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HomeMy WebLinkAboutMiscellaneous - 995 OSGOOD STREET 4/30/2018cn Date........ ... ........... . TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies t at .......�'05........... S� has permission to perform ...WOJZ L ......... ... wiring in the building of ......... .......................................................................................... at ..... .....(I...%...`..\....Q.S.f 6p....... .......... J .......... , North Andover, Mass. `Fee ............................... Lic. No. , i i G ELECTRICAL INSPtCTOR ,. Lr ,heck # 23a7 , C C-oinntonu�ealth o/ maddac"ted Official Use Only ! -- 2sparimeni of -tcre &Mw'm Permit No. _ BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev. 1/071(leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527JMR 12.00 (PLEASE PRINT 1NINK OR E ALL IN ORMATI01� Date: �'r� City or Town of.- To the Inspector By this application the undersign^ es no, 1\ a of his or h%in`ention to perform the electrical work described below. Location (Street f —" Owner or Tenant Owner's Address Telephone No. Is this permit in conjunnwa building permit? Yes ElL No _ (Check Appropriate Box) Purpose of Building Utility Authorization No. d Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature o oposed Electrical Work: , OC m letion the Ilowin table No. of Recessed LuminairesNo. of Ceil.-Susp. (Paddle) Fans o. OF of Luminaire Outlets of Luminaires of Receptacle Outlets of Switches of Ranges of Waste Disposers of Dishwashers of Dryers Heaters KW Hydromassage Bathtubs of Hot Tubs mining Pool grn-:--ame ❑ d ❑ of On Burners of Gas Burners of Air Cond.ota T___ Space/Area Heating KW Heating Appliances KW No. o o. if— Si S fSigns Ballasts No. of Motors Total HP No. of Meters No. of Meters waived by the Inspector of Wires. Generators KVA ALARMS INo. of Zones o. of Alerting Devices El'numct Cannertinnpal El Other No. or %,� `*/ Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value oElectrical Work: VIM . (When required by municipal policy.) Work to Start: �� 1 Inspections to be 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains an penalties ofperj ry, that the information on this application is true and complete. FIRM N LIC. NO._IIgq (, Licensee: voor �_ Signank]; LIC. NO.: QO (If applicable, enter " pt" in the It e e niter li .) Bus. Tel. No. X31 1 Address: Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-6 , security work Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance Owner/Agent coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one ❑owner EIowner's a ent Signature Telephone No. I PERMIT FEE. $ `��"� !� ,. J i a r Oig1M0AiiiVE�CLTH-OF-M" CHUSETfg:• IrL-ECTRICiANS 3 Y, } r I SSUES THE FOLLOW NG t I"DENSE S $ f <RE& ST€REO SYSTEM CONTRACT R ¢ � SE -CUR I Ty, CONS WrANTS-7' H PRESG4T7 S_i�tTH 240 BosT& ST -s U T(3PS F _C`E LB983 222 i Commonwealth of ',lass achuse,,s CeParltment of Public Safety License: SSCo -000302 z- HORACE P SNgTH . 240 ROSTO�i ST TOPSFIELD MA 01983 - L� Commissioner = Z 'ajson 05/16/2015 Date .////.(. ...Z.q.......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that+..r:............................................................................................. has permission to perform .-.----- T wiring in the building of.......................�............... �. ......................................................... As ...� ...at .........5....C.. .......s. .... . oAndovMass. Fee„1�--..... Lic. No��.l.��l ..../....,�....,//,�����•(�. /CTRICALINSPECIOR / Check # Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Onl/y,, 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 MFORM4TIOA9 Date: 1 i " ICI— / J City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her irate tion to perform the electrical work described below. Location (Street & Number) q Q _S" ©,'5 C/o© 5j Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes 19 No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts New Service la Amps / Volts Number of Feeders and Ampacity Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters f Location and Nature of Proposed Electrical Work:�� Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: 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- F]o. rnd. rnd. o mergency Lighting Batteiy Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste 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 Dr y Heating Appliances I(W 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 No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wtres. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule, 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability ' surance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE M BOND ❑ OTHER ❑ (Specify:) I certify, cinder the gins an penalties o per'ur ,that ze inforniatio on this a plication is true and complete. =1censee N L rV�e � LIC. .: Z, qb7e, Signature IC. NO.: Z / (If applica"exem " in the license num er line.) ! d0 Bus. Tel. No.• ' (® Address: 1 A9)( 16 % 2 3� -efi.-I / 9 Alt. Tel. No.: *Per M.G.L c. 147, s. 5T-6-1, iecurity 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. lam the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. Y❑ 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 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPE TION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comm ts: Inspectors Signature: Date: FINAL INSPECTION: Pass (] Failed 0 Re- Inspection Required ($.) ❑ Inspectors C mments: Inspect rs Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth ofMassachusetts Department of lndustrigl Accidents Office of Investigations 600 Washington. Street Boston, MA 02111 www•massgov/dia Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers •� w Name M (f -e S Address: ��� �, D 2 0 City/State/Zip: Jn [-e,✓u A) D,V 77 Phone #: Are you an employer?Check the appropriate box: - Type of project (required): 1. M I am a employer with ?i 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2. El am a sole proprietor orpartner- have hired the sub -contractors listed on the attached sheet. �• Remodeling ship and'have no employees working for me in any capacity. These sub -contractors have workers' comp. insurance. 8. ❑ Demolition g• ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] 13. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11.[] Plumbing repairs or additions myself. [No workers' comp. c.152, §1(4), andwehaveno 12.❑ Roofrepairs insurance . re uired required.] i employees. [No workers' 13.0 Other comp, insurance required.] 'Any applicant that checks box #f must also fill out the section below showing their workers' compensation policy information. 7 Homeowners who submit this affidavit indicating they bre 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: me r6Vl!�K Policy 0 or Self -ins. Lic. #: Expiration Date: r" Job Site Address: 0 Cit4y/State/Zip: � weed O%�7 Attach a copy of the workers' compensation policy $eclaration 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, fiui 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 maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. X do hereby cerfi& under the pains andpenalties ofperjury that the information provided above is true and correct. A —Date.• MM..WAh..�— Official use only. Do not write in this area, to be completed by clip 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 - - - C'nnfnrfPPrenn• - Phone ❑ 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 w`~ notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shallbe limited as to the time of ongoing construction activity, and maybe deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed Re—Inspection Required ($.) ❑ Inspectors Comments:. Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com I Ir ' iiWm Ci AN5 )RAO ....... wAz— .......................This certifies that.............................. . ...... . • has permission to perform . .................L ........5..........S... plumbing in the buildings of . . .. ..... ... . .. ............ U .. ..... .1 ........... ...................................... ................................. . North Andover, Mass. at ...... .. ... . . Fee ..... 1.10 . ..... Lic. No. . ...... ... ............... ........ PLUMBING INSPECTOR Check # TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING &N x MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK POWNER TYPE OR PRINT CLEARLY CITY1 MA DATE (— :1I PERMIT# Ib JOBSITE ADDRESS h 9 OWNER'S NAME ADDRESS I (At -V TEL OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL NEW: RENOVATION: Ix REPLACEMENT: Q PLANS SUBMITTED: YES Q NO Ell FIXTURES Z FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNERE] AGENT Imo! DEDICATED SPECIAL WASTE SYSTEM I hereby certify that all of the details and information I have submitted or entered regarding this application are true and acq6lLate tq the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co ce witfi)eib9C provision of the DEDICATED GASl01USAND SYSTEM PLUMBER'S NAME I LICENSE # SIGNATURE MIP0f JP CORPORATIONQJ #PARTNERSHIPD#LLC DEDICATED GREASE SYSTEM _.� ^I { DEDICATED GRAY WATER SYSTEM I _ J DEDICATED WATER RECYCLE SYSTEM I J � _ ^J i _ ! �_. _ I ._..__J ___I I _! DISHWASHER _(_ � _ I _I _� ! —J I—AED ! _ f DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR KITCHEN SINK LAVATORY _lI --J1 ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET 1 _J IV I INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES- 0NO 0 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 QI ,i 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: OWNERE] AGENT Imo! 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 acq6lLate tq the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co ce witfi)eib9C provision of the h4assachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I LICENSE # SIGNATURE MIP0f JP CORPORATIONQJ #PARTNERSHIPD#LLC COM/'P\`ANY NAME uP-nM R, n!"ADDRESS , 9 CITY Q� i C _ _ _j STATE ZIP (1 1 TEL FAX j CELL j EMAIL IV I rl LLI ME W . LLJ LL The Commonwealth of Massach usetts Department of IndustrialAccidints Office of Investigations 600 Washington= Street Boston, MA 02111 UV www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Address: City/State/Zip: �� 1 I��T� �i 0 �` 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. 1 am a sole proprietor or partner- 01;m listed on the attached sheet. hip 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.] � - lr� - 0 -� Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 1011 Electrical repairs or additions 11.0 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 ke 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 Policy # or Self -ins. Lie. #:, Job Site Expiration Date: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o. 152 can lead to the imposition of criminal penalties of a 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. Ido hereby`!?P�nderil�epA ns andpenalties ofperjury that the information provided above is true and correct v, �_C ()-o IW6 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 employeiis 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 enaployer." 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." s Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number."In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts - Department of Industrial .Accidents Office ofWestigations 600 Washington Street Boston, MA 02111 Tel, # 617-727-4900 ext 406 or 1-877:MASS.AFE Revised 5-26-05 Fax# 617-727-7749 w w.mass,govfdaa This certifies that .. )A,\A. nl �j \ Date..... ....::.. ......H .................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION has permission for ga installation ...'.. in the buildings of ..........:.r>�....... at........ .� s ..... ..... ... .......'�` ? Fee—....... Lic. NoY2:III........ Check # t 1 ......................................................... r �•-e-t+ ......................................................... North Andover, Mass. GAS INSPECTOR I 1 0 t v , V, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Oq CITY MA DATE (� IJ PERMIT # JOBSITE ADDRESS DOWNER'S NAME 4 G OWNER ADDRESS c�l�N i TE —ic>G !!f AXE— TWE OR OCCUPANCYTYPE COMMERCIALM EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: F-1 RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES 0 NOQ APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER L_ L 1 BOOSTER _ CONVERSION BURNER (_ _-_ _J -===== COOK STOVE DIRECT VENT HEATER - DRYER— FIREPLACEFRYOLATORFURNACE 0�-� GENERATORa (I-- GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER —__ _ I UNVENTED ROOM HEATER WATER HEATER OTHER a V1 INSURANCE COVERAGE I h*1 a current liabilily nsurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES ONO M 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OFCVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 0 AGENT �( SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accura to the brst of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia c 'th all P nen vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME I u LICENSE # SI ATURE MP tA MGF 0 JP ® JGF 0 LPGI © CORPORATION ©# PARTNERSHIP ®#� 9 LLC ®# COMPANY NAME. �; &O\K__tt�AJADDRESS V ft— CITY r STATE HQZIP 1 '� TEL 1 q FAX I CELL EMAIL I 1 0 t v , V, The Commonwealth of Massachusetts , - -' Department oflndustrial Accidents Office o• f fnvestigations t 600 Washington. ,Street .Foston, MA 02111 -ivww.rnass.govklia Workers' Compensation bsurance Affidavit: Builders/Conti°acforsfFIectr ic:ians/PIii mberr,s Name (Businessiorganization/indi-vidual): � t t V• UI AJkl~y V M A k A Address:k4 q City/State/Zip: \ til �� f 1 % i Phone #: D Are you an employer? Check the appropriate box: 'Type of project (required): 1. Q I am a employer with 4. El I am a general contractor and I 6. [] New c6ustraction employees (full and/or part-time).* have Hired the sub -contractors listed on the attached sheet. 7• E] Remodeling 2. I am a sole proprietor or partner- ship and'have no employees These sub -contractors have 8. E] Demolition working for me in any capacity. workers' comp. insurance. 9. El Building addition [No workers' comp. insurance 5. ❑ We area corporation and its 10.❑ Electrical repairs or additions required.] 3. [l I am a homeowner doing all work officers have exercised.their right of exemption per MGL 11. [1 Plumbing repairs or additions myself: [No workers' comp. c.152, §1(4), and we have no 12.❑ Roofrepairs insuraacere ed. a employees. [No workers' 1311 Other comp. insurance required.] XAny applicant that checks box#1 must also fll outthe section below showingtheir workers' compensatioupolicy information. 'Homeowners who submit this affidavit indicatingthey Aie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContraetors that cheakthis box must attached as additional sheet showtngthe name ofthe sub -contractors and their workers' comp. policy information. I am are employer• that is providing workers' compeizsation insurance for my em ployees Below is the policy andjob ori site information. Insurance Company Policy # or S elf ins. Lic. #: Expiration Date: rob Site Address: N City/ tate/tip: Attach a copy of the workers' compensatlon-p ollcy declaration page (showing the policy number and expiration date). Failure to secure coverage as xequireduader Section 25.A ofMGL o.152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or ones -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to $250.00 a day against the violator. Be advised that a copy of this statementmay be forwarded to the Office of. investigations of the DIA for insurance coverage verification. I do Herebya airis d penalties of perjury that the information provided above is true and correct. Simature• Date: n Phone #: I 1 1 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 Instrnctio- Massachusetts General Laws chapter 152-req4ires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person iti the service of another under any contract ofhire,• 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 j oint enterprise, and including the legal representatives of wdeceased employer, or the xedeivex 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 shalt not because of such employment be, deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapterhave beenpresentedtdthe 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 name(s), address(es) and phone numbers) along with their certificate(s) of insurance.' Limited' Liability Companies (LLC) or Limited Liability Partnerships (LLP) with mo employees oilier than the members or partners, are notrequired to carry workers' compensation insurance. If au LL C or LLP does have employees; a policy is required. Be advised that this affidavit maybe 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 ty or townthat the application fox tbepemut 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 ofthe affidavit for you to fill out iu the event the Office of havestigations has tc contact you regarding the applicant. Please be -sure to f in the permit/license number which will be used as a reference number, In addition, an applicant thatznust submit multiple permit/license applications �in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "J'ob Site Address" the applicant should write "all locations in(city or towh:)" 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 fflefor future permits or licenses..A. nevi affidavit must b e filled out each year. Where a homeowner or citizen is obtaining a license or -permit not related to any business or commercial venture (i.e. a dog license orliermit to burn leaves eta.) said person is NOT required to complete this affidavit. The Office of Investigations would J&e 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 CQmmonmalth of Mas�aahv.:sa�s - Dapax1.ant ofhtdu*1al .A.addenta • Qf�eo 4�7.nt�e��iga�iou� ' 6.00 Washuugtw fto,�t Boston, MA 02111 `, #17�727�40Q e4g6 Qx SAFE led ;ed 5 26-05 Fax 0 617-727-7749 �.x�ass,g0.v�clia - 1�1 DAVID 'ONG PO BOX 114 64 COO ST I 13IMZRICA0 MA 01821 INSURER F: COVERAGES CERTIFICATE NUMBER- RFVI3101JI NIIMRFR- THIS IS TO CERTIFY Tr INDICATED. NOTWITHANDING CERTIFICATE MAY BE EXCLUSIONS ANDCONPTIONS CERTIFICATE OF LIABILITY INSURANCE DATE (MMli° 6)14 TYPEOFIN URANCE ADO LSUBR HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON T14 CERTIFICATE HOLDER THIS ERTIFICATE DOES IBELOW. NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES THIS CE IFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACTBETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OF PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the er"Cate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and condi ons of the policy, certain policies may require an endorsement A statement on this certifii, to does not confer rights to the certificate holder in 6u of such endorsemengs). PRODUCER MED EXP proneperson) $ 15,000 CONTACT LESLIE HANNON James O r COnnel Insurance Agen PHONE FAX 978 667-6150 No): (978) 667-0587 572 Boston Rd 17APPLIES PER ( LOC E-MAIL ADDRESS: JIMINS@OCONNELLINS.COM Unit 7 AUTOMOBILELIABWTY ANYAU10 ALLOWNED AUTOS HIRED AUTOS Billerica, MA 111 1821 INSURERS) AFFORDING COVERAGE NAIC 8 I INSURERA:Merchants INSURED INSURER B DAVID 'ONG PO BOX 114 64 COO ST I 13IMZRICA0 MA 01821 INSURER F: COVERAGES CERTIFICATE NUMBER- RFVI3101JI NIIMRFR- THIS IS TO CERTIFY Tr INDICATED. NOTWITHANDING CERTIFICATE MAY BE EXCLUSIONS ANDCONPTIONS T THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED I BOVE FOR THE POLICY PERIOD ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENTWITH RESPECT TO WHICH THIS TISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, OFSUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPEOFIN URANCE ADO LSUBR THE EXPIRATION DATE THEREOF, NdTICE POLICY NUMBER PM DEY/Y F MMID� EXP LIMITS A GENERALLIABILITY X COMAERCIALGE111111JJJJJJ�RALLIABILITV CLAS_MADIFx]OCCUR- M� GOOD ST BOPI078445 3/27/14 3/27/15 EACH OCCVI RRENCE $ 1"000,000 OAMAGET RENTED $ 5500 000 MED EXP proneperson) $ 15,000 PERSONALAADV INJURY $ 11000,000 GENERAL GREGATE $ 2,000,000 GEN'LAGGREGATE LNI X POLICYPR 17APPLIES PER ( LOC PRODUCTS-COMP/OPAGG $ 2,000,000 $ AUTOMOBILELIABWTY ANYAU10 ALLOWNED AUTOS HIRED AUTOS SCHEDULED AUTOS NON-OWNEDPROPERdYDAMAGE AUTOS E.TIED161NGLELIMIT $ BODILY 1NJI[IRY(per person) $ BODILY INJURY (PeraccidenQ $ eracci e ) $ UMBRELLA LIAB EXCESSLIAB OCCUR CLAIMS -MADE EACH OCC(I RRENCE $ AGGREGA $ DED RETEN rION S I $ WORKERS COMPENSAT AND EMPLOYERS' LUIBI AWPROPRIETORlPAR OFFICE RMIEMBEREXCL (Mandatory in NH) If yyes describe under DESCRIPTION OF OPE N JTY Y 1 N ER/EXECUTIVE —`I ED? TIONS below NIA WCAATU- OTH- 11_ E.L. EACH CCIDENT $ E.L. DISEASIE - EA EMPLOYEE $ E.L. DIS EASE - POLICY LIMIT I $ i DESCRIPTION OF OPERATION PLUMBING AND GAS 9 CERTIFICATE HO I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Renerks Schedule, if more space Is regulred) WORK ER IS LISTED AS ADDITIONAL INSURED CERTIFICATE HOLDER CANCELLATION 1 J© 1988-2010 ACORD CO PORATION. All rights reserved. ACORD 25 (2010105) {{° The ACORD name and logo are registered marks of ACORD Phone: ; Fax: (978) 688-9542 E -Mail: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NdTICE WILL BE DELIVERED IN THE TOVN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVIS t NS. 1600 O GOOD ST AUTHORIZED REPRESENTATIVE BLD 20 SUITE 2035 NORTH OVER, MA 01845 1 J© 1988-2010 ACORD CO PORATION. All rights reserved. ACORD 25 (2010105) {{° The ACORD name and logo are registered marks of ACORD Phone: ; Fax: (978) 688-9542 E -Mail: m I TO 39dd 3dVW3n9N01 d GIAVG L9VSTL98L6 VS:LT PT03/6T/80 V 10803 This certifies that�I.,4 OU 9( ........ 4 1!-!! . ..... ....................................................... , ** .. y ..................................... J.4 has permission to perform ..4�9'-.It�... 6,to,".4 ...... .... .4? ................................. A, -,j 6q 4!�; -,� ' plumbing in the buildine,4 of.....— t7 ... d ....................................... 0 ...................................... at .... iYr.4-VI ......... 't Fee..�V:�.Yuc. No. ........................... ............. orth Andover, Mass. c2dWtp.......... .... . ...................................................... L UM BI NlN SP ECT0R Check # Date... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING TYPE OR CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Ora, .. ., FIXTURESPRINT ••' �OOOD©00000®®� = iMFMMEFMFMlPWiN—W—iM��lMfMFW—�lW DEDICATED WATER RECYCLE SYSTEM !F F F • -IWIWI�(OWlMfMl®FMI® FW—(M—ON WN IW • ' I��IlII®I[iII�I�I��Il W •. DISPOSER I—MI�[����FM—FM �[ IM—(M—[MI� FL4*R/ AREA DRAIN SINK , •. [�I�f�l■�f!®��l�l�l�l�[® [��f�[�[�lol���l�1f�l�l��l� - • • -IMKITCHEN I®I®I�[ol�ll�l�f�l®I��l�lM • -STALL • • I—)—FM—[—I—>M—I—IM—FM—[M—IM� FM [®f■� I®�l®I �FM—I9—W �I■�I®I��M WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING 6THER A INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES VNO 0 4I= YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 1 LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 01 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 E-11 AGENT 0 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 pli nc with all Pertinent provision of the (Massachusetts State Plumbing Coe (nd Ch r 142 of the General Laws. PLUMBER'S NAME I LICENSE # SIGNATURE MP 0I JP CORPORATION MJJ #PARTNERSHIP D# LLC �#I COMPANY NAME _ ADDRESS Vp 56,K -�-o CITY ; y« C�-Q n _� STATE ZIP 1 TEL FAX II CELL II, z .r. The Commonwealth of Massachusetts - Department of IndustrialAccidints Office of Investigations 600 Washington Street Basion, M4 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual):. Address: P__C2 a0e< % Q City/State/Zip: Lk g %. Phone #: /Xto 70 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction em yees (full and/or part-time).* have hired the sub -contractors listed the attached sheet. t 7. ❑ Remodeling 2. am a sole proprietor or partner- ship and'have no employees on These sub -contractors have 8.; ❑ Demolition working for me in any capacity. workers' comp. insurance.9, ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10. Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] employees. [No workers' 13.❑ Other comp. insurance required.] *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 ace doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. Yam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. 1�1 , / Insurance Company 7—If— Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address:City/State/Zip: Attach a copy of the workerscompensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Y do hereby cp�ify under thepains and penalties ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # 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 -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe 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 (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Conuwnwealth, of Massachusetts Department of Industrial .Accidents oftloe ofInVestigatlons 600 Washin&n Street Boston} M.A. 02111 Tel, # 617-727,4900 ext 406 or 1-877,7MASSABE Revised 5-26-05 Fax # 617-727.7749 www.mass,80VIdia k