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Miscellaneous - 35 MASSACHUSETTS AVENUE 4/30/2018 (2)
N vwi O D N� Qb CD') O C N Cl) O � O mo m z m m Date ..... / .. ..................... TOWN OF NORTH ANDOVER , PERMIT 'FOR WIRING Z' � 4. 5, 41? i reo This certifies that ........................................ .................. ...... has permission to perform ....... Id, x.1 ............ wiring in the building of ................. ................................................................. V at ..... ....... A ............ Andover, Mass7 Fee..,/07.". Lic. No.../.!.�p A :3 ........... 1- ..................... 41 ELECTRICAL INSPECTOR GCheCk # 10414 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 apppinted pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permitapplicanon. 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 or existence" during the qualifying period beginning on August 15, 2008 and extending"through August 15, 2012. "i�in//effect IR�-igule 8—PermiVDate Closed: `23 Note: Reapply for new per—nAtLb— Y 0 Permit Extension Act — Permit/Date Closed: ..1 Commonwealth of Massachusetts Official Use Only % Permit No. %b ``i �( Department of Dire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 amveblank 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 PRINTININK OR TYPE ALL INFORMATION) Date: — A A City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the el nci tical work described below. Location (Street & Number) Owner or Tenant© Owner's Address No. Is this permit in conjunction with a building permit? Yes Nl-'- No ❑ (Check Appropriate Box) Purpose of Building _1JCE_ Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters s New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and.Ampacity w Location and Natu� a of Proposed Electrical Work: sot 4vre� — .p��(` 1 V1, t rmmnle$nn nfthe following table may be waived by the Inspector of Wires. 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: %0 -;?6 -- // 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 the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: In t _,e LIC. NO.: Licensee: Signature 15Za1t6e, ��/ 4t&)LIC. NO.: (If applicable, enter "exempt" in the license nu her lin) Bus. Tel. No.: 5 Address: l r111) `� Ce_ ;T , J`�/ ` 1 � Alt. Tel. No.: o - *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 y signature be dw, I hereby waive this, requirement. I am the (check one) 5;4wner 1:1 owner's agent. Owner/Agen. ��� tTelenhnnp7�Tn9�n�-lJ./� 2a 7�1 PERMIT FEE. $ -- V No. of Total No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans Transformers KVA No. of Luminaire Outlets No. of Hot Tubs . Generators KVA No. of Luminaires Above In -0. Swimming Pool nd. El rnd. o Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALAR MS No. of ?ones N®..Iand No. of Switches No. of Gas Burners I[Detection nitiating Devices No. of Ranges To No. of Air Cond. No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained No. of Waste Disposers P Totals: - I I Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers ry Heating Appliances RW Security Systems:* No. of Devices or E uivalent No. of Water, No. of No. of Data Wiring: Heaters Signs Ballasts . No. of Devices or Equivalent Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP 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: %0 -;?6 -- // 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 the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: In t _,e LIC. NO.: Licensee: Signature 15Za1t6e, ��/ 4t&)LIC. NO.: (If applicable, enter "exempt" in the license nu her lin) Bus. Tel. No.: 5 Address: l r111) `� Ce_ ;T , J`�/ ` 1 � Alt. Tel. No.: o - *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 y signature be dw, I hereby waive this, requirement. I am the (check one) 5;4wner 1:1 owner's agent. Owner/Agen. ��� tTelenhnnp7�Tn9�n�-lJ./� 2a 7�1 PERMIT FEE. $ L . The Commonwealth of Massachusetts .4 t �, Department of IndustrialAccidents Office of Investigations have hired the sub -contractors 2. I .a.sole proprietor or partner- listed on the attached sheet 600 Washington Street ;\moi Boston, M4 02111 t ' www.ozass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricia milli ---1. ns/Plumbers r—.V— -_i__ Name Address: City/State/Zip:__,N1,F��al4�r�� . Phone #: Are you an employer? Check.the appropriate box: 1. 111- lim a employer with 4, ❑ 1 am a general contractor and 1 maTloyees (full and/or part-time).* have hired the sub -contractors 2. I .a.sole proprietor or partner- listed on the attached sheet ship and have no employees These sub -contractors have working for me .in any capacity, [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I din a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No-worke'rs' comp. c. 1.52, § 1(4),'and we have no insurance -required.] t employees. [No workers' comp. insurance required..] Type of pr9lect (required): b. [❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions JL[] Plumbing repairs or additions 12.❑ Roof repairs 13.❑ .Other i ---- --9 ,ous, wso nu our the section below showing their workers' compensation policy information, Homeowners who submit this affidavit Indicating they am doing all work and then hire outside contractors must submit a newufridavit indicating such. #Contractors that check this box must attnehed an additional shder showing t -h€ name of the subcontractors and their wmr? ess' comp- po!icj information. I arra asa emp Ayer that is,provid1119:tv0r1seps' cornpensUdan imuranre for my information ererpinyees: Beloav is else policy and job site Insurance Company Policy 4 or Self -ins. Lie. Expiration Date: Job Site Address: Cita/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 under the pains and tv penadt� erjury that elle information provided above is true and correct I 3 Town of North Andover Wiring Inspector I, Rosario LoFaro, Electrical License #11803-8, hereby revoke my electrical permits and any further responsibilities at the dwelling, located at 35 Massachusetts Avenue, North Andover 01845, owned by Rosario Motta, effective immediately on May 16 2012. This includes first and second floor apartments. Rosario LoFaro Electrician IWOX-1-4-b I Date.....%o z &-/j r TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that..........�...........I..a.-?ct.f...� ......b/!l,� has permission to perform wiring in the building of ........................... ke��?`............................. at ........................4,'�..."...................... ,North Andover, Mass. my /- Fee .........%........ LIc. No..././.fP................. >. E RIC INSPECTOR Check Ii y_ 104`15 I N1 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be-deemed.by the .inspector_o Wires abandoned.and-invalid_ifhe—_ .. _ or she has determined that the ad'ftiorized 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. s -r,- ivlo S S N C1 (�,Urti r EZ,&r- - L 11�57ea 15;5 plq ,Te Lo c-'(� NAME ADDRESS SERVICE AMPS / VOLTS NO METERS NEW _CHANGE PERMANENT TEMPORARY ADDITIONAL: OVER UNDER PERMIT NUMBER SR# ELECTRICIAN RECEIVED BY DATE CALLED Commonwealth of Massachusetts Official Use No. of Total /Only No. of Ceil: Susp. (Paddle) Fans De artent r ®f Fire Serviceses a Permit No. No. of Hot Tubs Generators KVA Occupancy and Fee Checked Above 'In Swimming Pool rad. rnd. ❑ BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank No. of Oil Burners APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN OR TYPE ALL INFORMATION) Date: /0 " 171)[� - I City or Town of: NORTH ANDOVER To the Inspector of Wires: %By this application the undersigned gives notice f his or her irate tion to Lrfiof-m the electrical k descn7,ed below. Location (Street & Number)�'� l . S t) I A/ Owner or Tenant (;,kk TelephoneNo. ' Owner's Address Is this permit in conjunction with a building p? Yes ER"" No ❑ (Check Appropriate Box) Purpose of Building I NO -al nP.- permit? ��X , - Utility Authorization No. a Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ r Number of Feeders and.Ampacity Location and naturg of Proposed Electrical Work: 2 No. of Meters No. of Meters /'*..,....., 7,.,;,,....f iH� { ll..,.,;— mhln —ni, ho u,niuM by tha Tnxnector of Wires. Arcacn auuutunuc ueluu t/ ucatic — uo ,-y-.,-w y ....-... 1w –.1 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 ElBOND ElOTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: 2J'�G�f \a L _[`J� M Signature 1XZQl t,u)� LIC. NO.: (If applicable, enter "exempt " in the license num er line.Wk6 A Bus. Tel. No.:l�Address: 1p� L�0iLJ!` oce�k Pz ./yG�`�� L� Alt. Tel.No.:` - —1�, *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 b ow, I hereby waive this requirement. I am the (check one) g<wner ❑ owner's agent. Owner/Agent � �Y 7 f Q 0!--c-- %, TP1PnhnilP Nn- 7�?zA4) (�'I PERMIT FEE: $ ®� No. of Total No. of Recessed Lummaires No. of Ceil: Susp. (Paddle) Fans Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above 'In Swimming Pool rad. rnd. ❑ o. o BatEmergency ig g ter Units No. of Receptacle Outlets No. of Oil Burners FIRE AL.A-RMS No. of Zones No. of Switches No. of Gas Burners No..of Detection and Initiating Devices No. of Ranges No. of Air Cond. 'TI'oonsl No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained Disposers No. of Waste Dis P Totals: ........... Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Municipal Local ❑ Connection ❑Other No. of Dryers Healing Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters ISigns Ballasts . No. of Devices or Equivalent Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or Equivalent OTHER: 5 Arcacn auuutunuc ueluu t/ ucatic — uo ,-y-.,-w y ....-... 1w –.1 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 ElBOND ElOTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: 2J'�G�f \a L _[`J� M Signature 1XZQl t,u)� LIC. NO.: (If applicable, enter "exempt " in the license num er line.Wk6 A Bus. Tel. No.:l�Address: 1p� L�0iLJ!` oce�k Pz ./yG�`�� L� Alt. Tel.No.:` - —1�, *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 b ow, I hereby waive this requirement. I am the (check one) g<wner ❑ owner's agent. Owner/Agent � �Y 7 f Q 0!--c-- %, TP1PnhnilP Nn- 7�?zA4) (�'I PERMIT FEE: $ ®� The Commonwealth of Massachusetts Department o fIndustrial Accidents Office of Investigations 600 Washington Street 9ii;[ r g Boston, MA 02111 t ' www..quas.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leoibly Natrte (Business/Organization/Individual):_ City/State/Zi L Are you an employer? Check.the appropriate box: 1. ❑ T am. a employer with 4, ❑ 1 am a general contractor and I employees (full and/or part-time).* '! have hired the sub -contractors 2. @ am .a.sole proprietor or partner- listed on the attached sheet. $ ship and. have no employees These stLb-contractors have working for me .in any capacity, [No workers' comp, insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ 1 din a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No•workers' comp, c. 1.52, § 1(4),'and we have no insurance -required.] t employees. [No workers' ads ..�:_ .�__ _ comp, insurance required_] Type of project (required): 6. [] New construction 7. ❑ Remodeling 8. Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.[] Roof repairs 13.❑.Other t --- � n must also nu out the section below showing their workers' compensation policy information, homeowners who submit this affidavit indjcating they are doing all work and then hire outside #Contractors that check this'box contractors must submit a new 'affidavit indicating such. must attached an additional sheet showing the name of the sub -contractors and their' rkers' conmp. Policy infer, ation. ! an empkper that i3}rrov1devgg:worhers1 cornpenseatdoq Erasaarancefor iny. eMployees. Below is the policymad job site information. Insura.nce.Company Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'.*compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a- line 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cert jy�nder the pains andfgoltip f perry that the information provided above is true and correct Official use only. Do not carie B.11 skis area, to be completed by city or town. offtcia$ City or Town: _ Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other A`__//_ a— Contact Person: Phone #: Y Town of North Andover Wiring Inspector I, Rosario LoFaro, Electrical License #11803-13, hereby revoke my electrical permits and any further responsibilities at the dwelling, located at 35 Massachusetts Avenue, North Andover 01845, owned by Rosario Motta, effective immediately on May 16 2012. This includes first and second floor apartments. 'Rosario LoFaro *Electrician A/ C It +Z -D - SA Z6-, Ft5�-� � ere. i'h ti ��Pci�e.,enl pelm.�- 35 �w� {fit. T J IlL«KS - �UnMc— Date.1..IJZ .I..q ................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION I" This certifies that ...1 ..... ................. OtIt- has permission for gas installdtion 6D ........... i... e, 12 4w in the buildings of .................. ........................... .............................................. at ..... ..................... . 2.- ....... ... .... ........ ..... . North Andover, Mass. Fee i�� ....... Lica No. GAS INSPECTOR Check# 9527 %\A MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK � 1—�-O--C' �-�. la iV�iJ e -r _�� MA DATE -��� PERMIT # CITY ��L691G- _ JOBSITEADDRESS�?�S_I� �'r,f-rOWNER'SNAME rO GOWNER ADDRESS S t -N , TEL��f l�2 —5�7 I FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL EDUCATIONAL RESIDENTIAL CLEARLY NEW:z RENOVATION: REPLACEMENT: El PLANS SUBMITTED: YES 0 NO E] APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER+ DRYER FIREPLACE FRYOLATOR �— FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT _ _ TESTj-__ UNIT HEATER I I �- fir— .f UNVENTED ROOM HEATER WATER HEATER�- OTHER_ ........... _.............. ._ - - - - - �-..1--� 1=�T�J� 1, _ - _ - —��- --- --- INSURANCE COVERAGE h4e a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch.142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ED OTHER TYPE INDEMNITY ® BOND OWNER'S INSURMCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts Genera a t my signature on this permit application waives this requirement. `— CHECK ONE ONLY: OWNER AGENT SIN TUBE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and acurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compl' I Pe ine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t PLUM BER-GASFITTER NAME . /LS06 LICENSE #U(512191 SIGNATURE MP MGF Fj JP ® JGF Q LPGI CORPORATION 0# � PARTNERSHIP ®#= LLC [J#= COMPANY NAME:1 ADDRESS CITY �/G % - STATE ZIP 10/9a.ITEL0�_ FAX CELL EMAIL --_-_-- _-moo - %\A O FMI M The Commonweal& ofMassachusetts DepaYtmant of Indifstrigl,4ccidats Office of Investigaflons 660 Washington Street .Foston, .MA 02111 www.mass govldia Workers' Compensation bnsurance Affidavit: Builders/Cont°actors/ElecfriciansfPlumbero Anpliean information Please Prcinfi Legibly Name (Business/Oxgani'zationftdividual): &/ /) /ZZ/ Address: �20� 3L City/Siaie0p:�iyaa- LT l Phone #: 97-6' Are you an, employer? Check the appropriate box: Type of project (required): 1. [( I am a employer with 4. ❑ I am a general contractor and I 6. [( New constraction f employees (full and/or part time) * 2. I am a sole proprietor or partner have hired the sub -contractors listed on the attached sheet. T 7. ❑ Remodeling ship and'have no.employees These sub -contractors have 8. ❑ Demolition working forme in any capacity. workers' comp. insurance, y, Building addition [No workers' comp. insurance 5. ElWe are a corpora�on and its 10.[I Electrical repairs or additions required.] 3. ❑ X am a homeowner doing all work officers have exercised.their right of exemption per MGL I L ❑ Plumbing repairs or additions myself [Eo workers' comp. c. 152, §1(4), and we have no UP �fixed. ] insurancere 7 employees. [No workers' 1311 other comp. insurance required.] "Any applicant that checks box#I must also fill out the section bel6w showing their Workers' compensation policy information. i Homeowners who submit this affidavit indicating they ftie doing all woilc and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached m additional sheet showing the name of the sub -contractors and their workers' comp. policy infonnation. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job ske information. Insurance Company Policy # or Self ins. Lic. Expiration Date; Job Site Address: City/State/Zip: Attach a copy o#the workers' compensation.policy declaration page (showing the policy number and expiration date). failure to secure coverage as requiredundex Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a ie up to $1,500.00 and/ox '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 n the rzs �araltles ofpetjury that the information provided above is true and correct. Phone #• �? 710 a(> (2> cn Z - Official use only. Do not write in this area, to be completed by city or toren official. City or Town: Permif/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical inspector 5. Plumbing Inspector 6. Other - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an eviployee 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, conshuction 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 ox 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority.." Applicants Please fill, out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) andphonenumber(s) alongwiththeir 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, apolicy is required. Be advised thatthls 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 whichwill be used as a reference number, In addition, an applicant that must submitmultiple permit/license applications in any given year, need only submit one affidavit indicating current p olicy information (if necessary) and under `°.Tob Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has be' n 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 ox permit not related to any business or commercial venture (i.e. a dog license orpermit to burn leaves eta.) 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 aodfaxmimber: The Go onw.oalAtofMammihusP�� - Dap rtmonl of TadwWal AccldauM Office offAvosiigAom X00ashigkore�l Bosta.,MA02111 TQL # 617-7-27-4900 ext 406 or 1-877;NM9AFE Revised 5-26-05 Fax # 617"727'7749 WWW= s,goV1CRa. Town of North Andover Wiring Inspector I, Rosario LoFaro, Electrical License #11803-13, hereby revoke my electrical permits and any further responsibilities at the dwelling, located at 35 Massachusetts Avenue, North Andover 01845, owned by Rosario Motta, effective immediately on May 16 2012. This includes first and second floor apartments. Rosario LoFaro Electrician lWa�-44-6 � Tis S-- - /7- l 2 Pooe I)Wy U Date..J-j TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .............. /Z ........ L.o ... twxz. o ................................. has permission to perform ..... (4.00e ... :S Xe..e . . .................................. wiring in the building of ...... Nxq.. T 1-4 ...................................................... at .......... ................Q................. ,North Andover, Mass. Fee ... Lic. No/-1**?D..3.'.*./3- ................. ... .... . / . ......... L J�sp E Pc�rRiPICALINSPE Check # 10673 lug Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No. 10 67 3 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07) 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 W INK OR TYPE ALL INFORMATION) Date: � d (� 0 :?, 6 % a City or Town of: NORTH ANDOVER To .the Inspector of Wires: By this application the undersigned gives notice of his or her intention tope form the electrical work described below. Locati S --- . on ( treet & N Owner or Tenant _ Owner's Address 5 Telephone No. Is this permit in conjuncts with a building permit? Yes � No N Purpose of Building_ 14,,6 ❑ (Check Appropriate Boa) Utility Authorization No. Existing Service 400 0 Amps /.20 / LNQ Volts Overhead Fq"' Und rd g ❑ No. of Meters New Service aQQ Amps / aaq(DVolts Overhead [9'*i� Und d g ❑ No. of Meters Number of Feeders and Ampacity )w � t �. _ Location and Nature of Proposed Electrical Work: [/ Et,) rvl\i,.r P No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers Heaters KW o. Hydromassage Bathtubs OTHER: INo. of Ceil: Susp. (Paddle) F No. of Hot Tubs Swimming Pool Above ❑ rnd. No. of Oil Burners No. of Gas Burners No. of Air Cond. Tot To Fa No. of --Total �' Transformers KVA Generators KVA In- o. o mergency ig g rnd. ❑ Batte Units FIRE ALAIII'"dIS No. of Zones No. of Detection and Initiatingal Devices Ton Space/Area Heating KW Heating Appliances No. of No. of Si s Ballas No. of Motors Total following table may be waived by thTn Tnr.,o,.t_ „r Err; Attach additional detail f 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 ED/( 'Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Licensee: 9 q LIC. NO.: F'`1nh/'s airy I _ r'��n n � c....��__-- _ . �:... i V (If applicable, enter "exempt " in the license number line. �+ ,' ru�ww�4y dtL T�,y�(� LIC. NO.: Address: l,,�j ter. i.� )r^� rJ C Q. 1j� .��F i1 U N �'''�V�j` ' �� Bus. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" Li e: Alt. Tel. No.: - _ fqq OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability ins Li ce coverage normally required by law. y my a e b ow, I hereby waive this requirement. I am the (check one) owner El owner's agent. Owner/Agent Signature Telephone No. �'� PERMIT FEE. $ t No. of Alerting Devices Kw.,,,••.. No. of Self -Contained Detection/Alerting Devices Local ❑ Municipal ❑ Other Connection KW Security Systems: No. of Devices or Eq uivalent is Data Wiring: No. of Devices or E uivalent HP Telecommunications Wiring: No. of Devices or Equivalent Attach additional detail f 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 ED/( 'Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Licensee: 9 q LIC. NO.: F'`1nh/'s airy I _ r'��n n � c....��__-- _ . �:... i V (If applicable, enter "exempt " in the license number line. �+ ,' ru�ww�4y dtL T�,y�(� LIC. NO.: Address: l,,�j ter. i.� )r^� rJ C Q. 1j� .��F i1 U N �'''�V�j` ' �� Bus. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" Li e: Alt. Tel. No.: - _ fqq OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability ins Li ce coverage normally required by law. y my a e b ow, I hereby waive this requirement. I am the (check one) owner El owner's agent. Owner/Agent Signature Telephone No. �'� PERMIT FEE. $ t 4- (,�w� dX--� z �i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 NZashington Street Boston, MA 02111 t I www_n ass gvv1dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Infornl<ation Please Print Le�bly Nairie (Business/Orgmization/Individual): Address: City/State/Zig: I�►\Q� - M ©�-� 015s1C Phone #. � 21K - � i I-- -;X_LL -1 Are you an employer? Check.the appropriate box: I . ❑ I am a employer with 4. ❑ I am a general contractor and I o riployees (full and/or part-time).* have hired the sub -contractors 2. V, am.a.sole proprietor or partner- listed on the attached sheet x ship and have no employees These sub -contractors have working for me .in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No -workers' comp. c. 1.52, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. [] New construction 7. [Remodeling S. ❑ Demoiition 9. ❑ Building addition 10 F7 Electrical repairs or additions 11.7 Plumbing repairs or additions 12.[] Roof repairs 13.❑.Other ------ w30 rill out me section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside conuacttns must submit a new affidavit indicating such. �Corttractors that check this box must attached an additional sheet showing. the name of the sub -contractors and their works ' cor^.p, pc!!c; in:orradon. lam an employer that is pmtriding workers' co►npensation insurance for my employees. Below information it the policy and joti site Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and pe of perjury that the information provided above is true and correct Si tire: Date: Phone #: - a — a 'L FF6.O l use only. Do not write in this area, to be completed by city or town. official Town: Permit/License # Authority (circle one): d of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector r Contact Person: Phone #: `! l Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute; an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the'foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. 'However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, g25C(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, nofthe 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 numberlisted 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 a ill be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating -current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give as a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia Town of North Andover Inspectional Services 1600 Osgood Street Building 20, Suite 2035 North Andover, MA 01845 Attn: Building Inspector Date: November 1, 2014 RE: Permit #7864 and #9161 To Whom It May Concern, I Gary McDonald am requesting to be removed from the following permits: plumbing permit #7864 and gas permit #9161, for the house located ata35-Massachusetts Avenue in North Andover, MA. The homeowner had other people come in and do all the gas work and finish the plumbing on the second floor without my knowledge or consent and to my detriment. On August 21, 2014, the homeowner contacted me to ask if permits were still in my name. He said he needed to get inspections finalized so he could move upstairs as soon as possible. On August 25, 2014, I met with the homeowner and upon arrival I was told he had a Master Plumber do work to the second floor. I had no knowledge of the work or of the homeowner's arrangement with the Master Plumber. I then examined everything and found several code violations including that the hot water heater and boiler were used equipment. I explained to the homeowner he could not do that without the inspector's permission and that he needed to fix several other gas code violations to get his inspections. He.said he would have them fixed and call me back. I never heard from him until September. In September a Plumbing Inspector went to the house for an inspection without my knowledge and without informing me at any time. He issued a second gas permit to someone else without proper written notice to me, and without proper investigation, he also told the homeowner I did not pull permits and that I was not licensed. His conduct is negligent, unprofessional, unethical and ,to my detriment. Upon inspection of the second gas permit, which he gave to a friend, he passed an illegally installed boiler which was used equipment with standing pilot purchased from Craig's List by the Page 1 of 2 homeowner without my knowledge or consent or that of the Inspector. There were several other code violations that were passed without being corrected. Upon my arrival for the start of the job the house had been abandoned and froze up over the winter. All copper had been gutted and stolen. I performed pressure tests on the first and second floor boilers and water heaters to see if they were salvageable. However, they all leaked and the boilers were cracked and had to be discarded. For the first floor only, I installed a new boiler and water heater, which the homeowner supplied. I received gas inspection for the first floor equipment only and rough plumbing inspection for first and second floor by the former inspector, Rick Danforth. I installed finish plumbing on the first floor only; no final inspections were ever done on the first floor. I did not install the gas stove on the first floor nor the plumbing or gas work for the second floor. As soon as I became aware of these issues, I made calls to the Plumbing Inspector on a few different occasions. I was told he would call the homeowner and have the illegal boiler removed and the violations fixed. I have never heard back from him. For these reasons I am requesting to be relieved of all liability on the job -site for the plumbing and gas permits for 35 Massachusetts Avenue, North Andover, MA. I was never made whole by the Inspectional Department regarding these issues. For many years, I, as a plumber in this state, have pulled permits which I rely upon to protect me and my livelihood. It is my position that as a result of the unprofessional conduct and negligence referenced above I have been damaged and incurred unwarranted burden by your department. I will be contacting the State Board to research further complaints. Sincerely, Oe4�y Gary McDonald 10 Anthony Road Tewksbury, MA 01876 IZ/ LO CD ��Q CDC6 0(7�h. ..Z a_—:,X,,M Cho rm -o [Lu,. g N 3 O¢ W Z'. F- m w V do ao O a v L /VV/AAI VV\ `•`^VT`n ^j V V v V v � � 9461 Date . A/� ?1%J. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ' •.i . `` ,SSACMUS� /j n This certifies that .. (/"/9i 1 C � 3�i� 1,4 . . ................. has permission to perform .,��Ai�'L4h-P✓/...�Gbzb`i� plumbing in the buildings of . 4,-gr-t.Q ..,I��l t ......... . at ...Sv,/�%9,f-s' ./9!/ ................. .North Andover, Mass. Fee .,05 s em . Lic. No.. Z//F r. , �,.-f PLUMBING INSPECTOR Check # clVrrr tDca MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: /�T/� J#»Do✓e% MA. Date: Permit# Building Location: ��}�✓ Owners Name:a Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration:E] Renovation: Replacement: ❑ Plans Submitted: Yes ❑ No [J clVrrr tDca If I. have a current liability insurance policy or its substantial equivalent which meets the. requirements of MGL. Ch. 142 Yes ❑ No If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNE 'S INSURANCE WAIV : I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass usetts ,and that my signature on this permit application waives this requirement. Check One Only Si nature of Owner or Own is Aaent Owner Agent E] 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 Know)eage ano tnat au piumrnng work ana Installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the M#sachusetts State Plumbing Code and Chapter 142 of the General Laws. ByQF Z4_ Type of License: Title ❑ Plumber SignatuFe of9mMsed Plumber Cay/Town ❑ Master 19 APPROVED OFFICE USE ONLY) 21oumeyman License Number: DEDICATED cc tq W 2i Z SYSTEMS Z v) 0 V) WY Z ~ v O Z a �j V) W x V) W a iA VI Z a F W Q H V) cQ G O Z_ O. Q� ry Q _ a: yj W • Q N O Q 3 W x d' 0 Q W Z F' 1L 3 H W J Q z x , Ir W d W CC W W = �, 0 O W 9 ! 3 W Q Y x `^ V) O 0 F. Z '� O 0 Y Z V� Q Q Q F 4 v! W } . Q Q m Q m o e LL x se S g o°c (A H SUB BSMT. BASEMENT i T FLOOR i 2 ° FLOOR % 3RD FLOOR 4T" FLOOR 5T FLOOR -W 'FLOOR 7T" FLOOR 8 FLOOR ` cj)0 L Check One Only Certificate # Installing Company Name: i4/cr y r / /9 ❑ Corporation nn Address: /0 /7,a,- y City/Town: % /3 �QY State: ❑ Partnership t„ Business Tel: Fax: W,PI'rm/Company.. Name of licensed Plumber: OitlL J� If I. have a current liability insurance policy or its substantial equivalent which meets the. requirements of MGL. Ch. 142 Yes ❑ No If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNE 'S INSURANCE WAIV : I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass usetts ,and that my signature on this permit application waives this requirement. Check One Only Si nature of Owner or Own is Aaent Owner Agent E] 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 Know)eage ano tnat au piumrnng work ana Installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the M#sachusetts State Plumbing Code and Chapter 142 of the General Laws. ByQF Z4_ Type of License: Title ❑ Plumber SignatuFe of9mMsed Plumber Cay/Town ❑ Master 19 APPROVED OFFICE USE ONLY) 21oumeyman License Number: The Commonwealth ofMassachusetts Department oflndustrialAccidents Office oflnvestigations 600 Washington Street Boston, MA 02111 'www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/ContractorslEIectricians/Plumbers lnlivanf Tnfnwrn ". Name (Business/Organization/Individual): Address: City/State/Zip: /01 c Phone #: q 19 - • 6 �d - ds Ss Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I (full and/or part-time).* have hired the sub -contractors 2. [�employees I am a sole proprietor or partner- �� JJ listed on the attached sheget. t ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.]officers 3. ❑ I am a homeowner doing have exercised their all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp, insurance required ] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.P�Plumbing repairs or additions 12.❑Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine Of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify and the pains and penalties ofperjury that the information provided above is true and correct. W��0 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 o r z7—zvJ% Contact person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a j oint 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 apartiiients 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers', compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,; please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/licemse applications in any given year, need only submit one affidavit indicating current Policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been'officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to• any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Col-xu1.ox0we,&Lh of A/Irassaeausetts Aepartme.at of Industrial Accidents Office of Investigations 600 Washington S`rieet Boston; MA 0211 X Tel. # 617-•7274900 ext 4406 or 1-877MA.SSA.F13 Revised 5-26-05 Fax # 617,727-7749 www.mamg-ov/dia I Date ..101,?7 ! ........ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies thatr. /-y_ . ,/�A./.. ....... /� / .. . has permission for gas installation , /4/c..1?; a lUve in the buildings of .. �s Sgriv „ AIAI ...... . . . ... . .... . . at .. 5 ,/`�/�.11..�� �! ................. N//orth ndover,,,M s. Fee..77.1?5? Lic. No.. -?11.V).. �GS GAS INSPECTOR Check # f C!� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING CityrTown: &Q -p vice , MA. Date: /0 Permit# Building Location: $ S /¢✓' Owners Name: Osihela Type of Occupancy: Commercial ❑. Educational ❑ Industrial Q Institutional ❑ Residential [ti New: Q Alteration: Q Renovation: Replacement: Q Plans Submitted: Yes ❑ No FIXTURES LUy Z W Y H fn U" m= o 0 W U to Fy- Q= W W 1�Q Z Z ij � W Z W O 0� 12 M N; W W Q m• O Ilial' a o OO Q F�- W V 0: Q W W W Z m= W 0 W iW' Q= 1i z W W Z O J f- N O Z '..l O LL m 2 Z W W m O Q m W W m .� O z O 0 t j Z H= 0 G c u.. (7 O=_ Om W�>> w 3 O SUB BSMT. BASEMENT 1' FLOOR 2 FLOOR � 3KOFLOOR 41HFLOOR 5 FLOOR —UR—FLOOR 7 FLOOR 8 FLOOR Installing Company Name: /� C Check One Only Certificate # Addres: ®f� y �� ❑Corporation s CityITown: elrJ,Z'Sf; a �'. State: Business Tel:-;� 7lO Fax: M*rrm/Company ❑ Partnership _ Name of Licensed Plumber/Gas Fitter: — � C o ���� INSURANCE COVERAGE: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy (] Other type of indemnity ❑ Bond ❑ OWNER'SgINSRA,tCEER: 1 am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mas ch, and that my signature on this permit application waives this requirement. Check One Only nature oA ent Owner Agent ❑ By checking this box ❑; 1 hereby certify that all of the details and information I have sub!(ore ared) regarding this application are true an4 •- 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. ey� � Type of License: ❑ Plumber L Title ZL/Z. ❑ Gas Fitter Signature of c sed Plumber/Gas Fitter ❑ Master City/Town Joumeyman APPROVED OFFICE USE ONL LP Installer License Number:. if ill The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 J www.mass govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers mlicani Information f Name (Business/Organization/fndividual): - c Address: 10 CA City/State/Zip:- Je-0 �SB y,� v �il s C #:_ 9 7 j HiQ D Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 2. Demployees (full and/or part-time).* dI am a sole have hired the sub -contractors proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing .officers have exercised their all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp, insurance reuired ] Type of project (required): 6. ❑ New construction 7. El Remodeling El Demolition 9. El Building addition 10. El Electrical repairs or additions 11. Plumbing repairs or additions 12.❑ Roofrepairs I- 13.E] other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. -lain an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: , City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine Of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the D9 for insurance coverage verification. Ido Izereby certify ur2d,�r fhe pains and penalti�7�'perjury that the information provided above is Prue and correct. - dsr3 vffccza[ 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 #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written.,, An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more Of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartinents 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/licerise applications in any given year, need only submit one affidavit indicating current Policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in I (city or town)" A copy of the affidavit that has been'officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: Ahe COR.'x ojawealth off Alassach setts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston; 1IA 0211 X Tot. # 617-727,4900 ext 406 or 1-877-AMSSAFE Revised 5-26-05 Fax # 61.7,727;7749 Www.rnass.>;ov/dia