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HomeMy WebLinkAboutMiscellaneous - 45 SHANNON LANE 4/30/2018 / 45 SHANNON LANE 210/107-A-0231-_ 0000.0 Date..... tb..� .�..�. . 1 ; 3 O�NOR7/y�ti TOWN OF NORTH ANDOVER O.t 9 PERMIT FOR PLUMBING A Ss,CHUs� D This certifies that........................ ........... .. �`'Q ......................... �• has permission to perform.............. ................................................................................... plumbing in the buildings of.........................e---........ . ................................................ at...... ... ?....... ...... !�+u.J. ........................ North Andover, Mass. / Fee .17....Lic. No. � ................................................................................. n n PLUMBING INSPECTOR Check# � ��2 Oto vy\. i a C�l MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY /lel/�G1 �� MA. DATE_ID- 7-/ az- PERMIT# 10 JOBSITE ADDRESS K 15k3 {j rj 0r1 OWNER'S NAME i POWNER ADDRESS 4-5 t &JefS,_ TEL FAX TYPE OR OCCUPANCY.TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL®� PRINT CLEARLY NEW:❑ RENOVATION:[ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO FIXTURES 7 FLOOR-- BSMT 1 2 3 4 5 6 7 8 9 10 11 12 '13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIUSAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK- TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which,meets the requirements of MGL Ch. 142.• Yes ] No❑ R IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® OTHER TYPE OF INDEMNITY ❑ BOND ❑ A 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 BOX ONLY: OWNER ❑ AGENT ❑ r nature of Owner or Owner's A entreby certify that all of the details and information I havesubmitted (or entered) regarding this application are true and accurate to the t of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER NAME Peter J. Crane SIGNATURE�n LIC# 21805 MP❑ JP❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME Crane's Plumbing & Heating ADDRESS: 70 Douglas Street CITY Haverhill STATE 11A ZIP 01830 EMAIL annacrane.ac@verizon.n /1 i It TEL 978.771.1155 CELL 978.771. 1155 FAX L J •. The Commonwealth of Massa.chusetts z Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Q � /y Address: J 3d City/State/Zip:,& ,,t,' PAO,, Phone# , Are you an employer?Check the appropriate box: Type of project()required): LE] m a employer with employees(full and/or part-time).* 7. ❑New construction 2.Y,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. F1 Demolition 4.F1I 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 I L E]Electrical repairs or additions proprietors with no employees. • 12.[]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-conlraciors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees.'Below is the policy and joh 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 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 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 certify under the pains and penalties of perjury that the information provided above is true and correct, Signature: Date: Pz 711 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): i 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 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 lure, 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 fbi 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 tRCOMMONWEALTH OF MASSACHISETTS .BQAR:D:�lF PLUMBER' AND GAS`F;ETTERS?' HE FOLLOW I`NG'LIC.ENSE" :`.,.::'` ' SSUES T L V f E.D ASA UR JpNEI'MAN:,N,PLUMBE! 1 R J CRANE 70 DOUGLAS ST L:L;:>: ':MA 018 a0 7 ..::I Date. .91411-7 MORTM OF 6 6 6 TOWN OF NORTH ANDOVER O �� p • . PERMIT FOR GAS INSTALLATION 'ISS CH 5Et This certifies that . . . . ?4�1c. . � .�. 1.?. . . . . . . . . . . . . . has permission for gas //installation . . ay. :-�Aww . . . . . in the buildings of . .,1��/J!�'�. . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . North An ver,,Mass. Fee ,.,: PLic. No..13S5 . GAS INSPECTOR Check# 8284 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE 2 � PERMIT# - - - JOBSITE ADDRESS ,, La .�•c —_ OWNER'S NAME _ GOWNER ADDRESS TYPE O OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINCLEARLY NEW:Q RENOVATION: REPLACEMENT: PLANS SUBMITTED: YESEl NOD 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 GRILLE INFRARED HEATER LABORATORY COCKS [_ j—J MAKEUP AIR UNITS OVEN __ — - - - — POOL HEATER ROOM/SPACE HEATER I --- - ROOF TOP UNIT ( _ J { . . ^ -- T_ __ . _ __ f .. I��_l TEST (-J L_�_J .___ __ --J ► _ ( ,_-T-1 - -- — — __�1 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER ......._ . . .... L. rs J ... . _ _ INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITYI 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 Eq AGENT ,[+,J] 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 compliance with aWertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBE ASFITTER NAME / ��f"l.ccJ LICENSE#/3675-1 SIGNATURE MP _. I MGF E] JP n JGF L LPGI CORPORATION V �l PARTNERSHIP 0#=LLC 0-1#= COMPANY NAME:/)1A N)Fj- - �ADDRESS kAA CITY .,_-_-- -� STATE ZIPf TEL FAX '3aY� l�vo�_ CELL AIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT Gl 2 FEE: $ PERMIT# PLAN REVIEW NOTES 1 ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations U1 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly low—Alilre � s Name(Business/OrganizatiorAndividual): Awz Cd Address: 57— City/State/Zip: 'City/State/Zip: 41 ,�,, f-�,�- 1/1 Phone 0/— Z/ q Are yo employer?Check the appropriate box: Type of project(required): 1.R41 am a employer with 3— 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.1 7• emodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3111 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.[J Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13J]Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. A 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 thepolicy and job site information. Insurance Company Name:. /�!_ �C a, �J Policy#or Self-ins.Lie.#:_ S 9A J Expiration Date: Job Site Address:__`7 �ll�?p�ll/�V City/State/Zip/J/ A..A� 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. I do hereby certto under the pains and penalties of perjury that the information provided ab a is true and correct. Si ature: G11� Date: Phone#: /,-Y-) g – eT3e� :? 1 f ? 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#: t 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." AF plicants 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 retumed to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of l dustrial Accidents Office of Investigations 600 Washington Street Boston,M.A.02111 Tel,#617-727-4900 ext 406 or 1-8777MASSAFE Revised 5-26-05 Fax#617-727.7749 wvvv�mass,gavldla Date. ..71e�o. . .. ...... NONTp TOWN OF NORTH ANDOVER O 9 _1.� + - PERMIT FOR INSTALLATION s + t ,SSACHUSEt This certifies that . . j7!t!.�?. .�d. ... . ... . . . has permission for gas installation . iil.!` in the buildings 11of . . .e.Xv.r.q,07 . . . . . . . . . . . . . . . . . . . . . . . . . at . . .lJ� .S! �?��?!�. . ` . . . . . . Northndoverj Mass. Fee. .71.0. . . Lic. No. SS� GAS INSPECTOR Check# 82733 (0m, R 3 %z-i3 e-t-,,A Pr_> c,- �Pluw.�► � � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _ ( MA DATE - J PERMIT# JOBSITE ADDRESS OWNER'S NAME � t _ � � 1..- POWNER ADDRESS oma- _ TEL . FAX f TYPE OR OCCUPANCY TYPE COMMERCIAL © EDUCATI -AL ® RESIDENTIAL[� PRINT CLEARLY NEW: [] RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO0 FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB f __-_-.J CROSS CONNECTION DEVICE --. ( -.., f I _...__� ___..._ J _..._.__E DEDICATED SPECIAL WASTE SYSTEM _,�1 .______f DEDICATED GAS/OIL/SAND SYSTEM �_I -_..-._._ —11 -1- . f I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM ( __.--_.._.-I DISHWASHERj ( __..__.._i -_-- J ..____.—E DRINKING FOUNTAIN { _._-...` FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR INTERIOR) I ___.. s J _ i _-I I I _ J KITCHEN SINK Tl _. ! _ . _J LAVATORY ------ _____-( .--____.J .'____._I .___..( _ _I ► .-_,-___ ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION f 9 � WATER HEATER ALL TYPES _J...- WATER PIPING f t ( _ ! i 1 _ - e _.( _.- 1 .I -. _-1 I OTHERAl 11L.J11 -J I J111 _ _ t INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICAT7TPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND Mf 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 J E( SIGNATURE OF OWNER OR AGENT E hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER' AME DU ICS 1 LICENSE# - f ! SIGNATURE IMP _ JP Q CORPORATION EJ# PARTNERSHIP _{# LLC COMPANY NAMES► Kcv ; ADDRESS i Sr CITY J STATE �ZIP Lql q Y T4 FAX TES FAX CELL -c EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY� FINAL INSPECTION NOTES -<5y J Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of Industrial Accidents 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/Organization/Individual): /?Z?i6z&Y ) fcc-CJ Address: ?/ 5 i City/State/Zip:/?'!/,,,�4- 6 , Gj!r Phone#: 97 k3(5-- z , > Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 3 4. ❑ I am a general contractor and I 6 employees(full and/or part-time).* have hired the sub-contractors 2.E] I am a sole proprietor or partner- listed on the attached sheet.I deling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]I employees. [No workers' comp.insurance required.] 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-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.#: �S'57,9AJ Q 2--2 p Expiration Date: 312 f Job Site Address:_L( 5 S'1Gfl�LUGG'v� '� City/State/Zip: �• Attach a copy of the workers' compensation policy declaration page(showing the policy num era 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. 1 do hereby certify under the pains andpenalties ofperjury that the information provided bove isggtrice and correct. Si nature: c - Date: 2(Vt Phone#: S �'c l 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#: �r Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of 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. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www,mass.gov/dia Date , sw�rtiun'��os TOWN OF NORTH ANDOVER r PERMIT FOR WIRING This certifies that . . .19!11?. . . . . . . . . . . . . . . .. . . ... . . . has permission to perform . � .''~. . . ��'Oka'e' -. . . . . . . . . . . . wiring in the building of . !��k-L 177. . n ✓3-�l^.!`. . . . . . . . . . . . . . at . n d^ . . . /!Z,- :. . . . . . . . . , orth Andover, Mass. fY Fee �U . . . Lic. No. .��.r. . .q�.-3 . . . . . EL CTRICAL INSPECTOR l Check# 10984 Commonwealth o f kadeachuJetb Official Use Only c� Permit No. / - Apartment of3 ire Service.4 Occupancy and Fee Checked ti BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: yV (- 4JOVB i• 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) 45 .50 my ry©w CA" Owner or Tenant Ht V,1; ') LTC--r 5 /C 14 f9t4K."t— Telephone No. 6f7-400-7®w Owner's Address "-f S CA—V- Is this permit in conjunction with a building permit? Yes Er No ❑ (Check Appropriate Box) Purpose of Building tt C-f t&,Z e-4v Utility Authorization No. Existing Service 2A�,_ Amps (7,Ci / 2gL/Volts Overhead ❑ Undgrd 0 No.of Meters J New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity lou Ate`P Location and Nature of Proposed Electrical Work: Qet �CSS C � 'Tac�{t�o O Utv Add &C-4L KL kf►�� t Md &Ld 44 -10 &W GJtwc Completion of the ollowin table may be waived by the Inspector qf Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total J Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ at oUnits Emergency ig mg rnd. rnd. Batter Units No.of Receptacle Outlets LfNo.of Oil Burners FIRE ALARMS No.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances Kms, Security Systems:* No.of Devices or Equivalent No.of Water� No.of No.of Heaters K�'�' Ballasts Data Wiring: 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 required by the Inspector of Wires. Estimated Value o Elec rical Work: i'� 70 (When required by municipal policy.) Work to Start: 2Z to iZ Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVE 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 of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the pains andpenalties ofperjury,that the information on this application is true and complete FIRM NAME: j wJ r C Cuo•/0A4-1X4 1"t- ae- z LIC.NO.:� +� � Licensee: t{y�¢c,� C e►Au-P/�GtyiF Signature 07 LIC.NO.: U 777 (If applicable,enter "exempt"in the license nu ber line.)) "� (� Bus.Tel.No.: - 1-71 T Y Address: _a J �b&kt✓LCc " � l�-�/rte s d l eT Alt.Tel.No.: *Per M.G.L.c. 1.47,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑ owner'sa ent. Owner/Agent PERMIT FEE: $ Signature Telephone No. f � �. ` .1. C� �.- 7 - 3 © ^ � 2 ��`'`- . . �, - �� - , . , . , �-_ } . . . � . � . ., _. The Commonwealth ofMassachusetts Department of Industrial Accidents r b 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/Orgabization/Individual): 4dJ et!J ��,gw �(.GL• Address: '3"7 ����.� ✓lc.� City/State/Zip: Ll 1?64-dt,, -HO- O i $'6 Y Phone#:__V1?- 7 V `7/ SY Are you an employer? Check the appropriate boa:; Type of project(required): . 1.U�Jl am a employer with 2-- 4. E] I am a general contractor and I employees(full and/or part-time). have hired the sub-contractors ti• F]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' cora insurance.$ 9. F1 Building addition [No workers'comp.insurance p• required.] 5. ❑ We are a corporation and its 10.E]Electrical repairs or additions r 3.0 I am a homeowner doing all work officers have exercised their 11.❑plumbing repairs or additions myself. (No workers'comp. right of exemption per MGL 12.[]Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they am 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: 44, Oc-9-c.l K-S v 4,,,e-tC 6 o!:,g 5 Policy#or Self-ins.Lic.MA W W C 3 SOa U. Expiration Date: /C) o-13 Job Site Address: ' `-�S' r44r.0.a.` Cwf City/State/Zip:. . .f .c<<d pt,...Ft CI -- --Attach-a-copy-of-the-wor-]vers'—compensation-policy-deelar-ation-page-(showing-the-policy-numbex�and-eacpiration-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 verific 'on. I do hereby certify rrr t pains and per ties erju that the inforrrration provided abov is true nd correct Sr ature: K® Date: T � ' Phone#: 5?'Z``. 7 7/ 7/1-rely Official rise 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 Cleric 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. r' 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 PIease 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.izov/dia Date.'�� .`. .'. . . o,<"< RT:'�o TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSACMUSE� This certifies that . .� /.�. . . . .�. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . f' .Y ./ , '(� at . . . ../ . : . . . . . . . . . . . . . . .. North Andover, Mass. Fee.-4 Lic. No..?. . . . . . . . . . . . PLUMBING INSPECTOR Checkk # ) �' 6683 (Type or print) MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TIDO LUMBI NORTH ANDOVER,MASSACHUSETTSDate Building Location SKIyN Owners Name Permit# Amount 2.0 Type of Occupancy New ri Renovation Replacement ®/. Plans Submitted Yes ❑ No ❑ FIXTURES w a G z w o w a U O zz Za z Cn z a °a w x 3 3 A x 3x a �' x A W w w H x z z H x SLRB : SAWN avr Isr.Hj" 4 M RAOM 4MHJ0CIR 5M MOOR 6M MOOR T—T- 7MHjOCR FT 9M FWM (Print or type) Check one: Certificate Installing Company Name /&—JUl (( Corp. Address .- . l�L�'��/� �-1- S © Partner. hLT1- MN UtrSyy Business Telephone r—�( ' S �Eirm/Co. Name of Licensed Plumber: —.J i � t>t ! :�.L Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above threeinsurance ignature Owner Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and install ions performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachuse S Plumbi o d Chapter 142 of the General Laws. By: igna ' o i n e um er Title Ty o ing License cJ City/Iownense um er Master E] Journeyman APPROVED(OFFICE USE ONLY NORTH 6 6 6 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION AcMUSEt This certifies that . . . /:<?.C. L'.�"... . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . . . . . . . . . . in the buildings of . . r s !.`?...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . at .`. . . . . . . . . . ., North Andover, Mass. n r , ? � ! . . . . . .. . ^ . . . . . .Fee. � Lic. No.. . ` ,'GASINSPECTOR ',Check# 2 `' 3ZLi "` MASSAC;NUSlTTS UNIFORM AF'PL11 � .tCA f 1{)N FCR 'PERMIT TQ ©a GASiTTtNG : � tPrrnt or Typel'.. ' � ../7N�/f'' �4- . Mass.' Date j� - t ...: t` r Perml , :% 1. . .- �L. - t # Y l3ulid[ng Location ��. - i�N Ovsrnsr's.Name � 1/-}�V° - �. j� TYPe of Occupancy 1. Ne..-9 C Renovation p Replacement (�"° Plans Submit#ed Yes {� No 0 '� N ,ri " to V 2 :� rn n: vl tC O j_ .vf r+l " w ac 0 0 t-. ..;C:. .j� .F -c cF, -� O Q r. . 1 z U. w a w } :w F- x >r H z i. w:: w c y W, _r c� m x :w y rr r-' s- m w ,> oc m Z. = 't z j.. O Aa -x a: O is z o v z 'u. 3 a s Q- s F- C sue >isMr: - BASEMEttr I i ,IST. R - $3iD FL40R ;. 3_HO FLa R _ .. <� �17ii FL ,a.:,, STK FLt30R t37ti FZOOR Fit f:LOOR It r Instaifing Company Name =G l L } {� ;Checlt one- Certificate' ,_ .Address r ` C — orporatton l� _� ♦ Z 11 ❑ ..Partnersh! r. P Business Telephone q ` ( �/�'l�- �j fl" Flr �Oo Name of Licensed Pirmber or Gas 3=3ttect— C��=l -11 ,/ INSURANCE GOV l.AGE '; 3`have r.a current bltity insurance poffcy or Itis substantial equivalent whlct frieets Ehe retiuirenents at MGL Ch. 142 Yes iVo p i(you Have checked es, tease t cats the 3t:_ P type coverage tby checking the appropriate box. A ilabltliy insurance otic Other f o p Y: ,... ype f indemnity Cl.; _ :gond :Q OWNER'S INSURANCE N'I r l R: ! am aware that the licensee does not have the Insurance'coverage rEqulred by Chapter - " of the Muss G:- ral-:taws;;and.that my signature on'this perrntt application waives this:regiitremer►t , Check ane. ,S+gnelu(e 1W Qwner or t?vrnet s Agent � t3wnerC Agent %❑ I hereby oertityihat all ot:the details.and it torinatian i have submiffed for enieted),in above appiicailon are'#rue and accurala t--the.best of+my knowlaIL and that A plumbing work and.Instaltations pedormed under tt�e ppermit issued for this;applicattott Will-,be tip cotnptiahce with sit pertin .nt':pransior s of the-Massachusetts-Stale Gas Code and grapier 14�of the t, '-r aI U,W r T e of License:' Tiffs _ Plumber :Si` u e o,: c ttise, um et or Gas titer astittor 1 Cilyltowr aster Ucense Number " 7� " Mf'tt(7vt A—TO JoucPeyman . ',..,:0 • . 7iO LCRTY/E 0 PLOT PL.4N OC.4TEO IN �R/5TIANS IV E 58 3Gl , /NC.5UMMER STREET AIQVERNILL,MA. yal 1\ 72,00 ol \Y J �► '3 c y � 4 a � . Fn/D. 0� LL �.S V ! ��N or M0 � 7- VC mi� 191 .00 S1ERE f Ty / CE-RT/FY Tg4T TWE 0FF6ET5 S/101- N Aff FOR 6TRUC7-L/F E BU/LD/N� SI1OWN ON T�/S ZONING DETERN/N4TION /6 PL 4N CONFO.eW5 TO T1/E ONLY 4ND 4fE NOT TO BE, .4 FLOOD ZON/NC BY-L4W5 OF Tf/E USED TO E5T,4BL/511 PW- 11.4Z4,PD h! !... ... OF 66. PE,eTY L/NES. ZONE. WREN CONST2LICTED.