HomeMy WebLinkAboutMiscellaneous - 95 OLYMPIC LANE 4/30/2018 (2)N
Date../ Z-12--12,
This certifies that .... .�./�'�, ..%may ............
has permission to perform ... (T�)ytlK sp -�
wiring in the building of ..... V4--.4 ........./....... .
at ,,� 1'> . Q� 'OP/ it........... . , North Andover, Mass.
Fee . No. �i��. .. .
ELECTRICAL INS ECT,OR
Check #. 2t 3 U
11303
. �-%rr
T$lis certifies that . .. ..... .../.... / . .. .. .
has permission to perform����
wiring in the building of . M. ��'j? :~ S� ...... ...............
at .... C,J ..! .. 4...... , NortAndover, Mass.
' ((i .�-
Fee �..... Lic'�1o. 3��-�`�.. . � ...... ...
ELECTRICAL INSPECTOR
Check #
11355
,p.
Commonwealth of Massachusetts
Department of Fire Services
a
4 BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. ( 1 -363 --
Occupancy
363Occupancy and e Che
Qd
[Rev. 1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Coe C), 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) 9 S_ ®(-,4,r\ p 1 (, (j,t l
Owner or Tenant
Telephone No.
Owner's Address �, =J
Is this permit in conjunction with a building permit? Yes_ No ❑ (Check Appropriate Box)
Purpose of Building (fir, Utility Authorization No.
- Existing Service'Z,�\c.) Amps/�,y-o Volts Overhead 54 Undgrd ❑
No. of Meters 1
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:\T\r�C Lr �.yJ �-{ �`� (, \o OC3
Completion ofthe following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires 1�
No. o f Ceil: (Paddle) Fans
Total
TransSusp.
Trsformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of LuminairesSwimming
Pool Above ❑ In- El
rnd. rnd.
o Emergency Lighting
Batter Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of SwitchesNo.
\�.
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 osers
p
Heat Pump
Totals:
Number
"
Tons
'''
KW
****............
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
S ace/Area Heating KW
P g
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security
o ofDevicesor Equivalent
No. of Water KW
No. of No. sof
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total IIP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of -Wares.
Estimated Value of El ctrical Work: G C3 n o (When required by municipal policy.)
Work to Start: .N-) -a Inspec ions to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE CO RA E: 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 [3� BOND ❑ OTHER ❑ (Specify:)
Icertify, under the pains and penalties ofperjury, that the information on this application is true and complete.
FIRM NAME: _ p Pl;r� C�.L�t L (L\ _ / /_ LIC. NO.:
Licensee:x-\\<X_XNq_,L Signaturejn�� LIC. NO.:
(If applicable, enter "exempt" in the license number line) Bus. Tel. No. __§Lo 10 -'�1��y
Address: Pb rl� f—�.� L L r��rl�� ram �� o13Z `l 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 norma ly
required by law. By m i aturqeow, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent te'-6_-1p � PERMITFEE. $
Signature Telephone Nor
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
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 1
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 ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass IN
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass 17XFailed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
FINAL SPECTION:
Pass •
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments: A,
Inspectors Signature:
Date: 3 " %
DEB WEINHOLD ... TOWN OF MERRIMAC, MA.
V
.dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
swww mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): IP{Z41[finVIT. (Z' L Z:a)
Address:- �?(:, Qc7X _,Z� i3
City/State/Zip: �� kLgs,,t, ZC�P4 —Z€'� 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/or part-time).* have hired the sub -contractors
2. [rI 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.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] i
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. A Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11. F1 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.
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.
am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
iformation.
r
isurance Company Name:
P
olicy #�r Self -ins. Lic. #:
Expiration Date:
:)b Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ne 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
Pup to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
tvestigations of the DIA for insurance coverage verification.
do hereby certify under the pains and penalties of perjury that the information provided above is trice and correct.
hone #:
Official arse 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 #:
1\
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract 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
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. r5
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, MA 02111
Tel. # 617-727-4900 ext 406 or 1.877-MASSAFE
evised 5-26-05
Fax # 617-727-7749
_ _ _ www.mass.gov/dia
Date
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that
has permission for gas installati n �.'^�...........+.
in the buildings of ..�! ...-..... .......... .
at .... . ..� . N •. , North Andover, Mass.
CID
fl
Fce A ... Lic. No.... . .. ..... .
GASINSPECTOR
Check # I Oji
8426
I
I
f `
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
-`
CITY MA DATE / ` PERMIT #
JOBSITE ADDRESSOWNER'S NAMEin}-;11� oCg��g II
G
OWNER ADDRESS TE
- - - - - - - - - - (d�� �7� � FAX - —
TPPPENOR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Ej RESIDENTIALa
CLEARLY
NEW: [Q RENOVATION: REPLACEMENT: - PLANS SUBMITTED: YES F-11 NOF
APPLIANCES"I FLOORS- BSM 1 2 3 4 5 6 7
8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER! _.. .— J ---1 _
COOK STOVE
DIRECT VENT HEATER1 F r--�--
DRYER I-- { _ T�FIREPLACE-
4-11
— { _
FRYOLATOR-FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER J ._ J J
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER _
UNVENTED ROOM HEATER
WATER HEATER
OTHER 1
INSURANCE COVERAGE
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO[�i
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY L OTHER TYPE INDEMNITY E] BOND
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER - AGENT
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER GASFITTER NAMEQ,-Y LICENSE #7.�:�(r,,_� SIGNATURE
MP 0 MGF JP l JGF [JI LPG] E] CORPORATION �J # PARTNERSHIP 0#=LLC [-J#
COMPANY NAME: ��5 Q�u,n vt nc ADDRESS
CITYn� STATEC'1ZIP Svc TEL
FAX CELL EMAIL
---
:-c -t3SSZ
n
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. 111 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. 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.]
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.] i
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. El Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit 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.
1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The 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. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
N2 9659 Date .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
SSACHUS�
This certifies that...... .......+I�'
(� ;r
has permission to perform P �G!� t -j ..........
plumbing in the buildings of n::R.... .................. .
at. V, �nt.'C ... , North_Andov r, Mass. `z
Fee Lie. Nollpll � ...... Ce . .
PLUMBING INSPECTOR
Check #
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
F1
L.
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
,4
CITY MA DATE �/� 9 -� ` PERMIT #
JOBSITE ADDRESS ciS C IAvy� it OWNER'S NAME
POWNER
ADDRESS s TEL _0_ '7�2Q FAX _ __II
TYPE OR
OCCUPANCYTYPE COMMERCIAL EDUCATIONAL Q RESIDENTIALd
PRINT
CLEARLY
NEW: td RENOVATION: REPLACEMENT: Q PLANS SUBMITTED: YES M NO�{
FIXTURES 1 FLOOR- BSM
1 2
3 4 1 5 6 7
8
9 10 11 12 13 14
BATHTUB _d _ d .____._ _a_ { f (___ __ { ____d __.._I ___._ i
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM _ ._...._..._( - (__._.____l ___.._.—_(
DEDICATED GRAY WATER SYSTEM L=I .__. ___f I __._.__!'
DEDICATED WATER RECYCLE SYSTEMV-7
DISHWASHER _d _ _ d ___.-_
DRINKING FOUNTAINFOOD
DISPOSER� . ____l (FLOOR/AREA
DRAIN 1
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY -Id---._-_J .._.__{ _--_-__d _------
ROOF DRAIN { __.._J __I .___ _d ._..__{ _.__) _._.__ d _.__.J .--_____1 ____.�{ _____..d ._.___...J _.__-_�
SHOWER STALL { _.__.. ____I ._ _._ ..._.___{ _____I .__--._.J
SERVICE / MOP SINK
TOILET
URINAL..._._ .....
WASHING MACHINE CONNECTION d _.._.._d__..J _-__.d __.___J _.._, ___... ._.___ ...._. J _-_ __{
WATER HEATER ALL TYPES
WATER PIPING _ _f _ �{ v^{ _._.._..d { __.-AL _-__.(
OTHER .__ _. i I _ i _I ----------- --J.._.--._-_J
JF 71F
INSURANCE COVERAGE:
the MGL Ch.142. YES &NO �{
I have a current liability insurance policy or its substantial equivalent which meets requirements of
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY DI BOND Q
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
E hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
. SI UREPLUMBER'S NAME
MP 0 JPn- CORPORATION R#PARTNERSHIP#= _ _- ; LLC
COMPANY NAME7's0,1 ,_�-_ j-�nT ; ADDRESS S- i�
CITY s - �.•�_ _ + STATE ft! j ZIP Cif s-&; _ it TEL
FAX CELLEMAIL
1
o"
Z"
�J H = f-
a w
iui
w
w
R ft
>f
4 Ilk
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): T$tn 2zx 1 15 19111m bt
Address: q5_ VV)11�c $ �.
City/State/Zip: S P�LAc<- yl'l t/{ 015-2 Phone #: 50V`w'0S` 0 -?06
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).*
2..
have hired the sub -contractors
t
1 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. ❑ Remodeling
8. ❑ Demolition
9. JOBuilding addition
10. El 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 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.
1 do hereby gertify under the pains and penalties of perjury that the information provided above is true and correct.
P
Phone #: ` S -60--985--0-76r0
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
—Q—/Z
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The 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. # 617-7274900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
k
,.0
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
1919096.UO
m
$ -
$
2,293.15
Plumbing Fee
$
286.64
Gas Fee 100 comm.
$
10.0.00
Electrical Fee
$
286.64
Total fees collected
$
2,966.44
95 Olympic Lane
343-13 on 10/24/2012
New Two Story Addition, Reno kitchen,
bath, basement, bath, siding, roofing
and deck
174 Date. .J)� -,7.1.. ...
a
TOWN OF NORTH ANDOVER
n PERMIT FOR MECHANICAL INSTALLATION
�11
This certifies that .►..�!h�!�.�.. !. !�!L .... .
................
has permission for mechanical installationd e. jer' �:(.4.
`�
in the buildings of . U Q'`!��7.�L'..........................
at . cl.� . 6) -� !� . ? ( .......... . , North Andover, Mass.
Fee.. Uc. Ido. 1- :.... ......................
GAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
A
Commonwealth of Massachusetts
Sheet Metal Permit
Date: •Ti 2� 2 ��� Permit #
1�
Permit Fee: $
Estimated Job Cost: $
Plans Reviewed: YES NO
Plans Submitted: YES NO
/
Business License #7.
Applicant License #
Business Information:
Name:
Street:
I�T�JOC�b
City/Town: ICS tz, uq2-j (f'� ¢�
Telephone: Al (,qo
Property Owner / Job Location Information:
a
Name:
Street:
City/Town: -
Telephone:
Photo I.D. required / Copy of Photo I.D. attached: YES NO
Staff Initial
(:ZJ-1 :/MD-1-unr stricted license
J-2 / M -2 -restricted to dwellings 3- -ries or less and commercial up to 10,000 sq. ft./ 2 -stories or less
Residential: 1-2 family . Multi -family Condo / Townhouses Other
Commercial: Office Retail Industrial Educational
Institutional Other
Square Footage: under 10,000 sq. ft. over J0,000 sq. ft. Number of Stories: _
Sheet metal work to be completed: New Work: Renovation:
HVAC Metal Watershed Roofing Kitchen Exhaust System
Metal Chimney / Vents Air Balancing
Provide detailed description of work to be done:
� v
INSURANCE COVERAGE:
I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 YeNo ❑
If you have checked Yes, 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 112 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
By checking this box[i, I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and
accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be
in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws.
Date
Duct inspection required prior to insulation installation: YES NO
Progress Inspections
Comments
Final Inspection
Date Comments
Type of License:
By ❑ Master
Title ❑ Master -Restricted
City/Town ❑Journeyperson Signature of Licensee
Permit #
❑Journeyperson-Restricted License Number:
Fee $ ❑
Check at www.mass.gov/dpl
Inspector Signature of Permit Approval
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