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Home My WebLink AboutMiscellaneous - 67 FOSTER STREET 4/30/2018 (2) 67 FOSTER STREET � 210/104 a005�0000.0 Date...... ... ....................... O`NORTH, TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 88,�cHU '. This certifies thff--�...:.J...............................::........... .... has permission for gas installation .... !.ef..1.! -" inthe buildings of........:.......!". F ................................................................:......:.....:...:... at....... .........t ......................:................................ North Andover, Mass. _ Feed . :...... Lic. No. . .... .�.......... ..................................................................... GASINSPECTOR Check# 9232 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 0 e- MA DATE f 1 PERMIT# JOBSITE ADDRESS (P-':Vr I— OWNER'S NAME J 1/ GOWNERADDRESS TE �$S 2 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL PRINT ® RESIDENTIAL CLEARLY NEW:® RENOVATION:® REPLACEMENT:® PLANS SUBMITTED: YES® N0[j APPLIANCES Z 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 , FRYOLATOR FURNACE GENERATOR GRILLE - INFRARED HEATER _ LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER -- ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER --� OTHER INSURANCE COVERAGEhave a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES E f NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND )WNER'S INSURANCE WAIVER:I am aware that the licensee does_ not have the insurance coverage required by Chapter 142 of the lassachuse4s General Laws,and that my signature on this permit application waives this requirement. f 1 CHECK ONE ONLY: OWNER AGENT SIGNATURE OF OWNER OR AGENT R 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 rid that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Perti nt provision of the lassachusetts State Plumbing Code and Chapter 142 of the General Laws. LUMBER GASFITTER NAME < C c)✓l U LICENSE#. 7 SIGNATURE PED MGF JP JGF LPGI CORPORATION PARTNERSHIP®# LLC[j# DMPANY NAMELEal ADDRESSQ J n r- vl TY ? _ STATE ZIP TEL — s kX - 21 CELL.. _ EMAIL I A-7 9 Z,y�� 06 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a d I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/OrganizatiorAndividual): Holden Oil, Inc. Address:91 Lynnfield Street City/State/Zip:Peabody, MA 01960 Phone#:978-531-2984 Are you an employer?Check the appropriate box: Type of project(required): 1.❑■ I am a employer with 45 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 E]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g• ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I l.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no as fittin employees. [Nb workers' 13.M Other 9 g comp. insurance required.] *Any applicant that checks box 41 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 sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must 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:HDI Gerling America Insurance Co. Policy#or Self-ins. Lic.#:EWGCD000014513 Expiration Date: 12/31/2014 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 ce der the ains a d p na ties of perjury that the information provided above is true and correct Si ature: 01-06-2014 Date: Phone#: 9785312984 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#: COMMONWEALTH OF MASSACHUSETTS PLUIIABER:S �4ND GASFlTTRS b CIC�NSED AS AN LP GAS !N�'�AL4" ly ISSUES THE ABOVE LICENSE T0:' NO �MIGHAEL_ J. . V'ICK 4t.1LATR, TER . . i 'I A DIl:4' MA- 01960.-510 III, , '9 42 Date. NORTq TOWN OF NORTH ANDOVER .1ablL 0 PERMIT FOR PLUMBING -e This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . xr . . . . . . . . . . plumbing the buildings of V f.. . . . . . . . . . . . . . . . . . . . . . 7 at. . . . . . . . . . . . . . . . . . . . . . . . .I North Andover, Mass. 0 F4 . . .Lie. No.. . . . . . . . PLUMBING INSPECTOR Check # I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town:�L1 Cl MA. ate: fl /?�// Permit# Building Location:—.6 Q Owners Name: Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential( ''� New:P Alteration: '1 ❑ Renovation:❑ Replacement:El Plans Submitted: Yes❑ No❑ FIXTURES o: DEDICATED N z SYSTEMS > Y N WCA En L3 Z h U H W j3 0 C aUj C Z 5 H Q Q W ZZ m Ln Ln N Y N} W W D: CC h z Q _ O ? = O A w j Z LL S Uj U ¢ N o o > o o ° z zLn W o N 3 a m m o o LL x Y g S N ra 3 3 a = ❑ Ln w } W 'SUB BSMT. O ¢ 3 BASEMENT 1sT FLOOR 2ND FLOOR a ' 3RD FLOOR 4T"FLOOR 5T"FLOOR 6T"FLOOR 7T"FLOOR 8T"FLOOR Installin Cglii ,(� � pant'Name:�� ./e,�✓y,L 2'O �dt'` Check One only Certificate# Address: Q ('�"L ❑Corporation ; City/Town:-11. �"---"-State: ofp Business Tel:- 7 -6 , Q - J El Partnership Fax:_ j We ` t[�Firm/Company Name of Licensed Plumber: u1J INSURANCE COVERAGE: 1 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 t ypeo f coverage by checking the appropriate box below. A liability insurance policy. Other type of ind . Yp emnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Si nature of Owner or Owner's A ent Owner ❑ Agent ❑ 1 hereby certify that ali of the details and information I have submitted(or entered)regarding this application are true and accurate -� r Knowledge and that all plumbing work and installations performed under the permit issued for this application will n ac compliance Pertinent provision of the Massachuse s tate Plumbing Code and Chapte 42 of a ate to the best o.my General La p with all � s. By Type of License: Title �/ L��lumber Signature of Licens Plumber --ity/Town Master APPROVED(OFFICE USE ONLY) ❑Journeyman License Number: { Date..... �:... .:ll ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING �sSCHUS This certifies that has permission to perform ... wiring in the building of `...... ....................................................... at.... 11.r�. ...�rQ 5. ..x...2........ ........:.................. orth Andover,Mass. Fee....1..1.. Lic.No.. 1 e d 7............ ..... x tI t Eta CT CALNSPEC'i'�� t Check 'I 10458 - Common-wealth ®f Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 Q,aveblank) 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 LNEVK OR YYPE ALL MFORWTIOA9 Date: fi— � — a City or Town of: NORTH ANDOVER To the Inspector of Mires: By this application the undersigns Ives notice of his or her intention to pertotm the electrical work described below. Location(Street&Number) 'W Fo 3�� Qi�c,�- Owner or Tenant Riywe k � ft}-L kcyy t Telephone No. Owner's Address 'LfS E.,S� gfnCr Is this permit in conjunction with a building permit? Yes [4-' No ❑ (Check Appropriate Box) Purpose of Building 40 Utility Authorization No. Existing Service %e-b Amps L 02 Volts Overhead [91 Undgrd El No.of Meters New Service Amps Volts Overhead❑ Undgrd FI No.of Meters Number of Feeders andAmpacity pp Location and Nature of Proposed Electrical Work: V ;VY_ Completion ofthe following table may he waived by the Inspector of Wires. No.of Total No.ofRecessedLumin-aires No.of Cefl.-Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets _3 No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above El 'EJ .of Emergency Lighting Rrnd. grnd. ❑ Battery Units No.of Receptacle Outlets No.of OR BUr'nersFIRSAL.A.RMS INo.of Zones No.of Switches No.of Gas Burners No..of Detection and A Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons Heat Pump I Number I Tons.....]KW No.of Self-Contained No.of Waste Disposers Totals:I-*....... ........................ .I ............. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local El Municipal 0 Other Connection No.of Dryers Heating Appliances KW Security Systems:* - ry No.of Devices or Equivalent No.of Water No.of No.of KW Data Wiring: Heaters Signs Ballasts. No.of Devices or Equivalent Bathtubs 77N Telecommunications Wiring: INo.of Devices or Equivalen No.Hydromassage Batlit o.of Motors Total HP OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: AAR (When required by municipal policy.) Work to Start:P - S -I/ 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 [t KBOND n OTHER'EJ (Specify:) I certify, under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME:IZ Xe W Te eA 7?a" LIC.NO.:////V,?- (I Licensee: RYAW Signattire LIC.NO.: J)1/4/2-0 (If applicable,Ater"exempt"in the license number line.) Bus.Tel.No.: Address: If S,)ya CLMUI Alt.Tel.No.: *Per M.G.L c.147,s.57-61,security work requires Dep&tMBrit,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 herebythis requirement. I am the(check one) El owner 0 owner's agent. Owner/Agent 7-'_ 111741 PERMIT FEE.-S 6A— i`9e CoMntoniferal 0�Q7SSA Department of Industrial Accidents Office of Investigations 600 Washington Street I Boston, MA 02111 www.taxass.gov/dia . Workers' Compensation Insurance Affidavit: IBuilders/Contractor°s/Eiee.tricians/Plumbers Applicant Information Please Print Legibly Nalne (Business/Organization/Individual): �w✓C-72P 1 ) Address: 15 Gc-r>1ne 4- ' City/State/Zig: C�-otx _r?1/l4 c)l$3 q Phone Are your an employer?Check.the appropriate-box: Type of project(required): 1.❑ I'am'a employer with 4, ❑ I am,a general contractor and 1 6 New construction employees(full and/or part-time),* have hired the sub-contractors 2.9-1- i-a.sole proprietor.or partner- listed on the attached sheet.$ �• ❑Remodeling ship and have no employees These su&contractors have 8. Q Demolition , working for me.in any capacity. workers' comp.insurance. 9 ❑Building addition [No workers'comp.insurance 5- E] We are a corporation and its required_] officers have exercised their 10.0 Electrical repairs or additions j 3.❑ 1 din a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself,[No•workers'comp. c, 1.52, §1(4),'and we have no 12,Q Roof repairs insurance re uired # ' -required.] .employees, [No workers comp. insurancerequired.] 13.M.Other *Any applicant that checks bob#I 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 aced then hire outside contractors must submit a new affidavit indicating such. - $contractors that check this'box must attached an additional shsst showi?g.01C name of the sub-contractors and their Baer?ass'comp,policy;nfo,;,aror. I a rt ass ea�spinyeP that iS Prz?PzdMg:wa;-hers compensadion in•formadoea. ansurapacefor y ePnplOyees: Vie!®av is file policy said job slte Insurance Company Name: ' Policy#or Self-ins.Lie.. 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-$1,300.00 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 apenalties of perjury that the information provided above is true and correct Sienature: Date: 1 Phone#:------------- Official use only. Do not tvrie hi iris area,to be co�;apleted by cuy or town offtciaL 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#- o , Date.. ......... . ... f NORTq TOWN OF NORTH ANDOVER ' PERMIT FOR WIRING CMus� This certifies that �'''� ? ............f...... . ...... ha'y ss permission to perform -. - ter. ,.ms s.- .. -' 4 t J. wiring in the building of.. ....... at f.. - at....lam. .... e"- ...... ....:....... . ... North Andover,Mass. ?� f Fee:..e.................:. Lic.No4,ff ................:.............. ........... /j ....... ELECTRICAL INSPECTOR[ Check # i / zo 8375 Official Use Only Commonwealth of Massachusetts Per Department of Fire Services mit N°. o� 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 W INK OR TYPE ALL INFORMATION)' Date: g a 3 Q 9 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or er intentio to perform the electrical work described below. Location(Street&Number) b / p S-r - S ' Owner or Tenant 14{r Telephone No. Owner's Address ! Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service 2J Amps / Volts Overhead ❑ Und rd g ❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.o eters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �'v Com letion pf 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 No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.of Emergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of SwitchesNo.of.Gas Burners No.of Detection and Initiating Devices No.of RangesNo.of Air Cond. Tons No.of Alerting Devices ' No.of Waste Disposers Heat PumpNumber Tons KW No.of Self-Contained Totals: -. ...-... ................ Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal E] Other 1 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. . r Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived b the y 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 cov rage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [7/ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains an penal •es of erjury,that the information on this plication is true and complete. FIRM NAME: (, f L LIC.NO.: Licensee: _ 1�,�, Signature LIC.NO.: 3,0 (If applicable, r'exe, t"in the 1' ense nu er line.) Bus.Tel.No. Address: (/- �� l!'�/hg C Alt.Tel.No.: *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,l hereby waive this requirement. I am the(check one) ❑ owner ❑owner's agent. Owner/Agent Signature Telephone No. IPERMITFEE. $gS—"� b ,� 14 14 r �, The Commonwealth of Massachusetts 1 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 Please Print Legibly 1 ) Name (Business/Organization/Individual): Address: City/State/Zip: P1/( ,In j G Phone #: Are you an employer? Check the appropriate b(ox: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. New construction (full and/or part-time).* have hired the sub-contractors2. employees am a sole proprietor or partner- listed on the attached sheet. 1 7. ❑ 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 III 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.] t 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. lContractors 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.#: tj� �-7,9 �j Expiration Date: A(gll<�, Job Site Address: b 1 �Q ,�� C , f City/State/Zip:�d �� LLV 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify er t`eA ins azgfpenalties of perjury that the information provided ah o a is tru and correct Si ature: 1 -3 CJ s� I Date: 5121 Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#• Date...... .... ° t"".•�"° TOWN OF. NORTH ANDOVER p PERMIT FOR WIRING CHU a This certifies that ........................................................��'..�. ............... .: has permission to perform ..........1; ' wiring in the building of......... �. �s-T...................................:............... roti at..............................�.......:� ' Official Use Only Commonwealth of Massachusetts Department of Fire Services Permit No. T�l ki BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.'1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL AL All work to be performed in accordance WOR K P with the Massachusetts Electrical Code(MEC) 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 0 M Q- City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the under�gned giyes_notice o intentio to perform the electrical work described below. Location(Street&Number Owner or Tenant t Telephone No. Owner's Address Is this permit in conjunction w'th a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building n)U j�Q Utility Authorization No. -S'�$ Existing Service ,06 Amps / Volts Overhead � Undgrd F1No,of Meters New Service �QQ Amps / Volts Overhead Und rd g ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: /�Le `e Completion of the followin table may be waived by the Inspector of Wires. No.of Recessed LuminairesNo.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- o.o Emergency Lighting d. .EJrnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No of Zones No.of Switches No.of Gas Burners o.of Detection and Initiating Devices No,of RangesNo.of Air Cond. Tons l No.of Alerting Devices No.of Waste Disposers eat Pump Number Tons KW No.of Self-Contained Totals: `_..____.._. __ .__. - Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Low❑ Municipal ❑ Other Connection r No.of Dryers Heating Appliances KW Security Systems:* No.of steto.of No.of Devices or Equivalent . Heaters KW NoofSi s Ballasts Data Wiring: . No.of Devices or Equivalent No.Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsWiring: OTHER: No.of Devices or Equivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required b municipalpolicy.) Y Work to P Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent The undersigned certifies that such cove ge is in force,and.has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify,under thepiuW and p naltiev of per'ury,that the information on this application is true and complete FIRM NAME: LIC.NO.: G 3 Licensee: i lure LIC.NO.: (If applicable, enter"exempt" 'n the liceumber;ie�.) Bn,TeL No. /.g Address: �e G Alt.TeL No.: *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 Signature Telephone No. PERMIT FEE:$ z The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street ti. a i} Boston, MA 02111 i t www.mass.gov/dia . Workers' Compensation Insetrance Affidavit: Builders/Contractorgmectricians/Plambers A licant Information Please Print Le-affil Name(Business/Oiganiza6on/Individual); 1� f J Address:_ City/state/Zix j�& ,�. /, 1574 O N P Phone #: . qx Are you an employer?Check the appropriate box: F7Re oject(required): 1.❑ l atn a employer with 4. ❑ I am a general contractor and 1 (full and/or part-time).* have hired the sub-contractors New construction 2.eI�a�limploayseomle proprietor or partner- listed on the attached sheet 2 odeling ship and have no employees These sub-contractors have o}ition working for mein any capacity. workers' comp:insurance. ing addRian [No workers'comp.insurance 5. ❑ We are a corporation and itsrequired•] officers have exercised their rical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL bing 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.) L3.[].Other "Any applicant that checks bort#I must also fill out the section below showing their workers'compensation policy information. r 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 mustattached an additional shaershowing the name of the sub-contractors and their workers'comp.policy information. I am an employer that.is prong workers'compensation insurance for my enwloyees. Below is the policy and job site informadom Insurance Company Name: 71t )G Policy#or Self-ins.Lie.#: 31� Q Expiration Date: lt�Job Site Address: City/State/Zip: r 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 f of up to$250.00 a day against the violator. 8e 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 certRdeir, penalties ofperjury that the information provided ab eis aand correct Si Phoned F only. Do notwrite inthis area,to be completed by city or town official n• Permit/Licensehority(circle one):Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector son: Phone#: 0 . Information and Instructions . e 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 shaU 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 zmtil 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 r necessary, supply sub-contractors)name(s),addresses)and phone numbers)along with their cwtificate(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 peFmit 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. Anew 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 Iavestigations 600 Washington Street Boston, MA 02111 Tel.#617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7744 www.aiass.gov/dia Date. . .1. 11. TOWN OF NORTH ANDOVER PERMIT FOR,PLUMBING ,SSACNUS This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform .k./S.4. . u-1k?4. . �' . . . . . ' plumbing in the buildings of . . . . . . . . . . . . . at . . . . . . a ' . . . . ! , North Andover, Mass. 671 Fee-7�0.*.t?0. .Lic. No.. .,��.3:�� .PLUNG INSPECT R. Check # � 784 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type.or print) NORTH ANDOVER,MASSACHUSETTS /� � �- rte— Date l Building Location (/� C �- �7 Owners Name Permit# Amount Type of Occupancy New Renovation 0 Replacement Plans Submitted Yes E No El FIXTURES o � U p im O IY� O W C7 O LO o) A A Q A S[B]Ei9.VIC fi491��+I�I' T F,Zna� �1II 1~F�2 M FLOOR 4II�)NIlSIEt SIFT FLOOR 6M FLOC t _ 7IFiIIt>CIR � gm.. (Print or type) ]� /1 Check one: Certificate Installing Company Name ,�! `✓ Address v Corp.�� Partner. D ?• Business leleptione i �Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate�e of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond F1 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 llatio performed under rmit Iss d for this application will be in compliance with all pertinent provisions of the Massa c s tts lumb' Cod d Ch er 142 of the General Laws. By: i wr o kens er Type of Plumbing License Title / City/Town kens umb er Master Journeyman ❑ APPROVED(OSCE USE ONLY