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HomeMy WebLinkAboutMiscellaneous - 65 RUSSELL STREET 4/30/2018 fr _ / 65 RUSSELL STREET J 210/071.0-0005-0000.0 9748 Date.... /..'....................l� �� �aORTM TOWN OF NORTH ANDOVER ' PERMIT FOR WIRING ��ss�c�eusf� This certifies that ............. 113 4............................................. .� sfz v� has permission to perform ....I.��.��............. ........................................... wiring in the building of................. .. ..2..ye.k..i............................ at...... S.ee.4, .... 2"..................... . orth Andover,Mass. Fee.. .....:�.�...... Lic.No../.. 6. h! .... t E CTRICALINSPECTOR Check # 1 &I-\- Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. N BOARD OF FIRE PREVENTION1WREGULATIONS Occupancy and Fee Checked 1 I [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 L (PLEASE PRINT W INK OR TYPE ALL INFO Rt1 OTION) Date: City or Town of: To the Inspector of Wires: By this application the undersi ed gives not' e of his or her intention to perform the electrical work described below. �. Location(Street&Number) Owner or Tenant (� Aw& _ kj<s,(`L Telephone No �iA- /7 Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No BLDG PERMIT# Purpose of Building Utility Authorization No. Existing Service _ Amps / Volts Overhead EK Undgrd ❑ No.of Meters New Service lGd Amps d-,)/ U Volts Overhead❑ Undgrd No.of Meters Number of Feeders and Ampacity 1 Location and Nature of Proposed Electrical Work: �^J�� ( Lu 4M !� Completion of the foZZowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No. of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No. of Luminaires LNo. ming Pool Above ❑ In- ❑ o.o Emergency ig mg rnd. rnd. A Units [No. o.of Receptacle Outlets Oil Burners FIRE ALARMS No.of Zones of Switches Gas BurnersNo.of Detection and -- Initiating Devices No. of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of self-Contained Totals: Detection/Alertinir Devices M No. of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Water No.of No.of 1 No.of Devices or Equivalent Heaters ' Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent ��.1 6.) Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Elec ical Work: it . (When required by municipal policy.) Work to Start: a11110 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO GE: 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 [Er BOND ❑ OTHER ❑ (Specify:) I cert,under the pa i�and penalties ofperjury,that the infor 'on on this a kation is true and complete. FIRM NAME: eA LIC.NO.: Licensee: Oil � Signature 434L LIC.NO.: (� /�(� (If applicable—en�er�'e`~x'em ' in a license number line.) Bus.Tel.No.• T Address: C7J lr Alt.Tel.No.: *Per M.G.L. c.147,s.57-61,security work requires Department blic Safety"S"Licen 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 Signature Telephone No. PERMIT FEE. $ ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR-DOUG SMALL 1.ROUGH INSPECTION: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: (Inspectors'Signature-no initials) Date 2.FINAL INSPECTION: Passed—[ ] Failed—voRe-inspection required($50.00)-[ Inspectors'comments: �-- G'iti't M (Inspectors'Signature-no initials) Date 3.UNDER GROUND INSPECTION: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: (Inspectors'Signature-no initials) Date 4.INSPECTION—SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: (Inspectors'Signature-no initials) Date 5.INSPECTIO -OTHER: Passed Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: (Inspectors'Signature-no initials) o 'eJ r q Date Z} DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED. II The Commonwealth of Massachusetts ' Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston,MA. 02111 www.mass.gov1dia Workers' Compensation.Insurance Affidavit: Builders/ColatTactors/JEiectlricians/plaa mbers Applicant Information Please Prink Legibly Name(B.usiness/Organization/Individual): , � �S j U( Address: City/State/Zip: I�LP,w�e.L c�. �1�. (D/ktr l Phone#: [2.0 re you an employer?Check the appropriate box: Type of project(required): ❑ I am a employer with 4. ❑ I am a general contractor and I ( E]Now construction employees(full and/or part-time).' have hired the sub-contractors I am a sole proprietor or partner- listed on the attached sheet.T 7. 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. 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 12.0 Roofrepairs insurance required.] employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or SeIf-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 u to$1 500.00 and/or one-year imprisonment,.as well as civil penalties in the form of a STOP O a e P � y p � p WORK ORDER and fin ofup to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Hereby certify u de thepains dpenalties ofperjury that the information provided above is true and correct. Si ature: lia,L Date: Phone#: 6�� a E only. Do not write in this area,to be completed by city or town official n: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector son: Phone#: Date....4 ....... NORTH TOWN OF NORTH ANDOVER 0 0 F 0 PERMIT FOR WIRING CHU This certifies that-:' . ........................................... ..................... has permission to perform ... .......... . ...... --e-, wiring in the building of...?'�" at..:°'.........f ............................................................. .North Andover,Mass. .......... .............. Fee..................... Lic. ........ ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK:Treasurer TW C0W0NWE4LTH0FMAYS4a&4M Office Use only DEPARTA�IVTOFPUBLICSAFM Perm '� it No. /y7 BOARD OFFMPREVEM70NRWUL4iT10 527CMR12.W 023 ' Occupancy&Fees Checked APPUCATIONFOR PERMIT TO P RlVI ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) 6�0-f-1 cee-)�.S1, Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes[:3 No L_6. (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service � Amps / )0 Volts Overhead UndergroundED No.of Meters ■- New Service Amps / Volts Overhead r-1 Underground No.of Meters s Number of Feeders and Ampacity `location and Nature of Proposed Electrical Work OUCT'Si6lb SP Sur - W t Hh Calfa/( No.of Lighting Outlets ' No.of Hot Tubs No.of Transformers Total t KVA No.of Lighting Fixtures / Swimming Pool Above Below - Generators KVA 1groundg1:3round No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets J ( No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local ® Municipal Other Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP 4 OTHER• htstraroeQmm@e.Pta9uant1o1hemW=aZ M%mdiseZG=WLaws Iha-veaamatLiabildyhmm=Pohcyutdu&tCon>iele Coteageorikssksbttialegivalat YES NO IfimesthnitledvalidpoofoNmriotheO>fmYES M NO [D IfyuharedvioJYES,p{emmdcmethetypeofootuagebydmkngthe Wpcpi INSURANCE. r7 BOND OTHER (� Y) 3- W G EViratimDak d-W.tU WodcbSlart 7 Estim*dva1uecf�icalWak% IrnFectimD*ReVesled Pough FM �/as- Sigrtedulda7�alfiesofpajtay / FIRM NAME ! r' SuLtceALint eNa UXI see _!yh P,t Gc,.l�r Sigma r4u Busirm Tel Na F - rWrF-M•--•---• AICTeLNa OWNERS]IJSURANCRWAIVER;IamawatethattheLioansedohtheicmraneoaaagetxirsst irlgialegtrivalatasieglmedbyMassad�lseusC,,a XJ laws aodthatmysi@Owonfispean&appfic admiwaiAS isM**Mwt. (Please check one) Owner a Agent El Telephone No. PERMIT FEE$ NORTH own of t EAndover �. _ 0% No. 64 Z I * - *� h , ver, Mass, 4COC L 64 S u BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT � ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, BUILDING INSPECTOR has permission to erect .......................... buildings on .(:.1� .�.�.�yS,s.:�.1�:5, .,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, Foundation � Rough ............ to be occupied as F�d�,��:��:�lr�:...�.�ris.�:'���....�.�::���.../...l.r."l.�`�"�Z..lSG7���,.... .rf.F�;�,,�.,c�/ Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in 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 CONSTRUCTIO STARTS Rough Service .. ...... .... ...... .....................OR... Final BUILDING INSPECT GAS INSPECTOR Occupancy Permit Reguir-ed to Occupy Building Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. wr Date...... .......4:7//4-t......... OF NOwrM,h TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING 88,�cHuss This certifies that ...................... ........... .. . .................................. has permission to perform ......... wiring in the building of z........ .......... .............................. at .....65 57' North Andover,Mass. ........................................................................................... Fee.. . ....Lic.No.Me:��............... ...... . .......... ... ......... .................... ......... .. .. d" Check# U 70 ELE -CAL. NSPE 12145 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 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 C),527 CMR 12.00 (PLEASE PRINT INMK OR TYPE ALL INFORMATION) Date: � i7 l/ City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. M Location(Street&Number) Owner or Tenant Telephone No. Owner's Address � �� ti. .tel /s, Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) (�\ Purpose of Building /t 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: y SCn Aj Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- IN-Elo.o mergency 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 No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: """"""............. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ 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 No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value o Electrical Work: 10,0 a p. (When required by municipal policy.) Work to Start: 5 I1 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 covera e is. force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) Icertify,under the ains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME (-Ef,?- tcA-L-- LIC.NO.: IN Licensee: AAA-C,-4- V Signature LIC.NO.: Z,7 (If applicable,enter "exempt"in the license number ne.) Bus, el.No.• D 3 6-LL-7,o?50 Address: � Pm epA, A-UL ( t S 1 Ol�✓� -t44 D3 3"6-S-- Alt.Tel.No.: 7 -2 Srb Z_.._ *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE:$ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the t notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: +' Pass 1E Failed Re-Inspection Required($.) ❑ Inspectors Comments: ` Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: +� Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comme ILI —1 Inspectors Signature: Date: FINAL INSP TION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com � r t The Commonwealth of Massachusetts �f Department ofIndustrlgl Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): A-(,4 ✓moi Address: _4;-V6- City/Stat 4-V6City/State/Zip: P N(s-r0k-J , k/vc D3 n�Phone#: °� 7 is 3-.2,5- -o Z__ Are yqu an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4• ❑ I am a general contractor and 1 ' 6. ❑Ne nstruion employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7• Remodeling ct 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 10.0 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.] employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy anal job site information. Insurance Company Name:. -d�-�O��vL Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: KA.,S S L''t _ S City/State/Zip: AJO, . Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerci under the pains and penalties ofperjury that the information provided above is true and correct. Si ature: Date: L b Phone#: d ? 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 y � i 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 employes,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 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)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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesfigatlons 6.00 Washington Street Boston,MA 02111 Tel,#617-727-4900 ext 406 or 1-877:MASS.AFB Revised 5-26-05 Fax#617-727-7749 wWW.Mass.gov/dia. Date�w/,........ 10378 �Noway, ot TOWN OF NORTH ANDOVER ° p PERMIT FOR PLUMBING Hu• 'fit''°��.�"�t�°j l lel,, //f Thiscertifies that.... .................................................................................................... has permission to perform........... � ........................................................................... plumbing in tthe buildings of.........7-k.Z..........L.L-��................................... at......... 625 ............. ...... /�.... ..............., North Andover, Mass. Fee.� r....Lic. No.�S7 s7...' ..................................................................... PLUMBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE / ( PERMIT# 1 JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS TEL —(FAX TYPE OR OCCUPANCY TYPE COMMERCIAL © EDUCATIONAL © RESIDENTIAL PRINT .5 CLEARLY NEW: RENOVATION:&� REPLACEMENT:Q PLANS SUBMITTED: YES NOD (I FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER S J_j DRINKING FOUNTAIN _ I ( j ( ._.__.. _j J ___-- f .-__-� ..__....._1 .. ...... I __-.-J __..__J __ ........! FOOD DISPOSER ( FLOOR lAREA DRAIN INTERCEPTOR(INTERIOR) ------i __1 __- KITCHEN SINK LAVATORY ROOF DRAIN I 1 _..__.J ._._i € _ .1 - ._. _j ._. j � �i � _J € SHOWER STALL SERVICE/MOP SINK TOILET I _ t f _ _._J .- I _ ___f ____ --i .t ILIFINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING _t _I . OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[ NO �1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 5d OTHER TYPE OF INDEMNITY © BONDE1 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 Q AGENT 10I SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all ertinent n of the (Massachusetts State Plumbing Code and Chapter 14 f the General Laws. PLUMBER'S NAME LICENSE# S ( SIGNA URE (UIP Fd JP L9 CORPORATION�J# PARTNERSHIPEI# LLC E#( .� COMPANY NAME f D ADDRESS ---- CITY G -. "STATE ZIP �.�/j 7 (� � TEL FAX € CELL MAIL ROUGH PL ING INSP TION NOTES BELOW FOR OFFICE USE ONLY FINAL INPECT OTES SS o� 1. Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 1 M � i The Commonwealth of Massachusetts - Department ofIndustrial 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 Legib Name(Business/Organization/Individual): t/VJAW, Address: City/State/Zip: ` 3�7 Phone#: 4 D 3—& S ,3 —1351"' Are;*you an employer?Check the appropriate box: Type of project(required): 1.m 1 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. �• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. E]Building addition [No workers' comp.insurance 5. ElWe are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3111 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑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. 7 Homeowners who submit this affidavit indicating they a're 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.#: ExpirationDate: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration dale). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP.WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert under ze pains and pens ies=the information provided above is true and correct. Si ature: Date: 6 7 Phone#• (p 3` F� 3 `ZJ 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#: r 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 hivre,• 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 cant'workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Tho COMMORWealth of Massachusetts Departmmt of hndustrial,Aeeldonts Office of InVestigations 600 WashiWon Streot Boston,MA.02111 TeX.#617-727-4900 oxt 406 or 1-877:MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass,gomfdxa W � »gpmmON H«r ASSAqd:. � £ - . ©. 10)#ERS ANO'ASIT-TE- 'D F7¢E G2� 'D AS A\ ASTER PLUM13 E Rkvt ! w� mue�E\mVELIm4fo\\d«&` ` \� � � ��:�� ):.\���\\\ . � - / ƒti L W .!KE � T t\NN \ \ , y\y/ , . P CHS! �,,tN| asO£&ƒ«Gda \. , . .. . . . . �. � . . . . , �y . Date.... .......................... 40RT#j o� , TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 8`4ACHUg� This certifies that .../'....!/. ' ./ .P.l../ .. has permission for gas_installation .....�PrJ S f ... in the buildings of........../....k.Z..........44-4 at..........t ... ., .s�.. ..151.................... North Andover, Mass. Fee/0..7.. Lic. No. 5.1.��:.... / ........ .......................................................... .... GAS INSPECTOR Check,f-12 �9 9101 6Y�?- A/ I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY __ MA DATE qW&Y-_j PERMIT# JOBSITEADDRESS5 .� OWNER'S NAME GOWNER ADDRESS TEL�� FAX TYPE OR OCCUPANCY TYPE COMMERCIAL RJ EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:[,1 RENOVATION:[d REPLACEMENT:13 PLANS SUBMITTED: YES 0 NO Q APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER .E_ . z: _ L::_ BOOSTER _ CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR l FURNACEJ GENERATOR - - -- - GRILLE INFRARED HEATER LABORATORY COCKS MAKEUPAIR UNIT _ r- - OVEN �— _ _s POOL HEATER r— j ROOM/SPACE HEATER _ ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER I INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I 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 0E AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of m kn pledge and that all plumbing work and installations performed under the permit issued for this application will be in complianc witha Pert' ent prow e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME _ LICENSE#_L�/S? SIGNATURE MP�MGF EjI JP © JGF[] LPGI 0 CORPORATION©#��PARTNERSHIP 0#=LLC®# COMPANY NAME:`= � -�� _ ADDRESS �- CITY �, STATE ZIP _ TEL FAX �9 CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION N TES Yes No Sl THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES