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HomeMy WebLinkAboutMiscellaneous - 91 WAVERLY ROAD 4/30/2018Date.(A.�41 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies thae,.,j�., . ..................................... ....... 'A ..... .. q--Q-gA rY,L -.0,! has permission to perform .................................. ............................... P . ............ ., wiring in the building of ..... � 4 ...... ose..,� ......................................... -'- r'l .............................. . at ............ .t ...... (.t.,,.VAQ.e.tJe * .. ......... P114 Noft Andover, Mass. N.......... lee .... .... Lic. No . .. .... a� ......... LECTRi . AL INSPECT . R .................. Check# 12 � -,-I I 1� ` Commonwealth of Massachusetts Official Use 0 ly Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATIOA9 Date: I City or Town oh 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) ) G u -on I , Q Cj Owner or Tenant b h e cj 4- (S05+s 4 C) C,,� ( V149 _ AC Telephone No. q_7SE! 43 Owner's Address P O , 13n Lain re me %f 1+ a 19 4- 2 Is this permit in conjunction with a building permit? Yes [�J- No ❑ (Check Appropriate Box) Purpose of Building rj �,,e �u H,,, , c� Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature Sof Proposed Electrical Work: —P)e io 10 CIO L Le. I(i , L ( Q hA {�= l 6g r�o f, v� er�e be -f pc- f,:, trf- Comnletion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- El rnd. rnd. o Emergency Lighting Battey 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 g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Dis posers p Heat Pump Totals: Number Tons ....................... KW I ....................... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW S P g Local ❑ Municipal E] other Connection No. of Dryers Heating Appliances KW uritSecNo. o 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 Ea uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: a , O O a (When required by municipal policy.) Work to Start: b -! -1 4 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 ❑ OTBER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: _3 G L.Qv v LIC. NO.: 9 Licensee: -JOSeh h k Lo - y tj Signature Q LTC. NO.: (If applicable, enter exempt" in the license number line) C�lr Bus. Tel. No.: 97X- W7 - Z 7f 3 Address: a n -f S'fy'9 e "� N©r � 1� (� KGI dUc' i' Pi A 0 tt, s Alt. Tel. No.: 14 7x -9LE,6 /o 3 5- *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' 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 • f 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 r✓ 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 (] Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass N Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: h Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INS ECTION: Pass IN K Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA. 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 1 6- Ls C, is k 1(-r,4 u« Co t Address: ?n,(,0. City/State/Zip: N. 0 he a u or O lk45 Phone #: q R &d 7, -Z 75- Are you an employer? Check the appropriate bog: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I 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. 04Y'e 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. F1 Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.O -Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company 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 requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andppaltiesqrferjury that 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 # �.AM 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 #: to 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 policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth, of Massachusetts Department of Industrial Accidents, Office of Investigations 600 Washington Street Boston, M.A. 02111 Tel, # 617-727_4900 ext 406 or 1-8777MASSAkE Revised 5-26-05 Fax # 617-727-7749 wwwanass,gov/dia JGLEV-1 OP ID: KM '4 "' CERTIFICATE OF LIABILITY INSURANCE DATo5/1z05/12DlYYYY) /1a THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Phone: 978 688 8829 Michaud, Rowe And Ruscak Ins. Fax: 978 557 2730 P.O. Box 188 North Andover, MA 01845 Lawrence R. Michaud, CIC NAME: CONTACT PHONE FAx AIC No ExtI: A/C No): EMAIL ADDRESS: GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR X Business Owners INSURERS AFFORDING COVERAGE NAIC # INSURER A: Preferred Mutual Insurance Co. 15024 04123114 INSURED J G Levis Electric, Inc. c/o Jack Pare INSURER B: DA GE10FIENIED PREMISES Ea occurrence $ 50,00 PO BOX 685 INSURER C: INSURER 0: Methuen, MA 01844 INSURER E: PRODUCTS - COMPIOP AGG S 2,000,000 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 1S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDLISUB POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXA MMIDOfYYYY LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR X Business Owners BOP0100718051 04123114 04123115 EACH OCCURRENCE $ 1,000,00 DA GE10FIENIED PREMISES Ea occurrence $ 50,00 MED EXP (Any one person) S PERSONAL & ADV INJURY S 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JFGTPRO LOC PRODUCTS - COMPIOP AGG S 2,000,000 S AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS Ea aulid ntSINGLE LIMIT 5 BODILY INJURY (Per person) 5 BODILY INJURY (Per accident 5 I PROPERTY DAMAGE Peraccidenl S $ UMBRELLA UAB EXCESS UAB HCLAIMS-MADE OCCUR EACH OCCURRENCE I S _ AGGREGATE is DED I I RETENTION 5 5 WORKERS COMPENSATIONIWC AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETORMARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? IMandatoryInNH) It yes, describe under opOF OPERATIONS below N I A STATU- OTH- E.L. EACH ACCIDENT $ EL DISEASE -EA EMPLOYEE S E.L. DISEASE -POLICY LIMIT S PROPERTY 1,000 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, II mora space Is required) SZectrical Town of North Andover 120 Main Street North Andover, MA 41845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD �dQR7H AND 9979`.,. Y• � • . � • Y YN • •. Y;a 1 V VV 1 YYY.YYV V Y De urtment of Public Health - v� D Childhood Lead Poisoning Prevention Program 1' ` Deleading N.otif cation Please complete•all sections of this form clearly. Incomplete or-illegible•forms will be returned, Lead Paint TnspectoT1an ct License #Y 31J Inspection Data . y Property Ownei T. Property Owner's Address_ I.SK _ �Ica�� n t -f- : Zip'Code ANuO p 01i•1�Cr% riirrg tirAJr1�: �08 ' (;• '. +1ON i ti zip= Telephone Number �7 0, .S 01 SMA Address where the work will be done: JUN 0, 2 2014 BuildirigName (if any) F100P Street Address A tNo. r N OF NORTH ANDOVER HEALTH DEPARTMENT p,,,µ„_ City 1,06 l;. ovr i V Jd0_ b a3i, Tho p:operl}- w a —m�tlil-ianiiiy singly fatnib►: D eleaft'1Vrethod(a1:,, a Making paint: intaot (high risk) B"" Making,paint intact (moderate c .Applying vinyl siding' oneictezior a Dauiolition risk) ' .D . C3 Scrlp140 Liquid cncapsulant 'Component removal.(low risk components) Component removlyreplaeemsrtt s� Covering n ci Dipper . btHOr:. Capping basoboards The work will begin an S lid ill and »riiY finish lry 61SLq- The work will be done to the ✓ m ,_pin or Zweekondsl la Case of Bmergenoy Contact �le Daytime Phone 978- SA—d- 46� tvening Phone q78 SSo14 The Property. Oivner must complete and sign the following informtation: T certify that only authorizedperaons wiio.bave compliedwiththe training requirements ofthe MassachusettsLeed-Poisoning. Prevention and Control Regulations, 105 CMR 460.000, will conduct deleading Work. I further oeztify tli' lho*authorixed persoa(s) svill not exceed the :scope- of his/her Authority'and will be performing. only those activities indicated above. A11'ef the ini`or� l-ition &Dntainod in this dooument is true, and correotto the best of my knoWledge and belies Date S ~ 30 - j q Signed _ The fdllowf�g peoplelageneies must be iagtified ten days before begWifing.Fork,:* 1. Occupants of the dwelling unit VA CA NF WJ f .7 2. All other'oocupants. of the residential promises, if any work will be done in tho oommon areas 3. Childhood Lead Poisoning Prevention Program, DKI Fax (781) 774-6700 MWRB'O S Randolpb Street, Canton, MA 02021 a. Asbostos.and.LeadPrugrsm, I)LS 19 ,Stamford St, l it Floor, Boston, MA 02114Fax (619) 626.6965 5. LoeM..Bdaid of Hcalih- G e-Erd'orcement-Ageficy ' lfthe home'is on the State Register of i3lstorio Places, call the MA.Histmical Commission at (617) 727.8470. KE Date ..... �.— s--- /0 ........................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........... .. ............. has permission to perform ..... &V7W.'e'velm. ......................................... wiring in the building of ..... ......................................... at .................. �./ ... 4��V Lye ... /Ob ...... NorthAwdover, Mass. Fee.:��. Lic. No. ............ .. ....... ....... I Check # dLEiCTRICAL IN�SP�ECT'OR 9277 t,ommoriu►salth o�a�tac4ct6ef Official U Only �7 cc�� c7 Permit No. 9- -?/ a[JePartin¢ni o�}ire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be nerformed.in accordance with the Massachusetts Electrical Code (ME0.527 CMR 12.00 (PLEASE PRINT WINK OR WE ALL INFORMATION Date: /.)o City or Town of: QY1-1 % -ems' To the Inspector of Wires: Bv this anolication the undersigned aives notice of his or her igtention to perform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address Telephone No. 9 7,-),3-43 _/0 Is this permit in conjunction with a building permit? Yes 9 No (Check Appropriate Box) oL Purpose of Building _ �,� Utility Authorization No. Existing Service L4A2_ Amps / y0 Volts Overhead Undgrd New Service Amps . Number of Feeders and Ampacity Location and Nature of Proposed No. of Meters Volts Overhead ❑ Undgrd ❑ No. of Meters Work: Comnletion nfthe fallrnvinQ tahle mnv he waived by tho ln.vnertnr of GiWires No. of Recessed Luminaires No. of CeiL-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVO► No. of Luminaires Swimming Pool Above EjIn- Md. zrud. o. of Emergency L—iglifing 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 _ T�Y KW _ No. o Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local Q Municipal El other Connection No. of Dryers Heating Appliances Kir Security Systems:* No. of Devices or Equivalent No. of Water �, Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications iring- No. of Devices or Equivalent OTHER: Attach additional detail ifdesired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start:__ ?AV /Q 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 covers a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE a BOND ❑ OTIJER C] (Specify:) I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete FIRM NAME: , y� 7 LIC. NO.:,?&, --7 . Licensee: 1/Y\.--.th7'„�'}t �vu �Ld Signature LIG NO.: (If applicable, enter "exempt” in the license number line) Bas. Tel. No: `i7 7 y .3-� Address: � - �!� �i� . �Irn, r, I7 - -A-e-rA Utyy) Alt. Tei. No.: - — L *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. c :, �, The Commonwealth of Massachusetts Department Of Industrial Accidents Office of Investigations 600 TEashington Street Boston, MA 02111 www.massgovldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip:,141e ;ems Phone#: 9�g,,,-' 42d Io2> > Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t tAn m.tin —aF.,. -1- }__L___u These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL C. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. E] Building addition 10. [1 Electrical repairs or additions 11.7 Plumbing repairs or additions. 12.❑ Roof repairs 13. ❑ Other uut u:c secnon veep••• snon^^g ="e * workers* compensation policy info.^n:iion t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractor; 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 emp information. loyees. Below is the policy and job site 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�enalties of perjury that the information provided above is true and correct ,� /% /1.-, U G .z > Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # il,pC.4 J ::?,D/U Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: r, Information as d Instructions s 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 notbecause 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), addresses) and phone number(s) along with their certificate(g) 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 a—plication for the pen3mtor 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 perinits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invest c ations 600 Washington Street Boston, MA 0:2111 Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-72.7-7749 www.mass.-oov/dia U00 Date. �- ?�/ 0 .... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING. This certifies that Jo:r ... 7. ....... has permission to perform ... ................ plumbing in tiie buildings of ................... at .... North Andover, Mass. Fee. Lic. No../��.!� . ...... ........ �P—Lul M -B -I -N -G INSPECTOR Check# � 2177.. Mw 1 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Owner New rl Renovation [3 Replacement, fa FTXTTTRFc Date Permit # J—A 7' Amount ( 2—'C' Plans Submitted Yes [—] No (Print or type) Check one: Certificate Installing Company Name ❑ .Corp Addres SR _ Partner. Business Telephone 13 Firm/Co. Name of Licensed Plumber: J�� �LS: C. � 19-- 'Q - Insurance Coverage: Indicate the type of insurance coverage by the c appropriate box: Liability insurance policy Other type of indemnity ❑ Bond IngMarice Waiver: L the dersigned, have been made aware that the licensee of this application does not have any one of the above ce ignature _ 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 pert ed under permit Issued for this application will be in compliance with all pertinent provisions of the MVsQiusetts State Pl ing Code and 42 of the General Laws. By: atu�51 ea rlumw Title Type of Plumbing License City/Town J— rcemse 114um= Master Journeyman APPROVED (OFFICE USE ONLY The Commonwealth of Massachusetts Department of fndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 __CDB- www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/orpart-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. Insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other - — YY••••••••• •••••• •••=:,;•r.:. inu, r.: ut::sl ».sU I1121 UU1 Lae Sel_to^ be,Sheir � WOrY.'KS' COW�;....SanoP. policy maii:Wat13n. Homeowners who submit this affidavit indicating they ubmit 2 new affidavit indicating such. are doing all work and then hire outside contractors must s $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. Iam an employer that is providing workers' compensation insurance for my employees. Below is the policy andjob 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 andpenalties of perjury that the information provided above is true and correct Signature: Date• Phone #: Official use only. Do not write in this area, to be completed by city or town offcial. City or Town: Issuing Authority (circle one): Permit/License # 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 7 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-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 e` `h L.. bt...� P is l LLR 19e r �5� r ;is e9 ` YP t;' 1 be. a�tE �_�_ to ___e C ur tdCan uxaa the au—u'- for he . matt orli ens, b inrequested, not .he Depart^ `ent. of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass_.govfdia 35'i 5 Date.. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that has permission for gas installation--'—�.—.�..�. .4 . ........... in the buildings of ... ......................... a t 9/.. r ............ North Andover, Mass. ... Lic. NoN?4�! ... Fee-�4 �x . ......... WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATON (Type. or print) NORTH ANDOVER, MASSACHUSETTS Building Locations kiwi 069f $ Owner's Name DO GAS FITTIlYG Date / & Zoo O Permit 9 Amount S New ❑ Renovation ❑ Replacement Plans Submitted ❑ r) w L f ti &ool (Print or type) Check one: Certificate Installing Company Name Ifi/IV t?4 P1t/,"/3;;JV ❑ Corp. Address P• o • 1302o, S7Z ❑ Partner. LAkl)?ei•Cc hlt4- 0fYg2— Business Telephone (p $ Sv 175:6 y ❑ Firm/Co. NameijfLicensed PlumberorGas Fitter '%Owl %y3//0,1 e^l INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes Non If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policyOther 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 Nlass. General Laws, and that my signature on this permit application waives this requirement. Check one: Sienature of Owner or Owner's Agent 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 pertormed under Permit Issued for this application will be in compliance with all pertinent provisions of the tilassachuserts State Gas Code and Chapter 142 of the General Laws. By. Signature of Licensed Plumber Or Gas Fitter Title ® Plumber<094 City/Town r7 Gas Fitter icenseN umoer ❑ Nlaster :APPROVED (OFFICE USE ONLY) [z Journeyman Non I (Print or type) Check one: Certificate Installing Company Name Ifi/IV t?4 P1t/,"/3;;JV ❑ Corp. Address P• o • 1302o, S7Z ❑ Partner. LAkl)?ei•Cc hlt4- 0fYg2— Business Telephone (p $ Sv 175:6 y ❑ Firm/Co. NameijfLicensed PlumberorGas Fitter '%Owl %y3//0,1 e^l INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes Non If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policyOther 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 Nlass. General Laws, and that my signature on this permit application waives this requirement. Check one: Sienature of Owner or Owner's Agent 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 pertormed under Permit Issued for this application will be in compliance with all pertinent provisions of the tilassachuserts State Gas Code and Chapter 142 of the General Laws. By. Signature of Licensed Plumber Or Gas Fitter Title ® Plumber<094 City/Town r7 Gas Fitter icenseN umoer ❑ Nlaster :APPROVED (OFFICE USE ONLY) [z Journeyman N2 4515 Date............ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...................................... has permission to perform ................... . ........ plumbing in the buildings of .............................. a t North Andover, Mass. jv Fe' -e --Z ...... Lic. No .......... k\x ............. .. ............. PLUM INSPECTOR Check # / 6 / WHITE� Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION F R PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS 2 S O Date Building (?o Owners Name if; o -t K a S kit Permit Amount Type of Occupancy Q AIC fli,v New Renovation Replacement ® Plans Submitted Yes No L FTXTTTRIF'.S (Print or type) f Check one: Certificate Installing Company Name nA llb qh A,' P1,V074,0V Corp. Address P 0 ' Dx Partner. I Aw 4 jAle a *414 • Gl fi V Z -- Business Telephone 6 y $•- 47S0 4 � Firm/Co. Name of Licensed Plumber. 7u Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance 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 Massachu ettsState lumbing Code and Chapter 142 of the General Laws. By: igna o kens Umber Type ofPlumbing License n License t mu er Master Journeyman ,D (OFFICE USE ONLY • • `9 1 M-.....-.M.MM.....-.--..M •' -.-..-M-.- .............. J / ' .� ....................... .MMONOW1 1 ' 0000000000000 ONE. •I' ...m..--..-. (Print or type) f Check one: Certificate Installing Company Name nA llb qh A,' P1,V074,0V Corp. Address P 0 ' Dx Partner. I Aw 4 jAle a *414 • Gl fi V Z -- Business Telephone 6 y $•- 47S0 4 � Firm/Co. Name of Licensed Plumber. 7u Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance 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 Massachu ettsState lumbing Code and Chapter 142 of the General Laws. By: igna o kens Umber Type ofPlumbing License n License t mu er Master Journeyman ,D (OFFICE USE ONLY