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Home My WebLink AboutMiscellaneous - 440 MAIN STREET 4/30/2018 __ �. _ 440 MAIN STREET - -- -- -- ---�._� _._._ 2101050000.0 -- �---- 1 Date. .?%G.S. . . i` �'.".��': �Mo. TOWN OF NORTH ANDOVER PERMIT.FOR PLUMBING 407 This certifies that . . . . . . . . . . . . . . . . . . .y. . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . . .' ... . . . . . . . . . . . . . . . . . . ... . . . . . plumbing in the buildings of . . . . . ..f.`.�. . . . .�` .). . . . . . . . . . . . . . . . . . at . `�`��! . 12.114 1`. . . . ...tom. . . . . . . . . . . . , North Andover, Mass. �� o.. IU � �i Fee. . . . . . .Lic. N . . . . . . . . . . PLUMBING INSPECTOR Check 8190 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK •J CITY/.Y MA. DATE: 7l D PERMIT# JOBSITE ADDRESd D (.�+ (� TC�7 �'1 /' � / OWNER'S NAME: T�I GOWNER ADDRESS?�p / it ik? TEL: FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL d EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:[ RENOVATION:❑ REPLACEMENT:ElPLANS SUBMITTED: YES ElNOCK APPLIANCES? FLOOR Bsmt 1 2 31 1 4 5 1 6 7 8 9 10 11 12 13 14, BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER j ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [YeN0 ❑ A If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY [r 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 p rmit application waives this requirement _ 1 CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT } hereby certify that all of the details and information I have submid(o[entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed[ender the permit issued for this application will be in compliance all Pertinent provision of the Massachusetts State Plumbing Code and Chapter tothe General Laws. ,rtePLUMBERIGASFITTER NAME: O�f � CENSE# !3559 r -IGNATLIRE COMPANY NAME:_ acA N, e I ADDRESS:—7. S r CITY: a e STATE A zip:- FAX: �r�g 97 Zir � TEL: CELL: 3tS' Z1 S I3 EMAIL: I � MASTER[JOURNEYMAN❑ LP INSTALLER❑ CORPORATION PARTNERSHIP❑# LLC[]# Date...... tAORT#f 0.*""* ,:-. TOWN OF NORTH ANDOVER PERMIT FOR WIRING HU This certifies that ................... ........P,& C5,goA�� ................................................................... has permission to perform ........ka.r— ............................................................. wiring in the building of...................... ......................................!..................... at Y.v .........�.) ...........I North Andover,Mass. Lic.No. • ELECMCAL INSPEM� Check 4t 11733 -C�N Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 1 l R Occupancy and Fee Checked r BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 7-1,1 - 13 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant / gWGW Telephone No. 1,8 77:5 0,363 Owner's Address -1w Is this permit in conjunction with a building permit? Yes Fr' No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service_?O/-) Amps J,7d /,24'D Volts Overhead �r Undgrd❑ No.of Meters t New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �/ � �✓� 7/�y,4 r Completion of the ollowin ta6/e may be waived by the Inspector of Wires. No.of Recessed Luminaires ( No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires 3 Swimming Pool Above ❑ In- ❑ o.of Emergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total Tons g No.of Alerting Devices No.of Waste Disposers Heat Pump J.KWNo.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water Kms, 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 /t OTHER: ( Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: C�2� (When required by municipal policy.) Work to Start: ? — /7 — / 3 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and enalties of perjury,that the information on this application is true and complete. FIRM NAME: 8r> G2 C D ;z LIC.NO.-,�� Licensee: --E>RRO )C-G izar=F Signature LIC.NO.:?9S-8 LL (If applicable,enter "�xempt"in the license number line. Bus.Tel.No. glFS �i'i h riS�l Address: pj� _ 6, G.o O1 �`I i'�E ��- WE[� . �Q $f[7 Alt.Tel.No.M`d 902 ti897 *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety "S"License: Lic.No. OWNER'S INSURANCE WAIVER: 1 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)11owner E]owner's a ent. Owner/Agenti r,J ✓yamPERMIT FEE: $ Signature (,t/�- I n f Telephone No i 7-- Ze 10042 Date 2/. f . . . LED , TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . . . . . . z . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . �•. . . . plumbing in the buildings of. . . ?G?�- 1. . . . . . . . . . . . . . at . . . . .4. . _- r � . . . Z. ,North Andover, Mass. . . . . PLUMBING INSPECTOR) Check# 2 J '� w^ MASSAE.HUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - CITY MA DATE ( PERMIT# `6O JOBSITE ADDRESS �(, n ' OWNER'S NAME , POWNER ADDRESS TEL _______.,..IIFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: _I RENOVATION:Isf, REPLACEMENT: Q PLANS SUBMITTED: YES 0 NOD FIXTURES 1 FLOOR-4 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 V__ I __J1 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM l _.__.. ._I ( ___.-._I _._._..I __ I I ___.. ) DEDICATED WATER RECYCLE SYSTEM _—! ..I ....__..._....._I _..__4 _...__._1 I _ -.I ._..____( .__..__....1 ...._..._._.f ._...._._._! __........-i _.._.__..E I .__.._..._.f DISHWASHER _..._.._.-! DRINKING FOUNTAIN FOOD DISPOSER ___JL _j FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHENSINK _; _.-..._.! _.____I _...._.._..._( ----_.__I .--,._._..� .._____L -.__._.__1 .__.___► -___._...{ _--_.-__ 9 ____..__I _..____I —I ......_......._i LAVATORY ROOF DRAIN SHOWER STALL -- SERVICE/MOP SINK TOILET _ s ___..__. 1 _. .___€ ...__ I _._._..__.1 _..____-� ..---_._.1 ._.__ --__._-1 __...___F . ._____ _.._..__� _--__-_— _ ,-•_...6 URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _i_ ( I _ i - _I _—Ii ._....___I � _...__1 .... _ _s .i , WATER PIPING _ .--I -___-_i _......__f .._- . f - -I _ I I _... i ._.._I _ _ ! 77_77= OTHER ___..- _-__I .--( I ...__.__.f ..__.._.._.l _.__.-! _I ______I ._..___...1 _..___.._! ._. __! ...._......_I ____I — I ... ---------- INSURANCE __.--_INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES W1190 Q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Q BOND 0 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 01 AGENT �D SIGNATURE OF OWNER OR AGENT B hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent rovis' n Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ . (LICENSE# SIGNATURE MP M/ JP I CORPORATION D# _ iPARTNERSHIPO#[__..__..—__._I=LLC D IF COMPANY NAME[ Gl � � -- I ADDRESS _ �1_ _ I CITY _ � STATE ! I ZIP � TEL _ —_ s FAX CELL MAIL GC 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 i 112 . p r� •+r The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 UqP www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legib Name(Business/Organization/lndividual): Address: 026 1Z Ci /State/Zi 44�Ly Phone#: City/Stat � Are you an employer?Check the appropriate box: Type of project(required): 1.[ 1 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.El am a sole proprietor or partner- listed on the attached sheet. E]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.❑ I am a homeowner doing all work right of exemption per MGL 11.E]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. 1 Homeowners who submit this affidavit indicating they sire 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 4 information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to-secure coverage as 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 DIA for insurance coverage verification. Ido hereby certo under the pain nd penaltiesof per' hat he information provided above's true nd correct. Signature: Date: Phone#: Official use only. Do not write in Ili is 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 M. 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 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-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating.current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate,to give us a call. The Department's address,telephone and fax number: , The Commonwealth ofMassachijsetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston.,MA 02111 Tel,#617-7274900 ext 406 or 1-877:MASSAFE Revised 5-26-05 Fax#617-727-7749 wwwaMss,govfdja Date .7h/ //3 . . kq'TLRL YGvd • TOWN OF NORTH ANDOVER �a PERMIT FOR GAS INSTALLATION This certifies that . . . . . .� . .f�,�� . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . . . . . . t in the buildings of. . . t��h. . .�r.�-�. ., 1 . . . . . . . . . . . . . . . . at . . . . 7,e�Az!! . . . . . . . . . . , North An o er, Mass. Fee ,�2U.. �). . Lic. No./-15,/-S..7 . . .�. . GASINSPECTO Check# 2-691 8776 �r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ..W CITY MA DATE l PERMIT# JOBSITE ADDRESS _ OWNER'S NAME GOWNER ADDRESS _ TEL= FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL 0J EDUCATIONAL �]j RESIDENTIAL CLEARLY NEW:[1 RENOVATION:Rr REPLACEMENT:Ell PLANS SUBMITTED: YES 0 NO[]Q APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER . . BOOSTER _ CONVERSION BURNER COOK STOVE .I DIRECT VENT HEATER . LL-- DRYER FIREPLACE FRYOLATOR FURNACE GENERATORS GRILLE !• — - m,J �J[-_ --- . T -__ - J _.�___ _.�_,:_ INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER - ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER Is ! L WATER HEATER OTHER -- INSURANCE COVERAGE!- �-All .- 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Iwo El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND 1-_I 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 E]I AGENT SIGNATURE OF OWNER OR AGENT 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 Peylne4 provi ' the Massachusetts State Plumbing Code and Chapter 142 of the G er Laws. PLUM BER-GASFITTER NAME LICENSE# 3'. SIGNATURE MP E?"MGF JP JGF ( LPGI CORPORATION D# PARTNERSHIP(# LLC[j#�. .... ___ COMPANY NAME: ADDRESS CITY .... . - --� STATE ZIP TEL FAX��CELL. _. -� � ,IL 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 Et 7D� . F 1 The Commonwealth of Massachusetts Ln Department of Industrial Accidents Office of Investigations quo 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibl Name(Business/Organization/Individual): 1AJ ,!— Address: r;?A e�4 City/State/Zip: 4 TtXPhone#: — J / pct Are yo�ran employer?Check the appropriate box: Type of project(required): 1.gII 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. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. [J Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.[i Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. At Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as 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 DIA for insurance coverage verification. Ido hereby certyyunder the p insan p7-=V hat the information provided above is true nd correct. - 07 Signature: Date: Phone#: /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 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 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 Conuponwealth of.Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,M,A,021 It Tel,#617-727-4900 ext 406 or-1-877rMASSAFE Revised 5-26-05 Fax#617-727-7749 www-mass,govldia t 'COMMONWEALTH OF MASSACHUSETTS l.!J 113EiZS Ail® GAN FITTERS P LI+GiS '17 AS 'A PJIASTEP.. l'l.U�vllaial� i ISSUES THE ABOVE LICENSE T0: ii I T G H A E.L tial KLU E'.L �0 KEN—NE-DY r— l6=l�011!).. ; -74161 1515 ' • 11 t1 0 ,.90 Date..:/d....c:..:..... ..... l NORTH TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �,SS�ICMUSE� This certifies that ..... -?..z .... ............................................... has permission to perform ... .................................................. C7 , wiring in the building of..... </- ................................................ at.... 14 6)v..... L-1 ......... ,North Andover,Mass. A ............... s Fee` Lic.Nol?< ........ . .......�.. ...... ELECTRICAL INS 10�2 Check # 90dq CominonwmA _g Official Use Only `7 Permit No. 5po fO 2eeat '� sem Occupancy and Fee Checked -`– BOARD OF FIRE PREVENTION REGULATIONS ev. 1/07] leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRWT AT I7VK OR TYPE ALL INPORMATIOIV) Date: /0 -/ -O 9 City or Town of: A164TN AiV&d E"6, To the Inspector of Wires: By this application the undersigned gives notice of his or her inintion to perforin the electrical work described below. Location(Street&Number) �/ O P9R11V 67—RX:�=r OwnerorTenant ___;2/f0N4)/3' Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No Ll (Check Appropriate Box) Purpose of Building 't� 5// n/T/ L Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps I Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: IIS/.�//l/�o �} /°1IKU) ��NE2�7a2 Completion Of the olJrnvin table may be waived by the Ins ctor of Wires. No.of Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans 'Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators / KVA Above In_ No.o mergency Ug hng F No.of Luminaires Swimming Pool rird ❑ grud. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones . No.of Switches No.of Gas Burners No.of Detection and Initiating Devices Total No.of Alerting Devices No.of Ranges No.of Air Cond. Tons g Disposers Heat Pump Number Tons No.of Self-contained No.of Waste Dis Po Totals: Detection/Alerting Devices. Municipal [] Other No.of Dishwashers Space/Area Heating KW Local ElConnect'on Dryers Heating Appliances KW Security Systems:* No.of D ry No.of Devices or Equivalent No.of Watero.of No.of Data Wiring: Heaters KWSigns Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications wiling: No.of Devices or Equivalent OTHER: Attach additional detail if desired or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the informaria n this W1 cation is true and complete: FIRM NAME: k eOS1 /•EJ f LIG NO.: / Licensee: ,Taitd;��'�A. '.P Signature LIC.NO.:0? (If applicable.enter"exempt"in the license number line.) Bus.Tel.No.; 0 Address: / "5i ,E'c5i –' .. ,�� Alt-Tel.No.:_70Sr *Per M.G.L.c. 147,s.57-61,security work requires Depal*yf of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the censee does not have the liability insurance coverage normally is agent. one) owner owne the check o ❑ requirement. I am )❑ required by law. Ey my signature below,I hereby waive s eq - Owner/-Agent Telephone-No. FEL: $.�5�4 V Signature Telephone No. �� `� � iZ � �� ; � ; f r Date. . . . . . . . . ..�: Of NORTH • F? °p TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �9SSACHUSE< This certifies that . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . in the buildings of . . ? . . . . . . . . . . . . . . . . . . . . at . .!. � '` ^"�. . . ., North Andover, Mass. Fee.-�_.2. .`^p Lic. No: � �,�f . . . . . . . GAS INSPE Check#.- 6967 6967 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING 'j1Vcity ow t/X72, Date: �-/ -U 9' Permit#. Building Locatic .'y VO /�/N Owners Name: Type of Occupancy: Commercial Educational Industrial fnsfitutionai Residential New:_ f Alteration: Renovation: Replacement: Plans Submitted: Yes No FIXTURES ui w w Y � e itit o ® x V 1.- 2 Q W I 1 � a: H � o z sn W- e m o 1 1- w La °� w t�! W It t- B ii W O Lu I- d[ W i�tl rA rA W i�i1 1- F O z t— > 1- o M a LU UJ a > °o a °o z u v o is o c� a >� W >� l- M z > 3: o SUB BSMT. BASEMENT I 9 FLOOR I 2 FLOOR . 3 FLOOR t 4TH FLOOR 5 FLOOR 6THFLOOR ? FLOOR 8 FLOOR Check One Only Certificate# Installing Company dame: Corporation % t .stSt :`MACitylTown:.Address:_ G J� S% � Partnership _. Business -Firmicompany,: .. Marne of Licensed Plumber/Gas Fitter:. INSURANCE COVERAGE: i have a current Ila bii' insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.942 Yes too If you have checked Yes.please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ✓ Other type of indemnity Bond OWNER'S INSURANCE WAIVER:.I am aware that the licensee doesnot have the insurance coverage required by Chapter 942 of the Massachusetts General Laws,and that my signature on this permit application waives Uft reequuir oeee t Only Owner Agent Si nature of Owner or Owners Agent submitted(or entered)regarding this application are true and By checking this box 0;i.hereby certify that all of the details and information i have accurate to the best of my Knowledge and that all plumbing work and Insteilatiofis performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing . and C 7 tate General Laws. I Type of License: r BY _Plumber J ✓ Gas Fitter Si-nab're of Licensed Plumber/Gas Fitter Title: Master y Cityrrown. Jou n staler License Number: -AppilovED 10 dit ij.SE ONLY) FINAL INSPL(MON BELOW FOR OFFICE USE ONLY PROGRESS INSPEC'{'lON(S! I Fl:I $ PERMIT# I APPLICATION FOR I'ERMIT'1'0 DO GAS FITTING I • I " NAMB&'1'Yrl?,OF RIJ) Ql JG I I c(! 'In Il RUM I)INK, i SKETCH r ,l I ;IZ.SIA...rti t..•1 t LIQ INS'CAI,� . . , , UMNSfi NUMBl.ilt: f " I 111IRMIT GRANTHD❑ DA VI: ' i ti. GAS I-TI`L'ING INSPIiCTIOR f G£3�tfr1i's 'E aLaL (7Fd�aSG �V� EALT ° P �Vt�4SSACHU ETT� MUSET T� IN PLUMBERS AND GASFt LA REGISTU RED AS A P UM®ING LICENSED AS A MASTER PLUMB ISSUES THIS LICENSE TO ISSUES THIS LICENSE TO KEVINKEVIN LEH M LEHANE �• ANE BARROS COMPANIES INC 80 PERRY ST80 PERRY ST APT .205 PUTNAM l `� PUTNAM CT -06260-225, . CT 06260-225 12868 2853 05/01/10 ., 05/O1/ip .. 441011 , _ 441 _ 012 . C it C0rlfU� 3NVEAL�'�9 C?F ,�SASSAGHl95ETTS IN PLUMBERS AND GASFITTERT LICENSED AS A JOURNEYMAN PL BEF ISSUES THIS LICENSE TO J� KEVIN M LEHANE 80 PERRY STS APT 205 PUTNAM CT 06260-22 21619 05/01/10 441013 r