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Miscellaneous - 82 MILLPOND 4/30/2018
T 09872 Date.-z��3... TOWN OF NORTH ANDOVER I PERMIT FOR PLUMBING This certifies that ...'. !............ � ..... k -a N/ .... ... has permission to perform .. 4M � !Yr'`I -�-_ plumbing in the buildings of .. SQ U-) .. , , , . , , , at ........ �oZ.. ! IJ. ........ , North Andover, Mass. 2l.3...... .! "................ ... Fee .� .... Lic. No. PLUMBING INSPECTOR Check # 4 ! MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' CITY MA DATE r PERMIT # JOBSITE ADDRESS C__YVI QA!�JOWNER'S NAME G OWNER ADDRESS TELE--- F TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL ® RESIDENTIAL CLEARLY NEW: [_Q RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES Q NO .._ APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 1 13 14 BOILER I. BOOSTER�_I CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR 1 _ - GRILLE INFRARED HEATER I _ LABORATORY COCKS_.I Ili. _ _. -_I I_ I _ MAKEUP AIR UNIT __.._ ..... _.- . OVEN POOL HEATER 1 ROOM / SPACE HEATER ROOF TOP UNIT TEST J I _ ��.I _T__.J_ _ _ I —_-I I -_--_i__ I UNIT HEATER f UNVENTED ROOM HEATER WiffER HEATER OTHER ----- - - -- - --- , ----�z--=- ___J INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ID NO __[�_I 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERA Y 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 sachusetts Gener I Laws, nd that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT Q SIGNATURE OF OWNER OR AGENT 1 hLreby certify that all of the details and information I have submitted or entered regarding this application are true and accur to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp 'ance wit 11 nent ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMEd LICENSE # G SIGNATURE� MPGF Ell JP D JGF [] LPGI1 CORPORATION _� # PARTNERSHIP D#- ( LLCE1# _ i# COMPANY NAME: if�lnh _ CO _-- ' _..-_-- ADDRESSP 14 oe 9f 0, of 1I CITY (�2N STATE �� ZIP _ _duw TEL FAXjC y - CELL -- --- - - EMAIL - -- - - - -- - V The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UV www mass gov/dia Workers' Compensation Insurance .Affidavits Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): 141,J1 Address: ,3 we/Wier City/State/Zip: I `1-e.404t—) Phone #:t�49db Arryan employer? Check the appropriate box: 1 a employer with 4. ❑ I am a general contractor and I employees (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. 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.]r employees. [No workers' comp. insurance required.] Type of project (required): 6..❑7emodeling instruction 7. 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roofrepairs 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 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:.__ Policy # or Self -ins. Lic. #: % 7 t Expiration Date: 0 T �j Job Site Address: 4 (�. M Aw City/State/Zip: k_1 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. X do hereby certto t?Aan enalfies ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: Information and. Instruction 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 emp2634nent be°deemed to be an employer." MGL chapter 152, §25C(6) also states°that`every state or local licensing agency shall'4vithhold 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 commotZ alth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceple 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 'y 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 zegarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference, number.. �i'additi6hn, an applicant that must submit multiple permit/license applications in any given year, need only'subinit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any ciuestions, 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 est 406 or 1-877- MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dla 11 I .i Date. �• �....�...`1 10492 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that....�...f hL .�..................................................... has permission to perform .......... --- .....1-�.a...... plumbing in the buildings of .... .``....'..1C.p.4•!p4,`'� at .... &a ....... �.�.�...... ..1.......'..G�:: North And ver, Mass. Fee..,5..... Lic. No...... f �.�".............................................................................. PLUMBING INSPECTOR Check # d MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY I A10, f� +/ MA DATE CJ7�� - / PERMIT # - JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS I a LL�'Ow r) TELR79- 7 SF 'p � AXI TYPE OR OCCUPANCY TYPE COMMERCIAL O EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW: EI RENOVATION: [2'�' REPLACEMENT: 0 PLANS SUBMITTED: YES 0 NO FIXTURES Z FLOOR- BSM 1 1 2 3 4 5 6 7 1 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER i INSURANCECOVERAGE: I have a current liabilit Insurance policyor its substantial equivalent which the requirements of MGL Ch. 142. YES 0 NO [[e IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY [—] BOND 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachrener I La s a d that signature on this permit application waives this requirement. yj- CHECK ONE ONLY: OWNER [AGENT 0 SIGNA URE OF OWNER OR AG NT I hereby certify that all of the details and informatiM I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pe ine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE # © SIGNATURE MP(Z JP ❑ CORPORATIONQ# PARTNERSHIPQ#O LLC [:]# COMPANY NAME ADDRESS Z CITY I J �G' ��I _ _. _ STATE 0 ZIPQ� p 7 TEL p FAX I I CELL EMAIL w F O z F U W a a � w z❑ a �❑ z �- o � w F W °z VW ft ow W O a LU a �i W 3 N a O a a w a m � J a CL V► � W x w LL. rA W F O z z 0 F U W a z oho a a V O O a The Commonwealth of Massachusetts , Department oflndustrial AccWhts Office of Investigations 600 Washington. Street Boston, MA 02111 www.mass.gov1d1a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electi Annlicant Information _ • Ple Name (Business/Orgadzation/i(uvidual): Address: /"Y-' 60k g(/"V n� City/State/Zip: 3A G9.M Af # 030 Z Phone if: 32 8 75 57 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 �mployees (full and/or part-time).* have hired the sub -contractors listed on the attached sheet. 7• Remodeling 2. I am a sole proprietor orpartnex ship and'bava no.employees These sub -contractors have 8. ❑Demolition worldng forme in any capacity. workers' comp. insurance. 9. Building addition [No workors' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised.their 11. WPlumbing repairs or additions 3111 am a homeowner doing all work right of exemption per MGL myself. Mo workers' comp. c.152,§1(4), and we have no 12.❑ Roofrepairs insuraucerequired.] t employees. [No workers' 13.0 Other comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. I -Homeowners who submit this affidavit indicating they Are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. f am an employer that is providing workers' compensation insurance for my employees. Below is the polley and job site } information. Insurance Company Name% Policy # or S elf ias. 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 tine 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. I do Hereby certtder the ai �ind,enadties ofperjury that the information provided above is true and correct. official use only. Do not write in this area, to be completed by city or town official. City or Town: PermMicense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,• express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a•deceased employer, or the receiver or trustee of an individual, partnership, association. or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced.acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of _public work until acceptable evidence of compliance with the insurance requirements of this chapter have beenpresented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes chat apply to your situation and, if necessary, supply sub -contractors) name(s), addresses) and phone number(s) along with their cer0cate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are notrequired to carry workers' compensation insurance. If an LLC or LLP floes have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be 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 maybe provided to the applicant as proof that a valid affidavitis on file for future permits or licenses. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e. a dog license orpermit to burn leaves eta.) said person is NOT required to complete this affidavit. The Office of Investigations would litre 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: `rho C onwealt� ofM-ossa..chu�Ptts Depajdmmt offudu&ial .AccXdants Off toe o:JrI.n.Veaizgatlon,% 6bQ Washlugtm Street Boson, MA 02111 Te . # 6Z7-`Z27-49QQ art 4Q6 ox z-877- .MASSA . Revised 5-26-05 Fax -0 617-727-7749 u wwaaagevid. is IF In • PF F'LUIVIBFRS AND GASFITTERS L:ICEN$,,ED ASA .MASTER PLLitIIIBBR . . e t: ISSUES THE,ABOVE LICENSE TO: '! GRFr,ORY G PHEL.AN FOX RUN. L`N SALEM NH 03079 12.II1 9718 .05/[!I/14 1875tF9 r t Date ........�/..."°'..... �.�..-.-. �� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .............................................�-�`' D ..!............�....`.:..`—e':7 ....... has permission to perform ......,,,,�„( �l'1&-� (�.................................................................................... wiring in the building of .......... `- .. L � D wf� nf ................................................. �2 IV((C.0 �% t `.... ............... , North Andover, Mass. at ............................................................... X.................. . Fee ..�S................ Lic. N.o..�'033� h Vi.. -G / ...............fir... ELECTRICAL INSPECTOR Check # 12303 lu 1A N DD q�� <C,.\ �ommonweal�� olcc/77i'/a�sac4u�e� Official Use Only MMFaLJePartmenE o� }ire �erviceS Permit No. Isom - Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Cor_, C), 527 CMR 12.00 71 (PLEASE PRINT IN INK OR PE ALL INFORMATION) Date: 3 - City or Town of: Nag &22 a✓sfz--- 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) ?2_ yl a !moo n/1% R --D Owner or Tenant (7, yljtm, Cf{EC /to MV01- i Telephone No. Owner's Address Is this permit in conjunction with a building permit? Purpose of Building Existing Service ov Amps t t 0/ Z o Volts New Service Amps / Volts Number of Feeders and Ampacity / - Zp A Yes EY No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd �No. of Meters �_ Overhead ❑ Undgrd ❑ No. of Meters F/0 /— 15 A AVO Location and Nature of Proposed Electrical Work: R rZecft'TG . elf klO P-'� EktS7iAJ 6- lfl7C d/�N l7GcT&7S 51,1/!-rCAl�S fb Agri✓ 44Youzr 4Do �t 'CLA/ W&gd lento 4rGK71WG Cilecu17'- Com letion of the followingtable maybe waived by the Inspector of Wires. No. of Recessed Luminaires 6a No. of Ceil: (Paddle) Fans of Total TransSusp. Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- E:] rnd. grnd. No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: I Number Tons KW .................... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of I Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent ' / / OTHER: C��11 L r X # Tii1 Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value f Electric 1 Work: (When required by municipal policy.) Work to Start: 3 i Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains an penalties ofperjury, that the information on this application is true and complete FIRM Z/ LIC. NO.: 3 G Licensee: ;1/{oMAS -S'PR l nJC?IC'O/ Signature LIC. NO.: F,31f /S%$ (If applicab e, enter "exempt " in the license number line.) Bus. Tel. No. • � 7k - 9/ 761 / 6Y7, Address: /58 S70,d5,3R104F- O/Z. l7/z4CuT IVA 065 Z4 Alt. Tel. No.: Z2!%? -37S-3 r(i Jt *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one)❑ owner ❑ owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $ V- w �. The Commonwealth ofltsassachusetts Department oflndustriglAccidents Office of Invesfigations 600 Washington. Street Boston, MA 02111 www.mas.s gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly Name (Business/organization/Individual):�--- Address:�To�eJ0izcr�GG�Z-- - City/State/Zip: oR�7� �' �g2 Phone #• ��8 r 17d - b5;7 Z— 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 employes (full and/or part-time).* have hired the sub -contractors listed on the attached sheet. T 7. Remodeling ❑ 2. ��Si a sole proprietor or partner- ship and'have no employees These sub -contractors have 8. Q Demolition working for me in any capacity. workers' comp. insurance. 9, El Building addition [No workers' comp. insurance 5. Q We are a corporation and its 10.Q Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL .11.[] Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. Q Roof repairs insurance . re uired required.] � employees. [No workers' 13.0 other comp. insurance required.] 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 7 Homeowners who submit this affidavit indicating they ftie 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. X am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lie. Job Site Address: Expiration Date: City/State/Zip; Attach a copy of the workers' compensationpolicy 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 rage vert cation. Xdoheti un er thepgOhrnd, enaltiofperjury that the information provided above is true and Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,• express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance With the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit lion file for future permits or licenses. Anew 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 Cox a.oxawealthofMsssachvsetts Departmeut offadustdal Accidents Office of avestigatiolls 600 WasWVoa Street BostonMA02111 Tel, # 617-727-4900 ext 406 or 1-877-MASSAW, Revised 5-26-05 Bax # 617-727-7749 WWW_mace onuhlln Date ...... .2. ................% TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ `.....!.......... pY.............................................. has permission to perform ......f ,SE/N•t!. !......................................... wiring in the building of L/ ,SA... �UG/�t/�$ orL ........................................................ at ..A"l���.I...�`......�2 , orth Andover, Mass. ............................. cvy� .r Fee .��............ Lic. No. 5— 2.0��l .���� ..................... �1 ELE RICALINSPECTOR S Check # 1 a90 7857 COmmonwea& o f Majdac4a6effj Official Use Only a1Jcc�� cc77 Permit No. 7d3 ePa�tment o�,.tire �ervices Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C), 127 CMR 12,00 (PLEASE PRINT IN INK ORLm- LL INF RMATION) Date: t 11 7 City or Town of: J o,, e, To the Insp cto of Wires: By this application the undersigned gives noticeofhis or her intention tuerform the electrical work described below. Location (Street & Number) )n'1 ill p on�l ��or� s IL;�- g ) Owner or Tenant Owner's Address Telephone No. 9 - 3 yew Is this permit in conjunction with building permit? Yes / No ❑ (Check Appropriate Box) Afo • tiva Purpose of Building A , 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: Cmmnletinn nftha fnllnwino tnhln - hn uinivo / h„ /ho All. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool rnd. ❑ rnd. ❑ o. o Emergency Lighting Batte Units No. of Receptacle Outlets l0 No. of Oil Burners FIRE ALARMS No. of Zones No, of Switches No. of Gas Burners o. of Detection an Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number " ' Tons "' """""""""""""""' KW """"""' o. of elf -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water Kms, Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of lec ical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C V RAGE: 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 0 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains nd enalties of perjury, th t the information. o i lication is true and complete. FIRM NAME: ;c LIC. NO.: Licensee: �4, , Signature LIC. NO.: (If applicable, enter "exem t" in the l' ease number line.) Bus. Tel. No.: 9'�d 7A7 to s Address: s- Alt. Tel. No.: --- *Per M.G.L. c. 147, s. 57-61, security work requires epartment o Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ W c� lo�� ol�c I/Z,,,, 74,,O --r PV 30 r.. MASSACHUSETTS UNIFORM APPLICATION FOR PERM] IT TO DO GASFITTIN1G . (Print or Type) !� NORTH ANDOVER Mass. Date tuiiding Location A; P A )'r 76 yy1 Permit # 2 O S77 Owners Name C ,—,Oz z- ,/�<:,,� ✓� �� ' z I �9 New Renovation II Replacement II Plans Submitted��- �'. (Print or Type) Check one: Certificate Installing Company Name A/u.1n�j• Corp. Address /�'j ' �`% Partner. ��j--3,4e-el _4.1� l7 -r- a, To," _ %r4 - 5, Firm/Co. Business Telephone: Name of Licensed Plumber or Gas sitter Insurance Coverace: Indicate type of insurance coverage by checking the appropriate box: Liability insurance policy Lam: Cher type of indemnity Q Bond Insurance Waiver: 1, the undersicned, have been made a,,vare that the licensee of this application does not have any one of the � c W tis f Q V Q F O of tai C = t- o) a ui d to Q N F� W 44 c yi O O O a W N d V - to W W < C C D }� W W 07 S W W W �` CS C - s{ W C © O •.. O (A I_I O OI �i GI t31.. GlI G� y Q o.t _I sasEreExT I I I i I l l l l{ I I I I I I I _' -! jIST FLOOR ZXla FLOOR 3RO. FLOOR aTx FLOOR 5TH FLOOR 6TH FLOOR f I{ I I { I I I I ( I TTX FLOOR a-rK FLOOR (Print or Type) Check one: Certificate Installing Company Name A/u.1n�j• Corp. Address /�'j ' �`% Partner. ��j--3,4e-el _4.1� l7 -r- a, To," _ %r4 - 5, Firm/Co. Business Telephone: Name of Licensed Plumber or Gas sitter Insurance Coverace: Indicate type of insurance coverage by checking the appropriate box: Liability insurance policy Lam: Cher type of indemnity Q Bond Insurance Waiver: 1, the undersicned, have been made a,,vare that the licensee of this application does not have any one of the above three insurance coverages. _ Signature of owner/agent of property Owner = Agent .Q - I hercby "rtiry that au or the details and information I have submitted (or entercd) in &tore avptieation are true and accurate to the beat of my iczoWtcdr,e and that aU piumbin; rock and initatlati0=-=f0rasw ucdC P"v-r..it .uced fo: this sppiiatjoa will be in eomptiartoa VWX ad pertL= at provisions of the Massae'jusetts State Gas Gide Arid Giapt= I<: u L%o Crunc::i Lawn. By Title Cit_/Town:! (1,_ APPROVED (OFFICE USE ONLY) TYPE LICBV GS ` ��✓` T ' i��d � ?luirtber „�. l Gasiitter Signature of Licensed l raster Plumber or Gasfitter journeyman %% -6, License Number .. s Date.././/. ......... N, To 2057 TOWN OF NORTH ANDOVER EE ry...;1 PERMIT FOR GAS INSTALLATIONC! CU This certifies that.. /Y1k-,�.4.7. uc L .................. has permission for gas installation ... t- R in the buildings of . �v .................. at ..... f,0...... .......N Mass. Fee. S' Lic. No.. YJ cjA Is INSPECTOFM WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File t MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) a e y G NO.ANDOVER , MA Mass. Date I P e rm it Building Location 4� MILLPOND Owner's Name NO . ANDOVER , MA Type of Occupancy, RES New ® Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ " No ❑ Installing Company Name CALLAHAN AIR CONDITIONING Check one: Certificate ' Address 91 B ..MONT STREET 13 Corporation NO . ANDOVER, MA . 01845 [1 Partnership Business Telephone 508-689-9233 ❑ Flrm/Co. Name of Ucensed Plumber or Gas Fitter JOSEPH KEVIN CALLAHAN INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142- Yes 42Yes R] No ❑ If you have checked Yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy ZI 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 -0 Agent C3 I hereby certify that all of the details and inlormation I have submitted (or ent�,e'rlm'l'tn rove application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the sed for this appllcatl will b In pllance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 othe neral Law ey Type of Ucense: •� Plumber 9 naturO of Licensed -um a or Gas (ter Title Gasfilter Master Ucense Number m-3440 ArY Journeyman 0 . N N S W N � y N X U s � � in ¢ N R O O N :. F•• W W J N Q O U m O F [ } _ '�' .O F' cc W, < a. c 01 ¢ ¢ a w V 4 W H F- v1 >. > S W ... ' W J 2 C Cr Q WF O W W - F- V V F- ._ -j F- + F W F• W N O ? Z O W o O to < W? Q W O Z < M < .� O O W a' O }1 F- = O C J U C: Y a 0. O SUB—BSMT. BASEMENT ISTFLOOR 2ND FLOOR 3RD FLOOR 1 I ✓I 4TH FLOOR STH FLOOR I 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name CALLAHAN AIR CONDITIONING Check one: Certificate ' Address 91 B ..MONT STREET 13 Corporation NO . ANDOVER, MA . 01845 [1 Partnership Business Telephone 508-689-9233 ❑ Flrm/Co. Name of Ucensed Plumber or Gas Fitter JOSEPH KEVIN CALLAHAN INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142- Yes 42Yes R] No ❑ If you have checked Yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy ZI 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 -0 Agent C3 I hereby certify that all of the details and inlormation I have submitted (or ent�,e'rlm'l'tn rove application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the sed for this appllcatl will b In pllance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 othe neral Law ey Type of Ucense: •� Plumber 9 naturO of Licensed -um a or Gas (ter Title Gasfilter Master Ucense Number m-3440 ArY Journeyman 0 . CTI C\ -04E TommonwcaU4 of Massar4u setts Office Use Only Department of Public Safety Permit No. l l BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 S Occupancy & Fee Checked 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date City or Town of 1 t rel -h A 1 / 61&E! To the Inspector of Wires The undersigned, applies for a permit to perform fthe /electrical work described below. Location (Street & Number) � / Owner or Tenant IJ t i Owner's Address c Is this permit in conjunction with a building permit: Yes ❑ No (Check Appropriate Box) Purpose of Building J,����, J�Utility Authorization No. Existing Service /OV Amp Volts Overhead LJ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity r ./ �/ �/Q �J/�/✓ Location and Nature of Proposed Electrical Work OTHER: -Eylr ,.iL = E FEB - J IQ° -r) INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws ! I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES O NOT O 1 hav_e-submitted.valid proof of same to this office. YES ❑ NO ❑ r r: r. '"�• If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE Ea BOND ❑ OTHER❑ (Please Specify) (Expiration Date) Estimated Value of Electrical Work $ Work to Start Inspection Date Requested: Rough Final Signed under the penalties of perjury: FIRM NA"F _ / LIC. N . / License�-IT/ c- t r Signature LIC. N`O. __ Address / / _ Bus. Tel. No ( � 030(Y"I Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachuse General Laws, and that my signature on this permit application waives this requirement., Owner Agent (Please check one) t Telephone No. PERMIT FEE $ J (Signature of Owner or Agent) TOTAL No. of Lighting Outlets No. of Hot Tubs No. of Transformers KVA A oveIn- 1:1rnd. ❑ No. of Lighting Fixtures Swimming Pool gmd. Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and I otal No. of Ranges No. of Air Conditioners Tons Initiating Devices of Sounding Devices. Heat Total TotalNo. No. of Disposals No. of Pumps Tons KW No. of Self Contained Detection/Sounding Devices No. of Dishwashers Space/Area Heating KW Municipal [3 ❑ LocalConnection Other No. of Dryers Heating Devices KW No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: -Eylr ,.iL = E FEB - J IQ° -r) INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws ! I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES O NOT O 1 hav_e-submitted.valid proof of same to this office. YES ❑ NO ❑ r r: r. '"�• If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE Ea BOND ❑ OTHER❑ (Please Specify) (Expiration Date) Estimated Value of Electrical Work $ Work to Start Inspection Date Requested: Rough Final Signed under the penalties of perjury: FIRM NA"F _ / LIC. N . / License�-IT/ c- t r Signature LIC. N`O. __ Address / / _ Bus. Tel. No ( � 030(Y"I Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachuse General Laws, and that my signature on this permit application waives this requirement., Owner Agent (Please check one) t Telephone No. PERMIT FEE $ J (Signature of Owner or Agent) V I�KB v nnr�E°P *I CITY OF HAVERHILL MASSACHUSETTS 01830 This is to certify Permit No. Date PERMIT FOR ELECTRICAL WORK (Electrician's Name - Please Print) has permission to perform electrical work on the building or premises located at Rough Insp. Service Insp. Final Insp. _ Remarks: The type of work will be escrl.ption of Work) Lic. No. Fee: $ Date Fee Paid (Signature of Inspector) 2841 0 �SS ACHU TOWN OF NORTH ANDOVER PERMIT FOR WIRING T.cx` 0� This certifies that ............. ................... s ........ F- . .. . ................... . i r- q.'j lvjt�-Ct C ......... . e . ................ has permission to perform ......................................... wiring in the building of .......a 0 L., g (1 -5 S 0 ........ ............................................................ at ...... el.; ..... W."A ..... P-4.4 ................................. .North Andover, Mass. Pee .....6 ... Qa Lic. NoRk.s.—� 3 ............................................................ ELECTRICAL INSPECTOR C tf 62A/66' 11:59 15.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File