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HomeMy WebLinkAboutMiscellaneous - Electrical Plumb & Gas Permitsa C7 S co .� _W O 0 co M COD N (ND U O O[*-Il-O N Q o � v V ` C Q oo a) � a) � a) N ® U N 2 O cc LL O U ti w d C d E ' 0 E U 0',0 U 0 W c D ❑ 40 in E a © 0 C, 0 loan@� v0 1 A C 3 H Ii o . w L o Oi N O Z = O d3 G . o m G w � •rn U G n. =a a= W4, Ww O F4- 0 c to Ul ',�0 U O L L O °� y U w o O oU n G G G 0 U V U O N Q a N ro-- `t E d r- m ya c c c O o m w U y = o O � y r Zm = �tll Y £ G L �• � O O w C (q 3 F� O N OI W U m w T r I 00gV •- 00 �Ma C d U G •� W 3 M M R m UI O•y-�Ul (p L O ---a, O uJ - O O C F-dcyo G Q ice+ L ci 2 L Z aw N -r N O O t IC G w W a N w IL ON d G O N Z W E U p •� 0 U d o-0 9 cn � a g 2 m Owa ° L O t- s ,. 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TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ,,,, , ..,,,L�,,,,.' .......................................................................... has permission to perform-77�q.,.-. a ... ut�rl- .9.. ...... ................. _� �oU� wiring in the building of....................:.................................................................................... at .....�.. ..... ..... " ?.. ............... . rth Andover, Mass. 063 Fee ...LP ..................... Lic. No, j..1.6 ...�...!(, •.... ................ ELECTRICAL INSPECTOR Check # 1336 2- Viz►- t� t�`h: 3�+���� A\,, t) , 4� be- 8-6-7< 4P.4 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. _T�h�Ji 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 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: O /� City or Town of. NORTH ANDOVER To the lnlpect4 of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) �j7' DSl'y��j` //h < ✓�aOL — ,5-3ey Owner or Tenant Q�� w0000" Telephone No. Owner's Address ms Is this permit in conjunction with a building permit? Yes [ 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: Completion ofthe following table may he waived by the Insnector of Wires. No. of Recessed Luminaires 17 No. of Cel Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No, of Luminaires AboveIn- Swimming Pool rnd. ❑ rnd. E]Batter o. o mergency ig ting Units No. of Receptacle Outlets No. of Oil Burners FERE ALARMS No. of Zones No. of Switches r 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 J.KW ...........Detection/Alerting No. of Self -Contained Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances Imo' Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Si ns Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: /®� - - (When required by municipal policy.) Work to Start: & �A�� Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE RAGE: 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 thepains andpenalties of perjury, that the information on this application is true and complete. FIRM NAME: R 'at` L, -t cal., Awl LIC. NO.: Licensee: (/t r aw/- Pe.4el6t Signature LTC. NO.: ��lGzQ� (If applicable, enter "exempt" in the license number line.) Bus. Tel. No. • . Address: Alt. Tel. No.: l!!Sr Gr *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) [] owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or shehas 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: V -3 Trench Inspec n (j(/rL b o YC� Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: &A Zw�—" Date: W. j SERVICE INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP TION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments:22�0 Q w All -- Inspectors Signature: Date: FINAL INSP TION: Pass Failed'❑ Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: /d'20 —lam DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massa chusetts z Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, HA 021142017 www mass.gov/dna Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information /� Please Print Legib e6l ly Name (Business/Organization/Individual): �'�/r�l ��%�/'!i!� �'GIG�I �Y -e! v�a;Y-AC Address: / 7 l/10ha City/State/Zip: Ol� lam[ Cl. Phone #: 2 9-1 — O� S / Are yon employer? Check t6tie,,appropriate box: 1. I am a employer with (l/ : employees (full and/or part-time).* F2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6. ❑ We are a corporation and its officers -have exercised their right of exemption per MGL c. 152, § 1(4), and we have no, employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. 0 Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.0 Electrical repairs or additions 12.E] Plumbing repairs or additions 13.0 Roof repairs 14. Fl Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. . t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees,'tliey must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. ,( Insurance Company Name: Policy # or Self -ins. Lic. #: �3✓I' �J ,( �- Expiration Date: Job Site Address: �r77d"t G,?- City/State/Zip: Attach a copy of the workers' coin nsation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify underflle pains a e ties of perjury 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 #: P 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 lure, 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia .-f fo-COMMONWEALTH OF MASSACHUSETTS."' ` 0 0 o Cl BOAEiD OF s ELECTRICIANS ISSUES THE FOLLOWINGLECTRiCIAN, :1 RE:GIST RED MASTER, . . N E LECTRI CAL''j CONT PERIN CAMPBELL E V i CTOR qure . 128 NOW'S 'ST WAKEF VELD. MA o1880-3329 17o3i A' 6 /31/16 32564 F.: .. ._....... ,. _....�.--.V...-..-^y,+"' '..'ter.-+w.x,... COMMONWEALTH OF MASSACHUSETTS o o ` BOARD OF t LECfiR I C ANS ISSUfS.THE FOLLOWING LICENSE AS ,A' `R'E JOURNEYMAN :ELECTRFC.I'A�i VICTOR J PERIN f. 1'5 'ANGLEwobb LANE ,` �v , N6 READING 10 o1864-2801 •. . 24625 E 071/31/) 32873' Date.�P.. 0.1.1............ 11189 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies tha ................................................... (A- .................................................................... has permission to perform ... &.M.(JA ............................................................. ......................................... plumbing, the buildings of ..... Ld.�� --oo at ..................................................... . ..... o Andover, Mass. Fee (p ..... Lic-' No. .............. .... .. . .. .... ..... ...... O�L LUMBI iB�I NAG S PE'* C** *T'* 0** R Check MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY COf _ MA DATE S . a -g 117'—IlPERMIT#. JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS TELL TYPE OR I OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PRINT CLEARLY NEW: RENOVATION: 0( REPLACEMENT: FIXTURES Z FLOOR- BSM BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER _ FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET f� WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER f— RESIDENTIAL ; PLANS SUBMITTED: YES Ell NODI M®® w INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO 01 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY R OTHER TYPE OF INDEMNITY D BOND F1 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 ONY: OWNER Q AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are e tdge and that all plumbing work and Installations performed under the permit issued for this application will be in co ce with all rt ent provision of the Massachusetts State Plumbing Code and Chapte,1 oftGen ��Ws.Zi r feeCC PLUMBER'S NAME [LICENSE # SIGNATURE MPIX- JP Q 41414 106 PORATION ED— �PARTNERSHIPP-1 # LLCs COMPANY NAMEi� ADDRESS O CITY]STATE I 1 ZIP lj/ TEL X79 -41 ' � FAX �[ CELL 1 ?7d - EMAIL I /IA4 C n/i. n., A rdw,,. K) o F1 z The Commonwealth of Massa.chusetts M Department oflndustrialAccidents I Congress Street, Suite 100 �t Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): L tg/ LGh. Address: /C /n�cvy �'fiy City/State/Zip: Phone #: l o Are Zyonemployer? Check the appropriate box: 1. employer with employees (full and/or part-time).* Type of project (required): 7. ❑ Ne construction 2.� I am a sole proprietor or partnership and have no employees working for me in 8. emodelirig any capacity. [No workers' comp. insurance required.] 9. El Demolition 3. Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. F1I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers' compensation insurance or are sole 11. Q Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13. F1 Roof repairs These sub -contractors have employees and have workers' comp. insurance) 6. F1 We are a corporation and its officers have exercised their right of 'exemption per MGL c. 14. ❑ Other 152, § 1(4), and we Kaye no, employees. [No workers' 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 submif this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I din 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. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance I do hereby der the i penaltie . perjury that the information provided above is true and correct. Sigr 7: 1;73�jk, /J�.��i>/�� n.+A. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract' or hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein:, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill -out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents foi" 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 permitYnoi related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia C, I ',T MIDIVISH 1J rcmoexllfiIi5NjOF1PI OFESSIONALJLICEI�SU!�E _i1t�= r. �Htt LARX ��,x'P�Se,88 110. r Date ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ')) b This certifies that L ........................................................................................................ has permission to perform ReN ov 5 .................................................................................................... wiring in the building of..,,U U Y................................................. at ......... I North Andover, Mass. ..................................... . . Fee Lic. No. .............................. ..... Z(:WSA INSPECTOR Check # 13 2 7-8' /I ICIX Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 2 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/991 (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 IN INK OR TYPE ALL INFORMATION) Date: April 30, 2015 City or Town of: North Andover To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 575 Osgood St. Owner or Tenant Edgewood Retirement Community Telephone No. Owner's Address 575 Osgood St. U Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) , pQ. Purpose of Commercial Utility Authorization No. G l 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: Renovations to amenities spaces and offices to include power (plugs & Switches, lighting, fire alarm & tele/data Completion of the_following table may be waived by the Inspector of Wires. No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA, No. of Lighting Fixtures Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o mergency ig ing Battery Units t 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: I Number TonsKW . ... 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 Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring. No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. 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:) Selective Insurance Estimated Value of Electrical Work: $115,000.00 (When required by municipal policy.) 4/23/2015 (Expiration Date) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains andpenalties ofperjury, that the inflation on this application is true and complete. FIRM NAME: D&D Electrical Contractors. Inc. / LIC. NO.: A11933 Licensee: Douglas P. Lynch Signature= x LIC. NO.: 24594 (If applicable, enter "exempt" in the license number line.) r Illus. Tel. No.:781-932781-932-0707 Address:1010 EverbergRoad Woburn, MAO MA 01801 Alt. Tel. 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 �gnature Telephone No. PERMIT FEE. $2,250.00 '1 I Y' R D&DEL-1 OP ID: LIC OF LIABILITY INSURANCE DATE (MM/Y)CERTIFICATE 04113/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Chase &Lunt LLC 65 Parker Street CONTACT NAME: Marcos W. Shaner FAX PHONNo Ext :978-462-4434 AIC No): 978465-6204 E-MAIL ADDRESS: Newburyport, MA 01950 Marcos W. Shaner 04/23/2015 04/23/2016 INSURER(S) AFFORDING COVERAGE NAIC 11 INSURERA:Selective Insurance Company MED EXP (Any one person) $ 15,00 INSURED D&D Electrical Contractors Inc INSURERS: Independent Casualty Ins Co Diane Lynch 10 Everberg Road INSURER C :Atlantic Charter ins Co PRODUCTS - COMP/OP AGG $ 3,000,00 Woburn, MA 01801 INSURER D: INSURER E: LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS NON -OWNED HIREDAUTOS AUTOS INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. /XP LTR TYPE OF INSURANCE POLICY NUMBER MM/DDS MM/DD E P LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ®OCCUR S2067317 04/23/2015 04/23/2016 EACH OCCURRENCE $ 1,000,00 _ DAMAGE TO RENTED PREMISES Ea occurrence $ 500,00 MED EXP (Any one person) $ 15,00 X EBL retro:4123/13 PERSONAL & ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY � JEST ® LOC OTHER: GENERAL AGGREGATE $ 3,000,0011 PRODUCTS - COMP/OP AGG $ 3,000,00 $ A AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS NON -OWNED HIREDAUTOS AUTOS A9099099 04123/2016 04/23/2016 COMBINED SINGLE LIMIT $ 1,000,00) Ea acc dent BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (Per accident) A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE S2067317 04/23/2015 04/23/2016 EACH OCCURRENCE $ 10,000,00 AGGREGATE $ 10,000,00 DED I X I RETENTION $ 0 $ B C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMSER EXCLUDED'/ ® (Mandatory In NH) H es, describe under DESCRIPTION OF OPERATIONS below N I A C1001201-00 - MA WC CA005661-00 - NH WC 04/23/2015 04/23/2015 04/23/2016 0412312016 X I PEROH- STATUTE ERT E.L. EACH ACCIDENT $ 1,000,00 E.L. DISEASE - EA EMPLOYEE $ 1,000,00 E.L. DISEASE - POLICY LIMIT $ 1,000,00 A A Equipment Floater Crime S2067317 S2067317 0412312015 04/23/2015 0412312016 04/23/2016 Leased 125,00 Crime 100,00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached N more space is required) Town of North Anodver 146 Main Street North Anodver, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD YYYY�YYIYYL Y.YYYYY� �',�yyy��'YYYYYYYYY IYYY�/ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 a www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): D&D Electrical Contractors, Inc. Address: 10 EverberQ Rd. City/State/Zip: Woburn, MA 01801 Phone #: 781-932-0707 Are you an employer? Check the appropriate box: Type of project (required): 1. x❑ I am a employer with 80 4. ❑ I am a general contractor and I 6. New construction employees (full and/or port -time). * have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance required.] comp. insurance. # 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no 13.❑ Other employees. [No workers' 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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Selective Insurance Company Policy # or Self -ins. Lic. M S2067317 Expiration Date: 4/26/2016 Job Site Address: 575 Osgood St. City/State/Zip: North Andover, MA 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 hereP�y cerfy under) the pains and# nafties of perjury that the information provided above is true and correct Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # 4/10/15 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 I . E NUMB F w ;t FJ(pIRATION AATE; 'SERIA4 NU.MBE Date. ... .... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that -VA �4, ....... 7 . .................•................ . ................... 'IJ has permission to perform...,4.6/ .......................................... ............... plumbing in the buildings of.... . ka�.e- a-1 ............... at ...... :515� !7 ........ North Andover, Mass. Il Fee !;�Lic. No. PLUMBING INSPECTOR Check # A14 I'IA - �l MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK e CITY Ove MA DATE PERMIT# JOBSITE ADDRESS _ STi� ct� f l OWNER'S NAME �D(, �Lvo© l) OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO FIXTURES Z FLOOR- BSM 1 2 3 4 5 1 6 7 8 9 10 11 12 13 14 BATHTUB _ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM ( c DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM!, DEDICATED GRAY WATER SYSTEM' ! DEDICATED WATER RECYCLE SYSTEM I DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK �., r _J=L.-j ( I ��. LAVATORY ROOF DRAIN --- SHOWER STALL Ei 130 =1=�I SERVICE / MOP SINK TOILET URINAL = i=.-..R, WASHING MACHINE CONNECTION WATER HEATER ALL TYPES...n_ WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 11] OTHER TYPE OF INDEMNITY [j 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 _Fhereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Joseph M. Whitney LICENSE # 9664 ^� SIGNATURE M P 0, JP F1 CORPORATIONS #1441 PARTNERSHIP #L= LLC F—j# COMPANY NAME North Shore Mechanical Contractors ADDRESS 6 Garden Street, Suite 2 CITYDanvers STATEMA ZIP 01923 TEL 1978.774.9800 FAX 978.774.9898 CELLis L53-by (EMAIL � n _ d IV 4 � t The Commonwealth of Massachusetts Department of IndustrialAccidents r,� •� Office of Investigations` 1 1 ' d I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): North Shore Mechanical Contractors, Inc. Address: 6 Garden Street, Suite Two i Danvers, MA 01923 Phone #: 978-774-9800 Are you an employer? Check the appropriate box: 1. ❑■ I am a employer with 78 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors !. ❑ 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. employees and have workers' [No workers' comp. insurance comp. insurance.: required.] ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] - Type -of project (required): 6. ❑ New construction 7.. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.,P=<., Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ABC Mass Workers Comp SIG/USI Insurance Solutions LLC Policy # or Self -ins. Lic. #: ABCMA00501615 Expiration Date: 01 /01 /2016 Job Site Address: S-7 rjc�Sc�o©d 5-(-. 1NOri� ���do�� �, M 4 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. Ido hereby certify under the pans and penalties of perjury that the information provided above is true and correct. Phone #: 9 '7 & - 4a3_- 6H 9, j .Z3 I -f - Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 11 Contact Person: Phone #: , 1, 11 NORTHS4 OP ID- RW CERTIFICATE OF LIABILITY INSURANCE DATE(MYYY) TYPE OF INSURANCE 06!226116/1 4 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 781-914-1000 TGA Cross Insurance, Inc. 401 Edgewater Place, Suite 220 Wakefield, MA 01880 Chris Hawthorne CONTACT NAME: PAIE AX CNNo Ext): AC No : E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Arbella Protection Ins. Co. 41360 INSURED North Shore Mechanical Contractors, Inc 6 Garden Street, Suite 2 INSURERB:Allmerica Financial Benefit INSURER Specialty P tY Ins. Co. 44776 Danvers, MA 01923 INSURER D: INSURER E: INSURER F: 07/01/14 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IPOLICY LTR TYPE OF INSURANCE DDL POLICY NUMBER ERF MMIDDfYYYYl POLICY EXP I (MM/DD/YYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR 8500059520 07/01/14 07/01/15 PREMISES (Ea occurrence) $ 1,000,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PROi L1LOC 17 POLICY X JEC PRODUCTS - COMP/OP AGG $ 2,000,00 Emp Ben. $ 1,000,000 B AUTOMOBILE LIABILITYa ANY AUTO ALL OWNED SCHEDULED AUTOS X AUTOS AWN991424501 04/15/14 04/15/15 EaBINEDtSINGLE LIMIT $ 1 000 000 BODILY INJURY (Per person) $ BODILY INJURY Per accident $ ( ) X HIRED AUTOS X NON -OWNED AUTOS PROPERTY DAMAGE Per accident $ CEXCESSLIAB X UMBRELLA LIAB X OCCUR CLAIMS -MADE 86467F130ALI 04/17/14 04/17/15 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 DED X RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N / A WC STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ (Mandatory in NH) If yes , describe under DESCRIPTION OF OPERATIONS below _ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT i $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) moor, r,n w r�- , ,n, .•.�.-. vI11\IiLLLM EVIDEN3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EVIDENCE OF INSURANCE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE W 1Do-4 u1 u AL uKLJ t UKVUKAI IUN. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD r Client#: 1010905 NORTHSH052 ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 12/3012014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: Kathy Wagner USI Insurance Solutions LLC a/c0 No Ext):413-750-4222FAX , No 610-537-9481 AIC 123 Interstate Drive E-MAIL kath wa ner@usi.biz ADDRESS: Y• g West Springfield, MA 01089 855 874-0123 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: ABC Mass Workers Comp SIG 99999 INSURED North Shore Mechanical Contractors INSURER B INSURER C : 6 Garden Street, Suite Two INSURER D: Danvers, MA 01923 INSURER E: INSURER F: wvrmAuta GERilFIGATE NUMBER: RFVISION NIIMRFR• THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTRNSRTYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DDlYYYY POLICY EXP MM/DD/YYYY LIMITS GENERAL LIABILITY EEACH��OCCCURRENCE $ COMMERCIAL GENERAL LIABILITY PROM ENEa occTu ante $ CLAIMS -MADE F � OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ POLICY PRO- JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS HIREDAUTOSNON-OWNED AUTOS PROPERTY DAMAGE $ Per accident UMBRELLA LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ EXCESS LIAB AGGREGATE $ DED RETENTION $ $ A TION WORKERS EMPLOY RS'LIAILIT AND EMPLOYERS' LIABILITY ABCMA00501615 1/01/2015 01/01/201 X WCSTATU- OTH- ANY PROPRIETOR/PARTNER/EXECUTIVEY 1 N OFFICER/MEMBER EXCLUDED? � N / A E.L. EACH ACCIDENT $1 000 000 E.L. DISEASE - EA EMPLOYEE $1,000,000 Mandatory In an If yes, describe under E.L. DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Proof of MA Workers' Compensation Coverage Insurance Verification Only QQ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE W © 1988-2010 ACnRn CnIZPnRATInu All A -k*- ­­­ ACORD 25 (2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S14033332/Ml3899076 VSPZP Date .= nk.-:) ........ 11059 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ........... ............................................................................... has permission to perform ...... . . e', ..................................... . .................................... plumbing in the buildings of .......4.<... ..................... V..� ............................................ ........... ............. rth over, Mass. 0 Fee -5-3. —... Lic. ...... ....... No.......g ....... .......... ........ . .. ..... ............................................ P lv M NG INSP CTOR Check'# J .A, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK W. CITY iNorth Andover MA DATE 3/20/15 PERMIT # JOBSITE ADDRESS 1575 Osgood st unit 5201 OWNER'S NAME Ed ewood POWNER ADDRESS 1575 Os ood St. TEL 978-738-6414 IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL .__; RESIDENTIAL Ej PRINT CLEARLY NEW:[] RENOVATION: ® REPLACEMENT: E] PLANS SUBMITTED: YES ® NO[Z] FIXTURES 1 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE - i DEDICATED SPECIAL WASTE SYSTEM _ _ DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL 1 _ SERVICE / MOP SINK TOILET URINAL d WASHING MACHINE CONNECTION _ . WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF 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 E] 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME[AnthonyFresco LICENSE # 9978 SIGNATURE MPE] JP® CORPORATION# 1850C PARTNERSHIP ®# LLC [:]# COMPANY NAME I A. Fresco, Inc ADDRESS I P.O. Box 1815 CITY Wakefield STATE ® ZIP 01880 TEL 781-944-2012 FAX 1781-942-7088 1 CELL 781-775-9744 EMAIL AFI AOL.com ;cam -t f l i Date .Z--. .1 i$ . 11057 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING .,,�This certifies that ....... ......... f�n ... ..... 7;7"1...01.d9........................ ............. . ............... . .... has permission to perform ........ ................................. plumbing in the buildings of ...... ........................................ at, 0;- /4/,-, X V'-7) ... ................................... J.11, North Andover, Mass. Fee... Lic. No..9 ..... ... .. ............................................................. PLUMBING INSPECTOR Itheck # 161 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY North Andover MA DATE 3/20/15 PERMIT # U"J� JOBSITE ADDRESS 575 Os ood st unit 3111 OWNER'S NAME Ed ewood POWNER ADDRESS 575 Osgood St. TEL 978-738-6414 1FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL RESIDENTIAL E PRINT CLEARLY NEW: E] RENOVATION: E] REPLACEMENT: E] PLANS SUBMITTED: YES[:] NOE] FIXTURES Z FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 --% BATHTUB _ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM _ -- DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _J=, DEDICATED WATER RECYCLE SYSTEM _®r DISHWASHER t 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY — *00F DRAIN SHOWER STALL SERVICE / MOP SINK -TOILET URINAL WASHING MACHINE CONNECTION _ _ WATER HEATER ALL TYPES WATER PIPING _ OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES E] NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [3 OTHER TYPE OF INDEMNITY E] BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ® AGENT SIGNATURE OF OWNER OR AGENT 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME jAnthony Fresco I LICENSE # 9978 SIGNATURE MPEI JP® CORPORATION# 1850C PARTNERSHIP# LLCEI# COMPANY NAME I A. Fresco, Inc 1 ADDRESS I P.O. Box 1815 CITY lWakefield STATE L mA ZIP 01880 TEL 781-944-2012 FAX 781-942-7088 CELL 781-775-9744 1 EMAIL JAFIRAOL.com 161 W The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 - www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Letsibly Name (Business/Organization/Individual): -e SCy C. Address: Phi, City/State/Zip: V✓akelrf Id pj (- D/g'0 Phone #: %FU–'F'y`/—a o/ Z Are you an employer? Check the appropriate box: 10I am a employer with,, employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4.F-1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6. ❑ We are a corporation and its officers have exercised their right of 'exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11. F1 Electrical repairs or additions 12. Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. / ) Insurance Company Name:, 7 rZ, v 5 T • - Policy # or Self -ins. Lic. #: Expiration Date: -7 i 7 DS �c� CUlviS ?l// 2�fiy Sacs 4 �%% Job Site Address: � 1 t City/State/Zip: ate/Zip: � r�z C6c.`P2 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office,of Investigations of the DIA for insurance coverage verification. Ido hereby the pains a cerrtify7Z nd pen • s of perjury that the information provided above is true and correct. Phone#: %,5-/ ^ '---) 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 #: x A Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub=contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom a of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia i'1 Date.,3-7 .o ................................ 11058 SOWN OF NORTH ANDOVER PERMIT FOR PLUMBING . 7 s has permission to perforin." ..? �l E'-2 ........................ . plumbing in the buildings of ... ��`... :��.�f."................................................. at ....67.� ��/u .... North Andover, Mass. Fee..........-........ Lic. No . ................................................................................................... PLUMBING INSPECTOR Check* �J MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY I North Andover MA DATE 3/20/15 PERMIT # JOBSITE ADDRESS 1575 Osgood st unit 2410 OWNER'S NAME Ed ewood POWNER ADDRESS 575 Os ood St. TEL 978-738-6414 IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL F-1 EDUCATIONAL RESIDENTIAL E] ' PRINT CLEARLY NEW.-[] RENOVATION:E] REPLACEMENT: PLANS SUBMITTED: YES [j NDE]` FIXTURES Z FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 .' BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM _ DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN n SHOWER STALL 1 SERVICE / MOP SINK TOILET _ URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER _ I of All INSURANCE COVERAGE: have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES E] NO E] IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [] OTHER TYPE OF INDEMNITY ® BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER [D 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME AnthonyFresco LICENSE # 19978 SIGNATURE MPEI JP® CORPORATION# 1850C PARTNERSHIP(# LLC E]# COMPANY NAME IA. Fresco, Inc ADDRESS P.O. Box 1815 CITY lWakefield STATE ® ZIP 01880 —� TEL 781-9442012 FAX 781-942-7088 CELL 781-775-9744 EMAIL AFI AOL.com Ax I m E � 1 n CERTIFICATE OF LIABILITY INSURANCEF10 DIDD TYPE OF INSURANCE /28/28/2001414 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Strategic Resource Group 27 Water Street, Suite 107 CONT NAMEACT Michelle Cordima PHONE (781)246-9002 FAAIX C No (781)246-9007 E-MAIL mcordima@strate icresource rou ADDRESS: 5 g p .net INSURERS AFFORDING COVERAGE NAIC # Wakefield MA 01880 INSURERA:Ironshore S ecialt Insurance INSURED A:~ -Fresco, Inc. - P.O. BOX 1815 INSURERB:National Union Fire Insurance 19445 INSURERC: INSURER 0: INSURER E Wakefield MA 01880 INSURER F: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MMIDD/ICYYYYFY MMIDDIYYXY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR RCS0015200 5/1/2014 /1/2015 DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 MEDEXP(Anyoneperson) $ 5,000 PERSONAL & ADV INJURY $ l_,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X1 POLICY JECTPRO LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY COMLI BINED SINGLE MIT Ea accident ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accident $ $ X UMBRELLA LIABOCCUR EXCESS LIAB CLAIMS -MADE EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED I I RETENTION$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ NIA EBU064845352 /1/2014 /1/2015 $ WC STATUJIM - OTH- TORY rp E.L. EACH ACCIDENT $ (Mandatory in If yes, describe under and E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CFDTICI!`ATC Ur%l nco mdeems@townofnorthandover. Town of North Andover Building Department Assistant Maura Deems 1600 Osgood Street Bldg. 20 Suite 2035 North Andover, MA 01845 Arr)Rn,2F rgninnai SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Crowther/KERRI � � -- v,U00-LU-IUAGUKU GUKPVKATION. All rights reserved. INS02519Mon.m n1 Tha AR(1Rn nnma nnrl Innn arc raniefararl mnrka of ArnPn AFRESCO-01 LCARtISn CERTIFICATE OF LIABILITY INSIINSURANCEDATE (MM ONYYY)1©r24r2014 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, D(CLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCERCONTACT S Salem Five Insurance Services, LLC 445 Main Street NAM PHONE FAX A/C No 6d : (781) 933-3100 AIC No): (781) 933-9048 Woburn, MA 01801 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE - MAIC INSURMA:Arbella Indemnity -- INsuRED msuRER B: Travelers Ind Co of AM 25666 A Fresco, Inc. Attn: Anthony Fresco INSURER C: INSURER D : P.O. Box 1815 INSURER E: Wakefield, MA 01880 INSURER F , t,V,V 1� rt V,llpCR. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, D(CLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE INSD S POLICY NUMBERMPOLIC EFF PNOI/UDD EXP LIMITS COMMERCIAL GENERAL UAB[L[Tl' CLAIMS -MADE FIOCCURRENTED EACH OCCURRENCE $ PREMISES Ea occurrence S MED EXP (Anyone person) $ . PERSONAL & ADV INJURY S _ GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ POLICY I ECT LOC PRODUCTS - COMP/OP AGG $ $ OTHER AUTOMOBILE LIABILITY - Ea COMBINEDSINGLE LIMIT - $ - 1,000,00 A BODILY INJURY (Per perm) $ ANY AUTO 102=81102 11105/2014 11/05/2015 ALL OWNED X SCHEDULED BODILY INJURY (Per acddenI) $ AUTOS AUTOS X HIRED AUTOS X NON -OWNED AUTOS PROPERTY DAMAGE $ Per accident $ UMBRELLA UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB - AGGREGATE $ I DED I RETENTION $ $ -E WORPMRS COMPENSATION TH- X AND EMPLOYERS' LUUNi rrY YIN STATUTE ER E.LEACHACCIDENT 1,000,00 B ANY PROPRIETOR/PARTNER/EXECUTTVE HUB-614SY40-3-14 03/1012014 03/1012015 OFFICERIMEMBER EXCLUDED? 0 N / A $ E.L. DISEASE - EA EMPLOYEE $ 1,000,00 DPY in NH) tapes, desrnbe under - E.L. DISEASE -POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS betosv - DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, AdMbnd Rem dm Schedule, maybe attadeed iI more space is required) _ AL�TelA ATI^ eek! erre- .. Town of North Andover Building Dept ASsistarlt - Marrra Deems 1600 Osgood Street Bldg. 20 Suite 2035 North Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ApUTH�ORLZED REPRESENTATIVE w -I yaa ZUT4 Ac;UKu CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD � .! Date TOWN OF NORTH ANDOVER \ , ` . ' � PERMIT FOR PLUMBING. plumbing in the buildinrs So ........ i�.e .. !��P.!?A ....................................... PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK uCITY w �v MA DATE �� ! PERMIT # /� d JOBSITE ADDRESS S7 SSG 0p 73a / OWNER'S NAME OWNER ADDRESS TEL= FAX j TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL Q RESIDENTIAL' PRINT CLEARLY NEW: Q RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES Q'.%.NOQ FIXTURES Z FLOOR--> BSM 1 2 3 4 5 6 7 8 1 9 10 11 12 -` 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM 1 __.., i ..... -A .__ 1 _ __._.I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM { ._ f I ( ' I __,.. - I _--_..-J DEDICATED WATER RECYCLE SYSTEM { _.__..__J _ _..:_.. ► __.J ._._._1 ._.._... J �.____I. __._._! _-_ .f .,....-.._f ____( _.___ I ._A_( DISHWASHER € __.___. ..... ` 1._77-! DRINKING FOUNTAINS FOOD DISPOSER FLOOR/AREA DRAIN i .. � [ ___J INTERCEPTOR (INTERIOR) KITCHEN SINK.._-_i ___.J __.__j LAVATORY ROOF DRAIN SHOWERSTALL SERVICE/MOP SINK { --___I ____ ! .-____I _— I __.__! ___J .-._._! _____► __! __ _i __ .__.�! .__._J TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES �— WATER PIPING OTHER INSURANCE COVERAGE: P?4ave a current liability insurance its policy or substantial equivalent which meets the requirements of MGL Ch.142. YES NO Q OF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Q BOND Qf 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 Q AGENT 11 1 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 d accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp fi with all i ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME�wc1 RifSC� C� LICENSE # 99) i SIGNATURE mpa- JP Q CORPORATION M# 50C_ i PARTNERSHIP Q# _ LLC Q#E COMPANY NAME , f _C_0 ADDRESS'D. CITY G✓ �J A (STATE ZIP TEL _ FAX Y�S-2piff$ CELL 1-976- 1`/ EMAIL fir-----ez - , C _ r _14 ti 14 The Commonwealth of Massachusetts - Department of IndifstriglAccu%nts Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Budders/ContractorsfElectricians/Plumbers Applicant Information . Please Print Legibly Name (Business/Organization&dividual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. [] I am a employer with 4. ❑ I am a general contractor and I employees (fiill and/or part-time).* have Hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship andhave no employees These sub -contractors have working for mein any capacity. workers' comp. insurance. y [No workers' comp. insurance 5. ❑ We area 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.] employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 1011 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they aie 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 N Policy # or S elf -itis. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL e. 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 DTA for insurance coverage verification. I do hereby cert& under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact 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 him, 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 employes." 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' compensailon affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) andphone 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 fox 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 obtains 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)" officially A copy of the affidavit that has been ocially 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 shpuld you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: Tho Common -w. ealth of M ssa chwats Depaftent offudustdal Accidents Qfflee of luvestigatious 6.00 WaWngtoa Woa Boston aM.AO2111 `101 # 617-7-21-4900 at 406 or 1-877" M[ASS.AFE Revised 5-26-05 Fax 0 617-727-7749 www waSspvfdia f A �sr.� �-�»c � O �f% 10823 Date AR 7bR'..../ .... ......... 7 ....... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that.AL4k..�\, ..... ............................... has permission to perform ......... vim..„ S �� ....................................... ,plumbing in the buildings of ... ....... at, .... 9 .......... ........."I........North Andover, Mass. Fee.5 ............. ji;;�/ ............................................................... .,�-.2.1t!. Lic' No. .Ae . . . " 6 -� PLUMBING INSPECTOR Check # C74 1*7111 1.;2 wpf,2. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK UlfCITY Andover MA DATE 10123/14 j PERMIT # JOBSITE ADDRESS 1575 Osgood St. unit 2303 OWNER'S NAME Ed ewood Retirement Communi , Inc. POWNER ADDRESS 575 Os ood. St. TEL 978-738-6414 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL - EDUCATIONAL RESIDENTIAL PRINT. CLEARLY NEW: E3 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YESO N0[D FIXTURES 7 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER _ FLOOR / AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL 1 SERVICE 1 MOP SINK .. . - .TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING --. — 'OTHER _ .. INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [] OTHER TYPE OF 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 [,--I AGENT E] 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 perforated under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME jAnthony Fresco LICENSE # 9978 SIGNATURE MP _Ea JP CORPORATION# 1850C PARTNERSHIP# LLC El# COMPANY NAME I A. Fresco, Inc ADDRESS I P.O. Box 1815 CITY Wakefield STATEF—m—A-1 ZIP 01880 TEL 781-944-2012 FAX 781-942-7088 CELL 781-775-97� EMAIL jafigaol.corn 1*7111 1.;2 wpf,2. 67 _i r* The Commonwealth of Massachusetts - Department ofIndustrial Accidents Office ofInvestigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation insurance Affidavit: Builders/Contractors/El ecericians/Plumbers Ulnoc+a Prinf Y,P.orIllli Natne (Business/Organization/fndividual): / / ° Address: ' `� ` `�'� / � � . �� Ciiv/State/Zip: t��'��' ! Z?41 Phone #: Are you an employer? Check the appropriate box: 1. K! am a employer with 4• ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors fisted on the attached sheet. 2, ❑ I am a sole proprietor or partner- These sub -contractors have ship and'have no employees working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their required.] 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no employees. [No workers' insurance required.] comp. insurance required.] Type of project (required): 6. ❑ New construction 7. [] Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1 1.0TIumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. t -Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 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 joh site information. % Insurance Company Name: Policy # or Self -ins. Lie. #: ExpirationDate: City/State/Zip: /U ` Alt, CIO U l Job Site Address: i 7 7S 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 fide 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. I do hereby Bert and a pains and pe ties of perjury that the information provided above is t ue an correct. - __. Date: / C) l Phone ff n 7 ? , "-7 V tl a � �'- Official use only. Do not write in this area, to he 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 - Phone #: Contact Person:_ Date ....... ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This, certifies that ................. .............................. has permission to Perform ........... wiring in the building of .............. .................................................... ,at ............. ... ....... ............................ . North Andover, Mass. ................. Q�/*X. le Fee.—I ... 2 ..... 5 ........ ........ Lic. No. eg'. �� Check # Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. '(2,7 _ 12S 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 IN INK OR TYPE ALL INFORMATION) Date:— City ate:_City or Town of: NORTH ANDOVER To the In pe for of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 6-75– 92E0,V�,/S7_ Owner or Tenant! t elacr� • Telephone No. IV Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building . 6'1a.&- fZ— , � iar`x�f 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: t ' k7 lac!/e Se e&,Q el ev-ewO ,A;,r Te 6n Lc,,' �e Td'I� /L <'ors�r// ane Gam' 9,e6 1Z�/Ja��� s exwe•e' ��vlTcl.Pr 7V D� D,` 6-- Completion of the following 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 Above In- Swimming Pool rnd. j4rnd. El o. o mergency Lighting Battery Units No. of Receptacle Outlets / No. of Oil Burners FIRE ALARMS No, of Zones No. of Switches No. of Gas Burgers 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 KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach 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 CO ERAGE: 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: 1NSURA_NCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under theains and penalties of perjury, that the information on this application is true and complete. FIRM NAME:. e At°✓I GY�?c� �/�� -� P�7`/2< LIC. NO.: L 7U3/ Licensee: -Pee �A eeA? Signature LIC. NO.: (If applicable, enter "exem t" in the license number line.) Bus. Tel. No. - Address: /t YIcY assesGr,, /l Alt. Tel. No.• *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the r 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 shallbelimited 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. 0. Rule 8—Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL, ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL., INSPECTION: PassX. IE Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts - Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ^ / Please Print Legibly Name (Business/Organization/Individual): P(Rt C%K� ` to,g, 111 ele r VCas! ` C Address: `�Zi� lrlC��lOtu City/State/Zip:_ wa4 e 9(.P (W 1*a, d( Phone #: 79/- A,re_,yo employer? Check the appropriate box: Type of project (required): 1. LlJ'I am a employer with 60, 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors 7• ❑ Remodeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet.1 ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 5. El We are a corporation and its 9. E] Building addition [No workers' comp. insurance required.] officers have exercised their 10. F1 Electrical repairs or additions 3. ❑ I am a homeowner doing all work 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.] i 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. 1 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 check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. Y am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company al"Cf Policy # or Self -ins. Lic. #:._ [it/ C — t2-�lt J �' 4 (p ExpirationDate: Job Site Address:- 9g -Ml �7` 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 sof 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. X do hereby certa unftr the paNF,�penalties ofperjury that the information provided above is true and correct. Signature: '`l/, ifi� Date: Phone #:�- Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: U/ 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 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 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. 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 a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial .Accidents Office of Iuvestigat+ious 6.00 Washingtoa Street Boston, MA, 02111 Tel, # 617-727-4900 ext 406 or 1.-$7TMA.SS.AJFB Revised 5-26-05 Fay, # 617-727-7749 www-mass.govfdia ` Date ........................................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...............:. t 1VL.bG� has permission to performM.- iFJG wiring in the building of................,G� k ......... . at :..,� � -5 .......,,, "'.... , North Andover, Mass. ........ Fee ../.Z. Lic. No.. 23 ..................... ................. .................. ..... ....:....... 'ELECTRICAL INSPECTORI Check # (J 12194 t Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 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 Electric o (1VIEC , 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: s y City or Town of: NORTH ANDOVER To the Inspector ofWires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) - Owner or Tenant Telephone No. Owner's Address^(\.y Is this permit in conjunction with a building permit? Yes ❑ No Wr (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Work: L Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters 'ompl ion ofthe following table may be waived by the Inspector of 1 No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers r KVA No. of Luminaire Outlets No. of Hot Tubs Generators, Z KVA No. of Luminaires Swimming Pool Above ❑ In- Elo. rnd. rnd. o Emergency Lighting Units No. of Receptacle Outlets —Battery No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burgers 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:..... I Number " ' '""'.....""'""""""' Tons KW "".......""' ' No. of Self -Contained Detection/Alerting Devices No. of Dishwashers I `�� Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances Kir Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent_, OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (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 cove . is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under th ains and penalties of perjury, that the information on this application is true and complete. FUM NAME:. V • L LTC. NO.: Licensee: I nv Signature ` LIC. NO.: L (If applicable, ent "e empt',in the li se numbe4line.) Bus. Tel. No.• Li D Address: � 2 i L 1 (1r 1))^, y F N Q1r1iM f r� �'� Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent IPERMITFEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shallbelimited 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. D. 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: a Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass R Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ i Inspectors Comments: Inspectors Signature: Date: FINAL, INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: 17,14,4 A Inspectors Signature: V Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com 4 The Commonwealth of Massachusetts Department ofIndustrialAccidents Office of Investigations VV 600 Washington Street Boston, MA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Z r Address: l G, by � mw* io � �-� 3 �{ City/State/Zip: �a) �, ©_� Phone #: Are you an employer? Check the appropriate box: I. ❑ I am a employer with 4. ElI am a general contractor and I 6ployees(full and/or part-time).* have hired the sub -contractors m 2. a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.® tricalrepairs or additions 11.0 Plumbing repairs or additions 12.0 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 ace doing all work and then.hire outside contractors must submit a new 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. Insurance Company Policy # or Self -ins. Lie. #: 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 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. ,Xdo hereby��rtiV under the p ' and penalties of perjury that the information prov fled above is true and correct. - Signature: �t�J [� 0 (�/� Date: �91, Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #• 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 may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The CQmMon ealth of Massachusetts Department of Industrial .Accidents Office of Iuvcstigatious 600 Washington Street Boston, MA, 02111 Tel, # 617-727-4900 ext 406 or 1-877rMASS.AFE Revised 5-26-05 Fax # 617-727-7749 ww�v.z>l�ass.govfdza T 10179 Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that. N � P C-�4 has permission to perform . 2.. R 2 plumbing in the buildings of . 9q- � r.);................. :57 5 o "' at <s1 North Andover, Mass. Fee .w ....... Lic. No .... t: ? .................. .. . Ion PLUMBING INSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Of W CITY _ o.��- ! MA DATE — ] PERMIT # _ JOBSITE ADDRESS %S �--- _ OWNER'S NAME T POWNER ADDRESS 121 Os' %t TEL— TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 1\10�0 FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM (.._ ( ( ....___ I _I DEDICATED GREASE SYSTEM ! I 1 ._.__ I i-..__.__._.j .: DEDICATED GRAY WATER SYSTEM I ._�( I _ I i (_ J 1--i DEDICATED WATER RECYCLE SYSTEM DISHWASHER _A= DRINKING FOUNTAIN _ ! ...__..___i---.-._ ___...___( ____ ! _( ____.._ ___.___i ._ :.__. __..__ .__-._._.� .__._. I FOOD DISPOSER _ ► ._._.__i _._ 1 1 f i _ _. i .___._ FLOOR /AREA DRAIN73 INTERCEPTOR (INTERIOR) KITCHEN SINK I 1 l _. l _..__ _1 i f ) __._..._i ____._.I _.__..I _ __I _._-- LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL _..J 1/VASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING i OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESA NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITYj BOND Q i C,4NER'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 Q AGENT ►��i] SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this applicat' ar ue and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will a in c lance with all Pertinent provision of the Massachusetts State Plumbing Code Erd Chapter 142 of the General Laws. PLUMBER'SNAMELJj LICENSE # SIGNATURE MPO[ JP Q CORPORATION Q#PARTNERSHIP 0# E LLC 0� j COMPANY NAME1 ADDRESS CITY —STATE I, ZIP Q i TEL FAX I >91 a73 qlpjCELL_6f_...S 3I EMAIL--- _S_ -- ...- - w H °z z 0 H •U W W `1 zo F] � d❑ z �- o rA GOD H W o W a z u LLI ® a W W5W LLJ N P; O � w p a z a 0 W a � U J IL M a Lu F- LL H z 0 H U W a z z as a a x F r 0 I r., Date... . . ................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ....... 91;2 ...................................... ............................................ has pe'nnission for gas installation ................... in the buildings of.. ..... at ........ &' 75- 6,4 . .. S. ............ . 0 . . ......... ................. .... . North Andover, Mas AA Fee /,.6 .. ..... Lic. No. IJW ....... . .................................................... GAS INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY u— MA DATE PERMIT # U JOBSITE ADDRESS X73 _ _ Cc��� - OWNER'S NAME GOWNER ADDRESS 7s c. TEL�p _ _jFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIALO— PRINT 4 CLF.•ARLY NEW: [Q RENOVATION: E] REPLACEMENT: J9 PLANS SUBMITTED: YESE."] NOJ5 APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER _- T _� _-- I I _) COOK STOVE) DIRECT VENT HEATER f hT (- DRYER FIREPLACE FRYOLATOR 1 FURNACE _.- J= � � I - - - — -� GENERATOR GRILLE.- INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN— POOL HEATER ROOM / SPACE HEATER I ROOF TOP UNITS k TEST UNIT HEATER ! I UNVENTED ROOM HEATER_ WATER HEATER OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES RNO 11 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY © BOND F OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application n accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be • comp `c with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME r,Y.. _ LICENSE # SIGNATURE MP P MGF 01 JP El JGF © LPGI CORPORATION [�# PARTNERSHIP ®#= LLC E]# COMPANY NAME: �_ � � � ADDRESS CITY _� STATE °l _ `j] ZIP ( TEL FAX CELL��EMAIL _- .. �1_N �ti m • `_ P H O o U WAN 00 W ' - i o a z o yrl w � � ~ W OF a Z LU � 3 U) W 5 o > a ' w W w N a o a a a U J E. a a Q. D w x w I-- LL- W H z z O F U - W P64 t C7 x C7 - °a :4, The Commonwealth ofMassachusetts Department of IndustriqlAccid&ts Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: BuildersfContractors/Electricians/Plmnbers Name (Business/Organization/Individual):t�a� �N 1,r Address: a 1 City/State/Zip:_ , , 1 Phone #: 79-( J_ `1,} 1 ZrJ_ Are you an employer? Checkthe pproliriate bog: 1. F!J I am a employer with 3 4• ❑ T 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 aud'have no employees 'These sub -contractors have working for mein any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL mys elf. [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 I I 1umbing repairs or additions 12.❑ Roof repairs 13. F! Other 'Any applicant that checks box#1 must also fill out the section bel6w showingtheir workers' compensation policy information. I Homeowners who submit this affidavit indicating they Ee doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showingthe 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. A Insurance Company Name:. Policy 4 or Self -ins. Lic. #: �es� Q 3 ,2 j" �/ Expiration Date: /J- Lf. y Job Site Address:_ -3'7:K� b S 15, 0 A City/State/Zip: Attach a. copy of the workers' compensation -policy ileclaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL 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 sof Investigations of the DTA for insurance coverage verification. Ido hereby u der the pains andpenalties ofperjury that t12e informationproviddeed a ove is tie and correct. - Si ature. Date: %''t'S—/ /3 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/lAcense 0 Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. PIumbing Inspector 6. Other Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. P 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 em ployeils defined as "an individual, partnership, association, corporation or other legal entity, or any two ormore 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 producedacceptable 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. Do 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 -P-lease be sure.that-the affidavit is-complete-andprintecl IegibIy. TheDdpaiiment'Kds 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. 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 orpermit to burn leaves etc) said person is NOTrequired 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 Gomlponwealth of miassadhwetts Dep.artmit ofzndwWal Accidents oface ofInvestigations 600 Washiigtou Street Foston, M.A, 021.1.1. ` QL # 6:1.7-727_4900 ort 406 ox 1-877;WS FF, Revised 5-26-05 Fa. # 617-727-7749 ................... .......... Fold, Then D etach Along All Perforations -,.COMMONWEALTH F MASSACHUSETTS SAC PLUMBERS ANI!! GASFITTERS NE M N PLUMBER I ASA JOIJ ISSUES THE ABOVE LICENSE TO: CHARLES F VAU00AN -,kiHsp.bUGH RD' .,.. wl BTLLERI,CA KA 01821-3004 19102018803 05/�oj/14 .. . ... . ...... Fold, Then Detach Along -Ail Perforations mp�gsACHUTTS Perforations Fold, Then Detach Along' r _ ,....dOMMONWEALTH OF MASSACHUSETTS PLUMBERS AND IGASFITTERS. RED AS.A.IPLUMBING CORP .�REGIST JSSUESTHE ABOVE LICENSE TU CHARLES' VALIGIIAN NNPLL MECHANICALro GRIL '11BROIJIGH, ST i L Lb' I -CA' -"01 tA 82 3 3482 05/01/14 2 5 0 5 5-9 Fold, Then DetacFAFoqg All Perforations z0 0 N o z � o O 00 Zgw--° E =o° 2 0 0 o a 00�7� Q Q ~ = Z o O w O O - z I zo U m N Q w Date .:....:...:...., TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................... ..(................................. '{ ............................................................... �, / has permission to perform ......� (/„ ,..... wiring in the building of.....:.p!r.. at ............ f................L......`'..: ........-��....................... re......... , North Andover, Mass. �!�'GT^ sl Fee ..... '.'' Lic. No........:.. �.........:.......... . ELECTRICALINSPECTOR Check # 7 '1719 C®IiA08 an wealth of Massachusetts Official Use Only Department of lire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [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 IN HK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant (2d Owner's Address S1 Telephone No. 916 0-1-53 Is this permit in conjunction with a building permit? Yes ❑ No [R""- (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 :7 l1 Aa r Location and Nature of Proposed Electrical Work: Comvletion ofthe following table may he waived by the Insnector ofWir s. 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.mm `a° f Luminaires swimming Above ❑ In- ❑ g Pool rnd. grnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No, of Zones No. of Switches No. of Gas Burners No. of Detection and InitiatinLy Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number " .... ' Tons ' - "'-"" * KW J------ " 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. o?f Water KW Heaters No. of No. of Si ns Ballasts Data Wiring: No. of Devices or Equivalent No.11ydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: �D plAttach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Wo fs-ri �' (When required by municipal policy.) Work to Start: P, l Ys 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 a BOND ❑ OTHER ❑ (Specify) A' certify, tinder thepains andpenalties ofperjury, that the information on this application is true and complete. FIRM[ NAME: Licensee: Signature LTC. NO.: _ LTC. NO.: (If applicable, enter "exe pt" in the license number line.) Bus. Tel. No. Address: la 5 �i Gln n c wc�t� (L cn P '� ; �, �G ��( Alt. Tel. No.: SXj 31-10 356; *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVE • I am aware that the Licensee does not have the liability insurance coverage normally required by By m i nature w, I hereby waive this requirement. I am the (check one) ❑ owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00.§ Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. 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 N Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ :R Inspectors Comments: Inspectors Signature: Date: PARTIAL, ROUGH INSPECTION: Pass N Failed Re- Inspection Required ($.) ❑ Inspectors Comments: w, l Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL. INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comrrient,9112 . hPA ,` Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Uf 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/Organizatiordlndividual): Address: City/State/Zip: 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. ❑ I am a sole proprietor or partner- listed on the attached sheet ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 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. El Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy-# or Self -ins. Lic. -#: - Expiration Date: Job SiteAddress: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failurei 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 certto under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone Information and Instructions ' Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -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 f be returned to the city or -town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current` policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or, town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department oflndustrial ,Accidents Office ofInvesfigations 600 Washington Street Boston, MA 02111 Tel # 61.7-727-4900 oxt 406 or 1-877rMASS.AFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia - .... Date .. ............... t TOWN OF NORTH ANDOVER PERMIT .FOR WIRING This certifies that........a.A.LA...... 6..L.,....��.. has permission to perform ... /?C..1.!......:...!t.�f�!- .:................................... wiring in the building of.......l..z� - . ... '. . .......................... H at...5.15...4 North Andover Mass. G f Fee ... '-TJ..... Lic: No. �� .. .. �!. ....... .. P.... ,..... -f . Check #196:11 . lCommo�zwealth o�ec77 a��act/Zuaei% Official Use Only nepadment o/,}ire Serviced Permit No. I BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked 'Ip ev. 1/07] (leave blank) APPLICATION FOR PERMIT T® PERFORM ELECTRICAL WORK All work to be performed in accardance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PPJNTLVINK OR TYpl ALL INFO Date: 3 (.0113 Ci or Town o$': NTI N) To the Inspector of Wires: By this application the undersigned gives notice of his or her iX enhon to perform the electrical work described below. Location (Street & Number) ``j '7.-9�- t") C (111 flrl) _ `'7V - 'a Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with id building permit? Yes ❑ NoCheck lam! ( Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters, Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 0, ,LLQ- .t`r-d e co tv-� No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers No. of Water .rl Heaters KW No. Hydromassage Bathtubs OTHER: i the No. of Ceil: Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool Above ❑ In• grnd. arl No. of Oil Burners t No. of Gas Burners No. of Air Cond. Total Space/Area Heating KW Heating Appliances KW 1140.01 Ballasts o. of Motors Total HP UE may e waived b the Iris ector o Wires Total mers KVA rs KVA ergency Ig mg nits ARMS No. of Zones tection and No. of Alerting Devices Local ❑ lvtumcipad Conn El other aro. nn No. of Devices or Data Wiring: Attach additional detail if desirea, or as required by the Inspector of Wires. Estimated Value of Eectr'cal Work: -� (When required by municipal policy.) ` Work to Sta�VERAAS: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE X BOND ❑ OTHER ❑ (Specify:) I certify, under thepains and penalties ofperjury, that the i rmation on this application is true and complete. FIRM NAME: f (} �-e i^c�. r- " r LIC. NO.: - q5� Licensee: f V1Q.r -- A�'.�� �l� Signature (If applicable, enter "exemp " m the license nu er line.. _ LIC. NO.: - �5i4 Address: c Bus. Tel. No.: ) -:!5'9 V Jy� �� Alt. Tel. No.: ''`Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" Li ' e: Lie. No. ( ) 9 Z3 � OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage nonnally required by law. By my signature below, I hereby waive this requirement. I am the check -one owner Owner/Agent ( ) ❑ ❑ owner's Ment. Signature Telephone No. PERMIT FEE: $ ,� 1 a I t Division of Professional Licensure: License Search The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Home State Agencies A -Z Topics Home > Division of Professional Licensure > .................... ............................................ ...............:..................... ............................... Check A Professional License By the Division of Professional Licensure LICENSEE Name:MARK A. BROPHY SR. Business: TYCO INTEGRATED SECURITY LLC WESTWOOD, MA **This Licensee has additional Licenses, click here to view them.** Licensing Board: ELECTRICIANS License Type: SYSTEMS CONTRACTOR TYPE CLASS: C License Number: 45 Status: CURRENT Expiration Date: 7/31/2013 Issue Date: 1/1/1992 Exam Date: School: This web site displays disciplinary actions dating back to 1993. This license has had disciplinary actions taken during this time. Click here to view this information. Page 1 of 1 Mass.Gov I ONLINE SERVICES I Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATED INFO Disclaimer Regarding Website License Searches Enforcement Process Glossary Glossary of License Status Codes More... The page above has been generated by the Division of Professional Licensure web server on Monday, April 08, 2013 at 4:13:23 PM. © 2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://Iicense.reg. state.ma.us/public/pubLicenseQ.asp?board_code=FA&type class=_C&lic... 4/8/2013 Division of Professional Licensure: License Search The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Home State Agencies A -Z Topics Home > Division of Professional Licensure > ...................................... ............................ .......... .......................... ................. .................. -............................. ...............:.......................:........:......................... Check A Professional License By the Division of Professional Licensure LICENSING BOARD TYPE LIC. # LICENSEE'S NAME CITY/STATE STATUS Electricians Systems Contractor I 45 MARK A BROPHY SR WESTWOOD, MA Current Electricians Systems Technician 116o MARK A BROPHY SR I MIDDLETON, MA Current The page above has been generated by the Division of Professional Licensure web server on.Monday, April 08, 2013 at 4:13:33 PM. © 2007-2011 Commonwealth of Massachusetts Page 1 of 1 Mass.Gov INLINE SERVICES heck a License Locate a Licensed Professional inline Address Change "ontact the Agency Aore... FERENCES & LATED INFO sclaimer Regarding ebsite License Searches Iforcement Process ossary ossary of License Status ides ore... Site Policies Contact Us http://license.reg. state.ma.us/public/pubILicsn.asp?board_code=FA&type_class=_C&licens... 4/8/2013 _n F PERMIT FOR GAS INSTALLATION This certifies that .. ..�iir Cy,�1 ......... has permission for gas installation &C-) �. � '? in the buildings of .. �-t .Com; i .. ?� c-2 '� ........ at ... ��. %.- . CZ60zx�.vV........... , North Andover, Mass. FeeLie. No. GASINSPECT Check # 8615 r� } IV MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY _ O T tpp kj l • z� MA DATE I BAR ?22IN PERMIT # JOBSITE ADDRESS ,�?_ ^ , . OWNER'S NAME GOWNER ADDRESS TE q'J�,��3 �FAx TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 1:11 RESIDENTIAL CLEARLY NEW: E3 RENOVATION: 0 REPLACEMENT: r5( PLANS SUBMITTED: YES 0 NO Pr APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER - BOOSTER CONVERSION BURNER�,_I COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACEJ J GENERATOR.) GRILLE INFRARED HEATER LABORATORY COCKS{ MAKEUP AIR UNIT OVEN I J POOL HEATER Ali _ _. I � -� -� - � �- .I ROOM /SPACE HEATER - - ROOF TOP UNIT TEST UNIT HEATER I -J UNVENTED ROOM HEATER WATER HEATER OTHER I INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES `NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW / LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0l BOND OWNER'S INSURANCE WAIVER: I am aware that the IYensee 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: OWNER0-1AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. A --AA— PLUM BER-GASFITTER PLUMBER-GASFITTER NAME t LICENSE # ( SIGNATURE MP MGF JP) JGF LPGI{ CORPORATION 19;% (PARTNERSHIP©{ #I..__.._ _. II LLC# ----------� C P4 ANY NAME:,ADDRESS CITY -� -���.� STATE ZIP (� TEL If III' I FAX D CELLEMAIL �. - IV 'r The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations kvi 600 Washington Street Boston, M4 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):�AA rcac ��NMx►J6, , �1 J Address: a w bZp� City/State/Zip: Oot Amnvy� /y4Q ' Phone #:_4/-)g � �b Are . ou an employer? Check the appropriate box: 1. NTJ am a employer with _ 2, .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 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 3111 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.] r 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. lambing repairs or additions 12. Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. 6AW� I s�LA:. Policy # or Self -ins. Lic. #: l,thi WC. 32( Expiration Date: Job Site Address: 5,75- QSG(y ST- City/State/Zip: +v0 ► to XD6 bw— 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 cqtfy under the pains and penalties of perjury 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 producedacceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials ` Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth, of Massachusetts Department oflndustrzal Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 Tel, # 617-727-4900 ext 406 or 1-877„N1ASS.FB Revised 5-26-05 Fax # 617-727-7749 www.mass,govfdia k /t/'5 -25D Date .. -.'2. !. 1 2,- TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...7:t.tg .44— �e-. Sf- !!�,.. .G, has permission to perform ..ol�E'i��%�� ..... . wiring in the buildin of ... N777�,—�.,4, ...T . at . .."'�..?..v.59?�, . 57-' ,North Andover, Mass. e ......... Lie. No.. .! 1 b a' e/6aA0 ELECTRICAL INSPECTOR Cleck # 11192 1-1,012,1— ZaS J 3, 411P'lD 4 i I K Commonwea& of Mam c4udettd Offici I Us Only t� cc77 .. .� IF 2epartment ol.}ir'e Serviced Permit No. { 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 IN INK OR TYPE ALL INFORMATION) Date: 10 �' I City or Town of: To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) - Owner or Tenant EA,,A C�J Telephone No. Owner's Address J Sem r Is this permit in conjunction with a buildin�Rerm't? Yes No ❑ (Check Appropriate Box) Purpose of Building tnv.,' 1 e,r12 [ Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd 0 No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: b at 0— 11 . 10- No. of Recessed Luminaires -- - No. of Ceff. Susp. (Paddle) Fans rru..cu u- ,r l/IJ GLfVr No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ n- ❑ rnd. rnd. o. o mergency Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of netemlon an Initiating Devices No. of Ranges Total No.. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers Heat um p Totals: umber .................................................................. Tons _ o. of Self -Contained Detection/Alerting Devices - No. of Dishwashers Space/Area Heating KW Local ❑ unicipal [I Other Connection No. of Dryers No. o Water KW Heaters Heating Appliances KW No; o o. of Signs Ballasts Securi Security ems.* No. of Devices or Equivalent Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of or Equivalent i p ` (Devices OTHER:.— Y\ & eI- Q Attach additional detail if desired, or as required by th Inspector of Wires. V'0- Estimated Value of Electrical Work: (When required by municipal policy.) yy � 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 LId BOND ❑ OTHER ❑ (Specify:) p', I certify, under the ains and penalties of perjury, that the information. on this application is true and complete. (5FIRM NAM ! eS LIC. NO.: 1,1Y 116 Licensee: C Signature LIC. NO.:' (If applicable, enter " xem t " in the license number line.) D/ Bus. Tel. No.: is Address: / Alt. *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public S fe y "S" License: Lia 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 LZ Signature Telephone No. PERMIT FEE: $ 2- -,?- o - / -PA, a At Murphy, Peter 16 From: Dan Forte [fortedan@edgewoodre.com] Sent: Monday, March 11, 2013 9:13 AM To: Gordon Stockwood; Murphy, Peter Cc: Brown, Gerald; Tom Roy Subject: RE: edgewood final electrical permit sign off will call ahead and take care of this. Thanks, Dan Forte Edgewood Retirement Community, Inc. www.edgewoodre.com 575 Osgood Street, N. Andover, MA 01845 Tel: 978-738-6414 Fax: 978-725-5997 fortedan@edgewoodre.com CONFIDENTIALITY NOTICE: This electronic mail transmission and any documents accompanying this electronic mail transmission are intended by Edgewood Retirement Community, Inc. for the use of the named addressee(s) to which it is directed and may contain information that is privileged, or otherwise confidential. It is not intended for transmission to, or receipt by, anyone other than the named addressee(s) (or a person authorized to deliver it to the named addressee(s)). It should not be copied or forwarded to any unauthorized persons. If you have received this electronic mail transmission in error, please delete it from your system without copying or forwarding it, and notify the sender of the error by reply e-mail or by calling Edgewood Retirement Community, Inc. at 978-725- 3300, so our address record can be corrected. From: Gordon Stockwood[mailto:gordon@gandbelectrical.com] Sent: Monday, March 11, 2013 8:46 AM To: 'Murphy, Peter'; Dan Forte Cc: 'Brown, Gerald'; 'Tom Roy' Subject: RE: edgewood final electrical permit sign off Hi peter Thanks for your help / patience while we worked thru the egress Igt issue w/ edgewood Hi clan Can you or someone from edgewood get down to see peter to get the permit signed off? See below thanks Gordon Stockwood, GM G & B Electrical Services, Inc. 31 Pleasant Valley Rd Amesbury, MA 01913 P: 1-978-388-7557 4 F: 1-978-388-9666 C: 1-508-962-8110 Master Licenses in MA, NH, ME & VT From: Murphy, Peter[mailto:pmurphy@townofnorthandover.com]o^ Sent: Monday, March 11, 2013 7:41 AM To: 'Gordon Stockwood'; ':fortedan@edgewoodre.com' Cc: Brown, Gerald Subject: RE: edgewood final electrical permit sign off Hi Gordon, Thank you for all your additional work on this important matter, I will forward the to the building inspector. The building card will have to be signed for the building inspector, I will sign the six units for them in the office 7:30 to 9:00 m -f (9786889545) have them call ahead to confirm I'm in the office that day. Again, THANK YOU Peter Murphy Electrical Inspector Town of N Andover From: Gordon Stockwood[mailto:gordon(&ciandbelectrical com] Sent: Thursday, March 07, 2013 3:08 PM To: Murphy, Peter Subject: FW: edgewood final electrical permit sign off Hi peter See below It has now been confirmed that all 6 bathrooms are backed up by the 250 kw generator Thanks for your patience I assume we are now all set Gordon Stockwood, GM G & B Electrical Services, Inc. 31 Pleasant Valley Rd Amesbury, MA 01913 P: 1-978-388-7557 F: 1-978-388-9666 C: 1-508-962-8110 Master Licenses in MA, NH, ME & VT From: Dan Forte [mailto:fortedan()edgewoodre com] Sent: Thursday, March 07, 2013 2:54 PM To: Gordon Stockwood Cc: Tom Roy; harry french Subject: RE: edgewood final electrical permit sign off Gordon, Good news!! Both Powder Rms are generated also. The bathrooms are next to the Auditorium in building 4000 on the second level. The circuit is in a panel on the other side of building 3000 in a basement emergency room behind an electrical room on a breaker that was once marked spare 24. It was at least 300' away and 2 floors down. You can assure him that all 6 are on the 250kw generator and he is welcome to follow up if he needs to. Thanks, Dan Forte Edgewood Retirement Community, Inc. www.edgewoodre.com 575 Osgood Street, N. Andover, MA 01845 Tel: 978-738-6414 Fax: 978-725-5997 fortedan )-edgewoodre.com CONFIDENTIALITY NOTICE: This electronic mail transmission and any documents accompanying this electronic mail transmission are intended by Edgewood Retirement Community, Inc. for the use of the named addressee(s) to which it is directed and may contain information that is privileged, or otherwise confidential. It is not intended for transmission to, or receipt by, anyone other than the named addressee(s) (or a person authorized to deliver it to the named addressee(s)). It should not be copied or forwarded to any unauthorized persons. If you have received this electronic mail transmission in error, please delete it from your system without copying or forwarding it, and notify the sender of the error by reply e-mail or by calling Edgewood Retirement Community, Inc. at 978-725- 3300, so our address record can be corrected. From: Gordon Stockwood[mailto:gordonC&gandbelectrical.coml Sent: Tuesday, March 05, 2013 11:46 AM To: Dan Forte Cc: 'Tom Roy'; 'harry french' Subject: RE: edgewood final electrical permit sign off Hi clan I had a permit for all 6 What he said to me yesterday was that if there wasn't egress lighting in each bath, he was going to advise the bld inspector of the same as it is the build inspector's requirement that had to be met I will work on getting you a couple of cuts for tomorrow Gordon Stockwood, GM G & B Electrical Services, Inc. 31 Pleasant Valley Rd Amesbury, MA 01913 P: 1-978-388-7557 F: 1-978-388-9666 C: 1-508-962-8110 Master Licenses in MA, NH, ME & VT From: Dan Forte [mailto:fortedan(a)edgewoodre.coml Sent: Tuesday, March 05, 2013 11:30 AM To: Gordon Stockwood Cc: Tom Roy; harry french Subject: RE: edgewood final electrical permit sign off Do you have a picture & specs. Also if there was no permit, what is he signing off on? Dan Forte Edgewood Retirement Community, Inc. www.ed-gewoodre.com 575 Osgood Street, N. Andover, MA 01845 Tel: 978-738-6414 Fax: 978-725-5997 fortedan(a�edgewoodre.com CONFIDENTIALITY NOTICE: This electronic mail transmission and any documents accompanying this electronic mail transmission are intended by Edgewood Retirement Community, Inc. for the use of the named addressee(s) to which it is directed and may contain information that is privileged, or otherwise confidential It is not intended for transmission to, or receipt by, anyone other than the named addressee(s) (or a person authorized to deliver it to the named addressee(s)). It should not be copied or forwarded to any unauthorized persons. If you have received this electronic mail transmission in error, please delete it from your system without copying or forwarding it, and notify the sender of the error by reply e-mail or by calling Edgewood Retirement Community, Inc. at 978-725- 3300, so our address record can be corrected. From: Gordon Stockwood [mailto:gordon@ciandbelectrical.com] Sent: Tuesday, March 05, 2013 11:27 AM To: Dan Forte Cc: 'Tom Roy'; 'harry french' Subject: RE: edgewood final electrical permit sign off Hi clan Thanks for info Is it ok to install an ebu in each so the inspector will approve? thanks Gordon Stockwood, GM G & B Electrical Services, Inc. 31 Pleasant Valley Rd Amesbury, MA 01913 P: 1-978-388-7557 F: 1-978-388-9666 C: 1-508-962-8110 Master Licenses in MA, NH, ME & VT From: Dan Forte [mailto:fortedan(a)edgewoodre.coml Sent: Tuesday, March 05, 2013 10:16 AM To: Gordon Stockwood Subject: RE: edgewood final electrical permit sign off Hi Gordon; The 2 powders rooms are not on any of the emergency panels. Dan Forte Edgewood Retirement Community, Inc. www.ed-gewoodre.com 575 Osgood Street, N. Andover, MA 01845 Tel: 978-738-6414 Fax: 978-725-5997 fortedan edgewoodre.com CONFIDENTIALITY NOTICE: This electronic mail transmission and any documents accompanying this electronic mail transmission are intended by Edgewood Retirement Community, Inc. for the use of the named addressee(s) to which it is directed and may contain information that is privileged, or otherwise confidential. It is not intended for transmission to, or receipt by, anyone other than the named addressee(s) (or a person authorized to deliver it to the named addressee(s)). It should not be copied or forwarded to any unauthorized persons. If you have received this electronic mail transmission in error, please delete it from your system without copying or forwarding it, and notify the sender of the error by reply e-mail or by calling Edgewood Retirement Community, Inc. at 978-725- 3300, so our address record can be corrected. From: Gordon Stockwood [mailto:gordon0gandbelectrical.coml Sent: Monday, March 04, 2013 3:58 PM To: Dan Forte; 'Tom Roy'; 'Kevin Tremblay' Cc: linda(abgandbelectrical.com Subject: RE: edgewood final electrical permit sign off Thanks dan Can you checkout the powder rms tomorrow? gordon From: Dan Forte [ma iIto: fortedan(abedgewoodre coral Sent: Monday, March 04, 2013 3:45 PM To: Gordon Stockwood; Tom Roy; Kevin Tremblay Cc: linda(a ciandbelectrical.com Subject: RE: edgewood final electrical permit sign off The second floor across from the din/rm are the same (generator). We have not been able to confirm that the 2 powder rooms are also generated yet. Tom is correct. There were only 2 permits taken out for the 2 downstairs bathrooms. I was with the Building Inspector last week and he confirmed that there were only 2 permits pulled. Dan Forte Edgewood Retirement Community, Inc. I www.edciewoodre.com 575 Osgood Street, N. Andover, MA 01845 Tel: 978-738-6414 Fax: 978-725-5997 fortedan _edgewoodre.com CONFIDENTIALITY NOTICE: This electronic mail transmission and any documents accompanying this electronic mail transmission are intended by Edgewood Retirement Community, Inc. for the use of the named addressee(s) to which it is directed and may contain information that is privileged, or otherwise confidential. It is not intended for transmission to, or receipt by, anyone other than the named addressee(s) (or a person authorized to deliver it to the named addressee(s)). It should not be copied or forwarded to any unauthorized persons. If you have received this electronic mail transmission in error, please delete it from your system without copying or forwarding it, and notify the sender of the error by reply e-mail or by calling Edgewood Retirement Community, Inc. at 978-725- 3300, so our address record can be corrected. From: Gordon Stockwood [ mai Ito: gordonOgg ndbelectrical.coml Sent: Monday, March 04, 2013 3:35 PM To: Dan Forte; 'Tom Roy'; 'Kevin Tremblay' Cc: IindWIgandbelectrical.com Subject: RE: edgewood final electrical permit sign off Hi clan Thanks for the info on the 152 floor bathrms Can you confirm if the 2nd floor bathrms are the same? Powder rms? thanks Gordon Stockwood, GM G & B Electrical Services, Inc. 31 Pleasant Valley Rd Amesbury, MA 01913 P: 1-978-388-7557 F: 1=978-388-9666 C: 1-508-962-8110 Master Licenses in MA, NH, ME & VT From: Dan Forte [ma iIto: fortedan@)edgewoodre coml Sent: Monday, March 04, 2013 11:32 AM To: Tom Roy; Kevin Tremblay Cc: Gordon Stockwood; Iinda(aciandbelectrical.com Subject: RE: edgewood final electrical permit sign off FYI The 2 bathrooms on the first floor have the back light, against the wall over the toilet (s) on an emergency breaker. The 2 Din/Rm 2 bathrooms are the same lighting but on a different emergency circuit. I Dan Forte Edgewood Retirement Community, Inc. www.edgewoodre.com 575 Osgood Street, N. Andover, MA 01845 Tel: 978-738-6414 Fax: 978-725-5997 fortedan _edgewoodre.com CONFIDENTIALITY NOTICE: This electronic mail transmission and any documents accompanying this electronic mail transmission are intended by Edgewood Retirement Community, Inc. for the use of the named addressee(s) to which it is directed and may contain information that is privileged, or otherwise confidential. It is not intended for transmission to, or receipt by, anyone other than the named addressee(s) (or a person authorized to deliver it to the named addressee(s)). It should not be copied or forwarded to any unauthorized persons. If you have received this electronic mail transmission in error, please delete it from your system without copying or forwarding it, and notify the sender of the error by reply e-mail or by calling Edgewood Retirement Community, Inc. at 978-725- 3300, so our address record can be corrected. From: Tom Roy [mailto:troy(o)kellyconstruction.com] Sent: Monday, March 04, 2013 10:39 AM To: Kevin Tremblay Cc: Dan Forte; Gordon Stockwood; Linda Beaulieu (linda(abgandbelectricalxom) Subject: FW: edgewood final electrical permit sign off Kevin., the electrical inspector is hounding Gordon . He needs to get back to him first thing in the morning. Reme.nber we did not pull permits for the second floor bathrooms . It was only cosmetic and should not apply anyway. Thanks, Tom From: Gordon Stockwood [mailto:gordon(a)gandbelectrical.coml Sent: Thursday, February 28, 2013 11:39 AM To: Tom Roy; 'harry french' Cc: 'Linda Beaulieu' Subject: edgewood final electrical permit sign off Hi tom On 2/20 the n. andover electrical inspector {peter Murphy} had asked me to respond to a ? regarding emergency egress lighting in the 6 bathrms. I asked harry to ask the proper person @ edgewood a ? which could mean that we are in code compliance w/ the bathrooms the way they are. Are the bathroom lighting circuits on the life —safety generator? I don't know the answer to that ? If not on the generator, the inspector will most likely not pass the installation It then would be necessary to install an ebu in each of the 6 bathrms On 2/26 1 heard thru harry that dan @ edgewood does not want to do anything about this. Either way I need to get back to the inspector so that I don't destroy his trust in G & B Please try to get an answer for me by Monday 3/4 thanks Gordon Stockwood, GM G & B Electrical Services, Inc. 31 Pleasant Valley Rd Amesbury, MA 01913 7 P:.1-978-388-7557 F: 1-978-388-9666 C: 1-508-962-8110 Master Licenses in MA, NH, ME & VT Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: hftp://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. Date. .7(°074......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION � This certifies that G ... ., I...oL�"� ... has permission for gas installation .... ... �:�.. . in the buildings of at .5:T5.. .. , North Andover, Mass. ,Fee �.: ?. Lic. .... .. GAS INSPECTOR 11" Check # J2j� Bi l 1 rte-` MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: IVO I �1f 1i�1/L.r , MA. Date: 04"14,11 Permit# Building Location: 0 Owners Name:Fa t&-r��c Type of Occupancy: Commercial I Educational ❑ Industrial ❑ Institutional ❑ Residential ❑ New: ❑ Alteration: ❑ Renovation: ❑ Replacements Plans Submitted: Yes ElNO IV Installing Company Name: _int I i%. NL-� DA Address: City/Town: A State: ` Business Tel: "7 / 141).1'74„-_ Fax:, giB• li%0 0 ISI -3 Name of Licensed Plumber/Gas Fitt Check One Only /Corporation ❑ Partnership ❑ Firm/Company Certificate # 1109- INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes o ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVR: 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 Signature of Owner or Owner's Agent Owner ❑ Agent El By checking this box ❑, 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. [APPROVE6D A Ty e of License: Plumber Gas as Fitter Signature of Licensed Plumber/Gas Fitter er Journeyman License Number: _ (OFFICE USE ONLY) ❑ LP Installer 1- • N woo, 0 WMMMMMWMMMMMMMMMMMMMM EMIR -1::1 MMMM J MMMMMMMMMMMM��� Installing Company Name: _int I i%. NL-� DA Address: City/Town: A State: ` Business Tel: "7 / 141).1'74„-_ Fax:, giB• li%0 0 ISI -3 Name of Licensed Plumber/Gas Fitt Check One Only /Corporation ❑ Partnership ❑ Firm/Company Certificate # 1109- INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes o ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVR: 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 Signature of Owner or Owner's Agent Owner ❑ Agent El By checking this box ❑, 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. [APPROVE6D A Ty e of License: Plumber Gas as Fitter Signature of Licensed Plumber/Gas Fitter er Journeyman License Number: _ (OFFICE USE ONLY) ❑ LP Installer I The Commonwealth ofMassachusetts Department of Industi al.Accidents Office ofinvestigations 600 Washington Street Boston, M4 02111 Www mass Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): � t - Address: - - City/State/Zip;Ao , A m-Ap tkyA mu 0 Phone 4. Are yon an employer? Check the appropriate box: 1.I am a employer with Z. 4. ElI am a general contractor and I employees (full and/or part-time).*' have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub --:contractors have worldng for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing officers have exercised their 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.] ,*A.ny Epplicant that cbeess bo—ml must also fill out -the section belor, Type of project (required): • 6. ❑ New construction 7. ❑ Remodeling 8. ,❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11'. lumbing repairs or additions 121. Roof repairs 13.❑ Other Homeowners who submit this affidavit indicating they are doing all work and then hireutside contractors must submit new affidavit indicating such. 1contractors that check this box must attached an additional sheet showing the name of the sub -contractors and (heir workers' comp, policy information. I am an employer that is providing workers' compensation information. insurance for my employees Belowis the policy and job site Insurance Compiny Name: Policy # or Self -ins. Lic. #:_ W6 SI 70 V? Expiration Date: 8 Job Site Address: 1:) 7 " QS �,op4—% C^j— • City/State/Zip.-_j0o AAAML4vt OM Attach a copy of the workers' compensation policy declaration page (showin ' OI g the policy y n umber and expiration date). Failure to secure coverage as required under Section 25A ofMGL 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 andpenalties ofperjuly that the information provided above is true and correct Sliilflt7lTA I til Official use only. Do not write in this area, to be completed by city or town official City or Town: Perm if/i St,Pnv. Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing 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 6r 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 bean 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 certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with -no employees other than the members or partners,. are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be -advised that this affidavit may be submitted.to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date -the affidavit. The affidavit should be r't Tas d to the city or toRrn that 'W5, a�vp';ioafiori for the pea-uh-or license is being requested, nV. the Dgpart ment 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 bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would'like to than you in advance f6r 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 ofInvestigatons 600 Washington Street Boston, MA. 02111 Tel. # 617-727-4900 ext 406 or 1-8.77 MASSAEE Fax # 6.17-727-7749 Revised 5-26-05 III, Date..................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �SAC-H U r This certifies that .... a. a., 9. ! -94 has permission for gas installs n .4134-64' in the buildings of at ... 47 ................ 0North An over, Mass. Fee: -$6',1. . Lic. No./a/`?:-.. GASINSPECTOR Check# Jb4�1 Z— ,_.b MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY (NORTH ANDOVER MA DATE10410512012 PERMIT # .y ES�b �, JOBSITE ADDRESS 575 OSGOOD ST APT 3309 OWNER'S NAME EDGEWOOD �� OWNER ADDRESS �,� I GTE� F�....... TPRINTR OCCUPANCY TYPE COMMERCIAL! EDUCATIONALj RESIDENTIAL CLEARLY NEW:0 RENOVATION: El REPLACEMENT: PLANS SUBMITTED: YES [3 NDE] APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 1 9 10 11 12 13 14 BOILER ' ,.. BOOSTER ...-.. i.r CONVERSION BURNER COOK STOVE DIRECT VENT HEATER�' I .. _ _._ 3 DRYER l FIREPLACE [ – _ E1 FRYOLATOR FURNACE I 1 GENERATOR n GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER M R ROOM SPACE HEATER..,'.. I ROOF TOP UNIT TEST �� � .. � ._ l.. i UNIT HEATER UNVENTED ROOM HEATER I WATER HEATER _ l r j E tea. d ....� 3• OTHER �'i�� -, � ;�..� ..,fie,. ,��� _saa��i .,..� d E i INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES !� NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0,, OTHER TYPE INDEMNITY BOND r 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 (n AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true n ccurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comps c ith all P rtinent vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /1 t` PLUMBER GASFITTER NAME JEFF HUTNICK LICENSE # 15212 ' SIGNAT RE ,� _. MP MGF El JP JGF � LPGI EJ CORPORATION ! �# 2 0 PARTNERS E IPEI#[ LLC �# �. » COMPANY NAME: CALLAHAN AC & HTG ADDRESS 91 BELMONT ST CITY NORTH ANDOVER STATE MA ZIP 01845 STEL[ 78-689-9233 FAX CELL REMAIL PLUMBING@CALLAHANAC COMgsr n 2\ The Commonwealth ofMassachu Department of Industrial Accide Office of Investigations 600 Washington Street www.rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciaus/Plumbers Apl�lzeant Information (''lease Print Legibly Ia111 (Business/Oroutization/Individual): Address: r-- Cit}I,11phone #:/lr A,rre,yyoou an employer'? Check the appropriate box: � 4• 1� 1 am a employer with, k� 5� '� ❑ I am a general contractor and I employees (full and/or part -tune).* have hired the sub -contractors !.El 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. employees and have workers' [No �vorkers' comp. insurance comp. insurance.$ required.] 5. [] We are a corporation and its Q I am a homeowner doing all work officers have exercised thein myself. [No workers' comp, right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): f. Q New construction 7. ❑ Remodeliti- 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repaius or additions 11.[? Y umbing 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 indicatingthey are doing all work and then hire outside contractors must submit a new affidavit indicating such. lConrractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. Ir the sub -contractors have employees, they must provide their workers' comp. policy number. urn an employer that is providing workers' compensation insurance for my err5ployecs. Below is the policy and job site inforrnatiort. Insurance Company Name: 6&( A.t— Policy �t or Self -iris. Lie. #:_� 12 Expiation Date:_ 01 _ Job Site Address: 41m) It Af j 36q Ciiy/State/Zip: /U•,�PA”( , 4Lld O4 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 penalries of a fine up to $1,500.00 and/or one-year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is trite and correct. Phone ft: O t f- f9 ? _;2_ a .3 Ujftcial use only. Do not write in this area, to be completed by city or town officiaL Ciiy or Town: Pertuit/1<.�it:rnsq i� Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector b. Other Contact Person: Phone #: Date. ........ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that..j��".".............. . . has permission for gas Inst Illation .. 9%l /. �rr!4C?.......... in the buildings of . -4.......... e-:.......... .... . at ..S% OSS ..... 53" Fee.SS'o v Lic. GAS INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY NORTH ANDOVER MA DATE 031 ®l12 PERMIT # JOBSITE ADDRESS575 OSGOOD ST UNIT 3202 OWNER'S NAME EDGEWOOD INC OWNER ADDRESS [5:7jO— TEC-- FAX TYPE OR OCCUPANCY TYPE COMMERCIALS EDUCATIONAL RESIDENTIALED PRINT CLEARLY NEW: RENOVATION: FA REPLACEMENT: 0 PLANS SUBMITTED: YES NO[] APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ._..�.�_ ...„,�.._ � L:: .�. .. „,. m � .3 . t BOOSTER CONVERSION BURNER € I _ _. i _ ,,_ .•_.;l� COOK STOVE j [, DIRECT VENT HEATER = i [ r—” DRYER _.. _==r FIREPLACEy s� fl . FRYOLATOR r FURNACE GENERATOR� GRILLEI,.. INFRARED HEATER LABORATORY COCKS _,, MAKEUP AIR UNIT OVEN POOL HEATER I {v ROOM /SPACE HEATER ROOF TOP UNIT_.E TEST„ UNIT HEATER UNVENTED ROOM HEATER _.... „_.. w. WATER HEATER E _ � ..n .. OTHER w l... Ing „I m a_ µ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY P 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 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 compl with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / PLUMBER-GASFITTER NAMEJEFF HUTNICK LICENSE # 15212 / GNATURE mm MP MGF [j JP P_ JGF [ LPGI E] CORPORATION# 2 48 0 PARTNERSHIPS# LLC:,]#J w COMPANY NAME: C: LM_HAN AC AND HTG ADDRESS 91 BELMONT ST CITY [ NORTH ANDOVER STATE ZIP 01845 TEL 978 689 9233 .� FAX CELL _ EMAIL ", �`N The Coinnionwealth of Massachusetts Department of Industrial Accidents 4 4 _'- - `x4_ = Office of Investigations 600 Washington Street K employees (full and/or part -tune).* err ,6oston, MA 02111 ~r=` www.rrtass.gov/dia Workers' Compensation Insurance Affidavit: ]Buildters/Contractors/Ele.ctricians/Plumbers Applicant Information Please. Print )Legibly // �laIllZ (Business/Ordtutizatiot>/Individual): ZL Address:y--- Cil /S 3to/Z>p 11ilhone #: i�7 � _' _ Type of project (required): Are you an employer? Check the appropriate box: I. LZ i atn a employer with ->-9 J_ 5_ '` 4. ❑ I am a general contractor and 1 employees (full and/or part -tune).* have hired the sub -contractors 6. ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. E]Rerrlodeling ship and have no employees These sub -contractors have g, ❑ Demolitioll working for me in any capacity, employees and have workers' 9. Building addition b [No workers' comp. insurance required.] comp. insurance.$ 5. ❑ We are a corporation and its 101-1 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised thea' 11. umbing repairs or additions myself. [No workers' comp, right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no 13.❑ Other employees. [No workers' comp. insurance required.] 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 11-10meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. !Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. if the sub -contractors have employees, they must provide their workers' comp. policy number. I a,ai an employer that is provide2g workers' compensation insurance for nzy employees. Below is the policy and job site inforntatiom Insurance Company Name: Gc.f Policy �r' or Self -urs. Lic. #:_ Expiration Dale:_� Job Site Address: 5-7,5— 66&0U6 5. % — kdpo &jk City/State/Zip: h14-/ ()% 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 penahies 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 Oif ce of Investigations of the DIA. for insurance coverage verification. Ido hereby cert under the pains and penalties ofperjury that the information provided above is true and correct Phone #: -j7 f /r ff 9 2— 3.3 Official use only. Do not write in this area, to be completed by city or town officiaC City or Town: Pern;iit/Livensg 4 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing .Inspector ti. Other Contact Person: Phone #: Date. 52 TOWN OF NORTH ANDOVER ' PERMIT FOR PLUMBING This certifies that ... 04 �?.... . has permission to perform....' 10J. . CIJ.....�z,,* ... ............. .. plumbing in the buildings of�) O� at ... os.6 ........... North Andover, ass. Fee. 3P .. Lic. No. KA54 . ...... IA1144V .0. 6� PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: MA. Date /J 'Permit# ... . .. �Building Location:. Owners Name: e�le w.. .: , Type of Occupancy: Commercial : Educational Industrial institutional Residential Re New Alteration ; Renovation placement:: •r Plans Submitted: Yes No FIXTURES INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ✓ ``No If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ' ._ Agent ^nature of Owner or Owner s Ag^^• reby certify that all of the details submitted (or entered) regarding this application are true and accurate to the best of my r%nowieage ana tnat all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. BYType of License: Title.✓ Plumber S nature of Licensed Plumber Master cityrrown Journeyman License Number: 10854 APPROVED OFFICE USE ONLY -•-=• • • - z U) co CAI O U)U (n X a. to fn z Q N Z r z J x W U O Q to W � x z Q w to x a LU cn ~ W a IQ- W rn >4 W z a X W ❑ O J m cn w ❑ Q rn Q H- W Q z W �- rr O !r ❑ e: W Z m W O J Z V H= a O y U 0.a' z< p p a z F W 0 1' >> g O x zQ txn x Q Q Q Q m m 0 u_ 0 x �c �n �n M O SUB BSMT. BASEMENT iST FLOOR --i'FLOOR -3u--FLOOR - 4 ' FLOOR 5 FLOOR -'d'FLOOR 7 1H FLOOR 8 FLOOR Check One Only Certificate # Installing Company Name AALANCO SERVICE CORP Corporation 2033 Address . 80B Turnpike Rd City/Towni Westborough State MAc;' -: Partnership Business Tel: 508-366-1449 Fax: 508-366-1196 - - - „,,,_.... Firm/Company Name of Licensed Plumber:'„Michael Gour INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ✓ ``No If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ' ._ Agent ^nature of Owner or Owner s Ag^^• reby certify that all of the details submitted (or entered) regarding this application are true and accurate to the best of my r%nowieage ana tnat all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. BYType of License: Title.✓ Plumber S nature of Licensed Plumber Master cityrrown Journeyman License Number: 10854 APPROVED OFFICE USE ONLY -•-=• • • - -*9666 Date .......... ,aoRTM TOWN OF NORTH ANDOVER p PERMIT FOR WIRING 41 This certifies that�...4/)m� . ............................................................. has permission to perform .........fie,�-Lo...... L f. -7z ................... wiring in the building of ......:.�.�ft.:.rr!....................................... at ...... �T - .tom.... S�rOe? �... ....... ,North Andover, Mass. ` Fee../. Lic. No...�.�%%...�._::............... ELECTRICAL tNSPER Check.. Commonwealth of Massachusetts Oficial Use Only Permit No. d L' Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. l 1199] 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 IN INK OR TYPE ALL INFORMATION) Date: 9--��-6 , City or Town of: Nc/� bLa< To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 6 Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No Check Appropriate Bog) Purpose of Building UtiUty'Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Meters No. of Meters / Combletion ofthe followiniz table may be waived by the Inspector of Wires. No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. Total s Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures SwimmingPool Above ❑ In- ❑ d. rnd. o. o mergency Lighting Bate Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches eL1 c;�� No. of Gas Burners No. I llnitiatin ting nand Devices No. of Ranges No. of Air Cond. Tonsl No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained No. of Waste Dis posers P Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating- KW S P g� Local ❑ Municipal El Other Connection No. of Dryers rY Heating Appliances KW Security Systems: No. of Devices or uivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or EQuivalent OTHER: Attach additional detail ifdesired, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coovveragesin force, and has exhibited proof of same to thepenyt issuing 9fiice. CHECK ONE: INSURANCE L9®BOND ❑ OTHER ❑ (Specify.) A,/11T/_ (Expiration te) Estimated Value of Electrical Work: (When required by municipal policy.) l Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the .jai and penalties of perjury, that the information o is plic ' n ' true and complete. FIRM NAM / / / LIC. NO.: Licensee: - 4&1 Signature LIC. NO.:. t� Bus. Tel. No.! Address: /)/ a)) Alt. Tel. No.:®' OWNER'S INSURANC AIVER: 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/AgentPERMIT FEE: $ SignatureturaTelephone No. w N H 0 z H tz m 1-3 � H � H H O � O H L w z H H � H H O rMz c yym cn Pi trrl H H C] 9 � y r d � It3l R 7 3� Date ............. TOWN OF NO TH ANDOVER 1.00 PERMIT FOR PLUMBING This certifies that .. o/lx... > has permission to perform .. *W.eit..vzi�,�... plumbing in the buildings of wo.4 .d ................... at ,,? 75 ...C? SSG.Q .. .(1n!!� � *S—, North ndove emass. ki may, /. . Check # �q& 8673 PLUMBING INSPECTOR Vaal FfXTURES -a t VMMU,NWEALTH OF MASSACHUSETTS _ ' II LICENSED AS A MASTER PLUMBER i ISSUES THE ABOVE LICENSE TO: ROBERT B BLANCHETTE PO BOX 728 cc NORTH ANDOVER MA 01845-0728 I 8597 05/01/12 788344 '' i The Commonwerxlth of Alassachusetts Department ofrnat'ustriaZ�ccidents Offace of-�pivestzgatioazs 60.0 Washington Street • C• $ostan, 1fv�Q 02111 wMv_Mas&1 oTv1dia Workers' Compensation Insurance Affidavit: �guflders/ContractorsXlectri'-- Plumbers n licant Tnforntaf�on Please Prim Leggbb Name, (Bs iness/Organization&diiridual): Aim 1?6y�-k td �kA 04 � R Address: ' ' pr, ...r 7�� City/State,/Zip:_ #: S78.470 • )79 3 - • • •Are you an employer? Check the appropriate box: ] I. I am a employer with. 2— 4. ❑ T am a general contractor and I employees (full and/or part time).* 2. ❑'I have hired the sub -contractors ain a sole proprietor orpariner- listed on the attached sheet ship and have no employees These sub—contractors have working for main any capaci4,r workers' comp. insurance. [No workers' comp. insurance. 5. ❑ We are a corporation and its required.]Officers 3.0 am a homeowner doing Work have exercised their •I all myself. [No workers' comp, right of exemption per MGL c. 152, 6-1(4), anal we have in required.] t no employees. [No workers' c.8mp. instYrancm.reg,,,, e d Type of project (required): fi- 0 Net construction 7• emodeling 8. Demolifion 9. 0 Building addition 10.[] Electrical repairs or additions 11.[] Plumbing repairs or additions 12.[] Roof repairs 13.0 Other r=n1, appT :t f5s_ ci Uo box. zip I i s�1c� nc� ere heal: a'.no:::%_^.� r.=irwcric ' F�OFf1cOWIIEYa WAO SllUTIlIt Th1S affidavit indieating h , _,ms s cou. �`oa •,,.,.�.. , LLb ...,_mi t_cy dc�g all ii aad = rJ� u u +Contract�Is that ch^ I- ' •- box ... h then hireoutside conametors I]I k su uit a new amdavit indicating such. '�� t•,:.- �� u••acu�, � additional sheet showinPthe - . aame"of the sub -contractors and theirworkas' conte. policy information l arrrn an employer that isproviding workers' compensation insurance for informatzan. my employees Eeloto, is the policy and job site. Insurance Company Name*.—AC a Policy # or Self ins. Lic. LJ C. Cod) 6 Expiration Date -�� `g Ib Job Site Address: S ?S D S 6�raoQ r U Ni -4y ' �,� cir /State/Zip; l VAg5 LM Attach a copy -of the workers' compensation policy declaration page (shavdng 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 fine up to $1,500.00 and/or one-year imprisonment, criminal penalties of a Of as well as civil penalties in the form of a STOP WORK ORDER and a fine up to $250:00 a day against the violator. Be advised that a copy of statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby ceriify under the pains and panalties of perjure thIxt the informarion provided above is true and correct Siffiature. Phone #: tY700-172. 179 Official use only. Do nat write'in this area, to be completed bJ, city or torn official a City or Town: 1 ermitUcense # )`ssrt� Authority (circle one): x. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing inspector 6.Other Contact laersort: Phone'#. Gllant8! 8755 aCORD. CERTIFICATE OF LIABILITY INSURANCE DAT! pNilAxllrYYY) 11/20109 PRODUCER Doherty insurance Agency, Inc. P.O. Box 1985 21.Elm Street Andover, MA 01810 THIS CERTIFICATE`I81SSUEDAAS A MATTER OFiNFORMATION WRIGHTS UPON THE CERTIFICATE ONLY AND. CONFERS,EXT HOLDER. THIS CERTIFICATE DOES NOT AMEND, END OR ALTER THE COVERAGE AFFORDED SY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAILS INSURED 4 White Rock Plumbing.and Heating Corp P.O. Box 728 North Andowl-MA 01845 INSURER A. Travelers' INSURER B: Guard. Insurance Group INSURER C: Pilgrim insurance Company INSURERD: INSURER E: THE POLICIES OF INSURANCE LISTEOBELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PEAIOD:INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDrION OFANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS; EXCLUSIONS,AND CONDITIONS OF SUCH POLICIES: AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. %'' TYPE OF INSURANCE POLICY NUMBER EFFECTIVEON LtlINTB. rA OF.IIERALS1ABIlNrY X` COMMERMGENERAL LIABILITY 680856SC599 11►18109 W18110 EACHOCCURRENCe SIA00,000 REN 0 a9OO CLAWS MADE ❑X OCCUR MED EXP (NW an* pa" $5,000 PERSONAL &AOV INJURY 510.0D 000 OENERALAGGREOATE <, $2000000 GEN.LAGGREGATE LIMIT APPLIES .PER: . PRODUCTS-CGMP/CP.AGG., x2000000 X. POLICY PRO•JECT LOC C" Auioaolal,EUABILmr ANY AUTO PGC10009898046 11118109 11/78/10NGLELIMIT $1,000;000 80DI.YINJURY ... X ALLOWNEDAUTOS, ammuLm AUTOS. BODILY INJURY (Per.aaridaML. S . X' X :HIRED AUTOS NON -OWNED AUT08 _ PROPERTY DAMAGE a '(Per [aide m) GARAGE tIABILI" 'MM ONLY'- EA ACCIDENT S O HERTHAN EA ACC S ANYAUTO AUTO ONLY; AGG 9 . EXCESSIUYBRELLAUkOlU Y OCCUR ID CLAIMS MADE EAC HOCCURRENC'ES AGGREGATE, S S DEDUCTIBLE 5. RETENTION 5 B WORKERS COMPENSATION AND WHW0009877 11/18/09 11118110 Y1C STATUOTH. 1-1 ::. E.L. EACH ACCIDENT - $500000 - EMPLOYERS' LNIBRITY OOFFICEWMEMBER XCLUDED I� E.L. DISEASE. EAEMPLOYEE $508000 E.L.DISEASE-POU LIMIT $500000 11 Eeialhe under OTHER DEBCRWTWN OF OPERATION8 / LOCATIONS I VEIRCLES I F-XCLUSWNS AD09D'6YENDOR8EMENT / aPEC1AL PROVISIONS Covering operations usual to White Rock Plumbing and Heating Corp... -0 i 4 Date.... �� .`�/.. lu....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING �� f1 This certifies that has permission to perform �-'-�---:'- � wiring in the building of ....�' ......'"``,,,,,,,,,,,,,,,,,, at .....................................5.%..North � �............... . , An v do er, l Mass Fee A .......... Lic. No 1.,.'%'/�,.............. 4LECTRI Check # 9350 4 ENECommonwealth of Massachusetts otcial Use Only :7 Department of Fire Services Permit No. l�`.3�5"� BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked/ ' [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL W Al] work to be performed in accordance with the Massachusetts Electrical Code (MEC)�CMR 2.00WORK (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: G City or Town of: NORTH ANDOVER To the Inspect r of Wires: By this application the undersigned gives noticeof his or her inten on to erform the electrical work described below. Location (Street & Number) °7S_ 0 Owner or Tenant re=e Owner's Address Telephone No. ,�, /-�r �,-e ,,,,a„ � Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps / Volts New Service Amps / _Volts Number of Feeders and. Ampacity Location and Nature of Proposed Electrical Work. lzn A, No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. jofSwitcheEs.No. ngesNo. oWaste Disposers -------------- No. of Dishwashers No. of Dryers Heaters KW Hydromassage Bathtubs OTHER: -Yes (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters Overhead. ❑ Undgrd ❑ No, of Meters c;omp[etion o -the followin No. of Ceil.-Susp. (Paddle) Fans No. of Hot Tubs Swimming P 0 Above ❑ In- ❑ rnd No, of Oil Burners No. of Gas Burners No. of Air Cond. Total table may be waived by the 1 ranstormers KVA Generators KVA ALARMS !No. of Zones Of Alerting Devices -- metection/Alertin Devices Space/Area Heating KW Local ❑ Municipal Connection ❑ Other 'Heating Appliances KW Secunty Systems:* No. of No. of Devices or Equivalent signs BallastO.s. of Data Wiring - No. No. of Devices or E uivalent No. of Motors Total Hp Telecommunications Wiring: No. of Devices nr Estimated Value of lee .'cal Attach additional detail if Work: desired, or as required by the Inspector of Wires. L (When required by municipal policy.) Work to Start 2 UInspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C VE GE: nless waived by the owner, nopermit 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 ❑ OTR El (Specify.) I certify, under the p nd penalties of p , that the information on this application is true and complete. FIRM NAME: e - Licensee: t; LIC. NO.: Signature LIC. NO.: (If applicab e, enter " pt " in the lice a nu ber he.)p Address: K o $W /� / Bus. Tel. No.: C 998- �z *Per M.G.L c. 147, s. 57-61, security work requires D (V° Alt. Tel. No.: OWNER'S INSURANCE WEER: I am aware that tthheLicens e doles not have the l abili Lie. No. required bylaw By si ature below, I hereby waive this requirement. I am the (check one) ms owner rance coverage owner's normally Owner/Agent/' Signature Com' Telephone No. PERMIT FEE. $ 4;v-, ` c .r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 ff-ashin ton Street Boston, MA 02111 r t www nzass.govldia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plnmbers Applicant Information /f Please Print Leeibli Maine (Bu&inesrJnramni"f;.- {..1:..:.f.._�,. . / Adaress: % L City/State/Zip:_ -------------- Phone #:. Z Z�I Are you an employer? Check the appropriate box: 1: {,I: am a employer with 4. ❑ I am ageneral contractor and I employees (full and/orpart-time).* 2. ❑ I am .a.sole proprietor or have hired the sub -contractors listed partner- on the attached sheet. I ship and have no employees These sub -contractors have working for me .in any capacity, [No workers' comp, insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ 1 am a homeowner doing officers have exercised their all work right of exemption per MGL Tyself. [No•workin' comp. C. 152, § 1(4),'and we have no insurance required.] t .employees. [No workers' comp. insurance required_] Type of Prot (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. (] Building addition 10.[] Electrical repairs or additions 11.❑ Plumbing repairs, or additions 12. [] Roof repairs 13.0 other `Any applicant that checks b& $ l must also fill out the section below showin their workers' co t Homeowners who submit this affidavit indicating they are doing all work and then hitt outside contractors penutioTi poiacy mfonnehon i submit a new 4contractors that check this box must attached an additional sheat showing. the rremF of the sub.contracom anaffidavit indicatias such .,tN. Pulicy RRAnriaiion. ! am an employer that is provi ft :workers' compensation inswance for My emptoyeesc information. below is the policy mrd job site Insurance Company Name: ' Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip. Attach a copy of the workers' compensation policy deciaration 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 Op, -nd a fine J 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 veninication. ! do hereby certafy/undyer the/ inks and pena> X of peri that the information provided abo is hue)and cotTect: Qf}°u W use only. Do not write in this area, to be completed by city or fawn officiaL .t . 11 City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Towu Clerk 4. Electrical Inspector 5. Plumbing Inspector Contact Contact Person: Phone #: ACORD CERTIFICATE OF LIABILITY INSURANCEF03/25/2010 TM DATE(MM/DD/YYYY) PRODUCER (603)878-4860 FAX (603)878-1273 Bellows -Nichols Agency, Inc. Town Hill Medical Prof Center PO Box 469 New Ipswich, NH 03071-0469 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Advanced Telecom Construction Co LLC 205 Hubbard Pond Road New Ipswich, NH 03071 INSURER A: Peerless Insurance Company 24198 INSURER B: INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR DD'TYPE NSR OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMIDDIYYYYI. POLICY EXPIRATION DATE (MM/DDIYYYYI LIMITS GENERAL LIABILITY CBP8465829 06/24/2009 06/24/2010 EACH OCCURRENCE $ 1,000,001 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE FKOCCUR DAMAGE TO RENTED PREMISES Ea occurrence S 300,000 MED EXP (Any one person) $ 10,000 A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY X PRO- LOC JECT AUTOMOBILE X LIABILITY ANY AUTO BA8403753 06/24/2009 06/24/2010 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 A X X X ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNEDAUTOS BODILY INJURY $ (Per person) BODILY INJURY $ (Per accident) X Business or PROPERTY DAMAGE $ (Per accident) Business Related GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY X OCCUR CLAIMS MADE CU8173481 06/24/2009 06/24/2010 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 A $ $ DEDUCTIBLE X RETENTION $ 10,000 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY OFFICER/MEMBER ARTNE /E?ECUTIVE Y I N (Mandatory in NH) yes, describe under S SPECIAL PROVISIONS below WC8295610 NH AND MASSACHUSETTS C8576858 RHODE ISLAND YES 06/24/2009 06/24/2009 06/24/2010 06/24/2010 X I TORY LIMITS OETH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE - POLICY LIMIT S 1,000,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS ichael Kinsinger and David Rapa are Excluded from the Worker's Compensation policy. lob: Washington Park Condos 237-357 North Main Street Andover MA 01810 aaK I IFIGA I E HULDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN The Town of Andover NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Paul Kennedy IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 36 Bartlett Street REPRESENTATIVES. Andover, MA 01810 AUTHORIZED REPRESENTATIVE Therese McHugh ACORD 25 (2009101) ©1988-2009 ACORD CORPORATION. All rights reserved_ The ACORD name and logo are registered marks of ACORD PDF created with pdfFactory trial version www.pdffactory.com Date 3/�.!! �.... . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SA Hus I - This certifies that /, ..... /.?. ( C. ............... has permission to perform .... �/-' O.L:,,: S7/1"" �- If- --(< ...................... L, -k r- 0 j ............................ plumbing in the buildings of . 1—f� I at .). 0�- . �. . ""r 9 .... North Andover, Mass. c? .......... Fee ... Lic. No. .. .... ........... ?5 PLUMBING NSPECTOR Check # '? ) 8522 X21 sd SUB'BSMT 3' 8 a tLu Check One Only Certificate,# Installing Company Name: 1, TL (4cie—D tA411i1,r1�'rMl � � 1h� jCorporation i1e0`1 ' Address: -7� CityiT_ own: ► State: ' Z p Coder . Partnership Business Tel: ��4�0172? Cel1. 9�88iS2aIt) F#x 47015793 [j Firm/Company Name of Licensed Plumber: QIAtXAC INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent"which meets -the requlrements of MGL. Ch. 2. Yes No If you have checked Yes, please Indicate the type of coverage by checking the appropriate box below.- A liability insurance -policy Other type of Indemnity -E]Bond ❑ OWNER'S' INSURANCE WAIVER: I am aware that the licensee does no6ave the -insurance coverage i.equired by Chapter 142 of the Massachusetts General Laws, -and that my signature on this permit application- waives this requirement. Check One.,O:nly owner. ❑ Agent ,❑ Si nature of Owner or Ownee§s Ak ent_. I hereby-ceitify that all of the detalls and; Information [,have submitted (or entered)°regarding this application are trueand accurate to the>.best of my Knowledge and that all plumbing work, and installations:.performed under the permit Issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing' Code and Chapter 142 of the General Laws. By Type of License: ruejPlumber Signaturedof:Licensed Plumber aster Q City[Town577 APPROVEOFFICE USE ONLY 11 Lj JoLicense Number: urneyman D .--r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: MA. Date: /YI 617010 Permit# y^Z L Building Location:57�,�, mZ S'"1" Owners Name: UNIT 44 ---(OV" Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residentialx New: ❑ Alteration: ❑ Renovation: El Replacements Plans Submitted: Yes E]NoX SUB'BSMT 3' 8 a tLu Check One Only Certificate,# Installing Company Name: 1, TL (4cie—D tA411i1,r1�'rMl � � 1h� jCorporation i1e0`1 ' Address: -7� CityiT_ own: ► State: ' Z p Coder . Partnership Business Tel: ��4�0172? Cel1. 9�88iS2aIt) F#x 47015793 [j Firm/Company Name of Licensed Plumber: QIAtXAC INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent"which meets -the requlrements of MGL. Ch. 2. Yes No If you have checked Yes, please Indicate the type of coverage by checking the appropriate box below.- A liability insurance -policy Other type of Indemnity -E]Bond ❑ OWNER'S' INSURANCE WAIVER: I am aware that the licensee does no6ave the -insurance coverage i.equired by Chapter 142 of the Massachusetts General Laws, -and that my signature on this permit application- waives this requirement. Check One.,O:nly owner. ❑ Agent ,❑ Si nature of Owner or Ownee§s Ak ent_. I hereby-ceitify that all of the detalls and; Information [,have submitted (or entered)°regarding this application are trueand accurate to the>.best of my Knowledge and that all plumbing work, and installations:.performed under the permit Issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing' Code and Chapter 142 of the General Laws. By Type of License: ruejPlumber Signaturedof:Licensed Plumber aster Q City[Town577 APPROVEOFFICE USE ONLY 11 Lj JoLicense Number: urneyman D .--r to W } U) U) Z d W to z to H Y Z LU u) Z Q N �e O. L+7 m Z W W p IL W t- Q U) .Z �- �" O y �. z co U) w U.a Y _ O p ~ W = zZI Q ..o. u. w 3:4 Y .; . . SUB'BSMT 3' 8 a tLu Check One Only Certificate,# Installing Company Name: 1, TL (4cie—D tA411i1,r1�'rMl � � 1h� jCorporation i1e0`1 ' Address: -7� CityiT_ own: ► State: ' Z p Coder . Partnership Business Tel: ��4�0172? Cel1. 9�88iS2aIt) F#x 47015793 [j Firm/Company Name of Licensed Plumber: QIAtXAC INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent"which meets -the requlrements of MGL. Ch. 2. Yes No If you have checked Yes, please Indicate the type of coverage by checking the appropriate box below.- A liability insurance -policy Other type of Indemnity -E]Bond ❑ OWNER'S' INSURANCE WAIVER: I am aware that the licensee does no6ave the -insurance coverage i.equired by Chapter 142 of the Massachusetts General Laws, -and that my signature on this permit application- waives this requirement. Check One.,O:nly owner. ❑ Agent ,❑ Si nature of Owner or Ownee§s Ak ent_. I hereby-ceitify that all of the detalls and; Information [,have submitted (or entered)°regarding this application are trueand accurate to the>.best of my Knowledge and that all plumbing work, and installations:.performed under the permit Issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing' Code and Chapter 142 of the General Laws. By Type of License: ruejPlumber Signaturedof:Licensed Plumber aster Q City[Town577 APPROVEOFFICE USE ONLY 11 Lj JoLicense Number: urneyman D .--r Date. ?.-,1 �y : ��...... . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 1 ,y •. J o ,..ty This certifies that ..17?'.L411) ..0, L, ......... . has permission for gas installation in the buildings of ... ?Qa?. .......................... . at ................. North Andover, Mass. Fee.1�0." .. Lic. No.,5a (®.... .................... ... GAS INSPECTOR Check # 7086 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) Mass. Date 121,i City, Town Permit # Building Owner's AT: Location Name 11r,ON - - kkff New Renovation Plans Submitted Yes ❑ No Type of Occupancy: Co m hn Replacement ❑ Business Telephone Name of Licensed Plumber or Gasfjtter b5-. oil P,4i�t�,, I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signature of Owner/ Agent I have a current liability insurance nolicv to include completed ppPrarions covers e ❑ By Title City/ Town APPROVED (OFFICE USE ONLY) FORM 1243 ata. SULKIN co. 1989 g• TYPE LICENSE: A. El Plumber 4S�tture of Licensed lumber or Gasfitter � Gasfitter Master 30/0 ❑ Journeyman License Number N - t./ Ix W P N . N W VD x O OW U O F-. F" = F. F z O W! Q Z O = F. N ¢ Q CO to l+ Q O F` 0 N ' IL O g LU FW^ N Wit y1 W ' JW Z O U Q W i of CNC Z W W W O > W Q W J Q .~ W yW, oO > t6 I.. U J O t- W Q OC W >" Y O (7 W: 7C U. Z M Q $ W O aa c9 Q J O U O GC W > _W O 0. W F. I— O SUB—BSMT. BASEMENT 1ST FLOOR.' 2ND FLOOR 3RD FLOOR 'P 4TH FLOOR y STH FLOOR . 0) 6TH FLOOR ! 7TH FLOOR 8TH FLOOR (Print or Type) Check One: Certificate Installing Company Name r(� �I -n C) 1-1 f I I�(' Corp. �'i � t - Address _ 1,1 h n i I — ��-- —. ❑ Partnership Q C`a ❑ Firm/ Company Business Telephone Name of Licensed Plumber or Gasfjtter b5-. oil P,4i�t�,, I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signature of Owner/ Agent I have a current liability insurance nolicv to include completed ppPrarions covers e ❑ By Title City/ Town APPROVED (OFFICE USE ONLY) FORM 1243 ata. SULKIN co. 1989 g• TYPE LICENSE: A. El Plumber 4S�tture of Licensed lumber or Gasfitter � Gasfitter Master 30/0 ❑ Journeyman License Number Z s � a m � 0 c z v c o v z z � o � o -a O v 0 0 D N, z c� In m m u The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Let-ibly �( Name (Business/organization/Individual): HOL 17 49 ® t L. 1/196. Address: q l 1-YIVA9Y'1C-Lb QTREtri' City/State/Zip:j 1�t4 Lae a�Y /1219 Ol, Pune #: 97� �3��29E7 Are you an employer? Check the- appropriate box: 1. P I am a employer with 1-15 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. e. 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. EJ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. F1 Roof repairs 13.❑ Other *Any applicant that checks box #I must also till out the section below showing their workers' compensation policy information: t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such lContractors 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. InsuranceCompany Name: )A1hSj,►5°AIR�-T,�L Policy # or Self -ins. Lia M " 000 314 U - 44 Expiration Date:_ 01 lo a /aoc5c Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). 'Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a V -me up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under, the pains a•n�d penakk.s of perjury that the information provided above is true and correct. Signature: 1s �-� _ _ Dater Phone #: q 7r-- ;-3/- o_ 9 X -q QJf1cial 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 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 af'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 infornption (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 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 of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 kevised 5-26-05 www,mass.gov/dia i 3rof: •�,;:_�"oo� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMus� This certifies that ..t h......................I...... ...... . has permission to perform ...' ............ \ ............ . plumbing in the buildings of ................. . at .. ............... . North Andover, Mass. C—,l Fee. �S Lic. No.. � :�! ... 0. ... ....... �} /'PLUMBING INSPECTOR Check # 4` ?03 8321 I Date 41, f ' TOWN OF NORTH ANDOVER 00 :. PERMIT FOR PLUMBING s � r • 0 7 1 SSACIN4 ,� / This certifies that . [/4!�r. (�!r.. 0 . has permission to perform .... P ...................... . plumbing in the buildings of e." pp..�................. at ... ,S.� S .C.s S�� . ... 14G0 I,' T 111PL- , North Andover, Mass. Fee.Cp�.`... Lic. No..§.-'Cj.7. ....... ........ LUMBING Z U R Check # 8302 i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or pmt) NORTH ANDOVER, MASSACHUSETTS Building Owner New ;ifRenovation • Date 30 'A "V Permit # 3 oz, Amount 4 'g Replacement ® Plans Submitted Yes No FIXTURES (Print or type) ri'i't Check one: Certificate Installing Company Name W )C t_ • P � SLY +k ' 6, rq Corp. ( (flog 1Partner. ^ 1 1 Firm/Co. Name of Licensed Plumber: JCQ9f F—r Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 9 Other type of indemnity ❑ Bond Insurance Waiver: L the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ® Agent 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Ma sett S lumbin C e and Chapter 142 of the General Laws. By: signature or Ltcvmuu riumuff Title Type of Plumbing License 22 lCity/Town icense Master Journeyman ❑ APPROVED (OFFICE USE ONLY The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street _ Boston, M4-02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Almlica.nt'Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate bog: 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. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working ' for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 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 - F-1 Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other .-...y aylJili; L u;UL U!Xu':s box it 1 -us- Fuse nil out the section below showing their workers' compensation policy information -Homeowners who submit this affidavit indicating they are doing. all work and then hire outside contractors must submit a new affidavit indicating such_. Contractors that check this box must attached an additional sheet showing the name of the sub=contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self ins. Lic. #:. - Expiration Date: Job Site Address: City/State/Zip.- Attach ity/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 certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 6. Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector Phone #: Information and Instructions 0 �, Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged. in a joint enterprise, and including the legal representatives of .a, deceased employer, or the _ receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to. construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if ' necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability .Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial r 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 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 of Investigations 600 Washington. Street Boston, MA 0.2111 Tel, # 617-7274900 east 406 or 1-8.77-MASSAFE Fax # 617-727-7749 Revised 5-26-05 u,um%rnass.govfdia � e TOWN OF NORTH ANDOVER DIVISION Of PUBLIC WORKS BRUCE D. TjgBODEAU, P.E. - DIRECTOR WATER TREAIMBNT.PLANT 420 GREAT POND ROAD, 01845-2909 Telephone (978) 688-9574 Dermis L. Bedrwian Fax (078) 688-0575 Superintendent COPY, EDGEWOOD RETIREMENT "COMMUNITY 11/13/09 575 OSGOOD STREET NORTH ANDOVER, MA. 01845 Re: PROPOSED BACKFLOW PREVENTION DEVICE INSTALLATION At: EDGEWOOD HORSE BARN - AMELIA 'WAY C trol Number• 3150093 on Dear DAN FORTE: The Town, of North.Andover Cross' Connect ion Control Department_ has reviewed your application and plans for the proposed •backflow prevention device mentioned above. The information submitted shows to install the following: DEVICE'TYPE MANUFACTURER MODEL SIZE LOCATION RPBP WATTS 0090T 1" IRRIGATION SYSTEM In accordance with Chapter 111, Section 160A of the Massachusetts General Laws and 310 CMR 22.22 of the Massachusetts Drirsking Water Regulations, the 'down of North Andover hereby grants approval for the installation with the following provisions: 1. Drinking and domestic water lines, lines for sefety showers and lines for eye wash units must be taken off (installed`) the upstream side of the backflow preventer for devices instal3ed as in=plant protection: 2. The: -bat ktlow: `preventer:shall be located so -,a.6 Ao permit easy acre-ss.and provide adequiate and Convenient space for -maintenance, inspection and testing,. 3. Tightly closing va3ves must.be installed at each end of the device. �s x C t r M k '�� � a � � � , �, .� "�` 'r�,'`,r''T'9,tii"�r,�`';y t :'x�,:� P'"� "�'Mk`�e„ hair v+�*', �`ev Mt. device must be 'protect'.f�com �' ,' �1 doge . fi h.. aha..:. The owner or owner's agent must maintain a spare parts kit and �yany special tools required for removal and re --assembly of the device. 6. The owner or owner' s.. agent must provide the,, necesarX labor to assist the Cross Connection Contr:ol'Inspector in- the initial inspection and testing of _the: installed device., 7. For devices isasta-ileci as in -.plant ;protection, the reduced. pressure=backf-low>prever�te-r shall be installed on,.t-he ocaner'.� ,side of the water meter on thepotable water supply lines. - 6. Before installing a reduced pressure backflow p - re all pipelines shall be thoroughly flushed to remove foreign mat erza'i 9. The owner of the device shall be able to shut down water lines after reasonable notice during. normal business hours to permit ` necessary testing and maintenance of the device. if it is not possible to meet this. requirement, a by-pass line equipped with an approved type of reduced pressure backflow.preventer shall be installed. 10. The reduced pressure backflow preventer and shut --off valves mustbe installed in a horizontal alignment between three (3) and `four (4) 1. feet from the floor and a minimum of twelve (12") inches from any wall:. Ill If the device is to be installed on:e.:hot water lane, a device approved for use at an elevated temperature must be used. 12. If a drain is to be provided for the relief port, there must be an approved air gap separation between the relief port and drain. line. To be approved, the air gap must be twice the internal diameter of the discharge line. 13. All water lines shall be color ceded according to the state. plumbing code, except that water filtration plants, pumping stations, sewage treatment plants and sewage pumping stations shall label all water lines in lieu of color coding. APPROVAL FOR DOUBLE CHECK VALVE ASSEr7BLI.ES 1. The double. check valve ,:assembly and shut :off valves must be installed in a horizontal .alignment .:with. the Moor_ The top of the check valves must be a minimtm-of thirty (30) inches and a. maximum of fifty-four (54) inches "from the floor, unless, othbrwise .approved by the Town of North Andover. 2. Thera must be a least (12) inches clearance -between the double check valve assembly and any wall. ill LY/GVVO VO.VO AVVLV I.VVV/VVI 3. The double check valve assembly must be provided with suitable connections and appurtenances for testing. In addition, the Town of North Andover Cross Connection Control. Department requires that the installation be completed within thirty (30) days after receipt of this approval letter._ Following the installation you must contact this office to make arrangements for the initial inspection and test. This approvaj is only for the installation of the hack£loa MoventiOn dei j*Q (a) . All other permits and approvals must be Obtained from the app"pr ante Town departments . As owner of this cross connection, you must be aware of the importance of maintaining these devices. Unprotected cross. -connections can and have resulted in the loss of water supply and public health damage. You are responsible for compliance with Massachusetts Drinking Water Regulations, 310 CMR 22.00. Failure to take any action deemed appropriate by the Department of Environmental protection or its Designee, the Town of North. Andover Cross Connection Control Department., or otherwise failure to remain in compliance in the future with the applicable requirements, could subject you to legal act`ioi� including but not limited to, criminal prosecution,. court imposed civil penalties or civil. administrative penalties. A.Civil administration \ penalty may be assessed by the Department of Environmental Protection for each day you are in noncompliance with the requirement referred to above The Town of North Andover Cross Connection Control Department strongly recommends that you obtain a copy of 310 CMR 22.22 for information on legal responsibilities associated with the installation of these devices. You may obtain copies of these regulations by contacting the State House Bookstore at (517) 727-2834. If you have any questions regarding this decision, please contact the Cross Connection Control Department at 1-888-932-878' or 978-688-9574. Sincere aDENN S+� B . MOSIAN SUPERINTENDENT 11/24/2009 09:09 #0020 P.005/007 FV. DEVICE MAINTENANCE AND T TING SCHEDULF-: Describe the maintenance and testing schedule Of the above device(s). 'Please refer to 310 CMR 22.22 or forth Andwer Town By. taw/Policy. V. CROSS CONNECTION PLAN SUavirlrrAt REQUIREMENTS Details must be provided to include at a minimum ;the dowing: criteria: A. Plumbing Plan: ;. Completed Tide dock (name, address.. date,, prVarer, scale, • etc) .2. Schematic of plumbing system (at least E ih" by 11") stwirIg accepted symbols, nornendature, de.tailln% etc: a. Clearances of device it aliadon. b, Location of upstr"m and downk-earn shutoff valves c. Make, model, size and alignment f Device d, location of Potable Watet ilnes. e. system, source, or equipment fe t'c#own r asn of 4 device, complete with infOrMatidn:on- ibe s ty tf tin et;tr, CiSettllISftC.) -a' f. t4igh�irflqcil�16014W etevtioh Submitted 01,— Address: Date: rye: Owner/.Agent Signetwv: 40 Ts3'd EC.9T 6.Et3L�s au}gwnld-ao3ya1�4M 41+� Zr+D i3� 603`L-�L-409J a Date ...... /. � -..z 0.. 6 ? TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................... 44. ................................................. has permission to perform .... wiring in the building of ........ at ...... ? ........ .......................... North Andover, Mass. Fee... Lic. No. .........5............... ........... . ..... ... 0 LEcTRICAL INSPECTOR Check # L 9075 / _ (.ommonruea& o/ MaJJac1Lt4L6eE6 Official Use Only �7 Permit No. �0 artment o1.}ire Jervice9 � BOARD OF FIRE PREVENTION LREGULATIONS Occupancy and Fee Checked ev. 1/07] J (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORD i All work to be performed in accordance with the Nlassachusens Electrical Code (INIEC), 527 C114R 12.00 ,:' PLEASE PRINT I.Y INK OR TYPE ALL INFORAIMT10:'Vj Date: /DI of City orTo«n"of: IV�ir l ?�0 vel— To the Inspector of Wires: By this application the undersigned eives notice of his or her intention to perform the electrical work described below. Location (Street & Num !r) 0 Owner or Tenant Owner's Address Ol= Is this permit in conjunction with a building permit? Purpose of Building C.&V — 471 ;ry Telephone No. Yes ❑ No ® (Check Appropriate Box) Utili6, Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd ❑ No. of Nleters New Service Amps / Volts Overhead -1 Undgrd ❑ No. of deters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Com letion of the followin table may b • d b 1 l .l{.. No. of Recessed Luminaires Q N`o. of Ceil.-Susp. (Paddle) Fans e vane i r to nsoectot 01 Ires. No. of Total Transformers KVA No. of Luminaire Outlets No: of Hot Tubs Generators KVA No. of Luminaires (Swimming pool -above In- ❑ ❑ o. o Emergency tg tine b Qrnd. arnd. Battery Units No: of Receptacle Outlets INo. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices Ni o. of Ranges. No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers (Heat Pum Number Tons KW .............. No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KWLocal _ Municipal ❑ Other tion No. of Dryers Heating Appliances KW S curity Systems: ' No. of Water KW No. of No. of ' P s or E ❑ivalent CZ Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Tetecommunications Wiring: No. of Devices or E uivalent OTHER:57 Attach additional detail if desired, or as required by the Inspector of 1{'ires. Estimated Value of Electrical Work: ' Wl- 9'0 . (When required by municipal policy.) Work to Start: 9-114 Inspections to be requested in accordance with NEC 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:) Self Insured I certify, under the pains and penalties of perjury, that the inj rmation on this application is true and complete. FIRM NAME: ADT Security Services LIC. NO.: Licensee: Mark A. Brophy Signature LIC. NO.: C- a 5 (" fapplicable, enter "exempt" in the license number line.) Bus. Tel. NO.- E 0 3 -59.1-5928 Address: 18 Clinton Drive Hollis NH Alt. Tet. No.: 'Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. 00953 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 Si -nature _ Telephone No. PERIVIIT SEE: S suupe{oNad IIV 6uu1V yoclap uayl'ploj S6L£S£ OT/I£/LO O S4 S6L£5£ 2094-Z90Z0 vw OOOMNON 1S 3SNOW Ili O- NS AHdONS V NNdW 'ONI `S33IA83S A1.INt 33S lOd 3 d 1 Ol 3SN30I1 SIHl S3nssi N01OVII1N00 W31SAS CIR131 S10311 d3 SNVIOIU10313 30 OavoF, S113snHOVSSVW 30 H1Id3MNOWWOO r- suorleIoVad IIV 6uoly 4oelaq ua41 •Pioj £fZ[ tibE (888) :N31N30 llb0 3JVS JIa tL Jauo!ss!yWo:) Z90ZO VN •OOOMLION 1S 3S8ovV t t t 301A83S A-wjn03S idtl :eSuaJ l S02i8 'd NL1t1W 0•L8t :cu Jl 6002/LO/ZO :sajldx3 996 t//.O/ZO : a;epg1 j! Ig £S6000 00 SS :;agwnN k! 3SN3011 - Srkmmam,S A13AVs onand 301N3W1�!Vd30 I I Date .... .//.-. 4/1. ........ T&ORTH yr F�Oya'..ao ,e,tiO 9 0 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS -INSTALLATION This certifies that has permission for gas in,�Ilation�'-,. in the buildings of ........ ................................. atl? ......n North Andover, Mass, Fee'....... Lic. No, �-.............��;ISSECTOR Check 6904 tlo MASSACHUSE,TI'SUNIFORMAPM ICATONFORPERMITTODOGASFrrnNG (Type or print) Date 9 ! NORTH ANDOVER, MASSACHUSETTS / Building Locations -Y75- _ v 7 S 563' 0 O ,) s T - Permit # z Foy � Amount $ V °i Owner's Name �'� ••I 4 tA2.n.�. __ �Ni IAG New Renovation Replacement. 13— Plans Submitted (Print or type) L ��R� k one: Certificate Installing Company Name 9 S Pzy/ t c� Corp. 2 n 'A l ® Partner. Firm/Co. Name of Licensed Plumber or Gas Fitter C %.4 C 6 oy Z INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 0� No If you have checked ,Yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy 0— Other type of indemnity 13 Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner [3 Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State %Code and Char 142 QW General Laws. (OFFICE USE ONLY) Si ature of Licensed Plumber Or Gas Fitter 13 Plumber. L S <, Gas Fitter lcense um er 'Master Journeyman T W �► W z o a O -RE d >+ A oOq O O SUB -BASEMENT C7 U POC A a BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR BTH. FLOOR (Print or type) L ��R� k one: Certificate Installing Company Name 9 S Pzy/ t c� Corp. 2 n 'A l ® Partner. Firm/Co. Name of Licensed Plumber or Gas Fitter C %.4 C 6 oy Z INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 0� No If you have checked ,Yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy 0— Other type of indemnity 13 Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner [3 Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State %Code and Char 142 QW General Laws. (OFFICE USE ONLY) Si ature of Licensed Plumber Or Gas Fitter 13 Plumber. L S <, Gas Fitter lcense um er 'Master Journeyman Date ............. f ,%ORTm 0 f TOWN OF NORTH ANDOVER 0 6- 4K PERMIT FOR WIRING This certifies that r........ ....................................... has permission to perform . .. ..................... wiring in the building of ................. ......... .............. ......................... at ...... ........................... ..... . North Andover, Mass. ............ Fee./ Tj . ........... At ........ ic. No . ........ ... ELECTRICAL ► Check # 88-10 I Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. —6?X/0 Occupancy and Fee Checked ASS BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] nPa�P l,la„v� 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 IN INK OR TYPE ALL INFORM1q TION) Date: pu 10, City or Town of: NORTH ANDOVER -�U --Ci �� To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) "�(� ®C &00 Owner or Tenant Owner's Address Telephone No. �`�,A,,,` Is this permit in conjunction with a Purpose of Building Yes E' No ❑ (Check Appropriate Box) itiLlty,�A�}t1loption No. Existing Service Amps / Vo is overhead /'PI 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: /�/ V n C AC PIP Cp6wfc- Com leh'On,of t�ollow�intgable may be waived b the Ins ector o Wires.No. of Recessed Luminaires No. of Ceil:Sus of p. (Paddle) Fan No. of Luminaire Outlets,. No. of Hot Tubs Transformers KVA Generators KVA No. of Luminaires Swimming pool Above ❑ In- " d• o, o mergency ig g No, of Receptacle Outlets md• No. of Oil Burners. Batte Units ARE ALARMS S No. of Zones No. of Switches No. of Gas Burners No..of Detection and No. of Ranges No. of Air Co d. Total Inifiaiin Devices Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number KW No. Self No. of Dishwashers "ons Totals: �" ""'-' Space/Area Heating KW of -Contained Deteeiion/Alertin Devices Local❑ 1Viunicipal No. of Dryers Heating Appliances KW Conne-cfion ❑ Other Security Systems:* vo. of Water Heaters KW No. of No. of No, of Devices or E uivalent 5i s Ballasts Data Wiring: vo. Hydromassage Bathtubs . No. of Motors Total lip No. of Devices or E uivalent Telecommunications Wiring: OTHER: No. of Devices or E uiv ent L4`'� it �L -046,0dG�-7/'� Cr f c"/ 6L1 ki f->/ Estimated Value of Electrical Work:12 ��fa � `mach additional detail if desired, or as required by the Inspector of Vi es. Work to S (When required by municipal policy.) b Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAG : 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 cove ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER I certify ❑ (Specify:) -'t d'� /C ✓�� under the pains and penalties of perjury, that the information on this application is trueandcomplete. FIRM NAME: Licensee: J(p�� LIC. NO.: ' C /LL. D Signature LIC. NO.• (If applicable, enter "exempt " in the license number line.) l) iZ Address: 69iGy Bus. TeL No.: -a *Per M.G.L c. 147, s. 57-61, security work requires D t71 �� Alt. Tel. No.: Department of public Safety "S" License: Lic. No. �a OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the IiabiIity insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) [I owner [I owner's agent Owner/Agent Signature Telephone No. rPERMIT FEE: $ The Commonwealth of Afassachuseti Department of Industrial Accidents Office of Investigations. 600 fflashingion Street Boston, MA 02111 www.mass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Mlicant fnfnTrrto•Finn Natne (Business/Organizafion/individual): Q}jyi �q�o �•L Address:_ S �L 7 --------------- City/State/Zip: �t v L i' itir 4'i 965 Phone #:. - % % y3 - 3 0 3n Are you an employer? Cheek.the appropriate box: I. ❑ I aro a employer with 4. ❑ I am a general contractor and I gees (full and/or part-time).* /aM have hired the sub -contractors 2. .sole proprietor or partner_ listed on. the attached sheet t ship and have no employees These sub -contractors have working, for mei' any capacity. [No workers' comp, insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ 1 am a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No -workers, comp, c. 1.52, § I (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 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ .Other - t .— wbu cul ou[ Inc secnon below showing their workers' compensation policy information. liameowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractors that check this box must atUmbed an additional sheet showing the name of the sub•corttaators and their workers' comp. oolicv infrn,nan„n in oyer that is protndimg:workers' rmadom compensation insurance for my emplayeea: Below is the policy and joh site Insurance Company Name: Policy # or Self -.ins. Lie. #: Expiration Date: -------------- Sob Site Address: - • City/State/Zip: Attach a copy of the workers' compensationpolicy 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 c nder he pains and Ps o er' f p jury at the information provided ve is true and correct Si tore: Oe7 Date: Phone #: _ 6 ficial use only. Do not write in thisarea, to be completed by city or town. official City or Town; Permit/License 4 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 4: Information and Instructions ti 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 mainiei ai nct, 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 empioyer." c 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 pm for Trance 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) acrd 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 numberlisted below. Self-insured comnanies 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 permitAicense 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 affidavitmust 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. ti The Department's address, telephone and fax number: + The Commonwealth of Massachusetts) Department of Industrial Accidents Office of Investtibstiions 600 Washington Street Boston, MA 02111 TeL # 617-7274900 ext 406 or 1-977-MASSAFE Fax # 617-727-77451 Revised 5-26-05 www.mass.gov/dia I , Date ................................. 2a. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............................................................ ....... c . .................. J, has permission to performZ wiring in the building of ................................................ at .... ..... 5Z . .......................... en% North Andover, Mass. Fee.:5,�� ...... Lic. NoZ:.3?-.3 . ................ cmicAL iNs PECTOR Check,, 5,4 V 88,03 Commonwealth of Massachusetts Official Use Only kipDepartment of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Cgde (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date' City or Town of: NORTH ANDOVER To the Inspector of fires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant LG Telephone No. Owner's Address - Is this permit in conjunction with a b ding permit? Yes ❑ No E] (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters New Service a,\ ,� Amps lap /_11—volts Overhead ❑ Undgrd � No. of Meters 1 Number of Feeders and.Ampacity Location and Nature of Pr posed Electrical Work: .� 7 } Completion of the ollowin 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 Elin-o. o mergency lg g d, rnd. ❑ Battea Units No, of Receptacle OutletsNo. of Oil Burners .` FIRE ALARMS No. or 7�nes No. of Switches INo. of Gas Burners No. .of Detection and fo. of Ranges o. of Waste Disposers o. of Dishwashers o. of Dryers Heaters K' o. Hydromassage Bathtubs OTHER: No. of Air Cond. Totals:I-._...._.-.....-_..:... - Space/Area Heating KW Heating Appliances \ KW', No. of o. of Signs Ballasts. No. of Motors o. of Alerting Devices o, of Self -Contained etection/Alertin Devices ❑Mu^nicipal l'ainn M. ❑ Other No. ofDevices -or Data Wiring: No. of Devices or Total HPI i eiecommunications No. of Devices or Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start: ' o� - 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 certify, under the afns and penalties of per ury, that the information on this application is true and complete - FIRM NAME: ,e t Licensee:1J1�1 n_ LIC. NO.: �, — - 'Q ti Signature LIC. NO.: .af applicable, K " empt " in the license number line.) , Address: Q ,'` (,l k � -r i V �t 11 D Bus. Tel. No.: ° r *Per M.G.L c, s 57 61, secunty work requues D Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that theLicensee does not havety 'the liability Lic. No. e normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner cover ❑ rance owner' agent. Owner/Agent Signature Telephone No. R p PERMIT FEE: $ T�J� 01--f" t.t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 fflashington Street Boston, MA 02111 V ' www.nwss.gov/dia Workers' Compensation Insiurance Affidavit: Builders/Contractors/Electricians/Plumbers DDliCant Tnfhr'rnafinn Name (Business/Orgmization/individual): Address: City/State/Zip:�f 1L Phone Are ygu an employer? Chee the appropriate box: FI I. am a employer with -- 4..Q I am a general contractor and I employees (full and/or part-time).* 2.[] I am a.sole proprietor or have .hired the sub -contractors listed partner_ on the attached sheet. $ ship and have no employees These sub -contractors have working for me .in any capacity. [No workers.' comp, insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ lam a homeowner doing officers have exercised their 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 -1 *Anv etmlf—o #h— ,.t.ea._ 'type of project (required): 6. Q New construction 7. Q Remodeling 8. Q Demolition 9. Q Building addition 10. Q .Electrical repairs or additions 11.Q Plumbing repairs or additions 12.0 Roof repairs M.Q.Other dam. Hameown+.{3 uut me section below showing their workets' compensation policy information. M who submit this affidavit indicating they are doing all work and then hue outside contractors must submit tContnt tors that check this box must attached an additional sheet showing a new affidavit indicating such the name of the sub-coatractors.and their workers' Damp, affidavit n information. 14m an empivyer that is provegng:workers' compensation insurance for try. employees: Below is the policy and job site information. Insurance Company Name: Policy # or Self -.ins. Lie. #: Expiration Date: Job Site Address: ' City/State/Zip- a � - M'J Attach a copy of the work�Vuolicydeclaration page (showing the policy number and expiration dated s 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 font 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 he�fY and under the vg * enalties o er' 1 P jp /ury that the information prnvitled above is true and correct n t Date: v'ol`U Phone #: 09xial use only. Do not write in this area, to he 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 S. plumbing Inspector 6. Other Contact Person• Phone #: ,—- i. i� 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 compiiance with the insurance coverage required." Additionally, MGL chapter I52, §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 cormwting 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), acid 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, nottthe Department of Industrial Accidents. Should you have any questiommgarding 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 Iicense number on the appropriate line. City or Town Officiais 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 permittlicense number which Nvill 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 bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would lace to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TeL # 617-7.27-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-77451 www.mass.gov/dia V t w Date . K NORTH TOWN OF NORTH ANDOVER 3 Ot ,.•o •1M0 PERMIT FOR PLUMBING r SSACMUSE� � .. r This certifies that _ . l>. 1f?.f.`.�'... fC J-:..... 101w " has permission to perform ......A-4'`.... ... . f ....... plumbing in the buildings of .................. . at. ,.... . � !: � ............. . North Andover, Mass. r" Fee"�% ,. :.�'.. Lic. No. �`.?.? ? .. ...... ...... .....C. �`"'` PLUMBING INSPECTOR Check # S 8067 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING �. (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Location �%SQ� Owners Namei��, > Permit # nn,w,�__t Amount Tyne of Occunancv i 4 L1G. %Tt iA a! New ri Renovation Replacement Plans Submitted Yes ❑ No ►I 1 / • i ilk -.�----.-��-.-M..-.---�.- . WWWW"M---.-M-..--..M---.NNNMWWMMNMMMM� „t .W-N-MMMM-.MWNMM.-----. W.111-10FI-61a NWMMMMNMWWW®MMNWNMWWMWMW� (Print or type) ` Check one: Certificate Installing Company Name U* -NA I<� Corp. Address` ❑Partner. 11ni AA UUY 1AAA n rD,tL Business Telephone -- 11 Firm/Co. Name of Licensed Plumber: �jLr�l e�II�71r • Insurance Coverage: Indicate th type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ - Bond ❑ Insurance Waiver: I, the uoersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Mass etts at tubing C C, apter 142 of the General Laws. By: ig aure o censeu Flumfler Title Type of Plumbing License City/Town 1cense um er Master Journeyman ❑ APPROVED (OFFICE USE ONLY The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Nrashington Street Boston, MA 02111 www_nwssgov/dia . Workers' Compensation Insiu-a.nce Affidavit-. Builders/Contractors/Electricians/plumbers 301ic Mt Information Nanne (Business/079mizafion/Individual): City/State/Zip Phone Are ou an employer? Check the appropriate box: I • I am a employer with '� 4. ❑ I am a general contractor and I employes (full and/or part-time).* have hired the sub -contractors • ❑ I am a:sole proprietor or partner_ ship and have employees listed on the attached sheet t e . working forme.' any capacity, These suis -contractors have workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing officershave exercised their all work myself [No•workers' comp, right of exemption per MGL c. 152, § 1(4), and -we have no insurance required.] t employees. [No workers' camp. insurance aired_] Type of project (required): 6.. ❑ New construction . 7.Remodeling 8. `Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I I Plumbing repairs or additions 12.[] Roof repairs 13.[] Other ;Any applicant filet checks bob #I must also flit out the section below sbow.ing their workers' 'aompensatioo poitcy mformahon I t tiomeowntirs who submit this affidavit indicating they are doing all work and then hire outside commchns must submit a new affidavit indi Contractors that check this box must attached -n additional sf showing• rite matte of the sub-condo;dors end st s workers' affidavit iii . • ca� such. t ant an employer that is provieing:workers' co errsai on " po trfnmtation. information. ! insurance for my employees: Below is the PnbCy and job site . Insurance Company Name: Policy 4 or Self -ins. Lic. #: Expiration Date: Job Site Address:_ % ©�®/1 ��� City/State/Zip Attach a copy of the workers' compensation policy declaration page (showing the policy numb Failure to secure coverage as required under Section 25A of MGL c. 15and expiration dale 2 can lead to the number fine up to $1,500.00 anr one-year imprisonment; as imposition Of er criminal penalties of a well as civil penalties in the form of a STOP WORK ORDER and In a to $25tions 0 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of a fine Investigations of the DIA for insurance coverage verification, I iartature:do hereby cert under the/pJai/nf s• andpena/ties ojperjury that the utformation provided above is true androrrecG O,T,10W ase only. Do not write in this area, M be completed by city or town oft iaL City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. CitylTown Clerk 4. Eiec 6. Other trica! Inspector S. Plumbing Impactor Contact Person: Phone #: Information and Instructions 11 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." j 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 includirig the legal representatives of a deceased employer, or the receiver ortnistee of an individual, partnership, association or other legal entity, employing employees. 'However the owner -of a dwelling house having not more than three apa-tmetits 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 evidencezir compliance with the insurance'coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither tlhe commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance witb the insurance requirements of thiszhapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation. affidavit compi4nntely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), addresses) 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 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.. Aliso 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, notthe 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 tine. 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/liceme number which will be,used as a reference numbed.' 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 f rt:ure 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 bepartment's address; telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TeL # 617-727-4900 ext 406 or 1-8.77-MASSAFE Fax # 617-727-7744 Revised 5-26-05 www.mass.gov/dia i Date......-..�.....�.. TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that ........:.!91r!C'....t //y'...� ............. has permission to perform�.,�'1 wiring in the building of L �r��� . ` ......... C ��� 2,oft ' T� .................... Win% at .. ...... , North Andover, Mass. Fee ..... :�-.'`��a Lic. No.e.:.:..1.3r� ...... �...... ... ..... ......... . 'g� 232 3 14c- Et ecrn�c�e Itvsr R Check # �! P63`Z Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked Lev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WO All work to be performed in accordance with the Massachusetts Electrical Cde (ME ), 527 CMR 12.00 RK (PLEASE PRWflV Il X OR TYPE ALL INFORMATION oDate: City or Town of: NORTH ANDOVER To`) By this application the undersigned gives notice of his or her intention to perform the electrical trical wector �k described below. Location (Street & Number) Owner or Tenant Owner's Address r Telephone No. Is this permit in conjunction with a building permit? Yes Purpose of Building NO ❑ (Check Appropriate Box) �tlJry�n Utility Authorization No. Existing Service Amps _/ _Volts Overhead ❑ Undgrd ❑ No. of Meters New Service �_ Amps b a / Volts Overhead ❑ Undgrd ®' No, of Meters --�_ Number of Feeders and Ampacity Lgation and Nature of Proposed Electrical Work: n _ - n - No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers ------------ No. of Dishwashers No. of Dryers Heaters KW o. Hydromassage Bathtubs OTHER: -' Com letion of the followin tab may be waived by the Ins ectoi No. of Cell: Susp. (Paddle) Fans No..of Total Transformers KVO, No. of Hot Tubs Generators KVA Swimming Pool Above ❑ .In_ o. o mergency ig g nd, rnd. Bette Units 77 No. of Oil BurLnPr g gF RE ALARMS. Na. of ;ones No. of Gas BurnersNo..of Detection and No. of Air Cond. To Initiating Devices Tons No. of Alerting Devices _._..:.-- Totals: Space/Area Heating KW Heating Appliances KW No. of No. of Signs Ballasts. No. of Motors Total HP o. of Self -Contained etection/AlertinQ Devices wal ❑Municipal Connection ❑ Other xurity Systems: * No. of Devices or Equivalent ata Wiring: No. of Devices or Equivalent aecommumcations Wiring: No. of Devices or EanivniFmt Wires. Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: Work to Start:---------^• (When required by municipal policy.) 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 V BOND ❑ OTHER I certify, under t ains and enaltiies of perjury, that the ❑ (Specify:) ~ o[ �3� P e information on this application is true and complete FIRM NAME: (. , Licensee: LIC. NO.• (If applicable, en te . mpt " in the ' ense number inej Signature 4 LIC. NOok Address: ( Bus. Tel. No.: *Per M.G.L c 147, s 57-61, security work requires D �Vnt ublic Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that Le Licensee does noSaft have "the liability Lic. No. required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ o�ercov❑eraa a normally agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ OA04 _lei V* 0 Rp 1 l &4fiq VO4 ��� �,��� ��� y 0 9 6TIC �U Date.......!... °:"`° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that...fF!L,//...........................E,-!G ......... has permission to perform . A�/..1/..00f!. /./.ft%�/�!%AF........�..... wiring in the building of .... .Q.��. .... atk.....!.1. ............................. . North Andover, Mass. Fee 13rj. !jl Lic. NoI qVe. % ...................... TR ELECICAL INSPECTOR 4 � Check # 7U- /�y .7ti 8566 Commonwealth of Massachusetts Officia] Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [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 PRWflV INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER By this application the undersi ed To .the Inspector of Wires: gn gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) j S Q S �po7j S T Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes Purpose of Buildin 1�1>>�1 /� NO ❑ (Check Appropriate Box) g G /C ' 2 ��'✓��Utility Authorization No. Existing Service /.;10 Amps //&L/j Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / _Volts Overhead ❑ Unclgrd ❑ No, of Meters Number of Feeders and.Ampacity �+ Location and Nature of Proposed Electrical Work: \ ! Com letion of the ollowin table maybe waived 6 the Inspector of Wires. No, of Recessed Luminaires No. of Ceil: Sus No. of Total . p. (Paddle) Fans Transformers No. of Luminaire Outlets Tubs KVA No. ' of Hot Generators KVA No. of Luminaires Swimming Pool Above ❑ In_ o. o mergency ig g d• No. of Receptacle rnd. ❑ _ Batter U • - tacle Outlets Units P No. of Oil Burners FIRE ALARMS No. of .mon.,,, oA No. of Switches No. of Gas Burners No. of Detection and ' No. of Ranges No. of Air Cond. Total Initiatin Devices Tons No. of Alerting Devices No. of Waste Disposers Heat PUMP Number Tons KW No. of Self- Contained Totals: _........._............................. I itection/Ale!*g Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal Connection ❑ Other j No. of Dryers Heating Appliances KW Security Systems:* _ No. of Water No. of Devices or E uivalent KW Heaters NO• of No. of Si s Ballasts . Data Wising: No. of Devices or Equivalent No: Hydromassage Bathtubs No. of Motors Total HE'' Telecommunications Wiring; OTHER:-� No. of Devices or E uivalent �Gi�J� ,��b 2 ��1� Gs 2/#AT GLc �os`6 G 73 � Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: S6 6GQ � i (When required by municipal policy.) 1 Work to Start: (J% (� Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO RAGE: 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 ec ! I certify, under the wins and enalties o P) ` P f perjury, that the information on FIRM NAME: this application is true and complete G C LFG%2iG % Licensee: Xo1962Tl LIC. NO.: OSI/� /' /L.�-,/� Signature (Vapplicable, eter exempW'?, "e lic a number ine.) LIC. NO.: Address:Bus. Tel. No.: *Per M.G.Pc.'014 7 , s. 57 ' Alt. my work requires Department of Public Safe Tel. OWNER'S INSURANCE WAIVER. I am Safety S License: Lic. No. aware that the Licensee does not required by law. B m signature have the liability insurance coverage normally Y Y gnature below, I hereby waive this requirement. I am the (check one) ❑owner ❑owner's agent. Owner/Agent Signature Telephone No. P PERMIT FEE. $ /l 0611'1-7 API Itl Olepy - -<., le 57KI -/ d-3 -7- 8 2-3 - t PI -7 G i d at a�� V- 0 lvadov 7 Raum-5, sm v '11PI'mal- Ci tJ Celt-" (-� o- Z 4 a KC J ,77-7� -,;-- ) z e- 95 --lo P41 _���� '-TL7.pj NO rzl�� Vj" )7C—,,Cfj-,s lu i� �� 2-2 - �o Date. / T NORTH tiTOWN OF NORTH ANDOVER PERMITFOR PLUMBING This certifies that Ya L� ki.i .�14 jc: .� has permission to perform Co. ................ plumbing in the buildings of .'-.-.°L � ........ at .: ?. . d .S. 5.0. 15. � .................. North A.ndov` e, Massa . PLUMBING INSPECTOR Check #J;vcm s '�' � 1VLA.SSA CF�[USTTS TJ?�1II�'® �� ERM APPLICATION FOR PELUMBTN (Type or print) NORTH ANDOVER, MASSACHUSETTS Building New E Renovation S7— Owners Nan Type of Occupancg Replacement 'My-Vrmr Y- ` _. Date//;L /0 9 �FmPgi' Permit # "2 Amount -f 3 , y-3 H �} Plans Submitted YesNo -- vr-i Installing Company Name_YDGt nQ_h�,,nn d G Z� Checl ne: Certificate AA561-and If .Corp, Address Z A 51 (.and -5-L ct 1, I 42Ap/ Q ® Partner. usiness elepbone _ O Firm/Co. Name of Licensed Plumber. w�.� ymunuhLoad Insurance CoveraL Indicate theme Ype of insurance c verage by checl-uto Liability insurance policy 1, /� Other type of indemr i t the appropriate bore: =� ® Bond Insurance Vi7aiver. I the undersigned, have been made aware that the licensee three insurance of this application does not have any one of the above Signature Owner El Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of m} lmowledge and that all plumbing wort and installations sac tts tatePyrformed under Permit Issued for this application will be in compliance with all pertinent provisions of the Mas By. D/ Chapter 142 of the General Laws, iQnarur of L�cri� Title Type of P1ut i ing License City/Town 1, APPROVED (oPrtCE USE ONLY Licens ivumo .r Master Journeyman 92 Date ....1. =1 5 e8 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that- ................................ has permission to perform .7' .:I�il.. 17,.,S ................... wiring in the building of .... ............................. at ......... _.7 ............. North Andover, Mass. Fee.... ....Lic. No.. ........ - .... 4f" ............ ELECTRICAL INSPECTOR Check # Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 0 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank Q 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 INIAW OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform .the electrical work described below. I Location (Street & Number) 7S Owner or Tenant Z./c,e d a A Telephone No. Owner's Address S Aler Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 7 a..j! , 7ww, dei' Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Zte_� Amps /pa / E6 J Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and.Ampacity � Location and Nature of Proposed Electrical Work: A T� w �� � j Me Attach additional detail f 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 ❑ (Specify:) I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: o� olr• c, LIG NO.: Licensee: 4 Signature LIC. NO.: (If applicable, enter "exempt " in the I ense number line.) Bus. Tel. No.• Address: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. L lc. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. B my si patur ow, I hereby waive this requirement. I am the (check one) ❑ owner �ner's agent. Owner/Agent Signature Telephone No. Q3 -2S•.s" , rs PERMIT FEE: $ •..0 L .. 0 -trig uum may ae waived by the inspector oJ 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-❑ o. o Emergency Lighting rnd. rnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No: of Zones No. of Switches No. of Gas Burners No. of Detection and Devices No. of Ranges TotInitiatin No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers eat Pump Number Tons KW No. of elf Contained Totals: Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Municipal LOCA ❑ ❑Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Water Heaters KW No. of No. of No. of Devices or Equivalent Data Signs Ballasts . No. ofitinDevices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail f 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 ❑ (Specify:) I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: o� olr• c, LIG NO.: Licensee: 4 Signature LIC. NO.: (If applicable, enter "exempt " in the I ense number line.) Bus. Tel. No.• Address: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. L lc. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. B my si patur ow, I hereby waive this requirement. I am the (check one) ❑ owner �ner's agent. Owner/Agent Signature Telephone No. Q3 -2S•.s" , rs PERMIT FEE: $ x 0 0 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 C-1 www.nxass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/individual): Address:' City/State/Zip:, Phone #:-. Are you an employer? Check.the appropriate box: I: ❑ I am a employer with 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a:sole proprietor or partner- have hired the sub -contractors listed on the attached sheet I ship and have no employees These sub -contractors have working for mein 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. 1.52, § 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 i 3. ❑ Other -Any appucant that checks bo)C # 1 must also fill out the section below showing their workers' compensation policy information, t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ,Contractors that check this box must attached an additional sheet showing the name of the sub•conttactorsand their workers' comp. policy information. I am an employer that is providing:workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). J 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 14 of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. 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 0 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 cavy 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, notthe 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 numberlisted 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 ofthe 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 fiiture 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 of Investigations 600 Washington Street Boston, MA 42111 Tel. # 617-727-4900 ext 446 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia Aa Datel TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........7- Z�7 /-, ..... ...................................................... has permission to perform ..... ...... ............ wiring in the building ofa�..994W.�.Z ......................................................... atg ............. North Andover, Mass. v Fee�r Lic. ....... . ........... �70?/ .�%4 '� /e ILECMC ILECTIUCAL INSPWC�� 112CMCAL INSP R -.4 Check# a2 40 8 5 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No.j�/ 7 Occupancy and Fee Checked [Rev. 1/07] I IP.AVP hj.ntrN 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 INNK OR TYPE ALL NFORMATION) Date: kL City or Town of: NORTH ANDOVER To the Inspector f Wires: By this application the undersigned gives notice of his r her intention to perform the electrical work described below. Location (Street & Number) 11 Owner or TenantT U - r y%� Owner's Address 6 elephone No. Is this permit in conjunction with a building permit? Yes ❑ NoCheck Appropriate p� �riatj 1Box) Purpose of Building Utility Authorization No. �CobJ) Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: estimated Value of Electrical Work: u urairea, or as required by the Inspector of Wires. (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 cov5pge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE V BOND ❑ OTHER ❑ (Specify:) I certify, under th Wains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: j .� �' (, LIC. NO.: a j _ Licensee: 1 �. Signature (If applicable, enter "exempt " in the license number line.) LIC. NO.: Address: Bus. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. TeLicNo, 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 ( Owner/Agent check one) ❑owner [I owner's agent Signature. Telephone No. PERMIT FEE: S 0 b The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 {' t www mass.gov/dia Worker's' Compensation insurance Affidavit Builders/Contractors/Mectriciaas/Plumbers Mnlir.gnf T..F�.......�.._ XS a (Business/0rganiza6on/Individual); Address: City/State/Zip-Phone #: . Are you an employer? Check the appropriate box: I. ❑ I am a employer with 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* 2.[] I am .a.sole proprietor or partner- have hired the sub -contractors listed on the attached sheet # ship and have no employees These sub -contractors have working for me .in any capacity. [No workers' comp, insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.) 3.[] 1 am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No -workers' comp. c..1.52, § I(4),'and we have no insurance required.] t employees. [No workers' ♦ A.. �u� comp. insurance required.] Type Of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions I I.❑ Plumbing repairs or additions 12.❑ Roof repairs 1.3.❑ .Other --, -rr•--••• ••...• ...•.w,.6 ��x K, must a,so n« out the section below showing their workers' compensation policy information. t Homeowners who submit this efFiiiavit indicating they are doing all work and then hire outside contractors must.submit a new affidavit indicating such. 4Contnrctors that check this box must attached an additional sheet showing the name of the sub-comreetots and their work=I comp. policy infonn ition. I am an employer that -is provW1ng:w0rkerx' compensation insurance for my. employees: Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the .workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under 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 fy under the pains and penalties of perjury that the information provided above is true and torted Signah re: Date; Phone #: Fician only. Do not write in this area to be completed by city or town offiefaL n: Permit/License # hority (circle one):Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspectorson: 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 commonweahh 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 cavy 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 c 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 we 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 dine; - 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 indieatiripcurrent 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 (Le. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit The Office of lnvestiptions would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call.. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations " 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-977-MASSAFE Revised 5-26-05 Fax # 617-727-7744 www.mass.gov/dia 0 Too Date ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING MC This certifies that ... . ....................... ...................... has permission to perform ... ................................................... wiring in the building of ..... .................................. .... Ste".................. ........ . North Andover, Mass. 300 3 P -3J -. Fee..................... Lic. No . ............. .......... ......... Check # 44.0497 85'1 1 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [Rev. 1/07] tleavP 1,1_t,� APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical C 4e, (ME(Q), s27 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of ices: ` By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 515�c Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes L71— Purpose 1Purpose of Building LIk I "jAl' Existing Service_ Amps __Volts New Service_ Amps / q Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: I Telephone No. No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ►� Overhead ❑ Undgrd No. of Meters No, of Meters 1 t:stunated Value of Electrical Work: -� """` """" u uratreu, or as required by the Inspector of Wires. ( .(When required by municipal policy.) INSURANCE COVE Work to Start� `� D Inspections to be requested in accordance with MEC Rule 10, and upon completion. RAGE: 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 cove 'overage is in force, and has exhibited proof of same to the permit issuing office. . CHECK ONE: INSURANCE (BOND ❑ OTHER ❑ (Specify:) I certify, under the sins and enaltaes o p �':) p f perjury, that the information on this application is true and complete. FIRM NAME: fi '� LIC. NO.: Licensee: i ¢ Signature 1i (If applicable nter " empt " in a license number linc.) LIC. NO.: Address: (j N .A O UM4 Bus. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of -Public Safety "S" License: Alt L cl. 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 Signature Telephone No. PERMIT FEE: $ v im- o��c 6-`�- a � f,��Pr�c a.s :�o/�� The Commonwealth of Massachusetts k� ! Department of Industrial Accidents Office of Investigations as 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractorsoectricians/Plumbers At►plicant Information Pie ase Print Legb(v Natrie (Bnsiness/Organiration/Individual);-1 Q Fp I.tt T Addres City/<State/Zig:_ Phone 0 Areyou an employer? Check the appropriate box: 1. �I Type of project (required): am a emplo er with __ 4. ❑ I am a general contractor and I 6. New construction employees ful d/or part-time).* 2. ❑ I am. a.sole proprietor or partner_ have lured the sub -contractors listed on the attached sheet. t 7. ❑ Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition' working for me .in any capacity, [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9 E] Building addition m9uired.] 3. [] 1 am a homeowner doing officers have exercised their 10•❑ Electrical repairs or additions all work right of exemption per MGL 11. F7 Plumbing repairs or additions myself. [No -workers' comp, insurance required.] t c..152, § 1(4), and we have no 12.❑ Roof repairs .employees. [No workers' 13:❑.0ther comp. insurance required.] -11­—­­­uux If I must arso nu out the section below showing their workers' compensation policy information. r Homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such ;Contractors ural check this box must attached an additional sheatshowing the name of the sub,contrEctom and their wOrkere' comp, policy information. I ant an employer ingt A -Providing workers' compensation insurance for my enW10yees. Below isthe policy aced job site information.. Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under 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 t of up to 5250.00 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 her under the airs and penalties of perjury that the information provided above is true and correct Si ature: 7� Date: Phone EBoardof only. Do not write in this area, to be completed by city or town official n: Permit/License # thority (circle one): I. Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector rson: Phone #: Information and. Instructions p VVV® 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 cavy 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, notte 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 dine. 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 infonnation (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 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 of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-774 www.mass.gov/dia Date. . t �Ar-- „oR,,, TOWN OF NORTH � `DOVER 0� •D y1h PERMIT FOR PLUMBING ,SSAC04US� This certifies that has permission to perform ... . !� � �.��. f . 1. , . . , . plumbing in the buildings of .. at . S. ?` .. OS.. ,North Andover, Mass. Fee U. G . Lie. No. PLUMBING INSPECT, R Check # 7736 40 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS qq� Date Building Location .5 –57S- C'S"00 T Owners Name 66gWoao 4WAMJrvtN permit # Type of Occupancy }} 3ru2�-L� Amountq 47 New ri Renovation Replacement "� Plans Submitted Yes No El Ti TYT1rT1D 1PC! (Print or type) Check one: Certificate Installing Company Name �}R/ �� C ( ► --�`'C_ ( � Corp. Address 7 JMT-ft duno ❑Partner. usmessI elephone El Firm/Co. n Name of Licensed Plumber: i' wt— Insurance Covera&e:. Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner1:1 Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of theM�chusetts to Plumbing Code and Chapter 142 of the General Laws. i y: APPROVED (OFFICE USE ONLY Type of Plumbing License o m icense Numml _ ` Master Journeyman ❑ Date............... AORTm TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SA HUS This certifies that ............ has permission to perform —"O�:�� .. ................... plumbing in the buildings of ... ............... at ........... ...... North Andover, Mass. Fee .N ........ Lic. "C PLU /13JNG INSPECTOR Check # C:' 17 7905 Date ....... ........... NORTH 6 TOWN OF NORTH AN/OVER 41 PERMIT FOR GAS INSTALLATION ...... This certifies that ........ has permission for gas installation-.,,," in the buildings Of .... lle�all.'r �. .................. ...... at "7. .,North Andover, Mass. Fee. Lic. N1'?V�l .. V ......... .0 ...... .. GAS INF_, OR Check # 63,57 V MASSACHUSETTS UNIFORM APPUCATON FOR PERNIIT TO DO GAS FITTING (Type or print) Date 117 NORTH ANDOVER, MASSACHUSETTS Building Locations ` j �`� (�Sr Dad �f�� � Permit �/ / v Amount $ L5 /VCS 1i//S/(J� o Owner's Name %✓V' L td ! I� T/�C:' � _. �yr??G' New Renovation Renovation11 Replacement ©� Plans Submitted D Name of Licensed Plumber'or Gas Fitter Check one: Certificate Installing Company Corp. Partner. Firm/Co. INSURANCE COVERAGE Check o 1 have a current liability Insurance, policy or it's substantial equivalent. YesEl No13 If you have checked ves, please ' dicate the type coverage by checking theappropriate box. Liability insurance policy Other type of indemnity Bond 13 Owner's Insurance Waiver: I'am aware that the licensee does_ not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent 13 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the ass chusetttsSt to Gas CodS�,aqj}C-hapter 14,2 of the General Lawc By: Title City/Town; APPROVED (OFFICE USE ONLY) Signature of Licensed Plu4b Or—Gas Fitter Plumber�� Gas Fitter Icense um er ®''Master Journeyman ,171-�Sz` �a oG C7 U w Z Edd- O CS F Z F Z x W W Cw7 a W U � z >oa� o o W a o� x 3 O C7 .a U C > O SU B -BASER ENT BASEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FL00-R 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR �x 7TH. FLOOR STH. FLOOR p Name of Licensed Plumber'or Gas Fitter Check one: Certificate Installing Company Corp. Partner. Firm/Co. INSURANCE COVERAGE Check o 1 have a current liability Insurance, policy or it's substantial equivalent. YesEl No13 If you have checked ves, please ' dicate the type coverage by checking theappropriate box. Liability insurance policy Other type of indemnity Bond 13 Owner's Insurance Waiver: I'am aware that the licensee does_ not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent 13 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the ass chusetttsSt to Gas CodS�,aqj}C-hapter 14,2 of the General Lawc By: Title City/Town; APPROVED (OFFICE USE ONLY) Signature of Licensed Plu4b Or—Gas Fitter Plumber�� Gas Fitter Icense um er ®''Master Journeyman ,171-�Sz` J I Date............................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... '.4 ..................................... has permission to perform ............................... I .................................... wiring in the building of............. ..................... .................... at ...................... ....... North Andover, Mass. ELECTRICAL 4P� Fee lc Lic.No Check# 8037 fi r I Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. ; `v3 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 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: J / ax City or Town of NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 5 75 O S Cao c, 57 - Owner jOwner or Tenant FQ) ke c --a as`?t i .,oc v to �" Telephone No. Owner's Address CS Ae Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building eu-11 Utility Authorization No. Existing Service Amps / Volts J OkerheadFl Undgrd ❑ No. of Meters New Service Amps / Vhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: '67 y C C-r✓A-JCC- - i GJ / R c A)?,,j s Com letion of the ollowin tablema b d b h 1 ' y e waive t ens ector o W No. of Recessed Luminaires il: No. of CeSusp. (Paddle) Fans fres. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- El _grnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: INumber Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of .Dryers No. of Water Heaters' Heating Appliances KW No. of No. of Signs Ballasts Security Systems:* No. of Devices or Equivalent Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsWiring: No, of Devices or Equivalent OTHER: A rath additional detail J desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: D 0 0 (When required by municipal policy.) Work to Start: !t 0'r 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 cove ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pa' s andpenaldes of perjury, that the information on this application is true and complete. FIRM NAME: *tLPA-(S C-Jec ,e e LIC. NO.: y4/ 7 A Licensee: � Ole C Signature LIC: NO_ �a�G ,3 _3 (If applicable, enter "exempt " in the license number line.) Bus. Tel. No. 7B) Address: _ 15' IA 111 5"h r 4 v e- t-✓ e 5 40 & o Alt. Tel. No.:427 —a7 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent ! `� Signature Telephone No. PERMIT FEE: $ r-.— �-13 4 p air, The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations i "�'" 600 Washington Street 't�it'�; r L k i Boston, MA 02111 rl www nwss.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers Applicant Information Please Print Legibly Name (Business/Organizafion/indivi Address: 1 S— (1I S 1 VX A V C- IL City/.State/Zip:_ W e ,gw, 01 �Yl Phone #:. C�r� �% S 7— ? Y 2.. Are y n employer? Check the appropriate box: 1. I am a employer with 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a.sole proprietor or partner- have hired the sub -contractors 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.) 3.[13 lam 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 required..] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I l .❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other -••, `--Z. rr— • ...o, -'—" UUx It, mus' luso nu out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they ate doing all wotk and then hire outside contractors must submit new affidavit indicating such. 4connaetors that check this box mustattached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I ant an employer thatis. providing workers' compensation ins information. urance for my. employees: Below is the policy and job site Insurance Company Name:_ (N e5 T-41, Owe r -- Policy # or Self -ins. Lie. #: Expiration Date:__ Job Site Address: 67 0.5 a ;moo S r, City/state/Zip:- N a A,,,,o Air,,, rte c9 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 WORT{ ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify undgi the pains and penalties of perjury 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. Plumbi 6. Other ng Inspector 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 ofthe'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 cavy 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 numberlisted 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 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 of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7744 www.mass.gov/dia Date ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that .............................................................................................. has permission to perform ..... ...................... ..... ... ... .. ... ........... . .. .. ... wiring in the building of .................... 76 V -&Wb V ..................... 4 ........................................ J _5'7_S- e:�'S 2�eob at......................................................................... . North Andover, Mass. Fee ... 2—.....0 ............. Lic. No . .... . ................. ..... .. ; .......... ....... LECTRICAL MpEcrOR Check # 7975' ,# LIN C'atnm 1111 th 11 a6aacLel% Official Use Only cc�� cc77 Permit No. %S eLJeftarEmenE o�.}ire �ervicel 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 •C), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /24 8 City or Town of: To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below.. Location (Street & Number)_] Owner or Tenant h�jm,1106 T Telephone No. Owner's Address ` > j U��g�___ _ Is this permit in conjunction with a bu Iding permit? Yes ❑ 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: yAf 20 02�1 J2 d' XI / �� ✓� ComDletion ofthe f011mvinv tnhla mow he wnivod by tho /ncnoptnr of n/iroe No. of Recessed Luminaires No. of Cell.-Susp. (Paddle) Fans TTotal r Transs formers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- E]o. rnd. nd. o Emergency Lighting Batte Units No. of Receptacle Outlets / No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No, of Gas Burners o. of Detection an Initiating Devices No. of I3aeebes No. of Air Coad. TotalNo. of Alerting g Devices No. of Waste Disposers eat Pump Totals: ._umber Tons '�' W ""-"� o. 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 WaterKW Heaters No. of o. of . Si ns Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value7,�771,1 al Work: Z 5 (0 U QWhen 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 cer iijy, under the pains and penalties of perjury, that the information. on this application is true and complete. FIRM NAME: ;,;V - LIC. NO.: Licensee: y� t� Signature LIC. NO.: (If applicable, enter "exempt" in the license numberelie)FYBus. Tel. No.•� - - 1911 Address: Z 6�, A14 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 (chec[one ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ Zd. N + TOWN OF NORTH ANDD R PERMIT FOR PLUM ING This certifies that ... L A c Af— ........... has permission to perform ........ plumbing in the buildings of ... t. � ... P'. -( ........... at. . S_ ? -0-S7 y-, � � ............. N.orth'Andover, Mass. Fee 0 . Lic. . ....... - INSPECTOR ....... L BING Check # 21 Z Q7 7615 DateZ`..._ TOWN OF NORTH ANDOVER 0- PERMIT FOR WIRING TWI * cie This certifies that ..... ....................................... has permission to perform . ..... ......................6............... wiring in the building of .... ! ........ ........ .......... at ... 4 ....... .. North Andover, -Mass. Fee—,P.. .70 Lic. NoAy';7'?'4 ............ LPCA� � . SPE R Check # 7855 Comtnotua¢a o� %�al9ace! Official Use Only AW;r c7 n Permit No. `�¢parfineni a�..tire J¢rvic¢3 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 C), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALINFORMATION) Date: ///,? J City or Town of: A64) wlf n To the In pector of W _ By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 5-73 CS 0,002) L4¢-,/1 jY/ . 7"& 2 07 Owner -or Tenant 'FAi. Loc9 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ 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: 216 , :L"- t� C Cmmnletinn of the f Unwins tnhlo m" ho wniyoii by tho 1--t— of w;— No. of Recessed Luminaires No. of Cefl.-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- ❑ rnd. d. o. o Emergency Lighting Batte Units No. of Receptacle Outlets No, of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. o Detection and Initiating Devices No. of Ranges No. of Air Cond. ons T No. of Alerting Devices No. of Waste Disposers eat Pump Totals: ._-umber Tons W__ No, of elf -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local[] Municipal El Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of aterKWNo. Heaters of o. of Signs Ballasts Data Wiring No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail iJ desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 2 -% W (When required by municipal policy.) Work to Start: 6 dw 4 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 [f BOND ❑ OTHER ❑ (Specify:)' I certify, under the pains andpenalties ofperjury, that the information. on this application is true and complete. FIRM NAME: r �eyv� c%� F d C' LIC. NO.: Licensee: d�J iv ���;J Signature LIC. NO.: 1,604- 7 bo, (If applicable. ter ' ex l" in the license-pu in O Bus. Tel. No.: 03 -age-/91/ Address: Aft. Tel. No.: ya l6 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER. I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one)❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. S Z0, 0O .,�r:...-. ..: .-..,.. «,-�.. 5c-�......,.,•r'+•,,.�r.,...-+-�-'",.,�.7�x�3Z...x.-tR....r.�...:�rn.s.,,�..„Y-:.v.,K+,-....,-'+.a.��,b,.. 44 O Date...... ..............,,7.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that has permission to perform.......'/".'t^''.......................................... .'"�.................................... wiring in the building of � .............. ....... %0— ,North Andover, Mass. Fee`-' ............. Lic. No..y,27 .: ELECTRICAL I SPECTO r Check # m; 4 " Permit No. 7V ? 8 Department of Fire Services Occupancy and Fee Checked { r� BOARD OF FIRE PREVENTION REGULATIONS [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 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: '7- 3 -0-7 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 57 �- C).'C�Gbo. Owner or Tenant FdAecW0Q0 6os4,p -+ r J)4d f,40ftTj Telephone No. 978- 738-W/V Owner's Address _ tSrNn► t Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Yes ❑ No � (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: 3,A610/1 al, QXOUAO,i, - Cmmnlotinn nithe inllm..;— i�hle », , A No. of Recessed Luminaires - - – -, ---�._.,......» No. of Ceil: Susp. (Paddle) Fans o. of otal Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ n- ❑ rnd. rnd. o. of Emergency Lignting Battea Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection an InitiatingDevices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat um Totals umber ................................................... ons o. o el - ontaine Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ unicipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. o Water Heaters KW o. of o. o Si ns Ballasts Data Wiring No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications firing: No. of Devices or E uivalent OTHER: l attach additional detail ydesired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 22 1 . 4y (When required by municipal policy.) Work to Start: 7, 9- U _ 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 certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: !!� (FrAAt?*1 Swett rt S LIC. NO.: IG417 A Licensee: 'jam l C t G fFAy Signature LIC. NO.: (If applicable, enter "exem t " in the license number line.) C�� a Address: Bus. Tel. No.:_l. 3-118 -/ g// �/Lo� ,�i:a /� �/�'�• Alt. Tel. No.:foo3-SYG-f3fL e [LiQ *Per M.G.L c. 147, s. �7-61, security work requires Department of Public Safety "S" Lic nse: 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 n Signature Telephone No. FPEI?MIT FEE. $ �j Date.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..C&4.4��,Yxl .....4- ? ,�i`%1,`.............. has permission to perform ........ vu...... ............... TZ -5 wiring in the buildin&of ........ ............... at ..... ..... .... ................................ North Andover, Mass. ic. Nod&).�:74f7 ........... Fee ..................... L Check DIS%lMMWOFP[1OWSUM7 rpt No. d BGW1�DtaRF��BPRLVFN11n11VR�ii1lAZ7g11�Sd7(11�1y,� . OMR" & Res Checked .�.,. APPUCATTONFOR PERW TSO PWORMEUCTR M WORK AM WOU TO ISE. MMRMW 24 ACCORDANCE w= nig MASSACWSS[3 EIFCrRi & CODs, 527 CMR 12:00 (PLEASE PRIW 1N INK OR TYPE ALL DMORMATION) D - `f Torn of Northlndova To the Inspector' of wires: ' The undersigned applies for a permit to perform the electrical work described below. Location (Sam d Owner or Tenant Owner's Address is this permit in conjunction with &)wilding permit Yes Co 140 0— (Cbech, WWWe Box) Purpose of Building Aom e Utility Authorization No. Existing Service Amps I Volts OverhadUnderg�d No. of Meters Services New Amp. outs Overhead UD&Wound ® No. of Meters Number of Fi6dea and A ipacity Location and Nature of Proposed Electrical WorkAt -Floor O r'' Na of Uandnj Oddm W of Hot Tabr No d Thnforrnmr Toot Na of Uahtins Fiutma Swbmnb* Pod. Above Bd w KVA KVA Na d Oil Bnrmes - No. of Rsappch on" Nd: of Ettlemm y U Batts y thda No. of Switch Odbtg No. dOar Barm s PIRG ALARMS No. of 7ooed No. of Rm►aa No. of Air Cool. TOW Tor W d Damcoon and Hm of Dirpadr- No. d Hat ToW TOW Toa Kw 1aidWgDdrfca No. of SOMAN Daricas i� No. of Dlahwdrbmr Spm Mea Neathu , : Kw . Na of Sdf Co who � f � c� a o od -- No' d Dryd�r Hemina Devkdr Kw No. of oma Hdatdn Kw Na d Na d SINN Beflub No. Hydro Munn TWo Na of Motaa Tow HP hL==CMWW PJWUID6ere41era� Cimmilsws Itvmaft*kdvatidpafaf=wWtmOffiz 711;9 C IWLIaN>t�� nrBCND[3 07i1taR wadcbsos< irapaDdreRMrsied 1itMNAIE NI�(7— _ goan dot mo 0 NO D lryouhstederled7lB4,pbrs;adcateftetJFGf neavby Ewt�nrbdValveaiRoo H 1k A44 Lk=N m _ LiobaeeNb a�et�tNa .47t9v q7�-6LZ 99-0 I C—d OV1TMSAbiJRANMWAMIemamelafttior3eey INWIN* aA& JLCL adfiawt seaifpaIpisdsit ols6edan#WbyMa udCnvWLa (Please cbeck one) Owner (M AIM Telephone No. ?ML% rr FEE S DR%ZMfiff0FPEKVSLvWy ftmu7/37 BO400FF�BPRi$ SWIWXlZ,G1MA1.WC Wnz N0` oocW=" A Rea Chalced =� APPUCA71ONFOR PERMIT TO PERFORMELECI'RICAL WORK AM WORK to ss rUu+o MIN AM wtm TW eussaCatusM mLcnuc& COM 527 CM t 12:00 (PLEASE PRINT IN INK OR TYPE ALL WORMATMN) f ,�! a T`uf.�I�ortlt.11ndover . To the Inspector of Wit es: The undersigned applies for a permit to perfomt the electrical work descbed below. Location (Saes A Owner or Tenant Owner's Address Is this permit in oonjunctim with s ' pKWk YeaC3 No (cbec} Appq,pjm Boj) Purpose of Banding((1° e M Existing Service Amps"../ .Vob Ovtuhgd New Service HMWNEMM� Amps I Volt Ovedlad Number of Feedera and A mcity *atkm and Natme of Proposed ElectrkN Wort _ _ Floor Utak Authorization No. U cv Undapouad No. of MMdas No. of Meters fu of zm ..�. hensanaeCl► AasstblieiagI 1111:T;ffil 11:!o iinene�(;mmilLow 13 13 IhareaamatL'sbi�dsaaanneR,ig► It>nesubrr�+dvddpsoddsnmebineOtii� YBShNedyededY dneddi�tle FkmiidaeftB4PCI(aote Wby 24KRAN35 BCM C3 am Q WanklD,v t , ErinlkdVAvdBm"W* s FMMNAM Ale 7k / LimaNa ali NI"I - 6v/*aa Lomel+b P Aft= AaAel OW18VSMMA=WANHt;Ian==WftL'oeta &ahWja Alt'INNa 7 _ 9 arddrtnr4�siBaraeanfispesrR�� 1°�edb1'GiesaiLsM (Please ebeck one) Owner Agpat Telephone No, mtmrr FB8.3 FRB ALUM ?armee rbul Told" Na artaeae" sed Tarr 8W , Darby o yKW V N&Gfso=d%Dnlk= n—m KW _ _"M1 Dnion —1 Lad fu of zm ..�. hensanaeCl► AasstblieiagI 1111:T;ffil 11:!o iinene�(;mmilLow 13 13 IhareaamatL'sbi�dsaaanneR,ig► It>nesubrr�+dvddpsoddsnmebineOtii� YBShNedyededY dneddi�tle FkmiidaeftB4PCI(aote Wby 24KRAN35 BCM C3 am Q WanklD,v t , ErinlkdVAvdBm"W* s FMMNAM Ale 7k / LimaNa ali NI"I - 6v/*aa Lomel+b P Aft= AaAel OW18VSMMA=WANHt;Ian==WftL'oeta &ahWja Alt'INNa 7 _ 9 arddrtnr4�siBaraeanfispesrR�� 1°�edb1'GiesaiLsM (Please ebeck one) Owner Agpat Telephone No, mtmrr FB8.3 Date '40R, TOWN OF NORTH ANDOVER it �.' pL PERMIT FO'R PLUMBING ,SSACMUS��5 This certifies that ... .,h. L ., `" .t. _ _ , , o .c.. ri ............... has permission to perform ...... .......................... plumbing in the buildings of C, .• . t{............... . at ....... ............... North Andover, Mass. E, Fee. 3.), . Lic. No.. k .i .7 ? ....... PLUMBING INSPE TOR Check # t ' ©(°,Z�g 3Zsa MASSACHUSETTS UNIFORM APPLICATION FOR -PERMIT TO DO PLUMBING (Print or Type) a�LL1r� , Mass. DateCjfGLS�'� S 20�_ Permit # _T Building Location .S75-0561 Owner's Name �� CeMn,Nl„ Type of Occupancy en1�4�1�[ New ❑ Renovation ❑' Replacement Plans Submitted: Yes ❑ No FIXTURES :SEWER.# --.----- � - ._.! crnr��_.._J „ •' i t I Ln Z O L r z = /n V LU Of LLJ f V Lr/ w V) l cn 2 F- U w to Y LL z z a z U Z LU m z w to ¢ w .O >- ¢ 1-- ¢. L z D c�r z a . O >L Q U> �O . Fz- O 3 c=n can n= cn E J z v) ,� d O O� z z o H• � �O Y w kL1B-BSMTU_�.- g ¢ m 2 cn Ln ¢ O 2 ¢ V) O u- ¢ O D 0 ¢ � � U m m= O _. _.. ,1... I BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR nstalling Company Name pp� f�c ?Lt_ AAA- Check ong: Certificate ,ddress YCorporation Nu• 4 A -A , hAA 0 1Pµ�!—� tusiness Telephone 17 T) • ��Q I Sg?� ❑ Partnership lame of Licensed Plumber or Gas Fitter����T IFy(.i�e��'1<A ❑ Firm/Co. INbUKAN(;F- COVERAGE: I have a current liability insurance policy or its substantial equivalent, which meets the requirements of-ffGL Ch. 142 Yes -Y No.0 If you have checked ves, please indicate the type of coverage by checking the appropriate box. A liability insurance policy 1' Other type of indemnity ❑ Bond ❑ OWNER'S INSURNACE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: Owner ❑ Agent ❑ iereby certify that all of the details and information I have submitted (or entered) In above application are true and accurate to the best of y knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with I pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Title Signature of Licensed Plumber City/Town APPROVED (OFFICE USE ONLY) Type of License: )Aaster OJourneyman License Number�sg7 .,..,. , .,.. �^..> ..._;......+.t.�...r�,.: ^cei..r � -� xEsn,..,,� �t..�'^.or.,.v,.,...�..•..•.—•?•..."'r Date...�`l 1� ....... { f MORTIj 3? TOW_ N OF NORTH ANDOVER PERMIT_ FOR GAS INSTALLATION •. 09 � �r . �a This certifies that . 1. ..1? G� ./I.. �L 5 ................ has permission for gas installation .. .T 11.. � ......... in the buildings of .. ........................ at ...J J. q o jc� ............ oo_Andover, Mass. Fee.,�!D ... Lic. No.. R) . 1 . GA INSPECTOR Check # 55,27 `I. Lv1ASSACHL SEM UNIFORM APPUCATON FOR PERNIlT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS IL Date A �j Building Locations S 7 S CEQcOLD '�I— Permit # S f Z Amount $ Owner's Name 2�e-Z112-�tJM,�c/�—�cMilt� � New Renovationa 11 ment„ ReplacePlans Submitted4TH. FLOOR (Print or type) ` C one: Certifi ate In tailing Company Name wEitom. I�crrG PLUlM(31N6,+- Mr�.tg-nN6 Corp. ��1 ElPartner. ElFirm/Co. Name of Licensed Plumber or Gas Fitter &(,— ej—Ati —. A e7yr, ' INSURANCE COVERAGE- Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes NoO If you have checked yes, please indicate the type coverage by checking the appropriate b Liability insurance policy j Other type of indemnity 0 Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent 0 i hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing :work and installations performed under Permit Issued for this application will be in _cmpliance with all pertinent provisions of the Nlassacl usetts State Gas Code and Chapter 142 of the General Laws. By: Title City/Town ,APPROVED,CFRCE (:SE 0 IY) Signature of Licensed Plumber Or Gas Fitter Plumber Gas Fitteric1J s Number Master Journeyman 6TH. FLOOR (Print or type) ` C one: Certifi ate In tailing Company Name wEitom. I�crrG PLUlM(31N6,+- Mr�.tg-nN6 Corp. ��1 ElPartner. ElFirm/Co. Name of Licensed Plumber or Gas Fitter &(,— ej—Ati —. A e7yr, ' INSURANCE COVERAGE- Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes NoO If you have checked yes, please indicate the type coverage by checking the appropriate b Liability insurance policy j Other type of indemnity 0 Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent 0 i hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing :work and installations performed under Permit Issued for this application will be in _cmpliance with all pertinent provisions of the Nlassacl usetts State Gas Code and Chapter 142 of the General Laws. By: Title City/Town ,APPROVED,CFRCE (:SE 0 IY) Signature of Licensed Plumber Or Gas Fitter Plumber Gas Fitteric1J s Number Master Journeyman Date ... ...... .... ... ... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...................... I ..................... s permission for gas installation— ........................ in the buildings of ......... . .............................. at Nqrth Andover, Mass. Fee .. Lic. No.. ......... Check # 4-6 5319 '4. ,j:2 Date.... TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING This certifies that ....... has permission to perform 4 wiring in the building of Fee ...... . A ......... Lic. Nd Check # 5680 6who ................................ ..........a .............. . North Andover, .. . .... .. uk.Mass. ........... 5 6 - v, AI& ELECTRICAL INSPECTOR 4 �'A Commonwealth of Massachusetts - Department of Fire Services BOARD OF FIRE PREVENTION REGULATIC APPLICATION FOR PERMIT TO All work to be performed in accordance with the Ma. - (PLEA SE a(PLEASE PRINT W INK OR TYPE ALL INFORMATION) City or Town of: North Andover By this application the undersigned gives notice of his or her int Location (Street & Number) 575 Osgood Street' Owner or Tenant Edgewood Retirement Community, Inc. Owner's Address 575 Osgood Street, No. Andover, MA Is this permit in conjunction with a building permit? Purpose of Building Residences Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Official UseOnly Permit No. Occupancy and Fee Checked g. -W [Rev. 11/991 leave blank ZFORM ELECTRICAL WORK efts Electrical Code (MEC), 527 CMR 12.00 Date: 03/22/2005 To the Inspector of Wires: to perform the electrical work described below. Telephone No. 978-725-3300 VYes ❑ No X (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters _ Overhead ❑ Undgrd ❑ No. of Meters Rewire Parking Area Lighting rmm.lati— nf'th, f llnw r,n t hl� ,,. . 1— , ,,,7 h,. sl.,. T-.----- -rill";- No. of Recessed fixtures No. of Ceil. Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑ - ❑o. rnd. grnd. of Emergency Lighting Batte Units No. of Receptacle Outlets No. of OR Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Devices No. of Ranges No. of Air Cond. Total Tons -Initiating No. of Alerting Devices g No. of Waste Disposers Heat Pum Totals Number Tons ......................................... KW o. of Se -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW SecuritySystems: No. of Devices or Equivalent No. o Water KW Heaters o. o No. o Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: .Yttacn aaaltional aetall J destred, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE X BOND ❑ OTHER n (Specify:) Estimated Value of Electrical Work: $17,000.00 (When required by municipal policy.) (Expiration Date) Work to Start: 03/29/2005 Inspections to be requested in accordance with NEC Rule 10, and upon completion. I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Landers Electrical Co., Inc. I LIC. NO.: A5912 Licensee: Vincent B. Landers, President Signature LIC. NO.: A5912 (If applicable, enter "exempt "in the license number line.) Bus. Tel. No—• 978-686-3828 Address: 1000 Osgood St., No. Andover MA 01845 Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally rnn.,irnil l.o ln.v Rv ms. nirrnnfi.rn 1-1— T h—U- thin rean..irnma»t T nm 41kn /nhnnL n»al n n�imar n __,v nnu»t P", -� Commonwealth of Massachusetts _ Department of Fire Services BOARD OF FIRE PREVENTION REGULATIC APPLICATION FOR PERMIT TO P All work to be performed m accordance with the Massa (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) City or Town of: North Andover By this application the undersigned gives notice of his or her int e Location (Street & Number) 575 Osgood Street 11 Owner or Tenant Edgewood Retirement Community, Inc. Owner's Address 575 Osgood Street, No. Andover, MA Is this permit in conjunction with a building permit? Official Use Permit No. Occupancy and Fee Checked` [Rev. 11/991 leave blank WORM ELECTRICAL WORK etts Electrical Code (MEC), 527 CMR 12.00 Date: 03/22/2005 To the Inspector of Wires: to perform the electrical work described below. Telephone No. 978-725-3300 Yes ❑ No X (Check Appropriate Box) Purpose of Building Residences I Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Rewire Parking Area Lighting No. of Meters No. of Meters t'.. ..l.,r:.. „FtL- l;.11,. ..L1_ . L_ L_. J_ L.__ _f rrl•. No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. o Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVO► No. of Lighting Fixtures Swimming Pool ove ❑ - ❑ rnd, rnd. o. of Emergency Lighting Battea 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 hdtiating Devices No. of Ranges No. of Air Cond. Total . Tons No. of Alerting Devices g No. of Waste Disposers Heat Pum Totals Number Tons KW No. o Self -Contained Detection/Alertinx Devices No. of Dishwashers Space/Area Heating KW Local ❑ municipal ❑Other Connection No. of Dryers Heating Appliances KW eeuntySystems: No. of Devices or Equivalent No. o Water KW Heaters o. o o. or- Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER rnllacri aaamonat aemit q aestrw, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE X BOND ❑ OTHER ❑ (Specify:) Estimated Value of Electrical Work: $17,000.00 (When required by municipal policy.) (Expiration Date) Work to Start: 03/29/2005 Inspections to be requested in accordance with NEC Rule 10, and upon completion. I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Landers Electrical Co., Inc. LIC. NO.: A5912 Licensee: Vincent B. Landers, President Signature LIC. NO.: A5912 (If applicable, enter "exempt" in the license number line.) Bus. Tel. No..• 978-686-3828 Address: 1000 Osgood St., No. Andover MA 01845 Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally ronnircii h.r lnnr R.. m�.. of m�nfi.rn holm.. T hnrnh- --i- thin T nm th. (^h—Ir nnul n n�imar n ntrnnr°r nnnnt -+s. -r......--,"... •w'•.,.,--. ;.,�-.....:«.^-+•,.--F.Y �� •--.-....,t.rn.s,.-a..r^.�•�""Jy-..'•.,,,,*-.-.^-^,.ter'+.-.--*'`.+.E-•..-n.� �'a Date.... ....................... 3:a::�``°:°•e �0 TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �,SSACMUS� i This certifies that ....................... I., ..... ...... ............................................ Y has permission to pe'` orm: .. ...., ...........:...... ..... ... .: /.1�..... wiring in the building of ... %. ... A, .........<. at ...�1,� ......... .......... _ .......... , North Andover, Mass. Fee:/ . � .......... LIc. No ........................................................... ELECTRICAL INSPECTOR Check,, &2 lz-e7l 5460 'i e Commonwealth of Massachusetts k Department of Fire Services BOARD OF FIRE PREVENTION REQ ULA MONS APPLICATION FOR PERMIT TO P All work to be performed in accordance with the ilass (PLEASE PRINT IN INK OR City or Town of: By this application the undersigi Location (Street & Nurser) Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Installation of Security system Official Use Only / Permit No. ��Q Occupancy and Fee Checked [Rev. 11/991 leave blank =ORM ELECTRICAL WORK etts Electrical Code (MEC), 5 COR 12,00 ^ Date:/ _ To the Inspector f Wires: to perform the electrical work described below. /l/!►/__1M 'l Telephone No. Yes ❑ No [9""' (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters _ Overhead ❑ Undgrd ❑ No. of Meters Cbmnletinn of the fnllnwinv tahle mnv by wnivod by the Incnortnr of W;roc No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of,Lighting Fixtures Swimming Pool Above ❑ In ❑ rnd. rnd. o. o Emergency Lighting Battery Units . No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers'. Heat Pump Totals: I Number I Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating p b KW i Local ❑ Connection Munical ❑Other No. of Dryers Heating Appliances Kit Security Systems: No. of Devices or Equivalent 45 No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. 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) (Expiration Date) Estimated Value of P lectrical ork: (When required by municipal policy.) Work to Start: X Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under t1lepains andpenalties ofperjury, that the information on this application is true and complete. FIRM�NAME:Security Nu LIC. NO.: 1 51.1c lkz Licensee: John S. Bassett Signature LIC. NO.: 1533C (If applicable, enter "exempt" in the license number line) Bus. Tel. No.: 603 594 5928 Address: Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Lidghsee 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 Signature Telephone No. PERMIT FEE: S ' f HORTh O �•��' �•. �0 0 F40 Date. '104AZI. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ......... has permission to perform (. ai� , >...� �..�,. plumbing in the buildings ofa. 6cl �C%-U �. (......: 1 ( at ..5 C/S' ............. North Andover, Mass. Fee .40:.... Lic. No.. �:-?:/.7 ............................. . PLUMBING INSPECTOR M Check # k. 5894 'MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING -- - : fPrfnt or Type) I�I,OK AfruDD J L ' Mass. Date Permit # y9 —V IEDG&JauooA 2E. te.IM c �t ..Bullding Location SCg00D ST—A s Name C.Qs,MtMu fNt't�/ i STC, Type of Occupancy Oran lli4t New ❑ . Renovation ❑ Re Plans Submitted: Yes ❑ No 1 FIXTURES IST FLOOR 2 fti 0FLOOR �� 3RD FLOOR 4THFLOOR �� STHFLOOR ��� STH FLOOR 7TH FLOOR STH FLOOR FCheck one:. Certificate Corporation O IVO. KNUOVWL, VMS V IM�❑ Partnership Business Telephone °11 S • 017S"-• 42.89 • ❑ Fum/Co. Name ' of Licensed Plumber (1ut_-y fi PA IA M W E't'r'6' INSURANCE COVERAGE: I shave a current liability insurance policy or its substant ia! equivalent which meets the requirements of MGL Ch. 142. N Yes No ❑ If you have ecked Yes. please indicate the type,,coverage by checking the appropriate box A liability Insurance policy Other type of Indemnity O Bond ❑ OWNER'S INSURANCE WAIVER: -I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this permit application walves this requirement.. : 41:�Check one: Owner•:p .Agent O Signature of Owner or Owner's Agent y I hereby certify that all of the details and 'information I have submitted (or entered) in above application are true and accurate to the best of my c knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with. all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the general Laws. &gnature of Ucensed Plumber Type of License: Master Journeymanatyrrovirn �.. APPF O IC U ONL license Number gso}7 . Y d • N O a O Z W r W oo' Y J J tll t V N D � QCC • m z N OC CC .: Z O Z q d J N W 9 _ r V < W O Z C a. p d d .X V Z O W d W cc < W D < M Q W r r W co p J N C ¢ U. .CC =l 0 w O V s .. 40 W •W j F~'' Is . ci.y„0= a 3 cci ® o "I IST FLOOR 2 fti 0FLOOR �� 3RD FLOOR 4THFLOOR �� STHFLOOR ��� STH FLOOR 7TH FLOOR STH FLOOR FCheck one:. Certificate Corporation O IVO. KNUOVWL, VMS V IM�❑ Partnership Business Telephone °11 S • 017S"-• 42.89 • ❑ Fum/Co. Name ' of Licensed Plumber (1ut_-y fi PA IA M W E't'r'6' INSURANCE COVERAGE: I shave a current liability insurance policy or its substant ia! equivalent which meets the requirements of MGL Ch. 142. N Yes No ❑ If you have ecked Yes. please indicate the type,,coverage by checking the appropriate box A liability Insurance policy Other type of Indemnity O Bond ❑ OWNER'S INSURANCE WAIVER: -I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this permit application walves this requirement.. : 41:�Check one: Owner•:p .Agent O Signature of Owner or Owner's Agent y I hereby certify that all of the details and 'information I have submitted (or entered) in above application are true and accurate to the best of my c knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with. all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the general Laws. &gnature of Ucensed Plumber Type of License: Master Journeymanatyrrovirn �.. APPF O IC U ONL license Number gso}7 ...... ......... ........ N2 e7 Date ......... 6/// TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... ........ c.... ...... ...................... has permission to perform ....... ........................................... wiring in the building of ...... .......... .................. at ^..... ............................. . North Andover, Mass 77% Fee,',�.73 .. .... Lic. No., ........ j/ .... ELECTRICALR Check # %12 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer ®` 1CImuulwy1VIvY►'Gfi1.111UrJV11%X"LL1UJC11J vwceuse only ►� _ DEPAR71t11�VTOFPIIBLICS4FF.TY Permit No. � RD 3.r/� BOAOF FIRE PREVE WONRW UL ATIOA S S27 CMR 12:(10 ' Occupancy & Fees Checked APPUCATTONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date (- -7 Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street 6 Owner or Tenant Owner's Address To the Inspector of Wires: Is this permit in conjunction with a building permit: Yes Purpose of Building ddj, Itd"7 s i� �Z46)941/ Existing Service 4 / 4 Am ps"volts New Service N A _ Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No M (Check Appropriate Box) urnoqal, Utility Authorization No. Over ead Underground No. of Meters Overhead ® Underground No. of Meters No. ofLighti�gOutlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground ground No. of RecepEacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges ` No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP a Iha%eammitLiabt1dyhumxPohcynijdugCar>plehe�'�CovaaWcritssijstEi>#i oVi� alad YES L.A NO u Iha%esubmftdvMprwfofsametotheOH're YES U NO IfjcuhmdledWYES,pkmmdc*t r.NxcfwmaWb5'&dmgthe INSURANCE L.2j BOND Lj OTE&R LJ (PleaseSpt�cdy) E imD* /-7 auc, A5 VahtecfP3actrioil Wodc $ i WedstoSlap ����_`� — D&Rqucs ed Ratgh -- �t 5 n e� Final eQS e Sig�edutrJa�ie%mlbescfpajtay/�► 1 i _ % i ^ Lbortw lC ✓l C2/� Y ° Ui 1/1 �! � T �7TA 62 � -- (a26 -- 4, Ul f AlTeNi OWNER'SINSURANCEW. I.arrtawatet AtbeIW t theittar=w►mwaritsmbsbrtialegdvalartasm#Wby&bmlmmCa>aalLam aodtlratmysm�spa�wai�s>}�slecgmai�, (Plea,se ch k on Owner, Agent 1 l V 1 I.e�.Telephone No. 6o - 6;? 6- 6(-)7c) PERMIT FEE 1 U 4 Date. -�.: ;< .:.G.!..... TOWN OF NORTH ANDOVER PERMIT FOR MECHANICAL INSTALLATION This certifies that ...D.�' Ems) .v ".......... .�.... has permission for mechanical installation .. n r4t.. ? �:.t. !.�..... . in the buildings of ...........:........................ at . 3 . %.� ... s �� �.. �............... North Andover, Mass. Fee.4: rfio t0' Lic. No........... .... ,�....... JGAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer TOWN OF North Andover 27 CHARLES STREET NORTH ANDOVER MA 01845 FURNACES, BOILERS, ROOF TOP UNITS, AIR CONDITIONERS, EMERGENCY, GENEREATORS �1 '19 Z00( The undersigned applies for a permit to install the following at: Location _'!S� 7-�;_ 056-oo 0 S T Owner of premises Address Name of mechanic DEA01V PL G- lt 14 VPf L Address Building occupied for Material of building Kind of fuel Chimney No. Of flues Size_ r I► Chimney Thickness Lining If steel stack location Diameter Height DESCRIPTION OF HEATING APPARATUS Kind of heater how many make BTU Location in bu Protected against fire as required How protected See the State Code (Pertaining to Chimneys, Smokestacks and Heating Apparatus) ROOF TOP UNITS OR EMERGENCY GENERATORS Make Weight Dimension Length Width Height Location of building how supported Size of roof timbers Material of roof timbers Span of roof timbers Distance on center, Protected against fire as required How protected AIR CONDITIONS Kind of apparatus make Date N2 3 0 0 0 TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING ................ ........................ ...................... This certifies that 51 has permission to perform...... X wiring in the building of ...... ... w..................................... -"t.; .... ............... ................... . Nerth And We !;-jdiss. Lic. No. .... ............. INSPECTOR C**T* 0** R ELECTRICAL Check #'*... 66 6( WHITE: Applicant CANARY: Building Dept. PINK: Treasurer i P. VQ r`tt,r F=ps Ir . p gR� i All vv i,: Lo be info n tcin accoi Cin C_ with -L-n=-M'assaCtS=us _j--cu-:Zai •moo;'. -tit -i .oil !V �_ _ r'.. llv~= l!`i)j Tj J'i/V1� ' _i S ADD % ff r 11 Date: Ci tv- or 1'o'vm G t N . . r _ h vvei� -.✓ 'L -.s n -D aTicm zl-,eS nnri ^:'_S -., ^ ^ ' O. e nr= t On �v ^ it ?- 1 Me le I' �i vJ Q -IC`ri i+ ui eS C`i0v°. � oil (SErec t�n�> r��r1 5-6 ©sejood 5� L�G '7000 • ir-tG"ei E•r I; eman � e w oC Ls thin ale`"" t 7n cQILi_Iim- io= 6":ity a bL' j&AEffi_m Iaa . 1t.' r o � NO El .Lspuirn A^mte'�eGaril ELrLu SedL1 4FF54'F � C()mD+tffCl/�` �pnQOs FJ�li)Jtt.' ur,: thotgor e. X91[—M ayn7iC �IID^S i Vchts OverheadI FJffiCg,rd e. �r � i of IVSie p oca ion mU I a F W of r >�os Faec r _ar. -^. �n- - + u Ne.- o^ ere%s Lr w% ,- 4 R� /+��resSablc SI M,oLex -3 /5" ova 36 [An1 1�la._eess'eo j_4�res T, ^ yc f c -� \ un, iS. Qui_ _L'.. -Sud . (- iy�� .,,. ..i.. >_ yw:S 1�c o aI P ` 1iui3e) .. iNO. OHF iarLnti no O'n'tri g. INN. of `H9t Ti1.,.,n' IGel-erl-rors ki �Jla d �s 1pwve M-. -�e�llmming pow, I I I_ ING.. of -K met�effic-',•'j =HTEi 5 -rnd. �rrud. ;matter -v Units lie. of Rec6pt2cie Oivati&mq INe. of iT BurnersIwo. of Zones 4 rejfA l I'Ql'. QT S Ftemes v.^..^.:=paA,^.'�' IT GAG j'^+i:eC - Ne Q - p'2 mL7es _- IrdQ . QDf _� ee -iia Devh-ec j s-1 1, (i C av, t O12.n1_:' i P. VQ r`tt,r F=ps Ir . p gR� i All vv i,: Lo be info n tcin accoi Cin C_ with -L-n=-M'assaCtS=us _j--cu-:Zai •moo;'. -tit -i .oil !V �_ _ r'.. llv~= l!`i)j Tj J'i/V1� ' _i S ADD % ff r 11 Date: Ci tv- or 1'o'vm G t N . . r _ h vvei� -.✓ 'L -.s n -D aTicm zl-,eS nnri ^:'_S -., ^ ^ ' O. e nr= t On �v ^ it ?- 1 Me le I' �i vJ Q -IC`ri i+ ui eS C`i0v°. � oil (SErec t�n�> r��r1 5-6 ©sejood 5� L�G '7000 • ir-tG"ei E•r I; eman � e w oC Ls thin ale`"" t 7n cQILi_Iim- io= 6":ity a bL' j&AEffi_m Iaa . 1t.' r o � NO El .Lspuirn A^mte'�eGaril ELrLu SedL1 4FF54'F � C()mD+tffCl/�` �pnQOs FJ�li)Jtt.' ur,: thotgor e. X91[—M ayn7iC �IID^S i Vchts OverheadI FJffiCg,rd e. �r � i of IVSie p oca ion mU I a F W of r >�os Faec r _ar. -^. �n- - + u Ne.- o^ ere%s Lr w% ,- 4 R� /+��resSablc SI M,oLex -3 /5" ova 36 [An1 1�la._eess'eo j_4�res T, ^ yc f c -� \ un, iS. Qui_ _L'.. -Sud . (- iy�� .,,. ..i.. >_ yw:S 1�c o aI I f LC�ngA�i•F°oT 5T,�� � iNO. OHF iarLnti no O'n'tri g. INN. of `H9t Ti1.,.,n' IGel-erl-rors ki �Jla ry„ PcQD'. QP7 r,A6%atF>F� 1 F sores �s 1pwve M-. -�e�llmming pow, I I I_ ING.. of -K met�effic-',•'j =HTEi 5 -rnd. �rrud. ;matter -v Units lie. of Rec6pt2cie Oivati&mq INe. of iT BurnersIwo. of Zones 4 rejfA l I'Ql'. QT S Ftemes _ ^ II�QI. 01 was ]r[nLeIlflffier. INc. of Dere: pion and 3ffiBlivarlE-cr 1 o7vrces 73 Ne Q - p'2 mL7es T?1tD. of Air- CoffiQi : k fl.21 IrdQ . QDf _� ee -iia Devh-ec j s-1 1, Tons - 1,40. o Wase LFspose:cs Fiery. P=p I ]'aU m -Der I r oan I KW Nc. of SeL-Contained Tmmir: I I pretectteDnWertiffiE Devices 11,4o. QfCishF'WsSei IU��e(�ieHeating Local l��isia^ �YC�ihe��1Conn�tion � Nc of ]wenn. 7,eri>m_ A, ppRances �in;k; See"'n7,, n7, , Svsre>.m s: _ j s pq'£^_p:'. QDL I�QEBiIF'r"'eIII i Ql. Ql- �r.. 1 VQi of `ek'�}alli Hast -m- AE i 1Q . QD �ICdc., o I�a> a Silas rAP asLS _i>T=_: No. o, I eva• es o �QaEat'aa°m{ Na. )✓nydram2- sage Bathtub.- Wo. of Moto is 'Poral[, Hffi. ehecomalmuwcations Wi-i rad: I I fl.'LL: Device; or- 1:Q)uh'12na nU!=- R ILP. I Atiacn addinonai deiail ij desired, or as required br [he inspector of }ihr es. �'l SUP 4-1IglC ' C0 -TF PLh GE, UnItSS Waived by the ovdner, no pemnit Tot the 1)C poi m an cc- o el-zL-m al worl; Tial issue llnles5 Tile llccnse° provide., prOOi Or aatli'lIt`', Insurance including. `'completed opera:ion ' covera�>e or Its substantial eo'ijiValent. The unce:si-ped Ce^Lttte `' such c i/erage Is I q c� as e;� r ^ ' S that O P. t and ll 11Svl:ed pmol O! Same To t[:' ^er:nit ISStIIt o OrTl:'. CsiLCKONE: DNSUB-.A_INCE � BOND ❑ OTHER ❑. (Specie,:) 0 ,206Vp�r tion Lalej estimated `vTalue of Electrical Work:. •70j ooO (VAen required by municipal policy.) Work to Start: �y -$� � inspections to be requested in accordance with K/IEC Pule 10; and upon complexion. CerFE JJ [2EtdMthe DE" PIIS fifrneriuF�f' zhG`t 2{fe ErU -ma- 1011 oB£ FEd• 4 [d7BlfCCF€dSY°i FS Elf"? 12.-eG C(2➢ aplPFe. MIMI T'4.A- TE: 1nLe' s -ate Elec -r� cal Se_�'t� C�f Corp LIC. NO.: 7� _ 2 17 Licensee: T>aSCrjjp le n_' � iibrand; Signature j LIC. No. (IfgLplicable, etuer "a�r�pt "-itt the license tfum�e; litae.J Bu s. Tel. Ne.: c i o ; t Address: 7 n'p r9 . 1\7 R1 1 1 ori cam.. MA 01 862 A K. Tel. Tic.: G1 Tv:K R5C PNS fL2L_j`gCZ 1 am aware that the` I 'cense c o 's net have the iiabiiity insurance cove, -ace nommily required by law. By m,r sim attire below, I hereby waive this requirement. I am. the (check one) El owner P-' ga rn Interstate Electrical Services The Difference is Atfltu e Effective 1/02/01 through 1/02/04 Department of Code Inspectors Wiring Divisions Attention: Reference: Gentlemen: Electrical Department Inspector Corporate Signatures Interstate/Massachusetts Interstate Network Systems Interstate Controls Northwood Executive Park 70 Treble Cove Road N. Billerica, MA 01862 Phone: 978-667-5200 Fax: 978-947-8259 Interstate/Northern New England Interstate Network Systems 15 Cote Lane Bedford, NH 03110 Phone: 603-627-3230 Fax: 603-627-3480 Interstate/Southern New England 58 Kent Avenue Warwick, RI 02886 Phone: 401-737-6100 Fax: 401-737-6127 www.interstateelectrical.com The following is a list of corporate signatures that are acceptable at Interstate Electrical Services Corporation for permit applications. ➢ Pat Alibrandi, Chairman (Master License #A5217) ➢ James Alibrandi, President ➢ Robert Parker, Vice President of Engineering r ➢ Alan Tiezzi, Vice President of Construction ➢ Thomas O'Toole, Chief Financial Officer ➢ John Sloane, Vice President Service Note. All otherlicense numbers are available upon request. If you should have any comments, questions, or require additional information please feel free to contact me at this office. Sincerely, I TATE ELEC RIC RVICES CORP. Pat Alibrandi Chairman Fold, Then Detach Along All Perforations _ J COMMONWEALTH OF MASSACHUSETT OF ELECTRICIANS EGISTERED.MASTER ELECTRICIA ISSUES THIS LICENSE TO 'INTERSTATE ELEC SERV.CORP PASQUALE A ALIBRANDI '70 TREBLE COVE RD I� NO BILLERICA MA 01862-220Q.: 5217 A 07/31/01 756912 Fold, Then Detach Along All Perforations Fold, Then Detach Along All Perforations COMMONWEALTH OF MASSACHUSETTS • • • • OF ELECTRICIANS AS A REG JOURNEYMAN ELECTRIC ISSUES THIS LICENSE TO PASQUALE A ALIBRANDI c 107 MILDRED CIRCLE 1 CONCORD MA 01742-37 4654EE 07/31/01 756237 I r Fold, Then Detach Along All Perforations Fold, Then Detach Along All Perforations CONTROL # B 2 4 8 4. ( 9 IMPORTANT If this license is lost or destroyed, notify your Board at the Division of Registration, 100 Cambridge St., 15th FI., Boston, Mass. 02202. If name or address shown hereon is changed notify your board of correct name or address to insure proper mailing of next Renewal Application. Always refer to your license number. License is subject to the provisions of the General Laws as amended. It is a personal privilege, and must not be loaned or assigned to any other person. Keep this license on your person or posted as required by law. Fold, Then Detach Along All Perforations Fold, Then Detach Along All Perforations CONTROL # L �� 4 7 8 0 B IMPORTANT If this license is lost or destroyed, notify your Board at the Division of Registration, 100 Cambridge St., 15th FI., Boston, Mass. 02202. If name or address shown hereon is changed notify your board of correct name or address to insure proper mailing of next Renewal Application. Always refer to your license number. License is subject to the provisions of the General Laws as amended. It is a personal privilege, and must not be loaned or assigned to any other person. Keep this license on your person or posted as required by law. Fold. Then Detach Along All Periorations Acca® CERTIFICATE OF LIABILITY INSURANCE TM DATE (MM/DD/YY) PRODUCER (781)681-6656 FAX (781)681-6686 7 Barry Driscoll Ins Agcy, Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 600 Longwater Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 9120 INSURERS AFFORDING COVERAGE Norwell, MA 02061 LIMITS INSURED Interstate Electrical Services Corporation INSURER A: Transcontinental Insurance Co. 70 Treble Cove Road INSURER B: Ohio Casualty Insurance Co. North Billerica, MA 01862 INSURER C: FIRE DAMAGE (Any one fire) $ 500,000 INSURER D: X COMMERCIAL GENERAL LIABILITY CLAIMS MADE D OCCUR INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICY NUMBER DATE (MMIDD/YY) DATE (MM/DD/YY) LIMITS GENERAL LIABILITY 1079954877 09/30/2000 09/30/2001 EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE (Any one fire) $ 500,000 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE D OCCUR MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 A GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X jE O X LOC PRODUCTS - COMP/OP AGG $ 2,000,000 'AUTOMOBILE X LIABILITY ANY AUTO 1079954894 (MA) 1077771112 (OTHER STATES) 09/30/2000 09/30/2000 09/30/2001 09/30/2001 COMBINED SINGLE LIMIT $ (Ea accident) 1,000,000 BODILY INJURY $ (Per person) ALL OWNED AUTOS SCHEDULED AUTOS A HIRED AUTOS NON -OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ ZXCESS LIABILITY BX052778963 09/30/2000 09/30/2001 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 X OCCUR F� CLAIMS MADE JIMBRELLA FORM $ B DEDUCTIBLE g RETENTION $ g WORKERS COMPENSATION AND EMPLOYERS' LIABILITY 1079954880 09/30/2000 09/30/2001 X I TORYLIMITS ER E.L. EACH ACCIDENT $ 100,000 A E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE -POLICY LIMIT $ 500,000 OTHER Installation Floater 079954877 09/30/2000 09/30/2001 Each Project: $100,000 A In Transit: $100,000 At Temp. Location: $100,000 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS GANGtLLA I IUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. B. Driscoll/BMP"""' " � N2 3007 Date.Y-/F-,C% e/... TOWN OF NORTH ANDOVER This certifies that ..................... has permission to perform wiring in the building of ................... 051- F ....... Lic. Check # P/ PERMIT FOR WIRING ............................ : ......................................... ........... ...................... I .. ............. :� .................................. ............. . North Andover, Mus. No.........::. 11;7S, ........ . �, / .. .&........................................ el — ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Al The Commonwealth of Massachusetts V"Le _. e! Pe retic No. : Department of Public Safety i �• Occupancy S Fee Checked BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1200 3/90 cleave blan*ML APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to bK performed In accordance with the Massachusetts Electrical Code. 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INrORm1TION) Date City or Town of 1166.7 fl ih-R— To the Inspector of Wires: The undersigned applies for a peerrn-iic to perform the electrical work described below. Location (Street & Number)cJ /� �j ij (3 (1 .j T Owner dr Tenant E���WOO D/ Owner's Address 4DLj4FIVO D ����b s� .xili- 14;/7bVr±(z Is this permit in conjunction with a building permit: Yes No ❑ (Check Appropriate Box) Purpose of Building GlU',01� Q A % --X Utility Authorization NO. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service 1466 111Amps W / Volts Overhead ❑ Undgrd No. of Yzters Number of Feeders and Ampacity (&�4,) Location and Nature of Proposed Electrical Work W60J 030 gLb,L., GilVo�y �v yfA7ey No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting FixturesSwimming Pool Above In- grnd. ❑ grnd. ❑ Generators KVA . No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALAR,11S No. of Zone3 No. of Detection and Initiating Devices No. of Sounding Devices No. o f Self ContaineDetecding devices Local ❑Municipal 1:1Other Connection No. of Ranges No. of Air Cond. Total tons No. of Disposals. No. of Beat Total Total Pum s Tons KW No. of Dishwashers Space/Area Beating KW No. of Dryers Heating Devices KW No. of Water Heaters KW No, of No. 07 Ballasts Sipns LowVoltage ng No. Hydro Massage Tubs _Wir No. of Motors Total HP tntmx: INSURANCE COVERAGE: Pursuant to the -requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES E] NO ❑ I have submitted valid proof of same to this office. YESID NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE 0 BOND ❑ OTHER ❑ (Please Specify) 1 X.4Vt=Lc:--2tS JAiLOI- Estimated Value of Electrical Work S&66 az Expiration Date lid Work to Start 4-146-0/ Inspection Date Required: Rough %) dScs Fina7XL V,66 4;:' Signed under the penalties of perjury: FIRM NAME MAKI ELECTRICAL INC. LIC. No. A11738 Licensee RAYMOND MAKI Signature LIC. NO.A11738 Address .100 NORTH ST. WORCESTER MA 6 ����T2-5662 Alt. Tel. No. 756-5553 OWNER'S INSURANCE WAIVER• I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as' required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) 0 O Telephone No.PERMIT FEE S Signature of Owner or Agent TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... 'rte 3 has permission for9 as installation -f. ........ in the buildings of .. "t ::. ....................... at . 3 Ox.,i .............. North Andover, Mass. Fee (//. -IP.41,.`Lic. No.. �' 3..4 \.l_. -� ...... . UGAS INSPECTOR Check #. L/ )I o 3 6 2-' 1 a MASSACHUSETTS UN'�ORM APPLICATON FOR PERMITTO DO GASFITTING �'Tvpe or print) NORTH ANDOVER, MASSACHUSETTS Building Locations S 7`5 Owner's Name New Renovation ❑ Replacement ❑ Permit # Amount SL—I fIF CgleE S aTCF- C- C-12, Plans Submitted ❑ (Print or type) Check one: Certificate Installing Company Name 17)F1Vie01V ® Corp. 2-O 6 i Address %ds F120N f Sii 2 E6% MIMCR,9ST-i-�e A-41. 3fa Business Telephone 60-1 - (,2Z—'11R6 Name of Licensed Plumber or Gas Firter \10 E ❑ Partner ❑ Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑ It'vou have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy j Other type of indemnity ❑ Bond ❑ Owner`s Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owners Agent Check one: Owner ❑ Agent ❑ nereov ce fry tnat au of the detaus ana Intormanon I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations pertormed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Qocte and ChaptjjrjIZ of the General Laws. IIv: Title ity/Town ASPRO ED (UFI--ICi= USF')NI-Y) nature of Lic::nsed Plu Mer Or Gas Fitter ❑ Plumber M — 7,7 q 3 ❑ Gas Fitter )cense Numoer 'Taste i rlJourneyman N2 4868 ► 40RTM O F , Date. V : 2.7.: `-. °. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .l.i. has permission to perform .`.:.. .:�......... .... . plumbing in the buildings of ..`. '.7 ............. . at ... > A 2>.... j. ................ . North Andover, Mass. Fee.�fiU,.'�ic. No.��,?S �.. ..... �._._.. "y� ....... PLUMBING INSPECTOR Check # — WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUM13I,NG (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Location ® Ownee r E Perm rs Namit # .3 e�R �.,..-�F' �z p Amount �- Type of Occupancy New 191 Renovation M Replacement ® Plans Submitted Yes ® No (Print or type) _ Installing Company Name V!F' V RW/ ?L6- IIII C, Address C05- FR Dl�r l 1 2 EST M' 1AAic& a Ii=2 ✓) 14- a-3 Business Telephone ('<-, Cb Check one: Certificate ® Corp. 2 Oho Partner. Firm/Co. Name of.Licensed Plumber: T p [ Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy R Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one ofthe above three insurance Signature Owner 11 Agent 11 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Ntate Plu'nMand ter 142 of the General Laws. By igna o c ns um er Type ofP robing License Title City/Town icense TNumDer Master ® Journeyman APPROVED (OFFICE USE ONLY No, 2384 0 Date... ........ rte....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ../) I .. ................ This certifies that :- P-- kii,.' ...... Z -:� ................................. has permission to perform .......... .2 wiring in the building of............ - -.e, ........ . ................................ North Andover, Mass. a........................%........ 7:r......:........... el-11 FeeZ� fV ....... Lic. No .............. ��................. ',�RICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 4 `1 d a _ C.mmonweallh of Ma99achuieffB 2'1.'a/1n1En1 .1-7i a .,.Je..icej - BOARD OF FIRE PREVENTION REGULATIONS kv--- - Official Use Only Permit No. �c j Occupancy and Fee Checked 162'. 41-11 Rev. 111991 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CNIR 12.00 (PLEASE PRINT LV INK OR TYI' ;ILL IWORAL1170N) Date: ,5_-..3/_ D0 City or Town of: /Vo �1Doyb—�_ To the Inspector of iYtres: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant 'Ef)&6- j,Oo 0 Q Telephone No. Owner's Address s�q n2�c Is this permit in conjunction with n building permit? Yes El No ❑ (Check Appropriate Box) Purpose of Building Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Antpacity Location and Nature of Proposed Electrical Work: Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ tea 1 V®L-'Tq&,,,-_ Glia 2 /A'G No. of Meters No. of Meters �D rt✓ - - Completion of the folhnvine table mayhe 1—Ned b„ the l"' No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Itut TubsGenerators KVA No. of Lighting Fixtures Swimming Pool Above EJ111-d.1:1I rtid. rnd. o. o u�ergency ig rang BatteryUnits No. of Receptacle Outlets No. of Oil Burners FIRE ALA AIS No. of Zones No. of Switches No. of Gas Burners No• of Detection and Initiating Devices No. of Ranges N11 o. of Air Cond. TonaTotal No. of Alerting Devices No. of Waste Disposers Heat Pump iVumper ITons IKW _ No. of Self -Contained Totals: DetectionlAlertino Devices No. of Dishivashers Space/Area Heating KW Local ❑ h"lwticipal Connection ❑Other No. of Dryers Heating Appliances 1{W Security Svstems: No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: IIeaters Sims Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total Iii' Telecommunications 1Viring: No. of llevices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. 'NSUIZ.- NCE COS ERACL: 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: INSUR-ANCE P BOND ❑ O'1'IIER ❑ (Specify: Estimated Value of Electrical Work: —,<0019,dd ©19, (When required by municipal policy.) (Expiration Date) Work to Start: ,S• 25 -pa Inspections to be requested hi accordance with MEC Rule 10, and upon completion. I certify, under the pains acrd penalties of peijurt•, that the information on this application is trite acrd complete. FIILII NAME: O tS ')r &'V6k_& % S�izy ccs �p� S /.v�LIC. NO.:/Z,'7L/I Licensee: /G yy CL Q St/2 1 Signature_�%f�f LIC. NO.: 10,C'72, fl (If applicable, enter• ..cre m i " in the license number line-) Bus. Tel. No.: 6/7 Y89 //yo2 Address: PD RCAN /"Q y Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by lnw. By my sionature below, I hereby waive this requirement. I all, the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature. Telephone No. PL"RRIIT TEE: S Date. 2 .? .. G N° 4432 TOWN OF NORTH ANDOVER .o p PERMIT FOR PLUMBING This certifies that ................ has permission to perform ...A, f� plumbing in the buildings of ...4. 45 r. l at .. ................ . North Andover, Mass. Fee. � .U..)^. `Lic. No.. .� � Z.. ? . � ...... .1..... �.....r.�.. . 1,,LUMBING INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) /� �y /� � �I� Mass. Date ` 2DOQ Permit # 2. L -9 ,A Building k New ❑ Renovation Owner's Occupancy _ /map-,&. 4JS , Repla eme - Plans Submitted: Yes ❑ No -0— FIXTURES . Installing Company Name F. A. W I L LI AMS , INC. Check one: Certificate Address BOX 148 12 BRIGHTON STREET0 Corporation 1934-C RFT.MQNT. MA 02478 Q Partnership Business Telephone 617-489-4770 ❑ Firm/Co - Name of Ucensed Plumber. Robert L. Ouellette, Jr. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes .. ,. ""Nd" � 1 If you have checked yes :please indicate the type coverage by;checking°the appropriate box. A liability Insurance policy' Other'type'of Indemnity' ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Aaent Owner ❑ Agent ❑ • 1101—y —1-Y u,a[ an or ute aetails and information I have submitted (or entered) in above application are true knowledge and that all plumbing work and installations performed under the permit issued for this application v pertinent provisions of the Massachusetts State Plumbinga and Chapter 142 of the General ws. / BY � Title SignaAu:(�en um r City/Town Type of license: Master Journeyman p OF IC S ONLY License Number 11255'' waa;urate to the best of my e in compliance with all Y • • • • ■■ENEMO®II����O�■®���I���MINK • • ■�������®!l�IIIStI®tl■®����NOUN • • • ®■�.�■®��.�.�■�. �■.■..S■.. • • ■■NO■■■■..■M.■■ ■..■■..■.■ ENNOMMANNNOM No NIEMEN NOON • • ■■.■■.■■■■■■■■■�■■10■■..■■■ Installing Company Name F. A. W I L LI AMS , INC. Check one: Certificate Address BOX 148 12 BRIGHTON STREET0 Corporation 1934-C RFT.MQNT. MA 02478 Q Partnership Business Telephone 617-489-4770 ❑ Firm/Co - Name of Ucensed Plumber. Robert L. Ouellette, Jr. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes .. ,. ""Nd" � 1 If you have checked yes :please indicate the type coverage by;checking°the appropriate box. A liability Insurance policy' Other'type'of Indemnity' ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Aaent Owner ❑ Agent ❑ • 1101—y —1-Y u,a[ an or ute aetails and information I have submitted (or entered) in above application are true knowledge and that all plumbing work and installations performed under the permit issued for this application v pertinent provisions of the Massachusetts State Plumbinga and Chapter 142 of the General ws. / BY � Title SignaAu:(�en um r City/Town Type of license: Master Journeyman p OF IC S ONLY License Number 11255'' waa;urate to the best of my e in compliance with all 3432 7 r ppRTM L Date S. .. Z. ?..'. ... . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .. F (-4- . t 1 . ... ..... . has permission for gas installation .. .................. in the buildings of ... ...................... at ...J. 2-1... 1,2s-..-- .4.a � ........ ,Forth Andover, Mass. Fee. �U' Lic. No..//?.). � GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPUCATION•FOR PERMIT TO DO GASFITTING (Print or Type) _ Qogn ANbou�„0 Mass. Date Building Location Own p>1n�P V 46' I G� New ❑. Renovation Replacement (] Permit # s Namer�= ` of Occupancy kx'l Plans Submitted: Yes❑ No -M-- Installing CMRMWyNaMe E. A. WILLIAMS, INC . Address aox 14.8 .12 BRIGHTON STREET BELMONT MA02478 Business Telephone 617 4 8 9- 4 7 7 0 Check one: Certificate X3 Corporation 19 3 4 - C ❑ Partnership ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Robert L. Ouellette, J r. INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 13No 1:1If you have checked yes, please Indicate the type coverage by'checking the approprlate box A liability Insurance policy. ❑ Other type of Indemnity ❑ _ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance covers a re ul Chapter 142 of the Mass. General Laws, and that my signature on this 9 q red by permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I hereby certiy that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowiedge and that all plumbing work and installations performed under the permit issued for this application will be in compli pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General taws. ca with all T of Uoense: 0 Title Plumber gnature o cense um r or Gas d Gasfitler $ City/Town Master license Number 11255 3a W�-"v vp IJ a S Joume I yman $ to P"�-,ov��aS ■��e��������r��■ rrrm ■ Mal ■��r��������l��rr�ANN ■■��r�il���rRI Nunn 0 Rol ■rrrnrr���r����rrrrr�nr��■ .. ... MONNOMMEN" rrrrrrr0rrNunn .. ■NOMMENNONN 0 morr�r�rr�■ ... ■OMMONNUMarorr�r��rrr■ ■�■ ... ■�rr�r���00000r0 0 mom no .. ■r�s�����er��s�r�MM�er�rr�� ... ■rrrrerr��.r���rrrrrrrrr�ur Installing CMRMWyNaMe E. A. WILLIAMS, INC . Address aox 14.8 .12 BRIGHTON STREET BELMONT MA02478 Business Telephone 617 4 8 9- 4 7 7 0 Check one: Certificate X3 Corporation 19 3 4 - C ❑ Partnership ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Robert L. Ouellette, J r. INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 13No 1:1If you have checked yes, please Indicate the type coverage by'checking the approprlate box A liability Insurance policy. ❑ Other type of Indemnity ❑ _ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance covers a re ul Chapter 142 of the Mass. General Laws, and that my signature on this 9 q red by permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I hereby certiy that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowiedge and that all plumbing work and installations performed under the permit issued for this application will be in compli pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General taws. ca with all T of Uoense: 0 Title Plumber gnature o cense um r or Gas d Gasfitler $ City/Town Master license Number 11255 3a W�-"v vp IJ a S Joume I yman $ to P"�-,ov��aS N2 2341 Date ..... TOWN OF NORTH ANDOVER . . . . . . . ... 1 0 PERMIT FOR WIRING This certifies that .. ..... ................ ........... .............. has permission to perform/--:--/ . .....Rte_.`..;I wiring in the building of ......... ...... ......................... . North Andover, Mass. Fee :04 'Lic. NdO.Ald ............................. -—ELECTRICAL 1NsPEc'r0R Check #4?�/ WHITE: Applicant CANARY: Building Dept. PINK: Treasurer off(ce Usc Only . ;� (� ,;_� The. Commonwealth of Alossachusetts Permit."'O. D t ; ffffllll epi rtment, of Public Safety. - Occupancy S fee Checke BOARD OF FIRE'RREVENTION REGULATIONS S27 CMR 1200 3/90 (leave blank) :!. . ,r .. . CATION APPLI' FOR 'PERMIT TO PERFORM. ELECTRICAL WO RK` All work to be performed In accordance with the Macsachusetu Electrical Code. 527 CMR 12:00 i (PLEASE PRINT IN INK OR TXPE ALL INPOPIIATION) Date 1-5 _40 _60 City or Town of 100-r1l 14-A�'061✓C;P1 To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) ¢ -�r! r L)616^66 Z) J Owner or Tenant &2)CW 6Q 12c -sem 4–W Z_ AVo v) , Owner's Address s:57,-5,65�j6C� v07 ».I 1 Is this permit in conjunction with a building permit: Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization NO. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps J Volts Overhead ❑ Undgrd ❑ No. of Ye tcrs Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work /,00R ,o4Sc No. of Lighting Outlets No. of Hot TubsNo. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above In- grnd. ❑ grnd. ❑ Generators i''V 1 No. of Receptacle Outlets No. of Oil Burners No: of Emergency Lighting Battery Units. No. of Switch Cutlets No. of Gas Burners FIRE ALAR.1-1S No. of Zone3 No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices Local ❑ Municipal.❑ Other Connection No. of Range's No. of Air Cond. Total tons No. of Disposals. No. of )Heat Total Total umns Tons KW No. of Dishwashers: Space/Area Heating KW No. of Dryers Heating DevicesIZFi No. of Water ';Heaters ((W No�;of o. o Si ns Ballasts Low Voltage Wirin No. Hydro.Massage Tubs No. of Motors Tota 1,1 -. U-LMK: INSURANCE COVERAGE:>'Pursuant to the - requirements of Massachtisetts�General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial .equivalent. YES EI NO ❑ . I have submitted valid -proof of same to this office. YESE) NO ❑ If you have checked YES, please indicate the type of coverage: by checking the appropriate box. INSURANCE � BONDE] OTHER ❑ (Please Specify) J �iQ l�'�GfrS /NSo�r 3 Expiration Date). Estimated Value of ' t'ork S'�(p (� -- Work to Start Inspection Date Required: RoughJ/Jd/S 6" Fina( Wl�l V/$4= Signed under the penalties of perjury: FIRM NAME ..MAKI ELECTRICAL INC. LIC. No. A11738 Licensee RAYMOND MAKI Signature /M' �"''1 LIC. NO. A11738 Address .100- NORTH .ST..'. WORCESTER, MA 016 , 0-5 Bus. Tel. No. -72-5662 Alt. Tel. No. 756-5553 OWNER'S INSURANCE WAIVER• I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please rherk .,.,a) e PERMIT FEES r Telephone No. Signature of Owner or Agent } UZI PHONE TO,'- - MAKI ELECTRICAL INC. I DATE.................................................................. .......................... ❑URGENT 100 North Street P.O. Box 7430-560 Lincoln Street WORCESTER, MA 01605 (508) 752-5662 TO Fax (508) 798-4817 ...................................................................................................................................................................................................... .................................................................................................................................................................................................................................... &1rL ref A'I ' 01c9,9f6- MESSAGE ZqZ �l j ?.iC° ........_..... l$ ................d ...............d E�✓�° G. �.'7'.. /z. __,'-10v _ /�O X 43 A- /Lei C i 1je7 O U A-- C Uc57X -5/ i e- REPL Y DA TE OF REPL V SIGNED a N2 2330 0 "6010im 0 Date.. ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that x�5 ............................. L ... .................................. ........... has permission to perform ,ze:?-:� ....... ...... wiring in the building of ....... ............. .................................................. NortH Andover, Mass. Fee .. ....... I ..... Lic. Nd� ...... L- A ..... ....................... ELECTRICAL INSPECTOR Check WHITE: Applicant CANARY: Building Dept. PINK: Treasurer It f (f1-111nW9-19 o1 Va.43RC/tfldet![j OffiCl:ll t1sC Only .(JeParr`nrenl o�.}ire SPermit No. (� ,rvicel REGULATIONS ( Occupancy and Fee Checked BOARD OF FIRE PREVENTION Cre _ 'Rev. 11/99) (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All wurk to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 ChIR 12.00 (PLEASE PRINT LV INK OR TYP -ALL hy['OkV.1 TION) Date: Town of: N , By this application the undersigned gives notice of itis onc� iu� entiou to peTortheni I pectoi °f pyi)-es: Location (Street & Number) �' �S �D k described below. Owner or Tenantfikl ( _ Tele honc \' Owner's Address p t _ �y-.r-Y�,+e� o. , Is this permit in conjunction with a building permit? Yes No J ❑ (Check Appropriate Bos) Pur•li)se of Building (�.SS,�Y`� Utility Authorization No. Existing Service Anips / Volts Overhead ❑ Undgrd ❑ No. of AIctcrs . New Service Anips / Volts Overhead ❑ Undord ❑ b No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: F A -A. e- i k r -e .c Attach additional detail if desired, or as required by fire h+spector of ]Vires. INSURANCE COVERAGE: Unless waived by ►he 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 covers a is in force, and has exhibited proof of same to the permit issuing CHECK ONE: INSUR-\NCE ;OND ❑ 0•THER ❑ (Specify:) -d — office. _ a`.�) Estimated Value of Electrical Work:* (When required by municipal policy.) (Expiration Date) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certifj•, unit •r the pours and penalties of perjurj•, that the infornfaliorr on this application is trite and complete. FIRM NAME: fi t a Ck.e. , r_ e _r`j %'C-LIC.�S NO.: lN k!5 4 4 � Licensee: G S L �. Signature 1C. NO.: �a�9 d Address: livable, eater "ercorp!" in the license number line.) Bus. Tel. No.: q'\ 8— 16 %"7 S.S f Address: All. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required bylaw. By nny signature below, 1 hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent .m•� Signat re 'Telephone Nu. FPi;-R31IT FEL• : S tC -�••• - w, •— jv ,jjj M wore stay De watvcd by the his ector of Wires. No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Falls No. of Total Transformers KV No. of Lighting Outlets No. of blot Tubs Generators KVA No of Lighting Fixtures Swimming Pool Above ❑ ln- ❑ t o. o mergency ig rung b crud. rnd. Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARAIS No. of Zones No. of Switches No. of Gas Burners t`Io. of Detection and Initiating Devices of Ranges Totallo. No. of Air Cond. Tons] No. of Alerting Devices ( Q No. of Waste Disposers Heat Punnp Number Tons KW No. of Self -Contained Totals: Detection/Alerting Devices No, of Dishirashers Space/Area Heating KW Local itiluuicipal ❑ Other Connection No. of Dryers Heating Appliances KIV Security Systenns: No. of Nater No. of No. of No. of Devices or Equivalent Heaters K Signs Ballasts Data Wiring: No. of Devices or E uivalent No. Hydronnassage Bathtubs No. of Motors Total IiP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by fire h+spector of ]Vires. INSURANCE COVERAGE: Unless waived by ►he 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 covers a is in force, and has exhibited proof of same to the permit issuing CHECK ONE: INSUR-\NCE ;OND ❑ 0•THER ❑ (Specify:) -d — office. _ a`.�) Estimated Value of Electrical Work:* (When required by municipal policy.) (Expiration Date) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certifj•, unit •r the pours and penalties of perjurj•, that the infornfaliorr on this application is trite and complete. FIRM NAME: fi t a Ck.e. , r_ e _r`j %'C-LIC.�S NO.: lN k!5 4 4 � Licensee: G S L �. Signature 1C. NO.: �a�9 d Address: livable, eater "ercorp!" in the license number line.) Bus. Tel. No.: q'\ 8— 16 %"7 S.S f Address: All. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required bylaw. By nny signature below, 1 hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent .m•� Signat re 'Telephone Nu. FPi;-R31IT FEL• : S tC N° 4213 Date./,;?. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING b '',, r. ° •'°� is / � J/�"f� ,SSACNUS� This certifies that ./. .-......^'`��. r has permission to perform , �....................... . l + plumbing in �helbuildings of .. /..... ..z�"_,...!............ . at ..... . .................. . North Andover, Mass. Fee.. . "�... Lia. Nor-/r� /(.�� .. \. � .. .. *11! r ......... ---Pi:-MBI I SPECTOR —Pi:-MBPECTOR Y3 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION E R PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS - _ .. Date Building Looati ' Owners Name Permit # a,2-11 -. --- - Amounts i - Type of Occupancy New -L❑ Renovation Replacement ® Plans Submitted Yes ❑ No - — - MTTTRFS (Print or type) � CCone: Certificate Installing Company Name ® Corp. Address / n Partner. Name of Licensed Plumber - Insurance Coverage:IiKicate theXpa of insurance e ge by checking the appropriate box: Liability insurance policy Other type of indemnity ® Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ® Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate; to the best of my knowledge and that all plumbing work and instal s performed un P Issued for this application will be in compliance with all pertinent prg�sia c tate Plumbin hapter 1 f the General Laws. By: o ns ype ofPlumbing License Title City/Town icenseum er Master® Journeyman APPROVED (OFFICE USE ONLY - a G • MWOMM (Print or type) � CCone: Certificate Installing Company Name ® Corp. Address / n Partner. Name of Licensed Plumber - Insurance Coverage:IiKicate theXpa of insurance e ge by checking the appropriate box: Liability insurance policy Other type of indemnity ® Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ® Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate; to the best of my knowledge and that all plumbing work and instal s performed un P Issued for this application will be in compliance with all pertinent prg�sia c tate Plumbin hapter 1 f the General Laws. By: o ns ype ofPlumbing License Title City/Town icenseum er Master® Journeyman APPROVED (OFFICE USE ONLY - ��--% N° 2045 Date.....................1.. NOR71� 3a;';``�-•° a"�O� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......... .:....F ......% wlc� (( f' C ............. ......... .......................... has permission to perform ......... 1 ........................ wiring in the building of ......:................................ at .......,C..,)� ...... Cr.%.`!v �. t N `�h AndoverfMass. jFee ..V�.(%:..!......... Lic. No. . 0 �� 1..........� ....................................... t1 ELECTRICAL INSPECTOR G/ I WHITE: Applicant CANARY: Building Dept. PINK: Treasurer s� uhP Lummunwralth of Imachu rtf� Otiice Use Only � Permit No. ? �rpartmrnt of ublir E-afrt F Occupancy A Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/so (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL�j�NFORMATION) Date City or Town of , -,"T To the Ins ector of Wires: The udersigned applies for a permit to perform the el ctrical work described below. p..,� Location (Street 8� Number) �P7,� �>-'ih'� MAP (0 3 f� fes- - , Owner or Tenant Owner's Address L Is this permit in conjunction with a building permit: Yes (Check Appropriate Box) Purpose of Building r/✓�'s • H C_ Utility Authorization No. Existing Service Am -J Volts Overhead ❑ Undgrnd ❑ No. of Meters New Service Amps _J Volts Overhead ❑ Undgrnd ❑ No. of Meters Number of Feeders and Ampacity ��► - - Location and Nature of Proposed Electrical Work 46e_ No. of Lighting Outlets No. of Lighting Fixtures No. of Receptacle Outlets A No. of Switch Outlets No. of Ranges No. of Disposals No. of Dishwashers f No. of Dryers �. Nn. of Wai�r N, No. Hydro Massage Tubs OTHER: No, of Hot Tubs Swimming Pool Above In- grnd. EDgrnd. ❑ No. of Oil Burners No. of Gas Burners No. of Air Cond. Total tons No.of Heat Total Total Pumps Tons KW Space/Area Heating KW Heating Devices KW 'iVJ l 5,yno`. Ballasts No. of Motors Total HP No. of Transformers Total KVA Generators KVA No. of Emergency Lighting Battery Units FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices LocalMunicipal ❑Other ❑ 'Connection .ow -Voltage _. . Wiring I INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES — NO — 1 have submitted valid proof of same to the Office. YES a NO [ If you have checked YES, please indicate the type of coverage by Checking the appropriate box. INSURANCE 0 BOND p OTHER O (Please Specify) '19 —. a,c�e-y Estimated Value of ElectricalWork 3 (Expiration Date) Work to Start 1Z - d, -%© f' Inspection Date Requested: Rough l'- •' /� C � L Signed under the Penalties of er'u Final r 1 ry: - FIRM NAME - re G. Licensee G LIC. NO. i+s //Signature .,,.i LIC. NO. /7t_lop Address -tf Bus. Tel. No. fl%-' FvY7 �.c Alt. Tel. No. OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re. quired by Massachusetts General Laws, and that my signature on this permit applicatio (Please check one) n waives this requirement. Owner Agent Telephone No PERMIT FEES �. W (Signature of Owner or beer i i x -65E5 3320 a NppTM,TOWN OF NORTH ANDOVER pf «o '64'O PERMIT FOR GAS INSTALLATION This certifies that .. ... �... �/. j .. r� ................ . has permission for gas installation in the buildings of ...` . 1 ....:': ........................ at ...Y* 7 ......... , North Andover, Mass. Fee..:.' . Lie. No..} .! < ; .?.. ....... GAS INSPECT. R WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERV�e ASRTTING �- (Print or Type) I)D �hQ/Qwr —.Mass. Date /2-3 19 Building Location 5 -2 05 da!2,0 S tT v��z Owner's Name a,/Ly a,/Ly00, Telephone �1 ,� u � - C y S-- Type of Occupancy CaEm rc_)e, /. G New. E%j Renovation ❑ Replacement ❑ Plans Submitted: Yeso No p Installing Company Name EnergyUSA, Inc. Address 2000 West Park Drive, Suite 300 Westborough, MA 01581 Business Telephone 1-800-822-1300 ext. 8051 Name of Licensed Plumber or Gas Fitter William_ Kent Corson Check one: Certificate C7 Corporation 115C ❑ Partnership Firm/Co. INSURANCE COVERAGE: EnergyUSA has .4X)M a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes W No ❑ If you havfi checked Les. please Indicate the type coverage by checking the appropriate box. A liability insurance policy E?' Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent O I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and .that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 o1 the General taws. By Tr�e of ticense: I -- ?_2el11- -e_ - Plumber Signature of Licensed Plumber or Gas Fitter TitleGaslitter 'Master license Number 3707 City/Town J Journeyman APPROVED (O RCE US . ONl i Y • • Y • =Moms MEMINMENE ■ ■IMEMIN MEMO .. ■����������t������t�■ SON Installing Company Name EnergyUSA, Inc. Address 2000 West Park Drive, Suite 300 Westborough, MA 01581 Business Telephone 1-800-822-1300 ext. 8051 Name of Licensed Plumber or Gas Fitter William_ Kent Corson Check one: Certificate C7 Corporation 115C ❑ Partnership Firm/Co. INSURANCE COVERAGE: EnergyUSA has .4X)M a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes W No ❑ If you havfi checked Les. please Indicate the type coverage by checking the appropriate box. A liability insurance policy E?' Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent O I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and .that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 o1 the General taws. By Tr�e of ticense: I -- ?_2el11- -e_ - Plumber Signature of Licensed Plumber or Gas Fitter TitleGaslitter 'Master license Number 3707 City/Town J Journeyman APPROVED (O RCE US . ONl T r N v m n -4 z D m m � m s r v -4 r_ 4 A m v � m T 2 � C G m T p O r � � c v z o z m O �+ O m A -4 m -4 C O N m O � 0 p z p r D � N 1 0 N° 4238 °': �•� :'� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING t ,SSACNus� ?� This certifies that ,-°���.�`7 f ...... . ................. has permission to perform .....,55. / .! ........................ plumbing in the buildings of ...�.{.% `'• '`.... • • • • • • • • . • • • .. . ?}- 0 $` c' C, C at ............... ./.............. North Andover, Mass. Fee ./4UGt .--Lie. No.. �.liC I T�Z:.......... �.. PLUMBING INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer r i MASSACHUSETTS UNIFORM APPLICATION FOR 'PE r r f j iPdnt or Type) RMIT TO DO PLUMBING —Anr�M . Mass. Date CSC Permit Building Location oocx wner's Name;�- New l Renovation ❑ Type of Occupancy / Replacement ❑ " " Plans Submitted: - Yes C�7 No ❑ FIXTURES IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR ,STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name . _. Address ANA FFEI PLUMBING, INC. G ,High St., IpswicF, MA 01933 Business Telephone TEL (978) 35&1122 .FAX (978) 356-8722 Name of Licensed Piu,,,,,cj f heck one: Corporation u Farinersnip ❑ Firm/Co. Certificate INSURANCE COVERAGE: ability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. I have a Curren l Yes No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above applicatio are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this I'cation will be in compliance with all pertinent provisions of the Massachusetts State Plum nd Chapter 142 of the Ge er law BY Title Sign censed P ber City/Town:W�:: Type of License: Master Journeyman APPROVED OFFICE USE ONL) License Number . O s = N z N W z O Y z ¢ f - W 0 O Y Z 0 J Q¢ N Q ..,F- ' z � V. CO Z W o: y m N S N F } V W 4'. ; f- Co N Y z ¢ C N a U.z O Q C W W z< to t=- W 3� Q y O Q G ¢ W -F- N D CQ J Z C a > x H o N N t- z o o y a ac z z m 3 Y ., m V) D p .� 3= < M o x sue—BSMT. BASEMENT PIP -- IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR ,STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name . _. Address ANA FFEI PLUMBING, INC. G ,High St., IpswicF, MA 01933 Business Telephone TEL (978) 35&1122 .FAX (978) 356-8722 Name of Licensed Piu,,,,,cj f heck one: Corporation u Farinersnip ❑ Firm/Co. Certificate INSURANCE COVERAGE: ability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. I have a Curren l Yes No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above applicatio are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this I'cation will be in compliance with all pertinent provisions of the Massachusetts State Plum nd Chapter 142 of the Ge er law BY Title Sign censed P ber City/Town:W�:: Type of License: Master Journeyman APPROVED OFFICE USE ONL) License Number . O s 0� M TowN or NORTH ANDOVER, MASSACHUSETTS Water Treatment Plant 420 Great Pond Rd, 01845 Dennis L. Bedrosian Tel: 978-688-9574 Superintendent Fax: 978-688-9575 TOWN OF NORTH ANDOVER CROSS CONNECTION CONTROL PROGRAM DESIGN DATA SHEET AND PLUMBIN<; PLAN I. NAM: to( G p—on4 YC �� �' c'e 6A e A WSJ "NA t ­k V VI i - Address : oc� STCe e �%�'��cQcIV e12 . Y Control Number!— II. umber:II. FACILITY Name: S m Address: Contact Person: %0,� 4 Vlf l Z Phone New or Existing Facility: k;z>C% L'CA General description of Facility: �QT�°fewtC�li—CaMr�.wt� III. DESIGN DATA Manufacturer: a:�S' — Model: UQ�` Type: RPZ % DCVA PVB r� P � Size: •(/.Gate Type:`�c_ t Elevated Temperature Device (Y/N): /V() Location:cJ��� �( Location of Potable WtLter Line: C_I�afA e— By-pass Arrangement (YIN): "0 From what Type ofContaminationis the Water Supply Protected? J00 _ftc How Many Other RPZ, DCVA or PVB Backflow Devices are Located in this Building? 10 I'd L560 Z£6 LL9 30IAd3S A13JVS a3lVM W02i3 WdLV=S 666L-7.l-li i IV. DEVICE MAINTENANCE AND TESTING SCHEDULES Describe the maintenance and testing schedule of the above device(s). Please refer to 310 CMR 22.22 C 11aAs- r uj Req u c r V. CROSS CONNECTION PLAN SUBMITTAL REQUIREMENTS Details must be provided to include at a minimum the following criteria: A. Plumbing Plan: 1. Completed Title Block (name, address, date, preparer, scale, etc.) 2. Schematic of plumb iag system (at least 8 1/2" by 11") showing .accepted symbols and nomenclature, detailing: a. Clearances.of device installation b. Location of upstream and downstream shutoff valves c. Make, model, size and alignment of Device d. Location of Potable.Water lines e. System, source, or equipment fed downstream of device, complete with information on the secondary system (operating pressure, chemicals, etc.) Submitted By : C. 2 ��� 1 �C Address : l S� �eQ-�- �i�su��^C�, Date: Owner/Agent Signature: 0M43 S. FJ(g-IVt Z d LS60 Z£6 Lt9 30IAb3S A133dS b3lVM WO83 Wdty=S 666t-Zt-tt -v H ro H 4r oa ztzi O s . MI -A m p MZ w td tri H Ohi <` m �cnb C 0 009� O O O z ,` C �u O d :d Hz H z z d 0 O �G xca En 0 H M N `� z �_ _. > m O c y Q O ttzi O EnOD Z t tCriyq > CYR W zd In OAo. O} z .... , . :F z z > d O C C1 . O Z t ?UP�u 0o F HCD 0 'fir %Ul z ,N{� r z v , Ot ZZ DO D D Z=Z I ' t� Azo lm 4-4 u Dmn Z tlj g -n7 6 0 4Q7 CA m ttj O r^ 00 'aMo G 0 �o _ m x OT. CD CL "�� � � > Z O H ro H 4r ztzi O s . MI -A w Az tri H Ohi <` hi 'FK O O O z ,` C �u O z � O N Z t In OAo. O} .... , . :F ?UP�u 3 'fir z s t z I _ z t� k u r^ C: \ O.:: a A� MI -A w Az X O O O N In p O} i No 1856 Date ..... 2.! /. ���... TOWN OF NORTH ANDOVER A PERMIT FOR WIRING a This certifies that T VN 1 f o 51CLk......1_. ( ec ,5� � J�'t to ................................... .................. ............. i� has permission to perform ...... ............................ 25.................................... o wiring in the building of r 4fi........... (-e (a .. . -. at .......... 5.. ti ...... S ......... � �?................... !>, North Andover - .ass o .J Fee. v f`1........ Lic. No .. ...... :..... ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer L P Q,,GM UtJWEaJt4 IIf 4Ra55arhU5E1t5 Oftice Use Oniy Department of Public Safety No. BOARD PREVENTION OF FIRE PREVENTION REGULATIONS 527 CMR 12.00 Occupanq• b Fee Checked NgPMARD 3190tlea•:e blank) APPLIERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance %vith the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date City or Town ofn66r The undersigned applies for a permit to perform the electrical work described below. To the Inspector of Wires: Location (Street & Number) Owner Tenant ` ) 17-.5� MAP or `, ONner's Address EL Is this permit in conjunction with a building permit: Ye 1 No ❑ 4 ) Purpose of Building Utility Authorization No. Existing Service Amps / Overhead ❑ Undgrd ❑ No. of Meters � (Volts Tew Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Me:ers Number of Feeders and Ampacity , Location and Nature of Proposed Electrical Work C411 S_Y6" No. of LiEhting Outlets No. of Hot TubsU L No. of T,.ansformers t Above grin - No. of Lighting Fixtures SwimmingPool Rrnd. ❑ grnd. ❑ , Generators } �, •y No. of Receptacle Outlets No. of oil Burners No. of Emergency LiShting Battery Units No. of Switch Outlets No. of Gas burners No. of Ranges Total Na. of Air Conditioners Tons FIRE ALARMS No. of Zonesa gbh No. of Detection and f..,iq Heat Total Total No. of Disposals No. of Pumps Tons otal Initiating Devices �L.1�� No. of Sounding Devices No. of Self Contained No. of Dishwashers Soace. -%rea He\V Dcte�ion.'Sou. ' ^ evices -- - '�o. of Dryers r" Heating Devices K\\r Mcpa local❑ ❑ Connection O:^er No. of Water Heaters No. of No. of K4\ Signs Ballasts Low Voltage No. Hydro Massage Tubs 11'iring r BS No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusnes General Laws 1 have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES � NO = ! have submi:ted vatic proof of same to this office. YES LX NO C If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE ®BONA ❑OTHER❑ (Please Specify) (See Attached) Estimated Value of Electrical Work S AM000 (Expiration Date) Work Signe Rough Signed under thto Star, SigneInspection Date Requested: Rh Will Call e penalties of perjury; Final FIRM NAME Interstate Electrical Services/ Licensee Pasquale A Alibrandi LIC. No. - Signature Address 70 TrebleCove Road N. $i, r UC NO. /862Bus. Tel. No. 667-5 0 OWNER'S INSURANCE 1A'AIVER: I am aware that the licensee does of have the insurance coverage or its substantial equivalent e Tel as required by Mas achusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) ` (Signature Telephone No. (Si 8 e of Owner or Agent) PERMIT FEE 5 �y T S.. 3341 Date...!���5 5.... ,ORTH TOWN OF NORTH ANDOVER py 4ao ,e ��OpL PERMIT FOR GAS INSTALLATION This certifies that ... P. (.-. 1'. l.? .. 1 ?/-. fT' .... ` ............ . has permission for gas installation .. .13 c in the buildings of .. `�...... • • ....... • • • • . J at '..... . �� .� ... ............. . North Andover, Mass. Fee. 3. `� Lic. No.. 3. Q ...r )y.�,, ._, ... . _GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 10 Date . ,� /. t : :.... . RTI, ti TOWN OF NORTH ANDOVER PERMIT FOR MECHANICAL INSTALLATION This certifies that ... �.� ....c .4 : ........................ has permission for mechanical installation ..,X- !7 :_.... ...... in the buildings of ... %; . S z ._.n_. f . .. .................... at ..... t...?..1 .. ': S = . ... • ............ , North Andover, Mass. No.. ; .�., .�...... ...�...,. _ .._.......... . GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 3rd 0. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO iGASFITTING (Print or Type) jQ0, �N�av� 2 , Mass. Date (J 19-ff Permit# Building Location S7S 0-sC ooh % Owners Name e-4-- CfiRe Cors "-t Map: Lot: Zone: Type of Occupancy New Renovation ❑ Replacement ❑ Plans Submitted: Yes ❑ No ❑ Installing Company Name JEN OM 1A G it 141J/4L Address S E mau e 6r=� 'IVA Estimate Value of Work: Check one: Certificate W Corporation 2-041 ❑ Partnership Business Telephone (9c):3 ❑ Firm /Go. Name of Licensed Plumber or Gas Fitter 8 E C L I= F jF 0-7 %.LE INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets.the requirements of MGL Ch. 142, Yr:syk No ❑ If you have checked es, please indicate the type coverage by checking the appropriate box. A liability instirance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent Cl Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 14 of the General Laws. By Signatu o Licensed PI ber Title Type of License: Master Journeyman U City / Town /►� " � APPROVED OFFICE USE ONLY / License Number ✓!' /"� 9-3 N Q W1� N N Y U Y C rt N F z ' W W Q cc O U m(- = Z 0 a ¢ m u ►W- 4 a ¢ _ O O r 4 C N W y W O p. d C •( > W W N N W 0 Z a W 2 = C a = W C C W O ~ 0 W W N C a F Z 4 z W .J F' At Z C~ W f' W i- O N O m > Z W O H U J Z W O W 2 4 W> cc z 0 K W O < Oc 4 4 j O c� O W D a H O SUB-BSMT. BASEMENT 2 1STFLOOR 12. 2ND FLOOR 1 3RDFLOOR —1 4THFLOOR STHFLOOR 8TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name JEN OM 1A G it 141J/4L Address S E mau e 6r=� 'IVA Estimate Value of Work: Check one: Certificate W Corporation 2-041 ❑ Partnership Business Telephone (9c):3 ❑ Firm /Go. Name of Licensed Plumber or Gas Fitter 8 E C L I= F jF 0-7 %.LE INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets.the requirements of MGL Ch. 142, Yr:syk No ❑ If you have checked es, please indicate the type coverage by checking the appropriate box. A liability instirance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent Cl Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 14 of the General Laws. By Signatu o Licensed PI ber Title Type of License: Master Journeyman U City / Town /►� " � APPROVED OFFICE USE ONLY / License Number ✓!' /"� 9-3 v m In m m i N X m A 1 r m i r O � 0 0 m 1 A � m > H � m ' o � z 1 r N2 421? Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .. ....1 .A. M has permission to perform G. . .............. . plumbing in the buildings of ... �..`�. y ``. �.`. ............... at .... .2 y .�. A ............... . North Andover, Mass. Fee. �� .G.v. Lie. No.. c7. (,J PLUMBING INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING n.\ (Print or Type) "a in NO. ANQat1X-K . Mass. Date G -3 19 Permit * G 1..( Building Location 76- OS G e1's Name LT F E C ARAE -segymc.fis C.Ogep./Type of Occupancy New X Renovation ❑ Replacement ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES Installing Company Name_ DO-42oN Pi-& $ OVA(- Check one: Certificate Address---- (6t6 PRnlyr STRr-ET ('Corporation Z -O 6 1 MANCIOEATEE N.N. 0-110 ❑ Partnership Business Telephone (L c3) fo27 -!el B ro ❑ Firm/Co. Name of Licensed Plumber Tp F- INSURANCE COVERAGE: I have a curren liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch., 142. Yes lX No ❑ If you have checked Vis, please Indicate the type coverage by checking the appropriate box A liability Insurance policy x Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code 4pd Chapter 142 of the General Laws. Title Signature of uct0sed Plumber City/Town Type of License: Master Journeyman C] APPROVED OFFICE USE ONLY) License Number /�%] `Y 7 9 z z Z m Y a N 1- d1Oj N O V Z Z W W N Y Z N J <� N < = N Z M O O Z N d M O N W_ H h O W N N S F V < Y< N a U. v Z < _ 0. Z < �. x V = Q O m O ¢< W cc 2< !- N W Z c < W z x a ¢ O 0 W ~ V> O Z 1- m O= n N �' y Z O NW W F 3¢ O V S is .<+ ai c o; 1<- vJi o< m o SUB—BSMT. BASEMENT 3 IST FLOOR 2 13 20 Z 2ND FLOOR Ztf I Zy i7 3 lZ iZ 3RD FLOOR 2.r( 12. Z'/ /] I 3 12 IZ 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name_ DO-42oN Pi-& $ OVA(- Check one: Certificate Address---- (6t6 PRnlyr STRr-ET ('Corporation Z -O 6 1 MANCIOEATEE N.N. 0-110 ❑ Partnership Business Telephone (L c3) fo27 -!el B ro ❑ Firm/Co. Name of Licensed Plumber Tp F- INSURANCE COVERAGE: I have a curren liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch., 142. Yes lX No ❑ If you have checked Vis, please Indicate the type coverage by checking the appropriate box A liability Insurance policy x Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code 4pd Chapter 142 of the General Laws. Title Signature of uct0sed Plumber City/Town Type of License: Master Journeyman C] APPROVED OFFICE USE ONLY) License Number /�%] `Y 7 9 N O D m 4 m n � O z as m 0 O C � ce<, r m v C Z w r' Of Q � z M p O Q N m 4 m n as m 0 O z ce<, w Of M p O m -4 o N v m o c c { 4,N° 16 9 7 Date ...... y .. �C�.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies ....................... ...''...�'.... i has permission to perform . �71�......... —.. —� wiring in the building of .. , ...... . �...mrM � ,. at. . �..�. . c2r;-� <- i!;..... - ................ .North Andover, Mass. (Ile Fee 5 M ......... Lic No. /f,Z� ...... ` f/ ~— ELECTRICALiINSPECTOR 05/27/99 14:57 5,000.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Office Use Only ' The Commonwealth of Massachusetts �� Permit Xo. Department of Public Safety Y_F.. Occupancy S Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 1200 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance with the Macsachusetu Electrical Code. 527 CMR 12:00 (PLEASE PRINT IN INK OR TT)PE ALL INFORMATION) Date City or Town of CYZ7_11 /40/ 6!/CZ To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) 57,5- Owner %SOwner or Tenant _ E fi 6=GUO 017 /�` Ts,���h% 7-- Ty (Z Owner's Address 0-540U� 5j /�G����f ��, ✓� Is this permit in conjunction with a building permit: Yes No ❑ (Check Appropriate Box) Purpose of Building G1411,t1 4 (�y,✓f-i2 j`� S Utility Authorization NO. Existing Service Amps I Volts Overhead ❑ Undgrd ❑ No. of Meters New Service 1660 Amps 4K///2o Zo6Volts Overhead ❑ UndgrdX No. of Yzters .- I I _ . Number of Feeders and Ampacity Location and Nature of Propose N � w.1 In 4.) (l 1� ;'-6 a L No, of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No, of Lighting Fixtures Swimming Pool Above In- grnd. ❑ grnd. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners BNo. of attery Emergency Lighting UniNo. of Switch Outlets No. of Gas Burners FIRE ALAPOIS No. of Zone:; No. of Detection and Initiating Devices No. of Sounding Devices No. o f Self ContaineDetecding Devices Local ❑ Municipal ❑Other Connection No. of Ranges g Total No, of Air Cond. tons No. of Disposals. No, of heat Total Total Pum s Tons KW No. of Dishwashers Space/Area heating KW No. of Dryers Heating Devices KW No. of Water Heaters Sig,Ballasts Voltage WirLow ng No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES E] NO ❑ I have submitted valid proof of same to this office. YES ® NO El you have checked YES, please indicate the type of coverage by checking the appropriate box. - INSURANCE A I BOND ❑ OTHER ❑ (Please Specify) 7,Z'AV4F1,5_ Estimated Value of = y`__l Work SJ�-0x6,666.00 Expiration Date =-� Work to Start Inspection Date Required: Rough Final Signed under the penalties of perjury: FIRM NAME MAKI ELECTRICAL INC. LIC. NO. Al 1738 Licensee RAYMOND MAKI S i g n a t u r _ LIC. No. A11738 Address .100 NORTH ST. WORCESTER, MA 1605 Bu's. Tei. No -772-5662 Alt. Tel. No. 756-5553 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) ' !� D Telephone No. PERMIT FEE $�-/ �DO Signature of Owner or Agent F A / �f h "'0"6 xAl 13 Pj /31A Excavation - depth and soil conditions Framing - r� Date: Date: Date: Inspector Inspector 4� O, HOM1F ,4 Insulation - , y F • r Town of Date: Inspector Inspector . e •: Electrical - rough - Plumbing and/or gas - rough - Other: NORTH ANDOVER Date: Date: BUILDING PERMIT INSPECTION REPORT Inspector PERMIT NO.: Plumbing and/or gas - final /0 -6 - Date: PROJECT: INSPECTION DATE: Inspector UNIT NO.: FLOOR: WING: BUILDING NO.: fit/ oil burner, tank, stove, smoke detectors (3 660k st REMARKS: �if1. % 'i1G t. „ tfkJa` t't`1► +'�1 )5:,o , U/VI S Inspector F A / �f h "'0"6 xAl 13 Pj /31A Excavation - depth and soil conditions Framing - Other: Date: Date: Date: Inspector Inspector Inspector Footings and foundations and drains - Insulation - Other: Date: Date: Date: Inspector Inspector Inspector Electrical - rough - Plumbing and/or gas - rough - Other: Date: Date: Date: Inspector Inspector Inspector Electrical - final Plumbing and/or gas - final Other: Date: Date: Date: Inspector Inspector Inspector Fire Dept - oil burner, tank, stove, smoke detectors Final inspection Certificate of Use and Occupancy .Date: Date: Date: _Cof 0# Inspector Inspector'- Inspector R.d e.a ti. -i. 4x a ., x . ,+y,.. •w :i,Jnv�'"-.'"e'r i';d:e�f�'�^�^i.ro_�.+3 ,l N+" '.'r... .., i1.ii�'kY� `P' .4 �, ' 1 NORIh - O� PERMIT NOJ 6 97 z-� UNIT NO.: C e Town of NORTH ANDOVER BUILDING PERMIT INSPECTION REPORT _PROJECT: T 0(11f INSPECTION DATE: FLOOR: WING: BUILDING NO." REMARKS: i��_y • �(.(�_. . "� "t r`t.if✓ •4" '.''' e i / ..^.' pd 1� h!" t l.' t.t r .e+.. �♦/ tr"'°' i I�! % r'� i if-_' ,,RR�✓)f��i o + 1. Inspector p• ' .( ;1] X11 jJ/q )j{ Y `.. /8/1�% ) l� ^+�' f• b£' / ! tit} Date: Inspector Inspector Inspector - Electrical - rough - Excavation - depth and soil conditions Framing - Other: Date: Date: ` Date: Inspector Inspector Inspector Footings and foundations and drains - Insulation - Other: Date: Date: Date: Inspector Inspector Inspector - Electrical - rough - Plumbing and /or gas - rough - Other: Date: Date: Date: Inspector Inspector Inspector Electrical - final Plumbing and/or gas - final Other: Date: Date: Date: Inspector Inspector Inspector'` Fire Dept - oil burner, tank, stove, smoke detectors Final inspection Certificate of Use and Occupancy Date: Date: Date: C of O # Inspector Inspector Inspector ✓V Y`.sT^•YF.%.: �$ti��•. i+^, i•a.,.'. 'c 4. _r.... ..- -. � .. .... _ _ . ,.. _. ,r �, s : R : Hti . :F :r., -tr... - � :. - - _ __ . ". <.a •.�'• P ` `�t4,...'.�s'�s(sV*'-+f,.: '".fF'.'I`'.i.�..•,.J ...•0 "Y.-A..s Lm •ti y.�„r.yy .+a,@,w.i''.' .l^'!: �. 1 HOFFh ,r l+ Town of r ,`�JS,'�',�''• NORTH ANDOVER C U BUILDING PERMIT INSPECTION REPORT PERMIT NO.: (o f PROJECT: E 'rKj_�1Lk)G INSPECTION DATE: UNIT NO.: FLOOR: WING BUILDING NO.: /6-0'0 _ REMARKS: aN �C, �.,✓�r. > ;�P C. %°!G X41 ry f C Nr Gc c�t� E1P r r C ff t r V , y� .a F 1" f �" C .s 31r J d,,. � F"' .� �1 ��f C -C, r r. P r' C c, (V -3 t' /,c'c r (,i s I ( o f� , ' Excavation - depth and soil conditions Framing - Other: Date: Date: Date: Inspector Inspector Inspector Footings and foundations and drains - Insulation - Other: Date: Date: Date: Inspector Inspector Inspector Electrical - rough - Plumbing and/or gas - rough - Other: Date: Date: Date: Inspector Inspector Inspector Electrical - final Plumbing and/or gas - final Other: Date: Date-- Date: Inspector Inspector Inspector Fire Dept - oil burner, tank, stove, smoke detectors Final inspection Certificate of Use and Occupancy Date: Date: Date: C of O # Inspector Inspector Inspector ti.. ..�;, -..e ri:1`. ri�'i>xw*c. ary-it: .1:��vfia: s.;.i y� .c ...r�:. �Sr . .�- ' X tF• C? ^'w"v.'S-;4 i '���".:v"'�^^Y�♦Yv�`'0"�"„4,�''—�`�h'..,iaS,�. L•is��"i-�"Azvw � n _ Town of ♦*,J=,�.�s`'� NORTH ANDOVER BUILDING PERMIT INSPECTION REPORT PERMIT NO.: PROJECT: E l 6 L W oc) d- INSPECTION DATE: '� UNIT NO.: FLOOR: �� WING: BUILDING NO.: REMARKS:rlc�xd. I n1t't c#'t rL �d�< r U ov /'I `i 8� Excavation - depth and soil conditions Framing- Other: Date: Date: Date: Inspector Inspector Inspector Footings and foundations and drains - Insulation - Other: Date: Date: Date: Inspector Inspector Inspector Electrical - rough - Plumbing and/or gas - rough - Other: Date: Date: Date: Inspector Inspector Inspector Electrical - final Plumbing and/or gas - final Other: Date: Date: Date: Inspector Inspector Inspector Fire Dept - oil burner, tank, stove, smoke detectors Final inspection Certificate of Use and Occupancy Date: Date: Date: CofO_# Inspector Inspector .Inspector , �..; ,�d ,�a�y�,t{ �;x'i�'4..P3 .R..Tjiy"„��;. �:�_j r�•:hf +� �-0+,lc.,.{'�,'.,.,tr.,�_.o.a.",.i�'�'`5y�`ti't!'i�':,%b'��.�:iX+gr,c°�i�tj?P�,ifi�n11 r'w'`'ti,L'w���"",y�._.�>,,,aiw..x i ..�i',.>+.� n1M •M1 Cr He.o .•,M1O Town of �,_=,���s'• NORTH ANDOVER BUILDING PERMIT INSPECTION REPORT PERMIT NO.: PROJECT: It1)L"ti V-1,20,1 INSPECTION DATE: "" rev� UNIT NO.: FLOOR: P -90L i 1-6- ! � L. WING: BUILDING NO.: REMARKS: r I L Excavation - depth and soil conditions Framing - Other: Date: Date: Date: Inspector Inspector Inspector Footings and foundations and drains - Insulation - Other: Date: Date: Date: Inspector Inspector Inspector Electrical -rough - Plumbing and/or gas: rough - Other: Date: Date: Date: Inspector Inspector Inspector Electrical - final Plumbing and/or gas - final Other: Date: Date: Date: Inspector Inspector Inspector Fire .Dept - oil burner, tank, stove, smoke detectors Final inspection Certificate of Use and Occupancy Date: Date: Date: C of 0# Inspector Inspector Inspector ?k ta.i.�`craa,. �e�✓Efirw'.-�'S K<t_ii''�'$M;•x,��:'s;.r/,� .d.�.�`'t"r.', �y *.�9:✓k='.yYt �d tom:; �i -- 7s . �'• s �7��':cx�.�.1T�'''•tY`$?�.x?ttt'�.a��''jW'r�'�r'+vi.�tF�triJ iti•``<.A, "'Ti.�d�8td L.y9;.,,.•.,'y;;.r §.,� ,,,,1a. 'n �. • HORTh - • � O n Town of NORTH ANDOVER BUILDING PERMIT INSPECTION REPORT PERMIT NO.: 27 PROJECT:l:06x-6W0 01) INSPECTION DATE: UNIT NO.: FLOOR: 01- J451C)Cjr• WING: BUILDING NO.: �1. REMARKS: >rEI //Vh5,2e(-r1 4, 0 o +L / .�e�rr�%• ,11rcA lillo cc)mYpal Excavation - depth and soil conditions Framing - Other: Date: Date: Date: Inspector Inspector Inspector Footings and foundations and drains - Insulation - Other: Date: Date: Date: Inspector Inspector Inspector Electrical - rough - Plumbing and/or gas - rough - Other: Date: Date: Date: Inspector Inspector Inspector Electrical - final Plumbing and/or gas - final Other: Date:. Date: Date: Inspector Inspector Inspector Fire Dept - oil burner, tank, stove, smoke detectors Final inspection Certificate of Use and Occupancy Date: Date: Date: C of 0 # Inspector Inspector Inspector r,�� vua. r. .. s � - •-' • �.y'r w'� �"'•t i s ?.�� � 4• e"�. L*:. -- r—� �y.. �i. v'4'-.fy,.:.,s�w. y.-. .«. ..,�_. .ss�`•`x�•r v'�:..:.s4i"*,c, ., •'s'�«& .+ .,�t�'e,%YV"`��4�'$+V`W'ik"ws �'`+kF*,sF�:'°rr?��°'p`�k„r°R q,'.'y�,o�.a;�r4,�4;�.�,.. ��-w, yj • . O y a Town of. NORTH ANDOVER BUILDING. PERMIT INSPECTION REPORT PERMIT NO.: J J PROJECT: f`..) (-C-w0Vd z INSPECTION DATE: I UNIT NO.: FLOOR: %`kll A WING: BUILDING NO.: REMARKS: P �].-V Ct .. i YV P(f(Yi C Al e)l- ui'! i rs c.)AJ jird %= f 6. /nV v,v, r #s Bio /Y/0 I Excavation - depth and soil conditions Framing - Other: Date: Date: Date: Inspector Inspector Inspector Footings and foundations and drains - Insulation - Other: Date: Date: Date: Inspector Inspector Inspector Electrical - rough - Plumbing and/or gas - rough - Other: Date: Date: Date: Inspector Inspector Inspector Electrical - final Plumbing and/or gas - final Other, Date: Date: Date: Inspector Inspector Inspector Fire Dept - oil burner, tank, stove, smoke detectors Final inspection Certificate of Use and Occupancy Date: Date: Date: C of O # Inspector r— YO= n..•1.... Inspector Inspector - - •(!•....iJJTiFi=''�i�i" .. ...dhQ' - i+...�.[ M..+�'iw � -.... i p �y p Town of us`'NORTH ANDOVER BUILDING PERMIT INSPECTION REPORT PERMIT NO.: PROJECT: (1Wd 74 INSPECTION DATE: UNIT NO.: FLOOR: WING: BUILDING NO.: L- k&" REMARKS:Q4A )fy_w)eC- ions t't/- .�.+frr rfU Orli Excavation - depth and soil conditions Framing - Other: Date: Date: Date: Inspector Inspector Inspector Footings and foundations and drains - Insulation - Other: Date: Date: Date: Inspector Inspector Inspector Electrical - rough - Plumbing and/or gas - rough - Other: Date: Date: Date: Inspector Inspector Inspector Electrical - final Plumbing and/or gas - final Other: Date: Date: Date: Inspector Inspector. Inspector Fire Dept - oil burner, tank, stove, smoke detectors Final inspection Certificate of Use and Occupancy Date: Date: Date: C of O#_ Inspector Inspector Inspector ' of HO olM 1y 0 • :: Town of r NORTH ANDOVER BUILDING PERMIT INSPECTION REPORT St PERMIT NO.: PROJECT: ' % INSPECTION DATE._ o""a)-� UNIT NO.: FLOOR: I WING: BUILDING NO.: IU" REMARKS: T'/' � iy cr x'40 c)9 t A.J �A cRt cai—. Service / ,' ry 1 tiCi I t LIP ' hA t �♦ r � /�1! eta ' ti/'w'i Gf.. �� '•ham i i. � i.✓t� w. Excavation - depth and soil conditions Framing - Other: Date: Date: Date: Inspector Inspector Inspector Footings and foundations and drains - Insulation - Other: Date: Date: Date: Inspector Inspector Inspector Electrical - rough - Plumbing and/or gas - rough - Other: Date: Date: Date: Inspector Inspector Inspector Electrical - final Plumbing and/or gas - final Other: Date: Date: Date: Inspector Inspector. Inspector Fire Dept - oil burner, tank, stove, smoke detectors Final inspection Certificate of Use and Occupancy Dater Date: Date: C of 0# Inspector Inspector Inspector N2 Date ...... , 'i 5 9 9 f NORTH � TOWN OF NORTH ANDOVER p PERMIT FOR WIRING V This certifies that .................................. has permission to perform .J. ......... _ .de.f.. wiring in the building of .................................. Z ....-:..,•. ......... at �j ......... , North Andover/, Mass. Fee45.0. .- ...... U Lic. Nog.1, 14. ...� ' f %oma � c.... .................. /i `� -ELECTRICAL INSPECTOR + 04/20/99 14:39 50.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 0 �\ office use only The Commonwealth of Massachusetts X99 t� Perm(c No. f1 a Department of Public Safety �f .:: Occupancy S fee CheckedV v BOARD OF FIRE PREVENTION REGULATIONS 5.27 12700 3/90 —�— ' (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance with the Maisachuseru Electrical Code. S27 CMR 12:00 �J (PLEASE PRINT IN INK OR TYPE ALL INI'ORIIATION) Date 7 -/� — 7 City or Town of To the Inspector of Wires: The undersigned applies for a pernit to perform the electrical work described belo:r. Location (Street & Number) 6-25 05 66 0 D ST ka�L il�, AwDo(/&-�Q- 44, Owner dr Tenant &—:Z>�c—a)000 .�-(- //%�%%CSC% Mr✓% /N� , Owner's Address_ 525 a 6-Gb O. S7- Po 1-711 Is this permit in conjunction with a building permit: YesIR No ❑ (Check Appropriate Box) Purpose of Building CoA,5/. %/1/4/ 67ZUtility Authorization NO. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Yzters Number of Feeders and Ampacity 6.2J5 ' "Yo J6� /4/-c/ / Location and Nature of Proposed Electrical Work 7—eW eo JC V/�� 7 (:?o us %/ZUCa.%/o/V %�LX/ / P�r�/c ,2tj,-)(I No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above ❑ In- ❑ grad, grad. Generators KV:1 No. of Receptacle Outlets No. of Oil Burners No. of Batter Emergency Lighting No. of Switch Cutlets No. of Gas Burners FIRE ALAKIS No. of Zonea No. of Deteceion and Initiating Devices . No. of Sounding Devices No. of Self Contained Detection/Sounding Devices Local Municipal 11 ❑ Other Connection No. of Ranges g Total No. of Air Cond. tons No. of Disposals. p No. of heat Total Total Pumps Tons KW No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Devices KW No. of Water Heaters KW No, of No. of Signs Ballasts Low Voltage Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES K] NO ❑ I have submitted valid proof of same to this office. YES® NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. - p q INSURANCE [K] BOND [J OTHER 0 (Please Specify) %�zty(FL. s /il)i/2 <S-3/— / / 1a.0- (Expiration Date Estimated Value of Electrical Work S 1�2-5-eO Work to Start ¢ — 1,5-9_l Inspection Date Required: RougV/QZ)U/S(F­ Final Vxz) V16 e Signed under the penalties of perjury: FIRM NAMEMAKI ELECTRICAL INC LIC. No. Al 1738 Licensee RAYMOND MAKI Signature J4'*IN'J .0m %'%�w� LIC. NO. A11738 Address 100 NORTH ST. WORCESTER MA 01605 Bus. Tel. No. T52-5662 Alt. Tel. No. 756-5553 OWNER'S INSURANCE WAIVER•'. I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as r@quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) �} O Telephone No. PERMIT FEE S `J (O Signature of Owner or Agent yThe Commonwealth of Massachusetts °"`r' `S# Onl% Department of Public Scfcty Pvr�lt b. r BOARO OF FIRE PREVENTION REGULATIONS 527 CMR 1200 3/90 oL°Iwn`�. + r" °"`°'e (Dare blank) r APPLICATION FOR PERMIT TO PERFORM ELECTRICAL NI Work to be periormed Jn accordance ""hc Maaaachusens Electrical Code 52 CMR 12;00 WORK (PLEASE PRINT IN nM OR TYPE ALL TNFORM&TION) Date City or Town of /fir Le,,, The undersigned applies fora permit to To the Inspector of Hires: P perform the electrical work described below. Location (Street & Number) -1 - ' S S - Owner or Tenant Owner's Address •' SN�c Is this permit in conjunction .with a building Permits Yes ❑ No ® (Check Appropriate Sox) Purpose of Building z Utility Authorization N0. , Existing Service _Amps / Volts NOverhead New ❑ qrc:�_ ❑ o: SetTip� �isCerS •. ps / Volts Overhead ❑ Undgrd Number of Feeders and Ampacity ❑ No• of iSeters-------� Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Lighting Fixtures No. of Hot Tubs No. of Transformers Total KVA Swimming Pool Above In- ❑ ❑ No. of Receptacle Outletsrrd. Generators KVA No. of Switch Outlets No. of Oil Burners No. of Emergency Lighting BatteryUnits No. of Ranges No. of Cas Burners FIR; ALARMS No. of Zones No. of Air Cond. Total cons No. of Detection and No. of Disposals No, of Neac Local Total Initiating Devices No. of Dishwashers Pu'os KW No. of Sounding Devices —_— Space/Area Heating K41 No. of Self Contained No. of Dryers Heating Devices Detection/Sounding Devices No. KW Not Local ❑ Municipal Connection❑ Other of Water Heaters Ku Si ns Ballasts Low Voltage Wirin No. Hydro Massae Tubs g No. of Motors Total HP INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liabilit Insurance Policy including Completed Operatiops,Coverage or s substantial equivalent. YES U NO 0 I have submitted valid proof of same to this office. YES NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE t BOND ❑ MM (P (Please Specify) Estimated Value of Electrical lWork S xp ration ate Hark to Start 4 In,peccion Dace Requested: Rau Signed under theenaltie, of perjury; �J Final FIRM NAME . f'' GG` -C Licensees. �2 LIC. N0. S`�3 Signature / LIC: NO. ///,J u Tel. No. 3 OWNER'S INSURANCE WAIVER; d atantlal equivalent aI am aware that the Licensee oes not have the insurance No. ce coverage s reor is au required by Masaachusetta.Cene application waives this requirement. Owner Ag srYBnature on this permit ly at c ): Telepho� Signature of Owner or Agent PERMIT FEE SS o .cul_ 2 21W z BUILDING DEPARTME(' d : Date .. ! .. { ! X42 107 TOWN OF NORTH ANDOVER PERMIT FOR WIRING c This certifies that::... l �.. ��.. .........'. ..... has permission to perform ...... 3 ....... :k .f...5:..: wiring in the building of �.... .:..: ()v�:. ....:........ at ..:...ti..... �. a L ............... ............: North Andover; Mass. .. , { Fee....... �'SI ......... ....:. .:....... ......,. .,............ ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer N Date. /-. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . �. !' �-.. . . Roc ./�— . . . /P� /�/- ... . ... . ............. has permission to perform ..... P . i .. 1. ....................... plumbing in the buildings of ... at .............. � North Andover, Mass. Fee .�-I?i Lic. No.. ...... PLUMBING INSPECTOR Check # 5493 445 � � ! h• ��{�^x({j��v' �1 I ° �' r. .1�'� }rk .J I�"� t y ti. 4 , � i {+ �, j , :,it-,� ,� 5 001.4.' MASSACHUSET'S UNIFL)RM APPLICATION F OR PERMIT TO DO PLUMB (P`rintorTypej�3 r, PLUMBING * �, • xr A 01'i f�ND(� ' Date Yl ?00 rar , , Mass. Permit y. # �~ OwnerEOG BbUdiriq� YLo�c tlo2 OSG,�,p� s Name tar�Q �ti(jti ' 5 rt,ict'" r� Serb 15 rtL t; Y I,�+it+.rr SF �1 Y�fq ;ae t i` ui?< r r S! A Type of Occupancy_ fLrc5f0�uuC.� 4C���w►wttd/1�h4� �c �;,�{a s�y,�,!;<� $ !Y enovaltfon ❑ Replacement Plans Submitted: Yes ❑ 9(ab yak t o t h NO �'�"°ik�t r4 B.P. fr L1 ,'r4,3, ilea SEWER FIXTURES SEPTIC# R 1 '11:4 t9 kyyr� 11, R = X Q tv 0a r rAy ' z • [ W ',°4, 4O { kyr '+"� a a x Z O Z Hcc a.► �.+ _ 4. a " Lei i' b k C t a' g �w1 k.• 4f dl U N W Z s k y :� ��.' : N cc } K �W.A. Q x E v -1 r �Ot `Ja �4� W W.� O K d1 0.N 60 Ic OC J p W G v `G ' r t b t 1Y a.�•'y k �' �. y j �' O 3' < X 0.• W (� $4 C', N F- _Z Z d W X 41 Y Q F•ia Vl M Z O O y �. !�! 0 0 Q A rl_ : < cc CC �'�Zi .iii t�• z L] < 3 tY �. r 'SUB.-=BSMT: , . BASEMENTS ,"i °FLOOR ¢ rt7t ,pp {. 4` P it T y - . fl .i y y 'i �SRDgFLOO FLOOR .�'��: {{i' ���; r'4TH,FLOORK� �� ��`��` ;I�'' li,+ � �' i• nXk\q STH FLOORS + r 6TH'PLO' OAa' r ` -TTH FI.00R� ' { + x ,. ? �: ` y 8TH FLOORr, w .� lily{lnr p Vi ��C°mPa►�Y Namea $ — , ,j�•, �y a.''tt`` v �; 3, Check one: Certmcate #, " • { i iW w`q.C�' ` �tll rav �{/ L" t ..( a. ��, k., ti r,., Corporation 1 h t r S ❑ Partnership ' t Rusin ass 4Telephone ❑Firm/Co. ...- f ff�i r`. Name dof Ucensed Piumber v 11G ------------ INSURANCE COVERAGE• have la Curr IfabUUy insurance Yes policy ortziy Its substantial equivalent which meets the requirements of MGL Ch. 142 a� Ne ❑a�F �4ri��vlsltl., If you Piave c ticked yg�• please Indicate the type coverage by checking the appropriate box: A Ilabillt Insurance policy, { p, pl lOther type of indemnity ❑ Bond OWNERf S INSURANCE WAIVEp tam aware that the licensee does not have the Insurance coverage required by �Chaptery42 of the Mass General Laws. and that my signature on this permit application waives this requirement. �7sn�i'f0.: Check one: ' 5 r r, ghature of Owner or Owners tint Owner ❑ . Agent ❑ 7 -� f ! 4 1 hereby certiy that all of the details�and tnfonnation';1 have submitted (or entered) in above knowledge and that a0 plumbing work and installations performed under the permit issued for this are true and accurate to the best of my per�nen piovtsions of the Massachusettst8tatO Plyh�bing Code and Ch application will be in compliance with all Q�, .1� x - .�, t ;, r• . ,�. Chapter 142 of the General Laws. V' •: s"4•C'i' ..} 4 ! o n a ; w„7r: ��,t�y ilif�#'.. rS. 17 4, 1�(LIMOU rIUMDer MaSte(Joume yman ❑ 4. o Y f 4f G..4••�`t� � u 4' It, � '� r.. 1 •SY;�q4 L��41� rd,� zdll�,:'x��I�4.. .. .. :.p _ , A l