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HomeMy WebLinkAboutElectrical, Plumbing and Gas Permits - Permits - 11-13 THIRD STREET 4/22/2019 Date ......... TOWN OF NORTHANC OVER _pERP,41T FOR WIRING Arc This certifies that ..................... .................. ....... ...... ................... I .......................... has permission to Perfcrl" ......... wiring in the building of—....., orth Anclovc:r•r, Mass,. at a r Check.k ... Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leavebLank --------------- APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEMSE PRTNTINJAW OR TYPE ALL INFORMATION)TION) Date: 9--,)I-K- 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) t jkt, Owner or Tenant C4 't'o Telephone No.-A2Y,2-�,05 �5! 7-( Owner's Address Is this permit in conjunction with a building permit? Yes F] No (Check Appropriate Box) Purpose of Building W'A 1, �S4 Utility Authorization No. Existing Service Amps J Volts Overhead[] Undgrd n No.of Meters New Service Amps volts OverheadF] Ujidgrd n No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: L"It Completion of the follo-win table may be waived by the Inspector of Wires. No. of Recessed Luminaires No.of Cell.-Susp.(Paddle)Flans No.of Total Transformers KVA No.of Lurninaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above [:j In- Wo-.—of Emergency Lig ifing grnd. grnd. Batte!y No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. es of Zones No. of Switches No.of Gas 13 urners No. of Detection and "- esd Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No. of Waste Dis Heat Pump j. her I Tons IOW No. of Self-Contained posers N!jfflTotals: .......... Detection/Alerting Devices Municippl Fj other No. of Dishwashers Space/Area Heating KW Local FJ Connection No. of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No. of Water KW No.of No. of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent.. Telecommunications WHIM No.Hydrom2ssage Bathtubs No.of Motors Total HP No.of Devices or Eyuivalent OTHER: Attach additional detail ifdesired, or as required by the-Inspector of Wires. Estimated Value of Electrical Work: tj C)c�� (When required by municipal policy.) Work toStart: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSIJRANCE-C�OVERAGE: 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 B[ OND D OTHER n (Specify:) -IV I certify, under thepains andpenaldes ofpe/jury,that the information on this application is true and complete. FIRMNAME-� 11AC', GkL,�C�L 'lv%r,, . LIC.N0.-_a&jV'L)A- Licensee: \)J Signature LIC.NO.: (If applicable,enter "exempt"in the license lumber line.) Bus.Tel.No.- Address: k-kq. ve, \J— Alt.Tel.No.: *Per M.G.L c. 147,s.51-61,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 ono)EI owner El owner's agent. Owner/Agent Signature Telephone No.__ PVRMIT 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 s 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 belimited 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 M Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required[$.)El Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n Failed Re-Inspection Required($.} ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.) LJ Inspectors Comments: Inspectors Signature: Date: FINAL INSPEC ON: Pass 's Failed Re-Inspection Required($.} Inspectors Com en Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. ....._.dweinhold@townofinerrimac.com - The Commonwealth ofMassachusefts - )),-PartfnentoffndustriqlAceldints Office Oflnvestigations 600 Washington Street Roston,MA 02.1.11 -www.mass:govlctta W©rkers' Compensation bsurance Affit-avit:Buffders/Conn.actoro/FIectrzclanslPIumbers A Meant Wormation Please krfnt Le L.b-I Name(Businesslorganization!Individual): 4L �k c Address: � - GitylStataT2%p: Are yonx an.employer?check the appropriate box: Type of project(required): 1.Q l am a employer with 4. ❑ I am a general contractor and 6. ❑New construction. employees(fall and3fox part-time).* have hAodth.e aab-contractors 2.❑ I am a sole proprietor or partb.ar listed on the attached sheet.T 7. Remodeling ship and`ltaveno.employees These sub-contractors have S. El Demolition worlang for mein any capacity. workers' comp,insurance. g. ❑Building addition [No workers' comp.insurance 5. We are a corporation.and its xequix'ed.] officers have exercisedtheir 10•n Electricalrepairs Oradditions 3. 1 am a homeowner doing all work right of exemptioaperMOIL 11.[�1'Zarohingrepairs or additions myself:[No workers'comp. c.152,§1(4),and tare have ne 12.❑Roof repairs in.surancercgL*ed.]; employees.[No workers' 13.❑Other comp.insurance regaired.] `Any applicant that checks hoxX must also jilt outthe section balaw showingthoir Y(orkers'compeaso onpolky wounation. T'Homeowners who sabmitthis affidavit indicatingthey#xe doing all.work andthen lure outside contractors must submit a nDw affidavit indicating such. tContractors that cheektUs box must attached aa dditioual sheet Aowingtha Dame ofthe sub-contractors andtheirworkers'comp.policy information. I am an employer that is providing workers'eompelasadon insurance for my employees .8e10W iy the policy cancl joD site information. Insurance Company Name: 1 r l c Rdioy#or Self iris.MG.#: f 3` L 1 ExpirationDafe: �'" �5 Job Site Address` — 13 14... w L Pity/Stata&ip._ 61 Attach a copy afthe workers'compensation.poucyileclaration.page(showing the policy umber and expiuraffou cute). Failure to secure coverage.as requiredmder,Section 25A of MCrL c. 152 can lead to the impositioit of criminal penalties of a fine up to$1,So0.00 andlax one-year lmprisop'Ment,as well.as civil panalties in.the form of STOP WORK.ORDER and a fine of-up to$250.001 day against the violator. Be advised that a coley ofthis statementmay be forwaxdedto the Office of 1nvestigationg of the DMA.for insurance coverage verification. .l do 1;creby eerf&unaier Aze facaW anal penalties of perjury that the information provided al ove is ftue and eoraeet, r ,Si atExre• rtj--.�� � Date• �'l' . Rhone�#: �l1 ti --�1� -- {�•� Official use unly. ,Da not write in flies area,to be completed by city or town of f ideal. City or Town: Permit/License g Issuing Authority(circle 6n.e): 1.Board of Health 2.Building Departmerdt 3.Citylfow)i Clerk 4.Electrical inspector 5.Plumbing bspector 6.Other - Contact JPerson: Pho�ae#1: GATE (MMIDDIYYYY) ,a►coRo= CERTIFICATE OF LIABILITY INSURANCE 12/0112014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(sj. PRODl10ER Phone: 978-688-4474 Fax: 978-327-6558 CONTACT DEGNAN INSURANCE AGENCY DEGNAN INSURANCE AGENCY PHONE CNan 978-6864474 978-327-6558 85 SALEM STREET A _ E MAIL cde Ran de naninsurance com LAWRENCE MA 01843 ADORES--- g @ -g -- ---- INSURER(S) AFFORDING COVERAGE NAIL q ----- INSURERA :MOUNT VERNON FIRE INSURANCE COMPANY 26522 _____._. .... INSURED _ ....... __. _.. VALLEY ELECTRIC INC. INSURERB 21 HYATT AVENUE INSURER HAVERHILL MA 01835 INSURER O: INSURERE INSURER F COVERAGES CERTIFICATE NUMBER: 24908 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 1S SUBJECT TO ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INBR: 'I'ypE OF INSURANCE I ADD'L SUER I POLICY EFF POLICY EXP , LIMITS --ETR_._. ..........- -------- --------- --------- =------ wv_D,.__ ......_.POLICY NUMBER--.....-- ........ . -(MMroom�YY�--IMARM ln'YY1 - ........... A GENERAL LIABILITY CL 2651542A 11114114 11/14/15 EACH OCCURRENCE $ 1,000,000 - - -- i DAMAGE TO RENTED 100 0w OCCUR PREMISES(Ea occurenceJ $ MED.EXP(Any one person) $ 5,0()0 _--,CLAIMS-MADE __. ........... ...._...... ..._.............. ..---... _......_.... .........- COMMERCIAL GENERAL LIABILITY ! I,., PERSONAL&ADV INJURY ! $ 1,000,000 -_.. GENERAL AGGREGATE _ $ 2,000,000 ..... ............. ..... GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG ! $ 2,000,000 _.._. JECT_ AUTOMOBILE LIABILITY ....... ----- --- --- -------- --------- -------. ,__...--- --.......I ------- --.._ .. ..... I I ' 1 COMBINED SINGLE LIMIT (Ea accident) $ -_ ANY AUTO SCHEDULED HODILY INJURY(Per person) $ -- -- ---;ALL OWNED BODILY INJURY Per accident $ i....._....AUTOS AUTOS '... ( ) NDN-OWNED PROPERTY DAMAGE- -_____ - HIRED AUTOS , , UTOS (peracdclent) UMBRELLA LIAS - OCCUR EACH OCCURRENCE $ 'EXCESS LIAB CLAIMS-MADE', :AGGREGATE $ WORKERS COMPENSATION - - --- -- .... :AND EMPLOYERS' LIABILITY --- $ DED RETENTION$ ..----- ---- .. .. ............... :............ .................. WC STATU- OTH TORY LIMITS ERYIN I $ ANY PROPRIETOWPARTNEWEXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) N!A ', E.L.DISEASE-EA EMPLOYEE $ • ....... .............. ...................... ................. .................... ........... If ye,dl s dhe under E.L.DISEASE-POLICY LIMIT - $ DESCREPTION OF OPERATIONS below i DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required) CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 120 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Andover,MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Attention: Electrical Inspector Carla M. Degnan ACORD 25(2010105) OO 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD PATE SMMIPOlYYYY) AcoRO' CERTIFICATE OF LIABILITY INSURANCE 12/01/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Phone: 978-688-4474 Fax: 978-327-6558 CONTACT DEGNAN INSURANCE AGENCY NAME: DEGNAN INSURANCE AGENCY PHONE LA—C No Ext). g78-_g..g. g 4474 �FP 978-327 655$ 85 SALEM STREET E-MAIL _.- ___ ....... --.._.._...... LAWRENCE MA 01843 ADDRESS. ede nan de naninsurance.com .... ......... ......... ....... _ INSURER(S) AFFORDING COVERAGE NAIC# INSURERA :NORFOLK AND DEDHAM INSURED___— VALLEY ELECTRIC INC. INSURER B 21 HYATT AVENUE INSURER C HAVERHILL MA 01835 INSURLRP: INSURERE INSURER F COVERAGES CERTIFICATE NUMBER: 24907 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. lNSR ADD'L SUBRi POLICY EFF ! POLICY EXP TYPE OF INSURANCE POLICY NUMBER _LTR ._-..__._ __...._INSRI UB (_ _- �_S_MOLICYYYY) ;POUC YYYYl--:___ _______ _-UMITS__-_-_ -. GENERAL LIABILITY iEACH OCCURRENCE $ �COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED - j PREMISES(EA.—re—) $ GLAIMS-MADE 'I -_--_ OCCUR .VIED.EXP(Any one person) $ i I PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER. Ali PRODUCTS-COMP/OP AGG [$ _......I PRO _ POLICY JECT _.._s i_._LOG .�'....... ---- .$ ...... ..... ---...- _ ._.. .. ........ _._ _... ___ -__. __ AUTOMOBILE LIABILITY COMBINLD SINGLL LIMIT (Fa accident] $ ------- -......_ ......... .......... ANY AUTO '� ', BODILY INJURY(Per person) $ - ALL OWNEDjNONOOWNED CHEDULED ? ........... . .............. .......... ................. _.-...... ......-- BODILY INJURY(Per accident) $ AUTOS UTSHIREDAUTOS - 'I UTOS .............,UMBRELLA LIAROCCUR (EACH OCCURRENCE $ - ---- ..... ....-. ..... ...... 'EXCESS LIAR CLAIMS MADE: AGGREGATE If$ TOED ' IRETENTIONOTH - WORKERS COMPENSATION WE132614A '' 11/13/14 11/13/15 1 ORY LIMITS ER $ A I AND EMPLOYERS' LIABILITY i --- --- -- --- -- - ANY PROPRIETORlPARTNERIEX3nCUT1vE Y!N - E.L.EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? N f A E-L.DISEASE-EA EMPLOYEE $ 100,000 DESCRIPTION OF OPERATIONS below (Mandatory to NH) II It yes,describe under '', E.L.DISEASE-POLICY LIMIT $ 500,000 .......... __ _ ............ ,....... ......... ......... ............... ,............... ............. ............... .............. ...... ......... .......... _.... _ ........ ._.__ -------- ----- _L---- -------.L DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 120 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Andover,MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. — -------- ------ -------- AUTHOR32ED REPRESENTATIVE Attention: Electrical Inspector Cana M. Degnan ACORD 25(2010105) O 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ::COAWO1V1l41 a EALTM OF MASSRCHt)S a F 'S 80AFt0©F' ELE'CTR ISRSUES f SF ANS OLOwfNG'ER f CSE ANS MASTER. ' VAL:LfY ELECTRIC Q RR1AN A WRS�> l �RAf?FDI2D o MA o1835gzzi . z018 0713i-Al 6 T63131 • i D � atC TOWN OF NORTH ANDOVER PERMITL FCHU f This certifies that. .............................................. has permission to perform ... '�, ................................. plumbing in the,buildings of...... .......at .... ........ . .,.... North Andover, .Mass. PLUMBING INSPECTOR Check i i I i MASSACHUSETTB UNI.11 FORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -------- � MA DATE dz/ �'� PERMIT CITY # - . ' _...�JOBSITE ADDRESS _ OWNER'S NAME _ OWNER ADDRESS �� w � �' f __-...- TEL �' � FAX _ f jr RESIDENTIAL TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL. ® PRINT ENT: PLANS SUBMITTED: YES 0 N0 0/ CLEARLY NEW: ; RENOVATION:® REPLACEM S 4 5 6 7 $ 9 10 11 12 13 1�} 9 FIXTURES l FLOOR- CROSS 65M 1 CR05S CONNECTION DEVICE �.� � �. [ ,...__I •--__._.� .__.___� _�l ,.. ..__.-.. ....._..�..., _ � 6. � DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIL1SAND SYSTEM DEDICATED GREASE SYSTEM __— DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM W _j FLOORI AREA DRAIN __._-_I ______1 ._.._._.� ._...__ INTERCEPTOR(INTERIOR) LAVATORY I__._.. SERVICE I MOP 51NK 9 -_—.— _--. _ TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES t WATER PIPING I I I OTHER _ ._._._ __ _ -_ _�: f i -'� INSURANCE COVERAGE: I have a current Iiabilit insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142, YES NO i _.�..�L IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW OTHER TYPE OF INDEMNITY _I BOND E3 LIABILITY INSURANCE POLICY surance cove, OWNER'S INSURANCE WAIVER:I am aware that the licenhsse�o_ not av wives this requirement. CHECK by Chapter t42 of the Massachusetts General Laws,and that my signature on papplicationAGENT CHECK ONE ONLY: OWNER Q SIGNATURE OF OWNER OR AGENT R hereby certify hat all of the details and informal under the permit issued for his applicationng t1fis pwrill be in compl compliance with 0 Periinenbt rn sion of the e ge and that all plumbing work and installations performed Massachusetts State Plumbing Code and Chapter 142 of the General Laws. SIGNATURE i LICENSE# gm PLUMBER'S NAME � - _ - - MP ; JP CORPORATION 0#i =PARTNERSHIP __+# _ =LLC COMPANY NAME ' ; ADDRESS ig i2c/> - - STATE �ZIP TEL 2F 3- � CITY d Co 1/15' - J l FAX � � CELL[:=EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLX FINALIlVSPEC O OTES THIS APPLICATION SELVES AS THE PERMIT Yes I' FEE: PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114 20.17 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers- TO BE P'II.ED WITH THE PERMITTING AUTHORITY. Azpplicant Information Please Print Le ibl Name (Jusiness/Organizationllndividiial): & 4 O '1 Address: �� �tr/.�(✓"i. City/State/Zip: A nwz,,Z)ex .fix, /ArPhone#: Are you an employer?Check the appropriate box: Type of project(required): L❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. rJ Remodeling any capacity.[No workers'comp-insurance required] 9. ❑Demolition3.Q 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 E]Building addition 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 I L E]Electrical repairs or additions proprietors with no employees. ]�,&�plumbing repairs or additions 5.❑I am a general contractor and I have hired the sorb-contractors listed on the attached sheet. 13.E]Roof repairs Thes'o siib-contractors have employees and have workers'comp-insurance.1 6.❑We are a corporation and its officers have exercised their right of exemption.per MGL c. 14•❑Other /�j 0 Pgg i 152,§1(4),and we have no.,employegs.LNo workers'comp.insurance required.]l 1 *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information Homeowners who subinit this affidavit indicating they are doing all work and then hue outside contractors must s4bmit a new affidavit indicating such. 1Contractors that check this box must attached au additional sheetshowing 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-iris.Lic.#: Expiration Date: rob 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 forth 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 the pains andpenalties 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 Autbority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#.: � 1f ry-y ate f gmon 0 TOWN OF NORTH ANDOVER PERM11 INSTALLATION i as permission f*or gas installationin r Efl � �....1 w,4 �,a Ud' ��0.'i, ................. at (� u ,� Andover, Mass, J, JbA INCheck# SPEC f 1 MASSACHUSE 'TS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY -.1� "'�-- - — MA DATE L.-��PERMIT# JOBSITE ADDRESS OWNER'S NAME r - 7- �7 _- ---- , OWNER ADDRESS.. _ .-_� �` �- �,. TEL _ _�_ - FAX[: �_ � TYPE OR EDUCATIONAL RESIDENTIAL PR)'NT OCCUPANCY TYPE COMMERCIAL� �I CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 0 N APPLIANCES 1 FLOORS BSI 1 2 3 4 5 s�l I 7« s� I s 10 111 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE . DIRECT VENT HEATER DRYER - FIREPLACI FRYOLATOR FURNACE FENERATORR INFRARED HEATER LABORATORY COCKS I _.l - _.. . _ I ,., 1 - _ 1 — -.... MAKEUP AIR UNIT - _OVEN - POOL HEATER ROOM 1 SPACE HEATER - iR00F TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER - _ INSURANCE COVERAGE 1 have a current Ijgt insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF CO�V,EERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY �I OTHER TYPE INDEMNITY E3 13OND �] OWNER'S INSURANCE,WAIVER:I am aware that the licen\see 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 accwith all e the best vi io knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pe inapt revision the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME : � _, w _- .. LICI�NSE# _ ' � IGNATURE ��---�----����� MP El MGF� JP 1 JGF EJ LPGI CORPORATION[3# PARTNERSHIP I# I_LC #I � COMPANY NAME: lf . v ._r'� '.___�__- ADDRESS _ CITY°; _ _ STATE ZIP �TEL _ FAX CELLF___-,_— EMAIL - ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NO , S Yes No4'44E� THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ PEE- $ PERMIT# PLAN REVIEW NOTES i i The Commonwealth of Mara ntss se Department o,f Industria u I Congress Sheet,Suite 100 „ a = Boston,MA 02114-20Z7 t www.mass.gov/die Compensation Insurance Affidavit:Builders/Contractors/ElectricianslPlumbers. ,�. Werkers'C p TO BE FII Ell WITH THL,pEp"TT3NG AUTHORITY- lease print Le ibl A licant Information Naine(Business/Organizatlon/lndividud): Address: ,, hone 9: CitylState/Zip: / Type of project(required): Are you an employer?Check the appiopriate box: 7. New construction 1,❑I am a employer with____=—employees(full and/or part time).* Remodeling Tjg�I am a sole proprietor or partnership and have no employees working for me in 1�To workers'comp.insurance required.] g_ ❑Demolition any capacity.L insurance required.]t 10❑Building addition 3.❑I am a homeowner doing all work myself.[No workers'comp. Iwill 11 �Electrical repairs or additions 4❑I am a homeowner and will be luring contractors-to conduct all work on my prope are sole or additions m' 12 plumbing repairs ensure that ail contractors either have workers'compensation insurance or roprietors with no employees, ttached sheet. 1Roof rep airs P ❑ S❑I am a general contractor and I have hired the sub-contractors listed onsjj n e x other These sub-connectors have employees and have workers'coin o£exemption par NiGL c. 1 6.❑We are a coiporafion and its o1lcreesave worker, fid the amp.i insurance required./ 152,§l{4},and we have no epp Y their workers'compensation policy infozmation #Any applicant that chocks box#1 must also dill out the section below work and b_eantractors and state wlrethar or not those entities have is affidavit indicating they aresection doing all work and then hire outside coirttactors must submit anew affidavit indicating such. t IiomeWA ners who submit th the name of the su mast ravide their workers'comp.policy number_ Contractors that check this bar must attache o ees they an additional shp et showing employees. Ifthe sub-contractors frave emp em ees.' Below is the policy and job site to er that is providing worlrers compensation insurance for my p la.Y .tam an emp y information. Insurance Company Name: Expiration Date: policy#or Self-ins,Lic.#: City/State/Zip: job Site Address: declaration page(showing the policy number and expiration date). Attach a copy of the workers' compensation policy punishable by a fine up to$1,500.00 Failure to secure coverage as required under MGL c. es i § 25A is a criminal violation p d a fine Of UP to$250.00 a ' one-year imprisonment,as vre11 as civil penalties the form of a STOP forwarded to the Office Oof Invest'RK ORDER as of the DM for insurance and/or y of this statement may day against the violator.A copy coverage verification- ena ies ofp j rY cfic y under tl:e pains and p er u that the information provided above is true and correct I do hereby f Date: 1 Si nature: Rhone#: official.. official use only. Do not wr ite in this area,to be comp feted by city or town off Permit/License# City or Town: Issuing Authority(circle one): own Clerk 4 Inspector 5.plumbing Inspector 1.Board of Health 2.Building Department 3.CitylT .Electrical 6.Other Phone#: Contact Person: Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: 11-13 Third Street, LLC c/o Anthony Conte Property Address: 11 Third Street Policy Number: FP1889033 Date/Cause of Loss: 1 012 9/2 0 1 2, CAT 90 File or Claim Number: 27132-W Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Wade Anderson On this date, I caused copies of this Notice to be sent tq(the persons named above at the addresses indicated above by First Class Mail. IL Siqffature and Date ANDERSON ADJUSTMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053 Date. . .. «. . . . , . . . d 1 No eauxaaTOWN OF NORTH ANDOVER PERMIT w 41 row ACM05 . . . . . Chis certifies that . . . . . . . . . . . . . . : . : . . . . tins permission to perform . . . . . . plumbing in the buildings of . . . . . . , forth Andover, Mass, Fee Lic. No. y PLUMBING INSP''E6T61`t Check # �-----�-----~- I CANARY:CANARY: Building Dept PIN Treasurer WHITE: Applicant MASSACHUSETTS UN17ORM APPLICATION FOR PERMIT TO DO PLUM BE O (Type or print) NORTHANDOVER MASSACHUSETTS � r Date Building Locatio❑ � ! Owners Name �,H� �� �' Permit#,' —_ Amount , Type ofOccu anc New Renovation Replacement Plan s ns Submitted Yes No FIXTURES ri H � N d � 5IR RDM 6m 7MRIM � , (Print or e) / o Check one: Certificate Installing CompanyName- _ �� „,� t i'/,'Ee Corp. 5 El Address Partner. .",�° Business Telephone � ° �' 4 " 7) Firm/Co. ------------ Name of.Liceused Plumber Insurance Coverage, Indicate the type of insurance coverage by checking the appropriate box; Liab'n>.ity insurance policy Other type of indemnity El 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)is above application are true and accurate to the best of my Iciaowledge and that all plumbing work and are t.�llations,perfbrmed,uPder Permit: �ued for this application will be in g an apter l,42 of the Gene'r-al Laws. compliance with all pertinent provisions of the Massach setts State Plumbin Cod u By �� v ii �3A16d1k�cl k " Type ofPlutnbingtictrise Title ,. Cit "FOWT2 �- Y aceus um er Master Journeyman APPROVED(oFFic F-usF ot4LY El