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Home My WebLink AboutMiscellaneous - 605 OSGOOD STREET 4/30/2018 605 OSGOOD STREET 210/035.0-0032-0000.0 i+ PO Box 55098 Boston,MA 02205-5098 617-951-0600 iq;�n 11135 1 Lis Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 RE: Insured: DOUGLAS D KEITH and KATHLEEN M-KEITH Property Address: 605 OSGOOD ST,NORTH ANDOVER, MA Policy Number: HMA 0303911 Claim Number: BOS00059508 Date of Loss: 2/2/2015 Company: Safety Property and Casualty Insurance Company Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Pam McPherson Claim Examiner 4/20/2015 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3521 Fax: (617) 531-2741 Email: PamMcPherson@Safetylnsurance.com Date.�.A9././7........ 10672 . * OF 00 r . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 88�c«ug� This certifies that.�........................cJ.......f � has permission to perform..`:�Tn�..4r-� �ti �c ao rel-oo f r?�.............. plumbing in the buildings of.......ff.' - ..... ............................................ ................... at..... .�.......�U ................... North Andover, Mass. ��5"- - Fee......................Lic. No. ................ ... ............................................................................... PLUMBING INSPECTOR Check#�� 3z- i 4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY / �G/' _ MA DATE G [ PERMIT# LN A, JOBSITE ADDRESS OWNER'S AME OWNER ADDRESS g e f TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL �_I) RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:011 REPLACEMENT: PLANS SUBMITTED: YES NODI FIXTURES 7. FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE t DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM _ - E _ I _ _ i _i ._. _.fI _! ._ ). _I �{ i ._f 4 DEDICATED GREASE SYSTEM ._.____ I f __ [ DEDICATED GRAY WATER SYSTEM i f I== DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) ._.- KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET LARINAL VMSHING MACHINE CONNECTION _—f +WATER HEATER ALL TYPES V+7ATER PIPING OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES dNO OF YOU CHECKED YES,PLEASE INDICATE THE YPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY _I BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the (Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Ll 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 d accurate to the best of kn ledge and that all plumbing work and installations performed under the permit issued for this application will be i ompliar e W allPertinent pro i o e (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ?d _ / LICENSE# c�.� SIGNATURE - MP JP CORPORATION �# // PARTNERSHIP 0#=LLC COMPANY NAME �/' ADDRESS CITY �!!i'Ydf/+��d�✓ -.-..-...--((STATE ZIP TEL FAX CELL _-.i EMAIL �I ROUGH PLUMBING INSIDECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTIAIK NOTES Yes No l THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of 1Vlassachusetts - Department of lndustriglAcciclents Office oflnvestigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation bsurance.Affidavit:Builders/Cony°actor6l lectric�iansfrIffi bens .A lieant information Please Print Le 'bl N2Me(Business/Oxganization/.tnd%vidual): Gt p wjfC4 Address: City/State/Zip: /(/LI /ari �9,1Phone#: 49, 7 7 S- Are yemployer?Check the appropriate box: Type of project(required): 1. I am.a employer with. 02. 4• ❑I am a general contractor and I 6. ❑Now construction f employees(full and/or part-time).* have hiredthe sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and'havena.employees These sub-contractors have 8. ElDemolition working forme in any capacity. workers'comp,insurance, g, ❑Building addition (No workers' comp.insurance 5. ❑ We area corporation and its 10.F1 Electrical repairs or additions required.] officers have exerdsed.their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions Myself [No workers'comp. c.152,§1(4),and we have no 12.❑Roofrepairs insurancere ed. employees.[No workers' a 13.❑Other comp.insurance required.] 'Any applicant that checks box#I must also fill out the section bel6w showing their workers'compensationpolicy informafion. i'Homeowners who submit this affidavit indicating they Aire doing&&work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this boar 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 andjob site information. Insurance Company Name: 9- G1oL Policy#or Self ins.Lic.#: Expiration Date: /01//,P /.f Job Site Address Or 2�ipa&� t) City%State/dip: Attach a copy of the workers'compensationpolzcy declaration page(showing the policy number and expiration date). Failure to secure coverage.as reguiredunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a fine u to 1500.00 and/or one= ear imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine p $ Y p of up to a y of this statement may be forwarded to the Office of $250.00 a day against the violator. Be advised that a cop Investigations of the DIA for insurance coverage verification. .X do hereby certp er fli pains and penalties ofperj t}i e information provided above is true and correct. O Si ature• Date: D Phone 4: Official use oufy. Do not write in this area,to be completed by city or toren official. Cite 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 Terson: Phone#: r . Information and Instrdction s Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Parsuarit to this statute,an employee is defined as"...every person in the service of another under any contract ofhire,- express orimplied,oral orwxitten." An eYnployep 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 txusfeo�ofan individual,partnership,association or other legal entity,employing employees. 1%,wGver 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 employes." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required:' Additionally,MGL chapter 152,§25C(7)stafas"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 beenpresentedtathe contracting authority." Applicants Please fill out the workers'corn pensallon affidavit completely,by checking tho boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation,insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for thepermit 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*orkexs' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their i self-insurance license number um r on the appropriate line. , City or Town Officials Please be sure that the affidavit is complete andprinted legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be-sure to fill iu the permitToonse number which will be used as a reference number. In addition,an applicant thatmust submit multiple permit/license applications in any given year,need only submit one affidavit indicating current PORGY information(ifnecessary)and under"Job Site Address"the applicant should write"all locations in. (city or town):'.A:copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit•is on file for fature permits or licenses. Anew affidavit must b e 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 orpermit 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 anal fax number: TtoG`A k?onwDaMof A4SSarhUgP S Dep.ariMelat Qf Wugtdal.Accidents Office of fwestiiatwaa 6,00 Wasbingkon Street Saston}MA 02'111 Tel, 617-7-27-4900 QA 406 Qx 1-877-MASS.AFM _ Revised 5-26-05 Fax#617-727-7m �vxa�ass,g¢��dia • Date...................... . ............... V40 Th, TOWN OF NORTH ANDOVER p g"= PERMIT FOR GAS INSTALLATION ,88,C14U5�t This certifies that AV41J �� .�� T / .............................................................//........................................./ if a !G /td C has permission for gas installation``L......................p in the buildings of......xcf ............................................................:................................... at... ............. ... North Andover, Mass. .................. z w Lic. No. �.� j Fee. .. .... ....../..:....-....`.............................................. GASINSPECTOR Check# Z- 9440 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY Iff'i/ MA DATE PERMIT# JOBSITE ADDRESS rS _�! �a OWNER'S NAME OWNER ADDRESS _ G _ , TE —IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:[1 RENOVATION: REPLACEMENT:Ed PLANS SUBMITTED: YES : No E3 APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE _._. _— _ �1 —J i —— C-._ I I.� FRYOLATOR FURNACE GENERATOR GRILLE I�.. _�_I INFRARED HEATER LABORATORY COCKS __ MAKEUP AIR UNIT OVEN ��-�1 POOL HEATER [ J ROOM/SPACE HEATER - ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER - — - - —-� L-3 =- ,� -- INSURANCE COVERAGE filive a current liability insurance policy or its substantial equiv lent which meets the requirements of MGL.Ch.142 YES 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE E BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ! OTHER TYPE 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 Ell AGENT �I SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are tru ccurate tothe best of my wled e and that all plumbing work and installations performed under the permit issued for this application will be in co liance ith all Pertinent provis' f Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER- ASFITTER NAME _a1t ,- ._�_..�/ - LICENSE# 3 pd SIGN URE MP MGF JP JGF OILPGI CORPORATION # PARTNERSHIPS(# LLC®# ® � � COMPANY NAME: .- _/ _ ADDRESS _ CITY / _ _- /d`�> I STATE ZIP -- TEL FAX CELL[ EMAIL I ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No SS (/— THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth ofMassachusetts Department ofindustriqlAccidints Office of Investigations 600 Washington Street Boston,MA.02111 www.mass gov/dia Workers.' Compensation Insurance Affidavit: uilders/Contractors/Ele,ctricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): e4 G ®7" Address: City/State/Zip: T2 /W 91 rP Phone" #: Are an employer?Check a appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have Hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 'l• ❑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 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]uiemployees.[No workers' q ]� 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they tie 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.M Expiration Date: Job Site Address: t �� O��'J 0�� •Pity/State/Zip: L 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi rider hepatus andpenalties o er' that the information provided above is true and correct. Simafore: A, Date: i y Phone#• sow 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#: F i Information and Instruction'-s Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance 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 anLT C or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to signand date the affidavit. The affidavit vit 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/lice'nse 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(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town 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: Tho Cornzxzu.anwealtla ofMgssachusot�s Dopaxtent offadustrial Accidents Office of fAvestigations 6.00 Washiogtoll Stxoet Boston}M.A.02111 Teel,#617 727-4900 ext 406 or 1-877�:MASSAFF, Revised 5-26-05 Fax#617-727-7749 'f V W_mace antrfrlia COMMONWEALTH OF MASSACHUSETTS >: p,e o o • - o COMMONWEALTH OF MASSACHUSETTS BOARD OE • ® o , , ® o PLUMBERS AND G'ASFITTERS ISSUES THE FOLLOWING LfCENSE (( SHEET METAL WORKERS f< REGISTERED AS A PLUMB ING COR j ISSUES THE FOLLOWING .LICENSE I MASTER UNRESTR I CT-ED ¢`f fz . DAVID M S U L L 1'VAN ;Q GARB ME CHAN 1:::C AL PLUMB I NG f HEAT I DAVID M SULLIVAN: 31 WEST ,51: r Iz — a y t. `S S " W I _ y . 31 WEST.. ST ;w WILMINGTON MA 01887-300]`':. • .- 331 05/01/16 214857 WILM�`NGTON to 01887 3007 I I 10545; : . 05/28/ 6 21485 COMMONWEALTH OF MASSACHUSETTS COMMONWEALTH OF MASSACHUSETTS o o 0 e BOARD OF PLUMBERSAadD GASFITTERSBOARDOfi PLUMBERS AND GASFITTE;RS j ISSUES THE fOLLOWI;tJG LfCENSE ISSUES THE FOLLOWLNG ,.LLCENS LbCENSEf) AS A MASTER PL—'UMBE ¢'� , ? L I GENSEiI A5 A JOURNEYMAN -PLUMtifr f2 DAVID M SULLIVAN:::* - Z DAU:1:D M SULLIVAN: R tt 4 W Ll : W; 31 WEST ST E., �� + s ,*� i i'fr �a v 31 WEST ,r fsht rf w' rt 1 a is ld i� WILMINGTON MA 01887 3007 E WILMINGTON MA 01887=3007 " + 124 214858 _ 05/01/16 23411 5/0t 2148G6 - -2148.56 _ .. .. .aa►�,a CERTIFICATE OF LIABILITY INSURANCE 08/12/2014D/YYYY) 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(les)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). g PRODUCER CONTACT Paychex Insurance Agency Inc PAYCHEX INSURANCE AGENCY,INC. PHONE FAX 150 SAWGRASS DRIVE 877-266-6850 . 585-389-7426 ROCHESTER,NY 14620 EMAILADDRESS, Certs@paychex.com INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: Nol-GUARD Insurance Company 31470 DARB MECHANICAL PLUMBING&HEATING INSURER B: INC 31 WEST ST. INSURER C: WILMINGTON,MA 01887 INSURER D: INSURER E: INSURER F: i' 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. LTR TYPE OF INSURANCE AD UBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS ?NSR D (MMIDDIYYYY) (MM/DDIYYYY) GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED EICIAIMS-MADE[::::]OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG POLICV PROJECT LOC $ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED SCHEDULED BODILY INJURY AUTOS AUTOS (Per person) $ HIRED AUTOS AUTOSWNED BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND XWC STATU- OTH- EMPLOYERS'LIABILITY DAWC550986 02/22/2014 02/22/2015 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000.00 OFFICERIMEMBER EXCLUDED? � E.L.DISEASE-EA EMPLOYEE $ '?00,000,00 (Mandatory in NH) I IN I N/A E.L.DISEASE-POLICY LIMIT If yes,describe under $ 500,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) 605 Osgood Street,North Andover,MA 01845 CERTIFICATE HOLDER CANCELLATION Town of North Andover MA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Building Dept. DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY Jim Hurley-Plumbing&Heating PROVISIONS,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR Inspector LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2010/05) @1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD g l Date... .. ....... TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING CHU This certifies that ...44 0 ...................................... ...... ..................... ........... ...LV6 has permission to perform ..��V--Z� '�. .......... ...... ....... ..... Avel ......o....... wiringin the building of..........I.................................................................................................... at .......... .......................................................................... N6Qh Andover,Mas Fee .........................Lic.No. e ..k.. ELECTRICAL INSPECTOR Check 4t 1245-A //�� j/� // Official Use 0 ly l.ommonwealth of/Y/aedachusetts 'I' 2epartment ol.} c� �7ire Services Permit No. i F t ( Occupancy and Fee Checked ` - BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLE,4SE PRINT IN INK OR TYPE ALL L'VFT13otIL--et TION) Date: �� d City or Town of- Z To the Inspector of Wires: ., By this application the undersigned gives notice of his or her interition to perform the electrical work described be ow. ' Location(Street&Number) ®� ®-S'�0Qy .57r Owner or Tenant 61En/ AF�%/ry/ Telephone No. Owner's Address 4-A-1 t: 1 Q& C4-UsSb Is this permit in conjunction with a building permit? Yes © No ❑ (Check Appropriate Box) J Purpose of Building Utility Authorization No. 17/7783 Existing ServicepU Limps /La /2-(/d Volts Overhead ❑ Undgrd OX No.of Meters New Service (J(/ Amps /20 /Tyra Volts Overhead❑ Undgrd © No.of Meters s Number of Feeders and Ampacityy�/f�j� 5�2V1 C,-- 7-0 y/a 7��1 Location and Nature of Proposed Electrical Work:- yl �� G ,09 41251 Completion o the ollowin table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total �1 t Transformers KVA F No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Units Emergency Lighting rnd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices TotNo.of Ranges No.of Air Cond. Tons No.of Alerting Devices ., — No.of Waste Disposers eat Pump umber Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection Security No.of Dryers Heating Appliances Kms, Systems:* No.of Devices or Equivalent No.of WaterNo.KW No.of No.of Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivaient OTHER: R , Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: W/. Q 00, — (When required by municipal policy.) Work to Start: 40 --12/-/y 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 i tl undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE K BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties qfperJury,that the information on this application ' true and complete. FIRM NAME: OC S ZJ�1 C_ OSI^ GA E(U-04 (LV - LIC.NO.: ( ( 9A Licensee:M lCl-(�CL Cf$(�� Signatur IC.NO.:1719? 4 (Ifapplicable,enter "exempt"in the license number line.) Bus.Tel.No.:41771936-11 Address: PO /30 x eZ 0.1 �E6/ f]• Off67 Alt.Tel.No.: *Per M.G.L.c. 147,s. 57-61,security work requires Dep ent of Public Safety"S"License: Lic.No. OWNER'S S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ r l ��eb 61 ,M. L;l r ti r r. � �cv IAy The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations _ 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Con,ractors!Electricians/PSu: ;e Applicant Information Please Print Leaib#g dam,, (Business/Organization/individual): 5 itNC �QS(�FA :address: PO sox oZD� Cite/State/Zip: R&�D iN G MO(S 6 7 Phone #: Are you an employer?Check the appropriate box: --_ p y 4. F1 i am a general contractor and I Ly pe of project(required,. s am a em to er with_� emp'ovees(full and/or part-time).* have hired the sub-contractors { 5 ❑ New construction: I am a sole proprietor or partner- listed on.the attached sheet. I [] Remodeling r ship and have no employees These sub-contractors have . ❑ Demolition working for me in any capacity. employees and have workers fNo workers' comp. insurance comp. insurance.=' ❑ Building additier: required.] 5. F� We are a corporation and its Electrical repairs Or LLJ officers have exercised theirPlumbingh l t am a homeowner doing all work i.� repairs ,�r myself. [No workers' comp. right of exemption per MGL insurance required.] + c. 152. §1(4), and we have no .` ❑ Root repairs employees. [No workers' 1;-❑ Other comp. insurance required.] Am applicant that checks box 41 must also fill out the section below showing their workers'compensation policN information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must Submit a new affidavit indicating curl, 'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and.rate��hether or not those eniit;c,I- € _n:rrlo,.ees. If the sub-contractors have employees,rhe} must provide their workers'comp.policy number. a um an emploper that is providing workers'compensation insurance for mi,!emplovees. Below is the pnlic t'anil1rr/z information. :nsurance Company Name: T.5rc(2—LE-S S °o!ic-, 4 or Self-ins. Lic. #: VVC S& 3 7 q 7 Expiration Date: 3 -a 0-•� �/`� ;,,t, Site Address: ®L5_ _City/State/Z_i� Attach a copy of the workers' compensation policy declaration page(showing the police number and expirationL. c= tc t aiiure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition ofcriminal pena.itie, : ! me up to$1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER an.C; up w$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Off ce :,vesti,ations of the DiA for insurance coverage verification. f -- 3 l do herebv certify under the pains and en ofperiury rhof the information provided above is true and correctl e 51a - P 71CeG Official use oniv. Do not write in thi.v area. to he completed br city or town official. Z.th or Town: Permit/License# ; i ii Issuing Authority(circle one): i. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing inspect F. Other i:ont;,cr Person: Phone#: i:,. Fold,Then Detach Along All Pertora:Fon-, COMMONWEALTH OF MASSACHUSETTS BEARD 6F ELECTRIC;ANS ISSUES THE FOLLOWING r_ ICEh_c � c . REGISTERED MASTER ELECT? OES INC MICHAEL F OSHEA 30 BELMONT ST z READING MA 01867-2625 17199 A 07/31/16 ..... 1 ACi;Zc CERTIFICATE OF LIABILITY INSURANCE } THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE H _''-F7 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED !BY f BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUREF<(S1, R`- REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. .. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. If SUBROGATION IS rVASvEt;'. a3cJ Js X41 the terms and conditions of the policy,certain policies may require an endorsement. A statement or,this certificate does not ca;,fel r;,�.r.�; I•�k' Certificate holder in lieu of such endorsement(s). PRODUCER CONTACT T�TanC i rti. NAME: y Theriaui% - T. Phelan & Co. , Insurance Agency Inc. PHONE �781)64T-720n AX A/C.No?: .;SSS-<� 1645R Massachusetts Avenue E-MAIL _..s ADDREss:nancy..theriau1 t@wtphelan.co.-n jI INSURERS AFFORDING COVERAGE q Arlington MA 02476 --- -----__-_ INSURER A:Peerless Insurance NSUREDIJ OE$, Inc- INSURERB:Excelsior INSURERC:Ohio Casualty IP O BOX 202 a INSURER D: --------{,�: : { ,Reading MA 01867 INSURER E --- ---- ---_ INSURER F COVERAGES CERTIFICATE NU MBER:CL1431708128 ,EVISION Glnaa — - THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSL P- VI` ON B :r LC CUM.-Ni ABOVE EQ f INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUN EST WI-, .,tSPC CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HER �S EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. SUS SUB!ECT P. ^ _ INSR LTR IJ. TYPE OF INSURANCE ADDL SUBR I POLICY EFF POLIC'f EXF — POLICY NUMBERMMlDDlYYYY MMlDD;YYYY' LHu;iTS GENERAL LIABILITY I I ' EACH CCCUr?PENCE COMMERCIAL GENERAL UABIUTY I DAMA G'- 2.O 9tN �C i PREMISES(ta CLAIMS-MADE OCCUR KS558858863/20!2014 13/20;2015 ED EXP(Any one oerscng t9SnhAL A0V INJL Y f ! GE-NERAL ACGREGA;E GEN'L AGGREGATE LIMIT APPLIES PER: c PRO- ! J�� -COM C 4;=G X POLICY LOC AUTOMOB,LE LIABILITY i !Ari 1 IO✓B,N IN L I ANY AUTO ALL OWNEDI P 7� , NiJu X AUTO SCHEDULED 1 A8634496 AUTOS c (3`20/2014 ,3/20/2015 y Pc ac X NON-OWNEDo € h—� HiHED AUTOS AUTOS i I YROEEP w pAMnu --- 't I 1Per aco,c,.ert) . i II .X. UMBRELLA LIAR X OCCUR ; '�edicai aavmers � c v j EXCESS LIAB I E'=•CI=•OL:CLI I?RSUCE c 2, CLAIMS-MADE l ------ 9 AGGREGATE DED X RETENTIONS 10,000 5055885886 3/20/202.4 /20/2015 ----" 4 A WORKERS COMPENSATION I 7 AND EMPLOYERi.JC QTP U I 6 S LIABILITY YIN ( 22. rn�� !nry, y I ANY PROPRIETOR/PARTNER/EXECUTIVE I OFFICER/MEMBER EXCLUDED? FN7 N/A I /20/2015 ACl-A( 9Gr.J S (Mandatory in NH) I C8637897 /20/2014 /20/2015 - 9 ff ves.describe under ! F DISEASE EA.EM J E S DESCRIPTION OF OPERATIONS below II ( i DtSEHSE PGLIC°'Llr,?2.T f I . DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101.Additional Remarks Schedule,i;more space is required) i i { FI' _CERTIFICATE HOLDER CANCELLATION K'> SHOULD.ANY OF THE ABOVE DESCR!BED POLICIES BE xC..A.tN'CEi_'_` Itil THE EXPIRATION DATE THEREOF, NOTICE_ WILL 8E Ar ACCORDANCE WITH THE POLICY PROVISIONS. Town of North Andover 1600 Osgood St. AUTHORIZED REPRESENTATIVE North Andover, Ma. 01845 — —-- R Ramsey, Jr-/THERNE - ACORD 25(2010/05) ©1988-2010 AC0P.D CORPORATi0N_ 'NS025 Q01.00501 The ACORD name and logo are registered marks of ACORD Date..... ..... Of AORTsl ?; o� TOWN OF NORTH ANDOVER o s PERMIT FOR WIRING sSACHUs� This certifies that ................00 ..............X.. ...0 ........................................ has permission to perform ....... wiring in the buildin of............k..............C` ..1...�...h-f................................................. at ........ 7 5.... ........) .........��...r.-............... orth Andover,Mass. *Fee.-J Z-.�---Lic.No. .... 7L ...............Ai�T--RICAL . .:;.. Ll �... ..... ©Q INSPECTOR - V h # III C eck 12497 l.omnwnwea& of MaMachuJettJ Official Use Only ---� _ 2ryc�� ]] Permit No. � �! 7 epartment of ire Service) t '4 - Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFX0a%-1eA_ TION) Date: y/ -a„3--/ City or Town of: ,tyo- To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described be:ow. Location(Street& Number) 6®S 3 Owner or Tenant AYj 171&&;F i l h ! Telephone No._ Owner's Address -54Mt: 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 Anaps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity 'DeZKy 0c_Q t/N A4&rZ v +00 rle/i Location and Nature of Proposed Electrical Work: wr'�<NL Gr �� ✓� 1 �4 Del Completion of thefollowing table may be waived by the Inspector of 1Vires. t No.of Recessed LuminairesNo.of Ceil:Susp.(Paddle)Fans No.of Total ,t Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA • No.of Luminaires /0 Swimming Pool Above ❑ In- ❑ o.o Emergency tg tng rnd. rnd. Batter Units No.of Receptacle Outlets 5— No.of Oil Burners FIRE ALARMS No.of Zones f No.of Switchest� No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tons Total No.of Alerting Devices r ' eat Pum umber Tons K _o of elf- ontatned No.of Waste Disposers Totals I Detection/Alerting Devices No,of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ other Connection No.of Dryers Heating Appliances KW stems:*SecNo.of Dees or Equivalent No.of WaterNo.KW No.of No.of Data Wiring: Signs Ballasts No.of Devices or Equivalent 2 No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent ` OTHER: ?!" /�CtL✓[ `j • Attach additional detail ifdesired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 4, 0 00. (When required by municipal policy.) Work to Start: al -Z 3 / Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unlesswaived atved by the owner,noermit for the an p performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The y' undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE K BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of9erJury,that the information on this application i true and complete. FIRM NAME: OE S =U C_ QSl^ L� �t2C� SE(LVI - LIC.NO.: ( _, Licensee:M ICl-{/-ACL-. ( S C A Signature �C. NO.:171 9 ' i� (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.:6!7 7! 936 !/ Address: PO 30>c 40a E A• illr6 Alt.Tel.No.: *Per M.G.L.c. 147,s. 57-61,security work requires Depart ent 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 i Signature Telephone No. PERM1rT FEE: S �. t • � 3 y , .. 1 _ _- 1 i . � ,�,,---/J-� . . �. � . . .. .} ,� _ .. , _ . '+,�. fir..' ;�'� 3r,... ..J .,. _ X*=1f i a `:_ CERTIFICATE OF LIABILITY INSURANCE , ' f THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICAT CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED,^. By T: Izl I BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INS!RER(St, AST 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. ;,;v i the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not s certificate holder in lieu of such endorsement(s). CDfer rid +'<: PRODUCER !? CONTACT Nancy y Ther�auit r -T. Phelan & Co. , Insurance Agency Irlc. PHONE (781)641-72pn ; rAx a 645R Massachusetts Avenue E-MAIL ADDRESS:nancy.theriault@wtphelan.com F (Arlington MA 02476 INSURERS AFFORD!NGCOVERAGE INSURER Insurance INSURED I INSURER B:EXCelSlOr �r €OES, Inc. INSURERC:Ohio Casual!" : P O BOX 202 2 ` INSURER D: i ,., >Reading MA 01867 INSURER E. _ INSURER F COVERAGES CERTIFICATE NUMBER:CL1431708128 - ,eElr6clO?ti NU^nE3'_�i: i THIS IS TO CERTIFY THAT THE POLICIES QF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE !tNISUR D r� .v=D PBOv - - i INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUV ENT Jh � ? CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED REIN is , I Ec a r e r ; EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAWS. c S 8 F IINSR ADD L SUBR .,rtk 7 LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP — GENERALLIABILITY j MM/DDlYYYY MM/DD,'YYYY1i LIMITS j IILIIII ( EP.C?A �OCCU?R;NCE -_- c I X COMMERCIAL GENERAL LIABILITY ' I - MAGr'O RtNTLn j-- a f PREMISES(Fa )coFrercei_ j __=4{ -}-- CLAIMS-MADE a OCCUR KS55885886 13/20/2014 (3/20/2015 '' ",�ED EXP(Any one person) ADV fN,;UQ- j GENERALA.G G4 E GA-E '��.. GEN'L AGGREGATE LIMIT APPLIES PER. I X POLICY PRO- LOC coimpiop AUTOMOBILE LIABILITY 0Me:N D SINGLE �M,- T j B d ANY AUTO Iidemi__ c — ALL OWNED a POD NJJRY,F,e. ALX SCHEDULED A8634496 �3{20/2014 13/20/201-5TOSP,UOSECiDIL`!iN,iUR�ire- "•,._ X X IN I actio - HIRED AUTOS AUTOS PROPERTY CAM4C ---- 7 { I I I i iPer acc,denil i ' _---.---_.- jJC7LAIMS-11�ADE led cai oa mems X� UMBRELLA LIAI EXCESS LIAR f f �: C I EAG Q^,CU�RENCE —-- "�.G.GREGA.TR DED X RETENTIONS 10,000 5055885886 /20/2014 3/20/2015 —' A }WORKERS COMPENSATION t AND EMPLOYERS'LIABILITY I ? ''NC STATU. ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N �` i 7R� irar4 + - i I OFFICER/MEMBER EXCLUDED? FNJ N/A� I _ EACH ACr D ` h !(Mandatory in NH) �7C8637897 /20/2014 /20/2015 - _._ if ves.describe under I II EL.DISEASE-EA EMPLOYES a r• DESCRIP1101IN OF OPERATIONS below j i f = DISEASE FOLIC c ( I aril: y DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) I . y r { CERTIFICATE HOLDER CANCELLATBON `' — ifY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCE)-=_c : --C.- THE EXPIRATION DATE THEREOF, NOTICE Wii_iL. SE: _ Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. - 1600 Osgood St. North Andover, Ma. 01845 AUTHORIZED REPRESENTATIVE R Ramsey, Jr./THERM - r ACORD 25(2010/05) ©1988 2410 ACORD CORPORATION. Ala 114S025(20,005).0! The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts r,_ . _ Department of Industrial Accidents +� Office of Investigations ,r 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/t iu.mr;e- -:; Applicant information k ` Please Print Legin3s � Nam,, (Business/'Organization/'Individual).'Q �NC �OSE.� ��Iv C_(L N (0 Address:_?o 'Rox ;_0 a City/State/Zip: ea-AD iN L 11_O($ (0 7 Phone #: 7 9- Are you an employer?Check the appropriate box: 4. ----- 1 am a general contractor and I Type of project(required;: I am a employer with ❑ employees (full and/or part-time).* have hired the sub-contractors 6 ❑ New construct 1-11) I am a sole proprietor or partner- listed on-the attached sheet. ❑ Remodeling ,. ship and have no employees These sub-contractors have 8. L Demolition. working for me in any capacity. employees and have workers l [No workers" comp. insurance comp. insurance..' E] Building addition required.) 5. ❑ We are a corporation and its !Gt.N Electrical repairs or - ❑ I am a homeowner doing all work officers have exercised their ;.❑ Plumbing repairs or ac;, myself.myself [No workers' comp. right of exemption per MGL insurance required.] c. 152, §1(4). and we have no 2-0 Roof repairs employees. [No workers' 1 3 ❑ Other comp- insurance required.] ! _ ar.•\ applicant that checks box 91 must also fill out the section below showing their workers'compensation poli^) Information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mus?submit a new affidavit indicatmg (ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and Mate-hether or not those enol c;t` _trnlm.ees. f f the sub-contractors have employees-rhe} must provide their workers'comp.policy number. I ane an emplover that is providing workers'compensation insurance for my employees- Below is thL policIT atm'iuh information. insurance Company Name: F,5rc2 LE:-S S ''olid # or Self-ins. Lic. #: 1NC g(o 3 7 q - --- --- Expiration Date: 3 -a O -ot Site Address: oi— ' . ,7'CitylStateZt• attach a copy of the workers' compensation policy declaration page(showing the policy number and expiratc,n ::<., t =<iliure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminai pena.t;e. C. ane up to$1.500.00 and/or one-year imprisonment, as well as civil penalties in the form ofa STOP WORK ORDER a c up io $250-00 a day against the violator. Be advised that a copy of this statement may he forwarded to the Office veSti rations of the DiA for insurance coverage verification. /do hereby certify under the pains and en olfDeriury lboY the information provided above iv true and correct. -- , L3 -/ 7 &/— '741d - 1P76 c , �- Official rose onlr. no not write in this area, to he completed btu city or town n rriaL ?! Cite or Town: Permit/License# a 'i Issuing Authority (circle one): i 1. Board ofHealth 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Inspects>s 5. Other C ontnet Person: Phone#: Y s• Fold,Then Detach Along All?,: OOMMONW �' � girl EALTH OF MASSAC_;-(USE-Tc bOF ISSUES THE x--K - ELECTR;CiANS FOLLOWING REGISTERED MASTER E ZE^ OES INC = MICHAEL F OSHEA - 30 BELMONT ST r READING - '7199 A M4 0►86%-%6_,; _ —— 07/3 !;6 • t. s 31F 1 Date.!... 7 — ........ ............... A TOWN OF NORTH ANDOVER PERMIT FOR WIRING US This certifies that ...... ........... ...................................... ...... has permission to perform wiring in the building of..........1 ...e ................................................................. at.. .......... ........... ...... .............. . North d.ov.e.r; 1...1....,.. ?Fee.— T: ....... Lic.No# . , ........ .�...�� 1,01LECFRI sR . Check # ,per fi QQ'' q�� Commonwealth of Ma6ack,6X6 Official Uke Only/ cc77� Permit No. �✓�l( parh ed o�}ire Ser>ricert Occupancy and Fee Checked :_ :• BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR•12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 942 1/11 City or Town oh b0,F"n - 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) (On G OSCI-00� � e-� �`� 1 �7.�d✓e Owner or Tenant 000 C, } k: 'tt A-f Telephone No. I71 Owner's Address (9(345 0 SST CSO� /',�A o✓e r Is this permit in conjunc •on with pa building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building .]c L-Iu. Utility Authorization No. Existing Service 9-W Amps lav / J'(U Volts Overhead❑ Undgrd No.of Meters r New Service Amps I Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ---Y\ �1 o.JY L t T L,ti-Nc,- Completion ,-Com lesion of the ollowin table ma be waived b the Inspector o Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA AboveIn- o.o Emergency Lighting No.of Luminaires 3 Swimming Pool rad. 11rnd. F1 Bane Units No.of Receptacle Outlets 3 No.of Oil Burners FIRE ALARMSNo.of Zones No.of Switches No.of Gas Burners No. Detection and Initiatin Devices o No.of Ranges No.of Air Cond. Toonsl No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of-Self-Contained p Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Secu of Devices or Equivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications tarring: No.of Devices or E uivalent OTHER: �tAttach additional detail ifdesired,or as required by the Inspector of 1111res. Estimated Value of Electrical WorkA,m 00 _ (When required by municipal policy.) Work to Start: 918 311 r 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 cgrtify,under the pains andpenalties of perjury,that the information on this application is true and complete: FIRMNAME: '1M^^�iT ale-c�ccti�- �-�lcc.> LIC.NO.: j I�5 7113 Licensee: )::�c J a;-, t2 . ,nom w.4- Signature - LIC.NO.: ^�1' ?1 ? (/f applicable,a ter"eg,�e�mpt"in thg license number i e Bus.Tel.No.- el -� �0 Address: f d /moo 9 ? `''t``/ ^ 2��fi'� �- o rg y 9 Alt.Tel.No.•It'7Y KY W-6(-3 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 requiremenL I am the(check one)❑owner ❑owner's agent Owner/Agent PERMIT FEE: $_ Signature Telephone No. ..., .. � , . � _ , .. _ :I .t�. . � � �� ` — � �. .._ .._ ._ i e _ .. .. � . . _. _ I T .. � � _ .. S i. .. .. G f, 1 1 � J t i � � .. i. t �. ' Via.. - - .. !y - , .. i i Y • Th e Common_Wealth ofMassach usetis Department of Industrial Accidents Office of Invesfigations 600 Washington Street Boston,MA 02111 _ - www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organization/Individual): C l P�G�'Yrc-r l .Se/r✓/ c2 S C Address: �U � 7�( City/State/Zip: /At M,e bU,\, CX CI��I Phone#: 9'7 �' ' 6 F7— 9 112 70 Are you an employer? Check the appropriate box: Type of project(required): 1.0I am a employer with ___3 4. F-1•I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7.Z Remodeling sub-contractors have ship and have no employees These 8, ❑ Demolition _ working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp.insurance comp.insurance.$ required.] 5. E] We are a corporation and its 10.❑Electrical repairs or additions 3-0 I am-a homeowner doing all work. officers have exercised their 1 l.❑Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees.[No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such- #Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they nAust provide their workers'comp.policy number. 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.Lic.#: C y 7 Expiration Date: Job Site Address: �C-) S Q ct S -� City/State/Zip:/�G'T)-fAir+d✓�1/ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. - Ido hereby certify nde 1h ' s andpenalties ofperjury that the information provided af/bove is true and correct. mature: ` Date:70 �( �3I 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#: 7 �� i �, � ✓ t _ s s .,. ' � , • f z �. _ .� 9428 VAORTM TOWN OF NORTH ANDOVER o PERMIT FOR WIRING SSACMUS� This certifies that .........al-I....1.. . f ........................................ has permission to perform ....... ......... ........ wiring in the building of............ r�C '................................................. at..... .................................... ..........`.-..................... .North Andover,Mass. Fee...... .....'.... Lic.No.��..........� ............. ... ..... .: . . ...... ..... /f/�j ........... LECTRICALINSPECTOR Check # ! i Commonwealth of Massachusetts Official Use Only Department of Fire Services Perm"No. ices - Occupancy and Fee Checked ` BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRIC All work to be performed in accordance with the Massachusetts Electrical Code M L WORK (PLEASE PM7flV INK OR TYPE ALL INFOR L4TJOA9 Date: ( E ,527 C 12.00 17 City or Town of: NORTH ANDOVER By this application the undersigned To.the Inspector of Wires: gn d gives notice of his r her intention Perform the electrical work described below. Location(Street&Number) �� C},S'� 7 ' Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes Purpose of Building No ❑ (Check Appropriate Boaz) Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead _ ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: . Completion of the o/Iowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total . No.of Luminaire Outlets No.of Hot Tubs Transformers KVA Generators KVA No.of Luminaires Swimming Pool Above ❑ In_ o.o mergency g ° d• - No.of Receptacle Outlets No.of Oil Burgers d• atte Units � E ALARMS No.of ZonesNo.of Switches No.of Gas Burners No. of Detection and No.of No.of Air Cond. otal Ranges Initiatin Devices T Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW o.of Self-Contained Deteetion/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal No.of Dryers Heating A Connection ED other ppliances KW Security Syevrstems:* L No.of Water ter No.of D ' �, No.of No.of ces or E uivalent Heaters Si s Ballasts . Data Wiring: No.Hydromassage Bathtubs No.of Devices or E nivalent g No.of Motors Total HP Telecommunications Wiring: `+Y No.of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: Work to Stark (WheD required by municipal policy.) 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"P ration" undersignedP coverage or i certifies that such coverage is in force, and has exhibited proof of same to the permit issu g office. mvalent The CHECK ONE: INSURANCE I BOND ❑ OTHER ❑ (Specify:) �jr&'1110�rS I certify,under the pains and pen ties of perjury,that the information on thu application is true and complete FIRM NAME: Licensee: '� SignaLIC.NO.: ture (If applicable, enter " �pv' in the lice a number li ,o LIC.NO.: Address: ,�/ ✓ 1$j/ t� AlA `Bus.Tel.No.: 32 *Per M.G.L c. 147,s.57-61,security work requires Department`( ty„ „ ,l� �t Tel.No.: OWNER'S INSURANCE WAIVER: I am aware tht the ense does not have the liability Lic.No. required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner ance coverage owner*normally t. Owner/Agent Signature Telephone No. PERMIT FEE. S 1 1 i yy 4 ` ,IIID t A }E �r A� 1 k A l .F 1 yyy Y 01e� e VVV �� The Commonwe¢It � hof M¢ssachusetts Department of rndunrial Accidents Office of fnvesigatwns i 600 W¢shi baton Street Boston, MA 02111 i wWw-Mzzss.gov1&a Workers' Compensation Insurance ATldavit: guilders/Contractors/Electricians/Plumbers Anplicant Information Please Frim Leaibiv Name(Business/Organization/Individual): Address: ( r _ City/Sate/Zip: � �/l� �� GliQIZ' /SAr Phone#:-?7(-q. S 0 Y VEI ou an employer?Check the appropriate boa: 1am a employer with 4. ❑ I am a- Type of project(7ed teneral contractor and I employees(full and/or part-time).* have hired the sub-contractors ti ❑New constr 2 I am a sole proprietor or partner- listed on 7. []Remodelin . the attached sheet x and have no employees These sub-contractors have working forme in an capacity. 8 Demolition y ca a.ci workers' comp.insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its 9 ❑Building ad required.] officers have exercised their 10•❑Electrical re 3.❑ I am a homeowner doing all work right of-exemption emption per MGL .11.❑Plumbing repairs or additions y4 myself. (No workers' comp. C. 152,§1(4),and we have no insurance required.] t employees. [No workers' 12.❑Roof repairs comp.tnstxrance required.] 12.7 Other Any 2ppEcaut that ch—k.:box-V mast nc secrirn beiot wet^a=_^ works s'coq^�� Ilomeowners who suomii this affidavit indicating the,,a d^W-aL r -• Y�b=; W- �u a wcr'b and mea hire outside con+:acte o L{Iwl submit a new affidavit indicating such. +Contractors that chwk this box must attached as additional sheet showing the name of the sub-contr xton and tbeir workers'comp.poiicy information. I am an employer that is providing workers'compensadon information, insurance for my employees Below is the poficy and job site Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration pale(sho a t Failure to secure coverage as required under Section 25A of MGL c. 152 can 1 d to the imposition of ri e polcy number and expiration date). ` fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the foram of a STOP WORK ORDER band offine ' of up to $250.00 a day against the violator. Be advised that a copy of this Investigations of the DIA for insurance coverage verification. statement maybe forwarded to the Office of I do hereby c under the pains and 'es o er .rP .%zay thcrt the information provided above is true and correct Si�ature: Date.:. Phone Official use only. Do not write in this area, to be completed by cit),or town official Cita or Town: Permit/License# Issuing Autbority(circle one): 1. Board of Health 2.Building Department 3. Ci 6. Other ty/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Contact Persun: Phone#: V 7552 Date. ./ /./... ....... ,apRTk TOWN OF NORTH ANDOVER • PERMIT FOR GAS INS ELATION �9SSACHUSEt k This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation in the buildings of . . ..�. . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . North Andover, Mass. Fee. 3G: .�— . Lic. No./ . . f ... . . . . . . . . GAS INSPECT0,,A/ Check# q, - 3 (73 ` 0904 - 10 ( MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING A i j, c/ ,Mass. Date //IiV . 20 1/- Permit# Building Location PS �s.�yvycA S j Owner's Name dG 'h4 )c�C Type of Occupancy New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes p No❑ Uri V) w a 0o Cn Cn O pq rn o w z W ¢ g z c7w ¢ E~ gO > GM w a ¢ W w t" a, WU c� a Q O F rx o 3 A v a > a H Q SUB-BASEMENT BASEMENT FIRST(I ST)FLOOR SECOND 2ND)FLOOR THIRD(3RD)FLOOR , FOURTH(4TH)FLOOR FIFTH(5TH)FLOOR SIXTH 6 FLOOR SEVENTH(7TH)FLOOR EIGHTH(8TH)FLOOR Installing Compan Name NGl H 1 %E o c±11,v S t -51 Address o rf �_ Check one: Certificate /-1 "'54 el t " ,-1 4 9" 9 a'Corporation Business Telephone 197 2&1- ' 3 ❑-Partnership Name of Licensed Plumber or Gasfitter / Ira 1Z /vl a ,rt, w ❑ Firm/Co. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes ❑ No❑ If you have checked yes,please indicate the type of 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 MGL,and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By Type of License: ,�\ ----- — --• Title ❑ Plumber Master Signature of Licensed Plumber/Gasfitter City/Town ❑ Gasfitter ❑ Journeyman License Number / f APPROVED(OFFICE USE ONLY) PLEASE COMPLETE REVERSE SIDE - The Commonwealth of Massachusetts Department of Industrial Accidents 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 Name(Business/Organization/Individual):,//Ile q a y �t� lam) C t) Address: 3 l ��r c S' a City/State/Zip: dl t A),, 0 / `hone#: 7,r- d) 4 . 2 ! 9 3 Are you un employer?Check the appropriate box: Type of project(required): 1.4.I am a employer with-_ 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El 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. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its officers have exercised their ME]Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f 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 subcontractors and their workers'comp.policy information. Iain an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. rr / Insurance Company Name: Policy#or Self-ins.Lic.#: N' /3 A -3 J 7t) Expiration Date/:f Job Site Address- U 0 5 c,6-cd S City/State/Zip: VC/- Attach t/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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: Dat, / Phone#: / ( � 3 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#: I 0 1 i 10NO LI ower r.- � - o dower, Mass., COCMICMEWICK y'I. %p RATED PY S BOARD OF HEALTH Food/Kitchen PERMIT Septic System THIS CERTIFIES THAT.............�Q v � s •�� BUILDING INSPECTOR 5.....�r...................... ........................................................ _.................. PiQn a n has permission to erect..... w .....& a .................................... C � .... ._.................. to be occupied as.......�. .... 3�.......... « .a.......lt d?L...... -............��c�.....,, ..«� Chimney provided that the person accepting this permit shall in every respect conform to the terms of the applicat non 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 EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU ST TS 6 - z �d Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building -GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wale To Be Done FIRE DEPARTMENT' Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. _ GENERAL BUILDING NOTES/CHECKLIST-NOT LIMITED TO ITEMS BELOW POST ALL LOT NUMBERS,ADDRESS, AND PERMIT(COPY 0K)..or no inspections INSPECTIONS: (Minimum) Excavation , Footing, Foundation, Frame,Insulation, Final. FOOTINGS: Continuous Full 2x4 Keyway r. Continuous strip footings for interior columns FOUNDATION: Rebar as required Anchor bolts or straps A= " � Damproofing - m Foundation drain-pipelstone/fabric filter/cover and'outlet connection. FRAME:Fireblock-over girts/plates between floor joist Penetrations for plumbing, heat,elec, etc. Walls at stair stringers. Windbrace corners and center bearing partitions. �� Size ridge to provide full bearing at rafter cuts. Hip and Valley rafters-watch bearing at walls. Ridge&Hip-Provide proper connections. - �', Cathedral roof rafters provide proper connections and use"Hurricane Clips"tie to plate. Stair stringers-watch cuts and heal support. me Joist hangers-fully nailed w/hanger nails. i Sill plates 2-2X6(1 PT)w/sill seal. ' em i Girls-solid brick or steel plate bearing at foundations '/"air space at sides in foundation pockets. Lateral bracing at ends. Certified calculations. required for Beams/LVL's Trusses. 1 Solid bearing support for Headers/Beams etc. m Check headroom clearances-stairways, under_beams ' Attic Access. (min.22x30 w/3'headroom above). Crawl space access. (min. 18x24). \ Bath exhaust fans to have metal duct to exterior(not in soffit). ¢ - �r� = Firecode S/R wood frame of"0"clearance fireplaces-&stoves �® m o Window Schedule or Every Habitable Room Must Have: Natural light equal to 8%of floor area r�of required glazing shall)be openable. Bedrooms required min.20x24 egress window or door. „ a _�D Vent attic spaces-"proper vent", soffit and required ridge vents. Firecode under stairs if used for storage FIREPLACES: Separate permit required. + Inspections at Footing-Smoke Chamber- Finish Smooth parging, clean joints, 8"solid @ combust: ' .h - Ca i�W , c ee DECKS: Lag to house, provide flashing. 4 Rails min. 36" high, Baluster max space 5"on center. Over 8'above grade, use 6x6 posts w/lateral bracing. Lag all posts and rails. R� Pier footings down 48", Conc. pad at stair base. FINISH: Handrails returned to wall/newall post. Guardrails required alongside open cellar stairs. Exterior grading complete. Certificate or occupancy required prior to occupying structure. Temporary Stairs required for inspection. ' 7�A Re-inspection fee- $30.00(Be Ready). c: Certificate of occupancy required prior to occupying structure •s � f Y F 1 1 r ♦ � .Ye....� _ ;4�,....i. < iii Location No. Date d MO�TM TOWN OF NORTH ANDOVER OL s 9 Certificate of Occupancy $ ,SSACMUSE�� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # /X3 22973 Building Inspector Date.. J!.U.. .. Of ~O DTH 1ti k O� TOWN OF NORTH ANDOVERI ' PERMIT FOR GAS INSTALLATION CH This certifiesthat f! . . . �?�. . . J-. . . . . . . . . . . . ��U v t has permission for;gas installation . . . . . . . . . . . . . . . . . . . . . . . . in the buildings of . . . '±� . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at { Gs " . . . y.� �. . . . . North.Andover, Mass. Feer2f r. , Lic. No.. R . . . . . . . GAS INSPECTOR Check# ' 73'12 'i MASSACHUSETTS LMORMAPPLICATON FORPERMIT TO DO GAS FITTING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations Permit# Amount$ Owner's NameP10 I- I New Renovation Replacement Plans ubmitted ❑ � w CID w o U2 .. o a °. z d .,� w � '-' H z H Awa w H U a rn a o a 3 a U a ° w SUB o. H o -BASEMENT BASEM ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR ti+ 4TH . FLOOR 5TH. FLO O R 6TH . FLO O R 7TH . FLOOR 8-TH FLOUR (Print o e Check one: Certificate Installing Company N e t,,_ 1 - ® Corp. Address ® Partner. Business Te ep one Firm/Co.- Name of Licensed Plumber or Gas Fitt INSURANCE COVERAGE Check one: I have a current liability Insurance policy Or it's substantial equivalent. Yes M No U If you have checked eses,please' nate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 0 Bond E Owner's Insurance Waiver: I am aware that the-licensee does not have the Insurance coverage required by Chapter 142 ofthe Mass. General Laws,and that my signature on this ennit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner t 0 I hereby certify that all of the details and' ormation I have submitt (ore red)in a ve a ation are true and accurate to the best of my knowledge and that all plumbing and installations p rf0 r Pe t d for this application will be in compliance with all pertinent provisions of the Massac as e Chap 4 of the General Laws. B Signature of icense umber Or Gas Fitter Y: Title Plumber a City/Town Gas Fitter License Number Master APPROVED(OMCEUSEONLY) Journeyman The Commonwealth of Massachusetts Department o f Industrial Accidents Office of Investigations 600 Washing ton Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): r U~ Q r Address: City/State/Zip: Phone#: �=� �"0 Are u an employer?Check the appropriate box: Type of project(required): 1. I am a employerwith_ 4. ❑ I am a general contractor and I employees(full and/or part have hired the sub-contractors 6. Ne constriction 2..❑ I am a sole proprietor or partner- listed on the attached sheet 1 ?• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. g, ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their lo.❑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' comp,insurance required.] 13.0 Other R A r ny applicant+hst checks box#1 must also rill eat£ne secticn bAt.,.. T,ti�,..on_ c •�b .. ompeas;.tionpolicyi^f'o^nation. T homeowners who submit this affidavit indicating they are doing allwork and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees Below is the information. policy and job site Insurance Company Name: t^d}a- Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address:_A l City/State/Zip: / QwZ 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 fin p to $1, 0 and/or one- ear imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine o up to$250.00 a d against violator. B ed that a copy of this statement may be forwarded to the Office of estigations of the D for' ance cov age v ri cation I do by certify u d ai nd penalties o erjury that the information provided above is true and correct Si Date: Phone#: (�' z No Official use only. Do not writ an this area, to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6. Other Contact Person: Phone#: 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 pe,rson.m 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 t7he 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 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. Also be sure to sign and date the affidavit. The affidavit should be returned to the v sy or t.Dwn!h aa the apphca`ion for the per—amtor"license is being req'ues a d,not the,�epaiZ.ment of Indt:strial 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"adl 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 perinits 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 Investibafaons: 600 Washington Street - Boston,MA 0.2111 Tel_. #617-727-4900 ext 40.6 or 1-8 77-MAS.SAFE Fax 4 6.17-727-7749 Revised 5-26-OS aWw_mam-gov/dia I Leathe, Brian From: dave@creativedgepoolsandspa.com Sent: Monday, July 12, 2010 9:25 AM To: Leathe, Brian Subject: pool permit cancel name Brian Leathe, I David Brabant of Creative dge Pools and Spa want t�take my name and both licenses(HIC# 166032 and CSL#93190),insurance binder,and contract off�t`e permit at 605 Osgoed�Sff et. I am no longer doing the work on the pool there,the contractor I was working for(Bill Knight Inc..Hopki��ng n MA)will be finishing the work himself,which i believe will be putting his name and licenses on permit now,insurance binder,and his own contract on file. I am no longer responsible for any work performed as of July 9,2010 for my contract was breached as of that date and there is no longer any contract on job.It was void as of July 9,2010 for none payment. Thank you for your time. Sincerely, David Brabant Creative Edge Pools and Spa (978)604-5747 r i i F ` Date... ...� . 40RTH TOWN OF NORTH ANDOVER 3? e••r ... ° OL p PERMIT FOR WIRING ;,IT$�CMUSE� 7— Scc4�oel 45 This certifies that ..:......... ................................ .........fit ......................... ?, has permission to perform ...... ........t"'KI wiring in the building of `� .......... ' .......... ...� .. . . .................................... f �60 at.........( .� ................................... ,North Andover,Mass. Fee..V,.5.." -:. Lic.No.............. ................ . .. ....................... ......... ... �7 �Uy �y�q�rx LECTRICALINSPECTO� Check # 8008 (,�mmoiscr�saLh o�,/ja3sarh�e�as Oclicial Use Only 11s arf.,utcf c }irs.�srvicsJ Permit No. � P l Occupancy and Fee Checked BOARQ,OF FIRE PREVENTION REGULATIONS Rev. 1/071 leave blank APPLICATt,ON FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code MEC 527 CMR I2.00 (PLEASEP=1Y WK OR TYP 4-LL LVFORMATIOA9 Date: o� .,;16- 6i City or Town of: NCS r I.! To the Inspector q' Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street&Number) (P 05 VSC9-U Q S Owner or Tenant 1F- dALac, e, l eleph.one No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No 't (Check Appropriate Box Purpose of Building Utility Authorizatior No. _ Existing Service Amps / Volts Overhead ❑ Undgrd I' No_of Meters New Service = Amps / _Volts Overhead ❑ Undgrti n Nc..of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: .�LL)7 �� p`}-i �, .a CCGLLr't'�� p,- -trt t.ctrrr Co-moletion o .the ol/�owrn iablemay be waived by the Inspector of Wires. '(Va 67 oto No_of Recess ed"Lu min aires No.of CeiL-Susp_(Paddle)Fans --�j-ransfo.rmers KVA No.of Luminaire Outlets No.of Hot Tubs (Generator: KVA y" Above r•• cTn_of E�Qe icy Lighting _ No.of Luminaires Swimming Pool 917nd. ❑ ornd. -��EattE.ry J,its No. of Receptacle Outlets No.of Oil Burners P'IRE A'.a.L7M-s No.of Zones.." ; No.of Switches No.of Gas Burners. 1.`�0.c Detection and „0 Initiating Devices No.of Ranges No.of Air Cond.�otal INo.of Alcrtina.Devices Tons I n No.of Waste Disposers eat Fump um er [To--,.,iso. o.S -e ta ontne Totals: Detection/Alerting,Devices No.of Dishwashers Space/Area Heathw .KWL9c% Municipal E] Other onne n No.of Dryers Heating Appliances K%V c a. evices—Equivalent / i o. Of atero_o. o.o n Heaters KW Eahssts DatNo.of Suns Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP e ecommunicaCons firing: No.of Deviccs or Equivalent OTHER: Attach additional detail if desired or as rectired by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) . Work to Start: Inspections to be requested in accordance with MEC Rule 10,anal 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 irs substantial cquivalenL The i undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit rm:ing office. CHECK ONE: INSURANCE ® .BOND ❑ OTHER ❑ (Specify:) 1 certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: PZ-T' Ce-GUrtT Scrv(CPS Lt#C.NO.: / S33 'C :Licensee: [-/.Y/:�/7 �, 7'/4Y/o/2- Signature /" ---_ —LIC.NO.: /L' lJ� (/japplieable, enter "eTempt"in the license nwnt e.) ` Sus.Tel.No.: �� '7 59Ra Address: 19 0 L l R1Tc l 1JH r--301�p N. Al!.Tei.No.: 'Pcr M.G.L.e. 147,s.57-61,security work requires Department of Public Safety "S"(.iccnsc: Lic.No. 6 S L OWNER'S INSURANCE WAIVER: I am aware that the Licensee does rov have the Iiability insutzrce coverage normally required by law. By my signature below, I hereby waive this requirement. i am the(check one) j] owner ❑ owner's ager:L Owner/Agent Signature Telephone No._— .F-PuVIT FEE: S , Department of Public S, - == One Ashburton Place, Rm 1' s Boston, Ma 02108-1618 License: CERTIFICATE OF CLEARANCE Number: SS CC 002577 Expirou- 12/2312009s WILLIAM M TAYLOR JR -- 118 CLINTON DR -- - j HOLLIS. NH 03049 Tr.no: 89 - Keep top tol DPS-CAI CP 5OM-07/07-PCe490 I ' • `�'\ ✓fir. (onararornrMrrll� r��•�%.rurrr•�uJe!!J _ � , DEPARTMENT OF PUBLIC SAFETY CERTIFICATE OF CLEARANCE Number: SS CC 002577 lug I Expires: 12/23/2009 Tr. no: 893.0 I , S-License: ADT SECURITY SERVICES I WILLIAM'M TAYLOR JR 18 CLINTON DR G— L HOLLIS• NH 03049 DIG SAFE CALL CENTER: (8 c, Commissioner <, COMMONWEALTH OF MASSACHUSETTS - t; r:,• ' REGISTERED STEM TECHNICIAN _ ISSUES THIS LICENSE TO ' WILLIAM M TAYLOR JRO W _ o f 27 . S'?'ONEHENGE RD c APT , L"ONOONDERRY NH 03G53-2437 10049 ri o7isi�lo 29116a Date...... ...... ..... .... ... . . ... 40RTH 0 TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING This certifies that ... ..... r - ........................... has permission to perform .................................... wiring in the building of.......45 ... . ........................................................ at... North Andover,Mass. ............................. Fee-.—f ....... Lic.No.11-1v7- ............-3................. . ...... .... ...... ..... L E�CT Ri IiC A L li'�S"iP� R Check # . 92'10 J aa// // L l-.ommonwea&o f Vaeaaclwetts Official Use Only 5rc� Permit No, Apartment of Jim 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(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /—0-0 /y City'or Town of: UC )f0,.&,y 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) 6D5 Owner or Tenant LQ%JS V.e"tj , Telephone No. Owner's Address a5' o S�e�,� s f�e4 t Is this permit in conjunction with a building permit? Yes [?�—No ❑ (Check Appropriate Box) Purpose of Building le 5 Utility Authorization No. Existing Service c9 00 Amps Cd J l 0"Volts Overhead Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and'Ampacity Location and Nature of Proposed Electrical Work: Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA I No.of Luminaire Outlets No.of Hot Tubs Generators KVA { AboveIn- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches (� No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contaihed Totals: ..... ....................................................... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. 1 Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: /'— d `O InspLtions 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 E4et-OND ❑ OTHER ❑ (Specify:) I certify, under the aims and penalties of perjury,that the information on this application is true and complete. FIRM NAME: Teyz417 —D LIC.NO.:11W713 Licensee: �yflw "r 'Yil�Z7 If ky Signature LIC.NO.: (If applicable, Alt�"exempt"in the license number line.) Bus.Tel.No.: 6- Address: r fi �yt 0f� Alt.Tel.No.: I ��-.�� s.� icy �vk�l 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 a ent. Owner/Agent PERMIT FEE: Signature Telephone No. i r �� ( .-dd_ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information I Please Print Legibly Name (Business/Organization/Individual): I- U) Address: City/State/Zip: Phone #: g 3 e a 5—d'3 -5 Are you an employer? Check the appropriate box: Type of project(required): 1.[:11 am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction "iployees (full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. E] Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.E] Electrical repairs or additions 0.❑ 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' comp. insurance required.] 13.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Caontractors 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. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine 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 der the pains andpenalties of perjury that the information provided above is true and correct. Signature: Date: ��U Phone#: FW`360 93'3 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#: Date.1 . . . NORTq �'.,�•° .1�o TOWN OF NORTH,ANDOVER PERMIT FOR PLUMBING s � •'� SSAemus� This certifies that . .. . . .�. S. ./. . . . . .. . . . . . . . .� !7 has permission to perform Aj)1Ae.`e.v''u'.'"'`.�t. Ft xry i plumbing in the buildings of . . U Ute' at. . (P.U.S. , , U 50JJp-.� , North Andover, Mass. Fee7t.S�.Lic. No.. . . .Q, 3 .� . . .`�. . . . . . . _ PLUMBING. . . . . . .e/. C�} Check # 846.3 ,�� i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Building Location & 0 0 S � DatePermit# Owner 6 V C ::`` Amount New rl Renovation Replacement Plans Submitted Yes No FIXTURES re C MUM B14+1mIIv! '� 1STI�DQt ZR IIDM 3M IIW 4M ROCR 5M 6M EWM 7M HDM S1H IIOQt (Pant or type) Check one: Certificate Installing Company Name �� S .�"�/ ❑ Partner. Corp. Address 6 �3 d k 0 ✓✓ C7 iJ /t-" �i a� Business Teleplwne []'Firm/Co. Name of Licensed Plumber: ell Insurance Coverage: Indicate the of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond El Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance signature Owner Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and ins erformed der P t Issued f this application will be in compliance with all pertinent provisions of the Massac S P umb'mdof $ e an pter the General Laws. By: SWUM of Zicens urn Title Type of PIumbing License City/Town License Flurnmr' Master Journeyman APPROVED(OFFICE USE ONLY El >w The Commonwealth of Massachusetts Department of Zndustraal Accidents Office ofInvestigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. [1I am a.general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. I 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp,insurance. o workers' comp. insurance 5. 9• Building addition � p. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 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' comp.insurance required.] 13.0 Other `.may applicant that cheers box#1 ms st also fill out the section belmv showing their worke x'compensation aoz�cy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to,$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date.: Phone#: [,,c:alnly. Do not write in this area, to be completed by city or town official : Permit/License# rity(circle one):ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector n: Phone#: it ' Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 15.2, §25C(6)also states that"every state or Iocal 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 coinpliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." 'Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es) and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC) or Limited Liability 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 homeowner or citizen is obtaining a license or permit not related to any business,or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-72.7-7749 Revised 5-26-05 vkvvw.mass.gov/dia C_f ........................ NORTry ottt�.o.�,� a? �• <<�,� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING lo -AcHUSE� This certifies that .................c7`'L /'� / �� v/z. ..� ...........�..........!... has permission to perform .... Q plf ©li�Gls wiring in the building of �o, 6p� ST" ...r,North Andover,Mass. Fee...-� '` Lic.No..I.t 7?/� .,.......... j 1 ..... .... . ELECTRICAL INSPECTOR 4 a'< Check 7 8093 Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev.1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical CodeMEC),5;7 CMR 12.00 (PLEASE PRINT'I1V INK OR TYPE ALL INFORMATION). Date: S^ City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to rform the electrical work described below. Location(Street&Number) Owner or Tenant �U<N 11. Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Boz) Purpose of Building Utility Authorization No. Existing Service Ams / p Volts Overheadnd d U ❑ No.of gT' ❑ Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No,of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: K5cwn !� Completion of the olloud table maybe waived by the Ins ector of Wires. No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans No,of Total Transformers KVA a No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ Ia- ❑ o.o mergency Lighting nd. d. BatteryUnits No.of Receptacle Outlets No. of Oil Burners FIRE ALARMS No of Zones No.of Switches Ly No.of Gas Burners No.of Detection and Initiatin Devices ::d No.of Ranges No.of Air Cond. TonSl No.of Alerting Devices. No.of Waste Disposers Hest Pump Number Tons KW No.of Self-Contained Totals: -_ __..._...__ ._ -- No. Devices No.of Dishwashers Space/Area Heating KW Local❑ Mumcipa Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No.of Water of No,of Devices or Equivalent No.of Heaters KWNo-Si s Ballasts Data Wiring; No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total gp Telecommunications Wfiring: ` OTHER: No,of Devices or Equivalent i Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: �'4 D (When required by municipal policy.) Work to Start: f�,S 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 Z BOND ❑. OTHER ❑ (Specify:) I certify, under the ains and penalties of perjury,that the information on this5pylicadon is true and complete. FIRM NAME: (Lo�Je�t �)e 6L, c,w) LIC.NO.: Licensee. ,7afr-1 <TW — V Signatur LIC.NO.: 61- � "Cl (If applicable, enter "exempt"in the license number line) � I Address: Bus.Tel.No.:4313 $ Alt.Tel.No.: 9'� a3//QS *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 Downer's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$. ':. _�� .L �� -off a� �� ,� � ' J { The Commonwealth of Massachusetts k, 616 ! Department of Industrial Accidents i Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia . Workers' Compensation Insurance Affidavit. Builders/Contractorsmectricians/Piambers Applicant Information Please Print Legibly Name(Business/Orgenization/Individttal); �V c ` Address: PO (o City/State/Zip:_ /014 (J 301 Phone you an employer?Check th appropriate box: J ( � : Type of project ro ect(required): 1. I am a employer with 4. ❑ I am a general contractor and I 6, New construction employees * ❑ on ees full and/ p y ( or p -time). have hired the soh-contractors 2.❑ I am a.soie proprietor or partner- listed on.the attached sheet. Remodeiing 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 10.7 Electrical repairs or additions !� 3.❑ I am a homeowner doing all work right of exemption per MGL, I I.❑ Plumbing repairs or additions myself.[No•workem'comp. c..1.52, §1(4),'and we have no 12.0 Roof repairs insurance required.]t employees, [No workers' comp. insurance required.] 1317 Other *Any applicant that checks bmC#1 must also fill out the section below showingtheir workers'oom pensation policy information t Homeowners who submit this affidavit indicating they ate doing all wotit and then hire outside contractors must submit a new affidavit indicating such Contractors that check this box mustattaehed an additional sheetshowirrg the nanr of the sub-contractors and their workers'comp.policy infamiaiion. I ant an employer that.0 pro"ng:workers'compensation insurance for Ory.employees: Below is the information. policy and job site Insurance Company Name: ' A NV&A15-17 Policy#orSelf-ins..�Lie.#: Expiration Date: l Job Site Address: 0ie City/state/Zip: / -t Nd d Uy— M/3 01�� Attach a copy of the workers''eompe tion 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 I do hereby cert' un de t o e 'u Jp � ry that the information provided above is true and correct Si tore: Date: t Phone#: l ! 1 J Of ficial 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 InstructionsP 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-the1bregoing 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 tine. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicatingcurrent policy information(if necessary)and under,"Job Site Address"the applicant should write"all locations in (city or town).."A copy ofthe 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, i please do not hesitate to give us a call.. The Department's address,telephone and fax number. P The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-8.77-MASSAFE Fax#617-727-7744 Revised 5-26-QS www.mass.gov/dia Date. l� �'.4 .0 R'r:1�o TOWN OF NORTH ANDOVER PERMIT FOR-PLUMBING ;. ,SSAC14US� This certifies that . . . :� `.`. . . . � . . .! . . . . . . . . has permission to perform , •,.�_�...�. . . . . . . . . . . . . . . plumbing in the buildings of .... .. . . . . . ... . . . . . . . . . . . . . . . . at. . .. . . . .. . . . i1?�. \� . . . . . ., North Andover, Mass. :;. Fet. . . . . . . . .Lir. No.. . . . . . . . . - . . . . . . . ' PLUMB NG INSPECTOR Check 9 7671 t; MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSE S (' p Date Building Location J Q Owners Nam el 6 Permit#—Z 6 / Type of Occupancy �(�S f �� Amount - c New Renovation Replacement Plans Submitted Yes No FIXTURES o w � o Zx x U A w " A ~ w W a ^a A H F y V Q G a A A A 4 as STSR��C FA4+1VII�' lS�FI�[t M FlOO[t 4M FLOCIR M FLOM 6M FLaR - 7M FIOM 9M FUM { (Print or type) j,�, Che one: Certificate Installing Company Name U"W 6b2'rl 19PI, Corp. f Address Partner. Q Business lelephone Q1 ❑ Firm/Co. Name of Licensed Plur: I� Insurance Insurance Coverage: Indicate the.tye ofd nsurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond Insurance Waiver: I, the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner A nt ❑ I hereby certify that all of the details d information I have submitt or entere i above 1 c on ar a an accurate to the best of my knowledge and that all pl bing work and installatio erformed sue plic ion will be in compliance with all pertinent provisions of the assac use tate mg a and h ter of e eral Laws. By: e 1cense um r Title Type of Plumbing Lic se 1. G ' City/Town - icenseIN UmDer Master Journeyman ❑ APPROVED(OFFICE USE ONLY Date �1 NORTH 1� TOWN OF NORTH ANDOVER - PERMIT FOR GAS INSTALLATION s^cHuset�y. This certifies that . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . !. .j. . . . . . . . . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . r t at . . ' . . . . . . 4'S. <. . . . . . . . . . . . .. North Andover, Mass. Fee. 3q. . -Lic. No..I.D 3 p!. . . . . .�r, . . . . . GAS+INSPECTOR Check# 2-1? 2 ;i 6303 A MASSACHUSETTS UNIFORM APPLICATION FOR'PERMIT TO DO GASFITTING22.-- �Ji (Print orrType) ( !� Ai � , Mass. Date / � 20�� Permit MIR Building Location t� _ S�r'� owner's Name"' C Type of OccupancyIMP New C) Renovation❑ Replacement❑ Plans Submitted: Yes❑ No❑ w � OC7 m n uapo Lr) Lz a �z _O >z � O LLJ �zw of LUQLU cl� 9 C). � J LU p MZ � > Q-U O ! SUB-BSMT BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR. 4TH FLOOR >r 5TH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR installing company NameIV t Check one: Certificate Address ---1764 )L L )L Corporation Birsiness Telephone �--7 —J Partnership Fi rm/C o. Name of Licensed Plumber.orGas Fitter INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, which meed the requirements of MCL Ch. 142. Yes No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURNACE 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 is perm application waives this requirement Check one: signature o Owner orOwner's Agent r ❑ Agent ❑ I hereby certify that all of the details and Information I have submitted for entered) n above 411cation are e a d curate best of my knovAedge and that all plumbing work and Installations performed under the p rmit Iss d for this a n 1 bei p! ante with all pertinent provisions of the Massachusetts state Gas Code and Chapter 142 of the ene La Type of License: �— By ',Er-PTumber S gna re o tensed lumber or Gas Fltter Title ❑Gzisfit*er Cityrrown aster License mber APPROVED(OFFICE USE ONLY) I p Journeyman D /� . . / . . . . _ . ke / \ {\ . d \\ / . «•~ \ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING y . `<� �w,�« . p «_s � . - 6 This certifies and . . 2 . . /A-7 . .. . . . . . . . . . . . . . . . . . . . . . . . . . . g \ . has permission to perform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing i the buildings o . . . f / ��. . ./. . . . . . . . . . . . . . . . . c . g . \� QTR°. . � NorthAndover, Mas z . % y re 2/ } :i. N m. �. \ . . . . . . . . . . . . . . > i/uIVIs NG INSPECTOR / «» Checkf y r �. . . \« G 7637 . . . MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town. / ✓ t3^ MA. Date: Permit# Building Location:� CIO� �/� wners Name: j Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential [ ' New: ❑ Alteration: ❑ Renovation: ❑ Replacement. Plans Submitted: Yes ❑ No ❑ FIXTURES z z O Y V z to N (n rn (n (L z Y Q (n J U w C7 Q cn x � � a W 0 W Q c~n Y cn -1 a X OMOW a J 0Q >" R wz rn O L) n uzQW nO PQz wQY = irOO � xQu. � aYaxWW Q ° aO = ° a a a Q - a o m m E u. CD Y J J W 0 W 3 3: 0 SUB BSMT. BASEMENT /0 0 —1'—FLOOR '. 2 FLOOR 3 FLOOR .4 FLOOR { -]5'FLOOR 6 FLOOR 7"' FLOOR 8 FLOOR Check One Only Certificate# Installing Company Name: ( �/j /► ❑ ��/�]] Corporation Address:F6 G14_ �ka City/ own: rV �1�/ i,�tate: ❑ � /- L G Partnership Business Tel: 92e-6 '"`J/� 43-�7�P Fax: �o J6�/ -J�7 54hrm/Company Name of Licensed Plumber: !�' -+ p/ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes❑ No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. 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 Massachusetts.General Laws, and that my signature on this permitpplf aives this requirement. Check One Only O ner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I haves bmitted(or entered)regardi this applic i n are true and curate the best of my Knowledge and that all plumbing work and installations pe ormed under the permit is ed for this a I' ation be i compli c th all Pertinent provision of the Massachusetts State Plumbing C e and Chapter 142 of General La r By Type of License: Title ❑ Plumber Ignature o icen d Plumber ❑ Master City/Town License Numbe . APPROVED OFFICE USE ONLY ❑Journeyman