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Miscellaneous - 425 JOHNSON STREET 4/30/2018
425 JOHNSON STREET 210/098.A-0022_0000.0 .-- `P�� ���� Y+ D� �/ - �` It.Y� VJ . ,� ��� ��- � �-zs �����.�� �211 � ��4x��i 1 � ��..�.�._ LAWRENCE H. OGDEN,P.E. 198 EAST MAIN STREET GEORGETOWN,MA 01833 978-352-8318 fax 978 352-2858 cell: 978-502-5921 April 29, 2016 Mr. John Lahood 425 Johnson Street North Andover,Ma. 01845 RE: Barn Structure 425 Johnson, Street North Andover,Ma. Dear Mr. Lahood As you requested I conducted a site visit 4/29/16 to review the installation of the Engineered Materials consisting of LVLs, beams utilized in the framing of the above project.. The Lvls are shown on plans prepared G.J. Bruno Associates dated 9/20/2010 with the framing plan sheet A2 certified by me 9/20/2010. I can certify that to the best of my knowledge the LVLs members and associated details utilized in the framing as shown on the drawings are installed properly and meet the loading conditions of the 7th Edition of the Massachusetts State Building Code for 1&2 Family Residences. This certification is based on what I could visibly see at the time of this visit when the framing was complete. The purpose of this site visit was to form an opinion and comfort level that the construction appears to be constructed in compliance with the drawings. This certification should not be construed as a thorough detailed inspection of the construction and framing. Please note at the time of this visit the house was framed,the roofing, siding, and garage door trim and ceiling dry-wall were in place,which limited the viewing of certain details. Nothing in this certification relieves the Licensed Construction Supervisor and or the permit holder of the responsibility for construction of this project per Section I I O.R5.2,and sub section I I O.R5.2.15 or of the Massachusetts Residential Code 780 CMR 51, or the proper execution of the details and framing requirements of the drawings, including but not limited to materials, blocking,manufacturers installation requirements and nailing schedules or other requirements of the code. Should you have any questions please do not hesitate to call. Yours truly, L wrence H. Ogden P.E. Structural 27765 Cc. Mr. Gerald Brown North Andover Building Commissioner F a sIST6�� ANAL E� ti95OU 7- 2 ;= �eD Date.................................. i NORTH °f•"`°:•'"° TOWN OF NORTH ANDOVER 3g �.,� .. _• of o ,Siam. p PERMIT FOR WIRING �,SSACIIus S �/ 0 rU � c This certifies that ..................................................�..... .T.......1.9.7 ........ has permission to perform .....-.-. u:r�"' ....... l. .. ........'S.....��l�E.�S ....................... wiring in the building of..................4. 4...1'qeP................................... ZS` ScrL S�— at..... .............�,}.�1.�............................................rOrth Andover,Mass. 5O o Fee.S. ......... ic.No � 6L ..................... .. ...... :........... ........ .... EL CTRICALINSPECTOR Check # �� LiV/I///IU//WCQILJI VI MC DPOWILIJCLL.7 --- - -- - ' Department of Fire Services Permit No. t Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To theIn pector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) yg,5— SC>t1�SC1� S% Owner or Tenant -'3rj',A iJ L�1�,y\%,-Oln Telephone No. 9 7S--3g 7 _`f 70 Owner's Address J 6 E C E L.r%.,3AJ 7.2 .-I* tJ Alt,300vftt Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building uX Utility Authorization No.-IT Q1/a 6°�02a Existing Service ,-- Amps Volts Overhead ❑ Undgrd❑ No.of Meters New Service '/-I:) Amps /,2Q/9`/C)Volts Overhead a Undgrd ❑ No.of Meters Nuinber of Feeders and Ampacity--%rr,1?,, —r�,C,pN,Fx Location and Nature of Proposed Electrical Work: -�7t.�p `S T Y Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- 1:1o.o Emergency Lighting rnd. rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Disposers Heat Pump Number Tons 1KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.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 Equivalent 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 1 BOND E] OTHER F1 (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: 2��J i",J CO. -, LIC.NO.: Licensee: q�LQ-M 7,,)c_,Pc Signature-::S:�/� LIC.NO.:ES/S'0 (If applicable, enter "exempt"in the license number line) Bus.Tel.No.•7714-0le-37�-� Address: ;77 f"`A OIbOQ•q_ 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)E]owner [] owner's Owner/Agent PERMIT FEE. $ Signature Telephone No. } r " The Commonwealth of Massachusetts Department of Industrial Accidents l Office of Investigations 600 Washington Street Boston,MA 02111 s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organization/Individual): N,3p ( $ s,;,y i%,,e L-\(z�c^ Address: -7$' City/State/Zip: z�c��� 2S-f cr, �_ Phone #: 7 2 LI- L,5G- 5707 Are you an employer?Check the appropriate box: Type of project(required): i.❑ I;lm a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction eloyees(full and/or part-time).* have hired the sub-contractors 2.ElI a sole proprietor or partner- listed on the attached sheet. ❑Remodeling e 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.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.F-1 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. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: T 3�r hof fl Q>"F'p Q 0 Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: L) City/State/Zip: k), F},LM7)y ul'3 Mr'T 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 pain alties of perjury that the information provided above is true and correct. Sign , �Z Date: '?bpi 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 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 9551 Date...............2:z:''J { NORTH 3�°,•,;�``°-:'�"° TOWN OF NORTH ANDOVER PERMIT FOR WIRING �. - SSACMus oYL5 � eZ�- �o y This certifies that .............8........ ...... .........7-0 ........... tqea has permission to perform 'V S wiring in the building of ,bD at..........y.2 ..Totiw 5.v�/ 5 i...... ,North Andover,Mass. Fee.. '. 7 2'....... Lic.No./ ............... .. .. . .. ELECTRICAL INSPECTOR Check # 370 0 01.5-31 r tim ,MgyDepartment of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 7 fay ) /6 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Ll g-5' �Cz t'sr yJ� S 1 Owner or Tenant Telephone No. Owner's Address It, Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building S V,,,)C„ �r�rv, Utility Authorization No. �f :— Existing Service Amps Volts Overhead ❑ Undgrd ❑ No.of Meters New Service 0�0 Amps /70/,oPyy Volts Overhead❑ Undgrd No.of Meters 1— N umber of Feeders and Ampacity 'x F a S I 2 A L Lo,,�ation and Nature of Proposed Electrical Work: y, , 4- N Ir J tin ft Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans t� No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. El In- El No' Units No.of Receptacle Outlets -70 No. of Oil Burners FIRE ALARMS No.of Zones No.of SwitchesNo.of Gas Burners No.of Detection and 3 Initiatin Devices 0 No.of Ranges No.of Air Cond. - Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW.......... No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances Kir Security Systems:* 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 Equivalent ` 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 5Q BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: 3O-i•SS CzQ £ `,F c.-ry \r-(,j-, Ccl . T,,j c LIC.NO.: ,9;.Q a 6 k Licensee: Signature „ 7� LIC.NO.: (If applicable,enter "exempt"in the license number line.) Bus Tel.No.- ZZ-7q-6 JG-37a� Address: 7r- L f>,iViE w nc?-c-f-% c► GVo00L— 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 Owner/Agent PERMIT FEE. $ 6 7z . Signature Telephone No. I 1 4 D" r COMMONWEALTH OF MASSACHUSETTS OF ELECTRICIANS AS A REG JOURNEYMAN ELECTRICIAN ISSUES THIS LICENSE TO BRETT M DUCA m 78 PROUTY LN WORCESTER MA 01602-2255 51507 E 07/31/10 380121 \ COMMONWEALTH OF MASSACHUSETTS SEREGITELECTRICIANS LECTRICIAN ISSUES THIS LICENSETO_ . - r ' BOYLST_ON ••ELECTRICAL COMPANY I .c' BRETT M DUCA =• 78 PROUTY. LN WORCESTER MA 01602-2255 ' 20266 A 07/31/10 313482 73 Date .?. U ........ MORT1y TOWN OF NORTH ANDOVER •� FO � P • PERMIT FOR GAS INSTALLATION • ,' a ISS CH SSCME < < t � This certifies that . . . . 5'. `: � � has permission for gas installation . !t `'` . . °.n.- . . . . . . . . . . . in the buildings of . .e/T!.�G' j at . . Y.t. ?.. . . . . . . . . . �. .. . Cf. . . . . North Andover, Mass. Fee A 0 Lic. No./ °` . . . . . . . . .� �� . . . . . . / GAS INSPECTOR Check# 9,91 -NLASSACITSEI'IS LMMRNi APPIKATON FOR PERMIT TO DO GAS FMING (Type or print) Date `l 2 © t NORTH ANDOV ER,NI4,9,S- ASSAf CCHUSETTS c � Building Locations 4,9,S- `SS^l o� N .56y� Permit# ^/3 r3 Amount$ Owner's Name New Renovation Replacement ❑ Plans Submitted O z z p FF J rA w W rn � d � °G a w � t7 Fd C Rz'. `' ��+ O z Oz rJ O J-4 O w 3 A v z y A a H c IL SUB -BASEM ENT BASEMENT 1ST. FLOOR 2ND . FLOOR 3RD. FLOOR 4T I3 . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type) � � { �� k \G, i C❑ ertificate Installing Company Name Corp.C L Lh h IV Address 1 'PIPER S� GQ(1\Q MASS Partner. oat(-:,9 Business Telephone a ` ! – 3 Firm/Co. Name of Licensed Plumber or Gas Fitter --T- JA©tM S V-�U 1q(t V— INSURANCE COVERAGE Check one: I have a current liability.Insurance policy or it's substantial equivalent. Yes 0 No If you have checked M,please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the :Mass. General Laws.and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent hereby certify that all of the details and information I have Submitted('or entered)in above application are true and accurate to the best of mN knowled e and that all plumbing work and installations pe1_f01TM:d under Perinit Issued for this application will be in compliance with all pertinent provisions of the),,Iassachu t ate Gas Code and Ch;I} er 14'? the General Laws. By: Signature of Licensed Plumber Or Gas Fitter Title Plumber / P City/Town Gas Fitter Lcenseum er Master APPROVED('OFFICE USE ONLY) M Journeyman Date.�J/i NORTH ti TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING r � r • o I SSACNus� This certifies that . . .. . . . . . . . . . . . .�. . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . . °... . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . at . . . . ? .). . . . . L !?.� 7 �./.R., . . . . . . . .,. ., North Andover, Mass. Fee a.?.? Lic. No. ,�c.SG/ . J�. �. r!). . . . . . . . /PLUMBING INSPECAR Check 01:. u ? TIIASSACRUSETTS UNUORM APPLICATION FOR PERMIT TO JDO PLUMBIl�IG (Type or print) Q G NORTH ANDOVER,MASSACHUSETTS pate v 1 2 �aS�p`1W SQ N �T Owners Name LL Q VA 0 0 Permit# " UZ Building Location _ Amount rf L Type of Occupancy ��S = New Renovation E Replacement Plans Submitted Yes No FIXTURES H o H U a A a 84SFIVI+NT L - M RJO(R f I •2ru�tocn I an MOM 4M M-CM 5MFLOCR 6MROR 7MRJOCR S'IS>IiOQt 1 Check one: Certificate (Print-or type) Installing Company Name V`����� '� k El corp.* Address (DUI k)CL( YO 45S, Partner. O Z 1 (o . Firm/Co- Business Telephone' U Name of.Licensed Plumber: —T �ACJY►N N'Sy 1 Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:Bond ❑ Liability insurance policy Other type of indemnity ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one ofthe above three insurance Signature 7 Owner Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are.true and accurate to the best of my Rowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Msetts State Plumbing C and C pter 142 of the General Laws. By: Signalure,5177censed Flumber Type of Plumbing License Title /00 7 /gMp ❑ Citynown icense Rum 5er Master Journeyman APPROVED(OFFICE USE ONLY ti a The Commonwealth of Massachusetts Department o f rndusftialAcddents ©f"ace Of.livestcgations 60.0 Washinbjon Street Boston, 3L4 02II1 MM Massgov/dia Workers' Compensation Insurance Affidavit: guflders/ContractorsXlectz-iciags/Plumbers An licant Information Please Print Lecgbly Name(Business/OrPnization/Individual): VL6i4�* >v Address: • • I o- City/tate/ZiP—lel V 1 �1 mass� Oa I�q Phone#: ® � [A-re you an employer?Check the appropriate box: [] I am a employer with 4. ❑ I am a a F project(required): ben.eral contractor and I employees(fiill and/or part timej. have hired the sub-contrantors Net consfauction I ama sole proprietor or partner- •listed on the attached sheet tmodeling ship and have no employees These subcontractors have working forme in any capacitSr, workers' comp,insurance. molition [No workers'comp. insurance 5. ❑ We are a corporation and its nldmg addition • - retluired] of have exercised their ectrical repairs or additions 3.❑.I am a homeowner doing all work right of ex emptron per MGL imbin r myself[No workers'comp, c. 152,§1(4),and we have nog epairc or additions insurance required.] t employees. [No R,orkers' of repairs comp,insTtrancp,required.] er `e 'a,P grant that-^htcks bo:u'm.,- ±s out Mc- t c secean imm. -. _ vrerkers come t: 'IIo-eowners Who submit'tFiis affidavit indica g l ,am d s r-r�_�Y��c�=°c.—.<r om fie} doing all and rhea hire outside contactors u4diq submit x new +Contractors that ch='„t`--bo*m,—,,t a acheii an additional Sbeet showine the am'davit incicating such. b name of the sub-contractors sad their workers'comp_policy information. lam an employer that is providing workers'compensation Of for my employees Beloit/is the policy and job site informataon, cc Tnsnrance Company Name: L V�V A-\ Policy#or Self-ins.Lir,.#: LOG a ?, ( 377(� o�(� 'Q 16 p Li `o�3 of CJI 1 E7: iration Date: Job Site Address: A. S TO t�SUS O► S-- y . City/State/Zip: N ` oU Attach a eopyof the workers'compensation policy declaration pane(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 ane up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of criminal penalties of a a STOP WORK OR of up to$250:00 a day against the violator. Be advised that a copy of this statement may be forwarded to the ORDERanda fine aa Investigations of the DIA for insurance coverage verification I do hereby cerci r the pains and penal 'es of erjuU that the information provideda ve rs#uf and correct Siaaaturc- Phone#: Fal only. Dv not write in this area, to be completed by city or town official n: 1 ermit/I-,icense# hority(circle one):Health 2.Building Deparbnent 3. CiWTown Clerk 4.Electrical Inspector 5.Plumbing Inspector son. Phone'#: 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,partnefship,•association,corporation or other'leeal entity, or any two or more of the foregoiag engaged in a joint enterprise,and including tiae legal representatives of a deceased employer, or the receiver or t ustee of an individual,partnership,association ox-other legal entity,employing employees. However the owner of a dwelling house having not more than tbree apartua ents and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,contraction or repair work on such dwelling house or on the grounds or budging 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 la-cal licensing'agency shaII withhold the issuance or renewal of a license or permit to operate a'business or to r`onstruct buildings in the comMmonwealth for any applicant who has not produced acceptable evidence of c0impliance 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 ira-�acceptable evidence of compliance with the incur-anre requirements of this chapter have been presented to the contca_eting authority." Applicants Please RE-out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if e necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of . incnrance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)-v#no employees other than the members or partners,.are not required to carry workers'comp ensalion;ncuran ce. 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 confirmaiion of insurance coverage. .Also be sure to sign and date the affidavit. The affidavit should b returned to the Ott Gr t.0—wm jitter'`'the l `r f the a - ��±?•�Q e� r� > e re uTieu ctiuttGau is tur p r�1lt Qr li %b ing. quess.:r;*not f._DepaIt'MM11:Or Industrial Accidents. Should you have any auesfions regardz^_.c the l l or if yon are��" s s aired to obtain a wor-l.ors 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. , o Cite or Town Officials Please be sure that the affidavit is complete and printed legibly. 'The Department has provideda.space at the bottom of the affidavit for you to fill out in the event the Office of Invesfigatonhas to contact you regarding the applicant Please be sure to fill in the pertnit/lice-we 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 cmrent 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 (Le.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations woWd like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a ca1L The Department's address,ielephone.and.iimnumber._.. The CGmmonwealh oflvlassachusettrs. DTartmmt of industrial Accidents Office of Inresti;,afions ' 6.0,0 WashiutQtn Street Boston,MA 02111 Tel. #617-7274900 ext 4=06 or 14 77-M.ALS.SAFE Revised 5-26-05 Fay:##6.17-727-7749 wVnI.mass._oov/dia OQ' 9 u 8 Date. -/, //./. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSACNUS� -• This certifies that . .7111we-r . . --eWeeJ41 ;X. . . . . . . . . . . . . . has permission to perform !. . . . . . . . . . . . . . plumbing in the buildings of . .70 h. f qq;a . . . . . . . . . . . . . . at _57 . . . . . . . .. North Andover, Mass. Fee.&.U. . . .Lic. No.. ./-/. . . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check # i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING . Cit Town: MA. Date: �-7PIans • mit# _ Building Location: %�S n&JiQ-7 CA Own Type of Occupancy: Commercial(] Educational[] Indusnal❑ Residential New: Alteration: ❑ Renovation:❑ Replacement: tted: Yes❑ No❑ •`5� ��' ` FIXTURES DEDICATED 2 SYSTEMS LLI H w Z y U Ln v� Gi O a z ,� z a En z a z m m v� cC O H p _1 ¢ LU ❑ Q Z � � � cr Y y C7 _j 4 X N vQiUj Q _ O w ❑ FO. ❑ ww ? W _z o LL Z f Q W U F.., = d 0 I U Q LL > d Y Q S W W R6 O W Q ¢ O O F O O O 2 cn 1 F. w ¢ m m ❑ ❑ x 4 g g W to Ln tQ- D 3 3 0 a LU a16 ¢ -SUB BSMT. Q BASEMENT ST IN FLOOR 2ND FLOOR 3RD FLOOR -; 4'FLOOR 5T"FLOOR k e FLOOR 7TH FLOOR 'FLOOR 1;1s1-:i,7ri��vt;�e.,;�r1•�emt:� (;F,��tt�!"t'��,�,'.' G�=-sw:iTiC?,i,�4.� Address: ❑Corporation ify/Town: ��i,' Stater Business Tel: �� El Partnership T-.---_���— C97�/� Fax: /�* ❑Firm/Company Name of Licensed Plumber: �/ ✓,�-� � d INSURANCE COVERAGE: I have a current Iiablik)nsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes No❑ If you have checked Yes,please indicate the-type of coverage by checking the appropriate box below. A liability insurance pol)cy_y� 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 app►ication waives this requirement. Check One Only >i nature of Owner or Owner's Agent Owner ❑ Agent ❑ 1 hereby ger:n that all of the details and information I have submitted(or entered)regarding Phis application are true and accur fo Knowledge and that a!!p!!�mbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision o the Massac usetts State Plumbing Code and Cha a•�tc the best of my p he General Law . i Type of License: :le umber Signa a Lt sed umber '!Mown aster �� PROVED(OFFICE USE ONLY) ❑Journeyman lCense Number: 5 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING Cit own: �C�O�h �dc i MA. Date: f3/S�-/f Permit# Building Location: �,s�c��J/� Owners Name:��`"CI( Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional❑ Residential New: Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES W W ui Lu � Z W Y N Q �. N H ca 2 O W 16- W L ) H 0 = co W 0 z Z p W W R O H M in W CO w m 0 Q a � 0 0 w X > Z H Lu — w ~ a w W W Z ag = CO W XZWWW Z W } Z O J F— F- O Z -U C7 LL FN- = W �— W w 0 o t=i 0 0 z 2 O a0 a W H > > > O SUB BSMT. BASEMENT I 1 FLOOR j I 2 Nu FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR Installing Company Name: v e, ,.4 d Check One Only Certificate# ❑Corporation Address:/ City/Town: , /,®,`-c L State: ❑Partnership Business Tel: Fax: �^ ❑Firm/Company Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes No❑ If you have checked Yes,please 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 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner 1:1 Agent ❑ By checking this box❑;I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plum Code and Cha r 142 of the General Laws., a of License: By Tylumber as Fitter Title S' ature Llcen ed Plumber/Gas Fitter aster City/Town 1,4ourneyman License Number: APPROVED OFFICE USE ONLY ❑LP Installer d, O The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MM 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Organization/Individual): GS / ,/� 1 Address: City/State/Zip: BGG Phone L. a n employer?Check the appropriate box: _ a employer with 4. ❑ I am a general contractor and I Typeof project(required):oyees(full and/or part-time).* have hired the sub-contractors6. >' ew construction sole proprietor or partner- listed on the attached sh%et. t ?• ❑Remodeling ;�'ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. [No workers' comp. 5. 9• ❑Building addition p ❑ 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.) 13.0 Other *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 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 ofcriminal fine up to$1,500.00 and/or one-year mprisonment,as well as civil penalties in the form of a STOP WORK ORDER t iand a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert nder the an nalties ofperjury that the information provided above is true and correct. N. Si nature: Bate: Phone#: Offtcial use only. Do not write in this area,to be completed by city or town official. City or Town: Per # 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 necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of lndustrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy;please call the Department at the number listed below. Self-insured companies should enter their ,self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111. Tel. # 617-727-4900 ext 406 or 1.-877-MASSA.FE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia ACOORV DATE(MWDDIYYYY) � CERTIFICATE OF LIABILITY INSURANCE 6/3/2011 PRODUCER (978) 667-9031 FAX: (978) 667-1018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MTMBrainerd Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR lA Andover Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Billerica MA 01821 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:Travelers Casualty Ins Co of 19046 JAMES 0'REILLY DBA 0'REILLY PLUMBING AND INSURER B:Hartford Fire Insurance 19682 HEATING INSURER C: 189 ANDOVER ROAD INSURER D: BILLERICA MA 01821 INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LIMBS LTR F A POLICY NUMBER DATE MM/DD DATE MIDDIYYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO X COMMERCIAL GENERAL LIABILITY_ -- PREMISES(EaENTED occurrence) $ 300,000 A CLAIMS MADE X OCCUR 16808243P259ACJll 1/31/2011 1/31/2012 MED EXP(Any one person) $ 5,000 X Blanket Addt Insd PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 X POLICY PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F_]CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION ORY LIMITS ER AND EMPLOYERS'LIABILITY ANY PROPRIETOWPARTNER/EXECUTIVE L E.L.EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? (Mandatory In NH) OBWECLI2452 11/24/2010 9/17/2011 E.L.DISEASE-EA EMPLOYEE $ 100,000 It es,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Plumbing and Heating Contractor CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WALL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE S Leavitt, CIC, LIA/S ACORD 25(2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200901) The ACORD name and logo are registered marks of ACORD SSACHUSETTS *VJ)7! - DRII� R� LICENSE f "' tMBE588368 �. E" y DOB T�Op' . . - `d'"'�. •"'t'1 ' 11-11=2613 11-11,-196V b 's `yo CLASS REST ACT 'OREILLY5-06 M JAMES J v MASS? 189 ANDOVER RD 'BILLERICA,MA a o IN PLUMBERS-AND GASFIATN R LICEN�R_A�E%8\q LIL'ENSE T0: I JAMES J OREILLY t 189 ANDOVER RD 1 BILLERICA MA 01821-1 46 j 7A971 i i ALTWOE MASSACHUSETT;; IN PLUMBERS AND GASFITTENSE ' LICE I uE�> A� �icE,Tkk _�LU JAMES J OREILLY 189 ANDOVER ROAD BILLERICA MA 01821 12585 t:In 7�97�i Date... ..... ........................ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION *w-4.- ,`QSgCHUs� This certifies that ...... .,,.:. 0..............L t has permission for gas installation ........ .�,.'e4Y64. ..................................... in the buildings of......................... _ .......... ................................... at.... •,�1{...............v �.V.)..... ...........I.. ,North Andover, Mass. Fee.:;�2:..w Lic. No. . .. L'. .. .��!'........................... 0 .r............ GASINSPECTOR, Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r CITY tiln.,1I _ MA DATE 4 !6' / ._ PERMIT# JOBSITE ADDRESS OWNER'S NAME GOWNER ADDRESS - TEL r� =FAX��� TYPE OR OCCUPANCY TYPE COMMERCIAL ( EDUCATIONAL 0 RESIDENTIAL 52/ PRINT CLEARLY NEW:F—j RENOVATION:Z' REPLACEMENT:® PLANS SUBMITTED: YES Q NO F APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE m1 - DIRECT VENT HEATER Ay Lm-- . - DRYER FIREPLACE FRYOLATOR FURNACE LJ GENERATOR GRILLE INFRARED HEATER [ -[` I- ..1 _ , ----- �__ _ _ - LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER knOF TOP UNIT U IT HEATER UNVENTED ROOM HEATERL j ( - WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES O/NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [RI'I OTHER TYPE INDEMNITY E] 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 Q AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compl• ith all Perti vision of the Massachusetts State Plumbing Code.and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME �� --� LICENSE# _ SIGNATURE MP[il �MGF JPL] JGF LPG( C RPORATION #=PARTNERSHIP0# LLC E1# COMPANY NAME: DRESS AD CITY STATE ZIP TEL FAX CELL EMAILIKA - 1 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR ONLY FINAL INSPECTION NOTES Yes No �`l' THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES .-'o 44 R •• The Commonwealth of Massachusetts r. F Department of Industrial Accidents QP X Congress Street,Suite 100 Boston,MA 02114-2017 dt www mass.gov/dia O1N S��v Workers,CompensationLisurance Affidavit:Builders/C ontractors/Electricians/1'lnm ers. TO BE FILED WITH THE PER2MT1T NG AUTHORITY- Please Print Le 'bl A licant Information Nance(Business/Oiganization/lndividual): ` Address: O t Phone 4: City/State/Zip: Are you an employer?Check the appropriate box: F8. n f project(required): em to ees full and/or part-time).* New'c6nstriict[on 1.E i am a employer with (• P y ( p ) 2.FJ I am a sole proprietor or partnership and have no employees Working forme in OR s any capacity. '' ca aci .[No workers'comp.insurance required-] 9, ❑Demolition 3.0 1 am a homeowner doing all work myself[No workers'comp.insurance required.]� 10❑Budding addition 4•❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole 12� P>uinbg repairs or additions ,,. proprietors with no employees. 5.❑I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13.,E]Rb6f reliairs These sub-contractors have employees and have workerscomp.insurance 14TJ Other 6.Q We are a corporation and its,officers,have exercised their right of exemption per MGL c. 152,§1(4),and we have rio empldydes-[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information Homeowners who submis Xmst attached aavit an additional g they are ahegshowing the name of the all-work and then hire sub-contrtside actors and state wrs must heth r or not those w affidavit entit}es bane h tContractors that checktlu P policy employees. If the sub-contractors have employees,they must provide their workers'com olic number. X am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. s Insurance Company Name: 9_0/3' Expiration Date:/ G Policy#or Self-ins.Lic.#: �t^4fXl/, _? fl J ,. 5 .. s'-) —City/State/Zip:�/ z2 J-- M Job Site Address: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). olation by a firlb up to 0-00 Failure to secure coverage as requited undaVlM enalties2in-the form ofS TOPal iWORK ORDER and a fine of up to $2050.00 a and/or one-year imprisonment,as well as p at may be forwarded to the Office of Investigations of the DIA for insurance day against the violator.A copy of flus stateme ;dreby overae verification. c i nder the a s a enalties of perjury that the information pro videdaZbove true nd correct. Date: 9 717 11-7 / Official use only. Do not write in this area,to be completed by city or town official. Permit/License City or Town: # Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#: Contact Person: P 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 We, 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 receiv&bt trustee ofan 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 ofthe 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(1)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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial-Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out,in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-AMSSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia 1 :� COMMONWEALTH OF MASSACHUSETTS s • • � • • m Ll BUARDraF PLUMBEf ANt) GASF ITTERS f ISSUES THE FOLLOWING LICENSE L f CEfVSED AS A :MASTER L"t1MBE --'•1.RA[1 .5 DOHERTY hh 38 S PdL.f C'Y ST tT.M. 1JH 03079 2928 �_ 1205/011:16 .. 212210 _ __� Date..7.-.2.z.-A ..................... OF V►ORTH TOWN OF NORTH ANDOVER ' PERMIT FOR WIRING CHUs� This certifies that t../A. U < C ............................... ...... .... ....... ..... ....�............................. has permission to perform ........ ..�..���........(?l..C ..4L%........................................... wiring in the building of...... 6 .Y)...... .�^.. .G.D. .................................................... at ... ..... n..�z.Q. s n.......... ..t ,North Andover,Mass. Fee.............................Lic.No ..........2.. ..........% ELECTRICAL INSPECTOR PEC Ot R ELECTRICAL INSPECTOR Check# Print Form Co�nmoruvealth o�/i'laeeachWe& Official Use Only Apartment of gire Serviceb Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: a 2-2— City City or Town of: Alpa7w Awa,-� 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) yl!5— d'0445-A ST Owner or Tenant :T tbtA L440M Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No Q (Check Appropriate Box ) Purpose of Building 6A&19- (,V96 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: (,J1QE R�zl � (✓I L�1-rif-1 L ACLyF ��► a�� Completion of the ollowin table maybe 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 �j Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting d. rnd. Battery Units No.of Receptacle Outlets 1 ,5' No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices Tot No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump umb...... r Tons KW No.of Self-Contained Totals: . .... .......... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal El other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Si s 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: (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,that the information on this ppl c i true and complete. FIRM NAME: DAVID ELECTRICAL CONTRACTING LLC LIC.NO.: Licensee: DAVID HAGGAR SignatureIWIJ,,"l CLIC.NO.:14963 (7f applicable,enter "exempt"in the license number line) Bus.Tel.No.;978-682-6262 Address: 87 BELMONT ST, NORTH ANDOVER, MA.01845 Alt.Tel.No.:978-375-5734 *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 a ent. Owner/Agent PERMIT Signature Telephone No. FEE. � --� �' f /-2-� JIy,�S ��� �o /�N� �i�h .� �� � �; The Commonwealth of Massachusetts Department of Industrial Accidents Office Investigations ff of 600 Washington Street kvi. e Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Dame(Business/Organization/Individual): DAVID ELECTRICAL CONTRACTING LLC Address: 87 BELMONT ST City/State/Zip: I NORTH ANDOVER,MA.01845 Phone#: `978-682-6262 Are you an employer?Check the appropriate box: Type of project(required): 1.9 1 am a employer with 4 4. 111 am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.Q 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. 9. Building addition [No workers'comp.insurance 5. We are a 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 I I.❑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' 13.0 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. 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: FEDERATED INSURANCE Policy#or Self-ins.Lic.#: 9353694 3/1/16 —� Expiration Date: Job Site Address: City/State/Zip: o 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 insuranceco gra7a veriatu1on. I do hereby certify under the pains p ury that the information provided above is true and correct -- Simature: '�- Date: L Z2 /L Phone#: 978 682-6262 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#• y� GOODFEiLAS rtr CONSTRUCTION 2Jhe ProfessionaCBuilding & Remodeling Experts Beverly Longveil Dorothy Giard August 13, 2010 926 Forest Street & 419 Johnson Street North Andover, MA 01845 Nor th ndover, MA 018455 69 Dear Dorothy, GoodFellas is aware that the side yard grass of your driveway was damaged during construction of a home being built by our company. It is the intention of GoodFellas Construction to repair the grass and apply grass seed to the repaired area._GoodFellas will help with the germination this fall of the grass to insure it grows back. GoodFellas will also ensure the grading of the soil be put in with a swell as the building inspector recommended. GoodFellas would like to apologize for any inconvenience you may have endured during this project. Should you have any questions please feel free to call me. Thank you 8 5/2 c),v Joseph Kupstas—President GoodFellas Construction 18 WAIT E STREET - WORCESTER., MA. 01604 PHONE: 508-363-1220 - FAX: 508-363-1444 BTWW.GOODFELLASLLC.COM Location t ' No. Date HORTiy TOWN OF NORTH ANDOVER Of ,.a° •1h O� +' •• OOH Certificate of Occupancy $ i � Building/Frame Permit Fee $ <� Foundation Permit Fee $ s�cMusE 1 Other Permit Fee $ SewerfConnection Fee $ �.rW.ater Connection Fee $ Building Inspector r Div. Public Works PER'lLIT NO. U S 7i "1 APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. C PAGE 1 MAP 4-40. LOT NO. 2 RECORD OF OWNERSHIP iDATE BOOK 'PAGE ZONE 7,Z3 SUB DIV. LOT NO. LOCATION �/�➢r^ v iJ�����,/i PURPOSE OF BUILDING �J� ��/%�' OWNER'S NAME! �1w, �z NO. OF STORIES .f/ SIZE OWNER'S ADDRESS BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAMEAJa� /'/J SPAN n � - C7 _ DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS LLL��L--- DISTANCE FROM STREET ' POSTS DISTANCE FROM LOT LINES-SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION t7- ,4e,,pe) tX IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST 310 0 Cq PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 - 12 SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED BOARD OF HEALTH SIGN ATU OF OWNER O&AUTHORIZED AGENT p 1-T F E E OWNER TEL.# pe PLANNING BOARD PERMIT GRANTED CONTR.TEL.# -f=(5v7z 19 CONTR.LIC.# tea BOARD OF SELECTMEN czy�.rc� BUILDING INSPECTOR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY S'-ORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY _ OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE _ _ d 1 2 13 CONCRETE BL K. PINE BRICK OR STONE -H RDW D PIERI PLASTER _ _ DRY WALL _ UNFIN. 3,1 BASEMENT il AREA FULL FIN. B'M'TAREA _ 1/1 1/2 1/1 FIN. ATTIC AREA _ N_O B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE ��_ WOOD SHINGLES EARTH ASPHALT SIDING HARDW D _ ASBESTOS SIDING _ COMMON — VERT. SIDING ASPH.TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STIRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I I POOR _ ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH (3 FIX.) _ GAMBREL MANSARD TOILET RM. )2 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO g FRAMING II 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. _ STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS GAS 7 NO. OF ROOMS OIL B'M'T 2nd _ ELECTRIC 1st ( 3rd NO HEATING l �� r NORTHo ---� �T Arn - do er T e OL ^•' An v ; aj; E-A., er, Dass., 1 ' SS BOARD OF HEALTH LD THIS-CERTIFIESTHAT(,�.�'.........� ......,,�.�w.�w.�i....�.�.�� ........... BUILDING INSPECTOR has permission to e .. . bui .. ldings on .. ...l... Rough � Lib Chimney to be occupied as.... .fi�s�.�.. �s...��.1�.�... ..�l�ii!'��............� 5 Final provided that the person accepting this permit shall in every respect conform to the terms of the application on file in PLUMBING INSPECTOR this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Rough Buildings in the Town of North Andover. Final VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST TION STARTS Rough service Final ............................................................. BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Final Display in a Conspicuous Place on the Premises - Do Not Remove Burner FIRE DEPT. No Lathing to Be Done Until Inspected and Approved by Smoke Det. Building Inspector F"0", OFFICES OF: or' .a '"rye°m Town of 120 Miliu SUCH APPEALS ;_ NORTH ANDOVER N`)''i' '`11SCt1�' '%''�:;;":�'�a0+ Mil.''>.SF)ChULJSCf1S O It34�i BUILDING CONSERVATION @s"QH sit I)IVISION OF ((i 1 7)(ifiS 4775 HEALTH PLANNING PLANNING & COMMUNITY DEVELOPMENT KAREN H.P. NELSON, 1)IREC'I'OR In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit Number (� ,� is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111, S 150A. The debris will be disposed of in: (Location of Facility) Signature of P ' mit Applicant ate NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector.