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HomeMy WebLinkAboutMiscellaneous - 984 TURNPIKE STREET 4/30/2018.✓' r� N O O v C7 O YQO' O O O O O `� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kqx n CITY NORTH ANDOVER MA DATE 8-26-2014 PERMIT # JOBSITE ADDRESS 984 TURNPIKE STREET OWNER'S NAME I DOCKHAM GOWNER ADDRESS TE FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIALE3 PRINT CLEARLY NEW:F--1 RENOVATION: [I REPLACEMENT: E] PLANS SUBMITTED: YES® NO® APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE _ GENERATOR GRILLE _ INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT _ OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT AMNON_ TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER NEW METER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES E] NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E] OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ® 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 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 comp ance with al Pe . e provi of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �. PLUM BER-GASFITTER NAME I KENNETH J ROBERTS LICENSE # 11934 SIGNATURE MP F1 MGF ® JP E3 JGF ® LPGI ® CORPORATION E]# 3304 PARTNERSHIP ®# LLC ®# COMPANY NAME: ABSOLUTE PRECISION ADDRESS P.O. BOX 1260 CITY I MIDDLETON STATE= ZIP 01949 TEL 978-475-1751 FAX 978-777-5371 CELL 978-475-1751 EMAIL KEN@A BSOLUTEPRECISIONPLUMBING.COM MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK s — b F t CITY NORTH ANDOVER MA DATE 8-28-2014 PERMIT # JOBSITE ADDRESS 1984 TURNPIKE STREET OWNER'S NAMEJ DOCKHAM P OWNER ADDRESS I SAME TEL_ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: El RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO® 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/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM _ DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK _ TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 _ WATER PIPING OTHER HEdEdEE INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E] OTHER TYPE OF INDEMNITY FJ 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 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 plumbing work and installations performed under the permit issued for this application will compliance th a e ent pro ' on the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME KENNETH J ROBERTS LICENSE # 01SIGNATURE MPE] JP® CORPORATION# 3304 PARTNERSHIP®# LLC E]# COMPANY NAMEABSOLUTE PRECISION ADDRESSI P.O. BOX 1260 CITY MIDDLETON STATE E7m7A1 ZIP 01949 TEL 978-774-8835 FAX 978-777-5371 CELL 978-7661475 EMAIL KEN@ABSOLUTEPRECISIONPLUMBING.COM 0 ACORV CERTIFICATE OF LIABILITY INSURANCE ATE D12/17/2013rr) 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(les) 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 CONTACT NAME: Andrew Atsaves Go Artex Risk Solutions, Inc. 8800 E. Chaparral Rd, Suite 230 Scottsdale, AZ 85250 PHONE 480 951-4177 (,FAX No): 480 951-4266 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Zurich -American Insurance Company 16535 INSURED INSURER B Genesis HR Solutions, Inc. One Burlington Woods Dr. Suite 203 INSURERC: Burlington, MA 01803-4552 INSURER D: INSURER E: INSURER F: MED EXP (Any one person) $ COVERAGES CERTIFICATE NUMBER: 14MA603806009 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 SUBR POLICY NUMBER POLICY EFF MMIDDIYYYY) POLICY EXP (MMIDD/YYYYJ LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP (Any one person) $ CLAIMS -MADE 1:1 OCCUR PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS L PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N OFFICER/MEMBER ANY /EXCLUDED?ECUTIVE ❑ NIA WC 48-41-995-03 01/01/2014 01/01/2015 X WC STATU- OTH- TORY E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below I I E.L. DISEASE - POLICY LIMIT 1 $ 1,000,000 Location Coverage Period: 01/01/2014 01/01/2015 Client# 1957 -MA DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Coverage is provided for Absolute Precision Plumbing & Heating, Inc. 5 Wildwood Road only those employees leased to but not Middleton, MA 01949 subcontractors of: CERTIFICATE HOLDER CANCELLATION Absolute Precision Plumbing & Heating, Inc. 5 Wildwood Road Middleton, MA 01949 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 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations /. 600 Washington Street Boston, MA 02111 kvi www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: / ' a f2 CJX 1.2- il, 0 City/State/Zip: /J'1 D 0 / L: %rn M,4 G% 1',k�F Phone #: Are you an employer? Check the appropriate box: L. g I am a employer with employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] Business Type (required): 5. ❑ Retail 6. ❑ Restaurant/Bar/Eating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing 11.❑ Health Care 12�]Other Cd/)5.7RUC T?G�+ *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. * *If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: Z (1 /2 -'C ff 9 "� Z /F -TC'49 J`ij j r✓ /.1 /3 7 C Insurer's Address: P 6) /3 ox- /,- g U City/State/Zip: /� �O O f To -t S 3 0/9 Y 9 Policy # or Self -ins. Lic. # w C — t✓cl S -O 3 Expiration Date: 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�p/ains aIde aloes ofperjury th t the information provided above is true and corrrect.''� �9! Date: 97F--7-1k-eP 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. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: wwWJ1L r,- ,.. ACORV CERTIFICATE OF LIABILITY INSURANCE DATE(IVINIDI]YYYY) 6/18/14 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 Circle Business Ins. Agcy, Inc 247 Newbury Street Danvers, MA 01923 CONTACT NAME: PHONE F FAX 978 777-5619 AI N01:078) 777-4898 MAIL ADDRESS: PaulaHalas@ CircleInsurance . net INSURE S AFFORDING COVERAGE NAIC # INSURERA:Utica Mutual 7/8/15 INSURED INSURER B: Safety Propertv & Casualty Absolute Precision Plumbing & Heating, Inc. Po Box 1260 Middleton, MA 01949 INSURER C: INSURER D: INSURER E: 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. ILTR TYPE OF INSURANCE ADDL SUBR Vivo POLICY NUMBER POLICY EFF M/DD/Y POLICY EXP MMIDDIYYYY LIMITS * GENERALLIABILITY }( COMMERCIAL GENERAL LIABILITY CLAIMS-MADE 7X OCCUR 4541084 7/18/14 7/8/15 EACH OCCURRENCE $ 1,000,000 DAMAIRE,GE T'ESO RENTED $ 50,000 MED EXP (Any one person) $ 10,000 PERSON4L&ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATELIMITAPPLIESPER }{ POLICY PRO- ,E CTLOC PRODUCTS - COMP/OPAGG $ 2,000,000 $ B AUTOMOBILE LIABILITY ANYAUTO ALLOWPED X SCHEDULED AUTOS AUTOS X HIREDAUTOS X NON -OWNED 6218367 7/8/14 7/8/15 CCE0,. �EDSINGLELIMIT $ 1,000,000 000000 BODILY INJURY (Per person) $ , BODILY INJURY (Per accident) $ —� PRO erraccatlentDAMAGE $ 1 000,000 (per. $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATIONWC AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) Ifs describe under DESCRIPTION OF OPERATIONS below NIA STATU- OTH- E.L. EACH ACO DENT $ E.L. DISEASE -EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101, Additional Remarks Schedule, if more space isrequired) 14-15 Term CERTIFICATE HOLDER rONrFI I OT'InN © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Proof of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Paula Halas © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: <° W Date .............. . �1.... . TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that..�..�(��......................,'....�,�..`1..................... has permission to perform .�...r:..... ......... ... ......... wiring in the building of.. ..... 1 f. f./.: .-41 ................ f .. /..0azlw..1V................... ............. . North Andover, Mass. ... Lic. NoA✓............................................................... RwAl iNCPF[`TnR Check #✓ / 5-161 �-� Commonwealth of Mas Department of Fire BOARD OF FIRE PREVENTION '% APPLICATION FOR4,)ERMI All work to be performed in cordance (PLEASE PRINT IN INK OR TYPE ALIINFOI ac�fisefts official Use Onl 2r� 7 Ices Permit No. GULATIONS Occupancy and Fee Checked I& U ' [Rev. 11/991 leave blank TO PERFORM ELECTRICAL WORK the Massachusetts Electrical Code (MEC), 527 CMR 12.00 TION) DAte: 04/14/2004 City or Town of North Andover I To the Inspector of Wires: By this application the undersigned gives noti ' of 's or her intention to perform the electrical work described below. Location (Street & Number) 984 Turnpike S t Owner or Tenant Sandra Newall Telephone No. 978-685-9600 Owner's Address 984 Turnpike Street Is this permit in conjunction with a building permit? Yes ❑ No X (Check Appropriate Boz) Purpose of Building Residence 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: Replace Service Wire and Weatherhead No. of Meters No. of Meters Completion of the following table may be waived by the Insnector of Wires. No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool rnd. Above ❑ - rnd. ❑ o. o Emergency Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS [No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump I Totals: Number . . .................... Tons KW No. of Sel - ontained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ unicipal ❑ Other Connection No. of Dryers Heating Appliances KW SecuritySystems: No. of Devices or Equivalent No. o Water KW Heaters No. o No. o Signs Ballasts Data Wiring: No. of Devices or Ea uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. 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 X BOND ❑ OTHER ❑ (Specify:) Estimated Value of Electrical Work $245.00 (When required by municipal policy,) (Expiration Date) Work to Start: Inspections to be requested in accordance with NEC Rule 10, and upon completion. I certify, under the pains and penalties of perjury, that the information on this application is true and complete. # FIRM NAME: Landers Electrical Co., Inc. „ LIC. NO.: A5912 Licensee: Vincent B. Landers President Signaturey%,, 46r >.6 rte—"` LIC. NO.: A5912 (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.; 978-686-3828 Address: 1000 Osgood Street, No. Andover, MA 01845 Alt. Tel. No.: 978-686-3829 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally 7 .,,,, tl,n I TOWN OF NORTH ANDOVER PERMIT FOR WIRING J This certifies that ...... .... 11 .... ................ .............. ....... e. has permission to performC . ... . . . ........ ...... t�.% .............. wiringin the building of ................................................................................... .......... ... .......... i� .......a ................. North Andover, Mass. Fee .A/,S.—.c'7 .... Lic. No/2/-Z.'P�.YK ....... ......................... t .......................... ELECTRICAL INSPECTOR Check # /J�Fo 5186 f.nrmmnraaa[Us o� aiiatl � For Office Use Only c� c7 (Rev. 11/99) �` r 1JaParintar o�,�`ira �srvicti / Permit Number. BOARD OF FIRE PREVENTION REGUL4T ONS occupancy &Fee J (ALL WORK TO BE PERFORMED WITH THE MASSACHUSETTS ELECTRICAL CODE 527 CMR 12:00) PLEASE PRINT IN INK OR TYPE ALL INFORMATION 1 Date:y City or Town of:,&e 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)- D Ll �L-If''-w L At C4. Owner or Owner's Address:_ <:: Gf!it,�Q Is this permit in conjunction with a Building Permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building:all f64,C 9�!')/L.�r Utility Authorization #: Existing Service: 2—S!--'zA mpsZ7y/1 Q volts Overhead Underground. ❑ # of Meters New Servicer - Amps / Volts Overhead ❑ Underground.❑ # of Meters: Number of Feeders and Ampacity: Location and Nature of Proposed Electrical Work: 4)/774 Q/MP` No. of Recessed Fixtures No. of Cell.-Susp. (Paddle) Fans No. of Transformers Total KVA No. Of Lighting Outlets No, of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool: Aboveground ❑ In Ground ❑ # of Emergency Lighting Battery U Its No. of Receptacle Outlets No. of Oil Burners Fire Alarms # of ones # of Detection & Initiating De ces No. of Switches No. of Gas Burners # of Sounding Devices: # of Self Contained Detection/Sounding De es No. of Ranges g No, of Air Conditioners TOTAL TONS: Local ❑ Municio Connection o Other ❑ No, of Waste Disposals Heat Pump Totals: Security System . Number.ONS: KW: No. of Devices r Equivalent No. of Dishwashers Space /Area He ting: KW Data Wiring, o. of Devices or Equivalent: No. of Dryers _ _ Heating Appliances KW Telecomm nications Wiring: No of Devices or Equivalen No. of Water Heaters KW No. of Signs: # of Ballasts: OTHER; # of Hydro Massage Tubs No. of Motors_ Total HP_ 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 O OTHER ❑ Please specify: Estimated Value of Electrical Work $ rr� (When required by municipal policy) Work to Start:� Inspections to be requested in accordance with MEC Rule 10, and upon completion. 9 1 certify, under the pains and penalties of perjury, that the Information on this application is true and complete. Firm Name: — LIC. Licensee: ���) 0���7J Signature: • LIG. //'')) (If applicable, enter "ex J�cense r line) OC/ Address:, \ ' ) - Bus. T � ' ' (1 Alt. Tel. # 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 a OR Agent ❑ Signature of Owner/Agent: Telephone # 1. PERMIT FEE: S OF NORT q� S�2_. OCG m o � Date 1191%/-- . . TOWN OF NORTH ANDOVER PERMIT FOR WIRING SACHUs� This certifies thzti i . has permission to perform .9-e ...,.`�✓. ..�i�'�� �-. e -1(x'16 #� - wiring m thGeLbuilding of Q 1111 ........................ . at .....0.7 .`'��`!f?'��. `g/'........ , North Andover, Mass. 1 1...Fee© • EIECT INSPECTOR Check # I 11125 Commonwealth of Massachusetts Officiial U/se Only Os Permit No. ` �` Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT ININK 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) Owner or Tenant IP� /% e �Ci C' kl?G',7 Telephone No. Owner's Address 7upl7pike Is this permit in conjunction with a building ermit? Yes. No ❑ (Check Appropriate Box) Purpose of Building -, oc C" Utility Authorization No. T - Existing Service 52e�� Amps 6� Q/ a IVa Volts Overhead W. Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: /• 1 �; H rtti� f nnu,;nn inhln mnv he waived by the Inspector of Wires. Arraen aaawonat uetutt y ue�tieu, «� . may..•. �� y •••� -•• r--•- -- Estimated Value of Electrical Work:O 6� CC (When required by municipal policy.) Work to Start:/0. ) - ) -,;I Ins 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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: 1NSURANCE-t�rBOND ❑ OTHER ❑ (Specify:) I certify, under the sins and penalties ofperjury, that the information on this application is true and complete. FIRM NAME:. Cr. / �' LIC. NO.:p9 3 %�<�— Licensee: Duiq/l/ = 1 Signature LIC. NO.: (If applicable, enter "exempt" in the license number line) Bus. Tel. No. - Address: 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 I PERMIT FEE. $ Signature Telephone No. ,•. No. of , Total No. of Recessed Luminaires No. of Cell.-Susp. (Paddle) Fans Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA of Luminaires ` (� Above In- Swimming Pool rnd. ❑ rnd. ❑ o. o mergency �g tingNo. Battery Units No. of Receptacle Outlets l No. of Oil Burners FIRE ALARMS No. of Zones No. of Detection and No. of Switches No. of Gas Burners Initiatin Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices Heat Pump Number KW No. of Self -Contained No. of Waste Disposers Totals:.. .Tons ................ Detection/AlertingDevices No. of Dishwashers Space/Area Heating KW ., Municipal Other Local ❑ Connection No. of Dryers. Heating Appliances KW Security Systems-* No. of Devices or E uivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or Equivalent OTHER: 6 C-) rJ w P ,.4 t.,. fti.� Tv.cnortnr nfWiro.c Arraen aaawonat uetutt y ue�tieu, «� . may..•. �� y •••� -•• r--•- -- Estimated Value of Electrical Work:O 6� CC (When required by municipal policy.) Work to Start:/0. ) - ) -,;I Ins 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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: 1NSURANCE-t�rBOND ❑ OTHER ❑ (Specify:) I certify, under the sins and penalties ofperjury, that the information on this application is true and complete. FIRM NAME:. Cr. / �' LIC. NO.:p9 3 %�<�— Licensee: Duiq/l/ = 1 Signature LIC. NO.: (If applicable, enter "exempt" in the license number line) Bus. Tel. No. - Address: 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 I PERMIT FEE. $ Signature Telephone No. J � J - ._ • �JJ1u�dJ.�.J.'���t'7(�'�(tJ�l-(r�p�..��-'lei/J-y.f��d��ly®p'j•�y'py,���^(�('[ .`-�.7��J:1`L.rJS.+S�.l`f .�lh+.+�®��e —.V'RLi-1l�.L.�C9.4..�ai.a.(.11.Y1=9.R.X'iY✓,f,®�," •• r •• � r . ��ssei��-• -- �'aileftH j � �e-�zspeetioxt x'egt�iz'ec7{$OAU) � j � 3�nspectprs' copzme�ats: - {xnspe oxs°�igaaiu�re v iii, a7s) _ jpage - ;. TM.7 R GROM JUiSROCl.ION. 'ass7ad -- j I ate- s eetzo� xec uixet ($x0.00) � j uspetor's' comments: cm pectoxs"ssig-u*w&W Pate . End—[ )'ailed --j Pe-7nspec�iottxequixes ($ O.OD) j ' 'Peetors9 eoxnmepfs; (Zttspectoxs's�igtz�ture�5io jnitiaTs) ]late ' `erg •, j � �:aiier�--� �. ' ate �nsp ection xer�wixe� {$50.00) •- [ � ectoxs" cozhm.eds: - ' S '@4spectors' Signature -no Jiffials) Plate 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 j Please Print Legiblv Name (Business/Organization/Individual):.���� Address: , a Coll� OZ� S 7 Citi/State/Zip: /�.��' P,(Z,/- Pj/ IVPhone #: 6 05 Are you an employer? Check the appropriate box: 1. .I am a employer with 4. El 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. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 1 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. ❑ Building addition 10. F1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box #I 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: P/ Policy # or Self -ins. Lic. #: Expiration Date: / Job Site Address: / `C City/State/Zip: -m/1 IGT/ -e a Attach a copy oft workers' compens tion 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 cer�nder the pains and pepa"of perjury that the information provided above is true and correct a 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 Fax # 617-727-7749 Division of Professional Licensure: License Search The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Home State Agencies A -Z Topics Home > Division of Professional Licensure > Check A Professional License By the Division of Professional Licensure LICENSEE Name: DUANE A. RICARD MANCHESTER, NH NEW SEARCH Licensing Board: ELECTRICIANS License Type: JOURNEYMAN ELECTRICIAN TYPE CLASS: JR License Number: 2372 Status: CURRENT Expiration Date: 7/31/2013 Issue Date: 11/26/2007 Exam Date: School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Monday, October 01, 2012 at 1:34:31 PM. © 2007-2011 Commonwealth of Massachusetts Page 1 of 1 Mass.Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change i Contact the Agency More... REFERENCES & RELATED INFO Disclaimer Regarding Website License Searches Enforcement Process Glossary Glossary of License Status Codes More... Site Policies Contact Us http://license.reg. state.ma.us/publiclpubLicenseQ.asp?board_code=EL&type_Class=JR&li... 10/1/2012