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Miscellaneous - 32 MEADOW LANE 4/30/2018
32 MEADOW LANE 210/045.G-0046-0000.0 .1 Date..... .4 I. ............... tOwrly, TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 88,�CHUgE This certifies that .................. ......................... .... ........................................................... has permission for gas installation in the buildings of....)-e." r� `n n ....................................................................................... �Z, T ".4 Pa*L.:,r-....�—r.'................... North Andover, Mass. Fee.� � ..-�'.... Lic. No.Ml,( ......... ���.✓..................................................... GG GAS INSPECTOR Check# 1 S2 ; 0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I N.Andover MA DATE 5/6/2014 PERMIT# JOBSITE ADDRESS 32 Meadow Ln OWNER'S NAME GOWNER ADDRESS I Same TEL — FAX= TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL® RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION:El REPLACEMENT:® PLANS SUBMITTED: YES❑ NO❑ APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER -� LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER Re lace 1 Gas Meter x and associated INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING 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 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 inco pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r PLUMBER-GASFITTER NAME I Joseph Marino LICENSE#18736 SIGNATURE MP❑ MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# 3285C PARTN SHIP❑# LLC❑# COMPANY NAME: RH White Construction Co ADDRESS 141 Central St CITY I Auburn STATE MA ZIP 01501 TEL (508)832-3295 FAX 1508-926-4347 CELL 508-832-4614 1 EMAIL JMarino@RHWhite.com r L 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 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 = tiiO�iViNEAi.1 H OF NfASS.4iC.HIUS- _'1_ =P1 UIUj ERS AND GASH TR ~ LIC SED AS•A..Maw• 1� - :<'ISUES T1=1�'ABOVE IGNSE 'I7[7R:G'E''S?`ER MA 0 - 0 °6 05/01/14 =% _G:C)i11iMf3PiWEALTH OF MASStACRf `PLIJTMaER5 AND GASFIT-T RSv 0"SN_ ED AS A JCLU.RNEYMAM.- UESTHEABOVE�LICENSETO =:- <' 's3`�: i•:' T :MARINO' _y��.=:F}�°RR�T�N GTO N ST '=i�-�r'=•`•� =. :-- -�-�1 it R r - =_ i i - CI4/013/LU14 14.CJ4 JUOOJLO/J1 Mn Wrll 1 11 UUINO I MUU I r Rur- YJL/rJL � . �® DATE(MM/DDNYYYI ,l CERTIFICATE OF LIABILITY INSURANCE Page ti F08/29/2013 THIS CERTIFICATE IS ISSUED ASA 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 RE=PRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)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 th is certificate does not confer rights to the certificate holder in HOU of such endorsement(s), PRODUCER CONTACT 94/11/4 oi` Maesacbusotta, Inc. PHONE PAX c/o 26 Ce'Atvey Blvd. 'N0 Exnw 977-945•-7378 _No): 886-467-2378 P. 0. Box 305191 -MAIL XRObville, TN 37230-5191 DDRK Coxti.f7.Cate>3rli-4111ifa.coni INSURER(0)AFFORDING COVERAGE NAIOP INSURED INSURERA: The Cba:Ctor Oak Fir9 IneuranC9 Compaay 25615-001 R. H. White Construction Company, Inc. INSURERS.Travalmrs property casualty Gogpany of Am 25674-003 41 CentrBox 257 P Yd7 Street 0. P. 0. BoINSURER C:Nueuranc* Coman ntional Union Fir,) Io£ 7,9445-001 Auburn, MA 01501 INSURERD;TrpvelerB indemnity company 25659-001 INSURER F; INSURER F; COVERAGES CERTIFICATE NUMBER:20287680 REVISION NUMBER; THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED,ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYpE OP INSURANCE DD' SUB P POLICY EFF POLICY EXP vulm POLICY NUMBER LIMITS A GENERALLIAB(LITY VTC2000 977RD948-13 9/1/2013 9/1/2014 EACH OCCURRENCEIs F 2 000 QOO X COMMFRCIALGENERALLIA911.17Y TORENTFD S Its oceurencr300,1 0 CLAIMs-MADE OCCUR MED EXP(Any one arson 10,000 PERSONAL&ADV INJUR2 000,000 GENERAL AGGREGATE 4".OOO OOO GEN'L AGGREGATE.LIMIT APPLIES PER; PRODUCTS-COMPIOPAGG P$1 ,QOO OOO PODGY PRO LOC i3 AUTOMOBILE LIABILITY VT.7CAP 977K955A-13 9/1/2013 9/1/201-4 OMgINED SINGLE.LIMIT X ANYAUTO .accNent t 2,000,000 BODILY INJURY(Perpereon) $ AUTOS NED AUT08ULED BODILY INJURY(Peraccldent) g X HIREDAUTOS X NON-OWNED X CMAC o Ded X Cv11SDed eraccldenl A S $ C UMBRELLALIA6 OCCUR BE8766140 /1/2013 9/1/2014 EACHOCCURRENCF $ 9�OOO,OOO EXCESS LIAR CLAIMS-MADE AGGREGATE $ $,000,000 DEO $ RETENTIONS ]0.000 $ D WOR EMPLQ r P'LI ATIONILIT VTRKUB 8205AI05-13 9/1/207.3 9/1/2014 X AND EMPLOYER$'LIABILITY YYY///NNN T KY V 11 ANY PROPRIETORIPARTNF.RIFXECUTIVE N(A VTC2XUB A203.A71A-13 9/7,/2013 9/1/2014 E.L.EACH ACCIDENT S 1,000 000 OFFICER/MEMSEREXCLUDED7 L" f MendetonrinNH) E.L.DI2EASE-EAEMPI.OYFE S 1,000,000 u�gvnn UN uH Of'tRATIONS below S,L,DISEASE-POLICY LIMIT is 1,000,000 DESCRIPTION OF OPERATIONS f LOCATIONS/VEWICLES(Attach Acord 101,Addltona I Remarke Schedula,It more epaee Is roqulred) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Evidence of InlaltZRslce AUTHORIZED REPRESENTATIVE Col1:4197604 Tp1:1694012 Cert::20267680 ©1988-2010ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 0 Ll / 820 Date . . �. TOWN OF NORTH ANDOVER f PERMIT FOR PLUMBING This certifies that .b . . . . . . . . . . . . . . . . . . . has permission to perform .'�.�^-h- . . . . �' .� ��". ! p : . . . . . . . plumbing in the buildings of.l yy 2—R P� L . . . . . . . . . . . . . . . . at . . . -32.. .. . . . . . . . . . North Andover, Mass. n Fee ,.h . . Lic. No. . . . . . .f1 b. . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR ' Check 9210) Z- A MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY s _ I MA DATE ( PERMIT# 940 0 JOBSITE ADDRESS 3 OWNER'S NAME POWNER ADDRESS I TEL FAX _ j TYPE OR OCCUPANCY TYPE COMMERCIAL Ell EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: _.{ RENOVATION:[Er REPLACEMENT: Q PLANS SUBMITTED: YES EQ NOD FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM f DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I ___..._..f .__._..__{ l ._..�_f I f I ! __.._._f .._..._ ( _. ._{ ____) ___I --___..._.l DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN ! ---.__.-) _--i { f —{ .___..__.1 _.-__..J f f .._..,.._._. _..... INTERCEPTOR(INTERIOR) KITCHEN SINK _1 _..__..l � ! ._.___.( f _.__.� J I ( I .._._.__.) 1 LAVATORY _f ! ._..._-) ROOF DRAIN SHOWER STALL _{ I I E I i ._.-.._.._I _f i -_ _fI .___....I ..--_.._I -.....__.I SERVICE/MOP SINK TOILET 1 _....__.-.{ ._. f . I _ � -.__.._J l ! _. E _._.. i ----------_ _._-._._) 'AJRINAL -11 j ._....___1 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING i - _—{ _-- -...._ } f ._ ! - ' _. _I __._. 1 _. {F=J I OTHER I INSURANCE COVERAGE: t 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES .._ NO _ E IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Q BOND 0 ^OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the yyMassachset Generali Laws,and that my signature on this permit application waives this requirement. 4� -A-✓ v t CHECK ONE ONLY: OWNER 0 AGENT 0 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMELICENSE# SIGNATURE MP L J JP Q CORPORATION D# PARTNERSHIP[-Jl# i LLC COMPANY NAME - ___lp !�(�• I ; ADDRESS E CITY paGV�---- STATE ®ZIP 6Li TEL FAX I CELL EMAIL ..7-he ciensc 43.- ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ p 44 FEE: $ PERMIT# „ PLAN REVIEW NOTES tAaVA ,s Y The Commonwealth of Massachusetts Department of IndustrialAceldints Office of Investigations 600 Washington Street Boston,MA 02111 Uf www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le zibly Name(Business/Organization/Individual): DAJ VV hal Address: l.� U AZ�J{sox 1'P City/State/Zip: vw M►- Phone 43 Jr 3 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. [:11 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. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers'comp.insurance. y p tY• 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.El Electrical repairs or additions required.] officers have exercised their 3.❑ 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.]t employees.[No workers' 13.[JOther 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. $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. Insurance Company Name:. Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do liereby cert! under the pains and penalties of perjury that the information provided above is true and correct. Signature: --w Date: G4 — 3 Phone#: �7�" lel ��Jr 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 M. Informati®n 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 employeiis 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-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 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 and fax number: The Commonwealth.of Massachusetts Department of Industrial,Accidents Office of Investigations 600 Washington Street Boston.,MA 02111 Tel.#617-7274900 ext 406 or 1-877:MASSAFE Revised 5-26-05 Fax#617-727-7749 wwwmass,gov/dia n • COMMONWEALTH OF MASSACHUSETTS Cp•.• ;.1 PLUMBERS AND GASFITTERS LICENSED AS A MATER PLUMBER ISSUES THE ABOVE LICENSE TO D'ANIE'L F MAHONEY I3 : JACKSON ST SALEM MA 01970-3025 `, 9.143 05/01/14 17296.:u • giumum ! ._ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . .�i, has permission for gas installation in the buildings of. . � J r �mi..A at . . ..Z . . . c=s ��. _ A. L. , ,P. . . . .,North Andover, Mass. Fee . l c30 . Lic. No. . . . . � . . . . . . . . . . . . . . . . . . . . . GASINSPECTOR Check # i 8625 f MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY eJ./ _ _ -. . MA DATEn� m - �' RMIT# — JOBSITE ADDRESS �,� Oc✓ OWNER'S NAME - ', TA_l> GOWNER ADDRESS TEL S _- AX TYPE OR PRINT OCCUPANCY E COMMERCIAL E] EDUCATIONALE] RESIDENTIAL CLEARLY NEW: __ RENOVATION:0 REPLACEMENT:El PLANS SUBMITTED: YES Q NO _.._ APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER --1 =--� -- . i .__ . �- -_ --- DRYER FIREPLACE FRYOLATOR _ .J _! . _ -- FURNACE GENERATOR --f GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN - POOL HEATER _ J T- _ I _. �— --- ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER ___..j _ I ► UNVENTED ROOM HEATER -1 WATER HEATER OTHER (�— INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ._ 0 [ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG NECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ____ OTHER TYPE INDEMNITY Ej 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. 2 CHECK ONE ONLY: OWNER �-1 AGENT [ s 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 com fiance wit all P ' ent vision of t e /� Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBE -G TIE RR NAME LICENSE# S GNATURE - _ MP _-_ MGF JP 0 JGF[�( LPGI 0 CORPORATION[3#©PARTNERSHIP 0#ELLC P# COMPANY NAME: ADDRESS r CITY STATE ZIP U TEL 6B- -- -- FAX CELIL �'5 i 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 The Commonwealth of Massachusetts Ln Department ofIndustrial 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 Legh Name(Business/Organization/Individual): %� 1'/r Address: c-) (� City/State/Zip.- / �/a/� Phone#: S08--�_c) - _9 Are an employer?Check the appropriate box: Type of project(required): a employer with 4. ❑ I am a general contractor and I 6. ❑New construction mployees(full and/or part-time).* have hired the sub-contractors 2. I am-a sole proprietor or partner- listed on the attached sheet. E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g- ❑Building addition [No workers'comp.insurance 5. ❑ 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 11.❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]r employees.[No workers' 13F1Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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. Insurance Company Name:. Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or ono-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby c tie pains en under zs of perju that the information provided above is true and correct Si ature. 2 Date: ' / G Phone#: s 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#: r 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 ofhire,- 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 may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be 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 not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachwetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA.02111 Tel.#617-727-4900 ext 406 or 1-877,MASS.AFE Revised 5-26-05 Fax#617-727-7749 WWW.Mass,gov/dia Division of Professional Licensure: License Search Page 1 of 1 v r The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency More... LICENSEE Name:WILLIAM L. DESANTIS REFERENCES& SALEM, NH RELATED INFO Disclaimer Regarding ""This Licensee has additional Licenses,click here to view them."" Website License Searches Enforcement Process Glossary Licensing Board: PLUMBERS Et GASFITTERS Glossary of License Status License Type: JOURNEYMAN PLUMBER Codes License Number: 18011 More... I Status: CURRENT Expiration Date: 5/1/2014 Issue Date: Exam Date: School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Monday,March 18,2013 at 9:11:55 AM. O 2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg.state.ma.us/pubLic/pubLicenseQ.asp?board_code=PL&type class=_J&li... 3/18/2013 .Q 10055 Date.. ...... Z �aORTH o� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �,SSACMUS� This certifies that ..........D�. S.. ..... 77,7, ............... has permission to perform ....A-00eA).. SL��Iii�. ............................... wiring in the building of..............Z)-. //fin 4 X................................ ................. . .... at..3.z.����4.�..�1.........................XE .... .North Andover,Mass. Fee..`r...... . T c.No..1. �1�?!'...... �`t/f1�.. ... ... .. ECTR1CAIlINSPE R `. Check N7 Commonwealth wealth ®f Massachusetts Official Use Only p Department of Fire Services Permit No. t BOARD OF FIRE PREVENTION REGULATIONS 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 (PLEASEPMEWINKORTYPE,ALLIWO TI0119 Date: City or Town of: To the Inspector of Wires: By this application the undersi ed gives no " e of his or her intention to perform the electrical work described below. Location(Street�&Number)_ � ' Owner or Tenant_F t o in a M A-U vi r.r pt)-1tr n4 v-P rc� ,� Telephone No. Owner's Address S 4 M Is this permit in conjunction with a building permit? Yes ❑ No [i/rBLDG PERMIT# Purpose of Building 1 1,�,,uS Utility Authorization No. Existing Service / n, ,,, 1 h 9 qT��6 �— Ps �i=/ l 2_Volts Overhead Undgrd❑ No.of Meters I New——Service 'a " Amps -:�110 / 110 Volts Overhead[ Und rd g ❑ No. of Meters Number of Feeders and Ampacity 3 Location and Nature of Proposed Electrical Work. . �PC-✓'A061?Go2r,/a ti C�,-1/I C-� -i�D 7iL'i� 4LAI 6,..Ifi-jag Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total. Transformers KVA, No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- o.o mergency ig tmg rnd. rnd. El Batte Units No.of Receptacle Outlets No.of Oil Burners F]RE ALARMS No.of Zones No. of Switches No.of Gas Burners No.of Detection and No. of Ranges No.of Air Cond. Total Initiatin Devices Tons No.of Alerting Devices No. of Waste Disposers Heat Pump 1�Tumber Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No. of Dryers Heating Appliances KW Security Systems:* No. of Water KW No.of No.of No.of Devices or Equivalent Heaters Signs Ballasts Data Wiring: No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: " OTHER: No.of Devices or Equivalent Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. j C�, (When required by municipal policy.) Work to Start: Z-/-Z 7 - 1 J Inspections to be requested in accordance with AMC 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 [r BOND ❑ OTHER ❑ (Specify:) Icertry, under the pains and penalties ofperjury,that the information on this application is true and completes FIRM NAME: d L 5 Z A iC C!�e{ �,c LIC.NO.: ,a l y l Licensee: 1-) (C h VI-4 I O LS7 �i� Signature__ (If applicable, enter "exempt"in the license number line.) LIC'NO"'�" Address: i(4(5- 4 Bus.Tel.No.: 578 it v��� �" O i 3 -7 - y i *Per M.G.L.c.147, 5', Wil,security work requues Alt.Tel.No.:epartment of Public Safety"S"Licen 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 Signature Telephone No. P ERMIT FEE: $ ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR-DOUG SMALL 6 1.ROUGH INSPECTION: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors'comments: (Inspectors'Signature-no initials) Date 2.FINAL IN PECTION: Passed— Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors'comments: 7-7 (Inspectors'Signature no initials) Date �. 3.UNDER GROUND INSPECTION: Passed—[ j Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: (Inspectors'Signature-no initials) Date 4.INSPECTION—SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: (Inspectors'Signature-no i tials) Date r 5.INSPECTION-OTHER: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-( ] Inspectors' comments: (Inspectors'Signature-no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED. The Commonwealth ofMassachusetts Department of Industrial.Acciclents ' Office of-Investigations 600 Washington Street Boston,MA 02111 UV 1vww.massgov1dia Workers' Compensation lnsurance Affidavit: Builde>rs/Contractors/JEleciriciansJPlumbers Applicant Information Please Print Legibly Name(B.usiness/Organization/Individual): h/ e I 0 L 5- Address: &a r I- City/State/Zip: h A h S, tp7 •a- #: q 2y-(4, A ren employer?Check the appropriate box: Type of project(required): a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction oyees(full and/or part-time).x have hired the sub-contractors sole proprietor or partner- listed on the attached sheet.i7. ❑Remodelingnd have no employees These sub-contractors have 8. 0 Demolition ng for me in any capacity. workers'comp.insurance. g, ❑Building addition orkers'comp,insurance 5. ❑ We are a corporation and its edofficers have exercised their10.❑Electrical repairs or additions homeowner doing all work right of exemption per MGL 1 I.❑Plumbing repairs or additions myself, [No workers'comp. c.152,§1(4),and wehaveno 12.[(Roofrepairs insurance required.]i employees.[No workers' 1311 Other comp.insurance required.] !Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Y 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. Insurance Company Name: i Policy#or Self-ins.Lic.#: J Expiration Date: Sob Site Address.- `3.z ln -e�'�cl�w L A y City/State/Zip: A/4-lot, ' 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Xa'ohereby cert! under thepainsandpenaldesofperjurythat the information pro videdaboveistrueand correct. Simmture• .., /y (), Date: Phone#: q,, Z47_ — 0 E only. Do not write in this area,to be completed by city or town official n: Permit/License# ority(circle one): $ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son• Phone#: Location �_ No. /�? Date NORTH TOWN OF NORTH ANDOVER �? • 0 p Certificate of Occupancy $ 14Aa y �, ' Building/Frame Permit Fee $ 0. ', ,SSAG MU�Et� Foundation Permit Fee $ Qther Permit Fee $ 1 �� 1 Sewer ction Fee $ V a %nnection Fee $ TA L $ d Building Inspector _ , �� Div. Public Works PER11IT NO. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE M'AP d-40. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK '.PAGE ZONE I SUB DIV. LOT NO. �I LOCATION ,7, C'����J/ PURPOSE OF BUILDING OWNER'S NAME ✓-5, NO. OF STORIES SIZE„ UC 4 OWNER'S ADDRESS S�N1� BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2NDy 3RD\7' BUILDER'S NAME SPAN -- DISTANCE TO NEAREST BUILDING E DIMENSIONS OF SILLS DISTANCE FROM STREET " POSTS DISTANCE FROM LOT LINES—SIDES REAR " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY of IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS i - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE'FILED 'AND APPROVED BY BUILDING INSPECTOR DATE FILED (�/w,G rv`A� BOARD OF HEALTH SIGN URE OF bWNER OR AUTHORIZED AbENT w FEE I� PLANNING BOARD PERMIT GRANTED 19 �_ BOARD OF SELECTMEN C BUILDING INSPECTOR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY I STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS, WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE a 1 2 13 CONCRETE BL'K. PINE BRICK OR STONE HARDW-D PIERS PLASTER _ _ DRY WALL _ -WN FIN. 3 BASEMENT AREA FULL FIN. B'M'TAREA _ '/. 1/1 '/. FIN. ATTIC AREA _ NO B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS II 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARD\'y'D _ ASBESTOS SIDING COMMCN VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH 13 FIX.) _ GAMBREL MANSARD TOILET RM. 12 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING II 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st C—I 3rd NO HEATING f J Town of North Andover BUILDING DEPARTMENT Homeowner License Exemption (Please print) DATE 44_131 JOB LOCATION 3 �E�9JI p(,(J Number Street Address Section of town :'HOMEOWNER" �D S�'Pff//1/� �D/�,l>�C�/�Os�� 6�-�`�/?"5 Name Rome Phone Work Phone PRESENT MAILING ADDRESS City Town State Zip code The current exemption for "homeowners" was extended to include owner occupied dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license , provided that the owner acts as supervisor. (State Building Code , Section 109 . 1 . 1) DEFINITION OF HOMEOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside , on which there is , or is intended to be, a one to six family dwell- ing , attached or detached structures accessory to such use and/or farm structures . A person who constructs more than one home in a two-year period shall not be considered a homeowner . Such "homeowner" shall submit to the Building Official , on a form acceptable to the Bulding Official , that he/she shall be responsible for all such work performed under the .building permit . (Section 109. 1 . 1) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other applicable codes , by-laws , rules and regulations . The undersigned "homeowner" certifies that he/she understands the Town of '' .North Andover Building Department minimum inspection procedures and ,;'requirements and that he/she will comply with said procedures and requirements . -HOMEOWNER' S SIGNATURE X ^ APPROVAL OF BUILDING OFFIC AL Note : Three family dwellings 35 ,000 cubic feet , or larger , will be required to comply with State Building Code Section 127 .0, Construction Control . V A S E VU E R* T-E R _-JIBNAL PLAWMN "0 FM " h'" _FINAL 0 d 01 11 over NO. 174 Mass, 17 19,71 717 C) K er, Mass,, PEF-IMPT HE.WICK ? I M`z' BOARD OF HEALTH 0 THIS CERTIFIES THAT...... I.. . . .... . ...... . .. ..... .... . . . .......... BUILDING INSPECTOR haspermission ..... ... ildings on .... .... .... .. ...... .. .. .... ... Rough to be occupied as ..... .. ....... Chimney Final provided that the person accepting this permit shall in every respect conform to the terms of the application on rile in PLUMBING INSPECTOR this office,and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Rough Buildings in the Town of North Andover. Final VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR Rough UNLESS CONSTRU TIO TARTS Service Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Final Display in a Conspicuous Place on the Premises Do Not Remove FIRE DEPT. Burner No Lathing to Be Done Until In' spected and Approved by STREET NO. Building Inspector Smoke Det.