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Date
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
3»
This certifies that .0.
has permission for gas installation . 2 ... , • _
in the building of ..... lh,)I� �? ..,,••„•,.•.••.....••..
at ... .. �,- �.1...C�..... North Andover Mass.
Fee ..7�--,.. Lie. No..1. 119.. M -, .............. ...
GASINSPECTOR
Check #
8824
A
d
U
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING W RK
CITY MA c.+� ,_ �- MA DATE�glbia PERMIT # ---
JOBSITEADDRESS CN OWNER'S NAMEy ;rY►y c�� ��A�,C,m- it
OWNER ADDRESS �t_ � _ TELF—_ _ FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL ._
PRINT
CLEARLY
NEW: 0 RENOVATION: 0 REPLACEMENT: 0 PLANS SUBMITTED: YES 0 NOD
APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILERsr
BOOSTER L -J I ._._... l
CONVERSION BURNER—
COOK STOVE
DIRECT VENT HEATER
DRYER
_.-�
FIREPLACE (-. I_ I ( - i l _l J -�
_ _ ,
FRYOLATOR
FURNACE -.__-:T:,1.
GENERATOR...__ - ( I_ — I ! (� J ---j _E
GRILLE
INFRARED HEATER __j 17 ___J
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER—�
ROOF TOP UNIT
TEST
f -
_
UNIT HEATER--
UNVENTED ROOM HEATER
WATER HEATER
OTHER —_ __ l �. L T! _ ! j 1=
:::.. _J _ I _
I I
_ 1_�– _- I i -._ _f ._ __ I ( -_- ,�_ - =- –=-- �- : � � r.-,�� I s_�_ J �_ __ _J _=r�� L--_ _z,► C_ ,�-1 -t
_ _
INSURANCE COVERAGE
Ch. 142 YES 1[ 0
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. _.�__�
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY � OTHER TYPE INDEMNITY 0 BOND
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER L--�] AGENT [�(
SIGNATURE OF OWNER OR AGENT
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
the
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all ert' a ovision of
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUM BER-GASF ITTER NAME GW\�� ea T....._.._— LICENSE #[?Sil._- J SIGNATURE
st . _ �I(
PARTNERSHIPLLC F]# f_-.,_. . - .._.._.�
MP �GF C� JP [_-] JGF ._- I LPGI .__( CORPORATION '# -_-= E]#=
<a`.a . -) ADDRESS
���._� � -
COMPANY NAME:kmmum
CITY. STATE _�J ZIP OI_. V` _ITEC
FAX I - 11 CELL EMAIL
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The Commonwealth ofliiassachusetts -
Department of IndustrlglAccidents
Office of Investigations
to 600 Washington Street
Boston, MA 02111
www.mass gov1dia
Workers' Compensation Insurance Affidavit: JBuilders/ContractorsfFIectricians/Plumbers
,applicant Information Please Print Legibly
Name (Business/Organization/individual):
Address:P� `VI u� ��1, a�
4
City/Stale/Zip:j Phone l ^ (04`19 WO
Are you an employer? Check the appropriate box:
Type of project (required):
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
6. ❑ New construction
ercyployees (full and/or pari time).*
have lured the sub -contractors
7. [remodeling
2. ElYa6 a sole proprietor or partner-
listed on the attached sheet. ?
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for mein any capacity.
workers' comp. insurance.
9. ❑ Building addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
10.(] Electrical repairs or additions
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
11.❑ Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12. ❑ Roof repairs
insurance required.] i
employees. [No workers.
13.❑Other
comp, insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information.
T Homeowners who submitthis affidavit indicating they Ste doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
.1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: _
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address:
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 requiredunder Section 25A ofMGL 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
-1do hereby certify ilnder thepains gA4enalfles ofperjury that the information provided above is true and correct
Phone#: I — l ,s - 9D r C
Official use only. Do not write in this area, to he 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. PIumbing Inspector
6. Other - - -
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 ofhire,•
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 legallontity, 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 b can presented to the, contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LL C or LLP does have
employees, a policy is required. D e advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage, Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that -the affidavit -is -complete -andprintedlegibly: The Depaiiment has provided a space at the liotfom
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 Min 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 (ifnecessary) 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 orpermit to bur 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:
Tho Gommolimalthofmlassachu otos
)3ap.arimeut offndustdat Accidents
Office o f Wcstigatiol
600 Waskbgton Street
Boston, MA 02111
TQL # 617-727_4900 at 406 or 1-877:MA8SABB
T..__.N rl" Mnr en
t COMMONWEALTH OF MASSACHUSETTS
P. IN . .• . :• ., • i
P Ui A.SERS AND GASFITTERS
E`. LICENEED ASP., MASTER PLUMBER.
f ISSUES THE ABOVE LICENSE TO:
I
t WILLIAM 1` HAR-'INGTON
�I
,
08 MAPLE TIDGE RD
METHUEN MA 01844=4166.''
13779 05/h 1./14 15663.5.
•m �� i
7794 Date ..'.
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that.t./.'1'Y..�'.. .' ................
has permission for II gas installation ..............
in the buildings of .... . ..........
at ... 4,&.11 //4:t.-1..- �'... , North Andover, Mass.
Fee. .". Lic. No........... .. ..... .
GAS INSPECTOR
Check # 3
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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City/Town: e
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13' , MA. Date: 26_ ZG f( Permit#
Building Location: "? � \i ` i ej� Owners Name: A 0k '-, lJ tI II o -;-I
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Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential VeK
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New: ❑ Alteration: ❑ Renovation: ❑ Replacements Plans Submitted: Yes ❑ No ❑
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Check One Only Certificate #
Address: Cj �E,r} %�
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City/Town: of State:
El Corporation
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Business Tel: 7 #-(er 1 "336
Fax: 9' ��'' (n�'S—�
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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 have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance polio Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
❑
Signature of Owner or Owner's Agent Owner Agent E]
By checking this box [J; I hereby certify that all of the Beta' and information I ha a submitted (or entered) regardin 's application are true and
accurate to the best of my Knowledge and that all plumbin work and installations erformed�pder permit i ed f -Ahis application will be in
compliance with all Pertinent provision of the Massachuse s State Plumbing Co and Ch t r f of a Ge eral L s.
TvDe of License:
Byffflumber
Title 3 1
EJ Gas Fitter Signature of Li ensed I er/Gas Fitter
aster
Cityrrown Journeyman License Num er. l0 30
APPROVED (OFFICE USE ONLY) ❑ LP Installer
a
9492 � it. Dateg' ��." t j .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that 1.r1.C. .....F .....................
has permission to perform ...(9 -..-........ .......*
plumbing in the buildings of .. .1 ell=.................
at .. /6 !?"' f.../ -f ......�jNo Andover, Mass.
Fee .3Q.. Lic. No .......... .......... ......
PCUMBING INSPECTOR
Check #
i
Z\ UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town: MA. Date: (� r
ZGf � Permit#
Building Location: e�
Owners Name:
Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional
❑ Residential
New: [] Alteration: ❑ Renovation:
❑ Replacement: 0 Plans Submitted: Yes ❑ No n
Instc-illing �fili3� c. i1}+ Name: 1 v 41 \1/ f FEIPartnership e 0.1i'r EreaVtis+
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(� &y- ��`� City�Town: I,,'dtion
State: WylBusiness Tel: (�j'S
— �Fax: 7 �!-1 — 66Name of Licensed Plum eb rmpany
��� ±:
INSURANCE COVERAGE:
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YesNo
If you have checked Yes, please indicate the.type of coverage by checkingthe ❑ E] appropriate box below.
A liability insurance policy Other type of indemnity El Bond E]OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage require by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permitapplicatIqon waives this requirement.
>i nafure ofOwner or Owner's A ent Check One Only
' Owner E]Annn�
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1 hereby ceriify that all of the details and information I hav submitted (or entered) r g.
Knowledge and that all plumbing Work and installations p rr'ormed under the per is
Pertinent provision of the Massachusetts State Plumbing ode and Chapter 14 f the
S�
3 Type of License:
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Pbumber Ignafure of Li
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��� ±:
INSURANCE COVERAGE:
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YesNo
If you have checked Yes, please indicate the.type of coverage by checkingthe ❑ E] appropriate box below.
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Massachusetts General Laws, and that my signature on this permitapplicatIqon waives this requirement.
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' Owner E]Annn�
rl
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S�
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Safety Insurance
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
Building Commissioner or
Inspector of Buildings
City Hall
NORTH ANDOVER MA 01845
Board of Health or
Board of Selectman
City Hall
NORTH ANDOVER MA 01845
Re: Insuied(s):
PAUL F KOCHANSKi & SHELL -Y A KOCHANSK! - - — -
Property Address:
79 ROCKY BROOK RD, NORTH ANDOVER MA 01845
Policy Number:
0101367
Claim Number:
BOS00013113
Date of Loss:
10-18-2010
Company:
Safety Indemnity
Claim has been made involving loss, damage or destruction of the above -captioned property, which may either
exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass.
Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a
reference to the captioned insured, location, policy number. Date of loss and claim or file number.
BRIAN MURPHY, Adjuster 11/23/10
Safety Insurace Company
Homeowners Claims Unit
P.O. Box 55098
Boston, MA 02205-5098
Phone: (617) 951-0600 x3422
Fax: (617) 531-8865
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CC012.001
Safety Insurance
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
Building Commissioner or
Inspector of Buildings
City Hall
NORTH ANDOVER MA 01845
Board of Health or
Board of Selectman
City Hall
NORTH ANDOVER MA 01845
Re: Insured(s): _
PAUL F KOCHANSKI & SHELLY A KOCHANSKI
Property Address:
79 ROCKY BROOK RD, NORTH ANDOVER MA 01845
Policy Number:
0101367
Claim Number:
BOS00007738
Date of Loss:
02-26-2010
Company:
Safety Indemnity
Claim has been made involving loss, damage or destruction of the above -captioned property, which may either
exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass.
Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a
reference to the captioned insured, location, policy number. Date of loss and claim or file number.
David McDermott, Adjuster
Safety Insurace Company
Homeowners Claims Unit
P.O. Box 55098
Boston, MA 02205-5098
Phone: (800)951-2100x1149
Fax: (617) 531-5776
03/02/10