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HomeMy WebLinkAboutMiscellaneous - 75 HAY MEADOW ROAD 4/30/2018 (2)N O 46 Date ................................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .. has permission to perform .....:,f.......r- �....�.:.................................. wiring in the building of ... „I f s....:..:.... ................. at ............. ....:...... ....,. ,- .:..:..:: :.:::... ......:.: :.. ,North Andover, Mass. Fee ... .:.............. UCJ No� r. ,: r.................... LECTRICAL INSPECTOR Check # _ FA It Date ............. ................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .....*./., 00�.................................................................... has permission to perform--l-Z�LZ/ ........... .................................................................. wiring in the building of ................................................ at ................... t rte/ .... ......... . orth Andover, Mass. Fee.!�6.3...... Lic.`Noxb-: ....... .. ........ . ...... Check # ELECTRICAL I PE 813 4 J 0 t�ommonwacl.ft o� //;;v�ari.u�eff6 Official Use Only Permit No. ISM 2apartm-e,2 of _Are Occupancy and Fee Checked T BOARD OF FIRE PREVENTION REGULATIONS ev. 1/071 leaveblankl APPLICAT ON FOR PERM. IT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical C:,de (MEC) 527 CMR 12.00 (PLEASE PRINT IN INK OR TYP�E )A)LL• .,W-FORMATIOM Date: City or Town of: /lel) e7w 4_,-)0 Vel To the Inspector of Wires: By this application the undersigned gives notice of his or her ;wxntion to perform the electrical work described below. !"tion (Street & Number) /J7 eC( . Cwner or Tenant e- Telephone No. Owner's .Address Is this permit in conjunction with a building peri: it? Purpose of Building Existing Service Amps / __ Vol's New Service Amps 1 V ^'*s Number of Feeders and Ampacity ' Yes ❑ No �0 (Check Appropriate Box) Utility authorization No. Overhead ❑ Undgrd ❑ OverltP.ad ❑ Undt*rd No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: •_ZK) S- O_ t le, 41 v» O = e -c LL r-ttK{ Sc l c-r-�.i aq Comoletion ofthe following table may be waived by the Inspector of Wires. No. B dromassa a Bathtubs No. or Motors Total FP ie-eeommun-canons vrrr y g iVo. of DeAces or Equ OTHER:/ Attnch additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Werk: - _ (When required by municipal poE;cy.) I Work to StartInspections to be requested in accordance wah M.EC Rule 10, and upon completion. INSURANCE COVERA M : Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insumi..ce including `:;ornpleted operation" coverage or its substantial equivalent. The undersigned certifies that such cove:4ge is in force, and has a -ted proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER (Specify:) I certify, under the pains and penalties of periury, that the information on this plication is true and complete "IRM NAME: e u,r ;44 S E/L v LIC. NO.: 1533 C Licensee: '� Signator LIC. NO.: v-� G °(Ifopplicable, enter "ex em t•' in the license rwnber line.) Bus. Tel. No.: s9o� Address: % 7 , ( 1_1 �%"� � 2 . llt1LLt '1•x'4 D � 0 �9 Alt. Tel. No.• A *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lir.. No OWNER'S INSURANCE WAIVER I am aware that the Licensee does not have the liability insurance -coverage normally required by law. By my signature below, I heresy waive this requirement. I am the (check one).El owner, [] owner's agent . Owuer/Agent r Signature __ _ Telephone No. PERWT FEE: S � � No. of Total Na. of Recessed Luminaires oo Ceii.-Snap. (Paddle) Fans Transformers KVA —�i.l` No. (if Luminaire Outlets1� io. of 11,)t'2•ubs Generators KVA No. of Luminaires AboveIn- Swimming Pool rnd. ❑ rnd. ❑ o. o Emergency Lighting Batteg a hits No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of and No. of Switches INo. of Gas Burners IDetection nitiatin Devices No: of Ranges No. of A!r Cosa. Total No. of Alerting Devices Heat Pumns p Number Tons ICVV No. of Self -Contained No. of Waste Disposers 1?� Totals: Detection/Alerting Devices of Dishwashers Space/Area Heating KW MuniciNo. Local ❑ .Connection al ❑Omer No. of Dryers ry Beating Appliances Kms, stems• / ewces or Equivalent No. of Water KW No. of No. of Data Wiring- Beaters Signs _ _ Ballasts No. of Devices or Equi valent No. B dromassa a Bathtubs No. or Motors Total FP ie-eeommun-canons vrrr y g iVo. of DeAces or Equ OTHER:/ Attnch additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Werk: - _ (When required by municipal poE;cy.) I Work to StartInspections to be requested in accordance wah M.EC Rule 10, and upon completion. INSURANCE COVERA M : Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insumi..ce including `:;ornpleted operation" coverage or its substantial equivalent. The undersigned certifies that such cove:4ge is in force, and has a -ted proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER (Specify:) I certify, under the pains and penalties of periury, that the information on this plication is true and complete "IRM NAME: e u,r ;44 S E/L v LIC. NO.: 1533 C Licensee: '� Signator LIC. NO.: v-� G °(Ifopplicable, enter "ex em t•' in the license rwnber line.) Bus. Tel. No.: s9o� Address: % 7 , ( 1_1 �%"� � 2 . llt1LLt '1•x'4 D � 0 �9 Alt. Tel. No.• A *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lir.. No OWNER'S INSURANCE WAIVER I am aware that the Licensee does not have the liability insurance -coverage normally required by law. By my signature below, I heresy waive this requirement. I am the (check one).El owner, [] owner's agent . Owuer/Agent r Signature __ _ Telephone No. PERWT FEE: S � � Date. c-�. Y-!.'. V V Ctl vi TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ..... .:... / ........ ..... r x' l/L- f . has permission to perform . ..... , . .... ........ plumbing in the buildings of/7- t at.. �.�r.. l�. .� ll.��.!�.�� ..........,—North Andover, Mass. Fee. Lic. No. �) .? � .... ........... I .. ...... PLUMBING INS Check 1 hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbi k g Code and Cha ter 142 of the General La By Type of Ui ense: Title❑ Plumber, Sb6iture of License umber CitylTElioumrneyan own License Number. ......r.. ,,.�r.,......�.- ..... �„ ❑Jo—,-- MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING �d C7" Permit# City/Town: •_ �/tii✓ , MA. Date .. 6ilk re Building Location: 64, w� 9wners Nam ' Type of Occupancy: Commercial ❑ Educational ❑ industrial ❑ Institutional ❑ Residential DEDICATED New: ❑ Alteration: ❑ RCnovation: ❑ Replacement: V Plans Submitted: Yes ❑ No ❑ 1 hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbi k g Code and Cha ter 142 of the General La By Type of Ui ense: Title❑ Plumber, Sb6iture of License umber CitylTElioumrneyan own License Number. ......r.. ,,.�r.,......�.- ..... �„ ❑Jo—,-- FIXTURES DEDICATED SYSTEMS LU cU z Z O Wz 4A Y LU in LUQ 0 0:Qo 0 a U V! a re Z ~ Y K = w Z H Vf Z a W N N a 4A Z_ 1�- a iJ Q y ~ W 4Z W N S ? Q W Q Z O}C 0LU 0 W Z W Z -j X U d LL Q W LU 0 a o 3 u> > o 0 a Z z vxi tW- Ui = a o � a} "' '" v~i a 0 a m m c c� x a'e g Ox g a: o a a 3 a 3 3 o a01 013 3 SUB BSMT. BASEMENT e FLOOR J 2 FLOOR I 3 FLOOR FLOOR f 5 FLOOR i FLOOR I 7 FLOOR 8 FLOOR L Check One Only Certificate # Installing Company Name: T G I [J 8rporation Address: C ty/Town: ' State: A LW ❑ Partnership �1 Business Telho-3— fl 7 2 (�C71`� Fax: _ ❑ Firm/Company Name of Licensed Plumber: 1&bezi INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ('ll'o, ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Er", Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: l 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 ❑ Sianature of Owner or Owner's Aaent 1 hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbi k g Code and Cha ter 142 of the General La By Type of Ui ense: Title❑ Plumber, Sb6iture of License umber CitylTElioumrneyan own License Number. ......r.. ,,.�r.,......�.- ..... �„ ❑Jo—,-- 0 f Date TOWN OF NORTM"ANDOVER PERMIT FOR PLUMBING This certifies that ... ... .. ... ... ..... ..... has permission to perform ... r �rrg� '' �':' �' " plumbing in the buildings of.. d'.r7 .`': 1 �: `'. �=.:`:�.............. . at ... 1. � . T.F f �............ . North Andover, Mass. Fee. %: ?..... Lic. No..:fir. .... ....... PLUMBING INSPECTOR Check f MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date ` Building Location 95' A y m ca d o w Rd Owners Name L a w re n t -e- Permit # Amount % Type of Occupancy Rex i do r7l7 a l New Renovation Replacement M Plans Submitted Yes ❑ No ❑ FIXTURE. (Print or type)Check one: Certificate Installing Company Name �1"e5 j G)2 rili , l W� q P l q =nc- ❑ Corp. Address 18 0-W ro'CW 12d Partner. STDl�Icv/GpY/ 04 6gl ko uusiness Telephone -7X 1 �-o Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicatethe ty e of msuranc coverage by checking the appropriate box: V 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 ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. T d�P,v' By: MUM o1 I-Xfolsumoer Type of Plumbing License Title /a38 % City/Town License Numner Master ® Journeyman ❑ APPROVED (OFFICE USE ONLY Date...`.. .. .... . 7 Of WORTH 1H o? TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .. Asa S Qa �''b �1°' has permission for gas installation . /o .............. in the buildings of at . .... . �. a ! L°!a ��'�' ............ , North Andover �M�a�ss. Fee.:?©'... Lic. No.f.�...t . .... .'!u ..�-y-,..``-' QQ GAS INSP&TOR Check 4908 4 . 1. MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations 75 Haymead New ❑ Renovation Date 10/29/04 Permit # Amount $ 41sName Kim Cormier ❑ Plans Submitted ❑ (Print or type) Eastern Propane Gas Check one: Certificate Installing Company Name ❑ Corp. Address 131 Water S t . ❑ Partner. anuPr ; MA 012P4 Business Telephone 1 B00 Hipp hhpq ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check I have a current liability Insurance policy or it's substantial equivalent. Yes ^ No ❑ Ifyou have checked 3Lqs please indicate the type coverage by checking the appropriate box- Liability ox Liability insurance policy Eh Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. Title VED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber Gas Fitter License Number ❑ Master ❑ Journeyman V. � Iw 1'ne to to se $30.50 w w a a U H d H o z � a w w 0 0 0° H a., w Gw w cn C x a a� ami a FO A -t SUB -BASEMENT BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type) Eastern Propane Gas Check one: Certificate Installing Company Name ❑ Corp. Address 131 Water S t . ❑ Partner. anuPr ; MA 012P4 Business Telephone 1 B00 Hipp hhpq ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check I have a current liability Insurance policy or it's substantial equivalent. Yes ^ No ❑ Ifyou have checked 3Lqs please indicate the type coverage by checking the appropriate box- Liability ox Liability insurance policy Eh Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. Title VED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber Gas Fitter License Number ❑ Master ❑ Journeyman COP ID H ORD, CERTIFICATE OF LIABILITY INSURANCE OP DATE (NlNfpDrYWY) 10/21/04 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION LTR ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Morse, Payson & Noyes P.O. Box 406 HOLDER- THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Portland ML 04112-0406 DATE RAMIDDfM Phone:207-775-6000 Fax:207-775-0339 INSURERS AFFORDING COVERAGE MAIC INSURED INSURER A: ONEBRACON IIQSURANCE GROUP 18458 INSURER B: - INSURER C: Kastern Propane Gas, Inc.ST AL P.O. BOX 1890 0 Rochester NH 03866 INSURER D: INSURER E: X1 COMMERCIAL GENERAL LIABILITY COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSRC TYPE OF INSURANCE POLICY NUMBER DATE OAWDDNY) DATE RAMIDDfM LIMIT'S GENERAL LUIBRM EACH OCCURRENCE $1,000,000 A X1 COMMERCIAL GENERAL LIABILITY QW126242 10/01/04 10/01/05 PREMISES (Ea ocaaence) $100,000 CLAIMS MADE � OCCUR MED EXP (Any one person) $5,000 PERSONAL &ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GENU AGGREGATE LIMIT APPLIES PER: PRODUCTS- COMP/OP AGG $2,000,000 POLICY jPERGCOT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea acaderd) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per per) $ `w BODILY INJURY $ - HIRED AUTOS NON -OWNED AUTOS (Per actidert) PROPERTY DAMAGE $ - (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EAACC $ ANY AUTO AUTO ONLY: AGG $ EXCESSAlMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR 0 CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND TORY LIMTfS ER EMPLOYERS' LIABILTrY E.L. EACH ACCIDENT $ ANY PROPRIETORIPARTNEREXECUTIVE OFFICERIMEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE- POLICY LIMIT $ SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION saamrac SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION } DATE THEREOF, THE ISSUINGNSURER WILL ENDEAVOR TO MAL 10 DAYS WRITTEN 7�� 1V O r V h And O V e r NOTA TO THE CBtTIFICATE HOLDEN NAMED TO THE LEFT, BUT FAILURE TO DO 90 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPAESENTATNES. (2001/08) G ACORD CORPORATION 1988 P N2 'I / � I Date... TOWN OF NORTH ANDOVER A PERMIT FOR WIRING g This certifies that ..... Q -f -:. ow,.I.Ss ....... ...... C 6.vl. V ............. I has permission to perform .... ANA. C... 0.1....... . o..�sx:.Ixl.�J wiring in the building of ...... JI.Y.-J. S)A. �:/. im ........................ at .... 9AIV') ... ............. ......... �, North Andover,? Mases Fee .'&.. � .......... Lic.No./..o.w****/-/`............... Ax? ... .................. L INSPECTOR C 91 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer a Ui oft(ce 1104 EPARCEL nTumnor Veal h of Massachusetts I ter"lt :to. Dcpartmcnt Public Sofey Qcup,ney 6 fee CT,ckad N REGULATIONS S27 CMR 1200 3/90 . (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code. S27 CMR 12:00 (PLEASE PRINT IN INK OR TYPE A I. INFORMATION) Date �O ��'cy City or Town of To To the Inspector of Wires: The undersigned applies for a permit to,perform the electrical work described below. Location (Street & Number) 7,S C(Lrf�It Cyo 7 /0. ! �� wper or Tenant V � � h r` _ 787^ 7^ �� 97 O Owner's Address Is this permit in conjunction with a building permit: Yes ❑ No ® (Check Appropriate Box) Purpose of Building HOME utility Authorization N0. Existing Service Amps / Volts Overhead �._.� Undgrd ❑ No. of Meters 4 New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters a M Number of Feeders and Ampac Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total ICVA No: "of Lighting Fixtures Swiimnin Pool Above -In- g grnd. ❑ grnd. ❑ ---- - -- Generators INA No. of Receptacle Outlets No. of 011 Burners No. of'Emergency LightingBattery Units No. of Switch Outlets No. of Gas Burners FIRE: ALARMS No. ._of -Zones _ No. of Detection and Initiating Devices No. of Sounding Devices g No. on Contained Deteecc tion Sounding Devices Local ❑ Municipal ❑ Other Connection No, of Ranges Total No. of Air Cond. tons No. of Disposals Po No. of [teat Total Total Pumps s T t• KW No. of Dishwashers Space/Area Ncating KW No. of Dryers Heating Devices KW No. of Water Heaters KW No, of No. of Si ns Ballasts Low Voltage - Wiring No. Hydro Massage Tubs No. of Motors Total lip OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liabillt Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES ❑ N08 I have submitted valid proof of same to this office. YES ❑ NO p If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE ® BOND ❑ OTHER ❑ (Please Specify) /xp ration• ate Estimated Value/of Electrical Work $ -� Work to Start // / % Inspection Date Requested: Rough COMPLETE. Final Signed under the penalties of perjury: FIRM NAME RESPONSE ELECTRIC SERVICES INC LIC. No. 1 6 2 4 9 A Licensee Anthony S. DePrizio Signature L C. N0. Address 153 Main Street/ Medford MA 02� 5 Bus. Te _ _7775 Alt. Tel. No._781 -395-5780 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not havg the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE $ ��1 4. The Commonwealth of Massachusetts Department of Industrial Accidents .. Office of Investigations 600 Washington Street s'1 Boston, MA 02111 www.nzassgov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizationlindividual): Address: City/State/Zip: : t : � 1 Jvkik OkY 4hone #: 791 - 311 :3 1 _�-6 Are yub an employer? Check the appropriate box: 1. I am a emplo er with 1 employees fu d/or 4. ❑ I am a general contractor and I have hired the sub -contractors part-time).* 2. ❑ 1 am asole 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 3. D i am a homeowner doing all work right of exemption per MGL myself. [Nonworkers' 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. ❑ Demoliti.on 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs I3.❑ Other *Any applicant that checks bo)CW I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contsactots must submit a new affidavit indicating such. ;Contractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers' comp. policy information. I ant an employer that is providing workers' compensation insurance for my employees: Below is. the policy and job site information. `` r Insurance Company Name: ' 1� Girt -t Of- o C (iro'ciri ello Policy 9 or Self -ins. Lie. #: CI 7 - — G 9 % % Expiration Date: Job Site Address: "Gi4 Irr,f.,n d n v r 2 rt. City/State/Zip: A16 , A -i 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. Ido hereby cerci ry u rider the pains an enalties of perjury that the information provided above is true and correct. Si ature: Date: a 06 G ` Phone #: -7 " Q 01A - 1-4 3 11 Official use only. Do not write in this area, to be completed by city ortownofficial 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 cant' 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, needonly 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 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia Commonwealth of Massachusetts Department of Fire Services Him BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No.y 9 .� Occupancy and Fee Checked [Rev. 1/07) (leave blank) �7 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: g I (o 0 - City or Town of. NORTH ANDOVER 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) -7jr Owner or Tenant Owner's Address .#, Cl,r t S 4, ( , ¢ Telephone No. c. 18 -6? 1-;13" Is this permit in conjunction with a building permit? Yes � No ❑ (Check Appropriate Box) Purpose of Building T --e S k d•e -, -k i c, i Utility Authorization No. Existing Service 01.23U Amps i 01 / 0--v Volts Overhead ❑7 Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters / No. of Meters Location and Nature of Proposed Electrical Work: 21 d �` �p�� Mat -le/ &+F rv6vr, ('enol . -icn Maskr, ar\rr) ctirS� Sub panrr \ No. of Recessed Luminaires -7 --- - --r No. of Ceil: Susp. (Paddle) Fans .1— v trm lrts cwur uj rr{res. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires 3 Swimming Pool Above ❑ In- ❑ o. ot Emergency Lighting rnd. grnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of fines No. of Switches ? No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges Total No. of Air Cond. No. of Alerting g Devices No. of Waste Disposers . Heat Pump Number Tons KW -.... *** No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑Other Connection No. of Dryers Heating Appliances KW Sectio. Systems:* No. of Water No. of No. of Devices or Equivalent Heaters KW s Ballasts . Sivices Wiring: of De or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsWiring: No. of Devices or Equivalent OTHER: GytciYre-, Attach additional detail if desired, or as required by the Inspector of Wires, Estimated Value of Electrical Work: Q(�_ (When required by municipal policy.) Work to Start: 0 g Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cove a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE M B OND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: - G C LIC. NO.: 00423 A Licensee: 2� ( e V lg, Q.y Signature LIC. NO.: SOd� (p f (If applicable, enter "exempt - in the license number line) Bus. Tel. No.: Address: 3 0 rXXA- V 0 -di 6 yr 1 -,,.c 131✓vim, A Cy i y 0--N Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $�_ i PO4� O- - a. 7- ocq- A"' si I I