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Miscellaneous - 305 BOSTON STREET 4/30/2018 (2)
r / 305 BOSTON STREET f 2101107.D-0005-0000.0 mt*SAUILDING FIL a Date..C....a...................................... NORTH °ft"`° '•�"° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING CHU r�This certifies that ................................................................... ........................ has permission to perform /tip--e A,�f ................................................................... ..... wiring in the building of.... 6......... .f...�....... 3 ,...e 4 ,f f �.... 5 �............�,North And ,Mass at......�`...... Fee.S Lic.No..I.Y 0 �. y .... ?:. <L' ECTRICAL INSPE �R t Check # `t 0872 . Oficial Use OnlyCommonweaIthof Massachusetts A Department of Fire Services permit No. �?Z_ BOARD OF FIRE PREVENTION.REGULATIONS [Reccl an�yandFeeChecked \ (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK S All work to be performed in accordance with the Massachusetts Electrical CodeC) 27 CMR 12.00 (PLEASEPRWTININKORTPPEALLINFORMATION) Date:_ � , i Z City or Town of.•FORTH ANDOVER To the Inspector of Wires: %N1 BY this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 3QS— Owner or Tenant ,4 Q� �� )2r&,Pe1WP Telephone No. Owner's Address Is this permit in conjunction with a bN"m lding permit? Yes ❑ No ❑ (Check Appropriate Box) l� Purpose of Building P1,--e Utility Authorization No. iA✓ C Q Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service ZOO Amps LIC/ Volts Overhead❑ Undgrd ZJ/ No.of Meters I Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �/� //ay S e Com letion o the ollowin table mavhe waived b,E the Inspector o Wires. No.of Receised Luminaires No.of Ceil.-Susp,(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators :A_7:d No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency ig rnd. rnd. Battery Units N[No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones of Switches No.of Gas Burners No.of Detection and Initiatin Devices of Ranges No.of Air Cond. Tons l No.of Alerting Devices of Waste Disposers Heat Pump Number Tons _KW N-0--of Self-Contained Totals: Detection/AlertingDevices i of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connectionof Dryers Heating Appliances , Security Systems:Y- o.of Water No.of Devices or Equivalent KW No.of No.of Data Wiring: Heaters Si s Ballasts No.of Devices orEquivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent / /Ittach additional detail if desired,or as required by the Inspector of Wires. Estimated Value f E ectr' al Work: ! of i�/ (When required by municipal policy.) Work to Start: !� $� 'Z Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVE GE: 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 ®-1BOND ❑ OTHER ❑ (Specify:) Icertify,udder theains and penalties oterjury,thn_t the information on this application is true and ConnI t* FIRM!NAME: �d�al T ��/e L fe v V % LIC.NO.: Licensee: S'g✓V1 Q Signature LIC.NO.: (Ifapplicable,enter`exempt"in the license nu a line.) f , Bus.Tel.No.;�'t 27G 73 Address: 1 C ti Ite e l+S /+ /1�/Q Alt.Tel.No.:'32k 1-62 IL919 'Per M.G.L c.147,s.57-61,security work requires Department o ublic Safety"S"License: Lie.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one []owner ❑owner's agent. Owner/Agent _ Signature Telephone No. PERMIT Y • .�+��I.I�V�{{I,.��-��-(�((/�+•(J�l�■•J'((Jyy{.��{�1■yt(J�U'/.J.1�•■�®p���' P`QQ�;{;Q�('T •}�{� .•V.{/.J�JIJV�V.ti7 ll������ � , •C(JUJ�.IV.f..RV.\J •Lj\��f•J-+\I�•.O•Lv.� • ^ . •• S .1..L40l.l AY�,•lJ.(17�.':+�.+JI�OJ.Vt �• •• , 7�assec�• I+aile8-[ ] �e-znspeetion requzz'ecT($50.00)•-X inspectors omme - (Z• sp ectors"Bi ature-n idijals) pate PasseaL Vaflearl I ate-xnspectiottrequired($50,00)-•[ � IMpectoris'commeafs: ft4ectors'higuature-•no Wtials) v� � • /Z �,ti date —?—/ 3.MDYR '10 TIND INgROCTION. , Dassetl- I+'afIecl--[ ate--ins action xequfrea($50,00)�[ ] Inspectors'comments: MI/ (Inspectors} ignatuxe-noiuifials) ))ate 4. )NSPECWON--,9WMV 0,: DI A.!l+l MILE,—0 N t x OM C-9:11); NAM: Ide-9nspectfonrequired($50A0)-•j � Inspectors'a meufs: . r (filspectors' ign�ture••Sao w 'als) Date 'assed-[ ) Iailed [ ]. 7Le xnsp ection require0($50.00) j asci ectors'co7o_unents: (inspectors'Signature-3ao xnffials) Date ' DOOR TAGS APX TO BE D'ZGEED OVI AT D IEF+T ON SITE N TBE•AREA.TO DE MPECT`.ED JCS NOT ACCESS-OU.AND•A.RE USPECTxON O)T-$50,Q D INTO 33F,CHARGED. - r ' r The Commonwealth of Massachusetts - Department of IndustriqlAccidiiits Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/fndividual): '`o�K T1 C P eV fiey �t . Address: I Pee;c J - City/State/Zip: 4 1,%s hvvy AAA Oil S L Phone#: C1 Z?O ?3 ?? Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 2- 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have lured the sub-contractors 2.El 7.I am a sole proprietor or partner- listed on the attached sheet. • ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. El Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.F1 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. o workers'comp. c.152,§1(4),and we have no y CN p 12.0 Roof repairs insurance required.]► employees.[No workers' 13.❑Other comp.insurance required.] '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. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. LL Insurance Company Name:. ��S e £}- L vYAT Policy#or Self-ins.Lic.#: 1 Expiration Date: Job Site Address: 305— ee S +pt S r City/State/Zip: V An Ive r 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby certa under thepains an p alties ofperjury that the information providedab ve is true and correct. ��� /2 Si afore• 4,42 -e - Date: / Phone#: C 7f 70 lir ?3 ? J Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: ,i Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,• express or implied,oral or.written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair`work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the 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-contractors)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 Industrial Accidents fox 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"s v i 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. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance.for your cooperation and should you have any questions, please do not hesitate to give us a call. • The Department's address,telephone and fax number: The Commonwealth,of Massachusetts De-paztoaert ofladustdal Accidents Office of Investigations 600 Washiogtoa Street Boston,MA,021 It Tei.#617-727-4900 oxt 406 or 1-877:,MA.SSAFF Revised 5-26-05 Fax#6X77277749 _WWW-Mass,govNia Date . . .g- ~� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . . . . . .. l. . .� � v!�. . . . . . . . has permission to perform . . . .'.S . ..�. . . . . . . . . . . . . wiring in the building of . . �.0 . . 2B �t7`� S. ./-C .�. . . . . . 1 . . . . . , orth Andover, Mass. Fee - °Q Lie. No. . . . . . . . . !. . . . . 1 ELECTRICALINSPECTOR f' Check# R 35- 11011 S11011 Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked ' aM ,' BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank 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 iNINK OR TYPE ALL INFORMATION) Date: ' N 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) ®7 1 //S�✓1 / A � Owner or Tenant e' .ed,l ��C' Telephone No. Owner's Address ( 6 P V 4 rh , A/ Is this permit in conjunction wi.h a building permit? Yes [JNo [J (Check Appropriate Box) Purpose of BuildingDL.Ve 1 n Utility Authorization No. Existing Service Amps / 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: Completion of the following table maybe waived by the Inspector of Wires. of Total No.of Recessed Luminaires No.of Ceil: Transformers Susp.(Paddle)Fans KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA AboveIn- o.o mergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. Satter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection andInitiating Devices No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal El Other P g Connection No.of Dryers Heating Appliances KW Security Systems:* Y No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. e of ec ical Work: (/®(�1�v When required by municipal policy.) Estimated Valu ( q Work to Start: 9P- 11 L 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under a ns an tlt penalties fperjury,that the information on this application is true and complete.,MIL FIRM NAME: . P C Cvf��')Lty LIC.NO.: 1 I Licensee: S�1 '"'�C Signature LIC.NO.: (If applicable,enter "exempt"in the license umber line.) Bus.Tel.No.:1Q)k 910? Address: 1'Z 1 6 r4 C h ,� S 4 I h""y M Alt.Tel.No.: '77 S" 7-6-X OLCZ ' *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. 72�sseu�•-, �C+'aile6(-�� � �e-xnspeetioxt�'e�uixet�($�O.DQ)�� � YI)GEemic"PAM T NO �spectoxs"�oJ�me�fs: - ' - -�Z nspeetoxsti�z ature�� itia'!s} _ date �'assec�•-[ �'ailec�--� � � 3�e�ns�ectio�,xea�uixec�($�0.00)-•[ � . �iz5�ectoxS'coznm.exfs: vfls�ectors'olpature-310wilals) Data —2l/L • '� 'assed•-,( IazIec7-j ate-SnspeetZo�xet�uiret ( 0.00)�[ tuspeetors"comments: . (Jtnspectoxs�,�ignatuze-aofsdffaTs) Pate •� . • 4 VVE WAD al .. sled--[ � �'afled--� � �e�xnspec;�ox.xequired($50.00)••� � ' "Pectors'eoTmmeph. - (f-tsp ecto)rs"0ggture-J o�glfials) Rafe gBFF+CTION-•O R" ' red- j +axlerT ]_ Re luspactionregvixed($50.00)•-[ - ECtOr�9 COTzlx77.�T1'�S: - • S �u�s�ectox "igzgxtature xto Jinifials} date ' 4 n-R-PA G;6 A'PV- ,TO 7-tT+'.'Ot 71",TNT)OITT AM TV,-e aV,gTTP,' i"b` F,.A'PVA,TO BE INSTEeTED YN NOT The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly P(4 e Name (Business/Organization/Individual): 2��h p/f Address: I 13�ic 4 RA City/State/Zip: Sa,1 ,�S h rery Phone#: `LZ 7d g 3 7 7 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition �- [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.0 I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.] employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insura�ice Company Name: `Aq se Lin Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address:_ 13(f� 60S-�OK RA City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c i nder th pains and Penalties of perjury that the information provided above is true and correct. Si nature: Date: Y 7 Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: - I Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." r Applicants .1 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(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 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 f 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 homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26-05 www.mass,govldia t� Date•6 ... ... . NORTIy 3� 1 6TOWN OF NORTH ANDOVER o PERMIT FOR GAS INSTALLATION 9 h SS US This certifies that .1—F.. . . . . . .—`A !i . . . . . . • • • • has permission for g s installation)4Q.�. ! ►09. . . . . . . . . . . . . in the buildings of . . Gf.N'.{L at . . . .!,. /t U "�. . . �A�2 eT, o r, ass. Fee.M.-'. . Lic. No l4�5Z� GASINSP CTOA Check#— !j? — 8200 Date.(PP!S 1 !Z 941 ,.ONTN TOWN OF NORTH ANDOVER p PERMIT.F.OR PLUMBING 4 CHU ��l. �. This certifies that3)e."N-\-Zz . . . . . . . . . . . . . .. re has permission to perform l .. . . . plumbing in the buildings of . ��tt4 . `). . ��- `. ... . . . . . . at. . . . �"�. . . s . . . . . . . , NAn e , Mass. Fee%.l..2!?. .Lic. No7'AL. - M PLUMBING SPECTOR Check # I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _____1j MA DATE PERMIT# JOBSITE ADDRESS OS:_ OWNER'S NAME POWNER ADDRESS. l/ —� TEL[2 F- FAX f TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL © RESIDENTIAL�- PRINT CLEARLY NEW: R RENOVATION: REPLACEMENT: 0 PLANS SUBMITTED: YES[] NO© FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _ �_E CROSS CONNECTION DEVICE I I DEDICATED SPECIAL WASTE SYSTEM _ f DEDICATED GAS/OIL/SAND SYSTEM I-11-__-. .i —f ._.-.__ ►. _.._ Al_. _._.,_I ___ f _�___. _..__f __.....__._( . DEDICATED GREASE SYSTEM 1 I _ ( -._.__._. ___....( __._.-..1 _I ___f DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAINFOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) -___.-._1 L_`I KITCHEN SINK LAVATORY -3-A ._--[ ROOF DRAIN SHOWER STALL SERVICE/MOP SINKi TOILET URINAL _I .... 1 ( J ..-.-_.__1 ; 1 _._._1 ...._.____I ....._._i f :...__A ..__..._. ._-77 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _-A _1 .-. --- WATER PIPING _( i I - t f . - _i _..-.._._1 _. ._. I ( ( ..__.......f -- _4 OTHER .6 L/fes I. _—_I=11 _._I _ __ _ I _____._f f __.-_.__f _____. .__._.. f ._-_____I ____ .----..__► _..__1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES F.f NO ®I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY DI BOND �]) OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER _f AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co liance with all ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME F_ �y1�� (ILICENSE# SIGNATURE MP i JP CORPORATION F1# _ _ f PARTNERSHIP 0# —- __ril�LLC COMPANY NAMEu ✓HCl/ ; ADDRESS T CITY _ril1�l�l GI ------ ---.................I STATE ZIP TEL FAX CELL 3�3_G I G�_..__I EMAIL _ ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES YS6 No THIS APPLICATION SERVES AS THE PERMIT FEE: $ PERMIT# PLAN REVIEW NOTES r �Y � ' a J• The Commonwealth of Massachusetts Department of rndustrial.Accidents Office ofinvestigations 600 Washington Street Boston, MA 02III www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbers Applicant Information Please Print Lebly Name(Business/Organizafion/individual): S7 14 j// - - Address: City/State/Zip ,e t#,1/ I1,q Phone#: Are you an employer?Check the appropriate box: [2. ❑ I am a em to er with 4. r7. �[] f project(required):'P Y ❑ I am a general contractor and Iemployees(full and/orpart-time).' have hired the sub-contractorsNew construction❑ I am a sole proprietor or partner- listed on the attached sheet,t Remodeling ship and have no employees These sub_contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. [No workers'comp.insurance 5. 9. []Building addition p ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑.I am a homeowner doing all work right of exemption per MGL I I -Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp,insurance required.] 1311 Other *Amy applicant that eL-ze:W box 41 IImn.4t also fill oat the section below show—mg their _ T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a-new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: A/ Policy#or Self-ins.Lic.#: Expiration.Date: — Job Site Address: -3 U �j..(�d�� �� City/State/Zip: Attach co oft workers'rkers compensation policydeclaration n page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a;fine of up to$250.00 a day against the violator. Be advised that a copy of this 'statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby certify u der the pains and penalties of perjury that the information provided above is true and correct Sienature: r . Date: `/ S Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbina Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer..,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three aparhnents 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'contractors)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. Lf an LL;C 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 ratarnGd to the G2ty o.-toCa,ntlast the ai'pllcau;fn for the pe.iit Or License is beLg req'u'ested,not the Dep2rtniont of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.. Please be sure to fill in the pemiit/lice'nse 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would'like to thank you in advance for your cooperation and should you have any questions, please do nbt-hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth c f Massachusetts Department of industrial Accidents Office of Investigatuns 600 Washington Street Boston,MA.02111 Tel. #617-727-4900 ext 406 or 1-977M ASSAFE Revised 5-26-05 Fax#6.17-727-7749 �"F�,^ •`� � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1 ow CITY A'!)u 'cM__�l 6L _ _ MA DATE I G�- /.ate PERMIT # ?1 JOBSfTE ADDRESSOWNER'S NAME GOWNER ADDRESS TE FAX TPRINT OCCUPANCY TYPE COMMERCIALF] EDUCATIONAL D RESIDENTIALB-- CLEARLY NEWT—1 RENOVATION:-11 REPLACEMENT:D PLANS SUBMITTED: YES❑I NOD APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER .�J COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE - GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT �- -�-1 - -__ _ —_ «r_.. IT.r. f �_ OVEN 7 _ _. h_ J I POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER I _ UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES'O-NO F] IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY � OTHER TYPE INDEMNITY Q BOND F OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ED AGENT 0 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compwith all P rtinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME �t/if ,!a ✓�cy� __ _ ( LICENSE#sof u SIGNATURE MP Fl MGF ! JP D JGF D LPGI CORPORATION D#©PARTNERSHIP El#=LLC D# COMPANY NAME: �1..L __--.- -_-- -` _.-.__-..._ ADDRESS CITY STATE ZIP � 3 TEL FAX CELL// EMAIL" ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No 6-12 THIS APPLICATION SERVES AS THE PERMIT FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of Indushlial Accidents Office of Investigations ..600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly• ' Name(Business/Organization/Individual):_,�7N J - - Address:_ 2 _U lc-- K City/State/Zip;h/4,rdQa,/l Phone#: 7�-3 r t 9 3 [Are you an employer?Check the appropriate boa;❑ I am a em to er with 4. Type of project(required):" P Y ❑ I am a general contractor and I emplo ees full and/or *' 6. ❑New constructionY ( part-time). have hired the sub-contractors •❑ I am a sole proprietor or partner- listed on the attached sheet.# 17. ❑Remodeling ship and have no employees These sub_contractors have 8. ❑Demolition working for me in any capacity. workers'comp,insurance. [No workers'comp.insurance 5. We are 9• Building addition ❑ eac . P corporation rp and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑.I am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions myself.[No workers'comp, c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.❑Other *41y Epalicant that checks box t+l mn4t zlso fill est the section belov.,�hoeym bcom_sa ion pot.y infom a�on. T Homeowners who submit this affidavit indicating they are doing allwork and then hire outside contractors must submit anew affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the came of the sub-contactors and(heir workers'comp,policy information. ' lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Compiny Name: /7,1 b✓ S Policy#or Self-ins.Lic.#: Expiration Date: /— / - / a S — Job Site Address: City/State/Zip:/l/ !v/�u, Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration xp n date). Failure to secure coverage as required under Section 25A ofMGL c.152 can lead to the imposition of criminal penalties o£a fine up to$1,500.00 and/or one-year' as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certi under thee pains andpenalties ofperjul)r that the information provided above is true and correct. Signature: G/� t Date: 2- Phone#: FFOther only. Do not write in this arert, to be completed by city or town offzciaL n: Permit/License# ority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing,Inspector son: Phone#: Y Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"'an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer.,or the receiver or trustee of an individual,partnership,association or-other legal entity,employing employees. However the owner of a dwelling house having not more than-three apartments and who resides therein,or the occupant of the _.dwelling house' .ofanother_who-employspersonsto-do-maintenance,.construction or-repair-workon.such dwelling-house-_ ---- - —_--- - or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152;§25C(6)also states that"every state or local licensing'aaency 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 coinpliance 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-contractors)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 Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date-the affidavit. The affidavit should by retL,.—.'vd to the c ty or tornyn th t thy app lica ion-for the ps-m-ni-or License 1°bema request.d,not the DFpartmont of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. 'The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be-used as a reference number. In addition,an applicant that must submit multiple permit/license applications in auy 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 and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investibations 600 Washington Feet Boston,MA.02111 Tel. #617-72.7-4900 ext 446 or 1-8.77 M&S.SAFE Fax#6.17-727-7749 Revised 5-26-05 _, Date. .7/, A-? .... .. NORTH 3�0y`..ao TOWN OF NORTH ANDOVER O � L • - PERMIT FOR GAS INSTALLATION s s s - �9SSACHUSEtt , This certifies thatrn�.'�`�! . . !�" .�-. . . . . . . . . . has permission for gas ,i sstallation in the buildings of . . .'`!^ at . . Q. .�'✓d??�?' . . . . . . . . ., North,Andover, M s. Fee , :5"? . . Lic. Noh l I: . . . . GAS INSPECTOFA� Check# 1,3&1 8234 1� +� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY �� MA DATE PERMIT# a JOBSITE ADDRESS OWNER'S NAME € OWNER ADDRESSTELA — X TYPE OR OCCUPANCY TYPE COMMERCIAL[[ EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: %' RENOVATION:( REPLACEMENT: PLANS SUBMITTED: YESIJNO APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER �m .... BOOSTER CONVERSION BURNER ..... ... .. i. COOK STOVE , . 1 € « $; DIRECT VENT HEATER . .. . ... '_ x DRYER ., _ FIREPLACE . ' I' _.n_j FRYOLATOR 4 FURNACE €� GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN � POOL HEATER €. aim ROOM I SPACE HEATER ROOF TOP UNIT m � �� ', �i r � { � TEST 1 ,. , UNIT HEATER Y� _;,� UNVENTED ROOM HEATER _J L„,. WATER HEATER OTHER .,.e.�rnwYnx�'at d6;m.-an'„x ,'.'.�-=+�rns'✓�.wActeef .av3D” `..... ,..;>...,-, ,,. ., ..,..._.....:....... ....is --rv. {.-,-m,... :,-«.-«... e } .�,._........ w.,„.,< _ INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES _4 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT ' SIGNATURE OF OWNER OR AGENT I I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in c pliance 'th ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER GASFITTER NAME, Ll ,\ �LICENSE# 1 NATURE MP?,j MGF JP � JGF LPGI •,w CORPORATION :# PARTNERSHIP F # LLC # COMPANY NAME` JADDRESSj j�-k CITY O Q, STATEW"' ZIP FAX ���, � L----_�.�. j `� '_ �Y ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ - FEE: $ PERMIT# PLAN REVIEW NOTES I 0 59' 34' 1 $ 86' D-BOX 1 1500 GA[ N/F // S, SEPTICS } DAVID METSCH& 36 j 3 /Q \� RENEE SCHLOSS If / / 1 moo z � / � LIMIT(: / /�, UFFEh;; MONITORING j / 10' \ WELL(TYP.) co 9 QUICK4 HIGH CAPACITY EXISTING INFILTRATOR CHAMBERS PER TRENCH(TYP.) FOUNDATION Tr\ TOP FND. �.. = 109.51' \ i k 1 ASSESSORS MAP 107D, LOT 5 'olclsV g AREA = 1 .14± ACRES DRIVEWAY NOT YET INSTALLED 1 4 3 Date. t f 4 NpRTH TOWN OF NORTH ANDOVER 3= p` PERMIT FOR MECHANICAL INSTALLATION f p 5 SACHU This certifies that A.f?.Gt k-7 . . . . . . . G. .: ./ �./. . . . has permission for mechanical installation . . . .� . '. .!'r . . . . . in the buildings of . ;� . . . -�.7 ./�. . . . . . . . . . . . . at ,p. . . . .. North Andover, Mass. Fee. . . . Lic. No.. . vo`� . . . . . . . . . . . . . . . .�t GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer Commonwealth of Massachusetts Sheet Metal Permit Date: Permit# Estimated Job Cost: $ CSG Permit Fee: $ Plans Submitted: YES NO Plans Reviewed: YES NO Business License# 211 Applicant License# yaq Business Information: Property Owner/Job Location Information: Name: Name: s Oc Street: Street: r'I 4 sh . City/Town: Irl"i1n City/Town: /Ixfl Telephone-'j?�) Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES C% NO Staff Initial X1(/M-1-un estricted license J-2 /M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. /2-stories or less Residential: 1-2 family t, Multi-family Condo/Townhouses Other Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft. �, over 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work: ✓' Renovation: /to HVAC lMetal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: -7-- os6(� d _o-ew at t% INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes❑ No❑ If you have checked Yes,indicate the type of coverage by checking the appropriate box below: A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will bei in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation:YES NO Prolzress Inspections Date Comments Final Inspection Date Comments Type of License: By ❑Master Title ❑Master-Restricted City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: Fee$ Check at www.mass.govldpl Inspector Signature of Permit Approval C MAh" Air Conditioning&Heating PROPOSAL 91 Belmont Street PROPOSAL#: 105690 No.Andover,MA 01845 (978)689-9233 FAX(978)689-7550 DATE: 3/27/2012 REP: KJM TO: JOB LOCATION: ��}.' KINGS OAKS PROPERTIES,LLC 305 BOSTON4 rD 17 HILLCREST DRIVE NORTH ANDOVER,MA HAMPTON FALLS,NH 03844 DESCRIPTION Total INSTALLATION OF NEW HEATING AND AIR CONDITIONING SYSTEM(GAS PIPING AND ELECTRICAL NOT INCLUDED)CONSISTING OF THE FOLLOWING:(FIRST FLOOR) V I A_GOODMAN MODEL#GMH95904CX GAS FIRED 95%HOT AIR FURNACE 90,000 BTU B_GOODMAN MODEL#GSX13361 13 SEER 36,000 BTU CONDENSER(R410A) C_GOODMAN MODEL#CAPF3642C 36000 BTU COIL D_FREON LINE SET E_ELECTRICAL BY OTHERS F_GAS PIPING BY OTHERS G_PVC FLUE AND COMBUSTION AIR PIPING THROUGH SILL PLATE TO OUTSIDE H_30 x 30 CONDENSER PAD [PRECAST] I_CONDENSATE PUMP AND PIPING J_INSULATED DUCTWORK WITH FLEXIBLE BRANCH LINES TO REGISTER K_CENTRAL RETURN REGISTER FOR FIRST FLOOR L_APRIL AIR HEATING AND COOLING MODEL#8463 DIGITAL THERMOSTAT M SUPPLY REGISTER FOR EACH ROOM INSTALLATION OF NEW HEATING AND AIR CONDITIONING SYSTEM CONSISTING OF THE FOLLOWING:(SECOND FLOOR) A_GOODMAN MODEL#GMS8090C GAS FIRED 80%HOT AIR FURNACE 90,000 BTU B GOODMAN MODEL#GSX13361 13 SEER 36,000 BTU CONDENSER(R410A) C GOODMAN MODEL#CHPF3636B 36,000 BTU COIL PAYMENT TERMS Net 30 Total All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate. All covered by Workman's Compensation Insurance's. Equipment warranty by manufacturer. Contractors labor warranty for one year. AUTHORIZED SIGNATURE: DATE: CUSTOMER ACCEPTANCE: DATE: **A signed copy of this proposal and deposit must be received for us to schedule this installation. (This proposal may be withdrawn by us if not accepted within 30 days.) Authorized rilaire' Partner in Comfort =�— Il--- 4 } C�rllaJlran Air Conditioning&Heating PROPOSAL 91 Belmont Street PROPOSAL#: 105690 No.Andover,MA 01845 (978)689-9233 FAX(978)689-7550 DATE: 3/27/2012 REP: KJM TO: JOB LOCATION: KINGS OAKS PROPERTIES,LLC 305 BOSTON ROAD 17 HILLCREST DRIVE NORTH ANDOVER,MA HAMPTON FALLS,NH 03844 �. DESCRIPTION Total D 'INSULATED DUCTWORK WITH FLEXIBLE TAKEOFFS E_ELECTRICAL BY OTHERS INCLUDING LOW VOLTAGE WIRING F,NEW APRIL AIR DIGITAL HEAT/COOL MODEL# 8463 THERMOSTAT G_SUPPLY REGISTER FOR EACH ROOM H_CENTRAL RETURN REGISTER I_B-VENT FLUE THROUGH ROOF J_GAS PIPING BY OTHERS K_PERMIT BY PLUMBING CONTRACTOR L_REQUIRED DRAIN PAYMENT TERMS Net 30Total All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate. All covered by Workman's Compensation Insurance's. Equipment warranty by manufacturer. Contractors labor warranty for one year. AUTHORIZED SIGNATURE: DATE: CUSTOMER ACCEPTANCE: DATE: **A signed copy of this proposal and deposit must be received for us to schedule this installation. (This proposal may be withdrawn by us if not accepted within 30 days.) — ;.� Authorized Apdiaiff Partner in Comfort G PROPOSAL rCnUsh r� Air Conditioning&Heating 91 Belmont Street PROPOSAL#: 105690 No.Andover,MA 01845 (978)689-9233 FAX(978)689-7550 DATE: 3/27/2012 REP: KJM TO: JOB LOCATION: KINGS OAKS PROPERTIES,LLC 305 BOSTON ROAD 17 HILLCREST DRIVE NORTH ANDOVER,MA HAMPTON FALLS,NH 03844 DESCRIPTION Total NOTE: THIS QUOTE INCLUDES NECESSARY SHEET METAL PERMIT AND THE REQUIRED D;JCT TEST. PAYMENT SCHEDULE: _FIRST PAYMENT DUE UPON COMPLETION OF THE ROUGH 12,000.00 BALANCE DUE UPON COMPLETION 4,000.00 PAYMENT TERMS Net 30 Total $16,000.00 All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate. All covered by Workman's Compensation Insurance's. Equipment warranty by manufacturer. Contractors labor warranty for one year. AUTHORIZED SIGNATURE: DATE: CUSTOMER ACCEPTANCE: DATE: **A signed copy of this proposal and deposit must be received for us to schedule this installation. (This proposal may be withdrawn by us if not accepted within 30 days.) Authorized rilaire' Partner in Comfort A�® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDI 05/29/201212 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: NORTH ANDOVER INSURANCE AGENCY, INC. j COMMONWEALTH OF MASSACHUSETTS SHEET ME 'AL WORKERS AS A MASTE�-UNRE,�TRICTED s' ISSUES THE ABOVE LICENSE TO: 4' KEVIN `J'. MCDON4lD 91 OELMONT ST ' NORTH ANDOVER II,1 01$45-2304 1404 05/28'14 164511 , =� C1lU E7`T8 ` f 17 }h ! yy 'ros y� UMBEP iY��,, �r u} ,YS15585�90 = � jGL.A'S5� REST HGT BEI( CIA ✓�D'/ «f 6 0 M. ei f $ 'il KEVIN J 1022 MAPLE-ST, '� k l 020481629 �