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HomeMy WebLinkAboutMiscellaneous - 712 GREAT POND ROAD 4/30/2018S r Date) ...................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......��/......... �! �l-...................... 1..'.,........., has permission to perform .......:....�....-W.....� -%Q r ..:............... wiring in the building of ..................... Z6 L© "'k -A a. ................................................ at ..... ,..!'...e-�'' c Y Kt North Andover, Mass. ..................................... Fee...... ............ Lic. No ................. ........................... E** C** T** R...*A**L" ..IN.....ECT.*C"T** OR .......................... j ELICAL SP Check # 2927 -� -L\ Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 21�� Occupancy and Fee Checked [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (ME ), 52 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Z;3 City or Town of: NORTH ANDOVER To the Inspe for of Wires: By this application the undersigned gives notice of his or her intention to wrlorm f the e lical work described below. Location (Street & Number) �yl'AJ'Yl Ci Owner or Tenant Km H e4e-s r® W i T Z Telephone No. Owner's Address n Is this permit in conjunction with a build in permI Yes El Purpose of Building s L I 1 -en No V2110, (Check Appropriate Box) Utility Authorization No. Existing Service Amps / Vols 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: yh SfA `( Z U 1K W C-n@M.n( oA Cmmnletinn of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: (Paddle) Fans V Total TransSusp. Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires SwimmingPool Above ❑ In- E]o. rnd. rnd. o mergency ig tmg Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection andInitiating Devices No. of Ranges No. of Air Cond. Tons Tot No. of Alerting Devices No. of Waste Disposers P Heat Pump Totals: Number � .......................................................... To KW No. of Self-Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal El Other Connection No. of Dryers Y Heating Appliances KW Security SDevicesx No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Eectrical Work: (When required by municipal policy.) Work to Start: "?oz Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COV RAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cove ge is in force, and has exhibited proof of same the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, tinder the pains and penalties of perjury, the t the in matii mz this a plication is true and complete. FIRM NAME: LIC. NO.: 9 33 Licensee: `� Q Signature LIC. NO.: -MA(If applicable, 5pter "'exempt" in.the license nu b r line i 1� Bus. Tel. No.: Address: / Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security WoTk requires bejiaent of Public Safety "S" License: Lic. No. IN 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 gent. Owner/Agentf PERMIT FEE. $ Signature Telephone No. . �aocTIo� , _ ��sset�•-� j � �+'ailebt-• j � �e-zx�speeiioxt x'equzz'ecT($�O.QO) � j � �nspectoxs' coxnnxe�ts: QCnspectoxs'zgaaiure - �oiiiiaTs) date �'asseci-- j ' �+'ailer�--j � � ��3�nspectioxtxe�uire$ ($0.00)-• j � _ . �'nspeetaz-s' comm.euts: fts�for Wature-.ac tials) date �'assed •- j � �'azlec�-- [ � �2e-ansp ecizo� xec�uixe� (,��0.00) � j ] • casuectors' comments. (lnspectoxs�aignaiuxe -�o ��`aTs) Pate asseri--[) �'a'rlec�--j) �e-fnspectionxequixe� (�50.OD) � j � ' spectoxs9 comm.eits: (Asp ectoral 81gadure •- io jhitiaxs) rs e d •-- [ � �`aiXer� •, j )- ' ate �zzsp ectioxt requiz'ed ($50.0 0) •- j � �ectox�' co�im.erifs: _ ' • 5 • �[,�sp ectox' i9zgnaiure xto JinitiaTs) date . 3 Qat. TAG15 .AIM TO EE YMED PUT AM Mr Odd` BYTE IF TBE .AM TO BE INSPECTED XO NOT AJL The Commonwealth of Massachusetts - Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: 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. t 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 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.]r 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. ❑ 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 aie 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. I am an employer that is providing workers' compensation insurance for my� employees. Below is the policy and job site 04e& Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert fyun r g an e lties ofperjury that the information provided ab a is _-Signature. '�" - Date: ! Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # and correct. 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 4: r 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 iscomplete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out % 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 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 . orr ox wealth of Massachusetts � Department of Industrial Accidents Office of Investigations 600 Washington Street Boston., MA 02111 TeX, # 617-72.7-4900 ext 406 or 1-877,MA.SS.A.FB Revised 5-26-05 Fax # 617-727-7749 w�vw.mass.gov/dia a. sRh IF 555 SALEM ST KOM ANWVER MR 0484-5- -4 A Fold, Then Detach Along All Perforations F a �qy nW ,3,a "" � ♦ . � �} ije±" �Fk�'� . -:: '� ' "� Wil.' . K � � t + r Y M P OF t (M MVPC Bo Interstates Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, I Meters Data Sources: The data for this map was produced by Merrimack — SR NORT1� . Valley Planning Commission (MVPC) using data provided by the Town of RoadsO tD 4r North Andover. Additional data provided by the Executive Office of %7, Easements ? Environmental Affairs/MassGIS. The information depicted on this map is e ❑ Parcels for planning purposes only. It may not be adequate for legal boundary to definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY f s Y OF THESE DATA, THE TOWN OF NORTH ANDOVER DOES NOT i of .r i ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION . SSACMUsp - 1 = 45 ft. Fs 'North Andover MIMAP December 1, 2015 - -063;0 722 EATPOND'R 71POND'RD -..-:R1 -_..-.._-_.:: = •. 063.0=0006 - Water Protection .• .. . _063 O 0021••'. ... ' ' .�''. 700'GREAT POND RD �Oaa Qord. �jCea 063.070018 U MVPC Bo Wetlands Zoning13 - - Municipal Boundary R Exempt Lands 13 trict C Bu Businee s 1 Diss 2 Disinct Horimntal Datum: MA Stateplane Coordinate System, Datum Ni— Rail Line - - C Busine s 3 District - Meters Data Sources: The data for this map was produced by Merrimack Interstates O ne s Busi4 District O Gerena Business District ORT NH q,�, Valley Planning Commission (MVPC) using data provided by the Town of. North Andover. Additional data provided by the Executive Office of — SR O Planne Commercial Dev 0 Corrido Development Dist pf�� t.ae . ��6 O • - �� Environmental Affairs/MassGIS. The information depicted on this map is It be for legal boundary — Roads j Easements R-Corrido Development Dist O Corrido Development Dist j? OM �" �+ A for planning purposes only. may not adequate definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING El Parcels Industr I 1 DisMcl S Industn 2 Distract T .. M y w x THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ZoningOverlay Y C Industn 13 District 1F o �t • ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF 0 Adult Entertainment Downtown Overlay District B Historic District O Industn I S District Reside ce1 Distract Reside 2 District � "" � '%lf o+Arao W THIS INFORMATION 0 Water Protection ce W Pn,idei ce 3 Distinct CNUS� - - O Hydrographic Features 1 1' — 45 ft deice 4 Distn t do ce 5 Distract �Fde -- Streams - ce 6 Distract �a a esidential District M140,04"Aftyl U14;T1 DATE: LOCATION: OWNERS NAME: GENERATOR kw ksu4) NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: PHONE NUMBER: c1a ELECTRICAL I bGA RESIDENTIAL COMMERCIAL TEMPORARY LOCATION OF GENERATOR: IdN 7A1eC7k *ZONING DISTRICT: II *CONSERVATION APPROVAL N , o � I 'fib f -: .� �r: .F ! ♦ � a . a ti ✓ ..+.1 t �r r ' - w ! 1r✓ .�wX,.f W.x �' v �'l,et ' �,y r t:, t �tS tr .y a Yx ': !.r t ,a l s -r r -.." ,*, ., i t rrSY at ` l< r• 3{ d .4 `f 1 1 bf.F 'I '" ♦ ti yf .r}b.J'k�! ".,t r •err r �. t -''i.` / ,��E'Z �b rf r.+ _ �, �'�_ �. h '",. ... �tP ri :s S: .,• ,tr• r i e ..w..�..... _ ..�., .. . ::>]'.-.,_ ..';'° .. .4. _ _ . � , . . , , • 4. ........�.. North Andover MIMAP 712 Great Pond Road - generator December 1, 2015 + ^a a r s eO t`` �p a, • Y y to � � �F'bt "&�.+`€� Es ► s � , Y Q J. 700 GREAT Q MVPC Bo Interstates (/'��e �/� /� �O Honzontal Datum: MA Stateplane Coordinate System, Datum NAD83, — I tJ `♦ VL, I� �� C - _ \ Meters Data Sources: The data for this map was produced by Merrimack — SR NORTH Valley Planning Commission (MVPC) using data provided by the Town of - Roads Of *`�e q� North Andover. Additional data provided by the Executive Office of 6 r Easements - ? -��� - �� �Q Environmental Affairs/MassGIS. The information depicted on this map is ❑ Parcels3 L for planning purposes only. It may not be adequate for legal boundary O to definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER Floodplain MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING El 100 Year Floodplain } >; THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY E3 500 Year Floodplain } _ _ .-+ * OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ♦ ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF " THIS INFORMATION sswcNusp 1" = 41 ft Date.. 7.... . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ..................... . has permission for gas installation .. in the buildings of . at ..... N Airdpver,/ . North Mass. Fee:,%P<qf?. Lic. No.. ..S%3% . GAS INSPECTOR?" Check # 814-0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY �j ee'r MA DATE PERMIT # 461+0 JOBSITE ADDRESS I Z OWNER'S NAME r Cd er/ 4 z GOWNER ADDRESS I TE 70 -?2/7 FAX PPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Q CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: Q PLANS SUBMITTED: YES ❑ NO Q APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE - GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS ti MAKEUP AIR UNIT OVEN _. POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER _ OTHER i INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Q NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [E] OTHER TYPE INDEMNITY ❑ 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• NER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding thi pp ion a e nd rate the best of my knowledge and that all plumbing work and installations performed under the permit issued for this appli . io 'll in m Ii nee ' all inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I Michael Bemasconi I LICENSE 15 7A URE MP El MGF 0 JP 0 JGF 0 LPGI 0 CORPORATION Q# 2806C PART RSHIP❑#LLC ❑#� COMPANY NAME: Central Cooling & Heating, Inc. JADDRESSF9 North Maple Street CITY Wobum STATE MA _, ZIP01801 TEL 781-933-8288 FAX 1 781-932-9017 CELL 781-8443424 EMAIL mbemasconi@centralcooling.com qd O C n m n a A y O f z c "I �I m _ C0 M � x a 7 0 a r cn m .� c m D El �° O z r ❑ c 'C z a r z M 0 z z 0 KA �•� '� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Map # Lost # 600 Washington Street Address: Boston, MA 02111 Permit # www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information. ' l Please Print Legibly Name (Business/Organization/Individual) C e a C 1 i + i"f PAI+ i n 9 T YI C. Address: 9 Ai 64A ma k Aree�- City/State/Zip:__(; nbufn , YY1 61Li Phone #: 7$ I -933-T-Z?8 Are you an employer? Check the appropriate box: 1.0 I am a employer with r70 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. employees and have workers' [No workers' comp. insurance comp• msuranceJ required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp.. right of exemption per MGL insurance required.] ,t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. E] Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions. 12:❑ Roof repairs 13.0 Other )4- , *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 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 subcontractors and state whether or not those entities have employees. If the sub -cont actors have employees, they must provide their workers' comp: policy number. I am' an employer that is providing worJkers' compensation insurance for my employees. Below is the policyand job site information. Insurance Company Name: G L 6,819 L SN Su Q I NCE IJ 6T Wd P 11 . I'AI C. Policy # or Self-ins..Lic. M 8�-Lpc-,n �� ��� Expiration Date: j 1961.261,7- Job 361.26/aJob Site Address: 71 Z G( CLL±,, 120 j�City/State/Zip: /U, ��Uy�. �► Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1;500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herebcerVfMnder thepains andpenalties ofpedury that the information provided above is true and correct use only. Do not write in this area, to City or Town: or town official, Permit/License # 36// L 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 (LLQ 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 permittlicense 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 Dep Artt>;ient of Industrial Accidents Office of Investigations 6W Washington Street Boston, MAA 02111 Tel. # 617-727-4900 W 406 or 1-877 MASSAFE Fax # 617-727-7749 Revised 11-22-06 VAMnI py/dia Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING °SACMUSE- e— --) This certifies that ...! ....................................... has permission to perform ...�-4�- -.� �.,<t{•�• • • • • • • • • plumbing in the buildings of . h,�--� <� ..._.............. . at.//..... � � � . ?,/ ..... North Andover, Mass. Fee.4'. 7 '... Lic. No.?.�, .. :..�-.,,yy'am . �PLUMBINr NSP�CTOR Check # /16 % ( C// 5279 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location 722,)-o �/ v�nW Owner New 1:1 Renovation R Replacement 0 FIXTURES Date -�/� Y4� Permit 4_! S Amount '�S "—&-Z7 Plans Submitted Yes 1:1 No ❑ (Print or type) Installing Company Name Check one: Certificate ❑ Corp. ElPartner. ® Firm/Co. Name of Licensed Plumber: , ,pAy L'p� Insurance Coverage: Indicate 146 type Ut insurance coverage by checking the appropriate box: Liability insurance policy ® Other type of indemnity ❑ Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner D Agent1-1 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work an i to ons pert ed under Permit Issued for this application will be in compliance with all pertinent provisions of the Mass c � State Code and Chapter 142 of the General Laws. . By: igna re o i ense um er Type of Plumbing License Title ! 11 City/Town icense um er Master ED Journeyman ❑ APPROVED (OFFICE USE ONLY