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HomeMy WebLinkAboutMiscellaneous - 39 UPLAND STREET 4/30/201813 Date ..3-�611 .. 5 ................ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 4his- certifies that C-) .......... �S� . ....................................... has perInission for gas installation )OA ... . . ...... .. ... . ........ .... ........ in the buildings of.... 6r. at ....... 3� ...... . ...... . ..... , North Andover, Mass. FeeteD. . ....... Lic. No. MP5 . ................ .................................... GASINSPECTOR Check# 09879 G TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY fJa R C /a �Uv s _ b z MA DATE y7 { II PERM T # 1. ( -c JOBSITE ADDRESS - U Pi�-,J �OWNER'S NAME �` e F f'►'i OWNER ADDRESS TEC -_-- FAX OCCUPANCY TYPE COMMERCIAL Ej EDUCATIONAL RESIDENTIAL NEW: Q RENOVATION: [ REPLACEMENT: PLANS SUBMITTED: YESE] NO FLOORS-► BSM ( 1 _.L.._..2Y�_ 3 4 5 6 7 8 9 10 11 12 13 14 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR T INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER I over -e iL INSUKANW:GUVhKAGt I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES 0<0 I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW - LIABILITY INSURANCE POLICY Lg--* OTHER TYPE INDEMNITY [ BOND 0 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 hereby certify that all of the details and information I have submitted or entered .regarding this application are true and accurate to the b my edge and that all plumbing work and installations performed under the permit issued for this application will be in compliance 't I Perti vis! the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE # a SIG TURE MP [--3'MGF ED JP- ® JGF 0 LPGI ® CORPORATION PARTNERSHIP ®#L 1 LLC E3#= COMPANY NAME:ee gro Sez,, «, _ ADDRESS s — CITY I was -(<j STATE' Int A ZIP 1 f Z 2- TEL FAX CELL s°� r�a6,1gg4 — EMAIL BOAI�D,{Qf, PLUMBERS "Alum G"ASF�I TT'ERSyF- 1 fr ISSUES' THE' FOLLOWI#f Q,'A Y E`N'bE u ¢p r'^7'y.�z 4 �� R ISTPRxD AS A P L'LtMB#I CORP Wk DAVM W GARF�IELDC a :. W s EtEN -Y. BR©THER'V SERVICE u, W 21 W RL L"; ROCK .ON MA 023044 36ll� oy%0111Gr `,� 2141' ,3 Ti11 C Date..4- ........................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies th ........... .Z�L ........... . — ............................. has permission to perform ......... ............. wiring in the building of ......... . . ...... L ........................................................ North Andover, Mass. Fee. ��. . ......... VLic. N6�-�2c?M4 . ............... .E�;�Rli�C�AL I&E Check # r, 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, §k. Permits shall -be limited as to the time of ongoing construction activity, and may be.deemed.by the -Inspector -of -Wires abandoned -and .invalidif lie—___ .. _ 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 entitystated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chanter 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. B—Permit/Date Closed: / J *** Note: Reapply for new permit 0 Permit Extension Act — Permit/Date Closed: -C-N Commonwealth of Massachusetts Emm, Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. FP 3-�)- Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: % City or Town of: NORTH ANDOVER To the Infpectdr of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below.. Location (Street & Number) Owner or Tenant Owner's Address Is this permit in conjction with a kuBding permit? Yes Purpose of Building 1�W ,ela i A Telephone No. No ❑ (Check Appropriate Box) Utility Authorization No. Exesting Service L Amps / /,le) Volts Overhead Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: Ir a.a o ., -_ _ _ J? e l J- i No. of Recessed Luminaires -11. ««�.� �� �.�r varuwtn No. of Ceil.-Susp. (Paddle) Fans raoce ma-oe waived by the Inspector of Wires. No. of Total Transformers KVA No, of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool AboveElin- ❑ o. o mergency Lighting grnd. rnd. Batte Units No. of Receptacle Outlets No. of OR Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. —of Detection and Initiatine Devices No. of Ranges No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number „ons._.. KW No. of Self. -Contained Totals: " _ Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑Other Connection No. of Dryers Heating AppliancesKW Security Systems:* - - No. of WaterNo. of No. of No. of Devices or Equivalent Heaters KW DataNo. Signs Ballasts . ofitinDevices or E uivalent No. Hydromassage Bathtubs No. of Motors Total Hp Telecommunications Wiring: of Devices or Eq uivalent kNo. OTHER: 94+k. -n ftL e d Arracn additional detail ydesired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: � Ute (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO RA E. 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, a pains and penalties of perjury, that the ' formation on this application is true and complete FIRM N j Z LIC. NO..&ZO,�-/4 Licensee: t� t �i,-h t 'Q / Signature t ! .`.cR LIC. NO.: (If applicable, enter "exempt " IV the licen a number line.) v!`3Sc,Bus. Tel. No.: Tb `412-417,321) Address: Z1110.A . Alt. Tel. No.:�0 2g: *Per M.G.L c. 147, s. 57-61, SeXurity work requires Departm t of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the icensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ ` ' -- I Lk The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 NZashington Street Boston, MA 02111 f ; www.mass.govIdia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A�plicant Information Please Print Legibly Name (Business/Organizadon/individual): i (Tj) t a f--� Address: City/,State/Zip:_, Z)ig rai Phone #:. . 5 ©e to f? /? S—O al Are you an employer? Cheek.the appropriate box: I . ❑ I am a employer with 4. ❑ I am a general contractor and I epliroyees (full and/or part-time).* have hired the sub -contractors 2. LV am a:sole proprietor or partner- listed on the attached sheet. # ship and have no employees These sub' -contractors have working for mein any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.) 3. ❑ i am a homeowner doing all work officers have exercised their 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_] Any applicant that checks b0i # l must filE Type of project (required): 6. ❑ New construction 7. Remodeling 8. Q Demaliti.on 9. ❑ Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.0 Other so out the section below showing then workers compensation policy information. t Homeowners who submit this affidavit indicating they are daring all work and then hire outside contractors must submit a new affidavit indioating such. 4contractors that check this box must attached an additional sheat showing the name of the sub -connectors and their workers' comp. policy informadon. I an employer that is protndi?ng workers information. ' compensation 'nsurancefor m1' employees: Below is the policy and job 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 here certify under the pains an penalties ofperjury that the information provided above is true and correct Si time: % r Date: 1:0� Phone #: EFOth6r only. Do not write in this area, to he completed by city or town official Town: Permit/License # hority (circle one): Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector `....; son: Phone #• �. Information and Instructions �t 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, SFT 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 bmstee of an individual, partnership, associatioin 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 requiredl to cant' workers' compensation insurance. Ifan 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, notthe 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 Iicense number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete acid printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating -current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-77451 www.mass.gov/dia Date 01 40RT" -4 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING",/ This certifies that ...... \'/ .......... has permission to perform ............................. plumbing in the buildings of ........................... / at .... ............. I North Andover, Mass. Fee..O. Lic. No../ ..... ..... z-1 .......... PLUMBING INSPECTOR Check # -341 7 8281 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or int) NORTH ANDOVER, MASSACHUSETTSDate �_ O Building Location l [ �� Pernrit # LOP—/ Owner iYLI G �� l - C � Amount New Renovation Replacement 13 Plans Submitted Yes O No FIXTURES (Print or type) D I Installing Company Name si Check one: Certificate Corp. Partner. Firm/Co. Name of Licensed Plumber: L Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy �. Other type of indemnity El Bond Insurance .Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature I Owner [] Agent I hereby 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 Sr umbing C,y and Chapter 142 of the General Laws. By: Srgnai-ureeo Licenseariameer Title Type of Plumbing License City/Town .�d rcense um er Master Journeyman ❑ APPROVED (OFFICE USE ONLY The Commonwealth of Massachusetts Jai Department of Industrial Accidents Office ofInvestigations 600 Wash iszgton Street Boston, MA -02111 www.massgoy/dia Workers' Compensation Insurance Affidavit: Builders/Cont ractors/Electricans/Plumbers Applicant Information Please Print Legibly .Name (Business/Organization/Individual): Address: 1 1 City/State/Zip:�A) Phone #: (O 3 -1)90 Are you an employer? Check the appropriate bog: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing 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.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other �;ny app11=, ;Hatt cr=Ks box --; —..= also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. xContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_% ��/ cmac 4.t. /4�^ Policy # or Self4ris. Lic. #: / Expiration Date: Job Site Address: U% ��'?�i City/State/Zip: A/, X -f 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 r the pains andrynalties of perjury that the information provided above is true and correct Phone #: 6:-_)- IP 70 ffc 21 Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License # r / r 7 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 apartrnents 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 requiredto carry workers' compensation insurance. If an LLC or LLP does have e% employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in . (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. . The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations. 600 Washington Street Boston, MA. 02111 Tel. # 617-7274900 ext 406: or 1-877-MASSAFE Fax # 617-72.7-7749 Revised 5 -26 -OS mww.rna&&.gov/dia Date ..//A/A.5 ....... .. TOWN OF, NORTH ANDOVER PERMIT FOWGASINSTALLATION Ib ACHUS This certifies that !-I ................... has permission . for gas installation C. -f-77. r -.( ... .......... in the buildings of . at ... ..............North Andover, Mass. Fee.. Lic. No' .1 . ..... GAS INSPECTOR Chec0k' '3.t/ 7009 �4 40 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date C NORTH ANDOVER, MASSACHUSETTS Building Locations '35 U P)a ^,_t Permit # 4 U f Amount $- 3a Owner's Name New❑ Renovation �' Replacement 13RenovationSubmitted Print or :a Check one: Certificate Installing Company Nam — � t- Corp. g P Y Name 1 iV Io Address 1:1 Partner. C -, usmess Teld-plfone Co d 0 Firm/Co. Name of Licensed Plumber or Gas Fitter Q P1 .� � Dc) INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes E3-- No If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond 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. Check one: Signature of Owner or Owner's Agent Owner 1:1 Agent 0 I hereby 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 States Code and0fapter 142 of the General Laws. (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber Gas Fitter License um.er Master Journeyman - - - - Print or :a Check one: Certificate Installing Company Nam — � t- Corp. g P Y Name 1 iV Io Address 1:1 Partner. C -, usmess Teld-plfone Co d 0 Firm/Co. Name of Licensed Plumber or Gas Fitter Q P1 .� � Dc) INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes E3-- No If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond 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. Check one: Signature of Owner or Owner's Agent Owner 1:1 Agent 0 I hereby 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 States Code and0fapter 142 of the General Laws. (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber Gas Fitter License um.er Master Journeyman The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electneians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate bog: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These subcontractors have working for in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t . workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1 (4), and we have no -employees'. [No workers' comp. insurance required.]. Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F-1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other `^r.r appile , ;nal cnecKs Dox;;, must also nfl out the section below showing their workers' compensation policy information. fi Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. 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. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct Sip -nature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town offwiaL 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, of 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 r 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 tie permit or 'license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. .. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in— (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog Iicense or permit to bum leaves etc.) said person is NOT required to complete this affidavit.. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Roston:, MA 0:2111 Tel. # 617-727490:0 ext 406 or 1-877-Na. Fax # 617-72.7-7749 Revised 5 -26 -OS vvvt�vv.maSs gov/dia Date. C A r TOWN OF NORTH =ANVER .pPERMIT FOR P G This certifies that ....{-!. .�' �^.;� .. .C',!n G .............. has permission to perform .... f. l.L L't r c' plumbing in the buildings of . 1�'.,.�..0 ��r'�? 6 ............ . at.. .rJ.. !t ,n ..`.(................. . North _Andover, Mass. Fee.. L'ic. N.o.. 1. U.`! ....... `6 1.� � ..... . PLUMBING INSPE(ITOH Check .N 811.4 F MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING 1 .. (Type or print) NORTH ANDOVER, MASSACHUSETTS / Date Building Location C� G Owners Name ✓i©L L Permit 1# Amount Type of Occupancy New Renovation Replacement Plans Submitted Yes ❑ No E (Print or type) Check .one: Certificate Installing Company Name V "1 -13 ." Corp. Address J ` l+^• S Partner. Business Telephone 0 Firm/Co. Name of Licensed Plumber: _bCt t^ ^t-/ Dy K Insurance Coverage: Indicate the type of insurane coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner ❑ Agent ❑ I hereby 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 Plumbing Spd7and Chapter 142 of the General Laws. By: Signature UT Eicensea r umber Title Type of Plumbing License 0 i, City/Town Irense NUMDer Master Pr Journeyman ❑ APPROVED (OFFICE USE ONLY .r i ilk MMM (Print or type) Check .one: Certificate Installing Company Name V "1 -13 ." Corp. Address J ` l+^• S Partner. Business Telephone 0 Firm/Co. Name of Licensed Plumber: _bCt t^ ^t-/ Dy K Insurance Coverage: Indicate the type of insurane coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner ❑ Agent ❑ I hereby 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 Plumbing Spd7and Chapter 142 of the General Laws. By: Signature UT Eicensea r umber Title Type of Plumbing License 0 i, City/Town Irense NUMDer Master Pr Journeyman ❑ APPROVED (OFFICE USE ONLY The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 ff,ashington Street Boston, MA 02111 www_massgov/dia: . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Pinmbers Dpiicant Wnrrnatinn Naille (Business/Organization/Individual): Address: City/,State/Zip: Phone #: . Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* 2. ❑ I am.a.sole proprietor. or have bred the sub -contractors listed partner_ ship and have no employees ori the attached sheet t These suli-contractots have working for me .in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.) 3. ❑ 1 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 required.] Type of praject (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I l.❑ Plumbing repairs or additions 12.❑ Roof repairs I3.❑.Other •Any applicant that checks bcrl # I must also Hil out the station below showing their workers' oom ? Homeowners who submit this affidavit indicating they are 8omg all work end then hire outside c ntmctors policy aBti ncw affidavit indicating such. ZConttactors that check this box must attech-4 an eAA;tioaal sheat showing• the name of the Sub •conen;ctors and their workers' jkf fi rail- ' r rrefommdort. I am an employer that is Protr>n�ing:warkers' co►npansadOn insurance for Ory. employees: Below is t/se policy aed job site information. Insurance Company Name: " Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: — Attach a Copy of the workers' compensation policy declaration Page (showing the policy number and expiration date}. Failure to secure coverage as required under Section. 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, s well e.s 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 penalties of pedury that the information Provided above is true and correct Si tore: Date: Of, iciat use only. Do not write in this area, to be compieted by city or town afficiaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitY/Town'Clerk 4. Electrical Inspector 5 6.Otber . Plumbing Inspector 11 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, assOdiation, corporation or other legal entity, or any two or more of the'fomping engaged in a joint enterprise, and includir-ag 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 ito 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 t3he commonwealth nor any of its political subdivisions shall enter into any contract for the perfarmaance 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 compictely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), addrms(es), and phone number(s) along with their certificates) 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' co=mpensation 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, notthe Department of Industrial Accidents. Should you have any .questions regarding the law or if you are required to obtain a workers' oompensatron policy, please call the Department at the number listed below. Self ingured oompanies -6 it,d Pnr�Prthr it self insuranee-license number on the'appropriate tine. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department hes 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 ofthe 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 fate a permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 4ffiee 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 6310 1-119- 0.41 Date ...... -/19— TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............ ........... ..... ........................... has permission to perform ............................... wiring in the, building of ................................ 9................................................ ,-3 2 L at ...... .......... ...................... ............ G . ........ . North Andover, Mass. ................... Lic. No. Fe� ... 22. .... .. ELECTRICAL I;�P-ECMi Check # 14 ".4 _ Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. C� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/051 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in --accordance with the Massachusetts Electrical Code MEJ). ). 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORM4 TION) Date: 1 G City or Town of: N p c, ' � N N Da'r(�r To the In Tector ql' Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant , �r nLiyz © Telephone No. flgQ70 8M-, Owner's Address '2,1 Uelwu �. Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of BuildingUtility Authorization No. Existing Service In— Amps 12-0 / O.40 Volts Overhead Undgrd ❑ No. of Meters New Service ® Amps -to /: , Volts Overhead Undgrd ❑ No. of Meters / Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: OPG, DC Completion of'thefiXowing table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ find. grnd. o. of Emergency I Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump 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 f 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: np Attach additional detail if clesired, or as required by the Inspector q/ 6Vires. Estimated Value of Electrical Work:(When required by municipal policy.) Work to Start: / 7 D6 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: RAGE: 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: LIC. NO.: Licensee: .T�/Z�y �, os;11'a Signatur LIC. NO.: )(3 9 (/f upplic•able, enter "exempt - inn the license munber line.) Bus. Tel. No.: M? 6.18-77,?P Address: '&4V 'y G/ �DAlt. Tel. No.: 9�R o 9 76 Py *Security System Contractor License required for this work; if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my i nature below, I hereby waive this requirement. I am the (check one) 0 owner ❑ owner's agent. Owner/Agent q�� PERMIT FEE. $ Signature Telephone No.