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HomeMy WebLinkAboutMiscellaneous - 369 WOOD LANE 4/30/20181.41 f 441If, atIl�" This is an e -permit. To learn more, scan this barcode or visit northandoverma.viewpointcloud.com/#/records/21099 of KoarH aN + r+ 5 �Q`SSAC HUSE�4 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that Shaun P Parsons has permission to perform replace kitchen sink dishwasher toilet sink and shower plumbing in the buildings of 369 WOOD LANE REALTY TRUST at 369 WOOD LANE, North Andover, Mass. Lic. No. 12465 Date: August 15, 2016 im . . 4-1 :i, Date.. ...... ............. 14 RT#4 TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING q14- 14U This certifies that ......... .................................. has permission to perform ........... ?aj..f .. .................................. wiring in the buildings uilding of ............................................ at............ ......W.0.0A A...re ..................... . North Andover, ass./ Lic. No. ........... / ... . .... ....... Fee OE � ..... /ELECTRICAL &-SPECTO Check # 1 A Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS M 1.^ Official Use Only Permit No. Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC , 527 MR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspec orf Ores: By this application the undersignedgiives notice of his or her intention to perform the electrical work described below. Location (Street &Number) •3 9 IJIdj 14, h9' Owner or Tenant S Telephone No. Owner's Address _ XPi Is this permit in conjunction with a building permit? Yes ❑ No El (Check Appropriate Box) Purpose of Building J�iif�r/1irei - Utility Authorization No. Existing Service New Service Amps / Volts Overhead ❑ Undgrd ❑ Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Meters No. of Meters C-omnletinn nftha fnllnwinQ table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans TransTotal Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In-E]o. Swimming Pool rnd. rnd. o Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No, of Zones No. of Detection and No. of Switches No. of Gas Burners Initiating Devices No. of Ranges Tot No. of Air Cond. Tons No. of Alerting Devices Heat Pump Number Tons KW_ No. of Self -Contained No. of Waste Dis osers P Totals; ' .......... Detection/Alerting Devices No. of Dishwashers g S ace/Area Heating KW P Local El Municipal El Other Connection No. of Dryers Y Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or E uivalent HP Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total No. of Devices or E uivalent OTHER: _ f iSF_•-. _ _ Attach additional detail iJ desired, or as required by me inspe-ur qt rr t, es. 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 m force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ND ❑ OTHER ❑ (Specify:) I certify, under the pains an penalties ofper'ury that the information on this application is true and complete. FIRM NAME: , ij LIC. NO.:^/6f AA Licensee: Wt-A&g& Signature LIC. NO.: (If applicable, enter"t', i the number ber line.) Bus. Tel. No.: exe 06 i Address: /f& br -5A eA*x Alt. Tel. No.: *Per M.G.L c. 147, s. 57- 1�, security work requires Department of Public Safety "S' L eci 'nse: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature _ Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the q permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8—Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass F?1 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION• Pass [a Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com Y/ Name The Commonwealth of Massqchusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Address: �'G5e r D r City/State/Zip: S c, L 14,) AJ q 63 b% 5 Phone #: Are you an employer? Check., appropriate box: b63 q �S_o b 77 1. ❑ I am a player with • ... ! employees (full and/or part-time).* 2, am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.FJ I am a homeowner doing all work myself [No workers' comp..insurance required.] t 4. Q I am a homeowner and will be luring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors Eve employees and have workers' comp. insurance.$ 6.0. We are a corporation and its offigers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no. etraployees. [No workers' comp. insurance required.] Type of project (required): 7. [] New construction 8. El Remodeling 9. ❑ Demolition 10 (] Building addition 1ect cal repairs or.additions 12: Q Plumbing repairs or additions 13-. [] Roof repairs 14. ❑ Other *Any applicant that checks b6x#1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who suhniif 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 state whether or not those entities have employees. If the sub.contractors have employees, they must provide their workers' comp. policy number. I aiiz an employer thai is ppoviding 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 MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a SWOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certifyun�ze pains an pens ' s o pe►jury that the information provided above is true and correct. Signature: % Date: Phone #• D 7 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 #: 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 enferprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing empl6yees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill -out the workers' compensation affidavit completely, by checking the* boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone numbers) 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 lndustrial Accidents fbr 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-ihsured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia i Date.........41-4.1.1.4......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Thiscertifies that............................................................................................................. has permission for gas installation .....�.... Ci As..-... ._._.� inthe buioldings of .......... .:......!. ��°:.................................................................................... at ... -.m.-�.........1...... ..... !`................................. I North Andover, Mass. Fee. ?....... Lica No. � t . ................................................... .......................... ......,....... (� I,, GAS INSPECTOR Check # � (� W 9223 i • ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I North Andover MA DATE 3/24/2014 PERMIT# JOBSITE ADDRESS 369 Wood Lane OWNER'S NAME I Shirley Wilson GOWNER ADDRESS I Same 1 TE978-683-7694 FAX TYPE OR OCCUPANCYTYPE COMMERCIAL® EDUCATIONAL® RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION:'® REPLACEMENT: ® PLANS SUBMITTED: YES[] NO❑ APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 1 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 I SPACE HEATER ROOF TOP UNIT TE T UNI HEATER UNVENTED ROOM HEATER WA4ER HEATER OTHER -F— F777IF77-1 F771 F771 Replace Gas Meter x and Pi ina as Needetl 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 ❑ 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?iinpliance with all Pertinent provisionof th Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Jose h Marino LICENSE # 8736 SIGN TURE MP ❑ MGF ❑ JP ❑ JGF ❑ -PGI ® CORPORATION ❑# 3285C PART❑# LLC ❑# COMPANY NAME: RH White Construction Co ADDRESS 141 Central St CITY Auburn STATE MA ZIP 01501 TEL 11508 832-3N5 FAX 508 926 4347 CELL 508-832-4614 EMAIL JMarino@RHWhite.com i W F O z z 0 F U W a a w �- zo ❑ W G N W } El � � W O W O LLJ W ~ w ca w w d W N ►a zz a Q F a a x J F a a a N w z w H LL W H O z z o H \ z d c� x 0 x ' �y, ,i'�1m:;;,;,.itt; ,,,. r=.tir �t•,:••11f7:tc:,;'�,�n%' .M! •h. ,r.. i,. (. pF e.. ...... ii .ili';i;,Icnk S LLW U) QLLI Z. v" 0 ria pG?)' a = Q LL .R;'. • a� w. :z.. .I- CD .:�*.,.:!.L�tflu ,,., `n F1 �,tl • 1,��ift l: '-L�:3'cJ 'iQrr r �.7 .,i�'i, i�!� .Q} ,,•411 ii u�t:y 1�,,, : t•p t^il.'Nt�r . uiL'. I'lY:q: Wit. !ifi'i��ti•iI°1i`��,'�n' t�n, �tM', 1�:o:,i;.;ri•'f::d ����.;::l..+r.�r.L;:1:'.c,r^'•!�+!?•?�;':.lF,'' i1;It "'! � rs,:,1: •far i. r � ' t • .: �� ' ��i �U"I%i✓ /iy, ? v. Kik .,�Mf .. ;i, .' ::'.. �',vAt ,_':: �.V'• ii: :ifil �'�•i. �1j1!: ,,!:: -Vii:... e4�� !�`:i: dr "n:'':.i �il� .i!: iii(:.' t,r ... i�i • • j�:i:�• ,.ip :;: ;i:,.':ii; 4:i:.!. iju>LL i o OD > d Zd m ¢ H o W ce 2 U) LUMN w Qin; " I�:.���•-' ?�f.'�;r•.r��i.',i�, I�•jir,[t.1+i `t::: :ii;: '�t!ii ti �i' `�'}ilr ; * i i^. lA'i' • l'; ^u;l : t:,:Y • i.C:(i• "l.:ri ih'r �:a rrr La,•f.: , `(i,'r ,:ri••.,, !;i(.(!.;r'i1,• ?:r`�:'.15�i.!iJ. rir.'i'iiAf •,°re�j7:§ r,. U4/ Ud/ 2U14 14: U4 SUt dJXb t0i KH WN1 11a ULIN,) I KUU I r'HUL UZI e1G DATE (MMIDDJYYYY► ..f CERTIFICATE OF LIABILITY INSURANCE page 1 of x 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 on ADDITIONAL INSURED, the Policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does notconferrights to the certificate holder In lieu of such endorsement(s), willia of Masadchueette, Inc. c/o 26 Cottvsy Hlvd. R. 0. Box 305191 Neghville, TN 37230-5141 R. X. White Constraction Company, Inc. 41 Central Street P. 0. Box 257 Auburn, MA 01501 INSURERA:The Chaxtes Oak Tire Sneurana9 Company 25615-001 INSURERS:TrdV419X9 Property CaeualtV Cor%any of Am 25674-003 INSURER C:NntiOktal Union Firo Sneuranco Cvmpaay o£ 7,9445-001 INSURERD;Traveless Indd=jty Company 25658-001 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. A GENERAL LIAINLITY X COMMERCIAL GENERAL LIABII.ITY CLAIMS -MADE OCCUR PER; B AUTOMOBILE LIABILITY X ANY AUTO AUToVIED AUT08ULED X HIRED AUTOS X NON -OWNED AUT08 Ca Ded X Ceii Ded noo X C UMBRELLA LIAR OCCUR EXCESS LIAR CLAIMS -MADE � DED I X_ RETENTION'S 10,001 VTC2000 977X9949-13 9/1/2013 '9/1/2014 EEAACHOCCURRENCE PR g(Eaoce�rtnc MED EXP(Any one ereo. PERSONAL &ADVINJUF GENERAL AGGREGATE PRODUCTS-COMP(OP VT.TCAP 977R955A -13 9/1/2013 9/1/2014 OMgI�RISINGLF,LIMI' BE8766140 19/1/2013 19/1/2014 2,000,000 BODILY INJURY(Perramon) 11 f BODILY INJURY(Peraodden!) 6 D WORKERSCOMPENSATION VxRRVB 8205A185-13 9/1/2073 9/1/2014 X0 - AND EMPLOYER&'LIABILITY Y N T_DRV LJ, D ANY PROPRIETOR(PARTNFRIEXECUTIVE NIA VTC2KUB 8203A71A-13 9/3,/2013 9/1/2014 E.L.EACHACCIOENT s 21.000.0 po OFFICER/MEMBEREXCLUDED7 LJ (MendelerryvinNN) E.L.DI6EA9E-EA@MPLOYFE 9 1.100,000 Ifyea, etnaIn 14) U�esOKill IiUNUI-UPERATIONSbehw El. DISEASE.PoLICYLIMIT S 1,000,000 Evidence of Inourance tee SHOULD ANY OF TWE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZEDAePRESUNTATNE C011:4197604 TPI:1694012 Cert::20297680 ©1988-2010ACORD CORPORATION. AlIrights reserved . ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD