Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 68 FERNVIEW AVENUE 4/30/2018
� _ �, _ �J Location 41 .r-1/7�_ ✓I nV�Q(iV No. Date • - TOWN OF NORTH ANDOVER LED • Certificate of Occupancy $ Building/Frame Permit Fee $ 2— � Foundation Permit Fee $ ,. Other Permit Fee $ TOTAL $L� . Check#4-2,2C7 r � r Building Inspector MASSACHUSETTS UW-ORM - •, FOR A PERMITTO POFORM GAS FrrMG WORK =s:— 0,11 Itz AMA 1 •reg �- ♦.,! I�-, � � .� .. . -�.IB� �i — — • # I`:m'.1t.no -�m = MIW am O I=Wil', fW.. - r -�.• .- I � �iii�.��;��� � �_� ��. Wit,__ a .. OW Am am. mWom em an mw Mo 1 � _ ... s : 22 IM Him, a•: r. . n - r ;iy -r rua 1 t ' The Commonwealth of Massachusetts Department of'Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 Bostoi4 MA 02.114-20.17 Www.mass goildia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly • Name(Business/Organization/individual): t Address: A City/State/Zip:tG, f . .Phone Are 'ou an employer. heck the appropriate box: 1. I am a employer with 4. L] I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. [Remodeling ship and have no employees These sub-contractors have: S. Demolition working for me in any capacity. employees and have workers' [No workers'comp. insurance comp. insurance'1 9. ❑ Building addition required.] 5. [ We are a corporation and its 10.❑ Electrical repairs o.r additions 3.E1 1 am a homeowner doing all work officers have exercised their I I.E?'Plutnbing repairs or additions myself, [No workers' comp. right of exemption per MGI,. insurance required.] t c. 152,§1(4),and we have no 12.0 Roof repairs employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also till 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 anew affidavit indicating such: 'Conti-actors that check this box must attached an additional sheet showing the name of the sub-wntractors and state mita fr or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. • t ain ars employer that is providing workers'compensation insurance Information. for my employees. Belowis the policy and job site d f Insurance Company Name: 1 � � �/ ,. Policy#or Self-ins. Lie.#: /� �1�� -EU-0- 1 l ,�,, , �� 1.�a� � Expiration Date��___� � � Job Site Address: kfiq FeWft Me- City/state/Zip:No.A� "� Mift oi�45 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 . fine tip 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. 1 do hereby cern r the pains and penalties oerju that the information provided above is true and correct Si mature: bate: 7 2 Phone#: 1 /� '& 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#: ACORN® CERTIFICATE OF LIABILITY INSURANCE 4 ACORV CERTIFICATE OF LIABILITY INSURANCE 3/23/2014 THIS CERTIFICATEIS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFIGsATE 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 poiicy(ies)must be endorsed. If SUBROGATIONIS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONMACT NAME: 1 AP INTEGO INSURANCE GROUP LLC wc"o,E r,: -C.No): 1250846 P: F: ADDRESS: PO' BOX 33015 INSURER(S)AFFORDING COVERAGE NAIC;' j SAN ANTONIO TX 78265 INSURERA: -art^OTC '1rz _IIs C INSURED INSURER 6: i INSURER C: { DURFEE PLUMBING & HEATING, LLC INSURER D: 2A HUNTINGTON AVE INSURER E: SOUTH YARMOUTH MA 02664 INSURER F: . COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS I ! CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE I TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Zr+t'SF TYPE OFDVSUR,3NCE ADDL SUER POLICYNU►SBFR POLIC'lM1L7f/DD/Y>•F POLICFI:AP I.AfLTs TR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS MADE ❑OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) S MED EXP(Any one person) c PERSONAL&ADV INJURY c GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE s POLICY I 1 PRO- PRODUCTS-COMP!OP AGG OTHER: S ACOMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Peraccident) g ( AUTOS AUTOS _ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) { UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE c DE RETENTION S ,p WOSGERS C0:WENS.4770A' X PER OTH- A,VDEMPLOYERS'LL4ff= ;AT I 1ER ANY PROPRIETORIPARTNERlEXECUTIVEYIN E.L.EACH ACCIDENT 1100, 000 c OFFICER/MEMBER EXCLUDED? ,VA i Mandatory in NH 70 ?`EG GZD023= 04/03/20_4 C_'/03/20 � E.L.DISEASE-EA EMPLOYEES" A ( J � 100, OQO If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE.-POL(CYUM:T S.Q.Q Q Q D F� DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICPMRD 101,Additional Remarks Schedule,may be attached if more space is required) Whose usual to the Insured's Operations. I CERTIFICATE HOLDER CANCELLATION '. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Northeast Electrical Services AUTHORITJrDPEPRESENrATIW 4 N MAIN ST E BELLINGHAM, MA 02019 Gc-fiLlc ©1988-2014 ACORD CORPORATION.All rights reserve ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Ft. `OMM©N{NirALTH t?F M11 .'CHiJSETfS ; . 4MMC3N'WALTH OF MASS '�Hfi3S ,. OMAN0:,W.� i r o mapn o 1 ��t ue�{ 41 PLUMBi:RS`"Ai D GASF 1TT RS PLUMBER ' 1ND GASF tT, 3 I s USS. SHE FOL IO aL i0E1 SE I SSV.E.5, THE FOLLOW "L i�irE Ll tri SEt) A'S A' JOL,i 1 .1 MAN PL BER' O*SE{I AS.,,,,A MASTER PLUM$ { €,,,tIP J DURFEE' :PiCiFLIP J DURFEE 51 FLAX "S'7 rv51 FLAB(".,ST'' t , !� NNt"S MA .02638 2417ttN!' MA 0263$ 24114 7 r a ob'R , 4n i i A Date... ..� ......................... a NORTIi, TOWN OF NORTH ANDOVER 9 PERMIT FOR GAS INSTALLATION '$BgCMU3� This certifies that :... s ' .!', .. .' .................. has permission for gas installation ...5' e.. ................................................... in the buildings of....... ..,.,. , l .................. ....................................................................... atIAP.. P.+e......`...P.. ?......................................... North Andover, Mass. Fee.. .!�. ..... Lic. No. 13"7-1''..... N..�--................................................... GASINSPECTOR Check# 2t2 r7RR7H Q`',g1.CD g�fj �� h4•tit , �sa� NORTH ANDOVER BUILDING DEPARTMENT °RTEn 5 1600 Osgood Street �SAcwus�K - North Andover Tel: 978-658-9545 Fax: 978-688-9542 .BUSMSS FORM FOR TOWN CLERK DATE: NM E._ .ADDRESS; (� ��ny►c 1u•� � A��rl ��r , n a��� mA 018'yJ ZON.rnrGMTIzCT: TYPE OF l3USINBSS.: -,-C)nn p,.. 34zr4 i ca-5 BUILDING LAYOUT PROVIDED: YES NO AVAILABLE PARKMG RAW: ZONING BY LAW USAGE: YES NO BUCLDIMG INSPECT6R SIGNATUPI E BUSINESS FORM FOR TOWN CLERK Date. C71.... .. WORTH 0* 4' 6' 0 6 TOWN ,OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION yy SACHUS This certifies that . . . .6.7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . . in the buildings of . . . ./( . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at .... . ... . . . . . . . . . North Andover, Mass. Fee. Lic. . . . . . . . . . . . . GAS INSPECTOR Check# 7 0 MASSACHUSETTS UNIFORi'di T PPLICATION FOR PERMIT TO DO GAS FITTING \� a� mit# v� CityrrowOZN . A`��OJQ.r MA. Date: Per Building Location:�Orqz, t"Q-'�"l1 J�Q.W S� Owners Name:�a t`t �►�t. �r`f`Q.�'t1 Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: ® Plans Submitted: Yes❑ No FIXTURES vi Z W V N ~ Q� W ix O l- p F- Z O Lu = w 0 a x w N w m O0 a a. ~ w 0 = LL to � w Z w O W a w w w z v� = w ~ = z w W z W } W ai a m w o z O y ~ > I,- Q t=- cOi o oLL ta7 i = g O a > >> O SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR 4 FLOOR 5FLOOR 6FLOOR 7 FLOOR 8 FLOOR Check One Only Certificate# Installing Company Name�T" `�Mb t r%Q cc . 50 Corporation Address�� �N�`�`h(�s��e CitylTown•J� �c.S��n State ❑Partnership Business Tel:L-w rolls INWwl Fax: ElFirm/Company Name of Licensed Plumber/Gas Fitter:V%94 tt: FINAL INSPECTION BELOW FOR OFFICE USE ONLY PROGRESS INSPECTION(S) FEE: $ PERMIT# APPLICATION FOR PERMIT TO DO GAS FITTING NAME&TYPE OF BUILDING LOCATION OF BUILDING SKETCH PLUMBER_GASFITTER.LP INSTALLER LICENSE NUMBER:` I PERMIT GRANTED❑ DATE: f S GAS FITTING WSPECTIOR F a _ Date a "°�':�ao TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING' . o ,SSACMUS� This certifies that . . . . . . . . . . . . . . . . • • • " • . . . . has permission to perform . . . . . • • • • • • . . . . . . . . . . . . . • • plumbing in the buildings of . . . . �./'•�• ` ` `' at . . . . . . . �` `"-. • • • • • • • •. North Andover, Mass. _ Fee. . . Lic. No..�7. s.`!. `� /?� ,.--. .. . . . PLUMBING INSPECTOR Check # l f 1 8241 .1" MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date d p4 Building Location Owners Name!,p��,p "2PPi✓ Permit# c tt v Type of Occupancy /,Vv/70, Amount 9 y New ❑ Renovation rl Replacement Plans Submitted Yes No ❑ FIXTURES y Cn a w w U w z A A O x H w w H z w ' l ASEVE1 >P M FLOC t M 1-OCIR 5MK-OM 6M H-" 7MRDM sly 1MM (Print or type) Check one: Certificate Installing Company Name -�15 1el ❑ Corp. Address Partner. Business Telephone �-� 24 oey 9 irm/Co C Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance 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 ❑ Agent I hereby certify that all of the details and i ation I have s bmitted(or entered)in above a lication are true and accurate to the best of my knowledge and that all plum ng work and installati ns perfo u r Per ssu or this application will be in compliance with all pertinent provisions f the Mass husetts tate mbina d Chapter 142 of the General Laws. By: ign re o icense um er T pe of Plumbing License Title City/Town icense u er APPROVED(OFFICE USE ONLY Master � Journeyman f ` The Common wealth of Masxachuset& j f i Department of.industrial Accidents Office of Investigations 600 N'ashi agton Street Boston, MA 02111 www_m=s.90v1&a Workers, Compensation Insurance Affitlavit Brulders/Contractors/Electricians/Plambers AR01iCaUt Inforinsfion �T Please Print Leaibf 1VaMe (Business/orpwirdtion/individual): Address: City/State/Zip: Phone k . FA you an employer?Cheek.the appropriate box: I am a employer with 4. ❑ I am a general contractor and ITOR= (required):eMPloyees(foil andlorpert-urns).* have hi4red the sub-eantractorstrvction I am.a.sole proprietor.or partner. Iisted on the attached sheet t ng ship and have no employees These sub-contractons have working for me in any capacity. workers' comp.insurance. on [No workers'comp, insurance 5. ❑.Weare a corporation and its 9- E]Building addition required.] officers have exercised their 10-0.Electrical repairs or additions 3.❑ Iain a homeowner doing all work right of'exemPtion M MOL11.❑ myself.[No•workers'comp. 152, §1(4),and we have no Plumbing repairs or additions � I2.❑ Roof insurance required.]t employees. repairs • P Yecs. [No workec+s y COMP• insurance required.] 13.❑Other `Any applicant tient decks bot(#I must also fat out the motion below showing their workars'compensation policy information t Homeowners who sathmit this affidavit indicating they ars doing an work sand then hire outride contractors ;Contractors that check this box moot Notched an additionsa sheer show' must'submit a new affidavit indi the rtwM of the sub-comrwtms and tie. S such l grit aez eiayer firer u ps:e ►vat their wodors'cera.polim•infonnadon. in ornrafiom g 'compensation insurance for my,aVlo e= &&w is the POR-7 f y F �J'area'jnb site . Insurance Company Name: ' Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' cortepeasatioua policy declaration page(showing the policy number turd expiration Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal ra6oa Brite), fine up to$1,500..00 and/or one-year imprisonment,as well as civil penalties in the form STOP WORK ORDER Of LIP to$250.00 a mat Penalties of a- day against the violator. Be advised that a copy of this statement may be forwarded to the R snd a fine Investigations of the DIA for insurance coverage verification. Office of I do hereby cerfify under the pains and penalties afPerj'uY tear the information provided above is true and Si tore; correct Date: Phone#: Official use only. Do not write in this area m be compldt�d b or town.ofciaL - y City or Town: Permit/License# Issuing Artthoti{y(circle one): 1. Board of Health 2' Building Department 3.City/Town Clerk 4.Elec 6.Othe'r trical Inspector S. Plumbing inspector Contact Person: Phone#: Information a. nd Instructions Massachusetts General Laws chapter 152 requires all emp Ioyers 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 ormore of the'foregoing engaged in a joint enterprise,and includi"g the legal representatives of a deceased employer,ar the receiver ortnrsteeof an individual,partnership,associaboin or other legal entity,employing employees. 'Howeverthe 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 mair►tenance,construction or repair wdr3 an such dwelling house or on the grounds or building appurtenartt 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 Hcensing agency shall withhold the issuance or renewal of a license or permit to operate a business or 1to construct buildings is the commonwealth for any applicant who has not produced acceptable evidence.o'F compliance with the insumnce'coverage required" Additionally,MOL chapter I52,§25C(7)states`Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performrance of public work- tmdl,acceptable evidence of compliance with the insurance requirements of this chapter have been preserrted to the contracting authority.- Applicants Please fill out the workers'compensation.affidavit completely,by checking the boxes that appiy.to your situation and,if necessary,supply sub-contractors)name(s),addm*es).mind 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,arc not required°to cavy workers'cornlomsetion insurance. lfan LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also•Ese sure to sign and-date the affidavit The affidavit should ' be returned to the city or town that the application for.the permit or license is being requested,notthe Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers, compensation policy,pleastcan the Department at the number listed below. Selfnrsured onmr+nie3—ahn-Lld e.►r +fi-b self insurance-lieense number on the'appropriate line. City or Town Officials Please be sure that the afndavit is complete and printed le;Wbly. The Department hes provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which w-ilI 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 futum permits or Iicenses. 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 investiRstions 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 IDepattmcnt oflmdustrial Accidents Office of Invsstibstions 600 Washington Str=t Boston, MASA 02111 TeL # 617-7274900 ext 406 or 1-977-MASSAFE Fax#617-727-774 iL wised 5-26-05 wwwmass.gov/dia Date. <.`�. ... .. . . !! '40RTly 3? TOWN OF NORTH ANDOVER' • PERMIT FOR GAS INSTA TION �9SSAC'HUSEt Y This certifies that . . . . . . .r ... . . . .�. . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . . . . . . . . in the buildings of . . .f:�'.t:: r ;, G n at . . . . . . . . . . . . .. North Andover, Mass. Fee. . . . . . Lic. No.5. . . . .`. . . . . . . . � '.. _ . . . . GAS INSPECTOR Check# 696 MASSACHUSETTS UNIFORM APPLICATON FOR PERNIlT TO DO GASG (Type or print) Date 7 NORTH ANDOVER,MASSACHUSETTS Building Locations 6�� ��i(///� c�CJ Permit# mount$ Owner's Name New❑ Renovation Replacement Plans Submitted ❑ U. W W O OV y x h z w Gz U x a a z A H w CW7 H z F E W C� ° > �, H U a rn w x o x W. ;D 3 a ° x° > A °a N o SUB -BASEM ENT BASEM ENT IST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8.TH . -FLOOR (Print or type) I j l Check one: Certificate Installing Company Name cV (y Corp. Address © ❑ Partner. Business Telephone 77Y 7— ZjV o. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No O If you have checked yes,please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity El Bond E] Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 0 Agent Q I hereby certify that all of the details and information itted(or enter ove application are true and accurate to the best of my knowledge and that all plumbing work d installation perform nder .t Issued for this application will be in compliance with all pertinent provisions of the M sachus tts Stat Ga e ter 142 of the General Laws. By: Signature of Licensed Plumber Or Gas Fitter Title Plumber ��P Fe City/Town 0 Gas Fitter 17cense Nuirlber ER—Master APPROVED(OFFICE USE ONLY) rl Journeyman dtr`h n,f 1�fQssachusetts Ip r o or DeP ►zt f:lRtliistriQl Accident . lee of.,�rvestid ation.� 601 armhh;vOn Street Bos2ora , MAOZIII Workers' ComPe aeafioa . ` '�gov/dia , A .cant Fasurance.AfFd� ers guRd /•CoII tz'acfors/Eie . Ormation r+tricraas/PiQmbers Please Print Leeibi BIDe (RudnmdOrganimfiam4ndividual): Address: CityGSta /Zip; Phone#: . Are you all emploYerT Cbeekthe approPrigte•bu= I:F1 I im a employer wi% Type of project(reqs 4. �] I am a gancral contractor and I =PIoY�(fun and/or p�{�>,� havo hired t}►o sub-cow ❑htew cori 2.El T am.asole 6' st ucdon . Proprietor or parizrrer_ Itste:d on the attsohed sheet 2 7. sh2p and haus no employees 7%e se []:Remodeling working fOr me in sub-eonfractota o wo ' capacity. work=s' eom in S. []Demolition. [Al rids comp,irami tee.. 5. Q We P on and i g, Q Buildi �) a corpos8tion and its ng addition 3•❑ I ain a homeowner °�� have exercised their !0.(]..��ic� myself[No•WUrk rs all work right of exemption pot MOL 11. ''ep -'or additions corrtp, c, L$ Piumbmg repairs or adaitiotts insuranct.requi�d,�.t � �I(¢�,�and,we have no .. •em'PZoyews.[No workrrs' 12.�Roof repairs Any apptamfAnturecks COMP. ff, uUrancerequired.] 13El bm#I Bute eiso fti I outt!==Ojj n Wow 01A°O € eribtnit this affi}i atrh ji g�� �o B thdrworkaa'compm iori policy m{o�oa _ SCaatratKnrs that eheak thisbm nvutae sn a .`tuam dvns'n vImt ssal aho end Mhmi bele outside conttaeters troist 1 ar:.rrn e�npfoperthin p autg;war • ' wa g eke�`oftlse a,�. � c�,nat n irrfornra}iom ca�;���n�saraacejor �1'Awes Brew a r Instaanct Company Nameie ,.msdiobr .. . Poii.Y#or 5etf-ins.Lic.#: Job Site Addrms: Attach a copy of the workers''r ompeQsation C1^Grp' Failure to Pow dee-Jam page(showing the oil sectre coverage as required under Section 25A of P ry Dumber and expitatioa da*4 . fine up to$1,500 oo endbr one-year miprisonm CiL C. 1 M can lead to�imposition of of up to X2$0.00 a ;as we1l as civil pmm fim in the form of a Etna(Pmoltim of a of i day apinstthe violator. Be advised that a Copy of this Smp WORK�RD�Rartd a fine €ations of the DIA'for insurance coy statement may be erage verification; forwarded to the Office of I do hereby ceWfy under the pants•acrd pm�of per�rvy rifim the in Si for+n�oc provided above is b'ue and Correa Phone#: Rate: �lci&use only, do not write in.this �4 to be c onipjetc-d by L'or town offGaL Ody or Town: Fssumg Authority(circle one): Permit/Lccause# 1. Board of Bealth L Baht n Department 3. OtbeCity/T ,D Clerk 4 Electrics!IDs 6 'r oAPector S.Flumhiup Inspednr Contact Person: Phone#: Lnrormatlon a- nC! Itstructions. Massachusetts General Laws chapter I S2 requires all emp;cry:M to provide workers' compensation for Choir employe-_s. Pursuant to this statute,an emnployae is defined as"..:avert' person in the service of another under any contract dhire, express or implied,oral or writtzm" i l� Am anFloyer is defined as"am individual partnership,association,corporation or othar legal entity,or arty two or more oftht'famping engaged in a joint enterprise,and includ'i"g-the legal rcpresartt6vcs of a deceased employer,ar$e receiver orbugee-of an individual,partrmrship,associatialn or other legal entity,employing employees,"Howemthe owner•of a dwelling house having not more thaw thea apa rtrnoft and who resides therein, or the occupatrt of the dwelling house of another who employs persons m do mairtte mce,construction orrepa' work on such dwellinghoum or on the grounds or building appurtenant thereto shall nat became of sucb muployimm t be d.,,--teed to be an employ ," MGL chapter 152,525C(6)also states that"every state ma-local licensing itr acy shat!withhold the issaamma renewal of a license or permit to operate a business or tv construct bnlidmga in the commonwealth for any apprcaut who ha oot produced acceptable evidence o,ir c*acpiisuee with the. ramce covera„�e resgair,ed" Ari tionally, MGL chapter 152, 925C(7)states`Neither tie commonwealth nor any of its-politicil subdivisions shad anter irmq arty contract for the pm fomsur ee of public woile maid==Pt ablm evident of cornpliairc:e with the insr==- requir=n=ds.of fids chapter have been pr=Mtl d ta.fim acx ttraa ing authority.- APplimufs Please fill out the workers'.campensation.affidavit compte--tely,by checking the boxes that.apply to your situation and,if nay.supply sub-contractnr(s)X104. Kos):a d.phan'e-number(s)along with their certificates)of msuran= Limited Liability Companies(6L-C)or Limited Liability Partnerships(111,P).wit6 no-esnploy=otherthan the mambers or.part nem,are not rrx}rrirzd,tco cany.work='cdTnp=safim instu m= Van LLC or-LLP do=have =ploy=,a policy is required. Be advised that this afmcL-mvit may be submitted to the Depanrtment flf lndustriel j .Accidents for confirmatian ofins ren=coverage. Arco EMPe sure to sip and'datie the stfidavit The affidavit should be.ret=md to the,city or town thX the appfication for the per¢or lineae is being requested,not`the Department of industrial Acaidaats. Should you have any questions raper-ding.the law or if you art required to obtain a workers' compensation poliay,please-tail the Dgmrt meet at the-nuombar.iiftd below. Selfinsumd mmpanim should ental their salt=ixrsvreiux license number an tir;c'approOiGte J1T,= Gty or Town Officials Please be sure that tint affidavit is complete and printed 1rg`bty. Tim Dcpwtnm t has provided a space at the botmm of the affidavit for you to fill out in.the event the.Office of Investigatimrshas>A contact you regaFmng arae app3icant Pleaist be sraz to fel in the permMicense numberwhicb v►•71 be used as a m eercn=number. In addition,an applicant thi r must submit multipie permh iicensc appiicadOns in arty given year,need only submit one of&vit indicating Mrrmit poliay'informaiim(if necessary)and under"Job Site Address"the appiicaat should write"all locations in (city or town)."A appy of1he affidavit that has b=m offi6aily stamped or marked by the afy or town may be provided to the applicant as proof that a Valid affidavit is on file for nriar a permits or licenses. A new affidavit must be filed out each year. Where a horst owner or cith=is obtaining a licenses or permitnot related to any business or commercial vtmnae (i.e. a dog license or permit to bran leaves ata.)said person is NOT.mquired to-complete this afndaviL The Office of invextiRitions would like to thank you in ad%rmnct{ yo, and should y©a have any gmsiions, please do not.hesitate to give us a call. Tire;Dopartmont's address,*zphone.and fax number: The Commonwemlth of M&WaclitLWM Dcpartineitt of lmdaasttial Accid=b OfficeoEf Euve iptions 600 Washinggton St>�w-t Bosfv MA 02111 TeL #617-727-4900 i=Opti or 1-11.77-M,4SSAFF- Revised 5-26-05 Fax;9 61 7-727-7741 WWVEMass gov/dia p ' Date. .. . . . .. ... . s 1 NORTk i j0y`` Sao ,e,�0 3 TOWN OF NORTH ANDOVER FO 9 PERMIT FOR GAS INSTALLATION • a SS^CHUSE R M .LAI F This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . .t�.�.�. 5. .... . . . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Zat . .(,. 0. . . . . . . . , North Andover, Mass. Fee. 3v. Lic. No. . . . . . . . . .... l�-^. :� . . . . . . . . . GAS INSPECTOt Check# 1 ; 691 6 MASSACHUSETTS UNIF.ORMAPPLICATION:FOR.PERMIT TO DO`-GAS FITTING CIty7own: W 0- IAfj. tfthl- ,.MA. ;Date: _ 1,0 t# /� , Euilding-Location::`ka`.F4a2/JV l I DOwners Name C-64 . Yp P Y ❑ `❑ Institutional-[] Residential - T e of Occu anc Commercial Educational❑ . Industrial: New: ❑ Alteration:❑ . Renovation: ❑ Replacement: P.1.ans Submitted; Yes.❑ N6Z FIXTURES: N U) W W Y H W: z h- . z w O F- Q. W LuQQ LU fY > U U,, zLul. rn C7 W. O 1,- 6LL V w Z. J ,.�. 1. O Z J. (7 LL :p, w F— . W Lu W y J m LU O, Z O .� > Z SUB BSMT BASEMENT 1 FLOOR 2 ;FLOOR 3RDFLOOR 4 `FLO.QR 5 fLOQR • 6 :FLOOR 7 FLOOR 8 FLOOR Check•One Only Certificate# Installing Company Name:` ��Corporattrstt D Address: gb'� 7245 CitylTown: NOr►Ana�o State: ❑P,artnershfp Business Tel: 417 0.1783 Fax: �})S ►AZOi'IS"', . ❑Firm/C:ompany Name of Licensed Plumber/Gas Fitter: CLAIX9 ' INSURANCE COVERAGE I have.a current liabihRV.:insura.nce policy. ,or its substantial equivalentwhich meets the requirements of.:MGLc.Ch 142 Yeses No❑.. If you have checked Yes;:pleaseandicate the type of coverage by.checking the�a.ppropnate box'f elgw. A liability insurance policy. [ Other type of indemnity.❑: Bottd::❑ OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does nom ave the=ihsurance do,etage requtr:et:'by Chapter 142 of the, Massachusetts GeneralLaws,.and that my signature on this permit-appiication.waives this requi`rementS Check One Only • Owner �. Agent,:❑ Si nature of Owner.or Owner's;A ent. By checking.thisbox❑,:;hereby"certify that all of the details and inforination have submitted(or'entered)�regar4ilrag thisappllcation are.true and accurate to the best:-of my'd<nowledge and that all plumbing work andanstailations performed under the perrhit�issued'fiorthis�applicattort Wlil'be in compliance with:all�Pertinent provision of the Massachusetts State Plumbing.C.ode and Chapter 142 of ifv94*eneral Laws, Type of License: By Plumber Title Gas Fitter Signature of Licensed Plumber:/Gas fitter Master. City/Town �JOumeymarrLlCense;Number: BSg� APPROVED OFFICEUSE'.ONLY ❑.LPinstaller Date. . .��/7�v 0 � f NpRTH 1 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SS.ACNUS� This certifies that . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . .D. w. . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . .C!J — . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . .. . .... . . . . . . . . . . , North Andover, Mass. Fee. ku. . .Lic. No.. .�.`'. ?. . �l-. -ti. . . . . . . . PLUMBING INSPECTOR Check # ? i C r 8222 i - I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT T-0 D.0 PLUMBING i b .�0► N�ocEro2 ,.MA. . Date• � 0o perm # LI, CItylTown; j I CO (oRr-1d11 ��^^ �OUI� owners Name:. VO I Building Location. T e:of.Occupancy: Cortmmercial M EducationaiC Industhal 0:. Institittiona40 Residential i, yp 1 New:[] F1Renovation: [] Replacement: LA Plans Alteratio n. Subrrlit#ed Yes El No I FIXTURES z :z O Z W J = F• W; w N a W. c� Z W W to . � C7 <,� a u;, W� . .Q Ws A3. Y: O a m n :o o, '1 UB:BSMT.. - BASEMENT. LOOR. 3 FLUOR:.. 4 FLOOR .. 5 FLOOR 6 7 PL . 8 FLOORGh+�ck One Only. Cettifida#e;# . .installing Ccrnpany Name: �1k Cts�OC -� I Corporation _ l0 Address: Citylfiown: O State. _ d Paytnership... Business Tel: Name of Licensed Plumber: Q LANG INSURANCE C©VERAGE; . t liability'insurance policy,ordtsaubstantial:equivalent which meets the reulrements of 1111GL Ch":142 Yes No[] have a curren if you have' hecked Yes,:please lntlicate the typeppr .of coverage by checking,the aopriate bo�c:below .A llabiIity)nsurance.policy Other type of indemnity Q 8dnd`[] 01iVNEF:'S INSURANCE WAIVER I am aware that the licensee does not havwth waivesth s r gtr<irement,uired py::Chapter 142 of Massachusetts General Laws,and that my signature.op this'permit app ---- CbeCk'One Only Ownpr'.C] Agent [� Si nature of owner or Ownel's A entration I hereby certffy that all of the:details and information l:hav6 submitted(or entered),reg8rdinghls apppc�lcationr iii b. In ampl atnce h h all t;of'my Knowled.ge:and.that"all plumbing.workand Instaliatlorts:performed under the permit issuedfor thisapp Pertinent provision of the Massachusetts.5tate piur►ibing Code and Chapter 142 ofsthe Ganeral.l.aws. BY Type.o$lacense Title ❑''Plumber.: Signature Of Lipensed Plumber []:M CitylTown []Journeyman License Number.: AppR NEE OFFICE USE ONLY)