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Home My WebLink AboutMiscellaneous - 858 GREAT POND ROAD 4/30/2018 (2)N O O w Q 0 O O O O O 112`0 Datew%/Z 1//..a5......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING "sACMvs" ill it This certifies that ... .............�......................�,'.'.!!........�~......................................... has permission to perform...............?............................................ plumbing in the buildings of...........''.......................................................... at .. 5.Z.3......... ..a-t�.....�'J"�.. ..'��c ............... North Andover, Mass 5a Feed. ...... Lic. No./ .3....74. . o.................................................................................. PLUMBING INSPECTOR Check # ��-� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT T PERFORM PLUMBING WORK iA 7, 1 CITY : o'�'' MA DATE / { PERMIT# b L JOBSITE ADDRESS OWNER'S NAME L1, OWNER ADDRESS TEL V FAX j TYPE OR OCCUPA CY TYPE COMMERCIAL EDUCATIONAL ® RESIDE PRINT CLEARLY N ( RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED. SPECIAL WASTE SYSTEM _I __.__.f, ___b _.___1 ____ J _..__ ! 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 —E-11 LAVATORY ROOF DRAIN SHOWER STALL SERVICE /MOP SINK _.E l _--_._( _--__.I _.—J _....__1 _..__._.J _.---.._._! TOILET URINAL_—_ - WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER _ _ � . fj ( INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES � NO IF YOkHECKED YES, PLEASE INDICATE TH TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE P ICY F OTHER TYPE OF INDEMNITY © BOND Ej OWNER'S INSURANCE WAIVE . 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. AGENT � CHECK ONE0 L OWNER Q R SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tru d curate 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 th all Pertinent rovisiofi of the Massachusetts State Plumbing Code and Chapter 142 o the General Laws. PLUMBER'S NAMELICENSE # 3 2� ' ( ATURE JP © CORPORATION R1 # PARTNERSHIP Of z LLC COMPANY NAME ADDRESS CITY _ — ----...__...._._...._I STATE ® ZIP a% TEL j� f FAX CELL ! EMAIL CID W O H H u r O Z ! t- Oly W O CL Z u LLI _ ~ CO co LLI co p o a • w � U J a Q C0 tii z w r LL. C4 H O Z O H U a z �7 a a O a The Commonwealth of Massachusetts z Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 021142017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): _ Address: City/State/Zip; employer? Check the aper k" Phone #: 1>r I am a employer with employees (full and/or part-time).* 2. r] I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6.❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no, employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11. E] Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ Other *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. #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. 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 and/or one-year imprisonmer day against the violator. coverage verification. / I do hereby certify under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a statement may be forwarded to the Office of Investigations of the DIA for insurance andpenalties ofpeijury that the information provided abode is true, 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=contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation'policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia '1�f d PLUMB E:l25 ANS GASFITT£RS r Date .�.%�.._ 94:89 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... ` has ermission to perform .. "✓. (G.� . plumbing in the buildings of ..�� ' ... at . ... ..v�..?;LU th1 cth V.ass. Fee.? .'.�. Lic. No.!r 4,60. . MBiNG INSP CTOR Check # �� MASSACHUSETTS UNIFORM APPLICATION FOR A PERM)T TO PERFORM PLUMBING WORK CITY MA DATE L PERMIT# JOBSITE ADDRESS "'✓� OWNER'S NAME� OW R ADDRESS 11 TEL _ FAX _ f TYPE OR OCCU ANCY TYPE COMMERCIAL ® EDUCATIONAL Q RESIDE TIA PRINT CLEARLY NEW: _ RENOVATION: REPLACEMENT: Q PLANS SUBMITTED: YES © NO FIXTURES -1 L R- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS101L1SAND SYSTEM DEDICATED GREASE SYSTEM �( ...... --_.I DEDICATED GRAY WATER SYSTEM ! DEDICATED WATER RECYCLE SYSTEM -_._.....___i _....-_ ___.._._(._........__..{ ._.___.._{ DISHWASHER _ ! ( __..--. .___... � -___-� { J DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR( INTERIOR KITCHEN SINK —! _.__._.__..f J E _._ -.._._..I LAVATORY E—JI -------{ ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL VVASHING MACHINE CONNECTION _.._ ! ._ �; __..__._.� . , _. ._.__ _� _,.,..._f _. ! .__ 1 ._ 1 _..__ ! .__..__ ._i . ___l WATER HEATER ALL TYPES ._.._-f WATER PIPIN OTHER _-- _ -- ---i INSURANCE COVERAGE: Q have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO -11 IIF YOU CHECKED YES, PLEASE INDICATE T TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE P -C l OTHER TYPE OF INDEMNITY Ej BOND _ OWNER'S INSURANCE WAIV • 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 ON Y: OWNER 0 AGENT �©l SIGNATURE OF OWNER OR AGENT B hereby certify that all of the details and information I have submitted or entered regarding this application are tr a 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 co a with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBE 'S NAME ._ �% iILICENSE #11 SIGNATURE P - JP D CORPORATION# PARTNERSHIP 0# LLC U� COMPANY NAME V/ 1 ADDRESS 1 CITY _ —_- -....._.__......._..._I STATE if .�' ZIP D% _ b j� TEL FAX _ t CELL �� EMAIL on z on ff. Iii LU IL The Commonwealth of Massachusetts Ln Department of IndustrialAccidints Office of Investigations kvi 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information '� Please Print Legibly Name (Business/Organization/Individual): (,% Address:d1r,6J4 City/S)ate/Zip: pe�& Phone an employer? Check the I am a employer with employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and'have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] Ti riate box: 4. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. # These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 1211 Roofrepairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. f Homeowners who submit this affidavit indicating they Aire 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' com ensation insurance for my employees. Below is the policy anti job site information. �� Insurance Company Name:. Policy # or Self -ins. Lic. #: i I Expiration Date: Job Site Address: 11 f L161,2 JL / � Al CL/ /C/—C/.,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 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 ofperjury that the information provided above is true and correct. Signature: Date: 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 is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 604 Washington Street Boston, MA 02111 Tei, # 617-727-4900 ext 406 or 1-877rMASSAFE Revised 5-26-05 Fax # 617-727-7749 www.iIl:ass,govaia p� NORTH F A "> r SSICHUSFt CERTIFICATE OF USE & OCCUPANCY 'OWN OF NORTH ANDOVER Building Permit Number #850-11 Dater March 9, 2012 THIS CERTIFIES THAT THE BUILDING LOCATED ON 858 Great Pond Road, North Andover, MA 01845 MAY DE OCCUPIED AS a Single ]Family Home with 3 Day Garage and 1Uninhabital Basement Storage (Non -Living Space)_ IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: David Tracy 858 Great Pond Road ( NORTH ANDOVER, MA 01845 Building Inspector Fee: 100.00 PREVIOUSLY PAID Receipt #24252 M Date ... � ....... 10478 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that./ e.... has permission to perform ............ ... em... .. ....... .. ................................. .. ........... plumbing in the buildings of ............................ !;� . ................................ ............ at .....4. ......C> .... /41 ........ North Andover, Feeik. 00 ... Lic. No. J 3.2 6� NA, ............. ..... .v ..................................................................... PLUMBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY ,, UDATE `' ' PERMIT # JOBSITE ADDRESSOWNER'S NAME OWNER ADDRESS TEL FAX TYPE OR __ OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENT PRINT CLEARLY NEW: 01 RENOVATION: REPLACEMENT: E][ PLANS SUBMITTED: YES ® NO© FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM _11 DEDICATED GRAY WATER SYSTEM L.1 - ._ _ -[ _— __ — (_ (_ _ ( _ _j ( jI DEDICATED WATER RECYCLE SYSTEM l _ ___J _._..__i ____.J � ._..__.._J I -� ._...,___( E .__j__I f —! DISHWASHER I .—.! �I _ DRINKING FOUNTAIN FOOD DISPOSER( -------- I _...._____1 __._.__w.l ._.__J _.___I -.._._. ___I [ FLOOR/AREA DRAIN � � t J INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN I l I I I SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _I I _ OwiagPING _ G . f ..I !E77i OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142: CYINO IF YOU CHECKED YES, PLEASE INDICATE T TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE PO CY _,I OTHER TYPE OF INDEMNITY 0( BOND OWNER'S INSURANCE WAIVER: 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: WNIDIER _i AGENT � SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true a • rate to the best of my knowledge and that all plumbing work and Installations performed under the permit issued for this application will be in compl' . th all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - PLUMBER'S NAMES IILICENSE # L IGNATURE P JP Q CORPORATION F]#�JPARTNERSHIP __t # _ LLC --- COMPANY NAME t ADDRESS 42 CITYI /✓ %� TEL — D _ � STATE ZIP FAX € CELL _!IEMAIL o F1 z N ❑ 6i W LL 0 -1" The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations kvi 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual)):_ Address: '9 A i � /—) City/Staff/Zip: %�'�- Phone #: e y an employer? Check the appropriate box: Type of project (required): 1. I am a employer with 4. ElI am a general contractor and I 6. El New construction employees (full and/or part-time).* have hired the sub -contractors EJ Remodeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have 8. ❑ Demolition workingfor me in an capacity. Y p t3'• workers' comp. insurance. 9. E] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10. El 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 o workers' comp. of rqyTr— insurancee required.] 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. t Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new 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. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy anti job site information. Insurance Company Name:. L Policy # or Self -ins. Lie. #: Expiration Date: % Job Site Address: � ��/� D City/State/Zip: i N 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 theimposition of criminal penalties of a fine up to $1,500.00 and/or one=year ' prisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day againse vi ator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA f9f tour cc coverage verificatiopl d I do hereby certify undelA6paihs and, the Ofdrioion provided Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License 0 correct. 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 0. , J Informati®n 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 menibers iers, are no required o 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 Tei, # 617-727-4900 ort 406 or 1.-877rMASSA]FB Revised 5-26-05 Fax # 617-727-7749 vw mass.gov/dia S.� 6A -I Date. e . ........ 7//..' >-/ � TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...... " a�,..47 ......... W. has permission for gas installation ..... —ln,4 ..................................................... in the buildings of .............. ...................... r at ..... -8 ..... ...... North Andover, Mass. Fee .�&%.".... Lic. No. ...... ............................................ 'GASINSPECTOR Check # U "M CITY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK MA DATE PERMIT JOBSITEADDRESSI r _ MY -61- I-- .OS&Lj ___.OWNER'S NAME GOWNER ADDRESS TIE FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDEN IAL PRINT CLEARLY NEWT -1. RENOVATION: El REPLACEMENT: El PLANS SUBMITTED: YES El NO APPLIANCES 7 FLOORS- I BSM X 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 1 10 1 11 1 12 1 13 1 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUPAIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER __ INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE PO ICY OTHER TYPE INDEMNITY ®( BOND Ejj OWNER'S INSURANCE WAIVER: I am aware that�W icensee 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 AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc and that all plumbing work and installations performed under the permit issued for this application will be in compliance Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PBE-GASFITTER NAME LICENSE #KZ _�� IMM K[ AGENT -01 sst of my knowl provision of the TURE 0 I MGF El JP El JGF E] LPGI © CORPORATION ©# PARTNERSHIP 0#= LLC E]# COMPANY NAME: _ f _ t/sV_ r ` ADDRESSI 91 CITY a STATE ZIP r%l TEL FAX j CELL AIL Columbia Gas® A NlSource Company cu of Massachusetts WARNING NOTICE — AVISO A I�AIb T'5� �"/ �`�t C OAO 1 'POWpETAR90 ts�isa CUSTOMER SUITE AD APARTAMENTO \ TTELEFONOE DIML PIPING AIR SUPPLY THE FOLLWING PROBLEM DUST DE CORRECTED IMMEDIATELY' I TUeERIAS ❑ SUMINISrROS C LOS SIBUIENTES PROOLEMAS DEDEN SER CORREBIOOS IMM, EDIATAMENTE: I ❑ APPLIANCE R EFACTO DE CiAB VENTING ❑OS DI EXPLIOUF, 441/d Ci0 Vi ! 4 - YOU MUST CONTACT A QUALIFIED CONTRACTOR FOR REPAIR: COM"ESE COG! UN CONTRATISTA ESPECIAIJZADO PARA EFECTOS DELA REPARACION: I7Ii ` Puihow ELECTRICIAN CHIMNEY CLEANER 1I OTHER: LL_ JJ PLOMERp i ❑ ELECTRICISTA ❑ PERSONA DUE LIMPIA EL CANON C� O HUMERO DE CHIMENEA OTRO. THIS;WARNING NOTICE IS FOR YOUR SAFETY AND PROTECTION. AFTER ESTE AVISO ES PARA SU SEGURIDAD Y PROTECC REPAIRS ARE MADE CONTACT COLUMBIA GAS OF MASSACHUSETTS STAURACION DEL SERVICIO COMUNIQUESE COI OF MASSACHUSETTS DESPUES DE QUE LAS REPT FOR RESTORATION OF SERVICE. ! SIDO HECHAS. GAS LEFT ❑ ON - CONECTADO METER LOCKEDES SI ? CONTADOR APPLIANCE LOCKED EL GAS SE CERRADO ARTEFACTO CERRAD ENCUENTRA LJ OFF - DESCOftCTADO, CON L VE ❑ NO NO DE GAS ON LLA CUSTOMER SIGNATURE:01 flRMA DEL CLIENTS; f ,) y ❑ TENANT LLIII INNO OP�PIETA PECHA DATEC( r TIME l . { Y ! JO�I EMPLOYEE M% r �—q, The Commonwealth of Massachusetts ' Department of Industrial Accidents Office of Investigations qu 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Le ibl Name (Business/Organ izatio dividual): ! V %Iv Address: �- ✓'C City/tate/Zip: �� Phone #: 9 �(J r3/ 6 , Are y6u, an employer? Check the appropriate box: I am 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. t ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ 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. 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 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 information. Insurance Company Nam Policy # or Self -ins. Lic. #: insurance for my employees: Below is the policy and joh site 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 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 certtfy under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: 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. Plumbing Inspector 6. Other - - - Contact Pers 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 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 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 Massachweats Depart out of Industrial .A,ccidonts Office of Investigations 600 Washingtoa Street Boston, MA 0.2111 Tel, # 617-727-4900 ext 406 or 1-877rMASSAFB Revised 5-26-05 Fax # 617-727-7749 www.mass.gov1dia �a 7807 Date ...l t.!./. !......... . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION r This certifies that has permission for gas installation ....a f:,..wre-.s'............. in the buildings of ...... rQ r ............................ at ...a S�..��7,v5q /.P.1.�? .. �,l .. , North Andover, Mass. Fee. %a.P .4V. Lic. No.l I!,�X� . GAS INSPECTOR Check# /z�eG C!� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town:®r 1///-1--' d ry MA. Building Location" -) Q (ar6®97'10W(yr / 4-1Cf' Type of Occupancy: Commercial ❑ Educational ❑ Alteration: ❑ Renovation: ❑ Permit# Owners Name: Industrial ❑ Institutio ❑ Reside tial Replacement: ❑ Plans Submitted: Yes ❑ Nb ❑ INSURANCE COVERAGE: I have a current lialAity insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑ If you have checked Yes, please i icate the type of coverage by checking the appropriate box below. A liability insurance .p icy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE W ER: 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 ❑ Signature of Owner or Owner's Agent Owner El Agent By checking this box ❑, I hereby certify that all of the details and information I have submitted (or enter regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installati rformed under th pe mit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing n ter 1 Ith General LpWs. By p �/ Title City/Town%,lo// Z APPROVED IOFFIr.F i ►sG nmi v. 3e of Licer Plumber Gas Fitter Licensed Plbmber/Gas Fitter Journeyman LP Installer I License Number: /3 2-4 U) W Cd a OF w CO) w o v M O_ co W m= z 9 z � m w IN— D W R MWW O i— D z in w W w w m 0 � � a a w I— W O a f w x > W I- W Q z w W w z u) x LU W� w F- x p z w} z O m N J Q i— w F- O m z w --I O O z LL 0 CO) y~> x W H z W W F- x V o O W 0 0 x tQ x < O 0 �0 iw— >>> ?� O SUB BSMT. BASEMENT 1 FLOOR 3Ku FLOOR 4 FLOOR 5 FLOOR 6 THFLOOR —f—FLOOR 8 FLOOR InstallinKC;omZpan Name: WC Check One Only Certificate # Address: City/State:�f -7-1 ❑Corporation ��El Partnership Business TeL•, �� / / Fax: f/j ❑Firm/Company Name of Licensed Plumber/Gas Fitter: .,I'f�l' �/ / INSURANCE COVERAGE: I have a current lialAity insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑ If you have checked Yes, please i icate the type of coverage by checking the appropriate box below. A liability insurance .p icy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE W ER: 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 ❑ Signature of Owner or Owner's Agent Owner El Agent By checking this box ❑, I hereby certify that all of the details and information I have submitted (or enter regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installati rformed under th pe mit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing n ter 1 Ith General LpWs. By p �/ Title City/Town%,lo// Z APPROVED IOFFIr.F i ►sG nmi v. 3e of Licer Plumber Gas Fitter Licensed Plbmber/Gas Fitter Journeyman LP Installer I License Number: /3 2-4 !0361 HORTI� 0 1 Date. `�'��..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ., A zv- -.............'..................................................... has permission to perform .....W 4.9)..��.�........ ................................. wiring in the building of v !,W 7-1 � ................... i.............................................. at .... .......te, h Andover, ass. Fee /......... Lic. No. 4`.xf4--).P..... 11- -^f •ELECTRI A NSPECTOR Check # 'SSI ! r �M. � "�=��►+_= fir, _w Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. p Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank 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 PRINTMINK OR TYPE ALL INFORMATION) Date: /P., r f C r f 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) Gia-( P,,0 j7!�-) Owner or Tenant ms's" ,o C -Z Telephone No. Owner's Addresses ~"— Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building 122c S , Utility Authorization No.sr Existing Service _g & Amps /''?d / ? (-Volts Overhead [X Undgrd ❑ No. of Meters New Service 7C0 Amps / 2 VQVolts Overhead ❑ Undgrd 1K No. of Meters 4— Number of Feeders and.Ampac' " Location and Nature of Propose Electric Work:�e ��w Gov �� e e - K -,T 412 Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil. Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ElIn- ❑ nd, rnd. o. o Emergency Lighting Battery Units No. of Receutacle Outlets No, of Oil Burners FIRW ALARMS JNo. of Zones No. of Switches No. of Gas Burners No. of Detection and InitiatingDevices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained No. of Waste Disposers p Totals: - - ........... Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal E] other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts . No. of Devices or Equivalent No. H dromassa a Bathtubs Y g No. of Motors Total HP Telecommunications Wiring: No. of Devices or E Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. / Estimated Value of Electrical Work: G g 40 (When required by municipal policy.) Work to Start: ::Ic 1 r( Inspections o be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVE GE: 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 c verage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE)U BOND ❑ OTHER ❑ (Specify:) I certify, under thI gains and p Ities of perjury, that the information on this application is true and complete. FIRM NAME:/ tJq '7` LIC. NO.: S ? Licensee:_ Signature LIC. NO.: _ (If applicable, engr�ex mpt " in the license number line.) r , / Bus. Tel. No.•'%v'/�f Address: S`> — I e4^ --t — W %G=�Zc /may Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. j Owner/Agent Signature Telephone No. PERMIT FEE. $I/O/ 607-V �/t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 r ' www yzass gov/dia . Workers' CtDmgensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers At plicant Information Please Print LeQtbly Name Addre; City/State/Zip: Are you an employer? Check.the appropriate box: I-❑ I am a employer with _ 4.01 2. El 3.❑ employees (full and/or part-time),* I am.a.sole proprietor or partner- ship and have no employees working for me .in any capacity, [No workers' comp, insurance required.] I am a homeowner doing all work myself, [No -workers' comp. insurance required.] t 5. Phone #: - am a general contractor and I have hired the sub -contractors listed on the attached sheet. t These sub -contractors have workers' comp. insurance. ❑ •We are a corporation and its, officers have exercised their right of exemption per MGL C. 152, § 1(4), and we have no .employees. [No workers' comp, insurance required_] Type of project (required): 6. [] New construction 7. ❑ Remodeling 8. Q Demolition 9. [( Building addition, 10.0 Electrical repairs or additions I I.[1 Plumbing repairs or additions 12-Q Roof repairs 13.[].Other 'Any applicant that checks boz'# t must also fill out the section below showing their workers' compensation policy in 1 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 the, workers' temp, policy infar a8on. ant an employer that is-provrding:evoriters i' compensation insurance for mJ' employees. Below is the policy and job site nformation. 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 ane -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 thdt file infornu'iion provided above is true and correct Signature: Date• Phone #: Official use only. Do not write in this area, to be completed by city or town offtcia � I� City or Town: _ Permit/License # issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 6.Other \ 4. Electrical Inspector S. Plumbing inspector Contact Person: Phone #: t) Date . 10.................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that 4 .................................................................. has permission to perform wiring in the building of ............. ... ....................................................................... N at ..... ......................................................................... d o iidver, Mass. Lic. No��512.1 ... .... . . ... Fee./ .............. ........ ..... ...... . .... .. ... .. ......................... L /CTRICAL INSPECTOR Check # 12536,-/ �5- ;--Z ,it 0 Z4 Commonwealth of Massachusetts OfflicialjJse Only. Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank M APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Cod p), 527 CMR 12.00 (PLEASE PRINT 1N NK OR TYPE ALL INFORMATION) Date: a 6, Zf —/ City or Town of. NORTH ANDOVER To the Inspect r 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&ea5 I'D Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction)%ith a building permit? Yes j< No ❑ (Check Appropriate Box) Purpose of Building S Utility Authorization No. - Existing Service Amps / . Z e�olts 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: (�j pC-► © 4Szcc Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑o. rnd. grnd. o 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 g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances Key SecNoto be icl s or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of ectrical Work: (When required by municipal policy.) Work to StartZ.7 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO GE: 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:) Xcertify, un der tl2e s andpenalties_ofper�ury, that the information on this application is true and complete. FIRM NAME: �3� LC-oAo wAK�=� LIC. NO.: 7 Licensee: Cj LySignature // LTC. NO.: (If applicable enter "exempt" in the license number line. �/ Bus. Tel`. No.- Address: W t L.. �f 0-r— v`1' Alt. Tel. No.: 'Per M.G.L c. 147, s. 57-61, security work requires Departm t of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent [P—P�RM7,TFEE.- $ f2kf Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.3he purpose of this act'is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic,four-year extension to certain permits and licenses conceming the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule ?l — Permit/Date Closed: *** Note Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed [N Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP TION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL, INSP TION: Pass 0 Failed " Re -'Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com t, 6i M . The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA. 02114-2017 www mass.gov/dia Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTIlVG AUTHORIT 3t. Name (Business/Orgaiiization/lndividual): Address: Are you an employer? Checit the appropriate box: C/ Phone #: 1.91 am a employer with _employees (full and/or part-time).* 2.❑ I a,n a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.[] 1 am a homeowner doing all work myself [No workers' comp. insurance required.] t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6.0 We are a corporgigii and its• officers have exercised their right of exemption per MGL c. 152 91(4) and We have no employees: [No workers' comp. insurance required.] Type of project Qequired): 7. ❑ NoVdonstruct[on 8. Remodeling 9. ❑ Demolition 10 [] Building addition 11.[] Electrical repairs or additions 12. ; Plumbing repairs or additions 13•. [] Rbof repairs 14.[] Other *Any applicant that checks.box#1 must also fill out the section below showing their workers' compensation policy information. Homeowners who subAq this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that checkthis box must attache(i an additional sheet showing the name of the sub -contractors and state whether or got (hose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. , I am an employer that is providingworkers' compensation insurance for my ernployees..Below is the policy and)ob site information. Insurance Company Name: ExpirationDate,. r Policy # or Self -ins. Lie. #: �5& City/State/Zip: Job Site Addxess:� _— Attach acopy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL e. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby ce tify under the pains and penalties of perjury that the information provided above is true and correct. r� �� -� bate: To ( ? 5; - %.I - Phone #: ?& ^ 7 F r � 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. 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 hii' express or implied, oral or written." An employer is' defmbd as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enferpri'se, and including the legal representatives of a deceased employer, or the receivef& trustee of an individual, partnership, association or other legal entity, employing emplbyees:.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." MGI, 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 requiieed." 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 oftbis chapter have been presented to the contracting authority." A.ppficants 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 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 retained 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 w6rkers' 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 All in the permit/license number which will be used as'a reference'number: In addition, an applicant thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "fob Site Address" the -applicant should write •"all locations tri (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's. address, telephone.and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia do Q rl' 6 3 Date..bjP.:J/ .......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ... / Owe 7- "/ /--/C - This certifies that ......................................................... has permission to perform ........ wiring in the building of .............. .............................. at ...... ...................... ...... or ................... North Andover, Mass. 0 r— Lic. No., ........... p� IN SPE r; T� TRICAL S Check # Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 1 6) Z te- -S 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 (ME 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: "® City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her int ion to perform the electrical work described below. Location (Street & Number) est Wr 'O /37/i-2 0 Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes 9 No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps /70 olts Overhead Undgrd ❑ New Service - Amps I e'V / 2 Volts Overhead ❑ Undgrd Number of Feeders and Ampacity _ X Location andNature of Proposed Electrical 61"4 - No. of Meters 1 No. of Meters ( Completion of the ollowing table may be waived bV the In ector o Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of . Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In -1:1 rnd. rnd. o Emergency Lighting Batter 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 g No. of Waste Disposers Heat Pump Totals: Number �� ** Tons .........."'"""' KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: `-.� (When required by municipal policy.) Work to Start: 3 (( Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE V AGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: -, .1f ' % LIC. NO.:'73S Z7 Licensee: �_ Signature LIC. NO.: 3)6�i (If applicable, enter "exempt" in the license number line.) Bus. Tel. NO.: Address: A '-4 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires DepAtm 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 Owner/Agent Signature Telephone No. PERMIT FEE. $ Isav 11 \ %Sc.c p - d e/, � I- pz-� 13 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 4;Z�M www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �CQ J ,.` J �e.••� . Address: ' i 1� City/State/Zip: —(.i� Phone #: Are you an employer? Check the appropriate box: 11C I am 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. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ 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 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: �it---t f� --X Policy # or Self -ins. Lic. Expiration Date:j ��// Job Site Address: �.�-� %-f %2 City/State/Zip: ' '`r/t ,,Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). N 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 lite information provided above is true and correct. j Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # -�, / `r Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other 11 Contact Person: Phone #: 11 `i0105 Z� -o Date ........... .... ............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .....(//—r° h S a .............................................................................. has permission to perform S.. " ' f ` s r G ....................................... .................. wiring in the building of �� J.W.....�.......... � ............. .... . , North Md r, U % G r Fee..................... Lic. No....... o.... ... ............................... ��.................... ELECTRICAL INSPECTOR Check # Commonwea& o f M4.4ac4wat Official Use Only cc�� Permit No. Apartma of3 ire �ervicee Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 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 INFORMATION) Date: MAY 20, 2011 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) 858 GREAT POND ROAD Owner or Tenant DR. AND MRS. DAVID TRACY Telephone No. Owner's Address Is this permit in conjunction with a building permit? Purpose of Building NEW HOME Existing Service Amps / Volts New Service -- - Amps ` - -/ Voits Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Yes ❑■ No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Completion of the o" -win table maybe waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets. t - No. of. Hot Tubs . . - Generators KVA 4 Above In- mg No. of Luminaires �' Swimming Pool rtrnd E] El No. omergencyigR..*+,.,.., TT–U- _ No. of Receptacle:Optlets , No. of Oil Burners FIRE ALARMS No: of Zones No: of Switches,r' "'' ' No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. TotalTons No. of Alerting Devices no. oI waste Disposers -"" "'""" "•"""�` •• i.u. vi ocu-� umameu II Totals ..................................................... ........................ nptPrtian/Alartinrt 111-4— No. 11-4 no No. of Dishwashers No. of Dryers No. of Water t Heaters Space/Area Heating KW Heating Appliances KW KW No. of No. of Signs Ballasts Local ❑ iv;tunicipai ❑ Other Connection Security Systems:* No. of Devices or Equivalent Data Wiring: No. of Devices or Eauivalent No. Hydromassage Bathtubs JNo. of Motors Total HP I elecommunications Wiring: No. of Devices or E uivalent OTHER: INSTALLATION OF FIRE/ CARBON MONOXIDE AND SECURITY SYSTEM Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: $3200.00 (When required by municipal policy.) Work to Start: JUNE 23, 2011 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit- issuing office. CHECK ONE: INSURANCE ❑■ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete FIRM NAME: SECURICOM SYSTEMS INC. LIC: NO.: 1174C Licensee: GRANT.M WASON - Signatur , IC. No.: 656D (If applicable, enter "exempt" in the license number line) Bus. Tel. No.: 603-362-4714 Address: P.O BOX 39 ATKINSON, NH 03811 Alt. Tel. No.: 603.771-8944 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. SS co 01086 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: $ 50.00 G P --u tk " og�,L 97-- 1-2--1 r 9"c V Date.. 01,111 ... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 01 v This certifies that .. ,f,5 .11i . c .................... has permission to perform ..... /.Ileh./..w,.11h�............. J"' plumbing in the buildings of ...... 9'--d v .................. at....../J.... , orth Andover, Mass. Fee /JZ/". fie Lic. No,f% /3 z..a . PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING �— j/ MA. Date: Building Type of Occupancy: Commercial ❑ Educational ❑ Alteration: ❑ . Renovation: FIXTURES Owners Name: b Industrial❑ Institutional ❑ Reside tia Plans Submitted: Yes ❑ No 111St�liili C,,,iiiGz.n ; / ! T !' Ui d �� ✓ Check brie ora }' i3tii� 1 L' Cf='reeFi�e?tnL jj Address:/ v ^� �� ❑ Corporation City/Town: g��at.lr State:[-_ Business Tel:a�� El Partnership Fax:0 , e1� 6 Name of Licensed Plumber: ❑Firm/Company INSURANCE COVERAGE: I have a current habil lnsuranCe policy or its substantial equivalent which meets the requirements of MGL. Ch.142 Y If you have checked Yes, please indicate the -type of coverage b checking the es ❑ No ❑ g y g appropriate box below. A liability insurance po "cy Other type of indemnity ❑ > ond WAIVER: I am aware thatthe licensee does o{ have the Insurance required by over E]Chapter 142 of the Massachusetts General Laws, and that my signature on thisrmit peapplication waives this requirement. OWNER'S INSURANCE ,i nature of Owner or Owner's A ent Check One Only Owner ❑ Agent ❑ 1 hereby cert►fy that all of the details and information 1 have submitted (or entered) regarding this app►ication are true and ,� fo Knowledge and that all Plumbing work and installation performed under the Permit issued for this app►ication will he i Pertinent provision of the Massachusetts State Plumbing code and Chat a�"z'z" to the best a riy pY2 of the General Laws. /) n compliance with all i :Yrrown 'PROVED (OFFICE i Type of License: �lgnure of Licensed Plumber License Number: f 3 24 d rY DEDICATED z z SYSTEMS w cn z " n z7 a w Z En Q Q ,n w C7 h a O ❑ ❑ cx p Ln m X W Ln w 0 ce _Z cn a F .cc Z y ii N H rr ❑ d ,�� = _ Q O tr Q 2 w ❑ ❑ x w z h w C7 2 u ° X LL 2 �' Q Q a w w c O w SUB BSMT. m m❑❑ LL z Y g g' ��°�� ' `� ~ a 3 a a z o d U l atun }� V Cn 3 BASEMENT 2sT FLOOR 2ND FLOOR 71 3RD FLOOR iT" FLOOR ;T" FLOOR FLOOR 'T" FLOOR 'T'FLOOR 111St�liili C,,,iiiGz.n ; / ! T !' Ui d �� ✓ Check brie ora }' i3tii� 1 L' Cf='reeFi�e?tnL jj Address:/ v ^� �� ❑ Corporation City/Town: g��at.lr State:[-_ Business Tel:a�� El Partnership Fax:0 , e1� 6 Name of Licensed Plumber: ❑Firm/Company INSURANCE COVERAGE: I have a current habil lnsuranCe policy or its substantial equivalent which meets the requirements of MGL. Ch.142 Y If you have checked Yes, please indicate the -type of coverage b checking the es ❑ No ❑ g y g appropriate box below. A liability insurance po "cy Other type of indemnity ❑ > ond WAIVER: I am aware thatthe licensee does o{ have the Insurance required by over E]Chapter 142 of the Massachusetts General Laws, and that my signature on thisrmit peapplication waives this requirement. OWNER'S INSURANCE ,i nature of Owner or Owner's A ent Check One Only Owner ❑ Agent ❑ 1 hereby cert►fy that all of the details and information 1 have submitted (or entered) regarding this app►ication are true and ,� fo Knowledge and that all Plumbing work and installation performed under the Permit issued for this app►ication will he i Pertinent provision of the Massachusetts State Plumbing code and Chat a�"z'z" to the best a riy pY2 of the General Laws. /) n compliance with all i :Yrrown 'PROVED (OFFICE i Type of License: �lgnure of Licensed Plumber License Number: f 3 24 d L Enter construction cost for fee cal 858 Great Pond Road Construction Cost $ 747,654.00 $ 8,971.85 Plumbing Fee $ 1,121.48 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 1,121.48 Total fees collected $ 11,314.81 David Tracy N l to use this formular simply cliq on the number 859,000.00 and change the first number to a different number and hit return. Sullivan Engineering Group, LLC Civil Engineers & Land Development Consultants July 8, 2011 Town of North Andover Building Department 1600 Osgood Street, Suite 2-36 North Andover, MA 01845 Re: 858 Great Pond Road Foundation As -Built Building Department; Enclosed is a copy of the Foundation As -Built plan for the above referenced property for your records. If you have any questions please feel free to contact me. VerA Truly Y 22 Mount Vernon Road — Boxford, Massachusetts 01921 — (978) 352 -7871 -Phone — 978 352-7871 - Fax i 0071 i Date .. 5....`...... ^:".1 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .................. ... ...... .... ........ ......... ...... has permission to perform .....% est.�.....;SE/l!/................................. wiring in the building of .......... . 2.00-.Y .................................................... 2373 h /z at............................................................................ o h An over, M e0a%sus, Fee .. "'" Lic. No,3-5-17 .......... �r................... f 5 'tel '7 / EL CTRICALINSPECTOR v I Check # �1_bo .) Commonwealth ®f Massachusetts Official Use Only Department t ®f Fire Services F"IM] mit No. 1� �' % Z BOARD OF FIRE PREVENTION REGULATIONS upancyandFeeChecked leave blank APPLICATION FOR PERMIT TO PER ®�� ELECTRIC �® All work to be performRK in accordance with the Massachusetts Electrical Code C), 527 MR 00 (PLEASE PRINTM NK OR Y PEALL INFO City or Town of: TION) Date: By this application the undersi ed gives no ' e of his or her intentio n perform the electricalTo the ctowork res:b Location (Street & Number) �'}�ed below. Owner or Tenant A J� Owner's Address , Telephone No. eI -7 � /-*_ Is this permit in conjunction with a building permit? Purpose of Building_ `ze- Existing Service Amps New- 1Ce (& Amps _Volts �yVolts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers "To. of Dryers Heaters KW o. Hydromassage Bathtubs OTHER: Yes ❑ NOE] BLDG PEPMIT # Utility Authorization No. Overhead ❑ Undgrd ❑ N of f Meters Overhead Undgrd ❑ No. of Meters 7� -vmplenon or the following table may be waived by the Ins ector of Wires. No. of Ceil: Susp. (Paddle) Fans No. of Total . of Hot Tubs imming Pool Above grnd ❑ gnrnd ❑ of Oil Burners of Gas Burners of Air Cond. Total Totals: ................................................ ice/Area Heating. KW sting Appliances KW T0___ No. of Signs Ballasts of Motors Total HP Transformers KVA Generators KVA, ALARMS jNo. of Zones o. of Alerting Devices ❑ ivtunicipal Connedinn ❑ other No. of Devices or to Wiring: No. of Devices or m ecomunications No. of Devices or Estimated Value of Electrical Work: /� GAttach additional detail if d fired, or as required by the Inspector of Wires. Work to Start: (When required by municipal policy.) Inspec ons to be requested in accordance with /�C Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalents he ss undersigned certifies that such coverage is in force, and has exhibited proof of sane to the permit issuing office. CHECK ONE: INSURA.NC BOND ❑ OTp�R I cert, urider� the pains and alties o er u that the information on this application is true and torte FIRM NAME: f J rY, Licensee: A--t,Y LIC. NO.;E�j L 73 (Ifapplicable, enter `exempt" in the license number fine.) Signature i LTC. NO.: Address: --.- c_ -4-%- e ^ % Bus. Tel. No.. - xPer M.G.L. c.147, s. 57-61, security work requires Dep N « „ cut of Public Safety S Licen fit' Tel. No.: O�'�'NER'S INSURANCE 9VAIVER: I am aware that the Licensee does not have fibs liability insurance coverage normally LIC. NO.. required by law. By my signature below, I hereby waive this requirement. I am the (check one owner y Signature ) ❑ caner ❑ owner's agent. Telephone No. PERMIT FEE: $ ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - ]DOUG SMALL 1. KUUGli i. FE{'C U N: rassea — i j Failed— L l Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspecto 2- FINAL INSPECTION: - no is) Date rassea — t i i+ ued — j Re -inspection required ($50.0.0) - [ ] Inspectors' comments: (inspectors, bignature - no initials) Date D®OR TAGS'ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. n The Commonwealth of.(Y1'assachusetts UVDepartment of Industrial.Accidents Office of -Investigations 600 Washington, Street Boston, MA 02111 VwW ragas.. govIdia Workers, Compensation InsuraneeAffidavit: 13niiders/Contractors)Electriciansjplmmbers Applicant Information Please Print Legibly Name (B.usinessiorganization/Individual)U,rV Address: �- u'( City/State/Zip: Phone Are you art employer? Check the appropriate box: 1. Iam a employer with 4. ❑ I am a general contractor and I employees (fall. 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 audits required.] officers have exercised their 3.E1. 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.] ► employees. [No workers' comp, insurance required.] Any applicant that check b #1 f I fill Type of project (required): 6. (] New construction 7. E] Remodeling . 8. 0 Demolition 9. El Building addition 10.0 Electrical repairs or additions Mn Plumbing repairs or additions 12.0 Roofrepairs 13.❑ Other s ox mus a so out the section below showing their workers' compensation policy information. 7 Home oWners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that zs providing workers' compensation insurance for my em information. ployees. Below is the policy and job site Insurance Company Name: / %�e �7 e` r-6,,ea Policy # or Self -ins. Lic. l2 Yob Site Address: <92 �/L2�a I ryc� City/State/Zip: �� Attach copy of the workers' compensation policy declaration page (showing the policy number A�andxpiration 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 ORDBR 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. I do hereby certify uncle • ep ins andpenalties ofperjury that the information provid'edabove is Prue andcorrect. Phone #: �, ffieial zcse o� y. ,�o not write in this area, to be completed by city oY town officiaz City or Town: Permit/License # Issuing Authority (circle one): :L Board of-Realth 233ulldingDepartment 3. City/Town Clerk 4. Electrical Inspector 5.I'Iumbinglnspector 6. Other Contact Person: Phone