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Miscellaneous - 5 MAPLE AVENUE 4/30/2018
5 MAPLE AVENUE 210/019.0-0015-0000.0 - y Date..... .� .........:...1 OF�►ORTIy,� TOWN OF NORTH ANDOVER * * PERMIT FOR WIRING CHU *-74 S� IIi This certifies that .. �..�/�`° �° JP ...�. . .................... .............../.. ................................ ✓Z��, 1s ..'t l..j!:s.....�.s.... has permission to perform /4.:......................�..............................7..... � �. wiring in the building f.... ``...^f..'��..L.-.-................................................................................. at .......'5.................................G;tO( ...... .�+.' .jG-'........................,North Andover,Mass. Fee.&q. ...........Lic.No.02?t°.� .................................................................................... ELECTRICAL INSPECTOR Check# - J06-t � 1 I�I, Commonwealth of Massachusetts Official Use Only Permit No. (Jd Q a Department of Fire Services Occupancy and Fee Checked ,M BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his qiher intention to perform the electrical work described below. Location(Street&Number) ��� 1 #Alowi i/ Owner or Tenant ( q Telephone No. 7 7,;P), Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: l w 7 Ne W i f C k/ rs. S QUt,T�r d-f Completion of the following table may be waived by the Inspector of Wires. Trans No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Total Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets S 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. 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 ElConnectiMunicipal El Other on No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No. of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail 1f desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: JOC O (When required by municipal policy.) Work to Start: / ,S / � Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE O 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under tlZe pa' s tend enalties of per ury,that the information on this application is true and complet FIRM NAME: . f C r C LIC.NO.:�(jC-?e Licensee:fiv 7--A C'Gi e w Signature LIC.NO.: (If applicable, ter "exem t"in the nse nz mber line.) Bus.Tel.No.:,/, d i Address: X c4 lic /VoyV 1'T a jG 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 PEhMIT FEE: $ 10 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 on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an 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 ofthe 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 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: i Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass IM Failed W Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ff� FINAL INSPE ION: Q,t n �7 A Pass Falled wo Ins Re d($.) ❑ Inspectors Comments: 4 41 Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com 11 . x� The Commonwealth of Massachusetts r. ._ Department of IndustrialAccidents M `9._ r��• r 1 Congress Street,Suite 100 _ tl021'14-2017 - - Boston,MA. N^ q` www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Piumbers. TO BE FILED WITH THE PERMITTING AUTHOffl'Y. Please Print Le bl A licant Information Name(Business/Orgariization/fndividual): Address: G?{ doJ�.� (j��`I� Phone City/State/Zip: V Are you an employer?Check the appropriate box: Type otproject(required): em toy ees full and/or part-time).* 7. E]New'construction 1.K(I am a employer with P 2.F]I am a sole proprietor or partnership and have no employees working forme in $. 1Zemodeliiig any capacity.[No workers'comp.insurance required] 9, ❑Demolition 3•0 I am a homeowner doing all work myse]£[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 Electrical repairs or additions 11.❑ ensure that all contractors either have workers'compensation insurance or are sole ' l?lUmbin1 repairs Or additions ' 12�r� proprietors with no employees. 13-.E]Rbof repairs 5.❑I am a general contract'or and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance x 14. Other 6.Q We are a corporation and its. ' officers have exercised their right of exemption per MGL c. 152,§1(4),and vre have no eMpl8ydes:[No workers'comp.insurance required] n policy *Arty out the se applicant that checks 1k, ,,v. indicating they are doing outtliese on all work andthen hire outside w g their-workers, aontrac o�s must submit new affidavit indicating such. Homeowners who submit•tlus,; this box must attached additional sheet showing the name of the sub-contractors and state whether or not those entities have $Contractors that check 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. 814 t 11v der po.Tj'd/"ri Insurance Company Name: Expiration Date' Policy#or Self-ins.Lic.#: S- 7 _ 7G�►�� City/State/Zip— Attach a copy of the vvoxkers' compensation policy declaration page(showing the policy number and expiration date). olation by a fuld Up to 0-00 Failure to secure coverage as requited under zil enalties?inthe form of a25A is a aSS`1'OPal iWORK ORDER punishable nd a fine of up to $250.00 a and/or one-year imprisonment,as well a p day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby certify under tliepains and penalties ofpesjury that the information provided above is true and correct. _- Date: � 7 � Si ature: Phone#: f S /0 official use only. Do not write in this area,to be completed by city or town official Permit/License# City or Town: 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: Information and Instructions n tions I 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 Wi , express or implied,oral or written." An employer is'd'efiried 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 Iicensing 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 applicaiit•wlio has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(l)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 thi's chapter have been presented to the contracting authority." Applicants j 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 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. Shouldou have an y y questions regarding the law or if you are required to obtain a workers' compensatiorl 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 I I COMMONWEALTH' M", USE' n o 0 0 0 1; t>ARWOIF ELECT' ICIAN: 1.:..,: {SSUES} THE .fOLLC SE AS,-::'A- :Dry A RfGI.ST,EREDMAS.IER FLECTRSI�'IA A0 `ELECTRIC LLC A4THONY JE BSA ll EU n / LU' ' 16 WORCESTER RD `s `� "W 1`OWNSEN �� � �� ! D - M� (. 1.46 'Q6'� >qn 7 69 82r'�6 . ' >< �. a, Date..... ....... "I 'l 5 ,/-, 0 40RT TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING CHU This certifies that............. ..................................... .......... ............... ...... ...... has permission to perform....... ....... ...61`46r. plumbing in ..I.the buildings of ............................................................ at..........5. .. 7 ........ .. .. ... .... .. .. ................... North Andover, Mass. ..... .. .... . ..7'***' Fee:'�. .O........Lic. No/!! .... ................................................................................. PLUMBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - CITYNORTHANDOVER MA DATE 61/6/2016 �PERMIT# JOBSITE ADDRESS 5-7 MAPLE AVENUE OWNER'S NAME DARER POWNER ADDRESS a TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL F RESIDENTIAL 1 PRINT CLEARLY NEW: 'I RENOVATION:,_ REPLACEMENT: PLANS SUBMITTED: YES E] N0[ FIXTURES-1 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE i .2 1111 1 1,. __ DEDICATED SPECIAL WASTE SYSTEMIw } � � DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM n - DISHWASHER . .. ,._, .. ..E DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) E E a E KITCHEN SINK m. r- i..._.- LAVATORY;_ -- ... 1 - ROOF DRAIN SHOWER STALL SERVICE/MOP SINK Imm TOILET t tr URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 2 -� WATER PIPING A OTHER I I _._ _. ._. _....,--.. ._ �,.,,_' ,...... ....,,.. ,,. -.....E ,. .. 3 .... .. .... ,-......_.__..._ .,. _..,-_ ,., INSURANCE COVERAGE: I have a current liabiliinsurance 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 � 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 E�3 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME MIKE CAPELESS LICENSE#X15851 NATURE MPO JPEl CORPORATION 1_.}#� 'PARTNERSHIP 11# LLC #� m COMPANY NAME CAPELESS PLUMBING&HEATING ` ADDRESS 160A PLEASANT ST _ .._.:.... _w.. E _ .. �. .,w.: .. x CITYNORTH ANDOVER €STATE MA o- ZIP 01845 TEL X978-3382-1017 FAX CELL EMAIL t - 'ti �� i I� I i �/ �� J�� Date.... ..................... ......... OF r►ORTh,� TOWN OF NORTH ANDOVER � � 9 PERMIT FOR GAS INSTALLATION CHU t `This certifies that ........ .'� t:.:: ?c........................................................... has permission for gas installation....19.-))�!-.5......................................... inthe buildings of................ �..42"1............................................................................ at............... ........j..... c'...................... ^.' , North Andover,Mass. Fee ."'... Lic. No ............ GAS INSPECTOR Check# �i j o MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _.. {{ bb CITY NORTH ANDOVER MA DATE11/6/2016 PERMIT# U _.. _.. JOBSITEADDRESS=5 7 MAPLE AVENUE OWNER'S NAMEDAHER� Few OWNER ADDRESS TYPE OR OCCUPANCY TYPE COMMERCIAL`; EDUCATIONAL RESIDENTIAL`,_,,,,`, CLEARLY NEW „j RENOVATION: ' REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES-1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 2 l ui ...._... .. BOOSTER -- ----,- CONVERSION BURNER - __ COOK STOVE _. T a - E.. .. ... m,3 t. ..L, DIRECT VENT HEATER DRYER : _ l .. .. . FIREPLACE ,.. p� {......�,.. T,,,,, .r, _ l. FRYOLATOR ( FURNACE .... . .. ... .. _ ..._.. s.... .,i, ,, I _F. GENERATOR µ GRILLE I' INFRARED HEATER LABORATORY COCKS _. MAKEUP AIR UNIT w 1 E . J, OVEN sE 3 f POOL HEATER _ _. s" ROOM/SPACE HEATER _L. „ ROOF TOP UNIT TESTi,. UNIT HEATER _. UNVENTED ROOM HEATER WATER._... ...__ E OTHERS 1. 1 4 i �_J_, =INSURANCE COVERAGE :.......... I 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 COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 'a OTHER TYPE INDEMNITY BOND El 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ......... ........................ .. PLUMBER-GASFITTER NAME[MIKE CAPELESS LICENSE#[15851 I SIG ATURE MP MGF[:1 JP[j JGF 1 k LPG] CORPORATION 14 PARTNERSHIP;,,. 4! ILLC, #i COMPANY NAME:L'CAPELESS PLUMBING&HEATING ADDRESS 160A PLEASANT STREET CITY N ANDOVER } STATE# MA iZIPE 01845 TEL'978-382-1017 FAX _.CELLS ,. __,!EMAIL l �'.• •;,,,,� ����� �_`�` V 3 y r 116/21)16 ACcela Cifimftc:ess Announcements Register for an Account I Lopin Need Help? For technical assistance in using this web application, please call the ePLACE Help Desk Team at (844)733-7522 or(844)73-ePLAC between the hours of 7:30 AM-5:00 PM Monday-Friday, with the exception of all Commonwealth and Federal observed holidays. If you prefer, you can also e-mail us at ePLACE helpdesk state.ma.us. For assistance with non-technical, please contact the issuing Agency directly using the links below. Translation Information-Click Here Alcoholic Beverages Control Commission Division of Professional Licensure Browser Compatibility: • For Application/Renewal:lf your application requires a file upload, Microsoft Silverlight is required to do so. Please see the link below for instructions to download Microsoft Silverlight.Silverlight Download • File a Complaint:lnstructions above apply for filing a complaint if you are uploading a file/picture. Home Manage Licenses&Permits File&Track Complaints Please refer to the Licensing Entity's website for additional information regarding the status and discipline information shown below. For DPL information,please visit the DPL website. For ABCC information,please visit the ABCC website. Information Pertaining To: Master Plumber 15851 Licensee Detail License Number: 15851 Licensing Entity: Board of State Examiners of Plumbers and Gas Fitters License Type: Master Plumber Type Class: M License Issue Date: 09/16/2011 License Expiration Date: 05/01/2016 Status: Current Current Discipline: Other Discipline: Name: MICHAEL N CAPELESS Business Name: DBA Name: Mfps-1/elicensing.state.maiNCCibzenA=ess/GenerdPrope ty/UcenseeDetail.asp(')bc:enseeNumber=1585184.iic Type=Master%2 timber a/1 CIS, • The Commonwealth of Massachusetts • Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 •' - ,�.�'t www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNUTTING AUTHORITY. Applicant Information / Please Print Legibly Name(Business/Organization/Individual): ,5--d- �7=n Address: fi,S�Ln City/State/Zip:N� )q d d Y\tr7M+018_gS Phone#: 3 �-- ®I Are you an employer?Check the appropriate box: Type of project(required): I Q, am a employer with r� employees(full and/or part-time).* 7. Q New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in $, ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.F1 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition 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.❑Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ $ 13.[:]/Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. ' Other 1 �/��� f•P 1Yl 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 am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. A/� , ]�� _ Insurance Company Name: /"I(,i.�I� e_• I— cS Policy#or Self-ins.Lie. 7/) Expiration Date: / Job Site Address:&/ IV4,gDl7° /s r City/State/Zip: fV, I W 01"j 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 �painnss hand penalties of perjury that the information provided above is true and correct. Signature: `��!Z�LX L �� ✓�� Date: 1/1,0 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#: 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 cant'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-MA.SSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia A� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 10/01/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Matthews Insurance Agency Inc PHONE g7g 681-1112 FAX (978)685-3855 182 Parker St ac No Ext: ( ) ac No: E-MAIL ADDRESS: Lawrence,MA 01843 INSURER(S)AFFORDING COVERAGE _ __ NAIC#_ INSURER A. Atlantic Casualty INSURED Michael Capeless INSURER B: Arbella 160A Pleasant St. ATLANTIC CHARTER INS CO North Andover,MA 01845 INSURER c: INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY L143000684 03/07/2015 03/07/2016 DAMAGE TO RENTED 1��000 PREMISES Ea occurrence $ CLAIMS-MADE F-I OCCUR MED EXP(Any one person) $ 1,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT _(Ea accident)--- __ 1 , _ANY AUTO HC357357 - 08/30/2015 08/30/2016 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per,accident)_ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- -— — -- AND EMPLOYERS'LIABILITY _ __.TORYLIMITS _._OER TH ._TH ANY PROPRIETOR/PARTNER/EXECUTIVE YIN F--1 N I A100708 05/16/2015 05/16/2016 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Heating or combined heating and air conditioning systems or equipment,installation,servicing or repair,plumbing NATIONAL GRID USA COMPANIES AND ACTION INC.ARE LISTED AS ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLATION Town Of north andover North andover,MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Date..51n. .......... 11310 TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING This certifies that.7 ....... ....... ........................................... has permission to perform...(,n, v4a......................................................... plumbing in the buildings .................................................. at...........I.......mcq.�...............tV PA",A.................... North Andover, Mass. Fee.......................Lic. NoZ.�h).... ................................................................................. PLUMBING INSPECTOR Check# �Z ,aeretsvreve eaevc.e a..e aseaee veee®s rae o s.evve s a.oea o ♦see ra a ceeeeae e e v e o..oee veer a s.wevwnvas B�eonee _. CITY NORTH ANDOVER MAA DATE !—1 PERMIT# I�D a _ JOBSITE ADDRESS /AL 6= !!r OWNER'S NAME �f O(/AJ 51-lell tla j OWNER ADDRESS SAME TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT - CLEARLY NEW:,-,.- RENOVATION — REPLACEMENT ✓ PLANS SUBMITTED YES a0 NO FIXTURES I FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN 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 1 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 Y IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY v✓= 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ;.- ' 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME i HOMAS HALLORAN LICENSE# 24833 SIGNATURE MP JP .e CORPORATION: ;# PARTNERSHIP # LLC. # COMPANY NAME HALLORAN PLUMBING ADDRESS 826 DALE ST CITY NORTH ANDOVER STATE MA ZIP 01845 TEL 978-685-9504 FAX 978-208-0540 CELL EMAIL tomhalloran@comcast.net 1 ` � f ! .� . .� ` i11 I C I 1 I I / � Date....... ................................... 40Rrj, 01r,".. 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ........1 .................................. ......... .......................... ....... .. ....... has permission for gas installation .............................. �Ie ��11 11-�....................... .......... ....... ........ in the buildings of ........ ........................... at...... CY. .le................Q........................................ North Andover, Mass. Fee.;k...... Lic. No2,�.M.... ..................................................................... GASINSPECTOR Check# ul 1:3 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY NORTH ANDOVER MA DATE 9—I–1 PERMIT# )D I Il w JOBSITE ADDRESS OWNER'S NAME S°11165XI r1vTT OWNER ADDRESS SAME TEL FAX TYRINT OCCUPANCY TYPE COMMERCIAL: EDUCATIONAL RESIDENTIAL] ,-CLEARLY NEWO RENOVATION: REPLACEMENT:✓ PLANS SUBMITTED: YES NO✓� 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 MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER INSURANCE COVERAGE ,..have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Z✓ NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ✓] OTHER TYPE INDEMNITY F_� 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: OWNERE3 AGENT`M 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 with all Pertinent p vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME THOMAS HALLORAN LICENSE#24833 SIGNATURE MPO MGFO JPS JGF LPGI: CORPORATION PARTNERSHIP# LLC:# COMPANY NAME:T.HALLORAN PLUMBING ADDRESS 826 DALE ST CITY NORTH ANDOVER STATE MA ZIP 01845 TEL 978-685-9504 FAX 978-208-0840 CELL 978-685-9504 EMAIL tomhalloran@comcast.net � r �� ���� _� r1� �1 1 �' r < The Commonwealth of Massachusetts = Department of IndustrialAccidents i' Office of Investigations 1 Congress,Street,Suite 100 Boston,IIIA 02114-2017 ,�. www.rnassgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricions/Plumlbers Applicant Information Please Print Legibly THOMAS HALLORAN Name (Business/Organization/Individual): Address: 826 DALE ST. CitylState/Zip:NORTH ANDOVER phone#.:978-685-9504 Are you an employer?Check the appropriate box: Type of project(required): 1.® 1 am a employer with 4. ® 1 am a general contractor and I employees(full and/or part-time). have hired the sub-contractors 6. ®New construction " 2.ED 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' [No workers' comp.insurance comp.insurance 9. ®Building addition required.] 5. ® We are a corporation and its 10.®Electrical repairs or additions 3.0 1 am a homeowner doing all work officers have exercised their 1 LO Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 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 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. 1 atrt an employer tliat is providing workers'cotnpensation 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 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 ofthe 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. Sisnature: Date" Phone#: 978-685-9504 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 IIS OMMONWEaCLTH OF MASaACHUSETTS PL UMt3E#t' / ASF!TTERS...=.> ISSUES. LOW., LICENSE LiCENSf#3 AS A JOURNElftAN PLUM13I3 TH,AiQS:M HALLO"N U) ''$2b DALlw S� �, � fRTH ANDOVER MA 01845 ]422 . J 24833' 0 /t)1/.1:6 223446 i I ;I Date • �'{'LNpy ' TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION his certifies that . -� j •�lt ��. . . VA, � has permission for gas installation . . . 40 *.— — 1 1 * * in the buildings of. . .S . ��� . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . .✓,r. .M. }'C . A�c.. . . . . . . . . . .North Andover, Mass. . Fee --�.. . . Lic. No...-2 ✓i ( �• . . . GASINSPECTOR Check # 8706 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY NORTH ANDOVER MA DATE "� �`3 PERMIT#_� JOBSITE ADDRESS A1,f PZdF- /-?ve OWNER'S NAME 70�ysJ OWNER ADDRESS � �/ ve TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL F� EDUCATIONAL ._' RESIDENTIAL?.0 PRINT CLEARLYNEW RENOVATION REPLACEMENT tp , PLANS SUBMITTED: YES ` NO G', APPLIANCES Z 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 - MAKEUP AIR UNIT OVEN POOL HEATER I ROOM 1 SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER U14VENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES i NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENTS; SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. > l PLUMBER-GASFITTER NAME LICENSE# 24833 SIGNATURE MP :,,. MGF JP j(; JGF LPGI�yFM CORPORATION ryT# PARTNERSHIP �,y# LLC COMPANY NAME:T.HALLORAN PLUMBING ADDRESS 826 DALE ST. J CITY NORTH ANDOVER STATE MA ZIP 01843 TEL 978-685-9504 FAX CEL&XV—:5 EMAIL The Commonwealth ofMassachusetts CIX _ Department o I ndustrial Accidents A, aceoIn vesti ations� 600 Washington Street V Boston, AM 021.11 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers lease Print Legibly Ap l><cant Information - Name(Business/Organization/Individual): / �� �' � "�' � Address: L '� IV4 Phone#: CitylState/Zip: ��j Are you an employer? Check the appropriate box: Type of project(required): 4. I am a general contractor and I 5 ❑New construction I.❑ I am a employer with have hired the sub-contractors employees(full and/or part-time).' 7, Remodeling listed on the attached sheet. ❑ Z. I am a sole proprietor or partner- These sub-contractors have g, M Demolition ship and have no employees employees and have workers g ❑ Building addition working for me in any capacity. comp. insurance I [No workers' comp. insurance 10.E] Electrical repairs or additions required.] 5• ❑ We are a corporation and its officers have exercised their 11.❑Plumbing repairs or additions 3.❑ I am a homeowner doing all work per exemption of right MGL myself. [No workers' comp. g P P 12.[:] Roof repairs c. 152,§1(4),and we have no 13.❑ Other insurance required.]t employees. [No workers' comp. insurance required.] 77--7777 *Any applicant that checks box 41 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Expiration Date: Policy#or Self-ins.Lie.#: 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 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 certify under the pains and penalties of perjury that the information provided above is trace and correct. Z--f.s Signature: Phone#: 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#: I r+ COMMONWEALTH OF MASSACHUSETTS'.: _ .• -• • jo • • • • II P. ERS A D GASFI RS .. I L{CENS£D' AS A JOURNEYMAN PLUMBER ` i ISSUES THE ABbVE LICENSE TO I i ITHOMAS M HALLORAN I }rn 826 DALE ST b it TH. AN. DOVER MA 0184577%'] 422 I� NOR +I 2483 Date....1.1. � ..//.�......... HORTF/ OF ,� TOWN OF NORTH ANDOVER W PERMIT FOR GAS INSTALLATION s3ACHU5� Thiscertifies that ...... .................................................................................................... has permission for gas installation✓ '... inthe buildings'' of................................................................................................................... at.z;.'.. .rrK1t�... .. ............. , N Andover, Mass. ... Fee-P!0...0......... Lic. No. GA I SPECT Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY -- - MA DATE / S PERMIT# JOBSITE ADDRESS Z- I OWNER'S NAME OWNER ADDRESS TE FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PST ® RESIDENTIAL CLEARLY NEW' RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES D NO APPLIANCES 1 FLOORS, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER -[_ )n, 1 .,_,_.1 _, l _ =I= BOOSTER CONVERSION BURNER COOK STOVE s_I . .._.... _ r _. I DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE _ _ GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT -- TEST UNIT HEATER UNVENTED ROOM HEATER MJER HEATER _ OTHER —_ L I— 117-111-1 I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ._1 NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY __I OTHER TYPE INDEMNITY 0 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 requir CHECK ONE 0 LY: 0 -I T �I SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this ap lication are true d ace to be of y nowledge and that all plumbing work and installations performed under the permit issued for this application 'll be in compli ce w I Pert' rovi 'o of the Massachusetts State Plumbing Code and Chapter 142 offtthe .General ws. PLUM BER-GASFITTER N E y` o i (I6}�-� ^�LICENSE# O (J NATURE MW-1 MGF[:J1 JP 0 JGF LP 1® CORPORATION 0# -?-i f3 11 PARTNERSHIP I#=LLC ]#�-�_� COMPANY NAM i (►tibLI� _ ADDRESS CITY , STATE ZIP O j �TEL LY FAX CELL ---` _ EM41L f "7 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION WTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES I - ' The Commonwealth of Massachusetts Department oflndustir'ialAccidents 1 Congress Street,Suite 100 _ - Boston,MA.02114-2017 �r www mass.gov/dia Workers'Compensation Insurance Affidavit:Builder/Contractors/l lectricians/Plumbers. TO BE FILED WITH THE PERMCTTING AUTH012II'. .Please Print Le 'bl A �licant Information Cm Name(Business/Oigatiization/Individu �- Address: Z— City/State/Zip: - ,<.,. Are yon an employer?Check tiie appropriate box: Type of project(required): em to ees full and/or part-time). 7. ❑N6W'construotion 1, m a employer with P y 2. I am a sole proprietor o partnership and have no employees�✓orking£or me in 8. Remodeling any capacity.[Nowork r' omp.insurance required.] 9, 0 Demolition 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 0 Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.0 Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12� .Plumising repairs or additions 5.FJ I am a general contracto r'and I have hired the sub-contractors listed on the attached sheet. 13TJ Rb6f rep airs These sub-contractors have employees and have workers'comp.insurance.t 14.I Other 6.FJ We are a corporatiori and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no .mpldydes.[No workers'comp.insurance required.] *Any applicant that check's bbk 41 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors that check this l"I must attache additional sheet showing the name of the sub-contractors and state whether or not(hose 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 jolt site information. Insurance Company Name: ~ S 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 . Failure to sec coverage as requited der MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or on ear im °sonment,as w as zvil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a da aga' t the•violat r.A opy of t 's st lement may be forwarded to the Office of Investigations of the DIA for insurance Y coverage verification. X do Isere y certify u de epai and i s ofperjury that the information provided a b ve is ueand correct. D Si ature: 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): LLhhe ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Phone#: on: r' Infoarmation 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 bite, express or implied,oral or written." An employer is d'efnied as"an individual-,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enferprise,and including the legal representatives of a deceased employer,or the receiv6f6r,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 b6 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 hasnot produced-acceptable evidence of compliance with the insurance coverage xeq'W 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=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"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-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Office�s��ly / 01 4e Tommunwrato of Magoar4ugef#s Permit No. - -' L/ 13epartment laf Public %fetq Occupancy& Fee Checked - BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CM 19:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date S s or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform the electrical w rk described below. Location (Street & Number) _ 7 e Owner or Tenant vy'+ sum Owner's Address Is this permit in conjunction with a b iiding permit: Yes ❑ No (Check Appropriate Box) Purpose of Building �t'�V �� ` UtiIJK Authorization No. Existing Service Amps ZZJ/ 71'-7 Volts Overhead Undgrnd ❑ No. of Meters New Service Z00 Amps �' Z�(J Volts Overhead Undgrnd ❑ No. of Meters Z Number of Feeders and Ampacity , J ' Location and Nature of Proposed Electrical Work �1�� 1f z,Fee ,, ILIN 60 TQ ;Rf-(v No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above In- grind. ❑ grind. ❑ I Generators KVA No. of Emergency Lighting No. of Receptacle Outlets ✓ No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ran es No. of Air Cond. Total No offtDet cion and g tons 9 No.of Heat Total Total No. of Disposals Pumps Tons KW No. of Sounding Devices No. of Self Contained. No. of Dishwashers I Space/Area Heating KW Detection/Sounding Devices No. of Dryers Heating Devices KW Local Municipal ❑Other ❑ Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Complgt4d Operations Coverage or its substantial equivalent. YES NO r= I have submitted valid proof of same to the Office. YES L;' G if you have c)Iecked YES, please indicate the type f cov rage by checking the appropriate box. /( ` ��� INSURANCE v' BOND Z. OTHER = (Please Specify) / Exp' ati n ate) Estimated Value of Electrical Work$ Inspection ection Date Requested: Rough Work to Start h Final P q g Signed under the Penalties per ury: - FIRM NAME ,T�C C LIC. NO. Licensee r th V Signature LIC. NO. Bus. Tel. No. -3-S93/ Address �✓ ��C « /"� Ljdt/-eKAlt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE S (Signature of Owner or Agent) x•6565 40 I N2J v ?J DatV-�1....................... HORTI♦ °f�"`°;•'"� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING sCHus�� This certifies that .. .... ............. .................................................... has permission to perform . G ti wiring in the building of�............ ...... ............ s at.................. .. ..... ............................................ ,North Andover,Massy FeO.v....:7........ LIC.Nd:r. ............................................................. ` ELECTRICAL INSPECTOR O WHITE:Applicant CANARY: Building Dept. PINK:Treasurer THEMOR1'O[-01 ®E®C-DAiIGROUP® .5 September 19, 2014 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B Building Commissioner, or Inspector of Buildings c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Board of Health or Board of Selectmen c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Fire Department or Arson Squad c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1479999 Insured: JOHN & BARBARA SHELLNUTT Address: 5-7 MAPLE AVENUE, NORTH ANDOVER, MA Policy No.: F0648703 Loss Date: 09/17/2014 Loss Type: Building or Other Structure Damage A claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to my attention and include a reference to the captioned insured, location, policy number, loss date and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property, and the claim will be paid in our customary manner. Sincerely, Michelle M. Roust Senior Property Claims Examiner 1-800-688-1825 x1171 NORFOLK&DEDHAM MUTUAL FIRE INSURANCE CO. 222 Ames Street,P.O.Box 9109,Dedham,MA 02027-9109 DORCHESTER MUTUAL INSURANCE CO. Telephone:(800)688-1825 FITCHBURG MUTUAL INSURANCE CO. 1 ® Fax:(781)329-1818 3455 Date../I-.F.:.!f........ NpR�ti TOWN OF NORTH ANDOVER of y e �p PERMIT FOR GAS INSTALLATION s � 9SSACHUSEt This certifies that . .13/}1 . S.?L . . . rte- . r has permission for gas installation . . . . . . . . . . . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . at . . ,�; * / /r. . �.-r.. . . . . . . .5, North Andover, Mass. ;.. .. Fee. . ?. Lic. No.. G. . . ...,� ..: . . . . . GAS INSPECTOR V WHITE:Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING UV (Print or ) Mass. Date modPermit # -3 Building Location_ Owner's Name X1=1 G/C�U 'emerOPV•- ),g %leQ Type of ccupanc New ❑ Renovation ❑ Replacement ( lans Su ttted: Yes❑ No ❑ N Y W N N N U � }�. W W cc O U ItOW t ~ W s0 Q m U ~ 4 cc UJ _ n 0 1' W 4 ¢ O O ~_ N t7 W Q = Z > y cc tl W O W W z Cr. N W W Ut a C r = a 0 1- z4 z 1. W W O O > W F- U .� H W z 4 W 4 C 1- >- N m z 0 z a 0 � S a W r a Wz. 4 x 4 y,1 .S O d W 3 a 0 J 0 C > Q CL M� O SUB—BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 4 STIR FLOOR I 6TH FLOOR TTH FLOOR STH FLOOR Installing Company Name BAY STATE GAS COMPANY Check one: Certificate # Address 55 MARSTON STREET X:1Corporation 1862 LAWRENCE, MA 01840 ❑ Partnership Business Telephone .687-1105 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery - INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No...11 If you have checked Yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy b< 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 AgentOwner❑ Agent [I hereby certify that all of the details and information I have submitted(or entered)in&- s. tion are true and aocur to to the best of my knowledge and that all plumbing work and installations performed under the permit iapplication will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Ge T of Ucense: Plumber Signature of Licensed Plumber or Gas Title Gasliitter Cit /Town Master License Number 8697 yO FIC SE ONL Journeyman BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE N0. APPLICATION FOR PERMIT TO DO GASFITTING NAME TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIG NO. r PERMIT GRANTED DATE GAS INSPECTOR Location h ���- 0'e, No. Date NORTIy TOWN OF NORTH ANDOVER L p Certificate of Occupancy $ + Building/Frame Permit Fee $ SSACMUSEt•� Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ t rn ✓ ` Building Inspector 12 8 G ?O/(15/98 10.17 1,;5.00 PAID Div. Public Works Location 4 No. Date HpRTq TOWN OF NORTH ANDOVER a Certificate of Occupancy $ ' Building/Frame Permit Fee $ ;1 b'•O''t�' CMUFoundation Permit Fee $ SSASE Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ i Building Inspector 'x)/05/9810:17 25.01A in �/ �� Div. Public Works r. -33 PF-4ZMIT NO. APPLICATION FOR PERMIT TO IIU1LI)********NORTH ANDOVER, MA AI U'NO. r 1.' 22.�HECO�HD OF ON'NI RS111PS DATE BOOK l PAGE V © cBx0 01 �}d� Q l ZONE SIIB I)IV. I.O'F NO. !/ o��{ � f4 PURPOSE OF BUII DING a L()( an()n v/ m�7' � Ute— O\VNER'S NAME .lbh le h 41 NO. Of STORIES SIZE OWNER'S ADDRESS BASEMENT OR SLAB ST ND RD ARCI IITECI'S NAME SIZE OF FLOOR TIMBERS 1 2 3 Will DER'S NAME v VA"o d W N >? .? SPAN DIS FANCF.10 NEARES'l BUILDING L DIMENSIONS 01:SILLS DIS FANCE FROM STREET DIMENSIONS O:POTS DISI'ANCE FROM LOT LINES-SIDES REAR DIMENSIONS OF GIRDERS AREA OF LOT FRONTAGE I IEIGI IT Of FOUNDATION THICKNESS IS BUILDING NEW SIZE Of FOOTING X IS BUILDING ADDITION M ATE RI AL OF CHI MNE Y IS BUILDING ALTERATION IS BUILDING ON SO ID OR FILLED LAND WILL BUILDING CONFORM TOREQUIREMENTS IIREMENTS CN CODE IS BUILDING CONNECTED TOTOWN WATER BOARD(N APPEALS AC PION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTOC'TIONS 3. PROPERTY INFORMATION LAND COST EST.BLIX;.COST PAGE: I FILL CN)T SECTIONS 1-3 EST. BLDG.COST PER SQ. FT. ES'I. BI.D(i.COST PER ROOM ELECTRIC METERS MUST BE ON(N)TSIDE OF BUILDING SEPTIC PERMIT NO. AI'TACHEDGARAGES MUSTCONFORMTOSTATE FIRE RE(;I1LA'D(N1S 4. APPROVED BY: PLANS MUST BE FILED AND APPROVED BY Bl)ILDING INSPECTOR c/ B(II .DING INSPECTOR DA F 1:11 1:1) / OWNERS-I'EI.M �Q ,J O(p C(N TR.TE I.n 4s CONTR.H(v OWN ( AI I � NSIGNAIll Ll ERR )RIZI:DA( T U.LGH I.I.I. I'I-KAIff GItANfll> -__J O I�� r NORT Town of over No. .�33 * _ _ dover, Mass., 19 0 s� LAKE �i A COCHICHEWICK i�''�• V BOARD OF HEALTH PERMIT T Food/Kitchen Septic System 0 t ' BUILDING INSPECTOR THISE TIF ES THAT.. ...WA)........... .............�......................IV........................................... Foundation has per is ion �M... �. �... 00jbuildings on...........�.......MA...P.16............�.V� Rough w a , to be occupied as..................................................... ..............4 !........... .u�.. .�.'..�.�1!.... ........... Chimney provided that the person accepting this permit shall in every r spect conform to the terms of the application 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 s Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU NS TS C Rough . ............ .......1 ............................... Service BUILDING INSPECTOR Final ,e Occupancy Permit Required to Occupy Building GAS INSPECTOR Display Conspicuous Place on the Premises — Do Not Remove Rough P Y in a Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det.