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HomeMy WebLinkAboutMiscellaneous - 70 SALEM STREET 4/30/2018 (2)REBAR 4 '� SET 125.00' — — REBAR SET � I I � I _ 30' REAR SETBACK _ 3 IN �I 70 SALEM STREET I �- MAP 96 BLOCK 41 LOT 0 I o VI AREA = 25,000 S.F. I U) of 0.574 ACRES \ N IQ I� N/F IJ I PATENAUDE, THOMAS w PATENAUDE, LIANNE o I 100 SALEM STREET N NORTH ANDOVER, MA 01845 I �y IoMAP 96 BLOCK 57 LOT 0 2 .8 ffN SK 10707 PG 349 b I(� N I GARAGE COVERED 21.4BULKHEAD OF CEM. CONC. PAD �O� TIMOTHY 9yc 00 J. �+ I 1 STY. WOOFRAME g WtNINGS > N No. 45099 I .O I r z 3 CONC. F _30' FRONT SETBACK 5 o> 0PAD > t�Z 8 ; DMH' REBAR FOUND v1ENT CDM�ALEM NOTE: POST & RAIL FENCE STREET THIS PROPERTY IS LOCATED IN THE R-3 ZONING DISTRICT BIT. CONC. SLK ESSEX COUNTY IRON PIPE STONE BOUND FOUND FOUND 696.86' ?O1 `E.C.S.B. EDGE OF PAVEMENT GRAPHIC SCALE 40 0 20 40 80 ( IN FEET ) 1 inch = 30 ft. AS -BUILT PLAN 70 SALEM STREET TTI ENVIRONMENTAL INC. MARCH 12, 205 ENGINEERING DIVISION PREPARED FOR: 100 Burtt Road, Suite 120 93 Stiles Road, Suite 201 BART F. WEITZ VF001 Andover, MA 01810 Salem, NH 03079 70 SALEM STREET (p) 978-749.9929 (p) 603-2261950 NORTH ANDOVER, MA 01845 (0978-7499920 www.ttienv.com (06°3-226-3235 PROJ #15-416 Date............................................. TOWN OF NORTH ANDOVER. PERMIT FOR WIRING This certifies that .....,,�:... .......... S. .................. ...` ......................................................................... has permission to perform ..... E...... ` " ........................................................... wiring in the building of...,,.�,4 , ,,,.,,,.,A -e T �` ................................................................... at .... ZV...... . fes"" .,.... , North Andover, Mass. ................................./,r fFee . .............. Lic. No.%.93r-O? .....................r.k». ............... t LECTRICAL INSPECTOR% Check # �3 SL V 11974 Commonwealth of Massachusetts Official U5e°nly Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLWE PRDVT.TN TNK OR YYPE ALI 1NF08MATIOA9 Date:_- M) — 3C Z 3 City or Town of:To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) cl Owner or Tenant _�4-- Al f Telephone No. Owner's Address w Is this permit in conjunction with a building permit? Yes No ❑ Building Permit # Purpose of Building Utility Authorization No. Existing Service Amps / • Volts New Service Amps ! Volts Number of Feeders and Ampacity Location and Nature of Proposed Overhead ❑ Overhead ❑ Undgrd ❑ Undgrd ❑ No. of Meters No. of Meters z Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans r ° ata Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Li Fixtures �� Swimming Pool Above ❑ n- ❑ � d. rnd. o. o Units I - Lig g Bette Units No. of Receptacle -Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners _ _ n and o. o Initiatin Devicescti No. of Ranges No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers Heat PumpNumber umer Totals: '.- ­.. ons ._ '._....._.... o. o Self -Contained Detection/Alert! Devices No. of Dishwashers Space/Area Heating KW Local [].Mnnlechal o ❑ Uther No. of Dryers �7' Heating Appliances Kyr ecurity Systems: No. of Devices or E uivalent No. of Water, Heaters o. o o. a signs Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP a eco of uni cgs Equi s n lent OTHER: Gfjv �' ti 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 coveragejsinforce, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:) - 0,—/y Estimated Value of Electrical Work: (Expiration Date) (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties of perjury, that the information on this application is true and complete. Current Insurance certificate must be on file in our a rce and affldavit must also be filled out with each application. FIRM NAME: / le %� LIC. NO.: y,F3 Licensee: z LS_ Signature 4 0l, o4Ic, LIC. NO.: -- (If applicable, en r "exempt" in the icense number line.) r us. Tel. No., — Address: - �'• Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Li�ee 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) 0 owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. ELECTRICAL PEM* T NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL 1. ROUGH INSPECTION: Passed [) Faded — [ ) Re -inspection required ($50.00),- Inspectors' $50.00)-Inspectors' comments: (Inspectors' Signature - no initials) Date 2. FINAL INSPECTION:, Passed — [ I . Failed — [ Re -inspection required ($50.00) - [ j Inspectors' comments: f%% 2- y (Inspectors' Signature - no in als) Date 3. UNDER GROUND INSPECTION: Passed — [ : j Failed _ [ j Re -inspection req uired ($50.00) -. ( j Inspectors' comments: ., (Inspectbrs' Signature - no initials) Date u 5. INSPECTION. OTHER: • Passed — ( ) Failed — ( j Re—inspection required ($50.00) - (j }Inspectors' comments: (Inspectors' Signature - no initials) Date DOOR TAGS ARE TO BE FILLED "OUT AND LEFT ON. SITE IF THE AREA TO BE IN IS NOT ACCESSIBLE AND A RE -INSPECTION .OF _$50.00 IS TO BE CHARGED. Date TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that. �CA N. q,, e ckl has permission to perform. 4>z . t�M .............. !!.ffP7— �. wiring in the building of .V"..j.............................. . ��''!`'? �.!!�.� �:T .... , No h ndover, Mass. Fee...... Lic. No. �.' 1.� U...'/...... ELECTRICAL INSPECTOR r Check #� 11262 C Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No. Z 2_ 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: City or Town of- By fBy this application the undersi Location (Street & Number) Owner or Tenant A6 [ ANDOVER To the Inspector of Wires: notice of his or her intention to perform the electrical work described below. Telephone No. Owner's Address M 24 UA,Sf Is this permit in conjunction with a buildin permit? Ves a No ❑ (Check Appropriate Box) Purpose of Buildings C.�� P t'S Q e Utility Authorization No. Existing Service Amps / olts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: V Completion ofthe followine table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans r o ata Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above d. E] In- ❑ Swimming Pool nd. o. o Units tng Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners o. of Detection an Initiating Devices No. of Ranges No. of Air Cond. Toota No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number ons_. _ _ _.. o. oSelf-Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ untc'pa ❑ Other Connection No. of Dryers Heating Appliances KW ecNo. ystems: No. of Devices or Equivalent No. of aterKW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP elecommun ca ons wirnq: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: �2 ac>0 . t.g (When required by municipal policy.) Work to Start: 11-2 8 —12 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 ❑ BOND ❑ OTHER ❑ (Specify:) I cert, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.._J Licensee: ( r,- cG o Signature �: LIC. NO.:��� (lfapplicabl , to exempt" in the�liceig Cber ine.) \ Bus. Tel. No.: Address: rpssp c c"i H l f -I r e. 't. 1 s %Opni Alt. Tel. No.: *Per M.G.L c. 147, s. 57-6 1, security work requires Department of Public Sa ty "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required bylaw. B myF'gnMatur.below, i hereby waive this requirement. I am the (check one El owner El owner's agent. Owner/Agent U _.2 Signature Telephone Na. PERMIT FEE: $ /Zi? eQLGi�a��� y rS yo, I SIV" 5�-f' 1k.. .-Ar's 10773 Datecl'.0'.14. ....... TOWN OF NORTH ANDOVER PERMIT FOR -PLUMBING s . L .. This certifies that.................................. ............................................................... C V-ftjQW-- SVV\. kW�o has pernussion to perfonn ............................................................................................. plumbing in the buildings of... at T( ........................................................................ North Andover, Mass. Fee ... -7. .... cyu .... Lic. No. �A.M,5. ............................................................ .... ..... I . ........ .... ....... PLUMBING INSPECTOR Check # 11111111INTFW-W FW -W W F M-- FM- FP -W FN -K- F W-- FN -W FM- F W-- MFM FM- F M-- WWIR I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK P TYPE OR PRINT CLEARLY CITYL -XSL jj(K MA DATE PERMIT #- JOBSITE ADDRESS OWNER'S NAME Me OWNER ADDRESS L=fl-Q MTEL T I - 6 :�:O:j 0::�!�Ax I OCCUPANCY TYPE COMMERCIAL Ll EDUCATIONAL 0 RESIDENTIAI:O Z7 - NEW: N9 RENOVATION: El REPLACEMENT: Of PLANS SUBMITTED: YES Ell NO[y FIXTURES -1 FLOOR- BSM 1 2 3 4 5 6 1 7 8 9 10 1 11 12 13 14 BATHTUB I l F ---J L-=�j E::1 17 -j -1 --- -1 CROSS CONNECTION DEVICE and that all plumbing work and installations performed under the permit issued for this application will be in complianc t all Pertinent provision of the DEDICATED SPECIAL WASTE SYSTEM PLUMBER'S NAME AILICENSE # SIGNATURE MPi P n-1 CORPORATION [—Jl# PARTNERSHIPM-I# LLC 6=6 DEDICATED GASIOIL/SAND SYSTEM —A FAX CELL EMAIL [: < cA,, ry DEDICATED GREASE SYSTEM I DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I _.___._.1 _._._._f __— (_..__� .__. ------- i __I ___.1 .___ ' ._._____[ _ L _____._I I —( DISHWASHER DISHWASHER DRINKING FOUNTAIN f FOOD DISPOSER FLOOR/AREADRAIN J INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY -J ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET --n im A I 11111111INTFW-W FW -W W F M-- FM- FP -W FN -K- F W-- FN -W FM- F W-- MFM FM- F M-- WWIR I v OTHER --7?t 1l E– -1 = E L I f I 1 -.7 JF� INSURANCE COVERAGE: Heave 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 TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY)o OTHER TYPE OF INDEMNITY 01 BOND 0 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: OWNERE-11 AGENT In— 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 complianc t all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. zf�70 PLUMBER'S NAME AILICENSE # SIGNATURE MPi P n-1 CORPORATION [—Jl# PARTNERSHIPM-I# LLC 6=6 COMPANY NAME ADDRESS LAW M CITY 9'T q jftf��- !JSTATEFK-A-6�1 zip_]� 0 ty5jp I! TEL I FAX CELL EMAIL [: < cA,, ry v oR z fn ❑ W w W LL i s VA The Commonwealth of Massachusetts r Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): L,T f conw2V4 Address: �3c_ " City/State/Zip:1G rWjb d dL66 Phone #: aW W7— Z7Y Are you an employer? Check he appropriate box: 1. i a employer with 4• El am a general contractor and I employees (fall and/or part-time).* have hired the sub -contractors 2"VI am a sole proprietor or partner- listed on the attached sheet. ' Xhip and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 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 6ic doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an"additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy anti job site information. < Insurance Company Name:. Nat r+�� 1 najNA� Policy # or Self -ins. Lie. #: N N q f3 1,5 _Z_ Expiration Date: -7 S. Job Site Address: 7G City/State/Zip: WA (IDU P. M Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). O t�✓ 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 cert& under thepains and penalties of perjury that the information provided above is true and correct. Phone #: R7V Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # W7 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other - - - Contact Person: Phone Informati®n and Instruction's - 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 ofhire,- 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 liave been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit 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 permithicense 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 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 ofzndustrial .Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel # 617-727,4900 ext 406 or 1-877:MASSAFE Revised 5-26-05 Fax # 617-727;7749 www.rmss,govfdla 0145o-1 10287 Date ... � . .... ... ..T5 .......... TOWN OFNORTH ANDOVER PERMIT FOR PLUMBING This certifies, that.. Di.e.-PAL. �c...5........................... has permission to perform .............................................{� plumbing in the buildings of at ...................... , North Andover, Mass. Fee.?,6� ... Lic. No. ........... PLUMBING INSPECTOR Check # I�Jf1 ATER HEATER ALL TYPES !NATER PIPING INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ['NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [�r OTHER TYPE OF INDEMNITY 0 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 0 AGENT Ell 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 p6d qbcurate too tt�-"st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp' nc ith all Pe a provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I -DE fn) — GZ t IILICENSE SIGNATURE MP 2, JP Q CORPORATION 0#r��PARTNERSHIPO# ; LLC #( COMPANY NAME �?,�� it ADDRESS CITY �c f 'cM - STATE �i ZIP �'} { � j � TEL FAX CELL I EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY 1 1 _ j MA DATE PERMIT # JOBSITE ADDRESS %a S OWNER'S NAME POWNER ADDRESS c TEL 781 --u-6.rj FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: � RENOVATION: ® REPLACEMENT: ® PLANS SUBMITTED: YES ® N0O- FIXTURES -1 FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM Fj.---J. DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL __ I SERVICE / MOP SINK TOILET j _-- _ I f 11 11 11 J URINAL , \ ASHING MACHINE CONNECTION _TI ------ _ __.l ..___ __.___1 ___--- III 111 1 1 I I�Jf1 ATER HEATER ALL TYPES !NATER PIPING INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ['NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [�r OTHER TYPE OF INDEMNITY 0 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 0 AGENT Ell 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 p6d qbcurate too tt�-"st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp' nc ith all Pe a provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I -DE fn) — GZ t IILICENSE SIGNATURE MP 2, JP Q CORPORATION 0#r��PARTNERSHIPO# ; LLC #( COMPANY NAME �?,�� it ADDRESS CITY �c f 'cM - STATE �i ZIP �'} { � j � TEL FAX CELL I EMAIL W F °z- 0 H U W W n1 ' o ❑ z a ❑ a Z LU (n W p a w 5 n W coco w � w p o a w� �c 0 a a � w s w F- a H O F U a t7 a a O a Date.) ... k. .... 72.. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that Lf) -) a:.'..47 ............................. has permission for gas installation in the buildings f. ..................... . e at..71C ........ ....... .� ........r.......VI ............................................... . North Andover, Mass. FeeV . ....... . Lic. No. H.9 ....................................................... GASINSPECTOR Check # 1N \ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY �C 1 U��. _�. U _� MA DATE /f a * 13 - PERMIT # JOBSITE ADDRESS '7O S' OWNER'S NAME Lt'�I0- G~ OWNER ADDRESS s f�rwe^ TE VE- io'70-66-1s'_ FAXL TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL ©J EDUCATIONAL RESIDENTIAL®" CLEARLY NEW: [Z RENOVATION: El REPLACEMENT: PLANS SUBMITTED: YES 0 NO APPLIANCES 7 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 r� GRILLE INFRARED HEATER _ J Emmmi_ LABORATORY COCKS ❑ (! _ �— _ I �- MAKEUP AIR UNIT -1L OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT __ I TEST UNIT HEATER UNVENTED ROOM HEATER �1 WATER HEATER OTHER — INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES 10NO Ej IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [21"' OTHER TYPE INDEMNITY ❑ BOND ❑I 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 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and ur to to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianc ith I Pertinent pro v' o of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMELGIy! S —, LICENSE# !a"c_st 6. SIGNATURE MP I MGF [3® JP JGF ,_[ LPGI WSW ❑ © CORPORATION ❑] # PARTNERSHIP 0#= LLC ®#= COMPANY NAME: lere�c�� ADDRESS U JWA CITY r _ I STATE ZIP ]TEL FAX CELL 78 &;i_1ts-1 EMAILd ' 1N \ rA O z 0 H U W awl Z ❑ >- 11W rA F� FAY U w ft _r W � � Go Q wC0 CL r� O LU > a. � w w a o a a IL a � w x w F- w H O z z O H U a C7 C7 O • a+ r+ The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations ®IN 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLibly Name (Business/Organizatiordfndividual):� ' an Al l a;r V Address: Sl�� v�l�. C& City/State/Zip: "�; u z �r� , kA, 61 ©t V� c)1 Phone #: 9, 7 8 - 66 V — A93 .% Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3111 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions l LN Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip; Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby cert un er tlt pains and p [ties ofperjury that the information provided above is true and correct. Sig -nature: Date: lv 2 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 #: 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 employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial .Accidents Office of Investigations 604 Washington Street Boston., MA 02111. Tel, # 617-727,4900 oxt 406 or 1-877rMASSAFB Revised 5-26-05 Fax ## 61.7-727-7749 vvvv�v.naaSs,govfdaia