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Miscellaneous - 90 BERKELEY ROAD 4/30/2018
1 N GOWNER TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM A�j PLICATI.ON FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: MofT A /lilGFoil� MA. DATE: I I/ PERMIT# U JOBSITE ADDRESS: Rb E&Z OWNER'S NAME: d-T-lrf` IL (hQ ADDRESS: ) -Pit llFAX: OCCUPANCY TYPE: COMMERCIAL [� EDUCATIONAL ❑ RESIDENTIAL NEW: RENOVATION: El REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO A APPLIANCES -1 FLOOR- Bsmt 1 1 2 31 1 4 5 6 7 8 9 10 11 12 13 14. BOILER , BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE I INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVEN$ED ROOM HEATER WATER HEATER I ro L- I INSURANCE I have a current liabili insurance policy or its substantial equivalent If you have checked YES, please indicate the type of coverage±by LIABILITY INSURANCE POLICY V OWNER'S INSURANCE WAIVER: I am aware that the licensee Massachusetts General Laws, and that my signature on this p6nnit • COVERAGE which meets the requirements of MGL. Ch. 142 YES EeN0 ❑ checking the appropriate box below. OTHER TYPE INDEMNITY ❑ BOND ❑ Joes not have the insurance coverage required by Chapter 142 of the . application waives this requirement _ CHECK ONE ONLY: OWNER ❑ AGENT ❑ 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 compliance ' all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 1142 of the General Laws. PLUMBERIGASFITTER NAME: O� f I LICENSE # 13�55� SIGNAT RE COMPANY NAME: I �A�DDRESS:.3l rts�l' ST CITY* e STATE: 1 ZIP: fi ��'t FAX: TEL:S S��`" ZI 5 CELL: 97 bre 36- Z� S I3 EMAIL: \ MASTER (JOURNEYMAN ❑ LP INSTALLER ❑ CORPORATION LTJ # 3a PARTNERSHIP ❑ # LLC ❑ # rr 11481 Date ....'.q./15..... TOWN OF NORTH ANDOVER PERMIT FOR PlMeffiQR40#W 4AS This certifies that .. ��- ^............................. ...............%��...... has permission to perform :.......V�t....!..:z�----.... �.. plumbin in the buildings of ...........Icy ...................................... at ............ ....... P....../.�..................... North Andover, Mass. FeeO�.A......... Lic. No. J... .5)7.................................................................................. I3 7 PLUMBING INSPECTOR Check # (� KIM Department�of industrial Accidents Office; of Investigations ' I Congress Street, Suite 100 Boston, MA 02114-2017 4 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ! Please Print Legibly Naive (Business/Organization/Individual): A G dc� % fi: 1 C © 4�_ Address:_-���c-eA S i City/State/Zip: /VN p, Arf I -e— Phone #: %� 17 Z /5 .3 Are you an employer? Check the appropriate box: 1.2 1 am a employer with 4. ❑ I am 'a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ Iam a sole proprietor or partner- listed on the attached sheet ship and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have employees and have workers' comp. insurance.: 5. ❑ We are a corporation and its officers have exercised their right! of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' coma. insurance reauired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.Nf Other_, P S �{�i.�-Q,r/,' *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. xContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: go, T �qyj Policy # or Self -ins. Lie. #: (J ,S /?/+C) d Expiration Date: i Job Site Address: I i City/State/Zip: IQ, , /`hr'ld�� 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 herebyeertiy under the pains and penalties of perfury that the information provided above is true and correct. Phone #: L -92-e` R 3 t'i — Z f 5 3 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 #: COMMCIMWEA �W H OFMASSACHUSETTS S, BOARD OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE REGISTERED AS A PLUMBING CORP 11-u MARK MAGNIFICA -Z MAGNIFICA BROS PLB&HGT,GAS FITTI 31 FOREST ST MIDDLETON MA 01949-2015 3266 05/01/16 204666 COMMONWEALTH OF MASSACHUSETTS :5q, BOARD OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE LICENSED�AS A MASTER PLU1413ER MARK 8 MAGNIFICA 10 31 FOREST STREET MIDDLETON IMA 01949-2015 --135.5.9 05/01/16 204667 CIG IMMONWEAI,t!',-, F -MASSACHUSETTS BOARD OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE LICENSED AS A JOURNEYMAN PLUMBER MARK B MAGNIFICO z 31 FOREST ST z s4l]101-15TON MA 01949-2015 25002 05/01/16 204668 ;4ccsRvr CERTIFICATE OF LIABILITY INSURANCE D/20/UDD/Y CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 3/20/Z015 5 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(tes) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER EA Stevens Company, Inc. 389 Main St. CONTA ; Eva C8 eron NAME• p PHONE (781)322-2324 FAX (781)397-7672 ADAIE •evac@eastevensins.com P. 0. BOX 188 Malden MA 02148 INSURERS AFFORDING COVERAGE NAIC t INSURER A -Mart ford Fire Insurance Company 19682 INSURED INSURER B :Saf ety Insurance Company 9454 MAGNIFICO BROTHERS PLUMBING HEATING & GAS INSURERC:Twin City Fire Insurance Co. 29459 INSURER D FITTING, LLC. 31 FOREST STREET INSURER E: MIDDLETON MA 01949 INSURERF: GUVEHAUES CERTIFICATE NUMBERe15-16 Master RFVICIAIU Pal11111RCQ. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR L TYPE OF INSURANCE A POLICY NUMBER i POLICY EFF M/D POLICY EXP MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES a occurrence $ 300, 000 A CLAIMS -MADE ® OCCUR 8SBA0 5370 Q � /24/2015 /24/2016 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 i GENERAL AGGREGATE $ 2,000,000 i GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY B JECT PRO- LOC $ AUTOMOBILE LIABILITYO BINE accident) LIMIT(Ea 1 1000,000 BODILY INJURY (Per person) $ B ANY AUTO ALL OWNED x SCHEDULED AUTOS AUTOS 5053635 /24/2015 /24/2016 BODILY INJURY Per accident $ ( ) x HIRED AUTOS x NON -OWNED AUTOS PROPERTY DAMAGE IPer accident $ Medical 2ayments $ 10,000 X UMBRELLA LIABx OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS UAB CLAIMS -MADE AGGREGATE $ 1,000,000 DED x RETENTION$ 10,000 $ OBSBAUQ5370 /24/2015 /24/2016 C WORKERS COMPENSATION x WC STATU OTH AND EMPLOYERS' LIABILITY Y / N EACH ACCIDENT $ 5QQ QQQ ANY PROPRIETOR/PARTNER/EXECUTIVEE.L. OFFICER/MEMBER EXCLUDED? ® N/A E.L. DISEASE - EA EMPLOYEE $ 500,000 (Mandatory in NH) 8WECRJ9050 /24/2015 /24/2016 NqS desedbe under E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below i DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) i I Hartford Fire Insurance Company One Hartford Plaza Hartford, CT 06155 ACORD 25 (2010/05) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Cares, Jr/EC �45— ''— ©1988-2010 ACORD CORPORATION. All rights reserved. initin7%iminmi n1 Tha annon name anti Innn aro ranic#arasl mar4c rA Arman 10404 - Date ..2.,...011 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ............................... ................................................................. This certifies that ...bl'A U A -,- has permission to perform.on r-, plumbing in the buildings of .......... fe ........ .......... ::qp .......................... .. .... ..................................................... at ......... .... &"ze ... ..... 0.*., i* J1. � . .... North Andover, Mass. Fee.� ..... 0 .... Lic. No. .....M6.............................................................. PLUMBING INSPECTOR Check# 11 "11 �Y"" �22--1`i N I Lojij P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY /Z/ ve-c MA DATEao? 0� PERMIT# JOBSITE ADDRESS 0rKe /e,. �d OWNER'S NAME OWNER ADDRESS D tgo-PAel TEL OCCUPANCY TYPE COMMER IAL EDUCATIONAL NEW: E] RENOVATION: REPLACEMENT: Ell 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 FT— TOILET - TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER _ J _ JIFAX RESIDENTIAL @I! PLANS SUBMITTED: YES E0 NOD M0® w INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 'NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [jj/ OTHER TYPE OF INDEMNITY QI BOND D 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 101 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 in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME � h .__...iia_ :- LICENSE # O 1 SIGNATURE MP JP © CORPORATION 01 #©PARTNERSHIP D# 1 LLC L COMPANY NAME Ma_r��_��ADDRESS DD �- CITY u v� ^_ STATE ZIP p Jgb6 TEL 7-T FAX I CELL gal-Baa-aiaa EMAIL O Wol H U W on z a Z w❑ O � W O wLU a Z C O a Lu M uj w co a p o w� a as U J a Q < Cl) ui s w H O O H U W P-1 a a p A The Commonwealth of Massachusetts - Department of Industrigl 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 Le2ibiy Name (Business/Organization/Individual):_ N1 Cs 4n a ACIIJI-)je7! Address: Ale City/State/Zip: Sa �, v_5 _ZVA 0 /90 6 Phone #: 17 - 775 — 73 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ T am a general contractor and 1 6. ❑ New construction ployees (full and/or part-time).* 2. U110am 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. [J Demolition working for me in any capacity. workers' comp. insurance. 9 E] Building addition [No workers' comp. insurance 5. El We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.[i Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they a're 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 ofup to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. f ---=7_-� Date: off( —2-6 /J Phone#: X6/7 — 775 "' 7'_5-_-3S — Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract ofhire, 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 Iocal 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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town 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 Commoawealth of Massachusetts Dopartuac at ofZndustdat .A.ccidouts Office of Investigations 600 Wasbington Street Boston, MA, 42111 Tel, # 617-727-4900 ext 406 or 1-877:MASSAFB Revised 5-26-05 Fax # 617-727-7749 wwwmass,gov/d a Date �........... ...c/ ............... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies thaw). Loa,......KL}�.n ..:..... �i �• has permission for gas installation ......:........ �!. .4ve inthe buildings of ....� fL."....�........................................................................................... � at ........ ..o........ ................................... , North Andover, Mass. Fee........... Lic. No... .... ..H�......................................................... GAS INSPECTOR Check # r /t -` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE 1 PERMIT # JOBSITE ADDRESS K�.lr OWNER'S NAME AM eff OWNER ADDRESS TE FAX TYPE OR OCCUPANCY TYPE COMMERCIAL © EDUCATIONAL ® RESIDENTIAL 51" PRINT CLEARLY NEW: [j RENOVATION: ®' REPLACEMENT: ® PLANS SUBMITTED: YES 0 NO F APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER....-- _ FIREPLACE I J FRYOLATOR j FURNACE GENERATORI GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN - POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT �l TEST UNIT HEATER a UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES O'N0 D I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF CYE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY [j BOND F 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 E] AGENT 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Thep),_ iUlc� ��'n_r7 LICENSE# )do 6 SIGNATURE MP E2/MGF 0 JP ® JGF Q LPGI ® CORPORATION ©# = PARTNERSHIP ®#= LLC ®# COMPANY NAME: /,r�tan� ADDRESS CITY Sc. u . z✓S _ STATE ZIP g71TEL 775- S;Z FAX CELL 7& EMAIL a`a Co Y\ COD 0 z 0 H w � Z, El Q N ❑ w ~ W O w O H a q z LU w � � 5 a WLU � a W O w w N a o a a a `rA U J H a co w x w 1- LL H 0 z 0 H U w PLqCID to 6 C7 °a The Commonwealth of Massachusetts Department of IndustrialAccldents c kaV 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): AGU,t�'a -7 n 14q Address: 00 E) 1!21 OO od A4 y r City/State/Zip: S a u5uS /t -\/r DI 9 D 6 Phone #: 617 — 77s - Are 7s - Are you an employer? Check the appropriate box: ployer with 1. [9N�amayseole 4. ❑ I am a general contractor and I s (full and/or part-time).* have hired the sub -contractors 2. I proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. [:]New construction 7. El Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they Are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. 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 cerdfv under the pains and penalties of perjury that the information provided above is true and correct. J Simature:9"v2 Z--'— Date: � 6 Phone #: 617 — 775- — 711S Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #' Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or Iocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston., MA 02111 TeX. # 617-727-4900 ext 406 or 1-877rMASSAk'B Revised 5-26-05 Fax # 617-727-7749 www-mass.gov/dia Rightfax C3-1 11/7/2013 7:14:48 AM PAGE 2/002 ...:. Y. f_F:RT1P1rATG f1G 1 IAR11 ITV IAIQ110AAIf%C Fax Server DATE (MM/DD/YYYY) TWQ4ERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRO CER AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), PRODUCER CONTACT NAME: PHONE FAX NICHOLAS A CONSOLE INS 153 ANDOVER STREET UNIT 111 (A/C, No, Ext): (A/C, No): DANVERS, MA 01923 E-MAIL ADDRESS: 27DKX INSURER(S) AFFORDING COVERAGE NAIL# INSURED INSURER A: HARTFORD UNDERWRITERS INSURANCE COMPANY MARCLANO, JOSEPH DBA MARCIANO PLUMBING INSURER B: INSURER C: INSURER D: 22 ELMWOOD AVE INSURER E: SAUGUS, MA 01906 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: ;ERTIFY TKAT THE POLICIES OF U45URANCE LISTED BELOW HAVE BEEN ISSUED TO E INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTAIT}iSTANDING ANY RECD REMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHCH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN ISSUBJECT TOALL THE TEPoMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMES SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR ADD SUB POUCY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMDD,YYYY) (MM,DD\YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE 0 OCCUR. DAMAGE TO RENTED $ PREMISES (Ea occurrence) ED EXP (Anyone person) $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PROJECT LOC PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ AUTOMOBILE LIABILITY ANY AUTO COMBINEDSINGLE $ LIMIT (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) BODILY INJURY $ HIRED AUTOS NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DEDUCTIBLE $ $ RETENTION $ A WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY YM UB -5B441774-13 06/15/2013 06/15/2014 XWCSTATUTORY OTHER UNITS ANY PROPERITOWPARTNE fE7(ECLJTIVE OFFICERME MBE R EXCLUDED? WA E. L. EACH ACCIDENT $ 100,000 E.L. DISEASE- EA EMPLOYEE $ 100,000 (MardatoryInNH) If yes, desYbe urder DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE WORKERS' COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR MARCIANO, JOSEPH. CERTIFICATE HOLDER CANCELLATION ''OWN OF NORTH ANDOVER 1600 OSGOOD STREET NORTH ANDOVER, MA 01945 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONJS:_� AUTHORIZED REPRESENTATIVE 25 (2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 n r m N � z� .O �Q Ci cn N O N' N D N C m cn 4 0 7 O oD F G) r m -,. O :L3F o (n � m m j- ., d �rtrtRiilliA ui o Date ... .�Z. 1"I ......................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that..k,? J,N ¢ ..�. ",`,,,, ........ ............................... P pp� ,pper 1 %6 , u�� has perrlussibn top ............. ?i' -t ..... .... ...i.. h.Q ?`...... ._ L 1 wiring in the building of ....... �<...A*. A-5............h ........................................................at .....1e �o...North Andover, MaFee..".."........... Lic. No0 ...�"!'`........1....................LCAL INSPECTOR ` 36/ U Check # 12391 05;28/2014 00:54 7816487778 GIBBONS ELECTRIC PAGE 02 `Mmonwea/th of Massachusetts Official Use Only -- No. of Cell: Susp. (Paddle) Fans Permit No, Department of Fire No. of Luminaire Outlets (Services Generators KVA V, BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked Swimming Pool Above ❑ n- ❑ rod, rnd. [Rev. 9/05] leave blank Nv: of Receptacle "APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WOR All FERE *EA110W work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 No. of Switches 1 (PLEASE PRINT IN ,INK OR TYPE ALL INFORMATI011� Date: � o, of FU.&r1lon an Initiating Devices City or Town of: f I-T� A -/over To the Inspector of Wares: By this application, the undersigned gives notice of his her intention No, of Air Cond. TonsNo. or to perfon theelectrical work below. No. of Waste Disposers cdescribed Location (Street & Number) pl .om er Owner or Tenant -- Telephone No. KW '.""""""""'.... Owner's Address 5Lqm el No. of Dishwashers Is Wis`permit In conjene"- with a. buildingpennh? Ne, ❑' (C,#eek„AppT0priAte 11ox) _ Local ❑ MunicipalD Other . Connection Purpose of Building Mej &LnZaz_- _ — Utility Authorization No. Heating Appliances KW Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters No. o Water KW Heaters New Service Amps Ovev%ead ❑ 'Undgrd ❑ TVo, of Meters 3 Number of Feeders and Ampacity- No. oTMffoes Total HP Location and Nature of Proposed Electrical Work: (`mm�lo/inn n!//fa lnllna.�nn �nRle ... ., 6a .. ..,.a 1... d... ►.._....�.... ,.�m�___ No. of Recessed Luminaires -- No. of Cell: Susp. (Paddle) Fans w ..'M. v,. = "Mf4J f:fuf V /IrCJ. o• o ota Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. -of Luminaires Swimming Pool Above ❑ n- ❑ rod, rnd. o. o mergency g ng Battery Units Nv: of Receptacle No. of 60 Buram FERE *EA110W Ne: of Zones No. of Switches No. of Gas Burners o, of FU.&r1lon an Initiating Devices No. of Ranges No, of Air Cond. TonsNo. of Alerting Devices No. of Waste Disposers eat u Totals: .om er ons .I I KW '.""""""""'.... No. or seir-co-n-ta—uner Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ MunicipalD Other . Connection No. of Dryers Heating Appliances KW echo of Devices or E uivalent No. o Water KW Heaters o, o o. -OF— Signs Ballasts Date Data Wiring: of Devices or Equivalent No,,,lffydromast:age BurMbs No. oTMffoes Total HP TelecommunicadwaWlring: No. of Devices or Equivalent O�XIIEit: ' Attach additional detail ifdesired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: '� �, a dy - O�When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C VERA : Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof -of liability tnsurancetnehtding "completed operation" coverW ePr4ts•substantral equivalent. The undersigned certifies that such coverage -is in force, and has exhibited proof of same to he permit issuing office. CHECK ONE: INSURANCE -W` BOND ❑ OTHER ❑ (Specify:) L i►O,�tll1��CaOdovD I certify, under the pains and penalties of perjury, that the Information on this application is true and complete. FIRM NAME: /7 a LIC. NO.: Q590 Licensee: j' e.�n&Th 3, S'iPR rfbi j Signature "LIC. NO.: (lf appllcab e, en1pr "exert l " in thf licensf number line.) Bus. Tel. No.: Address: _ CiA In/'14 Alt. Tel. No.. *Security System Contractor License Aluired for this work; if applicable, enter the license number here: 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, 1 hereby waive this requirement. I am the (check one)E] owner owner's a ent. Owner/Agent Signature 0. Telephone No. PERMIT FEE. j _ tri\ til?_glt-1 — 1g9 s N i 05/28/2014 00:54 7816487778 GIBBONS ELECTRIC PAGE 03 The Commonwealth of Massachusetts Print Form Department of IndustrialAccidents Office of Investigations 1 Congresssereet, smite 100 ,Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance AMdavit: Builders/Cotitractors/Electrieians/Plumbers ARIQUOnt Information Tp Please Print Let�bi N8tt1e(AuNness/Orgenisation/Individual): L,1� G _R Address: ?q 130AD i� y Ci /State/Zi ! Phone i#: " 7 i / Are you pa.employer? Check_theappropriate box:.. T 1. ® I am a employer with I& 4. ❑ 1 am a general contractor and 1 6_ ❑ New construction employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7. [] Remodeling ship and have no employees These sub -contractors have 8. ❑Demolition working- for me in any capacity_ employees end have workers' comp. insurance.t 9 Q Building additiorr [No workers' comp. insurance 5. E] We are a corporation and its 10.9 Electrical repairs or additions required.] re 3. [] 1 qu a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.. [No workers' comp. right per MGL 12.0 Roof repairs insurance required.] t ' c. 152, §l(4), and we have no , §1(4 ,and 13:0 Other employees. [No workers' comp. insurance required.] •Any applicant that checks box NI must also 1111 out the section below showing their workers' compensation policy information. 1 Homeowners who submit this affidavit Indiolling they are doing all work and then hire outside contractors must submit • new affidavit indicating such. lContraetors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities havo employees, If the sub -contactors have employees, they must provide their workers' comp. policy number. Lam anemployer that Is provIA ig.workers' compensadon,brsurancejammyzV1oyez&..B*Jow Is Ore policy and job site information. '., Insurance Company Name: Policy ff.or Self -ins. Lic. b: D N — FaD_017 017 Q -T ~ p 7 Expiration Date: �Q *Job Site Address: km -1 k J City/StatP1zi&Q(Q Ver 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 IDOL c. 152 can lead to the imposition of criminal penalties of a finf 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 One 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. do hereby ce#W& under the pohn awdpenah/es of pedwryMtn the Jq wswwelon provlded4bove Is true and correct. f oJf7elM aareentry. Do sot wrlathe ebb area. to be cowplefed by city twlown off9'clai City or Town: PermltfUcense N Issuing Aaattaority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone C 05/28/2014 00:54 7816487778 GIBBONS ELECTRIC PAGE 01 +IB�ONS 'E'LECfiRIC �'r 189990ADWAY AM1NGTON, MA 02474 LICENSED • INSUACO • BONDED LIT r HtAt POWER MASTEA LICENSE NO. A20NO PHONE 761.648 -Ml FAX -781,648,7M. EMAIL: irlbOp�bonselectric.mm WEH wwwpbbonaeiea=.com r 4,! & A 47V Yo: %T )�O- r From: lQ� C-7. FA P&= / - q _ _ vases -t xk,*c phom Deter ,moi /off 8/'JL/ Rs: CC: ❑ Urgentor Review O Please Comment O Please Reply ❑ Please Recycle • Comments: A 67^ fl�� 0C'n . owned and operated by Sparrow Electric LLC V(t- x Rj Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certo*es that ............ ...... . ..... ...... .................................................. .................... has penmssiori to pkrn �11:1� ................ ... �jt ...... wiring in the building of ........ kd,-�j ..... .............................................................................. at 7) e- .1 � 74 ...... . ........ . ........ .................... . N,,,ornthiA4,ndover,,Mv, Fee.. 55v .......... Lic. No2_0 . .. ........ .................. ELECTRICAL INSPECTOR Check# 12391 Commonwealth of Massachusetts Department of Fire Services 9 BOARD OF FIRE PREVENTION REGULATIONS w Official Use pOnnly Permit No. ` -J l2 (.P t Occupancy and Fee Checked [Rev. 9/051 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: 6hdaver 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) 51c; Owner or Tenant %-� %�'t h a No. of Total Transformers KVA Telephone No. Owner's Address 3714 el No. of Luminaires Swimming Pool Above ❑ In ❑ rnd. rnd. Is this.permit in conjunetien✓wMi-a-buRding- permit? - lies--® Ne, ❑ (meeI - .. repriate Box) Purpose of Building ` e Y;C1e e6 � j lq1 . 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: /'Cl• P/J a (1' Q f� 7' et 1,/ i te A/9i`i'6DCJl P r �O�itY L Space/Area Heating KW /�'PP�x►a� No. of Dryer's Security Systems:* Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In ❑ rnd. rnd. o. o Emergency Lighting Battery Units Nv. of Receptacle- Oetietr No. of-O*Burners FIRE S• Nw. 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 J.Number Tons J.KW No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ unicipal ❑ Other Connection No. of Dryer's 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 Na: Hydromassage > ilit�ebs No.,6f or's Total IIF Telecommuniratinnc Wiring. No. of Devices or E uivalent OTHER: Estimated Value of Electrical Work: hAttach additional detail if desired, or as required by the Inspector of Wires. �, d 0- OO(When required by municipal policy.) Work to Start:Lim i Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the-lieensee provides proof -of liability insuFance+wluding "completed operation'° coverage-or-Wv substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [a BOND ❑ OTHER ❑ (Specify:) t! iK',�iilics�G,C+vO I certify, under the ains_ and penalties of perjury, that the information on this application is true and complete. FIRM NAME: G-1, e eTr),C, LIC. NO.: ca Q_5ff0 A Licensee: I&Per4 SjPA r/bL-1 Signature LIC. NO.: (If applicable, en er "exempt" in th license number line.) Bus. Tel. No.: 271- •3� 1 Address: �% �i O—A wigy Alt. Tel. No.: *Security System Contractor License required for this work; if applicable, enter the license number here: 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 alZent. Owner/Agent Signature Telephone No. PERMIT FEE 5 , CC.) 19�1.T 14 00:54 7816487778 GIBBONS ELECTRIC JJ r`IM 110 IiRie� � onPnnnl narnlna a.4�/n�Bp �co N I(D 1 h EO cc ru C� M cc 1 �D to 0 ru a .a rm a .41 ru ma ru cmM PAGE 04 \ Date �� ............... TOWN OF NORTH ANDOVER PERMIT FOR WIRING 7`� l� This certifies that .....�.... et �....:......................................................................... has permission to perform ......1,i'Y1.j.............................................................. wiring in the building of........A C "-..'A ......................................................... ........ ................ ........ ........::. t ................................................�. �Pr........................,`North Andover, Mass. 9� .........../......... /�' ��``••�?F!...;:..... Fee .........:.�4................. Lic.No. ELE`4 7MCAL INSPECTOR Check # ,,. no /Q � / , / f��� �'p" 7` r Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. oZoZzP� Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: 3_ Ile -/I/- WORK City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his o her int ntion to performXthle`c/ ical wo k dfscribed below. Location (Street & Number) 7 ( 4, ;7� t��' UcJ Owner or Tenant Owner's Address Telephone No. 612 F% 7, Is this permit in conjunction with a building permit? Yes No LJ (Check Appropriate Box) Purpose of Building /K (t e du,Y 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: Si /L "1 U ,/ /i �'r"�( Cmmnletinn ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell: Susp. (Paddle) Fans V No, of Total Transformers KVA No. of Luminaire Outlets �j No. of Hot Tubs Generators KVA No. of Luminaires ,�(c'c. S 5 .3(% Swimming Pool Above ❑ In- ❑ g rnd. rnd. o. o Emergency Lighting Batte Units No. of Receptacle Outlets /0 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers P Heat Pump Totals: Number Tons .KW ......... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local El Municipal El Other Connection No. of Dryers Dr y Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the tnspector offires. Estimated Value of Electrical Work: 12 acv (When required by municipal policy.) Work to Start:�" �y 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 covera is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND El ❑ (Specify:) I certify, tinder the pains and pe alties perjury, tlt t i informatt n on this application is true and complete. FIRM NAME:. z%" /V -- ,, X� .�lt� /S, LIC. NO.: /0-)/ ll� Licensee: Signature LTC. NO.: (If applicable, enter "exempt" in the license number line) Bus. Tel. No.:�� Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. I -7 Fz F r6lr� ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the �t 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. 0. Rule R—Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass I] Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: „ Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Com nts: 1 Inspectors Signature: Date: FINAL INSPECTION: Pass [N K Failed Re- Inspection Required ($.) ❑ Inspectors Comm ts: Inspectors Signature: Date: cuL--,-T- --*>-f 06- D8IVE:7/�60 %- DEB WEINHOLD ... TOWN OF MERRIMAC, MA. ....... dweinhold@town finerrimac.com i . The Commonwealth of Massachusetts Department of Industrigl Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address:`J City/State/Zip: kv) //'g �° Phone #: t -S -J - 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 e ployees (full and/or part-time).* 2. I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. [J Remodeling ship and'haveno employees These sub -contractors have 8. ❑ Demolition workingfor me in an capacity. Y p t5'• workers' comp. insurance. 9. E] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10. ❑—Electrical repairs or additions required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL 11 EJ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] 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. 'J -Homeowners who submit this affidavit indicating they are doing all work and then.hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. ( knIf e e 4--s . - 2 Policy # or Self -ins. Lic. #: /,V 47 Expiration Date: 'l/J Job Site Address: 'l(� J` City/State/Zip: �" ` r� ` "IlIt`��` i e, 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 ofup to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of �ivestigations of the DTA for insurance coverage verification. I do hereby cert under the pains and penalties of perjury that the information provided above is true and correct. G Signature: G _ Date: 3 l/ / Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: Information and Instructs®ns Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance 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 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 CoMn ORM-alth ofAiassachusetts Department of Industdal Accidents Qface OURVestigatiom 600 Washington Street Boston} M.A, 02111 Tel, # 617-727-4900 ext 406 or.1-877:MASSA.FE Revised 5-26-05 Fax # 617-727-7749 _.WWW-Mass,govfdza f Claims Processing - Arnica Scan Center PO Box 9690 Providence, 8102940-9690 AUTO HOME LIFE Board of Selectmen and Building Inspector North Andover Town Hall North Andover, MA 01845-5253 File Number: 60001354988 Date of Loss: 10/29/2012 Owner/ Insured: Eric K. McCarthy Street: 90 Berkeley RD Town: North Andover Type of Loss: Wind To Whom This May Concern: Toll Free: 1-888-70-AMICA (1-888-702-6422) Fax: 1-866-381-3239 October 31, 2012 Please be advised that we insure the above named individual(s). A claim has been made for Damage to Real Property and as the insurer; we are presently in the process of adjusting the loss. We are mandated to comply with Massachusetts General Laws, Chapter 139 and as such, if there are any present liens on the above property, please notify us within 10 days of receipt of this letter. If we do not hear from you, we will be under no obligation to pay you any portion of this claim. Very truly yours, /6 w 11141, d.oz� Kim M. Conill CPCU, MSIM, AIC Claims Department 888-702-6422 x21104 KCONILL@AMICA.COM AMICA MUTUAL INSURANCE COMPANY AMICA LIFE INSURANCE COMPANY AMICA PROPERTY AND CASUALTY INSURANCE COMPANY Date.. N° 4448 • +ao TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that /�, X/ ......-.�`` ...... . ................ has permission to perform .......... �..... �................ . plumbing in the buildings of % ................ at ...... I! ..!:.: ............ . orth Andover, Mass. Fee Lic. No..?nyy' ...... . /..,._ PLUMBIN �NSECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building )n 10 o- /Z G It New [Ir Renovation )wners Name , �� OL V of Occupancy �� Ll ✓ •�, Replacement 0 Plants FIXTURES t Date es E] No (Print or type)/~ j Check one: Certificate Installing Company NameP(ZAI-t Gly �"V `7f Corp. Address ���) FL) A Partner. Business Telephone j H X In L x . f7 Firm/Co. Name of Licensed Plumber. a Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: ❑ Liability insurance policy L3--- Other type of indemnity ❑ Bond Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance ignature Owner Agent E] I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work an�iatio rform der Permit sued for this application will be in compliance with all pertinent provisions of the M umb' ode and apter 1 the General Laws. By: Signature ol Licenseaer T e of Plumbing License Title City/Town icense um a Master Journeyman ❑ APPROVED (OFFICE USE ONLY • f -------------------n.---- i 1 ' -®----------------------- .. / • ---.--.---M-------------- W. I11P I U 911' ---------------M--------- -- (Print or type)/~ j Check one: Certificate Installing Company NameP(ZAI-t Gly �"V `7f Corp. Address ���) FL) A Partner. Business Telephone j H X In L x . f7 Firm/Co. Name of Licensed Plumber. a Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: ❑ Liability insurance policy L3--- Other type of indemnity ❑ Bond Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance ignature Owner Agent E] I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work an�iatio rform der Permit sued for this application will be in compliance with all pertinent provisions of the M umb' ode and apter 1 the General Laws. By: Signature ol Licenseaer T e of Plumbing License Title City/Town icense um a Master Journeyman ❑ APPROVED (OFFICE USE ONLY P. W' Location 9y B"OpIlw1wx P No. Date NORTH TOWN OF NORTH ANDOVER i OL . y Certificate of Occupancy $ sc►+us t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ C� Check # ` > ,� /� m1 `r` r L 4 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLIISyH�-A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: % DATE ISSUED: SIGNATURE: Building Commissioner/1 for of Buildings Date SECTION 1- SITE INFORMATION -_ "1 �j 1.1 Property Address: % � 1.2 Assessors Map and Parcel Num rxkv�Q r, e _ i J /, ! ® Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: i Zoning District Proposed Use Lot Areas Fromm e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Er16✓ ¢ V) MC,G--1r�I n�J Name (Print) Address for Service MA -,.QQ4� , eTelephone +� b ll C3 / /" r of Recor Name Print ,r Address for-'ger-vice: �2, l.. � v 4- _ -Lev, ature Telephone SECTION 3 - CONSTRUCTION SER)qCES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Gt I i oyci `\Y( Licensed Construction Supervisor: License Number C�Xe�J� V ` y �- Address /j p-�� Jo, 4/;j, rYl� V `9 +6 0z, Expiration Date Sgnatur Tele on J 0 j3 V "br1ft , i 6 6 3.2 Registered Home Improvement ntractorr Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone 00 rn • 06,0 0 N 0 a\ 1 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 permit. Signed affidavit Attached Yes ......)6- No ....... ❑ 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:. V- UArewuM SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed bypennit applicant OFFICIALUSE ONLY' 1. Building i 17 D Q o (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) l / 4 Mechanical HVAC ® 5 Fire Protection 6 Total 1+2+3+4+5 DO Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTO APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property - o Hereby authorize to act on half, in all matter rel iv wor uthoriz d b this buil ing permit application r !? Si nature of Owner Date c SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR T MBERS 1 ST2No 3 SPAN DMIENSIONS OF SILLS DIN ENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 040Y Gln J .J1tE i?O'/1viN,4Xl[/P.(LLf./L 6�✓dZf�1aC�2�.t6P.�d BOARD Of BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 014431 Birthdate: 05/28/1957 Expires: 05/28/2002 Tr. no: 25869 Restricted To: 00 WILLIAM M JOHNSON 3 CHESTNUT STREET""'': WAYLAND, MA 01788 Administrator 4 M. 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Ic am a homeowner performing all work myself. 1 am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone #: Insurance Co. Policv # Company name: Address City: Phone # Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. l do herby certify under the pains and penalties of perjury t the information provided above is true and correct r Signature /17 +'4- Date" Print name / f!f�I No �+/� i,1b&&L01" Phone # 0 Official use only do not write in this area to be completed by city or town official' ❑ Building Dept ❑Check if immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person:_ Phone #: ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION M44 I SC e d - I( CD JN mi r r N Go N °°.I M. mug O N IngeG vt IN i. 3; d P;}l+. • � X4;3 of -I_3.1 s11h _ �oi t V VI q w x( 3,s N' u- co 04 N N cix CC) l C-� C]� } ' W COCVc nj ' e-- t- ` N i N N IM LCL I ---- �,0�— 0 o -- - � �, - - u, 0 Nr ca �n N ji t - - 4A Go _ __ O VS --—-Q0. �----- M � So CO Em M = 0 O Q' M ! :30 �c�i �cr° (D 0�M 0). toM 0) N --'` r- � M _`'r V— LO_�— r �- 1` N 1.() r m