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Miscellaneous - 90 MOLLY TOWNE ROAD 4/30/2018
a 4 IKI 1"13' V' V V TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ss�c►+�s� Thiscertifies that....................................................................................................................... has permission to perform ......... `ffs .�-......................./................................. plumb'n in the,b i din.RS Of........��.. �I ` �,t� j �} ; ................................................................. at ...... ¢ "..... ..1� ......./. v. ,^ ....�� .�.......... North Andover, Mass. Feev.............. Lic. No.f6ll.................................................................................... PLUMBING INSPECTOR Check # a i� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY �'l ( MA DATE ( PERMIT # JOBSITE ADDRESS( OWNER'S NAMEC I POWNER ADDRESS TELE __ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL © EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: Id RENOVATION: © REPLACEMENT: Q PLANS SUBMITTED: YES E11 NOQ FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 1 9 10 11 12 13 14 BATHTUB _( _ _ �( ( { ! I I=== _{ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISANDSYSTEM -I __ ,_.,__j _.__ I -_____If —1 1 G DEDICATED GREASE SYSTEM 3 DEDICATED GRAY WATER SYSTEM E I (_ ( —_, I _ .__ { I . (_ _j E7___I DEDICATED WATER RECYCLE SYSTEM i j j I .�_J !_( _ I —_.. _. j f I _..__ ( I A DISHWASHER ( _.J � __. _ J I 1 j ' _._..1 -� E -- -71 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL 1 ...__� _._ ! _.__._j _.__..,.I 1 SERVICE/MOP SINK TOILET URINAL WA,%iING MACHINE CONNECTION '11ATER AEATER ALL TYPES _. I��IIT I�JtL�It�1 ` INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES INO M IF YOU CHECKED YES, PLEASE INDICATE 7TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND.1 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 Q AGENT 10 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 f my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com liance ith II Pertin ision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM ER'S NAME _-_L+ �l�.y�c Q /t i�LICENSE # - SIG ATURE M JPQ CORPORATION#PARTNERSHIP DI#�--• 1LLC0� _ NA M' WFIN FAX �� CELL �Q(,� EMAIL o o z Q)FJ Name (a, Address: The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. City/State/Zip: &/11 (i' Sa 7 (p Phone #: Are you an employer? Check the appropriate box: 1. ❑ I a employer with .. ° employees (full and/or part-time).* 2. Lyl ` am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.: 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no, employees. [No workers' comp. insurance required.] O 1 —(T-) f Type of project (required): 7. ❑ New construction 8. Fj Remodeling 9. ❑ Demolition 10 ❑ Building addition 11. ❑ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hue 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 state whether or not, those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. lam an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi� underlhepains and that the information provided above is true and correct. Phone #: 6 63 "0 f � :/ 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 Phone 2 1 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 ofliire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill -out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub=contractors) name(s), address(es) and -phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Depaftment 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' compensatiori'policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia I This certifies that Date,. 15 1-3 / .................. q/ .......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION --- ------- - ------.C`.'......... ....................................... has permission for gas installation .��/ in the buildings of .......X6 '-a y .............................. .............:.;!°............................ ........................... at ....... 70... jc:ne .... P ..... . North Andover, Mass. Fee..&=... Lic. No/. GAS INSPECTOR Check # TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE ___ PERMIT # I M JOBSITE ADDRESS ,OWNER'S NAME OWNER ADDRESS TEL _jFAX OCCUPANC TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL Z NEW:bd RENOVATION: 0 REPLACEMENT: PLANS SUBMITTED: YES Q NDE] APPLIANCES'l FLOORS -4 11111".141CINOV(�fF�- F�-f�iF�-i flir11�-i l=- Wi F�-fl�11�-t ►.i-r�--r�i CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES dNO E 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE E BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND Eil 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 Q AGENT O 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 ertin t prov Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLU7GASIIITER NAME LICENSE # �S/Sy� SIGNATU E MPGF JP ® JGF LPGI © CORPORATION ©# PARTNERSHIP ©#�_�__�( LLC D# COMPANY NAME: _ ADDRESS _ CITY LAI_^ __� STATE ZIP 34 i TEL` i3g FAX CELL S EMAIL z z F a w a z0 ° ❑ z W drl >- Hw t W U W w* M 1- 4 Q w co w a O w w co a o a a Ei U J a a � w s w H LL W H °z 0 H U a �7 a° The Commonwealth of Massa chusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: City/State/Zip: r�� "14 JIM (jdI � Phone #: Are you an employer? Check the appropriate box: lm a employer with :--employees (full and/or part-time).* 2. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. S. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insuranceJ 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no. employees. [No workers' comp. insurance required.] S Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11. FJ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submif this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must -attached an additional sheet showing the name of the sub -contractors and state whether or not. those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name; Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certif"�yder tlippainsond p5qWt1,;0fperjury that the information provided above is true and correct ,,0'3 ,mss -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 Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current polio' y information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia w 0 Dat.e� ................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........................................ ................... ) ........ ....................................................... has permission to perform . ......... 7 ............. wiring in the building of ....... ................... .... 7 ....... at .............. 1.0........ . ....... e. -S North Andover, Mass. Fee 101W ........ Lic. No. r........ / 73), ELECTRICAL INSPECTOR Check IF /61� M Commonwealth of Massachusetts Department of Fire Services �BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. I771 e5�" 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 CMaZ4 (NEC), 527 CMR 12.00 (PLEASE PRINT INMK OR TYPE ALL INFORMATION) Date: ' ► �— City or Town of: NORTH .ANDOVER To the Inspector of Wires: By this application the undersigned Ives otice of his or her intention to pe orm the electrical work described below. Location (Street & Number) " 4 o t l a- P-0 T 1C-;1 Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction wit a building permit? Yes ✓❑r No ❑ (Check Appropriate Box) Purpose of Building M.l¢j Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps /,P0 / &2# Volts Overhead ❑ Undgrd Number of Feed s and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: 4i/4,/IOG d A45w /ft -no— 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, K'A No. of Luminaires Above In- Swimming Pool rnd. ❑ rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burgers 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 TonsKW ' .......... " "" """".... "' No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of 97res. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, tinder the p ins and penalties ofper�ury, that the information �71�Plicon istrue and complete. FIRM NAME: b LIC. NO.: o'23 9 -?Z Licensee: —�J 6 a; L is Signature LIC. NO.:,r.2 (If applicable, nter "exee-p�ppt" in the license number 1pce.) Bus. Tel. No.: 19 'PIr. b 6— A( Address: Q UAA4M&—ADdR1 4AN t Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Depa t of Public Safety "S" License: Lic. No. � OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owne ' a ent. Owner/Agent PEl?MIT 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 ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass EN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP TION: Pass M V/Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Z, Y, Date: — 6 FINAL INSPECTION: Pass M U% Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: ' Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, ALL 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name`(Business/Organization/Individual): vkp Ir Address: �o ����w .Z,4�qc City/State/Zi,;W,=—/4",VU y 0 Phone #: Are you an employer? Check the appropriate box: Type Of project (required): 1. ❑I a employer with employees (full and/or part-time).* 7. ❑ New construction 2. LJ I am a sole proprietor or partnership and have no employees working for me in 8. E] Remodeling any capacity. [No workers' comp. insurance required.] 9. El Demolition 3.Q I am a homeowner doing all work myself. [No workers' compAnsurance required.] t 10 ❑ Building addition 4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.E] Plumbing repairs or additions 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13.EJ Roof repairs These sub -contractors have employees and have workers' comp. insurance.$ 6. ❑ officers We are a corporation and its ocers have exercised their right of exemption per MGL c. 14. ❑ Other 152, § 1(4), and we have na employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that 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-coritraciors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance fop my employees.' Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verlrlcatlon,_==,. Ido hereby certify r zde ze p ' s d penalties of pefjury that the information provided above is true and correct. Sionaifirrn- / __ __ Date: 3 �b 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 r - 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 bf hire, express or implied, oral or written." ' An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation'policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 4 Alt Date......... �................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING v 61 This certifies that.....•.•.......,�,,,,,,,,,,,,,,,;1,.1..�'`il , �+ l) .................................................................... has permission to perform .../....0.. ...... ........ P...i-- .....��-.�...J, c.. wiring in the building of....... 1,,,,,.P R„r,t,,,,,, ,, r vr,�.. .......................... L o-� ! ��1\ ,�--�-G at......rr............................................... cc //.... ',North Andover, S. Fee...515— ................. ...... Lic. No. . ����1G! ............... 1..•,,la �r�i�. 1........... Check # [A W 0 r eommonwea& of Vadeac4weth 2cc�� cc77 epartment of -%, �erviee� BOARD OF FIRE PREVENTION REGULATIONS Official Use Qnly Permit No. Occupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INF RMATION) Date: 4pia-re6 . lds City or Town of: L'rz N To the Inspector of Wires: By this application the undersigned gives noti of his or er 'ntentlon to perf the electrical work described below. Location (Street & Number) � I tj a' `, H � 6", r-�1, Owner or Tenant ru),00 Owner's Address (c rjPr2-q Is this permit in conjunction with a building permit? N. A40 Yes ❑ No Telephone No. (Check Approprit Purpose of Building Utility Authorization No. Existing Service Amps / Volts New Service 60 Amps /oZ0 / p2 Volts Number of Feeders and Ampacity Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ©' 86o V,17U o. of Meters No. of Meters Location and Nature of Proposed Electrical Work: 4O At,,,g iittacn aaa:tionai detatt i(desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information is application is true and complete. FIRM NAME:: / � (w!'/ " iD LIC. NO.: Licensee: �c-Ea/ j �'��L,o Signature LIC. NO.:d2 S-609',- (Ifopplicable, enter "exempt" in the license numbliBus. Tel. No. G/�57/S-�`�%/ne.) Address: o LI t-79 O aW Z4xie a-eXf- Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Depa t of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one ❑ owner ❑ owner's agent Owner/Agent. Signature Telephone No. PERMIT FEE: $ u,r fultuwIrl luote may oe waivea Dy 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- No of o Emergency Lighting rnd. rnd. Batte 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 Initiatin Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump .., umber. 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. o ater No. o No. No. of Devices or Equivalent Heaters KW as Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP ITelecommunications firing: No. of Devices or Equivalent OTHER: iittacn aaa:tionai detatt i(desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information is application is true and complete. FIRM NAME:: / � (w!'/ " iD LIC. NO.: Licensee: �c-Ea/ j �'��L,o Signature LIC. NO.:d2 S-609',- (Ifopplicable, enter "exempt" in the license numbliBus. Tel. No. G/�57/S-�`�%/ne.) Address: o LI t-79 O aW Z4xie a-eXf- Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Depa t of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one ❑ owner ❑ owner's agent Owner/Agent. Signature Telephone No. PERMIT FEE: $ 0 .�l +. M HUSETTS t�� COMMONWEALTH OF MASSAC