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HomeMy WebLinkAboutMiscellaneous - 90 SPRING HILL ROAD 4/30/20184 Date.................�....................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that.......�,/................................................(`� '/�h h" i /�.�) J......¢ ................................................... has permission to perform ...5. � . / P�-- ....................................................................................... wiring in the build' of........ at ........... ©......p...!P . /.... t ..... . North Andover, Mass. Fee.:5!�* .......... Lic. No...................................................................................................... ELECTRICAL INSPECTOR Check #3 7- 2 3 A Commonwealth of Massachusetts Oficial Use Only EM Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07j (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 1.2.00 (PLEASE PRINT ININK OR TYPE ALL )7FORMATION) Date: 16' d % - i' City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersignIves notice of his or�jher intention to perform the electrical work described below. Location (Street & Number) ( ` SF1Za U G Pb . Owner or Tenant 6,4 Q2 pl�j �o Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building fZE54 0EN sqc Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters A Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: sQ t` w O CES 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- ❑R—O.—OTEmergency rnd. grud. Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No, of Zones No. of Switches No. of Gas Burners No. of Detection and Initiatinz Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number I Tons I KW ­ * No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or E uivalent 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 Fo—THER.- -4dach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: Q d (When required by municipal policy.) Work to Start: 10 6)/- 1 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: INSURANC ND ❑ OTHER ❑ (Specify:) �► I certify, under the ains and p rltles ofperjury, that the information on this application is true anti complete. FIRM NAME:�yqhf3 0%r60 Vl-3-*A0,) LIC.NO.: i�-Slgt9 Licensee:yr-0LfeV lLoV-Ibtj q:Z4:ArUSignature---.�,jg" LTC. NO.: (Ifapplicable, mer "exempt" in the jycense„nttmbech^� ��G �! O �� Bus. Tel. No. -761 ' -60-4"' Address: GCJWC'GL ItCd %'�J k b 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. ❑ 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 n Failed IN Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass IN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL IN ECTION: .. Pass M V Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: /l S DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com L 1 if N awl, W,ww ®:o• 1' The Commonwealth of Massachusetts Department of IndustrialAccidents X congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Compensation Insurance Affidavit: Builders/Contractors/Electricians/1'lumbers. TO BE FILED WITH THE PERMUTING AUTHORITY. Name (Business/Organization/lndividual) Address: 6�-- Lo City, Are you an employer? Check Elie appropriate box: M J�AtO V6 '-1 Phone##:_ 1.L] I am a employer with employees (full and/or part-time)."-' �l 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.[jI 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 1 have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. ❑ We are a corporation and its, officers have exercised their right of exemption per MGL c. 152 §1(4), and We have no employees. [No workers' comp. insurance required.] Type of project (xequired) 7. ❑ NoVd6nstr6ctlon 8. [] Remodeling 9. ❑ Demolition 10E] Building addition 10 ectrical repairs or additions 12_x[plumbing repairs or additions 11 [] Ro6f repairs 14.[] Other *Any, applicant that checks box 91 must also fill ont the section below showing their workers' compensation policy information. Homeowners who submitthis 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 attache bal additional sheet showing the name of the sub -contractors and state whether of 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 tivorkers' compensation insurance for° my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date . Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year 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 certify under thepains andpenalties ofperjury that the information provided above is true and correct. �1 'I Date: %©' 01/ js "7&i' `76D 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): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is• defnied 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 receivet'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 xequired. ' Additionally, MGL chapter 152, §25C(1) 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 certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. .Also be sure to sign and date the affidavit. The affidavit should be 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 thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year. Where a homeowner 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-MASS.AFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Date.... ... ................................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............... ........................... has permission to perform........ �.R .................. ....... �..Z .......... . wiring in the building of.....t . . ......... . ...................................................... at ........ ...... V.(... )J 4, RD-ftli Andover, Mass. ........... Fee..:�.6..... .............. Lic. No .................. .... .. t ELECTRICAL INSPECTOR Check 4t Q 0 ' Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev- 1/071 aeaveblank M 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 INFORMATION) Date: /© ` t�- i • 15 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 1 Q k)Pf--'1 CC Owner or Tenant 6.4 Ri PA -r Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building VF,*�t Q g'r pl-J. +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: j UU-l-c AUC w 0 UX T V5: 5PC--aT Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool ❑ ❑ o. o mergency Lighting rnd. rnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No, of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons KW .......... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: �-. Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work (When required by municipal policy.) Work to Start: 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'0 BOND ❑ OTHER ❑ (Specify:) I certify, unrler the��ai_ns and penalties of penury, that the information on this application is true and complete. FIRM NA1V. IE:) ) ft/4ES—byYt� c: rt-c�AJy ��C C�'RC �4 nJ LTC. NO.: E�S%6 Licensee: (If applical Address: *Per M.G LIC. NO.: Tel.No.•"1560'SdL/4 Tel. No.: 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. Owner/Agent Signature _ Telephone No. I am the (check one) ❑ owner ❑ owner's agent. PERMIT FEE. $ 5.r -- ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the er o permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed 1 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 f� 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 M 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 M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: / /! DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidents M I Congress Street, Suite 100 d Boston, MA. 02114-2017 `ter www mass.gov/dia cRM SV�v • yParkexs' Compensation Insurance Affidavit: Builders/Contractoxs/Electricians/T.'lum exs. TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print Le •bl A Ocant Information Name (Business/Orgauization/lndividual): Address: City/State/Zip:_ Axe you an employer? the appropriate box: Phone #: 1.0 I am a employer with employees (foll and/or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees Working for mein any capacity. [Noworkers' comp. insurance required.] 3.0 I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑I am a homeowner and will be hiring contractors to conduct all work on my properly. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.❑I am a general contracto and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t • 6. Q We are a corporaiiori and ifs. officers have exercised their right of exemption per MGL c. 152 §1(4) and We have no employees. [No workers' comp. insurance required.] Type of project (required); 7. ❑ NOW'd6nstr66tion 8. 0 Remodeling 9. ❑ Demolition 10 ❑ Building addition ILL] Electrical repairs or additions Plumbing repairs or additions 13•. [] Rb6f repairs 14. [] Other *Any applicant that checks bbac #1 must also fill out the section below showing their workers' compensation policy information. fi homeowners who submit•this affidavit indicating they are doing all work, 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 (hose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. X am an employer that is providing workers' compensation insurance for my employees. elow is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. Expiration Date:. Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DTA. for insurance coverage verification. X do hereby certify under tliepains andpenalties ofperjury that the information provided above is true and correct. Date: Signature: 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): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone Contact Person: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of 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 enierprlse, and including the legal representatives of a deceased employer, or the receivet'orr 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 occupani 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=contractors) name(s), address(es) and phone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be 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 thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "fob Site Address" the applicant should write "all locations 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-AIASSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia 0 Date....... .................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... Ae t-��1 u " r -e ... .......0. ................................. has permission for gals installation ....r2 t". - .... .............................. in the buildings of .... C7n.(2 !.....C. i 1� ..................................................................... j � `�'�' `�.....:...... . North Andover, Mass. at ..................................................................... Fee.. .. "..... Lic. No......!. .�Tb M �.................................................... GAS INSPECTOR Check # , (� J Date ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that.........................-J....................���1:.............................. has permission to perform ........... ,.wiring in the building of......�1...........C1-�/�/�I¢�?�................................................ at .......:1 ...... r !%TJ��......! .C�........................... North Andover -Mass. ` Fee ...... ..��...�a_"�Lic. No...../.......>>............1............./%%....... / ELECTRICAL INSPECTO/ Check # /) 9b v -Commonwealth of Massachusettts Official Use only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank) APPLICATION FOR PERMIT TO PERFORM .ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) c/o r�r�� n U,11 Owner or Tenant Telephone No. 7�4 — 66 A- A 70. Owner's Address 1:7 Q Is this permit in conjunction with a building permit? Yes ❑ No �' (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service. Amps /al0_9-YOVolts Overhead ❑ Undgrd 9 No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: LAS �J '. No. of Recessed Luminaires v­Ww No. of Ceil: Susp. (Paddle) Fans e"Um fauy Lie W"I veu Vy melns ecror o Wires. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- E3o. o mergency Lighting rnd. rnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No, of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons Alerting No. of Devices g No. of Waste Disposers Heat Pump Number. _Tons.......... KW.......... No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:x No. of Water No. No. of No. of No. of Devices or Equivalent KW 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: --J Estimated Value of Electrical Work: .nuuurn auaaionai aerau U aesirea, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NEC 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 Nt BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: atc LIC. NO.: //.236 A Licensee: ���, �`� �Signature (If applicable, enter, exec p in the lice se nunkr line.) V Bus. Tel. No.: 9yE'-1 7-1oX& Address: � ��e s �C�i-1 yam- o (?1—C Alt. Tel. No.: ff -3fS-0gYo *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. 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: $ • J • ELECTPJCAL PP�F�J%.��.J�IJ(L�J./■J{.xi�\®•�. �%j e�y FJ.<. J.!;V®.�\ .tiW�.:�3. �jl�.T� • — EFJ.L•IV.LJGL<.L.C7W(.li WSPE �. • .. ._ • . _ �_ r . passed-� [ ] - Nailed—[ j fie -inspection res�txixec7($50.OD) � j � Inspectors' co=eAts: - < v ,•. 5. (Xnspeetors'signatuxe -no snftxals) Pate 2..VMAL MSPEC N; . Passed— [ 7 xI+ailed—[ ] RO-xnspectionrequired ($50.00) -• [ Inspectors' commenfs: -LEE. -2 (lxispectozs'Signature -no ' 'fials date 3. MER GROUND INSRYMON Passed -[ ] Faffeci ?fie-inspectionrequireti ($50.00) - [ ] Inspectors' c eats: (Inspectors' ignatuz a zto inifials) Date 5. MBI?ECTTON -- OTBER: Passed Inspectors' corilm.ents: amu edors, SiRnafure -no ection required {$SO.OD) •- [ 'j - Date 1)0OR TAGS M TO BE FIDE' ED .AM EEFT ON SME N TM :AM TO BE INSPECTED IS .NOT ACCESSIBLE AND A RE J'SPECTION OF L50,00 IN TO BE CMRGED. 14 v The C©rnmonwealih of Massachtesetts - Department of Xndifstr'igl Aceld nts Office of Investigations 600 Washington. Street Boston, HA. 02111 -www.mass govIdla Workers' Compensation bsurance Affidavit: Builders/Contractores/El Pcs p���umb r Applicant Information gib (I'o Name (BusinessiorganizationlXndividual):^ �� ✓'`�- �y 3 Address: _i ��!`�✓� City/State/Zip:_ �rc_.J�— i%2l�} 41-� phone #:`l S7' lo�C Are your an employer? Check the appropriate box: i. ❑ I am a employer with 4. F1 I am a general contractor and I ______. employees full and/or part-time).* have lured the sub -contractors listed on the attached sheet. 2 I am sole proprietor or partner ship and'have no employees These sub -contractors have working forme in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its [Nb workers, comp. insurance officers have exercised their required.] 3. El I am a homeowner doing all work e right of exemption per MGL and myself. [No workers comp. c 152, § 1(4), have no employees. o workers' insurance required.] t comp. insurance required.] Type o£project (required): 6. ❑ New construction F 7. [] Remodeling 8. [] Demolition 9. [] Building addition 10.❑ Electrical repairs or additions 11.[] Plumbingrepairs or additions 12.❑ Roofrepairs 13.❑ Other 'Any applicant that checks box#1 must also fill outthe section below showing their workers' compensation policy information. -Homeowners who submit this affidavit indicatingthey 2"re doing all work and then hire outside contractors must submit anew affidavit indicating such. ?Contractors that cheekthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. lam an employer that isproviding workers' compensation insurance for my employees. Below as the policy ancix0 site information. Insurance Company Policy # or Self ins. Lic. ExpirationDate: Job Site Address: City/State&ip: 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 o. 152 can lead to the imposition of criminal penalties of a fins 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. X do Hereby cert under tliepains and penalties ofpertury that the information provided above is true and correct: —T;--a-Q, Date.• /�—%�"—%� Phone l# g7� ��'%— /0l6y-r 77Fs'—�1� —0�6 Official use only..Do not write in this area, to he completed by city or town ofciaZ City or Town: Permit/License issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town. Clerk 4. Electrical Inspector 5. Plumbingi'nspector 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 wdeceased 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 chapterhave 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 riumber(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, apolicyis required. De advised that this affidavit maybe submitted to the Department of Industrial Accidents fox 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 thepermit or license is being requested, not the Department of Iudustrial Accidents. Should you have any questions regarding the law or ifyou 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 Departmenthas 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 submitmultiple permit/license applications in any given year, need only submit one affidavit indicating current Policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has b een officially stamped or marked by the city or town may be provided to the applicant as pro of that a valid affidavit is on file for future p ermits or licenses. A new affidavit must be filled out each year. 'W ere a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license orpermit to burn leaves etc.) saidperson is NOTrequired to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should youhave any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: Tho Common wat of MfassachwPi Dopa voutofZndwWal,Acoldonta Q.f ce oi~InyoWgiat ions 60 Wasgtoa Smear Boston MA -02111 Tei, # 617-7-27_.4900 at 406 Qx 1 -8,77 -MAS, -"F, Revised 5-26-05 Fay, # 617-727-7m wwWaa.agov/dia v A GENERATOR APPLICATION DATE: LOCATION: 9 0 OWNERS NAME: GENERATOR kw 20 NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: ��ler:L / ►titer PHONE NUMBER: 77�r�_ 3l9 - a4Go (65-0� Or 21-Y-95-2- ELECTRICAL 1-Y--9 7 - ELECTRICAL RESIDENTIAL GAS COMMERCIAL TEMPORARY LOCATION OF GENERATOR: 5 Ae C&,m ho,,x)e- *ZONING DISTRICT: *PLANNING APPROVAL (IF IN WATERSHED) Alt tAz-- *CONSERVATION APPROVAL �' o' �)b Accepted Plumbing Products Online System by Massachusetts Board of Registration of P... Page 1 of 1 The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass. Gov Home State Agencies A -Z Topics Home > Division of Professional Licensure > Board of Registration of Plumbers and Gas Fitters > Accepted Plumbing Products Online System By the Division of Professional Licensure Table. ONLINE PLUMBING PRODUCTS SYSTEM: SEARCH RESULTS Search Criteria: There are [1] record(s) in our database Type: Gas fitting your search criteria. Please note that Manufacturer: Generac Power if your product is not displayed in the Systems, Inc search results, you can refine your search Product: criteria. Model: 6729 Displaying page10 of10 search results Description: pages New Search Requested products per page:50 . PRODUCT, DESCRIPTION, APPROVAL MANUFACTURER MODEL ACCEPTED EXPIRES CODE APPROVAL CONDITION Generac - Guardian 20kw engine generator Generac Power 006729 7/2/2014 7/2/2017 G1-0714-570 'Systems, Inc First Page I Previous Page I Next Page I Last Page © 2007-2011 Commonwealth of Massachusetts Mass.Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... Site Policies Contact Us http://license.reg. state.ma.us/pubLic/pl_products/pb_search. asp?type=G&manufacturer=... 12/15/2014 'Fo s,�V';,�y �,rr North Andover MIMAP December 15, 2014 107.A-0234 065.0-0304 107.A-0233 4668 3 54 SPRING HILL.RD M 66 SPRING,HILL,RD; 107:A-0235: !S0 107:A-0236 146, 167, 78 SPRING HILLAD. 10.7.A-0243 f 65 SPRING HILL RD S R2 62aMOLLY`TOINNERD 107:A-0242 107.A-0237 �90 SPRING HILL RD, —�•-� 106 C-001.1, off' 107:A-0241 . 102 SPRING HILL RD ft. 107.A-0238 115 SPRING HILL RD 114 SPRINGIHILL RD X. ` 107.A-0240 107.A-0239 .,1,• ..� 107A-0211 107.A-0210 107.A-0209: -106:0-0012 — Rail Line =. Wetlands Zoning Interstates 0 Exempt Lands " Businei _ 1 0 Businei s 1 District s 2 District Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, — SR Busine Busine Roads M Gene rEasemenls D Planne ❑ Corrido s 3 District s 4 District Business District Commercial Dev Development Dist NORTIIy Of ao �� �t� r• ? �� �� 00 Meters Data Sources: The data for this map was produced by Merrimack Valley Planning Commission (MVPC) using data provided by the Town of North Andover. Additional data provided by the Executive Office of Environmental Affairs/MassGIS. The information depicted on this map is OMVPC Boundary a Comido C3 Municipal Boundary O Corrid Development Dist Development Dist 3 L O rR h p for planningpurposes definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER ZoningOverla i Induslri Y BAdult Entertainment Ri Industri 11 District 12 District Y - • f s n * MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT � Downtown Overlay District Industri 3 District r >< o t • ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF Historic District I® Industri ® Water Protection Reside t.: Reside 5 District ce 1 District 2 District « 4 `� • - 9, b..'so SSACHO THIS INFORMATION ❑ Parcels C Rosidece ce 3 District f ` Hydrographic Features J� de — Streams 1" = 129 ft •i )rde T de ce 4 District ce 5 District ce 6 District ���age esidenlial District North Andover MIMAP December 15, 2014 107A-0234 065.0-0304 107A-0233 54 SPRING HILL RD M v M i 66 SPRING HILL RD 107A-0235 �0 107A-0236 14� 167, 78 SPRING HILL RD 107A-0243 65 SPRING HILL RD 6>2 MOLIYTTO1tYNE R 107A-0242 tiNb fj 107A-0237 j 90 SPRING HILL RD a 106 - 111 % 107A-0241 ti r 5Q 102 SPRING HILL RD > =, 107A-0238 - ' 2, a, 115 SPRING HILL RD 114 SPRING HILL RD 107A-0240 107A-0239 107A-0211 107A-0210 107A-0209. 106C-0012 — Rail Line C: Exempt Lands Interstates O WSP_ZoneA Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, — SR C WSP_ZoneB - Roads WSP_ZoneC 14011l Meters Data Sources: The data for this map was produced by Merrimack Valley Planning Commission (MVPC) using data provided by the Town of DE"Scl • . O� North Andover. Additional data provided by the Executive Office of C .Easements OMVPC Boundary0' j �� �� It i Environmental Affairs/MassGIS. The information depicted on this map is for planning purposes only. It may not be adequate for legal boundary definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER OMunicipal Boundary MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING O Watershed # # THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY '-.,-Watershed Sub -basin f i # # r f OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF ❑ Parcels .j� +p tto THIS INFORMATION L• Hydrographic Features — Streams Wetlands 1" = 129 ft R C7 Public Parks North Andover MIMAP December 15, 2014 Interstates — I SR Horizontal Datum: MA Staleplane Coordinate System, Datum NAD83, Roads Meters Data Sources: The data for this map was produced by Merrimack rEasemenls NORTH Valley Planning Commission (MVPC) using data provided by the Town of North Andover. Additional data provided by the Executive Office of OMVPC Boundary ? ��� r�+� 00 Environmental Affairs/MassGIS. The information depicted on this map is I .Parcels _ L for planning purposes only. It may not be adequate for legal boundary f to A definition regulatory interpretation. THE TOWN NORTH ANDOVER MAKES S NOO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING # THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY ♦ i ^ * OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT �F cow _ • ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF i "n_.K� ..►` i. THIS INFORMATION 1"=129ft •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE.. _II PERMIT # JOBSITE ADDRESS NAME 1/x II GOWNER mmOWNER'S ��, ADDRESS TEL^FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIALP PRINT CLEARLY NEW: [ RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES Q NO APPLIANCES 7 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER1 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLEr- INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OT ER Y - .--- - ---- INSURANCE COVERAGE I have liability insurance its the MOL. Ch.142 YES ff NO [� a current policy or substantial equivalent which meets requirements of 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY � OTHER TYPE INDEMNITY ® BOND Ell OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT 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 p ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. — PLUMBER-GASFITTER NAME,�, LICENSE #9� SIGNATURE MP P4MGFI JP El JGF D LPGI © CORPORATION ©#I PARTNERSHIP ®I#= LLC ®#= COMPANY NAME: ��� £�e.r�1� ADDRESS CITY _ �� _ STATE&' 2 TEL ZIP-3� FAX CELL�EMAIL W�W E� z z 0 U W W o El a z O �❑ W � � W [Oi a Z U w* W X _w con Q w co a W a � a o � � w co 0 a a a J IL CL D w x w F- LL H O z 0 H U W a The Commonwealth of Massachusetts " - Depait n nt oflnrlustrigl Accid nts Office Of Investigations 600 Washington- Street Boston, MA 02111 -www.mass:gov1d1a Workers' Compensation bisuran.ce Affidavit: Builders/Contractors/Electri.clansfflliimbers AppReant Information Please Print Leg% Name (Busiuessiorgauization/individual): C /� Address: �l'i�/_�2JA- cSi ' City/State/Zip: 4=eUtr_ Phone Are you an employer? Check the appropriate box: Type of project (required): 1. PYam a employer with _ 4• ❑ I am a general contractor and 1 6. ❑ New construction employees (fall and/or part=time) * 2. El am a sole proprietor or Partner- have r&ed the sub -contractors listed on the attached sheet. 7• E] Remodeling ship and1ave no employees working for me in. any capacity. These sub -contractors have workers' comp. insurance.9, 8. ❑ Demolition ElBuilding addition [No workers' comp. insurance 5. ❑ We axe a corporation and its 10 [] Electrical repairs or additions xequired.] 3. ❑ I am a homeowner doing all work officers have exercised.their right of exemption per MGL 11 Plumbing repairs or additions Myself [No workers' comp. c. 152, §1(4), andwehaveno 12.❑ Roofrepairs �ired. � insurance required.] employees. [No workers' 13.❑Other comp. insurance required.] *Any applicantthat checks box#1 must also fill outthe section be16w showingtheir workers' compensation policy information. t'Homeowners who submit this affidavit iudicatingthey k� doing all wor%and then hire outside contractors must submit a new affidavit indicating such. tContractors that cheekthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. f am an employeN that is vroviding workers' eompeiasation insurance for my employees Below is thepo_liey andjob site information. �, Insurance Company �� Policy # or Self ins. Lic. #: Expiration Date: Job Site Address: t� 1 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 xequired under Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a fine up to $1,50 0.00 and/or one, -year imprisonment, as well as civic penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against 1he violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. X do hereby cer. Underlihepamy and pe les ofpertcc that rite information provided above is true and correct, 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 Cleric 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. Pursuaat 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 repxesentatives 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 notmore 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 ofits political subclt4ions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with theins urance requirements of this chapterhave beenpresented to the cgntractiug authority." Applicants Please fill out the workers' compensaifon affidavit completely, by checlaug 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 notrequired to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that thisi affidavit maybe submitted to the Department of Industrial Accidents fox confirmationof 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 fhatinust submitmultiple permit/liceuse applications in any given year, need only submit one affidavit indicating current Policy information (ifnecessmy) 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 ox permit not related to any business or commercial venture (i.e. a dog license orpermitto 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 ciuestions, please do not hesitate to give us a call. The Department's address, telephone aiid fax number: 'heof onweaXth ofM.o hvS�its DOP artmout ofTadwtxlal.A`coldaixis Of x0o QUAVedtigationg 6bG WashfV(n meet So�ton,: . OLX x X Tel, # 617-72,' _4900 ext 446 or. 1 -•877 -MASS Revised 5-26-05 .`E CHAND 137 GARtw,. Nb- ILI Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......f,���.0 /�/ ... ...r.... .. 5............ZY le... ........................................... has permission to perform ......l+ ................��................ wiring in the building of.....1*A� I - i...... /y .,Z ?. at ..�U..........f lc.- -..... f....... ................... North Andover, Mass .. ..... Fee..,- ................. Lic. Nol2A/J%"......iL.................f..<..�.............. ELECTRICAL INSP R Check # /0 Z % APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be perfaooned in aaoniaaca vAh Oe b Electrical Code (IAK% 527 O&L 1200 (PL&MPRIN MXK Olt MEAU BWORIIIAT1010 Date: • C i `i 0 /, -7 • Citi► or Town of: of ,v jov-c 4 To the bupecfor of Wines: By this application the uadam9m ce of his or her fiar ion to perform the electrical woric deserted below. Locafiop (Street & Nnmber) (Y J QQ /Z i l G // / �- �.• Owner or Tenant 6 Owner's Address Jr Telephone No. Is this permit In conjunction with a building permit? Yes Q' No ❑ (Check Appropriate Boz) Purpose'ofBuilding_ Vit/ c // / ,n y Utflity Authorization Nm EAdmg Service Amps /-Volts Overhead ❑ Undgrd ❑ Na ofMeters New Service �_ Amps / Volts Overhead ❑ Undgrd ❑ No. ofNkhn Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work c �- .� c�.r c ✓L yr No. of Recessed Luminaires Na of Cel-� (paddle) Fags a o Transformers RVA Na ofLnminake, O»tlets Na of Hot Bobs Generators RVA No. of lAuninaires g Poolo. ElBa o ergesrcy d. d- Units o. of Raxptacle Outiefs No. of Oil Burners FIRE ALARMS Na of Zones No. of Switches N& of Gas Burners a on and I01 nitiatjn aofRangts NaofAirCond. Tons aofAtertingDeviexs Na of Waste Disposers otais umber I o� of etex�fon/Ale� Devices No. of Dishwashers Space/Area Heating RW 0 Connection ❑ Other No. of Dryers Heating APp�� RW No. o iter Hestas RSV o. o No. of ccs ore Data W Si Baalllasts No.of offDeMces orimdyMent Na Hydromassage Bathtubs jNo. of Motors Total HP eco - No. of Devices or ent OTHRM Estimated VahseofElectricalWork _- aeuzupa"Orinleguubwby&8'efW� (Whm required by >nunidpat I cy ) r 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 �CWSW provides proof of Iiabiiity immnance IDdudiing %=Pletad operation" coverage or its substantial equivaieat. The geed certifies that such coverage = in force;, and has exlu'b W p roof of same to the permit issuing office. CHECK ONE: D=tANCEa BOND Q OTHER ❑ (Specify:) 1 raft Amder lhcPaba andpenaltles ofPerjwy, that Urn Informadon on this appiicaaon is true mid conrlde- FII2MNAME:Buddy Electric Inc. LIC.NO­- 12017 A Iaeeusec Vincent B. handers Jr s,grra f�;�_�&j enter c _ �___ LIC. NO ; 2 gq E ffgW�abk =N0- nr the &ens�emmrber rm) Bus. Tel. Nor T73=975 --P 5 5 Addres= 24 rolda.te Dr X. dndnvPr. Ma el8dci AIL Tel. Ne_ *Per MGI.. e. 147, s. 57-61, security work requires Department &Public Safety -S'- License: Lic. No. OWNER'S INSIIRANCE WAIV$R: I am aware that the Licensee does not have the liabiility insurance coverage nasnally required by law- By my signature below, I hereby waive tins requirement: I am the (check one) Q owner owner'st. Owner/Agent o, Signature Telephone No. PERMIT ISE?~ $ d - 9076 Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMusfct This certifies that ..II ..�.! .1.... ........./. . has permission to perform .....�1 v4l'►'t� v j� plumb'! in the buildings of at ..." ....S ! ! h /.... , North Andover, Mass. Fee. ,/, Lic. No..... ,�� .................... PLUMBING INSPECTOR Check # y T t L )� Installing CorrpUny Name: I( �7-0 AL id / f� �-� � Cher -k One Only Geri"fic;ts � Address:/�D� Q /,Q L(^? j=0f� �� C��/ TT ❑Corporation �+ City/Town: J State:, Business Tel:._K%6❑ Partnership Fax: firm/Company Name of Licensed Plumber: I/ ! tp �� j INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy. Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Si nature of Owner or Owner's Agent Owner ❑ Agent E]hereby certify that all of the details and information i have submitted (or entered) regarding this application are true and accurate Knowledge and that all plumbing work and i nstallatlons 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. to the best of my By J -� / Type o License: Title Si n o lumber g ature of Licensed Plumber -itylfown E Master c2. APPROVED (OFFICE USE ONLY) ❑Journeyman License Number: ! d v G� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: /U >�IIN jJ o VPS I1'1 SSS 1 MA. Date: / f / Permit# L Building Location: �O SPf%N i `� • �/�jc°f,i� Owners Name: Q�a � ilU6--- -P Type of OccuPpancy: Commercial (] Educational ❑ Industrial ❑ Institutional ❑ Residential ©� New: ❑ Alteration: ❑ Renovation: E Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES LU DEDICATED LU z z z SYSTEMS c W Z a YUO F. y. ' Q y U En w z z ¢ z O 0 z z D Q Ln x � H Q y 0 x p m W F W l¢- ¢ Z Oa z o Z In C7 na X ?� w H w Ln Z ¢ Q ¢ N H ¢ S Q Q v~ CA v_ai O m m O O LL mLL Z F- u Q O 3 a Z 2 w Lou: w in F- F- 2 Y O Sl aJ O y w 1 Q v SUB BSMT. Ln H 3 O v) w Q G 0 (3 (3 3 BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4T" FLOOR 5T" FLOOR CH FLOOR 7' FLOOR 3T" FLOOR Installing CorrpUny Name: I( �7-0 AL id / f� �-� � Cher -k One Only Geri"fic;ts � Address:/�D� Q /,Q L(^? j=0f� �� C��/ TT ❑Corporation �+ City/Town: J State:, Business Tel:._K%6❑ Partnership Fax: firm/Company Name of Licensed Plumber: I/ ! tp �� j INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy. Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Si nature of Owner or Owner's Agent Owner ❑ Agent E]hereby certify that all of the details and information i have submitted (or entered) regarding this application are true and accurate Knowledge and that all plumbing work and i nstallatlons 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. to the best of my By J -� / Type o License: Title Si n o lumber g ature of Licensed Plumber -itylfown E Master c2. APPROVED (OFFICE USE ONLY) ❑Journeyman License Number: ! d v G� ` ^ Ul Signature ` ^ Date.. ... e . .... ° t``° '• "� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that ..... .:........... ...... ` ............................................................ ' 1 has permission to perform ...:...................... ............................................................ wiring in the building of ' —Q -- at........../ .......�.......... J.......... , North Andover, Mass. .............� ...... Fee: ....... Lic. No. �� ....... ............ ...................................... .............................. ........................... ELECTRICAL INSPECTOR =3W Check # 7254 Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services _ rt Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Cf® ,�;nrHilI —Rr71kJ Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes LV Purpose of Building { a� No L -J (Check Appropriate Box) 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: COmnletion of the followinS9 lahle finny he wniwil by the InvnPrYnr of 141irec 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. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number Tons KWNo. ..... of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances Kms, Security Systems:* No. of Devices or Equivalent No. of Water Heaters KW o. of No. o Signs Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: ib p Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE OV RAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 5?f BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: A LIC. NO.: Licensee: Signature _ LIC. NO.: /0(70 (Inapplicable, � ter "exempt" in the license number line) Bus. Bus. Tel. No. 9Nr it --373y Address: � Li �v 1i ') 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: 1 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) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: k: j� `� Signature Telephone No. AV f; 'I 02 �U r Date ....'..".. �l .... TOWN OF NORTH ANDOVER p PERMIT FOR WIRING k ,SSACMUSE� +i ........... F (6004.) This certifies that ..........� ... .` ....................... has permission to perform ..........✓....... ...... ............ wiring in the building of ............................................................. at ....Q....�/��!�%...!7.�. L�................� North Andover,, Mass. � o D i •� 3G E Fee ............... Lic. No. .................................................... . > ELECTRICALIN R r'' +t Check 4 / Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. i 2—,; Q Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: !�- - /-0 — City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intentyon to perform the electrical work described below. Location (Street & Number) Q ,S ! /st Z `j Owner or Tenant &,b A '�-svO Owner's Address Telephone No. E2,6 Is this permit in conjunction with Tbuilding permit? Yes � No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Servica;rZOd Amps/..?Oe!Volts Overhead ❑ Undgrd ❑ New Service Amps T / Volts Overhead ❑ Undgrd ❑ 4 Number of Feeders and Ampacity i Location and Nature of Proposed Electrical Work: No. of Meters No. of Meters RQ /24 Completion o the ollowing table may be waived by the In ector o Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of LuminairesSwimming Pool Above ❑ In- E]o. rnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number Tons ....... .... KW - ...... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent lNo. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: 6qlkl - Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: %r d�` r% 2 (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 Zj'�OND ❑ OTHER ❑ (Specify:) I certify, under the p s nd penaltie erjury, that the information on this application is true and complete. / FIRM NAME:/ j. C� LIC. NO.: t ®3�F Licensee: � j r„¢A� 4= � Signature 4�:-�� ^� LIC. NO.: (� (If applicable, e r ex t” in th licensemannb line.) Bus. Tel. No.:f 3 di Z —1�� 6 Address: , S S/' "S Alt. Tel. No.: *Per M.G.L c. 147, s. 7-61, security work requires Department of Public Safety "S" License: Lic. No. p/ OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's Owner/Agent PERMIT FEE: $ Signature Telephone No. �-+.� Oil � �" 6" C � �l cq f The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations UV, 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): - ,Or✓1 v fw-e4wooc Address: 0Z City/State/Zip: D 1 z/0 ( Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I ployees (full and/or part-time).* have hired the sub -contractors 2. LVIl am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation 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. EXRemodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of the information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 0 ate. 7 Z". G �" TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that V�? .. �.1/ �/"� .......... has permission to perform .. !4!'k77 .el"n"b"� plumbing in the buildings of .90 0 ...5?' A!? 1 My .. �? 14 at. ..r!Jlc'-"-^�-- ........... , North Andover, Mass. Fee .3 r--77. Lic. No.1!l1Q ....!. ...................... .. . PLUMBING INSPECTOR Check # 7326 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS • `�� Date—? Building Location?0 serme- fE�% /�l� Owners Name Permit Amount Type of Occupancy to 0 New M Renovation Replacement 1:1 Plans Submitted Yes [] No (Print or type) �J Check one: Installing Company Name li` �% rTi Lu :j4 Corp. _ AddressPartner.' C Business Telephone —3 Firm/Co Name of Licensed Plumber_L/1 To /4 L u Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity 11 Bond ❑ Certificate 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 Signature Owner Agent 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 and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus2j bin de and Chapter 142 of the General Laws. By: Signature of i7censeaum er p hype of Plumbing License Title O City/Town icense NUMDer Master Joumeyman ❑ APPROVED (OFFICE USE ONLY ..; _' tai ' _1 ' • ----W-------------------- =:� `Du B\I -.-.-.---M--M-..-...----M //' ---------------------U.-. m�DIDIBl,lummmmmmmmmmmmmmmmmmmmmummm '.1 //' ---------------------M--. '1. //, ------------------------- 1' //' -M----------------------- . 1' //' -....--M----------------- /1: e s 7mmmmmmmmmmm.mmmmmmmmmmmmm :11. o'mmmmmmmmmm.mm.mmmmmmm-mmm (Print or type) �J Check one: Installing Company Name li` �% rTi Lu :j4 Corp. _ AddressPartner.' C Business Telephone —3 Firm/Co Name of Licensed Plumber_L/1 To /4 L u Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity 11 Bond ❑ Certificate 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 Signature Owner Agent 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 and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus2j bin de and Chapter 142 of the General Laws. By: Signature of i7censeaum er p hype of Plumbing License Title O City/Town icense NUMDer Master Joumeyman ❑ APPROVED (OFFICE USE ONLY