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Miscellaneous - 48 WAVERLY ROAD 4/30/2018 (2)
Date ... .......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................. ........ . ..... ................................... has permission to perfonn%z�,2e -�...`1 I ..... 7 ... ) ..................................................... winiWalinthe building of...... ........................................................................................... at.. xv ......................... . North Andover, Mass. . .................................................. �/T'..... . i .............. Fee /0�5 . ........ L— - —...... - ..................... .. . .................................................................................... ELECTRICAL INSPECTOR Check* �7 Z,\rwial Use Only (!ommonw,,& � Vamac" 2arartmwd 4Sewka6 Permit No. occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. V07] (leave blank) '*X APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All Nvork to be. perfortned in accordance with the Massachusetts Electrical Code WEQ, 527 0414 12.00 (PLEASE PRINT IN JAX OR TYPE ALL INFORMAMA) Date: 2/3/16 City or Town oft North Andover To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perforru the electrical work described below. Location (Street & Number} Owner or Tenant Michael Xenakis Telephone No. 508-246-6798 Owner's Address 48 Waverly Road Is this permit in conjunction with,a building permit? Yes -RI No ❑ (Cheek Appropriate Box) Purpose of Building residential Utility Authorization No. Existing Service 200 Amps 120 j 240 Volts OverbeadF] Undgrd L] No. of Meters 1 New Service Amps -Volts Overhead 0l Undgrd L] No. of Meters .Number of Feeders and Ampacity {\- Locationand Nature of Proposed Electrical Work: Install 7.28 kw solar panels on roof. Will not exceed, roof panel but will add 6" to roof height. 28 total panels Cnnwlefinn ofthe following table nwa- be waived by the Inspector of Wres. .411achat, tiotictldetail ifdesired orasreqiitreanythe inspectoli:ujvrires. Estimated Value of I, ,lectrical Work. $24,000 (When required by municipalP olicy.) n ;Cndompletion. Work to Start: TBD Inspections to be requested in, accorda ec with. ME Rule.10,andu 00 INSURANCE COVERAGE: lJnlcss waived by the owner. no permit. for the perforinaricc of electrical workmay issue unless the licenseeiprovides proof of liability insurance including "completed operation" coverage or its substantii.l.equivalent. '.The undersigned certifies that such cov yage is in force. and has exhibited proof of same to the permit issuing office.. CIlLiCK ONE: INSURANCE fff BOND [] (ffHER F1 (Specify:) I cerfify, under the pains andpenallies o perju ;1 at the information an this a fication is true and complete, If T - . A FIRM NAME.. LTC. NO.-. 510 Licensee: Signatu LIC. NO.TZ" No.;-1-1L--ZaJ _A410 (/f `'applirrahle, enter exeMP12 &I Ihe license num ber tine, Bus. Te i J 14) 7. 15 61A .0ZWJ Alt Tel. No.:,W,.4 ZA Address: J Ak. g *Per M.G.L. c.. 1.47 s. 57-61, security vWrk requires Department of Public Safely "S" License: Lic. No. 01AINERIS INSURANCE WAIVER. 1. ant aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement; Iam the (check one)EI owner El ownef s Owner/Agent$ F Signature Telephone No. EE. Q No. of Total No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans Transformers KVA Tr No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires SwimmingPool o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No: of Zones No. of Detectlon and No. of Switches No. of Gas Burners In bate Nof Ranges Total No. of Air Cond. Tons No., of lerting Devices Ao. PFu,mnp Heat,Totals: N!kT lTns JKW o No, of-S—el—f-Contained No. of Waste Disposer, .,piiher Detection/Alerting DeYices No. of Dishwashers Space/Area Healing KW al Local ❑D ConMunnectpion El other No. of.Dryers Healing Appliances KW S stems:* �gcculrmf%f Levices or r Equivalent No. of Water KW No. 0 No. of Data Wiring: Heaters Signs Ballasts NO. of Devices or Equivalent No. Hydromassage Bathtubs . ...... No. of Motors Total HP Telecom munications Wfirino- No. of Devices or Etiuiv;:fcnt OTHER.- Install 28 solar panels on roof .411achat, tiotictldetail ifdesired orasreqiitreanythe inspectoli:ujvrires. Estimated Value of I, ,lectrical Work. $24,000 (When required by municipalP olicy.) n ;Cndompletion. Work to Start: TBD Inspections to be requested in, accorda ec with. ME Rule.10,andu 00 INSURANCE COVERAGE: lJnlcss waived by the owner. no permit. for the perforinaricc of electrical workmay issue unless the licenseeiprovides proof of liability insurance including "completed operation" coverage or its substantii.l.equivalent. '.The undersigned certifies that such cov yage is in force. and has exhibited proof of same to the permit issuing office.. CIlLiCK ONE: INSURANCE fff BOND [] (ffHER F1 (Specify:) I cerfify, under the pains andpenallies o perju ;1 at the information an this a fication is true and complete, If T - . A FIRM NAME.. LTC. NO.-. 510 Licensee: Signatu LIC. NO.TZ" No.;-1-1L--ZaJ _A410 (/f `'applirrahle, enter exeMP12 &I Ihe license num ber tine, Bus. Te i J 14) 7. 15 61A .0ZWJ Alt Tel. No.:,W,.4 ZA Address: J Ak. g *Per M.G.L. c.. 1.47 s. 57-61, security vWrk requires Department of Public Safely "S" License: Lic. No. 01AINERIS INSURANCE WAIVER. 1. ant aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement; Iam the (check one)EI owner El ownef s Owner/Agent$ F Signature Telephone No. EE. Q r The Commonwealth of Massachusetts Department of Industriral.Accidents d 1 Congress Stree4 Suite 100 Boston, MA 02114-2017 n� www mass gov/thea s AVorkers' Compensation Insurance Affidavit: Builders/Contractors/Eiectriclan&Tlumbers. TO BE FILED WITH THE PERAUTTING kUTHORITY. Nalne (Business/Organization/individusi) Address: City/State/ZiP: Wo Bork 01 Sol Phone #: Are you an employer? Check the appropriate box: 1. 9 I am a employer with __._,3_ ctnployccs (full and/or part-time). * 2.E] I am a sole proprietor or partnership and have employees working for me in any capacity. [No workers' comp, insurance required.] 3.(J1 am a homeowner doing all work myself. (No workers' comp: insurance required.) t 4.E] 1 am a homeowner and will be hiring contractors to conduct all work on my property; 1 will ensure that all contractors either have workers' compensation insurance or arc sole proprietors with no employees. 501 am a general contractor and I have hired the sub -contractors' listed on the attached sheet. These sub -contractors have employees and have wo kers' comp. insurance.-' 6.❑ We a corporation and its officers have exercised their right of exemption per MCrL c.. 152, §I (4),.and.we have no employees. [No workers' comp. insurance required.] M Type of project (required): 7.99New construction 8. Q Remodeling'. 9. ❑ Demolition I0 [] Building addition I LE] Electrical repairs or additions 12.❑ Plumbing repairs or additions 13.❑Roof repairs 14. ❑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 state whether or not those 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 insurance for my employees. below is the policy and job site information. Insurance Company Name: 5�� YR ' ) rCL Vr�, C- Policy # or Self -ins. Lic: #: "� 120 Expiration Date:. Job. Site Address: 48 Waverly Road City/State/Zip: North Andover, MA 01845 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;504.00 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 I do hereby rArdfy under the, information provided above is true and correct 2/3/16 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: Picone #: ACOR�70 CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 5/13/2015 TRIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Provider Group 160 Gould Street Suite 130 Needham MA 02494 CONTACT Dave Chrisos NAME: PHONENo, ('781) 444-0347 FAX No: (781)444-8961 E -MAI ADLDRESS: P g' dchrisos@ rovideri com INSURERS AFFORDING COVERAGE NAIC # INSURERA:Libert Mutual (PIC) 24198 INSURED Stalker Electric Inc 400 West Cummings Park Suite 1725-142 Woburn MA 01801 INSURER BAllmerica Financial Benefits 41840 INSURERC:The Ohio Casualty Insurance 24074 INSURERD:Star Insurance INSURER E: INSURER F: CAVFRArFR CERTIFICATE NUMRFR-15-16 Master Liabilitv REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MMIDDPOLICY EFF IYYYY POLICY EXP MM/DDIYYYY LIMITS R Hillberg/CATHYF GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 300 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ r MED EXP (Any one person) $ 15,000 A CLAIMS -MADE ❑X OCCUR BKS55932269 /23/2015 1/23/2016 PERSONAL & ADV INJURY $ 1,000,000 X ISO Form CG0001 X Contractual Liab GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OPAGG $ 2,000,000 $ X POLICYX PRO LOC I AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,000 BODILY INJURY (Per person) $ ANY AUTO B ALL OWNED X SCHEDULED WN8772911 9/12/2015 9/12/2016 BODILY INJURY (Per accident) $ AUTOS PROPERTY DAMAGE $ NON -OWNED HIRED AUTOSUTOS AUTOS Per accident Uninsured motorist combined $ 1,000,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 C EXCESS LIAB CLAIMS -MADE DED X RETENTION$ :LO , OOC $ US055932269 /23/2015 1/23/2016 D WORKERS COMPENSATION TWOSTATU- S1 X ER LIMI AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYE $ 500,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) NIA C0378029 9/12/2015 9/12/2016 E.L. DISEASE -POLICY LIMIT $ 500 I 000 If yes, describe under DESCRIPTION OF OPERATIONS below A Automobile Liability (MA) BAS55932269 4/22/2015 4/22/2016 Combined Single Limit 1,000,000 B Third Party Crime TBD 7/16/15 7/16/16 Clients Property 50,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) fICOTICIrATC unl nr-D CANCFI I ATIAN ACORD 25 (2010105) INSD25 (gninn-o m 9 1956-2010 AGUKD GUKPUKA I IUN. All rlgrtts reserved. Tho A(`()Rr1 name nnri Innn mro roniefororl m�rlr¢ of A(:(1Rn SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Stalker Electric, Inc. PO Box 155 AUTHORIZED REPRESENTATIVE Oracle, AZ 85623 R Hillberg/CATHYF ACORD 25 (2010105) INSD25 (gninn-o m 9 1956-2010 AGUKD GUKPUKA I IUN. All rlgrtts reserved. Tho A(`()Rr1 name nnri Innn mro roniefororl m�rlr¢ of A(:(1Rn Fold, Then Detach Along All Perforations COMMONWEALTH OF MASSACHUSETTS-, BOARD RD ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS A REGISTERED MASTER ELECTRICIA -STALKER ELECTRICAL CONTROLS INC WILFRED f -: STALKER 6 PERTH DR STRATH'AM 'NH 03885-2227 1!0,5& A 07/31/16 93540 .. .. .... ... Office of Consumer Affairs & Business iaraulation 7,fioMr-EPROVEMENTCONT,RA CTOR 'kegistrafton: 178990 Type: 619/2016 iIorpomtdorl STALKER ELECTRIC, INC, WH_FRED STALKER 400 VV. CUMMINGS PARK UTE 17 W,0Y.'ORN, MA -01801 Undersecretary O. 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TOWN OF -NORTH ANDOVER. PERMIT FOR WIRING This certifies that ..... ....................................................................................................................... has permission to perform ... // 1KA_,deW_f -er--c 16secle,1L., ........... 4 .............. I ................................... t ................... wiring in the building of ................... ................................................................................... dover, Mass. at ... v ....... ............. ... 4�7A /,?e� ....... Aorth An z ..................................... Fee._5�5 ... . ...... Lic-No . ................. Ak.)641- . . ..................... ELECIFRICAL INSPECTOR Check 4t 12 5 7 6 — � P,?k- W -K m4d;11--3 /_/Y�__ Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No.y� I Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL .INFORMATION) Date: KA / City or Town of: NORTH ANDOVER To the Inspector f YP 'es: By this application the undersigned gives notice of his or her intenti9pp perform the electrical work described below. Location (Street & Number) Owner or Tenant /11,0 R Owner's Address Telephone No( " W Is this permit in conjunction with a b ilding permit? Yes Rr No ❑ (Check Appropriate Box) Purpose of Building / /f/� �,f(� Utility Authorization No. - Existing Service, -W Amps /,101,,)b O Volts Overhead [Er"'- Undgrd ❑ New Service Amps Number of Feeders and Ampaci Location and Nature of Proposed Volts Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Electrical Work: Lo/- ,7 Nf' �tv Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans ✓ s Total Trsformers KVA Tran No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- rnd. rnd. o mergency ig ting Tq—El Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Tons Tot No. of Alerting Devices No. of Waste Dis osers p Heat Pump Totals: Number Tons KW ..... ...... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Secuur tof ysteinDevic: or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: 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 rvtres. Estimated Value of E ec 'cal Work: (When required by municipal policy.) Work to Start: / Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO 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 cover e 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 thA rmati n pn this application is true and complete. FIRM NAME: �f h Gia�Tit C/of"1 LIC. NO.: Licensee: /d► / I -e-. Signature LIC. NO.: (If applicable, enter "exe pt" in the license number line) Bus. Tel. No.: )� Address: 21 //gym/ r Alt. Tel. No.: L *Per M.G.cc. —147,,V51161','security wdrk requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ J� Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed K on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32W,81-, r electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑. Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Sign ure: Date: FINAL INSP CTION: Pass IN V Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: 0i DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Sheet, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Compensation Insurance Affidavit: Builders/Contractors/ElectriciansfPlumbers. TO BE PILED WITH THE PERMIT flNG AUTHORITY. Naine (Business/Orgabizaiion/lndividual): Address: r /1 / Ph #• City/State/Zip: one Are you an employer? Cheek t e a o 4ate box: 1, a employer with employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] [No workers' comp. insurance required.] i In 1 am a homeowner doing all work myself 4.1 I am a homeowner and will be hiring contractors to conduct all work on my property. ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 1 will 5. ❑I am a general contracto and I have hired the sub -contractors listed on the attached sheet. 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. 152 §1(4) and we have no employees. [No workers' comp. insurance required.] Type of project (riequired)' 7. eW-'c6nstr6d ion g,�emodelihg 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions IZU.pl=— bing repairs or additions 13,. [] Roof repairs 14.[] Other *Any applicant that checks box #1 must also f& 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 -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurancefor my employees. Below is the policy and job site information. J / Insurance Company �/ Expiration Date:. � 3 Policy # or Self -ins. Lic. #: y 7 k/ �� L % lob Site Address: j,�t Irl%y /( dl ! 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 requited under MGL c. 152, §25A is a criminal violation punishable by a fuie up to $1,500.00 and/or one-year imprisonment, as well as civil penalties O InvOestigat ons of the DIA fortisER and a fine of up to ?uran 0 a day against the violator. A copy of this statementmay b forwarded to the office coverage verification. I do hereby certify un erthepains andpenalties ofperjuYy that the information provided above is true and correct. na+P• k //r �/ official use only. Do not write in this area, to be completed by city or town offrciaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. PIumbing Inspector 6. Other Phone #• Contact Person: 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'orr 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 reg4red." 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 PIease 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-MASS.AFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia P I 11299 Date -lifliMt.1 ....... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... I ("),e- I I ........................... L .............................................................. has permission to perform ...1-:�7 ......... .................................. e P, °aI plumbing in the buildings of ........... ................ ..................................................... ... at ..A......... U. ............ .. .. . ......... . ..... , gNh Andover, Mass, ZRAFee ........ Lic. No. .. ....... ............ . ...................................... ChecL, 4 P m BING I SPECTOR FS kP MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY L PERMIT ,4_1 MA DATE I JOBSITE ADDRESS -,&CU Pop OWNER'S NAME 5 P OWNER ADDRESS TELr74?tdjFAX TYPE OR OCCUPANCY TYPE COMMERCIAL El. EDUCATIONAL Ej RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: El PLANS SUBMITTED: YES N NOE] FIXTURES -1 FLOOR--+ BSM 1 2 3 4 5 6 7 8 9 10 il 12 13 14' BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/01LISAND SYSTEM DEDICATED GREASE SYSTEM _j DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM ------ __j -------- .. ...... . ... DISHWASHER 777 DRINKING FOUNTAIN FOOD DISPOSER .. . . . .... ....... FLOOR / AREA DRAIN .........__.1 INTERCEPTOR (INTERIOR) ...... E KITCHEN SINK -E= LAVATORY .......... . ROOF DRAIN - -------- ---- . ..... SHOWER STALL SERVICE t MOP SINK . ..... ..... ........... .. .... ..... TOILET URINAL . .. .... WASHING MACHINE CONNECTION EZ, . . ..... WATER HEATER ALL TYPES I — ------F7 ,4NATER PIPING OTHER -------- ... .... J .............. . -1 77 E INSURANCE COVERAGE: I have a current liability policy or Its substantial equivalent which meets the requirements of MGL Ch. 142, Y NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY E] BOND Ej OWNER'S INSURANCE WAIVER: I mawa re 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 R-1 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 urate 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 A all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# SIGNATUR�-- J# PARTNERSHIPD#L LLC [j# MPF. JP '-4\4%j CORPORATION N COMPANY NAME CIO ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CITY ZIP TEL FAX CELL EMAIL --- urnp. FS kP 4 The Commonwealth of Massachusetts Department of IndustrialAccidents I 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. Naive (Business/Organization/Individual): Address: ,�d Stl�% pe -i 'k-, t City/State/Zip: &kA�:, � G LSkD Phone #: --IT 1 -_)Q `lp &S k Are you an employer? Check the appropriate box: 1.❑ I am a employer with employees (full and/or part-time).* 2. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 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 proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.= 6. F1 We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] \\ CG Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12. Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ 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. 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 -contractors have employees, they must provide their workers' comp. policy number. I atn an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date:. Job Site Address"'City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as 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 $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify ut�derjhe pains and penalties of peijuty that the information provided above is trite and correct. Official use only. Do not write in this area, to be completed by city or town officiab City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: r « NJ►l671 L919ILV,W;d �tw,._m_.I �?BoAFl P PLUMBE . w.� a � z\NB GAS {}T , \ .d 2s « f&SU S HE FOLLOW]#&`(ice NSE J/\ , �©®w� I \E A§ A.fAST P R M E, \� ^ ...: v° � :° » /(L J ELL � ° ... 30, SOS . t � xx s • w R. §|#G qk OlB6$-!$)§ }\ K/A ,zAIL + d« *», „ 77:3 Date. .-. , .. . i...... . ° o TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . V" ....................... . has permission for gas installation. �� v �-r .. �� +a .1 � I ..... in the buildings of .. A -vi .ci ......................... at .. LI .`.. W 'I . !U... . , North Andover, Mass. Fee. ..&-.0.. Lic. GAS INSPECTOR Check # % (Yj % FIXTHRFS MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING LU City/Town: MA. Date: `'� ° �'� ' Permit# Building Location: U AQt J \L1j .SlLJ • Owners Name: \/eQ �e 1 Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: [% Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTHRFS 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 have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policyOther type of indemnity ❑ Bond E] OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Sianature of Owner or Owner's Aaent By checking this box ❑; 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Type of License: By ❑ Plumber Title ❑ Gas Fitter Signatu a of Licensed Plumber/Gas Fitter ❑ Master 11 \ Cif Cityrrown ❑Journeyman License Number: 1 CTI 1 APPROVED OFFICE USE ONLY ❑ LP Installer LLI LU U) Z< Q N N U = H W W m= 0O W () W �} 0 o: H 0 0= 0 2 z y H W LU m° Q Z a ~ o w w x W to W U Z 0 0 W W 0 W H p= LL' r' ` i 0 W Z 0 J I— H 0 Z J 0 u_ N= W W ~ ww Z 0 W >- a W N 'I 0 Q x Q z MWO O a z 0~ H>>> H O 0 LL 0 SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 Ru FLOOR 4 FLOOR 5 FLOOR 6 FLOOR --i 'FLOOR P FLOOR Check One Only Certificate # Installing Company Name: \\ CC) . El Corporation Address:_�O SQ%nQ City/Town: K3AL c� State: ❑ Partnership Business Tel: 'l 1 �'11� U 3 \ Fax: 1-7!t 1 ct `(Z i(4 a1 irm/Company Name of Licensed Plumber/Gas Fitter: 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 have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policyOther type of indemnity ❑ Bond E] OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Sianature of Owner or Owner's Aaent By checking this box ❑; 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Type of License: By ❑ Plumber Title ❑ Gas Fitter Signatu a of Licensed Plumber/Gas Fitter ❑ Master 11 \ Cif Cityrrown ❑Journeyman License Number: 1 CTI 1 APPROVED OFFICE USE ONLY ❑ LP Installer f, 9658 Date.... 91 ... 2—.-Z.,.1&? ... .... .. ........ (00"OO'.oTR" 0, _'.;1ti 0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................. has permission to perform ...... ................................................................... I wiring in the building of ..............1.!.1..?...?...................................... 1('? z-.. /"A , N rth Andover, Mass. at.................................................... ....... v ........ .. . orth Ando Fee...Lic. No. Ze .................................. ELECTRICAL �S ��R Check 4t 1 �•. 5oW17ffluffWwa lUff 6 5'4?Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank �M 5� V`• APPLICATION FOR PERMIT TO PERFORM�ELode 1ECTRICCA a WORK All work to be performed in accordance with the Massachusetts Electrical (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER -.--To the Inspect r of Wires: By this application the undersigned gives notice of his or her' to form the electrical work described below. LocationStreet & Number)JA44- /Z` ( Telephone No. Owner or Tenant Owner's Address Check A ro riate Box) Is this permit in conjunction with a building permit? Yes � No ❑ ( PP P Purpose of Building "Al 6 / Utility Authorization No. Volts Overhead Undgrd ❑ No. of Meters Existing Serviq::,Amps b Y Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / _ / F Number of Feeders and AmPacit y w/o -( ✓^-+� ✓"^� �� 1 Tl I Location and Nature of Proposed Electrical Work: &&aheh Completion of the following table may be waived by the Inspector 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 ig ing No. of Luminaires Above In- Swimming Pool rnd. rnd. ❑ 6.16f mergency BatteKy Units FIRE ALARMS No. of Zones No. of Receptacle Outlets No. of Oil Burners No. of Detection and No. of Switches No. of Gas Burners Initiating Devices Total No. of Air Cond. Tons No. of Alerting Devices No. of Ranges Heat Pump Number. Tons KW .....•... No. ofSelf-Contained Detection/Alertin Devices No. of Waste Disposers Totals: Local ❑ Municipal ❑ Other No. of Dishwashers Space/Area Heating KW Connection Security Systems: Heating Appliances KW No. of Devices or Equivalent No. of Dryers of No. of Data Wiring: No. of WaterNo. KW Signs Ballasts No. of Devices or E uivalen t Heaters Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or E uivalent OTHER: -Attach additional detail if desired, oras required by the Inspector of Wires. Estimated Value of Electrical Work: a • (When required by municipal policy.) Work to Start: 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 K BOND ❑ OTHER ❑ (Specify:) I certify, under the pais s and penalties of perjury, that the information on this application is true and complete. 'e f'r✓1-r LIC. NO. FIRM NAME: ✓�'e. /� LIC. NO.: --wo, Licensee: PviH� _Signature Cr (If applicab e, enter "exempt" in the license number line.) Bus. Tel. No.: Address: S `tiG�Al- Alt. Tel. No.:����� *Per M.G.L c.147, s. 57-61, security wor requires Departm nt o public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have th6 liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) [] owner ❑owner's Owner/Agent Telephone No. PERMIT FEE:. Signature The Commonwealth of Massachusetts Department of Industrial. Accidents Office of Investigations 600 Washington Street t Boston, MA 02111 �,. ,• • www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):✓I C' pee Address: r,27, /�� City/State/Zip: Xl _��,{i/ \16� Phone #: Are ,yo n employer? Check thea 'i priate box: 4. ❑ I am a general contractor and I 1. I(� am a employer w' employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its [No workers' comp. insurance officers have exercised their required.] 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other, *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. f 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: LIF /r�/ y 41 City/State/Zip: N �Yi> v, --,-- Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine •, of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido Hereby certify un er t e pains and penalties of perjury that the information provided above is true and correct. Si ature: Date: Z Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: - Date... af..�. f pORTH , p to h, 6 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION .t �..�.This certifies that .�- .......... ...... has permission for gas installation�r: - . IV i in the buildings of ... -�-� ............. at ............ . ............ , orth Andover, Mass. Fee..A2,. e•'.:" Lic. No... ;�E&... .. ............ GA$�11 CTOR ;Check # �1J A m IVIASSACHUSETTS UNIFORM APPUCA (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations L Owner's Name New ❑ Renovation Replacement D FOR PERMU TO DO GAS FTI'I C Date9— Permit# W�Z/ Amount $ Plans Submitted (Print or type)%L' Chec one: Certificate Installing Company Name ffe--IV7 l / Corp. Address " `'� `' v Partner. uslness Telephone — 77 Firm/Co. Name of Licensed Plumber or Gas Fitter Lf� _p ti OS INSURANCE COVERAGE Check one/- I have a current liability Insurance policy or it's substantial equivalent. Yes No If you have checked yes, please ind- a the type coverage by checking the appropriate box. Liability insurance policy E Other type of indemnity 1:1 Bond 0 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 D Agent 1 i hereby certify that all of the details and inlormatton 1 have subnutted (or enterea) in aoove appitcanon are true ana 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 S to s Co and Ch ter 142 f t1je General Laws. own S69natuVof Licensed Plumber Or Gas Pitter Plumber L Gas Fitter tcense Numl5er Journeyman -jASEM ENT AST. FLOOR 13RD. FLOOR -6TIi. FLOOR (Print or type)%L' Chec one: Certificate Installing Company Name ffe--IV7 l / Corp. Address " `'� `' v Partner. uslness Telephone — 77 Firm/Co. Name of Licensed Plumber or Gas Fitter Lf� _p ti OS INSURANCE COVERAGE Check one/- I have a current liability Insurance policy or it's substantial equivalent. Yes No If you have checked yes, please ind- a the type coverage by checking the appropriate box. Liability insurance policy E Other type of indemnity 1:1 Bond 0 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 D Agent 1 i hereby certify that all of the details and inlormatton 1 have subnutted (or enterea) in aoove appitcanon are true ana 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 S to s Co and Ch ter 142 f t1je General Laws. own S69natuVof Licensed Plumber Or Gas Pitter Plumber L Gas Fitter tcense Numl5er Journeyman -r Date � ? //G - ez� . +..... . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...... - has permission for gas installation. u''...1/ .... . 4 i the buildings of ....................... . Ik at . ` �.. �'� ...... . North Andover, Mass. Fee ...... . Lic. No...'`.. ........ . GAS INS., R Check # r_� 5035 MASSACHUSETTS UNIFORM APPLICATION (Print or Type) ,Le j .Mass. Date G Building New ❑ Renovation ❑ I PERMIT TO DO GASFITTING �✓ ?errnit # �,3�� "' Owner's Nam L-J7�w Type of Occupancy_ Plans Submitted: Yes ❑ No ❑ Installing Company Name :2(-jAi (2_A . -,�51M MA Tri r 0 Check one: Certificate Address _ 3 Q Or)A C >a h ,4. pj `NI ❑ Corporation Ih E 7H Ue 0 18- 01 ❑ Partnership Business Telephone691 — 9 9-7 f 2-,hrm/Co. Nasse of Licensed Plumber or Gas f=itter "f o AE P T A - 5 A M rYl r9 Tr4 n INSURANCE COVERAGE: I 'bave a current I�'ability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes [' No ❑ If you have checked rtes, please Indicate the type coverage by checking the appropriate box A liability insurance policy 0 Other type of Indemnity ❑ Bond ❑ 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 theed for this application ' be in compliance with all Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ne Laws. TYD9 of License:L� T-IPlumber n ure n _. u or itter Title tter tt License Number V3-�) Journeyman I ' 4 I Installing Company Name :2(-jAi (2_A . -,�51M MA Tri r 0 Check one: Certificate Address _ 3 Q Or)A C >a h ,4. pj `NI ❑ Corporation Ih E 7H Ue 0 18- 01 ❑ Partnership Business Telephone691 — 9 9-7 f 2-,hrm/Co. Nasse of Licensed Plumber or Gas f=itter "f o AE P T A - 5 A M rYl r9 Tr4 n INSURANCE COVERAGE: I 'bave a current I�'ability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes [' No ❑ If you have checked rtes, please Indicate the type coverage by checking the appropriate box A liability insurance policy 0 Other type of Indemnity ❑ Bond ❑ 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 theed for this application ' be in compliance with all Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ne Laws. TYD9 of License:L� T-IPlumber n ure n _. u or itter Title tter tt License Number V3-�) Journeyman I ' W t d F Z_ P W N O O ° O H F- a O O Z Z d � ° a J O O Z W O 0 f' W V } J � IL < d Q W � ul � Z F f