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HomeMy WebLinkAboutMiscellaneous - 976 TURNPIKE STREET 4/30/201806/20/2017 TUE 11:03 FAX U002/002 Massachusetts Electric Company do Nantucket Electric Company (d/b/a National Grid) M.D.P.U. 1248 Edward Storey g1jr0flicate.2rCemolletion for Simplified Process Interconnections InstalMign Infor—mgm. ❑ Check if owner -installed Interconnecting Customer: Sunnoya. Energy Co. Contact Person: EgMpralda Mgrtinez Mailing Address: PO Box 56229 City: Houston State: TX Zip Code: _ 77256 Telephone (Daytime): 2R1-9RS-9900 (CYen ing): Facsimile Number. E -Mail Address: Address of Facility (if different from above): 976 Turnpike Street. North Andover. MA Electrical Contractor's Name (if appropriate): Brian MacPherson Mailing Address: 32 Grove St. City: Plyinnton State: MA Zip Code: 0 ,3r,7 Telephone (Daytime): 50g :577-339j„_ (Evening): Facsimile Number: 509-291-0040 E -Mail Address: brian.macphersoa(a rl i-sol_ar.com License numbor: 21233A Date of approval to install Facility granted by National Grid: 03/15/2017 Application ID number: 23746842 Insrr,c�tion: The system has been installed and inspected in compliance with the local Building/Electrical Code of (City/County): Signed (Local Electrical Wiring Inspector, or attach signed electrical inspection): Name (printed): License #: Date: 0 + As a condition of interconnection you arc requited to send/c-mail a copy of this form along with a copy of the signed electrical permit to National Grid: National Grid Attn: Distributed Generation 40 Sylvan Rd Waltham, MA 02451 H: mail: distributed.�tlerata�tn�Inationalgrid.00ral MassaohusoUs:huu://www.aalionalttrisli�s s omlmaxtietlectric/home/en ryet►il�4t�enelntiott asp Nantucket: IMP' !/WWw.nAtlonalgrid us.eom/nributed aaeneration,a Page I of I Date ... 57 ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that i ll. /,-, 4 )e. haspermission to perform .......... V ......... L ........ ............................................... wiring in the building of e:"�Ve .............. . ............................................................................................. at t7 -7iA North Andover, Mass. .............. . ........... . .................................... ............... Fee....,t....... Lie. No. ELECTRICAL INSPECTOR Check # 141t) 1 2552 -/ Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 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 (NEC), 527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: -3 IS City or Town of: NORTH ANDOVER To the Inspector of fres: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. S% Location (Street & Number) Owner or Tenant 1-1 , Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes g No ❑ (Check Appropriate Box) Purpose of Building fn/ `, L L h ig Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Meters No. of Meters Cmmnletinn nfthe fnllnwinn table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell: Susp. (Paddle) Fans v No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- 1:1o. rnd. rnd. o Emergency ig ting 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. Tons Tot No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number Tons KW ....................... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑Other Connection No. of Dryers Heating Appliances KW SecurityNo. Systems:* st ie : 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: '5'0 -� u� Attach additional detail f desired, or as required by the lnspecror 47 wires. Estimated Value of Electrical Work: �jQ _ (When required by municipal policy.) Work to Start: Inspections to e requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVE] GE: 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 UL BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME:. G/� �/ G LIC. NO.:379 /�Z �6 Licensee: df A LA44 I jZ Signature LIC. NO.: L (If applicable, enter "exempt 11 in he license number line.) Bus. Tel. No.: A 0 Address: 4/ gypA, Pj :5—,7- 01, 5e' ^7/0, O> WK 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 0 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 R? Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSP ION: Pass 1fl Failed'❑ Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com U v' p 0 N `The Commonwealth of Massachusetts s Department of IndustrialAccidents congress Street, Suite 100 tl Boston, MA 02114-2017 oM 5Y. V@ www mass.gov/dia VVorkers, Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMCTTING AUTHORITY. Name (Business/Orgaf&ation/ludividual): L % . Address: City/State/Zip:1-I?� S � r e Phone #: �l Are you an employer? Check the appropriate box: �I am a employer with employees (full and/or part time).* I am a sole proprietor or partnership and have no employees working £or me in 1y capacity. [No workers' comp. insurance required.] 3.❑ I am a homeowner doing all work myself [No workers' comp. insurance required] t <1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑I am a general contract.o or and I 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 Rlm and we have no employees. [No workers' comp. insurance required.] 70< . 6,4-/ Type of project (Tecluired): 7. ❑ NoVdonstructlon 8. [] Remodellfig 9. ❑ Demolition 10 [] Building addition 11.❑ Electrical repairs or additioAs 12. D.Plumbng repairs or additions 13•. [] Roof repairs 14. [! Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information t Homeownerscan who chdsub­oks box" affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have loyees, they must provide their workers' comp. policy number. employees. if the sub -contractors have emp X am an employer that is providingworkers' compensation insurance for my employees. Below is the policy and job site information. Xnsurance Company N Policy # or Self -ins. Lic. #:. Expiration Date, City/State/Zip: fob Site Address: oficy declaration page (showing the policy number and expiration date). Attach a copy of the workers' compensation p Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a foie up to $1,500.00 and/or one-year imprisonment, as well asInst b �orwarorm of a STOP ded to the Office o0RK £lnvORDER es� gaitOns of the D7A. for insurance a day against the violator. A copy of this statementY coverage verification. X do hereby cert under thepains and pnalties of pe�u� jat he information provided above is true and correct. in this area, to be completed by city or town officia Official use only. Do not write l. 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 de£iuied as "an individual; partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enierpri'se, 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 ofthe 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 b6 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('1) 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 Pleasb 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 that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.go•v/dia -9 This certifies that .... H. ..��--..��,A e L] Date� . �.......... ................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING has permission to perform .....re-vy!O�'`�......, t. tom} e e -,-IA .— ............................................... wiring in the building of...� o.f.r&op. c .96e. at ...... .......... LA ke!�.�:,.Lc; a,...:'... ................. rth Andover, Mass. c� Fee ...`. ��...-- ....... Lic. No. �?� { �� .. ........... ...�.. ff't. ELECTRICAL INSPECTOR Check # I Commonwealth of Massachusetts Official Use Only A Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank M 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 WINK OR TYPE ALL INFORMATION) Date: % O City or Town of. NORTH ANDOVER To the Inspei By this application the undersigned gives notice of his or her intention to perform the elect of Wires: work described below. Location (Street & Number) 716 TG /v /,i /y G .z Owner or Tenant —4 l" /'y 4e C 1i 7y & r'O v p Telephone No. Owner's Address Is this permit in conjunction with a building permit? YesR Purpose of Building G✓ % /r3 0 No ❑ (Check Appropriate Box) Utility Authorization No. - Existing Service Amps / V lts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: % %✓f XAly &AL — el, 4(5o l- otj-, oOQ, s w — e-Aq No. of Meters No. of Meters rJ Completion of the following table may b�waived by the Inspector of Wires. No. of Recessed Luminaires 7 No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets S" No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool rnd. [irnd. ❑ o. o Emergency Lighting Battery Units No. of Receptacle Outlets -30 No. of Oil Burners FIRE ALARMS I No, of Zones No. of Switches C/ 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 Dis posers p Heat Pump Totals: Number Tons I.KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal El other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: v 6A(When required by municipal policy.) Work to Start: / a� S fe I � ections 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 cov rage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: 1NSU_RANCE, . BOND ❑ OTHER ❑ (Specify:) X certify, cinder the pains and penalties ofperjury, that the information on this application is true and complete. ,t FIRM NAME: wl l;G r 6 LIC. NO.: 7 Yr.2G Licensee: %'t��/�(" fjy/�//-� Signature LIC. NO.: (If applicable, enter "exemljt" ' 1,he license number lin G�� �� b ��Bus. Tel. No.- -% Y/ % Address: �d`L� i� IV +D N I �l4 �% i� 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 no 11y required by law. By my signature below, I hereby waive this requirement. I am the (check one) Elowner Elo er's a ent. Owner/Agent Signature Telepb one No. PERMIT FEE: ❑ 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. f Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence". during the qualifying period beginning on August 15, 2008 and extending -through August 15, 2012. ❑ Rule 8 — Permit/Date Closed:** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n Failed [N Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INS TION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: iv Date: 61, FINAL INSPECT Pass M V Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com VF The Commonwealth of Massa chusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Ledbly Name (Business/Organization/Individual): G✓/-,�/ % ji�G I r j C Address: City/State/Zip: i��L%Cy Sr /114, Phone #: % 4% IZ 1--a U 9 % 9 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with : employees (full and/or part-time).* 2. (WI am a sole proprietor or partnership and have no employees working for me in y capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. oyees. [No workers' comp. insurance required.] 152, §1(4), and we have no. empl Type of project (required): 7. ❑ New construction 8. Remodeling 9. ❑ Demolition 10 ❑ Building addition 11. FJ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who suhn if this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check thisbox must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub-contractors have employees,1hey must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company N Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofpeijury that the information provided above is true and correct. Signature: �%v� l� Date: j U �) t/ /✓ G �!% I S Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): ; 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person Phone #: r Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract 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 fbir confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia *.;COMMONWE . ALTH OF MAtSACHUSETT ..-MARW.A WH I It . ..... ..... 422. L E BANON :':STR E E.T-.:: nost -j --,...A 02176-3'. w .4 Date .��!!.�.��.�......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .........:h...ti.v'........................�........................... has permission to perform ..........U. P, ... �-r�.d... . plumbing in the buildings of.......... . n........P*Ojq--'�..... at ..............4.........�'.: ........a'. North Andover, Mass. Fee... 2 ........ Lic. No... �. ?. 3................................................................................. O 7 / PLUMBING INSPECTOR Check # � (r -CN- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK low- CITY J_North Andover MA DATE F §/17115_ PERMIT# JOBSITE ADDRESS 976 Turnpike_ St OWNER'S NAME J JEM Property Group P OWNER ADDRESS 976 Turnpike St j TELT— 91493-0992 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL Q RESIDENTIAL Ej PRINT CLEARLY NEW: F -I RENOVATION: Q REPLACEMENT: F-1 PLANS SUBMITTED: YES E] NOE] FIXTURES 7 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIIJSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK 1 E LAVATORY ROOF DRAIN SHOWER STALL HE SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liabili!y insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [71 NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [a OTHER TYPE OF INDEMNITY [:] BOND Fj 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 r-1 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are e and accurate the b - of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in iance with all ertine provisio the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I Shaun Lindmark LICENSE #16038 SIGNATURE MPF -1 JPQ CORPORATION Q# 3600 PARTNERSHIP[::]# LLCD#0 COMPANY NAME I Lindmark's Plumbing & Heating Co.,inc ADDRESS 113 Gove Rd 771 CITY FBillerica -,'STATEF——MA -1 ZIP I 01821 TEL 978-670-0840 FAX CELL 1 978-5024335JI EMAIL [lindmarksplumbingQgmail.com S,2- :fO \ The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 e�M SV'�P www.mass.gov/dia VPorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE pERMITTING AUTHORITY. Please Print Le 'bl . � A licant Information 1 Name (Business/Organization/Individual): L i r Address: 13 �" c �`') City/State/Zip: AA- ONKDa \ Phone #: -67 a- Are you an employer? Check tlie appropriate box: l.ram a employer with p-. employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor or partnership and have no employees Working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑1 am a general contractor and I have hired the sub -contractors listed of the attached sheet. These sub -contractors have employees and have workers' comp. insurance 6. Q We are a corporation and its, officers have exercised their right of exemption per MGL c. 152 61(4) and we have no e'mploydes. [No workers' comp. insurance required.] Type of project ()required); 7. ❑ New'c6nstr66tion 8. dRemodeling 9. ❑ Demolition 10 ❑ Building addition 11.[] Electrical repairs or additions 12^[]Plumbing repairs or additions 11E] Ro6f repairs 14. [] Other *Any applicant that check's box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this davit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not (hose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. compensation insurance for my employees. Pelow is the policy and job site X am an employer that is providing -workers' information. Insurance Company Name: o C0v►."rcV-0 a-AS'Ar-A ,k Policy # or Self -ins. Lic. #: Vii C- 7 ot i L` "I`101 Expiration Date:. 16 /w/1 /) S y `� A YJ— V V cT Ci /State/Zi Job Site Address: aI7C� S } N p Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiratiorx 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 Dae, 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 verificatio X d eby cer " der thepains dpenald ofperju Izat the information provided///a//bove is t� 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): 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 enterprise, and including the legal representatives of a deceased employer, or the receiver"or. trusted 6f an individual, partnership, association or other legal entity, employing emplbyees. - 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 theperformance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Pleasb 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 IndustrialAccidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.inass.gov/dia To: Page 2 of 2 2015-06-17 12:36:06 EDT From: Jules Jessup LINDPLU-01 JJESSUP ACORO°' CERTIFICATE OF LIABILITY INSURANCE `---�� DAT 6/1 17/20115 712 5 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(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 Welsh & Parker Insurance Agency, Inc. / Hudson Office 131 Coolidge Street, Suite 100 Hudson, MA 01749 CONTACT NAME: PHONE --- SAX -- Arc. No. Ext): (978) 562-5652 �c Na : (978) 562-7120 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Central Mutual Insurance Company 20230 INSURED INSURER B: Commerce Insurance Company 34754 Lindmark's Plumbing & Heating Co. Inc. INSURER C: CLAIf1S-PAADE OCCUR INSURER D: 13 Gove Road Billerica, MA 01821 INSURER E : -EACH DAPTAG�i`ZSR€NSD.......................................................-- I PREMISES Ea occurrence INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR LTR TYPE OF INSURANCE ADDL INSD SUBR I WVD POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MM/ODIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY OCCURRENCE I S 1,000,000 CLAIf1S-PAADE OCCUR CLP 7914748 10/15/2014 10!15!2015100,000 -EACH DAPTAG�i`ZSR€NSD.......................................................-- I PREMISES Ea occurrence - S MED EXP (Anyone person) S 5,000 I & ACV INJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ...PERSONAL --5.._._ GENERAL AGGREGATE ..............................- S 2,000,000 POLICY L_; JECTPRO- ) LOC PRODUCTS -COMP/OP AGG S 2,000,000 OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea.accideni) S 6600 000 + B ANY AUTO MN4303 1 10/15/2014 10/15/2015 BODILY INJURY (Per person) S ALL OWNEDX AUTOS AUTOS S 60DILY INJURY (Per accident) S _ XX ! NON -OWNED I PROPERTY DAMAGE........-_.....---...._..- ----_..-.... --- _......... - HIRED AUTOS _ .I AUTOS (Per accident) i S UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIABj CLAIMS-MADEI A� GGREGATE S DED RETENTIONS S j i I WORKERS COMPENSATION i PER 01`H - AND EMPLOYERS' LIABILITY I N ......._.__ STATUTE._ ER A ANY PROPRIETORiPARTNER/EXECUTIVE WC 7914749 10/15/2014 10/15/2015 E, L. EACH ACCIDENT --- S 100+000 OFFICERMEM6EREXCLUDED? NIA E.L. DISEASE - EA EMPLOYE S 100,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT S 500+000 I. I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) nULUCK Town of North Andover 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 V ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD *�� COMMONWEALTHo OF iVlAS5 1�CHliSETT:�`` ° e RD OF PLUMBERS AND GASFITTERS. ISSUES THE FOLLOWING LICENSE ,1 LICENSED AS A MASTER PL -UMBER-, ,- s SHAUN R L I NDMARK z j 13 GOVE 71 �£ �� lz BILERI`CA MA 01821-131$`J to 16038 . ' .05/0,/1.:6;:::.:;:::,>'203813 Page 1 of 2 2015-06-17 12:36:06 EDT FAX COVER SHEET TO COMPANY FAXNUMBER 19786889542 FROM Jules Jessup DATE 2015-06-17 12:35:40 EDT RE Lind mark's Plumbing&Heating Certificate COVER MESSAGE This message contains a report as a PDF attachment. WWW.EFAX.COM From: Jules Jessup