HomeMy WebLinkAboutMiscellaneous - 75 SURREY DRIVE 4/30/2018O m
z �s'
Date......�.................................. ,
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ......................
has permission to perform ..,�'�- \ �E' CMc>=.................................
...................................................................................................
wiring in the
building of..... .. 1 .c)``.......................................................................
f)u`e e E'h ndover, Mass.
at.......................................................... .......................:
Fee.. .' ............. Lic. No. ,�! �?.� .... .. ............. ""�'...."""'...........
ELECTRICAL INSPECTOR
Check # —71(c
d
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
I
Permit No. I Zq`e!
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 (NEC), 527 CMR 12.00
(PLEASE PRINT MINK OR TYPE ALL MFORMATION) Date: �2 crZ1 r
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) 7 5- 80-�`-
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building IV / />t, �-4 Utility Authorization No.
- Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: W �'r j of N W
Completion ofthe following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑In- ❑
o. o Emergency Lighting
rnd. rnd.
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Number
-���
Tons
............._...........�'�'��"'��.'"".....
KW
No. of Self -Contained
p
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: F6V (When required by municipal policy.)
Work to Start:V-2i / 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 certify, under thepa'sand penalties ofperjury, that the information on this application is true and complete.
FIRMNAME: LIC. NO.:
Licensee: Aoh^�,s toSt Signature LIC. NO.: /y0/y"/f
(Ifapplicable, enter "exempt" in the 1'cense member line) Bus. Tel. No. -
Address: /U /N1604 f.► r!o w 7 ' Av H 03 X 93 Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent PERMIT FEE. $
Signature Telephone No.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the a
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed '
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an /
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the G
notification of completion of the work as required in M.G.L. c. 143, § 3L. r
Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written S
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
❑ Rule 8—Permit/Date Closed: *** Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass R
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH IN CTION:
Pass
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
124
Inspectors Signature:
Date:
FINAL INSPEC ON:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
4 4e
Inspectors Signature:
Date: cp', d/S
DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
Department of IndustrialAccidents
- ; = 1 Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERIVHTTING AUTHORITY.
Name (Business/Organization/Individual):
Address: I U N 1(0 -C dr
11*11 . &I-ec fi (' i"(.
City/State/Zip: _Sar, down / Li 14 6g-93 Phone #: q7f - S �0-S)) 7
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with employees (full and/or part-time).*
2.[ am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insuranceJ
6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c.
152, §1(4), and we have no. employees. [No workers' comp. insurance required.]
Type of project (required):
7. ❑ New construction
8. ❑ Remodeling
9. ❑ Demolition
10 ❑ Building addition
11. F1 Electrical repairs or additions
12. ❑ Plumbing repairs or additions
13. ❑ Roof repairs
14. ❑ Other
*Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information.
i Homeowners who submif 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 sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer iliat is providing workers' compensation insurance for my employees.' Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Expiration
Job Site Address: 75— SJ r r e y City/State/Zip: A/- &7 el v{/ r 0/5F-
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a 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 time of up to $250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties of pef jury that the information provided above is true and correct.
Signature: Date:
Phone #:
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #•
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-contractor(s) 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 burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
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D ate ...71..`l��l..�r' ...
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
Thiscertifies that..........................................................................................................
has permission to perform .......... �e 1'- w e- � � / --
......................................................................
plumbing in the buildings of....� _� r...f I..'9^/ ....................................................
at............?.r/I..P.......!J.......................... North Andover, Mass.
Fee ' ,e/..`��...... Lic. No......... �/8! ................................................................
:....
..........
...
PLUMBING INSPECTOR
Check # 2
12710-14�10(7 j -ism 6/2 (�% /1-
4,
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
ly '
CITY _ 4 I MA DATE PERMIT # _ I I 7,L+1
JOBSITE ADDRESS U/'�� OWNER'S NAME
POWNER
ADDRESS D TEL
TYPE OR
OCCUPANCY TYPE COMM 'CAL EDUCATIONAL ® RESIDENTIAL
PRINT
CLEARLY
NEW: 01. RENOVATION: REPLACEMENT: 0 PLANS SUBMITTED: YES E11 NO
FIXTURES 7 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 f — _J11--fl— _—J _—{ f
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER,.{
DRINKING FOUNTAIN _ I 1 ---. f f ( {--.-_..J � --J ___-- E
FOOD DISPOSER
FLOOR/ AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK[ _ { _. 1
LAVATORY --.-i -_-_I .___{ .—_J _-_-{
ROOF DRAIN. {
SHOWER STALL { —..__.I ___{
SERVICE / MOP SINK
TOILET { -- -- I _ ___.k
URINAL
WASHING MACHINE CONNECTION i
WATER HEATER ALL TYPES
WATER PIPING
OTHER
• _.__. _ _ f . -___J _ �{ ----{ _{ ._�J { --- -I -- J _..------J . -{ _.. _._{ ..._ A
_—
-31
INSURANCE COVERAGE:
have a current liability insurance policy or its s stantial equivalent which meets the requirements of MGL Ch. 142.
IF YOU CHECKED YES, PLEASE INDICATE TH PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY _ OTHER TYPE OF INDEMNITY_{ BOND �]f
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNERF-11 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and ac ate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in c nce all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME _ G✓r1 (/ I LICENSE #F
310 SIGNATU
IVIP Of JP _ CORPORATION #PARTNERSHIP O# s LLC C
COMPANY NAME ADDRESS ,-� S
CITY STATE ZIP__
- _ I_ L_b {I TEL
FAX L 11 CELL 1 _ Q X153 t EMAIL LLJ.
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The Commonwealth of Massachusetts
Department of lndustrialAccidents
1 Congress Street, Suite 100
0. Boston, MA 02114-2017
o�M 5Y.
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITT NG AUTHORITY.
Name (Business/Organizafiongndividual):
- wi ----\
Address:
City/State/Zip: d" 1 � vP� ��l�t�'�f Phone #: � 7 03f5Tr
Are you an employer? Check the appropriate
i.0 Ia employer with employees (full and/or part-time).
2.1VI am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
<1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no eiriployees.
5.❑I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.t
6. ❑ We are a corporation and its, officers have exercised their right of exemption per MGL c.
152 § 1(4) and We have no employees. [No workers' comp. insurance required.]
Type of
7. n N
9. U Demolition
10 [] Building addition
11.❑ Electrical repays or additions
12. El P1`wnbing repairs or additions
110 Ro6f repairs
14.(] Other
*Any applicant that checks bbac #1 must also sill 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 anew. affidavit indicating such
#Contractors that check this box must attached im additional sheet showing the name of the sub -contractors and state whether or not (hose entities have
employees. If the sub contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees..Below is the policy and job site
information.
Insurance Company Name:
Expiration Date,-
Policy # or Self ins. Lic. #: A 9 AA
y9
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensati n policy declaration page (showing the policy number and expiratio date).
Failure to secure coverage as requiued under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER. and a fine of up to $250.00 a
ay be forwarded to the Office of Investigations of the DTA. for insurance
day against the violator. A copy of this statement m
coverage verification.
Ido hereby ce undue thepains andpenalties of perjury tliat the information provided above is true and, correct.
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License ##
issuing Authority (circle one): i
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector
6. Other
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
receivef'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 o£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
PIease fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub=contractor(s) 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. B e 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
thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MA.SSAFE
Fax # 617-727-7749
Revised 02-23-15 wwwmass.gov/dia
I
6:l.-,V:.COMMONWEALTH OF MASSACHUSETTS
The Commonwealth of Massachusetts
F Department of Industrial Accidents
1 Congress Sheet, Suite 100
Boston, MA 02114-2017
< www mass.gov/dia
OIM 5�V
• e Affidavit: Builders/Contractors/lJlectricians/l'lumbers.
Workers' Compensation Insuranc
TO BE FILED WITH THE PERMITTING AUTHORI T Y. �, ,
A ' licant 1nTormaiion �tJ� -7
Name Business/organizationllndividual) : G T�
Address: 10 a— oil( �) LJ
City/State/Zip:
LAI
dl� ✓�— Phone #:
q?8 ('%S,- 7Vto
Are you an employer? Check the appropriate box:
1.�I am a employer with �loyees (full and/or part-time).*
2.❑ I am a sole proprietor or partnership and have no employees Working for me in
any capacity. [No workers' comp. insurance required.]
3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t
4. ❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
s. ❑I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.$
6. ❑ We are a corporation and its. officers have exercised their right of exemption per MGL c-
152, § 1(4), and we have no employees. [No workers' comp. insurance required.]
Type of project ()Vequired);
7. ❑ New'donstr66`tion
8. E] Remodeling
9. ❑ Demolition
10 ❑ Building addition
ILL ] Electrical repairs or additions
12,[] Plumbing repairs or additions
13•. [] Rb6f repairs
14.0 Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information'.
� Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not (hose entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
,a L44 -
Insurance Company Name: v
�?j p ? Expiration Date:
Policy # or Self -ins. Lic. #: 9/y y 3 L'
City/State/Zip: l F,j- ^) "'rA
U✓lj1
Job Site Address: 77
Attach a copy of the workers' compepsation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a full up to $1,500.00
and/or one-year imprisonment, as well as civil penalties in the form of a S'T'OP WORK ORDER and a fine of up to $250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance
coverage verification.
c v hereby certify un ns a ti s ofperjury that the information provided above is true and correct.
�.,���� /�i(w /� Date: % ���
Phone #: v s S 0
Off tial 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 _
Phone
Contact Person:
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 enferprise, and including the legal representatives of a deceased employer, or the
receiver'or, trustee 6f 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 r'equired."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub contractors) name(s), address(es) and phone number(s) along with their certificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
industrial -Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.go•v/dia
OP ID: CH
Al GATE (MMIDD/YYYY)
V CERTIFICATE OF LIABILITY INSURANCE oe' I,. �
THIS CERTIFICATE I$ ISSUED A$ A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER -
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If S BROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement, A statement on this certificate does not confer rights to the
r_erflflrs to holder In lieu of Such endorsement(s).
PRODUCER 978-975-1300 Nor.: AX
.e rave & Hall Insur.Assoc.lnC 978-975-7596 i No f N°
305 North Main St. EMAIL
Andover, MA 01810 DDRESS:
Michael L. SegreVa RODUGERID b' FLUET-1
INSURERS AFFORDING COVERAGE NAIC 0
INSURED Richard Fluet Contracting Inc. INSURERA:Arbella Protection Ins. Co. 41360
102 Bridle Path Lane INSURER 9:COmmerce Insurance Co. 34754
Methuen, MA 01844 INSURER C
INSURER D!
UV'tKAC7t5 � L.Jx , u .—. , .- ,.,.,,..—..
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY 115QUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO 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, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF INSURANCE
GENERAL LIABILITY
A X COMMERCIAL GENERAL LIABILnY
CLAIMS -MADE � OCCUR
GEN'L AGGREGATE LJMIT APPLIES PER
X I POLICY 0 PRO- LOC
AUTOMOBILE LIABILITY
UMBRELLA LIAB' I OCCUR
EXCESS LIAR HI --(I CLAIMS -MADE
DEDUCTIoLE
460
06/12/15 1 06/12/16
12/01/14 1 12/01115
I WORKERS COMPENSATION
AND EMPLOYERU'LIABILITYYIN
03131115 03/31/16
A ANFICERI RIETOREMDER ARTNUCLLDEpE ECUTIVE ( NIA 9104340312
(Mandatory In NH) �I
If yy6ea, descritw under
DESCRIPTI N F OPERATION claw
DESCRIPTION OF OPERATIONS If LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, I1mQm speCe Is required)
Town of North Andover
Building Deparment
1600 Osgood St.
North Andover, MA 01845
LIMITS
EACH OCCURRENCE S
1.000,00
ANY AUTO
$
1 OO'00
ALL OWNED AUTOS
B
X
SCHEDULED AUTOS
$
X
HIRED AUTOS
$
X
NON-OWNEDAUTOS
UMBRELLA LIAB' I OCCUR
EXCESS LIAR HI --(I CLAIMS -MADE
DEDUCTIoLE
460
06/12/15 1 06/12/16
12/01/14 1 12/01115
I WORKERS COMPENSATION
AND EMPLOYERU'LIABILITYYIN
03131115 03/31/16
A ANFICERI RIETOREMDER ARTNUCLLDEpE ECUTIVE ( NIA 9104340312
(Mandatory In NH) �I
If yy6ea, descritw under
DESCRIPTI N F OPERATION claw
DESCRIPTION OF OPERATIONS If LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, I1mQm speCe Is required)
Town of North Andover
Building Deparment
1600 Osgood St.
North Andover, MA 01845
LIMITS
EACH OCCURRENCE S
1.000,00
OCC nce
$
1 OO'00
n one person
$
5,00
& ADV INJURY
$
1,000,00
GGREGATE
$
2,000,00-COMP/OPAGG
JRrMrS.E11Ea
8
2,000,0CSINGLE
LIMIT)
ODILY INJURY (Per person)
$
100,0(
Ll';:ODILY INJURY (Pcr SoddenI)
$
300,0(
PROPERTY DAMAGE
(Per scAident)
100,0(
$
EACH OCCURRENCE
$
AGGREGATE
WC STAU-OTH-
E.L EACH ACCIDENT
$
500,01
E,L. DISEASE - EA EMPLOYEE $
600101
E -L. DISEASE - POLICYLIMIT
$
500,01
NORTHAN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL SE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIT-1=11 REPRESENYATIVE
Michael L Segreve
®1986-2009 ACOR
ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD
All rights reserved.
Massachusetts - Department of Public Safety
Board of'Building Reg
uiations and Standards
%-61'-%truct-j0fi Supervisor
License: CS -050710
"\k I rid - It
RICHARD A FLuor - / -
102BRIDLE PAU48mvp
MITHUENMA 0184
UV
Expiration
Commissioner 04/2212017
---------------
Office of Consumer Affairs & Business Regulation
VME IMPROWN! ENT d0NTRAf,,T0,Fk
legistration: f 620 type:
xpiration: 7d4jrW-&=- Private Corporation!
xI .1
RICHARD FLUET CO'lTRACTd N
G 01C.
Richard Fluet
102 Bridle Path Lane
Methuen, MA 01844 Undersecretary
- 014c Tornwunw ato of Masour4uatto
+3epartment of Public 3afetg
' a BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00
Office Use Only
Permit No.
Occupancy & Fee Checked
3/90 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 /
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date k-'��—,g(
City or Town of NORTH ANDOVER To the Inspector of Wires:
The udersigned applies for a permit to erform the electrical work described below.
Location (Street &QNupmnber)
Owner or Tenant
Owner's Address
Is this permit in conjunction with`a building permit: Yes ❑ No (Check Appropriate Box)
Purpose of Building �Ua� Utility Authorization No. SO 3 S S
Existing Service Amps %/ y0 Volts Overhead ❑ Undgrnd ❑ No. of Meters
New Service Z- 0 C Amps/ Z `i V Volts Overhead ❑ Undgrnd ❑ No. of Meters
Number of Feeders and Ampacity /� c
Location and Nature of Proposed Electrical Work A26 W 2-620
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers Total
KVA
No. of Lighting Fixtures
Swimming Pool Above In-
grnd. ❑ grnd. ❑
Generators KVA
No. of Emergency Lighting
No. of Receptacle Outlets
No. of Oil Burners
Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection and
No. of Ranges
No. of Air Cond. Total
tons
Initiating Devices
No. of Sounding Devices
No. of Self Contained
No. of Disposals
No.of Heat Total Total
Pumps Tons KW
No. of Dishwashers
Space/Area Heating KW
Detection/Sounding Devices
LocalMunicipal
❑ ❑Other
Connection
No. of Dryers
Heating Devices KW
No. of No. of
Low Voltage
No. of Water Heaters KW
Signs Ballasts
Wiring
No. Hydro Massage Tubs
No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES ❑ NO ❑ I
have submitted valid proof of same to the Office. YES ❑ NO ❑ If you have checked YES, please indicate the type of coverage by
checking the app opriate box.
INSURANCE Z BOND ❑ OTHER ❑ (Please Specify)
(Expiration Date)
Estimated Value of Electrical Work $
Work to Start 4 - 2-2 -1 (—
Signed under the Penalties of perju17
FIRM NAME (,U r't
Licensee
Inspection Date Requested:
Rough Wil -L. e,QL-L_ Final
LIC. NO. A63 bg
I if- Mn
// ^^�� (�/) (� V s. Tel. No.
Address /Ot6 G -504Z-L... Sr r" V • t� I��� �L= �')^ 0 / � Alt. T.I. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re-
quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent
(Please check one)
(Signature of Owner or Agent)
VN
Telephone No. PERMIT FEE $
x-6565
2346
cf •otic
0
Date .....,la.... ..c�-�...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that........5..!...-.................-.......t.,C.....................
i
has permission to perform . .....{�%�,.�.....�t...... �i..�G.....(�?�!
wiring in the building of .... .... "� ..... /..�:� i .........................
at.J
.,................... . North Andover, Mass.
Fee.....�.�..W.. Lic. No.C:./. `��...................................................I.......
�ELECTRICAL INSPECTOR
34419/91 16.13 35.00
PAID
WHITE: Applicant CANA u ing Dept. PINK: Treasurer GOLD: File
-- The Commonwealth of Massachusetts
(' Department of Industrial Accidents
600 Washington Street
J Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
name:60W4yf— l�
n I am an employer providing workers' compensation for my employees
on this job.
ri I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors
the following workers' compensation polices:
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or
one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
Idoherebyz
�tify under the pains and penalties of perjury that the information provided above is true and correct
< n 0 e L
Print name 6bw 4 2
Niiti��
•i
official use only do not write in this ar a to be completed by city or town official
city or town: A Q d . U (� e permit/license # �t T Building Department
❑Licensing Board
❑ check if immediate response is required f y❑Selectmen's Office
� Q d ❑Health Department.
contact person: phone l; �
❑Other
(revised 3195 P1A)
AV
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", 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 section 25 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, 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.
'n` y , j �.--...:.i,.'i,z '�'�.y,=!�:'��'��°*;�:arcs, __. _._`' f.�.....�" �;("���J, ?"r:� �,':r /�y y� :fi✓ ,r„i�a1�.fa-�.,��`�"ay� er�s 'b,�.:rs
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names, address and phone numbers as all affidavits 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.
�.
ME,
` .y,Y°3
a+
POWN
City or Towns
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. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone
The Commonwealth Of Massachusetts
Department of Industrial Accidents
office of Investigations
600 Washington Street
Boston, Ma. 02111
fax #: (617) 727-7749
phone #: (617) 727-4900 ext. 406, 409 or 375