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Miscellaneous - 60 MOODY STREET 4/30/2018
210108 }�' 4 ................... OF NORTH,h TOWN OF NORTH ANDOVER * ww; PERMIT FOR WIRING t =;.,'•� • X17 ++iw• q'� $3ACMU5� C Thiscertifies that ..................'.. .~.`.. .................`.......(............................................... has permission to perform-.�A' �.. U..S /1-e ..................... wiring in theqb 'Iding f.... �......v ...................................................................................... R 1 �t n_� n at ... .............. ........(.......-......... l.....................l...!,North Andover,Mass. Fee... ^ Lic.No.211U51�� . .................. LECTRICAL INSPECTOR✓ Check# _ U / h r Ht'rUt.#A 1 iyN rum rcmim i i v rr-nr%jmm cL.r-L. i Rlvr+` .rvF%r% All work to be performed in accordance with the Massachusetts Electrical Code QfQ 527 CMR 12.00 ++7 (PLEASE PRINT IN INK OR TYPE ALLI VJ�ytt— TION) Date: v57— City or Town of l✓6o To the Inspector of Wires: By this application the undersigned gives notice of Ws or her intention to perform the electrical work described below. Location(Street&Number) 60, Owner or Tenant 1,k�/ ['R'N's - Telephone No. i� t� ids e Owner's Address G Is this permit in conjunction with a building permit? Yes No' ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders_and_Ampacitx Location and Nature of Proposed Electrical Work: J S6t Completion ofthefollowing table ma be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans o.of Tot al Transformers KVA No.of-Luminaire Outlets No.•of-Hot Tubs Generators KVA No.of Luminaires SwimmingPool Above r-1 ❑ o.o Units Emergency Lighting d. d. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.o Initiating D and Devices No.of Ranges No.of Air Cond: Tons^ No.of Alerting Devices No.of Waste Disposers eat Pump ,._umber ons No.o e - ontamed Totals: __.._�_ . ._.........._ � Po Detection/Alerting Devices No.of Dishwashers Space/Area Heating KWLocal❑ icipal Connection ❑ firer No.of Dryers Heating Appliances KW ecystems:" �'Y NoNo..of Devices or Equivalent No.of Water Kw -o.- hio...o Data Wiring. Heaters signs Ballasts No.of Devices or E uivalent TelecNo.Hydromassage Bathtubs No.of Motors Total HP No of Devices or nivg No.of Devices or uivalent OTHER: Attach additional detail if desired or as required by the Inspector of Wires. Estimated Value of Electrical Work:✓ c (When required by municipal policy.), Work to Start: $' Inspections to be requested in accordance with MEC Rule 10,and upon completion. j INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless E the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under Hie pains and penaltiels of rjury,t�1iie information on this application is true and complete FIRM NAME: !✓�l s_ / ,rJ c / dra. o /OSS GLC LIC.NO.: I Licensee: Signature LIC.NO.:., BOJ applicable,enter"exempt"i the 1' ens number line. Bus.Tel.No.: Address: 9 GtJ�1hrclrs /(/o��' Nnr � SLY-,) Alt.Tel.No.: 'Per MG.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)E]owner ❑owner's agent. \ Owner/Agent PERMIT FEE: $ Signature Telephone No. 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 iii 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 th e receiver or;trustee of an,individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having notmore than three apartments and who resides therein,or the occupant of Me 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 employes." MGL chapter 152,§25C(6)also states that"every state or local lie-ensiung agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally.,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapterhave 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 notrequired to carry workers'compensation insurance. If an LL C 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,n of 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 ai'fidaAt 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 thatmust submitmultiple permit/liceme applications in any given year,need only submit one affidavit indicating current policy information(if necessmy)and under"Job Site Address"the applicant should write"all locations in (city or Cowin):'A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proofthat a valid affidavit•is on file for future permits or licenses. A.new affidavit must be filled out each __— _ year Where-aheme-owner orcitizenis-obCaining_ahcense.-orpefmitnotrelafed oanybusitie§i or,commeicial.venturo (i,e.a dog license orpermit to burn leaves etc:)paid person is NOq'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 an:d fax number: `I'heamon wealth ofMassac�hv.:sPtts - Depat`G`lxtent of fndust a1Accidents Office ofJAVIOStigatim 600 Waftg m fte,(ot Boston,MA 021.It TOL#61M-27_4.900 0A 406 or 1-$77•:MIASSAFE _ Revised 5-26-05 Fax 0 617-72T-7749 • vt[fiFV�.�IaSs,g4?vfctZa r Y Comonweatth of Mas usetts m Division of Registrati \ Board of Electri MICHA _ 9 WAVE ;! a NORTH A ! 4 Y/ Master Elec ' "a 008172 0713112016 Serial No. ° 21705-A Expiration Date. License Nn. T ' nn Date . TOWN OF NORTH ANDOVER ��: -�: '• °oma F 9 PERMIT FOR PLUMBING 4,.ott 84,�CMUS� r This certifies that....v .........!!v?Gf!Iti2,........................................................................ has permission to perform... .td7.../T.v `.................................................. plumbingin the building of............................................................................................. ,/�j i at...6e...f..CIP G...... ,,.................................... North Andover, Mass. Fee�.�7.a--)....L No.- 37 /1 .. :::.:: . . . ....................................... ,vPLJM�ING INSPTOR Check# The Commonwealth ofAlassachuseas aa/ct } /� fan �p � pai leirt of Indr:strial Accidents r ;LO tit Town■6 Ol DSII U V� I I' e 3:0,`V 6:• t =�, �t:._ . a _ 36 Bartlet Street �- : . Office of Investigatiotrs Andover, MA 01810 .i 600 Washington Street "f Boston 11'!A 02111 . ''�`H° '' � Plumbing & Gas Fees tvivtv.ilrass.gov/dia Effective September,2012 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers pplieant Information Please Print Legibly Plumbing Inspector Richard Danforth (973)623-8305 ame (Business/Organization/Individual): Fax No.: (978) 623-8320 Office Hours: 8:00 a.m.- 10:00 a.m. Adress: O NEW:New Construction and Additions D RENOVATION: Plumbing within the existing system ity/State/Zip: . Phone#: D REPLACEMENT: Removal and replacement of a fixture to the existing piping e you an employer? Check the appropriate box: Type of project(required): ] I am a employer with 4. ❑ I am a general contractor and I 6_ ❑ construction New consttion ALL TENANT F1T-UPS ARE CONSIDERED"NEW" employees(full and/or part-time).*' have hired the sub-contractors ALL GAS BOILERS AND WATER HEATERS REQUIRE A PLUMBING PERMIT ] I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling WATER HEATERS AND OIL BRUNERS REQUIRE AN ELECTRICAL PERMIT ship and have no employees These sub-contractors have 8. F1Demolition workingfor me in an capacity. employees and have workers' t PLUMBING FEES Y P h'• i 9. ❑ Building addition I - [No workers' comp. insurance comp. insurance. 1 Residential 5. We are a corporation and its 10.❑ Electrical repairs or additions required.] ❑ New Domestic Construction —up_t!o 3 Units $100 plus$5 per fixture officers have exercised their 1 I_ Plumbing repairs or additions ] 1 am a homeowner doing all work ❑ g p New Domestic Construction—4 units or more $_QO plus $5 per fixture myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs Renovation $50 plus $5 per fixture t c. 152, §1(4), and we have no insurance required.] 13.❑ Other � e Replacement- Existin Fixtures ONLY $50 lus $5 per fixture employees. [No workers' Backflow Preventer $50 plus $5 per fixture comp. insurance required.] Residential and Commercial applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information_ (for boilers and irrigation systems) neowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. New Commercial/Industrial $200 plus $5 per fixture tractors that check this boz must attached an additional sheet showing the name of the sub-conuactors"and state whether or not those entities have oyees. if the sub-contractors have employees,they must provide their workers'comp.policy number- Commercial—Renovation $100 Itis $5 per fixture Commercial Replacement—Existing Fixtures ONLY $100 plus$5 per fixture :an employer that is providing workers'compensation insurance for snip eirrplovees. Below is die policy and job site rmation. GAS FEES ranee Company Name: Residential New Domestic Construction— up to 3 Units $75 Plus $5 per appliance cy# or Self-ins. Lic. #: Expiration Date: New Domestic Construction —4 units or more $150 plus$5 pera liance Ci /State/Zi Renovation (Domestic) $50 Itis$S erappliance Site Address: �' p= Replacement(Domestic) Existing Appliances ONLY $50 plus$5 pera liance ich a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Gas Boiler/Furnace/Conversion Burner(Domestic) EACH $50 plus $5 pera liance ure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a New Commercial/Industrial $150 plus $5 pera liance 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 Commercial—Renovation $100 plus$5 pera liance p to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Commercial Replacement— Existing Fixtures ONLY $100 plus$5 pera liance :stigations of the DIA for insurance coverage verification. Gas Boiler/ Furnace/Conversion Burner(Commercial}EACH $100 plus $5 per appliance hereby cerlifi_,under die pains and penalties of perjury that the information provided above is true and correct. MISCELLANEOUS iature: Date: Gas Log/Fire Place $50 plus$S pera liance Gas Stove/Heater $50 Plus $5 pera liance !ne#: Utility/ Bar Sinks $50 plus$5 per appliance Re 3ffreird use only. Do not write in ibis area,to be completed by city or town offrcia! Red Sewer Lines $50.00 Re-inspection Fee _ $50.00 '• Inspection after hours(minimum fee) $200.00 amity or Iowa: Permit/Liccnse# Work started without a ermit _ Double Permit Fee I issuing Authority(circle one): I.. Board of Health 2. Building Department 3. City/'Town Cleric 4.Electrical Inspector 5. Plumbing Inspector 5. Other MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING CITY."v4 Opt-4tpOVoar MA DATE �' �—�� PERMIT# � �-l"I''J JOBSITE ADDRESS 0 � OWNER`S NAME Govt w jr OWNER ADDRESS . _ TEL FAX Q H TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑ V O PRINT Z CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:9 PLANS SUBMITTED: YES❑ NO-[j z Z O FIXTURES Z FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 z _ U BATHTUB w CROSS CONNECTION DEVICE CL z DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) jxa KITCHEN SINK LAVATORY Q ct i ROOF DRAIN Q w Q SHOWER STALL SERVICE/MOP SINK Z O TOILET x URINAL O V WASHING MACHINE CONNECTION w WATER HEATER ALL TYPES WATER PIPING z OTHER E— INSURANCE COVERAGE: I have a current liabili[V insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 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 0 Massachusetts General Laws and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ �` ''• l..Sh.� SIGNATURE OF OWNER OR AGENT •������ w Z E-- U 1 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 �, tY and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the LL LL) Massachusetts State Plumbing Code and Chapter 142 of the General Laws- Q_ Q � d PLUMBER'S NAME � �>° `� LICENSE# a3G SIGNATURE O MP[ JP❑ > CORPORATION# 33y 7 PARTNERSHIP El ft- LLC E1# a. COMPANY NAME n S/.J.leml,, I q ADDRESS V m CITY y�/ 7y/^r �n.list/u STATE 222<,l— ZIP d/ y-5" TEL 7 FAX �'i9viz� CELL FlJr- 7 3SC EMAIL �[ n Date.`.��. .��........... 1 • V ♦ c.J TOWN OF NORTH ANDOVER ° p PERMIT FOR PLUMBING ` 88ACHu5E i This certifies that�.............. .....'. `....... . c"pp ``P=S .............,. .. .................q..... ................... has permission to perforir%�,.:1.(1.�.....Y ?.: plumbing in the buildings of..04-0............................................................... at............ .>....±."..` ?.! '." ....'!!!!::4..:..................... North Andover, Mass. Fee...........Lic. No. ... ..... ......................................................... PLUMBING INSPECTOR Check# "'�0, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY' MA DATE `PERMIT# JOBSITE ADDRESS OWNER'S NAME) POWNER ADDRESS �~ TEL,1 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW[] RENOVATION:ED REPLACEMENT:L PLANS SUBMITTED: YES N0[j ��- FIXTURES Z FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 3 ' I 1 BATHTUB I CROSS CONNECTION DEVICE Y DEDICATED SPECIAL WASTE SYSTEM ; i f{ DEDICATED GAS/OIL/SAND SYSTEM ___. ... �... .. ..- DEDICATED GREASE SYSTEM I �� DEDICATED GRAY WATER SYSTEM - a DEDICATED WATER RECYCLE SYSTEM ,I -� I 1� - � t DISHWASHER r 1' DRINKING FOUNTAIN FOOD DISPOSER ... . .I . _. ... .._ . FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY s ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET _ URINAL WASHING MACHINE CONNECTION 'r WATER HEATER ALL TYPES I - WATER PIPING _ €_ – –II~ ! FF-- OTHER $r 77, INSURANCE COVERAGE: w I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW `. 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [] AGENT L SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia=ith��ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME mike careless„ J LICENSE#,158 SI ATURE MP El JPE] CORPORATION# PARTNERSHIP'. #( o LLC # COMPANY NAMEthe boiler guy ADDRESS 160a pleasant st — CITY1 north andover JSTATE11 ma ZIP 101845 TEL L978-382-1017 FAX _—� CELL' EMAIL 1 0 Date...'�. �I.k....y ..................... NOwrM pF �.•o ,•,~p TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 4• . /' gBACNUS� .Ibis certifies that .................:..........�.. ...... .`f...................................................... ...p SS has permission for gas,installation Tom?.!1 Pc' .�,:I � in the buildings of...........:....��-�-- ...................................... ............................................... at.10.X .. ,..(- c;LA , North Andover, Mass. Fee..O.:: ... Lic. No.45Z-�, ..... 'M� . ...............................................:..................... I GASINSPECTOR Check# �2 ` i� J63 i I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITYc; � �� `�l✓- MA DATE PERMIT _ __v.. x_ y , aw H..,. JOBSITE ADDRESS? �OWNER'S NAME i U G OWNER ADDRESS TEL FAX I TYPE OR OCCUPANCYTYPE COMMERCIAL[] EDUCATIONAL RESIDENTIAL=, PRINT CLEARLY NEW RENOVATION: ` REPLACEMENT:t 'a PLANS SUBMITTED: YES NOµr APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER - BOOSTER CONVERSION BURNER ....,,._,` -'m COOK STOVE r _.... _.. DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR '�_ba.. l.. : FURNACE w GENERATOR - .,. GRILLE INFRARED HEATER (— i. LABORATORY COCKS f, I MAKEUP AIR UNIT OVEN 'N POOL HEATER - . ROOM/SPACE HEATER w ROOF TOP UNIT [ € TEST Jz - F � , 1 UNIT HEATER € y UNVENTED ROOM HEATE 41 WATER HEATER F OTHER .._.,_._....._,__. __..._._.,_. .,. _._ ...:E pK -�_.... -------- ,—.�.-., �--.. ._..... __,,.... ., f.. ,._., ro�."A,N,.sr».wknurtiis:,,,+w:•.,�.�::rrc.xava» r..rcs.,_n L _,.,.—s ra,:...-.-re i. .<... ,....f€s,.., ,.,....-, _..:...-._.... ,<.r.:.x..:,.L. ,:.u.,�, ,„<% P— v,.:.....,...>«.w.ww.w..:..,..o...... :.,ww....w.....w.. �.ru..,.:wc.�,.aw.0 .<::.a... .....:..... .. i,. .,-,.� ,..-< .,......... INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW • LIABILITY INSURANCE POLICY = tt OTHER TYPE INDEMNITY' BONDI € OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ` w AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Perti nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER GASFITTER NAME MIKE CAPELESS LICENSE# 15851 SIGN URE MP` MGF , JP JGF LPGI CORPORATION # mm PARTNERSHIP; ^#,�_ LLC #� COMPANY NAME:THE BOILER GUY � 1 ADDRESS 160A PLEASANT ST CITY NORHT ANDOVER ' STATE; MA I ZIP!01845 JrTEL 19783821017 i FAX CELL! EMAILE I The Commonwealth ofMassachusetts - Department of lndustrk.Mccidents Office Oflnvestigations 600 Washington Street Boston,MA.02111 www.mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians&lumbers Applicant Information Please Print Le 'bl Name(BusiuwdOrganhxffbnffndMdual): Address: 1 Q City/State/Zip: �C� , I I�� (�i/ e L'I one#: ` ✓" Ase ou an employer?Check the appropriate bog: Type of project(required): employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(M and/or part time).* have hired the sub-contractors 2.El am a sole proprietor orpariner- listed on the attached sheet.: 'l• F1 Remodeling ship and'have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. 0 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 1111 Plumbing repairs or additions myself.[No workers' comp. c.152,§I(4),and wehave no 12.QRoofrepairs insurance required]t employees.[No workers' 13.❑Other comp.insurance required] *Any applicamthat checks box#I mmstalso fill outthe section below showing1heirwbikers'compensationpolicy information. 'Homeowners who submit this affidavit indicaftthey tie doing allwork and then hire outside contractors must submit a new affidavit indicating such. TContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy infomsation. I am an employer that is providing workers'compensation insurance for my employees: Below is the policy and job site information. lnsttrance Company Name:.. -Hont c- �IJUO�� Policy#or Self-ins.Lie.#. `l ( � .y lSG 6 `1 Expiration Date• VI Job Site Address: M02d4lCity/State/Zip- Attach a copy of the workers'comp onpolicy$eclaration page(showing the policy I 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 civitpenalties in the form of a STOP.WORK ORDER and a fine ofup to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office-of Investigations of the DIA for insurance coverage verification. I do laereby ertify and r thepains andp les of perjury that the infonnationprovNed above zs true and correct Si atare• Date: Phone#: 6, offccial use only. Do not write in this area,to he completed by city or town official City or Town: Perm Ucense# issuing Authority(circle one): 1.Board of Health 2.BuildingDepartment 3.City/Town Clerk 4.Electrical l! Vector 5.Plumbing]Inspector 6.Other - - Contact Person: Phone#: 1 II ACCO" 111/12/12/22014014 CERTIFICATE OF LIABILITY INSURANCE DATE CERTIFICATE ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the Certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Matthews Insurance Agency Inc NAME: PHONE g7g 681-1112 FAX (978)685-3855 182 Parker St ac No Ext: ( ) ac No: E-MAIL ADDRESS: Lawrence,MA 01843 INSURERS AFFORDING COVERAGE NAIC o INSURERA: Atlantic Casualty INSURED Michael Capeless INSURER B: Arbella 105 Tyler St - — - -- -- __ -- Methuen,MA 01844 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY DIIYEYXYY LIMITS LTR GENERAL LIABILITY _EACH OCCURRENCE $ CODAMAGE TO RENTED MMERCIAL GENERAL LIABILITY L143000684 08/07/2014 08/07/2015 PREMISES Ea occurrence $ 100,000 CLAIMS-MADE 71OCCUR MED EXP(Any one person) $ 1,000 PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO LOC $ AUTOMOBILE LIABILITY HC357357 08/30/2013 08/30/2014 COMBINED SINGLE LIMIT Ea accident $ ANY AUTO HC357357 renewal 08/30/2014 08/30/2015 BODILY INJURY(Per person) $ 300,000 ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ 300,000 AUTOS AUTOS $ 300,000 NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident 1 L $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- I OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER — ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ 890911-0937696 02/13/2014 02/13/2015 F_.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE_E4 EMPLOYEE $ 100,000 If yes,describe under — DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Heating or combined heating and air conditioning systems or equipment,installation,servicing or repair,plumbing 1407 Great Pond Road in North Andover CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD ..is„••;rilw�Tc�llwr�'sllll.rlrl'rrvr'r'•lPwwlrac� a gm PLUt BER SF TT'ERS - # ISSUES. THE Ft1LLt3WI NG I 1;fNS`E . .L ICE AS;.,A MASTED P'LUMB'E t .. MICHAEL .'N CAPELE'SS ` f 105 JY!;W. ME1UEi Mk:O1$4� 190 22307; • M• a Date...7.....3..x.. ................. pT~, TOWN OF NORTH ANDOVER * PERMIT FOR WIRING �8'�C/IIJg� This certifies that ........................ �,1 rn�.lL ............... .......................................................... ...... ` , , has permission to perform ........... �. .M,�......,,,,...... .....�� .... .......................... . wring in the buildin Y,of.... ... at ......CO.............'..../U..tl.Ct.Y......��?J ................erthAndover,Mass Fe (. .........Lic.No � ELECINSPECTOR Check# 3 9 Commonwealth of Massachusetts Official Use Only Permit No. 1114 1 Department of Fire Services " Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATIOA9 Date: 17_ — / City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her inten' n to perform the electrical work described below. Location(Street&Number) Owner or Tenant i/ y Telephone No. Owner's Address Is this permit in conjunction with a building permit? YesNo ❑ (Check Appropriate Box) Purpose of Building Xr— Utility Authorization No. - Existing Service:�G d A ps / Volts Overheadndgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. 1 No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans TransTotal Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burgers No.of Detection and TotInitiating DevicesNo. of Ranges / No.of Air Cond. l Tons No.of Alerting Devices No.of Waste Disposers �' Heat Pump Number Tons KW No.of Self-Contained p Totals: - ........... •••••••••••............ Detection/Alerting Devices Munical No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑ Other No. of Dryers Heating Appliances KW SecN o Dev lc s or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wtres. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,tinder the pains nd penalties ofperjury,that the information application is true and complete. FIRM NAME: fn. 9 l� `li t c•l 4 LIC.NO.: � Licensee: L— Signature 44WLIC.NO.:_ (If applicable,e er "exempt"in the license nzzmb r e.) Q Bus.Tel.No.: Address: hl ,,tel le �—�G Alt.Tel.No.: *Per M.G.L C. 147,s.57-61,se rity wor requires Department o ublic Safety"S"I icense: Lic.No.� OWNER'S INSURANCE AIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my sig ature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent rPE7P, IT FEE.$ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed IN Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: 4 SERVICE INSPECTION: e Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL IN ECTION: Pas ? Failed (] Re-Inspection Required($.) ❑ Inspectors o ents: Inspecto Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations IN 600 Washington Street Boston,MA. 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly Name(Business/Organizatiordlndividual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑New construction employees(fall and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. �• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. E]Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'-comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.[i Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they tire doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lie.#: Expiration Date: Ab Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Simature: 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 employeiis defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Gomnc ORWCalth of Massachusetts Department of Industrial.Accidents Office of Investigations 6.00 Washington Street Boston.,MA.02111 TO,#617-727-4900 oxt 406 or 1-877rMASS.AFB Revised 5-26-05 Fax#617-727-7749 vw.mass.govldia 10060 Date .' . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . s. P .f'?�� !. . . /. . . . . . . . . . . . . has permission to perform . . . .� l�Q r►�d plumbing in the buildings of. .( !2_. . . . . . . . . . . . . . . . . . . . . . . . at . . . .W.Q. . .! ./.Q 6.J . , . . . . . . . . . . North Andover, Mass. —7 � - M� Fee . ./. -r. . Lic. No.t . . . . . . . . . . . . . . . . . . . . 3�O PLUMBING INSPECTOR Check# 6140 A-- 77-/�/ v)-L 7/3�3 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY Av t-A- MA DATE j PERMIT# JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL 0 RESIDENTIAL 0� PRINT CLEARLY NEW: RENOVATION:® REPLACEMENT: �' PLANS SUBMITTED: YES[] NOD FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _._f 1 _f � ( 1 f _._.__J CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM ._..-.._.--_1 DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM f DISHWASHER f ..1.-_ DRINKING FOUNTAIN .1 FOOD DISPOSER _ I .1.. ._1 1 f 1 I t __...._1 { .-.._.__J I FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) -_----J KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL - f { _.---_f E I _.._-__-_.)F-- SERVICE/MOP SINK I ....._ J I -_-_-- t ._._.I _.._--._! . J I __—_f TOILET URINAL WASHING MACHINE CONNECTION I WAT.ERHEATER ALL TYPES WATER PIPING71 OThS -J ------j ` t INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES�NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Q BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the PJlassachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are nd accurate to he best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in mpli ce h all Pe inent pr ision the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMELICENSE# . 3 _ -_' GNATURE MP JP[j CORPORATION #�PARTNERSHIP 0# LLC COMPANY NAME ADDRESS J�!' �- -- CITY `Yt STATE dLc ? ZIP TEL FAX ____ CE�Z._8`j5..73. _�,± EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTE Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# M� �r -�/2 T/�3 PLAN REVIEW NOTES The Commonwealth ofMassachusetts - Department of IntfustriqlAccidJnts Office of Investigations to 600 Washington Street Boston,MA 02111 www.rnass gov/dia Workers' Compensation Insurance Affidavit:Builders/ContractorslElectricians/Plumbers �Ulicant Information Please Print Legibly Name(Business/Organization/Individual): Address: A d k --/C Y City/State/Zip: ,>7 y . �y UZ" Wgjione ZD A�r-e-,yyoou an employer?Check the approliriate bog: Type of project(required): 1.uv 1 am a employer withy 4. ❑ I am a general contractor and I 6. El Now construction f employees(full and/or part-time)x have hired the sub-contractors . 2.El am a sole proprietor or partner- listed on the attached sheet,t emodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.[]Electrical repairs or additions 3.E] 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[Noworkers' comp. c.152,§1(4),and we have no 12.❑Roofrepairs insurance required.]i employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submitthis affidavit indicating they iiie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. I am an employer that is providing workers'compensation insurance for my employees Below is thepolicy and job site information. Insurance Company Name:. )�l 0 l?� Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a.copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL c.152 can lead to the imposition of criminal penalties of a rine up to$1,50 0.00 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. B e advised that a copy of this statement maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. Ido 71ereby ce a u e7thepains dpenalti ZofpeuYy that the information pYOYided above 1s true and COYYBCt. - Si afore: - Date: -7 v Phone#: cj ' 0 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/IfAccuse# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - ..-/...:-:....... NORTOI °�t"`°;•�"� TOWN OF NORTH ANDOVER o % PERMIT FOR WIRING �,SSACHU`�� ( �This certifies that .......�.�......��.f...................................................... has permission to perform . .:.:.......��'�.c.l.. ............ ............. wiring in the building of.../„� v.'.. ........ :-�.............................. at. .G...../0 rl. .............. .......,-Z North Andover, ass. at.� Fee. :.... ...... 1slc.No.f,/ y,,� ................ er..... iY LECTRICAL INSPE R Check #l 7 L Z..--- `! 0665 Commonwealth of Massachusetts Official use only Department of Fire Services EvM tNo. O 4 �S BOARD OF FIRE PREVENTION REGULATIONS ncy 'd Fee Checked . 71 eave.blank APPLICATION FOR PERMIT 'TO PERFORM ELECT All work to be Performed in accordance with the Manachusetts Electrical Code ELECTRICAL WORK (P,LWEP=TJNINKOR TYMUZDWORM 27OA9 Date: — /1 CMR 12 .E City or Town of: NORM ANDOVER — —/ By this application the unders' To.the Inspector of Wires: d gives notice or hest intention to perFotni dre electrical work described below. Location(Street&Number} d do Owner or Tenant i o, Owner's Address Telephone No. Is this permit in conjunction with a building Permit? yes Purpose of Buildtag — NO Q (Check Appropriate Box) Utility A thorn- tion No. T=fsting Service Go Neer voltsOverhe;ad`e' Undgrd 0 No.of Meters L_ ce Amps /_-Volts Overhead t�---'tt Nmuber acf of Feeders and.Amp t5 u UnBgrd u No.of Meters Location and Nature of Proposed Electrical Work; w Co etion o the ollawin'table be waived b the ctor o � l3'ires ' No.of Recessed Luminaires / No.of Cefl.-Susp,(Paddle)Fans °• Total No.of Luminaire Ovidets Me -4—M-t 1�. �'ransformers Dull i. 4Z .,. . a,.j�•, Swimmiing Foal �►b e ] .Q ,o Um cy g No.of Receptacle Outlets (� No.of Oil Burners FIRE ALARMS No:of ZonesNo.of Switches No.of Gas Burners on an No.of Ranges �tia ' ' devices . No.of Air Cond., o Tuns No.of g Devices To No.of Waste Disposers tP r one o.o on t�sls: "'""--- teetio No.of Dishwashers Space/Area Heating KW DenlAI Devices uni No.of Dryers Local Counec on El fie' eating Appliances KW ecurity tems: o. Heaters 0.eKW o.o No, Devices or uivalent d a � of, S s Ballasts. ��W No. No.of Devices or-E. ninaient Hydromassage Bathtubs No.of Motm.s Total HP ecornum a ons OTHER: No,of Devices or t Estimated Value of Electrical Work: Attach addih'ona!detail if desired ar as required by the Inspector of wires. Work to Start: J. -/ L (When required by municipal policy) y/ Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSfi1RANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee.provides proof of liabtiity insurance ineludiag"completed undersigned certifies that such c��eOTmm' operation"coverage or its substantial equivalent. The and has exhibited.proof of same to the permit issuing office. C 3ECK ONE: INSURANCE C3 (Specify I COO,under the pains aced p sties o er ) ' 09 P fmY,#leaf the lr}onmrahFu�a on dsls gvpJica*x rs true and complete FZRM NA14a: Licensee: . LIC.NO: 6�s• ,�:� �`/ Signature (If applieabl,su r"exempt"in the Ucense manber line.) LIC.NO Address: Bus.Tel.No.: *Per M.G.L c. 147,s.57-61,security work rexluires 13eparbozerrt Alh TeL Na: OWNER'S INSURANCE WA Public Safety S License: Lic.No. AiVER: I am aware t eat the Lice=ee does not have the liability, required by law. By my signature below,I hereby waive this u• mmm mce coverage normally Owner/AgentQ requirement T am the(check one owner ❑owner's Signature Telephone No. PER1lIIT F,L�E: d_ `" ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR-DOUG SMALL 1.ROUGH SPECTION: Passed—[A Failed— ) Reins tion Hired $50.00)-f Inspectors'comments: (Ins rs' atnr no i frisk) Date 2.FINAL IN PECTION: Passed—[ Failed—fRe—inspection required($50.00)-f I Inspectors'comments: (Inspectors,Si nature-no initials) Date 3.UNDER GROUND INSPECTION: Passed—I I Failed—[ I Reins tion re wired($50.00}-[ l �. Inspectors'comments: (Inspectors,Signature-no initials) Date 4.INSPECTION—SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed—( l Famed Inspectors'comments: Reinspection required($50.00) (Inspectors'Signature-no initials b Date S.INSPECTION-OTHER: Passed 71 l Failed—I Reins eetion required($50.00 Inspectors' comments: l (Ins ors'Signature-no initials) Date DOOR TAGS ARE TO BE SLED OUT AND I,Err ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE ANDA REINSPECTION OF SS0.00 IS TO BFB nr„ED,