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HomeMy WebLinkAboutMiscellaneous - 79 BOXFORD STREET 4/30/2018 (2)� -5 ° coal N v c'1 p m" q v i� o ;? o •�� U p CJ Pa 'C1 R' .q 4� w {��jy R la w o C7 m o q ami 'q N �� O d o b❑ O,N•t .^tea 0 ^QOj ti c'�l bA y U t-. •O Lei pq� N R1 �' f 4 O bdo X N Y-/ y 0 cd o w A ,� cpi q O .� 4y . � •a •C .y N .0 O � q0 �= � a 4,3 O 0} O 4a O 0. a- t'7 ��I ]� q 4� 'R ti 'b � � '.-p^•. ogo cps .O .a iv �1 4�., O ,`+3-'�y.,' y''-+ p u�cn ti w o . � �.ao-' d �b A � o b0 boo N b t -I H w p q .n pc O O O t_ '9 p 7W O c �5 O O b 4 .a V O m y p w El N N O h A o d bo q cl,'a •o 'G P. on. p.�' y o q °� O � N � b � a�3i .� `c� api by p,� by T •`� �".- o N ro m w 9 N ZSp t���+ 4..ii U.44 1Ui 4 VC 2 N Uy , U O Flbll rt�l U .ti O$ o. -11 0 y •p .ate E •g N q b 'b o rn •q 4o .M.coq E-' u� abi . �l I cd ... w rO� PWµ, in w a] p Fi U 4ti V 0 p ,y ori! U 1y 0 7Fi p, Date ... 1. — 7,, 4�-- /Z, ............................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING % -T�C- ertifies that .... ..................... This c ... has permission to perform ..... 4,.9.d?Px— wiring in the building of ................ ...................................... at ..... n !!�Ox 1*,OL) Sr .. ............................................................ North Andover, ass. Al -!� ........... - Fee...._.... ............. Lic. No... . .......... CrIuc INSPECTOR Check# 15 " 7j .10606 lr (f1mftwnwea& of )WaedachuaeffJ e1.Jepar�ment o��ire �erviced BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMAT ON) Date: x�a3,111Z City or Town of:' o.:T� .�. s mac. 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) ] 9 &AA* r, d -;- Owner or Tenant Q LaE,C .0 s if .s Telephone No. Owner's Ad, 5"7—n-1 .1 N A Is this permit in conjunction with a building permit? Yes ❑ No 2- (Check Appropriate Box) Purpose of Building �& - q f c n" 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: sic o2 _ /N1 ACLIc� 8� �/iJf.2S �Cpf .$NtJGJ I't �C%i.tf Cmm�letinn nftha fn llnwina tnhlo mm� ho wn;vo.i h„ ��o !»�„e..in.. ..f W;.�.. 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 ❑ n- ❑ lNo. ot Emergency Lighting rnd. grnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. o Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of.Alerting Devices No. of Waste Disposers eat Pum um, er ons o. o e m - ontae Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KWSecurity ystems: No. of Devices or Equivalent No. of iter K,,i, Heaters No. of No. of Data Wiring: Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsWiring: No. of Devices or Equivalent OTHER: a Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: _ / ,y,�, . (When required by municipal policy.) Work to Start: j&?ft� z Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑, OTHER ❑ (Specify:) I cert, under the pains and penalties of perjury, that the information on this a pli tion is true and complete. FIRM NAME: 5q,13 — + S. a%3 -, LIC. NO.: /lapag Licensee: 1"A i C4tQ If� S.nA,- RAJ Signature LIC. NO.: &,2p; 4 (If applicable, enterVempt" in the license number lin 7Y'y Bus. Tel. No.: 2-- P4r-Z , Address: we Nat_ O/P/3 Alt. Tel. No.: 7Y-LrS 6- e3 *Per M.G.L. c. 147, s. 57-61, security work requires Dep ent of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that4be Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts Department of 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 Please Print Legibly Name (Business/Organization/Individual : Address: ?j �a /7 ..,,— Rd City/State/Zip: Phone #:_2 Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition. 10,M Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must' also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ( % i Policy # or Self -ins. Lic. #: `f T tJR A R G. �� 1,7 ? t l Expiration Date:Q/,� Job Site Address:__ 79 City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as 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 unr the pains and penalties of perjury that the information provided above is true and correct. Si nature: Date: / Z 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 Cleric 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Are you an employer? Check the appropriate box: LI am am a employer with /y 4. ❑ I am a general contractor and I employees (full and/or part-time). * have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. $ ship and have no employees These sub -contractors have working for me in any capacity. workers' comp, insurance. [No workers' comp, insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. C. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required ] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition. 10,M Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must' also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ( % i Policy # or Self -ins. Lic. #: `f T tJR A R G. �� 1,7 ? t l Expiration Date:Q/,� Job Site Address:__ 79 City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as 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 unr the pains and penalties of perjury that the information provided above is true and correct. Si nature: Date: / Z 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 Cleric 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: N . oo 3 a a •U (� � G U U l� •� W O 41 cra' C aCi C .N-� O pcd tU�..Nr .fl p+ y �y s �L� 4 � ��b^'bo 3 ao o N o ob 7 a o od nai 0 'Cl 1~ 'o d a, � a ^� ❑ 3_V_�rca aan o°Aaxi`a Old ° aho ° y n UN y+". C o v~a O y O G`V v H p q C .� U� W w42 '-r❑❑-'I G c�pi ' C O N O c00 .O .0 y M W � Op i0 N N ti cr.,p p Coa `� p .0 v w o N Op i., (� U UXr O O •gid ?.� G 2 0 . OU pin 0 ❑ C cNa C O 2 is O •N nz ^ U •� 'O O •� y0 N GL N V p i td' O" W .r. -t' ow L �� ywo.�.wo a.. o+ o d 3 0 W v B o w'4 C [��b W o o ��y� w O tC ^� C a�Ci 0 W � C A U � � �.,,' O A N •� W .0 a NO a� y •FL' a4. mi of GLS '� `n •O O (n 1 N a. 0 G P+ 0 ca ,. H c a := N Date ....7--g7.z7. �f TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........... :�� /-ov ..... R.t;;'L) ....................................... has permission to perform .... t.t.0 ....... pxvnl).................. wiring in the building of ............ ........................................ .. .......... at ...... ) . . .... .. .......:5 . ................. North Andover, Mass. Fee .4...�.5. .... �77e. ......... Lic. No. 2 i�S�ECTO ..... iE �RICA Check# /L/O/ Z-3 8909 A Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 990j BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.l/07) (�PavPhlanl.\ APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 C R 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date:�of Q City or Town of: NORTH ANDOVER To the Insp foiYes: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number)��(i �o,�Fy Owner or Tenant �, yam/ „ Af Owner's Address Telephone No. b uer of Feeders and. Ampacity Location and Nature of Proposed Electrical Work: Is this permit in conjunction with a building permit? Yes ❑ No Purpose of BuildingL N (Check Appropriate Box) — �`es7�'.t���/ Utility Authorization No. Existing Service Amps / Volts Overhead❑ -- Undgrd ❑ No, of Meters New Service Amps _ / Volts Overhead ❑ Undgrd ❑ No. of Meters Nm No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires - No. of Receptacle Outlets Ean ches es te Disposerswashersrsr Heaters KW it No. Hydromassage Bathtubs OTHER: 0 Com letion -,"the No. of CeiL-Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool -d e ❑ �- ¢rn No. of on Burners No. of Gas Burners No. of Air Cond. Total Tons Space/Area Heating KW Heating Appliances KW No. of No. of Signs Ballasts table may be waived by the Inspector of Wires No. of Total Transformers KVA Generators KVA ❑ IN D. or Lmergency Lig nhI'i g— Batte Units _ FIRE AL ,CRM_S No. of Zones o..of Detection and Initiatin Devices No. of Alerting Devices o. of elf -Contained Detection/Alerting Devices Local❑ unicipal Counectinn ❑ Other No. of Dei Data Wiring: No. of Dei of Motors Total HP ITelecomn No. of or or Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (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 andpenalties of perjury, that the information on this application is true and complete. FIRM NAME: Licensee: �T�ti ? � LIC. NO.: (.f pp Si:�� ature LIC. NO.�fO$, L (Yapplicable, licable, enter "exempt " in e license line.) Address: /` dU JJ`` Bus. Tel. No.: Jf�Grt o?J(r, ®y *Per M.G.L c. 147, s. 57-61, security work requires Departrnent of Public Safety "S" License: Alt TelLic. 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 El owner's agent Owner/Agent Signature Telephone No. PERMIT FEE. $ 0 c r The Common wealth of Massachusetts Deportment of Industrial Accidents Office of Investigations 600 Arashington Street Boston, MA 02111 t ' www.nwss gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aaolicant Information Please Print Lembly Name (Business/Orgmization/individual):_ 0��70 "'W" _ Address: City/State/Zip: 9>,.- Phone #: Are you an employer? Check -the appropriate box: l I am a employer with 4, ❑ 1 am a general contractor and I employees (full and/or part-time).* 2. El am.a:sole proprietor or have hired the sub -contractors Iisted t partner- on the attached sheet ship and have no employees These sub -contractors have working for me .in any capacity. [No workers' comp. insurance 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. 1.52, § I (4), and we have no insurance required.] t employees. [No workers' comp. insurance required..] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. Q Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I I S7 Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other rut our me S=1011 below showing their workers' compensation policy information, t homeowners who submit this affidavit indicating they doing all work and then hire outside contractors must submit a new affidavit indicating such. tContracffidare tors that check this box must attached an additional shear showing the name of the sub -contractors and their workers' comp- peiir Jr fr.1brrnction. I am an employer that is. proviing:workers' compensation jnsurancejor)M employees; information. Below is the policy aced job site Insurance Company Name: 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 dale). 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 andpenaldes of perjurythat the information provided above is true and correct Si tore: 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): I. 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 coritracting 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), addresses) amd 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 t 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 numberfisted 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 ofthe affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-8.77-MASSAFE Fax 4617-727-7749 Revised 5-26-115 www.mass.gov/dia Date. 6 ........ TOWN OF NO PERMIT FOR GAS INSTALLATION This certifies that ...� C..l.. .../,.G.! S.0 . 6........... ........ has permission for gas installation .. c C tz �'l`.� in the buildings of ...{4. /.. Lt r.P s .......................... at ..... xt.U11 ............. North Andover, Mass. Fee. 3.q' Lic. No. .... ..... F. ! /,I....... . G�S INSPECTOR Check # t c, 6878 rty ❑ Bond ❑ Owner's Insurance Waiver l.am aware that the licensee does not t the Insurance coverage required Cha Mass. General Laws, and that my signature on this permit application waives this requirement. by Ater 142 of the Signature of Owner or Owner's Agent Check one: I hereby certify. that all of the details and information I have submitted Owner ❑ Agent ■ best of my knowledge and that all plumbing work and (or (or entered) in above a app] compliance with all pertinent provisions of the Massachusetts 5 Performed under Pe pp cf ron are true and accurate to the nnit Issued for this application will be in Code an 142 df the General Laws. C/ . By: Title City/Town • _ APPROVED (OFFICE USE ONLY) ❑Signature of Licensed Plumber Or Gas Fitter Plumber � ® Gas Fitter tcense umber ® Master Journeyman MASSAC'H[1SET'Is UNwORM APPLdCATON FOR PERMIT TO 1)0 GAS SING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date \.,%U 1 �S Q Building Loqations y Pennit # )01 V�Owner's Name L`�N no Amount S s- N ew � Renovation � Replacement El � � 1 hd us � Plans Submitted ❑ � ca Iz! ' � C w w �' � a , zW p � m� •� N �" � � [• w U w to -• d rn ate' a C = O �• Z FO C �' > F x e4 W F C w SU B-BASEM ENT z w S a BASEMENT. > G O ]ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR `5 TH. FLOOR 6TH. FLOOR J 7TH. FLOOR 8TH. FLOOR. (Pr int or type) Name Che Address ne: Certificate Installing Company Corp. c usiness a ep one �?' �S ❑ Partner. Name j�j E.�,S Firm/Co. of Licensed Piumber'or Gas Fitter INSURANCE COVERAGE I have a current liability Insurance,.policy or it's substantial equivalent Check one: yes ❑ If you have checked Yes, please indicate the type coverage by checking No Liability insurance policy, the ❑ . Other type of indemn' appropriate box rty ❑ Bond ❑ Owner's Insurance Waiver l.am aware that the licensee does not t the Insurance coverage required Cha Mass. General Laws, and that my signature on this permit application waives this requirement. by Ater 142 of the Signature of Owner or Owner's Agent Check one: I hereby certify. that all of the details and information I have submitted Owner ❑ Agent ■ best of my knowledge and that all plumbing work and (or (or entered) in above a app] compliance with all pertinent provisions of the Massachusetts 5 Performed under Pe pp cf ron are true and accurate to the nnit Issued for this application will be in Code an 142 df the General Laws. C/ . By: Title City/Town • _ APPROVED (OFFICE USE ONLY) ❑Signature of Licensed Plumber Or Gas Fitter Plumber � ® Gas Fitter tcense umber ® Master Journeyman p. (, �? IQ ., , r, OJ Marsachusear Department Of Indtcstrial Accidents . Vice of Investigations 600 Wasizinaton Street Bosstoaa, M,4 (12111 Workers, Compensation Insuranceffid n t.ftoz�� )ficant Information �vit: Buuders/Contractors/Eiectridians/P'iumirers Name (Business/OrganizabclnM&ividual}: - City/Slate/zip, Are yon an employer? Check thea appropriate PP priate box: 1 • ❑ I am a etnp}oyer with ----. 4' ❑ 1 am a merleml contradtor and I Type of project (required); emp}oyees (iu71 andJar part-time).* have hired the subcontractors .6 New construction 2 ❑ 1 atn asole proprietor or partner_ Iisted . St and have no empioyem Theses Lite attached sheer 1 ?' ❑Remodeling . working for me in any capacity. workers b cOn ors have ' Cornp. ins 8' ❑ DernoIition [No workers' comp. insurance 5. P want„ required ] We are .a corporation and its 9' ❑ Building addition L [ am ahomeowner doing all work right have exercised.their 10: of ex„ ❑ Electrical repairs or additions myself. [No workers' comp. c. 1$2 �mpt7on per MLrL 11.❑ P}tmlbinQ r. insurance required.] t ' 1(4), and we have no impairs or additions 'employees. [No workers' 120 Roof repairs comp. insurance required.)' 13•[] Other `Any appiicant.fhat cheeks box # I .must aiso fill our the section below sho i Fiomnowoea who submii.ihis agdavit indieatin� they arc orf,, to w�tir�ng their workers' compensation ori , Kona -tors that check this bax Must r •--occ Shen hire outside coniructurs Pati summit tew attached an additional sheet showing the name.of the sub c�„tots and their work=' amciavii in_imring each. I raraz as employer that ;Providing wore 5' cm mmP• Policy iaronnntion. ig for rtadm mP��rz i'U';U�e• for , e // � mployees Below is the pofic3' and job site Insurance Company Name: k;QL,Pc-e *T'' Policy # or Self-.irm Lid. #: D S v v Job -Site Address: ,�0S Expiration D — G� . Attach s copy of the workers' compensation policy declat-ation a Cts/Sta ip: v�� P.. showi r< P Failure to secure coverage as required under Section 25A of ( the policy number and ex I ' ' fine up to 51,500.00 and/or one-year imprisonment, as well MGL c. 152 can lead to the imposition of to . Of up to .5250.00 a day against the violator. Be civil penalties in the form of a STOP f criminal penalties of a advised that a pppy of this stat r) the May RDER and a fine Investigations of DIA for insurance coverage verification_ be forwarded to the 'Off ce of ••, _e. cod cerajy u th paint and P ojperJu?' ilial the Si �rtafvre: informafinn Provided above is true and correct official use only. Do not write in kris area to be rorrrp 3 citJ� or town ofdal Cite or Town: issuing Authority (circle one): Permit/License # I. Board of Healtb 2. R"ding Department 3. City/Tov�.n Clerk 4. Electrical inspect., S. PiumbinQ e Iaspector Contact Person: Phone # iLnivi maLlvu i=a itu 1u15Lt ucrio IS a Massachusetts General.Laws chapter 152 requires all employers to provide workers' compensatior for their employees. Pursuant to this statute; an employee is defined. as y. 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 incluci-ng the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, associati on or other legal entity, employing employees. However the owner of a dwelling house -having not more than .three ap: a -trn ' sand who resides therein, or the occupant of the dwelling house of another who employs persons to do mintenance, construction or repair work on such dweiiing house or on the grounds or building appurtenant thereto shall not because of such employment be d.-,-mmed to be. an employer." MGL chapter 151 §25C(6) also states that "every state ar local ii=miag agency shall withhold the issuanceor renewal of a license or permit.tb operate a business or- to construct bubdings 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) sues "Ne"rther -the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public wor% until acceptable evidence of compliance with the insurance requiremearts of -this chapL-r have been presented to the contracting authority.". Applicants Please fill out the workers' compensation affidavit coMP'll-etsly, by checking the boxes that apply to your situation and, if i 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. rf an LLC or LLP does haveAk ._ employees, a policy is required. Be advised that this affiel-avit maybe submitted to the Department of. Industrial Accidents for conformation of insurance coverage. Also ]be sure to sign and date the. affidavit. Theaffidaviishould 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 re_*�-ding the -Lam, or. if you are required to obtain a workers' componsabon policy, please call the Deparnnent at the Taximber,Iist.ed below. Self-insu rcd conra„ies should enter their self-insurance lic~rnse number on the arnronriaxe line. City or Town Officials Please be sure that the affidavit .is complete and printed Ie�rbiv. The Department has provided a space at the bottom of the .affidavit foryou to fill but in theevent the Office of Investigations has to contact you regarding the appiimnL Please be sure to fill in the parmitAicense number which will be used as a reference number. In addition, an applicant that most submit multiple permit/hcense applications in arty 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 official}} 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 Iirenses. A new affidavit roust be filled out each year. Vrhere a home owner or citiz,-n is obtaining a ticens` or permit not related to any business or commercial venture (i.e. a. dog license or permit to burn 1maves etc.) said pe -non is NOT required to complete this afndavit. The Office of Investigations would Iike to thank youin 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 far, number: The Commonwealth of lasma chusetts Departmml of Lmdumtrial Accid:,>'rts Office of Lxtvestigations 600'WashLi gtQn Strict Boston; lA (12111 Tel. # 617-727-4900 *--1406 c r 1-877-MAssA.FE Revised 5-2645 Fax 4 61 7-72.7-7749 WWW-Mass.gov%dia ,r • O w rte,, * PNO wi O V VI IM M a 4J Cd rf U V V co I \ N y a v N Off^^/ V L W C O W ev L N O N ti ti W co 00 U o 0 N N w r N r LO rz� w co W Of ,40RTH o 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... . .................. has permission for gas installation .414 .............. in the buildings of r. f ............................ at ........ North Andover, Mass. Fee. A Lic. No........... Check# GAS INSPECTA 5 '/'- 6 ) MASSACHUSETTS UNIFORM APPUCATON FORPERMPTTO DO GAS FTrrING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date --� DD y l () ✓t—� v! Permit # .� z^ G Z" Building Locations Amount $ A_C Owner's Name 14 o h44 New (�/' Renovation ❑ Replacement ❑ Plans Submitted ❑ 0 z F c a0i F � O � o. O °G � E+ `n w E O p� F z O w U H CW7 zz a W� E. z 1] U' 0W 0 w N 04 JE O aC O A C7.0 A SUB-BASEM ENT B A S E M ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR STH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type) Name Address L) 2 Check one: Certificate Installing Company Corp. 0 Partner. ❑-Firm/Co. Name of Licensed Plumber or Gas Fitter �i /� 414 `Z/' ,Q - INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes o--- No ❑ If you have checked yes, please indic a the type coverage by checking the appropriate box. 13Liability 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with ail pertinent provisions of the Massachuset tat as Code and C apter 142 o he General L ws. A v� c� VED (OFFICE USE ONLY) Signature of Licensed plumber Or Gas Fitter Plumber ) 3 ❑ Gas Fittericense'Number 0—Master 1:1 Journeyman Location 2 9% l . No. "-- Date, NORTH TOWN OF NORTH ANDOVEPe cS Certificate of Occupancy $ y -BuUding/Frame Permit Fee $ U y+s cHmst CHU Foundation Permit Fee $ s� F Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL /�� °° _--'S/ Building Inspector 9873 Div. 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C C Z CD V 0. 0� coC co -55959 DEPARTPIENT OF PUBLIC SAFETY 55959 ONE ASHBURTON PLACE, RM 1301 BOSTON, HA 02108-1618 CONSTRUCTION SUPERVISOR LICENSE Number: Expires: Birthdate: CS 054.268 05/11/1998 05./11/.19.61'; Restricted To: 00 MAY `> j 1996 - -- CHARLES J WOOSTEP. � Detach bottom, fold sign on PO BOX 8051 hack, and laminate license card. LOWELL, MA 0185.3 Keep top for receipt and change of address notification. ✓lee �omrmroN.uea,/,�z o� �ifaaea�rroe%YJ Restricted To: 00 HPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE 00 - None Nurber: Expires: Birthdate: lA - Masonry only CS 054268 05/1111998 05/11/1961 16 - 1 & 2 Family Hoes Restricted To; 00 Failure to possess a current edition of the "' Massachusetts State Buiilding Code CHARLES J WOOSTER is cause for revocation of this lirense, PO BOX 8051 LOWELL, MA 01853 55959 NHUNU5AL Proposal No. "WE'RE ALWAYS ON TOP iii, 0",,,i. ', .I ALL TYPES OF. ROOFS' Sheet No. CHARLES WOOSTER LOWELL—(508) 459-1501 Date 4/12/96 f; LAWRENCE—(508) 689-2174 REASONABLE • • ' • • NASHUA, NH—(603) 886-6818 , Put Your pool under the protection of Our Umbrella DEPENDABLE P.O. Box 8051, Lowell, MA 01853 Proposal Submitted To Work To Be Performed At Name `Lyndon Holmes Street Street.179 Boxford St. City City'4 .No.. Andover State Zip Code Date of Plans ,.State�f�_ - Zip Code 01845 Telephone Number 682-0928'-.,975— 0 Architect We hereby propose to furnish the matena s and perform the labor necessary for the completion of the following job. Strip ' the entire roof rown to the roof deck a chiding the rear addi-ti.Qn 1 ' Reilace anrotted roof decking at $1.50 per foot, 2., Install 8" aluminum dri,Pedge on all raked eaves, 3 .Install GAF Weather Watch ice and water 4 "Pa er:"i-emainder of roof with 5 Inst 11 -Bird seal Kingi.25 year shingles, 6 Install ne o f 7. I " round soff I it vents every 32" on all eav-. 8. Clean ana-dispose of all debris. OPTION T... Y r e,h a -tin a ul Il. Workmanship guaranteed for 10 years. We are fully insured with workers' compensation as well as liability insurance. Please return copy of proposal. All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and spec- ifications submitted for above work and completed in a substantial workmanlike manner for the sum of Dollars ($ 3 , 75 0 0 0 .-4Mith payments to be made as follows: Job paid upon com - Respectfully submitted Call For Our Refeepees — _ ote--Thi . proposal may be wRhdrawn by Fully Insured' us if not accepted within days. -- ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are-hefeby-accepted--You are authorized to do the work as specified. Paymerit will be made as outlined above. Date Signature t S, :i1:• -ens.' '. OFFICES OF: — __ _ ` _-� _ EAt.S North Andover, RPP �.y. =NORTH ANDOVER BUILDING t,e MassaCtlusetts O I8 -ss CONSERVATION DIVISION OF HEALTH - --- PLA-N-NING PLANNING & COMMUNITY DEVELOPMENT 4 KAREN H.P. NELSON, DIRECTOR In accordarce with the;re: sic �t z;f MC;. c _;, S c- c cor,�+ic:en of Building PermitNumbers that ,••e de�ris resulting Prem this work shall be dispose:.' of in a prcne: _-�;� _olid ;ast..is^^s�. , as ... C44 by .NIGL. c II'. S i ne debris will be disposer! cr in - 5 -,"f �,, Sic .'a:::e Of Pcrtnit Applicant Date udarr� ,l�ff_ Demolition permit fro= the Tota of :forth Andover must be obtained for this project through the Office of the Building Inspector. ol2 3797 t1- Date. 1 Date . l TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that /�'... %'. °� ........ . has permission to perform... g.r ........................ . plumbing in the buildings of .. f�o.1,Wc.s.. , at ... .......... North Andover, Mass. Fee.3,�t Lic. No. V % . ............................. . PLUMBING INSPECTOR 03/24/98 09:1408/24/48 09:14 35.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 4-4 4%A ^rrL.A%0AjjUn r%jn rrnffljj &%j Lj%j NORTH ANDOVER, M118L [)at,@ CIF Building Location f7 9 New 0 Renovation Replacement IFIXTUREd Permit 10000000100� 01 Owner's Name X0, 13 Plans Submitted: Yes [3 No. C3 installing CAMpany Address business Name of Licensed Plumber — Check one: "C. 13 Partner ship 0 Firm/Co. INSiJRANCE COVERAGE: 1 —11 ; che I have A current IlablIty Insurance Policy or Is substantial equ"enL - y,,cvm No 11 9 Y�u have checked yjj. pies Indicate- the type coverage by checking the appropriate box liability Insurance policy Other type of Indermily (3 Bond 13 Cadvicate 6a�3 6WHER'S INSURANCE WAIVER: I am aware that the 11centies does not ham the insurance coverage required by I Chapter 142 of the Mass. General Laws. and the . (my I signature an this Pormit application waives this requirement., Check one: SiNtuff of ownst or Own"'$ Agent Owner 0 Agent (3 I husby wilty, that all of the details Lnd InImmation I have gubmitled W onterso In ebm spofiuUm are * .A , , 0 and that all 4umbInQ'Woik and installations performed undw the pgnM Issued W: true and accurate to the best of my ;Wk;e—nrPfo,As1ons - of go Monschusetts State Plumbing Code wW Chaptw 142 of Vw Gum =!katlonwill be In complance with a . A 0"MID (OrFICE USE ONLY) Sign&ItXS Of LJ=3od bor Licanu Numbee &/j q Type of Plumbing Ucense: Master 19101 Jouinsyman 0 - - - - - - ... . ... F I' I CrTT-rmjXm MENNEN N MENEM EWEN rcnm", ENNEEMEM ME MEMO ME MMEMENNERNME ENEMENE NONE MAMEMENIMENUM installing CAMpany Address business Name of Licensed Plumber — Check one: "C. 13 Partner ship 0 Firm/Co. INSiJRANCE COVERAGE: 1 —11 ; che I have A current IlablIty Insurance Policy or Is substantial equ"enL - y,,cvm No 11 9 Y�u have checked yjj. pies Indicate- the type coverage by checking the appropriate box liability Insurance policy Other type of Indermily (3 Bond 13 Cadvicate 6a�3 6WHER'S INSURANCE WAIVER: I am aware that the 11centies does not ham the insurance coverage required by I Chapter 142 of the Mass. General Laws. and the . (my I signature an this Pormit application waives this requirement., Check one: SiNtuff of ownst or Own"'$ Agent Owner 0 Agent (3 I husby wilty, that all of the details Lnd InImmation I have gubmitled W onterso In ebm spofiuUm are * .A , , 0 and that all 4umbInQ'Woik and installations performed undw the pgnM Issued W: true and accurate to the best of my ;Wk;e—nrPfo,As1ons - of go Monschusetts State Plumbing Code wW Chaptw 142 of Vw Gum =!katlonwill be In complance with a . A 0"MID (OrFICE USE ONLY) Sign&ItXS Of LJ=3od bor Licanu Numbee &/j q Type of Plumbing Ucense: Master 19101 Jouinsyman 0 R s • .Y � r L�F�^• ,: �t�r1r j: �, � r.� � i .....:e.t'�}�",, ate.,. , .rx% v >,+� ` � :, -. C \ Office Use Only7_3� P - = 014tLfommnnwra1t4 of Ioont�uoE#s Permit No. R +9epartment of Public $afeitr Occupancy &Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 (leave blank) -y�OL 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 (%* or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Owner or Tenant - Owner's Address �d Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Buildings IT�) V_:Z fv <V2- Uti 'ty Authorization No. Existing Service Amps __I Volts Overhead ' Undgrnd ❑ No. of Meters New Service Amps _J Volts Overhead Undgrnd ❑ No. of Meters Number of Feeders and Ampacity p /� i Location and Nature of Proposed Electrical Work © �cA-MA C-14 'F—)(AST1 0 G ?—L5V—:CL No. of Transformers Total No. of Lighting Outlets No. of Hot Tubs KVA No. of Lighting Fixtures I Swimming Pool grna. r- grnd. _ In-77 grnd. '_ I Generators KVA No. of Receptacle Outlets I No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Cutlets I No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained DetectionlSounding Devices Municipal Local ! ! Connection Other No. of Ranges No. of Air Condi Total tons No.of Heat Total Total No. of Disposals Pumps Tons KW No. of Dishwashers I ScacetArea Heauna KW No. of Dryers Heating Devices KW No. of Water Heaters KW No. of No. of Signs Sailasts Low Voltage Wiring No. Hydro Massage Tubs I No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the recuirements of Massachusetts general Laws — I have a current Liaoiiity Insurance Policy including Com c:Q ec Operations Coverage or its substantial equivaient. YES NO I have suomitted valid proof of same to the Office. YES _ NC = If you have checked YES. please indicate the type of coverage by checking the appy riate box. INSURANCEBOND OTHER = (Please Scec:fy) — — — (Expiration Date) Estimated Value of Electrical Work 5 Work to Start Inspection Date Recuesteo: Rough Final Signed under the Pfn�enaities of perjury: y�' + FIRM NAME TtJ 1.�� �1CAL— " LIC. NO. Licensee W ` -K—ANQhZZ SignatureLIC. NO. �++ Z� Bus. Tel. No. _�-7S �Z I 1 Address L V� Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee coes not have the insurance coverage or its substantial equivalent as re- cutred by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent {Please check one) / [, d0 Teieonone No. PERMIT FEE S / (Signature of Owner or Agents x-5565 Date ..... 2652 ,koRTH TOWN OF NORTH ANDOVER 0 p PERMIT FOR WIRING ,Sg�CMUSEt This certifies that ...... ( ........ / ............ has permission to perform ..... ........... W.:t ............. wiring in the building of ........... /Vzklll!� .. . ............................................. .. at ...... v... sr ........................ North Andover, MM S. Fee../,5.,W... Lic. No... /13-710V . ......... ECT CAL INT OL 11/01/95 10- 15.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File Date..I. //.. . (� .7...... . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ..... .: � ... �.......... °. t ..°..... f /-/ ................. has permission for gas installation in the buildings of ... t !.................................... at C<. Y..1: ......... , North Andover, Mass. Fee. 3.�. `.... Lic. No.:.`. '.`....... �... c :r �.......... . if GAS INSPECTbR Check # /079/ 4313 MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) ' Date LL I)`4 :3 NORTH ANDOVER, MASSACHUSETTS Building Locations _ _ _7 / 13o X f J 2l c)� Permit # Amount $ 3 New Renovation ❑ J Owner's Name Replacement ❑ Plans Submitted ❑ (Print or type) ��— ` ec one: Certificate Installing Company Names �%� /� -4- -e. Corp. Address -- !�(U� c� ❑ Partner. �. <—L L -' :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 ❑ Ifyou have checked yga, please indicate the type coverage by checking the appropriate box. 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ i nereuy cemry mai an or the aetaus and mrormation i nave submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for is application will be in compliance with all pertinent provisions of the lVlassachus tate Gas Q0de and ChavW 142 ofthfGeneraiZws_ [City/Town VED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber 2Z,7' ? ❑ Gas Fitter Icense N11 er F:] -/faster ❑ Journeyman • (Print or type) ��— ` ec one: Certificate Installing Company Names �%� /� -4- -e. Corp. Address -- !�(U� c� ❑ Partner. �. <—L L -' :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 ❑ Ifyou have checked yga, please indicate the type coverage by checking the appropriate box. 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ i nereuy cemry mai an or the aetaus and mrormation i nave submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for is application will be in compliance with all pertinent provisions of the lVlassachus tate Gas Q0de and ChavW 142 ofthfGeneraiZws_ [City/Town VED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber 2Z,7' ? ❑ Gas Fitter Icense N11 er F:] -/faster ❑ Journeyman