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Miscellaneous - 40 MARBLEHEAD STREET 4/30/2018 (4)
BUILDING FILE � Date... X/4./.............. TOWN OF NORTH AN-DOVER PERMIT FOR WIRING CHU This certifies that'i. .......I... .................. "`�' . ...........I/.................................................................. has permission to perfom;—'�-.Awa.......W..AZ.5_V/ ..........................�* q0 k � ejZ ,wiring in the building of....... _,.S_e 6a ............................................................................................................... at .2k.- �orth Andover M ss. ......... ................ ................................... orth An er,M Pee......120S........................Lic.No-3.41- ELECTRICAL I E T Check* -A-- W2 j Date.... $ .` .................. OF 40RT TOWN OF NORTH ANDOVER a PERMIT FOR WIRING .;•.o•�r'or.�.1g CHUS�t Thiscertifies that ....................................................... ................................................................... has permission to perform ...r. ..................................... wiring in the building of...:w.Py/`, .f at ......... ..-.`!. .....� .t 2..A:GC. orth Andover,Mass. ..... ................ Fee..... ..............Lic.No .. ........ .. ..... 'e ! ..... �! L CTRICAL INSPECTOR Check 4t !D p. .. � Offic' 1 U e Only Commonwealth of Massachusetts I Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT IN MK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires.- By ires.By this application the undersigned gives notice of his or her intention to perform the electrical work described below. LocationSt reet&Number LO Ar 8)e 4,-,V <�; Owner or Tenant we S't"«" Telephone No. Owner's Address i4 0' & 1-71 q kp Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate]Box) Purpose of Building 0 1~e 11 ''f 9 Utility Authorization No. 11 �9.ulcz - Existing Service 100 Amps 110/ 9 t-/v Volts Overhead P� Undgrd❑ No.of Meters New Service .I= Amps J11' / l-/OVolts Overhead[A-'— Undgrd ❑ No.of Meters Number of Feeders and Ampacity "'t/0 L e S105/e � e Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No.of Total Transformers 0 KVA No.of Luminaire Outlets No.of Hot Tubs 0 Generators o KVA No.of Luminaires Swimming Pool Above ❑ In- El o mergency i kiting rnd. rnd. Batter Units No.of Receptacle Outlets S 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 No.of Alerting Devices g Tons No.of Waste Disposers Heat Pump Number Tons KW.......... No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other 1 P g Connection No.of Dryers r Heating Appliances KW Security Systems:* No.of Devices or Eciuivalent No.of Water KW ? No.of No.of Data Wiring: Heaters 1 Signs - Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: f'�, t?`' C `�` (When required by municipal policy.) Work to Start: 1 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, tinder the pains and penalties o�f perjury,that the information on this application is true and complete. _ FIRM NAME: �� T� I 1�y �_ 'P C LIC.NO.: Licensee: ���� �I'J f y Signature %�� LIC.NO.: (If applicable,enter "exempt"in the license number line) Bus.Tel.No.- Address: Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent / c� Signature Telephone No. PERMIT FEE. $ / � aJ_ ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass F?1 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: p g SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed ❑' Re-Inspection Required($.)❑ Inspectors Comments: 17, D Z,C Inspectors Signa ure: Date: ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Commen i Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth ofMassachusetts Department of IndustriglAccid nts Office of Investigations �V- 0 600 Washington.Street Boston,MA.02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Aunlicant Information Please Print Legibly Name(Business/Organization/Individual): I'Gy / C Address: 17 / CO3JA/ k+14 S+�a 0 L 47 3 �G� `3 ,yy � City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g• ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.n Electrical repairs or additions 3.El am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.E]Roofrepairs insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] -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 Sire doing all work and then hire outside contractors must submit anew 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 thepolicy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: ExpirationDate: 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 DTA for insurance coverage verification. Ido liereby cern `unjr th Tinsand pen ties ofperjury that the information pro vided ab o ve is true and correct. Simafore: Date: Phone Phone#: 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 d.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: Information and Instruction's Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire,• express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a j oint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three 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 notrequired 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 onfile for future permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Colnmonwealth of MassachiusPtts Depaftent ofIndustdal AccUpts Office of westigatlouq 600 Washington.Street $ostona M.02111 \ `t`el,#617-727-4900 a.t 406 or 1-577-MASSAFF, Revised 5-26-05 Fax 4 617-727-7749 l �F COMMONWEALTH OF MASSACHUSETTS e o • - o o j » d I ELECTRICIANS ISSUES THE FOLLOWFNC� -L I`CENSE.:: AS A RE6 JOURNEYMAN :ELECTRICI'AN j JOHN; J TULLEY �o Z 48 xy MILLER` 57 � ; ��. . Z IW ETHUEN ::.M'A 01844-51 G8 1 34637E 07/31:/ 6 111007 Date.........7.:.../.0...... .y� OF r40RT#1 q �?; oo� TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,sSACMu5�S This certifies that ................. lJ......... .. ......................... has permission to perform .....(.�r ..... .(� lG ...................................... wiring in the building of................. `�. T`�t�.:....... ............. ... ............... at ................ ...... <! :............................ .......,North Andover,Mass. o� Fee.-�-�'"..Lic. No. J. 9 4?a..........1!... .......... ...........:.� .: ................. „M V' ELECTRICALkVSPECTOR Check# 3 (�oinnurruvealtic o�cc � Official Use Only aL JePartnaercE o��`ir¢�erviceJ Permit No. � Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS ev.1/o7] (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 PRINTW INK OR TYPE ALL XFORIVATION) Date: City or Town-of: A�t b To the Inspector of Wires. By this application the undersigned gives notice of his or her intention to p form the electrical workdesc bed below. Location(Street&Number) j x-- � �� CA Owner or Tenant �l 6l Ce) 61.E Telephone No. Owner's Address 0 Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / 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: Completion o the ollrnvin 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- El o Emergency Lig hfing d. rad. 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 Initiating Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices Tous g No.of Waste Disposers Heat Pump Number I Tons I KW W_ No.of Self-Contained Totals:I I Detection/Alerfing Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW SecuritySystems:* N No.of Water. No.of No.of o.of Devices or Equivalent Heaters KW Signs Ballasts No. Wiring: No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or FquWalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation'coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,thatthe information on this%piclagzstrue and complete:FIRM NAME: DAV i P E L it C: r`R i CA I_ C0N 1-P,A C. LIC.NO.: Licensee: TD 4\1 i t7 4466 4n Signature LIC.NO.: J H Cl b -3 (Ifapplicable,enter`exempt"in the license number line.) — Bus.Tel.No.:37t '&,!Z:L^.1 Z Address: ;7 D 0 i..in G N r a t-y u 2?H JJPD,-i7 i:12 n14 W+3 Alt.Tel.No:q 1 i3 *Per M.G.L.c.147,s.57-61,security work requires Department of Public Safety"S"License: Lie.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 El owner's a ent. Ogent Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ` 1 Congress Street, Suite 100 Boston,K4 02114-2017 www.mass.gov/iva Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:DAVID ELECTRICAL CONTRACTING LLC Address:87 BELMONT ST City/State/Zip:NORTH ANDOVER,MA 01845 Phone#:978-682-6262 Are you an employer?Check the appropriate box: Business Type(required): 1.❑ I am a employer with 8 employees(full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ 1 am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl. real estate,auto,etc.) employees working for me in any capacity: i [No workers' comp.insurance required] g ❑Non profit -3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing no employees. [No workers' comp. insurance required]** I i.0 Health Care j '4.❑ We are a non-profit organization,staffed by volunteers, ELECTRICAL CONTACTING with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#l. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:FEDERATED MUTUAL INSURANCE CO Insurer's Address:PO BOX328 City/State/Zip: OWATONNA, MN. 55060 Policy#or Self-ins. Lic. # 9353694 Expiration Date:MARCH 1, 2015 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 t violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for'ns ce erage verification. I do hereby certify,under lze ai s rl_ allies of perjury that the information provided a ve i tru and correct. Si ature: Date: �6 Phone#: Oficial use only. Do not.wr&e in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): L Board of Health 2.Building Department 3.Eityirown Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#• www.mass.gov/dia Date .....................7�/ ....... ................... ! ' OF NORriy,� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION g8'�CN1J8� ke 0� This certifies that ...... .................. .......... �.J""................,...............................,....... ,. .... has ennission or as Inst lati n ........ � ... ? ............................... in the buildings of......W.e" A.......................................................... ,- ........................ . at... .... .�.t North Andover, Mass. Fee lk."."'.... Lic. No. ..... C)N)... Mb:....................................................... (,� ( GAS INSPECTOR Check# (p I �. 9568 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY �NQ���,/�".:-��eT�_mMA DATE 4,� � � PERMIT# JOBSITE ADDRESS c c_ _ :OWNER'S NAME r I&C b r' _ GOWNER ADDRESS TE FAX TYPE OR OCCUPANCY TYPE COMME AL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:[ RENOVATION: — REPLACEMENT:® PLANS SUBMITTED: YES F--1 NO APPLIANCES 7 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER r._ �.._ F--j =j=j BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER _n._ DRYER FIREPLACE FRYOLATORu FURNACE --.._ � ._ :-_► �!�� -.�= --, .( _ _ �,r__ _--1 - 1. _ �1 GENERATOR .._._ ( .—_.. � 14_..� 7-11 GRILLE INFRARED HEATER -- I _--_1 — r[—D. LABORATORY COCKS MAKEUP AIR UNIT OVEN - POOL HEATER ROOM/SPACE HEATER T. I RCtF TOP UNIT I Ur:yT HEATER UNVENTED ROOM HEATER WATER HEATER _ OTHER . INSURANCE COVERAGE as have a current liability insurance policy or its substantial equivale hich meets the requirements of MGL.Ch.142 YES 1 0 IIF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNERF—] AGENT DI SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge j and that all plumbing work and installations performed under the permit issued for this application will be in compliance Vfthlall Pertinent rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLU;�MMGF FITTER NAME ( ;n �� LICENSE# SIGNATURE MP �( JP ® JGF 0 LPGI 0 CORPORATION©# PARTNERSHIP© � # -LC D# COMPANY NAME: . —� ADDRESS CITY 1_-�r us�r�c G� —� STATE r✓ (ZIP ]TEL FAX CELL _ EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTIO NO Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 1A I The Commonwealth of Massachusetts Department of IndustrialAccidii1ts Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information I j (� Please Print Le0bly Name(Business/Organization/Individual): �� 0� �' 1\ �. I� Address: 2 )9J0r ',A City/State/Zip: LL-_1 I A t r K, /Y'611 Phone#: AWitma employer?Check the appropriate box: Type of project(required): 1. employer with_ 2 4. [1I am a general contractor and I 6. E]New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. [J Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers' comp.insurance. 9 y p ty E]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i-Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit anew 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:. Aof Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: M G11r �� �pc✓ City/State/Zip: 0 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. X do hereby cert unrler_thepmn d penalties ofperjuty that the information provided above is true a d correct. Si ature: Date: . /'Y-1 Phone#: Z ceff Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit0cense# 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#: 1 Informati®n and Instruction's Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or.written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. AIso 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 shouid 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 Commonwalth of Massachusetts - Dep.arttnent oflndus-foal Accidents, Office of Investigations 604 Washington Street Boston,NIA,02111 Tel,#617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax##617-727-7749 vtWw.m,ass,govaa 10/7/2014 Division of Professional Licensure:License Search The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) .a 'Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home> Division of Professional Licensure> ONLINE SERVICES ............................................................................................................................................................................................................................................................... .................... Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency More... LICENSEE Name: KEVIN P. RAYMOND REFERENCES& LAWRENCE, MA RELATED INFO < NEW SEARCH I Disclaimer Regarding **This Licensee has additional Licenses, click here to view them.** Website License Searches Glossary of License Status Codes Licensing Board: PLUMBERS Et GASFITTERS License Type: MASTER PLUMBER More... License Number: 15321 Status: CURRENT Expiration Date: 5/1/2016 Issue Date: 10/13/2007 Exam Date: 10/13/2007 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web sewer on Tuesday, October 07, 2014 at 9:13:16 AM. O 2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg.state.ma.us/public/pubLicenseQ.asp?board_code=PL&type_class=_M&Iicense_number=000015321&color—blue&Ib=PL 1/1 C®fU16VIGNWEALTIi ®F MASSCtiilp tila PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMBER ISSUES THE ABOVE LICENSE TO: KEVIN P RAYMOND I 2 PILGRIM RD \ Q LAWRENCE 01843-371 15:321 05/01/14 176365 • I I �a M f �F tl t f:� 255 Date. .,/' .`4 ... . . l� NorrTN TOWN OF NORTH ANDOVER pf 1ti PERMIT FOR MECHANICAL INSTALLATION F F s s • SACHUSESS This certifies that has permission for mechanical installation . . .,r�" in the buildings of . . 1.6-A,/ G? . (mac fsyr--- . . . . . . . . . . at . . . .j.0. . . . .!.!.. . . J'. .. North Andover, Mass. Fee, . Lic. No..r� . . . . . . . . . GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer I Commonwealth of Massachusetts J Sheet Metal Permit Date: 161 14 , Permit# Estimated Job Cost: $ � !S00 Permit Fee: $ ." Plans Submitted: YES NO Plans Reviewed: YES NO Business License# q 1 Applicant License# q6 Business Information: Property Owner/Job "Location Information: a�� r� Name: � za J�'cz5 Name: VC,�c y� ja Street: 01 BAYYtc1,at A Street: City/Town: ��� �� City/Town: llyul* A c/vt� Telephone:Lq-* 691 -U-33 Telephone: va Photo I.D. required/Copy of Photo I.D. attached: YES ANO Staff Initial J-1M-1- nrestricted license OM-I- c� 1- 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 t• Institutional Other Square Footage: under 10,000 sq. ft. ver 10,000 sq. ft. Number of Stories: Sheet metal work to be ompleted: New Work: Renovation: HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing t Provide detailed description of work to be done: 2, 9q6)vil 07-LI INSURANCE.COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes No❑ If you have checked Yes,indicate the type of coverage by checking the appropriate box below: A 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 112 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 Owner's Agent I I By checking this boX2,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. Duct inspection required prior to insulation installation:YES NO Progress Inspections Date Comments Final Inspection Date Comments Type of License: By 174aster Title ❑ Master-Restricted _. City/Town ❑Joumeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: 70 V Fee$ ❑ Check at www.mass.gov/dpl Inspector Signature of Permit Approval OP ID:PS ACORO' DATEIMMODIYYYY) CERTIFICATE OF LIABILITY INSURANCE 11101/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 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 INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCERCONTACT Phone:978-688.226 NAb,E. North Andover Insurance AgencyPNONE FAX M.J.Foster Insurance Services Fax:978-686-6410 AIC No): 163 Main St. E�L North Andover,MA 01845 toN&_ CALLA-1 Stephen Sullivan INSURER(S)AFFORDING COVERAGE NAIC 0 INSURED Callahan A C and Heating INSURER A:PEERLESS INSURANCE COMPANY Services,Inc. INsunite:GUARD INSURANCE COMPANY Callahan Air Conditioning and INSURERC: Heating,Inc. 91 Belmont Street INSURER D: North Andover,MA 01845 INSURER E: IN URER COVERAGES CERTIFICATE NUMBER: REVISION 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 TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR NSR ADOLPOLICTYPE OF INSURANCE POLICY NUMBER POLICY EFP MMID Y EDLP LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1.000100 A X COMMERCIAL GENERAL LL421UTY CBP4016154 09/25/2013 09125/2014 PREMISES 000611oncoll S 100.00 CLiUMS MADE I I OCCUR MED EXP(Anyone porion) $ 5,00 CONTRACTUAL LIAB PERSONALS ADV INJURY s 1.000,00 GENERAL AGGREGATE S 2,000,00 GERL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG S 2.000,00 POLICY FX PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,00 A ANYAuTo BA4544036 09/25/2013 09125120. (EaaWdent) BODILY INJURY(Per poison) $ X ALL OWNED AUTOS BODILY INJURY(Par mideM) S SCHEDULED AUTOS PROPERTY DAMAGE i X HIRED AUTOS (Per aeodenl) S 7X NON-0WNEDAUTOS I s I �s X UMBRELLA LIAB X OCCUR EACH OCCURRENCE 3 0,000,00 EXCESS UAS CLAIMS•MADE AGGREGATE S 5.000100 A CU8809334 0912512013 0912512014 DEDUCTIBLE S _ RETENTION S WORKERS COMPENSATIONWCSTATU• X OTH• AND EMPLOYERS'LIABILITY B ANY PROPRIETORIPARTNERIEXECUIWE YIN CAWC471731 0912512013 0912512014E.L. EEACHACCIDENT S 500,00 OFMCERIMEMBER EXCLUDED? QN NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 500,00 11105 Sd P O OAF OrPERATIONS below i El DISEASE•POLICY LIMIT S 500,00 I F_ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(AttatA WORD 101.AddlUonal RemarU Schedule.If mon,spaco is regulred) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. fax#978 688.9542 AUTHORRED REPRESENTATIVE BLDG.INSPECTOR 1600 OSGOOD STREET ORTH ANDOVER,MA 01846 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 26(2009109) The ACORD name and logo are registered marks of ACORD ."— '^'-•_s'---'�'7-;. � �.ks="'�'"°,^:?:=—r:ate+-� Bh.OZ0 y vw.'OlAusm 1S 3'14vw..zzbL ` P NUk" of COMMONWEALTH-OF MA9sAc;HUSETTS` SHEET ME PAL Wolk KERS AS A MASTE k-UNREaTRtCTED } ISSUES THE ABOVE LICENSE TO: KEVZN J" MCDON4LD 91 BELMONT ST NORTH ANDOVER 0A 01845-2304 A, 3 22404 05/28,'14 3.6451:1 Page 1 Residential Heat Loss and Heat Gain Calculation 7/10/2014 In accordance with ACCA Manual J Report Prepared By: Callahan A/C & Heating For: Richard Webster(1st Floor) 40 Baldwin Street North Andover, MA 01845 Design Conditions: Lawrence Indoor: Outdoor: Summer temperature: 72 Summer temperature: 87 Winter temperature: 72 Winter temperature: 0 Relative humidity: 50 Summer grains of moisture: 95 Daily temperature range-Medium Building Component Sensible Latent Total Total Gain Gain Heat Gain Heat Loss (BTUH) (BTUH) (BTUH) (BTUH) Infiltration 1,258 1,919 3,177 14,320 Walls 1,563 0 1,563 6,048 Windows 2,977 0 2,977 4,611 Duct 0 0 0 3,308 Floors 250 0 250 2,896 Ceilings 1,404 0 1,404 2,592 Glassdoors 882 0 882 1,842 Doors 198 0 198 765 Skylights 0 0 0 0 Misc 1,200 0 1,200 0 Fireplaces 0 0 0 0 People 1,200 920 2,120 0 Whole House 10,932 2,839 13,771 36,382 ( 1 tons) HVAC-Calc Residential 4.0 by HVAC Computer Systems Ltd. 888 736-1101 Load calculations are estimates only,actual loads may vary due to weather and construction differences. Page 1 Residential Heat Loss and Heat Gain Calculation 7/10/2014 In accordance with ACCA Manual J Report Prepared By: Callahan A/C & Heating For: Richard Webster(2nd and 3rd Floor) 40 Baldwin Street North Andover, MAO 1845 Design Conditions: Lawrence Indoor: Outdoor: Summer temperature: 70 Summer temperature: 87 Winter temperature: 70 Winter temperature: 0 Relative humidity: 50 Summer grains of moisture: 95 Daily temperature range:Medium Building Component Sensible Latent Total Total Gain Gain Heat Gain Heat Loss (BTUH) (BTUH) (BTUH) (BTUH) Infiltration 4,294 6,245 10,539 26,461 Windows 9,552 0 9,552 9,379 Walls 2,576 0 2,576 8,759 Ceilings 3,434 0 3,434 5,863 Duct 0 0 0 2,523 Skylights 0 0 0 0 Glassdoors 0 0 0 0 Doors 0 0 0 0 Misc 1,200 0 1,200 0 Fireplaces 0 0 0 0 People 1,500 1,150 2,650 0 Floors 0 0 0 0 Whole House 22,556 7,395 29,951 52,985 2.6 tons HVAC-Calc Residential 4.0 b HVAC Computer Systems Ltd. 888 36_ 1101 Load calculations are estimates only,actual loads may vary due to weather and construction differences. Callahan PROPOSAL A/C&HEATING SERVICES PROPOSAL#: 107466 91 Belmont Street North Andover,MA 01845 DATE: 6/19/201.4 www.callahanac.com REP: KJM 978-689-9233 TO: JOB LOCATION: RICHARD WEBSTER 40 BALDWIN STREET NORTH ANDOVER,MA 01845 DESCRIPTION Total INSTALLATION OF NEW HEATING AND AIR CONDITIONING SYSTEM(GAS PIPING AND ELECTRICAL NOT INCLUDED)CONSISTING OF THE FOLLOWING:(FIRST FLOOR) A_GOODMAN MODEL#GMH95453B GAS FIRED 95% 2-STAGE HOT AIR FURNACE 45,000 BTU B_GOODMAN MODEL#GSX13181 13 SEER 18,000 BTU CONDENSER(R410A) C_GOODMAN MODEL#CAPF 1824B COIL D_FREON LINE SET E_ELECTRICAL BY OTHERS F_GAS PIPING BY OTHERS G_PVC FLUE AND COMBUSTION AIR PIPING THROUGH SILL PLATE TO OUTSIDE H_30 x 30 CONDENSER PAD [PRECAST] I_CONDENSATE PUMP AND PIPING J_INSULATED DUCTWORK WITH FLEXIBLE BRANCH LINES TO REGISTER K_CENTRAL RETURN REGISTER FOR FIRST FLOOR L_APRIL AIR HEATING AND COOLING MODEL# 8463 DIGITAL THERMOSTAT M SUPPLY REGISTER FOR EACH ROOM INSTALLATION OF NEW 1-ZONE HEATING AND AIR CONDITIONING SYSTEM CONSISTING OF THE FOLLOWING:(SECOND and THIRD FLOOR) A_GOODMAN MODEL#GMH80803BN GAS FIRED 2-STAGE HOT AIR FURNACE 80,000 BTU B_GOODMAN MODEL#GSX13301 13 SEER 30,000 BTU CONDENSER(R410A) C_GOODMAN MODEL#CHPF2430B COIL D_INSULATED DUCTWORK WITH FLEXIBLE TAKEOFFS E ELECTRICAL BY OTHERS INCLUDING LOW VOLTAGE WIRING PAYMENT TERMS 1/2 deposit 1/2 completion Total All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate. All covered by Workman's Compensation Insurance's. Equipment warranty by manufacturer. Contractors labor warranty for one year. AUTHORIZED SIGNATURE: DATE: CUSTOMER ACCEPTANCE: DATE: **A signed copy of this proposal and deposit must be received for us to schedule this installation. (This proposal may be withdrawn by us if not accepted within 30 days.) — Authorized ,Haile' Partner in Comfort Pagel y' Callah an PROPOSAL A/C&HEATING SERVICES PROPOSAL#: 107466 91 Belmont Street North Andover,MA 01845 DATE: 6/19/2014 www.callahanac.com REP: KJM 978-689-9233 TO: JOB LOCATION: RICHARD WEBSTER 40 BALDWIN STREET NORTH ANDOVER,MA 01845 DESCRIPTION Total F_NEW APRIL AIR DIGITAL HEAT/COOL MODEL# 8463 THERMOSTAT G_SUPPLY REGISTER FOR EACH ROOM H_CENTRAL RETURN REGISTER I_B-VENT FLUE THROUGH ROOF J_GAS PIPING BY OTHERS K_SHEETMETAL PERMIT AND REQUIRED DUCT PRESSURE TEST L_REQUIRED DRAIN i it PAYMENT TERMS 1/2 deposit 1/2 completion Total All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate. All covered by Workman's Compensation Insurance's. Equipment warranty by manufacturer. Contractors labor warranty for one year. AUTHORIZED SIGNATURE: DATE: CUSTOMER ACCEPTANCE: DATE: **A signed copy of this proposal and deposit must be received for us to schedule this installation. (This proposal may be withdrawn by us if not accepted within 30 days.) Authorizedrilaim' Partner in Comfort =' Page 2 C ahan PROPOSAL A/C&HEATING SERVICES PROPOSAL#: 1.07466 91 Belmont Street North Andover,MA 01845 DATE: 6/19/2014 www.callahanac.com REP: KJM 978-689-9233 TO: JOB LOCATION: RICHARD WEBSTER 40 BALDWIN STREET NORTH ANDOVER,MA 01845 DESCRIPTION Total INSTALLATION OF A NEW DUCTLESS SPLIT HEAT PUMP SYSTEM CONSISTING OF THE FOLLOWING: (FOR ROOM OVER GARAGE) A_MITSUBISHI MODEL#MSZ-GE24NA 24,000 BTU EVAPORATOR COIL B_MITSUBISHI MODEL#MUZGE24NA 24,000 BTU OUTDOOR UNIT C_WALL MOUNTING BRACKETS FOR CONDENSER D_NECESSARY MOUNTING MATERIALS FOR EVAPORATOR E_ELECTRICAL CONNECTIONS NOT INCLUDED F ALL NECESSARY REFRIGERATION AND DRAIN PIPING PAYMENT SCHEDULE: 1/3 DEPOSIT UPON ACCEPTANCE OF ESTIMATE 7,200.00 _NEXT PAYMENT DUE UPON 1/2 COMPLETION 7,700.00 BALANCE DUE UPON COMPLETION 7,600.00 PAYMENT TERMS 1/2 deposit 1/2 completion Total $22,500.00 All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate. All covered by Workman's Compensation Insurance's. Equipment warranty by manufacturer. Contractors labor warranty for one year. AUTHORIZED SIGNATURE: DATE: CUSTOMER ACCEPTANCE: DATE: **A signed copy of this proposal and deposit must be received for us to schedule this installation. (This proposal may be withdrawn by us if not accepted within 30 days.) Authorized AD111aire Partner in Comfort Page 3