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Miscellaneous - 44 ROYAL CREST DRIVE 4/30/2018 (2)
�� 1 I G _._S i i r Date.v�� ..V:5.............. OF 40RT#1 3a;� °oma TOWN OF NORTH ANDOVER a PERMIT FOR WIRING IlThis certifies that�c�'�'� ld � ................................................................................................................. has permission to perform SG � .. Y..Vis.S . wiring in the building of.,]..�1.✓`�.�'P ....................................................................................... 44�- at .............. ..... ... .. .�........C�?� ...........,North Andover,Mass. ............. Fee...P ............Lic.No.,,?, . P........ ....! ./ ELECTRICAL INSPECTOR Check#aU�z 13 3 QA NIS" n�� 1 Official Use t�omn,ontueat v�//li+aeach�eae� hl Ilerinit Ni ��part►r,en#,v��iae.��are»c�e 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 pedbrmed in accordance with the Massachusetts I?icetrical C'odo(MEC),527 CMR 12.00 (PLPASL,PRINT IN INK OR T)'P ALL 11VTOR1b1AT1O.N) Date: �—9—1 ` City or Town of: NQ`M A_s�t�c��rC _ 7b Ilse lmspeclor of Willes: � By this application the undersigned gives notice of his or her intention to perform the electrical work described beloL� • Location(Street&Number), V,cG�t._ ��.� ' \W- t `�_.A swulo + -- Owneror'T'enant ky\-r-t) _ Telephone No. Owner's Address 50 � aIM LSC (Jr� _N �_ ►Qr NIA. _T j Is this permit to conjunction with a building permit? Yes No (Cheep Appropriate Moat) Purpose of Building ?Wt4 t:, UN I— _-- Utility Authorization No. _-- Existing Service Amps Voltq Overhead 0 lindgrd❑ No.of Meters New Service Amps / _Volts Overhead F� Undgrd 0 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: c�►ul� roa,e.e�R1x_ Rork. a Ta Q,t? .crZ Qty r�x^C Da r' .� e v�► '"°` -�'1�,� ►tw EL A C:'om�Ictkm r7'tire bIlawin table may be waived by the Ins VC10F Of MYes.U5Tet al No.of Recessed Luminaires No.of Ceil,Sus Paddle rains o Tat e p•(Paddle) Transformers ICVA No.of Lultltlliinaire Outlets No.of Hot'Tubs Generntors KVA L No.of Luminaires Swimming Pool Above ®, Tri�� o.of Emergency rg ,ng rnd. rrtcl. Ratter Unita No.of Receptacle Outlets No.of Oil Burners RIRE ALARMS No.of Zones ' n and No.of Switches No.ofGas Burners o.o Initiating Nf Devices No.of Ranges No.of Air Cond. : Tuns No.of Alerting Devices eat ump Number 'l'ons KW o.o'Se1k=C:onta,ne No.of Waste Disposers Totals: Detection/Alerting,Devices No.of i)ishwashers Space/Area Heating KW LOCAL� Unicipal `", Of7ter _ C 4gnection No.of Dryers Heating Appliahce9 KW Security Systems: No.of Devices or E uivnlent o.o Water No.of o.of Data Wiring: Heaters KW signs Ballasts No.of Devices or E uivnlent No.Hydromassage 13at:htubs No,of Motors 'Total HP c ecommil cfltions n.,n y No,of Devices or E uivaTent OTHER: Attach addilional tlranil it desireel,or as required 111;the inspector of Nib cs, Estimated Value of Electrical Work: i BOO (When required by municipal policy.) Work to Start: i; Inspections to be requested in accordance:with NIEC'Rulc 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for 0w 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 prooi'of sante to the permit issuing office. CHECK ONE: iNSURANCtr'' Ox BONDE] OTHER [] (Specify:) certify,under the paths and peva/lies of perjun?,that they itt ftlrmadmi on this application is trt,ey and complete FIRM NAME: Newpon Eloctric LIC.NO,, A20803 Licensee: David McMullen Signature IAC.NO.: mm (1lapplicable,enter "exempt"in the license number line.) - - Bus.Tel.No.:_4.0_t.-293.0527_ Address: 700.1-1ig point Ave. Portsmouth,,RI.02871_.__--_ _ Alt. rei.No.: 617-908-44193 *Per M.G.L.c. 147,s.57-61,security work requires Department of public Safbty"S"License: Lic,No. OWNER'S INSURANCE WAIVER: i stn aware that the Licensee doe's nvl have tilt;liability insurance coverage normally required.by law. By any signmurc below,I hereby waive this requirement, f ant the(check oncj[x]owner ❑owner's a ent, Owner/.Agent Signature Telephone )?mtT IEEE:$ �`�S Date../Ojr .�.r57.... 1142 �NOwrry� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING S`SACHu9(� /�1 tfvc This certifies that................................ .......... 6a .................................................... has permission to perform...--�...�ur.,. ^.... A........................................... =-,,,..,c plumbing m the ybuildings of................................�....�,�.................................................. . 1 C✓eti�t '�'' i`-��, North Andover, Mass. at.....................P.O.,.,.. .............................. . ��-- Fee.'.....................Lic. No. .....1.....{P �'J. . ................................................................................. Check# J-71 ellPLUMBING INSPECTOR 4 -b i S ' •�' \y� i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY N(-XNrN An6DATE PERMIT# I"I JOBSITE ADDRESS bf Uft1hLA9--Q3)WNERS NAPE GINNER ADDRESS: TEL: 7 } AX:TYPEOR 3 FRrN7 OCCUPANCY TYPE: COMMERCIAL EDUCATIONALr ❑ RESIDENTIAL❑ CLEARLY NEW:.[] RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO[� FIXUTRES 1 FLOORS E3smt1 2 3 4 8 6 7 8 9 i 12 13 14Q 1t BATHTUB l CROSS CONN DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS101IJSAND SYS DEDICATED GREASE SYSTEM I DEDICATED GRAY WATER-SYS DEDICATED WATER REUSE SYS DISHWASHER DRINKING FOUNTAIN FOOD WASTE GRINDER UNIT FLOOR 1 AREA DRAIN INTERCEPTOR INTERIOR K1TCH.EN SINK t ; LAVATORY SHOWER.STALL. SERVICE 1 MOP>SINK a TOILET 1 URINAL WASHING MACHINE CONNECTION (NATER HEATER ALL TYPES WATER PIPING INSURANCE COVERAGE I have a current liabiiit 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 co erage by checking the appropriate box below.. LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have:the Insurance coverage:required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. f # SIGNATURE OF OWNCHECK ONE ONLY: OWNER ❑ AGENT M ER OR AGENT t i I hereby certify that all`of the details and information i have submitted(or entered)regarding this application are true and accurate to be .of my Knowledge and that all plumbing work and installations performed.under the permit issued far this application be I omplarce th al .eminent provision of the Massachusetts State Plumbing Code and Chapter 142 of the Generai.Laaas. PLUMBER NAME: LICENSE# MGfo } SIGNATURE I COMPANY NAME` ADDRESS: CITY: STATE: ZIP: FAX: -, TEL. '" b' CELL: EMAIL: I F MASTER JOURNEYMAN❑ CORPORATION[# a PARTNERSHIP❑#U LLC❑# OVER 3 I The Comwntvea7th c f Havachuseas i Depura new ofAndtaftfidAccidents 4f.xe ofln-vesfigadons f 600 Washingoa Sired Not^MA 021,11 w.ft sgovl Workers'.Compewati€u I nsuruce davits.lgpie Contmton/FAec aauslf'lumbgrs Apel cant taforma€loa P Primt Let biv "N=e(BUsii l0W izationgndivift90: Mag-Oo tack Plumbilka, Tnc AddMS: 17 Bridge Stteet Zit /l iateaip: Bjaiarica , MA 0182.1 phone Are you an employer?Check the appropriate box. Type of projee€(recptirEd): 3 I.-I alit a.employer wah 4. [3 I am a general warmer and I empioyces(full an(tor part-time),' have hired the sub-oontractm New construction 10:I am a sole proprietor or partner- lusted on the attached sheaf. 7. a Remodeling ship and have no employeesThese sub-contractors have $. [Q Demolitionworking,for me in any capacity.employees.and:have workers' [No workers'comp:insurance comp,insurOnce 9. Building addition required.] 5.:0 We area corporation and its 10.0 Nerttical repairs or additions ofoers have exercised their I amahomw erdcin ,ail worm 11.0 Plumbingm�repairs or additions . . of e: tti ttan ., xny vroxkers'i amp: l7 per IVEC1L 12. . Roof rep ' insurance required.]# c.152,§1(4),and we have no $mployees.[No workers' 13.0 Other comp..inset uce required:) *Atsyatspwwwlhatahe�dssboxfliaustalsofitloutthesez�abelow*shnwbStheirwoiimecompem3rwupolicymon f Homos ado submiCtlsls affsdaviG iwfi=IWg they aodoing all wwk and that hire outside e�rm must submit anew afftdt bNow7mg.such. teftfteunshat.A6*".box=*k sttacheaam201tionatsheetshowingthenameo€thesub.Gor>iractorsandstarewhetheaaraotthoseesetiliahwe amplOyees: Cf sesubaas[cactots have a mptiryees,they nw prdvi8e t3ielr workae rDiuA Po y amber. _..:. lam ars sa eloper that isprvv uueg workerscoWensadon insuraance for lily employees Below is Ihepoftq tr=djob site informadan.. �Ittsurmtce Company Name- ,AmGuard Insurance Cotmpgn Policy#OrSelf-ins.Lie MAWC578693 lick#oh Bats`/011112015 Job Site Azlress: GifylStatelip: Attach:a copy iiithe workers'ccnapeusation pol£ey declaration poges:(showing the pulicyaumiber and espiratiowdate). ftilm to secure coverage as required under Section 25A of MGL c.152 cap:lead to the imposition of criminal penalties of a fine up to$1:500.00 andlor 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 fo vmted.to the Office of rnvesttgations of the DIA.for insurance coverage verification. r den hereby cmVy under arhe:Paans aml pmn es n.f perjuri'that McWormat e n pmyMed above Is true andwrMxt F Si natssre Date: Ph©ne '. 92-8-663-953.0 (Ijf rclef use onj54 Do not wAte in this area,to be comps ted h1'rite or town offidal City or Town: PermiAicense ff . Issuing Aiftority(drele one:): LBoard of Oftlith 3..Building Department 3.City/Town Clerk 4.Electrical Inspector S.>' "g Impodor 6.othet Go�ttaetl'ersQzt: rhtme#: • f ACQ OP ID;PP CERTIFICATE OF LIABILITY INSURANCE DATE(MM'°°"""'' 1011414 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR.NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE.AFFORDED.BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S);AUTHORIZED REPRESENTATIVE-OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the:certificate-holder is an ADDITIONAL INSURED,.the poliey(ies)must be endorsed. If SUBROGATION 1S WAIVED,subject to the terms and conditions of the Policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in.lisu of such endorsement(s), PRODUCERtiPhone:781-BW-8480 NST CT 3 DeSanctis insurance fs�ycy,Inc, NAMM 100 Unicorn Park Drive Fax 781-9.33-SUS FAX Wohum,.IWA 01801 EMAIL DRESS: PUOSDIFCmi MACCO-1 INsi1R MCoi ntacic PlPlumbing lnc. INSU s APFOR�ac covERAGE LWCo 17B'ritge Street Suite 203 INsu,�RA:Amelican Souitlern Home 41998 Billerica,MA 01821 INSURER S-.Plymouth Rock AssuranceGrau 1:4737 INSURERc-Am card Insurance Coria 42390, INSURERD.Nautilus Insurance Company 1.7370 INSURERS:MerchanteMUhnf insurance Co 23329 /NsuRa_KRF: COVERAGES CERTIFICATE NUMBER REVISION.NUMBER( THIS IS TO CERTIFY THAT THE POI IGIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY:PERIOD INDICATED.. NOTW THSTANDING.ANY REQUIREMENT,TERRA OR EONDMON OF ANY CONTRACT;OR OTHER DOCUMENT UURH-RESPECT TXT WHICH THIS CERTIFICATE MAY BE.ISSUED OR SUCH PERTAIN,THE INSURANCE AFFORDED:BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS; IXCLUSIONS ANOCONDiI IONS OF SUCH POLICIES LIMIT'S SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.. LTR rMOFINSURANCE - c. EFF POLICY"NUMBER yIMM3 GENERALW1BlLTfY EACHCCURREfdCE $ 1,0OQ,O A ? cf r 3cuti riEadLLu�lim .. A=L0001557 . �Ot71T14.. TOliil#s ,mens Ili, . . j 'CLAIM 4-x F.Occult. MED EXP(AM em person} 8 fill, X Blkt Gohfi* tuaf X XCfi Hazards PERSONAL&-ADV INJURY $ 1,000... . GHdERALAGGREGATE S 2,000j00 G ftAG6REGATE LIMITAPPLIES PER: PROD[lCTS-COMPlOPAGG .$ 2.000, POLICY X 'PRO- LOC $ AUTONOMLEUaslLriY umrT s 1,000,0 . BODILY INJURY(Per person! 5 ALL OWNED AUTOS B X iOcw uLEDAufos PRC00001003156 .1011IM4 1011111.5 BODILYMAW(Per aecidara).s X HiREoAUTos PROPERTYDAMAGE {Pmac�ena 5 X NOMOWNEb AUTOS g S X UMBRELLA LIAR IVI..I OCCUR EACH OCCURRENCE $ tirOOD, EEDUSSLWB CLMMS-MADE AGGREGATE. $ 6;000,0 D CtIP0001373 10M11'14 1.011t115 DEDUCTIBLE s X. RETENTION S 10,000 $ WORICERON WC3TATU 0TH-X. .AD EMPUUTY ; i YIN C ANY PROPRIETORfpARTNERIEXECt1TIVE� WC578693 1. 10/1/114 10MI115 Ef.EACHAcemeirT $ OFF9NMEMSEREXCLUDEDZ ON N/A (ftyeri8,dasyinNH) fMA,R1,NHS E.L.OISEASE.-EAEMPLO $ 1,000 1AM 'OpoPiRATION36elowPollution Lia , D E:L aLSEAs€-POLICY uMlr $ 1,000,00. PL201083300 01130/14 011301/5 Limits $1(y OCCUR I Mold Coverage S2M Agg DESOMP11011 OFOPERATIONS'I LOCATIONS I VEHICLES(AUfth ACORD 101,Additnal Remarks Schedule,If nwm some is requtred) j Evidence of Coverage CEpt-nFICATE HOLDER CANCELLATION EVIDE-1 SHOULD ANY OF THE A13OVE.DESCRIBED.POLICIES BE CANCELLED BEFORE EVIDENCE OF INSURANCE TiM EXPIRATION DATE THEREOF, NOTICE WILL BE DEUV£RED IN ACCORDANCE WITH THE POLICY PROVISIONS AUTHORiZED[<EPRESENTA t�1985-MO ArrORD CORPORATION.,AN rights reserved. ACORD 25{2009109y The ACORD name and logo are registered marks of ACORD ......... _....... x INIT is t4 r 1�' ' f A9 i}Y1� •. ���. •� s�• too (w1r�MMotNwo a r � Date... .�.....1............... of NowrM,h i TOWN OF NORTH ANDOVER PERMIT FOR WIRING Ss'�CHuS� This certifies �lCt ....1...................................'.!"7..............................................(.`...... has permission to performl�� '1,. .P.�, !� .Q. -..... .0. ............ .. /w� ng in the building�of..... 0.. :............................................................................. at .... .. .'......v.".. .......! ..............................:.....j,North Andover , ass. Fee,. ...'.......,Lic.No. I13� ... .�.............� ...� - r.: /I/�...�.... ELECTRICAL INSPECTOR .� Check#3 1 2 J (fIlmownwea&o f Ma4mclutielli Official Use Only a nepartawnt o�Ji �ervice3 Permit No. Jim 1 �� Occupancy and Fee Checked BOARD OF EIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be petilortned in kc0rdame with the Massachusetts Electrical Code(MEC'),X27 CMR 12.00 `(PLEASE PRPVT PV I.IVK OR,TYPE ALL 1VFORAIAT10,Y) Date: December 2, 2014 City or Town of: North Andover To the Inspector of Wires: By this application.tlie undersigned gives notice-of his or her intention toperform the electrical work described below. Location(Street&Number) ..50 Royal Crest.Drive Building # 44 Owner or Tenant Royal CrestApartments: Telephone No.978-6$1_1$22 Owner's Address 50 Royal Crest Drive North Andover, MA 01845 Is this permit in conjunction with a building permit? Yes ❑ No Q (Check Appropriate Box) Purpose ofBuilding Commercial -:Apartment Buildings 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: Heater Flue Had Problems and Electrical Inspector Disconnect Service Switch. Check and reconnect as needed. completi0q pf..the ollolvin table ma* he waived ky the Ins Ceclor of f-Ores. No:of Recessed Luminaires No.of Cel Susn,`(Paddle),Fans No.of Total Transformers KVA No.of Luminaire Outlets No.ofHot TubsGenerators KN'A Above In- o.o mergency Lighting No.of Luminaires• Sivitiitining Pool. rnd. ❑ rnd. ElBatter Units No.•ofReceptacle Outlets. No;of Oil Burners FIRE ALARMS No of Zones No.of Switches No.of Cas Burners. No.of Detection and Initiating Devices Total No.of Ranges No.of.Air Cond. Tons No:of Alerting Devices No.of Waste Disposers 1 eat PumNumber]'Tons o.of Se - ontarne Totals ... ....• Detection/Alerting Devices No,of Dishwashers Space/Area Heating KW Local F, unicipa Outer - Connection Security No.of Dryers Heating=Appliances KW 3 Systems:" No.of Devices or Equivalent No.,of Water KW No.of No.,o Data Wiring: Heaters. Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs Na.,of Motors 'Total UP a ecommunications. firing. No.of Devices or'E uivalent OTHER: :attach additional dctail if desired,"or as m4ui ed by=the Inspector Estimated Value of Electrical Work,,-.. (When required ny municipal policy.) Work to Start: 11/30/2014 Inspections to be requested in accordance with MEC Rule 10;and upon completion. RA INSUNCE COVERAGE: Unless xva ved by the opener,no permit for`the performance of electrical work may issue ut ess. the licensee provides proof of liability insurance including"completed operation"coverage or its,substantial equivalent. The undersigned certifies thatsuch coverage is in force,and has exhibited proof of same to the permit issuing office. C14ECK:ONE: INSURANCE, FX1 BONn ❑ OTHER ❑ (Specify:) I certifj Y,under the pains and penalties of perjurJ that the inform ation on this application is true and cotrrplete. FIRM NAME: The Electricians 8� Co.. Inc. _ LIC. NO.* A10737 Licensee: Michael J. Parzie le Signature LIC. NO.: E20269 (If apnlieuble,onlera'exempi"in the lieett n.iir))Nr line./ Bus.TeL No.: 781-322-9344 Address: 60 Branch`Street Malden, MA 02148 Alt.Tel.No. 781_kMion ''Per M.G.L.c. 147,s.57-6a,security,work requires Department of Public Safety"S Licenser Lic.;No. SS CO 001021 OWNER'S INSURANCE WAIVER: I am aware that the Licensee docs tot{.urge the liability insurance coverage normally required by law. .By my signature below,I hereby waive this requirement.-I am the,(check one)❑owner ❑ownur s a gent. OH per/Agen't r Signature Telephone No, PERMIT FEE. $ t The Commonwealth of Massachusetts " Department of Induvrial Accidents T4 W Office of Investigations 600 Washington Street Boston MA 02111 www.inass.gov/dia Workers' Compensation Insurance"Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information; Please Print Legibly Name(Business-0rgaiiimtlioi ihdi�idual):, The Electricians&c0., Inc. Address,: 50 Branch;Street City/State/Zip Malden, MA 02:148 Phone#: (781) 322-9344 Type of project(required): Are you an employer?Check the appropriate boa:: 6 New construction 1.7X ❑ emploj ees(fulfand lot"par trine):" ha e hiredethe subtcontract rs ❑ X ❑ b 2.❑Tana a sole proprietor or:partllet- listed on the attached sheet, 7. ❑,.Remodels»g ship"and have no employees These sub-contractors'have 8, ❑Demolition working.for me in, employees and have workers' 9a, ❑Building addition [No workers-cofnp.,instlrance requireil.] �5. ❑ We are a comp.insurauce.�" corporation and.its 10.❑X,Electrical repairsor additions officers have exercised their 3.EJ1 am a hoirteowner�doing all Work. l 1.❑Plumbing repairs or additions myself[No workers':comp. right of exemption per MGL 12:❑Roof repairs insurancerequired:] c. 152,�1O,and we have no employees. [No workers' 13.❑other comp.insurance required.] "Any appl ica itthat checks titiz,{?i mu5falso fill.out the sect pu behw showiiig tlieir.tt=r rkers'c�.)tlipehsation pplicy`inforinatioti, "Homeowners wbo submitAis affidavit indicating the}•are doing A%%ork and then hire outsi&contracays Must submit uew.aftldavit i0dieatin4 swell. 't omractu s that check this box must attached a additional sheet showing the name of the sub-contractors and:state whether car ftot those.cnuiics have: employees, lr the sub-contraetors have employees,they must provide their workers"comp.policy uumbcr:. f am an entploi er thiii is providing workers'eornpensution itisuriince for my employees. Below is thepohc ll and job site information `Insurance Company N me-. Hanover lnsurance'Company Policy 9or Self-ins. Lic.4: WHN 6055762 Expiration.nate: 09/0112014' I Job Site-Ad Tress: 50 Royal Crest Dr. Building #44 City/State/Zip: North Andover, MA 01843 Attacha 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 MC L c. 152 can lead to the imposition of criminal penalties of a fine up to$1.500.00 and/or one-year in prisoninent as.S,vell as civil penalties.in the form.of a STOP WORKORDER and a fine of up to'$250:00.0 day against the violator. Be advised that.a copy of taus statement mAy be forwarded to the Office of Investigations of the DiA for'insurance•coverage verification. I do hereby cerfift-under thepains rrtxl petirrlties o/-perjurs?Oat the in/ormatiort provider!above is,true and correct: Silanature: Date: December 3, 2014 Phone*: (781) 322-9344 Official use on1v. Do not ivrite in this area,to be'completed by city or town official.., i City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building.Department 3.Citv/Town Clerk 4.Electrical inspector 5.Plumbing Inspector 6.Other Contact Person: Phone 77 ®s..>OMMONWEALTH OF M ` H 5 BOAR tai EL>: Ik 161 1 ANS ISSUES TH.E..FOLLOWING 1ICEN5E�A5 A "J FREDMASTS# ELECTRICIAN THE : LECTR ICIANS AND COMPANY iNC�' _� ... ` MrCHAEL „� PAN !fALE 50 'BRAFtCIi'`Sl' W ; A !1lLOEN I`4A 02148-4304 r 1o73 .A 07/3.1/:>16 65846 . . COMMONWEALTH OF VjVilolo Imawale) Lou, BOARD'QF ftR ISSUES THE FOLLOWING LITENSE ' " A$<:A;. G JOURN, YMA-N: ELECTRI C lA MICHAEL J PARZI.ALE 107 LOCd§ STREET W DANVERS SIA 01923-22 ... `� 20269:E.. 07/31<%.16 . 64865 4 ACORQ, CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/DD/YYYY) 09/02/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Appleby & Wyman Insurance Agency Inc. PHONE Ext: 978.922.2288 ac No):978.922.2731 152 Conant St. E-MAIL ADDRESS: Beverly, MA 01915PRODUCER 00003385 CUSTOMER ID#: INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: Berkley Assurance Company 39462 The Electricians & Co., Inc. INSURER B: State Auto Ins. Companies 25135 50 Branch Street INSURERC: QBE Specialty Insurance Co. 11515 Malden, MA 02148 INSURER D: Hanover Insurance Company 22292 INSURER E: INSURERF: COVERAGES CERTIFICATE NUMBER: 14-15 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUB POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY GENERAL LIABILITY VUMC006825 09/01/2014 09/01/2015 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE (RENTED $ 100,000 PREMISESSEa occurrence s CLAIMS-MADE FX1 OCCUR MED EXP(Any one person) $ Excluded A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO- F—] LOC $ JECT AUTOMOBILE LIABILITY BAP2360955 09/01/2014 09/01/2015 COMBINED SINGLE LIMIT $ (Ea accident) 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ B X SCHEDULEDAUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON-OWNED AUTOS $ UMBRELLA LIAB X OCCUR MQSX0000514 09/01/2014 09/01/2015 EACH OCCURRENCE $ 5,000,000 C X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WHN6055762 09/01/2014 09/01/2015 X TORYLIMITS ER AND EMPLOYERS'LIABILITY Y/N ANY 0 OFFICER/MEM ER EXCLU ED?PROPRIETOR/PARTNER/EXECUTIVE r—] N/A E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yyes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION t SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of North Andover Attn: Wire Inspector AUTHORIZED REPRESENTATIVE ��YlanuntlC� 1600 Osgood Street No th Andover, MA 01845 Lisa Marciano/VAL ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD I Date.... ........... ................... fi V40RT#f OF TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING ... ...... ..... /...... P.e...HY This certifies that has permission to perform ................... ................... ................................................. wiring 'in t e building of.... ...... a vy�o 0 ............ .................................................................................... orthAndover,Mass. Vee....[..75.........Lic.No.: cry, ..... ELE ............ I AL N P C 0 Check# Commonwealth of Massachusetts offioial use only Department of Fl Permit No. Fire Services BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked _ [Rev. 11/99] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.0o (PLEASE PRINT ININK OR TYPI'AL4 INFO TION) Date: City or Town of: NOrNR ( �/�`(' TO the aZ By this application the undersigned gives notice o is or er intention to perform enelectrical work k described below, Location(Street& Number) Owner or Tenant A co Moil d Owner's Address A1111(1,4 LL C Telephone No, 97g &F5�, Za OC Is this permit in conjunction with a building permit? Yes Na°v� Q 1 C," �S :I I C Purpose of BuildingNo (Check Appropriate Box) �w�"�'� � Utility Authorization No. Existing Service Amps p rd Volts Overhead❑ Und$ Amps / ❑ No, of Meters _—Volts Overhead❑ Und rd Number of Feeders and Ampacity g ❑ No,of Meters Location and Nature of Proposed Electrical Work: %W t-.e r :�.es (INJA U e c,�re t�S�IU Ck S1111111111,1111Nrit letion a 'the oJJowin table ma be waived b the Ins ector o Wires. No.of Recessed Fixtures No,of Cell.-Suans sp.(Paddle)Fo.o No.of Lighting Outlets Transformers vVA No.of Hot'Pubs Generators KVA No,of Lighting Fixtures Swimming Pool rn'e ❑ 11'rin ❑ o'o niergency g ng No,of Receptacle Outlets Batts Units No.of Oil Burners No.of Switches FIRE ALARMS No.of Zones No.of Gas Burners o, o etee on,an No,of Ranges Initiatin Devices No.of Air Con d' otal No,of Alerting Devices ea um No.of Waste Disposers p um er ons KW— 11 ns Totals; ' Det ction/Alertin Devices No, of Dishwashers Space/Area Heating KW untc a No.of Dryers Heating Appliances ocal onneetion [I Other o,o ater KW ecur V ystems; Heaters KW . 01001 of Devices or E uivalent o,o Data Wiring: Signs Ballasts Total HP No. f Devices or E uivalent No,Hydromassage Bathtubs No.of Motors a ecommun cat on r ng: IM2r T OTHER; �j Glac�'�1t No.of Devices or E uivalent kmT\i all INSURANCE COVERAGE; Unless waived by the owner, no permit for the performance of electrical`�NeY M�SY4�Y Attach addlJlonot detail tfderired,or as regttired by the Inspector of Wires. the licensee provides proof of liability insurance including`bompleted 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 work may issue unless CHECK ONE; INSURANCE [ 13pNp (� OTHER p issuing office. ❑ (Specify:) Estimated Value of Blectrical Wor _ (When required by municipal policy.) (i xpirahon Date) Work to Start; � Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify, ander the pains and penalties o er ur that the Information on this application is true and complete, FIRM NAME: Ne,,a fP J Y, Licensee: LTC. NO.:�Q �j (Ifapplicable enter "exempt"in the lice se number line,) Signatur Address; D LIC.NO.: (,d lcll� Pnto�l pc�rP �ti'' Por �nnm��ti Q�. n,a4 `t i Bus.Tel.No. o, OWNER'S LNSURAN E W A Y.r..R i am aware that the l Alt.Tel, No, Al Y ra uirod b law. B icensee does not have the liabili r 3 9 Y y my signature below,I hereby waive this requirement, I am the(check one insurance coverage normally Owner/Agent owner Signature owners a ent. Telephone No. PERMXT FEE; $ 5 0 111e (.0111man")ealth of'Alassach►csetts �ar,"','�k"FAIT119,,W—1 01'Par tllent of Illd►istrial Accidents h a Of f rco of Investigations X Cbttgress Street,Sicite 100 ,Bostoi, MA 02114-2017 W1M-iftass govIdia Workers' Cor>tapcnsatzon Insurance Affidavit: Builders/Contractolrs/Electrl(!Ians/P)lumbcrs A, licant�>aiforrlaatxoia ).case Pell, In int Ec i,b)< Name(1Busirxess/Org��a1nisation/Individual): � �.� �►�. A,ddress:_CQpt r 1 Ir?f A City/State/zip: + ll Phone##: •., -� F2,[1 ou an employer?Check the appropariate box: 1.am a employer. wig, 4. I am a.general contractor and I Type of project(required): employees(fall and/or part-time).* have hired the sub-contractors 6. ,Ll New construction 1 a.m a'sole proprietor or partner, listed on the attached sheet, 7. ].Remodeling ship atld have no employees 'hese sub-contractors have working, for me in any capacity. employees and have workers' $' Demolition n3 [.No workers' comp, insurance comp, insurance.l 9• D] uilding addition Ione 3.❑ required.] 5, We are a.corporation and its 10 X electrical repairs or additions 1 am a homeowner doing ail work officers have exercised their myself, [No workers' comp. right of exemption per MQL 11.©Plumbing repairs or additions insurance required.]t c. 152, §1(4),and we have no 12'� Roof repairs ctnployees. (No workers' 13.11 Other ' comp, insurans~e required.] "Any applicant that ehacks box#fil must also fill ottt Ilya section below showing their workers'compensation policy information, 1 'Homeowners who submit this af[1davit indicating thoy are doing all work and then hire outside cobtractcsrs nasi submit a new affidavit indicating such, tContractors than check this box must attached an octditionai sheet showing the name of the sub-contractors and Stain whether or not those entities have ctnployccs, tithe sub-contrpctors have employees,tixey must provide their wnrkors'pomp,policy number, I arra ail employer that is prvpirling-workers'cnrrrpensatitlit insa!rra►rce fbr my employees. Below is the policy and job site information. Insurance Company Name: n^ Policy irk or Self--i;L,,_e_V4J . �( expiration Dale Job Site Address: � I"! City/State/lip: Veli Attach a cagy of the workers, compensation policy declaration page(showing the policy number and expiwatipn 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 atrd/or one-year imprisatxmen.t,as well as civil penalties in the form of a SCOP WORK ORDER and a.fine Of up to$250.00 a da.y against the violator, Be advised that a copy of tFais statement may be forwarded to the Office of Investigatiorts of the.DIA for insurance coverage verification, I do frereb certi 1,unda?r tlr am nd ejaaIties o 'ger itr,that the in ormativn Provided above is true and correct. Si nature: — — — — --— Date• .� p Phone OfIeial use only. Do not write in this area,to be completed by city or town official, City or Town: PCrmMt/Lig ense# Issuing Aut,horit:y(circle one): 1, Board of health 2,Building Department 3.City/Town Clerk 4,Electrical Inspector 5- PlumbinInspector 6. Other g Contact Person: Phone#: I I a;COMMONWEALTH OF M .SSAliUS :: IF )~�,ECTR P C i AN ISSUES THE , FO.LLOWING Iwi E!NSE, S FRED MASTER fiLEC,TA7CIAN NEF1PgRT,t ELECTR I C P()ORAT'»!!!ll g k DAV1 D `A MCKUL- EN :. l �i.4 1.OWEL� f r MA 01852 4026 2p803. h' . 071'3.1.f.1 I A 39 r`�O M�NWE�LTH`�J�M�i CHIS " . r £L£ TRICIAN S- -7 HE THE FOLLOWi1�iG LICENSE A £ JOURNEYMAFi ELECTRi C,IFA s MCMULLE N F ` l p��TSMOUTH �t 1, 0287;1 5802 ' .> NE /P013 OP ID: LS �..�---- CERTIFICATE OF LIABILITY INSURANCE DATE(MMI, THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON T 01/1 0/2014 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLI BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING CERTIFICATE AUTHORIZED R. THIS I REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. CIES ( ), AUTHORIZED IMPORTANT: If the certificate holder Is an ADDITIONAL IN8URED,the policy(les) must be endorsed. If SUBROGATION IS WAIVED,sub ect to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in Ileu of such endorsements, J PROOUCER 30 Dwyer Agenvy D.F. D_ er Insurance A enc 36 Bellevuei4venue P -•-- Dan el F RI 02840 401-846-9629 F 5,_,q 401.846.9629 nooREsa.dfd(Ddfdwyencom "� -- INSURE 6 AFFORDING COVERAGE — INSURED Newport Electric Construction .....- - INSURER A:Foremost NAig a Carp INSURER B:Scottsdale Insurance Com an - 200 High Point Ave,Suite 8641297 INSURER Beacon Mutual Insurance " ` -- 41297 Porl�mouth, RI 02871 _ INSURER 0: -._._....._....... .___,.. INSURER e: COVERAGES CERTIFICATE NUMBER: P THIS IS TDO CERTIFY THAT THE PbLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD REVISION NUMBER; INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYO ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, INSAEXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS: TYPE OF INSURANCE —� GENERAL LIABILITY POLICY NUMBER -- __ LIMITS A X COMMERCIAL GENERAL LIABILITY SCP006046448EACH OCCURRENCE $ 1,000,00 CLAIMS MADE XoccuR 12/30/2013 12/30/2014 ssccrzosal_.. $ _300,00 MED EXP An one arson $ 10,00 PERSONAL 8 ADV INJURY S 1,000,00 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY PRO- LE LIABILITY PRODUCTS-COMPIOP AGG S 2,000,00 LOC AUTOMOBI $ A ANY AUTO OMB NED SINGLE LIMIT SCP005046448 E 1,000,00 ALL NED X SCHEDULED 12/30/2013 12/30/2014 BODILY INJURY AUTOS Person) $ HIRED AUTOS X NON-OWNED BODILY INJURY(Per accident) $ AUTOS FIR RPERTY0 GE $ ---- -- UMBMLLA II X OCCUR $ B x EXOE88 LICLAIMS-MADE 8800196984 AGGREGATE EACH OCCURRENCE $ N 1213012013 121301201 0 b ETE I WO $ 6,000,00 RKERS COMPENSATION AND EMPLOYERS,LIABILITY 3 C ANY PROPRIETORIPARTNERIEXECUTIVE YIN WC STATU- 0TH• OFFICER/MEMBER EXCLUDED? ❑ N/A 68861 01118/2014 01N 8/2016 (Mandatory In NH) E.L.EACH ACCIDENT $ 600,00 DED yea describe under PTI NOF PERATIONS below E.L.DISEASE-EA EMPLOYEE 3 500,00 GSR A Empi Prac LJab SCP006046448 12/30/20 12/30/2014 E.L.DISEASE•POLICY LIMIT $ 600,00 13 60,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Awoh ACORD 101,AddMonal Remuks Schedule,If mor°apaoe Is required) CERTIFICATE OLDER CANCELLA ON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Insured's Copy THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE Daniel F. Dwyer III ACORD 26(2010/06) 0 1988-2010 The ACORD name and logo are registered marks of CORP ACORD CORPORATION.. All rights reserved. i 3 ✓ 6 f 9356 Date. .� Z .12,.. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING i ,SSACHUS� 4 This certifies that . . .. .� has permission to perform U-'&A �. .�P.o 47:. �No- v,—e. . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at. . .44- 90 . . . . . . . ., North Andover,, Mass. Fee.�. . . .Lic o,��� 48�ING INSPECTOR Check # � — �a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK. CITY el MA DATE Z - /Z- PERMIT#f JOBSITEADDRESS Y! C �.s ��l ( OWNER`S NAME] 6C yrs"C_ OWNER ADDRESS ] TEL IFAX] I TYPE OR OCCUPANCY TYPE COMMERCIAL j ( EDUCATIONAL RESIDENTIAL ICK PRINT CLEARLY NEW.( I RENOVATION:( , REPLACEMENT:(X! PLANS SUBMITTED: YES( l NORI FIXTURES-1 FLOOR BSM 1 2 3 4 5 6 7 ff 9 1 10 11 12 13 14 BATHTUB _. . CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER i 1 DRINKING FOUNTAIN FOOD DISPOSER FLOORIAREADRAIN INTERCEPTOR(INTERIOR) 4 KITCHEN SINK I LAVATORY I _ ROOF DRAIN SHOWER STALL 1 f SERVICE/MOP SINK TOILET URINAL - WASHING MACHINE CONNECTION e WATER HEATER ALL TYPES WATER PIPING - .OTHER ;; — I INSURANCE COVERAGE: I have a ctirrent liability iiisitralice policy.or its substantial equivalent which meets the requirements of MGL Ch.142. YES( NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY!A OTHER TYPE OF INDEMNITY I ( BOND(, OWNER'S INSURANCE:WAIVER:I am aware that the licensee.does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. - _ CHECK ONE ONLY: OWNER ( AGENT ( ) SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of lie details and information I have submitted or entered regarding,this application are true and accurate to th best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in coniplia ice e t provision of the Massadmusetts Slate Plumbing Code and Chapter 142 of Hie General Laws. PLUMBER'S NAME( �1 LICENSE#11ler l', SIGNATU MP( ( JP(k! CORPORATION{ lit! !PARTNERSHIP( lit! LLC) Jill COMPANY NAME Ste`,/L ie Ste` J ADDRESS J l4"�> -C i CITY ld'514 ArlwC� STATE 1 11 j.4 ¢ZIP 3 2 # TEL FAX ]CELL] I EMAIL . . . I .ROUGH PLUMBING NG IINSPECnONNO' E-9 ,BELOW FOL.©M- C)E USY ONLY FINAL INSPECTION NOTES Yes Ito THIS APPLICATIONN-SMYES AS THE PERMIT ❑. ❑ FEE::$ PERMIT 9 PLANT PVMW..NOTES � s The Commonwealth ofMassachusetts Department oflndustria[Accidents Office of Investigations, 600 Washington S'tr'eet Boston,MA 02-11.1 U. www.mas..gov/did Workers' Compensation insurance Affidavit:Builders/Contractors/EIectricians/PIumbers AM scant Information please Print Legibly Name(Business/Organization/tndividual): Address: /T2, e z1� 6�1 rS'i City/State/Zip: OqsvCQ, — 414 Phone#: Are you an employer?Check the appropriate box: 1.❑I am a employer with 4. Type of project(required): ❑I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner listed on the attached sheget.1 7. ❑Remodeling ship and have no employees These sub-contractors have 8. []Demolition working for mein any capacity. workers'comp,insurance. [No workers comp. 5. 9• E]Building addition ' p ❑ We are a corporation and its required.] officers have exercised their 10.0 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. - e.152, §1(4),and we have no insurance required.]i employees. 12•❑Roofrepairs [No workers' comp,insurance required] I3.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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 information. Below is the policy and job site Insurance Company Name: tr.tifi lC/�� DAA' IAB C/,J/J C"C? Policy#or Self-ins.Lie.#: -�E S- �' �Y 4-e,-/?z Expiration Date: =Z 2. Job Site Address:_ �.9/r¢G C/�1 i . City/State/Zip: ��•� ti f��I/ 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 G. 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 Izereby certify under tit ns and enalties o P P fperjury that the information provided above is true and correct. Signature: d . Date: :�"-Z Shone#: Offrcial use only. Do not write in tliis area,to be coinplefed by city or town official. ' City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk. 4.EIectricaI Inspector 5.Plumbing Inspector 6.Other ContactPerson: 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,orad.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 apartinents 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 ofsuch employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall wjthhold 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 insurancd 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 ofpublic 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 referencd 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 (cify 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 NOTrequired 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 Cotuniormc-a to of.tvfassachjjsetts Department of kdustrzal Accidents Ote of InveStigatlona 600 Washington Sfrcet Boston;.l A.02111 Tol.4 617.727•-4904 ext 406 or 1-877-MASS.FB Revised 5-26-05 Fax#617-727-7749 WWW..naass.g-ovMa