HomeMy WebLinkAboutMiscellaneous - 30 MARTIN AVENUE 4/30/20181 --7
P m
Date
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that
. .........................
has permission to perform . 6
. .............................
plumbing in the buildings of . 11 ...................
at ... North Andover, Mass.
h
Fee T,,(--. �-n
PLUMBING INSPECTOR
Check # K 2--OZ4(.0 log or)5
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
j]PERMIT#
CITY MA DATE 1 1 _S_:
JOBSITEADDRESS MAIM ----= OWNER'S NAME
POWNER
ADDRESS %___ __1 TEL __IFAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL DI EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY
NEW: Or RENOVATION: REPLACEMENT: Ell PLANS SUBMITTED: YES 0 NO
FIXTURES -1 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 —A
DEDICATED GREASE SYSTEM L_j L__3
DEDICATED GRAY WATER SYSTEM . . . . . . .
DEDICATED WATER RECYCLE SYSTEM .---j J I _J
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER L_J
FLOOR /AREA DRAIN -------
INTERGEPTOR (INTERIOR) =77-3
KITCHEN SINK 7_73 -1 ____j
LAVAPORY i _2-J J ___3
__�Q_QF
—DRAIN
rc\
-M E -7—D — - -----
L 11
SHOV�'ER STALL L_J ___1
_j
ERV ICE/ MOP SINK I j
01 ET
00
RINAL F - __j - ------ _J
I ASHING MACHINE CONNECTION
TER HEATER ALL TYPES
WATER PIPING
OTHER
J 11.1—-j L_,I
F -7-7-11
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES Eq NO Ell
IF YOU CHECKED YES, PLEASE INDICATE 7TPE 01 COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 01 BOND F-11
tWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance cove rage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details information I have or entered regarding this application are true and accurate to the best of my knowledge
and submitted
and that all plumbing work and installations performed under the permit issued for this application will be in complianceAvith all Pertinent provision ofthe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. fiun44 -
PLUMBER'S NAME # SIGNATURE
MP De ip [I CORPORATION [:]# PARTNERSHIP 0# = LLC
COMPANY NAME ADDRESS
CITY STATE ZIP TEL
FAX CELL EMAIL F
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The Commonwealth ofMassachusetts
De
,partment of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Buflders/Contractors/Electricians/Plumbers
A-Pplicant Information Please Print Legibly
NaMC (Business/Organization/Individual): T)ftiq R464+41b-c
Udress:_2410 wcstimaoroN
City/State/Zip:"t4 M4 02,1SO Phone 4: 6(J 4; 4 - WI:;0
,re you an employer? Check the appropriate box:
F1 I am a employer with
4. El I am a general contractor and I
epaployees (fall and/or part-time).*
-in
have hired the sub -contractors
E31- a 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' comp. insurance
5. El We are a corporation and its
required.]
officers have exercised their
F1 I am a home -owner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees.. [No workers'
comp. insurance required.]
Type of project (required):
6. New construction
7. E] Remodeling
8. E] Demolition
9. EJ Building addition
10. F1 Electrical repairs or additions
11. F1 Plumbing repairs or additions
12.E] Roof repairs
1311 other --
y applicant that checks box# 1 must also fill out the section below showing their workers' compensation policy information.
)meowners Nvho submit this affidavit indicating they are doing allwork and then hire outside contractors must submit a new affidavit indicating such.
Aractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. poli6y information.
n i7n employer th at is providing workers' compensation insurancefoT Yny empl . oyees. Below is thepolicy andio� site
)rTnation.
irance Company
icy # or Self -ins. Lid.
Site Address
Expiration Date
City/State/Zip;
ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
ure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
up to $1,500.00 and/or one-year imprisomnent, as well as civil penalties in the form of a STOP WORK ORDER and a fine
p to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
,stigations of the DIA for insurance coverage verification.
h efeby certify under th e pains an dpen alties ofterjury th at th e information pro vided abo ve is trite and correct
00
01
D'telal itse only. Do not write in'this area, to he completed by city or town official
,ity or Town:
Permit/lAcense
;suing Authority (circle one):
)Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
Other
'-4
Informaflon and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defiried 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 entit:� 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 therem",' or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling libuse
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 operatea 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 contract' authority."
1119
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessaM 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
)f the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
:'lease be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
hat must submit multiple permit/license applications in any given yearneed only submit one affidavit indicating current
)olicy information (if necessary) and under "Job Site Address" the applicant should write "all locations in city or
own)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
Lpplicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
'ear. Where a home owner or citizen is obtaini�g 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 NOTrequired to complete this affidavit.
."he Office of Investigations would like to thank you in advahce for your cooperation and should you have any questions,
,lease do not hesitate to give us a call.
he Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office, of Investigations
600 Washington Street
Boston, MA 02111
Tel. 9 617-727-4900 ext 406 or 1-877-MASSAFE
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
...........................................................................................................
has permission to perform "- rb--po'-�
..........................................................................................
wiring in the building of .........................................................................
o .......... �&je�6 . . ........ -North d
An over, Mass.
Pee ......... Lic. No.'�
.....................
ELE=CAL IOSPEIC�TO�R
Check #
11584
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 11 5B4
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 (MEC 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORW TION) Date: 9' 1 �, 'IS
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) 3 6 M AC k -i OJ
Owner or Tenant TC, P, &J tj &- y of t Telephone No.
Owner's Address
Is this permit in conjunction with a budding permit? Yes 19" No R (Check Appropriate Box)
Purpose of Building �, S N4 �t ttoo m-�, Utility Authorization No.
Existing Service 106 Amps A) ZZ Volts Overhead Undgrd No. of Meters
New Service — Amps Volts Overhead Undgrd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: -50-C4CAJ 000C df- �IOK6
Completion ofthe followin-e table mav 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
Above [3 In- o
Swimming Pool arnd. grnd.
Ao. of Emergency Lighting
Battery Units
No. of Receptacle Outlet
No. of Oil Burners
FIRE AL
o. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
Total
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Tons
I KW
o. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local [] Municipal [] Other
Connection
No. of Dryers
Heating Appliances KW
-Se—curity Systems:*
. No. of Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Eauivalent
No. Hydromassage Bathtubs
No. of Motors Total HP '=Teecommunications
W ring:
No. of Devices or Equivalent
OTHER:
rk� Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Wo (When required by municipal 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 [9�' BOND [3 OTHER rl (Specify:)
I cerWfy, under the pains andpenafties ofperjury, that the information on this appfication is true and conrlete.
FIRM NAME: L I C. N 0. -- C--3- - 5 4 S�A
Licensee: -e�). �c C0/3, Signature_ LIC.NO.:
(If applicable, enter "exem ". th I' ber line)
pt in e 1c nse num Bus. Tel. No.-,
C -tN -
Address: A 0 (4qL( Alt. Tel. No.: lk)s
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. sq-eq�
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the li ility insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (chec: c one) [] owner 11 owner's aaent.
Owner/Agent
Signature Telephone No. PERWT FEE: $
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Pit,
The Commonwealth ofMassachusetts
Department of]ndustrialAccldi�ts
Office of Investigations
600 Washington Street
Boston., MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/ContractorsAElectriciansIPlumbers
Applicant Information Please Print Legib
t t..- 4
NaMe 03usiness/Organization/Individual).
Address: 3 L Lat it
City/State/zip: v\k61v%A
_vb-10 L k*t 6141ILD phone, #: 3
Are on an employer? Check the appropriate box:
Type of project (required):
171 am a employer with
4. El I am a general contractor and 1
6. El New construction
employees (fall and/or part-time).*
2.0 1 am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet $
7. [:] Remodeling
ship and'have no employees
These sub -contractors have
8. E] Demolition
working for me in any capacity.
workers' comp. insurance.
9. [] Building addition
[No workers' comp. insurance
5. El We are a corporation and its
I O.CfElectrical repairs or additions
required.]
3. 0 1 am a homeowner doing all work
officers have exercised their
right of exemption per MGL
ME] Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12.E] Roof repairs
insurance required.] t
employees. [No workers'
Mr! Other
comp. insurance required.] _J
!Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
T Homeowners who submit this affidavit indicating they are doing all. work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is
information.
Insurance Company Nan
workers'compensation insurancefor my employees. Below is theTollcy andjob site
tf -, 4 (JN4 � (R �0
Policy # or Self -ins. Lic. Expiration Date: It
Job Site Address: f 0 pity/State/Zil': NO (tin, A4,1 VJ VW I hA
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one --year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Idohereby,�c�und,eriliepainsandpenattlesofperjuryt7iattlieinforinationprovidd bove rYrue and correct
N. Date: 13
Phone#:
Official use only. Do not write in this area, to be 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
Contact Person: Phone
Information and Instr4"u'dion - S.
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for, their employees.
Pursuant to this statute, an employee is defined as "....every person in . the service'of another under any contract ofhire,
express or implied, oral or written."
An employeiis 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 t6 be an employee,
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 requ,ired."
Additionally, MGL chapter 152', §25C(7) states "Neither the commonweafthnor any of its political subdivisions shall
enter into any contract for the performance ofpublic work -until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
e ir rtif te(s) 0
necessary, supply sub-contrartor(s) name(s), address(es) and phone numb r(s) along with the ce ica f
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 confim�ationof 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 lic�nse 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 Rue.
City or Town Officials
Please be sure that the affidavit is complete and printedlegibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Pleas ' e be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications mi'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 faturepermits or licenses. A now affidavit must be filled out each
year. Where a home owner or citizen is obtaftiffig 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 Investigationswould like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachwetts
Department ofindustrial Accidents
Office of Investigatio-lis
600 Washington StQet
Boston, MA 02111
TO, # 617-7274900 ext 406 or 1-877,:MASSAFF,
Revised 5-26-05 Fax# 617-727-7749
__WWW-mQss,goV/dia
���-,%,OMMONWEALTH OF MAS8ACkUS
ETTS
ELECTRICIANS
:AS A, U
Lq JOU SN ELEC'
ffN
ov A TRICIAN I
S THE A Lyl CME N E "TO:
-'-.,..�DAVID,� Ct,ROBINSON
-4 q
3 1 -W E S T W IN D D R
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E T NO E N
This certifies that
Date ..... on.I't�
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
-1 �)w Rt��-"p'j
............................................................................................................................
has permission to perform . .... .... P ....... A ..... j ........ z ....... �f . .....................
.... ..... ...... .......
winngin the building of ................................. ...... ............... ....................................
H Andover, Mass.
a, (x JL -
............................................... 0
. ....... Lic. No.-Z)C5�3.6 ........... t4.6r*.-'.-'.*.'.�.'.. .. .
................ ....
L** E- C M C A L
Check'4
11533
Commonwealth of Massac'husetts Official Use Only
Permit No.
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. i/o7]
(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
(PLEA SE PR1NT IN HK M. TYPEA LL J NFORMA YYON) Date: C:�., / c — /-3
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) o M ek (-+ 1 14
Owner or Tenant \�o P, &zk,)fr P'a I gel Telephone No.
Owner's Address CNV,,.0
Is this permit in conjunction with a building permit? Y 0' (Check Appropriate Box)
Purpose of Building IE:�[ F'C,+ r rc-tt t 5 49 r -i-, CC �J r� Kili qyAuthorization No. ((412 36q,5
Existing Service tk� Amps fZ40 / 2SUYolts Overhead Undgrd No. of Meters
New Servic t0b Amps 19'0 /7-,COVolts Overhead Undgrd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: esf-A &Y- H" -f - Ori Ll e k--�-,L
el - (k I- r, 4-cv-t a- r 0 r- kt*r—t
Completion ofthe followin-e table mav be waived bv the Inspector pf Wires.
No. of Recessed Luminaires
No. of CeiL-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminalre Outlets
No. of Hot Tubs
Generators KVA
lNo. of Luminaires
Above Ei In-
Swimming pool grnd. grnd. El
Bat-tefrE mergency Ligliting
V Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
IN'o. of Zones
No. of Switches
No. of Gns B urners
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
J.KW ...........
...........
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local E] Municipal El other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
. No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total lip
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
4 CJ�/ Attach additional detail i(desired, or as required by the Inspector of 07res.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: A
,4t4p Inspections to be requested in accordance with NIEC 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 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.
CHECK ONE: INSUIRANCEE] BONDE] OTHER 0 (Specify:)
I certify, under thepains andpenalties ofperjury, that the information on this application is true and com lete.
p
FIRM NAME: LIC. NO.:
Licensee: 4��, A p1r, Signature V(D-t4VZO LTC. NO.:
(If applicable, enter t', in thedicose number lipe.) Bus. Tel. No Il 3a;
Address: exein Or. Ab�R� PKP. Alt. Tel. No.
.yt W
*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 (che one)EI owner E] owner's agent.
Owner/Agent
Signature Telephone No.— MHITFEE.- $
q1)
�5-0
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. 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 commended 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,
El Rule 8 — Permit/Date Closed: Note: Reapply for new permit 0
0 Permit Extension Act — Permit/Date Closed:
Trench Inspedion-
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass
Failed
Re- Inspection Required 0
Inspectors Comm nt4n
i,J )I- -
r /
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass M -
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass M
Failed M
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
�IN:)PECTJON:
Pass
Failed
Re- Inspection Required El
Inspectors Comm%�ts:
�7-
Inspectors SignAture:
I ",/D a t e:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac-com
The Commonwealth ofMassachusetts
I 1W Department of IndustrialAccid��ts
Office of Investigations
600 Washington Street
Boston, MA 02111
VV www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/ContractorsfElectricians/Plumbers
Applicant Information Please Print Le2ib
Name (Business/Organization/Individual):
Address: 1, '17
City/State/Zip: YWVIC�03 YAK GO 0 Phone
Are pu an employer? Check the appropriate box:
1. 9 1 am a employer with 4. E] I am a general contractor and 1
Type of project (required):
6. n New con,struction
employees (full and/or part-time).*
have hired the sub -contractors
7. F1 Remodeling
211 1 am a sole proprietor or partner-
listed on the attached sheet. �
ship and'have no employees
These sub -contractors have
8. E] Demolition
working for me in any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5. El We are a corporation and its
9. E] Building addition
10. O'Electrical
required.]
officers have exercised their
repairs or additions
3.0 1 am a homeowner doing all work
right of exemption per MGL
ILE] Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12.E] Roof repairs
insurance required.] t
employees. [No workers'
13.[i Other
.1
comp. insurance required.]
!Any applicant that checks box #1 must also fill out the section below showing their workers'compensation policy irformation.
T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showm*g 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 thepolicy andjob site
Insurance Company
Policy # or Self -ins. Lic. (42d Expiration Date:
J
-2
Job Site Address: 76 MAK-6 N- AU)bf Citv/State/Zh): &k *401/67C,
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Idoherehyx.er4&ui�derfile I ams andpenalfies ofterjury that the information provided qhove trueandeorrect.
Sianature: �kl,_ Date:
Ir 4CA Ut IQ rrf-f 6 , Lr ("
Official use only. Do not write in this area, to he completed by city or town official.
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone N:
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 oftire,
express or implied, oral or written."
An employeris 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 Eno.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant,
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 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 aiid . fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office offavestigation,%
600 Washington Street
Boston., MA 02111
Tel, # 617-727-4900 oxt 406 or 1-877rMASSAFE
Revised 5-26-05 Fax 4 617-727-7749
www.mass,gov1dia
-COMMONWEALTH OF MASSAd
HUSETTS:-_.
-ELECTRICIANS
-AS A, JOU
Lp 'ELECTRICIAN
TO;
IS U S THE Aff0VVjfflSNE
��---DAV I lj,-'-C, ROB I NSD
3 .-WESTWIND
it
THUEN
ME'
M A 0 184.
4
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATIO�
Permit NO: Date Received
Date Issued: ��] 3
—IMPORTANT:
LOCATION'.
PROPERTY (DW - NER JOS
1;00
MAP,N-0: P, A R C IE L: M-'-' �
must
,ornplete all it ems on this
MaChine.�bnop, V,111
na',
no,.
no
.TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
[I New Building
6<O'ne family
El Addition
0 Two or more family
[I Industrial
--W
Alteration
No. of units:
El Commercial
El Repair, replacement
11 Assessory Bldg
El Others:
El Demolition
D Other
El Sepft, 0 We#;'
_0 F 16 o- d' lain- 0 Wetlands
0. W�fbrihed; D-istrict,
D Waterl8ewer
DESCRIPTION OF WORK TO BE PERFUKMhU:
VYA>Y,q
VoAwaj� 2 -
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
()y4le—
Address:
I
Hi om& [Mprovement'License,
;0. Date:
ARCH ITECT/ENGI NEER Phon
Address:
Reg. No
FEE SCHEDULE: BULDING PERMIT. MOO PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON 125.00PERS.F.
'2
Total Project Cost: $ (2t2L FEE:
Receipt No.:
Check No.: ��L2
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
gnafdr&d ontfactor--:�'.:
"',--wher c
gilA'
Plans Submitted Plans �ai)Ud 0 Certified Plot Plan D Stamped Plans
Building Department
The folitowing is a list of the required forms to be filled out for the appropriate. permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
u Building Permit Application
u Workers Comp Affidavit
u Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Li Copy of Contract
• Floor Plan Or Proposed Interior Work
• Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
• Building Permit Application
• Certified Surveyed Plot Plan
• Workers Comp Affidavit
• Photo Copy of H.I.C. And C.S.L. Licenses
• Copy Of Contract
• Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (if Applicable)
• Mass check Energy Compliance Report (if Applicable)
• Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
• Building Permit Application
• Certified Proposed Plot Plan
• Photo of H.I.C. And C.S.L. Licenses
• Workers Comp Affidavit
Lj Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (if Applicable)
• Copy of Contract
• Mass check Energ y Compliance Report
• Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all casci if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the app�-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subin'tted with the building application
Doc: Doc.Buhding Permit Revised 2012
Dimension
Total square feet of floor area, based on Exterior dimensions.
Number of Stories:— 2
C—
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21 A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use
D Notified for pickup - Date
Doc.Building Permit Revised 20 10
Plans Submitted [I Plans Waived 11 Certified Plot Plan [I Stamped Plans 11
T�TE OF -SEWERACTE.DISPOSAL
Public Sewer
Tanning/Massage/Body Art F]
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales
Private (septic tank, etc.
Permanent Dumpster on Site F1
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED
PLANNING & DEVELOPMENT F1
DATEAPPROVED
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decisionlreceipt submitted yes_. -
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/signature & Date Driveway Permit
DPW Towo Engineer: Si g -nature:
Located 384 C
FIRE �D�PA'P,'TMEN-'T'''-"Te"'m-p Dumpster on site yes no—
Located at'U4 Main'Str6et
Fire Depa'ai4br�ii-sii�n'a'tUtb/dato,
COMMENTS
ood Street
Location �.5 a a a, �-,o ef7e-e—
Date
MOMM M-
Check,_1 7
26396
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $X—�
Foundation Permit Fee
Other Permit Fee
TOTAL
Building Inspector
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
21,200.00
m
-$
$ -
$
254.40
Plumbing Fee
$
31.80
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
31.80
Total fees collected
$
418.00
30 Martin Avenue
766-13 on 5/15/2013
Renovate 2 Bathrooms
:ISOTEC REMODELING INC PROPOSAL 06512012
113 - Breeden's Lane - Revere - MA - 02161
Phone:781-443-5665 or 781-983-1682
Date: 12/3012012
Proposal Submitted to,
Jo Ann Foley
30 - Martin Ave - North Andover - MA
DESCRIPTION OF THE WORK TO BE DONE
Full Bathroom remodeling
1 - Demolish bathroom and remove all trash related to the job.
2 - Upgrade carpentry, plumbing and electric where necessary.
3 - Install applaiances
4 - Install insulation, green board, ciment board inside shower.
5 - Install playwood and cement board on floor.
6 - Install tiles inside shower.
7 - Install mold and baseboard where necessary.
8 - Install tiles on floor.
9 - Paint.
2nd Bathroom remodeling
I - Plumbing and electrical instalations
2 - Build wall to separate the new bathroom from the old one
3 - Install new applaiances
4 - Install insulation, green board, ciment board inside shower.
5 - Install tiles inside shower.
6 - Install tiles on the floor.
7 - Paint
Client is responsible to purchase the following:
(Tab shower, sinks and vanities, toiletes, faucets, floor tiles, wall tiles,
shower valves, mirTors, granite counters top and decorative lights)
Total Labor Cost and rough materials
$21,200.00
Payment:
50% at the beginning of the work
30% when pass rough inspection
20% when the job is completed
Costs for all necessary permits are included.
All material is guaranteed to be as specified, and the above work to be performed in
accordance with the drawings and specifications submitted for the above work and
completed in a substantial workmanlike manner for the sum above,
Any alteration or deviation from the above specifications involving extra costs will become
an extra charge over and above the estimate.
All agreements contingent upon strikes, accidents or delays beyond our control.
Acceptance of Proposal
TO" OF NORTH ANDOVER
OFFICEOF
BUILDING DEPARTMENT
....1600 Osgood Street Building 2o, -Suite 2-36
North Andover, Massachusetts 01845
Gerald A. Brown
Telephone (W) 688-9.545
Inspector of Bm"Idings F�x (978) 688-9542
HOMMORNER LICENSE EXEY2TION
BUIDINGPERMT APPLICATION
Liege R�
rin
DAM,
JOB LOCATibN:
f
63 9 VADL A-WUL UN6 MaplLot
on88Sb2-IS9
WYMOWNER — -----
Name Rome Phone h
WorkPhone
PRESENT MAILING ADDRp_SS
VJOA/4-7
D
Qt� To-vlm zip Code
The current exemption for'lomeow—nere, was r
,Xtenaed to -Laiclude owner-occlipied dwellings ta two units T less anr
to allow su"b horn ` Own ers to el 'gage, an in d i vi dual for b ire Who CIO eS I lot P D S S CS S a* -11 Mns e, pro v! ded th at th e o wner
acts as supervisor). State Buh djug (Code Section 108.3.5. 1)
DEFINITION OF 1-jolymoWNER
Person(s) who
_9wns aparcel of land onwhichhelsheresiaes orintonds t6reside, o which creisorisintendedto
be, a on' n th
e or two fimily structures. A person who constructs more that one home in a two-year period shall not be
considered a homeowner.
The undersigned "homadwneel assumes responsibility for compliances with the State Building Code, and other
Applicable codes, by-laws, rules andregulations,
The undersigned "homeownor"certifies t
hat he/she lmderstands the Town of 11orth Andover Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements,
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
ROVISed 7.2009
Form Honieowners Exmmpfion
13DAR*D OF APPEALS 688-9541 CWSERVATION 688-9530 BEALTH 688-9540
PLANNNG 688-9535
ompensatij,
Workers' C
The Commonwealth ofMassachuseas
Department ofJhdustriqlAccW�ts
Office of Investigations
600 Washington Street
Boston., MA 02111
NaMe (Business/Organization/Individual):,
www.mass-govIdia
Affidavit: Buflders/Contractors/Ele,ctriciansfPlumbers
Address: MIK-ti V1 _V
City/State/Zip: AJ� VY A 01
M 7 (S 0- to 2(c��9
C98
Are you an employer? Check the appropriate box: -
LEI I am a employer with
4. El I am a general contractor and I
employees (M and/or part-time).*
have hired the sub -contractors
2. F1 I am a sole proprietor or partner-
listed on the attached sheet.
ship and'have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. El We are a corporation and its
required.]
officers have exercised their
AI am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1 (4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Typo of project (required):
6. [] New construction
7. boemodeling
8. [] Demolition
1
9. El Building addition
ME] Electrical repairs or additions
ILE] Plumbing repairs or additions
12.Q Roof repairs
nFl other
'.Uny applicant that checks box #1 must also fill out the sectionbel6w showing their workers' compensation policyinformation.
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 checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that isprovialng workers'compensation insurancefor my employees. Below is thepolicy andjob site
information.
Insurance Company
Policy # or Self -ins. Lie.
Job Site Address:
Expiration Date:
Pity/StatelZip:
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fme,
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 herebv certM under the pains andpenattles ofperjury that the information provided above is true and correct.
Information and -Instruction's
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation foi 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 em
ploydis 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 constiruct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence of compliance with the insurance coverage requ,ired."
Additionally, MGL chapter 15�, §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 anLLC orLLP does have
employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents far confirmationof insurance coverage. Also be sure to sign and date'the affidavit. The affidavit should
be returned to the city or town that thei application for the permit orlice'nse 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 printedlegibly. 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 * a 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 applicationsi any given year, need only'submit one affidavit indicating current
Policy information (if necessary) and under "Job Site Address" . the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit ii on file for future Permits or licenses. A new affidavit must be fillQd 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'emiit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations . would like to thank you in advance for your cooperation and should you have any questions,
pleas a do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commo-Moalth of Mossaphv
Department ofindustrial Accidents
Oface of filvestigatiom
600 Washington StrQet
Bostm, MA 02111
Teel, # 617-727-4900 ext 406 or 1-877,MASSAFE
Revised 5-26-05 Pax# 617-727-7749
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