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Miscellaneous - 78 JEFFERSON STREET 4/30/2018
r Date.. �U ..�1 ..5 ........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... .`..!....�.7.....`G-.......................:...................:.............. has permission to perform ..n y'Oi''.t?........................................ ........... wiring in the building �of.......,.................................................................. at ....................... l P,l , ..,......!Scar.`1........................ .North Andover, Mass. Fee...../,�?YJ .7........ Lic. NoZO..../......................................................................................... Check # ELECTRICAL INSPECTOR l,.`..{�6'.:yl 1278J—/ f Commonwealth of Massachusetts OfficiUse Only � Permit No.� Department of Fire Services Occupancy and Fee Checked aM BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code MC), 527 CZMR 12.00 (PLEASE PRINT W INK OR TYPE ALL .INFORMATION) Date: 11,q/S City or Town of: NORTH ANDOVER To the Insp ctor df Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 8 , Owner or Tenant t Owner's Address 79 _ Telephone No. Is this permit in conjunction with a building permit?, Yes R�J�No ❑ (Check Appropriate Box) Purpose of Building C 0,11 0/0 Utility Authorization No. Existing Service �Q Amps /dYV 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: , ne A "0.'✓1 �ei�d oh Completion of the following table maybe 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 Above In- Swimming Pool rnd. ❑ rnd. ❑ o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of SwitchesNo. 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 Totals: Number ""' Tons ""'"''""'' KW ...................... No. of Self -Contained 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 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, — aa�r Im --' Attach additional detail if desired, mss reguiredAy the Inspector of *Vires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: I 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:) Icertify, sander thepains andpenalties ofperjury, that thein nzation on this application is tr and complete. FIRM NAME:. c . d. C r ' IC. NO.: Q Licensee: ,�� , �( Signal e LIC. NO.: (If applicable, enter "ex t" in the license number line. �.,,,�! Bus. Tel. No. - 6 C�3 `Zf/-V C q Address: 63 >^� e /rr&k-&210 7 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. $ ✓ffl'� 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 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 notification of completion of the work as required in M.G.L. c. 143, § 3L. 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 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 M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: - Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass (] Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSP CTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: 4--- Date: jl > DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com Name The Commonwealth of Massachusetts :. F Department ofIndustrialAccidents 1 Congress Street, Suite 100 Boston, MA. 02114-2017 9r www mass.gov/dia Workers, Compensation Insurance Affidavit: Builders/Contractors/Electricians/1'lum ers. . — „T,. -pyr V'n AVIFTA TAF: PF,RMITTING AUTHORITY. / Phone #: �7.�9 City/State/Zip: ,�. . Type of project (required): Are you an employer? Check theappropriate box: 1.[] I am a employer with employees (frill and/or part-time).* 7. E]New'donstruction 2.❑ I am a sole proprietor or partnership and have no employees v✓orking for me in 8. El Remo deling any capacity. [No workers' comp. insurance required.] 9, ❑ Demolition 3.Q I am a homeowner doing all work myself, [No workers' comp, insurance required.] t 10 ❑ Building addition 4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑ Electrical repay s or additions ensure that all contractors either have workers' compensation insurance or are sole 4 proprietors with no entplo . 1. lZ ;°.� Pliunbing repairs or additions 5. ❑I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 11 Roof repairs These sub -contractors hoyees and have workers' comp. insurance. ave empl14.0 Other 6.FJ We are a corporation and its. officers have exercised their right of exemption per MGL c. 152, §1(4), and We have no employees: [No workers' comp. insurance required.] *Any applicant that checks boxd#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 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 (hose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. X am an employer that is providing workers' compensation insurance for my employees. Bei is thepolicy and ob site information. / /C l " a 0,- J A 1!,o e� Insurance Company Name: ' o© Policy # or Self -ins. Lic. 0/4y "©� Expiration Date: 0 City/State/Zip: Job Site Address:T� I �al-e . Attach a copy of the workers' compensation posey declaration page (showing the policy umber 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 fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby certify undergie pains and paltiesi p--,/—erjury that tiie information provided above is true and correct. , •Tr /,0 -1 A! r' 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 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 hlr"e, 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 trustdd 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 b6 deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage regi fired. " 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 certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial -Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and 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-NMSSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 7 f 11432 Date /.2 TOWN OF NORTH ANDOVER - PERMIT FOR PLUMBING This certifies that ....... i-ler..... 6�'*&-.ICI. has permission to perform ...../Y11.... .......!.......... .......... plumbing in thZou*.Idings of ort� Andover, Mass. ... .... . t at ... ... ..... ... &-) .... ��f Fee.,5.�.Ob.. Lic. No. . .......... ............................ F LU GING TOR Check rOWNERADDRESS A/CnHUSETTS UNIFORM APPLICATIO.N FOR A PERMIT TO PERFORM PLUMBING WORK MA. DATE PERMIT # ESS 7 � Fe�s�'� OWNER'SNAME �R3`^-1 K,,PF' TEL FAX TYPE OR YPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES -1 FLOOR BSMT 1 2 3 4 5 6 7 8 9 10 11 12 '13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIL/SAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which, meets the requirements of MGL Ch. 142.• Yes] No ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ 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 Massachusetts General Laws, -and that my signature on this permit application waives this requirement. CHECK ONE BOX ONLY: OWNER E3 AGE NT ❑ Signature of Owner or Owner's A ent 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 Plumbing Code and Chapter 142 of the General Laws. PLUMBER NAME Peter J. Crane SIGNATURE % 2 LIC # 21805 MP ❑ JP Q CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME Crane's Plumbing & Heating ADDRESS: 70 Douglas Street CITY Haverhill STATE 11A ZIP 01830 EMAIL annacrane.ac@verizon.net' TEL 978.771.1155 CELL 978.771.1155 FAX 12,� aG, . w�,��,� �wr� r��S���� O WILLIAM J. SCOTT Director (978) 688-9531 Town of North Andover Of NORTH -1ti '61 OFFICE OF a�� °�� a O L COMMUNITY DEVELOPMENT AND SERVICES A 27 Charles Street * t p9 ' North Andover, Massachusetts 01845 Ms. Judith D. Walker August 8, 2000 78D Jefferson St. North Andover, MA'01845 Dear Ms. Walker: Fax(978)688-9542 Please be advised that after review of your letter dated July 22,2000 the issues addressed should be brought to the attention of the Condo Association. All routine maintenance to structures is the responsibility of the owners of said property. With this property belonging to a condo association you as part owner are responsible for your dwelling unit, and the association is responsible for all common areas. I wish you success in working these problems out with the association. If I'may be of further assistance please do not hesitate to contact me at 688-9545 between the hours of 8:30 —10:00 AM and 1:00 — 2:00 PM Respectfully, Michael McGuire Local Building Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 O78DI efferson Street North Andover MA 01 ente845 July 22, 2000 Ms. Lisa Allis Property Manager, Village Green Diversified Funding Incorporated 39 Farrwood Avenue #1 North Andover, MA 01845 Dear Ms. Allis: I have spoken to you many times about the various problems in and around my unit at 78 Jefferson Street. Specifically these problems include no routine maintance being done, water in the basement, leaking pipes near electrical wiring in the basement, outside lights not working or go* ng off"and on, electrical problems with lights in the hallway, heat staying at 80 degrees or going off completely, broken curbstones and other electrical problems such as the heat or the outside lights causing the circuit breaker to go.off. OIn June 1999 the gutters were finally cleaned after I had contacted your office for a year and a half. By that time a section of the gutter come loose which . caused water to come in my kitchen window down the wall and on the floor causing rot to the window, the wallpaper to peel and the floor tiles to come loose. This summer I again had to call because the gutters were not cleaned and water poured into my bedroom windows. On several occasions during the past two years there has been water in the basement caused, I was told by water coming through the chimney. This problem has not yet been resolved. Today I discovered water is now coming through the floor of the basement. as well and I have significant water damage to my belongings. Phone calls made to you are often not returned and/or handled rudely. Weekend calls are usually impossible to even get through to the answering service. Indeed I have called at least 10 times today and been hung up on or got no answer at all. I finally got through to the answering service but received no call back. After 3 hours I got through again and left a second message. OI feel there are clear concerns with water seepage and electrical problems in the building. These are the major problems although there are others. I would like some answers in writing within 10 days of receipt of this letter. I am asking that necessary repairs be made to take care of the water problems and that the electrical wiring be inspected immediately. I would also like to know why routine maintaince like gutter cleaning is not done with the owners contacting your office. Sincerely, W 1JTith D. Walker Cc Diversified Funding Incorporated, Boston Claudia Johnson, Trustee Pat Byrne, Trustee William D. Lush, Trustee John Lage, Trustee Town of North Andover Health Inspector OTown of North Andover Building Inspector Q r CI` c - ec s 0 �� flo 9,592 Date..... g—.1..?-.za.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... v ............. ........ has permission to perform .... Z-'. e-7 k- ...... / wiring in the building of ..... . ............. T a .... ...5 T.... .6North Andover, Mass. Fee Lic. ......... � . .. ............ 5 ...' Z./ .......... 4LEc ELECTRICAL INSPEL40R Check # VV111111V11 vMa"1l U1 Ma.. Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) F' 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 IN INK OR TYPE ALL INFORMATION) Date: 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) 4y of $per _c7i: I A ,A Vq 6 Owner or Tenant /-AptM i F,54prVcs U -C Telephone No. Owner's Address 564 D�MQ%, Sf Lou" " c`1 y'r Is this permit in conjunction with a building permit? - Yes No ❑ (Check Appropriate Box) Purpose of Building 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: e p fw-p— N p l.e x', eZ e ep7W,6! S LGA f t x iU ii �-•S � l t0 S'l"Y� /� S rwK-e O f TQG firer] S , r'mmnletinn of the following table may be waived by the Inspector of Wires. &D Attach additional detatt tj aesirea, or as regiarea oy ine trespecsur u•/ rr„eo. Estimated Value of Electrical Work: B, (When required by municipal policy.) Work to Start: 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 the pains and penalties of perjury, that the m/brmatio is application is true and complete. FIRM NAME: os -& if mcn LIC. NO.: Licensee: )OS•elp N h�c/L,7r^n'i1,,� Signat re ------ L -W NO. X04 4,P:(If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: f1i Z�83 Address: (9 %5el- i 4 It, 4- GGl I m 5F,00 _A U(� Z y Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61T security work requires Department of Public Safe "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 Owner/Agent PERMIT FEE: $ Signature Telephone No. v No. of Recessed Luminaires No. of Ceil:P• (Paddle) SusFans TransTotal Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs A Generators KVA No. of Luminaires AboveIn- Swimming Pool rnd. ❑ rnd. ❑ o. o Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of and No. of Switches No. of Gas Burners IDetection Initiating Devices No. of Ranges No. of Air Cond. Tonal No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained No. of Waste Dis osers P Totals: ...... .................. ....................... 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 Systems:* No. of Devices or Equivalent No. of WaterKW No. of ''No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or Equivalent OTHER: &D Attach additional detatt tj aesirea, or as regiarea oy ine trespecsur u•/ rr„eo. Estimated Value of Electrical Work: B, (When required by municipal policy.) Work to Start: 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 the pains and penalties of perjury, that the m/brmatio is application is true and complete. FIRM NAME: os -& if mcn LIC. NO.: Licensee: )OS•elp N h�c/L,7r^n'i1,,� Signat re ------ L -W NO. X04 4,P:(If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: f1i Z�83 Address: (9 %5el- i 4 It, 4- GGl I m 5F,00 _A U(� Z y Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61T security work requires Department of Public Safe "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 Owner/Agent PERMIT FEE: $ Signature Telephone No. r ��z t pOR�1y O 9 ♦ i „ 7 s o a ,SSACNUS� w Date.CF//.97/!G . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that Al e`7 ................. . has permission to perform ..12.E :17 Or ;-, ........ plumbing in the buildings of e-9�.�.... . %......... . at ... 7....J .�. ,�% �� sc .'.:............. . North Andover, Mass. Fee. L��?:..Lic. No. ?.. .......Lu ....cl�..!....... MBING INSPECTOR Check p le- V I 8397 P �.ING } -MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUM33 (Type or print) NORTH ANDOVER, MASSACHUSETTS j" L C � �`d ate /V Owners Name 1 tf - GS Permit #-L- Building " Building Location Amount qq s voo ve-C' T e of Occupancy New Renovation ER Replacement El Plans Submitted Yes N0 � T7`PTTii]Ti G • (Print or type) Check one: Certificate installing Company Name H2fr' �Y �� e Corp. n Address Partner. Business Telephone Firm/Co.- Name ofLicensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the box: Bond ❑ Liability insurance policy Other type of indemnity Insurance_Waivea: I, the undersigned, have been made aware that the Licensee of this application does not have any one ofthe above t surance rgn tune �s Owner Agent I hereby certify that all ofthe details and information I have submitted (or entered) in above application are.true and accurate to the best of mylatowledge and that all plumbing work and inspyations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massa State PlumMg ogle and Chapter 142 of the General Laws. D (OFFICE USE ONLY Type ofPlumbing License 7.7 Lrcense rquinver Master D Journeyman The Commonwealth of 111assachusetts �► " Department of rndustrialAccidants f Office of hives9e ations 60.0 Washinbaton Street G• - ' Boston, -1i A 021II wWv_nzccssgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electri 2krocians/Plumbers Brant fnformafioII Please Print Leqbll Name (Business/Organization/Individual): Address: City/State/Zip:_ Phone #: Are you an employer? Check the appropriate box: I. ❑ I am a employer with 4. ❑ I am a general contractor employees (fd and/or part time).* 2. ❑ I am a sole and I have hired the sub -contractors proprietor or partner_ listed on the attached sheet. I ship and have no employees These sub contractors have working for mein any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its retluiredJ 3 . ❑ T am a homeowner doing work officers hake exercised their all myself [Ito workers' comp. right of ex �p tion per MGL c. 152, 61 (4), and we have no inc„rance required.] t employees. [No workers' cdmp, insurance required.] `ny 9PPBI a..r that bo : #r must alSo tial oat the eecitr n Flomeowners Type of project (required): 6. ❑ Nein construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions .11. ❑ Plumbing repairs or additions 12.[] Roof repairs 13.❑ Other sucmit 4Ufi3davrt mdicatmg they a V doiag all ek and = +Contractors that cheok this box MLIst aQ thea an additional sheet show ham hireflutside evn2acton 4":t aubmit x new affidavit indicating such. ¢m an employer that isprovuiing w '� the aame of the sub -contractors and their workers' comp. policy information. f orkers' compensadon insurance for my employees BeIoNy is thepoficy andjob site inform¢tzon. Insurance Compiny Policy # or self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip- Attach a copy of the workers, compensation policy declaration page (showing the policy number•and expiration datej. Failure to secure coverage as required under Section 25A ofMGrL c. 152 can lead to the imposition of cri fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalises in the fminal penalties of a orm of and a zine a STOP WORK ORDER a Of up to $250.00 a day against the violator. Be advised that a copy of this statement may f forwarded to the. Office a Investigations of the DIA for insurance coverage verification I do hereby certify under the pains and pet aloes of perjury thrzt the information provided above* true and correct -• , Official use only. Do not wrzte'in this area, to be completed by city or town ofJacial City or Town: IsSUM, Authority (circle one): 1. Board of Health 2. Buildiab Department... 6. Other Contact Person: I"ermitucense # 3. City/Town Clerk 4. Electrical Inspector 5. PIumbinb .Inspector Phone'#-: 'AInformation. an. d Instructions Massachusetts General Laws chapteer 152 requires all employers to provide workers' compensation for their employees. Putsuant 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 employeris defined as "an individual, partnefship,•associz--rtion, corporation or other legal entity, or tiny two ormore of the foregoiag engaged in a joint enterprise, and including t -J e legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association o:x7 other legal entity, employing employees. However the owner of a dwelling house having not more thm three apart ents and who resides therain, or the occupant of the dwelling house of another who employs persons to do maintevance, 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 10 -cal licensing'agency shall withhold -the issuance or renewal of a license or permit to operate a business or to c--avkruct buildings in the commonwealth for any applicant who has not produced acceptable evidence of co3impliance 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 thei performanco of public work u>z 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, cheelang 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 carryworkers' comp ensation insurance. `an ce. If an LLC or LLP does have employees, a policy is required Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. .Also be r-V1r•e to sip and date the affidavit The affidavit should lie returned to the city or t o-�'n that the-hica.uon fixe the a license '�re ra r' r ¢ane p rmait or li .s ing . a.iest-Q,*not .Depart.-^ent of Industrial Accidents. Should oa have an �estions re di'=- the � U Y Y 4L Ia:: or, if you are req°sirea to obtain a workers compensationpolicy, please call the Department at the numbe=r 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 legibl3r. The Department has provided '& space at the bottom of the aff davit 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 cun-cut 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 ofInvestigations woi4d lrlm to thank you in advance f6r your cooperation and should you have any questions, please do not hesitate to give us a call • . The Department's address, telephono and fax member._.. The CGmmonwealtt2 ofMassachuset€s. Department of Faduustrial Accidents -Office of InweRdaat ons 600 WL'Ena:Ean Street Briton,, MA 02111 Ta 0 617-727-4900 est *D6 ar 1-8 "7-M.•4SS.A.FE Revised 5-26-05 Fay. # 6.17-727-7749 VMrVV-M.as--o,ov/dia 1 To: Town Of North Andover Pro -Care Disaster Restoration Services has finished all work needed to be done for the prior owner and does not work there anymore. Mani Estates, LLC I n� T . . d MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date IAP" t"0 BuildingPermit # Location ±%� ���Sea:v s'f�- ��.l'I9�-� Amount z Owner Owe rz� t�1AhE1 �. a=B�e�'✓�' ��'A iv�Ut✓� /� - - New 1:3 Renovation 0-' Replacement 0 Plans Submitted Yes No FIXTURES Date. .'!!A/- / 6)_ . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... PA.(-.-.. 1r�% , e.. . ........... . . . . . . . has permission to perform .. tk_ C ..... II. G<?. 1- .................. plumbing in the buildings of ...�`....... . at ... "'2 . JP .(.=.F ......5,�r... , North Andover, Mass. Fee .3 Lic. No../.0„✓f -2 k ..... . (�'..., . ` "'TTTPLUMBING INSPECTOR Cheek # /'3 `1 7 '�; By: Title City/Town APPROVED (OFFICE USE ONLY Partner. nFirm/Co. coverage by checking the appropriate box: r type of indemnity El Bond ❑ Certificate aware that the licensee of this application does not have any one of the above Owner 11 Agent 11 ion I have submitted (or entered) in above application are true and accurate to the and installations performed under Permit Issued for this application will be in issachusetts State Plumbing Code and Chapter 142 of the General Laws. igna ure 01 Licenseaum er Type of Plumbing License /'0S>0 �,/ (cense user Master E Journeyman 11 ",,Andrew DaSilva Pluinbing-Manager ; Aecount Executive ro-Care . 3 North Maple Street Wobum, MA 0180.1 Ph: 781-933-7400: '. Fax:781-933-1222. :Cell: 617-82878740. , "Restoring homes; businesses, andrew@pro-careinc.com . and livEs since 1987” ,". www. pro-careinc.com Fire Water M014 Plumbing By: Title City/Town APPROVED (OFFICE USE ONLY Partner. nFirm/Co. coverage by checking the appropriate box: r type of indemnity El Bond ❑ Certificate aware that the licensee of this application does not have any one of the above Owner 11 Agent 11 ion I have submitted (or entered) in above application are true and accurate to the and installations performed under Permit Issued for this application will be in issachusetts State Plumbing Code and Chapter 142 of the General Laws. igna ure 01 Licenseaum er Type of Plumbing License /'0S>0 �,/ (cense user Master E Journeyman 11 7358 Date..CJ/�.5�r.�......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that •... h r has permission for gas installation ... T . 't! ). : ............. . in the buildings of . ,f�1.E� ' /. r�14 /'/ . Check # l 2 r .......... North Andover, Mass. Fee. 3.!>.. ... Lic. No. 2 . ? /. ... I;a-I n........ INSPECTO Check # l 2 r A MASSACHUSETIS UNIFORM APPUCATON FOR PERWr TO DO GAS RTTJNG (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations 14 T lQ k±Lkc�^C,�, rk---' Cyr -it -r) Owner's Name New ❑ Renovation ❑ Replacement Date Permit # Amount $ ,l� � N 1 • �sS'�e S LL Plans Submitted ❑ Check one: Certificate Installing Company ❑ Corp. ❑ Partner. ❑ Firm%Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes © No© If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy1:1Other type of indemnity E]Bond ❑ Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 ofihe +,M�aGenera A s and that my signature on this permit application waives this requirement. Check one: e of Owner or Owner's Agent Owner Agent L L L 1 - ••�• f.y ���•.y Luau -1 .,. Luc. u�Mui5 �Iu w,uiivauun i navc summuea dor entereo) m 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 & Gas Codehapter 142 of the General Laws. own I 1 t1[ t tCV V P -L) (OFFICE USE ONLY) I Siftnature of 1 ❑ Plumber ❑ Gas Fitter ❑ Master Journeyman L vt �i 0 F (r C7 vi O FF U W d O O Z W W C7 U m C�� �" rr W c�q 0 a O O W a p W SUB -BASEM ENT U BASEMENT 1ST. FLO O R 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR - 8.T•H. FLOOR Check one: Certificate Installing Company ❑ Corp. ❑ Partner. ❑ Firm%Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes © No© If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy1:1Other type of indemnity E]Bond ❑ Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 ofihe +,M�aGenera A s and that my signature on this permit application waives this requirement. Check one: e of Owner or Owner's Agent Owner Agent L L L 1 - ••�• f.y ���•.y Luau -1 .,. Luc. u�Mui5 �Iu w,uiivauun i navc summuea dor entereo) m 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 & Gas Codehapter 142 of the General Laws. own I 1 t1[ t tCV V P -L) (OFFICE USE ONLY) I sed Plumber Or Gas litter Z X dS / License Number Siftnature of 1 ❑ Plumber ❑ Gas Fitter ❑ Master Journeyman sed Plumber Or Gas litter Z X dS / License Number The Commonwealth of Massachusetts .. Department o f Industrial Accidents Office of Investigations ..600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Plea Print Leaibiy Name (Business/Organiza6on/Individual): Address: City/State/Zip: Phone #: 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 comn=satzon 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 sub -contractors and their workers' comp. policy information. lam an employer that isproviding workers' compensation insurance for my employees Below, is thepolicy and job site information. Insurance Company N Policy # or Self -ins. Lie. Expiration Date: Job Site Address: / cJ cs o YU City/State/Zip:p p� Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). nev4q 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 certify under the pains and penalties of perjury that the information provided above is true and correct Simature: 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: b Phone #: Are you an employer? Check the appropriate box: L ❑ I am a employerwith 44. ❑ I am a general contractor and I employees (full and/or part-time).* 2, ❑ I have hired the sub -contractors 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.) 3. ❑ I am a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp, insurance required.] e *:.ny applicant that checks box #1 must also fel c:ut fat: section below 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 comn=satzon 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 sub -contractors and their workers' comp. policy information. lam an employer that isproviding workers' compensation insurance for my employees Below, is thepolicy and job site information. Insurance Company N Policy # or Self -ins. Lie. Expiration Date: Job Site Address: / cJ cs o YU City/State/Zip:p p� Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). nev4q 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 certify under the pains and penalties of perjury that the information provided above is true and correct Simature: 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: b Phone #: Information as d 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 perrson 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 maintemance, 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 coxnpliance 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 certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with.no employees other than the J 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 rettuued to the city or town that the application for the pernaitor license is being requested, not the Department of T.ndustrial Accidents. Should you have any questions regard:rLg the law or if you are required to .obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only'submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business. or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. . The Office of Investigations would Like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call, The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investibat ons 600 Washington Street Boston, MA 0.2111 Tel. # 617 -72.7 -4900 -ext 4016 or 1-877-MASSAFE Fax # 6.17-727-7749 Revised 5-26-05 Wmm,-mass.-gov/dia . COMMONWEALTH 0 MASSACHUSETTS IN PLUMBERS AND GASFITTERS LICENEgg��, V#AN PLUMBEF <:. HARRY 'TIERNEY ! 5 OLD DERRY RD P LONDONDERRY NH 03053-2221