information (if necessary) and under "Job Site Address" the applicant should write "all locations in
cly (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
I 00A
Date.�.. ..... /X ... .... 13 .....
.. ... ..... .. .........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .... .......
has permission to perform .... !�� ... ............. t .........
wiring in the building of ......... A.1.0�...K-v.3 ... n ....................................................................
at..2,S'l . ............. �,-/ . . ................... . North Alndovef Mass.'4" -
....................
Fee...'O��. . .......... Lic. I Z,
Check 0 LECTMRtCAL INSP R
11657
(N
N Commonwealth of Massachusetts Official Use Only
Permit No.
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07)
(leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Cod 527 CMR 12.00
(PLEASE PRNT.TNNK OR TYPEALLHFORAMTION) Date: r. 714 - (,3
City or Town of.- NORTH ANDOVER To the Inspector of Wires:
13Y this application the -undersigned es notice of his or her intention to perform the electrical work described below.
Location (Street & Number)_
Owner or Tenant Telephone No. (v / -7
Owner's Address
Is this permit in conjunction with a building permit? Yes [Ir No F] (Check Appropriate Box)
Purpose of Building U) I rfrI5 Y &pn I k-% kL,�ej, Utility Authorization No.
Existing Service240 Amps ' /2J Ord'Volts Overhead [��UndgrdE] No. of Meters
Hew -Service Amps Volts Overhead El UndgrdF] No. of Meters
Number of Feeders and Ampacity /0 2-0 Avif 10
Location and Nature of Proposed Electrical Work: I/ dd� K14CJ-111L�A f ck�t��4
C'n Win, Mrfl- -ru,74—
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. o f
Transformers KVA
No. of Luminalre Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming pool Above M In- Ei
grnd. L -J Lyrnd.
No. of E—mergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE
0. of Zones
No. of Switches
No. of Gas Burners
f Detection 2Dd
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
..........
J.KW ........... 'No.
...........
of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local El municipp, ri Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
. No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total TIP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail ifdosired, or as required by the Inspector of 07res.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 7-�3-lnspections to be requested in accordance with NMC 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 in rance including "completed operatioif 'coverage or its substantial equivalent. The
undersigned certifies that such c ve e is in force, and has exhibited proof of same to the permit issuing office.
CBECK ONE: INSURANCE ;; �BONEDEI OTBER 0 (Specify:)
I certify, tinder thepains andpenalties ofperjury, that the information on this application is true and complete.
FIRM NAME:, -It *L, LTC. NO.: A IT,
C _Jlct
Licensee: Signature LTC. NO.: r
cc. -\U -S M4q:3,,-Z, !7 3 (V i -LI
(If applicabl "exeiwt" in the license number U e) Tel. No. --6,1 1! - IJ(d
Address: Fr c"kA S-0 7
*Per M.G.L c. 147, s. 57-6 1, security work requires Department of Public Safety "S" License': Lic. No.'.
insurance coverage normally
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability",
required by law. By my signature below, I hereby waive this requirement. I am the (che oRe) [I owner El owner's agent.
Owner/Agent
Signature Telephone No._ PERMIT FEE: $ Y3
0 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G1 c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act ftirthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
0 Rule 8 — Permit/Date Closed: Note: Reapply for new permit 0
El Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass R
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass M
Failed
Re- Inspection Required 11
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature: 1J9dr1*2Z1.Y
115.
Date:
ROUGH INSPECTION:' /
Pass n?
Failed
Re- Inspection Required ($.) El
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPECT ON:
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
A
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
1%
up
lcx The Commonwealth ofMassachusetts
Department of IndustriqlAccld&ts
Office of Investigations
600 Washington Street
Boston, MA 02111
www'.mass.govIdla
Workers' Compensation Insurance Affidavit: Builders/ContractorsfEle,ctriciansfrIumbers
Applicant Information Please Print Ledbly
NaMe (Business/Organization4ndividual):.
City/State/Zip: Phone #:,
Are you an employer? Check the appropriate box:
I - I am a employer with
4. El I am a general contractor and I
employees (fall and/or part-time).*
have hired the sub -contractors
2. El I am a sole proprietor or partner-
listed on the attached sheet T
ship and'have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' cornp. 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 p or MOL
myself. [No workers' comp.
c. 152, § 1(4), and we, have no
insurance required.)
employees. [Noworkers'
comp. insurance required.]
Typo of project (required):
6. F1 Now construction
7. rl Remodeling
8. E] Demolition
9. U Building addition
10.E1 Electrical repairs or additions
I LEI Plumbing repairs or additions
12.Q Roof repairs
1311 other
Mny applicant that checks box #I must also fill out the sectionbel6w showing their workers' compensation policy information.
T Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that isproviding workers' compensation insurancefor my employees. Below is thepolley andjoh site
information.
Insurance Company
Policy # or Solf-ins. Lic. 9: Expiration Date:
Job Site Address:
Pitylstate/Zip:
Attach a copy of the workers' compensation -policy aeclaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A ofMGL c. 152 can load to the imposition of criminal penalties of a
'fine up to $1,500.00 and/or on& -year imprisonment, as well as civil penalties in the fonn of a STORWORK 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 certio under thepains andpenalties ofperjury that the information provided above is true and correct.
Signature: Date:
Official use only. Do not write in this area, to he completedby city or town off7cial
City or Town: PermitUcense 9
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Persom- , Phone 9:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their enaployees.
Pursuant to this statute, an employee is defined as "....every person in the service of another under any contract ofhiro,
express or implied, oral or written."
An employeils defined as "an individual, partnership, association, corporation or other legal entlty� 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 local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor aiiy of its political subdivi ! sions shall
enter into any contract forthe performance ofpublic work until acceptable evidence of compliance withtho insurance
requirements of this chapterhave been presented to the contracting authority."
Applicalits
Please fill out the, workers' compensation affidavit completely, by checking the boxes that apply to 'our situation and, if
y
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If anLLC orLLP does have
employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirm�ationofinsurance 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 lice*ase is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Pleas * e be sure to fill in the pennit/license numberWhich will be used as a reference number. In addition, an applicant
that Must submit multiple permit/license applicationsI any given year, need only'submit one affidavit indicating current
policy information (ifnecessary) 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 fature permits or licenses. Anew affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or*permit not related to any business or commercial -venture
(i.e. a dog license or p*'ermit to bum leaves etc.) said person is NOT required to complete this affidavit.'
The Office of Investigations'would Me 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 Commo.UwDalth of Massachusetts
De-partmeut of Industrial Accidonts
offke ofluvestigatiou
600 WasMooji Str��t
BosfuMA02111
Tol, # 617-727-4900 (3ya 406 or 1-877-MASSAFF,
Revised 5-26-05 Fax # 617-727-7749
XVV1rW M.9.R.Q CrAvIA-19
Division of Professional Licensure: License Search
'rhe Official Website of the Office of Consumer Affairs and Business Regulation (OCABR)
Division of Professional Licensure
Mass.Gov Home State Agencies A -Z Topics
Home > Division of Professional Licensure )
- .............. �.. 1-.1-1. -, .......... I .......... ...................... I ..................
Check A Professional License
By the Division of Professional Licensure
LICENSEE
Name: CARLOS L. MONIZ
SALEM, NH
NEW SEARCH
**This Licensee has additional Licenses, click here to view them.**
Licensing Board:
ELECTRICIANS
MASTER ELECTRICIAN
License Type:
TYPE CLASS: A
License Number:
15325
Status:
CURRENT
Expiration Date:
7/31/2016
Issue Date:
Exam Date:
6/3/1995
School:
This web site displays disciptinary actions dating back to 1993.
This license has had no disciplinary actions taken during this time.
The page above has been generated by the Division of Professional Licensure web
server on Tuesday, September 10, 2013 at 9:13:34 AM.
C 2007-2011 Commonwealth of Massachusetts
Page I of I
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http://license.reg.state.ma.uslpubliclpubLicenseQ.asp?board—Code=EL&type_class=—A&li... 9/10/2013
mThis certifies that ..... ................
has pennission to perfonn ..
wiring in the building of ...........
Date ..... ......... . ....
TOWN OF NORTH ANDOVER,.,"'.-'
PERMIT FOR WIRING
& ......................................................................
..... ......
"61.U..5 ..........................................
............ f-, .................. ......
at. ............................... V . .................. .z ...... ..... 9 .......... . North Andover, Mass.
Fee..N5�.... Lic. No. ......... ... .......... .... ........
ICAL SPE OR
Check#
11845
NZ
A
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Ofcial Use Only
Permit No. I �9 L(31,1
Occupancy and Fee Checked
[Rev. 1/07]
11 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASEPRNTININK OR YYPEALL INFORMATION) Date:
City or Town oh NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) vl�
Owner or Tenant Telephone No. 617 -
Owner's Address -<Z 0- Y -V, 0
Is this permit in conjunction with a building permit?
Purpose of Building (Ap'vt all �Vi5e- L
Existing Servlce-2-�-,O Amps /W/ F-L(,�Volts
�iew —Service Amps Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
4 W %13 C -V, . C, 1 4
No. of Recessed Luminaires
NO. of Luminaire Outlets
of Luminaires
W. of Receptacle Outlets Y-0
INO. of Switches
No. of Ranges
No. of Waste Disposers
N
N
o
0
0
0
f
f
R
Wa
an g
Stees
Disposers
No. of =Dishwashers
r
No. of Dryers
No. of Water
H R r KW
-A eaters
N RY romass ge B
0. Hydromassage Bathtub7s
-� 10THER:
Yes No (Check Appropriate Box)
C(i re Utility Authorization No.
Overhead Fj"�UndgrdE] No. of Meters
O'verhead.EJ Undgrd 0 No. of Meters
C � �- 61 Nts
e-- k -q QP 4, 14 Q � t \"% � r-�-L�J-Lr - � ci 3s,.e
INo. of Cell.-Susp. (Paddle) Fans
No. of Hot Tubs
Swimming Pool Above
Und. El Ignrl
No. of Oil Burners
No. of G2s Burners
Total
No. of Air Cond. nn___
Space/Area Heating KW
Heating Appliances KW
No. of No. of
— Signs - Ballasts
No. of Motors Total IR
wing table may he waived by the Inspector of Wires.
.No. of Total
—.Transformers KVA
Generators KVA
A Q. of Emergency Lighting
Battery Units
[FMME�ARMSNo. �6f Zones//�O
0. 01 Detection on
o. of Alerting Devices /,� /10
F iauniclj I
11,nnnaon El other
0. Of Del
Wiring:
No. of
- 6,� � Attach additional detail i(desired, or as required by the Inspector of Wires.
,j
Estimated Value of_Electrical Work: J � I ' ` (When required by municipal policy.)
WorktoStart: Is-ly-6 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the. performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CMCK ONE: INSLTIRANCEE] BONDEI OTIER El (specify:)
I certify, under th epains andpenalties of verjury, thatthe information on this application is true and complete.
NAML 'M
IFIRM' Qvi �7� FLtL�e& LTC. NO.: A
Licensee: ( 2A( 0�k " 1 /0 1�,n% Z- _ _ Signature 0 LIC. NO.: r-7 S-�,
applicable, enter " e 4-4 e icense number line)
Bus. Tel. No.- �-/-7 - f� 1=, M
Address:
Alt. Tel. No.: 7(ii-
*Per M.G. 147, s. 57-6 1, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (che one) El owner El owner's agent.
Owner/Agent
Signature Telephone No._ ERMITFEE.- $
JP
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
El The Permit Extension Act Was created by Section 173 of Chapter 240 of the Acts of 20 10 and extended by Sections 74 and 75 of Chapter 23 8 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
0 Rule 8 — Permit/Date Closed: Note: Reapply for new permit 0
0 Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass M
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Inspectors Signature:
Date:
PARTL4,L ROUGH INSPECTION:
Pass F?1
Failed
Re- Inspection Required El
Inspectors Comments,'
Inspectors Signature:
Date:
ROUGH MSPECTION:
Pass M
Failed
Re- Inspection Required El
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSIVEMON:
Pass M Y
Failed
Re- Inspection Required 0
;, '\ent
Inspectors Comm 't
-7
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
�p
The Commonwealth ofMassachusefts
Department ofIndustriqlAccidints
Office of Investigations
600 Washington Street
Boston, MA 02111
qu www.mass.govIdla
Workers' Compensation Insurance Affidavit: BuUders/Contractors/Ele.ctricians/Plumbers
A Please Print Legibly
___pplicant Information
Name, (Business/Organization/Individual):
Address:
city/state/zip:
Phone:ff:'
Are you an employer? Check the appropriate box: -
1. El I am a employer with
4. n I am a general contractor and I
employees (Rill and/or part-time).*
have hired the sub -contractors
211 1 am a sole �roprietor or partner-
listed on the attached shoot.
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
re4uired.]
officers have exercised their
3111 am a homeowner doing all work
right of exemption per MGL
tjiyself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No -workers'
comp. insurance required.]
Type of project (required):
6. New coAstruction
7. Remodeling
8. El Demolition
9. El Building addition
10.E] Electrical repairs or additions
ILF1 Plumbing repairs or additions
12.E] Roof repairs
13..Fi Other
�Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
T Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit a now affidavit indicating such.
lContractors that check. this box must aftached an, additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that isproviding workers'compensation insurancefor my employeeg. Below is thepolicy andjob site
information.
Insurance Company Name:.
Policy # or Solf-ins. Lie. M Expiratlon.D.ate:
lob Site Address: Pity/State/Zip:
I
*tiach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requireclunder Section 25A ofMGL 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 fma
of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
investigations of the. DIA for insurance coverage verification.
I do hereby certify under thepains andpenalties ofperjury that the information provided above is true and correct.
Signature: - Date:
Phone4:
Official use only. Do not write in this area, to he completed by city or town official.
City or Town:
PermitUcense
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
ContactPerson: -
Phone 0:
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 ofhiro,-
express or implied, oral or written."
An em er -
ploy 'is 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 arim'dividual, partnership, association or other legal entity, employing employees. Howeverthe
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 lieensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence of compliance with the insurance coverage requ.1red."
Additionally, MGL chapter 152', §25C(7) states "Neither the commonwealth nor any of its political subdiv�sions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers, compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If anLLC orLLP does have
employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for corifirm]ationof insurance coverage. Also be sure to sign and date"the affidavit ihe affidavit should
be returned to the city or town that the' application for the permit or lic6nso 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 printodlegibly. The Department has provided a space at tho bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that r�bst submit multiple p ormit/liceris e applications'Mi any given ye ar, need only. *submit one, affidavit indicating current
Policy information (ifnecessary) and under "Job Site Address" . the applicant should write "all locations ia-(City or
town)." A copy of the affidavit that has boon 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*p-ermit 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 advancefor 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:
Tho Comy4onwalth of Mossoch-o -
�, Sttt,9
De-Padmeut of Industdal Accidents
Too Of Invesfigatioln
60G Wasbingtau Sfxt��t
BostQnMA02111
TQL # 617-727-4900 oxt 406 or 1-87MASSAFE
Revised 5-26-05 Fay,# 617-727-7749
10 1 68 Date
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that.. v\1
............. ............
has permission to perform ... � Nv,-Q,. . �'.e. o .................
plumbing in the buildings of ... We:��-A ....................
a
........................ North Andover, Mass.
Lic. No.�J' e7- N.6 ................. ...
PLUMBING INSPECTOR
Check —.7D
a-0
L—,T-
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY MA DATE PERMIT#.
JOBSITE ADDRESS OWN E R'S N AM E L --Q. Iic--
POWNER
ADDRESS TEL[__ __,_IIFAX
TYPE OR
OCCUPANCYTYPE COMMERCIAL E0 EDUCATIONAL EO RESIDENTIAL
PRINT
CLEARLY
NEW: RENOVATION: REPLACEMENT: Ell PLANS SUBMITTED: YES [I NO01
FIXTURES I FLOOR- BSM 1 2 3 4 5 6
7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
--
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER I --J -J
FLOOR / AREA DRAIN I _J
INTERCEPTOR (INTERIOR)
KITCHEN SINK
-i L -j - -- ----
LAVATORY j a-�j
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK -211
TOILET
URINAL .... . . .....
W�SHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
_J
OTHER
EA =1 I
INSURANCE COVERAGE:
I have
a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES M'NO
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 01 BOND MJ
0WNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
10
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 101
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 com nce with e inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME IdL--IILICENSE# SIGNATURE
MP L-111 ip 9-' CORPORATION E-11#=PARTNERSHIP Eb LLC
COMPANY NAME I S4C ��l —ley 6 ADDRESS
CITY STATE ZIP TEL
FAX CELL MAIL
------- -------
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The Commonwealth of Massachusetts
Department of lndustriqlAccid�nts
Office of Investigations
600 Washington Street
Boston, MA 02111
U www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leizibly
NaMC(Business/Organization/Individual): VY) 3'1 n) fz�
Address: fy
City/State/Zip&i6cn MA Q)V(:�O�o Phone#: CQO�'�)
Are you an employer? Check the appropriate box:
1. El I am a employer with
4. El I am a general contractor and I
(fall and/or part-time).*
have hired the sub -contractors
2. eployees
l aim a sole proprietor or partner-
listed on the attached sheet
ship and'have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. El We are a corporation and its
required.]
officers have exercised their
3. 1 am a homeowner doing all work
E]
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. E]yw con * struction
7. &Remodeling
8. E] Demolition
9. E] Building addition
10.El Electrical repairs or additions
ILEI Plumbing repairs or additions
12.E] Roof repairs
13.0 other
*Any applicant that checks box fil must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit 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.
lam an employer that isproviding workers'compensation insuranceformy employees. Below is thepolicy andjob site
information. r,\ /-,
Insurance Company
Policy # or Self -ins. Lic. 9: &Q)6koD _)C>&c9 cf ExpirationDate:
Job Site Address: At 4/71DOL)(Ir C tate/Zip: X) 41) do
— I ity/S
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 orie-year imprisonment, a's 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 certo4inder thepal
ps,anypenalties ofperjury that the information provided above is true and correct
Phone#: 29, C) -7
Official use only. Do not write in this area, to he completed by city or town official
City or Town:
Permit[License 9
=WAdMN60
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone N:
M
Information and Instructiolas
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "....every person in the service of another under any contract of hire,
express or implied, oral or written."
An employerls 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 local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work -until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-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 line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in _(city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is' on file for future permits or licenses. A new affidavit must be fille , d out each
year. Where a home owner or citizen is obtaining a license or*permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have anyquestions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Strec,-t
Boston., MA 02111
Tel. # 617-727-4900 oxt 406 or 1-8777MASSAFF,
Revised 5-26-05 Fax # 617-727-7749
__wwwmass.gov1dia
!-,-��t=MONWEALTKOF I�ASSACRUSETT& I`
--PLL-11"P.ABERS ANr,','k,.�,A�FITTER�;-.\--���'k
ISSUES THE ABOVE LCCENSE'T0:
CIRG S�U"SflAf�, JR
r.T
AMES R D.'
V,18AU G U S ( Y.
r ql�
10
Date
I ....... I . ...... 7 ...... .........................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
vv� AJ
This certifies that .... ...... .. ..................................
has pernussion for gas installation ...... ................................................ .
in the bu ildings of ......... ............
at ....... ........ . .............. . North Andover, Mass.
FeeAw—
................... Lic. No..hly..�. .......................................................
GAS INSPECMR
Check 0
88 1 76 (2)P I Loo - 1 -5
&USETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
MA DATE PERMIT #
jUB 81 -r-E ADDRESS
n X,
OWNER'S NAME C3
OWNER ADDRESS
TEd_______:=FAXL_-
TYPE OR OCCUPANCYTYPE
PRINT
COMMERCIAL
EDUCATIONAL RESIDENTIAL 53 --
.'�
CLEP-Ly NEW: RENOVATION: REPLACEMENT:
El PLANSSUBMITTED: YESD NOF-]
APPLIANCES -1 FLOORS-
BSM 1 2 3
4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
L—j
DIRECT VENT HEATER
E --j -A I
DRYER
FIREPLACE
FRYOLATOR
FURNACE
. . . . . . . . . . -
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
RO?V / SPACE HEATER
ROOF TOP UNIT
IUMT HEATER
UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES I[] NO Ej
IAIF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY G2" OTHER TYPE INDEMNITY El BOND 0
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 ED AGENT FO
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 compli ith all Per rit provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 77
PLUMBER-GASFITTER NAME Gr --C& LICENSE #L
MP El MGF El JP 26GF D
LPGI E] CORPORATIONF-1
1# PARTNERSHIP ED#= LLC 01
:ADDRESS
COMPANY NAME:
CITY 0 STATE M ZIP TEL Y C�Q
� -d --GUS LOWIQX-7 1-J&-25- - ---i
FAX CELL[ EMAIL
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ISSUES THE ABOVE LICENSE TO:
A
-0 S, A LSP N. J R.
ST ,-.JAHE 8 RD'
NU MA" 0
0 5
309 Date. . dz.1.3 ........
TOWN OF NORTH ANDOVER
PERMIT FOR MECHANICAL INSTALLATION
I'This certifies that ......................
has permission for mechanical installation"'DVIA ........
in the buildings of . -�? -R . ./� ��Irw � �-'v ... �-r .................
at ........ ............... North Andover, Mass.
Fee. ... ....... 111/' '
,dAS vis�ic�oln**
WHITE: Applicant CANARY: Building Dept. 0,41INK: Treasurer
r r _?0 -7 7 �
00
Commonwealth of Massachusetts
Sheet Metal Permit
Permit #
Permit Fee: $
Plans Reviewed: YES NO
Applicant License # 7,17,5
Date: q10z_1z,;,15
Estimated Job Cos#3���o . �L90
Plans Submitted: YES NO Y -
Business License #
Business Information:
Name: hty
aA Aj IZD t loj
Street: 14 14 U A
Pu me_6g4m , w -in
City/Town: !�oMiWAZU&k, POA—
Telephone: 7
Photo I.D. required / Copy of Photo I.D. attached
Property Owner / Job Location Information:
Name: t,
Street: 201 Y)46 Aj S_711�94�
City/Town: IV.
Telephone:
YES �4 NO
Building Type:
Residential:, 1-2 family Multi -family Condo / Townhouses
Commercia 1: Office Retail Industrial Educational Institutional
Building Cubic Footage: under 35,000 cu. ft. over 35,000 cu. ft.
Sheet metal work to be completed: New Work: 4- Renovation: *4 -
HVAC 4- Metal Roofing Kitchen -Exhaust System Chimney / Vents
Provide brief description of work to be done:
e� A s
I V
Alz�l. j CAj.-,.,7A.4 --L J /0/) 7) f I A hr- J, 9,V rl C I -Jr-Af'(
6) -7 7 1
09 C-72 Y_ QQP/ !�� ?) - qzj
k
INSURANCE COVERAGE:
I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 YesEl NoD
If you have checked Yes, indicate the type of coverage by checking the appropriate box below:
A liability insurance policy Other type of indemnity El Bond
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the
Massachusetts G neral Laws, and that my signature on this permit application waives this requirement.
Check One Only
owner El Agent
Signkt re of Owner or Owner's Ag'ent
By checking this boxE], 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 sheet metal work and installations performed under the permit issued for this application will be
in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws.
Progress Inspections
Date Comments
Final Inspection
Date Comments
Inspector Signature of Permit Approval
Signature of Licensee
License NumbQ: —24 2--7---
Check at www.mass.gov/dpi
Itz
Type of License:
By
rhmaster
Title
F] M aste r- Restricted
City[Town
Eliourneyperson
Permit #
DJourneyperson-Restricted
Fee $
El
Inspector Signature of Permit Approval
Signature of Licensee
License NumbQ: —24 2--7---
Check at www.mass.gov/dpi
Itz
. 'k
Sheet Metal Commercial Guidelines / Life Safety / Critical Systems
Inspection Checklist
Yes No N/A
Set of stamped engineering documents and detailed description of
mechanical system to be installed has been provided
All workers performing sheet metal work onsite has valid Massachusetts sheet metal
license
All sheet metal work being performed with proper journeyperson-to-apprentice, ratios
Fire dampers with access door properly installed and chtcked for operation
Smoke and combination fire / smoke dampers with access doors properly installed -
actuator chocked for proper operation (May also be verified by fire department during
fire alarm testing)
Duct smoke detectors with access doors properly located
(May also be verified by fire department during fire alarm testing)
Smoke / atrium exhaust systems installed and operation verified
(May also be verified by fire department during fire alarm testing)
Stair pressurization systems installed (where required) and operation verified (May also
be verified by fire department during fire alarm testing)
t
Grease / kitchen hood exhaust system installed with all scams and connections welded
airtight with properly located cleanouts. Proper 6611'anoes, fire rated enclosures and
A,�
pressure testing required..
installod -WhUt6tequired.bn bqdpment and du,.b:.,)rK
Duct penetrations in fire'rdtQv,!all:3 and flo"ors" sealbd'
Metal roofing systems installed watertight -using proper materials and fasteners
Flexible duct runs installed 6'-0" maximum length
Ductwork installed using proper hanger spacing, hanger stock, threaded rod and angle
iron
Ductwork / plenum connections scaled substantially airtight
Ductwork insulated by means of external covering or internal lining
Volume'dampers installed for each supply air branch duct
New/clean - properly sized filters installed (final inspection)
Testing and Balancing report complete (final sign -off)
Sheet Metal Residential Guidelines / Inspection Checklist
Yes No N/A
Detailed description and sketch of sheet metal system to be installed has
been provided
All workers performing sheet metal work onsite has valid Massachusetts
sheet metal license
All sheet metal work being performed with proper joumeyperson-to-
apprentice ratios
Equipment sized per heating / cooling load calculations
Duct work sized per manual "D" calculations
Bath / shower rooms contain mechanical exhaust fan vented outdoors
Electric dryer exhaust properly installed maximum total ran 35'-0",
maximum flexible run 8'-0"
Flexible duct runs installed 14'-0" maximum length
Volume dampers installed for each supply air branch duct
Ductwork installed using proper gauges and hangers
Ductwork / plenum connections sealed substantially airtight
Ductwork insulated by means of external covering or internal lining
New/clean - properly sized filter installed (final inspection)
Testing and Balancing report complete (final sign-ofo
I/
1.
Fold, Then Detach Alono All Perforations
ZOMMONWEALTH OF MASSACHUSETT
. ..... ...... .
Eim-Do
.BOARD
S H WORKERS.,�
S m
AS.
TYPE
A
W I L LIAM "'i SOUZA
mi
,:EXCEL,:MECHANICAL INC
��39Z MCGR-ATH HWY
.S.OMERVI.I'LE MA 0 2 14,3-, 21116'.,:
13266'4
'm
Emma 11 116
Fold, Then Detach Along All Perforations
A,, CORAOr
`ift� CERTIFICATE OF LIABILITY INSURANCE
M-M"MW"
1 05QW3
-_THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
�RTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS
ERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR
PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms
and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder
in lie of such endorsement(s).
PRODUCER
FEDERATED MUTUAL INSURANCE COMPANY
HOME OFFICE: P.O. BOX 328
Rkec' CLIENT CONTACT CENTER
Who, Exti: 888-333-4949 Ng); 507446-4664
RpAss, CLIENTCONTACTCENTER(aFEDINS.COM
OWATONNA, MN 55060
INSURER(S) AFFORDING COVERAOE NAIC #
9336403
INSURER A: FEDERATED MUTUAL INSURANCE COMPANY 13935
04/2912014
INSURED 330-508-3
INSURER 8:
EXCEL MECHANICAL INC
392 MCGRATH HIGHWAY
INSURER C:
INSURER D:
SOMERVILLE, MA 02143-2116
[INSURER E:
I INSURER F:
AUTOMOBILE
X
UILIVEKAULb CER11FIVATE NUMBER: 0 REVISION NUMBER- 1
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS
AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INS
LT R9
TYPE OF INSURANCE
SUBR
WVD
POLICY NUMBER
PO
(MM I
LIMITS
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIA131LITY
CLAIMS -MADE [ X] OCCUR
N
N
9336403
04/29/2013
04/2912014
EACH OCCURRENCE $1,000,000
DA AGE TO RENTED $100,000
PRME MISES (Ea occurrencel
MED EXP (Any one person) EXCLUDED
PERSONAL & ADV INJURY $1,000,000
GENERAL AGGREGATE $2,000,000
GE N'L AGGREGATE LIMIT APPLIES PER:
PRO-
x1poucy F�JECT F LOC
PRODUCTS - COMP/OP AGG $2,000,000
A
AUTOMOBILE
X
LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
HIRED AUTOS AUTOS
N
N
9336404
04/29/2013
04/29/2014
COMBINED SINGLE LIMIT $1,000,000
(E, ood."t)
BODILY INJURY (Per person)
BODILY INJURY (Per accident)
PROPERTY 7AMAGE
(Par ,dt
A
UMBRELLA LIAS
EXCESS LL42
X
OCCUR
CLAIMS -MADE
N
N
9336406
0412912013
04/29/2014
EACH OCCURRENCE $5,000,000
AGGREGATE $5,000,000
TDED
RETENTION
A
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNER[EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If �es, describe unde
D SCRIPTION OF OPERATIONS below
NIA
N
9336405
04/29/2013
04/29r2014
TATU TH-
TW&RY' LIM j.S OER
E.L. EACH ACCIDENT $500,000
E.L. DISEASE - FA EMPLOYEE $500,000
E.L DISEASE - POLICY LIMIT $500,000
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarlm Schedule, if more space is required)
THIS COPY IS NOT TO BE REPRODUCED FOR ISSUANCE OF CERTIFICATES.
01
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ERTIFICATE HAS BEEN FILED WITH EACH OF YOUR CERTIFICATE ACCORDANCE WITH THE POLICY PROVISIONS.
oOLDERS.
AUTHORIZED REPRESENTATIVE
(9 191ISO-ZID1111 AGUKU IL;UKFVKA I IVN. All rignts reservea.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
For: Wessel Residence
281 Main St., North Andover, MA
Notes:
M-1127MM
Vn I I n f 6 t i Q Null-,
Weather: Boston Logan Int'l AP, MA, US
Winter Design Conditions
Summer Design Conditions
Outside db
0 OF
Outside db
88
OF
Inside db
70 cF
Inside db
70
cF
Design TI)
70 cF
Design TD
18
OF
Daily range
L
Relative humidity
50
%
Moisture difference
38
gr/lb
Heating Summary
Sensible Cooling Equipment Load Sizing
Structure
58728 Btuh
Structure
32839
Btuh
Ducts
33964 Btuh
Ducts
23597
Btuh
Central vent (0 cfm)
0 Btuh
Central vent (0 cfm)
0
Btuh
Humidification
0 Btuh
Blower
0
Btuh
Piping
0 Btuh
Equipment load
92692 Btuh
Use manufacturer's data
n
Rate/swing multiplier
Equipment load
0.93
Infiltration
sensible
52260
Btuh
Method
Simplified
Latent Cooling Equipment Load
Sizing
Construction quality
Average
Fireplaces
0
Structure
4508
Btuh
Ducts
4327
Btuh
Heating Cooling
Central vent (0 cfm)
0
Btuh
Area (ft2)
4088
Equipment latent load
8834
Btuh
Volume (ft3)
32703 32703
Air changes/hour
0.28 0.15
Equipment total load
61094
Btuh
Equiv. AVF (cfm)
153 82
Req. total capacity at 0.70 SHR
6.2
ton
Heating Equipment
Summary
Cooling Equipment
Summary
Make
Make
Trade
Trade
Model
Cond
AHR I ref no.
Coil
AHRI ref no.
Efficiency
80AFUE
Eff iciency
0 SEER
Heating input
0 Btuh
Sensible cooling
0
Btuh
Heating output
0 Btuh
Latent cooling
0
Btuh
Temperature rise
0 cF
Total cooling
0
Btuh
Actual air flow
2906 cfm
Actual air flow
2906
cfm
Air flow factor
0.031 cfm/Btuh
Air flow factor
0.051
cfm/Btuh
Static pressure
0 in H20
Static pressure
0
in H20
Space thermostat
Load sensible heat ratio
0.86
Boldfitalic values have been manually overridden
Calculations approved by ACCA to meet all requirements of Manual J 8th Ed.
wrightSOft'
Right-SuiteO Universal 8.0.24 RSU16265
2013 -Sep -13 13:53:12
ACKA C:\Users\Owner\Documents\Wrightsoft HVAC\Wessel. rup Calc = MJ8
Front Door faces: N
Page 1
Project Summary
(Rest of House)
Excel
Job: 10-44535
Date: August 201h, 2013
By:
For: Wessel Residence
281 Main St., North Andover, MA
Notes:
�VWM —
�,71 lmswgj
E mm -, -f , M" , 7s UAWININ 6&SW0&9%
Weather: Boston Logan Int'l AP, MA, US
Winter Design Conditions
Heating
Summer Design Conditions
Outside db
0
.............
,.rdlect,
88
nforma.
iqm,�,-
For: Wessel Residence
281 Main St., North Andover, MA
Notes:
�VWM —
�,71 lmswgj
E mm -, -f , M" , 7s UAWININ 6&SW0&9%
Weather: Boston Logan Int'l AP, MA, US
Winter Design Conditions
Heating
Summer Design Conditions
Outside db
0
OF
Outside db
88
OF
Inside db
70
cF
Inside db
70
OF
Design TD
70
OF
Design TD
18
OF
Temperature rise
0
OF
Daily range
L
cfm
Air flow factor
0
cfm/Btuh
Relative humidity
50
%
Space thermostat
n/a
Moisture difference
38
gr/lb
Heating Summary
0
Sensible Cooling Equipment Load Sizing
Structure
17652
Btuh
Structure
10640
Btuh
Ducts
7020
Btuh
Ducts
4315
Btuh
Central vent (0 cfm)
0
Btuh
Central vent (0 cfm)
0
Btuh
Humidification
0
Btuh
Blower
0
Btuh
Piping
0
Btuh
Equipment load
24671
Btuh
Use manufacturer's data
n
Rate/swing multiplier
0.93
Infiltration
Equipment sensible load
13848
Btuh
Method
Construction quality
Fireplaces
Simplified
Average
0
Heating Equipment Summary
Make n/a
Heating
Cool
V6
Area (ft2)
1236
1
Volume (ft3)
9885
9885
Air changes/hour
0.25
0.14
Equiv. AVF (cfm)
42
22
Heating Equipment Summary
Make n/a
979
Btuh
Trade n/a
1126
Btuh
Model n/a
0
Btuh
AHRI ref no.n/a
2105
Btuh
Efficiency
15953
n/a
Heating input
1.6
ton
Heating outpu�
0
Btuh
Temperature rise
0
OF
Actual air flow
0
cfm
Air flow factor
0
cfm/Btuh
Static pressure
0
in H20
Space thermostat
n/a
Latent Cooling Equipment Load Sizing
Structure
979
Btuh
Ducts
1126
Btuh
Central vent (0 cfm)
0
Btuh
Equipment latent load
2105
Btuh
Equipment total load
15953
Btuh
Req. total capacity at 0.70 SHR
1.6
ton
Cooling Equipment
Summary
Make n/a
Trade n/a
Cond n/a
Coil rVa
AHRI ref no.n/a
Efficiency
n/a
Sensible cooling
0
Btuh
Latent cooling
0
Btuh
Total cooling
0
Btuh
Actual air flow
0
cfm
Air flow factor
0
cfm/Btuh
Static pressure
0
in H20
Load sensible heat ratio
0
Boldlitalic values have been manually overridden
Calculations approved by ACCA to meet all requirements of Manual J 8th Ed
A- 2013 -Sep -13 13:53:12
I- + wriightSOft' Right-SdIeO Universal 8.0.24 RSU16265 Page 2
ACCK C:\Users\Owner\Documents\Wdghtsoft HVAC\Wessel. rup Calc = MJ8 Front Door faces: N
Test
Project Summary
2nd Floor
Excel
For: Wessel Residence
281 Main St., North Andover, MA
Notes:
EMEMM
law-sk";
Weather: Boston Logan Int'I AP, MA, US
Job: 10-44535
Date: August 20th, 2013
By:
Winter Design Conditions
Heating
Summer Design Conditions
Outside db
0
IF
Outside db
88
OF
Inside clb
70
cF
Inside clb
70
OF
Design TD
70
OF
Design TD
18
OF
Temperature rise
0
OF
Daily range
L
cfm
Air flow factor
0
cfm/Btuh
Relative humidity
50
%
Space thermostat
n/a
Moisture difference
38
gr/lb
Heating Summary
0
Sensible Cooling Equipment Load Sizing
Structure
20767
Btuh
Structure
12848
Btuh
Ducts
12283
Btuh
Ducts
9580
Btuh
Central vent (0 cfm)
0
Btuh
Central vent (0 cfm)
0
Btuh
Humidification
0
Btuh
Blower
0
Btuh
Piping
0
Btuh
Equipment load
33049
Btuh
Use manufacturer's data
n
Rate/swing multi lier
0.93
Infiltration
Equipment sensigie load
20768
Btuh
Method
Construction quality
Fireplaces
Simplified
Average
0
Heating Equipment Summary
Make n/a
Heating
Cooling
Area (ft2)
1403
1403
Volume (ft3)
11223
11993
Air changes/hour
0.32
0.17
Equiv. AVF (cfm)
60
32
Heating Equipment Summary
Make n/a
1622
Btuh
Trade n1a
1491
Btuh
Model n/a
0
Btuh
AHRI ref no.n/a
3113
Btuh
Efficiency
23882
n/a
Heating input
2.5
ton
Heating outpu�
0
Btuh
Temperature rise
0
OF
Actual air flow
0
cfm
Air flow factor
0
cfm/Btuh
Static pressure
0
in H20
Space thermostat
n/a
Latent Cooling Equipment Load Sizing
Structure
1622
Btuh
Ducts
1491
Btuh
Central vent (0 cfm)
0
Btuh
Equipment latent load
3113
Btuh
Equipment total load
23882
Btuh
Req. total capacity at 0.70 SHR
2.5
ton
Cooling Equipment
Summary
Make n/a
Trade n/a
Cond n/a
Coil n/a
AHRI ref no.n/a
Eff iciency
n/a
Sensible cooling
0
Btuh
Latent cooling
0
Btuh
Total cooling
0
Btuh
Actual air flow
0
cfm
Air flow factor
0
cfm/Btuh
Static pressure
0
in H20
Load sensible heat ratio
0
Boldli'alic values have been manually overridden
Calculations approved by ACCA to meet all requirements of Manual J 8th Ed.
,& * wrightsoft, Right-SuiteG Universal 8.0.24 RSU16265 2013 -Sep -13 13:53:12
C:\Users\Owner\Documents\Wrightsoft HVAC\Wessel.rup Calc = MJ8 Front Door faces: N Page 3
4
Project Summary Job: 10-44535
Date: August 20th, 2013
KyDyO5E By:
Excel
Test
For: Wessel Residence
281 Main St., North Andover, MA
Notes:
IE'M,212
Weather: Boston Logan Infl AP, MA, US
Winter Design Conditions
Heafing
Summer Design Conditions
Outside 1
0
OF
Outside db
88
OF
Inside db
70
cF
Inside db
70
cF
Design TD
70
OF
Design TD
18
cF
Temperature rise
0
cF
Daily range
L
cfm
Air flow factor
0
cf mi
Relative humidity
50
%
Space thermostat
n/a
Moisture difference
38
gr/lb
Heating Summary
0
Sensible Cooling Equipment Load Sizing
Structure
20309
Btuh
Structure
13954
Btuh
Ducts
14662
Btuh
Ducts
12829
Btuh
Central vent (0 cfm)
0
Btuh
Central vent (0 cfm)
0
Btuh
Humidification
0
Btuh
Blower
0
Btuh
Piping
0
Btuh
Equipment load
34971
Btuh
Use manufacturer's data
n
Infiltration
Rate/swing multiplier
Equipment sensible load
0.93
24801
Btuh
Method
Construction quality
Fireplaces
Simplified
Average
0
Heating Equipment Summary
Make n/a
Heafing
Cooling
Area (ft2)
1449
1449
Volume (ft3)
11595
11595
Air changes/hour
0.26
0.14
Equiv. AVF (cfm)
51
27
Heating Equipment Summary
Make n/a
1906
Btuh
Trade n/a
1710
Btuh
Model n/a
0
Btuh
AHRI ref no.n/a
3616
Btuh
Efficiency
28417
n/a
Heating input
3.0
ton
Heating oui
0
Btuh
Temperature rise
0
cF
Actual air flow
0
cfm
Air flow factor
0
cf mi
Static pressure
0
in H20
Space thermostat
n/a
Latent Cooling Equipment Load Sizing
Structure
1906
Btuh
Ducts
1710
Btuh
Central vent (0 cfm)
0
Btuh
Equipment latent load
3616
Btuh
Equipment total load
28417
Btuh
Req. total capacity at 0.70 SHR
3.0
ton
Cooling Equipment
Summary
Make n/a
Trade n/a
Cond n/a
Coil ri
AHRI ref ni
Eff liciency
n/a
Sensible cooling
0
Btuh
Latent cooling
0
Btuh
Total cooling
0
Btuh
Actual air flow
0
cfm
Air flow factor
0
cfm/Btuh
Static pressure
0
in H20
Load sensible heat ratio
0
Boldlitalic values have been manually overridden
Calculations approved by ACCA to meet all requirements of Manual J 8th Ed.
191 + wrightSoft' Right-Suileb Universal 8.0.24 RSU16265 2013 -Sep -13 13:53:12
AC':;k C:\Users\Owner\Documents\Wrightsoft HVAC\Wessel.rup Calc = MJ8 Front Door faces: N Page 4