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HomeMy WebLinkAboutMiscellaneous - 871 FOREST STREET 4/30/2018This certifies that Date ........ ViVil(.0... . TOWN OF NORTH ANDOVER PERMIT FOR WIRING dI t .............................. �,�Gn!�............. ...... ............!�^....... . �� has permission to perform ..... .................................................... wiring in the buildin of.......�� .................. at.......................n.................... . North Andover, Mass. Fee..`.12........... Lic. No. �,�.1..... .................................................................................... ELECTRICAL INSPECTOR Check # � 7 'n .00 Commonwealth of Massachusetts Official Use Only( Department of Fire Services Permit No. I ' 1 Occupancy and Fee Checked �M BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07j (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 27 CMR 12.00 (PLEASE PRINT )ATINK OR TYPE ALL INFORMATION) Date: b I (o 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. r Location (Street & Number) p.'►•t,LZ `j-7-- Owner or Tenant p��/ �� Telephone No. S�. Owner's Address �� j +� / Z Is this permit in conjunction with a building permit? Yes [9" No ❑ (Check Appropriate Box) No. of Luminaire Outlets 3 Purpose of Building�:�'S t (� �,y�� Utility Authorization No. No. of Luminaires 3 Swimming Pool Above ❑ In- ❑ rnd. grnd. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters FIRE ALARMS New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters No. of Detection and Initiating Devices Number of Feeders and Ampacity No. of Air Cond. Total Tons No. of Alerting Devices J Location and Nature of Proposed Electrical Work: Number ' .. ' .""' Tons I."""""""""'......""....'""""'.'" KW Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed LuminairesNo. ?> of Cell: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets 3 No. of Hot Tubs Generators KVA No. of Luminaires 3 Swimming Pool Above ❑ In- ❑ rnd. grnd. No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No, of Zones No. of SwitchesNo. 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: Number ' .. ' .""' Tons I."""""""""'......""....'""""'.'" 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 E uivalent OTHER: OD Attach additional detail if desired, or as required by the Inspector of Wfres. Estimated Value of } ectrical Work: JQ, 600. (When required by municipal policy.) Work to Start: t b t k 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 cover e is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I" certify, under the gins and penalties of perjury, that the information on this application is true and complete. FIRM NAME:.sVl LIC. NO.:LAJ I? Licensee: to df�A t ignature LIC. NO.: (If applicablA enter "exempt" in the license number line.) Bus. el. No - '•� Address: t ,p , 9 0'/- 'XIOLZ — l L4:9 N ,1 0,1 �, MA- - 01 &3�'— Alt. Tel. No.: Z_ *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. Owner/Agent FPEj IT FEE. ,$ Z — 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. The 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 concerning 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 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP . CTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSP TION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: ti /�-- Date:'- - 1-4; DEB WEINHOLD ...TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com M The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, HA 02114-2017 �t www mass.gov/dia • 'r�'TM Sy'�� yWorkers, Compensation Insurance Affidavit: Buildexs/Contxactoxs/Electricians/Plumbers. TO BE FILED WITH THE PERMITTIlVG AUTHORI Y. _. r 1 , Name (Business/Orga7iization/rndividual): AA " Address: City/State/Zip:_ Are you an employer? eek the approprlate box: #: 1. I am a employer with_employees (frill and/or part time).* 2-ElI am a sole proprietor or partnership and have no employees working forme in any capacity. [NoworkI rs, comp. insurance required.] 3.0 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 erriploye6s. 5. ❑I am a general contractor'and I have hired the sub -contractors listed on the attached sheet. These sub -contractors' employees and have workers' comp. insurance.' 6. ❑ We are a corporation and its. officers have exercised their right of exemption per MGL c- 159 § 1(4) and we have no employees: [No workers' comp. insurance required.] Type of project (required): 7. ❑ Neve' "`nsiriiction 8. emodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additiops 12T[] Plinnbing repairs or additions 11 [] Ro6f repairs 14.[] Other *Any applicant that check's b6k 41 must also fill. out the section below showing their workers' compensation policy information. Homeowners who submit•thie afirdavit indicating they are doing all work and then hire outside contractors must submit a new. affidavit indicating such 6l. 'Contractors that check flus box must attached an additional sheet showing the name of the sub contractors and state whether or pot those entities, ave employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. X am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:v v'K— LN 5 Policy ## or Self -ins. Lic. Expiration Date:_ $� t ,LGs 5 1 City/State/Zip: /�%�•..�4��� Job Site Address: p ) 045,Y6 Attach a copy 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 ay be forwarded to the Office of Investigations of the DIA. for insurance day against the violator. A copy of Ibis statement m coverage verification. X do hereby certi under tliepains andpenalties of perjury that the information provided bonle is true and correct. \ � t� 1 0 0 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. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone #: Contact Person: 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 W6, 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 receivef'6rr, trustee 6fan 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 occupaui 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 iequi'red." 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 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 au LLC or LLP does have employees, a policy is required. B e advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial -Accidents. Should you have any questions regarding the law or if you are required to obtain a w6rkers' compensatioji 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 thai 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 '! 'i J *12 Date.........../7 / ........ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ......... ............ .................................. has permission to perform ..1.....'�`�-� ✓O ^" .......................................... plumbin in the buildings of............��l!'................................... at ............ 71.........�s...................................... North Andover, Mass. Feell °7.r...... Lic. No....................................................................................................... PLUMBING INSPECTOR Check # S76-3� .610 /�o vn. /Z�Z t� Sr t-l� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY 61"40--'ec- MA DATE 'lo' /fo I PERMIT# JOBSITE ADDRESS 21 OWNER'S NAME POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY ' NEW: M RENOVATION: � REPLACEMENT: Q PLANS SUBMITTED: YES ® NOQ FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 1 9 10 11 12 13 1 14 � BATHTUB 1 ( ___._ f ( ( —I __j —I 1 ____.J J I I CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM REASE SYSTEM DEDICATED GREASE Eff DEDICATED GRAY WATER SYSTEM __-.._._-__ ___._ DEDICATED WATER RECYCLE SYSTEM _._-.-J1f _.___.� DISHWASHER .�j -_._.._-__-,_- .._._._.-_._._ DRINKING FOUNTAIN __J1I(. ..__.._.-.- .Il(I FOOD DISPOSER FLOOR/AREA DRAIN ___1 __j ----- INTERCEPTOR (INTERIOR)IJf KITCHEN SINK LAVATORY ROOF DRAIN 1 _.__ ._.-__J .___J ___._J _I _._.._- ._..vi .__ -.. -a ..__._- ___._J t ...___..I —. SHOWER STALL.1 SERVICE / MOP SINK L—j TOILET I _-...._ . __- I __.__.i URINAL ____J WASHING MACHINE CONNECTION J f _ ___-f .____. _.. WATER HEATER ALL TYPES ( I ,___J I J _{ __ E ___J ____._J ___ f __. AL -11 i WATER PIPING _ J . _i f _.. _ _ _ 1 _ ._._._1 .... __. __. _.__f J __._.. 1-111-1 _ OTR ! 1 . I F -_..I [ __E _...____I .______J _._.__1 I .__ __ (.-_ ► (_._-J INSURANCE COVERAGE: NO 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW IF LIABILITY INSURANCE POLICY _LJ OTHER TYPE OF INDEMNITY Q BOND Q OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 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 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 ' ompliance w' a Pertoen r ision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME (CENSE # SIGNATURE ^� _ IMP d- JP EA CORPORATION D# PARTNERSHIP DI # LLC i COMPANY NAME rilMADDRESS ��L�/N ► CITY _. __..._._...._) STATE W�":. I1 ZIP ® 3 P o _ it TEL d 3 FAX ��� CELS �, EMAIL 1 N op z W CL w w LL Date .....�1...7.�!!.. 4* ...................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .h ........................................................ ............................... has permission for gas installation ... 4 !.' ............................................................... in the buildings of ...... liJ� I; -j ./.... . r.................................................................. ....... . at .........d. ..... ... .......J.!•ri.......................... North Andover, Mass. Fee/Al -- Lic. No ........................... GAS INSPECTOR Check #� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY /E/4 . / �v v e r MA DATE ! - CF, PERMIT # JOBSITE ADDRESS 7/Fa W--e�w- S OWNER'S NAME G" OWNER ADDRESS TELE—FAX�� TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL © EDUCATIONAL RESIDENTIAL CLEARLY NEW: F—j RENOVATION: REPLACEMENT: 0 PLANS SUBMITTED: YES 0 N00 APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _:, ED L:j L::::I I L . ['7j E: . BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER .._.___ DRYER FIREPLACE_ FRYOLATOR FURNACE GENERATOR (- r(� I --. E._ - —1 .. C--1 __ ==.1 J F�I GRILLES INFRARED HEATERLABORATORY COCKS COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT - TEST UNIT HEATER UNVENTED ROOM HEATER ( ,—. G WATER HEATER OTHER( (' - .............. ........ ...... .... _..... ... ...... _- - INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. -142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ed"" OTHER TYPE INDEMNITY E] BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co lance with ertinentpion of the Massachusetts State Plumbing Code.and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME d��'i1A rev LICENSE # `/8 SIGNATURE _ _ MP YMGF El JP [I JGF D LPGI © CORPORATION ©#�� PARTNERSHIP ©# LLC E]# COMPANY NAME: ,9er¢-.J6L P L9 7- t -f ADDRESS CITY STATEW ZIP ; TEL d 3 3 oZ a FAX CELL _d37(o S'jaS3Y) EMAIL �El W Iii LU LL The Commonwealth of Massachusetts Department of IndustrialAccidents X Congress Street, Suite 100 Boston, MA. 02114-2017 www.mass.gov/dia OiM SJ' V • Workers' Compensation Insurance Affidavit: Builder/Contractors/Electricians/Plumbers. TO BE FILED WITH TBE pEgM(TTING Ai3blicant i-t—mauon Name (Business/6iganization/lndlvidual): /UO 41l4 AJ Address: City/State/Zip: LOW-) Y Are you an employer? Check the appropriate box: 1.❑ I am a employer with employees (firll and/or part-time). 2. �I am a sole proprietor or partnership and have no employees working for me in an aP c- acity [Noworkers' comp. insurance required.] Y 3.Q 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.FJ We are a corporation and its, of 6cers,have exercised their right o£ exemption per MGL c. 152 §1(4) and we have no employees: (No workers' comp. insurance required.] Type of project (required), 7. ❑ NdVd6nstrudion 8. Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Elecirical repairs or additions 12.�Kti-rmbing repairs or additions 110 Roof repairs 14.r] Other *Any applicant that checks' bk 41 must also fill out the section below showing their workers' compensation policy information. 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 attaciied'an additional sheet showing the name of the sub -contractors and state whether or not chose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. X am an employer that is providing workers' compensation insurance for my elnployees. Below is the policy and job site information. Insurance Company 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 required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year coverage.imprisonas r as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a ay be forwarded to the Office of Investigations of the DIA for insurance day against the violator. A copy of this statement m coverage verification. coverage hereby verification. 2== dp alti ofper'ury that the information provided above is true and correct. 1 " Date: Phone #: official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License A. Issuing Authority (circle one): i 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 We, express or implied, oral or written." Ala 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 b6 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 applica)at who has not produced acceptable evidence of compliance with the insurance coverage xequiired" Additionally, MGL chapter 152, §25C(1) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contact for the performance of public work until acceptable evidence of compliance with the insurance r requirements of this chapter have been presented to the contracting authority." .Applicants Pleasb 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 Accidenis. 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 thai 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. 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 burrs 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 Q. COMMONWEALTH OF MQSS.ACHUSETTS 40ARD OF a PLUMBERSAND GASF ITTE,RS pw ISSUES_THE FOLLOWING LICENSE LI'CENSEb AS A MASTER PLUMBER F NORMAND P BERUBE + - A � W Jt . N 12 LINCOLNRbf NEWTON NH 03858-3103` 115$8 054 01/lb 237.119 0 � Safety Insurance Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B Building Commissioner or Inspector of Buildings City Hall NORTH ANDOVER MA 01845 Re: Insured(s): Property Address: Policy Number: Claim Number: Date of Loss: Company: Board of Health or Board of Selectman City Hall NORTH ANDOVER MA 01845 DANIEL RYAN & CATHERINE RYAnI 871 FOREST ST, NORTH ANDOVER MA 01845 0070694 BOS00007708 02-25-2010 Safety Indemnity Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143 Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139. Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number. Date of loss and claim or file number. Bryan Savosik, Adjuster Safety Insurace Company Homeowners Claims Unit P.O. Box 55098 Boston, MA 02205-5098 Phone: (800)951-2100x2070 Fax: (617) 535-5841 03/01/10 CC012.001 0,40RTOI 01 S40 41O 8, *0 Date/ TOWN OF NORTH ANDOVER PERMIT FOR WIRING 'e4e-' This certifies .................................... has permission to perform ........ j ..... ............... wiring in the building of .......... .................................................. - at —e? .....71 ....... ...................................... I North Andover, Mass. Fee A ... . ....... Lic. No/45.r:':$ . .................... � ....................................... ELECTRICAL NSPE�MR Check # Y 7108 a I'd JIM LU1MV1U1v rrr AUJ n Ur iVM63ae1% ULh-Ml i u �•••w ��- �•�, DF.RR711 WOMBUCS4FNY Permit No. ���'�J BOARDOFFMPREMMONREGULMOMSlM2120 �� o Occupancy & Fees Checked APPUCATTONFOR PERMUTO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) DatL U16 Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical w described below.c_ Location (Street & Number) — � j, � 7 , Owner or Tenant Owner's Address / Is this permit in conjunction with a building permit: Y,5F Y,5No (Check Appropriate Box) Purpose of Building SinUtility Authorization No. Existing Service Amps. volts Overhead Underground No. of Meters New Service Arnps�/V otts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work AAA 2— 2 No. of Lighting Outlets No. of Hot Tuba No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above[71 Below Generators KVA and and No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Puma Tons KW Initiating Devices No. of Sounding Devices No. of Dishwasher Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal _ Other No. of Dryers Heating Devices KW Connections No. of Water Heater KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motor Total HP OTHER• h»roeCovaage Putsttantblhe Iha aftriWdv&pioafafsatnebdteOEian YM ctiffftw MLRANCE ppm BOI�ID OIFIER �'leaseSpec�j+) WC&k)%u h>SperlicaI)ateRor}rstad FRMNAME Cioal�e �P�. Ty1�A OWNER'SMJRANLEWAIVER;tarnmmeIh ftInothm andthatmysgmkwonalispemitappimbmwanesMrogtiariait (Please check one) Owner Agent Signaturl of Owner 0 Y)uuhnedrdlad � I , r��.� �.. ALTdNa &hWWqPWatasmpWbyMmxfa0GmnWLam Tt lephone No. PERMIT FEE S