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Home My WebLink AboutMiscellaneous - 3 HARVEST DRIVE 4/30/2018North Andover Board of Assessors Public Access 0 c"us Click Sea] To Return Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial Page I of I North Andover Board of Assessors Ism% 74property Record Card Parcel ID:210/108.C-0038-0204.0 FY:2008 Community: North Andover SKETCH No Sketch Available PHOTO No Picture Available Location: 3 HARVEST DRIVE Owner Name: PARSONS, DENISE V. Owner Address: 3 HARVEST DRIVE #204 City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 0 Land Area: 0.00 ac Use Code: 102 -CONDOMINIUM Total Finished Area: 1245 sqLft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 288,000 0 Building Value: 288,000 0 Land Value: 0 0 Market Land Value: 0 Chapter Land Value: http://csc-ma.us/PROPAPP/display.do?linkld=l 183339&town=NandoverPubAcc 8/12/200 North Andover Board of Assessors Pu�,Iic Acc�ess Page I of 2 http://csc-ma.us/PROPAPP/newSearch.do?noOwner--027�/�3BO34`/�3BO84�/�3BO5... 8/12/20( North Andover Board of Assessors MATCHING PARCELS c US Click on a column title to sort data by that column Click Sea] To Return 154 items found, displayi g 51 to 100. [First rev] 1 1 2 1 3 1 4 [Next/Last] Fiscal Year Parcel ID St.No. Street Owner Name 2008 210/108.C-0038-021 I.0 3 HARVEST DRIVE HOWARD, JENNIFER A., 2008 210/108.C-0038-02 10.0 3 HARVEST DRIVE JAIN, SUMEET K., JAIN, NEHA Search for Parcels 2008 210/108.C-0038-0312.0 3 1 HARVEST DRIVE SENARIAN, DAVID R., Search for Sales 2008 210/108.C-0038-031 I.0 3 HARVEST DRIVE CALVO,NANCY, 2008 210/108.C-0038-031 O.0 3 HARVEST DRIVE SERVIZIO, LEONARDO, SERVIZIO, PATRICIA 2008 210/108.C-0038-0112.0 3 HARVEST DRIVE RETHMAN, LINDA M., RETHMAN, NICHOLAS L. 2008 210/108.C-0038-0201.0 3 HARVEST DRIVE LYNCH, JULIE M., 2008 210/108.C-0038-0202.0 3 HARVEST DRIVE DOUCETTE, MICHELLE, 2008 210/108.C-0038-01 OLC 3 HARVEST DRIVE VALLEY REALTY DEVELOPMENT, LLC, 2008 210/108.C-0038-0109.0 3 HARVEST DRIVE VALLEY REALTY DEVELOPMENT, LLC, 2008 210/108.C-0038-0108.0 3 HARVEST DRIVE MARTENS, ELIZABETH, 2008 210/108.C-0038-0106�C 3 HARVEST DRIVE NIELSEN, ROBERT A., NIELSEN, JEANNE 2008 2101,1108.C-0038-0105.0 3 HARVEST DRIVE VALLEY REALTY DEVELOPMENT, LLC, 2008 210/108.C-0038-0104.0 3 HARVEST DRIVE DESMARAIS, ELIZABETH A., 2008 210/108.C-0038-0103.0 3 HARVEST DRIVE NAGGER, DAVID, 2008 210/108.C-0038-0102.0 3 HARVEST DRIVE SLOVIN, BRUCE, 2008 210/108.C-0038-0107.0 3 HARVEST DRIVE HILL, WILLIAM E., MARCIN, MARY ANN 2008 210/108.C-0038-0208.0 3 HARVEST DRIVE CONNELLY, JOYCE E, CONNELLY, HARRY M. 2008 210/108.C-0038-0207. 3 HARVEST DRIVE THERRIEN, RENEE M., 2008 210/108.C-0038-0206.0 3 HARVEST DRIVE VALLEY REALTY DEVELOPMENT, LLC, 2008 210/108.C-0038-0205.0 3 HARVEST DRIVE BEKEL, MARY LOU, 2008 210/108.C-0038-0204.0 3 HARVEST DRIVE PARSONS, DENISE V., 2008 210/108.C-0038-0203.0 3 HARVEST DRIVE BYRON, AMY, 2008 210,1108.C-0038-01 10.0 3 HARVEST DRIVE VALLEY REALTY DEVELOPMENT, LLC, 2008 210/108.C-0038-0308.0 3 HARVEST DRIVE SMITH, JOAN A., 2008 210/108.C-0038-0209.0 3 HARVEST DRIVE NENCETTY, JOSEPH P., 2008 210/108.C-0038-0113.0 3 HARVEST DRIVE GRIFFIN, JENNIFER M., 2008 1210/108.C -0038-0122.N 4 HARVEST DRIVE VALLEY REALTY DEVELOPMENT, LLC, 2008 210/108.C -0038-0216.N 4 HARVEST DRIVE LICHTMAN, MINDY E., 2008 210/108.C -0038-0217.N 4 DRIVE VALLEY REALTY DEVELOPMENT, LLC, IHARVEST IC/O NORMAN P. GILL 2008 210/108.C -0038-0218.N T DRIVE IKARL, KATHRYN, I http://csc-ma.us/PROPAPP/newSearch.do?noOwner--027�/�3BO34`/�3BO84�/�3BO5... 8/12/20( Am, k c1c CLAIMS DEPT. Ccmmerce Insurances - The Ccmmerce Insurance Ccmpanysm Citaticn insurance Company - Members of The Commerce Group, Inc. - 11 Gore Road, Webster, Massachusetts 01570 (508) 949-1500 www.Commercelnsurance.com December 14, 2012 BUILDING COMMISSIONER or INSPECTOR OF BUILDINGS TOWN/CITY HALL NORTHANDOVER MA 01845 RE: Our Insured: ELIZABETH MARTENS Property Address: 3 HARVEST DR 108 Policy#: BBKKST Date of Loss: 12/14/2012 File#: CNWH26-XRHP81 Board of Health or Board of Selectmen Town/City Hall Claim has been made involving loss, damage, or destruction of the above captioned property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to my attention. Please reference the above captioned insured, location, policy number, date of loss, and file number on any correspondence. JOHN E RICHARD Telephone: (508)949-1500 Ext: 15984 Clm Representative II, Subrogation Toll Free: 1-800-221-1605, Ext: 15984 On this date, I cause copies of this notice to be sent to the persons indicated above, at the address above, by first class mail. December 14, 2012 CcmmCrc CcImpanies .... COME GROW WITH Us CIC 254 (Rev. 4/95) MAIL 150 '10050 Date ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............ has permission to perform .......... . . ........ wiring in the building of ....... ....................................... at J. ...... &��'Z . .... 310.7 North Andover, Mass. Fee ... r ................. Lic. No...,-.) ......... .. .. ..... ........ - e � LE�CTRICAL SPE� �-i R Check# Official Use Only (f-Intntonwea& / Mamac4ujetb 2.padd .13ie Semice., Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (1,,vebl,,k) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical C MEC), 527 CMR 12.00 (PLEASE PRINT IN 17VK OR TYPE ALL INFORMATION) Date: OZ.-\A��-o it City or Town of. no �oi 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) k * '�6 ;a - e V -f -&Q 11 U Owner or Tenant N1 rlo- �,:Cavv)J%�ko Tel eph one N ol Owner's AddressQS&&q-qe&-\- Is this permit in conjunction with Purpose of Building Existing Service Amps New Service Amps Number of Feeders and Ampacity Volts bverheadEl Overhead 0 Undgrd Undgrd (Check Appropriate Box) No. of Meters - Completion of the following able maybe waived the In ctor rd Wir No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators K -VA No. of Luminaires Above Swimming Pool grnd. El 'nud. gr F1 No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Buirers FIRE ALARMS JNo. 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 I Number ---' . ............. I Tons ......... ... ............ JIM ........... No. of Self -Contained Tota]R.* Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Municipal Local El Connection 0 Other No. of Dryers Heating Appliances KW Security S stems:* ;evices No. of or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts I No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail i(desired, or asrequired by the Inspector of fYires. Estimated Value of Electrical Work430- 0 , 0_0 (When required by �nunicipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE R1 BONDE] OTHER F1 (Specify:) I certify, under the pains andpenaldes ofperjury, that the information on this application is true and coniplete. FIRM NAME: J.P. McCurdy Electrical Services, Inc. — /I / 2 1 LIC. NO.: 20172 A Licensee: (' V, S, I -Y. " , - Signature LIC. NO.: _�] �qqS'15- (Ifapplicable, enter "exempt " in the license number line.) Bus. Tel. No.: 781-595-7074 Address: 17 Walnut Road, Swampscott, MA 01907 Alt. Tel. No.: 781-595-2431 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. SS CO 000914 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) 0 owner 0 owner's aEcnt. Owner/Agent Signature Telephone No._ PERMIT FEE: $ The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): J.P. McCurdy Electrical Services, Inc. Address: 17 Walnut Road City/State/Zip: Swampscott, N4A01907 Phone #: (781) 595-7074 Are you an employer? Check the appropriate box: Type of project (required): 1. [Z I am a employer with 7 4. [-] I am a general contractor and 1 6. M New construction employees (full and/or part-time).* 2. El I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7. E] Remodeling ship and have no employees These sub -contractors have 8. E] Demolition working for me in any capacity. employees and have workers' 9. n Building addition [No workers' comp. insurance 5. comp. insurance.T We are a corporation and its 10. 0 Electrical repairs or additions required.] 3. n I am a homeowner doing all work officers have exercised their ILE] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.E] Roof repairs insurance required.] c. 152, § 1(4), and we have no 13.F1 Other employees. [No workers' como. insurance required] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. -Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurancefor my employees. Below is the policy andjob site information. Insurance Company Name: ACE Property and Casualty Insurance Company (TPA Insurance Agency, Inc.) Policy # or Self -ins. Lic. #: Job Site Address: 46353304 Expiration Date: 9/5/2011 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verificatio /Y� I do hereby cerO,--ander , 49e PaO�ndrenalfieofierjd�j t#at the information provided above is true and correct -IF" Xd Date: 595-7074 Official use only. Do not write in this area, City or Town: completed by city or town official Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: Property Address Policy Number: Date/Cause of Loss File or Claim Number: Elizabeth Martens 3 Harvest Drive, #108 12/14/2012, Water Damage 27415-R Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Ryan Werner On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. 0/� /o— and Date ANDERSON ADOSTMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053 AdOlkh, WoSafety insurance Fonn of Notice of Casuafty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 0 1845 RE: Insured: Property Address: Policy Number: Claim Number: Date of Loss: Company: MELISSA N ARILLOTTA 3 HARVEST DRIVE UNIT 208, NORTH ANDOVER, MA HMA 0352384 BOS00034427 12/14/2012 Safety Insurance Company Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chqpter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chqpter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Lisa Monette Claim Examiner Safety Insurance Company Homeowners Claims Unit P. 0. Box 55098 Boston, MA 02205-5098 Phone: (857) 233-8618 Fax: (617) 535-5833 Email: LisaMonette@SafetyInsurance.com 12/17/2012 nNg-sp-IMAPFRE The Commerce Insurance Companysm Citation Insurance Companyw Commerce "'ore Road, Webster, Massachusetts 01570 INSURANCE" 508.949.15001 www.commerceinsurance.com November 03, 2014 BUILDING COMMISSIONER or INSPECTOR OF BUILDINGS TOVVN/CITY HALL NORTH ANDOVER MA 01845 RE: Our Insured: ZI YAN - Property Address: 3 HARVEST DR UNIT 203 Policy#: BGCBCR Date of Loss: 11/02/2014 File#: JPPY74-HHCHH7 Board of Health or Board of Selectmen Town/City Hall Claim has been made involving loss, damage, or destruction of the above captioned property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to my attention. Please reference the above captioned insured, location, policy number, date of loss, and file number on any correspondence. MEGANFINACOM CLAIM REP 1, PROPERTY Telephone: (508)949-1500 Ext: 15847 Toll Free: 1-800-221-1605, Ext: 15847 On this date, I cause copies of this notice to be sent to the persons indicated above, at the address above, by first class mail. November 03, 2014 CIC 254 (Rev. 4/95) MAU, 786 r-� � - �4 �0�\ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . elecal, vell ................ ........... ......... ... has permission for gas installation ..... ne- ' 0 in the bulld-in s of at �N Fee.,A Lic. No..�4ZP�'�. GAS INSPECTOR Check # 7 / Z& 7916 ,C\ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING WC&y/Town:_)()' MA. Date: Permit# B ,ildTo I .. 3 uilding Location klArsl- Unl� bi Owners Name: ai"74 G. Type of Occupancy: Commercial El Educational El Industrial 0 Institutional El Residential New: El Alteration: Ej Renovation: E] Replacement: E] Plans Submitted: Yes [--] No - t10 el e -7- ) XWO FIXTURES W co C6 W W co z W �e Cd co U) Q W Im 0 W W 0 co co 6i 0 W L) (a 1-- 0 W W Z.-�>- W 2 U)02ww 0 z 0 W W Lu W :3 co LLJ 60<i-- > z W X W 0 0 W W W LU Co 0 W W W W < 0 W X Lu 1-- W 0 >OWZ -JW39W CO3:ZLLJWW ZW�'WU)-Jl--l--0Z-J0LL�- wi--Ww <<133W0z0Wt>zI--X 0 < 2 W W > 0 0 W Z Z W < I.- I 0 Q 0 LL 0 0 X X 0 W M --3 > 0 SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR 4 FLOOR 6 FLOOR 6 FLOOR fFr'F--LOOR —Pr -F L 0 —OR Check One Only Certificate # Installing Company Name:t1g2&-e �Iojw Address: U116/orporation OW �Z' City[Town: State: Business Tel: -? Fax: Partnership �-- �7 Name of Licensed Plumber/Gas Fitter: Firm/Company INSURANCE COVERAGE: I have a current liability nsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes �(No El If you have checked Yes, plea cate the type of coverage by checking the appropriate box below. A liability insurance policy 7 . Other type of indemnity E] Bond Ej OWNER'S INSURANCE WAIVER: I am aware that the licensee ELOes —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 Signat re of 0 vner or Owner's Agent Owner 1:1 Agent [j By checking this box[]; I hereby certify that all of the details and in mration I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the Gen rall-aws. the Gen ral Laws. Ty4le of License: By -17 Plumber Title E]Opas Fitter aria.. ;:itt. S I gn in aa- t - r L�Master ure Licens d Plumber/Gas Fitter City/Town E]Joumeyman License Number: APPROV (OFFICE USE NLY El LP Installer A The Commonweauh ofm assachusetts Department oflndustrlalAccide�ts Office of Investigations, 600 Washington Street Boston, M4 02111 Workers' Compensation Insurane Www-mass-govldia wlicant Ynforynnfin-n e Affidavit: BuRdersIContractors[Electricians[Plumbers Name (Business/Organization/Individual): Address: City/State/Zip: C. I Phone#: _� Y — __� / (a .— 0 /7 -) Ar _ 9�you an employer? Check the appropriate box: I am a employer with 4. El I am a general contractor and I employees (full and/or part-time).* 2.El I am a sole proprietor or have hired the sub -contractors listed partner- on the attached shget. I ship and have no employees These sub -contractors have working for me in any capacity. Workers' cOmp. insurance. [No workers' comp. insurance 5. We ate a corporation and its required.] 3. E] I am a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1 (4), and we have no insurance required.] f employees. [No woikefs, cOMP, insurance re ;r-11 1`yPe of project (required): 6. [] Now construction 7. EIRemodaing 8. El I5emblition 9. El Building addition 10 -El Electrical repairs or additions I I -E1 Plumbingiepairs or additions 12.El R �,ofrepairs 13.J��Oth !A-nY aPplicant that checks box #1 must also f 10 J L fidavit indicating they are doing all work and then hire outside c on Policy inform4ion. T I-Iomeowners who submit this af 11 ut the section below showing their workers, compensati I tCO12tractors that check this box must attached an additional sheet showing the name of the sub -r Ontradors must submit a now affidavit indicating such. I 'Ontractors and their workers' comp. Policy information. IaM an e7nployer that isproviding wo"'ers"Oompensation 11zsUranceJor MY eMP/oVees. Below is thep information. i 011cy andjoh site Insurance Company Policy # Or Self -ins. Lic. #: Expiration Date: Job Site Address -3 t" City/State/Zip: — - .A?kxl— Attach a copy of the workers' compensation Policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required Wider 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 P nalties Of Up to $250.00 a day against the violator. 0 in the form of a STOP WORK ORDER and a fine Be advised that a copy of this statement may be forwarded to the office of Investigations of the DfA for insurance coverage verification. r do hereb c - V th ePa1*7.s;—a1n�jp en r ofperjury & at th e infOTMation pro vided ab o ve is tru e an d correct. - - - . - /I I / '. Date: `JJ`;" use 0H(Y- DO not Write in th,is area, to he coinpletedby city or town official City or Town: PermitfUcense Issuing Authority (circle one): I. Board Of Health 2. Building Department 3. CRY/Town Clerk 4. F'Jectric 6. Other al Inspector 5. Plumbing Inspector ContactPerson: Phone 4:_ Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee i;defined as "...every person in the service of another under any contract of hire, express or implied, orA 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 ajoint ente ;seandincludin the legal representatives of a deceased employer, or the rpri 9 receiver or trustee of an individual, partnership, association or other legal entity, empl owner of a dwelling house having not more than three ap Oymg emPlOYees. However the artEments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenaricc, 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 shallwithhold the issuance -or renewal of a license or permit to operate a business or to construct buildings in the commonwealth forany applicant who has not produced acceptable evidence 0* f compliance with the insurane'd coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the common ealth nor any of its political subdivisions shall enter into any contract for the Performance OfPublic work until acceptable evidence of com�liance with th s c requirements of this chapter have been presented to the contracting authority.- ein uran e Applicants Please fill Out the workers' compensation affidavit completely, by checking the boxes fhat apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phorienumber(s) along with their certificate(s) of - insurance. Limited Liability Companies (LLC) or Limited Liability partilerships (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 In'dustrial Accidents for confirmatioaof insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retained 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 qyestions rega�ding the law or if you are required to obtain a workers' compensation policy.;please call the Depaitment 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 juves ligations has to contact you regarding the applicant.' US a Please be sure to fill in the Permit/licensc number which will be ed, s a reference number. In addition, an applicant that must submit multiple permithicense applications in any given year, need Only submit one affidavit indicqing current Policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in ty idavit that has been'officially stamped or marked b town)." A copy of the aff _(ci or y 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 ta any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT requited to complete this affi&vit. The Office of Investigations would like to thank you*in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: T U10 COMMoxwealt]-a- ofAflusachfusetts Department of Industrial Accidents Office of Investigati' . Lons 600 Washington Stmet Boston;M-A,02111 T01. R 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5 -26 -*05 Fax # 617-727,7749 Www.mass.jz-Gv/dia I- ) L;ujyjjvjvl-4vw------ - �:*-§ 0 kND GASFITTERS IN PLUMBERS A R Ap A&Vp Nkj�OPLUMIB I LICE��kq RICHARD J DOMEK DENAULT DRIVE MA oIB87-345 WILMINGTON Date.///,�a/��"/"�� .......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION so �4e This certifies that ........... has permission for gas installation J00 . /�w x .... 441 . ?� .......... in the buildings of .............. at Z�Z/17, N,orth,,,�,ndov-e.r.,-_-M.a.s.s-. Fee. Lic. GASINSPECTOR Check # 79 18 -CN- M TO DO GAS FITTING City/Town:-,& 40 MA. Date: 11-17— // Permit# Building Location::�� 4ryesr sz- Owners Name: AY"Ll G. Type of Occupancy: Commercial El Educational E] Industrial E] institutional El Residential New: Ej Alteration: Renovation, El Replacement: F� Plans Submitted: Yes No / ZJZZ�5z 7- ----FIXTURES co W W W z l-_ �d I- C6 U) U3 L) 0 IM M 0 Lu Uj 0 co co I-_ M l-_ 0 W W ZF- (D -J>- W — Mozww 0 z g z F) W W z W W 0 1-- DTM 55uj COLLJ wdo<� > LLI (L W W W Z 0 W WOWW .6LL W I- W < 0 _j LU V) 3: W W 0 > z 0 z _j 0 LL ZW>-WM_-J<<CQW0z0I-l._LUI--WW 0 25 W 0 > z = =)<WW- >090W Zw I oaowooxx-� [OR 0 SUB BSMT. BASEMENT I FLOOR 2 FLOOR 3 FLOOR 4 FLOOR 6 FLOOR 6 FLOOR 7 NFLOOR I---- �FL 0 �O�R -------- [—I -- Check One Only Installing Company Name: Corporation Address: City/Town: State:#I& El Partnership Business Tel: Fax: 01� El Firm/Company Name of Licensed Plumber/Gas Fitter: ?,ICAArd Q)OME4 INSURANCE COVERAGE: I have a current liability insurance policy or I . ts substantial equivalent which meets the requirements of MGL. Ch. 142 Yes)(No If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy)� . Other type of indemnity El Bond [_1 OWNER'S INSURANCE WAIVER: I am aware that the licensee Aoes —not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner El Agent By checking this box E]; I hereby certify that all of the details and intormation I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be In compliance with all Pert!Pent provision of the Massachusetts state Plumbing Code and Chapter 142 of the General Laws. By TLYpe of License: WrPlumber Title Gas Fitter Signature of Licensed Plumber/5-as �Fjtter 94aster City/Town Eliourneyman APPROVED (OFFICE USE ONLY) 0 LP Installer License Number: 0 V S The Commonwealth ofMassachusett Department ofindustrialAccidents 0 ffice of Investigationg 600 Washington Street Boston, MA 0211-1 www-mass,govldia WO-rkers' COMP ensation hsurance Affidavit: Builders/ContractorsfElectricians[Plumb ers mlicant rnforrnnfin-n Name (Busincss/Organizationffndividual) Address: City/State/Zip; #dLr& Phone#: Ar4you an employer? Check the appropriate box: I I am a employer with lb 4- El I am a general c ontractor and I employees (fWl and/or part-time).* 2.E1 I am a sole proprietor or have hired the sub -contractors listed partner- on the attached shget. t ship and have no employees These sub -contractors have, working for mein any capacity. [No workers' comp. insurance workers' cOMP. insurance. 5* El We aie a corporation and its required.] El I am a homeowner doing officers have exercised their all work right Of exemption per MGL myself. [No workers' comp. c. 152, § 1 (4), and we have no insurance required.] t employees. [No workers' comn- snrnni-A — —.4 '4pe of project (required): 6. 0 Now construction 7. El Remodeling 8. El liemblition 9. El Building addition 10. El Electrical repairs or additions 11.0 Plumbingiepairs or additions 12.0 Roofrepairs 13-RCther Afi,�, Y)r<-f_ !Alli aPPlicantthat checks box#1 must also fill Out the section be IV J I - . ' I low showing their workers' compensation Pullcy Intormation. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractOrs must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. -ram an e"PloYer that isproviding workers' Compensation insurancefor ----------- information. MY elnPloyees. Below is thepolicy andjoh site Insurance Company Name: MiCY # Or Self -ins. Lic. #: 604 0077,-)07 Expiration Date: 57—/_7� Job site Address:3LH4,,&,c;-,v- unl 3 City/State/Zip-A��,A-_/— Attach a copy of the workers' compensation Policy declaration page (showing the policy . number and expiration date). Failure to secure coverage as required Wider 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 fine of lip to $250.00 a day against the vidlator. Beadvised that a copy of this statement may be forwarded to the Office ok Investigations of the D9 for insurance coverage verification. rdohe under ffiefalns�\ndpenalt�s ofperjury illattIze '7 iftf0fillationprovided above is true and rnrrori D 7A uiilcialuseon,�v. DO not write in this area, to he completed by chY Or town official City or Town: PermittLicense Issuing Authority (circle one): I. Board of Health 2. Building Department 3. CitYlTown Clerk 6. Other 4. Electrical Inspector 5. ]Plumbing Inspector ContactPerson: Phone#. A IV Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee i;defmed 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 iii 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 apartiments and who resides therein, or the occupant of the dwelling house o . f 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 issua r r Bee .0 enewal of a license or permit to operate a business or to construct buildings in the commonwea th forany applicant who has not produced acceptable evidence Of compliance with the insuranc6 coverage required." Additionally, MGL chapter 152, §25C(7) st�tes "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpubhc work until acceptable evidence of com�liance 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 fhat 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 (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Irdustrial Accidents for coriffimatiort 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 qVestions rega�diug the law or if you are required to obtain a workers, compensation policy.; please call the Depahment 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 pennit/license number which will be used s a ref re c umber. ad tion, an applicant that must submit multiple Permit/license applications a e R 611 In di in any given year, need only submit one affidavit indic�ting 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 filebor future perruits or licenses. A now affidavit must be filled out each y6ar. Where a home owner or citizen is obtaining a license or permit not related tor any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affiddvit. The Office of Investigations would like to thank you*iu 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: IN, 1110 COMMOWKWealfla ofl\/Eassaclausetts De-pattment of ladustrial Accidents Office of lnve�tjgaflous 600 WashiWon Stmet Boston;MA-02111 Tol. 4 617-727-490o ext 406 ox 1,877-mAsSAFj3 Revised 5 -26 -*05 Fax # 617-727-7749 wwvv.mass.g-Qv/dia Date..///er�w/e`/*�"*,/�/a .......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 8-eqnl /, Z�� ............ This certifies that ................ ......... has permission for gas installation ee k -s / AV AR . .................... in the buildings of ........................................... at . . ,$!. / .,-5-77. aA, /./6-3 . I North Andover Mass. Fee. Lic. No./,?.40-'.. /� .e� .................... GAS INSPECTOR Check # 717-,5 79*17 Emd 95�:N MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town:./Q,A0 JCA/iff MA. Date:__J[Lj -7- Permit# W � .1 1 Building Location //63 Owners Name: NALI ib A111689 - Type of Occupancy: Commercial Educational E] Industrial 0 Institutional 0 Residential G. New: Alteration: El Renovation Reel ,�cement: E] Plans Submitted: Yes 0 No A A FIXTURES W (1) Cd LU W C* r4 z Lu �e C6 C/3 (0 Q Z: M Lu 0 (1) co 0 LLI Uj 0 co 0 W Lu 1`-- 0-1 COOMWIX z >- W 2 W 0 z Z z)- W Lu Lu W 0 F- M LU to LLJ 0 1-- . 0 < i -- co > UJ z 1-- < a. LU X 1Z co 0 Lu Lu LLI (0 0 LU I-- Ce < LLJ z 9 W M: Lu I-- > L) uj z F- 1-- 0 z -J! 0 ILL X: z ui Z uJ >- W C) -J f2 LU I.- LLI LU < < In LU 0 z 0 ca != > z 11- X: 0!�1X=)<lXu.jLu�>090LuZZuJ �- LL 0 0 X 0 > 0 SUB BASEMENT 15'FLOOR 2 Loo FLOOR 3 FLOOR 4 UH F OOR 6'" FLOOR dTw-F--LOOR w -F- L 0 -OR 8Tw-F-LOOR ............ rN 1 111,, 1111-111 � Check One Only Certificate # Installing Company Name: 6aa Aq �61-, Address City/Town: State: dCorporation A0 I qtl El Partnership T Business Tel: -11 -OIL[ Fax: Firm/Company Name of Licensed Plumber/Gas Fitter, A, -viwM4, INSURANCE COVERAGE: I have a current liability insurance policy or 1 . ts substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No El If you have checked �Les, please indicate the type of coverage by checking the 'appropriate box below. A liability insurance policy �Nl - Other type of indemnity [I Bond Ej OWNER'S INSURANCE WAIVER: I am aware that the licensee gLoes not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner 1:1 Agent By checking this box 0; 1 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 w ill be In complian C th H P rtinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the G neral Laws. I - --- - - ". "" ..' ' th G y e of License: P B y -6-4 'lumber E],,Gas Fitter S Tit, __jitt 1 n o Licens Signature o Licens Plumber/Gas Fifter Master City[Town []Journeyman APPROVED (OFFICE USE F1 LP Installer License Number: The Commonwealth ofMassachuseas DePartmfflt OfIndustrialAccidents OffIce Of Investigations, 600 Washington Street Boston, MA 0211-1 Www-massgovIdia Workers' Compensation Jnsurance Affidavit: Builders/Contractors[Flectricians[Plumbers )PHeant In 2ormation Name (13usiness/OrganizatioiAndividual): Address: IM City/State/Zip 177 ,A r on an employer. Check the appro riate box: P Iamaemployerwith. 4. El I am a general c ontractor and I employees (full and/or part-time).* 2. EJ I am a sole proprietor or have hired the sub -contractors listed partner- on the attached shgat. ship and have no employees These sub -contractors have working for me in any capacity. [NO workers' comp. insurance Workers' comp. insurance. 5. We aie a corporation and its required.] 3. El I am a homeowner doing officers have exercised their all work myself [No workers' comp. right Of exemption per MGL c. 152, § 1 (4), and we have no insurance required.] f employees. [No workers' comp. insurance re ;_-A I Type of project (required): 6. E] New construction 7. El Remodeling 8. El liomblition 9. El Building addition 10.0 Electrical repairs or additions 11 -El Plumbingr'epairs oradditions 12.E]Roofrepairs 13. [I-J"Other !Any aPPlicaut that checks box #1 mustalsofill out the section below showing their workers- compensation Policy inform&ion. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tCOntractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' COMP. Policy information. I am an employep th at is pro viding workers I cOM information. pensation insurancefor my employees. Below is thep011ey andjob site Insurance Company Name: f414 00� Policy # or self -ins. Lie. #: —)-Do-] — � �_ Expiration Date.:5- �) Job Site Address:—z &Vveu s -f 11VJ City/State/Zip Attach a copy of the workersq c * .iv, &)�,e ItIA ompensation Policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required Wider 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 fine Ofup to $250.00 a day against the violator. Beadvised that a copy ofthis statement may be forwarded to the Office Ot Investigations of the DU for insurance coverage verification. rdoh b le arns ere�� U re'r 11� alPenaldes OfPeriury Mat the !,,fo.,,,,,,,10,,p,.OIe, above is true and correct. _ 1, N , V -/ ?- z C=016�_Wff Off-'clal use only. DO 710t Write in this area, to be completedby c1V Or town official City or Town: PermitUcense # Issuing Authority (circle one): I. -Board of Health 2. Building Department 3. CitY/ToWn Clerk 4. Electri 6. Other calhspector 5- Plumbing Inspector Contact Person: Phone 4: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee i;defined as "...every person in the service of another under any contract of hire, express or implied, or�l 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 apartirtents and who resides therein, or the occupant of the dwelling house of anotber who employs persons to do maintenanee, 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 shallwithhold the issuanceor renewal of a license or permit to operate a business or to construct buildings in the commonwealth forany applicant who has not produced acceptable evidence of compliance with the insuraned coverage required. - Additionally, MGL chapter 152, §25C(7) st�tes "Neither the commonwealth nor any of its political subdivisions shall enter into any contract f6r 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 phonenumber(s) along with their certificate(s) of - insurance. Limited Li6ility Comp ' L th n anies (LLQ or Limited Liability Partnerships ( LP) with no employees o er tha the members or partners, are not required to cany 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 In'dustrial Accidents for confmation 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 qVestions regqding the law or if you are required to obtain a workers' compensation policy;please call the DepaAment 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 fM in the Pcimit/licensc number which will be used as a ref r c umb r. addit o , applic t that must submit multiple pennit/license applications in any given year, need e en 611 e In i n an an only submit one affidavit indicqing current Policy information (ifnecessary) and under " Job Site Address" the applicant should write "all locations in ty r town)." A copy of the affidavit that has been officially stamped or marked b o y the city or town may be provided to the applicant as proof that a valid affidavit is on file for future penjaits or licenses. A now affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related ta any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidivit. The Of -fee of Investigations would like to thank you'in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: Irl, Alle COMM-Ormealth o-04assach uietts Department of Industrial Accidents Office of ]Investigations 600 Washin&n Street Boston;MA-02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-'05 Fax # 617,727-7749 WWW.mass.jZ-QvJdja 7. Date ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... .................................... ....................... . .............. has permission to perform -1: .......... wiring in the building of ................ v at ............. . North Andover, Mass. > Fee./l.;V-? .......... Lic. Nol..4.,,,�. ................................................ I ELECTRICAL INSPECTOR,�' Check # 7846 OR N !L\ Commonwealth of Massachusetts MMMSMENOM Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. /Tev k Occupancy and Fee Checked Z [Rev. 9/05] (leave blank) L— APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), F7 CMR 1�60 (PLEASE PRBVT LV INK OR TYPE ALL LVFORMA TION) Date: 11,49� A77 I City or Town of: A046�� To the Inspeefor of ft -`es. - By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) -3 L6t:e-1-f- 04 - Owner or Tenanp Owner's Address Is this permit in conjunction with a building permit? El (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead [-] Undgrd [] No. of Meters New Service Amps Volts . OverheadEl Undgrd F-1 No. of Meters Number of Feeders and Ampacity a�w& -- 7;? No. of Self -Contained Detection/Alerting Devices Location and Nature of Proposed Electrical Work! _:277 lkal� 12 4yaiic� ,S�&Oal 41 -0 f- I �> 2�-) 1 JI" rr 7 Ad Completion q[MAe following ble ma2 be waived ky the,�Seector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of 1 .1 1 otal Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool grnd. d. - of Emergency Lighting Br4aftery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS ]No. of Zones No. of Switches No. of Gas Burners N—o.ofD&tec�Aad .. Initiatinz Devices Municipal No. of Dishwashers Space/Area Heating KW Local [:1 Connection 0 Other 3ec stems:* No. of Dryers Heating Appliances KW uNrol%=Aevices or Equivalent No. of Water No. of No. of Data Winhig: Heaters KW Signs Ballasts -- No. of Devices or Esuivalent :3o Telecommunications wiring: No. ]Rydromassage Bathtubs No. of Motors Total HP No. of Devices or Equivalent IOTHER: Attach additional detail if desired or as required by the Inspector of Wires. Estimated Value of Elptrical Work: 'Ir" (When required by municipal policy.) Work to Start: -ZZ1,A!2 /0 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE-C6VERAdE: Unless waived bythe owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE (2- BONDE] OTHER [] (Specify:) XPIRaT4QN DATE 9/30/2008 1 certify, tinder thepains andpenalfies ofperjury, thafthe information o is app n is ue and conplete. FIRMNAME: HELCO ELECTRIC INC. ro -L1C--N0--A16238 Licensee: Sb�r� (1-bg-4vv Signature LIC. NO.: (1fapplicable, enter "exeinpt " in the license nwnber line.) ,,��Bus. Tel. No.-q7R- 12-7ciOO Address: ZERO CENTENNIAL DRIVEx PEABODY, MA 0196 Alt. Tel.,No.: *Security System Contractor License required for this work, if applicable, enter the license number here: OWNER'S INSURANCE WAMR: I arn'aware that the Licensee does not have the Uability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check -one) E] owner [] owner's agent,, Owner/Agent Signature -- Telephone No. FPEZW T FEE: S Z&19= No. of Ranges Total No. of Air Cond. Tons No. of Alerting . Devices No. of Waste Disposers Heat Pump Totals: I Number I Tons No. of Self -Contained Detection/Alerting Devices Municipal No. of Dishwashers Space/Area Heating KW Local [:1 Connection 0 Other 3ec stems:* No. of Dryers Heating Appliances KW uNrol%=Aevices or Equivalent No. of Water No. of No. of Data Winhig: Heaters KW Signs Ballasts -- No. of Devices or Esuivalent :3o Telecommunications wiring: No. ]Rydromassage Bathtubs No. of Motors Total HP No. of Devices or Equivalent IOTHER: Attach additional detail if desired or as required by the Inspector of Wires. Estimated Value of Elptrical Work: 'Ir" (When required by municipal policy.) Work to Start: -ZZ1,A!2 /0 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE-C6VERAdE: Unless waived bythe owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE (2- BONDE] OTHER [] (Specify:) XPIRaT4QN DATE 9/30/2008 1 certify, tinder thepains andpenalfies ofperjury, thafthe information o is app n is ue and conplete. FIRMNAME: HELCO ELECTRIC INC. ro -L1C--N0--A16238 Licensee: Sb�r� (1-bg-4vv Signature LIC. NO.: (1fapplicable, enter "exeinpt " in the license nwnber line.) ,,��Bus. Tel. No.-q7R- 12-7ciOO Address: ZERO CENTENNIAL DRIVEx PEABODY, MA 0196 Alt. Tel.,No.: *Security System Contractor License required for this work, if applicable, enter the license number here: OWNER'S INSURANCE WAMR: I arn'aware that the Licensee does not have the Uability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check -one) E] owner [] owner's agent,, Owner/Agent Signature -- Telephone No. FPEZW T FEE: S Z&19= %Z1 The Commonwealth ofMassachuseds Department ofIndgtrial Accidents 01 office ofInvestigations 600 Washington Street Boston, MA 02111 www.mass.gov1dia U. Workers' Compensation insurance Affidavit: BuUders/Contractors/Electricians/Plumbeis Applicant lifformation Please Print Letzib Name (Business/Organization/Individua . 1): Helco Electric, Inc. Zero Centennial D:�ive Address: City/State/Zip: Peabcldy, KA 01960 Phone 0: �978-532-7500 A u an employer? Check the appropriate box: Fam, 4 1 am a g6nierai contractor and I 1, a employer with employee<�nd/or —part-time).* have hired the sub -contractors I 2,0 1 am a sole proprietor or partner- listed on the attached sheet, ship and have no employees These sub -contractors ha,�e, working for me in any capacity. workers' comp. insurance. We area corporation and its (No workers' comp, insurance officers have exercised their required.] 3. 1 am a homeowner doing all work right of exemption per MGL myself. (No workers' comp. c. 152, §.1(4), andwe have no employees. (No workers' insurance required.]. t comp. insurance required.] Type of Project (reqn1red): 6, D New construction 7. E] Remodeling 8, F] Demolition 9, D Building addi.tion 10,VElectrical repairs or additions. I I,E] Plumbing repairs or additions 12.[] Roof repairs 13,E] Other, on Oil InforMatiOn. compensati P LCY *A,hy applicant that checks box #I must also fill out the section below showing their workers' tHomeowners Who submit this affidavit indicating they are doing all work and then hire outside contructcrs mustsubmit-a tContractors that check this box must attached an additional sheet showing the name ofthe sub -contractors and their workers' comp. policy inTormadon. I ant an entployer that is providing workers' compensation insurancefor my .. �ntplqyees. Below is thepolicy andjob site information. Insurance Company Name: :-nurance Co. Policy # or Self -ins. Lie. WC1 . - 1.0-0 06010 0 Expiration Date: 9-1. 0-12.0. 8 .1 - — 'F e-- * -Z'4 Job Site Addrem _=� / ( Z e74k2-1 , 4 v ' r AttRch a copy of the workers' compensation policy declaration page (showing the policy number and expieation date). Failure to secure coverage as required under Section 25A of MGL c, 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the.Office of ance fication.. investigations of the DIA for i* �9� I do hereby certify under ty,?pains -6-djoenalties '7 C n n that the information provided above �7 true anVorrect official use only. Do not write in this area, to be completed by city or town official. City dr Town: issuing Authority (circle one): 1, Board of Health 2. Building Department 6. Other Permit/License # 3. City/Town Clerk 4. Electrical In8pector S. Plumbing Inspector Phone contact Person: 4 :�-� I �;. > 72 Or 0 40 - to Ur C, -0 00 s IS 4.1 o A Z CD CD ca 0 W Z, E 0 .02 kn 00 r. C) cd C4 cm ct cr, qu Q Q > 72 Or 0 40 - to Ur C, -0 00 s IS 4.1 o A Z CD CD ca 0 W Z, E 0 .02 coloc" tes tote aL - e 1 0�2 Ya% 3 VsL �el,15C fu iWinp) colgao, yholle*. Naa-ress*. C:Ity . State-. 1)e,vevoVl-- j,t Vealty IB Nortlivo StTeet� sxilte '13, SVftoli MX 01945 �Sorth AsIdOvev' glg_3,21-6540 p abo-ut 0'a, Of OAIT i-aformatjol:� . �Ie form beIO'w -v O -r s 'Please f -A IIN itle coynvmll� VIP code*. -�,O �,-Qw Qpwp!,;�� )WOITW-5 QQW-0— - SN,V�� '.x 0 Y- 0 VKJ') /— � 1 5 /7�T= zY/ 6- jyl� 09d )),41 4i,� Ic-fi 6 rt /L r"co Northpoint Realty Development - Contact Massachusetts - Maplewood / Oakridge - Powder Mill Square - Peachtree Farm - Maritime Landing Price Range: Select one I . How did you hear about us? Comments: C Northpoint Realty Development, Corp. Each Community is Independently Owned and Developed http://www.northpointllc.com/contact/ Page 2 of 2 7/30/2008