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Home My WebLink AboutMiscellaneous - 59 SUMMER STREET 4/30/2018 (2) 59 SUMMER STREET 210/065.0-0025-0000.0 y � � _ _ -- ___ ---- - - __- - ��1 ��/c� Ste._ E 1 PO Box 55098 Boston,MA 02205-5098 617-951-0600 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 RE: Insured: VALERIE KOZDRAS Property Address: 59 SUMMER STREET,NORTH ANDOVER, MA Policy Number: HMA 0320196 Claim Number: BOS00055465 Date of Loss: 3/11/2015 Company: Safety Indemnity Insurance Company Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Eric Gill Claim Examiner 3/13/2015 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 i Phone: (617) 951-0600 EXT 3321 Fax: (617) 531-5774 Email: EricGill@Safetylnsurance.com I I Date ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING S CHUS This certifies that ............. ................ �. .............................. has permission to perform .. .. ............................................................ wiring in the building of .......................................... at. A5. ........... North Andover,Mass."4 Fee/7 -7 .......... Lic.No.��................. PLEC-*rRIUCAL Check # 9*129 Commonwealth of Massachusetts • Official Use Only Department of Fire Services Permit No. �' 1! BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked A0 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 flV AW OR TYPE ALL INFORMATION Date: City or Town of: NORTH ANDOVER To the By this application the undersigned_gives notice of his or her intention to perform the Inspector electrical workles abed below. Location(Street&Number) � Sli M MM—fz, Owner or Tenant «v 2 e- 4 S S V Telephone No. Owner's Address Is this permit in coni unction with a building permit? Yes Purpose of Building ��(;.£ �NO ❑ (Check Appropriate Boa) Utility Authorization No. -2— Existing Service G Amps _ / _Volts Overhead ❑ Undgrd❑ No.of Meters New Service '2_4 U Amps /ycr l Z Sfo Volts Overhead Und-grd No.of Meters Number of Feeders and.Am aci P tY Location and Nature of Proposed Electrical Work: Yf l Completion of the followin table may be waived by the Inspector of Wires. [No. of Recessed Luminaires No.of Ceil:Sus No.of Total p.(Paddle)Fans Transformers KVA of Luminaire Outlets �j No.of Hot Tubs Generators KVA of Luminaires Swimming Pool Above In- o.o mergency g g No.of Receptacle d• ❑ d. BatteryUnits acle Outlet s P &6Na.of Oil Burners F1PE . ALARMS No,of Zones No,of Switches No.of Gas-Burners No..of Detection and No.of N Ranges Initis Devices g o.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposersat Pump Number Tons KW No.of Self-Contained J. f` Totals: W"' `� Detecti-on/Aler*g Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal N Connection ❑ Other No.of Dryers i'Y s Hea ' ting Appliances KW Security Systems: No.of Water No.of No.of Devices or'F_ uivalent Heaters KW No.of Data Wiring; Si s Ballasts. No.Hydromassage Bathtubs No.of Devices or Equivalent No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or E uivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: Q U O , Work to Start (When required by municipal policy.) Inspections to be requested m accordance rdance with MEC Rule 10 and URANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may it sue 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 2—BOND ❑ OTHER I certify,under the aims and enalties ❑ (Specify:) P PM7u►y, that the information on this application is true and complete. FIRM NAME: ��fGv �P /J Licensee: LIC.NO.:/ ,5 3`0 C!• Signatur (If applicable, ter « empt'•in the license nu ber line.) LIC.NO.: Address: V �57- 1, ✓L� / a rY ,�► 027 Bus.Tel No.: ►9 Ty__T_&_2_0 *Per M.G.L c 147,securi work re Alt:Tel.No.: security quires Department of Public Safe S Lice OWNER'S INSURANCE WAIVER: I am away �' ,License: Lic.No. e that the Licensee does n required by law. By my signature below,I herebywaive of have the liability insurance coverage normally Y this requirement wire me nt. I am q the the , Owner/Agent (check one) � owner ❑ owner's agent. Signature Telephone No. PERMIT FEE: $ i �� / /D� /�� l �- �� ` .-� `� .� M The Commonwealth of Massachusetts s .: Department ofIndustrial Accidents Office oflnvestigations 600 Washington Street Boston, 11,L4-02111 www.massgoy/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumber.s Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: a/- m ot9 t4 Phone Are you an employer? Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I EDI (full and/or part-time).* have hired the sub-contractors 6. E] New construction . 2. 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 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, §.l(4),and we have no 12.❑ Roof repairs insurance required.] t employees. No workers' COMP. insurance required.]. 13.❑ Other *.S:.y applicant that check--.box#I :Iso'-dl out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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. y Insurance Company Name: Policy#or Self-ins. Lie.#: Expiration Date: p, Job Site Address: . V, r7— City/State/Zip: �� P`�0C K1,1, Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine , of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certAunder the paingizndpenallies ofperjury that the information provided above is true and correct. Siggafore: Date: Phone#: &3 Y u 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 toprovide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." . An employer is defined as"an individual,partnership, association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a.deceased employer,or the _. receiver or trustee of an individual,partnership,association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs.persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to.construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of.compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability.Parinerships(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 confumation 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, R please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth.of Massachusetts Department of Industrial Accidents. Office of Ingations 600 Washington Street � Bkoston, MA.02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-72.7-7749 Revised 5-26-05 NArww-mas.zovkha Date.................................. koRTII ; 0 TOWN OF NORTH ANDOVER Z. 11 PERMIT FOR WIRING S'q use This certifies thatL - '`` .. ................................... has permission to perform wiringin the building-of.....!�.......................:..... ............................................. at........................._............................................ .. .... ,North Andover,Mass. Fee.........l........... Lic.No.� ........... .. . /� A'r�C z ELECfRIc NSP Check 8742 Commonwealth of Massachusetts Official Use Only r Permit No. p7y`)- Department of Fire Services Occupancy and Fee Checked 5T 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 PRINTININK OR TYPE ALL INFORMATION) Date: 5116/ O 0 City or Town of: NORTH ANDOVER To the Inspector By this application the undersigned gives notice of his or her intention to perform the electrical workldescribed below. Location(Street&Number) 5"9 s u m m lr- S� Owner or Tenant 1/01IG r i e, kA. $p Telephone No. Owner's Address J-9 Svmn, r s� Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building �� i 57ert Ce Utility Authorization No. (o{A OS 9 Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service 16o _ Amps 12o / z yo Volts Overhead❑ Und rd g ❑ No.of Meters A_ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: e m S-+P�t V i Completion of the followin table may be waived b the Inspector o Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans N,0.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Pool SwimmingAbove in- o.o merge ncy ig g rnd. ❑ rnd. Batte 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. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number.._Tons.. KW.... No.of Self-Contained Totals: ""' Detection/Alerting Devices No.of Dishwashers Space/Area HeatingKW Municipal Local❑ Connection ❑ Other i No.of Dryers Heating Appliances KW Security Systems:* No.of WaterNo.of Devices or Equivalent Heaters KWNo.of No.of Si s Ballasts . Data Wiring: of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total Hp Telecommunications Wiring: OTHER: No.of Devices or Equivalent 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 StartT/-7/0!2 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 9, BOND ❑ OTHER ❑ (Specify:) A I certify,under the pains and penalties of perjury,that the information on this application is true and complete- FIRM NAME:�r,'c,-� -rt c w LIC.NO.: 3- Licensee: -2 ;a n S7 W Signature LIC.NO.: ti (If applicable enter"exempt"in the license number line) Bus.Tel.No.:c17$ 5�-7 Z 2 y2 � g Address: ZSo�,T L, oe,4 kl �p YI S .lhran 1114 O 83-3 Alt.Tel.No.: *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner ❑owner's agent. Owner/Agent Si o� �ature Telephone No. PERMIT FEE: $�� i The Commonwealth of Massachusetts k� ! Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.nzass.gov1daaa . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers Atiplicant Information Please Print Le-vibly Narrie(Business/organization/Individual): (' ,'Cz yiIAIJ S TQC Address:,2 69 9 SavTh �Ld r, , n� rG>7 O City/State/Zip: ffp r,S,n -ray, h t+ 0 38 33 Phone #: . q78 y37 7 Z z y Are you an employer?Check-the appropriate box: 1.❑ I air a employer with 4, ❑ 1 am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.X 1 am.a.sole proprietor or partner- listed on the attached sheet x 7• ❑ Remodeling ship and have no employees Thesesub-contxa sub-contractors have 8. �Demoliti.on working for mein any capacity, workers' comp.insurance. 9 (� Building addition [No workers'comp. insurance 5. [3 We are a corporation and its required.] officershave exercised their 10.F-1 Electrical repairs or additions 3.❑ I am a homeowner doingall work right of exemption per MGL I I.❑ Plumbing repairs or additions myself.[No-workers'comp, c. 1.52, §1(4),and we have no 12. Roof insurance required.]t employees. ❑ repairs 9 ] [No workers' comp. insurance required..] 13.❑.Other *Any applicant that checks bcrlr#t must also fill out the section below showing their workers'compensation policy information t Homeowners who submit this affidavit indicating they are doing all work and then hue outside contractors must submit a new affidavit indicating such. ;Contractors that check this box musta_ttaebed an additional sheat showing tjhe.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 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 las civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Sienatttre: Date r— Phone#: Y.577 z y� O fficialonly. Do not write in this area,to be completed by city or town official n: Permit/License# ority(circle one): ealth 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector son: Phone#: J ^Y 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 contact 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 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,notthe 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 nurnber listed below. Self-insured companies should enter their self-insurance license number on the appropriate tine. 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 of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel.# 617-7274900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-7749 4vww.mass.govrdia -...-.......... ... _..._.. Gelina5 5hdural � qineerinq LLC Phone 978.465.6436 Daniel L. Gelinas,P.E. Fax 978.465.5160 579A North End Blvd. Salisbury,MA 01952-1738 email danlgelinas@comcast.net November 24, 2009 Steve McCullough Red Tail Design-Build 733 Turnpike St Unit 192 North Andover MA 01845-6157 SUBJECT: 59 Summer St,.N Andover, MA Dear Mr.McCullough: Per your request Gelinas Structural Engineering LLC(GSE)went to the above site on today. The purpose of � Y this trip was to perform a walk thru and confirm the LVL framing satisfies code and the Lateral Wall Bracing requirements. The following are the results of our observations: Executive Summary: All LVL framing observed is per the drawings and satisfies the Massachusetts State Building Code 70' Edition One &Two Family Dwellings [MSBC] The Garage Wall bracing is acceptable as is when considered with the remainder of the framed structure. MSBC Section 5602.10 is satisfied. Please call with any questions. J�A OF off' g DANIEL L- Very Very Truly Yours, o v STRUCTURAL No 33994 Daniel L. Ge in ,P. �is , Ll framing 09069.doc10A3Pt� Date. �T TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING 40 A 40 i A SACMUS This certifies that T. . . . . . . . .. . .!.! . . . . . . . . . . . . has permission to perform_. Vic?.-. : . /� . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of ....... . . . . . . . . . . . . . . . . . at� �' .1 .,. . . . . . ., . . . . . . . . . . . . . . . . . North Andover, Mass. Fee /. . . . .Lic. Noll. '6. . . 4 � . . . . . . . . . . . PLUING INSPECTOR Check # / 1�2 111 9 8269 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUM BYNG (Type or print) .. NORTH ANDOVER,MASSACHUSETTS ` Date �a Building Location SidaN1lM�Pi� Owners Name �eV v Pernut# Amount Type of Occu anc New Renovation Replacement Plans Submitted Yes No FIXTURES y Ln a wcc a o o d F A C40 O ]Sly 1H1AClt 7j I f � i � 2J\II FIDOR 3M F OCR 4IH MOO?. M FIDOR 6M KJOCR _ 7M RfM SIH I�IDC[t (Print or type) Check one: Certificate Installing Company Name , (,1 Al Y14.1 0,1z v., Co 1 11 rP Address to 1 4 Wi L Partner. IL ustness Telephoneto Firm/Co. Name of Licensed Plumber. i o Insurance Coverage: Indicate type of insurance co age by chec ' appropriate box: Liability insurance policy Other type of Li indemnity Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ 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 under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and d Chapter 142 of the General Laws. By. Signature o icense um er Title f Type of Plumbing License CI-/Town ` 0 icense um er Master Journeyman ❑ APPROVED(OFFICE uss ONLY i The Commvnwer&k of Massachus e its • ta Department of industrial Accidents t , Oflice of Investigations iii;y{t i 600 9 ashinafon Street Boston, MA. 62111 c wwiwnzassgov/dia . Workers' Compensafion Insiu-ance Affidavit: Builders/C Alicant nformation ��ontractors/EieotriciaasipfI Please Print blv N8IIi8 (Bnsincss/Orgenizafion/individual): t Address: City/Stale/Zip: tVV VKA ! S f S Phone#: . �! Are you an employer?CheeIt.the a ro rbox:PP iate p • . 1. I uirn a employer with 4. ❑ I am a general contractor and I Type o Project(required):' employees(full and/or part time).* have hired the sub- 6• (�ew construction . 2• Iam.asole contractors�� PmP partner- listed on the attached sheet,? 7. Q Remodeling ship and have no employees These suli-contractors have working forme in any capacity, workers' comp.insurance. 8• Q Demolition [No workers'comp. insurance 5. ❑ We are a corporation and its 9• ❑ Building addition I am requ2 ho officers have exercised their 10.0 Electrical repairs or additions myself 3•❑ i am a homeowner doing all worst right Of exemption per MOL 11.0 Plumbing repairs or additions [No workers'comp. Q 152, §1(4),and we have no 12 ce required.]t em Io ees •❑Roof repairs P Y [No workers' comp. insurancemquired..] 13•❑_Other 'Airy applicant that checks boat#I must also tilt out the section below showing their workers'compensation policy infornzation t Komeownd'n who submit this affidavit indicating they are lain an , — =Contractors that check this hoz must g work and then hie outside contractors must submit a-new affidavit indicating a an additional sheet showing,the name of the sub-contractors and their work=s'co •• comas such, !mart an e-51POyer thx i; r0� : comp.Policy infomiadon. { ieaag:woriters comperfsa&n insurance for NV emPloye= Below it the o utfornra!<on, p IccJ'affd job stir . Insurance Company Name: ' t L4 D�( ��,lc Policy#or Self-ins Lie.#: 1�gC7 3 C J Expiration Date: J Job Site A C ddress• Sj u IA� a City/Statezi Attach rP� a copy of the wor P3 lice rs.compensationit den Po cY £su=itor Page(showing fire policy number and expiration date). . Failure to secure coverage as required under Section 25A of tion of_ MOL c. 152 can lead fine up t4$1,500.00 and/or one-year imprisonment,as well as civil penalties in fire farm of a SrTOP WORK ORDER inal �artti a fine In a to S250.0tion(0 a day against the violator Be advised that a copy of this statement may be forwarded to the Office of investigation of D1A for insurance v ge verification. I do hereby c u er the pains aatd en o e .1•P rjwy that the infornfadon provided above is tulle Si and correct lure: D 0}J`3cia1 ase only. do notwrite in this area,m he complete 'd or o � �!' town fffciaL City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2 Sodding Department 3.Crty/3ovvunCierit 6.Othe'r 4. Electrical Inspector 5. Plumbing inspector Contact Person: Phone#: I v, Information a nd Instruction Massachusetts General Laws chapter I S2 requires all emp 3 oyers 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 includir-ig the legal representatives of a deceased employer,or the receiver ortarstee-of an individual,partnership,associatioin or other legal entity,employing employees..'Howeverthe ownerof 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 maimtenance,construction or repair wort 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 license or permit to operate a business or to construct buHdings in the commonwealth for any applicant who has not produced acceptable evidenceaC compliance with the insurance'coverage required" Additionally, MOL chapter 152,§25C(7)states"Neither t3he commonwealth nor any of its political subdivisions shall . enter into any contract for the performance of public wort- until-acceptable evidence of compliance with the insruancc requirements of this chapter have been presented to the contracting authority." . Applicants Please fill out the workers'compensation.affidavit compie tely,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 requiredito cant'workers'compensation insurance. lfan 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 Ewe 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 r egar-ding the law or if you are required to obtain a workers' compensation policy,please-call the Depart hent at the number_listed below. Self a+td crrr �i Q<Zo„ld e*rt�d, self-insurance-licenae number on the'appropriate tine. City or Town Officials Please be sure that the affidavit is complete and printed Iegibly. The Department hes 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 applicanL Please be sure to fill in the permit/license number which%-ill be used as a reference number. In addition,an applicant that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicting-current a 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 futrae 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 bum leaves etc.)said persons is NOT required to complete this affidavit The Office of Investigpations 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 Deparhnent's address,telephone and fax number.' The Commonwealth of Massachusetts Department of F3dustzial Accidents Office of Lnvestigat tions 600 Washington Street Boston, MA 02111 TeL#617-7274900 Ext 406 or 1-8.77-MASSAFE Revised 5-26-05Fax#617-727-7749 vvww.mass_govldia F Date.. ........................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING CH This certifies that ...... ....................................................................................... has permission to perform ... .......................................................... wiring in the bwldi,n of././ .................................................. ........................... .......North Andover,Mass. Fee,*-5............. Lic.No.............. .......... . .. .......... ELECTRICAL INSP Check # 9006 -� Commonwealth of Massachusetts Official Use only Department of Fire Services FOccupancy mit No. BOARD OF FIRE PREVENTION REGULATIONS and Fee Checked`^' [Rev- 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CC0WORK 0 (PLEASE PRINT WINDate:K OR TYPE ALL INFORMATION ��.---� 0 1 City or Town of: NORTH ANDOVER By this application the undersigned gives notice of his or To.the Inspector of Wires: her intention to perform the electrical work described below. i Location(Street&Number) -I S il *`A My Q ST Owner or Tenant V A L.c=2 (E7 '{ S Owner's Address _� ,,, Telephone No.Q 2 f 9 S � �nw, Is this permit in conjunction with a building permit? Yes E-y Purpose of Building 1)��(� u NO ❑ (Check Appropriate Box) � G" Utility Authorization E3isting Service Amps /_Volts Overhead ❑. Undgrd❑ No.of Meters New Service Amps _ / _Volts Overhead❑ Unilgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: T1s i A L_L i-y G 6a ►��1� S,:FRV1 ee Com eiion of the ollowin table m be waived b the Inspector o Wires. No.of Recessed Luminaires No.of Ceii.-Sus No.of p.(Paddle)Fans Total No.of Luminaire OutletsTransformers KVA No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool AbovE] re Inn& U mergency lg g d. ❑ B No.of Receptacle Outlets No.of Oil Burners atte nits FIRE ALARMS No.of Zones 1 No.of Switches No.of Gas Burners No..of Detection and No.of RangesNInitiatin Devices o.of Air Cond. Total lb Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number ons KW No.of Self-Contained Totals: "`�'M'�" �'� — -- Detection/AlertingDevices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems: No.of WaterNo.of No.of Devices or E uivalent Heaters KW o of Si s Ballasts Data Wiring; No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or E uivalent Telecommunications Wiring: OTHER: r. / No.of Devices or E uivalent (D � d 4S— 3 Attach addifional det 1 if desired, or as required by the Inspector of Estimated Value of Ele Inspections Work: Work to Stalt (When required by municipal policy.) Wires. nspections 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 cove is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑under the OTHER I certify ❑ (Specify:) pa' sand penalties of erjury,t at the information on this applica ' is true and complete. FIRM NAME: /YG'->rt� -jl tQ / /�� Licensee: LIC.NO,:,'4�2 2'a- Sibaatur LIC.NO.: (Ifapplicable, enter" emt"in the license number ne. Address: /C^SL � jQ0 OZ 3�� Bus.TeL No.4 ir3� '�Q *Per M.G.L c. 147,s. 57-61,security work requires D ty„ „ Alt.Tel.No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee doles not ehave the liability Lic:No. normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑ owner cover- ❑rance owner's gent. Owner/Agent Signature Telephone No. PERMIT FEE: $Q: The Common wealth of Massachusetts Department of Industrial Accidents ;Fr ! Dice of Investigations esti;U f�. 600 T zshington Street Boston MA 02111 ` www_massgov/dia . Workers' Compensation Insurance Affidavit. Builders/Contractors/Electricians/plumbers Applicant Information Please Print LeQibl Narrate (Business/organization/individual); n r C Address: E VQ S City/.State/zip:_ 0'ey:p) 0:L{ VV\ 0 Phone#: t- % 2b Are you an employer?Cheek.the appropriate box: 1.❑ I am a employer with 4 Type of project(required): ❑ I aart a general contractor and I e (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. am e:sole proprietor or partner- listed on the attached sheet.x 7. ❑Remodeling ship and have no employees These sub-contractors have working forme in an g Q Demoiman Y capacity, workers' comp.insurance. [No wotlters'comp. insurance 5. ❑ We are a corporation and its 9• ❑Building addition required.] officers have exercised their 10•❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself,[No-workers'comp. M 152, §I(4),'and we have no insurance required.]t .employees. [No workers' 12.[]Roof repairs comp. isnsurance required.] f 3.❑.Other "Any applicant that cheeks bogy;fs t must also fill out the section below showing their workers'compensation policy mtonnation. t homeowners who submit this affidavit indicating they ars doing all work and then hire outside comnicto�s must submit a new affidavit indicating such. tCorrtractors that check this box musratrached an additional sheet showigg the creme of the sub. cotnr'actom and their wormers'e,mp.policy iniarmaaIuc I am an employer that is providing:workers'compensation insurance or e f ' eec: in or»ration. mP�J' Below is the f oli P cJ'andjob site . F Insurance Company Name: ' Policy#or Self-ins.Lic.#: Expiration Date: -------------- Job Site Address:_5 S U V'' of o e„(,f_ �0C) City/State2ip: I�^ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage asuired under Section on 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 of up to$250.00 a day against the violator. Be advised that a copy lof this statement s in the may be fom of a rwarded dOO RK to the fftc of ORDER d a fine Investigations of the DIA for insurance coverage verification. Ido hereby c nder the pai en of perjury that the in OrmatioR f pcavided above is true and carred Si tore . Date. //' Phone#: Official use Only. Do not write in this area,to be cn L mp eAnd by city or town ofciaL 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#• 1; Information a nd 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 includirtg 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',c overage required." Additionally, MOL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation•affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractors)name(s),address(es)mind 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 requiredu carry workers'compensation insurance. lfan 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,notthe Department of Industrial Accidents. Should you have any questions regaswding the law or if you are required to obtain a workers' compensation policy,please call the Department at the nurnber.listed below. Self-insured companies should entErtheir self-insurancelicense number on the'Approprieft tine. City or Town Officials lease be sure that the affidavit is complete and printed legibly. The a artm. has provided P P PP P d a space at the bottom of the affidavit for you to fill out in ffie event the Office of Investigations has to contact you regarding the applicarrL Please be sure to fill in the permit/license number which%%-ill 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 valid affrdavrt is on file for future permits or licenses. A new affidavit must be filled out each year. When 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 hike to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of 1ndusixia1 Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel.#617-727-4900 ext 406 or 1-M-MASSAFE Revised 5-26-115 Fax#617-727-77451 www.mass.gov/dia Date. . . ...�4. . ... .. NORTH .TOWN OF NORTH AND4 ER s ; ; PERMIT FOR GAS INSTALLATION 5 y9SSAf MUSES4 Cj-�. . . This certifies that .�.-�-�7"`-:":-• . . . . . . . . . . . . . . . . . . � v � has permission for gas,(�installation— � ... . . . . . . . . . . . . . . . . in the buildin s of . !�. . .:� '. . . . . . . . . . . . . . . . . . . . . . . . . . . ,� . . . . . .. North Andover, Mass. Fea��. . Lic. No f/��'.y. : . . �( _ . . . . . . . . . . . . GAS�11a1S� CTOR Check# 6991 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GASp'FT171IN�yG V (Type or print) Date I �b 0q NORTH ANDOVER,MASSACHUSETTS Building Locations �� ` 1 V�r►1�( Permit# Amount QdPA ��-'a °�Owner's Name ..Kwsras New'v ' Renovation Replacement ❑ Plans Submitted x �d ° o F a z o z w w w dd x a w _ a�w1 U COD Z w O O w > x O w! a x o x w 3 a c� u a > o oa F o SUB -BASEM ENT B A S E M ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6 T H . F L O O R 7 T H . F L O O R 8TH . -FLOOR (Print or type) Check one: Certificate Installing Company Name Corp. v Address law artner. 04 t Business Tel6phone oV5 V6 LoU Firm/Co. Name of Licensed Plumber or Gas Fitter ` �\S (,(� (10W) INSURANCE COVERAGE Check one: I have a current liability Insuran policy or it's substantial equivalent. Yes No If you have checked yes,please dicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 0 Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent a I hereby certify that all of the details and information I h eLmitted(or enter in above application are true and accurate to the best of my knowledge and that all plumbing work and in alformed r Permit Issued for this application will be in compliance with all pertinent provisions of the Massachu s Cod Chapter 142 of the General Laws. B Signature of Lice sed Plumber Or Gas Fitter Title By: Plumber do City/Town Gas Fitter lcense NumbOr Master APPROVED(OFFICE USE ONLY) Journeyman The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA-02111 lip www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): ULl Address: 11 City/State/Zip: 1400- ✓q Phone#: (QA7 �9S/ Are you an employer? Check the appropriate box: Type f project(required): 1.❑ I am a employer with 4. El 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 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 i l.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §l(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] *:ay app- that checks box�:a. t also fit]out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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. 9 , Insurance Company Name: t � Policy#or Self-ins. Lic.#: lYg �' $ S Expiration Date: kQ .Job Site Address: -d VtM P/✓ C� 6�-� 11 Vb��J� r City/State/Zip: W vf'1 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine . of up to $2 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigati o?%e DIA for insurance coverage verification. I do hereby ct' uder the pain a penalties of perjury 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.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 apartrnents 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 Liabihty.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 Deparnrient 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 h 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 Iicense 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.of Massachusetts Department of Industrial Accidents. 4i ce of Investigations 600 Washington.Street Boston,MA 0.21.11 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-72.7-7749 Revised 5-26-OS www-mass.gov/dia ONO°TM q O s A ,SS,SCNUSf CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 156 Date: August 12, 2010 THIS CERTIFIES THAT THE BUILDING LOCATED ON 59 Summer Street, North Andover, MA MAY BE OCCUPIED AS a new single-family IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Valerie Kozdras 59 Summer Street North Andover MA 01845 Building Inspector Fee: $100.00 Receipt: 22360 Commonwealth of Massachusetts Official Use Only Department Of Penult No. S'f�lJ P Fire Services BOARD OF FIRE PREVENTION REGULATIONS [Occupancy and Fee Checked�$��-� _ [Rev. 1/07] Qeave blank APPLICATION FOR PERMIT TO PERFORM ELECTRIC All work to be performed in accordance with the Massachusetts Electrical Code AL WORK (MEC),527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: P. City or Town of: NORTH ANDOVER To the By this application the undersigned gives notice of his or her intention to perform the eic trical woector ofrk �ies described below. Location(Street&Number) q J yy\M%V- ST Owner or Tenant V A Lt: A& D K Owner's Address Telephone No.q'� 2 231317 S v W1 v.r, -12 s Is this permit in conjunction with abuilding permit? Yes U-)�C�� G- � NO E] (Check Appropriate Bog) Purpose of Building_ Utility Authorization No. Eidsting Service Amps _ / _volts Overhead ❑ Undgrd❑ No, of Meters New Service Amps _/ volts Overhead ❑ Undb d ❑ No.of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: "1 S TA L.LtA S�R�1 Com etion of the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No,of CeiL-Susp.(Paddle)Fans No.of Total No.of Luminaire OutletsTransformers gyp, No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- o.o mergency lg g �d rnd. Battery Units —. No.of Receptacle Outlets No.of oil Burners FIRE ALARMS No,of Zuaes No .of Switches No.of Gas Burne .of D Burners o. et eciion an d No.of Ranges Devices No.of Air Col Total Tons No.of Alerting Devices No.of Waste Disposers eat 11111:111P Number ons 0.0 Se -Contained Totals: Detecbon/Alertin Devices No.of Dishwashers Space/Area Heating KW Local * cipal No.of Dryers ❑ Connection ❑ Other Heating App�nces KW Security Systems:" No.of Water No.of Devices or E uivalent Heaters KW No.of o.of S"Dris Ballasts . Data Wiring' No.Hydromassage Bathtubs No.of Devices or E uivalent No.of Motors Total Hp Telecommunications Wiriag; OTHER: No.of Devices or E ung: nt Estimated Value of Electrical Work: mach additional detail if desired, or as required by the Inspector of Wires. i Work to Start (When required by municipal policy.) Inspectons 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 cove rs in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the p and penalties of erjury, that the information on this appUc is true and complete. FIRM NAME: /YG-il r� A4 j4 C_f A Licensee: LIC.NO.:h'5'2 2 Signator LIC.NO.: (If applicable, enter"e�em t"in the license number ne. Address: SC- /2 j.I®4• � 02 3 Ito 4f Bus.TeL N6.4W e3,f �'Q *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: AILL ci 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. PE r� RMIT FEE: $, �