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Miscellaneous - 409 BLUE RIDGE ROAD 4/30/2018
BUILDING FILE r Date....... �............... 3r;`'``;;';�•�oo� TOWN OF NORTH ANDOVER n PERMIT FOR WIRING ,r w, w t sS,CHUS� This certifies that 4M. ......................................... ...........s ) .. .:...�!`�rV-e... has permission to pefform ....rY.� cad..fy-?.4 ..... . .:Q-�: . ....................... wiring in the building of.-.. .... xnln. t•.�..,/.�^^�. /�off............. . \ C j-.....`c..`-�:..:., orth Andover,Mass. at ...X1. ....1 ..�`a-..... .�..�,:... ... Fee....�+.�...............Lic.No. S�t� ...yM�...... EL CTRICAL INSPECTOR Check# �l0 2 Commonwealth of kamachuselb Official Use 0 ly c� c�aUepaatinent o�,}ire�eruice3 Permit No. I l BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked UY ev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC).527 CMR I2.00 (PLEASE PRINT INNIi OR TYPEALL INR'ORIVIATIOt9 ➢ate:__9(y�ao t y City or Town of eQ iy �d t v TO the Inspector of Wires: By this application the undersigned gives noticed his or her intention to perform the electrical work described below. Location(Street&Number) L/Q qv�(�10,6-,6-2o,to Owner or Tenant Sco tT i-- SA5-'k Telephone No.%/- 31,S-- a?b'oY Owner's Address _ S(A w� Is this permit in conjunction with a building permit? Yes � No ❑ (Check Appropriate Box) Purpose of Building 5 &/ C.,_ Utility Authorization No. Existing Service 0( Amps 12o I dY0 Volts Overhead Undgrd❑ No.of Meters IF New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: k,5 til Ne vJ W t A ktl l o✓li Tld�trS. Com lesion of the followin table may be waived bv theIn ector o Blues. No.of Recessed Luminaires Id No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire outlets No.of Hot Tubs Generators KVA No.of Luminaires o2; Swimming Pool Above ❑ In- o.o ergency igBring arnd. arnd. C] m Baste Units No.of Receptacle Outlets IS' No.of Oil Burners FIRE ALARMS INo.of Zones No.of Switches /VNo.of Gas Burners No.f etecti InitiatingDevices t4 No.of Ranges No.of Air Cond. Toni No.of Alerting Devices No.of Waste Disposers Beat Pum Number Tons No.of Self-Contained Totals: Detection/Alertina Devices a No.of Dishwashers Space/Area Heating KW Local❑ Municlpai ❑ Other Connection No.of Dryers Heating Appliances KWSeCNo of Devices or E Divalent No.of Water No.of o.Nof Heaters KW Si Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage BathtubsNo.of Motors 'Total IIP Telecommunications Wiringi OT No.of Devices or 1u uivalent I�IIER: �Rl.. K'� Attack additional detail if desiredor as required Inr the Inspector of illires. Estimated Value of Electrical Work: 0 0.00 (When required by municipal policy.) ;Mork to Start: 9! 5�_ plT/ 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:) 1 certify,under the attts andpenalties ofperjury,that die information on this application is true and completa FIRM NAME: t A11c 7J– 'Le–ClI'Z-t Vtc_AC LIC.NO. s- 71 9 Licensee: .v /1. vine Signature LIC.NO.: /S?!9 (If applicable,ens�,r- exgg((r�rpt"in the license number line.) Bus.Tel.No.: 770 Address: f'0 N�0>L 79 / /`1 i (, �•� M/� (�I �c, Alt.Tel.No.: (p3� *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety S License: Lic.No. �,LQ OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by Iaw. By my signature below,I hereby waive this requirement I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. I'ERIT.FEE. 8�.EX3 '� /� 3-i �� �:� �, / �C L .mss The Commonwealth of Massachusetts Print Form �=== Department of Industrial Accidents � � Office of Investigations I Congress Street,Suite 100 Boston DIA 02114-2017 F'` www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aualicant Information Please Print Legibly Name(Business/Organization/Individual): E7 GLS���1 C'fjL j� VJCG S_ 1ti/C . Address: J. 1-5D � /)c/ City/State/Zip: /''I/0016%off /N,-f 0/� hone#: 9`Y'� Are you an employer?Check the appropriate box: Type of project(required): 1.&am a employer with—� 4. ❑ I am a general contractor and I employees(fulland/or part-time).** have hired the sub-contractors 6. C]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9. []Building addition [No workers'comp.insurance comp.insurance.: required.] 5. corporation We are a co oration and its 10.2 Electrical repairs or additions ❑ 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions m self. o workers'comp. right of exemption per MGL 12.E]Roof repairs y t p c. 152, 10),,and we have no insurance required.} § ( � 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. 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-contractor;and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information- Insurance nformation. [ - L Insu ance Company Name: /7�1 /- �r� ��St/�G/JrE' �✓�y� Policy#or Self-ins.Lie.#: Qg�yC C� g�7� Expiration Date: Job Site Address: ,Y001 0 Vr 1el DV c-&� City/State/Zip:/t/d a i /�4 wyy Ac 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of. Investigations of the DIA for insurance coverage verification. I do hereby certify u der t p ' nd penalties of perjury that the information provided above is true and correct. Si ature: Q Date: 9 l`Il 0101 Phone#: Oficial use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: .f E,;t COMMONWEALTH OF MASSACHUSETTS • • • • • BOARD"+ E_:CTR I C I €.'SSUES THE;;FOLLOWI NG L::I'CE`NSE I REGISTERED MASTER; ELECTRICtI•AN: ` 'Zi ;KEVIN: R EMMETT W N Pa B;ax 794i<> M.I DDLETON M`A 01949_2794 57 9»A`<;;< 07/3:1;4 . ; 5077$ Date.`a.I.A.1 0�............. e' r 1 �+ r "ORT" ti TOWN OF NORTH ANDOVER 9 PERMIT FOR PLUMBING ss�CHU This certifies thatN..!.C!�.(1,Q,..So vv( 0 . . . . .......................................................................... has permission to perform..... � .Vie...!.:^ plumbing in the buildings of: ..h✓.no. .1 .......................................... at........i."I North Andover, Mass. Fee.'T�.............Lic. No. i` ?3`... ...Mo ............................................................... PLUMBING INSPECTOR Check# .. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE PERMIT# It)� JOBSITE ADDRESS V OWNER'S NAME JGo4 ,Ser^ POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:� REPLACEMENT:© PLANS SUBMITTED: YES[] NO[:] FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR 1 AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK _ TOILET URINAL WASHING MACHINE CONNECTION - WATER HEATER ALL TYPES WATER PIPING - OTHER 0-1-11----11- JI. 11 - INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICYE] 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 ONLY: OWNER ❑ AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application et d accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be' co Ii ce�Perfinent ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I Nicholas Sawas LICENSE# 15234 SIGNATURE MPO JP❑ CORPORATION❑#®PARTNERSHIP❑#®LLC❑#� COMPANY NAME I Nicholas Sawas Pig.&Htg. ADDRESS 115 Silvestri Circle#24 CITYFperry STATE F NHZIP 03038 TEL 978-804-3303 FAXI CELL 978-804-3303 EMAIL Isavvaspigagmail.com Q yThe Commonwealth of Massachusetts , - Departmant of Indi;sNg1 Accid&ts Office Of Investigations 600 Washington.,Street Boston,MA 02111 www.massgov/dia Workers'Compensation.Insurance Affidavit:Builders/Cony.actors/Elecfricians/Plumbers AppHcant Information Please Print Legibly Name(Busynessiorganizationllndividual):—LI I(/VIiU � )CLS Address: V� City/State/Zip: bf,, ' 63 03 K Phone#: Areu an employer?Check the appropriate box: Type of project(required): 1.["! I am.a employer with. .3 4• ❑ I am a general contractor and I 6, n New cOnstraction employees(fall and/or part-time).* have nod the sub-contractors 2.❑ 1 am a sole proprietor or partner listed on the attached sheet. 7• ❑Remodeling ship and'haveno 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 area corporation and its 10.[]Electrical repairs or additions required.] officers have exercised.their 3.[] I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself[No workers' comp, c. 152,§I(4),and wehave no 1.2.QRoofrepairs insurance required-] employees.[No workers' �ired.a 13.❑Other comp.insurance required.] XAny applicant that checks box#1 must also fill out the section below showingtheir workers'compensationpolicy information. i-Homeowners who submit this affidavit indicating they 2'ra doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that cheek 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 Bellow is the polley and job site information. Insurance Company Name:. L ►W` Tia Policy#or Self-ins.Lic.#: TwU 'lam�V 1 Expiration Date: Job Site Address:e-loo 2, , City/State/Zip:ALprAz LIIJ� Attach a copy oMe workers'compensa ion-polley declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one: imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day ag ` violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D f urance coverage verification. X do Hereby cert' the p ' s alties q fparjury that the information provided abbbov is true and correct. - ' afore: Date: 0 l� Si Phone#: official use only. Do not write in this area,to be completed by city or town official. City or Town: Pexmi-Mcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumibing 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 hi 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 Iegal 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 au LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for con&mation 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 he. 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. Iu 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 .(citor town)."A copy of the affidavit that has been officially stamp ed 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 CQWJ:aonwu'Dafth Orm-assarhimetfs Depatient ofTuduaX Accident Office of flaveStigations 6.00 WasW gtm Stone t Boston,MA 021 It `Fed,#617-7-2.7,4900 e R6 or 1-8177-MASS AFE Revised 5-26-05 Fax 0 617-727-7749 WWW-Mass,govldia i i I i i E i COMMONWEALTH OF MASSACHUSETTS; x P ® e o A ' BOARD OF PLUMBERS<AND. GASFIT:TERS ISSUES THE FOLLOWING. LICENSE LICENSED AS A MASTER PLUMBER i N I,CHO-AS P SAVVAS' AI !y HA MARY.J© LANE03 ;y 1 U { D ERR Y NH 03038 462;3 15234 05/01/1.6 2o6g63 w ............... L r►OR7/� TOWN OF NORTH ANDOVER o�: -�: '• °off PERMIT FOR WIRING 88�cHU This certifies that 4 .)4:P�!.^LMS .......................................................................................................... has permission to perform ..6 r' ��'✓`^�� .............................................. ..................................... wiring in the building ............................................................................................................... at ...U. �1....... L&Q........i2 k? -... �...:.... North Andover,Mass. Fee.... 1. .........Lic.No.� .1.1. ....... �t � ELECTRICAL&SPkC Qi� Check# 159 !000 07 000 S1vr'j Commonwea&of Vama4we& Official Qw Only L ` eUe�artmerzt oQ..tire,.,?eruicel Permit No. l Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. I/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MFC),527 CMR 12.00 (PLEASE PRINT INJ7VK OR TYPEALL INFORMATION Date: V6 o 1!z City or Town of•. AIORI-77 d'1 o e"-- 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) y0 9 1 UE 1 o&c 1`4/j 0 OwnerorTenant '�CL1Jf- 1- S0'R-t1-t-} 101MMo,41) TelephoneNo. 7Y/ -315-aY0Y Owner's Address Sgiw•e-- Is this permit in conjunction with a building permit`' Yes R No / ❑ (Check Appropriate Box) Purpose of Building /2,5(Zeit W- Utility Authorization No. Existing Service --9w Amps / / )4()Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Und rd g ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 7� Completion of the olloivin table may-be waived by the Inspector of Wires. No.of Recessed LuminairesNo.of Total No.of Ceil.-Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires 3 Swimming Pool Above ❑ In- ❑ o.o mergeacy Lighting �- arnd d Batte Units R No.of Receptacle Outlets o2 No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices CT No.of Ranges No.of Air Cond. TO�' No.of Alerting Devices No.of Waste Disposers Heat Pump Number I Tons KW No.of Self-Contained Totals:I I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:V No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: �-- Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring• No.of Devices or E uivalent OTHER: rioCl,Z / 'f�i NI/3'T — N Attach additional detail lfdesired,or as required by the Inspector of 137tres. Estimated Value of Electrical Work: v75�� U(, (When required by municipal policy.) Work to Start: 5191.201(l 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 9 BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete FIRM NAME: 6 w 7/ . . Licensee: Signature LIC.NO.: 15 7/ 4) (If applicable,eater " �pt"in t1geli license number line.) (� r Bus.Tel.No.: g'in - 79 a Address: tE/U 1L '12V r ct I��t fly( - �i t/g Alt.TeLNo.: P- -5�3l *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:$ r L V � 'J The Commonwealth of Massachusetts ®, Print Form Department of Industrial Accidents Office of Investigations s' 1 Congress Street,-Suite 100 Boston, MA 02114-2017 w cow. ma ss. ov/di! a Workers' Compensation Insurance Affidavit: Builders/Contractors/Elec ' trac><ans/Piumbers Applicant Information �' Please Print Legibly Name(Businesstorganization/individual): G rme-rF ,l t��'((',IL SC: ey i`,e f c, Address: PG 6, 09- 7qq City/State/Zip: c�c��� /� Phone#: ��'- �O�'I / L Are ou an employer?Check the appropriate box: lI am a employer with J 4. ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. []Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers9 ❑Building addition [No workers'comp.insurance comp•insurance.* required.] 5. ❑ We are a corporation and its 14,KElectrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their 11.❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13.❑Other comp.insurance required.] "Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. r 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that isproviding workers'compensation insurancefor my employees. Below is the policy and job site information. �j Insurance Company Named r'C' .L/1�(f/-Ct�ce Gn Policy#or Self-ins.Lic.#: �� � L"G !S7tjp Expiration Dater Job Site Address: -'7 Q / 6 N UC 16t� o — IC.Q,/] 7 � City/State/Zip:0-/Idtflf --lJ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby ce nder par d penalties of perjury that the information provided above is true and correct. ��Si ature: 5 6 Q - Date: Phone#: 7 2- 922,rJ 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#• Division of Professional Licensure: License Search Page 1 of 1 The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) 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 LICENSEE More... Name:KEVIN R. EMMETT REFERENCES& MIDDLETON,MA RELATED INFO Disclaimer Regarding **This Licensee has additional Licenses, click here to view them.** Website License Searches Glossary of License Status Codes Licensing Board: ELECTRICIANS MASTER ELECTRICIAN More... License Type: TYPE CLASS:A License Number: 15719 Status: CURRENT Expiration Date: 7/31/2016 Issue Date: 6/24/1996 Exam Date: 6/1/1996 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 server on Wednesday,May 07,2014 at 1:49:18 PM. ©2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg.state.ma.us/public/pubLicenseQ.asp?board_code=EL&type_class=_A&Iic... 5/7/2014 w 2 R aSCNU`'f4 CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 575 Date: December 16, 2010 THIS CERTIFIES THAT THE BUILDING LOCATED ON409409 Bluerid�e Road, North Andover, MARoad, North Andover, MA John Carroll MAY BE OCCUPIED AS a new new single-familyfamily IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: John Carroll Buil ing Inspector Fee: $100.00 Receipt: 21055 C NORTIy '� Town of �_ LA.== - © dover, Mass.,' O COC MICFIEWICK �11 7�S RATED �i BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING.INSPECTOR THIS CERTIFIES THAT........................................d.... .G ................................................................... has permission to erect. ......................... buildings on .....<:. �. ....I& 61 C....�"� �� � R,u tobe occupied as.............................................. e...................:I........:::........................................................................ provided that the person accepting this permit shall in eve respect conf rm to the terms of the application on file in P P P � 9 P every P � PP� ' al this office, and to the provisions of the Codes and By-Laws relating to th'e Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING SP�FeTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. ug,/`' PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTIONS ELECTRICAL INSPECTOR TS �-- :: ^fin-r .......... .�y................... Service BUILDING IN__'EGT�OR r 5-_ r C9 4�5, Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough �p Display in a Conspicuous Place on the Premises — Do Not Remove No LathingD Wall To Be Done � or � FIR EPARTMENT -� Until Inspected and Approved by the Building Inspector. B ner . Street No. d . ,= SEE REVERSE SIDE Smoke Det. 12-- 1_�� r� M NORTH 4 0� �4SP /,1ti 4F n DA�i/D APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION Building Permit# `0 S ADDRESS/LOCATION OF PROPERTY :—Z/0,7 &u 1z/1) Ma �� Parcel `� Lot Number SUBDIVISION ' DATE REQUESTED FILED/READY FOR INSPECTION /-/v/. /0 CLOSING DATE ON PROPERTY: FIVE(5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN-OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE- INSPECTION FEE OF TWENTY DOLLARS$20.00)WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. I G- I l llt 1^JJMGV t\�. V v/ 1 0A./ /l. iS'�/ .4R �'✓ S i ��� •rte" l�' Address �� S�� ,�-� a i 7 SIGNED ROU-TIN CONSERVATION PLANNING' DPW,WATER METER SEWER/WATER CONNECTION NOTE DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPW :b . o Signature Fite: Application for OC form revised Jan 2007 74VJ Date����c�` ...... TOWN OF NORTH ANDOVER p PERMIT FOR WIRING "'SA US This certifies that ..A;44.✓.9........ .di./�......... "-"— has permission to perform . u. p�. ..... u.�, .................................. wiring in the building of..J.o. ,�......r ,.�. 1. ... ........................ �.,. �.(........ ....y. .. ...... .t ...�Z, I.I ... z .(. ............ ... ,North Andover,Mass. . Feel`'��i..-""� Lic.No. ..���ur.y.3........... 2�TRI�;I .INSPECTO v Check # w mmonealth of Massachusetts Use Only Official ✓� Department of Fire Services Permit No. ��5� BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev, 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 WORK (PLEASE PRINTININK OR TYPE ALL INFORMATION) Date: Sly 10 Ci or Town of: NORTH ORTH / / ANDOVER To the —Inspector Ins ector B this a li o Wires Y p cation the undersi P f P geed gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) �/ -�8 41F t d Owner or Tenant JohnCA�r� �PA Ies Owner's Address 1501 MAA SA, . S,,, e 15 -rw s Telephone No. 97� g r y 51 Is this permit in conjunction with a buildin permit? Yes No (Check Appropriate Box) Purpose of Building �jcow ah154ri je,�h ❑ ❑ Utility Authorization No. Existing Service Amps / Volts Overhead New Service a� Amps a ❑ Undgrd❑ No.of Meters aYO Volts Overhead 0 Undgrd Number of Feeders and Ampacity ❑ No.of Meters Location and Nature of Proposed Electrical Work: r coin letion o the ollowin table may be waived by the Inspector of Wires, No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans 0.0 Total No.of Luminaire OutletsTransformers KVA No.of Hot Tubs GeneratorsKVA Abov No.of Luminaires Swimming pool e In- .o mergency Ig g d. � � otte Units --, No.of Receptacle Outlets No.of Oil Burners d. Ba FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and No.of Ranges Initiatin Devices g No.of Air Co d. o Tons No.of Alerting Devices No.of Waste Disposers Heat PSP umber Tons Self-Contained Deteetion/Alertin Devices No.of Dishwashers Space/Area Healing KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* o.of Water , o No.of of No.of Devices or E uivalent Heaters Data Wiring: Si s Ballasts . No.Hydromassage Bathtubs No.of Devices or E uivalent No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or E uivalent Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of le trical Work: 15�O Work to Start 5 /'/ 10 (When required by municipal policy.) Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE OVERAGE: 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.) P �'.) I certify,under the pains and pen ties ofI1 erjury,that the information on this application is true and complete. FIRM NAME: l��v,n orkCrEcrlC,ah / ,n Y LIC.NO.: Licensee: Signature (If applicable, enter "exe pt"in the 'cense umber li7 LIC.NO.: 3%5� 3 Address: --a—CA, rr�+t ,��T�, r /IjA 01E 7 6 Bus.Tel.No.:9_ ar-7 /ys 2 *Per M.G.L c 147,s.57-61,security work requires D „ „ Alt.Tel No.: 9�g hyo o�s,Z epartrnent 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. S �r��� ,��� s� The Commonwealth of Massachusetts Department of industrial Accidents Office ofinvestigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeQ><bIy Name(Business/Organization/Individual): Address: 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 employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑Remodeling 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 required.] officers have exercised their 10.El 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' comp.insurance required.] 13.❑Other *Any apiilY^-8'1t that Chi CF IYJy rl must»1S4t 1111 out the Sector b_l^v•shoti.i �. d ^e1 work'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. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date Phone#: Official use only. Do not write in this area, to be completed by city or town official 7 City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three 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 15.2,§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 .7�..N+ 4 at...a a ~ r a n9 license i als re t i be returned -the city or town�a<the applicator.nor the r rrut Qr li ens s being requested,nQ the Departmen 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 r 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 Fax#617-727-7749 Revised 5-26-05 www.mass-gov/dia Date. S�. �/. . . . .... .. RTIy NO Of .o I o� TOWN OF NORTH ANDOVER i io i PERMIT FOR GAS INSTALLATION n.•' qh SACHUSEt This certifies that . .1.7 r . . . . .1 ?` .� . . . . . . . . . . . . has permission for gas installation . . .,/1.T .(._ . .//G :'. . . . . . in the buildings of . J.r,.4 . . . . . . . . . . . . . . . . . . at . .y0 .c7. . .�1 T. . .r! .t.a.�.K. . . . . ., North Andover, Mass. _ , Fee�OG. . . Lic. No./1.3 i .5. . . . . .�.. ... � . . . . . . 4GA INSPECTOR Check# 3 C 72U `i R r MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS (Type or print) Date /� 0 NORTH ANDOVER,MAS77t4 SETTS f Building Locations / q � /� 0 Permit# /`4 y r `� ) s ount$ S 3 Owner's Name New Renovation ❑ Replacement Plans Submitted ❑ d x w a U O co x Q a ° C, z F w o w [w- z H x w a w w w x x w w a z G Q O z o° z o w aa > ° F o SUB -BASEM ENT BASEMENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR .8TH . •FLOOR (Print or type) -ff' Check one: Certifi e Installing Company Name t U // //1 r7 vow Address A D 4 N y ElFarmer. usme s e ep one Firm/Co. Name of Licensed Plumber or Gas Fitter Ci.v It. /,•, r —L� INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No[3 If you have checked yes,please in 'Pate the type coverage by checking the appropriate box. Liability insurance policy Other LLI type of indemnity Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent I hereby certify that all of the details and information I have submitted(o nter i above ap ion are true and accurate to the best of my knowledge and that all plumbing work and installati ns p rm der Perm' ed for this application will be in compliance with all pertinent provisions of the Massachus t as C e and Chap ?rof the General Laws. By; ature of Licensed Plumber Orr Gas Fitter Title Plumber 1 /v City/Town Gas Fitter1-icense.Number P3- Iaster APPROVED(OFFICE USE ONLY) Journeyman The Commonwealth of Massachusetts Department o f Industrial Accidents Office of.investigations UT 600 Washington Street Boston, MA 02111 www-mass govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers APPUcant Information Please Print Legibly Name(Business/Organization/Individual): •� (4 kt . Address: �-q A 0 (4 11 City/State/Zip: rt�vK �u /�'l 1 dG 4bone#: Are you an emplpyer?Check the appropriate box: 1. am a employer with�_ 4. ❑ I am a general contractor and I Type of project(required): employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. ' [No workers' comp. insurance 5. [1 We are a corporation and its 9. ❑Building addition 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' comp.insurance required.] 13.❑Other any applicant that checks box#1 must also :p out the section beinw shn.s z b their wows-compensation polis,infold tion T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp_policy information. Iam 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.#: (p 1V!" V 2 Expiration Date: Job Site Address: �'! (�t /�! City/State/Zip:'A g,(1/V V1,4, 't'f Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day againstthe viol . Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for incur a cov, a verification. I do hereby cerci n r ains an ties of perjury that the informa�Da provided abov is tr a and correct Signature te: 5 �d Phone#: Eonly. Do not write in this area, to be completed by city or town officiaL n: Permit/License# hority(circle one):Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone#: 1 Information an d 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 apartazents 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 notbecause 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 coxnpliance 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." r Applicants t 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 nuniber(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,ret rued to the city or town that the application for the perrmit 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 per mittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washmgton Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-8 77-MAS.SAFE Fax:# 617-72.7-7749 Revised 5-26-OS v r,-w,.mass.--ov/dia The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AM 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Le�ibl Name (Business/Organization/individual): :47 � Address: L e �!� 0 (,(,q City/State/Zip: �-tv� Phone#: A,ree,you an employer?Check the appropriate box- 1•LJ 1 am a employer with�_ 4. Type of project(required): ❑ I am a general contractor and I employees(full and/or part-time). have hired the sub-contractors 6' New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. []Demolition working for me in any capacity. workers' comp.insurance. . insurance 5. 9. Building addition [No workers' comp. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.7 Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.E]Roof repairs insurance required.] t employees. [No workers' comp.insurance required.] 13.0 Other *:MY=^.alicant t3st chF W box#1 must also{ill out the section below S __ ation- t T?omeovrners who submit this affidavit indicating they are doing all worksand then hireoutside contrac ors-oust 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'com enation ins information. urance or my employees. Below,is thepolicy and job site p f Insurance Company Name: �Jl✓'�[ 0 i_ Policy#or Self-ins.Lie.#: XV/e-1 C Zl l Expiration Date: Job Site Address: 0 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 violates Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for incur e'covera fication I do hereby c der the s and ties of perjury that the information provided e ' true and correct Sienature: Date: < Phone#: __�9 — �� Official use only. Do not write in this area, to be completed by city or town offrcW City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three 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 r 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 F4trned to the city or town that the app. icafion for the permit orlicense is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of lnvesfibafdons 600 Washington Street Boston,MA 02111 Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 vtT.mass.govldia f MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,GMASSAC SETTSf� Q Building Location 14 Ci I Lir {` I /� G� Date Permit 5-1- 101119 f Owner �r ce, � G Amount t 7`l,3 1 New Renovation [3 Replacement ❑ Plans Submitted Yes rl No FIXTURES Sr ELM f 2MROM 4 i 3M1QOCR aM>anaR 6M Hf= 7MIUM 9M ROM (Print or type) / Check one: ertificate Installing Company Name (moorpC y U Address Lq (6 4 kt,0 it ' //( Partner. Busin ss Telephone (� ® Firm/Co. Name of Licensed Plumber: X 64 H'i 'et, (Iii Insurance Coverage: Indicatethe typeof insurance coverage by cffecking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond Insurance Waiver: L 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 mfommtion I have submi d )in ve application are true and accurate to the best of my knowledge and that all plumbing work and' llati p un ermit Issued for this application will be in compliance with all pertinent provisions of the Massa a and Chapter 142 of the General Laws. By: Sipaure,ol LicensF37Tu—m"�— T 'Plumbing License Title ,/ City/Town APPROVED(OFFICE USE ONLY icense umoer Master Journeyman F1 �. a . .. ' t Date.J /.o /G "oaTM TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING . . s o� �• a ,SSACMUSE� This certifies that . . . .W.f. .`J. . . . . . . . . .�.�. . . . . . ... . . . . . . . . . . . . has permission to perform . . . . . . VF.'` . plumbing in the buildings of . .� �.�.�. . C ,lf+hops . . _ . . . , . _ . at . .y . .`. . . . ... .`. . . .�.��.5. . . . . . . . . . . N�rth Andover, Mass. Fee.77c 3. . .Lic. No. . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPEECTIOR Check # A5,9 , s` Building Commissioner Town of North Andover 1600 Osgood Street Bldg 20, Suite 2-36 North Andover, MA 01845 October 30, 2008 Re: 409 Blue Ridge Road, Map 65 Parcel 15-2 (formerly known as Lot 15-2 Salem St) Dear Commissioner, A single family building permit was issued to me for the above referenced lot on April 7, 2008, at a cost of$6,552. Owing to current market conditions the foundation has not yet been constructed. In short, I could not risk pouring a foundation only to find that a potential buyer wanted something else within the approved footprint. The abutting lot, 810 Salem Street has been constructed, as you know. It is my belief that "construction started"upon the demolition of the previous structure which included excavation, location and capping of utilities on site and the ensuing inspections. I am seeking your opinion regarding the same. If we concur, I would appreciate a letter from your office stating that my permit remains in full force and effect. If we are not in agreement, kindly consider this letter as a request for an extension of the permit for an additional 6 month period. As you know, a variance was granted for this lot for contiguous buildable area on December 18, 2007. 1 believe that the rights authorized by the variance have been exercised by the various aforementioned actions. I think it is important, however, to clarify these issues prior to any perception of expiration of rights. Please let me know your thoughts. Sincerely, John Carroll 1501 Main St, Suite 15 Tewksbury, MA 01876 978-851-4841 or fax 978-858-0213 / r d �� 00 NORTH Town of No. CN o dover, Mass., o� COCMICMEwICK �� ADRA7ED S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.................. �...�. ........ '.� . " Foundation has permission to erectr�/j buildings on .....17/d.��..../J.. U.F......�'�...�/�.E........ ............. Rough /fj1 � 7 Chimney to be occupied as........ ....... ...:....................., .............. ................................ ....................................................................... provided that the person accepting this permit shall in every respect cont rm to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to t e Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning-or Building Regulations Voids this Permit. Rough �u Z y Final PERMIT EXPIRES IN 6 MONTHS � ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STAP xTS Rough Service BUILDING IN R Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT until Inspected and Approved by the Building Inspector. Burner Street No. • SEE REVERSE SIDE Smoke Det.