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HomeMy WebLinkAboutMiscellaneous - 696 OSGOOD STREET 4/30/2018 (2) OSGOOD STREET 210/1/1 00.0-0006-0000.0 �i Date..... ... . .................... NORrN TOWN OF NORTH ANDOVER �= PERMIT FOR GAS INSTALLATION This certifies that 1,a'.� .LQ,.---..-K4W.........:................................................... 4-as permission for gas installation .1N: ...4-m.-f1...................................... inthe buildipnggs,of................................................................................................................... at.b.1 ......tuc , .... �".................................... North Andover, Mass. Fee//d l>q,1)Lic. No. ../.;�.. 9 .7 ... .. ................................ A�INSPECTOR Check# 9535 Date.!�>4/1.11............ 10744 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that....,..( ... + 1 .,.................................................................. has permission to perform..... .............................................. plumbingin the buildings of............................................................................................. at.A,�A ............................. ........ . North Andover, Mass. Fee..Z.�,4_9P Lic. No. /15)-If ........... U!PLBING I SPECTOR Check# r� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK I CITY t I MA DATE LY�� PERMIT# JOBSITE ADDRESS _f OWNER'S NAME p./k POWNER ADDRESS I TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: IV/ RENOVATION:® REPLACEMENT: ® PLANS SUBMITTED: YES® NODI FIXTURES-1 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICEf DEDICATED SPECIAL WASTE SYSTEM 1 .__._J I 1 ___._1 .__.,_._l _ .__J __ MI-711 __._.I € DEDICATED GAS/OIL/SAND SYSTEM ( _,_DEDICATED GREASE SYSTEMDEDICATED GRAY WATER SYSTEM 4 ( _ I __IDEDICATED WATER RECYCLE SYSTEMi DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) E KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 1 __ _ .( _ __ji __T_.f ___. _i ---j ._.____I URINAL — ( ....___ I � _.._._ � I ...____ f _-___.J. ._____- WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING [ _ f OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE YPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i OTHER TYPE OF INDEMNITY 01 BOND Q 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 _1 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wi II P rtine r n of the Massachusetts State Plumbing Code and Chipterf of the General Laws. All OC P PLUMBER'S NAME� _ LICENSE# S I SIGNATURE MP 4� JP Q CORPORATION MJ#�---�PARTNERSHIP 0#�--�-� /�• j�' �J �LLC COMPANY NAME ( ADDRESS - - -- E CITY _j STATE ZIP EL FAX CELL ENTAILZge R GH PLIQVINGINSPEWIDA NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION N4TES �S S 9h l Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES t The Commonwealth ofMassachusetts - Depariment of Industrial Accidents Office oflnvestigatzons 600 Washington Street Boston,MA 02111 www.mass gov1d1a Workers'Compelasation Insurance Affidavit:BuildersIContractors/Electricians/Plumbers Applicant Information Please Print Led.1 Name(Business/organizationllndividual): Address: A City/State/Zip:p / (� 7 4 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. 0 I am a general contractor and I 6. n New contraction f mployees(falland/orparttime)* have,Redthesub-contractors 2.0 1 am a sole proprietor or partner listed on the attached sheet.t 7. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition worldng for me in any capacity. workers'comp,insurance, 9. E]Building addition [No workers'comp.insurance 5. ❑We are a corporation and its 10.nElectrical repairs or additions required.] officers have exercised.their 3.❑ I am a homeowner(ting all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.EEO Workers,comp. c.152,§1(4),andwehaveno 12.QRoofrepairs insurancerequired.] employees.[No workers' 13.0 Other comp.insurance required.] 'Any applicautthat checks box41 must also fill outthe section below showingtheir workers'compcnsationpolicy information. 1'Homeowners who submit this affidavit indicating they 6'rse doing all work and then hire outside contractors must subinit anew affidavit indicating such. tContractors that cheokthis box must attached an additional sheet shov&gthe name of the sub-contractors and their workers'comp.policy information. X am an emyloyer that is providing workers'eompeiasation insu anee for my employees Below is thepoliey anri`job site information. Insurance Company Name% Policy#or Self ins.Lic.ff: Expiration Date: Job Site Address: City%State/Zip: Attach a copy of the workers'compensation-p olley declaration page(showing the policy number and expiration date). Failure to secure coverage.as required.under Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a flue 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 ane of up to$250.00 a day against the violator. Be advised that a copy of this statementmay be forwarded to the Office sof Investigations of the DIA for insurance coverage verification. X do hereby cert&under the pains and penalties o per' ry that flee information provided above' tray anti torr eet. - Siff-nature: Date: /4� Phone i#• Oficial use only. Do not write in dais area,to be completed by city or town offeial. City or Town: Permiaicense 0 Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.C41T. owu Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other " Contact Person: Phone#: Informati®n and InstructD s OHS Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for thein'employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract od biro,• express or implied,oral or written." An employer'is defined as"an individual,partnership,association,corporation or other legal entity,or anytwo 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 havingnotmore than three apartments and who resides therein,or the occupant ofthe dwelling house of another who employs persons to do maintenance,construction,or repair work on such dwelling house oron 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 chapterhave beenpresentedto the contracting authority." Applicants Please fill out the workers'compensailon affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),addresses)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with noemployees other thanthe members or partners,are notrequiredto carry workers'compensation insurance. If an LL C orLLP does have employees,a policy is required. De advised thatthisaffidavit maybe submitted tothe Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be,returned to the city or town that the application for thepermit or license is being requested,not the Department of Industrial Accidents. Shouldyou 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. • u City or Town Officials Pleasebesure that the affidavit iscomplete and printedlegibIy. 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 fdl inthe permitpicomo number which will be used as a reference number. In addition,an applicant thatmust submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant shouldwrite"all locations in (city or town)."Acopy of the affidavit that has b sen 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 orlicenses. Anew affidavit must be filled out each year,Where ahome owner or citizen is obtaining alicense oxpermitnotrelatedto anybusiness or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address;telephone and fax number: T'hoGo on—malthofM_ossachu&-t-s l?opartmout ofTWUMal.Aculdeata Office o�Tnvesti���'tou� 6.40 Washiugtm re t Sp�t¢n� .Q�111 TO.9 617-727-49-00 e 406 or 1-877-MASSA Revised 5-26-05 lea 617"727` 749 wtv .Ma8,%g4V1& /I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE PERMIT# JOBSITE ADDRESS (��1 / T„l Xc 6„ OWNER'S NAME GOWNER ADDRESS L TEL ^— FAX TYPE OR OCCUPANCY PE COMMERCIAL� EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: . RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO Q APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE ED Q!I j _ DIRECT VENT HEATER [ _ DRYER FIREPLACE FRYOLATOR - �_�- �_- - _( � -- - - .. --- .. - [..m�._I FURNACE �_,1 -__r�_I _ _ _ GENERATORf GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN I I _ POOL HEATER ROOM/SPACE HEATER I ROOF TOP UNIT TEST UNIT HEATER _ _ ► I UNVENTED ROOM HEATER WATER HEATER CTHER .... �( _ f f INSURANCE COVERAGE - I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES IB—N--0 0 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAQkW CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY _iJ' OTHER TYPE INDEMNITY E( 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 D 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 my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBEFiGASFITTERNAME iC _- _ LICENSE# S_ SIGNATURE MP~�I MGF ]I JP ® JGF LPGI 0 CORPORATION PARTNERSHIP�I#=LLC Ell# COMPANY NAME:� = _ -¢ �' ADDRESS CITY f2 I STATEZIP FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTIONINOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 4 • a ' The Commonwealth of Massachusetts , EY I DepaYtment of 7nclacs€YzrcrAcciciets Office of-Investigations 600 Washington Street .Boston,MA 0211.1 www.rnass govIdla Workers,Compensation Insurance Affidavit:Builders/Contraetors/Eiectricians/PIumberg Applicant Information Please Print Legibly 'Name(Businesslorganl-zation/Individiial): 64 .Address: o20 City/State/Zip: �� Phone#: —1$ / Are you an employer?Check the appropriate box: Type of project(required): .1111 a employer with 4. 111 am a general contractor and I 6. ❑New c6nstruction employees(full and/or part-fime).* have Medthe sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and'haveno.employees. These sub-contractors have 8. E]Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exereised.their 10.❑Electricalrepairs or additions 3.El I.m a homeowner doing all work right of exemption per MGL 11.[]Plumbing repairs or additions myself[Toworkers' comp. c.152,§I(4),and wehave no 12.❑Roofrepairs msurancerequired.]; employees.[No workers' 1311 Other comp.insurance required.] Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. -Homeowners who submit this affidavit indicatingthey kk doing allwork and then hire outside contractors must submit a new affidavit indicating such. rContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. f am an employer that&providing workers'compensation insurance forrny employees. Below is thepoliey an4job site infomadon. Insurance Company Name:_ Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: pity/state/zip: Attach a copy o#the workers'compensationpolicy declaration page(showing the policy number and expiration date). Failure to secure coverage.as required.uader Section 25A ofMGL o.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 iti the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Do advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I j -1 do Hereby cert ur2der the pal an allies o ry that the information provided above is,1rueandeorreel Simature: Date: Phone#: Official use onfy. Do not write in this area,to be completed by city or town official. City or Town: Permif/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector S.Plumbing Impector 6.Other - - - Contact Person: phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an ernployee is defined as"...every person in the service of another under any contract ofhire,• express or implied,oral ox 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 anindividual,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 workcxs'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone numb er(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,axe not required to carry workers'compensation insurance. If au LLC or LLP does have employees,a policy is required. B e advised that this affidavit may be submitted to the Department of Industrial Accidents for con&mation of insurance coverage. Also be sure to sign and date the affidavit. 'phe affidavit should be retumed to the city or town that the application for fhe 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 pxinted 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 pemrit/license number which will be used as a reference number. In.addition,an applicant thatmust submitmultiple,permit/license applications is any given year,need only submit one affidavit indicating current policy information(ifnecessary)and under"Job Site Address"the applicant shouldwxite"all locations in (city or town)."A copy of the affidavit that has be' n officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid a£fidavit•is on fd'e,for:future permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i,e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you i a 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 CQxt ox�Wueat�of Massachusetts - Depat`t;aa.ent ofb dusWal Acclolmts Moe Qi:f votzgau0na 6.04 WasWugtqa eet Boston,MA 02111 `del,#617-Z2-°-4900 az,406 Qx 1-87-7-MAS Revised 5-26-05 Fax 4 617-727-7749 wc�w.xpa�s,gc�vfc�a . Date 1-1-s �-]-i............. ,&ORT#f TOWN OF.NORTH ANDOVER 0 PERMIT FOR WIRING • o.. -.1 `43,CHU This certifies that .. . .....4.......... ...... . has permission to perform .. .1 ... .......... .......................... wiring in the building of A.a7....... ....lr=.................................... ............ .................................................. Fee ......................North er,Mass. rzcA................................ ....... . .... .. . .......... ...�.03, ............Lic.No. % ELECTRICAL INSPECTOR Check# 1270 . i • . Official Use Only Commonwealth of Massachusetts '- Permit No. 12--706 o Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 leaveblank I 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 WINK OR TYPE ALL INFORMATION) Date: 114 City or Town of. NORTH ANDOVER To the Inspector oJ Wires: By this application the undersigned gives notice of his orb intention to perform the electrical work described below. Location(Street&Number) �Qj O s (:,00-- 5-1 ... Owner or Tenant Telephone No. Owner's Address P011 ZS ^` ^ Z J Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building s ` �Ce�siZ �� Utility Authorization No. 1`7b:5 Y3 f Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service 7COO Amps 10/ olts Overhead❑ Undgrd �_No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell: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- 1:1o.o mergency Lighting rnd. grnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gns Burners No.of Detection and Initiatin Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat pump Number Tons KW No.of Self-Contained p Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW 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 Equivalent i OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated ValUVtRAGE: f Electrical Work: O (When required by municipal policy.) Work to Start: t Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE 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 C�ov,era is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE LTJ' BOND ❑ OTHER ❑ (Specify:) X certify,under the pains and penalties ofperjury,that the information on tl:is application is true and complete. FIRM NAME: • G l s LIC.NO::\M (Z-1 1, Licensee: L(y-m Ael— /�1,���il�t, Signature LTC.NO.: f-7 7 5k--D, (If applicable enter " empt"in the license number line. Bus.Tel.No.- Address: ,- 1 Alt.Tel.No.: 32,5109-62 — Address: 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. 1 am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE:,$ Signature Telephone No. I ❑ 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 s, on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application, Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. t Permits shallbelimited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he d 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 M Failed Re-Inspection Required($.)❑ Inspectors Comments: n. 1 Inspectors Signature: Date: SERVICE INSPECTION: Pass❑? '� Failed 0 Re-Inspection Required($.) ❑ Inspectors Com s: . r f Inspectors Signature: I Date: PARTIAL R QMH INSPECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: C Inspectors Signature: v.- `Z J Date: - —/ ROUGH INSPECTION: Pass n Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass❑' Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Q Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department oflndustriglAccidents Office of Inves9gations 600 Washington Street Boston,MA 02111 www mass.gov1dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): A,,,AJ,kC_ Address: 1Q, c77 � _ City/State/Zip: U),kZb vR,V-k,, A A Phone Are you an employer?Check the appropriate box: Type of project(required): 1.51am a employer with 4. ❑ I am a general contractor and I 6. Qv 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.t ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition worlds for me in an capacity. workers' comp.insurance. g y p fY- 9. E]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its ` required.] officers have exercised their 10.E]Electrical repairs or additions 3.E3 I am a homeowner doing all work right of exemption per MGL 11.E]Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.] employees.[No workers' 131i Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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. -1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and joh site information. Insurance Company Name:- J4_A,J Oy 6-V\_ LAJ S Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: L 0 5(,o6--p f l City/State/Zip: Lb, A n.�( Wc57 U,- ,A4 A Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Endure 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. X do hereby cert' under the pains and penalties ofperjury that the information provided above is true and correct. Si afore: Date: q 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 M Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,• express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 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 E 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 CoMM011Wealth Of MassachvsPtts Department of Industrial.Accidents Office olInvestigatiions 600 Washington Street Boston}NMA 02111 TeX,#617-727-4900 ext 406 or 1.-877-MASS.AFE Revised 5-26-05 Fax#617-727-7749 wwwxnass,go�fclaa it - -- -- -- -- - Date ,.. ` . .: NORTH °� "" '•�� TOWN OF NORTH ANDOVER PERMIT FOR WIRING 88ACMUSB This certifies that . �.Y ., .. 1.� 04 has permission to perform ....4..Q.s....... ........:� .C....................... wiring in the building of...... ................ �..1..��............:....................................... at ...(on... ,...... r�tX..... � ................... ..North Andover Mass. � � U Fee.. _ .........Lic.No. �.:. . �. 1. :.. . ..... ...... ..... .. . f EC CALINSP TOR Check# i "!'I 12362 _ The Commonwealth of Massachusetts Depaphnent of Indi!strigl Accide is Office oflnvestigations 600 Washington Street .Boston,lVIA 02111 www.mass gov/dia Workers'Compensation Insurance Ali d-avit:BuilderstContractoxs/Electrxezans/PXumber.s Applicant Information Please W tLeaibXy Name(Business/OrgauizationlXndividual): CLt,C1-t Address: �-Ob - U��3s City/State/Zip: U/4— Ab Lt _ Phone#: A,ree an employer?Check-the appropriate box: Type of "J ct(required): 1.L`� I am.a employer with 4. ❑x am,a general contractor and I 6.Type construction employees(full and/or p -time) have Hired the sub-contractors 2111 am a sole,proprietor or partner- listed on the attached sheet. 7• F1 Remodeling ship and'ltave no-employees These sub-contractors have 8. []Demolition working forme in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑We are a corporation and its 10,❑Electrical repairs or additions requked.j officers have exercised.their 3111 1 am a homeowner doing all work right of exemption per MGL 11.[1 Plumbing repairs or additions + myself.[Noworke_rs'comp. c.152,§1(4),and we have no 12.gRoofrepairs insurat cerequired.)i employees.[No workers' 1311 Other comp.insurance required.] !.Any applicant that checks box#1 must also fill out thio section bel6w showing their workers'compensationpolicy information. T'Homeowners who submit this affidavit indica&igey bio doing allwork and then hire outside contractors must submit anew affidavit indicating siiob. tContractors that checkthis box must attached as gdditional sheet showingthe name of the sub-contractors and their workers'comp.policy information. I am an employer that isproviding workers'compensation insuranceformy employees. Below is thepolicy andjob site information. Insurance Company Name:. Policy#or Self-ins.Lric.#: Ex0rationDate: Job Site Address: b e �. S (��ro lJ `�i fCity%State/Zip:_ 00, �`t��(� v� ` � c'� Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). I'ailure�to secure coverage,as.t uiredunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a flue 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 Osis statement may be forwarded to the Office flf. Investigations ofthe DIA.for hisurance coverage verification. X rlo Hereby cert`' under the pains and penafties ofperpry that the ire,formation provided Bove is true and cornett. - Si ature• Date: Phone#• �7� ���?�t�6 `Z Ojr,reial use only. .Do not write in dais 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 M .;COMMONWEALTH OF MASSACHUSETTS. e s o s o I . BOARD OF ELECTRICIANS ISSUES -THE FOLLOWING` Ll CENSE: AS'A REG JO URN EYMNELECTRIC AN ti MICHAEL F MACDONALD { � PO;;B0Xj'8062 :HaVERFIILL MA 01835-0562 4j 7805 E 07/3lfl6 75208 a^ 4� COMMONWEALTH OF MASSACHUSETTS 3 ' BOAR:p OIF #. E'LECTRICIANS i i.. 1-,SSUES .THE FOLLOWING L'I CEN5E qS A' , REGI TERE-D MASTER ELECTR 8 ELECTRICAL SERVICES M'I`CHAEL F �MACbO;NALD PO BOX<:=8062 \\ f HA'E-RH I LL ,. MA 01835-0562 Date. ,l {•. .. . Ta F N°RTM , TO.�yN,OF NORTH ANDOVER °L o A P RMIT FOR GAS INSTALLATION �iFD nPP'��5 �9SSACHUSEt - This certifies that . . . . . has permission for gas installation . . .1:{.: in the buildings o � .' % r .! .(�" 1. < �.,�-r. . . . . . . : . . . . at . . . .C."�J. f/t . . . . . .. North Andover, Mass. Fee. .30!-'Lic. No./3 ql. ,<..:..:.. . ... . .. GASINSPECTOR d WHITE:Applic nt ANARY: Building.Dept. PINK:Treasurer GOLD: File Commonwealth of Massachusetts Official Use Only r Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.i/o (leave blank M APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(N.MC),527"CMR 12.00 (PLEASEPRINTIN-INK OR TYPEALL)NFORMATI0A9 Date: 5(N. 1 �C/I City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned ' es notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant J 1:b Telephone No. r � Owner's Address ?&- 6-&C-,4-j pp 1 Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) (JL*51H 1 Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity M�I2 C) Location and Nature of Proposed Electrical Work: (Z- ,vj P eE, S ti-),W,L Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No.of Total Transformers KVA r No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above In- o.o Emergency Lighting rnd. ❑ rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burgers No.of Detection and InitiatinLy Devices C No.of Ranges No.of Air Cond. TotalTons No.of Alerting Devices 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 E] other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent U/ 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 Telecommunications Wiring: Hl' No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Mres. Estimated Value o Electrical Work: (� ��, ` (When required by municipal policy.) Work to Start `� t f 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 cover is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) Icertify,under thepains and penalties ofperjury,Ihatthe information on Ais application is true and complete. FIRM NAME: . L �C�C-�t LIC.NO.:1� &Q,6, Licensee:t:� ,LC44 O�L— LAA��c)yA,i ignature LIC.NO.: Z7 kQ (If applicabl�g��jenter "exempt"in the license number line4l Bus.Tel.No.: 3 if 2 °L Address: Vt O ® 1 Z Ls-A-%0\ U L-e—. AA 4 -32 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 PERMIT FEE.$ Signature Telephone No. 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions permit application form to provide notice of installation of wiring shall be uniform throughout the Commonw alth,and applliio tions 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 q electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and maybe 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 Chanter 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 effector ex11 11 i11 ste11 11 n11 ce11"d11 u11 ri11 ng the qualifying period beginning on August 15,2008 and extending"through August 15,2012. 11 ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: ----------------- Trench Ins ection Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass n? Failed 0 Re-Inspection Required($.)❑ Inspectors COMments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass F?1 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: � E20UGH INSPECTION: Pass 0 Failed Inspectors Comments: I Re-Inspection Required($.)❑ l i Inspectors Signature: Date: 'INAL INSPECTION: Passe Failed 0 Re-Inspection Required($.)❑ nspectors Comments: Inspectors Signature: Dat :13 WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com .:.:`!'.`s s fir.p.Krq.,+.: ��:�i..C;.•t5",,;°1"y 1L:_'y_��:� izMs' `C•-�'�""d'�. (Print or Type) 'MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO QASFITTINQ NORTH ANDOVER , Maas. Date 19A X30 65-1i Building Z J Location r $ S/— Permit �r�• �� Owner's , 0�9Name ff New Renovation p Replacement p Plans Submitted: Yes O No [I h O u x d n ac a g o oc M h ac d J h W am a w st o` dx d� V tl0 C� x s. A a X w H 10 h <s 0 N ' QQ at ; �. J W ` Z O d OUR— aaT. DAOEMENT IST FLOOR NOM FLOOR ,RDFLOOR ITH FLOOR { > O d N O OTHFLOOR i StHFLOOR 7TH FLOOR 0TH FLOOR , Check one: CerlHlcale Instaping Company Name V z 14?�,s Cy, is/%� • Corp. Address Q d. Partnership L Firm/Co. Business Telephone Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE: Check one have a current liability Insurance policy or its substantial equivalent. Yes C9" No O If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy VA Other type of IndamnRy D Bond Lj 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: %nature of Owner or Owner's Agent Owner O Agent O I=hereby certify that all of the details and Information I have submitted(or entered)M above application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance with all pertinent provls{ons of the Massachusetts State(]as Code and Chapter 142 of the General Laws• Tr Ucense: mber Title fltler We o ansa um er or as er ,� ster nse Number: . Master APPFIOWD(OFFICE USE ONLY) BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES -- PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING' - / 1 NAME d TYPE OF BUILDING LOCATION OF BUILDING ' PLUM BER OR GASFITTER -•-- LIG NO. .. . . • I PERMIT GRANTED DATE 19 i GASINSPECTOR