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Miscellaneous - 585 CHICKERING ROAD 4/30/2018 (2)
- L 585 CHICKERINC ROAD(B) _..- 210/084.0-0028-0011.B / Date...X, e TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that....1 ................................................ has permission to perform..A.o4...4..S( , , ,-. I,- v/ plumbing in the buildings of............................................................................................ ru ....+.I..0.. ..... ......I...0.. ...... N rth Andover,Mass. Fee.MNVU . No ..... .. ... .................................................. Check# 4iK U-MiB�I NwINSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY �O yt� } MA DATE i "��� PERMIT# r JOBSITE ADDRESS C._ t OWNER'S NAME w._........; POWNER ADDRESS ; t TELL FAX: TYPE OR OCCUPANCY TYPE COMMERCIAL' EDUCATIONAL '„ RESIDENTIAL PRINT CLEARLY NEW `,///RENOVATION: REPLACEMENT: " PLANS SUBMITTED: YESNO FIXTURES Z FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 7—!' ,L. ._.... . _ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM 1 If iµ. r- $i..:_..w..r DEDICATED GREASE SYSTEM ,_.M. i i DEDICATED GRAY WATER SYSTEM _._ _ _ # DEDICATED WATER RECYCLE SYSTEM DISHWASHER _.. _.::... -- DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) i it I KITCHEN SINK _ _ LAVATORY _ ... st I' ROOF DRAIN SHOWER STALL _._. I _..... r SERVICE/MOP SINK r, ,,...... TOILET _ URINAL WASHING MACHINE CONNECTION y WATER HEATER ALL TYPES WATER PIPING OTHER :. _ - r=:--._.._ ,.__ INSURANCE COVERAGE: 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 TYP OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND y 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 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 the General Laws. • _.... ' r... PLUMBER'S NAME " .<< :LICENSE#!_,��,� _.' SIGNATURE �` MPV_' P _; JP CORPORATION!—'_ ��CAPARTNERSHIP # LLC # ; COMPANY NAME; ((rj i ADDRESS' �� — ..,., ��� �P w ., f ,M cry CITY ? :STATE ! ��l_ .' ZIP TEL I FAX CELL ?EMAIL OP ID:SS AcoR� CERTIFICATE OF LIABILITY INSURANCE DA 06/09/201 Y) 06/09/2014 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: Durso&Jankowski Ins Agcy LLC PHONE I FAX 198 Massachusetts Avenue L/c No EXtJ._.____._. ._ ___-___ North Andover,MA 01845 E-MAIL No)` —-— Durso&Jankowski Ins.Agcy. ADDRESS: PRODUCER KANNA-1 CUSTOMER ID#: INSURER S)AFFORDING COVERAGE _ _ NAIC# INSURED Kannan&Pricone Plumbing& INSURER A:Zurich Small Business Heating,Inc. 3 West Ayer Street INSURER B:Liberty Mutual Ins.Co. _ Methuen,MA 01844 wsURERC:ACE/USA 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 7ypE OF INSURANCE ADDL SUBR POLICY EFF i POLICY EXP I ----- -— LTR INSR WVD POLICY NUMBER MM/OD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY I. . EACH OCCURRENCE S 1,000,000 DAMA E ( RENTED "--" - B X COMMERCIAL IS-MADEERAL X LIABILITY OCCUR BKS56003225 04/01/2014 04/01/2015 PREMISES Ea occurrence) S _500,000 _— MED EXP(Any one person) S 10,00 PERSONAL&ADVINJURY S 1,000,000 GENERALAGGREGATE IS 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG I S 2,000,000 tr I POLICY I PRO- LOC I - _... ..____.I S _____—_. _____ r2 !AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT i$ 1,000,000 I (Ea accident) ANY AUTO BAS56003225 04/01/2014 04/01/2015 BODILY INJURY(Per person) S ALL OWNED AUTOS BODILY INJURY(Per accident) S B i X SCHEDULED AUTOS PROPERTY DAMAGE B I X1 HIRED AUTOS I (PER ACCIDENT) B X-j NON-OWNED AUTOS ---- i S I S X UMBRELLA LIAB X OCCUR ; EACH OCCURRENCE i S 5,000,000 CLAIMS-MADE i -- ---- 'AGGREGATE S _ I X DEDUCTIBLE _.__ '- B • RETENTION S � 10000 US056003225 � 04/01/2014 04/01/2015 $ WORKERS COMPENSATION X WC STATU- O�TH- C ANY PROPRIETOR/PARTNER/EXECUTIVE 288050014156125393 06/01/2014 1 06/01/2015 TORY LIMITS !. AND EMPLOYERS'LIABILITY Y/N OFFICER'MEMBER EXCLUDED? a N/A E.L.EACH ACCIDENT 5 1,000,000 (Mandatory d and If yes describe under ory in E.L.DISEASE-EA EMPLOYEE'S 1,000,000 � ! � ------ ---- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000 I I i I DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Plumbing & Heating I CERTIFICATE HOLDER CANCELLATION NORTH13 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 384 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD Date..f/,VI.y....... I C U Url Rr"�tia TOWN OF NORTH ANDOVER look PERMIT FOR PLUMBING • 88,CMUg� 4 This certifies that.:.......... ........... has permission to perform... ... ................................................................... plumbing in the buildings of ... ............ .................... . . . . ........ ..... ..................................�.o rt Andover, Mass. �A Fee Oa...-"....Lic. No. ...........� ... .. .........1., •..:v... ............................................... PLUMBING INSPECTOR Check# � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Af CITY w MA DATE ( PERMIT# JOBSITE ADDRESS OWNER'S NAME [ POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL LQ EDUCATIONAL © RESIDENTIAL Q PRINT CLEARLY NEW: RENOVATION:D REPLACEMENT: Q PLANS SUBMITTED: YES® NOQ FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB J __-_` CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM I - .. I J �._f ( I======== DEDICATED WATER RECYCLE SYSTEM DISHWASHER �� I ..___� __..v --_j ._-__l __._l _____1 __ J DRINKING FOUNTAIN __ [ 11--if._...._.J ____l __.__._.I .__..___I .__---} _._ .._.._...� -___._.I -_...._[ FOOD DISPOSER J*LOOR/AREA DRAIN INTERCEPTOR(INTERIOR) _-7--.1 __.__-_) KITCHEN SINK LAVATORY ROOF DRAIN � L—A—l! .__.._l! SHOWER STALL _._.[ SERVICE/MOP SINK _.—_.I TOILET URINAL [ _. -Li _ l _.. I ___.._� .._.____.i _..---._-_.( ___._._( _-_._j __.__._I ..._____� ._.__._� ...._.- { WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES L- NO 01 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY'j OTHER TYPE OF INDEMNITY Q BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER _i AGENT 10 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli ce with all inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME L _ yy!/Jf1 — 1ILICENSE# r SIGNATURE MPD[ JP CORPORATION n# PARTNERSHIP Q# LLC j COMPANY NAME ADDRESS - CITY __------...._........_ STATE ZIP TEL - ( j FAX CELL MAIL UGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES yrs s F Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES R t y X The Commonwealth of Massachusetts - Department of industrial AccW nts SAM Office of Investigations 600 Washington.Street Boston,MA 02111 www.mass:gov/dia Workers'Compensation Insurance Affidavit:Buildens/Cont°actors/Electricians/Pliimbers Applicant Wormation Please Print Legibly Name(Business/Organizationn&dividual): Address: - city/state/zip:A.-A A Q�Pd &J= Ql5y' Z Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.Q T am a employer with 4. Q I am a general contractor and 1 6. Q New construction F employees(full and/or part-time).* have liked the sub-contractors j 2.X1 am a solo proprietor or partner- listed on the attached sheet. 7. []Remodeling ship and'haveno.employees' These sub-contractors have S. []Demolition working for ane in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. Q We area corporation and its 10X]Electrical repairs or additions y required.] officers have exercised.their 3.Q 1 am a hoaneowner doing all work right of exemption per,MGL 11.❑Plumbing repairs or additions myself[7Vbworkers' comp. c.152,§1(4),and wehave no 12•Q Roofrepairs insurancere iredemployees.[No workers' � .� 13.❑Other comp.insurance required.] fAny applicanfithat checks box#1 must also fill out the section below showingtheir Workers'compensationpolicy information. T'Homeowners who submit this affidavit indicatingthey 9doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that ohdk this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees Below is thepolley and job site information. Tnsuxance Company Name:. Policy#or Self-ins.Lie.#: Expiration.Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensationlaolley declaration.page(showing the policy number and expiration date). Failure to secure coverage as requireduadex Section 25A ofMGL 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 fine ofup 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 DTA for insurance coverage ver cation. .l do laereby cert rider the pains an enaltie�s ofperjury that the information provided above is true and correct. - Si afore• Date: Phone#• Official use© Iy. 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 Cleric 4.Electrical Inspector 5.Plumbing luspector 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 ernployee is defined as".. express or implied,oral or written." .everyperson tri the service of another under any contract of hire, An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two ox more of the foregoing engaged in a joint enterprise,and including the legal representatives of a:deceased employer,or the receiver or tnistee 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 ofthe dwelling house of another who employs persons to do maintenance,construction or repair work on such,dwelling house ox on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employes." 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 chapterhave beenpreseutedta 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 notrequired to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised thatthis affidavit maybe submitted to the Department of Industrial Accidents for confvmation of insurance coverage. Also be sure to sign and date the affidavit. the affidavit should b e 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 Towns Officials Please be sure that the affidavit is complete andprinted 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;rill in the permit/Rcense number which will be used as a reference number. In addition,an applicant thatmust submit multiple permit/license applications in any givenyear,need only submit one aflxdavit indicating current policy information(ifnecessary)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 maybe 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 eta.)said person is NOT required to complete this affidavit. The Office 6f 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 Caonweadt oMassa..c husets - Depaximent oflndwtrial.A.cc d0.nta (Moe OffAvostiga-aoia 6.9()leas-atgtan1xee Boston,MA 02111 1 tel#QM27,-4900 OA 406 Qx 1-877-MMSAFE sed s-26-o5 Fax#617-727-7749 WWW- .aagQV",a 08/04/2014 22:05 9786821560 R.HADDAD INS.AGNCY PAGE 01/01 ■ CERTIFICATE OF LIABILITY INSURANCE DATE(MWppryYM 08/05/2014 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 cert) cafe holder is an ADDITIONAL INSURED, the policy(ies) muBt be endorsed. I SURROGATION IS WAIVE6, subject to the terns and conditions of the policy, Certain policies may require an endorsement. A statement on this certificate Woes not •confer rights to the Certificate holder in lieu of such epdomement(s). PRODUCER CONTAUI NAME: ARELI S GOME Z R- HADDAD INSURANCE AGENCY PHONE , (978) 682 — 1409 (AIC,No,Ez): (AlCN,):(97 8) 682 -- 1560 9 WAVERLY ROAD SUITE 3 ADDRESS: arelis@haddadinsurance.com NORTH ANDOVEIR, MA 01845, INsuRER(6)AFFORDING COVERAGE NAIL F INS ERA:THE TRAVELERS INSURANCE INSURED LEOANDY GUZMAN INSURER 9: INSURER C: DBA: PLUMBING & HEATING INSURER D 138 PELHAM ST 07 INSURER E: METHUEN, MA 01844 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT TEAR 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 RTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, OLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE,BEEN REDUCED BY PAID CLAIMS. NSR TYPE OF INSURANCE POLICY EF L7n IN3R WVO POLICY NUMBER (MM/ODA'YYY) (MM/DD/YVYY) LIMIT'S GENERAL LIABILITY EACHOCCURRENCE E 1,000,000 x COMMERCIAL GENERAL LIABILITY PREMISES EO oaa0n¢nae) e 300,000 CLAIMS-MADE ❑OCCUR MED EXP(Arty one person) S5,000 A 680-03BP391 01/1.2/14 01/12/15 PERSONAL&ADV INJURY 11 11000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIEaPER: PRODUCTS-COMPIOPAGG s 2,000,000 POLICY PRO- JECT LOC $ AUTOMOBILE LIAPILJTY (Ea aa)dent) $ ANY AUTO BODILY]NJ URY(Per pemnn) 8 ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accidenl) S NON-OWNED HIREDAUTDS AUYOS ¢r aaddcntl S E UMBRRLI,A LIAD OCCUR EACH OCCURRENDSH 8 EXCESS LIAB CLAIMS-MADE AGGREGATrz J DED RETENTION $ $ WORKERS COMPENSATION �, _ AND EMPLOYERS'LIABILITY YIN TORY LIMIT ^a ER _ ?j ANY PROPRIETOR/PARINER27(ECUTIVEr�I LTB-1.828X21-8-10 12/20/13 1,2/20/14 E,L,E;ACHACCIDENT a 100,000 OFFICER/MEMBER EXCLUDED? 1 I NIA (Mandatory In NH) 1J Ityse.describe under E,L,pI$EA6E-EA EMPLOYEE E 100,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 'ESCRIPTICN OF OPERATIONS/LOCATIONS I VGNIGLW(Aftch ACORD 101,Additlon;II Remgtko aChedole,H more space is Mqulled) - CONTRACTOR :ERTIFICATE HOLDER CANCELLATION 'OWN CY NORTH ANDOVER SHOULD ANY OF THE ABOVE OrSCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THP POLICY PROVISIONS, AUTHoI%IX RESENTA ® M ACORD CORPORATION, All rights reserved- .CORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank 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 PRINTWINK OR TYPEALL INFORMATION) Date: R1 It f 1<4 T f12TAT �rnrami_i_A.,T7714S7L�p}� ?'„ o-"C!"O.,- n.f,Wirp.S' By this a d below Location �MA� Anl 1Owner o Date... ................ Owner's ' Is this pec� � TOWN OF NORTH ANDOVER teBox) Purpose ,o PERMIT FOR WIRING - Existing ; o * ters New Ser c;,�sEt tens Number Location This certifies that ........................3i' ✓1. _ //�� ........................................................................ �- has permission to perform ............................................n�.s?...... . Inspector of Wires. No.of wiring in the building of.............. �A4 a/ S Total ..........................................................................' KVA No.of at .....................................................Clc o.c ►C.� KVA ......... ......................................... o' Andover Mass. �. No.ofl Fe�.1a5 ............Lic.No.��!......... M g tm E ECTRICAL INSP "TOR No.of Rt 4Check# �aa- of Zones No.of S R No.of c No.of Waste Disposers Heat Pump Number Tons KW N-6.03 Sett=t ontatneu' To .......... ..."".... "".'"........... Detection/AlertingDevices 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 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 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:) p f3':) I certify,under the pains and penalties ofper�ury,that the information on this application is true and complete. FIRM NAME: . ��j{yl / ��f/SGL✓ LIC.NO.: Licensee: Signature LIC.NO.: / o I a licable enter exempt"int ehe license number ine. _ ^° (f PP " ) ----- Bus.Tel.No.:(q 7g) c7�z Address: " F (� — Alt.Tel.No.: *Per M.G.L c.T4-7,s.57s.57-61�curity 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 PERMIT FEE.$ 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. :d 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-tern 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 1fl 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 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP CTION: Pass IN Failed Re-Inspection Required($.) ❑ r Inspectors Com n s: Inspectors Signature: r Date: FINAL INSPECTION: Pass ?;' Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: (� Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com • The Commonwealth of Massachusetts - Department of Industrigl Accidents Office of Investigations 600 Washington Street Boston,MA.02111 UT www.mass gov/dia 'workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): l 1 1T Address: a.,K City/State/Zip: A,1_HA Z /"\ Oak gs Phone#: 7 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/or part-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. 9. ❑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.❑Roofrepairs insurance required.]i 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 a're 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy anti job site information. Insurance Company Name Policy#or S elf-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 requiredunder Section 25A of MGL 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 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 ofperjury that the information provided above is truce and correct. Signature: Date: Z/l//`t Phoneg: Cq201 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 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. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-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 t 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 Ma ssachwetts Department of Industrial Accidents Office of Investigations 600 Washia&a Street Boston.,MA 02111 Tel,#617-727-4900 ext 406 or I-877 MASSAFE Revised 5-26-05 Fax#617-727-7749 __WWW-Mass,govfdia r COMMONWEALTH OF MAS CIiC1SETf; ... , E .irk i E 1 A5 ISSUES 'TIiE FOLLOW ING�L�1iE1V5AS :R OtS' EREU MASTER-,EkE Er SALMI M M ALASMAFt a 38 MARYLau' ST � t y �lro --N ' _ MA 01844-2' 1410? 50146 hr