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HomeMy WebLinkAboutMiscellaneous - 89 WINDSOR LANE 4/30/20180 � � z v N O �� Z m C 9800 Fredericksburg Road R� San Antonio, TX 78288 USAW 04664.1YBX3.JSS1066665395.01.01.4491 BUILDING DEPARTMENT 1600 OSGOOD STREET BUILDING 20, SUITE 2035 NORTH ANDOVER MA 01845-1057 Reference: MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B Attention Building Commissioner, I am writing regarding the claim referenced below. Policyholder: Stephen J Wiles Reference #: 003134377-15 Date of loss: March 25, 2015 Location of loss: North Andover, Massachusetts Address: 89 WINDSOR LN, 01845 June 17, 2015 A claim has been made involving loss, damage or destruction of the property referenced above, which may either exceed $1000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to my attention and include the reference #. You may submit correspondence or questions to me. My contact information is: Address: P.O. BOX 33490 SAN ANTONIO, TEXAS 78265 Fax: 800-531-8669 Phone: 800-531-8722, Ext. 61136 Sincerely, irt= Yvonne Daniels Property -SAT -E UNIT 7 USAA Casualty Insurance Company Phone: 800-531-8722, Ext. 61136 Fax: 800-531-8669 MIS/YD 003134377 - DM -04664 - 15 - 6774 - 58 54577-0914 Page 1 of 1 Date ......1. [..`. ..-�.4� ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... ).!f�......./k..L.Sn.........Z�........................ has permission to perform ............ ..L.. �w................................................... wiring in the building of ........................................ w C L............................................................... W D SM %—/✓ /1.... , North Andover, Mass. Fee,�G�--...... Lic. No. ................�E ......................... ELECTRICAL INSPECTOR •.'. 4` Check # t 2 Date!,....... 7 . 71.5 TOWN OF NORTH A DOVER PERMIT FOR WIRING This certifies that 4 4/ 71,je Zr, "/ ......................................................... I ket, I /0 VVI <, _z .. .le� ......................................................... has permission to perform ........... wiring in the building of... at ............. I ............................................................................................ . Pjorth Andover, ss. orth Andover, .F ,:d� ............. ...... T ........ Fee �� ................... Lic. No/ov / Check 4 E RICAL INspEc-r 13 0 17, Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. I 7W 3 L Occupancy and Fee Checked [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 INMK OR TYPE ALL INFORMATIOA9 Date: WC - j 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) �I al Owner or Tenant hi A -T W A, 1.1 ii Lsj Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes 0 No ❑ (Check Appropriate Box) Purpose of Building 5 y pje . :L_ V-'t!jM a Ly' Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: M,� C Completion ofthe following table may he waived by the Insnector 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 5 No. of Luminaires ._ Swimming Pool Above ❑ In- Elo. rnd. rnd. o Emergency Lighting Batteiy Units No. of Receptacle Outlets (, No. of Oil Burners FIRE ALARMS No, of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number I ITons I "* """ * IKW ­""'* 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 al as Ballasts Signs Ba Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring. No. of Devices or E uivalent OTHER: -Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wtres. (When required by municipal policy.) Work to Start: 11— � — i IA 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: INSURA-NCE © BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: Licensee: (If applicable, ens Address: I *Per M.G.L c. l I LIC. NO.: 187;1;4 LIC. NO.: ? ? j Tel. No. • " t `V0 " 1 ZS9 Tel. No.:) 'J 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 PERMIT FEE: $ 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 maybe 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 EN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ 9 Inspectors Comments: JP Inspectors Signature: Date: FINAL INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspec s Co ents: of , Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth oflMlassachusetts Department of lndustrialAccirlents Office of Investigations IV 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lep-ibly Name (Business/Organization/individual): A + _J U—iJ,_ ` Address: I 2 _ �' '� �c S -C - City/State/Zip: S ALx .s, zg4.&- C)l Phone#: 2&(_ (Z::-,`, Are you an employer? Check the appropriate box: - Typo of project (required): 1. [�d I am a employer with a_ 4• ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. t 7• ❑ Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g, [] Building addition [No workers' comp. insurance 5. El We are a corporation and its 10J9 Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11. El Plumbing repairs or additions myself. [No workers' comp, c. 152, §1(4), and wehave no 12.❑ Roofrepairs insurance required.] i employees. [No workers' 13.❑ Other comp. insurance required.] 'Any applicant that checks box41 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is thepolicy anal job site information. Insurance Company Name% �� Policy # or Self -ins. Lie. M V CJC, l (DOC,, Qt a-� 0-1 ?_0H. 4 Expiratiou Date: 3 n -3 — i s Job Site Address- 8 9 C,5 f is CTbci �_Q City/State/Zip: 0 • ;4 I�J 0 C>.y 4Z Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL c.152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA. for insurance coverage verification. I do hereby certify under the pains and penalties of perjury Aat the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other C'nnfnrVP[rennt • Phone 9: ❑ 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 maybe 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 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 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: N Trench Inspection Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com a i V- 10930 Date' )WN OF NORTH ANDOVER PERMIT FOR PLUMBING ...................................................... . ............. has permission to perform ..... -4Y�y ....... 7 ....... .................................... plumbing in the buildings of.....?. � ................................................................. at ......... cP /0 /,V, ......................................................................... .... North Andover, Mass. Feekt�"—.... Lic. No.�. ............ ... .......................................................... 7 . 3 / (,& t- PLUMBING INSPECTOR Check #c,�7 P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE PERMIT #. ( M o JOBSITE ADDRESS OWNER'S NAME ti/,`� Lel OWNER ADDRESS TEL FAX OCCUPANCY TYPE COMMERCIAL p EDUCATIONAL EQ NEW: 0 RENOVATION: ® REPLACEMENT: g FIXTURES I FLOOR- BSM BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION W TER HEATER ALL TYPES WATER PIPING OTHER F ! I-- RESIDENTIAL IN PLANS SUBMITTED: YES ® NOAi 10 1 11 1 12 1 13 1 14 INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES PO NO 011 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY WI OTHER TYPE OF INDEMNITY P 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 © AGENT If 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 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 compli nce ith all ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME S. D I LICENSE # 3 I SIGNATURE QUIP 0I JP Ni CORPORATION D#=PARTNERSHIP 0# ; LLC COMPANY NAME �° G�te� ADDRESS jf(oc 1t Jx CITY -- Q� - _. -- - -I STATE ZIP TEL Zr Yyj () 1 FAX CELL EMAIL ---------- --------- - ._.... ------ - - _.....-- - --- - H °z H U a o� z O w z Gzl aLLJ � W U) W 5 a O � co a co a p o w � ' J CL m Q N w s w F cn H zz 0 H U a a w� a ' MI The Commonwealth of Massachusetts - Department of IndustrialAccWnts Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance .Affidavit: Builders/Contractors/Electricians/PIumbers Applicant Information Please Print Legibly -' Name (Business/Organization/Individual):/ Address: eQ Lk City/State/Zip: Q-1J%7g Q /t6T 7 Phone #: t;�ff %yd Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2. [ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. ❑Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working forme in any capacity. workersp• insurance.' comp. 9. ❑Building addition [No workers' comp. insurance 5. El We are a corporation and its 1011 Electrical repairs or additions required.] 3. ❑ 1 am a homeowner doing all work officers have exercised their right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' 13. ❑ Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who 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 N 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 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 certlf y uniler the pains and penalties of perjury that the information provided above is true and correct. Phone #• Z_?/ 73 7 Wo Official use only. Do not write in this area, to be completed by city or town offrciaL 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 a 0C 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 employeiis 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of 1udustarial .Accidents Office of Investigations 600 Washington Street Boston, MA, 02111 TO. # 617-727-4900 ext 406 or 1-877,MASSAFF Revised 5-26-05 Fax # 617-727-7749 www.mass,gov1dia Dateh?h#�. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ......... ... ............... .................. ....................................... ----------- has permission for gas installation.... It. ...... ...................................... in the buildings of ........ �,-0/ I. -e-4 ... .... .. . ..... C), 'r Z ra at ................................................ ,Prth Andover, Mass. 6 f� Fee....................... Lic. No. ............... ..................................................................... GASINSPECTOR Check # 9763 �foa-/5"n�. �a/1>�J V r� i V 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY Qr ✓Pl MA DATE PERMIT# L9 -? JOBSITE ADDRESS Z LO OWNER'S NAME ," d.✓►� e V _� OWNER ADDRESS 1 TEL _ _jFAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL j9 EDUCATIONAL RESIDENTIAL CLEARLY NEW: © RENOVATION: ® REPLACEMENT: EM PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKSMAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT - TEST UNIT HEATER rJ UNVENTED ROOM HEATER WATtR HEATER OTHERF� f INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES, NO FA IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY MI OTHER TYPE INDEMNITY ® BOND E[] 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 AGENTJ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information 1 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 complia e w h all Pertinent p ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME re _ LICENSE # SIGNATURE MP 0 MGF 0 JP 0 JGF © LPGI CORPORATION ©# © PARTNERSHIP ©# LLC E]# COMPANY NAME: Die ��4 11ADDRESS - �`- _ — CITY STATE ZIP0 6__jTEL FAXCELLW�EMAIL V r� i V 1 0 U W � a� d � d O Nrl � W o °z W :ml w Q w a � � w w c a z a � o w Q J a a N LLI x w H L.L. O Z O H U W u 4 U' U' r� a t4 The Commonwealth of Massachusetts - Department ofIndustrigl Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Uf www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly r Name (Business/Organization/Individual): Address: l� City/State/Zip:ke Ji, IY7# QIrg 7 Phone #: ;W/ �% 9� Ye Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2. [ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. �• ❑Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. E] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 1011Electrical repairs or additions required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roofrepairs insurance ] ired. re q ur employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they tie 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 and job site information. Insurance Company N Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy'declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A 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 certa ung'er the pains and penalties of perjury that the information provided above is true and correct. V 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 #: fvk 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 employeiis 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 shallnot 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's 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 ofIndust>r%a1Accidents Office of Investigations 600 Washington Street Boston} MA, 0211.]. TO, # 617-727-4900 ext 406 or 1-877 MASSAF& Revised 5-26-05 Fay, # 617-727-7749 www-mass,govfdia 01880-3 Date .....:.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............(8 rz ( . "( — 7- ,_s C ..............................................................................:.................. has, permission to perform?Jdrt(� ........,/l�.s, .......... ................... wiring in the building of .............. < S, .............................................................................. a '.$`¢ ....fw!.h ...5.11&...................�-'� , North Andover, Mass. .................... . Fee .,..... Lic. NAM-5-1/��� .' . *....... ELECTRICAL INSPECTdt v Check # ' (Y 6 2- 11782 p SN- Commonwealth of Massachusetts Official Use Only f) p ( Permit No. / / 7O Z— Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical CodeC), 527 CMR 12.00 (PLEASE PRINT IN NK OR TYPE ALL INFORMATION) Date: Y/ 2-1 ( City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perfo the electrical work described below. Location (Street & Number) wuN;b so 2 q Owner or Tenant WL C-& S Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building t�V�N7N 4-4-- Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: w t.��s' F"S F� N P�^,(�•1 Comnletion 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 Above In- Swimming Pool rnd. grnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets S No. of Oil Burners FIRE ALARMS No, of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No, of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW _ ............ No. of Self -Contained Totals: 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 No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total IIP Telecommunications Wiring: No. of Devices or Equivalent OTHER: �a Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Ele trical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO RAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such covera's . force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, tinderthe ins and penalties of perjury, that the information on this application is true and complete. FIRM NAME:. w� LTC. NO.: /"�FNC Licensee: t&L (AAIR,,.4Z I1,tA-C,( ature LTC. NO.: ') (If applicable, en "exempt" in the license number e.) Bus. Tel. No. )p Address: fC � •0"l t �4rV G �651�� ✓ 1� Alt. Tel. No.- r&Z„ *Per MAIL 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 rPERMIT FEE. $ 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 0 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 F?1 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECT ON: t' Pass IN Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: y Inspectors Signature: Date: FINAL INSPECTION: Pass 0 ", ' Failed 0 r Re- Inspection- Required ($.) ❑ Inspectors Comments: ° 4 1 =^ ac? Inspectors Signature: Date: i WEINHOLD .. TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com r c The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address:_ _$ QA%,AA,010L A --t City/State/Zip: 1P4y!%-Cbue4 kook$_ 03 914 -Phone Are an employer? Check the appropriate box: Type of project (required): ,yo%u 1. [S am a employer with _ k 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors ,�, 7• +�<emodeli-ng 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # ! ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 5. El We are a corporation and its 9, F1 Building addition [No workers' comp. insurance required.] officers have exercised their 10. F1 Electrical repairs or additions 5. ❑ I am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they aie 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:_JAA.ti/ OJ C%A,C- ( --f S Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: �'� t../Lw/ 0 �- l..►%• 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 Rile 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 certi nder the pains and penalties of perjury that the information provided above is true and correct. Sienature: CZ % Date: r 1 I'd ( V, ?,T -c7 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 Pers 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 loeal 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 5ubiiiitmultiple 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: 3 The Commonwealth of Massachusetts" Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TO, # 617-727-4900 oxt 406 or 1-$77.TMASS.AFE Revised 5-26-05 Fax 4 617-727-7749 wwwanass,gov/dia Date. ......... A P0 TOWN OF NORTH ANDOVER 0 PERMIT FOR GAS INSTALLATION SSACHUS This certifies that, has permission for gas installation in the buildings of .... at North Andover, Mass. Fee�--�!'—.. Lic. No.. .3-. ..... ........... -x OAS INSPECTOR Check# 7090 MASSACHUSETTS UNIFORM APPLICATON FOR PERMif TO DO GAS FITTING (Type or print) Date 5 c® NORTH ANDOVER, MASSACHUS TTS Building Locations Permit # New ❑ Renovation - —0'e Name Replacement Amount $ ,2e. —i N, Plans Submitted ❑ (Print or e Name Address, 2 r Ch 17,-77 ©NQ .Z Name of Licensed Plumber or Gas Fitter beck one:Certificaje Installing Company ic Corp. LA Partner. ® Firm/Co. s INSURANCE COVERAGE Chec one: " I have a current liabili Insurance policy or it's substantial equivalent. Yes No If you have checked yes, se indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permi Issued for this application will be in compliance with all pertinent provisions of the Masta� msetts State Gas GQde and Vhapter1X2 of the General Laws. itle APPROVED (OFFICE USE ONLY) Signature of] Plumber Gas Fitter Master Journeyman sed�}mber Or`Gas Fitter License Number WD U a HZ UPI x o w W N Q z Ga z � U W x z a c a> w. F Z U w xj w > H w F W W �Oq > F WU W. x O x j w° z d 3 a d ¢ O O Wa x O w Fx- c a u a a F o SUB -BASEMEN T B A S E M E N T 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR - 8.TH. FLOOR (Print or e Name Address, 2 r Ch 17,-77 ©NQ .Z Name of Licensed Plumber or Gas Fitter beck one:Certificaje Installing Company ic Corp. LA Partner. ® Firm/Co. s INSURANCE COVERAGE Chec one: " I have a current liabili Insurance policy or it's substantial equivalent. Yes No If you have checked yes, se indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permi Issued for this application will be in compliance with all pertinent provisions of the Masta� msetts State Gas GQde and Vhapter1X2 of the General Laws. itle APPROVED (OFFICE USE ONLY) Signature of] Plumber Gas Fitter Master Journeyman sed�}mber Or`Gas Fitter License Number The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations 600 Washington Street Boston, MA 02111 www massgovldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: City/ State/Zir_: _ Phone Are you an employer? Check the appropriate box: I am a employer with � ' 4. El am a general contractor and I employees (full and/or part-time).* 2. ❑ 1 have hired the sub -contractors 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.] 3. ❑ I am a homeowner doing all work officers have exercised their 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 1 ❑ Roof repairs X1 . Other�� ���.� vur me secuon Qeto••• sa�wm r_nar workers! cempcnsation Police .y information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outsidecontractors 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:__�� (I C 1w Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip. ,�& O 1 ", Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under the pains an enalties of perjury that the information provideabov is true and correct Sisnature: _ �� %� \� Phone #: v Cht Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 3 6. Other Contact Person: Permit/License # City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 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 ox- 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 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 Inv-estigations 600 Washington Street Boston, MA 021.11 Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-72.7-7749 wvwl.mass._gov/dia t. Location ~ No. ,�. Date TOWN OF NORTH ANDOVER �, ...mac:.. ,• , Certificate of Occupancy $ '7b'•�•'''�<�'' Building/Frame /Frame Permit Fee $ 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 4Check # 147' Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION Td. CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING NQ BUILDING BUILDING PERMIT NUMBER: 7. DATE ISSUED: 2 c� C 66-,L� SIGNATURE: /// A/ Building Commissioner/Inspecrtor of Buildin2 Date perty Adddress: PAI 1.2 Assessors MMap and Parcel Map N mber (� Number: Parcel Number 4-,,V 4)0Vp r 4 01 �([�� 1 i 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area (sf) Fronta e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R aired Provided 1.7 Water Supply M.GL.C.40. 54) 1.5.. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ SEC'11ON 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record -6 fic Ile A) Name (Print) Address for Service ISignature Telephone I 2.2 Owner of Record: IName Print Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor:An n ) Address �` W Signature Telephone 3.2 Registered Home Improvement Contractor Company Name 6 Address Address for Service: Not Applicable ❑ License Number Expiration Date Not Applicable 0 Registration Number Expiration Date SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building unit. Signed affidavit Attached Yes .......❑ No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: • SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be� Completed by ennit a ltcant * 3, •a -i- - s . ed vra,';9 ` ti t I. Building 6P 00 (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) c 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 cr, nm■rw. n Check Number --------• •— ••�.,,.,:.�.v...v.�JLJLvlw iv Dr.l%YJLVJrLnLrju WrMI'N OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My bel alt; ui l mai rs relati � work authorized by this building pennit application. Signattue f0",6 Date—/ SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, ,as Owner/Authorized Agent of subject Properly Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief e 4 r iJn1V1 - U L!V 1 I%x LL' t&0L' 1' "INIV1 INSTRUCTIONS: This form is used to verify that all -necessary approval / permits from k —1— ! Boards and Departments having jurisdiction have been obtained. This, does not relieve the applicant and or landowner from compliance with any applicable requirements. i Baa■■aaa■aaa■a.0aaa0aaaaaaaaaa.aaa0a0aa0aaa.-a■aaaaa■aa.■aa..■a■•aa■a 00aa■a0a i j APPLICANT I E' �✓ k }} I tf"s PHONE 6 Y— 0) 3 1 i ASSESSORS MAP NUMBER D LOT NUMBER �. SUBDIVISION LOT NUMBER W UO`J so ft rw -�- STREET STREET NUMBER J0aaaaaaaa.aa■..araar.aa.... was mass a..aa..a■ OFFICIAL USE ONLY 1asaw ■aaaaaa.aa.aaa.a.a....a.■WON .aaaaaaaaaaaone aaaaa.waaa.aaar..aaaa■..aaaaa. RECOADAENDATIONS OF TOWN AGENTS DATE APPROVED 4— CONSER VATION ADM NISTRATOR DATE REJECTED Co DATE APPROVED TOWN PLANNER DATE REJECTED COMIv��N TS FOOD INS R - HEALT H C SPECTOR - HEALTH DATE APPROVED DATE REJECTED DATE APPROVED_ DATE REJECTED Y-c� � r�-��-t: cam -.-s vL-•�Y M �. ,.� ; .- �... � PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COvMNTS RECEIVED BY BUILDING INSPECTOR _ DATE WN Z O lu 04 v W (14 1.0-,9Z vi wa WN Z O lu 04 v W (14 1.0-,9Z s 7 F7 BUILDING J.N L%Au raiNi.+v r L1\ CONSERVATIONHEAL a''�w' otvsio:� of PLASM-ING PLANNING & C01NLNlUN TY DEVELOPMENT -t CHI:e= APPLICATION AND PERMIT DeiTE �-' PERMIT T LOCATION 10 -NAV t Wk /e -- OWNER' S NAc1E �i /AJ)4 be u • jj G BUILDER'S NAME: 201 ,M It- SS/ AJC il MASON'S NAME 31214M `i'i PJS :Fi e 1-0 MASON'S ADDRESS HASON' S TE L,rPEOilE MI A TER'r L. OF / V i J �.D/ V A INT=RIOR C::I.4NEt,1 �% _..{TLRIOR �P-C C� Nl/A_:c AND SiiJL V- 1 _... c� AG-"/ 5 /x f 4 a L..%--al=SS OF HEART--' T1'I _, �r�l i -1T fi r► __ a= .�•.�. .�.. -..s r... ... � 4 —=«. - }• -Z W-4 e � o f' _ cc rem, eats o� ..ne code ar. have rules and recu_az_. ms oeer. received: D�1T� l 2-� q i SIGNATURE OF MAS Oii COidTR. LIC. i042,3' EST . CONSTRUCTION COST. c: C::: �iCT PRICE PERS _I =' GRnliT.J �� F=- �oCN ✓ C�� ROBERT NICET'-'A, RE:�'RKS RFOUTRED THIS PZIUNUT 21UST BE DISPLAYED ON T'riE PR RISES CA* 0x-7? ea L4sV � '�OtS H • �. IDEf c W vlir !0 Ni�'�'� NO3831i 03NIVINOO NOUVM aIO�NI A V VO VNIAMIG S/HI JO 3sn UMNOMInviv/1 311 NOV .fll1/B/SNOdS3dl ON 53J/Yl /98.3S v N35NY/.ISMfH3'031/9/HOdld SI 35n 03ZlEImumn ANY ONY 3Nl 19b3S v N3SNYU5/dIH9 !O AMdOMd 031H0/NAdOO 3HI S/ 9NIMYbO S/Hl 3bDmaq%UNw ON/ ISMS V N3SNY/ISIBHO JO,NOIVSIM&3d Af-W I l 5661 `91 8380100 -31 t/0 09:=, l �37d0S 'd/N. `d-7AOONd Hl?lON 133t/1S `c13nPVnS VOl 107 =N0/14007 1N3170 3AOHV 3H1 Ol HOMEOWNER LICENSE EXEMPTION Please print j DATE / Cr /C JOB LOCATION ® [ tA tA)11V �✓J C) Number Street Address Map of �avx r,i O o + ` • 0 N p � Y ssACse1 "HOMEOWNER Name Home Phone Work Phone PRESENT MAILING ADDRESS • City Town State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does . not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1)' DEFINITION OF HOMEWOWNER: ; Persorl(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that he/she understands the Town of No_ Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATU APPROVAL OF BUILDING OFFICIAL f Town of North Andover Building Department • 27 Charles Street . North Andover, MA. 01845 D. Robert Nicetta Building Commissioner (978) 688-9545 ....:(978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print j DATE / Cr /C JOB LOCATION ® [ tA tA)11V �✓J C) Number Street Address Map of �avx r,i O o + ` • 0 N p � Y ssACse1 "HOMEOWNER Name Home Phone Work Phone PRESENT MAILING ADDRESS • City Town State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does . not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1)' DEFINITION OF HOMEWOWNER: ; Persorl(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that he/she understands the Town of No_ Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATU APPROVAL OF BUILDING OFFICIAL f Jc�,r,e 1, 2 ex�1 Project Plan Name Stephen J. Wiles Address 89 Windsor Lane No. Andover, MA 01.845 Description Finished Basement (Recreation Room) Dimensions 18' x 23'6" (est. 425 sq.ft), finished ceiling 7'4" Floor 3/4" CDX on 2x4 pressure treated sleepers 1.6" center, 1 '/2" foam insulated plus clear polyethylene vapor barrier, carpeting Walls 2x4 stud walls 16" center, insulated plus clear polyethylene vapor barrier backing, '/2" wallboard 3/4" x 6" vertical pine paneling with chair rail Ceiling 12" square tiles stapled on strapping Wiring New 20 amp circuit for 5 outlets New 20 amp circuit for 4 outlets Add 12 recessed lights to existing 15 amp basement light circuit Recessed lights on 2 dimmer zones (6 lights on each dimmer) One thennostat for heating Heating Baseboard heating, forced hot water, new zone on furnace Refer to attached sketch of basement plan. t I cz r� • c y'- •m 0 a c a c � a O ` C p• 1 O C = O A c9� w2 a° U co w c�° w U w a° w a zCO tw) a° w W w w cin o cn N 01 y y .E CDL CL co nr. C O co 0 m CL COD 0 w CL CO) C O U, O 'c c CO2 0 ''o vJ LU cr W W crLU • c y'- •m 0 c c � O ` C p• 1 O C = O a E5� U ♦+ a,r E •' � tm�:m`�0 :m3�r A E m mocm �: H= OCf •n Ca S L: az m mocm 0• � . g.0. Z a c F- a � ym� •o. V) LJJ O •N � r.+ C r=.+ O •r �. oC•E d=_ C c •y Z CD LLJCD U Q V� d A Ocm M O� .0 zoo � y •O = CL a N 01 y y .E CDL CL co nr. C O co 0 m CL COD 0 w CL CO) C O U, O 'c c CO2 0 ''o vJ LU cr W W crLU t 3 3 ., 4 No Date .................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING l This certifies that .......!� i.: �%......! ..:'.-:' ...::,'%............................................... 3 �— has permission to perform '%wiring in the building of... .:'.. J. r... . I ................................................................. r lx ....... . North Andover, Mass. � v Fee �,� Ltc. No. ,....� c r ................................................................................. ELECTRICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer DEPARTMFVT0FPUBL1CS4FEIY Permit No. BOARD OFFLREPREYEWONREGUL4710ANS27CUR 120 Occupancy & Fees Checked i APPL.ICATTONFOR PERMIT TO PERFORM ELECTRICAL WORK I ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) DAL. % Dto Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. i Location (Street & Number) i Owner or Tenant h (' Owner's Address44 YJ4 Is this permit in conjunction with a building permit: Yes 10 No (Check Appropriate Box) —r�I Purpose of Building -�71 'n / ;SA C -d AV ra� Utility Authorization No. Existing Service CO Amps / Volts Overhead Underground No. of Meters aN� New Service Amps Volts Overhead Underground Q No. of Meters Num ber ofFeeders and Ampacity Location and Nature of Proposed Electrical Work ` No. of Lighting Outlets No. of Hot Tubs 90. of Transformers Total j I KVA No. of Lighting Fixtures / Swimming Pool Above Below Generators KVA ground ground a No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets 10 No. of Gas Bumers No. of Ranges No. of Air Cond. Total FIRE ALARMS No. of Zones Tons No. of Disposals No. of Heat Total Total No. of Detection and Pumps Toils KW Initiating Devices No. of Dishwashers Space Area Heating KW No. of Sounding Devices No. of Self Contained Detection/Sounding Devices No. of Dryers Heating Devices KW LocalMunicipal Other- Connections No. of Water Heaters KW No. of No. of Signs Bailasis No: Hydro Massage Tubs No. of Motors Total HP %THEIR hsuartoeCa Pastantbthet8gtmartalsof�SadGataalLaws ® f�dJ Iha%eaaj=tLiatnTdyhrst ==PbhtyarhxmtgCaTV,M ComWoricssiosfadiaf0whaiat YES iw Iha%eahnnadvandpofofsmmlodieOTmYES M NO IfycubawdradWYlr,,pleasemdc*ttc4Wefe crWbydockirgthe box INSURANCE BOND[—] O1HR (PleaseSpacifj� WaktoSlatt hgectimD*Racxad Signedunda� etjury FIRMNAME FstiniadVahrd Ebdiral Wa& $ Rouffi . FM U=W111a Lioa>sae Signa Lioa>SeNo Btsi =Tel.Na a AiTeLNa OVVMXSMJRANCEWAIVER;i.anaw=hatthelioa dmict +efemmto o"ageoritss>lra[e aste#mdbyMmmdms&CaraalLaws aoci atmysgrl setarduspam� w regtlmnent (Please k Owner Agent ® q 2 Telephone No. ! 70' '�� 3 r PERMIT FEE $,--4(S