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HomeMy WebLinkAboutMiscellaneous - 456 SALEM STREET 4/30/2018 456 SALEM STREET � 210/038 0000.0 -� �.� NORTH 0 Of 6 Andover 0 '' J1or �` dower, Mass.,s t pan O COC HIC Ht WICK �� �AORATED V'Pa\�'`� BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System i I BUILDING INSPECTOR THISCERTIFIES THAT.....�D�!.Q- !d. ........V. .................................................................................................. Foundation I has permission to'eree ....,Msw,�Q............... buildings on ..... .... 5......�a...2V..................................... Rough . buildin ��" � .��. .5... Chimney to be occupied as....P.Jegwr.........cue-Q,,.... .... Q........................._...........:....:.. provided that the person accepting this permit shall in ever respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough ` L09117) PERMIT EXPIRE 6 MONTHS Final UNLESS CONS C N TA ELECTRICAL INSPECTOR Rough Service BUILDING INSPECTOR Final Occupancy Permit Required t0 Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough P Y P Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner PLANNING FINAL CONSERVATION FINAL street No. Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT 9 ?( d rDate ... . ................ �F NonrM,� r; oom TOWN OF NORTH ANDOVER o ' PERMIT FOR WIRING o � oma. a -. �� • sSACHU5� This certifies that .. 1 //.. .............................................................. has permission to perform .................................. ,�. . wiring in the build' of...........��........' ? J` �.................................... N ........................... . at .:.....: {� .................. ...........................,...............North Andover,Mass. Fee .. Lic.No `a !7. ......... . ................................................................. ELECTRICAL INSPECTOR Check m Commonwealth of Massachusetts Official Use On Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 'L.c7` City or Town of. NORTH ANDOVER To the Inspector o Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 4,( A � ,n� � e �• Owner or Tenant M\.C:t-k-c-Nt N5JIJ Telephone No. Ck--J,U- Owner's Address Stm1�-- Is this permit in conjunction with a building permit? Yes ;�J_ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service 7(�L Amps 12U / 2AO 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: Completion o the followinjZtable ma be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fanso.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires 3 Swimming Pool Above ❑ In- 1:1o.o mergency ig mg rnd. grnd. Ba!l=Units No.of Receptacle Outlets -t No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.o Detection an Initiatine Devices No.of Ranges \ No.of Air Cond. Tonsl No.of Alerting Devices IS, No.of Waste Disposers b Heat um umber Tons o.oSelf-Contained P .. ..... . ................_......................... Totals: ������������ " ��� Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ unicipal [IOther Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.o aterKW o.o No.o Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wirm No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value o Electrical Work: (When required by municipal policy.) Work to Start: 2 Inspections to be requested in accordance with NEC Rule 10,and upon completion. L INSURANCE RAGE: 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 M BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: "" Tom. I a- ,CSC (- LIC.NO.:7 A S-7 S-A Licensee: �L i N - G�FR�A. Signature LIC.NO.: (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.•-7�A'"700 0^3Q 12- Address: Ate 6—YC S�= E A d,O ESIxA NEN � "L l Alt.Tel.No.: *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)[]owner ❑owner's agent. Owner/Agent IPE"ITFEE. $ 7Q Signature Telephone No. r i r 1 t 1 � I The Commonwealth of Massachusetts _ Department ' l Accidents is of In dusty n Congress Street,Suite 100 MA 02114-2017 Boston, www mass.gov/dia 7i^M Sy�V9.. Wolrkere Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print Legib A '•licant Information � -VIA Name(Business/drgaWation/Individual): � Address: Oto City/State/Zip: vV1 b �Z l Phone Y P• ' Pp P Type of project(required): ' Are you an em foyer. Check thea ro riate box: cin to ees(full and/or part-time). 7. ❑N6Vs1'constr&flon 1.❑I am a employer with P y I am a sole proprietor or partnership and have no employees working for me in 8. E]Remo dellhg y capacity.[No workers'comp.insurance required.] 9. Demolition 3.0 lam a homeowner doing all work myself [No workers'comp.insurance required.]' I will 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. l l ❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole - += 1F°`:: ° l2, "Plumbing repairs'or additions proprietors with no_einployees. 5.❑I am a general contracfo:and I have hired the sub-contractors listed on the attached sheet. J 3i,]R06krepalrS These sub-contractors have employees and have workers'comp.insurance. 14.Q Other 6.Q We are a corporafioii and its,officers have exercised their right of exemption per MGL c. 152,§1(4),andwe.Rave;no employees`:[No workers'comp.insurance required.] box#1 must also fill out the section below showing their workers'compensation policy information. *Any applicant that check's I Homeowners who submitsth ys 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 of not(hose entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurancefor my employees. Below is the policy and job site information. Insurance Company Name- Expiration Date, Policy#or Self-ins.Lie.if City/State/Zip- fob Site Address: Attach a copy of the workers'compepsation policy declaration page(showing the policy number and expiration date). e by a fide Up to$11,500-00 Failure to secure coverage as requited under MGL e. es i the form of§25A is a criminal TOP violation WORK ORDERland fine of up to $250.00 a and/or one-year imprisonment,as well as civil penalties n th ay be forwarded to the Office of Investigations of the DIA for insurance day against the violator.A copy of this statement m coverage verification. X do hereby cert{ under h i andpenalties ofperjury that the information provided above is true and correct. Date: 3 Z2 Z� Si ature: -- Phone#: O f only. Do not write in this area,to be completed by city or town official. n' Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Phone#: son• r 'o. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employ es. 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 d'efiited as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enferprl'se,and including the legal representatives of a deceased employer,or the receiver'0 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-wh(i1as not produced-acceptable evidence of compliance with the insurance coverage r'equi'red:' 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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employee-s'other than,the members or partners,are not required to carry workers'compensation insurance. If anLLC or LLP does Have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation'policy,please call the Department at the number listed below. Self-insured companies should enter their self 4usuranoe 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"fob 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-AIA.SSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia �i COIVIINIONWEALTH OF Mi4SAe`HUSETS �QARD t�� IrLECTRICIANS I�SS�ES TME FAL LQWI NG SLI CINSf {I > DAIdWE GRIFFITH f x , 46 ,co�KST ,j BI I.LER I GA l a IA 0�8t55T�7 � Date..�A�..................... 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .................................................................................................................... has permission forgas installation -1-5?1�ve. ........................................... in the buildings of .................................................................................. at........ :.S- T. ....... ......... North Andover, Mass. .. . ............................... Fee.g�...Dlel ... % ......... ....... Lic. No.322.3.2.. ..................................................................... GAS INSPECTOR Check# 10474 DateN.Pilz�..... 11663 40Rr#j TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING CHU This certifies that.....j ................................... ................................... has permission to perffirm.................-5.....7......../L....... z"X-L.A . plumbin�gtn the buildings of. ................................ at..... ............... North Andover, Mass. ..... Fee ................. ................................................... ........... .........Lic. No: 2 732- PLUMBING INSPECTOR Check# /�0 -�I��I � ,�,�, -�-z.: .� � ����i�, �1 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) ` NORTH ANDOVER.MASSACHUSETTS Date Building Location Owners Name 6A&d Amount Type of Occupancy New 0 Renovation Replacement a Plans Submitted Yes No El FIXTURES rfw w �d O a w x w H 3 a z d x z � o w d a s A w a O w � F W) d O d as S1B1Bgv1r. Bk9a l M I+I � � LS'1CIHIDOR 1 � 3�1 IIfX]I2 3M M 4M 1H10CIR 5M HDM 6M 11UR R 7M ROS 9M H1= (Print or type) l Check one: Certificate Installing Company Name S\ ,c,W`I i 6 , {e Corp' Address 4A', Kj) N e- r,) -d r-c Partner. 01 Business Telephone Firm/Co. Name of Licensed Plumber: wt) t C�e- Insurance Coverage: Indicate the ty, e of insurance coverage by checking the appropriate box: Liability insurance policy �' Other type of indemnity El Bond Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent E] I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate tot e best of my knowledge and that all plumbing work and in lations pertb!70 under Permit Issued for this application will be in compliance with all pertinent provisions of the Massa tat lu g, d apter 142 of the General Laws. By: eoI Licens-e-d-Flumoer y.(�e of PI bing License Title p� T 7 City/Town Icense um er Master Journeyman Ell PPROVED(OFFICE USE ONLY a F I� { y r .. . yl i I i MASSACHUSETTS UNNORMAPPUCATON FORPERM T TO DO GAS FITTING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations [ �q 67 Permit# r Amount$ MOwner's Name „! •GA,a,�I F&dre46 New Renovation ❑ Replacement ❑ Plans Submitted ❑ Y g W z w w a p U H x z z F z C4 W �W F z d w d a FW- O z w O a h a c o x a o o a w F o SUB-BASEM ENT B A S E M ENT IST. FLOOR 2ND . FLOOR. 3RD . FLOOR 4TH. FLOOR 5TH. FLOOR 6TH . FLOOR 7TH. FLOOR 8TH. FLOOR (Print or typ �\_ Check one: Certificate Installing Company Name \ )�U.0') 'y�,G\CPI fl ❑ Corp. Address C4 ❑ Partner. CAlphn(, fiord Business Telephone 7 3e , ( ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter 1 (ice Te. INSURANCE COVERAGE Check one• I have a current liability Insurance policy or it's_substantial equivalent. Yes No❑ If you have checked}—es,please indi e type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity13Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ 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 installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts St Gas de pp 142 of the General Laws. By: ature of License Plumber Or Gas F'tter Title Plumber City/Town Gas Fitter License Number ❑ Master APPROVED(OFFICE USE ONLY) 0 Journeyman '-tk��3j ���; J- -, �V � -<< r � ... � f � - _.. .. J .1 t l The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02119-2017 www mass.gov/dia •`` WWorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Anulicant Information / Please Print Legibly Name (Business/Organization/Individuai): V h %,, l 1 Address: r c yr e- �� � ',eco'^ c /�c City/State/Zip: /11/q 0 2 c f Phone#: y 15 V3 0 Are you an employer?Check the appropriate box: Type of project(required): LE]I am a employer with employees(full and/or part-time).* 7. ❑New construction 2' l I am a sole proprietor or partnership and have no employees working for me in 8.remodeling TT any capacity.[No workers'comp.insurance required.] 9. Demolition In I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4:❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.FJ We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.0 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. $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 I am an employer it:at isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site information Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: I 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 a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pail: d penalties of perjury that the information provided above is true and correct. signature: ' ? Date: Phone#: / to) Ll ?90 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person' Phone#: i i r W!adt?NWEALTH'`C}F a a=- « ROM, � In Sum 1 { f '2 F ` 1146 of"oRT"'ti TOWN OF NORTH ANDOVER ° p PERMIT FOR PLUMBING CHUS� '*This certifies that.. .....d -, ..... LSV. ....: ......................................... has permission to perform...X ..... :: . :c-. ....�. :......... plumbing in the buildings of -�- t2. ?s ..e �L.. 0.�1.. at.......... . ,- ; ............... North Andover, Mass. Fee.. ..Q.—...Lic. No. 1. a1�� ................................................................................. ,G — PLUMBING INSPECTOR Check# • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY r d✓SCI ________ MA DATE �? PERMIT# lG JOBSITE ADDRESS OWNER'S NAME I Mle /� ✓r tG•�o POWNER ADDRESS TEL 31O�°!/ 7 FAX TYPE OR OCCUPANCY TYPE COMMERCIALEDU ATIONAL RESIDENTIAL 4M PRINT CLEARLY NEW: RENOVATION:� REPLACEMENT: PLANS SUBMITTED: YES NO 01 FIXTURES 7 FLOOR--' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE ; $ _ —$ �I ,_.._( ____-..m) DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN I ..-__-_{ _ ___ ._( .._._$ __$ _.__._I __.____t .__ __; .._.__ J __.,. .E FOOD DISPOSERFLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK I 3 —1 ____2------- LAVATORY .--__LAVATORY t _ ( ____ _._.__$ ___.____t __ $ ROOF DRAIN SHOWER STALL _$ __— ( c$ ( _. s t _j _'____j _.____.f.- SERVICE/MOP SINK TOILET 11__-__ ____ —_$ 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 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D 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 _I AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wyi hall erti nt provision of the Massachusetts State Plumbinc de and Chap t 142 of the General Laws. PLUMBER'S NAME�_ �— IILICENSE# _ s' SIGNATURE MP 0( JP M CORPORATION Q# {PARTNERSHIP _1# LLC COMPANY NAME (,et, �_ f ADDRESS f CITY ..__._._�STATE ZIP 0`P� �� TEL 'T 7 FAX m _ - -- ` CELL��EMAIL - - ---- - ------- -- ------..._._.. --... ----------- - _ ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTJMq NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES \ 4� The Commonwealth of Massachusetts Department of Industrial Accidents Congress Street,Suite 100 Boston,MA 02114 2017 �t www.mass.gov/dia Workers'Compensation Insurance Affiidavit:Builders/ContractoxslElectricians/Z'lum els. TO BE FILED WITH THE PERAUTTING AUTHORITY. Please Paint Le 'bl A licant Infoxmation ' Name(Business/Org anization/Individual): Address:- ,, City/State/Zip: Phone#: ._ r , . -7] y .? 1? p Type of�project(required); Are you an emplo er.Check thea ro riate box: ees em to frilland/or part time).• 7• F1N&O'constriiction i.0 I am a employer with P y 2 I am a sole proprietor or partnership and have no employees working forme in 8. Remodeling any capacity.(No workers'comp.insurance required.] 9. []Demolition 3.❑I am a homeowner doing all work myself.jNo workers'comp.insurance required.]= 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11. Electrical repays or additions ensure that all contractors either have workers'compensation insurance or are sole 12 plumbing repairs or additions proprietors with no employee's. 5.❑I am a general contracto�and 1 have hired the sub-contractors listed on the attached sheet. 13'.[]Rbof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.[]Other 6•❑we are a corporation and its.officers have exercised their right of exemption per MGL c. 152,§1(4),and we have rio employees:jNo workers'comp.insurance required.] *Any applicant that check's box 4i must also fill out the section below showing their workers'compensation policy information. Homeowners who submit•.this affidavit indicating they are doing allwork and then hire outside contractors must submit a new affidavit indicating such tContractors that check this box must attache have 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. and job site compensation insurance for my employees. Below is the policy I am an employer that is providingworkers' infor=mation. Insurance Company Name' Expiration Date, Policy#or Self-ins.Lic.#: City/State/Zip: Job Site Address: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). punishe by afhibupto$1, Failure to secure coverage as reunder civil pthe form ofS TOPLolation WORK ORDEBI d f up to $2500.00 0-00 a and/or one-year imprisonment,as wel25A is l evenalties in day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cert! u er aepain sandpenalties of perjury that the information provided above is true and correct. Date: G , `30 do (r . Signature: Phone#: 4 V3 _ 74 Official use only. Do not write in this area,to he 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 Phone#- Contact Person: V • N Information and Instructions Massachusetts General Laws chapter 152 requires all emptoyers to provide workers' compensation for theiremployees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of bbre, 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 enferpri'se,and including the legal representatives of a deceased employer,or the recei-vbfor trustee of an individual,partnership,association or other legal entity,employing employees.•Howevex the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant o£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 Pleasb fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractors)name(s),address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia Date.......... ...... . ........................ r►ORT�y TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION } S`SACHUSE This certifies that ..........:.... �"z..^3.... ✓'�J ...... ....... ................ has permission for gas installation- .. s ............. 2. .................................. in the buildings of. ..........................►........�-... .. ................. ......... at .. S.CUP.r'f ...�� , North Andover, Mass. Fee....;1,0�.:.... Lic. No.15151........ ..................................................................... GASINSPECTOR -Check#__ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I ---- -- I----- CITYU'� MA DATE o -f3�7o]PERMIT# O �� _.---0 — JOBSITE ADDRESSOWNER'S NAME 47 ^ S� OWNER ADDRESS TE _ r FAX L TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:13 RENOVATION: REPLACEMENT:UO PLANS SUBMITTED: YES Fj NOD APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 1 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER .... _ -.. ._. .__-. DRYER . —D . FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE -- INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT _.. . r.. -- -_ OVEN --1 C-� - �Y J - (--J 1=_s- POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT - - - - - I - - - - - - - �� .. . I TEST ' _ I.� _ 1 -- ! -�_. —a1 _ .�I T _ l � UNIT HEATER UNVENTED ROOM HEATERWATER =OTHER ..— ......... . ............ ... . _ J-- - J C __ L--- - - -^- INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES IM NO D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY t1I OTHER TYPE INDEMNITY 0 BOND Ell OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT 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 ith all Pe ' e t vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ! PLUMBER-GASFITTER NAME GI Wn VZ) G�,/l LICENSE# SIGNATURE MP ED MGF El JP [A JGF 0 LPGI CORPORATION©# PARTNERSHIP LLC El#L COMPANY NAME: Gu..M fi ]]ADDRESS CITY J^ STATE4 ZIP K TEL FAX CELL t EMAIL � y - _ _ _ ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No �L�S CI `j THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES ;F Fold,Then Detach Along All Perforations ( COMMONWEALTH OF ETTS. B.GA D"OF 1 sR PLUMBERS> ►KD GASFITTl;RS iSS1ESFOIWING iICENSE E0SOUP".' Y:MAN PLUMBEf2 i 5HA'�1N P St,V0 5 MI DCW rW. �A' 01354-9708 M 315 3 05%o1/1b 208320 I . II . .- ..�_ Date.................................. t �4ORTH 1 TOWN OF NORTH ANDOVER o p PERMIT FOR WIRING IL , CH r q This certifies that a, has permission to perform ......... ........... !S/ ........................... wiring in the building of �6 s?- S North Andover,Mass. 3' Fee.. .. Lic.No�g�.a-�.-.......... .. /} ............: li.l - ELECTRICAL INSPECT`O'R Check # Q � 676 C2 /�/,// r/I��)) Official Use Only ommonweaL"th of f!/Iai4acli.Wett9 / �7f Permit No. 6y `l eLJerartment oJ�ire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS (Rev. 11/99) (1eaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 C//MR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: b - I, - 0 (a City or Town of: ,ry To the Inspector of Wires: By t 's application the undersigned givesnotice of his his or her intention to perform the electrical work described below. ocation(Street&Number) Y JL `� � �Yf- . p q Owner or Tenant �'C � Telephone No. /8 ^ 663 ^ /1,00 Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No Ej;,,�(Check Appropriate Box) Purpose of Building fee . 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 r Location and Nature of Proposed Electrical Work: e � Completion of the following table may,be waive by the Insp for of Wires. No.of No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans Traransf To Tsformers KVA No.of Lighting Outlets No.of Hot TI ubs Generators KVA No.of Lighting Fixtures Swimming Pool Above In ❑ No.of Emergency Lighting g g g grad. ❑ gmd. Battery Units N .4of Receptacle Outlets - No.of Oil Burners - FIRE ALARMS No.of Zones No.of Detection and No.of Switches _ - No.of Gas-Burners_ Initiating Devices Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number __Tons _ __KW _ No.of Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal❑ Other P g Connection Dryers Heating Appliances KW Security Systems: No.of D rY g PP No.of Devices or Equivalent No.of Water No.of No.of Data Wiring Heaters KW Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: 1 Attach additional detail if desired,or as required by the Inspector of Wires. 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 t overage is in force,and has exhibited proof of same to the permit issuing office. (.� CHECK ONE: INSURANCE BOND OTHER El (Specify:) ` Gid►, � l— .L � (Expiration Date) Estimated Value of/Electrical Work: (When required by municipal policy.) Work to Start:�A '�"b Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify, under the pains and penalties of perjury, that the information on this application is true and complete, FIRM NAME: _ _ _._.. .._. __ LIC:NO.: Licensee: f oa. - Signature LIC.NO: C t� (If applicable,enter "exempt"i� the license r ber la e) Bus.Tel.No.: . Address: t (�j [,. �7-t�v`� ,� t Alt.Tel.No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not hr e the liability insurance coverage normally required by law.By my signature below,I hereby waive this requirement. I am the(check one) D, owner [I owner's agent y Owner/Agent Signature Telephone No. PERMIT FEE: $ I lam" �'C� (��L- � ,— / �'/�-- ® �'a Q G% _- - - -- --_- t � --_- - - _ i I I