HomeMy WebLinkAboutMiscellaneous - 390 Main StreetV \.
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This certifies that ...... b.��4
has permission to perform ... Z ... 6;V -S . ........
wiring in the building of . .-S-77. . . P-44I.C-S .....................
at . .................. A�orth Andover, Mass.
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Fee. ) ....... Lic. No../ Ll W3 .......
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BOARD OF FIRE PREVENTION REGULATIONSOWEPamy and Fee Cb�'c�ced
APPUCATIOM FOR PERM T TO PERFORM ELECTRICAL WORK
M We* to be pwf=mw ID 8=016= wj& ftAfinukusem sw*dCom -W CMR 12"
(P.LEAMPRfMI'MDX OR M?, ASLWONalyDh) Date: P L ! 2City or Tov_
y�e� TOrhe ec f
B this = g�w�e ofhfs c�rherintWm to 2 MW work desari'bed below.
Locution (Shvet & Number; 7�'V /2 432411—t
Owner orTenaat _ 5 � ��,t 'S rf✓ �. TelePhsae No.
OwneYs Address
1s this Permit is u►njma¢tioe NIM a btdbding Pam" Yes p No ❑ (Chock Appropriate ]lux)
paapose of Borg Uii&ty AmtBartzaiia$ No.
Amps ! Wits Overhead p Undgrd ❑ Na.ofMeters
Never Servue -Amps I Vohs Overhead ❑ Und tt--��
Number of Feeders and Ampaei€y t_I l4 of Meters
Location and Nature of proposed Elect Work.. C, /,
Estimated Vahie OfElcdbcat @4 e& `j"'�' aaUMw= 112 w97 a artrgauvrl �arofiFires
Waal` to StarthwPmdow tobe� � y }
"DMNCKCOVERAGrE: D MEC 14& 1tl,andvpon(edw,
the pm by am �' no P�tfor#hc ofde t&dwork may issue wd=
m�asigoed des that � coverage i4 iu a� fuer eadu'i� prcxsfafsa� Wit- 'Me
CHECK 0NE_ INSUItA ICE di BOND p MIMR
I cif y m7&r the pahw andpmaNa ofpaiW
FWM NAME:l7fE1i i i? moi, c %T:tt CAL irse and emapf
C.cxT t n _ _ M_t — IAC: No--
Licensee: �: f�A b f.
Address: % � ST IVA Bt�Td. y -EI; �b2�Z
*Per irl.G.L c 147, s 57-62, Duty wa& wqdres LmpmftW of Public Fafiw "Sa Alt: Tet. Noe 47.19- 3 7: -5'73
0WNl R'S 1NSURAINC2 WAri ; 72 Lim No.
reqWzW aware tient lite L�eosee dues iu�tlmve t2ze
by �'. Rl* ��� beiaw, There�ywaive taus xeq. � the{ _nbftb=mm=
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siguatuie - _ _
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rim Of P- ' Fars
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Gene ales 1 VA
o. of Luminaires
swilumfing POW ❑ affiragmulffiffy
lagning
No. of Recgybm& onaeft
of til s
Units
No. ofd
ML of Gras
ALARKS
. oft ones
Of
No. afRaages
N& efAir Coad, T
Devices
Toms
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No. of Waste Disposers
not
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Taiaia:
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No, of Dryers
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Heaters ICW
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SiEnsBallasts
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No. Hyl Bflt
o of Motors Total HP
Niof Devices or Equivalent
leT.ummnmicaIIons ' g:
Estimated Vahie OfElcdbcat @4 e& `j"'�' aaUMw= 112 w97 a artrgauvrl �arofiFires
Waal` to StarthwPmdow tobe� � y }
"DMNCKCOVERAGrE: D MEC 14& 1tl,andvpon(edw,
the pm by am �' no P�tfor#hc ofde t&dwork may issue wd=
m�asigoed des that � coverage i4 iu a� fuer eadu'i� prcxsfafsa� Wit- 'Me
CHECK 0NE_ INSUItA ICE di BOND p MIMR
I cif y m7&r the pahw andpmaNa ofpaiW
FWM NAME:l7fE1i i i? moi, c %T:tt CAL irse and emapf
C.cxT t n _ _ M_t — IAC: No--
Licensee: �: f�A b f.
Address: % � ST IVA Bt�Td. y -EI; �b2�Z
*Per irl.G.L c 147, s 57-62, Duty wa& wqdres LmpmftW of Public Fafiw "Sa Alt: Tet. Noe 47.19- 3 7: -5'73
0WNl R'S 1NSURAINC2 WAri ; 72 Lim No.
reqWzW aware tient lite L�eosee dues iu�tlmve t2ze
by �'. Rl* ��� beiaw, There�ywaive taus xeq. � the{ _nbftb=mm=
oQ y
siguatuie - _ _
Telephone INo. PF.�`F.EE; �
moo.. The Commomvealth of Dlus wknsetts Print Form
_
DqmrbneW ofh9hUWdAcudenis
jOfflce ofaffew
l CoAgress S&V4 Smite 100
MA 8211¢21917
WW .mWMgov/arra
Workers' Compensatioit limmmnce Affidavit Bdide; s/Comictors&1ee#ricians/P1=ben
Applicant Information Please Print Lobb-
Name (8usinesslOjgarhzqnonnndmd t); DAVID EIE Tit & CONTRACTING ILC
Address: 87 BELMONT ST
Lrty/S - 1gUK 1 h ANUUVt_K, MA. LI1845Phone : 978-682-6252
Are you an enpleyet' Check the appropriate bo= Type of Pi81� tom}:
I -Q I am a esnpIoyerwith 7 4❑ Iain anal oo>itEatamd I
emouyces (��/ar)-* . have Deer the � 6- Q Nrw etU9rUcfion
20 I amtasolepnprietworpartum
ship and have no employees
v6ding for nmin any c y-
P4Ds' Camp. inoe
r'o9ohed-j : -
3-0 1 am abomeawnerdoipgali wodc
kw3rancm3►se>£ jNo waalres'r.�tp.
e required.] T
Fisted onthe Amt
Thew sub-(x�s have
and have mss'
gyp- -`
5_o Weare a corps and its
1ave,excicisedfindr
right ofexempEion per MGL
t:. 152, § 1 (4), and vie bave no
employ- [No workers'
comp. insurance reanire&T
7- ❑ ReMDdeimg
S- ❑ Dernoliiion
9 ❑ Bm-IchngadMon
10.0 Electrical repairs or additions
l l_0 Plumbing repairs or additions
120 Rmofrqx&s
13 -CI oilier
-- :+ -rr�•-•••• •.•w �..•..�n.� wa rri U u6L aLW tUI UM UM SMUM bMW -cbDW g UleU W� pp po� ,
#HomeaUMM whosubmit dns afbdamin kaft they are douigali work and d= hireaatshie convactom mustsubmita new 2WKbY ire satxc
'Co� dint dw* disboxm+st a mbcd m ad&d mal sbeetsbowag &e . of ttm and stft whd..ar aat dm entities have
employees. Tf dw sab•coabactms have employees they amst pmvide dinar Tv+n&CW =MP. pohC+�mber
rnanemptoyer�Eis pro,i&W workers' c o on in�rnm wefor jnww Below is ftepo&W mtd jobsite
forra�ron.
Insurance Company Name: THE HARTFORD
Policy # or Self -ins. Lie. #: 08 WEC C18293
Expiration Date: MARCH 1, 2013
Job Site Address:'�-
�--�
Attach a copy of the workers' compeasaatson policy declaration page (showing tate policy number and
j Failure to secure coverageas expiration date).
required tinder Section 25A of MGL c 152 can testi to the imposition of ctknhW penalties of a
fine up to $I,5(IO.f}0 and/or one- znimemt, as well as civil penalties in the foam of a STOP WORK ORDER and a fine
�of up to $250.00 a day against th // "olator. Be � 'that a copy of this statement may be i}te office of
+esfons of the DIA for instuancx oa�i�a�+el`rV't;�ra
IdDkmrdrrthe
Phare # 978 -M -SM
OffidauseosR Doaetwriteinit &area6gobeanWh!gLvdbycayorateofaoai
s eaad roomed
71
- 1 Z -
City or Town: P rMwLicense#
Issag Antheray (erode one),
L Board 6. Uth� oflHeaUb 2. D ent 3 �ityrl'own Clerk 4.Electricals S r
ContactPerssm Phone #.-
It
Date ...
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ...
has pennission for gas insta
ation.. ......
in the buildings of. P(A,
at .... .............. North Andover, M- a* ss'
Fee. 40N. Lic. No.
GASINSPECTOR
Check # 4 r -D
8435
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
, www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): - / _U - q
Address:
City/State/Zip: MIJ OlbqPhone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
er}floyees (full and/or part-time).*
have hired the sub -contractors
2. am a sole proprietor or partner-
listed on the attached sheet. t
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ 1 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.] i
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ El trical repairs or additions
11. 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 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 Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: S90 0 �GC � ✓L C��4Y 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.
f do hereby certify un e pans an#1nalties of perjury that the information provided above is true and correct.
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
kms.
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, §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 number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is 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 Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05
Fax # 617-727--7749
www.mass.gov/dia
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY i/JA/L T rr _. MA DATE----", 7 PERMIT #
JOBSITE ADDRESS Lei OWNER'S NAME
GOWNER
ADDRESS _ - _ _ _ _ _ _ TELT—
TYPE OR
PRINT)
OCCUPANCYTYPE COMMERCIAL __( EDUCATIONAL RESIDENTIAL D
CLEARLY
NEW: d RENOVATION: D REPLACEMENT: PLANS SUBMITTED: YES Ej NO
APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER - —�
CONVERSION BURNER
COOK STOVE I- _ a . I. _ .- . 1 1 _J1 . (
DIRECT VENT HEATER _ . [J1—
__ I
DRYER
FIREPLACE (_ _j L. __ I —1 L =j
FRYOLATOR
FURNACE
GENERATOR
GRILLE -
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST _I I_ _.a _J L l __I
UNIT HEATER _ -_J v1
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
1 have a current liab_ ility insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES BW0[]__I
1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND �__i
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER r_–] AGENT (
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted or entered regarding this application are trueand accurate t the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complia a with al inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME , �.–� — LICENSE # % SIGNATURE
MP ED MGF JP JGF Q LPG] _.j CORPORATION Q# � PARTNERSHIP O# LLC I#
COMPANY NAME: _ . _ '_ ADDRESS
,,,, ��_
CITY - --- - _ .... _ _ I STATE L'. M"I ZIP O TEL _ -
FAX CELL ~EMAIL _ _
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TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ... V,,2.-� -4�p,
........... .............
Cj
has permission for gas inqallatign . .......................
in the buildings of....
at ...
... North Andover, Mass.
Fee.4v.— ic. No.1 ... ....
................... ...
GASINSPECTOR
Check #
hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accur to to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application will bee with all Pertinent
provision of the Massachusetts State PI bing Cod and Chapter 42 of the General Laws.
PLUMBER/GASFITTER AME: yCLL LICENSE # W� % SIGNATURE
COMPANY
COMPANY NAME: dc ADDRESS:Ux
CITY �auti STATE: 10 -ZIP: FAX:
TEL: CELL: 7/ 010 EMAIL:
®i
MASTEk& JOURNEYMAN ❑ LP INSTALLER. ❑ CORPORATION [1,# PARTNERSHIP ❑ # LLC ❑ # to\�
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
U9
GOWNER
TYPE OR
PRINT
CLEARLY
CITY: _ /OAC_ MA. DATE: RMIT # U
JOBSITE ADDRESS: U ry-' V i�tOWNER'S NAME: ��plg'�X ,-�2
ADDRESS: SEL: (iG_A4_1r_� FAX:
OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL
NEW: ❑ RENOVATION: ❑ REPLACEMENT: [,\ PLANS SUBMITTED: YES ❑ N0�'
APPLIANCES-. FLOOR-Bsmt 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 COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOFTOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES r<NO ❑
If you have checked YES please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND [:1
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 F]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 accur to to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application will bee with all Pertinent
provision of the Massachusetts State PI bing Cod and Chapter 42 of the General Laws.
PLUMBER/GASFITTER AME: yCLL LICENSE # W� % SIGNATURE
COMPANY
COMPANY NAME: dc ADDRESS:Ux
CITY �auti STATE: 10 -ZIP: FAX:
TEL: CELL: 7/ 010 EMAIL:
®i
MASTEk& JOURNEYMAN ❑ LP INSTALLER. ❑ CORPORATION [1,# PARTNERSHIP ❑ # LLC ❑ # to\�
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Date -2. �e �. �-� .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
I I
This certifies that ...
................... I .......
has permission to perform 4-t-� ..............
plumbing in the buildings of
...........
at ......
....... North Andover, Mass.
Fee ... Lic.NoJA�.,Q... tAb .................... ...
PLUMBING INSPECTOR
Check #
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
pOWNERADDRESSILL
TYPE OR
PRINT
CLEARLY
CITY _/�fC�77�1 CUYi>>'L MA. DATE Z Z PERMIT #
JOBSITE ADDRESS A414—) OWNER'S NAME �7 = �' wC L
FAX
OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL RESIDENTIAL
NEW; ❑ RENOVATION: ❑ REPLACEMENT:,,.�{{
�I-- PLANS SUBMITTED: YES ❑ NO}�
FIXTURES 1 FLOOR— BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIUSAND SYS
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS
DEDICATED WATER RECYCLE SYS
DRINKING FOUNTAIN
DISHWASHER
FOOD DISPOSER
FLOOR /AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which, meets the requirements of MGL Ch. 142. YesNo [I
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
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
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE BOX ONLY: OWNER E]AGENT ❑
Si nature of Owner or Owners Agent
1 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 i sued for this application will be In
compliance with all P rtinent provision of t e Massachusetts State Plumbing Code and Cha tQr 14 he General Laws.
PLUMBER NAME/ C SIGNATURE
LIC # (� MPpx JP ❑RP TION ❑ # PA ERSHIP ❑ # LLC E]#
COMPANY NAME / �. ADDRESS:
CITY STATE `� ZIP EMAIL
TEL CELL FAX
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The Commonwealth of Massachusetts
Department ofIndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name
Address:
City/State/Zip: �� �� L J Phone #:
C
03 YV60s�,
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 construction
employees (full and/or part-time).*
�
have hired the sub -contractors
listed on the attached sheet. #
Remodelin
E]g
2. am a sole proprietor or partner-
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance.
9, ❑ Building addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
10.❑Electrical repairs or additions
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
11. El Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12.E]. Roof repairs
insurance required.] ui
q ]
employees. [No workers'
1311 other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
T 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 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 requiredunder 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 cert ui rr pis andpenalties ofperjury that the information -provided abo is fru and correct.
Si ature: Da e:
Phone # D �,_ 0U&l
11 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 #'
r.:
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, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is 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 off dustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
Tel, # 61.7-727-4900 ext 406 or 1.-877:MASS.AFE
Revised 5-26-05 Fax # 617-727-7749
www.znass,govf�ia
.1 .
168 Date ... //,4
TOWN OF NORTH ANDOVER
PERMIT FOR MECHANICAL INSTALLATION
. . . . . . . . . . . . . . . . . .
This certifies that. �. 4.. /� ...
has permission for mechanical installation .................
in the buildings of ..................
at ........... ........ North Andover, Mass.
Fee./3(-?-4�,Lic. No ........... ..........................
'� (/(� �licant CANARY: Building De GASINSPECTOR
7� �� WHITE: App Pt. . PINK: Treasurer
1
Commonwealth of Massachusetts
Sheet Metal Permit
Date: /
Estimated Job Cost: $ pQ
Plans Submitted: YES NO %'
Business License # M G
Business Information:
Telephone:
Permit #
Permit Fee: $
Plans Reviewed: YES NO
Applicant License #199
Property Owner / Job Location InformCa�tion: i
Name:-
Street: Z07n Ha c n S1 ,
City/Town: ,N - 0 C Pjq Q 2q S -
Telephone: 3- 1-,5--/ n
Photo I.D. required / Copy of Photo T.D. attached: YES NO
a
�Staff Initial
-1 /unrestricted licen3e
J-2 / M -2 -restricted to dwellings 3 -stories or less and commercial up to 10,000 sq. ft. / 2 -stories or less
Residential: 1-2 family Multi -family Condo / Townhouses Other
Commercial: Office Retail Industrial Educational
Institutional Other X
Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. Number of Stories:
Sheet metal work to be completed: New Work: Renovation:
HVAC I Metal Watershed Roofing Kitchen Exhaust System
Metal Chimney / Vents Air Balancing
Provide detailed description of work to be done:
INSURANCE COVERAGE:
I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes„ 3' No ❑
If you have checked Yes, indicate the type of coverage by checking the appropriate box below:
A liability insurance policy" a Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
/ Check One Only
Owner 12� Agent ❑
Signature of Owner or Owner's Agent
By checking this box[], 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 sheet metal work and installations performed under the permit issued for this application will be ,
in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. `0
Date
Date
Duct inspection required prior to insulation installation: YES NO
Prol?ress Inspections
Comments
Final Inspection
Inspector Signature of Permit Approval
Comments
#10
Signature of Licensee
License Number:
Check at www.mass.gov/dpl
Type of License:
By
aster
❑ Master -Restricted
Title
City/Town
❑Journeyperson
Permit #
❑Journeyperson-Restricted
Fee $
El
Inspector Signature of Permit Approval
Comments
#10
Signature of Licensee
License Number:
Check at www.mass.gov/dpl
ac o®
CERTIFICATE DATE(MWDDPfYYY)
THISCERTIFICATE IS ISSUED AS A MATTER INFORMATION O F LIABILITY INSURANCE . 9/7/2012
ONLY AND 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 IN$URER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the POI(cy(ies) must be endorsed. If -SUBROGATION IS WAIVED pub ect to
the terms and conditions of the policy, certain policies may require an endorsement..A statement on this certfficate does.not confer rights -t
rmo the.
certificate holder In lieu of such endorsements).
PRODUCER NAME: Linda Bogdanowicz
INSURANCE SOLUTIONS CORPORATION PHONE (603) 382-4600 FAX
60 Westville Rd IAJC,(609)382-2034
lindab@iscinsures.com
Plaistow NH 03865
INSURER AMerchants
INSURED
INSURER B :Merchants
Correct Temp, Inc. INSURERC:
5 Meghan Circle _
aaJ em NH 03079 IN
COVER�'GFS rCOTICII�ATC
._------ KEVISION NUMBER:
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:TA ALL THE TERMS,
ESL" LUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NSR
LTR
TYPE OF INSURANCE
GENERAL LIABILITY
IINSR
POLICY NUMBER
MMIDDY EF
MW D EXY
LIMITS'
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE D OCCUR
OP1051627
/1/2012
/1/2013
EACH OCCURRENCE i. r 000, 000
I �� t 50O OQQ
000
MED EXP An one non $ 1.0,
PERSONAL.& ADV INJURY i INCLUDED
GENERAL AGGREGATE S 2.j 000,.QO.O
GEN'L AGGREGATE LIMIT APPLIES PER:
X POLICY PRO JECT [7 LOC
PRODUCTS - COMP/OP AGO: $ 2 F.O.00',.000
S
A
AUTOMOBILE
X
LIABILITY
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
HIRED AUTOSNON•OWNED
AUTOS
PI052971
/1/2012
/1/2013
COMBINED SINGLnIMIT1400'.000
BODILY INJURY (Per perm) S
BODILY INJURY (Por acddent) S '
PROPERTY DAMAGE S
Uninsured motorist combined $ 110001,000
A
UMBRELLA LIAB
EXCESS LIAR
HCLAIMS-MADE
OCCUR
CUP9142810
/1/2012
/1/2013
EACH OCCURRENCE i
AGGREGATE S
OED I X I RETENTIONS 10,000
$
WORKERS COMPENSATIONWC
AND EMPLOYERS' LIABILITYFR
ANY PROPRIETORIPARTNERIEXECUTIVE YIN
OFFICERIMEMBER EXCLUDED?
(Mandatory In NH)
Ifyes, describe undor
N / A
CA9097852
/6/2012
/6/2013
STA 07H•
E.LEACBHAQCIDEN7 $ Z OOO.00O
E.L. DISEASE• EA EMPLOYE S 1 j 000. 000
E.L. DISEASE • POLICY LIMIT S, i'000,00
OESCRIPTION OF OPERATIONS below
DESGRIPTICKOF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Romarks Schedule, If more space Is required)
I IF•K.A I t rtULUtK
SHOULD.ANY OF THE ABOVE DESCRIBED.POLICIES BE CANCELLED: BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
ACORD 25 (2010105) 01988-2010 P—ORD C{-RPORATION. All rights reserved.
INS025 poioo6).ot The ACORD name and logo are registered marks of ACORD
r
11/15/2012 16:29 FAX 19786888701
Correct Temp Inc.
4
C-
SI :EET METAL WORKER
ASW IWA aTER-UNRESTRI-E-0.
ISSUES THF A30VE LICENSE TO-
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G-1)EP .i� K' MARTIN
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Certificate of Occupancy $
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4&0rchaa Street
4aveM4 MA 01830
-PhOM# 979.372-3721 Fax #. 978-521-2192
ST. PAUL'S -EPISCOPAL CHURCH
STEPHANIE WILSON
390 MAIN STREET
NORTH ANDOVER, MkG1845
P.O. NUMBER
TERMS I SALESPERSON
NET'30 1. DC
PMP�t
Dater
f Prqposal-#
12/11/2009
7659
ftern
Description
'Qty
Price Each,
Total
120
SITE SURVEY AND CLIENT MEETINGS TODATE.
1.
110.00:.
110.00
10Z
GRAPHIC DESIGN TO DATE.
110.D0T
-856-
LABOR AM EQUIPMENT NECESSARY FOR THE INSTALLATION OF
995,00
895M
ONE ENTRY SIGN DESCRIBED ABOVE TO SOFT SOAPED SURFACE IN
ONE TRIP, DURING REGULAR BUSINESS HOURS, UNDER NOR -MAL
DIWINGANaWORICNG CONDITIONS WITH FINAL LANDSCAPING TO
BE PROVIDED BY THE CLIENT.
CLIENT T 0 PROVIDE THE SIGN PERMIT
Sales Tax - EXEMPT
0.00
0.00
50% REQUIRED AS DEPOSIT/ BALANCE NET 30 DAYS
Total $5,760.00
All -material-irguaranteedto be asspecified 'All Vmrktobecompletedin aprofessional Authorized Signature
manner ac to standard practices, Any alterationsfrom, above -specifications, involving
extra- costs will be executed only -on written orders andwill be an, extra charge over and
above the estimate. AM agreements contingent uWn -strik,,,.,ccident,,o, delays beyond our
control. Owner to carry all necessary insurance. Our workers.are fully covered by Workeft
Compensation insurance.
NOTE: This proposal may be.whhdrawn by us if not acceptedwithin days
The above prices, specifications and conditions are satisfactory and hereby accepted.You,
are authorized to do the work -as specified ' Paymentwill- be.made.asoutlined above. All Signature
signs remain the property of The Sign Center until paid in full.
Page- 2
40- Orchard Street
Haver N11, MA 01930
Phone # 979-3723721 Fax # 978-5212192
ST. PAUL'S -EPISCOPAL CHURCH
STEPHANIE WILSON
390 MAIN STREET
NORTH ANDOVER, MA 01845
P.O. NUMBER I TERMS i SALESPERSON
NET'30 f DC
Proposal
Date
Proposal #
12/11/2009
7658
Item
Descripbon
Qty
Price Each
Total
"DOUBLE SIDED ENTRY -SIGN
-900,
OPTIONA
1
3,895.00
3,895.00T
H X 481, W DOABLE SIDED ENTRY SIGN FABRICATED FROM
TWO V SIGN "FOAMPANEL&WITH ONE .125 ALUMINUM SUBSTRATE
WITH RED ACRYLIC POLYURETHANE pAINTALUMRRM TUBE
FRAW, V -CARVED AND PAINTED GOLD GRAPHICS TO READ; "ST.
:PAUL'S EPISCOPAL CHURCH WELCOMES -YCU-, SIX 13"HX IG"W X
1/4"ACRYUC REMOVABLE PANELS - Two BLANK, OUR WITH
FORWARD CUT HIGH PERFORMANCE VINYL GRAPHICS TO MATCH A
CLIENT APPROVED LAYOUT.
QUANTITY OF ONE SIGN AT $3995.00
900
OPTION
10.00
O.00T
57.5" HX 481, W DOUBLESIDEDENTpLy.sIGN, FABRICAT
_EDFROM
TWO I" SIGN FOAM PANELS WITH ONE.125 ALUMINUM SUBSTRATE
WITH RED ACRYLIC POLYURETHANE PAINTALUMINUM TUBE
FRAME V-CARVEDAND23K GOLD LEAF FILLED-GRAPIRCS W[TH
BLACK HAND PAINTED OUTLINE TO READ- "ST- PAUL'S EPISCOPAL
CHURCH WELCOMES YOU", SIX 13" H- X 10" W X 1/4" ACRYLIC
REMONABLE PANELS -TWO BLANK, FOUR WITH FORWARD CUT
HIGH PERFORMANCE VINYL GRAPHICS TO MATCH A CLIENT
APPROVED LAYOUT.
QUANTITY OF ONE SIGN AT S5285.00
900
TWO 4")C4"X 101 STEEL POSTS WITH FLUTED ALUmmw- POLE
1
750.00
750:00T,
t
COVERS AND CLASSIC CAPSAND MOUNTING BRACKETS.
50% REQUIRED AS DEPOSIT / BALANCE NET 30 DAYS.
Total
Al material is guaranteed to. be as.specified. fid[work to be. completed in a professional Aldhoilized Signatum
manner aowrcfihg-to-standard pracfibes. Any alterationsfromabove specifications invoMng-
extra costs Wit be executed only on wrwan orders, andyAll be an extra cbarqe over and
abovethe estimate. All agreements contingentupon strikesaccidents or delaysbeyond our
control. Owner to carry all necessary insurance. Our workers are,fully covered by Workers
Compensation insurance.
NOTE: This proposal may be withdrawn by us if not accepted within days.
The.above prices, -specifications and conditions are saftsfactory and hereby accepted. You
are authorized to do the work as specified. Payment will be.madeas outlined'above. All skinature
signs remainAhe property of TheSign Center unfit paid in full.
Page -1
U
40 -Orchard Street
Haverhill, MA 01&30
-Phone-# 97"72-3721 Fax' # 979-521-2192
ST. PAUI:'S EPISCOPAL CHURCH
STEPHANIE WILSON
390 MAIN' STREET
NORTH ANDOVER, MA 01845
P.O. NUMBER
TERMS 1 SALESPERSON
NET 30 I' DC
Propyl
Date
Proposal-#-
12/11/2009
7658
item
Description
Qty
Price Each
Total
120
SITE SURVEY AND -CLIENT MEETINGS TO DATE.
1
110:00
- 110:00
102
GRAPHIC DESIGN TO DATE.
1
110.00'
110.00T
856,
LABOR AND EQUIPMENT NECESSARY FOR THE INSTALLATION OF
1
895.00
895.00
ONE ENTRY SIGN DESCRIBED ABOVE TO SOFT SCAPED SURFACE IN
ONE TRIP, DURING REGULAR BUSINESS HOURS, UNDER NORMAL,
DIGGING ANDVtitORKiNG CONDITIONS WITH FINAL LANDSCAPING TO
BE PROVIDED BY THE CLIENT.
CLIENT TOPROVIDE THE SIGN PERMIT
Sales Tax - EXEMPT
0.00
0.00
-50%. REQUIRED -AS DEPOSIT / BALANCE NET 30 DAYS.
Tota$5,760.00.
tillrnaterialisguaranfeta
ed6eaf�All
.asspeed..vu�tc3abe:completedin.aprafessionat AuthorizedSlgnatum
manner according to standard practices. Any alterations from above specificationsinvolving
extra oostawillbe exemded:only on wrdan orders, and:wiflbe: an extra charge -over and
above the estimate. Alt agreements contingent upon shkes,accidents or delays beyond our
control. Owner to carry all necessary insurance Our workers are fully covered by Workers.
Compensation insurance.
NOTE: This: proposalmay bewkMmwn by us if not acceptedwithin days
The: abomprices; specti'rcations and conditions am satisfactory and: hereby accepted. You
amauthorized to do the work -as specified: Payment Mr be made as outlined -above. All Signature
signs remain the property of The Sign Center until paid in full.
Page -2
LISUMM
40Orchard Street
Haverhill, MA 01M
Phone # 978-372-3721 Fax 9 978-521-2192
ST. PAUL'S EPISCOPAL CHURCH
STEPHANIE WILSON
390 MAIN STREET
NORTH ANDOVER, MA 01845
P.O. NUMBER I TERMS I SALESPERSON
NET 30 [ DC
Proposal
Date
Proposal #
I2/11/2009
7658
Item
Description
Qty-
Price Each
Total
DOUBLE: SIDED ENTRY SIGN
'900
OPTION A
1
" 3,895.00
3,895.00T
5715" H X 48"' W DOUBLE SIDED ENTRY SIGN FABRICATED FROM
TWO 1" SIGNFOAMPANELS WITH ONE .125 -ALUMINUM SUBSTRATE
WITH RED ACRYLIC POLYURETHANE PAINT,At.UMNUM TUBE
FRAME, V -CARVED AND FAINTED GOLD GRAPHICS TO READ: "ST.
PAUL'S EPISCOPAL CHURCH WELCOMES -YOU", SIX 13" H X 10"W X
1/4" ACRYLIC REMOVABLE PANELS-TWGBLANK, YOUR WITH
FORWARD CUT HIGH PERFORMANCE VINYL GRAPHICS TO MATCH A
CLIENT APPROVED LAYOUT.
QUAN1TfY OF ONE .SIGN AT $3895.00
900
OPTION B
0.00
0.00T
57.5" H X a' W DOUBLE, SIDED ENTRY .SIGN. FABRICATED FROM
TWO 1" SIGN FOAM PANELS WITH ONE. 125 ALUMINUM SUBSTRATE
WITH RED ACRYLIC POLYURETHANE PAINT,ALUMINUMTUBE
FRAME, V-CARVEDAND23K GOLDLEAF FILLED GRAPHICS WITH
BLACK HAND PAINTED OUTLINE TO READ. "ST. PAUL'S EPISCOPAL
CHURCH WELCOMES. YOU", SIX 13" H X IO" W X 1/4" ACRYLIC
REMOVABLE PANELS -TWO-BLANK, FOUR WITH FORWARD CUT
HIGH PERFORMANCE VINYL GRAPHICS TO MATCH A CLIENT
APPROVED LAYOUT.
QUANTITY OF ONE SIGN AT $5285.00-
900
TWO 4"X 4"X 10' STEEL POSTS. WITH FLUTED ALUMINUM POLE
11
750:00.
750:OOT
COVERS ANDCLASSIC CAPS AND MOUNTING. BRACKETS.
50% REQUIRED AS. DEPOSIT / BALANCE NET 30 DAYS
##
Total
- Al material is guaranteed to. beas. specified. All-vvork.to. becompletedina. professional /�lLtftdti� Signature
U[
manner acecrding-to standard practices. Any alterations -from -above spedications-involving
extra costs, veil be executed: only on wrBten: orders,and.wil be an -extra. charge over and:
above the estimate. All agreements contingent upon strikes,accidents or delays beyond our
controE Owner to carry all necessary insurance. Our workers are fully covered by Workers
Compensation insurance.
NOTE: This proposal may be withdrawn by us. I not acceptedwithin days
The above -prices, specifications; arch cenditim are: satisfactory and: hereby accepted. You
are authorized to do the work as specified. Payment vigbe grade as outlined above. AB:
S gna#ure
of T
signs remain the property The center until in fu1L
Page. I
50 CONCORD STREET, NORTH READING, MASSACHUSETTS 01864
978-470-2860
FAX 978-470-1017
May 3, 2001
Health Department
Town of North Andover
27 Charles Street
North Andover, MA 01845
RE: Asbestos Abatement
`=390 -MainStreet; Rectory, French Memorial, Parish Hall
Dear Sir or Madam:
Dec -Tam Corporation will be performing an asbestos abatement project at the above referenced
location. This work is scheduled from June 18, 2001 to June 29, 2001.
All applicable local, state and federal agencies have been notified of this work.
Please let me know if you have any questions.
Sincerest regards,
Brenton D. Mo ns
Sales Estimator
JP/jmp
Enclosure
4
,d
ASBESTOS ABATEMENT LEAD ABATEMENT INDOOR AIR QUALITY
www.dectam.com E-mail: dectam@aol.com
1IISMUCTIons
I. All smM nfs of oils
Conn must be coufplalorl
In order to comply wilh
Ilio Uopaflnf01d of
Fnvharnomdal
Protection n01111calloll
requlmnaids of 310 CMII
7.15 (len ivorAinp a,ys
Pilot nulilimhorl is
requirod of anyabalernoti
Pr%cl): and Die
Uopafhnoul of Labor
and Industrial
nofilimllon requiremeris
of 453 C61116.12 (lan
days prior noliliralion is
mquirnl v1ANr
ahalemmd Proiad prealar
Than Ihrca linear or
squaw loo.
2. Submit Uflulnal Fann
T o:
Commonwealth of
Massaclfusolls
Asbestos Program
P.O.13.120007
Boston, MA 02112-
0007
3. 1Ills lunn may be
used lot nulllyinp 0fo
U.S. Fnviromneulal
Pf olecllon Agency I ieplon
I of asbestus rkn'olilion/
fenuvaliun ullmalions
subject to N[SI IAPS (40
Cru suhpail M).
i « nn�ey ite uny
iudGuo, i
IlorlrnJ Ihln
6 nilAn.om
nn
COI) mOnwaaifh of Massachusetts v.
Asbestos Nofificafion Form — ANF -001
57599
' /Is6estusALalemerrP Descripllvn
1. Facliily location:
Hann
Addmzr .___........
.........
Clfygoxn —wT
IIP axk lalrldmur
ItUaf Is ma nurAsllo Aia1100 blinding 1121110, r, xinp, llorfr, nwrn
2. Is the facility occupied? M Yat 0 No __.. _..__ .... . .
3.
Asbestos Contractor:
Dec—Tam Corpora _ion
Nan10
CI%
_5D ncor.d Street
Adorns:
North Reading, rtA
01864
cny/lowa
(978) 470-286U
AC000035
Ulmonse
Written
CatlraU
4.
On-5ile Project Supervisor/Foreman:
Han+v
5.
Project Monitor:
Name
6.
Asbestos Analytical Lab:
Same as 5
Namu
7.
Project start dalo_�/D( and dale / l/Ofspecllicworkhours(Mon.-Frl.)
(Sal. uUll.)
B.
What type of projoet Is lhis7 (Chill 0110): damolmon
9.
Describe Ute asbestos abatement procedures to be used
mPalr mrxinllfin carer/erp/alnJ
(circle):grove Wp
w=vlallan dhyrosa'nnlY WmrloarnahrJ
encAuvm /u1/caMalnrmd rJranup
10.
Is Ilia job b01n6 conducted is indoors D outdoors ?
1 L Total amount of each type of Asbestos Containing Materials (ACM) to bo handled on pipes or ducts (linear It.) � l)r other
surfaces (square 11.) to be removal, enclosod or encapsulated:
iinearvsqual'e Met
boiler, breaching, dud, f iLk e,pi peace clalio,s. • thermal, solid cae pipe Insulalion......
corrugated or Jayarerl paper pipe iruulaliorl....
spray -ort fireploohnp......... hisulalingCement..................
clauts, woven 15mics....... --/ LF01MYs121ay'erCoatings ..............
aprer fpkeso dascriheJ......... —/ uursile board, wall board .............
12. Describe the deconlaminoUon system(s) to be used:
(I M�a P__
13. Describe the call lalnelltalf01l/disponiqSal methods to comply will' 310 CMR 7.15 and 453 CMR 6.14(2)(6): —
ri�1 irh amenripij wnt-pr 111A
� gs to h---�iulfinnrrPrl Ln -,n -� gri It le_si;�_uul_po.l.)'—_-.
14. For Emergency Asb stos Abatement Operallons, 1110 DEP and DLI Officials will) evaivaled the emego c};
Munn nlruFngplrlaf
U11nafA 11mruallun —_
1121110 o1O110/prJal
)Ills ..._�----------------- ----...._
LulaoJAulhoruaflon
15. Do plevailinti wage rales apply as per M.G.L. c. 149, § 26, 27, or 27A - F to this project? C Yes & No
Note: Transfer
Stations must
cnmply wilh the
Solid Waste
Division repula-
lions 310 CMR
18.0
Nals: Contractor
must sign this
form for DLI
notification
purposas
Ka racllity Description
1. Current or prior use of facility:
2.Is "Is facility owner-occuplad residential with 4 units or less? 0 yes 0 No
3. Facility Owner.
Nairn ��' �- l 1�f?1r.t �elOf9[dwli
3 � Al �
Zlp roofs Telephone —•—.
4. Facilily's Owner's On-Siia Manager.
tvvp- At �
Nlnn
ArWrac
------------------
Glly/Town
Ilp rade Telephaie
5. General Contractor.
Name
Address
Zlp coda Telephone
New Hampshire Insurance ZJC1026148
6. What Is the size of the facility? ConfraclorsWolkarsComp.lnsunr 1228/01
Pollry/ Exp.Dale
i (sq to -_�,_ {tr of floors)
LU Asbestos TranspDrtatlon and Dlspnsal
1. Transporter of asbestos -containing waste material from site to temporary storage elle (If necessary) to final disposal elle:
Service Transport Inc.
Nann 58 Pyles Lane
AT,-
New Castle DE 19720 877) 999-9559
Ilp Telephone
2. Transporter of asbestos -containing waste malarial from removal/temporary storage slia to final disposal site:
Same as 1
Name
Adrlrws
Clryyrown
IIP C0d0 Telephone
3. Refuse transfer station and owner (If applicable):
Nene
Address
C(ry/rown
TaleQlwne
4. Final Disposal Site: IIP Cade
Greenridge Reclamation
taravinNalm USA Waste Systems
Owmrs Name
Landfill Road
Add/Cis
Scottsdale PA 15683
clryaaxn (724) 887-9400
. Zlpmde Telopllone
° CartlticatlDn
The undersigned hereby slates, under the penallles of per)ury, that he/she has read the Commonwealth of Mas sac 11 UsOtt a Reputations
for the Removal, Coniainmanl or Encapsulallon of Asbestos, 453 CMR 6.00 and 310 CMR 7.1 S. and that th6 Information
this notification Is Irue and correct to the best of his/her knowledge and belief. contained In
t he 11V Vf ®b e4. NI -9943
PNnlNarro S ��®
AuUlaNtedSlpnalure Dais
twg5 _
!lu'llgxl?lae —
1>uc�'I'ntli Cn,rgnrn..Lnn___--
lblueseraby/ ralaplxum .—_ .. .___—. ..
50 Concord Street North Reading, MA
Address 01 8 6 4
Clp/Toxn Zlp cone
Fee exempt (City, Town, district, municipal housing alfihorif)', owner -occupied residential of four units or less) ? l7 yos lel' no
Slicker/ (from Iron[ of form): S=g
9
Date .....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............... . � 1.1--) ........ 1��&� ........................
has permission to perform .......... ..t..7 . ...... ;Ilf- o .. S .......................
wiring in the building of ........
at ....... 3f49 .....
. ........................... . North Andover, Mass.
Fee.3 Lic. No. .......
1P 'i Ald
Check # 30
6897
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 6 e % 7
Occupancy and Fee Checked
[Rev. 9/051 (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 IN INK OR TYPE ALL INFORMATION) Date: I{ Z Al y(-
City or Town of: kl Yom► To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number)�AnVIA)
Owner or Tenant tYT &f 60-14600,11 eh&9,--h Telephone No.
Owner's Address
Is this permit in conjunction with building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building- S�Jz�%` 3Pr, ,f)Utility Authorization No.
Existing Service Z0'0 Amps / Volts Overhead ❑ Undgrd ❑
New Service Amps / Volts Overhead ❑ Undgrd ❑
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
No. of Meters
No. of Meters
Completion of the following 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-
rnd. ❑ rnd. ❑
o. o Emergency Lighting
Batter Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
Hear Pump
Number
Tons
KW
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:
No. of Devices or Equivalent
No. o Water Kms,
Heaters
No. o o. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring.
No. of Devices or E uivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: �� b 0 (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify, underlite pains and pen ties of perjury, that the information on this application is true and complete.
FIRM NAME: � 1, A C—C e� LIC. NO.: nzye
Licensee:
LIC. NO.:
(If applicable, enter "ex nip," in the license number line.) • I Bus. Tel. No.:
Address: ..�� dC( r4 f -sr i h��9t uj, 11MA Alt. Tel. No.:
*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 signature below, I hereby waive this requirement. 1 am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE. $
A )
.Date
has permission to perform .... ..............
plumbing in the buildings of .................
at ... rth Andover, Mass.
-(Ao
-C, 7
Feei Lic. No..
.... ...... . ......
-P L* U, M, *8 I'N G I N S P EX'0 R
Check # 13 o.
7543
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
'AM
This certifies that ...
.................
has permission to perform .... ..............
plumbing in the buildings of .................
at ... rth Andover, Mass.
-(Ao
-C, 7
Feei Lic. No..
.... ...... . ......
-P L* U, M, *8 I'N G I N S P EX'0 R
Check # 13 o.
7543
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location
ne�cs Name7' /L�" c/ G S ��Da
S Permit
Amount
Occupancy f � W f /l
New 0 Renovation E] Replacement �� Plans Submitted Yes
FIXTURES
No 11
(Print or type)� 1Check one: Certificate
Installing Company Name V/ P �o�- l7� [] Corp.
Address Partner.'
Business Telephone [Firm/Co.
Name of Licensed Plumber.
Insurance Coverage: Indicate the Me of insurance coverage by checking the appropriate box:
Liability insurance policy [I 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 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 'iinstal0tions performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massing C e and Cha 142 of gte General Laws.
v r-�
BY:
'Signalure oi.Licensea Plumber—
Type of Pl mbing License
Title
City/Town ►cense um er Master ( Journeyman ❑
APPROVED (OFFICE USE ONLY u
— -1 -,.- I-, -,-, - I- - , -, - , - � - - - '-,
r000!
0
0
1 09
AO;R-ev
Date .............
TOWN OF OATH ANDOVER
(!5
PERMIT FOR PLUMBING
Nz!�
This certifies that
. ..........................
has permission to perform ...... 1.
...........
plumbing in the buildings of .
at �?. ?�?. . .:� . Q, ........ North Andover, Mass.
.............
Fee -3.low
6 ...... Lic. No ...........
P =,G' SPECTOR
LUM13i'IN 11�
Check #
7519
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBIN
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location 3 6
New 0 Renovation ri
V" Owners Name
Type of Occupancy
Replacement
FIXTURES
j n Date %j%
Amount
Plans Submitted Yes No ❑
(Print orCompany
e) p y � � -I— A `CG . Check one- (� Certificate
installingCom an Name 1�_ F'j]�� , � /
Address �t!J �`��� u' E] gamer.
Business Telephone Firm/CO.
Name of Licensed Plumber: �itif ` +�ij21a L� l9y�ij !�'1
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy D Other type of indemnityBond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
threeinsurance
ignature Owner r 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 erformed under Perm Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts �tlur:�j C d Chapter 142 of the General Laws.
Type of Plumbing License
icense u I er Master
OVER (OFFICE USE ONLY,
Journeyman ❑
26 �.
PP
k
Date ..... � 7-4 ... ... 0.:7
'6
TOWN OF NORTH ANDOVER
0 -
PERMIT FOR WIRING
7-1
This certifies that ............ lb....#.A�n .... 4�lpz� ....... A�7ra ............
has permission to perform ..7WV44,�r ' / - ?"t '01 ...................
wiring in the building of a.'6�P'av
at ...... 3. -S.,, . 7 ......................... . North Andover, Mass.
Fee ..................... Lic. No... 7A.27R.S.7 .............
Check # /qL/7 ELEcTRicAL INSPECMR
7488
Commonwealth of Massachusetts
Department of Fire Services I Permit No.
cial Use Only
7-//"
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/071 (leaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:,
1A.C.
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 electrical work described below.
Location (Street & Number) Sr
Owner or Tenant
Owner's Address
Telephone No.
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building_ � A" r- Utility Authorization No.
Existing Service _V Amps / Volts
New Service i� Amps /ZO / 2L,pVolts
10 Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Overhead ❑ Undgrd ❑ No. of Meters
Overhead Undgrd ❑ No. of Meters %
CJ I .
ComDletion nitho {nlln, in In;,/
I L_ . .I__ 1
- - 6 •��
No. of Recessed Luminaires '_7
No. of Ceil.-Susp. (Paddle) Fans
"'"Y UG rvuiveu uy tree Irw/�eclor ol.wtres.
No. o Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above-[], In-
ove❑In- El
o Emergency Lighting
rnd. rnd.
Batte Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALAREE0:07fZones
No. of Switches
No. of Gas Burners
No. of etection an
Initiatin Devices
No. of Ranges
No. of Air Cond. TotaTons l
No. of Alerting Devices
No. of Waste Disposers
Heat PumpNumber
...........
ons
I KW
No. of Se[U-05n—tained
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ unic'pal ❑ Other
Connection
Security Systems:
No. Devices Equivalent
No. of Dryers
Heating Appliances KW
No. of Water
Heaters KW
No. of .
Noo
of or
Data Wiring:
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications firing:
No. of Devices or Equivalent
OTHER:
- <V • c o a ytiacn additional detail iJ 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-irrTorce, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify, under the p ins andpenaldes ofperjury, that the information on this application is true and complete.
FIRM NAME: LIC. NO.: �1i771
Licensee: Signature LIC. NO.:
(If applicable, enter "exempt " in t to license number line.)
;
Address: ZS/ �91 i3O •ems cv-- ,,yyli ��/ "A' Bus. Tel. No.:
Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $
P6-tl� p< 6-0,9-0-7 P47
5 � Oc `( .14 - 67 (�
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: iQ I Jl'1 fS f
City/State/Zip: g, d Ag 61w Phone #: 9`?9-587 " Z` 7
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
eam
yees (full and/or part-time).*
�sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet. $
These sub -contractors have
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.❑ Electrical repairs or additions
1 LEI 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.
t 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 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 thegains and penalties of perjury that the information provided above is true and correct.
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 #: