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HomeMy WebLinkAboutMiscellaneous - Exception (83)rmo A 11 Date ........ �k7�.".�.....1 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that R. ot7, V, 4 le— ..................................... ........................................................................................ . /,,- --5 �30 --17'm, has permission to perforin ........................... wiringin the building of,,...,,. ... d ............................................................................ at .............................................................................. North Andover, Mass. Fee Lic. No.026J'7 .............................. ................. ...... ELECTRICAL S ............ PECTOR Check # Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. ) ?nI 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 C 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: ,5— & City or Town of: NORTH ANDOVER To the Inspeofor of Wiles: By this application the undersigned gives notice of Vs or her ' ention to perform the electrical work described below. Location (Street & Number) Pz—t `��y(s �T► Owner or Tenant Owner's Address L ov,-- Telephone No. Is this permit in conjunction with a Wilding permit? Yes E' No ❑ (Check Appropriate ]Box) Purpose of Building •eg i D-�evn 1 %41 Utility Authorization No. - Existing Service 0 Amps i Iy /Z ?14) Volts Overhead Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Natu e�°fProp%ed Electrical Work:/ Q� Q D 1� q 1'C�S (�J11'•t ©?l O/08V`'t �%hwfSi��,-ov�3rn 6u /?,�n Completion of the following table may be waived by the Insnector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans y No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets v No, of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number .'.......""".... Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water 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 Wt'res. 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 e is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)�—dv,e vh *0 7:Zh s - I certify, under the pains and penal ies !f erjury, that the information on this application is true and complete. FIRM NAME: ,ctn e�, �T LIC. NO.: a Licensee: 8 AM &- SA /4 tbVf - Signature LTC. NO.: (If applicable, enter "exemp " 'n the license nz er line. Bus. Tel. No.-? 7 ak -9 ` 1- O FS7 Address: i dh ,G A r- r Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires DepIrtment of Public Safety "S" License: Lic. No. NER CE WAIVER: I am aware that the Licensee does not have the lia ' ' e coverage normally required by law. By my Signa�re eck one) [I owner El owner's agent. Owner/Agent Signature Telephone No. PERMITFEE. $ ❑ 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 r' 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 151 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass R Failed ❑' Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 (9k—. Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: ` Date: FINAL INSPEC ON: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: x16 OY1e C e _ S/ 44,4 Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts = Department oflndustrialAccidents 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. Name (Business/Organization/Individual): Address: City/State/Zip: A 6&0 Phone #: � 2 � o Are you an employer? Check the appropriate box: 1. ❑Xanimployer with employees (full and/or part-time).* 2. e proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. Q 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.Q 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 0 Building addition 11.0 Electrical repairs or additions 12. Q Plumbing repairs or additions 13. F1 Roof repairs 14. ❑ Other *Any applicant that checks box #1 must also fill 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 state whether or not those entities have employees. If the sub-coriliactors have employees,'tliey must provide their workers' comp. policy number. I am an employer that is pioviding 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 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 DTA. for insurance coverage verification. I do hereb under the pains and enal ies of erjury tliat the information provided above is true and correct- ;_J orrect Signature\�y�� C1�`�� T)atP- r� /� //"-,7 -7q- 07 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): ; 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #• r" Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone numbers) 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 fixture 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 t � d, P I 1 1, 6j" Date ..V - .?/z ... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING / lk-7c; , ( t -5-"' fI� This certifies that ................................... I has permission to perform ....... 4 ..... I .... .................................. .... ..... ..... plumbing in the buildings of., .... / ....... ........ ............ C ....... L ....................................................... at ......... ....... �.)A'1 -5 North Andover, Mass. ................................................................ . Fee .�?07 Lic. No. / 3 5� S1 ........... ..................... ............................................................. PLUMBING INSPECTOR C>2ti? Check - 0.7— 1. -\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY Andover I MA DATE r05/2812015_ PERMIT#j JOBSITE ADDRESS 51 Davis Street, North Andover OWNER'S NAME Amy Smid POWNER ADDRESS Same TEL 339-203-0492 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ® REPLACEMENT: ® PLANS SUBMITTED: YES[j NOQ 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 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL -- WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING _ OTHERtying wdsiting vents through roof INSURANCE COVERAGE: have a current liabiliq insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY EJ 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 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 accuFate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in c p�iance with ll Pe nFprovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I Timothy F. Cossette LICENSE # 13568 SIGNATURE MPE] JP® CORPORATIONQ# 3296 PARTNERSHIP®# LLC®# COMPANY NAME I Titan Plumbing & Heating ADDRESS 1445 Main Street CITYTewksburkriv y STATE Ma ZIP 01876 TEL 978-851-2486 1� FAX CELL EMAIL I teamtitanplumbing@yahoo.com ROUGH PLUMBING INSPECTION NOTES I BELOW FOR OFFICE USE ONLY Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT # PLAN REVIEW NOTES FINAL INSPECTI NOTES The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 M SJ•vw www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. .., Name (Business/Orgauization4ndividual): Address: City/State/Zip: PhnnP �f' 33f' 2d—? — 0 7 (L' Are you an employer? Check the appropriate box: 1. ^ am a employer with _employees (full and/or part-time).* 2.01 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. F1I 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 t 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 g,odeling 9. ❑ Demolition 10 ❑ Building addition 11. EJ Electrical repairs or additions 12.' Plumbing repairs or additions 13. [] Roof repairs 14.0 Other section below showing their workers' compensation policy information. *Any applicant that checks box #1 must also sill out the Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. I o Homeowners that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have loyees, they must provide their workers' comp. policy number. employees. If the sub -contractors have emp I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Expiration Date - Policy # or Self -ins. Lic. #: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under thepains a - alties ofperjury that the information provided above is 746- T)atP� and correct. V � 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(1) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants 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 pennit/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 IL A This certifies that ...//.*,. �..t....k.I Ut s 5o #e/// AV�/j ................. .................. ............... .......... .. . has permission to perform ....... . ......b.4.6(....... ............ plumbing in,the buildings of .............. * ............................ ..................... at ..... ........ ... .... h Andover, Mass. Fee.0 . . ..... Lic. No. ...... . ... ...... . .. .. .. . . .............................. Check #2-*��* B NG INS CTOR TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING �� 2�-i`f-Ihd1L `1��ll�zi P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY I North Andover I MA DATE PERMIT # 16 JOBSITE ADDRESS 51 Davis Street OWNER'S NAME Amy_S* OWNER ADDRESS Same as above TEL 339-203-0492 FAX NIA OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ NEW: (RENOVATION: ❑ REPLACEMENT: FIXTURES -1 FLOOR— I BSM BATHTUB if - 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 (INTEf KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE 1 MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER RESIDENTIAL El PLANS SUBMITTED: YES ❑ N0E] 10 1 11 1 12 1 13 1 14 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 a LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY ® BOND 01, VNER'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 compliance ynth ILP nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I Timothy F. Cossette J LICENSE # 13568 SIGNATURE MP❑ JP❑ CORPORATION ❑# 3296 PARTNERSHIP❑# LLC E]# COMPANY NAME I Titan Plumbing & Heating Inc. ADDRESS 11445 Main Street CITY Tewksbury STATE MA ZIP 01876 TEL 978-851-2486 FAX 978-851-2535 CELL N/A EMAILTeam 5 0> 1 i Y The Commonwealth of Massachusetts - Department of Industrigl Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant; Information Please Print Le2lbly Name (Business/Organization/Individual): Address:—A Ve(✓I t �J City/StatPhone Are yo n employer? Check the appropriate box: 1. I am a employer with �0 4. El am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- 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 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.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction f 7. ❑ Remodeling S. ❑ Demolition 9. ❑ Building addition 1011 Electrical repairs or additions 11.�umbing.repairs or additions 12.❑ Roofrepairs 13.❑ Other 'Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. i -Homeowners who submit this affidavit indicatingthey ace doing all work and then hire outside contractors must submit anew affidavit indicating such. ?Contractors that checkthis 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 Sol£ -ins. Lic. #; Job Site Address: Expiration Date: City/State/Zip: Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as 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 WORD 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 CCYti under the pains andalties ofperjuYy that the information providedISO ve r fe and correct. Siemature:.�-1—�J`�^`� TTatP 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 6. Other - - Contact Person: 4. Electrical Inspector 5. Plumbing Inspector Phone ti -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 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 of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be. used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (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 ox 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: Tho Commonwealth of M -O sa chmetts Department of Zndustxzal.Accidents Office of Intvesiigat::ion.a 600 Wasbington Stxeot Boston} M -A. 021.1.1 Tel # 617-7.27-4900 oyt40,6 ox 1-877.-MASSAFE Revised 5-26-05 Fax # 617-727-7749 v+tww.Mass,gov"a t i t COMIIAONWEARTH OF MASSACHUSETTS *. 1 p ,. CtiARO 4F . PLUMBERS Aho GASFITTERS ISSUES THE FOLLOWING LICENSE REGI5TEREO AS A PLUMBFNG-CORP TI'MOTH-Y COSSETTE `T'ITAN PLUMBING.& HEATING 1 -NC, i 1445 MAI l / S U I T E;-2 7 TEWKSBURY _ '";MA 01876 ` O*V01 / i 6 .' ° `° 210041 RlegcF:77iD1irlfaay'.r�.rtiar�, i . 'INATION DF 4 u Date ...... I..(....`" Z `�Y TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........... OL.. � .T.... .............. . �......^... C ................... has permission to ............................. wiring in the building of ....... ................. at.................. �.................S.^.................... North Andover Mass. / t Fee..�T$`�'............. Lic. No. .�/..........., �....... ,;........ ..................... ELECTRICAL INSPECT R Check # Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 1 Z Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/051 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: 11/06/14 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) 51 Davis Street Owner or Tenant Amy Smid Telephone No. Owner's Address same Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building Single Family Residential Utility Authorization No. 339-203-0492 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: Laundry/Bathroom/Rear Entry Com letion o the fn1lowingtable ma be waived Ay the 1--c— wi No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans o ares. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires 5 Swimming Pool Above ❑ In- ❑N-o-.-oTEmergency rnd. grnd. Lighting Batte Units No. of Receptacle Outlets 2 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches 4 No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No, of Waste Disposers Heat Pum Total p Number � ' ' """ Tons """"' "'""""" KV1' "'"'.............. 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. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 1.1/05/14 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 thislication is true and complete FIRM NAME: Folsetter Electric, Inc. -1117 _ LIC. NO.: 20421A Licensee: Robert Folster Signature LIC. NO.: (If applicable, enter "exempt" in the license number line) Bus. Tel. No.: 978-658-9975— Address: 30 Parker Avenue, Tewksbury, MA 01876 Alt. Tel. No.: 978-387-9709 *Security System Contractor .License required for this work; if applicable, enter the license number here: 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: ,$ 35.00 The Commonwealth of Massachusetts Printform Department of Industrial Accidents Office of Investigations 600 Washington Street . Er Boston, MA 02111 ` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly NaMe (Business/Organization/individual): Folsetter Electric, Inc. Address: 30 Parker Avenue Tewksbury, MA 01876 Phone #: 978-658-9975 Are you an employer? Check the appropriate box: 1.2 I am a employer with 3 4. n I am a general contractor and I employees (full and/or part-time).* 2. ❑. I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.2 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.: 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 reauired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. [] Demolition 9. ❑ Building addition 10.2 Electrical repairs or additions I LF❑ Plumbing repairs or additions 12.❑ Roof repairs 13.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. f 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:, Policy # or Self -ins. Lic. Peerless Insurance, Co. WC1235167 Job Site Address All Loacitons in... Expiration Date: 08/07/15 City/State/Zip: N. Andover, MA 01845 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 undWhre pains and penalties of perjury that the information provided abovf is trite and correct. Phone #: 978-658-9975 ' 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 #: Date..~`. 6.7. ,3?�.<� ��;:'�aaL TOWN OF NORTH ANDOVER % PERMIT FOR PLUMBING SSACMUS� �/ This certifies that.. N7 /................. .....�� �.............. . has permission to perform ..� ................. plumbing m the buildings of .. 4_._ Q'.................... at ..d:/... 1. v ..:.......... North Andover, Mass. FecJ7.. .. Lic. No. 2,/./2..h--:....... . G� ``�PLUMBI NSPECTOR Check # a 7432 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS r� I Date�,�,_ Building Location b S Name Permit #�--W-01 Amount `3 . Type of Occupancy JQ New Renovation�d'Replacement Plans Submitted Yes No ❑/ FIXTURES V (Print or type) c ' Installing Company Name _ 4 Addressy (► Business one Name of Licensed Plumber. Insurance Coverage: Indicate Liability insurance policy Insurance Waiver. I, the under three insurance Check one: Certificate P�, Corp. ❑ Partner.' 7 ❑ Firm/Co. (—Ise \�� of insurance coverage by checking the approp box: Other type of indemnity ❑ Bond have been made aware that the licensee of this application does not have any one of the above 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 wo an installations ed it ped for this application will be in compliance with all pertinent provisions of theas,4 tat Pl C e Ch Ot 142 of the General Laws. r By: 01 LIC=eaum er e o dumbing License Title City/Town cense um er Master Journeyman 13APPROVED (OFFICE USE ONLY a o ; Date ..f..-. . ``.3"..°.7.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .. ....... / 'L ..c .... .� ,.......................... ............................ has permission to perform ..'....-- wiring in the building of ::-�........................................................................... Vim/ n - at ................15�.� ,'.�"° .. � ....................... , North Andover, Mass. Fee.���...... Lic. No.13..`...°.................................................... . . ELECTRICAL INSPECTOR i Check # 7596 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. '75 —7� Occupancy and Fee Checked ? [Rev. 1/07] PAVP ,1_vN 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: 2 - 11- 0 % 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 (�{�, �y` j) Telephone No. 6- 03 SOL .S 26 Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No Lam' (Check Appropriate Box) Purpose of Building 5,.,� t (� 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: &ly 61 rL 17 l COmDletiOn nfthe fnllnuiina mhlo .., 1— ,, a Z....L- r-___ No. of Recessed Luminaires - - No. of Ceil: Susp. (Paddle) Fans -� .��. ��" �.�C .,�� ecwr O� mires. No. of Totat Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ O. o cy ig ng rnd. rnd. Batter Units Units No. of Receptacle Outlets S No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches 2 No. of Gas Burners No. of Detection and Initiating Devices No. of Alerting Devices No. of Ranges No. of Air Cond. Tons No. of Waste Disposers Heat Pump Number -"** * ' ' .Tons KW No. of Self -Contained Totals: Detection/Alertin a, Devices Local ❑Municipal E]Other No. of Dishwashers Space/Area Heating KW Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices Equivalent No. of WaterNo. Heaters KW of Noof . or Data Wiring; Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of MotorsTotal HP Telecommunications Wiring: No. of Devices or Equivalent / OTHER: ) Ott 5' r� e'--. (tic+✓ / 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: e Z. l 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: s $ IA,* L% :c�'t, ei �9,ti LIC. NO.: % 3 %0�)} Licensee: �.p;� I Signature y r' Q., LIC. NO.: �� (If applicable, enter "exempt"int license num a line.,h ,(�'( Bus. Tel. No.: S'7fi (� L,BS Address: ] 1 1nt�55,i /- / /i3 f 5j!/� J 7y/�_ *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt Lic. No. 603 38�_�17 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: $�j"-ems pa-,t,� 0-k- 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 Legibly Name (Business/Organization/Individual): Address: City/State/Zip:-ILLI S i rt,✓ i Phone #: 6-03 3�a. Are you an employer? Check the appropriate box: Type of project (required): L ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors 2.4I'am.a.sole proprietor or partner- listed on the attached sheet. t 7• ❑ Remodeling ship and have no employees These sub -contractors have 8. [] Demolition working for mein any capacity. workers' comp. insurance. g. Building addition [No workers' comp, insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions myself. [No -workers' comp. c. 1.52, § 1(4), and we have no 12.[] Roof repairs insurance required.] t employees. [No workers' comp. insurance required..] 13.❑ Other ar,Y..,.�1....�UL UMUCK9 oox s r muse also tall 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 infamration. l am an employer that is.providing workers' compensation insurance for ray employees: Below is the policy and jobs — information. Insurance Company Name: Policy # or Self -ins. 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 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 and a ies of perjury that the information provided above is true and correct Si nature: / Date; Phone #: Off ial 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 4. Electrical inspector 5. Plumbing Inspector Contact Person: Phone #: *e. 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, nofthe 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 nurnberlisted 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 permittlicense 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: w The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 42111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7744 www.mass.gov/dia c� Date ... 2. . �. ` . ....... 3 TOWN OF NORTH ANDOVER o ' PERMIT FOR GAS INSTALLATION ' This certifies that .............. . has permission for gas installation ........... in the buildings of ` ..... ........................... at .. .. ..r.:.. , North Andover, Mass. Fee?A��.... Lic. No.. /o? U,�3! �` rr ..... "(-<:........ GAS INSP_CT Check # 6048 MASSACHUSETTS UNIFORM APPUCATON FORPER/,Date DO GAS FITTING (Type or print) 10-1 NORTH ANDOVER, MASSACHUSETTS . V J� . n Building Locations New 13' ' Renovation 11 Owner's Name Replacement 6 Plans Submitted Permit # V.4 Amount $ 3 (Print or Name i Address Tu -sl Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company Corp. Partner. INSURANCE COVERAGE Checkne: I have a current liability Insuranc policy or it's substantial equivalent. Yes Uj No[3 If you have checked Les, pleas indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity C3 Bond 13 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. . I Check one: Signature of Owner or Owner's Agent Owner A ent I hereby certify that all of the details and information 1 best of my knowledge and that all plumbing work ano, compliance with all pertinent provisions of the MasslG By: Title City/Town APPROVED (OFFICE USE ONLY) g submitted or entered) in above application are true and accurate to the PMj pe or under Permit Issued for this application will be in St e G C and Cher 142 of the General Laws. S nature of Licen:A�Vaer PI tuber G Fitter License um er Master Journeyman a w w Ov x H zc a H a z �a a m w c z o= oo z H wx z d �. w F W q w w v, .. 04 � Ems„ x z z w z Z a Er .. w �. c� p m > z w o z u w o x 'o a> a SU B-BASEM ENT a F o BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7 T H. F L O O R 8TH. FLOOR (Print or Name i Address Tu -sl Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company Corp. Partner. INSURANCE COVERAGE Checkne: I have a current liability Insuranc policy or it's substantial equivalent. Yes Uj No[3 If you have checked Les, pleas indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity C3 Bond 13 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. . I Check one: Signature of Owner or Owner's Agent Owner A ent I hereby certify that all of the details and information 1 best of my knowledge and that all plumbing work ano, compliance with all pertinent provisions of the MasslG By: Title City/Town APPROVED (OFFICE USE ONLY) g submitted or entered) in above application are true and accurate to the PMj pe or under Permit Issued for this application will be in St e G C and Cher 142 of the General Laws. S nature of Licen:A�Vaer PI tuber G Fitter License um er Master Journeyman