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Miscellaneous - 999 OSGOOD STREET 4/30/2018
teo., Dat ................ ( ......... I TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION "I'AS111-0 Thiscertifies that .............................................. . ..................................... has permission for gas installation 1� ... t�* ............................................................... T� sof L0, - in the b 'Id' ..... ... . . atl ........ .......... ..... .. .............. North Andover, Mass. Fee..56 . ............ Lic. No. M,2 .......... ..................................................................... GAS INSPECTOR Check 0 '11001 GOWNER TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY anNn MA DATE PERMIT # JOBSITE ADDRESS OWNER'S NAME _ ADDRESSTE AX - .-- OCCUPANCY TYPE COMMERCIAL _ EDUCATIONAL _ RESIDENTIAL NEW: _ RENOVATION: _ REPLACEMENT: 200" PLANS SUBMITTED: YES` NO— OAPP APPLIANCES IANCES T FLOORS- BSM 1 2 3 4 1 5 6 1 7 18 9 1 10 1112 13 14 B I I!R BOOSTER CONVERSION BURNER COOK STOVE DIRE T VENT HEATER DRYER FIREPLACE FRYOLATOR UR ACE GEN BATOR ILL INFRARED HEATER LA12RATORY COCKS MAKEUP AIR UNIT OVEN P L HEATER ROOM / SPACE HEATER ROOF TOP UNIT TE UNIT HEATER UNVENTED ROOM HEATER WAfi HEATEV OTHER INSURANCE COVERAGE I have a current I y,insurance policy or its substantial eauivalent which meets the rarmiramante „r Duni t% 4A13 VP�/Jklp%- . - - -W Ur-, I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Vr OTHER TYPE INDEMNITY i BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does, the Insurance coverage required by Chapter 142 of the Messachusett# General Laws, and that my signature on this permit application W Ives this requirement. CHECK ONE ONLY: OWNER i AGENT -r, .,- . y • �a._ %4.w,a ally rrno,n,drwn , nave suQmutea or entered regarding this application and that Oil plumbing work and installations performed under the permit issued for this application will be in my Maseachusetta State Plumbing CodA and Chapter 142 f the General Laws. - - PLUMBER•GASFITTER NAME �,/ LICENSE # ATURE MP : MGF JP JGF _ LPGI _ CORPORATION lftt S' PARTNERSHIP _# LLC COMPANY NAM ¢' �F71P CITY (,� `Y1 STATE TEL FAX I •► O ► _ CELL , _ , � _ _ -MAI: r �iDI/Y1 r11 n v Tite Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations , t t 600 Washington Street Qy f M4 OMI ` W%'xi.mzs.gov/dia 'Ik J r' urance Affidavit.-BuildersiCoatractorslEl Pi ase Workers$ Compensation InsPrbt L210 Name (Iiusint:s..'()rg=—.,;scion Indi%iduuh: Phone Y: — Are you an etaployer? Check the appropriate box: r �.: : 1 a,-: -sr 2tr:i :ontravor and . 1. 1 am a eMptoyer %vith �.. _..._. s hasa hires tho suo•contractors employees (full and ur part•tittttl). !:stat: or. the attached She'.t. ®I a sole proprietor or partner, These ,ub•coatractors hz d ship and have no dmploy eosrkt:rs' working for mein am capacit} . comp. insu ance, Ad it';ration a N owor. iniuranco arc a corpt ofticors nay a exercist:d their r4etired.j ri•=ht of exemptian M SIG!. 3,❑ lam a homeowner doing all noel: c,1S:. I1r.t,, anj v;r have no myself [No workers' cutup. " • rmplo} r:s. j�o �+orl:rrs insurance required. 3 coma. ituurunce rdquired.1 Type of project (required): e. j❑ New construction 71 Remodeling 8. [3 Demolition Q. ❑ Building addition 10.❑ Electrical repairs or additions 11.[1 Plumbing repairs or additions Roof repairs 13.] Other_ appl ttt that �;lirosa box F! mat u:ao tilt jut tha sa.'t:..is aalou thuw:ng thC:t wi:n:A' ..�m(�; 1a3t1J2! yOW$ 1.1fotn2umn. #`F�tliiltAigi{0la who ttuhai,t t(ii►:1ll.t•.t tt ina Westing th..w arc Juin. a.: Mark u,J thea 3:1,i a:taiJ..::dtie:jta must +21 Woe ii ruses tit'p poli indit:tstttia 21i2CtS. 'ttWttrt{ClOtS filet aht�it this bay trsut tut,u:hr� ars sihtttioriui �.'s�tit >twu iti} :9. rime af::.0 auti•:AntPlt;tur. and tt►etr wixkers' comp pOJi;y ioforrttetioa. d � � ernplp}�er that ds prm'1d1rtA x�orkars' c'ompdnstttion inxuranctf jvr n(r emplv}•ees. Below ds the pudicYand job stir iaformarlo�r• 1ASUrj= company Name:- . Policy :i or Self -in.. Lir. Job Site addMq: Janet a COPY Of the workers' cotapettsatioa policy declaration page (showing the policy number and expiration dete). i. , r;;s;; iz3d iJ the :nt osition of Criminal penalties of a Failure to securt: co�•aragc ss r�'c;uirc'd tsnJv.* aa�ti��r; :�� vi tiuL p iuic up to S l.s oo.00 and or ono-` :Lr inlprisonrsen:, U d oll U c:� is Petr tit:rs it: tl a sorra of a STOP WUItiC ORDER and a: fate of up us S?58.Ott a day against tho vi�lat�ir. Be ao� ibes this s ropy u2 :.'-6 statement may be forwarded to the Office of lnvgsUbations of the DIA for insuranca co<umgg,e tenllcatior.. I do herreby c ' A�ruJer fly pry nw and &alties iif perjur} ha inlvrmtttfvn prvs�Jtled abv�t` Is crag a correct .W fA ##/" �,�tt1a1 usronh'. Dv nuc xvite in tltis arra, tv ho complerad Ar cio• of town t)claJ. City or Town: PrrmitiLicense suing Authority (circle one): I. board of health I Building Department 3. CityrTo%n Clerk i. Electrical Inspector S. Plumbing. Inspector 6. Other ?hoar a: Contact Person: Date ...... .......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... RU� .. has permission for gas installation * - in the buildings of at....... 15� ... Fee. ..... Lic. No. Check # 1706 1 9000 yy\w)a-` 0 .................................... ................................................... P4�,O...... �-L .-S ........... ....c..., ................. , North Andover, Mass. GASINSPECTOR i 1 Ifi TVV GMEGK9V 7195, FLEAR INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 7' OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not ha_ 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 ' .,r,vvr r.i %l'r 4„m. an w1. %1vtom ano inrormguon nave suomitted or entered regarding this application and that all plumbing work and installations performed under the permit issued for this application will be in M h 3 P my asseo usetis tate Iumbtng Cod and Chapter 142 f the General Laws. -C -11 - " "-"• N'Y•wwu ,� PLUMBER-GASFITTER NAME .,/ LICENSE # ATURE MP'V MGF 7– JP _ JGF i LPGI _ CORPORATION V * PARTNERSHIP „# LLC COMPANY NAMJ[ ¢' E.ADDRESS CITY i% STATE ZIP TEL FAX CELL . , , �IMAM a ro r G�!/Yt /'/l n .A MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 1". MA DATE . PERMIT # JOBSITE ADDRESS OWNER'S NAME GOWNER ADDRESS $ TE FAX TYPE OR PR 7 —-- OCCUPANCY TYPE COMMERCIAL — EDUCATIONAL _ RESIDENTkk' CLEARLY NEW: _ RENOVATION: _ REPLACEMENT: Y PLANS SUBMITTED: YES NOi APP IANCES FLOORS+ BSM 1 2 3 4 1 5 1 6 7 8 9 10 11 1 12 13 14 B I IR BOOSTER 7-1 CONVERSION BURNER COOK STOVE 7-1 DIRECT VENT HEATER DRYER 1-1 FIREPLACE FRYOLATOR F R ACE GEN BATOR GRILLE INFRARED HEATER RATORY 92CKS A P AIR UNIT OVE P HEATER ROOM / SPACE HEATER RO T P UNIT TES UNIT HEATER UNVENTED ROOM HEATER WATER H T R OTHER INSURANCE COVERAGE I have a current liabilitv,insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES U–L-/NO 1 Ifi TVV GMEGK9V 7195, FLEAR INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 7' OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not ha_ 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 ' .,r,vvr r.i %l'r 4„m. an w1. %1vtom ano inrormguon nave suomitted or entered regarding this application and that all plumbing work and installations performed under the permit issued for this application will be in M h 3 P my asseo usetis tate Iumbtng Cod and Chapter 142 f the General Laws. -C -11 - " "-"• N'Y•wwu ,� PLUMBER-GASFITTER NAME .,/ LICENSE # ATURE MP'V MGF 7– JP _ JGF i LPGI _ CORPORATION V * PARTNERSHIP „# LLC COMPANY NAMJ[ ¢' E.ADDRESS CITY i% STATE ZIP TEL FAX CELL . , , �IMAM a ro r G�!/Yt /'/l n .A 4 TI:e Commonwealth of .Massachusetts Department of I1:dustrial.4ecidetlts Office of Investigations ` # - t 600 Washington Street } � • ' Briton1L-I 0'4111,.. r' W%%l.mass.gov/dia Workers' Compensation Insurance Affidavit: guilders/CoatrtzCtt)!slEl plem t resin t umbersLmdbk Nanit (Iiusint.•sa'0r9=/;46urt 111di%idual1: Citti/J.tate/Lip: Art YOU an employer? Check the appropriate box: �. '7 1 ,ama �:C:i�r li ,ontracAor and 1 1. ❑ I ant a ettipto?`er with _,.. _...._ have hire the sub -contractors i ) eittploycts (full and or part-timos. li�ta6 oP. th2 anaehod sheet. t �, ❑ I am a sole proprietor or partner -,These sun•contractors 'ray e ship and have no entpluy acs rkers' comp. insurance. working forme in any capacity. *arc corporation anj its } (yo workers' comp. insurance oftic,:rs gave exercised their i required.) 1 ani s homeowner doing a1l tk ork rig E of exemption per %1G1. i 152. alt -1,, anti V%r have n+) myself: [No workers' cump. " c emplo) ers, [No %k orkdr+ insurance required. } coma. ins r nce required.j 1 Type of project (required): o. ❑ New construction ❑ Remodzling 8. ❑ Demolition ` 0. ❑ Building addition lo.[] Electrical repairs or additions 11.❑ Plumbing repairs or additions 1:.1= Roof repairs 13. ❑ other--- L ther_.. •At►i' applrt a»t that oho"- s bag $0 m.ut a:aA tilt out the $440..:+ =tituu thou.n; the:c wura.t+' ..,mp, nostwn P6+ktq tnt'uttts:ttu�n. s r emora 'Ahasubmit d+ds u!'tiSsrtt tndioatinyt :h w are.i„�n; t wars a�,d thrn a:tatde .:.Xa;'04 must . elmit s ACV, aitidaYtt ittdieatutQ tlilCh K't>ttttapers than chi c1t thu bar must attuned an a"I ionui Shoat Av%ins :a: aamc. et' MA bua.t+ntt,`tur, =d their u,t�rkon' cump policy intortaritioa. 1 ant art unp4*-er that is pros idint; workers ' eompdnsretion insurance for n;v employees. Below is the polley and job site lnJormatio� • Name:_.�.__...__...__.---..�..—.....- ,MrattceCompany police• ra or 5rli--ins. �. . _ ... __ _ ..._. •-- — - -... _ ---•— Cin State Zip:_ Job Site Addrt~+e: Attaeb a copy of tiro workers' compensation policy declaration page (shoa'!na the policy number and expiration date). Failure to secure covomge as r'tcluired unJer Sc�tittr..: of \SuL c..>: c:cr ia3d to flit imposition of criminal penalties of a rMc up to $1,500.00 and or ant; -y ear imprisontt:en:, as �►ali c.� is pe:i3it:t a .t: the foal of a STOP WORK ORDER and a fate of up to 5250.00 a day again.t the e'iulat�+t. Be s4\ ibaa that a cop} vi :r.ib statement may be fon arded to the Office of Invg6agations of the DIA for iiuurance co�ers;_a erincatior.. Ida htrreby� c j' g$der tl�e prep=a ural &alties of perjun; tftut:ha infvrrnurlvn prvviried ab 'e Is rraq earl aorrecl: ` ♦ / � do . IA"/0, official use onh'. Do nor K,rite 1n this urau, to ha vompleied br c1¢• or lawn afficial. C:°ity or Town: PermitiLicense 0 issuing Authority (circle one): 1. Burd of Health 3. Building Deportment 3. City,,Town Cltrk i. Electrical Inspector S. Plumbing Inspector b. Otber Contact Person' ?hoar 8- S -_ Date................................ TOWN "SF NORTH ANDOVER PERMIT FOR WIRING C�l7 eff IL Ft- . This certifies that .................................................................... ....... ..... ........ ... has permission to perform ........ ....................................... wiring in the building of.. ... .......... .. .... ......... .............. ,.00 ......................... .......................................................... .. . ,North Andover, Mass. Fee../.Z:--2.��ic. No. ........... .... ........... . spEcroR./ Check # l 7 T l71 C�� `t cam' S��rf� 11766 Commonwealth of Massachusetts Official Use Ont 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 INEff OR TYPEALL INFORMATIOA9 Date: ?L-5—/13 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her irate on to p rfo the �ectrical work described below Location (Street&Number) �R (�sq�j�f'j�,t�'� p-y'Mi T,d'.�,s;�yGtl,� Owner or Tenant OJ!J&4vhZ�'r� epr� t� S Telephone No. Owner's Address 6i Is this permit in conjunction with a building permit? Yes 9 No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ 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: Wk L lro tr ILA A Lo Or` bot Completion of the %IlowinQ table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No, of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- El rnd. grnd. o. of Emergency 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 No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number .Tons "" KW *'*"-"*'*"""* No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water IAV 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 E uivalent � ^ OTHER: 13 © 1 13 --re— Attach additional detail ifdesired or as required by the Inspector of Mres. y; 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 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 cert, under the ains and enalties ofp rjury, tliat�tlze infornta,t{t�n on tl(rs application is true and complete. FIRM N � � — �' C� ✓ !°r lI C �' S LIC. NO.: 21 Al Licensee: Q Signature LIC. NO.: / (If applicable, nter "e t' in the license number jmg) ` 1 q Bus. Tel. No.•giST �/ 7 Address: (fit � (�� (j'? �jGL1 �' t/1n �1.i C7 8 3o z ( 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/Agento. Signature Telephone No. PERMIT FEE. $ 115 , ❑ 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 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: , Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass F71 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass Failed?❑ Re- Inspection Required ($.) ❑ Inspectors Comment . Inspectors Signature: Date: DEB WEINHOLD TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com A The Commonwealth of Massachusetts 02 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UV www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): c rA (/i ntl �� (�� �y l C e Address: City/State/Zip: f). 1 >? rM X iJ 0 ! Phone #: q,? Are y u an employer? Check the appropriate box: 1. EYI am a employer with 1— 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other !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 2te doing all work and then hire outside contractors must submit a new affidavit indicating such. ttontractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lic. Job Site Address:. Expiration Date: City/State/Zip: Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well .as civil penalties in the form of a STOP WORK ORDER and a fine ,of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert ruder the pains and penalties ofperjury that the information provided above is true and correct.. Z-- x/79-" 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 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 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, i 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 Tei. # 617-727-4900 ext 406 or 1-877rMASSAFB - Revised 5-26-05 Fax # 617-727-7749 wwwmass,gov/dia Date ... oh�h ................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING I�nAx- This certifies that ... . ............................................................................. has permission to perform ..... .................. ................................. wiring in the building of ............ Ll ........... .......... .................................. at ........./.... .91 ... aft C/ North Andover, ass. .. ............................................ ............. ' , i/ Fee .... ............. Lic. No . .... ;ZSPECrO ............. . ..... 'j 'rEX �C� Check # 1 rltfach additional detail if desired or as required by the Inspector of Wires. 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 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 ❑ (S ecify ) Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. � 11 J 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 (MEC), 527 CMR12. (PLEASE PRINT 1NJYK OR TYPE ALL INFORMATION) Date: --1 7� City or Town of. NORTH ANDOVER To the Inspector of YYires: By this application the undersigned gives notice of his or her in ntion to perform the electrical work described below. Location (Street & Number) 49 � Owner or Tenant C),5qoC&rO r , Q L l✓ Telephone No. Owner's Address 61 `S' Tu et -b . t _ r5 l) Is this permit in conjunction with a building permit? Yes NT No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service X00 Amps % ®/ 20,?Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed E Completion ofthe following table may be waived by the Insnector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- Elo. rnd. rnd. o mergency Lighting RA#�eH 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 No. of Waste Disposers Heat Pump Totals: Number I Tons 1 '----1""" I KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ 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 Eq uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: 3 I cert, under the pains and rzlties ofper 'wry, t1 at tie information on this triplication is true and complete. FIRM N :. LIC. NO.: 1 r� Licensee: Signature LTC. NO.: oC (If applicable, a ter "exem t', in the license nu ber line. us. Tel. No.• Z �L .7 ` /,/` e Address: _ (��[ 1 n ��^ �_ Alt. Tel. No.: Per M.G.L c. 147, s. 5 -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. $ aSignature 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 ($.) ❑ Inspectors Comments: Inspectors Signature:. Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH IN TION: Pass Failed 0 Re- Inspection Required ($.) ❑ { Inspectors Comments: Inspectors Signature: xc lj� Date: - %%— ;Z -G63 FINAL INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth ofMassachusetts - Departmint, of In dustrigl Accidents Office Oflnvestigations IN 600 Washington Street . Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Address: T c602 V v,_ / City/State/Zio: _ Q14 A Phone #: ch? Y _ V Are,v6u an employer? Check the appropriate box: - Typo of project (required): 1. M I am a with employer . 4. F1 I am a general contractor and I 6. ❑New construction employees (full and/or part-time) � 2. El am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. �• ❑Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g. ❑ 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. F1 Plumbing repairs or additions myself. [No workers' comp. 0.152, §1(4), andwehaveno 12:❑ Roof repairs insurance required.] t 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. i Homeowners who submit this affidavit indicating they are 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. 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. #: ExpirationDate: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page.(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. " Ido hereby 5enWurnderthepains nd penalties ofper' zat the information provided above is true ana 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 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 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 ofpublic 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 cant' workers' compensation insurance. If an LT 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 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 worker's' 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 m=ist submit multiple permithicense 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 io•give us a call. The Department's address, telephone and fax number: The CaxnWRW—ealth of Ma ssachu-sei<ts Department of zo duddal Accidents Office of Investigations 600 WasWa Ga Sheet Boston} MA 42111 `1'e1, # 617-727-4900 eft 406 or 1-877;MASSAFF, Revised 5-26-05 FaY 0 617-727-7749 ■rx:rxc:r.rr•n nn .:r.rrF,j.:.. . ... ....... ........ I./.3.......... Date 16 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .....p.: . has permission, for ga installation ......... in the buildings of ...... ........... . ........ .. . . . . .. . . ............ .. Fee . . ..... Lic. No..'W ....3 . ....... Check # 12A -W .............................................. /e ry 14r -.s— . . .......... JQ .... . North Andover, Mass. ..................................................... GASINSPECTOR 6171j3 R IN -- 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 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 a and accurate t e best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in m Iia wit IIP ant provision of e Massachusetts State Plumbing Cod and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE # ATURE MP ✓MGF _ JP _ JGF _ LPGI _ CORPORATION 7/# 13—AjT— PARTNERSHIP # LLC COMPANY NAM . go ��-�fiZADDRESS CITY a STATE ZIPM TEL FAX e- CELL r EMAIL, d M Q ,0 rn r i /,Pllis� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I moi✓ MA DATE PERMIT# 22�ZC-- JOBSITE ADDRESS S OWNER'S NAME GOWNER ADDRESS TE ,q)( TYPE OR _ —` OCCUPANCY TYPE EDUCATIONAL RESIDENTIAL PRINT _ CLEARLY NEW: _ RENOVATION: _ REPLACEMENT: 1/000 PLANS SUBMITTED: YES_ NO�, APPLIANCES Z FLOORS- 8SM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 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 TEST UNIT HEATER UNVENTED ROOM HEATER WATER dEATER OTHER INSURANCE COVERAGE I have a current Ilabilb insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YESNO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THF ecaonaaIere etnv eel Aul -- 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 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 a and accurate t e best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in m Iia wit IIP ant provision of e Massachusetts State Plumbing Cod and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE # ATURE MP ✓MGF _ JP _ JGF _ LPGI _ CORPORATION 7/# 13—AjT— PARTNERSHIP # LLC COMPANY NAM . go ��-�fiZADDRESS CITY a STATE ZIPM TEL FAX e- CELL r EMAIL, d M Q ,0 rn r i /,Pllis� 5 PLUMBERS AND.GASFITTERS LICENSED AS;.:A .MASTER.PLUMBrq .. 1SSUES,,�HE�AB6VE-LICENSE 70 , _.ROBERT A SAMMATAROn 8 DUN -RAVEN ',RD ,WINDHAM` �\ `"NH/ 3 b87 1263 9333 %05/U1114 170 ' - COMMONWEALTH OF MASSACHUSETTS REGISTE--RED As A PLUMBING CORP ISSUES THE ABOVEILICENSE TO i .'ROBERT A �SAMMATAR" 'h ROBERT , -A SAMMATARO.:•INC 8 ;DUNRAVEN :RD .• WINDHAMx° NH10087,12.63 ; 3373 ,05/01%14 140820 Zol L:mar�r����� . L7 A The Commonwealth ofltlassachusetts - Department oflndustriglAccid nts Office oflnvestigations 600 Washington Street Boston, AM 02111 www.massgov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers Name City/State/Zip MUM Are you an employer? Check the appropriate boa: 1. Ella am employer with 4. El am a general contractor and I employees (fall and/or part-time).* 2.01a m a sole or have hired the sub -contractors listed the x proprietor partner- on attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. rkers' comp, insurance. [No workers' comp. insurance 5. We are a corporation and its required.] . 3. ❑ T am a homeowner doing all work officers have exercised their _ right of exemption per MGL myself. [No workers.' comp, c.152, § 1(4), and we have no insurance required.] t employees. [No workers' comp, insurance requireq *Any applicant that checks box#1 must 1 - 11 - Type of project (required): 6. E] New construction 7. E] Remodeling 8. El Demolition 9. ❑ Building addition 10.E] Electrical repairs or additions 11-ElPlumbingrepairs or additions 12.0 Roofrepairs 13.❑ Other aso r outt esectionbelowsnowingtheirworkers'compensationpolicyinformation.. Homeowners who submit this affidavit indicating they Ate 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. lam an employe? that 1s providing workers' compensation insurance for my employees .Below is thepolicy and job site information. Insurance Company Name:. Policy 4 or Self -ins. Lic. #: — Expiration Date: Job Site Address: CitylState/Zip: Attach a, copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. Ido hereby c t' unde? tli airs andp Mes ofpe ' e information p?ovirled abo zs a and correct. Si afore: Phone 4- Offcfal use only. Ito not write in this area, to be completed by city o?town offrcial. City or Town: Permit/License a Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other - Contact Person: Phone #: Information and InstructIloliS 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 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 ofthe foregoing engaged in a jtioint enterprise, and including the. legal, representatives of a deceased employer, or the receiver or trusfiee:of an 1a4livdua1, partnership association or other legal ntity, employing employees. However the owner of a dwellin`houss havingnot more than three aparttnents and ,�;vl o resides thetein, or the occupant of the dwelling house of another who employs persons to do maintenance, co'hstruction or repair work'on suchidwelling`bouse or on the grounds or building appurtenant thereto shall'hitt beeause ofssuch employment b'e deemed to be an eirployex." MGL chapter 152, §25C(6) also states'#hat evei-y-state or local lieensirig agency shall with'Foid th`e 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 commonwealthnor 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 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 notrequired to carry workers' compensation insurance. If an LLC or LLP floes 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 retumed 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' compensationpolicy, 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 affidavitis-complete -andprinted IegUy. TheDepatUeht leas provided a space at th e 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 subunit 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. Anew 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 The Department's address, telephone and fax number: The GommonweeliofMassarhusotts Dopa ant offadustdal .Accidouts Offioe OflntyeAlgatiom 600 Washihgtaa Stxeet Boston, SIA, 02111 TO, # 617-727,4900 ext 406 ox 1-877,MASS.AFF, /26-05 FaX# 617-727-7749 Date .�AAI' TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ,1 -Q.. �J' ..................... r .... t has permission to perform .("(- !!!�'� :. 7�...1�. -?X. ,?�t� ...�... • plumbing in the buildings of s �L. IQ�W . •4L;� • at ..�?. 0". . �� 7��"North Andover, Mass. �Fee .Lic. No. . PLUMBING INSPECTOR -,,Check # -II// / V 060 -4 J�sa - 3 �,�, &/-7//-3 P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _ MA DATE E 1 PERMIT # /0 Me JOBSITE ADDRESS `j'�' oS o (J/ OWNER'S NAME OWNER ADDRESS _ TEL —FAX' OCCUPANCY TYPE COMMERCIAL P- EDUCATIONAL 0 NEW: Ea- RENOVATION: [3 REPLACEMENT: QI RESIDENTIAL DI PLANS SUBMITTED: YES © NODI FIXTURES 7 FLOOR- I BSM X 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 1 10 1 11 1 12 1 13 1 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 DISPOS)ER FLOOR /AREA DRAIN KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET- URINAL' WASHING MACHINE CONNECTION DATER HEATER ALL TYPES WATER PIPING have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES O—NO D IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY EI BOND El NER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the fassfichus s General Laws, and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT 8 heWl5y certify that all of the details and information I have submitted or entered r< and that all plumbing work and installations performed under the permit issued for Massachusetts State Plumbing Code and Chapter 142 of the General Laws. CHECK ONE ONLY: OWNER GENT 0 Jing this application are true and accurate to the best of my knowledge application will be in compliance with all Pertinent provision of the PLUMBER'S NAME _ �'!-� �✓ i �-!L _ ( LICENSE # SIGNATURE CORPORATION# PARTNERSHIP O# LLC 0 COMPANY NAME ADDRESS Q U %cti. / /� I CITY STATE N ZIP TELF 60 3ff3.6,3IN 4 30 3 -z- FAX I CELL I H O z 0 wLU O F U a `Q U oc 3 w - a, G LU a W U o ❑ z N ❑ W s,. wLU O a z U oc 3 G w a, LU a W w � co 3 W a p z g° a w a CL a EE w W O z z O H U ALIH s,. The Commonwealth of Massachusetts Ln Department of Industriql Accidents Office of Investigations IV 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ,� % Address: 3 74 City/State/Zip: r�IV654e,7 o , o3z Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I gmployees (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. y [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required] t employees. [No workers' comp. insurance required.] Type of project (required): 6. aJ1Te`w construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other "Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. G!!V, -Policy Expiration Date: - Job Site Address: !2 ,`1' ff S COD S2 City/State/Zip:./&A Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I -do hereby ce�� under the pains and penalties ofperjury that the information provided above is true and correct, Phone #: Cha 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 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 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 _t yoprovided .a space at the bottom of the affidavit for You to fill out in the event the Office of Investigations has to contacu 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 TO; # 61.7-727-4900 ext 406 or 1-877:MA.SSAFB Revised 5-26-05 Faze## 617-727-7749 wwwanass.govfdia