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Miscellaneous - 43 BRIGHTWOOD AVENUE 4/30/2018
/ 43 3RIGHTWOOD AVENUE 210/066.0-00240000.0 i C a �Notfh AndoverSts!f Ra- X l`'$inbox-mctrox�nardw X S6fy Dane-Google Drara X X{Tcnofk; th,Codovec X 011umbinghm:it:2105 x E. C A L.)https:i/northandoverma vtewpointcloud.com//recordst11096 9 ►/ Q ' 8 ' Q P,J Q t` j o Aper fij notthandoverma.gkw bookmarks ((j Suggested Sites -eagte•tnburm Naws t; P lViewP.int Penmttirg Time&date calendar NcriEem Essex Coun•. ....... Town of North Andover,MA Q Search_ Horne 21096 My Profile "Plumbing Permit-Replacement of Fixture/Appliance(Commercial or Residential) Records ( 71MFLINF (_S Przn Approvals s ® Submission received a? c •o' c� 1,j Payments Aug 12,2416 a:&:24am a '-n- :: c 2 ( Inspedions Plumbing Perrnit Review �f�r as In progress y AFIA—m ecnon © Permit Fee Joseph Ashford 43 SRIGHTw00D AVENUE,NORTH Analyticsp t E03-770-1908 ANDOVER,MA 9 map 0 jashfordGashfordpi..- e mer V Permit Issuartce TINIER-ERIN txw„m.. a Help Attachments :. —)UP tl Fte r _0TBTN9I00I Frl_Aug_12"016_12:29:.PDR 7.J ,waded AiiEu12,2016 by kl ry.c CF ... hips/trorthandwemzvirypointdaud.ccm/s'/remrd.122095 Xerox DonAbte 3175 US Lett-(DW—)(PDF) _ _ t -Node:VA&Alvhte G No .owkx -Pape:9.Svx tl.00' Scan -U*V aaity ina9e prokasiv Friday,Aug 12,2016 08:30 AM f:®North AndmrStaR Po x MTnbox-mchase@st;Z x 1&My 0rex-Ccmgle°Jrwe X Town of Nanh Andover, x- '�j'Gas Dermic d2109J-Vie x ---------------- ---------_._ ----------- _ ---------------- -. F C A [}haps://northandoverma.viewpointc loud.com/=/records/11097 Q u Apps Gl northand-erma.go bookmarls 0 suggested sites i eagle-tribune News t: p WmPointPe ming Time&date calendar U NcrtF—Essex Cour n; Town of North Andover,MA Q search... - i 21097 �-d:na prnjett 'Gas Permit-New Construction Commercial or Residential NOT In conjunction with Building t a I n Permit) ( J 8 ) 77MEL1Mf Submis loo received G o c5 Aug 12,2016 e:6:34am `% �• �� L Gas Permit Review $ K in Drog— Cir A�pticant lec'aauon �y Permit fee Joseph Ashford 43$RIGHTWOOD AVENUE,NORTH (,,,j PdY*'°c°'r <603-770.1908 ANDOVER,MA jashford&ashfordpi... _r 0 Permit.issuance TINER,ERIN 0 Attachments 3 t°Noa%.F„ l -OTYYUFI001P Eti_Aug_12 2016 12:34:.PDF _..___-._..-...-.. trpSonded Au_fs.1J,2^16 by Aiery'+0t.0 ©iii J Xe—Doa#1ete3125 E3 US letter(Duplex)(Pon -Made Bla&MVNte 0 200 dpi 0upkx -.,..... -Pape:a.50,x11,00- 5� -US9 Awty mage p—m V Friday,Aug 12,2016 08:35 AM I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY /fAvVecr / 1&V2,(' MA DATE //I// II PERMIT# JOBSITE ADDRESS OWNER'S NAME GOWNER ADDRESS ?'_ t�l/��d S I TEL "7 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PRINT � RESIDENTIAL CLEARLY NEW:01 RENOVATION:E] REPLACEMENT:® PLANS SUBMITTED: YES D NO Q APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE - GENERATOR ...>1 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER j ROOM/SPACE HEATER _ ROOF TOP UNIT �r TEST UNIT HEATER I T UNVENTED ROOM HEATER WATER HEATER OTHERr � - i _ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES J J NO 0 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF CERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i OTHER TYPE INDEMNITY BOND Ell 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 EI] AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information 1 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 awprti rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASATTER NAME LICENSE# .�7 ( SIGNATURE I MP© MGF El JP [�'JGF[ LPGI D CORPORATION©#[=PARTNERSHIP®#=LLC - COMPANY NAME: r DDRESS -6 ----�� CITY �Go�. _ _ _ STATELV ZIP[:& -!I ]TEL 3 7 FAXCELL (J ' AIL _ -- — — - i ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES n The Commonwealth of Massachusetts z F Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 �°t www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Ledb Name (Business/Organization/Individual): 06�4 X1 Address: C O I+fk4 V�C f L City/State/Zip: i� o' i� Phone#: 609 Are you an employer?Check the appropriate box: Type of project(required): 1.Q I am a employer with employees(full and/or part-time).* 7. ❑New construction 26al am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.Q I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition 0 4.F1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. 12.KPlumbing repairs or additions 5.F1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors hale employees and have workers'comp.insurance.# 13.0 Roof repairs 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no,employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they 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 is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: In-s wr'""—t-` �Cy� :r s��o..✓�� Policy#or Self-ins.Lie.#: 3f3'>3 Expiration Date:./ / lit- Job Site Address: r69k��_06Cl � City/State/Zip: ./V / rL . Attach a copy of the workers'co pensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi n t ains and penalties of perjury that the information provided 7ahoais t eandcorrect. Si nature: Date: � 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#: I Information and Instructions a M Massachusetts General Laws chapter 152 requires all employers to provide workers compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and-phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you'are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The 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-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK `d ' CITY '' �I MA DATE _! PERMIT# JOBSITE ADDRESS l.4T� OWNER'S NAME POWNER ADDRESS �' ! TEL �g-$��)� „FAX TYPE OR OCCUPAN TYPE COMMERCIAL EDUCATIONAL E171 RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:© REPLACEMENT: Q PLANS SUBMITTED: YES Q NOD FIXTURES 7 FLOOR--' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB i _ - ( _ _ E __I --f — --...i •� [ 1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM ! DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM i .__ ! ,._j DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN � FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) -_--.J!-1{f!e _.._-_-_...y...-._.-__.-.._..___.__.._.___ KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK F-71 TOILET URINAL .. . .D _ --) - ` WASHING MACHINE CONNECTION __ M__ -iIF!i WATER HEATER ALL TYPES __ -' i _r _ _ ( _.. .-__1 -._-` WATER PIPING OTHER i t r I t ! f � t _ INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES&NO Q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY i BOND D 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 F-1 AGENT 10 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia ce with all P rtinent provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME . LICENSE# `o3 . SIGNATURE (VIP oI J CORPORATION ..,# PARTNERSHIP -i# LLC COMPANY NAME S i 6— - f ADDRESS o _ CITY�J _C�.�--5 a n _ STATE f. _a ZIP Lp ZC f/ j TEL Jr C�L I ('� EMAIL i FAX _. ._...__...._..._-... ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES Y Tile Commonwealth of Massachusetts :. Department of IndustrialAccidents I Congress Street, Suite 100 _ Boston,MA.02114-2017 www.mass.gov/dia ASM S��V Workers,Compensation Insurance Affidavit:Builders/Contxactors/Electricians/Plum ers. TO BE IILED WITH THE PERMITTING AUTHORITY ..Please Print Legibly A �licaut Information tt k Lc Name(Business/OiganizationAndividual): L Address: '��`� L City/State/Zip: -� Phone#: � — . Type of project(xequixed); Are you an employer?Cbecic the appropriate box: em to ees fiill andlorpam-time). 7. E]Nb V�constr&tion l.❑I am a employer with P y 2.l. ip ain a sole proprietor or partnership and have no employees working forme in g. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3. I am a homeowner doing all workmysel£[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,[ PlulnbC., repairs or additions proprietors with no eiriployees. 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13; Roof repairs These sub-contractors have employees and have workers'comp.insurance$ 14.0 Other GL c. 6. We are a corporation and its.officers have exercised their right of exm ptiopar M No workers'comp.insurancerequired.] ave no em loyees.[ 152,§1(4),and we h ,- P *Any applicant that checks bbic#1 must also fill out the section below showing their workers'compensation policy information: i Homeowners who submit•this affidavit indicatingd they are sheet showing tall work he name of the sub-contractors and state wen hire outside contractors must hether or thoset a now.affidavit ent tieshave $Contractors that check this box must attached employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. orkers'coin enation insurance for my employees. .8elow is the policy and job site er that is providing-workersp I am an employ P information. l Insurance Company Name: Policy#or Self-ins.Lic.A- 30373 Expiration Date: lob Site Address: �13 ,r�,� ��1 City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). olation punishable bv a fiAb up to Failure to secure coverage as req0-00 uired under iMp nalties?m§he form of a25A is a aSSTOPnal iWORK ORDER and a fine of up to $250.00 a and/or one-year imprisonment, be forwarded to the Office of Investigations of the DIA.for insurance II day against the violator.A copy of this statement may coverage verification. I do hereby certify der thepains nd alties ofperjury that the information provided above is true and correct - I � L� Si ature: 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 Phone#• � Contact Person: j 'V 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'defuied as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enferprise,and including the legal representatives of a deceased employer,or the receiver'or trustee 6f 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 b6 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 xequiired." 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 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-insura'nc'e 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-NtASSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia Date ........... 10305 OF r►ORTI♦,�O TOWN OF NORTH ANDOVER ° PERMIT FOR PLUMBING .� ��,�'•-;,'•,: %.;-its � gs�cMuss Thiscertifies that................................... �. ...............(................... ................................ has permission to perform.............I....'^...'�'.— 2 ..,...:�?` plumbing in the buildings of...A P Gtr................................................... at... � . ......��........ North Andover, Mass. Fee.51"....Lic'No. 3 �.` ....... M� ".................................................................. PLUMBING INSPECTOR Check# 2crl MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK is CITY v.reJ dy� MA DATE II PERMIT#. JOBSITEADDRESS3 6� Woad WV 's OWNER'S NAME N Ad-e-(ALU— OWNER ADDRESS hn TEL= =HFAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL ® RESIDENTIAL.R' PRINT CLEARLY NEW: RENOVATION:W REPLACEMENT:Q PLANS SUBMITTED: YES E11 NO© FIXTURES Z 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/OIL/SAND SYSTEM I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM ( ., I _ — i __ { _,___� __ ( ___- [ I DEDICATED WATER RECYCLE SYSTEM DISHWASHER _j DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN I __.._._! � i ! 1 _ _.__.0 ___--( .. - ___._ .-_._i INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ,I 1 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL i I — _._--I ----1 --.___I _------( ___._ _.__ _-_.._J WASHING MACHINE CONNECTION t ____I _ !1====== __:__` .....__ —j __1 11i(ATER HEATER ALL TYPES J ! ___ ► i I I _ ( i WATER PIPING HER __I -—._! __----J _ l INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ---..; NO Q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW l LIABILITY INSURANCE POLICY Eir OTHER TYPE OF INDEMNITY 0 BOND Q 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 10 f SIGNATURE OF OWNER OR AGENT o 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all P ment provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. I r PLUMBER'S NAME LICENSE# \ 1 i I SIGNATURE (VIP 0 JP N' CORPORATION F#PARTNERSHIP 0#®LLC COMPANY NAME P\vvrtW —S 11ADDRESS a__C-rte`^'�Of S� *4 a CITY=0V.i2l _..__..._.__I STATE ZIP (��,��y � TEL -7 - a Q l-- (d `? FAX g CELL L-. EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No l THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: PERMIT# PLAN REVIEW NOTES t. .G The Commonwealth of Massachusetts Department of IndustrialAceldiks Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ) Please Print Legibly Name(Business/OrganizatiorAndividual): �`Q ��'� S Address: City/State/Zip: �0 ©I Wt Phone#: 7 1-1 — N 7 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. �• Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]f 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 a're doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby certtfy under the pains and penalties of perjury that the information provided above is true and correc4 Signature: L Date: Z/ ( I 2,&( 9 Phone#• <373- a6 Lt— l d "7 / Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: 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 employeils defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who.has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe 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(ifnecessary)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 Comm. ouwoalth of Mossacl?usetts Department of Industdal.Accidents Office ofInvestigations 600 Washington Stzeet Boston}MA,02111 `1'e1,#617-727_4900 ext 406 or 1-877:N1ASSA]FE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia COMMONWEALTH OF MASSACHUSETTS t %LUM:BERS AND GASFITTERS LICENSED AS A JOURNEYMAN PLUMBER � ISSUES THE ABOVE LICENSE TO; . I KEVIN .P ELLIS 92 CRAWFORD ST � I z LOWELL MA 01854-2712 31114 05/01/14 183584 ` . . Fold,Then Detach Along All Perforations �I `f I Date ...................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ..../....... ........................................... ......................................................... has permission to perform .... ...l.. ................. .e-&— 4.z .............................. ........... . ....... . . wiring in the building of............ ............................................................ at ................... .. ............... ......................................................................JbIprth Andover,Mass. (?Fe ... ..........Lic.No. ................. .......4..0 ��Ki=? 1&: .. .... Check# 12124 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Zi 2 Occupancy and Fee Checked ,M 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 ININK OR TYPE ALL INFORMATION) Date: Ll City or Town of. NORTH ANDOVER To the Inspector of>3�ires: By this application the undersigned gives notice of his or h ' tention tp perform the electrical work described below. Location(Street&Number) !�J W d 0* wn or Tenant SGL t> Telephone No. Owner's Address9 V Is this permit in conjunction with a building permit? Yes © No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: j3 Z "" - 1-a y & 4, / Completion of thefollowing table may be waived by the Inspector of Wires. No. of Recessed Luminaires / No.of Ceil:Susp.(Paddle)Fans No.of Total C Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires O� Swimming Pool Above ❑ In- ❑ o.o cy Lighting rnd. rnd. Battery Units Units No.of Receptacle Outlets3 No.of Oil Burners FIRE ALARMS No. of Zones No.of SwitchesNf GBurners No.of Detection and -� o.oas Total Initiating Device s No.ofRan es No.of Air Cond. Tons No.of Alerting Devices s Heat Pump Number Tons KW No.of Self-Contained No.of Waste Disposers Totals: '' .._..."""......"".""'.""'"'"'" Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection Heating Appliances Security Systems:* No.of Dryers g PP KW No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Ballasts Signs 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 regtdred by the Inspector of WYres. Estimated Value oflectric 1 Work: (When required by municipal policy.) Work to Start: ta6 /1 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERA E: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:) q� X certify,sander flte pains and penalties ofperjnry,that the information on this application is true and complete. �— FIRM NAME: . LIC.NO.: Licensee: Yt G d L Jrl"q, Signature LTC.NO.: rJ j 2d (If applicable,enter " empt"i the l�{'cense n er IineJ us.Tel.No.�%`6' Address: �, (�. ; (�. � '1 �''�� �1 Alt.Tel.No.: *Per M.G:c 147,s.5V-6 1,security work requires Department of Public Safety"S"License: Lic.No. /L_— 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 PERMIT FEE.$ �j Signature Telephone No. - �L 1�".i t)��e Lwa 1, %E ew.6,ra p.,,,�.1/11t/� , I 1 ��A...�,Q__ - �-s✓� c*— 1(�,�I�,Q A"/ W ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the r permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed ' on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166, §32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass F?1 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Com e Inspectors Signature: - Date: FINAL INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Commen Eors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com 1 The Commonwealth of Massachusetts Department of IndustrialAccWnts Office of Investigations 600 Washington Street Boston,MA. 02111 UIP www.massgov/dia Workers' Compensation]insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information lease Print Lepdbly Name(Business/Organza'on/Individual): Address: �� Dr—, ' Alp o �� City/State/Zip: 0 C Phone If: !Ff (363 . 4 ' Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.® I am a sole proprietor or partner- listed on the attached sheet. F1 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.E1 Electrical repairs or additions 1 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.❑Roofrepairs insurance required.]t employees.[No workers' 13.[i Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they hire 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. lam an employer that is providing!yrs'compensation insurance for my employees. Below is the olicy andjoh site Insurance Company Name% l/ 6A_ Policy#or Self-ins.Lic.M Expiration Date,: Job Site Address: R 006R/ �� City/State/Zip:X Q d(3/'2/,C)� ..S Attach a copy of the workerscompensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a me up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby cert uncle the pai and pe hies o perjury that the information provided abo a zs true a d correct. Signature: Date: / a 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#: e Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or.written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe 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(ifnecessary)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 ConuMORWalth.ofMassachusetts Department of Zndustriat Accidents Office ofIuvestigatzons GOR Washington Street Boston.,MA 02111 `del,#617-727-4900 ext 406 or 1-877�MASSAFE Revised 5-26-05 Fax#617-727-7749 www-mass,govldia Date../!.. .................. t CF NOwTM,h TOWN OF NORTH ANDOVER 9 PERMIT FOR WIRING * wwi � +► 88,�C�SE Thiscertifies that ..................................................................... ...:...:........................................... has permission to perforffiT........... .... ` .................. ...... / � ........................... .. wiring in the building of.....,/... '. �^ 6''u-" ............ .................................................... at .... ....! !. �� �? •........... ..N rm Andover,M s. / °� 70 Fee../ ..... .......Lic.No. �"... ...... . ............... ....... F E MMUCAL INSPECTOR • Check# � d , J- �I3��ZCA� Ite.s-5e_ V 1 � Commonwealth of Massachusetts Offi�cialUseOnly ' Permit No. Department of Fire Services - Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07j (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 MINK OR TYPE ALL INFORMATION) Date: /// Y // y City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to pe rfo the electrical work described below. Location(Street&Number) q3 r"I he or Tenant /� jp- l.� Telephone No. Owner's Address d� Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building - Utility Authorization No. 0&1 - Existing Service Amps /o-ZO/oWOVolts Overhead® Undgrd❑ No.of Meters New Service Amps oZyDVolts Overhead Q Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Xec rical Work: �vt CJZ__ -}-- S C t� Completion the following table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA i No.of Luminaire Outlets No.of Hot Tubs Generators KVA { No.of Luminaires �, Swimming Pool Above ❑ In- ❑ o.o mergency Lig ting ,� rnd. rnd. Battery Units No,of Receptacle Outlets 3 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. Tons TotNo.of Alerting Devices -� No.of Waste Dis osers Heat Pump Number Tons ' J.KW No.of Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers Space/Area HeatingKW Local❑ Municipal ❑ Other Connection uriNo.of Dryers Heating Appliances KW Sec No o Systems:* e 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: 1 Attach additional detail if desired,or as required by the Inspector of 97res. Estimated Value of lec 'cal Work: (When required by municipal policy.) Work to Start: ///0// 4/ Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE OVE GE: 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 ofme to the permit issuing office. CHECK ONE: INSURANCE RBOND ❑ OTHER [:1 (Specify:) sm CAQ � I cert,under the pains and penalties of perjury,that the information on this application is true anti complete. FIRM NAME: LIC.NO.: Licensee: ©vrl Signature LTC.NO.: (If applicable,enter "exem t"in the license numb ling) us.Tel.No.: 1 Address: S �t' 1 t/ 4 ��'" G Ol Alt.Tel.No.: *Per M.G.L c. 147, .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 PERMIT FEE.$ Vig ture Telephone No. 4 •❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of ongoing construction activity,and may bedeemedby the Inspector-of Wires abandoned-and invalid if he..- or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: t Inspectors Signature: Date: •"'� PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed M Re-Inspection Required($.)❑ Inspectors Comments: G r Inspectors Signature: U V Date: DEB WEINHOLD ...TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidiiks Office of Investigations 600 Washington Street Boston,MA. 02111 Uf www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information lease Print Le ibl Name(Business/Organization/Individual): t CXC, Address: �� o i �4r City/State/Zip: AX_ Z'5 Phone#: 6�7 1 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.01 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions F 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.] r *Any applicant that checks box ft 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 cheekthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that isproviding ers'compensation insurance for my e ployees. Below ' the policy and job site information. / �C % Insurance Company Name:. o V�- (((( �- -- S Policy#or Self-ins.Lic.#: Expiration Date: d l y i Job Site Address: / �v 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 certger the pams and penalties of perjury that the information provided above is t71a nd correct. - Si afore: Date: �. Phone#: !,�N z 1�a 3 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,- express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe 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 N Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number.'In addition an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The CommonwealthofmossachusPtts Department of Industrial Accidents Office.of Investigatitons 600 Washington Street Boston,MA 02111 TO,#617-727-4900 ext 406 or 1-877rMASS.AB& Revised 5-26-OS Fax#617-727;7749 wwwanass,goVI(Ma