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Miscellaneous - 8 ROCK ROAD 4/30/2018
N O O I Ap0 O O J � O 0 v 0 o Date.....? ..2..5_d .j TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......e......// . � ...... /7f . 1ce ............ has permission to perform ........... (.5-10 ... Ao:��4 ......................... wiring in the building of ...... /7, ....... .......................................... at ............... ....�.o North Andover, Mass. Fee 0.067 1�9. =... Lic. No. f.9 02... .......... ..... Check # 7,,7 1 ?3 /' 7666 commonwealth of Massachusetts official Use only Department of Fire Services Permit No. 2Z 16 BOARD OF FIRE PREVENTION REGULATIONS 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 INM 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) Owner or Tenant C��©I—V Owner's Address 15A_ -I- A. Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Boz) Purpose of Building Q S iCkti C -t 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: �S �p u no r Ile, nuuca aaamonat aetau t� aestred, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) i 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 covers force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE. BOND ❑ OTHER ❑ (Specify:) I certify, under the ins a pe altie of perjuy5Aat the information on is cation ' ue and complete. FIRM N t fol LIC. NO.: Licensee: /` [ 5 r / rUt Signatu LIC. NO.: �, �! (If applicab e, enter "exempt " i t license numbe line.) Address: DGIw/~ , , ,Bus. Tel. No.: g SOS �� NU Alt. Tel. No.. �3 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the Iiability 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 Industria! Accidents Office of Investigations 600 Washington Street Boston, MA 02111 K, , www n ass gov/dia . Workers' Compensation inshrance Affidavit: Builders/Contractors/Electricians/Piumher£ Address::IZ2 � . 7 r wa o _0 z-v-c- City/State/Zip:_ Nc, AAWV-ev vt vt Phone #:. Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repair; or additions I I Plumbing repairs or additions 12.Q Roof repairs 1.3.0 other *Any applicant that checks 6C # I must also fill out the section below showing their workers' 'compensation policy information. t Homeowner¢ 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 mustattsehed an additional shectshowing the new of the sub-contractms and their workers' comp. policy information. 1 ant -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. 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 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 DTA for insyrartce coverage verification. I do herei and t pen perjury that the inlforn adon provided above is true and correct Si afar c Date: —8 — 9-33 Official use only. Do not write in this area, to be connpleted by city or town o�ciaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building. Department 3. City/Town Clerk 4. Eintrical Inspector 5. Plumbing Inspector 6. Other, Contact Person Phone #: Are you an employer? Check the appropriate box: l . ❑ f am a employer with 4. ❑ 1 am a general contractor and I ployees (full and/or part-time).*. have hired the sub -contractors 2.0211am.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.[13 1 am a homeowner doing all work right of exemption per MGL myself. [No•workers' comp. c. 1.52, § 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.❑ Electrical repair; or additions I I Plumbing repairs or additions 12.Q Roof repairs 1.3.0 other *Any applicant that checks 6C # I must also fill out the section below showing their workers' 'compensation policy information. t Homeowner¢ 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 mustattsehed an additional shectshowing the new of the sub-contractms and their workers' comp. policy information. 1 ant -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. 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 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 DTA for insyrartce coverage verification. I do herei and t pen perjury that the inlforn adon provided above is true and correct Si afar c Date: —8 — 9-33 Official use only. Do not write in this area, to be connpleted by city or town o�ciaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building. Department 3. City/Town Clerk 4. Eintrical Inspector 5. Plumbing Inspector 6. Other, Contact Person Phone #: Date ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ............................................................................................. has permission to perform ......... 15 eF�/.fir/ ...... ........ wiring in the building of .... ...... ............................... at ........... ..... . Nprth Andover, Mass. 0�7 Fee ........... ..... Lic. N .... ......... LECTRICAL INSPECTOR* r'* Check 0 .89A9 V, _ rn p Official Use Oni (f rywnweahk of Ma9.acItuiet ) Permit No. f 2eparfinent of5�\7 ire �JerU6Gei — Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (lease blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK Al! work to be performed in accordance with the Massachusetts Electrical Code (IMEQ 5'7 C%JR 12.00 (PLEASE PRLVT 1,V IAW OR TYPE ALL IjVFOR.,bL4TIOA) Date: k� City or Town of: Ak-jW 4'-ba✓-eiL/ To the Inspector of Pf•'ires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number)_ Owner or Tenant //,�1��t i Owner's Addressi me --e Is this permit in conjunction with a building permit? Yes ❑ No Telephone No. q;6 ek (Check Appropriate Box) Purpose of Building Utilit' authorization No. Existing Service Amps / _Volts Overhead ❑ Undgrd ❑ New Service Amps ! Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacit} Location and Nature of Proposed Electrical Work: 0- , t l No. of Meters No. of tNfeters Comr,'-tion of the ibl/owing table may be waived by ,he lnsoecror of lVires. .Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electri al Work: / (When required by municipal policy.) Work to Start: f Inspections to be requested in accordance with NEC 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 li?bility 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:) Self . insured certify, under the pains and penalties of perjury, that the' ormation on this application is true and complete. FIRM NAME: ADT Security Services LIC. NO.: Licensee: Mark A : • Brophy Signature LIC. NO.: C- 4 5 (If applicable, enter -exempt •' in the license number line.) Bus. Tel. No.: 603-59.4-5928 Address: 1-8 Clinton Drive Hollis NH Alt. Tei. No.: _ *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. 00953 OW'NER'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 r� Signature _ _� _ _ Telephone No. PERMIT FEE: S7S' No. of % Total No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fasts Transformer KVA — Generators .CVA o.�L:�nergencv tg tinZ INo. J Luminaire Outlets No -.of Hot Tubs Above ln- Swimr.•ina Pool Qrnd. ❑ '-� No. of lmninai_•es 2:-nd. - - Battery Unis No. of Receptacle Outlets No. of Oil Burners i FIRE ALAI;LNIS No. of Zones No. of Switches No. of Gas Burners No. of Detection and InitiatinQ_Devices No. of Alerting Devices 74o. of Self-(,�untainecl No. of Ranges No. of .=sir Cond. Total Tons- _ No. of Wast Dispose _ s L ti e,t Pump .....N..um.ber .. .. T ons KW Totals: Detection/Alerting Devises ?o. of DishwashersMunicipal Space/A: ea Heating KW Heating Appliances Kit Local ❑ Connection ❑''r Security Svste:.ts:x No. if be:ices or Equivalent No. o: Dryers No. of WaterKWNo. _ of No. of Data,Wiring: ` Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent _ OTHER: / 0/ % .Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electri al Work: / (When required by municipal policy.) Work to Start: f Inspections to be requested in accordance with NEC 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 li?bility 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:) Self . insured certify, under the pains and penalties of perjury, that the' ormation on this application is true and complete. FIRM NAME: ADT Security Services LIC. NO.: Licensee: Mark A : • Brophy Signature LIC. NO.: C- 4 5 (If applicable, enter -exempt •' in the license number line.) Bus. Tel. No.: 603-59.4-5928 Address: 1-8 Clinton Drive Hollis NH Alt. Tei. No.: _ *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. 00953 OW'NER'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 r� Signature _ _� _ _ Telephone No. PERMIT FEE: S7S' ,v�;:,al:,Jlyd•°1YS�rl�pv�41'Di°i . 56L2�S: OT,�(�/L0 0 Sly 56LS� Zogh-Z9,0ZO VH ao01'laON lS 3S0W.'T�r 0- �s , Hdo�a', d ��VH oNI . s3�1'n�3s Aii1 ,n33J.((v 013S H30n cin s3nssl .. ' 01.0dM03 fflls�S GDPdIISiO3kl • •. sidi0i2�J.:)13 �o .. avoa SLL]SoH,r)V,SSVN �o-Hi. VI MNGIAwoo lVC0101iJlybuoly,plloly;u11'Pio j e R ,a�:aFclwwo� E£ZL'V94 (oRB) 2131N J l Ids •:yS DIG t/IV U00' 1bON •uoi}c-ll)llou S50JPPU {o 66UN3 PUt ldleooj Jo) dol denN 0•LLL ;ou j N. 3SaoW �'-'I naAs IlI�InO l a�a5�'�'S `-1f ( .1133VS 0IlHnd-401N3W1tR dU / 6Yln7.l'.00tVJYtiHr7300.00rou-W0� U tN?•:JC Z90Z0 b'W '000MUON i's 3SRION 111 IdS A1-.IdOldi V >RfVW 00 :0.1. PQP14so�' sa�rdx �a wn --- _-__L-LOZ/LOIZO 3 E90000 »SS 9 N 8 L9 L-80 2ol eW `uo�so8 -' LO L We `aoeld uolingysy auo oN d �o ;uGw eda ? � Q is - T Date......................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... Ch-eld 4- hIdmIe— ............................ ........................... has permission to perform .......... ....................... ......... ............ wiring in the building of at .... . ........ ............. North Andover, Mass. Fee .-�r ........... Lic. No.02�1/�-S .......... 6T. -EL . ... ... .. . ...... .......... ...... RI A INSPE Check # FAWO �\ �n %/�� //�� // / OFFICIAL USE ONLY l�ovv monwea& o f i ! jaj3achuJett3 cC�� Ji" Permit No. 1 Avarfinent 0j .}ire Seruiceb Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [REV. 11/991 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 IN INK OR TYPE ALL INFORMA77ON: DATE: City or Town of: NX 11- }' /1�004 a, ir/2 To the nspeetor of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below Location (Street S Number) J� _� Owner or Tenant X.4 A, Telephone No. Owner's Address ,.:f Ar— zIs No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets Isthis pennit id conjunction with a buildinb permit? Yes � No ❑ (Chet]; Appropriate Box) Purpose of Building D(,, CJ I In 3 Utility Authorization No. Existing Service Amps 1 Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps 1 Volts Overhead ❑ Undgrd ❑ No. of INleters Number of Feeders and Ampacity He: Pump Totals:f NumberI -e A?? Location and Nature of Proposed Electrical Work: & Wj yQt CRI" R6 a /IN Completion ortl:e%Ilmrinr table Wray be ]railed by dic hispector oris Cres. No. of Recessed.Fixtures No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators RN"A No. of Lighting Futures g b Swimming Pool Above ❑ In- ❑ b grad. rnd. o. o mergence Lighung Battery Units No. of Receptacle Outlets No. of Ott Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners i o. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total No. of Alerting Devices No. of Waste Disposers He: Pump Totals:f NumberI Tons I KW No. of If -Contained Detection/Alerting Devices I No.. of Dishwashers SpncelAreaHeating KW Local ❑ Municipal ❑. Other Connection No. of Dryers Heating Appliances kNV Sec No of stemseNicor Equivalent No. U NVater , I,1� No. of IN 0. of Data Wiring: Heaters Signs Ballasts No. of Devices or E uivalent No. Hydromassage Bathtubs No: of Motors Total HP Telecommunications Wiring: No. ofDevices or Equivalent OTHER: Attach additional detail tJdesired, or as required bv.the Inspector of Ivires. INSUR.kNC OVERAGE: Unless waived by the o%mer, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance includirig "completed operation" coverage or its substantial equivalent_ The undersigned certifies that such cove ge is in force, and has e.�dubited proof of same to the permit issuing office. CHECK ONE: INSURANCEBOND ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: / 0-2— Inspections to be requested in accordance with IIMEC Rule 10, and upon completion. I certify, under tfil pahzl acrd penalties of perjury, sl at the information an this application is lnte acrd complete: FIRM NAME: A 4 LIC. NO.: Licensee:({' i3 Signature (lf applicable,,enteer- exempt' i Ih license mrmber lineal Address: (cam /-Li,i{—Z',�'1/`-- OWNER OWNER'S INS - , E y V: I am aware that the Lac ns does required by law. By my signature below, I hereby waive this requirement. O Fyn er/Agcri t Signature Teleplionc No. _ I3us. Tel. No 7N-; 9—�f C� �4� � Alt. Tel. No.: not have the liability insurance coverage normally I am the (check one).[] owner ❑ owner's agent. FFM11.7 FE• E. S ELECTRICAL PERMIT FEES statutory reference(s): Mass. Gen.L. c143 a. 3L., 527 CMR 1200, Ordinances of the City of Chelsea, 3.4-50 Residential Electrical Permit Fees &W a� f �,?7 � (m's `7 Coo mmercial and Industrial Electrical Permit Fees Permit Fee Permit Basic wiring - with 100 amp service (including meter) $ 50.00 Each additional 25-100 amps 20.00 Services Each additional meter 20.00 Upgrading per 100 amps $ 40.00 Underground trench inspection 20.00 101 - 200 amps 60.00 Basic wiring - 2 inspections 40.00 201 - 400 amps 75.00 (sub panel - additional charge) ` © 401 - 600 amps @601 100.00 Services - 1200 amps to to -V 1200 amps and over (per 100 amps) 200.00 25.00 Temporary service $ 25.00 Meter 25.00 Service change (relocation) 25.00 Sub Panels (with meter) 69/199 amps (each) $ 25.00 each additional 100 amps 15.00 Service Upgrade 240 volt machine Per 100 amps $ 25.00 A/C unit - heat cool unit (each) $ 40.00 Each additional 100 amps 20.00 Window air conditioner 25.00 Add public panel 25.00 Lighting - outlets - devices Add public meter 25.00 1 - 10 $ 15.00 11-25 30.00 Alterations - remodeling - miscellaneous 26-100 40.00 Sub -panel $ 20.00 101 and over (each device) 1.00 Siding or signs 20.00 Transformers / Generators 0 - 10 KVA $ 40.00 Electrical Outlets - devices - fixtures, etc. 11 - 50 KVA 60.00 1 - 10 $ 10.00 51 and over 75.00 11-25 20.00 Vaults and equipment 75.00 25 - Over 30.00 Carnivals, fairs, circus, etc. 100.00 Major Electrical Appliances Annual continuous maintenance permit $ 150.00 Dryer - electric range - hot water heater - disposal (exception: major renovation) dishwasher - window air conditioner - other $ 15.00 Electric heat - per KW 5.00 Demolition $ 40.00 Central air conditioning or heat pumps 25.00 Gas or oil burner 30.00 Explanatory Notes Alarms, fire and burglar (2 inspections) 1. If work is started and a permit is not obtained on or within (with panel) plus devices 30.00 five (5) days or without the consent of the wire inspector, Fire and burglar detectors - each (without panel) 2.00 the fee will be doubled. Motors - each horsepower or fractional 2.00 2. Tenant wiring in a commercial, mixed use building requires Generator 25.00 a separate permit. Low voltage wiring - per device 2.00 3. Minimum wiring permit shall be $40.00 Swimming Pool Wiring Above ground $ 40.00 In ground 50.00 Take - over permit - rough - service - final (each) $ 25.00 Reinspection permit for defective work $ 25.00 Renewal Permit $ 25.00 Demolition Permit $ 25.00 Explanatory Minimum wiring permit fee shall be $ 25.00 Permits Expiration dates are: New work - one (1) year Remodeling - six (6) months Pool - three (3) months Minimum 200 amp service required for three family residences J a 4 The Commonwealth of Massachusetts Department of Industrial Accidents " Office of Investigations d 600 Washington Street tW Boston, MA 02111 �. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: City/State/Zip: Z /-) � V '�_ D Z Phone.#: (—^ Q 7" Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I ployees (full and/or part-time).* have hired the sub -contractors 2. I 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. employees and have workers' [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. insurance required.] t right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (requiredy.,. 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 *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. :Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer 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. #:_ Job Site Expiration Date: City/State/Zip: x 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 under the pains and penalties of perjury that the information provided above is true and correct. 112110 Phone Official.use only. Do not write in this area, to be completed by city or town official. City or Town:' Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6,., Other Contact Person: Phone #: 1 L' 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,operaWa business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for. the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 1122-06 www.mass.gov/dia ` NORTpl f Oft `w •,�O FO 9 4 / • ,SSACNUS� This certifies that Date. . ............. f TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING has permission to perform ............ ..................... plumbing in the buildings of .. .......................... at ....................................... . North Andover, Mass. Fee........... Lic. No.......... .. :,......... ................ PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location U \� DLk Owners Name ` 6z t-�x 111 - of Occupancy S� Date//—/ 3 / Permit # _ D Amount New 0 Renovation ©. Replacement 1:1 Plans Submitted Yes 11 No rl wy n .r -mom -...-.--------------- (Print or type) Installing Company Name * Address CO / 6G' 7 `"` Name of Licensed Plumber: '- ' (— Z_ 5 , r W -A c Insurance Coverage: Indicate the type of -insurance coverage by checki Liability insurance policy F1 Other type of indemnity Check one: Certificate ❑ Corp. rlPartner. _ © Firm/Co. _ Ut oL,k too 0000 c. f appropriate box: %'D 12-6 D S— Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above threeinsurance Signature Owner n Agent F1 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac tts State Plu m ode ngLChapter 142 of the General Laws. BY 7ignaLure 01 Licensedum r Type of Plumbing License Title l_70 O Z City/ cense um er Master ® Journeyman ❑ APPROVED (OFFICE USE ONLY Date1 '. . Of "ORT„ TOWN OF ORTH ANDOVER PERMIT FOR PLUMBING This certifies that .(_-� l c ........................... has permission to perform ... . T ....................... plumbing in the buildings of . ...................... at. 5.. 8(, c. ................... North Andover, Mass. �v Fee .3". ..... Lic. No..?-. A J... ....... q-';7 ................ . PLUMBING INSPECTOR Check # 7501 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location ? D Owners' o d O Date Permit � Amount Type of Occupancy i< C S / f New Renovation Replacement �/ Plans Submitted Yes No FIXTURES IT. fe• ..0oI• . i• *4• 11 I: N '11-147191 (Print or type) p y ^ LLA / h P 4 c- � ' / Check one: Installin Com an Name C_/+ �+- t l�,[ 7` pv(.otp, ❑-� Partner Certificate J --V Y -- Lj Firm/Co. Name of Licensed Plumber. `•J rF U %IJV j G kr Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ` _ Other type of indemnity 11 Bond 11 Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signal= Owner rl Agent El I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massach S g Code and Chapter 142 of the General Laws. r By igna icensea Flumber T e Plumbing License Title City/Town Li nse7 um er Master 0---Joumeyman ❑ APPROVED (OFFICE USE ONLY Date ..,,`�'..2 �/..°..? ..... NORTH pf to o� TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION ,SSACHUSEt .� This certifies that.. has permission for gas installation ."fl.. ':...z�!`�. in the buildings of .............................. at ... . Ac S. �? ... i 1. .......... �,� North Andover, Mass. Fee.3 2 ?` . Lic. No. .� �� �i c ... .... * •(.. .!�...... . GAS INSPECTOR Check # % -� ? ? '► 6147 MASSACHUSETTS UNIFORM APP! ��--- ICATtON FOR PERMIT TO ®O GASFiT e tNG (Prin t or Type) Mass. Date Permit # Building Location%zo C, t�� Owner's Name Type of Occupancy !2 j=am New ❑ Renovation 0 Preplacement Ej—' Plans Submitted: Yes❑ No ❑ I lr.s,alling Company Name ,y � /; c" f � Check one: Certificat,. � Address E� Iony- „�—i •' ;a��'� 4'`,�% ❑ Partnership Business Telephone` �� j{`;"j,� ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter � /� C�i1%1 f-4-14-it/L% INSURANCE COVERAGE: i have a current Ilabliity insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ❑—_ fro if you have checked yes, please Indicate the type coverage by checking the appropriate box. A Ilabiifty Insurance policy [?— Other type of indemnity ❑ Bond ❑ OvYNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance cover -age 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 certit`y 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 the permit Issued for this application will be In compilance with 6pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. Plumber By T e of License: Title rSig- tome of Ljc6nseHumber or Gas Fitter er- -- City/Town aster Ucense Number u f tXD—� Journeyman O.t , N En w N N U z.. S N of w K W N M r[ C) O U � cm = F J N u ~ r ra z �' r W a m a E- d c: O Q c- .o p C } y yr 4 = �: F- to > 4 'r : N W N p > W E- U J h w x a < w> W o cc u w z. Fw- <¢ 3 d W z o o o z w w o X LL o cs J v ¢ Y o op SUB—SSP.{T, E BASEMENT / ISTFLOOR 2ND FLOOR 3RD FLOOR ATH FLOOR, STt{ FLOOR s 6TH FLOOR 7TH FLOOR 8TH FLOOR B I lr.s,alling Company Name ,y � /; c" f � Check one: Certificat,. � Address E� Iony- „�—i •' ;a��'� 4'`,�% ❑ Partnership Business Telephone` �� j{`;"j,� ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter � /� C�i1%1 f-4-14-it/L% INSURANCE COVERAGE: i have a current Ilabliity insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ❑—_ fro if you have checked yes, please Indicate the type coverage by checking the appropriate box. A Ilabiifty Insurance policy [?— Other type of indemnity ❑ Bond ❑ OvYNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance cover -age 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 certit`y 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 the permit Issued for this application will be In compilance with 6pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. Plumber By T e of License: Title rSig- tome of Ljc6nseHumber or Gas Fitter er- -- City/Town aster Ucense Number u f tXD—� Journeyman O.t , PATRICK J. DONOVAN ASSOCIATES, INC. Claim and Loss Adjustments PO BOX 110 WAKEFIELD, MA 01880 TEL. (781) 245-5540 - FAX (781) 245-7016 October 15, 2003 Building Commissioner City or Town Hall North Andover, MA 01845 Insured David & Maeng - Property Address _Kristi �6__kockRoad, NorthAndover Insurer Hingham Mutual Insurance Companyan Y Policy Number H00104484 Type of Loss Tree/Roof Damage Date of Loss 10/15/03 Our File # WAP35181 Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000 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 file number. On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Vern Laws, Adjuster VL/mn SCALE: l = 30' JULY 8,1983 MORTGAGE PLOT PLAN 8 ROCK ROAD NORTH ANDOVER, MASSACHUSETTS BUYER: EDWARD AND CAROL JACOBS �6 1 /�'�23 3D ri 0 r NOTE: THIS IS NOT A SURREY AND IS TO BE USED FOR MORTGAGE PURPOSES ONLY. p� « N.B.- DO NOT USE OFFSETS FOR ESTABLISHING LUT LINES FOR THE �- ERECTION OF FENCES, WALLS, HEDGES, ETC. .0If 7oit I HEREBY CERTIFY THAT THE BUILDING ON THIS PROPERTY IS LOCATED AS SHOWN ON PLAN AND DOES NOT COMPLY WITH THE ZONING SET BACK REQUIREMENTS OF THE TOWN OF NORTH ANDOVER. CYR ENGINEERING SERVICES INC. I FURTHER CERTIFY THAT THE ABOVE. PROPERTY IS NOT LOCATED 300 CANAL STREET IN A FLOOD PLAIN ZONE. LAWRENCE,MASSACiUSETTS "NOTE: REAR YARD REQUIREMENT IS THIRTY FEET. MASSACHUSETTS UNIFORM APPUCATION FOR PERMIT TO DO P �..1 (Print or Typal NORTH ANDOVER, , Meet, Oat• _10� 141 BuHdina �C PermR eA- Loc2ilon (moo Owner's Name a New ❑ Renovallon p Replacement U Plant Submftted: Yes ❑ , No ❑. FIXTURES Check one: Certklcste Installing Company Name ANDOVER PLG. & HEATING CO. , INC. 0/ p. 2122 Address 573 112 SO'_ UNION ST ❑ Partnership LAWRENCE, MA. 01843 ❑Firm/Co. Business Telephone 508 685-8383 Name d Licensed Plumber GEORGE LAROSE INSURANCE COVERAGE: Chec x qxe I have a current Ilablfty Insurance policy or As substantial equNWenL Yes C�' No ❑ It you have checked In. please Indicate the type coverage by eheckktg the appropriate box A liability insurance polcy L''1 . 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 d the Mass. General Laws. and that my signature on We permit application waives this requirement., Check one: Owner ❑ Agent ❑ Slonatme o er a Ownef sicsnt I hereby certfty that aA of the dataAa uxl Information I have submitted tot ontoradl in above appikstton we true and acerata to the best of my knowied a and that aA plumbing work and InatsAattons pa (xnwd tender the pom A Issued We appiicatlon vnl be In wmpAancs with L1 putinent provtskns of the Massachusatis State Phimbing Cada and Chaptar 142 of Vve'Werw Lam. ey Tftfe Ctty[Town A Mf'1YNED (OFFICE USE ONLY) uc nse Numb« 9983 Type of Plumbing License: Master Journeyman ❑ si ra = ! w 01 - N i t >~ as u 1� < aIc » s i y w= 16 t:< a U = O a • w .4 r r < i< r a~a y ! a a = t O et s a at > po ji s a 0 <Id !! ! K Y � �• 1- _ w r < 1- o < .+ 0 �' M < s s r 4 i 0 0 u < rc r o o� f= f- r r a o e s• o tut-18MT, SASCM114T 1ST FLOOR IND FLOOR 3110 FLOOR 4TH FLOOR ITH FLOOR sTHFLOON 7TH !'L0011 is T'FLOOR -im, Check one: Certklcste Installing Company Name ANDOVER PLG. & HEATING CO. , INC. 0/ p. 2122 Address 573 112 SO'_ UNION ST ❑ Partnership LAWRENCE, MA. 01843 ❑Firm/Co. Business Telephone 508 685-8383 Name d Licensed Plumber GEORGE LAROSE INSURANCE COVERAGE: Chec x qxe I have a current Ilablfty Insurance policy or As substantial equNWenL Yes C�' No ❑ It you have checked In. please Indicate the type coverage by eheckktg the appropriate box A liability insurance polcy L''1 . 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 d the Mass. General Laws. and that my signature on We permit application waives this requirement., Check one: Owner ❑ Agent ❑ Slonatme o er a Ownef sicsnt I hereby certfty that aA of the dataAa uxl Information I have submitted tot ontoradl in above appikstton we true and acerata to the best of my knowied a and that aA plumbing work and InatsAattons pa (xnwd tender the pom A Issued We appiicatlon vnl be In wmpAancs with L1 putinent provtskns of the Massachusatis State Phimbing Cada and Chaptar 142 of Vve'Werw Lam. ey Tftfe Ctty[Town A Mf'1YNED (OFFICE USE ONLY) uc nse Numb« 9983 Type of Plumbing License: Master Journeyman ❑ Date..? 3254 + TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SA US This certifies that ....• • . •� • �.• has permission to perform. / AtiLC ... W • - •'• plumbing in the buildings u. .. Cl. .... �— .......... .. ............. North Andover, Mass. Fee -2-'D. n... Lie. NO..�� .3. . PLUMBING INSPECTOR (om`~ )1 1 (' / 743/05/97 08:51 25.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer r 4b MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER. Mass. Date 9 building Location Permit # 2. Owners Name - p ' s New 77 Renovation D Replacement lel Plans Submitted1] T 1 =G (Print or Type) Check one: Certificate Installing Company Name ANDOVER PLG. & HEATING CO_, Corp. 2122 Address 57371/2 SO UNION ST. Partner. LAWRENCE, MA. 01843 Firm/Co. Business Telephone: 508 685-8383 Name of Licensed Plumber, or Gas Fitter GFORGE I ARncF Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnityE] Bond Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. • • • • • Y • .. SEEM .. ... 0mME SEE iniE Wittig EMEMMEM NONE smommomms Emmons so MR MEMOSERIS (Print or Type) Check one: Certificate Installing Company Name ANDOVER PLG. & HEATING CO_, Corp. 2122 Address 57371/2 SO UNION ST. Partner. LAWRENCE, MA. 01843 Firm/Co. Business Telephone: 508 685-8383 Name of Licensed Plumber, or Gas Fitter GFORGE I ARncF Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnityE] Bond Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner 7 Agent El I hereby certify that all of the details and I.nfOrmation 1 have submitted (or entered) in above application are true and accurate to the test of my knowledge and that sU plumbing Work and InstAdations performed under Permit iuLed to. this application will -be in compliance with all pertinent provisions of tho Massachusetts State Cas Gude and Quptet 14: of the General Laws. By YPE LICENSE: Plumber Titleasfitter Signature of Licensed City/Town: _ Master Plumber or Gas. fittler Journeyman 998 APPROVED (OFFICE USE ONLY) License Number . 1 2455 0 W +! 40RTN pf4��ao ,+.,ti0 �♦ e p L t • Date ...'.. ... ! . . ... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION S �^ T* certifies that. hag permission for gas installation in the build' s of it.. . at Fee Lic No f ° . . . . . . .. ... . . . . . . . . . . . . . . , Nofth Andover, Mass. ..� ........... 7 j GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 + (Print or T el; Mass. Mass. Date kuilding Location g d�. Perri .� Ow rs Name New 77 Renovation D Replacement Plans Submitted (Print or Type) Chec ne: Certificate Installing Company Name ANDOVER PLG. & HTG. CO. INC. Corp. 1051 Address 5731 SO. UNION STREET Partner. LAWRENCE MA. 01843 Firm/Co. Business Telephone: 508-685-8383 Name of Licensed Plumber or Gas Fitter Insuranc^ Coverage: Indicate the type of insura,.-ice coverage by checking the appropriate box: Liability insurance policy Other type of indemnity F7 Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner 0 Agent F7 1 hereby certify that all of the deans 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 petformed under Permit iuued for this application wiU be in compliance with all pettlsicnt provisions of tha Massachusetts State Gas Code and Chapter 142 of tho Genual LAws. A BY TYPE LICENSE: AWA 1 Plumber Title V6616 Z QHS Gasfitter Signature of Licen ed Master Plumber or Gasfitter Gity/Town , Journeyman 6739 APPROVED (OFFICE use ONLY) License Number • • • • • Y • MnEMSEM13nOMENS MONOSSON MUM EMSEEMMEMIMMEMSES so (Print or Type) Chec ne: Certificate Installing Company Name ANDOVER PLG. & HTG. CO. INC. Corp. 1051 Address 5731 SO. UNION STREET Partner. LAWRENCE MA. 01843 Firm/Co. Business Telephone: 508-685-8383 Name of Licensed Plumber or Gas Fitter Insuranc^ Coverage: Indicate the type of insura,.-ice coverage by checking the appropriate box: Liability insurance policy Other type of indemnity F7 Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner 0 Agent F7 1 hereby certify that all of the deans 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 petformed under Permit iuued for this application wiU be in compliance with all pettlsicnt provisions of tha Massachusetts State Gas Code and Chapter 142 of tho Genual LAws. A BY TYPE LICENSE: AWA 1 Plumber Title V6616 Z QHS Gasfitter Signature of Licen ed Master Plumber or Gasfitter Gity/Town , Journeyman 6739 APPROVED (OFFICE use ONLY) License Number P Date ..................... ,ORTN TOWN OF NORTH ANDOVER Qy ST QED ,e,ti0 p PERMIT FOR GAS INSTALLATION This certifies that ..................... .. ............. . has permission for gas installation ............................ . in the buildings of ......... ...F... ....................... at ..... ............................. . North Andover, Mass. Fee......... Lic. No........... .......................... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File