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HomeMy WebLinkAboutMiscellaneous - 60 JOHNSON CIRCLE 4/30/2018 60 JOHNSON CIRCLE 210/097.0-0059-0000.0 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date c�2—/d9-41D NORTH ANDOVER,MASSACHUSETTS Building Locations (/J T 4,yyeq,-�-A Permit# /�a0 / " r7 Ake-yl C f T Amount$ Owner's Name New❑ Renovation ❑ Replacement rM Plans Submitted ❑ U o Z W V F Z W p� U r� W > W a Z Q a d Q O O W SUB -BASEM ENT BASEMENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR .8-T H . FLOOR (Print or type) p Check one: Certificate Installing�'� ! ✓'YL► ` �. � -+4 7'/ 7l ��n�P� / Company P Y Name ....rp T' AddressLif l L S T ❑ Partner ysmess Telephone _9 V Firm/Co. Name of Licensed Plumber or Gas Fitter L t4kP. .e�`� (J 1 r r7—i INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No If you have checked des,please m* ' to the type coverage by checking the appropriate box. Liability insurance policy r711111 Other type of indemnity Bond 11 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 0 1 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 in allations performed under Permit Issu r this application will be in compliance with all pertinent provisions of the Massac etts State Gas Code and Chapter 142 o Laws. By: gn ture of Licensed Plumber Or Gas Fitter Title 0 Plumber / O J & 0 City/Town 000 rGitter icense um er r APPROVED(OFFICE USE ONLY) Joumeyman The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, M14 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le�ibl Name(Business/Organization/Individual): Address: �L City/State/Zip: kpA-,cQ (o Pbone#: 7Iam ployer?Chec a appropriate box; ployer with 4. ❑ I am a general contractor and ITie of project(requited): s(full and/or part-time).* have hired the sub-contractors 6. ❑New construction le proprietor or partner- listed on the attached sheet 1 7• ❑Remodeling ship and have no employees These sub-contractors have 8. working for me in any capacity. workers' comp.insurance. . Demolition [No workers' 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 1 1.❑Plumbing repairs or additions myself. [No workers'comp, C. 152, §1(4),and we have no 12.❑Roof repairsinsurance required_]t employees. [No workers' COMP.insurance required.] 13.0 Other -sy amlicmt that checks box E1 must alsti fill out the section below showing*x_. .a>. 'c _ fi 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 must attached an additional sheet showing the name of the sub-contractors and their workers'om Policy information P P° cY Iain an ion. 'employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: r L 1 L �X-- ,,/���lT Policy#or Self-ins.Lic.#: ��/ Q �� ,� ��_ Expiration Date:��� Job Site Address: —City/State/Zip:/V, 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 certify nder the pains andpenalties of erjury that the information provided above is true and correct Signature: Date.: Phone#: — E only. Do not write in this area, to be completed by city or town official n: Permit/License# hority(circle one): Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone#: i Information an d 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 notbecause 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 coxnpliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented.to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Alto be sure to sign and date the affidavit. The affidavit should be retuned to the city or town that the application-for the permit or license is being"quested,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 of Massachusetts Department of Industrial Accidents Office of Inv-estibations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax #617-72.7-7749 Revised.5-26-05 vcmnvmass..gov/dia 7o,.., Date. f NORTH 3?0.,; °„•_1�ooL TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,s.1 CHUS� ++ This certifies that . . . . C: UC. r,6; . . . . . . . . . . . . . has permission to perform . . . . P C.h . . . . . . . . . . . . . . plumbing in the buildings of . . . . . !C.. ( . . . . . . . . . . . . . . . . . . . . . . . at . . .� J 41!. .r.( A C. tj . . . . a. . ., North Andover, Mass. -u Fee.L/7��` .Lic. No.)?.�1 c. . . . . . . . PLUMBING INSPECTOR Check # Z ) MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: Iv a(ix ��c��J L , MA. Date:-1 ) Permit# Building Location: 6 U �l n St,a-\ C I (r e Owners Name: M61 f1 Ij Type of Occupancy: Commercial❑ Educational❑ Industrial ❑ Institutional❑ Residential New: ❑ Alteration: ❑ Renovation: [I Replacements] Plans Submitted: Yes❑ No> FIXTURES i z Y 0 V N d X z la- Y } r = N m z ull z aa' Z a Q y z D 3 m X to rn W — 1— w — I- rn p ? h 0 m rn w a a � N } a a`� N Y fn -i — X G W Q Q W O a W Z W J Z U ll LL 3 o I- rn — Q Y O H QinmsoU. 0 = Ygg00 � � � 3330 SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6111FLOOR 7 FLOOR 8 FLOOR e6x-1S Installing Company Name: l S47�—v Check One Only Certificate# Address:L&6r )3 Ci ty n CV (i1 (Corporation 1 /TowState• Business Tel: I J S V r' Fax: 0)�� ❑Partnership 1 '"\ � ❑ Name of Licensed Plumber: 1 r, 1� Cyv"kS Firm/Company INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Ye' , No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy'D 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Si nature of Owner or Owner's A ent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance wkh all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: ? Title ❑Plumber Signature of Licensed P mer Cityfrown Master APPROVED OFFICE USE ONLY Journeyman License Number: r COMMONWEALTH OF MASSACHUSETTS REGISTERED AS A PLUMBING CORP r ISSUES THIS LICENSE TO BRIAN POWDERLY POWDERLY & SONS PLUMBING 8 HEAT: 10 OLDE HILLSIDE ,N BILLERICA MA 01821-1715 3126 05/01/12 759065 LICENSE NO. EXPIRATION DATE SERIAL NO. r COMMONWEALTH OF MASSACHUSETTS iimmmmsmm LICENSED ASA MASTER PLUMBER ISSUES THIS LICENSE TO BRIAN G POWDERLY '� PO BOX 436 �N NUTTING LAKE MA 01865-043 12026 05/01/12 759368�� Date. . 9408 TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING 40 SSACMUS� This certifies that .QD.w ., . . . � . . . . . . . . . . . . has permission to perform . . ouv.�v . . . . . . . . . . . . . . . . . .`. . . plumbing in the buildings of . . . . . . . . ... . . . . ... at o A over, Mass. Fee.��. .Lic. No.. .r�` t -400 0 ' ' PLUMBING SPECTOR Check # ' MASSACHUSETTS U DORM APPLICATION FOR PERMIT TO ID O PLTTIIOIlNG (1,pe or print) NORTH ANDOVER,MAjS�CHUSETIS Date -l� 'y 5, '� Ci ei Owners Name / � '''� Permit - BuildingLocation Amount • T eofOccu /�`��' . New Renovation Replacement Ef Plans Submitted Yes No El F)XTURES a ° ° I a a rn a H w. w H � °, a ° 14 a d A -)l H sx W M RO[R 1 i ZDF D(R 3MROCR ... 41S ROCR 5'1HRDCR ' 6TSFIDCR 7IH RO R SIHROClt • POWDERLY & SONS Check one: Certificate (Pant or type) PLUMBING&HEATING,INC. 1/ Corp. fit' Installing Company Name NUTTING LAKE, MA 01865 ❑ Partner. Address Business Telephone D Firm/Co- Name of.Licensed Plumber: On %"�� �" Insurance Coverage: Indicate th type of insurance coverage by checking the appropriate box: ❑ Liability insurance policy Other type of indemnity ave an one the above ,Insurance waiver: I,the undersigned,have been made aware that the licensee of this application does not h y threeinsurance Signature �, Owner Agent - I hereby certify that all ofthe details and information I have submitted(or entered)in above application are.tnre and'accurate to the best of mylmowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions ofthe MassachState Bing and Chapter 142 ofthe General Laws. 1� By: UITTaTffdoMicenseciFlumber Type of9mbingLicense Title .�...-o�� ElI.CitdTown Lreense um er Master Journeyman .APPROVED(OFFICE USE ONLY - - The CoMMOnweidth of Afassachusetts Department o f£radustr-ial_Qcaidents IV Of/'lce of.�Vesi4gw Ions 60.0 Washington,street Boston, AM 02X11 'w-masagor din Workers' Compengation Insurance AMdavit: BuHders/Contractors/Electricians/Plumbex s .4.n lieant•Tnfornzaiion WD R ,&' NS Please Print Legibly NaMC(Business/Organization/Individml): PLUMBING&HEATING, INC. Address; ' NUTTING LAKE, MA 01865 (978)663-0164 City/State/Zip: Phone#: •Are you an employer?Check the appropriate bot: _ 1. I am.a employer with io'� 4. ❑ I am a a Type of project(required): ---- ben eral contractor and I employees(full and/or part time) have hired _ 6• ❑Nein cons the sub contractors construction 2.E3•I am a sole proprietor or partner- Misted on the attached sheet t 7• ["�Remodeling ship and have no employees These sub-.contractors have 8. working De b for me m any capaciiyf workers' comp.insurance. ❑Demolition [No workers'comp. insurance 5. ❑ We are a corporation and its 9' ❑BmIdmg addition required.] of have exercised their 10❑Electrical repairs or additions 3• ,I am a homeowner doing all tivork right of eempti'on per MGL 11.❑Plumbing r airs or additions Myself [No workers'comp. • c. 152,§_1(4),and we have no • g insurance required.] t employees. [No workers' 12.❑Roof repairs , A wimp.insUranc f,required.] 13.❑Other ='plic_^.t the'checks bo:,tet m•,•*r also 01 cc:•the s >t homes] neTS '-L"L''.._C_.OP.':.hC;;�-'„•+„_=-^.^..i V•orl=aS'Camp^-•..,.S,m,,,_'3p,....t:..... who submit'ttiis affidavit indicating they,asr dc�g all'::t„ anis 2llen hlre eursld8 C(]nt3a^t L— fContraetors That ebec'� ztlss lion , ached an additional sheet showing ors 16dst subr�urt.a new imdavit indicating such. the z�ame'of the s6-contractors and theirworkczs'comp.Pommy information. Fam an employer that is providing workers'compensation assurance for m information. y employees Beloit,is the poficd,and ob site ` Insurance Company Name: Z&/f Y_j / Policy#or Self-ins.Lic.#: EA[Je__,otyQ 0 �S 4. 7 Fkpiration.Date: 3--I J'ob Site Address: 66 Attach.a COPY-of the workers,comp ensafioar Policy declarafi. Cid/S /Zip:,�+�� Q/ /s on page(slaowingthe policy number•and expiration date). Failure to secure coverage as required under Section 25A of MGrL c. 152 can lead to the imposition of criminaj penalises of a nne up to$1,500.00 and/or one-year imgrisgnment,as well as civil penalties in the form of a STOP WORK ORDER and a a n es to tions 0 a day against the violator. Be advised that a copy of this statement may be forwarded to the.Office offine Investigations of the DIS for insurance coverage verification 1 do herehy certify under the pains and penalties ofperjure shirt the information provided above rs true and correct Date .VV ' - Official use only. Do not write•in this area, to be completed hi,city or tom,n official City or Town: Permit/I,icense# Fsscur�Authority(circle onej: I.Board of Health 2.Building Department 3. City/Town Clerls 4.Electrical Inspector 5.PIumbinQ 6. Other ,,Tnspectar Contact Person: Phone'#: Date... `....���.............. NOR7F� 0"9;;'; �oo� TOWN OF NORTH ANDOVER PERMIT FOR WIRING �gB,cMU This certifies that -...p � ..................... has permission to perform ! ... � .........k....... .. ............... ...Q...:.—...- ................... wiring in the building of........... at .... .....V .............North Andover ass. . ................. ........................................... Fee .....Lic.No. ... MM EL CAL PECMK Check# ��� rOfficial Use my t '.-� Commonwealth of Massachusetts Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07] eaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical CodeC),527 CMR 12.00 (PLEASE PRINT IN NK OR TYPE ALL INFORMATION) Date: ,S a / City or Town of: NORTH ANDOVER To the Inspector of Wires: ' By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 60 J0 N NA)H C!6ci.(,$- Owner or Tenant ,S L'htf— iT,& ' Telephone No. Owner's Address _Y171-f6 �- Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building H00.) 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 3 Location and Nature of Proposed Electrical Work: 11,01' pt,_tm(, j04 Coo 1r0? W,#LL 004+1 lot Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No.of Total Transformers KVA S No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency ig ting rnd. rnd. Batter Units p�1 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 Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained .................................................. Totals: Detection/Alerting Devices _:Jr- "x No.of Dishwashers Space/Area Heating KW Local ElMunicipalEl Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of water KWNo.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 d OTHER: ae- Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: /D OU (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 S undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 6 BOND ❑ OTHER ❑ (Specify:) ' 1 I certify,ander the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: . LIC.NO.: Licensee: Fl?,lkg4 per r V cfl Signature LTC.NO.:,F_3jd f r (If applicable,enter"exempt"in the license number line.) Bus.Tel.No.- Address: ?-0 , AUX a�U 8 iH6lt�I+�J'r f 1�► 41 P(� Alt.Tel.No.:S0 'S'"D '%,1� \1` *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 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 r' on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§ 32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ r Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: v* Inspectors Signature: Date: ROUGH INS TION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: f - Date: FINAL INSPECTION: Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Co nts: Inspectors Si nature: Date: DEB WEINHOLD. ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccid&Is Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly >? v Name(Business/Organization/Individual): r( Address: P, U • 00 x A 0� City/State/Zip: -4 VNvti>r r`l19 Phone#: 7J-6 70 - ?P/-� Are you an employer?Check the appropriate box: Type of project(required): 1.4 am a employer with / 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/@ .* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t �• 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.E:1 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]r employees.[No workers' comp.insurance required.] 131]Other *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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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: Lod J?0l-IJJ0 G, 12-CC t� _City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided abo 7srue and correct. Si afore: Date: � Phone#: ?7,P-6 70—F? 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 ofhire,- express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local 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 producedacceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license or permit to 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 ofMassachvsetts Department of Industrial.Accidents Office of Investigations 600 Washington.Street Boston}MA 02111 Teti,#617-727-4900 ext 406 or 1-87T MASS-AFE Revised 5-26-05 Fax 4 617-727-7749 www.mass,govfdia Division of Professional Licensure: License Search Page 1 of 1 w The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES ........................................................................................................................................................................................................................................................... Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency LICENSEE More... Name:FRANCIS J. DEPTULA REFERENCES& PINEHURST,MA RELATED INFO Disclaimer Regarding Website License Searches Licensing Board: ELECTRICIANS Enforcement Process I Glossary License Type: JOURNEYMAN ELECTRICIAN TYPE CLASS: E Glossary of License Status License Number: 31255 I Codes Status: RIGHT TO RENEW STAYED BY DOR More... Expiration Date: 7/31/2013 Issue Date: 9/28/1987 Exam Date: 8/1/1987 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. I The page above has been generated by the Division of Professional Licensure web server on Thursday,May 02,2013 at 10:49:12 AM. ©2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://Iicense.reg.state.ma.us/public/pubLicenseQ.asp?board_code=EL&type_class=_E&Iic... 5/2/2013 Location `�� No. SS;"D Date lk � a ,.ORTIy TOWN OF NORTH ANDOVER' pf t�.�o .�1ti0 O? •' .� O� „ Certificate of Occupancy $ *co Building/Frame Permit Fee $ Foundation Permit Fee $ r Other Permit FeeTC KYX $ Sewer Connection Fee $ Water Connection Fee $ C"M _ r TOTAL $ Building Inspector 7' 37 Div. Public Works PERMIT NO. _ - PPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. T PAGE 1 MAP K40. LOT NO. �o 2 RECORD OF OWNERSHIP iDATE BOOK 'PAGE — ZONE SUB DIV. LOT NO. 1 i 1 Q� i 3 I `� l ta��, LOCATION �� ����� L\v PURPOSE OF BUILDING O`WNER'S NAME / \S NO OF STORIES , SIZE OWNER'S ADDRESS \ i� BASEMENT OR SLAB ARCHITECT'S NAME lo- �+ SIZE,OF FLOOR TIMBERS 18TH� T:x 2ND 3RD BUILDER'S NAME \rte�L\a f- SPAN f_R -- DISTANCE TO NEAREST BUILDING l', DIMENSIONS OF SILLS DISTANCE FROM STREET its C " POSTS DISTANCE FROM LOT LINES-SIDES REAR •" GIRDERS vt \D AREA OF LOT r1' `T � �� . FRONTAGE 1 11 HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW �^ SIZE OF FOOTING k`�� I < IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE -°�[ IS BUILDING CONNECTED TO TOWN WATER v BOARD OF APPEALS ACTION. IF ANY O IS BUILDING CONNECTED TO TOWN SEWER �� e `V IS BUILDING CONNECTED TO NATURAL GAS LINE s©� INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST 1 PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 - 12 SEPTIC PERMIT NO. ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILT AND APPROVED BY BUILDING INSPECTOR DATE FILED RAaKt&�- &%M'D �7 1 r NUILDING INSPECTOR SIGNATURE OF OWNER OR AUTH RIZED AGENT F E E OWNER TEt.1/ PERMIT GRANTED CONTR.TEL.# 19 q CONTR.LIC.N C{ H.I.C.# t o's `�� BUILDING RECORD 1 OCCUPANCY 12 r SINGLE FAMILY _ s�)RIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA- APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE B 1 2 13 CONCRETE BL K. PINEHAR BRICK OR STONE 6RY D W —_ —— PIERS — PLASTER — — — DRY WALL l UNFIN. 3 BASEMENT I �V AREA FULL FIN. B M'T AREA _ 1/1 1/7 1/1 FIN. ATTIC AREA N_O 8 M FIRE PLACES HEAD ROOM _ MODERN KITCHEN _ l'y 4 WALLS I 9 FLOORS CLAPBOARDS 8 _L3 3 DROP SIDING CONCRETE WOOD SHINGLES EARTH �\ Q ASPHALT. SIDING HARDW D �- ASBESTOS SIDING _ COMIACN VERT. SIDING ASPH.TILE STUCCO ON MASONRY STUCCO ON FRAME- BRICK ON MASONRY ATTIC STRS. & FLOOR I_ BRICK ON FRAME CONC. OR CINDER BILK. N STONE ON MASONRY WIRING STONE ON FRAME SUPERIOR IIPOOR _ �r ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE HIP BATH (3 M. ( — GAMBREL MANSARD TOILET RM. 12 FIX.) �r.�/r� FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY _ WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING ( 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING C� RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS \ (� OIL B'M'T 2nd _ ELECTRIC 1st 13rd I NO HEATING Town of �� E over No. 5 5 8 o V, iort y dover, Mass.,1�o eniarz 2Z 19`t4 T O LAKE �, T 1' COC-ICHE WICK IA{. P ry T E D P BOARD OF HEALTH .= s PERMIT T D , Food/Kitchen Septic System a l jam. BUILDING INSPECTOR THIS CERTIFIES THAROeagT.....UR)CA-69............................................................................................................ Foundation has permission to emet. 77t0 .......... buildings on .(100..... ..........QS.` .................................. Rough to be occupied as AAO.....(ox AZ..7W .T...Ubiruz.......?...................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXP 6 MONTHS ELECTRICAL INSPECTOR UNLESS CON TRI' 1 Z Rough ....... . ....... ........................ ............................. ................. Service BUILDING ECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough No Lathing or Dry Wall To Be Done FinaFIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner PLANNING FINAL CONSERVATION FINAL Street No. Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT COMMONWEALTH DEPARTMENT OF PUBLIC SAFETY OF ONE ASHBORTON PLACE MASSACHUSETTS BOSTON,MA 02108 C�odil� �to�► �pp •rjc LICENSE ,k EXPIRATION DATE C 0�)S T R. ^U P C R V I S 0 R CAUTION •) FOR PROTECTION AGAINST n o /19 9 5 A EFFECTIVE DATE LIC-NO. R I ON THEFT, PUT RIGHT THUMB NONE 06/30/1993 028538 PRINT IN APPROPRIATE BOX ON LICENSE. MICHAEL V RODDEN 47 PRESCOTT BLASTING OPERATORS ,���FI SS IV 033-38-7014 N ANDOVER MA 01845 m MUST INCLUDE PHO PHOTO(BLASTING OPRONYh EM1 S �Y,• ' •' :i Its .t,+s f} .i.pi,,:(V . -TVAUO UNM SIGNED BYLICENSE AND OFfl IALLV.d s`ri>6T+IMPED-bR-SK3NATUREOiTNfiCOMM1$SIONER '..'•� dii: ; .rr + t .• a ,_ o. HEIGHT: r DOB: JUL 09/05/1948 ,lr'' s �Y _ +•� THIS DOCUMENT MUST BESIG ' « NASO \ ` IGN T EO ICENSEE r--� �ELI �} CARRIEDON THEPERSONOF U THE HOLDER WHEN EN- OTHERS-RIGCo..". HT N- ts OTHERS-RIOHT THUMB PRINT GAGEDINTHISOCCUPATION. COMMISSIONER !"+t••'e Irl'� f� �� r _ .. .. .. _ _ _ - I. rb'�i 'air •'�, s erI '`- �` � ` " �� ��� ,r '://N,TOor►�o'lalQ�v�..>cf !f r - - - - ' HME IMPROVEMENT CONTRACTOR ' Registration 105903 All Type °INDIVIDUAL 07/ZI/96' Expiration 'Mlichael V. Rodden _ 7 , k 47:1Prescott Street J Al, o, Andover MA 01845 r f t "rt ''r�r d ADMINISTRATOR ` Nyt�.Y ,✓ fit' 11� a'. r d 2 4 Date....., `7�..... .. F o NORT TOWN OF NORTH ANDOVER pf t��to �^,ti0 i PERMIT FOR GAS INSTALLATION �9SSA C HUSEtSh t� 1f 1 $ m d This certifies that . . has permission for gas installation . . . . . . .� in the buildings of . V`1*7(A l .V. . . . . . . . . . . . . . . . . . . . . . . . at th Andover, Mass. Fee. .�-►.' . . . Lic. No.. 9�?. . . . . . . . . kGASINSPECT R WHITE:Applicant CANARY:Building Dept. PINK:Treasurer GOLD:File -��• •.. �•••• •,• ���.ri1ww ruts t'CHMII (j UU (iASFITTING (Print or Type) &A 74A AYldDti P/� Mass. Date— lz�� _ 7 19 Permit# Building Locations 0 JaA* SOS C- jl�Owners Name n Type of Occupancy New Renovation ❑ Replacement ❑ Plans Submitted: Yes[] No ❑ N U m ac t XWN Q Z Cr N UCr N cc G N O N OC 0 N W !Z- F. nw' }"¢ a pQm N O F- C N 0 W C = W �. N C G W Q N C: W Z V W N w Q a O' Q > W W W 07J Q = C it Q C W h W ~ Z N a Y 4 W J Q C N H W O W f- W J }` W ?- of m Z. O Z W O N X Q vl > W z. Q W Q ¢ '.s O c7 S a. Z) � o d U a > Q a 1 O SUB—BSMT. BASEMENT IST FLOOR 2ND FLOOR I 3RD FLOOR 4TH FLOOR STH FLOOR 6THFLOOR 7TH FLOOR STH FLOOR Installing Company Name BAY STATE GAS COMPANY Check one: Certificaterr Address 55 MARSTON STREET XJ Corporation 1862 LAWRENCE, MA 01840 ❑ Partnership Business Telephone 508-687-- 1105 ❑ Firm/Co- Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked res, please Indicate the type coverage by checking the appropriate box. A liability insurance policy � / 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: Signature of Owner or Owner's Agent Owner❑ Agent E] 1 hereby certify that all of the details and information I have submitted(or entered)in abo plication are true and accu�te to the best of my knowledge and that all plumbing work and installations performed under the permit issu f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. ��as EAPPfKYVED T e of Ucense:PlumberSignature of Ucensed Plumber o gJourneyrnan Gasfitter Master Ucense Number 8697 FFICE SE ONLY) _ 2215 A C pORT/y TOWN OF NORTH ANDOVER ! pFt��ao ,e14'O Vj '.: PERMIT FOR GAS INSTALLATION41 CU O p � �9SSCMUSEt�y h^,J fE ttti�� O� This certifies that ! t'f.t has permission for gas installation . /.?K:!4<.-P . . . . . . . . . . . . i {<RS in the buildings of . . .�. . . . . . . . . . . . . . . . . . . . . . . . . . . at . .6,9. . . , Nrth Andover, Mass. ` Fee.-2:> . .r.'. . . Lic. No.p?06 3 . . . . . . . . . .GAS INSPEC• j WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File j 4 s •, .2 r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTiNG (Print or Type) t NORTH ANDOVER Mass. Date _ . uilding Location (�(o Permit s Z '� Owners ' New _ Renovation Replacement Plans Submitted FIXTUR=(z N W N ¢ N x O N = F 4t Yl z ,Cxdx to ~ 0 .4 .� X N Cc 0 t- it" a 0 xw - oLU X - l- o x � 0: 0 tu UJ o W Ca W W - C3 F Cr w < a TO Z O NQ > l , < tC dU0yWoWO O U. .4 Q ts. t- O SUE(-13S,%lT. BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR - (Print or Type) Check one: Certificate Installing Company Name C I oyhei' V-v H Q Corp. Address noel e-r--im, LI Partner. EVt"**F i r m/Co. Business Telephone: 663- 0 8S Name of Licensed Plumber or Gas Fitter 0-69Plif `-1 of-nei�- Insurance Covera e: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy �ther type of indemnity 0 Bond Ej 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 coverages. Signature of owner/agent of property Owner U Agent I heteby certify that all of the devils 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 issLed fo: this application will-be in compliance with all pertinent provisions of the Massachusetts State Cas Code and Chapter 142 of the General Laws. By CG E LICENSE: Title mber fitter Signature of Licensed Cit ten Plumber or Gasfitter y/Town: urneyman rq APPROVED (OFFICE USE ONLY) License Number