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Miscellaneous - 58 MOLLY TOWNE ROAD 4/30/2018
BUILDING FILE Date.. ....... ��10RT11, 3?; ` TOWN OF NORTH ANDOVER o 9 PERMIT FOR WIRING sSACHus� t..4 This certifies that ... ....................... f............................. ................................ has permission to perform ......�.r ........ ?..:.. /.�� ....................................... wiring int build'ng o ............`.f..-.-......�.'..s.�......................................................... - �i .. -- . at ......... .':-:e.. `.. . ...........No Andov r,Mass. Fee.... ... .:.....Lic. No/3 .. .:....... . .......' f 4-.... w•Z�—... ELECTRICAL INSPECTOR Check# 1 2 44 t ^ Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No.Occupanc12 0 Chec BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 y andFee(leave blank lank) d °M APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC) 527 CMR 12.00 (PLEASE PRINT IN WK 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 o her intention to perform ectrical work described below. Location(Street&Number) ,fg eaJ q Owner or Tenant le—$$ G.a Telephone No. Owner's Address Is this permit in conjunction ith a building permit? Yes Kr 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: Wlre, y �p jJL �Y Completion of the following table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- lNo.of Emergency Ugliting rnd. grnd. —Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and !� Initiatin Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers HeatPumpNumber Tons KW No.of Self-Contained Totals: - ......'......."""" "" """"" Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection ' No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KWNo.of No.of Data Wiring: t Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Eq uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of 97res. Estimated Value of Electrical Work: (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 cover3g6 is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE V BOND ❑ OTHER ❑ (Specify:) I certify,under the ains and pqnalties of perjury,that the inTormation on this application is true and complete. ^� FIRM NAM ' ./� ,r LIC.NO.: Licensee: m+2L Signature LTC.NO.: (If applicable,enter "exempt"rn the license number line.) Bus.Tel.No.. Address: &t,,I A,e 22✓!4 ��vITP� CaH!� 1V// 42rf— Alt.Tel.No. *Per M.G.L c. 147,s.57-61, ecurity 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 FpEgmTFEE: $ Signature Telephone No. cob— ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the A 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 �1 notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑ Permit Extension Act—Permit/Date Closed: Trench Inspection „ Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass R Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: r ROUGH INSP TION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: txw Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com a h The Commonwealth of Massachusetts Department oflndustrialAccidents i -=-• d 1 Congress Street,Suite 100 Boston,MA 02114-2017 - www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: g`� ��� IeLfe vi City/State/Zip:CP V 6 ' Phone#: � - Are you an employer?Check the appropriate box: Type of project(required): 1.❑Tama employer with employees(full and/or part-time).* 7. ❑New construction 2.Vaam a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.EJ I am a homeowner doing all work myself,[No workers'comp.insurance required.]t 0 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 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.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no,employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submif 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: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under the pains a d penaIt* s of perjury t the information provided above is true and correct. Signature: n Date: /O� -� S Phone#: �M-- �FY-5 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 theiremployees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub'contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Depaftment 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 bum 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-NIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia i COMMONWEALTH OF MASbACHUSE .., �' • i �, TTS BOARD OF ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS A REG JOURNEYMAN ELEC TRICIAw RICHARD J HAMEL 184 PATRIDGE RUNul. l CENTER CONWAY NH 03813 1389JR 07/3.1/16 37927 ' 9 e a t1x� 1' 's_.rom°vNot�cT•i�irdu ~\ t Ir }!JT ' MATCH LINE DEP FILE#242-1296 �A+�q' ' d I iLI trRCPDRAd SEE SHEET 2 S 4 a tH -b�.._��.68 'd / 1 I�1 wM•2080] •Aaae .w 191 CEID ,rd•xds=,D) J I RFAdAMa OF - BN,z IN•2dM(Ca„) „^Bee] ATKIN / '�// dV1YdlrexplAD .r�' q /-0 itioQ ED I, /p!� LOT 12A EwsnND 9" ue --____ pFWORK /6t )01p���J/' 11 NIF "NOaE Wtt JMff90'AHOE]A 0 108 -------_- -- )• /\O/yB I "REALNPPVFA. wM.2D5Ae �'1'e td i � -� ,,,,,,��.��.yyyyy INV1YOUf•201.93 4 ' / �-•�J TOP FND. % IR ,¢ia � B/ �� WA ERpM.VN '$ J R /oma LOT 11 � o-P�s STORAGE AREAS,DETENTION POND#1 4 �C A 1m© q LaMOF wP ELEVATION IFf.)DESIGN SU AREA LSF)A58tRLT NtFACEAREA 6 --- __ woRx 9/ "oREAr""iTrA"mRORnYm. EDDE I m u.�e ieied9 d5 �`c+p LOCUS MAP 101 K(i 4 4P'L> roPFNO. PAVEAfEM N/F 1]9 1),455 Qe• C 312x8' (11' 8U8AN LLlOURNFAU NOTE:TIE 10)YEAR PEAN SrOflAGE ELEVATION-1>0.9Fr. LEGEND RflAUM80F �/// na//i+IA9 11 11 RCFHEACNAL. 6rONEW.W. RCONDTCIauMR �/ ///� �/i� �'i I pN3p'VA'OiCN•1]&IB ��0 � 9MH • "1F NOWORF°RMETRV OF CFWOw( /aJ' p�yd t18C �t i( N 09E >/ Q aDRMN MANHDLE I AccEesa LOT 10 rsx Q N-- uTUT+aABdANOORAdncEPme se 40a /qr�Alntq M1 ,d/ �j�11 oEASEMErrr NaRntA"rimoveR 1dzi5�4 � � FWxm tRro er-cnaxa wRRrr Zit MEHYORAW 'a11 I LOT LOT4 (i I' (I �emON p I I� O aRUW T1lpN —mow- WATERMAINafUTE VALVE 1 R .L �T \E— WATEiLSEIMCEBHIIf-0FFVALVE zo 1/1111(1 f 15 IPOND 01 ,��II 1- crausmPxERwxo m— eExvLMANxpLen sEwERMAm P I/ T' J Yt— BEwEHBERVICEstua i p 110°II J4RIP— 'I 1(1 LOT 9 A aWEIR ��/(a(I p xousEtmHDOOius"m° LOT 3• aFd ( LE).{,II wM•20]90 EgDIdG—AIIIDI NTOUR $ Rf-0mREOR�.LY LHrll HMRANT � NVOUT-20]'Q! CP+CaEWER --'m-- „/ ` �_ � � nJ �- app0 �.�..� wET ANOf AOA AEOGEOF aOMERdo ,p L \\\\ 1 1 WATERBERVICE H0U9E 128 VEOETATm WETLAND \pt\'N\ `\`6�1,� \ I/ wP .•INC BEWER 1 ' ✓ aHUfOFF RYP.) 'Rt T�F�. —tm— lA1ROFiW'BUFFFH ZONE \\\\ a I EwSi1N0 •9898 21 \ ,`a 1Y RGPDMOt eMN —m Loaf OFBD NDOURDZONE \ �'•\ \ \\\\\`-• 1 �21•CPP•iTBTB LOTS B La9T 014-1 Ra ZONE ----_--- \\ xrOPP DRAB xtDmrM"�PrtatET2 t owe wc ' o- seArn LOT smDewrA11nnox CONtROI INVOUr-x0199 mGEOF IURnIEn a.__ roPFxo, aM•znA+ sMx 9�+-- •ztazr smx 1 IINd-xB+.m n \ OWi9A "l aFANCEBNB(IYP.) BORDFf9N0 I R a \ \ dV2{•N�1T99e Cee E%Iai1ND eY� EXDiTINO JERENI'HILLWtY ----- LOAROFWow( VEGETATm 19 ,tea I CO] PAVEAIENr(rvP4 YARL5.V0 a I I WOPi(P 1 I 'NVxPOUF.fl99S RIM.21N.1T w .xd91 y[� 9ta 8Aw(MU.CHm IMI IOPFNO. 9 i W1D8CAPEAREA DMH. CO2(DDLORAI� 989 te�.•� q q / i PAVma J: DS�NO wMexd,x/ wM-9BA9 �t HOUSE INV 1r d-19921(OMH6) BN 1r OUr•201.M / �L /ID INV tYd•iPo.19(CB.) q q `LIMITOFW I LOT INV 1Yd-1889.(C8n aMH `\ NO8V, I roPFN0. DN tYOUr•t90.10 \-p 20NE� aCpT]IANOERB 20894 C°' p IrMROP2@ 1 NfliCNRF irRCP OMMM WA 1WIro 3r I NO-0EON. BATIdO/PIfcNIND pp,V,l RD9.20098 IIN1r OUT-2493 TER 1401q / ,p1\ I CA¢6 WfIHCRU9IED I�+YM•19e.19 `LIFBf OFIW eroNE 90R0EA sM, I tY OUT.t9e.W DWI / aDFFEfl ZO.S I OPEN SPACE B z�" 'a L81) °�p° LOT 1 p I /' xA'CPP OIIAd UNtrd•xd88 aSz) MOVBE mw,ea dvtr¢ur•am.te n wN•10192 RICAR00CC pUBE OPEN SPACE A LOT I i °H°p0 INVtrd•tDiez Toa FN4 PLAN a10 INv,row aLd .nan av o as eo' 31WO7EACCE99 I I BRUNNOwi01 roPFNO tSRCPONAIN HTDRANT P nORNNIDE I •xM9R SCALE;1'-aO 20'WIDe DWS °�"M".pn0e t cxa A sENasER EASEMEM i FDA9R EYEME 8•PVO9fle>Tx "wv MIN-INM(DW4) 0N1Y�N�iPoN )1) 1YRCP DRAB CONSERVATION AS-BUILT PLAN o�SHEET 1 OF / pMHB I /A RIIxNIMvVtx•o-riedOaIR=t-tette l1 �I ________ _ 1ST ORT/JN BRWN t 12a _ ---------- 71 SC W 0) oN1r•IN-190.Y lCB A) °AUTUMFNOR CHASE" AC -----COS -- N OENFEG5IN9EOENRA L DWI 1 DA914 wM•1Pom DRAINAGE d 1 I wM•19]S INV 1S d-1d.B3 $ I I 1 INV 16'IN•1W.d INV IC DUT•1d92 �� 1C GPP -� 1 C°4(oeLORATE) NORTH ANDOVER,MASS. Oae(DeLOMTE) INV 15'OUf=1955 �� ��� RIM•2024 M-1D221 -�� INV 1r OUi-iW3e lr our-1.993 APPuwNr. _-----_-_ - Oy')p•A Cas DR({TY ��� wM-w2.n NORTH ANDOVER REALTY CORPORATION axx te•CPP DIIUN 00.055 ,� ulv,r our.tDe9D as sPwxo wu RDAo,NOR>H AxoovErt,uaBle4a sNH PHILIP 4 cHR19TIANSEN,P.E ouxT and SUMMER STREET { PROFESSIONAL ENGINEERS a LANG SURVEVORa DAM-18x013 Ix"dv m8...ao(ca s) Ce D(UeLOMTE) CHRISTIANSEN&S ERGI IN RNC. +r-Badu,tnrrols 1r IN•188 I.B) RIM•t92]5 RHHt MMAEEAC%9l0.TS01630 TN9C0 INV 16'OUf•tD8T4 MV 1r OUi•t8B.0o eI EN¢R.0 N OWO.N49T0..03e a Date..�/V/.................. TOWN OF NORTH ANDOVER o * ; PERMIT FOR WIRING SSACHUS� 6le—& II16This certifies that �°C. ?�.J ... .. ........ ....................................................................... has permission to perform .............�..P.^�. /. ��n�-- ...................................................................... wiring in the building of......../.U..A..A �t................... ................................. at ..... ........ 0/,/ ,.. .G.....16r9.d.................. rth Andover,Mass. r /7) .....Lic. No. l?�.�J..... ...1...1. ... ELE RICAL INSPECTOR Check# 60 w Commonwealth of Massachusetts OfficiaCl�Use Only Department of Fire Services Permit No. - Occupancy and Fee Checked s 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(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 4 Jt3c 4 --�o I � City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) �v /AUC Z y7OG<l ts�",P�. �o Z° #/`z— Owner or Tenant A ofzrn-1 /�,y9a✓E-iZ'��74G Telephone No. Owner's Address 4�/,6dV,--2� Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. 171-IT-397 Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service !) Amps 40 12, Volts Overhead❑ Undgrd No.of Meters / Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: (,J//Z IAA d mE Com letion of the followingtable ma be waived by the Inspector of Wires. No.of Recessed Luminaires p No.of Ceil:Susp.(Paddle)Fans o.o Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Batter Units No.of Receptacle Outlets 7d No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.o Detection and Initiating Devices No.of Ranges No.of Air Cond. ;�— Total No.of Alerting Devices Tons g No.of Waste Disposers eat Pump umber Tons KW No.of Self-Contained Totals: Detection/Alerting Devices unicipal No.of Dishwashers Space/Area Heating KW Local El Connection Connnectinection ❑ Other No.of Dryers l Heating Appliances KW Security Systems: No.of Devices or E uivalent No.of Water KW o.o No.o Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Equivalent No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (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:) I certify,under the pains and enalt'es of perjury,that the information n tht application is true and complete FIRM NAME: K EA/ LIC.NO.:c�-)O F9;1— Licensee: d(EFy C�o!!�� Signature LIC.NO.:.2—3 YP?-- (If applicable,enter "eU t"in the license nurryber line.)^ � Bus.Tel.No.97,P & 6 Address: �UK/�t04W .c11r E'7's2 Alt.Tel.No.: *Per M.G.L c. 147,s. 57-61,security work requires Departm 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 Signature Telephone No. PERMIT FEE. $ _ - __ � y. y The Commonwealth of Massachusetts Department of Indtfstrrnl Accidents Office of fnvestigations 600 Washington,Street .Boston,MA 02111 www.massgov/ctza Workers'Compensation bsurance Affidavit:Bufldere/Contex°actors/Blectr icianslPliimbers Applicant Information. Please Prim Le 'bl Name(Business/Organization&dividual): C� 0 .Address: L U� w City/State/Zip: /fe4ka- - Phone#:_G7/- �. 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. []Now construction F employees(full and/or part time)* have Dire dthe sub-contractors 2.VI am a sole proprietor or partner- listed on the attached sheet.I 7. [�Remodeling ship and`have no•employees These sub-contractors have 8. [[Demolition woxking forme in any capacity. workers'comp.insurance. 9. Building addition Wo workers'comp.insurance 5. [] We axe a corporation and its 10.p Electrical repairs or additions required.] officers have exercis a d.their 3.E1 I am a homeowner doing all work right of exemption per MOL I LE]Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and wehave no 12.❑Roofrepairs insurancerequired.]; employees.[No workers' 13F]Other comp.insurance required.] ,Any applicantthat checks box#f must also fill out the section bel6w showingtheir Workers'compensation policy information. T'Homeowners who submitfhis affidavit indicafingthey Re doing all workand then hire outside contractors must submit a new affidavit indicating such. TContractors that checkthis box must attached m additional sheet showing the name of the sub-contractors and their workers'comp,policy information. f ain an employer that is providing workers'competasation insurance fovmy employees Below is the policy andjob site information. Insurance Company Name% Policy#or Sei£ins.UG.#: Expiration.Date: lob Site Address: City/State/Zip: Attach a copy of the workers'comp ensatioxrpolley declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMOL o.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 fm.e 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 iilsuran.ce coverage verification. X do lieteby cep u ' triepa' s andpenalties of perjury Mat tris information•provided abov is true and eoraect. Si ature: Data: -'Bone#• Official use only. .Do not write in this area,to be completed by city of town official. City or Town: PermitMeense# Issuing Authority(circle one): 1.Board of Health 2.Buildingbepartment 3.CitylTownt Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Caatact 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 ernployee is defined as"...every person in the service of another under any contract ofhire,• express or•implied,oral or written.." An employes is defined as"an individual,partnership,association,corporation or other legal entity,or any two ormore of the Foregoing engaged in a joint enterprise,and including the legal representatives of a-deceased employer,or the receiver ox trustee of an individual,partnership,association or other legal entity,employing employees. )Iowever the owner of a dwelling house having not more than three apartments and who resides therein,or the o ccupant 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 ba 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 license or permit to operate a business or to construct buildings iu 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 beenpresented 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),addresses)andphone numbers)along with their certildcate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are notrequired to carry workers'compensation.insurance. If au LLC or LLP does have employees,apolicyisrequired. Be advised thattb affidavit itedtotheDepartmentof 7ndusixial Accidents for cor rmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be xetornedto the city or town that the application for thepera it or license is being requested,not the Department of Iudustrial Accidents. Should you have any questions regarding the law or if you are required to obtain,a* rkers' compensationpolicy,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 thatthe affidavit is complete and printed legibly. The Department has provided a space at the bottom of the allidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be-sure to fill inthe penmit/Iicense number whichwill be used as a reference number. In addition,an applicant thattia-ust submitmultiple permit/license applications in any given year,need only submit one affidavit indicating current Policy information(ifnecessary)and under"Tab Site Address"the applicant shouldwrite"all locations in (city or towiu):'A copy of the affidavit that has been officially stainped or marked by the city or town may be provided to the applicant as proof that a valid affidavit-ii on fila'for fature permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license orliermit to burn leaves eta.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance fox your cooperation and should you have any�uestlons, please do not hesitate to give us a call. The Department's address,telephone abd fax number: �'h�Go�ox�wea�t�Z ol,Mas�achv.:sP�� .- DePaxtment Offndufxzal Accidents Of e off mSlZga a 00 wash ngtm slxt; Bo9Qn,MA02111 TO,�67`�H -2'x,49.00 u406 Qx 1-877MUFF, Revised 5-26-05 Fay,9 617-727-7749 ,www—MR s,gOVARa <t "COMiiV1ONWSALTHOF MASSACHUSETTS IM 11 kyj li lei ki Kel - • F1 I ELEC: R I C I ANS s fSSUES THE.-:FOLLOWING Lf -ASE A5 :A REG iSTEREDMASTER ELECTR.I,C AN KENNETH J DIGUILI0 f� 50 OAKMEADOW LN METHUEtJ MA 01844-7 609MR 07/3.1/16 „ 64450 4M Date..Z,2./ `/........ OF Rrh TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING W.,-.o This certifies.that......'.......�.'.. '�1 .- /r P/,/�.� has permission to perform........... ...... ............ ........................................... ......................... plumbing in the bui dings of/ /60,4-`/Y*- *-........ at............. ... .... .............. North Andover, Mass. Fee.!. ......... Lic. 0. .......................................................... .. ................ PLUMBING INSPECTOR Check# 6?0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK AiCITY r ( MA DATE 1`' PERMIT# 105b2�- I JOBSITE ADDRESS u I _ � Q _� OWNER'S NAMET- OWNER ADDRESS TEL FAX I�TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW: Id RENOVATION:® REPLACEMENT:0 PLANS SUBMITTED: YES 0 N00 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/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM _._._( _ __—1 ( ! _..__-j ....._._1 DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN .-. .__.f FOOD DISPOSER FLOOR/AREADRAIN _I -.-_ ! F .___. _._ -( _...__� 1 .__.__..._.i ( .-_-_-( _..._._._1 ! I I INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION _4 _ ( __._.� ___..._I .__.._. - ____.._._f . 1 —J== __..___1 _.... -i -i J WAT�cR HEATER ALL TYPES WATER PIPING OTHER _-- _ _ __.� _I ( i 1 ...._...-._.� ---.._J i i ---. I _.._._► ... -- - ( I Eag— " INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES VNO 1AYOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 10 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 ith all Pertinen ' n of the h4assachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMELICENSE# F7 �S 7 SIGNATURE MP B?r JP[J-1 — CORPORATION F# PARTNERSHIP 0# _;LLC j COMPANY NAME fy/�P/1�---� ; ADDRESS CITY �t _ 'STATE ZIP _ - -I TE 30�_ �1 / FAX i CELLAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ art FEE: $ PERMIT# PLAN REVIEW NOTES ...� 1 4Q . The Commonwealth of Massachusetts Department oflndustriglAccidents 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 Leizibly Name(Business/Organi'zation/fndividual): Z,�/ Address: - City/State/Zip: �� �� Phone#: 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 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. �• E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.] employees.[No workers' q a 13J]Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they Lire 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 ibe,policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: 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 requiredunder Section 25A ofMGL 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 .�certi under th ep sins andpenalties of perjury that the information provided above is true and correct. Signature: c �+ Date: Phone# fT rf 3! 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 luspector 6.Other - - Contact Person: Phone#: r Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire,- 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 licensinga shall withhold agency the issuance renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any r 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 ofits political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LL C or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retumedto 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 Gainmonwalth of Massa.—tts Depaximent of f dustniai Accidents • Off�iee o�In,�estiga�zQ.ns 600 Washington Street Boston,MA 02111 Tei,#617-727-4.900 est 406 oz 1-877�MASSA F, Revised 5-26-05 Fax#617-727-7749 v�v�r_mace o-n�rlrlia Date...... //' ................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION gsAcaus� 4-t Thiscertifies that ........................... .................................. ,....J.'.................................... has permission for gas installation ............./ ��-�— .. .............. in the buildings of..,.Z�,,,,,,,,,,,,,,,,, ,,,,,,,,, �� �y0 ( �v'`�r- e R......- , North Andover, Mass. at.....................�................ ...........� Fee.. ..... Lic. No. Z..........4—'"...... �f'....................................................... GASINSPECMR Check# a=�a �' S 5 S&5-/ 213 ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK n I CITYgzkll1/�/I �� MA DATE „ PERMIT# JOBSITE ADDRESS C / cel r/b ,�Lc�--MOWN R'S NAME d - OWNER ADDRESS TEL — FAX TYPE OR EDUCATIONAL OCCUPANCYTYPE COMMERCIAL PST ( ) ® RESIDENTIAL CLEARLY NEW:Ef, RENOVATION:D REPLACEMENT: PLANS SUBMITTED: YES F---] N00 APPLIANCES'l FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER (EZI ._.. . I BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR �_ j -- FURNACE GENERATOR - GRILLE __ INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT _ ( OVEN _ POOL HEATER ROOM/SPACE HEATER �– ROOF TOP UNIT 2 _ TEST UNIT HEATER tJNVENTED ROOM HEATER WATER HEATER OTHER ........_._...................... . .......... .................... - - I T. INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES I[ZN0 YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW �. LIABILITY INSURANCE POLICY L 1 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0l AGENT Ell 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 I Pe -Hent pr vis' of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME LICENSE# aJ SIGNATURE MP 5?f"MGF El JP D JGF Q LPGI[J-1 CORPORATION 0# PARTNERSHIP[D#=LLC[]#= COMPANY NAME: ADDRESS CITY STATE ZIP G_d'7 FAX —^�CELL �' —JSb�EMAIL ,Cd Dyyi ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES S's Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES i L tk The Commonwealth of Massachusetts - Department ofIndustrial Accidents Office of Investigations kiip 600 Washington Street Boston,MA.02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibl Name(Business/Organizationgndividual): Address— City/State/Zip: .C,l U Phone 3 — 3-- 1251 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. F1 New construction employees(full and/or p -time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]i employees.[No workers' 13.1-1 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 aie doing all work and then.hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 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 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 certify under the pains and penaltiesof erjury that the information provided above is true and correct. Signature: 'A"XDate: Phone#: 3 3 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#: A: 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 ofpublic 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. De advised that this affidavit may be in 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.ad.og 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 . oMmoawealth of Massachusetts Department of Industrial Accidents Office ofIuvcstigations 600 Washington Street Boston}MA 021 It Tel,#617-727,4900 ext 406 or 1.-877,7MASSAF.E Revised 5-26-05 Fax#617-727-7749 WWW-Mass,govldia 1 / b w.... . COMMONWEa1-TH OF MASSACHUSE7TS>>>` BGARPLUMBE- AND B;t)F SSUE:S,:.:..TT.HE FOLLOWIKG"L`ICENSE . ; L#LENSED AS .A...MASTER PLUMBER �a t ,�, , a CHWE L W K E L L E R I 20 KENNEDY D J >:`>P:: `L AF1 < :ral -260'5 o : 03076 a: > <i 21.2)8B