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210/035.0-0068-0000.0
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Date...!..� . ...Y..............
NORT�y
°� ° '•�~ TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
88'�CMug�
This certifies that ........... .. ..............7..(. . ..Q'1........................................................
has permission to perform ....... P- ...... (X..t.. h-,..............................
wiring in the buildin of (9,� d �/e--
.............................................................................
at .............
•...... k4 ��• ,no
Andover Mass.
...... ..................�................................................
Fee./�..<....... "...Lic.Noo..6./..... ..:...../... �........... ........ .. :. .
ELEC77tfCAL INSPECTOR
Check#
n
1 , I - �h 7-/ o�. Ir z 113
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
Occupancy and Fee Checked
,M 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 PRINT IN NK OR TYPE ALL INFORMATION) Date:/ — /,p-% j
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&Nu bS" ea, + <N
Owner or Tenant 111 ,w Telephone No.
Owner's Address
Is this permit in conjunction with a Puilding permit? Yes No ❑ (Check Appropriate Box)
Purpose of Buildingb_ 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: al., �
Completion of the following table may be waived by the Inspector of Wires.
` No.of Recessed Luminaires No.of Ceil: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- ❑ N-070TEmergency Lighting
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
Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
g Tons
Heat Pump Number Tons KW No.of Self-Contained
No.of Waste Disposers Totals: '' "' "" """ ....."". " Detection/Alerting Devices
No.of Dishwashers S ace/Area Heating KW Local❑ Municipal [j Other
p g Connection
Dryers Heating Appliances KW Security Systems:*
No.of Dr
y No.of Devices or Equivalent to
No.of Water IW No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications
No.of Devices or Equivalent
OTHER:
r--
Attach additional detail if desired,oras required by the Inspector of Wires. L
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. 1
CHECK ONE: INSURA-NCE ❑ BOND ❑ OTHER ❑ (Specify:)
X certify,under the pains and penalties ofp rjury,t iat the in o niatto on this application is true and complete. T
FIRM N r
EDW 4/L-J) I— ✓ LIC.NO.:��Licensee: � Signature LTC.NO.:/(Ifapplic 1e " t in the lice e n ber ne.) / I Bus.Tel.No.:,,�fl YS`1— 976
Address: �`�/ �� - d ���V Alt.TUI.NO.:
*Per M.G.L c. 147,s.57-61,security wor equire 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. �/'
to c
❑ 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 f
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 ifhe... .
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 Failed Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass 0 Failed Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
PARTIAL R UGH INSPECTION:
Pass Failed Re-Inspection Required($.) ❑
Inspectors Comme
Inspectors Signature: Date:
ROUGH INSPECTION:
Pass 0 Failed Re-Inspection Required($.) ❑
Inspectors Com ts:
Inspectors Signature: Date:
FINAL INSPE -TION:
Pass Failed Re-Inspection Required($.)❑
Inspectors Comme s:
Inspectors Signature: Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts -
Department of IndustrialAccidints
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 Leeibly
Name(Business/Organization4ndividual):
Address:
U
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 I 6. ❑New construction
yemployees(full and/or part-time).* have hired the sub-contractors
2. I 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. [J Building addition
[No workers' comp.insurance 5. El We are a corporation and its 10.El 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.]t employees. [No workers' 13.❑Other
1 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 tiie 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.
lam 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 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
6f 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 d penalties f Aerjury that the information provided above is true and correct.
Signature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector
6.Other - - -
Contact Person: Phone#:
r
J
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 employeiis 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 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 CoaonweaXthofMassa,husPtts
Department of Industrial Accidents
OfRec of Investigations
600 Washington Street
Boston}MA 02111
Tel,#617-727-4900 ext 406 or 1-877:MASSAFE
Revised 5-26-05 Fax#617-727-7749
wWW_Mass.gov1dia
OF'�60&1MONWEgLTH
'`' . • MASSACHUSS ..
� ' • •
EkQA;'�3 i'3f
?' ISSUES THE FOL LOWI
h1 L1 .E� E
A S A R:E G
J;OURNEYMA.N .ELEC TRI-,C.I
A
: W.ARi G HAJJAR
200 $pEj.:<S;,�. '``` rta
1 1.. to
t,
NORTH
17982 07Y3.1./1:62;
�_:.._.. 7350 I
t
• COMMONWEALTH OF MASSM,HUSETTS:;?<€:`'
60A
Et1;CTR I C i AIDS
15SU;ES THE FOLLOWING L CElNSE AS
R1 D MASTER„ ELECTRO G1 AN \
.: ;
-
EDWAJRG HAJJAR
1200 SAt.EM
ANUOV.E.R:: :;:::MA 01845-4924'
NOtTN 27351
1 6368 A o7y3 �16. .
a •
Date..:�4//................
NORT�y
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
83�cHU
/ �
Thiscertifies that ...........�`......�....................�. •.....................................................................
has permission to perform ........................... ��..............................................
........... f..........
�1A// ,/
ClR F�7f
wiring in the building of.........`.........../..J..,.,..®..................................................................................
at,. .... 1..� ............................................N rth Andover,Mass.
Fie Gam..........Lic.No��01.... �.`�. ............ M* AT
.
.. ....
EL M* AL SPECTOR
Check# ?�
i
t ' Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
1Z�
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.w7] (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 INNK OR TYPE ALL INFORMATION) Date:�—// — / V
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives not' a of his or her intention to perform the electrical work described below.
Location(Street&Number)
Owner or Tenant Telephone No.
Owner's Address dr✓`'L�
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building 'd - Utility Authorization No.
- Existing Service Amps / Vkolts Overhead ❑ Undgrd No.of Meters
New Servic Amps / Volts Overhead[IUndgrd [jNo.of Meters
Number of Feeders and Ampacity
Location a d Nature of Prop ed Electrical Work: a
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above [j In- Elo.o Emergency Lighting
rnd. rnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones \f
No.of Switches No.of Gas Burgers No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
g Tons
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
p Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other f
Connection 4�
No.of Dryers Heating Appliances KW Securitio o Deviic s or Equivalent
No.of Water KW No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
WirinNo.Hydromassage Bathtubs No.of Motors Total HP Telecommunications No.of Devices or Equivalent
OTHER:
Ij
Attach additional detail if desired,or as required by the Inspector of Tnres.
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. fit`
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:) "
f certify,cinder the i2ains and p realties o erjury,that the information on this application is true and complete. Q i
FIRM NAME: . � LIC.NO.: G��
Licensee: s ,�y.�� Signature WW LIC.NO.: 0
(If applicable,enter "exempt"in,���e.�license it be�r 'ne.) Bus.Tel.No.:
Address: �l ��"' /"�' jZ 4/ Q 3�7 Alt.Tel.No.:
*Per M.G.L c. 147,s.57-61,security work requires epartment 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)0 owner ❑owne•'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 t
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.
0.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($.)❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments:
Y
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass IN Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
ROUGH INSPECTION:
Pass❑7 Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
FINAL INSPECTION:
Pass Failed Re-Inspection Required($.)❑
Inspectors Comment§r,.")
Inspectors Signature: V Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts -
Department ofIndustrial Accidents
Office of Investigations
kvi 600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legib
Name (Business/Organization/Individual):
Address:f y J
City/State/Zip: D3 ' 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 I 6. ❑New construction
ployees(full and/or part-time).* have hired the sub-contractors
2, am a sole proprietor or partner- listed on the attached sheet.T 7• ❑Remodeling
ship and'haveno 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
3111 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 12.0Roofrepairs
insurance required.]t 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.
I Homeowners who submit this affidavit indicating they tie 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:
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
fin@ 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 DIA for insurance coverage verification.
Ido hereby certify under these pains a d en,ifes of perjury that the information provided above is true and correct.
Signature: ` l Date: y
Phone#: �� y b l ✓
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other - -
Contact Person: Phone#:
t
P .
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
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 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,o£'Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel,#617-727-4900 ext 406 or 1-877rMASSAFB
Revised 5-26-05 Fax#617-727-7749
www.mass,govaa
¢ COMMONWEALTH OF MASSACHUSETTS
BOARD OF
IE,,ERICTR I Cil ANS
ISSUES THE FOLLOWING II:CE.NSE AS
LU
REG,15TEM.M MASTER. ELECTR;'GI'A,N
G: HAJJAR
1200 SAL.E`M ST
N. i 'ANDOV:E.R ;>h► ....01845-492'4'<'_>;::::> > a
6369.:::::::A:,>::<>< oy'/3;l<✓ : ?;;;<<: <: 27351 ;>
;GOMMONWEAL.H OF M{ SACHl3SE!°TS
• • • OF
BOA;:
I _ EL�GTJ� LfCENSE
ISSUES .THE FOLLOWING `
MAN ELECTR �
`&!.'3.;OURNEY ,,_:>.'.;. rc,
RE, Y-=
AS .:A �, F %; Ic�
EDWA`:Rb;:;G HAJJAR `3R
'>l
1200 SA:L.ENL»`gT -.
,:.845-492'4'' : <,
2735p
7
07%31:.1 :�
Date�.. .. .2.. . . . . . . ... . .
,HORT1y 14'
TOWN OF NORTH ANDOVER
O F
PERMIT FOR GAS INSTALLATION
�'Iss CHUSEt
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This certifies that . . . . . . . . . ... . ..`. `. . . ' . . . . . . .. . . . . . .
has permission for gas installation . . �f.?l.... .. . . . . . . . . . . . . .
in the buildings of . � . . . . . . . . . . . . . . . . . . . . . . . . . .
at �. .`!. .:: .!- .!. ' :. .'.`. . . �:� �. . ., North Andover, Mass.
Fee. . . . . . . Lic. No.. .`. . . . . . . . . . . . . ... . . . . . . .
'y.
GAS INSPECTOR
Check#
5 E,.
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASF=NG
(Print or Type)
Q U!/✓��—MA Date 20 02 Receipt# Pertmt# t d 7
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Building Location -5—/1*, O/ �( Owner sName"� � �i 'eVWi=U
Map:_ Lot:_ Zone: Type of Occupancy z5i /5- �f New ®/ Renovation ❑ Replacement❑ Plans Submitted: Yes❑ No Cl
Fee: (n `n
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SUB—BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
! 3RD FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR
7TH FLOOR
STH FLOOR
Installing Company Name EASTERN PROPANE & OIL, INC . Checkone: Certificate
Address 131 WATER ST DANVERS MA 01923 Corporation
Estimate Vaiueof Work: ❑ Partnership
Business Telephone 800-322-6628 ❑ Firm/Co.
Nameof Licensed Plumber orGas Fitter
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ❑--� No ❑
If you have checked yes please indicate the type coverage by checking the appropriate box.
A liability insurance policy Q/ Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner 0 Agent❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of
my knowledge and that all plumbing work and installations performed underthe permit issued for this application will be in compliance with
all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen a s.
BY Type of License:
Plumber Signature of nsedPlumber orGas Fitter
Title ase
Master
r License Number Gpy��
City/Town RJoumeyman
APPROVED (OFFICE USE ONLY)
Reirisea�i�roo
r
BELOW FOR OFFICE USE ONLY
FINAL INSPECTION SKETCHES PROGRESS INSPECTION
FEE
NO.
r
APPLICATION FOR PERMIT TO DO GASFITTING
NAME & TYPE OF BULIDING
•f'
LOCATION OF BULIDING
PLUMBER OR GASFITTER
LIC. NO.
PERMIT GRANTED
DATE 20
GASINSPECTOR
