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HomeMy WebLinkAboutMiscellaneous - 52 FERNVIEW AVENUE 4/30/2018 h2. IJ :nw BUILDING FILE 0 9 8 3 5 Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . . .- �( ,G�has permission to perform . ,yam . . . . . . . . . . . . . plumbing in the buildings of. . . .�' ,ft.nJ �l•CvC.� ' , , , , , , , North Andover, Mass. Fee .399— - Lic. No.�/.' ;�.� . . . . . . . . . . ..Znolv' .. . . . 3d,SD. PLUMBING INSPECTOR Check# ap1 � t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK v CITY MA DATE PERMIT# JOBSITE ADDRESS2 OWNER'S NAME POWNER ADDRESS (./Le TELO7�t�Qd TYPEOROCCUPANCY TYPE COMME IAL© EDUCATIONAL RESIDENTIAL CLEARLY NEW: RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES E1 NOD( FIXTURES 7 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 A-___- _11 I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEMV=-DEDICATED WATER RECYCLE SYSTEM ( ! ( 1 J I ( I DISHWASHERDRINKING FOUNTAIN .JFOOD DISPOSER .—_( _.___1FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK _( -.-._._.f __._...._1 _..__1 .__._.__I _-__-- ---_._._J __._._.� d ------� LAVATORY ROOF DRAIN ! SHOWER STALL _.J SERVICE/MOP SINK TOILET ( ._( 1 URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING _I .. __..I - I - -_.-.( I i E _ ' OTHER ( -1 .._..._-_-j--------J I ► _-__ _.1 __.._....-1 _... ( -- I .------_( INSURANCE COVERAGE: • 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES .. 1 IF YOU CHECKED YES,PLEASE INDICATE T TY E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY DI BOND Q OWNER'S INSURANCE WAIVER:I m aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,an that my signature on this permit application waives this requirement. CHECK ONE ONOW �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 d cur t the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in corn n wit II inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME � � I (�j��y�j� I LICENSE# .. ( SIGNATURE S� M V, JP�_1 CORPORATIONS ZY PARTNERSHIP DI_# _ _ i LLC E COMPANY NAME _ ; ADDRESS ` CITY -..._._...._..I STATE � ZIP Q w.5 � TEL 0237- Z1_02,c7 111 lNt1 FAX g CELL EMAIL �l ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington:Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLyiblv Name(Business/Organization/Individual): Address: ?�U City/State/Zi] �` Phone #: �D.S 37?C Z Are pu an employer?Check t e appropriate box: Type of project(required): 1. I am a employer with 4. I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7e todeling ship and have no employees These sub-contractors have g. []Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp. insurance comp. insurance.1 required.] 5. ❑ We are a corporation and its 10.[1 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] 'My applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they arc 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 subcontractors 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 r,,L� Policy#or Self-ins.Lic.#: " Gt/CG T 2 �7' Expiration Date: 7—"2 3-1 Job Site Address:�p� e1VV1e4(,) City/State/Zip: �1Z&VaVC. 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 a Inst iolator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the I for' ranee coverage verification. I do hereby cer a de pains and penalties of perjury that the information provided above is true and correct. Si atur - Date: Pho #: 7, '� Off tal 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#: ACORD� DATE(MwoOrYYYY� LIABILITY INSURANCE CERTIFICATE OF LIAB 1-0/23/2012 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 cortificate holder is an ADDITIONAL INSURED,the policy(lss)must be endorsed. If SUBROGATION IS WAIVED,subject fa the terms and conditions of the policy,certain pollc193 may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such ondorsomont(s). PRODUCERA Kathleen Millar, CISR, CPIN INSURANCE SOLUTIONS CORPORATION NE M. (603)382-4600 (403)382-2034 CO Westville Rdkmillareiscinsures.com INSURER(Sl AFFORDING COVERAGE NAIL 0 Plaistow NH 03865 INSURER i lerchanta 3329 INSURED INSURERS.-Hartford Underwriters Ina. Co. Powerhouse Plumbing & Heating Corp. INS C: PO Box 896 IN RERD. INSURER E: Plaistow NH 03865 INSURER F: COVERAGES CERTIFICATE NUMBER CL1273005932 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 PATO CLAIMS. VOL,5vaRl LTR TYPE OF INSURANCE INqR wvn POUCY NUMBER M M LIMBS GENERAL LIASHM EACH OCCURRENCE $ 1,000,000 ENTED X COMMERCIAL GENERAL LIAINUTY S 500,000 A CLAMS-MADE OCCUR BOP1065491 /1/2012 /1/2013 MED EXP M err $ 15,000 PERSONAL 8 ADV INJURY S Included GENERAL AGGREGATE S 2,000,000 GENT.AGGREGATE UL1rT APPUES PER PRODUCTS.COMPIOP AGG S 2,000,000 X POLICY rPRO• LOC $ AUTOM06LEwBILnT 1 000,000 X ANY Auro BODILY INJURY(Perp w) s A ALLONMEDSCHEDULED API058154 /1/2012 /1/2013 AUTOS AUTOS NEO BODILY INJURY(Per alaWerlU PROPERTY DAWLAIN i MREDAUTt1,S AUTOS S #A*** a 0 UMBRELLA LIABOCCUR EACH OCCURRENCE s EXCESS LIAa HCLAIM54AADE AGGREGATE S DED I I RETENTION S S B WORKERS COMPENSATION A U- H AND EMPLOYERS'LIAaUTY YIN I, ' FR ANY PROWpETORNARTNERIEXECUME❑ NIA E L EACH ACCIDENT S 100ODO OFPC�EXCLUDEW 4WECIT2490 /28/2012 /28/2013 Et. DISF-ASE-FAEMPLOYEI S 100,000 Itfi�rrees,deacfte wider DESCWPTION OF OPERATIONS Iwlow E L DISEASE•POLICY LIMIT S 500,000 neermsmeu OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACOR0101,Additional Remar"Schedule,U mon.Pace U required) I � CANCELLATION T SHOULD.ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPiwnOlif DATE THEREOF, NOTICE VALL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. .� AUTHORIZED REPRESENTATIVE f K Miller, CISR, CPIW/ '�' t 01988-2010 ACORD CORPORATION. All rights reserved. • ro'e Ietararl morire M Ar non .. t -PLUMBERS 'IND GA �aTERS LOCENSe.R, A5 AAST� OLUMBEF2;�`< { ISSUES THE�IBOVE LICENSE TO ;p,ME +;5 A U R E 0 P �.. e. 1.-5 HAMPSTEAD R;? f DANVIL:LE :`' i'{! 0381.9 51.00 _ . �+ 1-067 5/ ;Al 1636.04 A.{ .ciy` ..• r ail V cs .l J '...j. PLUN119.5_ks ANp1 GA yFfTTERS x tl `l POISED AS AJOURNUMAN PLUM'DRR ISSUES THE ABOVE LICENSE TO: JAME '. S LAl!RENCIQco 1:5 HA. 'STEAD RD DANVIL, . Nei a�38�13 51UQ � I 2634,1 163'603 1 i /1 11 I t 0 ; 897 ` Dated /.!3 . . . LED TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,This certifies that . Pot".� �' i Gj Q. 1�4,nn�" as permission to perform . 5, �'_ � .'�-n�A-?.�. . . . . . . . . . . � . y II • plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . , North Andover, Mass. Fee 25b:-077. . Lie. No. .... . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check#-� 1 u�4� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _ CITY]t __.._. MA DATES PERMIT# - JOBSITE ADDRESS .............1 OWNER'S NAMET �_ I POWNER ADDRESSZ- - - - -- —_ .� TEL�O _�/ _Db --)FAX ! TYPE OR OCCUPANCY TYPECOMM ® EDUCATIONAL Q RESIDENTIA 4 PRINT Y� CLEARLY NEW:F-1RENOVATIO REPLACEMENT: PLANS BMITTED: YES Q NOE FIXTURES Z FLOOR-4 JfISM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB J _-, _ ------- CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM . ..................I _.-_-_ _ -_f __-- -. -- __.M..:... -J ! _-.._._. .__. ._I I -__I ._._---_.1 DEDICATED GASIOILISAND SYSTEM _1 ..__ .., ......_ _ 1 -_- -. .� __ - -_ - _--J _l I _ I ___-_. M DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _J _--_ ! _ .-- 1 - _-� __--' i .._..._..! DEDICATED WATER RECYCLE SYSTEM __-! ....-_-_ —.` ------.. ..___-_- ----- DISHWASHER _ _DISHWASHER _ .._.J _ _ _J ...__._I __-- _l ._.-._.__. ._-__.J .._ _ 1 _.__..._.i ... ..___..J _. .__..I ................ .i DRINKING FOUNTAIN _._._1 _.._-J -. ..__.....: -----_._ -__.._ _ --! ...... --.-.__--- -__...._-I _..-_...._.! _ _. __._..._I _....._J .._..__` FOOD DISPOSER _. ...__.I .......___.! ------ FLOOR/AREA DRAIN --FLOORiAREADRAIN _ _-1 .___J _..___ INTERCEPTOR INTERIOR __..__-i .. _-__! .-----._.. ......_ .... ._.,.. -- KiTCHENSINK _. _..._.__1 _ _ I _...__..I __3 .__J ...__.._..i .___. I -__J _...__. I .. __._I ..__.. I 1 ..............I LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL ► WASHING MACHINE CONNECTION WATER HEATER ALL TYPES - _ 1 .. _-- __1 _i - I --__._-_I ._._.__l ___...__J .___.I __.._-_I WATER PIPING ? ---.-. .... OTHER .._.. _._..._ - - -- --.l _. _._.. .. -- --- - - --- _....... - --- FIN -........ I ' -- ._...._........._................. INSURANCE COVERAGE: GI have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. Y - NO �I IF YOU CHECKED YES,PLEASE INDICATE T YPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLiC OTHER TYPE OF INDEMNITY [j BOND E OWNER'S INSURANCE WAIVER: am aware that the licensee does not have the insurance coverage required by Chapter 142 of their. Massachusetts General Laws,a d that my signature on this permit application waives this requirement, CHECK ONE ONLY: OWN __; 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 d ura o the best of my knowledge and that all plumbing work and Installations performed under the permit issued for this application will be in oom nc t Pe t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAM <. (LICENSE# SIGNATURE M JP[] CORPORATION � PARTNERSHIP #F LLC 0# _ _ .. COMPANY NAME _ - _._ _) ADDRESS ___ CITY . - 1�S�i,J-- STATE ZIP —G� TEL FAX CELL _ j EMAIL -- - - _ -- (l - -- I- t^'P'!' u __Urr►_- _ C I rO f/-> � �( 5'�� �� /�'. ` The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ky 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zipp /�i�f� �` �S Phone#: 60_337?—CO Z Are pu an employer?Check t e appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I 6 ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 5e-�rtodeling ship and have no employees These sub-contractors have g. []Demolition workingfor me in an capacity. employees and have workers' Y P h'• 9. ❑Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.EJ Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.❑ 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. 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 insurance for my employees. Below is the policy and job site information. Insurance Company - Policy#or Self-ins.Lic.#: 77 2 `'T Expiration Date: 7 2 3r� Job Site Address: 14w 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 a inst t iolator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of th 1 for' ranee coverage verification. I do hereby�Udepains and penalties of perjury that the information provided above is true and correct. Si natur Date: /57_/ Pho #: D 7S--00 &614l only. Do not write in this area,to be completed by city or town oJj'iciaL 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#: colza • ' k-..../ CERTIFICATE OF LIABILITY INSURANCEF10/23/2012� 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(les)must be endorsed. If SUBROGATION IS WAIVED,Subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement an this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CA04fUthleen Miller, CISR, CPIW INSURANCE SOLUTIONS CORPORATION PHONE (603)382-4600IM 09-EXIL (4Q3)382-2034 60 Westville RdEAWL .kmiller@iscinaures.com INSURERS AFFORDING COVERAGE MAIC t Plaistow NH 03865 INSURER A Merchants 23329 INSURED m unReHartford Underwriters Ina. Co. Powerhouse Plumbing b Heating Corp. INsu C: PO Box 896 INSURERD: INSURER E: Plaistow NH 03865 INSURER : COVERAGES CERTIFICATE NUMBER CL1273005932 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. INSRJ ADOLSUOR POLICY EX LTRTYPE OF INSURANCE POLICY NUMBIR IMMi 7/1/2013 UItaTS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENT10- X COMMERCIAL GENERAL UABIUTY PREMISES $ 500,000 A CLAIMS-MADE JOCCUR Pi065497 /1/2012 MEOFXP ore S 15,000 PERSONAL a ADV INJURY $ Included GENERAL AGGREGATE S 2,000,000 GENL AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMPIOP AGG $ 2,000,000 }C POLICY Jr T LOC I S AUTOMOBILE LIABILITY BINED SINGLE LIMIT11000,000 A X ANY AUTO BODILY INJURY(Per pow) S ALL OOt54ME0 SACCHHOWLED 1058154 /1/2012 /1/2013 BODILY INJURY(Per actidsn!) SAUTS l.._.� NON-OvIMEO PROPERTY DAMAGE : HIRED AUTOS AUTOS rr.dlc.l = 5,000 UMBRELLA UAB HOCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE AGGREGATE S DED I I RETI_NTIOtJ S S B 1VORKERS COMPENSATIONA L AND EMPLOYERS'UABIUTY Y I N ANY PROPRIETORIPARTNERIEXECUTIVE❑ NIA E.L.EACH ACCIDENT S_ 100,000 OFFICER EXCLUDED? 4wItCIT2480 /28/2012 /28/2013 (Mandatory M NH) E.L.DISEASE-EA EMPLOYEI S 100,000 N yes, 1- ,I a under DESCRIPTION OF OPERATIONS balaw E L.DISEASE-POUCY LIMIT S S00,000 nceratPMN OF OPERATIONS I LOCATIONS I VEHICLES{Attach ACORO 101,AdditeAl Remarks Schedule,N rmm space Is rpulrsd) CANCELLATION a 31k SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE U THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE X Miller, CISR, CPIW/ � 41988-2010 ACORD CORPORATION. All rights reserved, r1 ramef.mA marUe of&r.n n t Date.... . I. . .�-� .................. NORTH, o�;�"`,;';y��op TOWN OF NORTH ANDOVER c * t PERMIT FOR WIRING BS,��56 This certifies that ....HL(A.Aw..P.-i( A .... ............................................. .......................................... has permission to perform ... .... cr., ........P P e_�;,, wiring in the building of....... ..e. .0.,,....................................................... at ......��Z.........E'tr-.�.{,e ,.J ................ ,N ndover,Mass. Ems' Fee......5..."-.........Lic.No.`h't"►v"1 ....... ....................... . ................................... .. CAL INSPECTOR Check# rr , t:E , Nnly Commonwealth of Massachusetts Official Use 0 Department of Fire Services Pem"tNo . i p Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] peaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: �-- By this application the undersigned gives notice his or her intention to perform the electrical work described below. Location(Street&Number �2 `{n U ' w V1VP7---,'1" Owner or Tenant Telephone No. Owner's Address „ �L-4 M `Q Is this permit in conjunction with a building permit? Yes 10 No ❑ (Check Appropriate Box) Purpose of Building (2 Er ( \ 9) 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 Am aci P tY Location and Nature of Proposed Electrical Work: en-1 ?, �D C Completion of the following table maybe waived by the Inspector of Wires. 6- No.of Total 9, No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA "A.) No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ IN o.of Emergency Ligititing rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches 2 No.of Gas Burners No.of Detection and Total Initiating Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices 715 No. of Waste Disposers HeatPump Number Tons KW No.of Self-Contained P Totals: - Detection/Alerting Devices ~i No.of Dishwashers S ace/Area Hearin KW Local❑ Municipal ❑ Other P g Connection No.of Dryers Heating Appliances KW SecN to.o Systems:* or Equivalent NTo.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Bathtubs No.of Motors Total HP Telecommunications Wiring: No.Hydromassage No.of Devices or Equivalent OTHER: c � c� Attach additional detail if desired,or as required by the Inspector of Wires. 1 Estimated Value of Electrical Worky' � , (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 ❑ BOND ❑ OTHER ❑ (Specify:) X certify,under tltepains and enaIt' of. . ju ,that t1z info ration on this application is true and complete. FIRM NAME: . IC.NO.: 'Z yg8 W E Licensee: Signatur IC.NO.: (If applicable,e r "e mpt"in the lice se n ber line. Bus.Tel.No.: 2-0 00 Address: 6dH Alt.Tel.No.: *Per M.G.L c. 147,s!57-61,se'euritywoikrequirel Department of Public Safety"S" icense: 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/AgentPERMIT FEE.-FEE. $$ _ _ Signature __ Telephone No. �a ❑ 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 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 M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: - Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ' ROUGH INSPECTION: Pass M Failed ❑' Re-Inspection Required($.) ❑ Inspectors Com ents: / / gr U4 l _ Inspectors Signature: ate: FINAL INSPECTION: Pass❑' Failed Re-Inspection Required($.) ❑ Inspectors Co ts: Inspectors Signature: V U Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts - Department of Industritll Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name(Business/Organization/Individual): f t `y �~ Address: r j O 5 6 City/State/Zip: a m ���d Phone#: 6o3 V 4 1 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6 ❑New construction employees full and/orpart-time).* have hired the sub-contractors 7. Remodeling 2. ] I am a sole proprietor or partner- listed on the attached sheet. These sub-contractors have 8. ❑Demolition ship and'have no employees working for me in any capacity. workers' comp.insurance. g. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 1011 Electrical repairs or additions required.] officers have exercised their right of exemption per MGL 11.E]Plumbing repairs or additions 3.❑ I am a homeowner doing all work c g 52 1 4 and we have no myself. [No workers comp. ,§ ( )� 12.❑Roof repairs insurance required.]r 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 ai�e 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.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Atiach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cert fy under the ains and p n ies of p rju that the information provided above is true and correct Si ature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License 0- 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#: x Information and Instruction's 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 loeal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 TO,#617-727-4900 oxt 406 or 1-877:MASSAFF Revised 5-26-05 Fax#617-727-7749 www-nass,govaa . :COMMONWEALTHOF MASSACHUSETTS. ::;: . ELECTRICIANS ASA LECTRIC, MATTHEW-J ..STRO BEL . A - HAMPSTEAD �NH 03841. 0514 { f s^ ;v r t -, I Date. . 11.� i.c.. . ... . . NpRTN pF �..o stip � o� TOWN OF NORTH ANDOVER ' Vw PERMIT FOR GAS INSTALLAf ION �9S SACHUSEt 9 .This certifies that . . . . / _. . . . �. . . . has permission for,gas installation . . . . �3. . . . . . . . . . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . .1. -. .? . . . .r.C.P.A. . . . .. North Andover, Mass. Fee. Z.(?. . . . . Lic. J GAS INSPECT R Check# r- 7231 7231 MASSACHUSETTS UN[FoRMAPPLICATON FOR PERMIT'PO Do GAS FrrrjNG (Type or print) Date )itlyh. NORTH ANDOVER,MASSACHUSETTS Building Locations �� �/ / 2 r✓ ✓I,r--.�,.7 Permit# 7 2 )Vnount$ to Owner's Name %nip �y e�1� 72v� :\ New❑ Renovation Replacement Plans Submitted w vi W < a 0 O z W wL) a z w x C a � 0 k, SUB-BASEM ENT .. w = ° C > w o B A S E M ENT IST. FLOOR F2ND . FLOOR 3RD. FLOOR 4THEIR3 . FLOOR FLOOR LOOR LOORLO O R (Print Name_.]'or type � v �� �� 1 J eck one: Certificate Installing Company - f� t�1 l �`/ Corp Address '+v 0 ( 0.s— Partner. usmess a ep one Name of Licensed Plumber or Gas Fitter 7),q U f IN `y INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. yes No13 If you have checked yes,please indicate the type coverage by checking the appropriate box Liability insurance policy 13 Other type of indemnity Bond 13 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. Signature of Owner or Owner's Agent Check one: Owner 13. Agent I hereby certify that all of the details and information I have submitted(or entered)in above appli ' n are true and accurate to the best of my knowledge and that all plumbing work and in 'ons perfo ed under Permit Is ed for is application will be in compliance with all pertinent provisions of the Massac setts tate G d d Cha 14 f General Laws. . By. Signature of Lic ed Plumber Or Gas Fitter Title Plumber 9 9 y City/Town Gas FitterIcense Number Master APPROVED(OFFICE USE ONLY) 0 3oumeyman Date. �-k . TOWN OF NORTH ANDOVER ' PERMIT FOR PLUMBING- . . ,SSACMUS� This certifies that . . . . f9 .`'.�. .�. . . � has permission to perform . . . . . . .14 - .�. . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . f . . .�. . . . . . . . . . . . . . . . . at . ..f 1 .—)" .0. . .FC P.11%. t` t . . , North Andover, Mass. Fee. Z0.77--Lic. No.. (.. . . . . . .T. . . 7Z�-- .--" . . . . . . . PLUMBING INSPECTOR Check # 8624 • 1/• 11 ■ 1 1 1 1 1 � -, %4:111'/ � . t •II i.1 • ■ mrz I: ,� ■i■■■■im■immmn■■�■i■■■i�■�■s■�■�i■■■■■i■ ■■i■m■i■i■■■■■imm�■i■■�■i■�■��■�■i■�■�■i■is■i■ • i■i■■■i■M■Mi■MMMM■i■ii■i■M■iMMM■ mom MI 11: rd• •11 1• r 1- ,- • 1 1 1 r' M•• It• 11 %•. •, ,-• • 1: 1 :!1 r ,./ /- 1 { 11•:'ill/ ■ :416 ill :• 1. 1 ;II r' •11: 1 1 ■ r i� 1 ■ t- / II .fit•• �•�- :tt 1• , 111 t11� • • to l tf111, •:1 1/11-f Too, �1 r/ t % 1. :t•l 1- 11 {111• 1 r- t f.1 •II-• ,•. •1 • t•' t .� . ' tll,It • 1 •• 1 (oFmcE usE oNLY1� i Liberty Mutual. Liberty Mutual Insurance New England Region Central Property Unit INSURANCE 75 Sylvan Street Danvers,MA 01923 Tel:(800)566-0323 November 8,2012 Town of North Andover Attn: Building Inspector 120 Main Street North Andover,MA 01845 Re: Property Address:52 Fernview Ave Unit 8,North Andover,Ma 01845 Policy Number: H6521257662640 Underwriting Company: LM Insurance Corporation Claim Number: 024487591-0001 Date of Loss: 10/20/2012 Attn: Town/City Official Pursuant to M.G.L. c. 139, § 313, please be aware that a homeowners insurance claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or causes the condition of a building or other structure to render Mass. General Laws, Ch. 143, § 6 applicable. You are required to notify Liberty Mutual by certified mail in accordance with Mass. General Laws Ch. 175, §99, if you intend to initiate proceedings designed to perfect alien pursuant to Mass. General Laws, Ch. 139, § 3A &B, or Mass. General Laws, Ch. 143, � 9, or Mass. General Laws,Ch. 111,5 127B. This letter should not be construed as a waiver or estoppel of an of the terms conditions r pp Y � o defenses afforded by the policy or applicable law. Please direct your notice to the attention of the undersigned and include a reference to the above captioned property address,policy number,claim number,and date of loss. Sincerely, Kristen Hart Liberty Mutual Insurance New England Region Central Property Unit 1-800-566-0323 Ext. 70417 E-mail: Kristen.Hart@LibertyMutual.com I I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING i l\�. /�/nl/!P/1/ MA. Dat • Permit# CitylTown: �- ., . Building Location: :ra 1 rtiy/ezt) 441 � Owners NameA ,Pents-- 9,laagl Type of Occupancy: Commercial❑ Educational❑ Industrial ❑ Institutional❑ Residential New: ❑ Alteration: ❑ Renovabon:❑ Replacement: Plans Submitted: Yes❑ No❑ i FIXTURES rn � vi 2 m # V _ W O M0 x O� 0 � aNC Z U) O 2 w Ix ZO Z Z to 0 O F Nw w � � m0 � o � wx w Lu LU w o Lu> 0 W Z "'i H E= O Z -j 0 W N W tW- w W Ozw w a � w m W O z O 02 z l Ix- o o n0. x° > > > O P SUB BSMT. t BASEMENT 1 FLOOR 2NwFLOOR 3pa FLOOR 7 ' 4 1H FLOOR 5 FLOOR 6 FLOOR 7 TH FLOOR 8 FLOOR c Check One Only Certificate# Installing Company Name. >I' orporation Address: ity(rown: State: El Partnership Business Tel » Fax: ❑Firm/Company Name of Licensed Plumber/Gas Fitter: 4�o lx�W INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the re quirements of MGL.Ch.142 Yes[�lo�❑ If you have checked Yes. lease indicate the a of coverage b checking theappropriate box below. Y �P type Y 9 A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:1 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 Owner's Agent By checking this box❑;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 PI u ing Code and Chapter 142 a General Laws. By Type of License: ❑Plumber AS A A 7L aster Title a Fater Aa ure of Licensed lumberinas Fitter a CitylrownJourneyman License Number: APPROVED OFFICE USE ONLY) ❑LP Installer