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Miscellaneous - 347 WOOD LANE 4/30/2018
N NO QbN (vO� O O O O O Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: Property Address: Company: Policy/Claim Number: Date/Cause of Loss: Our File Number: James & Mary St. Hilaire 347 Wood Lane Merrimack Mutual Fire Insurance Company HP0508918, HP0508918 3/1812016, Windstorm/Tree on Wires 33250-M Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Mike Peterson, Ext. 115 On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Signature and Date ANDERSON ADJUSTMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053 Cc: Health Department 1600 Osgood Street Building 20, Unit 2035 North Andover, MA 01845 North Andover Fire Department 795 Chickering Road North Andover, MA 01845 f ..�........................... TOWN OF NORTH ANDOVER PERMIT FOR GAS. INSTALLATION This certifies that..�` �: �...�'.�� Gt --� ............. ........ has permission for gas installation .'. �`5 -t �' inthe buildings of ................... I......i................................................................................ at .... .`.!"........... W E...v.............. �--.r`'.:.................... North Andover, Mass. Fee . .'3 ....... Lic. No... t )63 ��/ GAS INSPECTOR Check # CXR :'220 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK � CITY I North Andover MA DATE312412014 PERMIT JOBSITE ADDRESS 347 Wood Lane OWNER'S NAME I James St Hilaire GOWNER ADDRESS I Same TE 978-683-3597 IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ® PLANS SUBMITTED: YES❑ NOM APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 1 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 ISPACE HEATER ,AROOF TOP UNIT TEST UNIT HEATER NVENTED ROOM HEATER WATER HEATER OTHER Replace Gas Meter x and Pi inq as NeededI=H I =1F INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ❑ NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q 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 in ompliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I Joseph Marino LICENSE #8736 NATURE MP ❑ MGF ElJP (❑ JGF [jLPGI ❑ CORPORATION ❑# 3285C PARTRSHIP ❑#LLC ❑#= COMPANY NAME: RH White Construction Co ADDRESS 141 Central St CITY I Auburn I STATE MA ZIP 01501 TEL(508) 832-3295 FAX 508-926-4347 j CELL 508-832-4614 EMAIL JMarino@RHWhite.com / w F 0 z z 0 h w w a zo ❑ z O N ) w � ~ W O a z ft w a F- rA w W W> O � zza w w d w � a �7 z a a a � U J F a a a w x w O � \ 0 w a 0 0 x r 0 (OLU W <Z p. ¢..� cam LL • o . ad .o o M: � • zLo a LU W Ln '� ,>•".iU,)�;` �rf:i �•.;i�j;o Ips 1��•, rte ':" '�l�i!! 1171•.�i... :: ' .fr.'rtti,l:: fy.... Ij :i i1j�i' �. ��jJi" Iil: . ... '.'� :�:y ,i%,i�fl`i, :�:,;':{„ .(i:�: •,'t�fi���� �' 0 04/03/2014 14:04 5088326751 RH WHITE CONSTRUCT PAGE 02/02 ACC)R® CERTIFICATEDATE"IDDlYYYY► OF LIABILITY INSURANCE page 1 oQ 08/29/2013 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLYAND 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)muet 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). willio of MaeaachuaettE, InC.. C/o 26 corituay Blvd. P. 0. Box 305191 Na,ghville, TN 37230-5191 R. H. White ConatruCtion Company, Ino. 41 Central Street P. 0. Box 257 Avhurn, MA 01501 cs�a =2.wa INSUREKA:The Ch*XteI Oak Fixe Inauranco Company 25615-001 INSURER9:Travol9r2 Property Caaualty company o£ Am 25674-003 INSURERC:National Union Piro Insurance Company of 19445-001 INSURERO; Travelers Ind=nity Company 2S659-001 INSURER F,: NVYGrC/-1VGCl c;LKI[H(;ATE NUMBER: 20107680 REVISION NUMBER; THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURI`D 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 OrINSVRANCE DD"SUB POLIGYNUM13ER POLICY EFF POLICY EXIS LIMITS A GENERAL LIABILITY VTC20CD 977R9948-13 9/1/.2013 -9/1/2014 DEEACH0CCVRRENCE F 2 000 0_0( I[ COMMPRCIALGENERAL LIABILITY P� 18 Eeeauoncrf 300.Q0 CLAIMS^MADE OCCUR MED EXP (Anyone person) 3 B C D D PER; AUTOMOBILE LIABILITY X7 ANY AUTO WORKERS COMPENSATION AND EMPLOYER87LIAOILITY yfN ANY PROPRIETORIPARTNFRIFXECUTIVEY NIA OFPICERrMEM9RREXCLUDED? LL'JJ Myandetcry�r In NN) uttl VKII% I IUN u d Uf'tRA7ION3 below TE HOLDER Evidence of Inmurance VTSCAP 977R955A-13 9/1/2013 9/1/2014 SS8766140 9/1/2013 9/1/2014 820SA185-13 19/1/207.3 9/1/201A A203A71A-13 9/7,/2013 9/1/2014 epees 2,000,000 BODILY INJURY(Per person) Is BODILY INJURY(Peraccldenl) $ E.L. EACH ACCIDENT 3 11000.000 E.L.DWEASE-EAEMPLOYEE 3 1, 000, 000 SL,DISEASE-POUCYWMIT S 1,0001000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 8E CANCEI.I.ED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE UQA1:1lr7bo4 WPL:1594012 Cert:20287680 ®1988-2010ACORD CORPORATION. All rights ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD NED AUTO$ AUT 8WLED X HIREDAUTOS -i-NON-OWNED AUTOS X Co Ded X Coll Ped 8500 UMBRELLA LIAa X OCCUR $ E%CESS LIA6 CLAIMS -MADE DED I $ RETENTIONS 10.00( WORKERS COMPENSATION AND EMPLOYER87LIAOILITY yfN ANY PROPRIETORIPARTNFRIFXECUTIVEY NIA OFPICERrMEM9RREXCLUDED? LL'JJ Myandetcry�r In NN) uttl VKII% I IUN u d Uf'tRA7ION3 below TE HOLDER Evidence of Inmurance VTSCAP 977R955A-13 9/1/2013 9/1/2014 SS8766140 9/1/2013 9/1/2014 820SA185-13 19/1/207.3 9/1/201A A203A71A-13 9/7,/2013 9/1/2014 epees 2,000,000 BODILY INJURY(Per person) Is BODILY INJURY(Peraccldenl) $ E.L. EACH ACCIDENT 3 11000.000 E.L.DWEASE-EAEMPLOYEE 3 1, 000, 000 SL,DISEASE-POUCYWMIT S 1,0001000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 8E CANCEI.I.ED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE UQA1:1lr7bo4 WPL:1594012 Cert:20287680 ®1988-2010ACORD CORPORATION. All rights ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD 09946 Date .6-. b,;rr riY1,, "4 TOWN OF NORTH ANDOVER m PERMIT FOR PLUMBING S This certifies that ... a L.. f k.z has permission to perform ...6 44 .+ ✓�G� ?� plumbing in the buildings of .3?. w U dd . 147y at ....... G.y ,North An ovr, Mass. Fee 85 :. Lic. No... PLUMBING INSPECTO Check # �� S INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES W NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [A OTHER TYPE OF INDEMNITY Ej BOND Ej 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 0 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 andaccurateto the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comma/% ith a Pertin�nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. I/ PLUMBER'S NAME f - ,Ptd_ _ I LICENSE # lmiij SIGNATURE MP oil JP © CORPORATION D# I PARTNERSHIP F]!# LLC D� [. -!i , COMPANY NAME, ; ADDRESS IV CITY'rd�,/ - .__...._....__+ISTATE ZIP f� l��i -- i TEL FAX _ - - ; CELL V& /S2.%.....� EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK POWNER TYPE OR PRINT CLEARLY CITY _ D• fk7✓d0� _ _ MA DATE .S _^jj.._jjPERMIT# JOBSITE ADDRESS L 3,19 dvood DOWNER'S NAME .i .e s .+✓ ADDRESS _ _ TEL FAX OCCUPANCY TYPE COMMERCIAL M EDUCATIONAL .© RESIDENTIAL NEW: ©I RENOVATION:E] REPLACEMENT: PLANS SUBMITTED: YES ®I NOQ 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 I I I _.....,._� ... _I DEDICATED GREASE SYSTEM L---- J ...__.-.__! __._.__} _._._._J __.__1 I __.__._J ___.,_} _-_-_I _....___f DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN i } I ' J (I __-..-.-_-' FOOD DISPOSER FLOOR/AREA DRAIN _( _._......._1 ___-_ ___-_J L --j —J -__-._--1 _--._...,J --_._I _.--,_-,-.I INTERCEPTOR INTERIOR - I I .___._.._i I 1 ! I _—_1 ____-I KITCHEN SINK LAVATORY ----- _.._.1 ROOF DRAIN — } } i 1 ---_-__I SHOWER STALL SERVICE I MOP SINK TOILET URINAL 1 .-_....-_.� __—_-I J __--J 1 1 1 `! � 1 _.._.__l I ._._._._.1 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _ _( ! ! _ 1 -..-- WATER PIPING OTHER_1 --J= __ __I _ _ _f INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES W NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [A OTHER TYPE OF INDEMNITY Ej BOND Ej 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 0 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 andaccurateto the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comma/% ith a Pertin�nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. I/ PLUMBER'S NAME f - ,Ptd_ _ I LICENSE # lmiij SIGNATURE MP oil JP © CORPORATION D# I PARTNERSHIP F]!# LLC D� [. -!i , COMPANY NAME, ; ADDRESS IV CITY'rd�,/ - .__...._....__+ISTATE ZIP f� l��i -- i TEL FAX _ - - ; CELL V& /S2.%.....� EMAIL O z z 0 U W a o z N ❑ O H � W � w O w O z ILLu W �* oCO) W 5 N a w w d w a p o a � w a J a a Q co w x w � w F O z O -J H U a F C7 O a The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 up. www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers &Pplicant Information/ _ Please Print Legibly NaMC (Business/Organization/Individual): !"Ay � gg_ U 9 �v�'— Address: City/State/Zip:/ylG-'_/ M,/J- Dad -(Y Phone if: �1�� � s � 1c�' 2 - ,re you an employer? Check the appropriate box: Type of project (required): ❑ I am a employer with 4• ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. # 7• E] Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition working for mein any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.E] Electrical repairs or additions required.] E] I am a homeowner doing all work officers have exercised their right of exemption per MGL l l ig Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs insurance required.] f employees. [No workers' 13.❑ Other comp. insurance required.] y applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. )meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. itractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. n irn employer that is providing workers' compensation insurance for my employees. Below is the policy and job site )rmation. trance Company N icy # or Self -ins. Lid. #: Expiration Date: Site Address: ?g I C�Ovc� I-IV tom— City/State/Zip:, ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ure to secure coverage as required Linder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a Up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine p to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of :stigations of the DIA for insurance coverage verification. h ereby certify under � pghjs and penalties of perjury that the information provided above is true and correct. fficlal use only. Do not write in this area, to be completed by city or town official. :ity or Town: Permit/License ,suing Authority (circle one): .Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector . Other t IInformatlon 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 ormore 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 Athe affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. 'lease be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant hat must submit multiple permithicense applications in any given year, need only submit one affidavit indicating current )olicy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or own)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each rear. 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. he Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, Tease do not hesitate to give us a call. he Department's address, telephone and fax number: The Commmwealth of Massaobusetts Depaztm.eat of Indilstrlal A,cclde>ats Office, of Investigations 600 Washington Street Boston, MA. 02111 TP.1 1# (17_777_AQnO P,rtAOrii nr 1..R77_11/tACCAFPF. Date ... �.'. �.� LRD r. ' : • TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .. �. � C U «---J has permission for gas installation .. co 6. . • -C. . , • • . , , ', in the buildings of. .-.Tk. ... , . • . , . • . , , ... . at ......... N. (/UC) G) ........ orl h n ow, Mass. Fee 30.. '%I.. Lic. No.... GASINSPECTOR Check # r 8695 by .v, 671 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY t<1 Ny fi0�- _ _� MA DATEr�-/ �1-13 yII PERMIT # JOBSITE ADDRESS OWNER'S NAME z e II - -- - G OWNERADDRESS-c_- _ TEL] —FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL& CLEARLY NEW: RENOVATION: 0 REPLACEMENT: PLANS SUBMITTED: YES FII NO .,D_I APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER I ,_.�.J {J COOK STOVE a! T _ _ IIE=X__ _-z._! .,J DIRECT VENT HEATER [y-T_ I DRYER FIREPLACE FRYOLATOR FURNACE- GENERATOR GRILLE INFRARED HEATERr_ �1 _ I _ _ _- _--:. r - - - _. I _ -_.: - 1 f LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER _ E� I .__ 1 _ r- . _ L ..� ! =J- =1T! ..T.__1 _. _I__I ROOM /SPACE HEATER _. I .! _ _ — I, _. I. _ �.-- ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER L �� I---J _ ! _ __ — I I _-----I —___ F_ _ — _I INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES {IO ��_I 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Z OTHER TYPE INDEMNITY Lj BOND I__( 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 [j 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME S,c�.,_. . LICENSE# ._� .�� SIGNATURE MP ® MGF i JP JGF [) LPGI�___i CORPORATION D# [= PARTNERSHIP Di#LLC [J11# COMPANY NAME: ADDRESS CITY -�!!? � rte"`? .; .__� STATE ZIP _ _ .. TEL FAX CELL.,, EMAIL by .v, 671 H O z 0 H U W W z� W %- F- W LU O U w # z W .< ly a a W a �a > o w W N ,a � O a P -i Q U ��••ii J CL a CO w x w F- LL. H O z z 0 H U W W Ch a° 40 The Commonwealth of Massachusetts Department of IndustriqlAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leyibly Dame (Business/Organizatio0ndividual): _ X71 �� Address: 1, C9 b09C -2-0-06 City/State/Zip: M& -T9,, - e12,404�� `F Phone #: Are you an employer? Check the appropriate box: Type of project (required): L ❑ I am a employer with 4. ❑ I am a general contractor and 1 6. [] New construction employees (full and/or part-time).* have hired the sub -contractors listed on the attached sheet. * 7. [1Remodeling 2. ® I am a sole proprietor or partner- ship and'have no employees These sub -contractors have 8. E] Demolition working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its g, (� Building addition [No workers' comp. insurance officers have exercised their 10.❑ Electrical repairs or additions required.] 3. I am a homeowner doing all work ❑ ri ht of exemption per MGL g p 11.W Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] s employees. [No workers' 13. ❑ Other comp. insurance required.] *Any applicant that checks box #t must also fill out the section below showing their workers' compensation policy infonnation. 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. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: fit/fides - _ 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 certify unAr th5pains an yenalties ofperjury that the information provided above is true and correct. 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 #: Informati®n and Instruction's Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract 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 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 ou 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 Massachilsetts Department oflndustriat Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tei, # 617-727-4900 ext 406 or 1-877rMASSAFB Revised 5-26-05 Fax ## 617-727-7749 www.mass,gov/dia Date : �� 1 ................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... v!,� .,..,.„ c/o/, 4,4 ...... ............................................................................ has permission to perform�*� ��e SSD , �✓Ic �� 7th ......................................................... wiring in the building of......... �5�...... `x..1,10 ! r— ................................................. .... at .......& .T.4Q.v�e..... 4�,�........................... . North Andover, Mass. Fee.............................. Lic. No.................. ............................... ............................................. ELECPRicALINSPECPOR Check # 32 NonrM,h � o # i ii• n X17 o++ieo 'I`,`'l•1 8`4ACMUgF' Date : �� 1 ................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... v!,� .,..,.„ c/o/, 4,4 ...... ............................................................................ has permission to perform�*� ��e SSD , �✓Ic �� 7th ......................................................... wiring in the building of......... �5�...... `x..1,10 ! r— ................................................. .... at .......& .T.4Q.v�e..... 4�,�........................... . North Andover, Mass. Fee.............................. Lic. No.................. ............................... ............................................. ELECPRicALINSPECPOR Check # 32 p- Commonwealth of Massachusetts Official U11se Only Permit No. Department of Fire Services 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 (MEC), 527 CMR 12.00 (PLEASE PRINT WINK OR TYPEALL )NFORMATION) Date: d City or Town of. N( By this application the undersigned Location (Street & Number) Owner or Tenant " r 3 Owner's Address S� ER To the Inspector of Wires: or her intention to perform the electrical work described below. S2 Is this permit in conjunction with a building permit? Yes R'- No ❑ Telephone No. (Check Appropriate Box) 61 � - Purpose of Building Utility Authorization No. Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Completion ofthe fnllnwino table mnv ha waived by the h,mj2rtnv nfWin- 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- ❑ rnd. gyrnd. o. of Emergency Lighting Battery Units Outlets �$ No. of Oil Burners FIRE ALARMS No, of Zones FofReceptacle s /Q r No. of Gas -BurnersNo. of Detection and Initiatin Devices % Total No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers HeatPump Totals: Number " """" Tons """""""""""" KW """"""'""""" No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: 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. 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: INSU_RA-NCE ❑ BOND ❑ OTHER ❑ (Specify:) 1 certify, ander the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME; _ _ _ LIC. NO.: Licensee: rt -n X 6A&f--,h t Signatur LIC.NO.: E V Q'5- (ffapplicable, enter "exempt" in Me license number line.) 011 Bus. Tel. No.• VZ-7�f f/ 1�, Address: Alt. Tel. No.: *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 p PERMIT FEE: $ f % Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, ars 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 inval id 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: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass❑' Failed IN Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: UA Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed 0 Re- Inspection Rquired ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com a The Commonwealth of Massachusetts Department ofIndustriglAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation ]Insurance Affidavit: Builders/ContractorsfFlectricians!Plumbers Applicant Information Please Print Lep-ibly Name (Business/Organization/lndividual): )LZ1JCA INkck^-c )•. Address: City/State/Zip: 4,A#M&6.Q1&3d- Phone k <m— cw% o y Are you an employer? Check the appropriate box: Typo of project (required): 1. [] I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction paiployees (full and/or part-time).* havehireclthe sub -contractors listed the 7• Remodeling 2. ['`' lam a sole proprietor orpartner- ship and'have no employees on attached sheet. These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance.g. Bg addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL I Ln Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12.E] Roof repairs insurance required.] t employees. [No workers' 13.[] Other comp. insurance required.] 'Any applicant that checks box #1 must also fill out the section below showingtheir workers' compensation policy information. I Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that 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 Policy # or Self -ins. Lic. Job Site Address-, Expiration Date: 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 requiredunder Section 25A of MGL o. 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 DTA for insurance coverage verification. Ido Hereby cerci �anndyr the pains and penalties ofperjury that the information providedab Vers ue a d correct. Signature: GJ� Date: A ��SY13 Official use only. Do not write in this area, to be completedby 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. PIumbing Inspector 6. Other - - - Contact Person: Phone #: Information and Instructiolm's Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract ofhire, - express or implied, oral or written." An 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 Weal 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 ofits 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 cgntracting 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 notrequired to carry workers' compensation insurance. If an LL C 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 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' compensationpolicy, 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 fufure 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 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: Tho Commonwealth ofM-assarhwats Depadmeot ofIndustdat hooxdenta Offxoe off1westigation 600 Washing= Street Boston? MA Q2X X X Tel, # 61.7-727-4900. eyt 406 or 1-877 MASSABB Revised 5-26-05 FaY0 617-727-7749 i t r� Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: Property Address: Policy Number: Date/Cause of Loss: File or Claim Number: James & Mary St. Hilaire 347 Wood Lane HP0508918 2/7/2013, Theft of Plumbing 27973-W Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Wade Anderson On this date, I caused copies of this Notice to be sent the persons named above at the addresses indicated above by First Class Mail. Si nature and Date ANDERSON ADJUSTMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053 Date. N— �: %l ,ORTh "o TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING SS US This certifies that ......! ....................... . has permission to perform .4.�-f'-r- ,......... II .... . plumbing in the buildings of . �-7 �`f! �I/ /. �+ ,/ at .. —?���de) .... - ... . ; North Andover, Mass. Fee. 7Y.--� ... Lic. No..... � � . �.... �ING'INSPEOR .PLM Check # 7988 MASSACHusETT$ UNIFORM APPUCA'TON FOR PERMIT TO DO GAS FI'T'TING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Logations 214 7 woo, ( L N Owner's Name New D Renovation ❑ Replacement ❑ Date Permit # V Y Amount $ .sf k�1a;r- Plans Submitted ❑ W a�IC4 Z, ' c F F z z H W W O C O rZ F W W v� Z U W m Z F p > W d S a y W q 2 d W Q % F W W U p > U. W U x y Cx W O W F� } �' e4 Z O Z W C 3 O V O w SU B-BASEM ENT > 0 00. p BASEMENT 1ST. FLOOR A 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR b 5TH. FLOOR 6TH. FLOOR 7T H. .FLOOR STH. FLOOR (Print or type) 1 % Name I ` �, �� �-i Check one: Certificate Installing Company I ❑ Corp, Address 2 PJn l,v f-r_a (Z' gF P usmess a ep one234- 0619irm/Co. _ Name of Licensed Plumber or Gas Fitter _1 iG' u j �p,y AA o/1 d �INSURANCE COVERAGE I have a current liability Insurancep icy or it's substantial equivalent Check one: lf you have checked es pleas i irate the type coverage by checking the appropriates 1:3 No❑ Liability insurance policy Other type of indemnity EDBond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: Owner ❑ Agent 1:3hereby certify that all of the details and information i have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and C_hr 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber 115--22-1 ❑ Gas Fitter License um er Master ❑ Journeyman Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: Property Address: Policy Number: Date/Cause of Loss: File or Claim Number: James & Mary St. Hilaire 347 Wood Lane HP0508918 1/23/2013, Fire 27592-W Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Wade Anderson On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. /// //W— 1-31-13 S' n ure and Date ANDERSON ADJUSTMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053 � S Date .............. ................ NORTI{ °ft"`°;•'"° TOWN OF NORTH ANDOVER a p PERMIT FOR WIRING o+ i o+•r•o �'•��� �,ssACMUSE� This certifies that ......,. ........................ :r ... ................................... has permission to perform.. f. $. _ :.L�..-;------ wiring -!%wiring in the building of . ` ......,_. ! .,/ Orr � �r .................. U at . ......L.... a-n-,�.. �-�........... ...... .North Andover, Mass. Fee...:!,... ... Lic. No:�rl�sz................................................". ` �� / LECfRIC INSP � Check # 8225 P 'A"N Lommonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. S— Occupancy and Fee Checked 6+►' :ev.1/07] (jeavPhin.L1 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 INEX OR TYPE ALL WFORAUTION) Date: &e~r —0 0 City or Town of: NORTH ANDOVER To the pector of Wires: By this application the undersigned gives notice of his or er intention to perform the electrical work described below. Location (Street & k umber) j Y T tn, / f Owner or Tenant' Iy 01 / Owner's Address —�—� Telephone No. Is this permit in conjunction with a building permit? Purpose of Building Yes ❑ No (Check Appropriate Bos) Utility Authorization No. E3:isting Service 10 Amps 4 GVolts Overhead Undgrd ❑ No. of Meters New Service Id 0 Amps Volts Overhead Uncle d ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of 'o. of Recessed Luminaires o. of Luminaire Outlets o. of Luminaires c. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers -I -- "Heaters KW No. Hydromassage Bathtubs I Electrical Work:&j G Completion of the No. of Cell.-Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool Above ❑ In- d No. of Oil Burners No. of Gas Burners No. of Air Cond. Total Space/Area Heating KW Heating Appliances KW No. of No. of Signs Ballasts. No. of Motors Total HP mam be waived by the Generators KVA No. o + mergency ig g Batte Units FIREALAlRAJS ,No. of Zones o. of Alerting Devices ❑ mnmcipal — i'_nennr(in.. ❑ Other No. of Devices or Data Wiring. No. of Devices or elecommunications No. of Devices nr Estimated Value of Electrical Work: Attach additional detail if desired, oras required by the Inspector of Wires. Work to Start Inspections to be re(When required by municipal policy.) quested 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 the pains and enahies o er p ) ( fP ! , that the informatwn on this application is true and complete FIRM NAME: Licensee:©� C LIC. No.: Signature C. NO.: Z (If applicable, enter "exempt �n the license7nmter line.) !� Address: /� U� i 4 p �G Bus. TeL No.: *Per M.G.L c 147, s 57-61, securitywork re uu es D Alt. TeL No.: q epartment 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 Iaw. By my signature below, I hereby waive this requirement I am the (check one) [I owner [I owner's agent Owner/Agent Signature Telephone No. PERMIT FEE: The Commartwea&k ofMassachusetls ? Department oflndustria[Accidents 1 Office of f Investi; ations . 600 Washington Street �1 Boson, MA 02111 www m=s ffov/dia . Workere' Compensation insurance Affidavit: Builders/Contractorsmectriciaas/pfambers Applicant Inforntatinn Name fBusiness organizafionfindividuaw Address: av/ ----------------------- City/State/Zip:�j 7M -41'7 Are you an employer? Check the appropriate box: ' 1 • 111: tim a employer with 4. ❑ I am a general contractor and I ployees (full and/or part -tune).* 2. have hired the sub -contractors I am.a.sole proprietor. or partner. listed on the attached sheet t ship and have no employees These su.1:s-contraetors have working for me in any capacity, [No workers' comp, inset-ance workers, comp. insurance. 5. Q We are a corporation and its required.] 3. Q I ain a homeowner doing .: Office= have exercised their all work right of exemption per MGL myself, [No•worke' at comp, c..152, § 1(4),'and we have no insurance required.) t . .empltsyees. [No workers' comp. insurance re uired ) Type of preject (required): 6•. Q New construction 7. ❑ Remodeling S. Q Demolition' 9. ❑ Building addition 10-Q Electrical repairs or additions I1 -Q Plumbing repairs or additions 12.[] Roof repairs q I3.(].Othcr 'Arty applicant that cheeks bat I must 11131) fill out the section below showing their workers' cont T Homeowners who submit this afFWavit iadic�ting they ars doing all work end them hire otnside eon�ttacton must utiofi submit eaniew affidavit indicating such. ;Contractors that check this box Mustattaehed an additional sharshowing the ram.- of the sub-conuactots and their workers' camp. policy ia%tmation. I ant an employer that.is-providing:workers' Compensation insurance for nV e infor»eaiinn. mA�Yees Below is the policy mrd job site Insurance Company Name Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: Cily/StaftZ;p. Attach a copy of the .workers' coatpensation Policy declaration page (sbowing 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 penahies of a .00 fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form a STOP WORK ORDER anal a fns Investigations of thImposition Of up to S250a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of e DIA for insurance coverage verification. I do here c by under the pains and pen of perjury thrtt the utfnrnmtt �v above is tMe and soSi rted Date: Z 7�0 Phone #: C l( Ofrwiat use only. Do notivrite in.this area, 'Mhe completed by Cluj, or town off'u:ial City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitY/ own Clerk 4. Electrical Inspector S. Pinmbing Inspector 6. Other 11 Contact Person: Phone #: Information a lid 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, exprrss or implied, oral or written." An employer is defined as "an individual, partnership, assvoiation, corporation or other legal entity, or any two ormore ofthe%regoing 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. •Howeverthe owner. of a dwelling house having not more their 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 iteensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth far any Applicant who has not produced acceptable evidence0t compliance with the insarance coverage required." Additionally, MGG 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-corttractor(s) name(s), address(es) said 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 Depar menf 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 regained to obtain a workers' compensation policy, plmsrcall the Department at the numberlisted below. Self-insured companies should enter their self-insurance- license number on the'approprkteline. 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 v+,ilI 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 shouldwrite "all locations in (city or town).",A copy of Eire 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 parson, 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 13ndusuial Accidents Office of Investigations " 600 Washington Street h Boston, MA 02111 TeL 4 617-72-7-4900 ext 406 or 1-877-MkSSAFE p Revised 5-26-05 Fax 4 617-727-7744 wwwmass.gov/dia