HomeMy WebLinkAboutMiscellaneous - 323 CHESTNUT STREET 4/30/2018 323 CHESTNUT STREET
210/098.C-0051-00000
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Deems, Maura
From: McCarthy, Fred
Sent: Tuesday, December 08, 2015 9:S0 AM
To: Deems, Maura
Subject: 323 Chestnut St
Hi Maura,
I received a call from the contractor from this address. He stated there was no work done on the fire alarm system and the scope of construction did not impact
fire alarm. I am fine without looking at this home. If you need or want me to inspect fire alarm I will do that. His name is Ryan from Elite Const.
Let me know.
Thanks.
Fred
978-688-9590
Date-80 ...........
OF NOwrM,h
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
7 CHU
Va
This certifies that
............................
.... .......
.(L.......e.................V . .................. ......
has permission to perform ..............................I
..........................................................................
wiring in the buildi2g of..............(11,..../......4. ......................................................
at . ..................... ............................... NorbAndover,Mass.
Fee ......Lic.No?Y�q6. -a- 0-uel.....................
ECT CAL INSPECTOR
Check
127.78 -/ -Wo/4, o, ld�
Official Use Only
Commonwealth of Massachusetts
Department of Fire Services Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00
(PLEASE PRINT ININK OR TYPE ALL.INFORMATION) Date: 10 /1 g / 1 C- �`
City or Town of. NORTH ANDOVER To the Inspector of Wires: k
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) y CLI a yrs v
Owner or Tenant W calla Telephone No.
Owner's Address C4 rK r-
Is this permit in conjunction with a building permit? Yes Q No ❑ (Check Appropriate Box)
Purpose of Building re-- ,1c�.r—e- 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 thefollowing table may be waived by the Inspector of Wires.
s No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
j No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- Elo.o mergency Lighting
rnd. rnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ MConnunicipectional ElOther
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water Imo' 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: e,,Ir e V4 Lop`1-%^ g e Cr r S 2 C C.,
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify,under thcpains and penalties ofperjury,that the information on this application is true and complete.
FIRM NAME: 4e,11 y C frz 4%r 1 c LIC.NO.: Z '4 6?
Licensee: Signature LTC.NO.:
(Ifapplicable,enter "exempt"in the license number line) Bus.Tel.No.-
Address: 17,/ /Ofr !%04e KJ kw�,p�06^ Alt.Tel.No.:
`Per M.G.L c. 147,s.57-61,security work requires Department ofPublic Safety"S"License: Lic.No.
OWNER'S INSURANCE WAIVE4: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my . a ow,I hereby waive this requirement. I am the(check one)❑owner owner's agent.
Owner/Agent PERMIT FEE:$
Signature Telephone No. —�
f"aai 2 3 6 Y,02
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule S: In accordance with the provisions of M.G.L.c-143,§3L,the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an
electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c.143,§3L.
Permits shall be limited as to the time of ongoing construction activity,and may be-deemed by the Inspector of Wires abandoned and invalid if he �.
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012.
❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑
❑Permit Extension Act—Permit/Date Closed:
Trench Inspection
Pass M Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass Failed Re-Inspection Required($.)❑
Inspectors Comments: r
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass Failed Re-Inspection Required($.)❑
Inspectors Comments:
i
Inspectors Signature: Date:
i
ROUGH INSP TION:
Pass M Failed Re-Inspection Required($.)❑
Inspectors Comments:
I
44
Inspectors Signature: ---, Date:
I
FINAL INSPE TION:
Pass 0 Failed❑' Re-Inspection Required($.)❑
J
Inspectors Comments:
Inspectors Signature: Date: l! 30 A'�
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimae.com
11/ iVI VV lYV LI .V2 •aaJi VLI 4VY �'iLV a••-'✓a VaW ✓vaaJ.Iaa.Y .iva a• .0 vvv
j
The Commoawealth of Massachmsetts
o<s;, �.._..::;.._ Aepartme►tt of1ndustrial.Accidcrtts
Office ofYnt�estigations
T l
Boston,MA 0.2111
`a'i�yWWiV. ��'OV�llIQ
Workers' Compensation Innsua-ance.davit:Builders/Contractors/Electnici2ms/Plumbers
Applicant Ynforrimataon please Print Lc�ibly
Name(Boiacss/organizationlindividual):
Address:
City/StateMp1: Eaa jn MY"1 ( Phone W. j c �c6
Are you an employer?Check the appropriate box: Type of project(regnir+ed)_
1.❑ Tarn a employer witll 4. ❑ T am a general coc&actor and T
* have hired frit sub-contractors 6. ❑New construction
rt ti
employees(full and/or pame). 7. Remodelin
2.[] I am a sole proprietor or partner- listed on the attaed sheet.t ❑ f5
ch
ship and have no employees These sub-comractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
(No worl='"oornp.insurance S. ❑We are a corporation and its
"Uired.) officers have exercised their 10,E]Electr"�1 repairs or additions
3.Q 1 am a homeowner doing all work right of exemption per MOL 1 I_❑Plumbing repairs or additions
myself.(No workers'comp. c. 152,§1(41 and we have no 12.1]Roof repairs
insumneerequired.]t employees.[No workers' 13.❑Other
comp.lasurance required.]
May applicant that checks box 91 must also till out the section below showing their workers'compcnsation policy information.
t 14omcownes who submh this affidavit indicating They are doing all work and that bins outside contractors must submit a new affidavit W wtiug such.
?Contractors that duxk.this box must attached an additional shut showing lite name of the sub.cnntmciors and thea workers'comp.policy iMfotaiation.
I am an employer thel is providing workers'compensation&mrnnce for my employees: ,Below is the,pegry mrd joh site
rrifornrakon.
Insurance Comparry Name: ct3myy\- ��a�
Policy#or Self-ins.Lri�c.#_ (�U)(�'� n w k(� Expiration Date: A
Job site �t� L.1 �6tsS `(11� �� City/StataZip:�Ot�1 � "V►U"tJ
Address:
Attach a copy of the workers'compensation policy declaration page(showing tLe policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year i mprisonmcat,as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of Irp to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to to Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify u e ..,penalises of pe*7 that the Infornmdon protMed abev--h ime im f con a
i Date:
Uf W&f use only. Do not write in Als area,to he completed by city or town officPaL
City or Town: PermidUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Cle ebtical Inspector S.Plumbing Inspecbr
G.atter
Contact Person:
Phone*
0Mmof WEAITH;0F
SSIfE� EafO. Ow1NG fi�1LtlSf AS 'Aar';
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14 NORM°�A !
A +�2375
16..666; " O7'/3 .Ilx 73279 '
agx01VIM0MAIEA'sL7H OF MAS ACHI�SE `.
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14 NOR ILAO A a, y
IA' 03 .32
315
24635-
_ 9800 Fredericksburg Road
San Antonio,TX 78288
USAW
04664. 1S6XR.JSS1011327671 .01 . 01 .270
CITY OF NORTH ANDOVER February 28, 2015
1600 OSGOOD STREET
BUILDING 20, STE 2035
NORTH ANDOVER MA 01845-1057
Reference: MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B
Dear Building Commissioner,
I am writing regarding the claim referenced below.
Policyholder: Shaun M Callagy
Reference #: 003025008-23
Date of loss: February 14, 2015
Location of loss: North Andover, Massachusetts
Address: 323 Chestnut St. 01845
A claim has been made involving loss, damage or destruction of the property referenced above,
which may either exceed $1000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143,
SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139,
SECTION 3B is appropriate, please direct it to my attention and include the reference #.
You may submit correspondence or questions to me. My contact information is:
Address: P.O. BOX 33490
SAN ANTONIO, TEXAS 78265
Fax: 1-800-531-8669
Phone: 1-800-531-8722
Sincerely,
Kyle Hennessy
Property Field
United Services Automobile Association
PO Box 33490
San Antonio, TX 78265
Phone: 1-800-531-8722
Fax: 1-800-531-8669
003025008 -DM-04664- 23 -06768- 50 54577-0914
Page 1 of 1
Date......jam..... ...............-...
Q�; ooh TOWN OF NORTH ANDOVER
* PERMIT FOR WIRING
8s'�CHUB�`
l/This certifies that ......::/)... .`� ...................................................
has permission to perform .....
wiring in the building of...........: .. . ..!t.. .. ................................................................
at . .Z ��:.�`C t�sf �7-" Sr.�,North Andover,Mass.
. ...................................................................... .
Fee .c�Lic.No.Zf7oy./t` �' 'l!T -
.............. .. .....................
.. .�......
ELZCMCAL INSPECTOR
Check# a d d
12248
l.ommonweah4 o1 Vamachubett4 Official Use Only
c7 Permit No. 2
2epaz y
rtment of_7tre servicer
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. l/07] eaveblank
i
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code C),5�7 CMR 12.00
(PLEASE PRINT IN INK OR TYPE A L ITor-,
TION) Date: 3 �/s
City or Town of: /I/r� �, c>�r To the Inspector of Wires.
By this application the undersigned
��gives no't�il ,eof his or herdtention to perform the electrical work described below.
Location(Street&Number)
Owner or Tenant S�j�t�/r� Cp>' �9 y Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes 2Q No ❑ (Check Appropriate Bog)
Purpose of Building 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..A.mpacity
Location and Nature of Proposed Electrical Work:
Completion of the followilg table m!y be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans NO•of of
Transformers KVA
No.of Luminaim Outlets ' No.-of Hot Tubs Generators KVA
t No.of Luminaires Swimming Pool Above ❑ n- ❑ o.o Emergency Lighting
nd. rnd. Batteuv Units
No.of Receptacle Outlets No.of Oil Burners EIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.o Detection an
Initiatina Devices
No.of Ranges No.of Air Cond: Tota Tons No.of Alerting Devices
No.of Waste Disposers eat Pum Number ons o.o m
el - ontaed
Totals I '' Detection/Alerting Devices
No,of Dishwashers Space/Area Heating KW Local❑ unicipal El
Cyyonnection
Oth
No.of Dryers Heating Appliances KW eCNo.�of De i es or E uivalent
No.of- ater
Heaters KWNo.o. .o,=4')1ttt9 Wiring:
Si s BalNo.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP a ecommunications rang
No.of Devices or E uivalent
OTHER:
e
Attach additional detail if desired or as required by the Inspector of Wires.
Estimated Value of E! i 1 Work: (When required by municipal policy.)
Work to Start: S 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 thepains and penalties of orjuryZT�l
information on this application is true and complete
FIRM NAME: �. �� r,<.: o v 1ao- GLC LIC.NO.: .,21?0,—)
J 1
Licensee: Ci / ,y,,o1 Signature LIC.NO.: 0 90;5A
(Ifapplicable,enter "exempt"i theIlh�' ens number line. r
/� /'J
/f �1���� Bus.TeL No. ��I
Address: _ GtJ�U c�+c /'�o� nr r t Alt.TeL No.: /r) - _2
*Per MG.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 a ent.
Owner/Agent v
Signature Telephone No. PERMIT FEE: $
1�
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e
� i � � ..
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S. ,
3
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed Uf
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c.166,§32,an !'
electrical permit shall be issued to the person,firm or corporation stated on the permit application.Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c.143,§3L.
Permits shall-be limited as to the time of ongoing construction activity,and maybe.deemed.by-the.lnspector_of-Wires abandoned_and_invalid-iflre—. ._
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or•the installing entity stated on the permit application.
The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending"through August 15,2012.
KRule 8—Permit)Date Closed: r-l� —� ***Note:Reapply for new perm'
'M-P unit Extension Act—Permit/Date Closed:
Date......../-/,..7...
NORTH
Of
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
SUCHUS
.r4
This certifies that ..................... Arr
.. 4 .................. .................
has permission to perform .....
...............................
wiring in the building of.........
................. ..... ................................................
at............................................. ................. .North Andover,Mass.
Fee...?SJ�
.... ........ Lic NoQ.'.( ............
ELECTRICAL INSPE ^
Check #
8693
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Pe'n'is No. 7.3
BOARD OF FIRE PREVENTION REGULATIONS [Revc1/07]yand Fee Checked
(leave blank
APPLICATION FOR PERMIT TO PERFORM ELEC RICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 27 C 1 .00
(PLEASE PM7&V INK OR TYPE ALL INFORMATION) Date: o
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice ohis or her in ntioq to perform the electrical work described below.
Location(Street&Number) 3 1�13 ch
Owner or Tenant s li tV
Telephone No.
Owner's Address ,�1AC
Is this permit in conjunction Vath a building permit? Yes No
❑ (Check Appropriate Boz)
Purpose of Building s-djL Utility Authorization No.
Existing Service�0 Amps / Volts Overhead❑ Und rd No.of Meters
g ❑
New Service Amps l Volts Overhead❑ Und rd
g ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: ,
4.7 2
Com lesion of the ollowin table may be waived by the Inspector of Wires.
No.of Recessed Luminaires j 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 ❑ - .do.o mergency ig g
— No.of Receptacle Outlets r
d. nBatt= Units
d No.of Oil Burners FIRE ALARUMS No.of Zones
No.of Switches a No.of Gas Burners No.of Detection and
Iniiiatin Devices .
No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices
No.of Waste Disposers , Heat PUTP I Number Tons KW _ No.of Self-Contained
Totals: Detection/Alertin Devices
No.of Dishwashers , Space/Area Heating KW Local Municipal
Connection Other
No.of Dryers Heating Appliances KW Security Systems:
o.of waterNoof No.of Devices or Equivalent
.
' Heaters KW of
Ballasts Data Wiring:
No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors TotalHp Telecommunications Wiring:
OTHER:
No.of Devices or Equivalent
i
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: -Z 09 Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE C VERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
r 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 0 BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains an4penaltes of erjury,that the information on this ppC a ' n is true and complete
FIRM NAME: t?7 t /l ,•,�
eq LIC.NO.:
Licensee: P gig ture
I applicable, LIC.NO.:�
(f pp 'cable, enter`exempt"in the license number line.)
Address: Bus.Tel.No.:
Alt Tel.
/g
*Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: L c.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage no
rmally
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 FEE.$
t
r .
1
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
ations
C:a
600 Washington Street
Boston, MA 02111
{\j www mass govl&a .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers
A1212licaut Information
Please Print Lembl
Name(BusinesslOrganiza ion/Individual): � I it I
Address:
City/State/Zip: 1
Are you an employer?Cheek.the appropriate box:
I.❑ I am a employer with 4 Type of project(required):
❑ I am a general convector and 1
„� nPloyees(full and/or Part-time).* have hired the sub-contractors b ❑New construction
2• am.a.sole proprietor or partner_ listed on the attached sheet x 7• ❑Remodeling
ship and have no employees These sub-contractors have S. Q Demolition
working for mein any capacity, workers' comp.insurance.
[No workers comp.insurance 5. �• ❑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 l.❑Plumbing repairs or additions
myself.[No-workers'comp, c, 1.52, §1(4),and we have no
insurance required.]t employees. [No workers, 12.[]Roof repairs
13.[].Other
camp. insurance required.]
"Any applicant that checks bob#t ewer also fi[I out the section below showing their workers'oompensation policy information,
t Homeowners who submit this affidavit indicating they are doing all work and then hue outside contractors must submit a new affidavit indicating such.
4contraetors that check this box must attached an additional sheershowittg the name of the sub-contmcrors and their!vorker:' mF M?icy inStmadon.
1 am an employer that is.proriding:workers'co ensmdon insurance or
information. f H'eMP10YftL- Below is the policy and job site .
Insurance Company Name:
Policy#or Self-ins.Lie.4. �� 3. �',
Expiration Date: y/� f0 d -
Job Site Address: >11
/`'�!✓
City/Statcaip:
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'nsurance coverage verification.
I do hereby certify er the ins nd pe les of p r'ury that the information provided above is tree and comma
• Si tore:.
Date: 969
Phone#:
Official use only. Do not write in this area,to be completed by city or town officfal
l
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#:
y. .
Information and Instructions 12-3-
17
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for theirmeployees.
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 eompiience 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 cant'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 shoed enter their
self-insurance license number on the appropriate line.
City or Town Officials 1'
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 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 investi.0ions would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give as a call.
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts ti
Department of Industrial Accidents
Office of Investigations t%
600 Washington Street
Boston, MA 02111
Tel.#617-7274900 ext 406 or 1-977-MASSAFE
Fax#617-727-7744
Revised 5-26-05
www.mass.gov/dia
Date. . . . . L:. . . . .
H�'°T:1tic TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
�SSCHUS
This certifies that . . . . . . ... . ... . . . . . . . . . . .
has permission to perform . . . . . . . .
r
plumbing in the�bS�ingsf . . . . . . . . . . .�J-�j.-��. . . r. . . . . . . . . . . . .at m:. . .t . . . . . . . . . . . . . . North Andover, Mass.
v
Fee/-�„/.. . . . . .Lic. No.. . .� . . . . . . . . . . . . . . . . . .
PL ,,B NIG INSPECTOR
Check #
8035
` MASSACHUSETTS UNIFORM APPLICATION FOR PE
RMIT TO DO PU M ING
(Type or print).
NORTH ANDOVER,MASSACHUSETTS
Building Location 701# / Date
Owners Name
Petmit#
Type of Occu anc l v���f Amount :
New Renovation Q Replacement
Plans Sub tted Yes No ❑
FUTURES
a
U O a7
f-r
SLSl$4V1� C,b q �
&l,4+1VIIVI' I
�1i2 T"IfJQ2
3MffioaZ I.
4IH� I
SAH NIDQZ
61H
8M i
I
(Print or type)
Installing Company Name �D _/_., Check one: Certificate
Address Corp,
Partner.
susut ss Telephone
` �umlCo.
Name of Licensed Plumber. , L 7 YT �/�lL2ta
Insurance Coverage Indicate the of insurance coverage by chckm
Li$bility insurance policy Other type of indeche a appropriate box:
ty, Bond
Insurance Waiver. I, the undersigned,have been made aware that th
three insurance e licensee of this application does not have any one of the above
7gnature ❑
Owner Agent ❑
I hereby certify that all of the details and information I have submitted
best of my Imowledge and that all plumbing work and installations (ori )in above application are true and accurate to the
compliance with all pertinent provisions of the M cin Perf°rmed under Permit Issued for this application will be in
By:
��e.�`uumb C°de a hapte 42 of the Gemeral Laws.
Lure or Lrcensea
Title 'Type of Plumbing License
City/Town lr�
APPROVED rotes�sE orrr Y License umoA�r"�— Master
�Joumeyman ❑
The Commonwealth of Massachusetts
artment of
° De P Industrial Accidents.
Offece Of Investigations
1; W tlf 600 ashin,Qion Street
Boston
, MA 02111
C '- W►�'-»ZasS.gov/din
Workers' Compensation Insurance.A:)<fiday.it: guilders/ContractorsTlectricians/Plumbers
Appfinant Info.rmaion
P}e$se Prinf Leai6lFr.
Namt (Business/OrganizationMdividual :
I
Address: t7�{ j
Ci /State/Zi. :-
Are you an employer?Check the appropriate box:
I•LI 1 am a employer with ?�- 4. ❑ I am a general contra for and I Type of protect(required):
employees(trill and/or part-time).* have hired the sub-contractors 6 ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet �• �Remodeling.
ship and have no employees These sub-oontractors have
working for me in any capacity. workers' comp. insurance. g' ❑ Demolition
[No workers' comp. insurance 5. ❑ We are a corporation and its 9• Building addition
3.❑ required_] officers have exercised.their 10.❑ Electrical repairs or additions
[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
insurance required.] t employees, [No workers' 12❑ Roof repairs
camp. insurance required.] 13•❑Other
+*Any applicant.that checks box#I must aiso fill out the section below showing their workers'compensation oli
.
riomeownert who submit.@iis affidavit indieariug ti4ey art duiti•E:':V. 4t;a Enc P cy twormation.
e L
1Conttactors that the k this box must sitacheti an additional sheet shnwitag the mac=e of tti uta wntrackon;muni submit a novo affidavir in;:i�er.g such.
orMwtom and their workers'comp,poli"information.
I an employer that is provider workers'compensation insurance for m3'a to ees. Below is he
afi t
infoinformation. y p cy and job sue
Insurance Company Name:
Policy#or Self-.ins. Lic.#:
J Expiration Date:
Job Site Address: �-3 (Z
City/Statezzip'-11 r 4-11d L
Attach a copy of the workers' compensation policy declaration page(showin;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 forrn of a STOP WORK ORDER and a fine
of up to.S250.00 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 hereb9i cert' u er the p I' and enaWas of perjury that the informat on provrded above is true and correct
Sionature:
Dat (1
Phone# r !� Z�
Of ecia!use only. Do not write in this area, to be completed b3:city or town oJf<cial
City or Town Permit/License#
Issuing Authority(circle one):
1. Board of health 2. Bubdine Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person.
Phone
Information E- .rid Instructions r
Massachusetts General Laws chapter 1 S2 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined.as"..ever-y 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,orthe
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 sucZP
h employment be deemed to be an employer."
MGL chapter 152,g25C(6)also states that"every state o r local licensing agency shall withhold the issuance or
renewal of a license or permit.to operate a basiness or to construct buildiad in the commonwealth for any
applicant who has not produced acceptatiie evidence mf compiiance with the insurance coverage required."
Additionally, MGL chapter 152,g25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
entzr 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 coritra.cting 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 c,-rdficate(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 LLCDr LLP does have .
employees, a policy is required. Be advised that this afficLavit may-be submitted to the Department of Industri.al
Accidents for confirmation of insurance coverage. Also be sure to si;n and date the affidavit. Theaffidavit should
be returned to the city or town that the application for the perma-, license is being requested,not the Department of
Industrial Accidents, Should you have anyquestions regi rdirm the I?w or if you are required to obtain a workers'
compensation pioiicy;please call the Department at the nm-.n
b--listed below. Selma 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 Iegibly. The Department has provided s svace at the bottom
of the affidavit foryou to fill out in the event the Office of Investigations has to contact you regarding the appiioent:
Please be sure to fill in the permitriicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permitllicense applications in an},given year,need only submit one affidavit indicating currerit
poiiey information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the afndavh 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. VAfhe:re a home owner or citizen is obtaining a iicensa 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 L-ridustrial Accidents
Office of Investigations
600 Washington Street
Boston; MA 6211 l
Tel. # 617-727-4100 ext 406 or 1-877-MASSAFE
Revised $-2645
Fax#617-r-7-7749
V WVi'.I ass.gov/did