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HomeMy WebLinkAboutMiscellaneous - 7 COLBY COURT 4/30/2018 I CJ 0 ts' n 0 n rt I Date....Az 1. .......... pF NORT�y,� TOWN OF NORTH ANDOVER Ots:' -`: ••• Opp PERMIT FOR PLUMBING gs'�CHUS� I This certifies that...... ........ ...... 1..----r'Qct .!' .. ........................................... has permission to perform................. .. nn:: . :. ..:....................................... plumbing in the buildings ofJuu1 at........t........ d.'L��.... .................................................. North Andover, Mass. Fee. ........Lic. No. ..�. ............................................................................:.... PLUMBING INSPECTOR Check# �2�- i I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK l CITY _ I. MA DATE [ PERMIT# ` JOBSITE ADDRESS LL 6 j OWN R'S NAME GG � .�/ '_ __ t POWNER ADDRESS UtAje42 4--eTEL _ FAXi _ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: M RENOVATION: REPLACEMENT: �!]�" PLANS SUBMITTED: YES Q N0 2-- I FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13j 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM ,J=====—J .._ ! __.__(= ___1 ._..._ C _( . DEDICATED GAS/OIL/SAND SYSTEM I —jI DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM ( _ { I _( j _ --j= --.-. i DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSERl FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWERS TALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION -_,I WATER HEATER ALL TYPES WATER PIPING 6THER 1 .....___( I -._-__l .__...._I __.77.=.r AJI INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES TO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY El BOND M OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT Id SIGNATURE OF OWNER OR AGENT I I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and acc o t e best of y kno Ladge and that all plumbing work and installations performed under the permit issued for this application will be in complia a ent rov on Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME .IiLt ��,_ _ __ LICENSE# i SIGNATURE �, / i MP� JP Ell CORPORATION F. #PARTNERSHIP 0# [LLC i COMPANY NAME � � �i ADDRESS — � I CITY _ STATE ZIP TEL [ I FAX CELL EMAIL - ------- -- - _..__ --- - --- _.............. i I i ^ i The Commonwealth of Massachusetts Department of IndustrialAceldents 1 Congress Street,Suite 100 I =: F Boston,MA 02114-2017 b ' r www mass.gov/die T�d'Ihl 5J'y Workers,Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORI'1;:'Y. hcantln£ormation .,Please Print Lesribly AI Name(Business/Orgabizatiott fndividual): Address: I City/State/Zip: Phone#: Are you an employer?Checictlie appropriate box: Type oftproject(vequired): i I 1.❑I am a employer with employees(frill and/or part-time).' 7. ElNdxi''d611str66ti0n I 2.❑I am a sole proprietor or partnership and have no employees Working for me in 8. Remo del�rig any capacity.[No workers'comp.insurance required.] 9, Demolition I � I 3.Q I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10E]Building addition I 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ❑ 11. Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole 4 t,. proprietors with no employees. 12.« Plumbing repairs Or additions 5.❑I am a general contracto'and I have hired the sub-contractors listed on the attached sheet. 13.,0 Rb6f repairs These sub-contractors have employees and have workers'comp.insurance., 14.[]Other--- 6. ther 6.Q We are a corporation and its,officers have exercised their right of exemption per MGL c. I 152,§l(4),andive have no employees. . [No workers'comp.insurance required.] I . I *Any applicant that checks boic#1,must also SII out the section below showing their workers'compensation policy information. 1 Homeowners who submit.thi affidavit indicating they are doing all work and then hire outside contractors must submit a new afdidavit indicating such. i "` Y attached an additional sheet showing the name of the sub-contractors and state whether or not those entities•have ,Contractors that check' box mus employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. X am an employer that is providing workers'compensation insurance for~my eINT ees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: xpirati a I Job Site Address: ity/State/Z' . i Attach a copy of the workers, compensation policy declaration page(s wing t o 'cy number and expiration.date). � e to secure coverage as requited under MGL e.152,§25A is a criminal violation punishable by a fine up to$1,500-00 0 00 a Fpm and a fine of u to $ , • and/or one-year'imprisonment,as well as civil penalties in the form of a STOP WORK ORDER p day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance II coverage verification. p p fP 1 y X do hereby certify under thepains and enalties o er ur that the information provided above is true and correct. . ISi Date:ature: i I Phone#: I Official use only. Do not write in this area,to he completed by city or town official. i I City or Town: Permit/License# i I Issuing Authorrity(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector I 6.Other Phone#• Contact Person: I I I DateAA.A..z: 5..................... Of r►ORTN TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION CMU5� This certifies that ....Ae...�;:r.�................................................................................. has permission for gas installation ....�, d-..0 R.......�n�-�t........................... in the buildint s of.....WI-0.0A...!l..��.�..-.`..�. ............................. at..�.....Ce.... .. . :.<............................................ North Andover, Mass. Fee.2d...`..... Lic.. No. �. 5 ... ..................................................................... GASINSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE PERMIT# i In A JOBSITE ADDRESS OW ER'S NAME OWNER ADDRESS TE 'Y'YPE OR EDUCATIONAL OCCUPANCYTYPE COMMERCIAL PST I ® RESIDENTIAL PRINT NEW:El RENOVATION:E] REPLACEMENT: PLANS SUBMITTED: YES NOQ�-- APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 1311 14 BOILER BOOSTER 1 CONVERSION BURNER -- - -- A I --- COOK STOVE _ DIRECT VENT HEATER _._. ' DRYER FIREPLACE _ FRYOLATOR ! I FURNACE - - GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS -- MAKEUP AIR UNIT "— I OVEN POOL HEATER ROOM/SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER _ »I UNVENTED ROOM HEATERS WATER HEATER OTHER ......._---....—.. . .......................................... -- r� - INSURANCE COVERAGE I I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW j 1 LIABILITY INSURANCE POLICY E2--� OTHER TYPE INDEMNITY ® BOND 1 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. I 1 I. CHECK ONE ONLY: OWNER 0 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 ac rate a est of my kno I g and that all plumbing work and installations performed under the permit issued for this application will be in compliance h al erti n vi n e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME LICENSE# !'— SIGNATURE 4 MP MGF 0 JP ® JGF 0 LPGI QJ CORPORATION�}# PARTNERSHIP®#=LLC D# COMPANY NAME: 1� "u� ADDRESS CITY ��� � STATE ZIP / TEL FAX� CELL_� EMAIL _T" _ _ I i � I i i i The Commonwealth of Massachusetts ` Department ofIndustrial Accidents X Congress Street,Suite 100 Boston,MA 02114-2017 y www.mass.gov/dia ers,Compensation insurance Work Affidavit:Builders/Contractors/EleetriciansfPlWbers. TO BE FILED WITH THE PERMITTING AUTHORITX • . ,Please Paint Legibly Ap•hcant Information Name(Business/Oigahization/Individual): i Address: i City/State/Zip: Phony Are you an employer?Check the appropriate box: Type of project(�ecliiired): ! 1.Q I am a employer with employees(full and/or part-time).' 7. ❑NeVV'donstruCtion � 2.❑I am a sole proprietor or partnership and have no employees working forme in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.0 lam a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition P 4.❑I am a homeowner and will be hiring contractors to conduct all work ce orY roPerty. I will 11.0 1? Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole ... I proprietors with no enployaes. 12.Q Ptulribing repairs or additions I 5.❑T am a general contractor ted on the attached sheet.and T have hired the sub-contractors lis 13.[�Rbof repairs These sub-contractriirs have employees and have workers'comp.insurance.t 14.0 Other ' 6.Q We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and We have no employees.[No workers'comp.insurance required.] *Any applicant that checks,bbx#1 must also fill out the section below showing their workers'compensation policy information. 1 Homeowners who sub 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 q not(hose entities have employees. If the sub conixactors have employees,they must provide their workers'comp.policy number. ' employer---7---- isprovidingworkersI compensation insurancefor my employees. Below is thepolicy andjob site an Iam information. I Insurance Company Name: Expiration Date-- Policy#or Self-ins.Lie.#: I City/State/Zip: Job Site Address: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by a falb 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 f this statement may be forwarded to the Office of Investigations of the DIA for insurance day against the violator.A copy o I coverage verification. ' Ido Hereby certify under tlaepains andpenalties ofperjury that the information provided above is true and correct. I Date: Signature: Phone#: I Official use only. Do not write in this area,to be completed by city or town official i i City or Town: Permit/License# i Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing inspector i I 6.Other i Phone#• Contact Person- ' i i Ii I II I i • I i a COMMONEALTH OF MA '.°. " HUSET rS I'LUMBEER '>>R'ND GAS: a:TT. RS<E ISSU, . ..:::THE FOL' OW 1 1:.r&iJSED AS A MASTERS ' C HGLMES 6 RUTH cIR f.. uf ;: :;..< >'<<{1A 01832-S 42434 I I I . I I 1•VCOMMONW ALTH OF MA5SACHUS TTS... I • • - - • • I BOARD'QF ;. I ?LLIMB ER:`'JAWD CIES 3H FO__o�ll�£ LICENSE; ,r--w. I L I ct-651 0 4S A JOURNEYMAN R;,.LLIMB AI?AA C HOLM-s 5�. Iz 6 RUTH ;. CLE :::...::. :.. ..: HIi..L A 0183•_ ,> I I�ltlai�6`]aRIL4lagagl�l:L� •i �_ � I ��rSar I I I I I I � I I ( I e I I I I I I I I .............. 1 4u o�,".fpr"�tia TOWN OF NORTH ANDOVER * PERMIT FOR PLUMBING .`This certifies that...........:........... `, -j,,%has permission to perform......... ...........,...................................... ..... t �..... plumbing 'n t e building of......� ............. .`...... ...."."................................ o°Q�')............. North Andover, Mass. at.. ....... °.J.... ....... - ..:...............C�.......... I � PLUMBING INSPECTOR Check# 3-72-7— i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK W -It A CITY U I MA DATE ll / J PERMIT# JOBSITE ADDRESS CAN_ NAME- POWNER ADDRESS /Z r, OP . TEL=___ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: Q RENOVATION:Q REPLACEMENT:®'ter PLANS SUBMITTED: YI S Q NO FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 1 9 10 11 i2 13 14 BATHTUB _I _ I ( _._ E [ € ____.... I _ I ___A-I CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I 1 I _j DISHWASHER DRINKING FOUNTAIN I ) ------ ------- LW JE_ FOOD DISPOSER _..i ._._.._f __._.! ___._._( __.__) I _ ___ -__.__._! .._...____[ _-.__I .._._._I . ..! ._i_-! I 1 FLOOR/AREA DRAIN I ____.._! ____ ___. _.__ I _____ ____._! -_.__.I ____ ._.____ INTERCEPTOR(INTERIOR) I J __._ __..._.r. ____ I I __.__I _._� ___._i __ i _.___ I ,_.._.! I _I __J KITCHEN SINK I __.I _ _! -----A LAVATORY _i -_..._.-.._� ROOF DRAIN I __._! _____I .__I SHOWER STALL _I __._._! ____( SERVICE/MOP SINK TOILET URINAL _.._.__ f .__.�! ._.� WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WAT,' PIPING OTHER 1 -_----i INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ,_ � IF YOU CHECKED YES PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 2--- OTHER TYPE OF INDEMNITY QI 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 Q AGENT 10 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 ac to the best'of my_k ledge and that all plumbing work and installations performed under the permit issued for this application will be in compli c ith ali P rtinent 'vi ' oft e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME11 LICENSE# SIONATURE m 9/1P QI CORPORATION Q# j PARTNERSHIP Q# s LLC[� COMPANY NAME� � }� ; ADDRESS CITY[ �Q^� � —STATE ;C-- Ce I ZIP TEL FAX CELLF_ .G EMAIL -- --- - -- i i The Commonwealth of Massachusetts I Department of IndustrialAccidefits M _ 1 Congress Street,Suite 100 y Boston,MA.02114-2017 " • _, �` www mass.gov/dia Workers,Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMTTING AUTHORgY_ please Paint Le 'bl A ' licantlnformation Name(Business/orgariization/lndividual): Address: 1rr Phone#: � 3 /� `I . • . . City/State/Zip: Are you an employer?Cl,ecictlie appropriate box: Type of project(required); i em to ees full and/or part-time).* 1. New dOnstraction 1.[]I am a/em&y r with p y ( p 2.®'Iain a" sole proprietor or partnership and have no employees working for me in 8. �Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.❑I am a homeowner doing all work myseltr[No workers'comp.insurance required.]t 10 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.F1 I am a general contr4cto r and I have hired the sub-contractors listed on the attached sheet 13 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 1<1 Other 6.Q We are a corporatiori and its,officers have exercised their right of exemption per MGL c- 152,§1(4),and We have no empldyees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: affidavit I Homeowners who submit-this affidavit a new t indicating they are doing all work and the e of the hire sub-contride actors and state wrs must hether or not thoseent tieshave�� tContractors that check flus Box must attached an additional sheet showing the nam employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. X am an employer that is providing workers'compensation insurance for my employees. Below is the policy and)0h site information. , D Insurance Company Name Ar I c-( Expiration Date: Policy#or Self-ins.Lic.#: Job Site Address: City/State/Zip: 1 Attach a copy of the vvoxkexe compeUg;a ti policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL a.152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the to the ffie of a STOP WORK Investigations of the DIA for insurancER and a fine of up to e a day against the violator.A copy of this statement may be forwarded coverage verification. X do hereby certify u r tIa ns and penalties ofpe ry/h he information provided abo a is ue and correct. Date: Si ature: Phone#: 4-37 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): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#• Contact Person: i Date............ �....�. ................... 0 NORTIy�� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION s`SACHU � Q This dertifies that .......:................... ........................................ ......................... has permission for gas installati n .... z .......... . r in the buildings of.......... ?.i .........' --.. -:... .`.........-:....'......................... at......... ..... . ..1. .. i .'..................................., North Andover, Mass. FeeG''....... Lic. No. �. .. ...... ..................................................................... GASINSPECTOR 2—2— Check# � .I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GA9 FITTING WORK CITY r7Ztf�( f,C'�J �.�-cr � MA DATE 3 PERMIT# DZ1� �--- "- JOBSITE ADDRESS d _ � G - OW ER'S NAME GOWNER ADDRESS �_ - i �e TE FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:E-I RENOVATION:El REPLACEMENT:B-' PLANS SUBMITTED: YES NO APPLIANCES 7 FLOORS--+ BSM 1 2 3 4 5 6 7 8 9 10 jj11 12 13 14 BOILER - 1 BOOSTER CONVERSION BURNER COOK STOVE - . _ __ __--.._ DIRECT VENT HEATER DRYER ' - FIREPLACE FRYOLATOR FURNACE r GENERATOR , GRILLE INFRARED HEATER - .. - LABORATORY COCKSr - I _ ( MAKEUP AIR UNIT OVEN �_ l POOL HEATER ROOM/SPACE HEATER ROOFTOP UNIT -_ TEST -- (�- ---! - -- -_, _ - - I I 1 UNIT HEATER i UNVENTED ROOM HEATER WATER HEATER OTHER .................._--.—....... . .......................................... - - — - � - INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES BITO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY � OTHER TYPE INDEMNITY ® BOND F] 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 AGENT SIGNATURE OF OWNER OR AGENT I 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate a est of my kn ge and that all plumbing work and installations performed under the permit issued for this application will be in compliaince>Ah Per pr ' io the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME ®S LICENSE# SIGNATURE MP GF Ell JP JGF LPGI F--I CORPORATION©# PARTNERSHIP[J#=LLC E]# COMPANY NAME: _L ADDRESS CITY i _ ^� STATE E? ZIPTEL FAX CELLIIEMAIL _ - I 1 � I ,.The Commonwealth of Massachusetts - Department of IndustrialAceldents - 1 Congress Street,Suite 100 d Boston,MA.02114-2017 www mass.gov/dia Wolkers'Compensation Insurance Affidavit-Builders/Contractors/electricians/Plumbers. TO BE PILED WITH THE PERMITTING AUTHORTJ<''Y. ApOcant Information Please Print Legibly Name(Business/Oigabizationftdividual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(Tecluired): 1.❑I am a employer with employees(hill and/or part time). 7• [❑Nevi'construction 2.Q I am a sole proprietor or partnership and have no employees working forme in 8• F1 Remo del!Ag any capacity.[No workers'comp.insurance required] 3.E]I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. F1 Demolition 10 FJ Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11•❑Electricalrepairs o:r additions proprietors with no employees. 12Q:Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13%Q Roof repa'ir6 These sub-contractors have employees and have workers'comp.insurance.t 6.Q We are a corporation and its,officers have exercised their right of exemption per MGL c. 14.[]Other 152,§1(4),and W, have no employees:[No workers'comp.insurance required.] *Any applicant that check's poic#1_idust also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such n,;• tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and state whether c r not those entities,have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. -Tam an employer that is providing workers'compensation insurance for my employees. .8elow is the policy and job site information. 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 requited under MGL c.152,§25A is a criminal violation punishable by a f b 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: I I 1 i 1 e I I I I '1 I _ I I I i OMMONWEALTH OFHSETT • . . • PLUMBC GA&FITT, f�S;;> I ssu:E :.:THE FOI L1;�.CNSE>D NSE AS A MASTER P'�l�M »r A€7'A`f C HG LME S f '4 v 6 RUT ., H CIR � Ef. 0, Z ?lAERH l . . ; 1a 01832-`,fin 74243 l I �d�:1~OMMONWEALTH OF MASSAOHUS Lol k • mu.,18IJ Eel BOARD Of , ?LLiMBEi?5";.> i 'G GA Sf::::I TT :RS°j H_ F 0__OBJ(t� LIC E N S E;' L l t EhISE J A; A J.OURNE i MAN«,!r'.L'UM R . C H0LAt� P"a 6 RIJTH"*':`C I'*RCLE IJ 11NERH ILL., 01832-8,.ft,0 4 ?I Ill.lab'1a��111P11:1aa�:/JI:I'\�G7�Ip, I � I i I I i 1 I I I I c I I I I • I 1 I 9 Information and I nstrnctions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an erycployee 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 receivef6r 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 b6 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 prod-aced-acceptable evidence of compliance with the insurance coverage requhred." 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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. .Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial=Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation.policy,please call the Department at the number listed below. Self-insured companies should enter their self insurance license number on the appropriate line. - City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on.file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and flax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass-gov/dia ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No 5 &-A�§ THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES A 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 ofthe foregoing engaged in a joint enferpri'se,and including the legal representatives of a deceased employer,or the receivef6k trusted 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 applicazitwho has'not produced-acceptable evidence of compliance with the insurance coverage xequired." 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. I£an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial=Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies shod enter their self-insura'nc'e 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 1.00 Boston,MA 02114-2017 Tel. #617-727-4900 ext.7406 or 1-877-MASSAFE Fax#61.7-727-7749 Revised 02-23-15 wwwmass.gov/dia ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY 02 FIN INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES Officeu 0 'se nl u11e 00MR10111ue01tli of flitt0oddlunflo Permit No. 14 Eepartment of flublir Ohfetq Occupancy A Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date I Ww or Town of-Ao RIH ANDOVER To the Inspector of Wires: The uderslgned applies for it permit to erfor the electrical work described below. Location (Street & Number) Owner or Tenant (�a Owner's Address (Jf I Is this permit in conjunction with building permit: Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps _J Volts Overhead ❑ Undgrnd ❑ No. of Meters New Service Amps -Volts Overhead ❑ Undgrnd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work �/e - r No. of Lighting OutletsTotal 9 9 FNo. 01t Tubs No. of ltansformers KVA No, of Lighting Fixtures g Pool Above In i grnd. ❑ grnd. ❑ Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners Battery Units No. of Switch Outlets, No. of Gas Burners FIRE ALARMS No. of Zones No. of Flanges Total No. of Detection and 9 No. of Air Cond. I tons Initiating Devices { No. of Disposals No.of Heat Total Total Pumps Tons KW No. of Sounding Devices No. of Self Contained i No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices No. of Dryers Heating Devices KW LocalMunicipal ❑ ❑Other, Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage 1Lbs No. of Motors Total HP T OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws have a current Liability Insurance Polley Including Completed Operations Coverage or Its substantial Equivelent. YES C NO I have submitted valid proof of same to the Office. YES -- NO G If you avyyychecked YES. please Indicate the type of coverage by checking the appropriate box. /� � ©� INSURANCE 4 BOND C OTHER G (Please Specify) Estimated Value of Electrical Work! (Expiration Date) Work to Siert el Inspection Date Requested: Rough Final Signed under the nallles of per FIRM NAME__ L{censee z; G LIC. NO. Signature UC. NO.�fJ-S.�("�.7 / / Bus. Tel. No. Address �� _ �ey All Tel. No. OWNER'S INSURANCE WAIVER: i arm aware that the Licensee does not have the insurance coverage or its substantial equivalent es re- quired by Massachusetts General Laws. and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE i (Signature of Owner or Agent) X-6565 Date.....!.. ..1.. ..�1. f poRTM 1 }�;.,;�``°:••"�a� TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACMUS� L / This certifies that ... �.`....`? . �r has permission to perform .........�1(... QQ `P Cf./��1 ........................................ wiring in the building of... cl c1 r �t`/gip..........(,/UM(° 5 �v �`� T. .mass at.............. ................. .............. ... North Andovveer� Fee e- .S',�u. Lic.No. ............. ......... !.�.,- ....... ./,lT... ...r�' ELECTRICALINSPECTGR Check # ��°` 4 ., 56 t VII-MI(VED) 0 ,31 RICE & HOU UHP EEHHH, INC. (W)19MMIN I?. m aepofteflt of llublte 'Mill Occupancy 6 Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3190 peeve Worth) 9 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WOR'K All work to be performed In;accorda4ce with the Massachuseils Electfleal Code. 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ILL INFORMATION) bate 0IYi or lbwn o1 WR .. To the Inspector of Wlrewl The udersl ned applies for ors erm RP p I t erfor the oleclrlCal work described below. I Location (Street dr Numb I er) Owner or Tenant t�a Owner's Address Is this permit In conjunction will bulldlrtq permit: Yee No [1 (Chock Appropriate Box) i I purpose of Building Utility Authorizatlon No. I Existing Service Amps--_ / Vofls Overhead ❑ Undgrnd ❑ No, of Meters ew, Service Amps`/ Volla Overhead Undprnd ❑ IJa. of Meters f Number of Feeders and Ampaclly Location and NaWrs f Proposed Electrical Work No.of Llgming outlets No.of Het Tubs No.of Tlansformere� Total KVA NO. Of Lighting Rlelurss S"If"Ming fool Ahoy* In. grn0. ❑ grnd. ❑ Generators KVA No, of Recs otic outlets No- of Emergency Lighting No_of Oil Burners 96t19ry Units P1o,of Switch Outlets � No.of Oas Burners FIRE ALARMS No.of Zana � I + No.of nanoss No.of Alf Cond. Total Ne.or Detection end tons Initialing Devices No.of Disposal. No.01 Neal Total Total Pumps Tone KW No. of 5ounding Devices No.at OiohwashareNo.of Sell Contained t7pacefMea Haannp KW No. Devices N0,of Dryers Nesting Devkae I(W LocalMunlclpsl ❑Other 0 Connection r No.of Water Hitalera KW Signe �1'JW Low Vothga Wiring No.Hydro Massage Nba No.al unlorsrtl HP iOTHER_ INSUPIANCQ COVEnAGE;Pursuent to the ravuirements of Most<aohusens general Laws I I have a current Liability insurance policy Including Completed Operations Cavorage of III subelanlitll equivalent, YES C NO C I have Oubchecking 11110 a prod proof or same 10 ihs Offies. YES = NO G 11 you hnve eheclkad VES, pleee9 Indicate the type of coverage ay checking the appropriate box. INSURANCE C @OND C OTHER G (Please Spacify) fsltmrred value o1 Electrical Work! (I:xpuatlon Date( Work 10 61stt inspection Data nFlauested: Rough Flnnl Slgnnd under the Penalties of perluty; F1bM NAME Lksitsea LIC.NO. Slonaturs C.NO. Address eve.Tet.No. i OWNER'S IN5URAHCE wA1V All.1%].Ne. > R:1 am swsne Ihat the Licensee does not have the insurance covwrnge or Its subsianttai equivalent s r quires by Mait.achuseas Oaneral UW1, arta That my algnatm (Ptesee check onel e on thispsrmq application wetvae this requlgntenl.Owner Talaphons No. PERMIT FEE i t� (5�pnntute of O+rner er Agent) ►+lSes I 3745 � �... .. Date.... � NORTH 1 AL TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSAcmUS� This certifies that .... ..........`�U. `..!. .( fit k ... , rc.....- y ..... ..... has permission to perform P .`�!. c` ,/r wiring in the building of W U........... ...........11ll °S / at../—..�.... ll ...C.. ............... ............... orth Andover,Mass. Fee. (,),O... Licc.NoI'f, (e) .......... .. ? - INSPECTO ` 1pV J V Check # I I I s• Contmonwea� o� a��cu/ettaelEl Official Use Only 2c� �] Permit No. 9parintenl ol.tirs�iruicea BOARD OF FiRE PREVENTIONREGULATIONS Occupancy and Fee Checked j Rev: i 1/99j (leave blank) j APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 1MEC),527 CbiR 12.00 (PLEASE Pi&T ININK OR TYPE:ILL hVFOX-V1,-ITI0N) Date: City or Town of: stn �Uc.ez To th.Inspectorof wires,- 13y this application the undersigned gives notice ofhts or her intention to perform the electrical work described below. Location(Street & Number) Owner or Tenant G OdCt 44mr S —__>�1 t7udr�`c1 t-c. 1`�gvI S Telephone No. p Owner's Address Is this permit in conlumctiom with a buildin-pernnt? yes ❑ No ,t �;t (Check Appropriate Box) It 1'urliosc of Ituilding {StC�-CUI�t' Utility Authorization No. ' i o. Existing Service _W amps /24_L0?r leo 1'olts Overhead ❑ Umd rd g tit No:.of illeters 1 I :'Oils V cr,'icad�j. N Undard ❑ b °:of Meters. , Number of Feeders and Ampacily t Location and Nature of Proposed Electrical Work: YJ�V 14 if >t Completion orth- oll nine table may be waived b the bis`cctor o/tVlres No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Falls N o.° oral Transformers KYA No,of Lighting Outlets No.of blot Tubs Generators KVA No.of Lighting Fixtures Sirimniing Pool Above ❑ 1n- ❑ N10.o mergency tg i t»g I rtid. rad. Batte Units No.of Receptacle Outlets No.of Oil Burners 7FIRIEI ARilIS iYo.o{ZAonesiso.of Switches No.of Gas Burners Detectaoil and Initiating Devices } No. of Ranges No.of Air Cond..Total Tons Ifo,of Alerting Devices I No.of Waste Disposers Hcat Puni:�nff= Yo.oSel- ontaincd TotalDetection/Alerting Devices No.of Dishwashers I iv ashers Space/Area Heating KtiVocal �' wucipa Lil ❑ Connection ❑ Other No.of Dryers Heafing Appliances KW Security Systems: � ' No.of Devices or E uivalent t o.of Water No.of No.of Heaters KW Data Wiring i Siniis Ballasts No.of Devices or E uivalent No.H�•droinassage Bathtubs 1V o.of Motors TO,%!HP I elecomnlunica(ions W, ring- OTHE R: 'firing- OTHER• No.of Devices or E uivalent Attach additional detail if desired,or as required by the Inspector of Wires. INSURAi`i CE COV E1tAGE: 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. Tile undersigned certifies that such coverage is in force,and has exhibited proof of same to theer p mit issuing office. CHECK ONE: INSURANCE BOND ❑ O"I'I-IER ❑ (Specify:)__ Ltia�t r'TY ,j" d 2r I Estimated Value of Electrical Work. (When required by municipal policy.) .. (Expiration Date) i Wort:to Start: 7, Inspectioiu to be requested in accordance with MEC Rule 10,and upon completion. 1 f cern ruulcr the paras acrd peliallics of perjury;that the informaiion on this application is trite and complete: II I'' I FlWil NAME:- a 2t LIC.1\O.• Licensee: c I �� AA ' '�cC E Signatur �(�' LIC.NO.: _,IF- (fjalJplicable,er er "crCarnt"in die license• 'umber 1��`/� , Bus.Tel.No - O�VNER'S INSUIZ�NCL\VAIVEI : I atm aware that the Licensee does not Have the abilityAlt.Tel.No.: I insurance I re •, ace co�•erage norrnatt �uitce!by law. l3� my si�naturc belo��,i hereby��•aive lliis requircincut. I am the(check one ❑ ,y I Owner/Abeml )❑owner owner's aeent: I I Signature 'Telephone No. Pj,"RMIT FEE; S ?.,dO,OtJ I i NORTH ANDOVER HEALTH DEPARTMENT 120 Main Street • North Andover, MA 01845 Telephone (508) 682-6483, Ext. 32 Housing Inspection Report COMPLAINT # Wr COMPLAINANT ADDRESS OF PREMISES OCCUPANT h1 i OWNER WOW II,A�nnnnVVI MI-NVIAKILI OWNER'S ADDRESS d ` DATE OF INSPECTION HOUR I ROOMS/VIOLATION: R t VV\RM ilo ui l I I I INSPECTOR \ rm#HIR-1 Action Press 6857000 0 U A O U I i