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HomeMy WebLinkAboutMiscellaneous - 56 Royal Crest Building 23 I _rte' 4: Date.... .`..1..." .. ...... r►ORTf, or; ooh TOWN OF NORTH ANDOVER * PERMIT FOR WIRING %� �SSgCgU9E Thiscertifies that ........................................................ ......................................................T. has permission to perform Ae> L:'� .1.., 1 .�/�,'`,.' ,, (L,.. l!?P r. wiring in the building of......... .6��...4 / „_,.( J/ { /r ................................................ at ......25......,°o �...(�. -5�.. <, with Andover,Mass. Fee..`.. Z Lic.No. . ...:..... ................. f '` �..f..5........... ........................ . ELECTRICAL INSPECTOR Check# . 4 =' commonwealth of Massachusetts Official Use only 6 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 Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned givesotice of his or her intention to perform the electrical work described below. Location(Street&Number) 2 3 VeQy Owner or Tenant Amem. Telephone No. Owner's Address Is this permit in conjunction with a building ermit? Yes No 0 (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service c00 Amps J'Z /2 Volts Overhead❑ Undgrd V No.of Meters New Service (nOC7 Amps [20 / 2\413Volts Overhead❑ Undgrd [q No.of Meters �3 Number of Feeders and Ampacity l 2 R-Q_ "1,S ISO pp, p (Location and Nature of Proposed Electrical Work: _eaap,to yyR\VA <:-.Q�\C9- I Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- El o mergency 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 Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No. of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained .. ........................................................ Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local El Connection ❑ Other 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 I Signs Ballasts 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: 3L. pCv (When required by municipal policy.) Work to Start: - �- Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability' surance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 5Z BOND ❑ OTHER ❑ S ecify:) I certify,under the pains and penalties of u ,that the inf rmati o tis a plication is true and complefe. ` FIRM NAME: . c n D LIC.NO.: Z bA- Licensee: Signature LIC.NO.: �2g 716A: (Ifapplicable,enter "exempt"in the lice se umb e.) 01-OZ-1 '�Z Bus.Tel.No.•�1�'(o�� �Zq Address: 51 SOA c-2Q( s ad Alt.Tel.No. 1a- '?.b`-1- oo 36 ci-A *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 permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed i on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an >' electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass❑' Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: T SERVICE INSP TION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: - Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass[N LIX Failed Re-Inspection Required($.)❑ Inspectors mments: sPt V,e, Inspectors Signature: Date: 4., ROUGH INSPECTION: Pass❑' Failed M Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECT N: Pass V Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com .d s The Commonwealth o assahusetts Mc , . f Department of IndustrialAccidents 1 Congress Street,Suite 100 '- Boston,MA 02114-2017 www nass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legib Name(Business/Organization/Individual): Address: lsc)4\00�_ City/State/Zip: MA C�1�2�Phone#: � ��' (q l I eg l Are yo n employer?Clrecktlie appropriate box: Type of project(required): 1.as employer with �1— employees(full and/or part-time).* 7. Q Ne3San1ruction 2.F1 I am a sole proprietor or partnership and have no employees working for me in 8. emodeling any capacity.[No workers'comp.insurance required.] 9. ❑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.❑Electrical repairs or additions proprietors with no employees. _ — 12.E]Plumbing repairs or additions 5.F1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs 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. 14.Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 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-coritraciors 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.#: 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 co y of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverag eri lc n. I do her ertify r the i s an kpenalties ofperjury that the information provided above istrueand correct. Signature: c� Date: Phone#: I l� 1 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i. 1k f 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' compensatioii'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 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 dor 1-877-NIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia VIA- i NORTy 1 Q* 7 AERATED I.PQ` .�5 �SSACHS Town of North Andover BUILDING DEPARTMENT CONTRACTOR AFTER HOURS REQUEST FORM CONTRACTORS NAME: ADDRESS: � Z CITY/TOWN:1::>JM 3 STATE: ZIP. BUS. PHONE: 9 �� I CELL: [ MA. LIC #: MASTERS: t2 , 16 A JOURNEYMANS: PERMIT# 1 2"14 — 3 N-GRID SR# REQUESTED DATE: " `� �. I TIME: JOB LOCATION: a OWNER: W1 i ' yy �� ` J'.1 ` \i �A2ZU PHONE: l0 0 (P�l CpdS Z WORKERS CELL: REASON FOR REQUESTED INSPECTION AND JOB DETAILS: i CONTRACTOR SIGNATURE: NORTH ANDOVER SUPERVISOR SIGNATURE: Contractors requesting INSPECTIONAL SERVICES due to weekend or after hour operations such as service related planned updates or special situations,will be required to provide a four hour minimum charge of$150.00 paid to the Town of North Andover at that time. Community Development Division,1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9545 Fax 978.688.9542 Web www.townofnorthandover.com r i Date..... ...:./z ............................ �P►ORry TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHUS� f; This certifies that K&-L14— ... ...................................................................................... has permission to perform ....U[ ...!!C'f `! cr. . .:..:...� _%... ....... wiring in the building o ....... ...„ ''? s at .... ......... ...........31.......... ®�� .&/�1 W— /.... . ............, h Andover,Mass. Fee..LC5.. ....Lic.No. 2.ct74 ...� , .................................................. ELECTRICAL INSPECTOR Check# l'�f 7 13373 Date....7.'.f.�.. .. ......... O�r►ORr/y TOWN OF NORTH ANDOVER O PERMIT FOR WIRING CHUS�S This certifies that ..........e �L�'r..Y........../ C� ............................................ has permission to perform ..1�?e � -.�..,S. .. wiring in the building of......... f1 to ( .f`..................................... at .......��..:,;.,........�� :�.....0/���np ......, rth Andover,Mass. Fee...... ........Lic.No. ................. .... ......... . ..................................................... Check# 1 12440 `s� 1962 ELECTRICAL SOLUTIONS , ENTERPRISE BANK &.TRUST COMPANY LOWELL. MASSACHUSETTS 53-274-113 51 SCHOOL STREET DUNSTABLE,,MA:. 01827' r PAY TO THE >'' ORDER OF L'RS a • IL MEMO " 1 AV 11100 1j196:2ii° m':0 1 1 30.2 74 2i: S02 4will 56ii' w , r x„Y � Date............................................. OF r►ORTH ?.•_ �o� TOWN OF NORTH ANDOVER o PERMIT FOR WIRING ss�cHuS� This certifies that .............................................................G..`..Lc'' ..:..................................... has permission to perform ....v�/?QP/rq���� /��cr1.S.ifes' wiring in the building o ....... ............ G ......`...� ....................!.......................................... 3 No h Andover,Mass. �..........................G. 0 sr at .... ... / A�..�........ Fee..�.�:t --. ...Lic.No �..zy?lo 'l 4 ....�.. .............. ............................................. ELECTRICAL INSPECTOR Check# 1117 13373 Common wealth of Massachusetts Official Use Only 9 \ Department of Fire Services Permit No. ?2�� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/o7j (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 (PLEASE PRINT ININK OR TYPEALL INFORMATION) Date: Co— l 2.— I City or Town of NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives no ice of his or her intention to perform the electrical work described below. Location(Street&Number) a �( C j Owner or Tenant A r`\CQ.(i�p Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate iBox Purpose of Building l�\ Utility Authorization o. r -11 - Existing Service_ Amps / dVolts Overhead ❑ Undgrd No.of Meters New Service Amps 17-0 /ZqOVolts Overhead❑ Undgrd No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: AC6 (cM A M gIM D\SC 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 Swimming Pool Above ❑ In- ElR-o.—of Emergency Lighting rnd. grnd. Batter 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 No.of Alerting Devices g Tons No.of Waste Dis posers Heat Pump Number ToKW No.of Self-Contained p Totals: '' "' "ns" ' '"......"'.."'. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW SecNoto ys ims:ces or Equivalent 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 E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Ypres. Estimated Value of Electrical Work: 000 (When required by municipal policy.) Work to Start:-(* 101- 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 ofrjury,that the inf rnt ' n this application is true and complete. aFIRMNAME: .-" LIC.NO.: Licensee: X41 L`Ak, Signature LIC.NO.: (If applicable enter "exem t"in the lic zzmbe ) Bus.Tel.No.: �� 1791 Address: 5 � ��A �� �] Alt.Tel.No.:A'�F-FA�-W38 *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"L ciTen :e 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: $ t -Z ❑ 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 aPlication form to provide notice of installation of wiring shallbe 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-tern 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: 'd Trench Inspection Pass Failed Re-Inspection Required($.) ❑ I, Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ L Inspectors Comments: Inspectors Signature: Date: FINAL INSP TION: Pass V Failed (] Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: — Date: 7 / DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street,Suite 100 Boston,'1VIA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information 1 Please Print Le ibl EName(Business/Organization/Individual): QQ_1Kr UCS Address: City/State/Zip:kD0NGVf0k_ Phone#: qt5 — CWW ' Z-9 Are yo n employer?Check the appropriate box:. Type of project(required): 1. I am a employer with employees(full and/or part-time).* 7, ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t ❑4.4.E]I 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 I L❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs 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. 14.❑Other 152,§1(4),and we have 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 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 ands 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.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 coverage n. I do her erti nde ze p in and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: as 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#: i t, 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 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-MASSA-FE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia COMMONWEALTH OF MASSACHUSETTS BOAf3:D�� E°l_ECTR I C I ANS ISSUES ;THE FOLLOWINGlt.-ME AS u, `+ REGI-STERED MASTfR ELECTR,fCL''AN�,r`�,,.�a Z ,.'STATEWYDE ELECTRIC INC "ROBERT W FfOA�� f iz PO BOX 174 ` {)UNSTABLE %MA 01827 0174 1747(, A fi o . Ilq Date......................... .................. TO TN \ °� "" '•�ti° TOWN OF NORTH ANDOVER * PERMIT FOR WIRING `4`SACHUS� This certifies that ......../� !' :.................... .......... ......................................... has permission to perform '.. P_ (%-}.2.I C A..........(.. -� ............................... wiring in the building of., �- t'� �P .................................. .......................................................... , ,,�� .at .,. ..../ ..................... .. rth Andover,Mass. . ....... ................. ..............:....... Fee.............:................Lic.No. .�. .. ..... ELECTRICAL INSPECT Check# I I Q J 13032. Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 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 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: be C 9q i i g 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 electricalworkdescribed below. Location(Street&Number) S (� Owner or Tenant A M,C.C: mor ii� Ani o G k e r Ux . Telepholie No. Owner's Address 8wl&1r1Q 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: �e K Lo '����o��( Con n,e o-.6 ph 1 S tak 3QSCboo-rc,-k (_k2 et C eA-� L3n�" V Ot CSP n�ritio S rz� +S CAy�cll ( �f L i,�t-�- b -e k�15 �C,eji"Oy Completion of thefollowing table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell: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- ❑ NOT-of mergency Lighting rnd. rnd. 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 ti Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained p Totals: - Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection No..of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of WaterKW 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 if desired,or as required by the Inspector of Wires. Estimated Value ofiElectrical Work: ,G� (When required by municipal policy.) Work to Start: 1 Z1 za t iL- Inspections to be requested in accordance with MEC Rule 10,and upon completion. -`1 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: INSURAIQCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury,that the information on this application is true anti complete. FIRM NAME: . 4 iv 12l P V LIC L C, LIC.NO.: A Licensee: -()A( ;o (> Vii t) Signature P Vi. LTC.NO.: 1b 56 G (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.: _ Address: 1 D P0 L= S 4- lAJoJ&g VA , Ih A 1 Alt.Tel.No.: U� *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 PERMIT FEE:$_ 12— -- Signature Telephone No. The Commonwealth of Massachusetts .�� Department ofIndustriglAccidents Office of Investigations 600 Washington Street Boston,MA.02111 www.mass.gov/dia oWorkerslompensation Insurance Affidavit: Builders/Contractors/Elbers Peici Print Le-CAmibl Applicant Information �j Name(Businesslorganization/Individual):_ rJ � � � y 1 � ��'" `) �' Address: City/State/I :��Y'1 L`G1�V►il �Y1 ®a ) Phone#• Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with '+ 4. ❑ I am a general contractor and I 6. ❑New construction employees(fall and/or part-time).* have hired the'sub-contractors 2listed on the attached sheet.$ �� ❑Remodeling.❑ I am a sole proprietor or partner- These sub-contractors have 8. FJ Demolition ship and'haveno employees ' .insurance. r working for me workerscoin in any capacity. p 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10,❑Electrical repairs or additions required.] officers have exercised their 11. Plumbing repairs or additions right of exemption per MGL g p 3.❑ I am a homeowner doing all work g �§1(4)gyp p 12.[]Roof repairs myself. [No workers' comp. c. 152 and we have no insurance required.] employees.[No workers 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill outthe section below showing their workers'compensation policy information. i'Homeowners who submit this affidavit indicating they a're 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 job site information. Insurance Company Name:. t t �- + °' r0`t-t C Policy#or Self-ins.Lic.#: `JG� _0 '� ( Expiration Date: i Job Site Address: 5 b tot-QcL` cr�j� D. _City/state/Zip: tJ(�OLrC� U� G I 4S Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as xequired.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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereb cert under the pains and penalties ofperjury that the information providedaboveis true and correct. - Signature:= v Date: e l U)(9- jig- Phone 4 ig"Phone# `SQ S()6t� C { Official use only. Do not write in this area,to be completed by city or town official. j City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - J Phone#: Contact Person: T.Y E. COMIIAONWEALM OF MASSACHU$ETnTS _ BOAR OF ' ELEC'TRIZ-11A N I SSUES THE; FOL`LOWI NG L f CENSE AS A ' F RfGISTEFED MASTER :ELE�TRICIAt A DANIEL 0 VITA LE ti � tia�iuWi 190 DA1 E ST TOM.. MA 02451-3 15795 A ._ 07/31f16 35001 e r9COMMONWEALTHAF MASSACHUSETTS , p ARWO ELECTRIC ANSI ISSUES THE FOLLOWING LICENSE AS A R1G JOURNEYMAN ELECTRICIAN ; DANIEL P VITALE {,{ �U i +' 190 DALE 5T Z W WAtTHAM MA 02451-3. 773 31850 E 07/31%:16 35002 i i I � ' I fir•' c. lioc+o hSC-e«� ® CERTIFICATE OF LIABILITY INSURANCE 8/26/14 OR ALTER THE COVERAGE AFFORDED BY THE POLICIES a f[TTE DOE IS ISSUED AS A MATTER OF INFORMATION ONLY AND END CONFERS NO RIGHTS UPON THE CF-KI HOA�HR�TZ ISD �,CATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXT JV. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER PRESENTATIVE OR PRODUCER,AND THE CERTIFlCATE HOLDER. otic les must be endorsed. If SUBROGATION IS WAIVED,subject to PORTANT: If the certificate holder is an ADDITIONAL INSURED,the p y( ) ��ie terms and conditions is the policy,certain policies may require an endorsement. A stafiement on this certificate does not confer rights to e certificate holder in lieu of such endorsement(s). NAME: T LESLIE HANNON NAME: FAX (978) 667-0587 PRODUCER PHONE 978 66'7-6150 AI No: ,James O'Connell Insurance Agen E-MAIL JIMINS@OCONNELLINS-COM ADDRESS: NAIC# 572 Boston Rd INSURE S AFFORDING COVERAGE Unit 7 INSURER A:Merchants Billerica, MA 01821 INsuRER B:A.I.M. Insurance INSUREDINSURER C: DANIEL P VITALS ELECTRIC INSURER D 190 DALE ST WALTHAM, MA 02451 INSURERS: INSURER F REVISION NUMBER: OD COVERAGES CERTIFICATE NUMBER: R CONDITION OF ANY CONTRACT OR OTHER 0cUMEN IS SUBJECT EC T THE TERMS TIFY THAT THE POLICIES OF INSURANCE LISTOED BELOW HAVE BEEN ISSUED TO THE INS B ED NAMED ABOVE FOR THE POLICY PERI TCH THIS HIS IS TO CER I INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERMBY CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BEEN u OD BY DESCRIBED o CL EXP LIMITS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN R POLICE Mm EF PAID LI Y ILTR POLICY NUMBER $ 1 000 000 TYPEOFINSURANCE IN R WVD BOP9098053 9/12/14 9/12/15 EACH OCCURRENCE $ 5OO OOO DAMAGE TO RENTED A GENERAL LIABILITY o c15 000 XCOMMERCIAL GENERAL LIABILITY MED EXP(Anyone person) $ CLAIMS-MADE ❑X OCCUR PERSONAL&ADV INJURY $ 1 000 OOC GENERAL AGGREGATE $ 2 000 OOC PRODUCTS-COMPIOPAGG $ 2 -000,00( $ GEN'LAGGREGATE LIMIT APPLIES PER COM BINEDSINGLELIMIT $ PRO- LOC a accident }{ POLICY T AUTOMOBILE LIABILITY BODILY INJURY(Per person) BODILY INJURY(Per accident) $ ANYAUTO SCHEDULED PROPERTY DAMAGE $ ALLOWNED AUTOS Per accident AUTOS NON-OWNED $ HIRED AUTOS _._.AUTOS $ EACH OCCURRENCE UMBRELLALIAB OCCUR AGGREGATE $ EXCESSLIAB CLAIMS-MADE WCSTATU- OTH- DED RETENTION$ 10/11/13 10/11/14 }{ $ O WORKERS COMPENSATION WCC5006538012009 E.L.EACH ACCIDENT B AND EMPLOYERSLIABILITY YIN10 O 10 ANYRIPARTNER/EXECUTNE NIA E.L.DISEASE-EA EMPLOYEE $ 5OO O� OFFICERIMEMBCERIMEMBER EXCLUDED? E.L.DISEASE-POLICY LIMIT $ (Mandatory in NH) If yes describe under DESCRIPTION OF OPERATIONS below marks Schedule,if more space is required) DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (Attach ACORD 101,Additional Re ELECTRICAL WORK :.i• I i•- CAN CELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEF THE EXPIRATION DA ACCORDANCE WITH THE POLICTE Y.PROV S OTICE NS WILL BE DELIVERED TOWN OF NORTH ANDOVER MA 120 MAIN ST AUTHORIZED REPRESENTATIVE NORTH ANDOVER, MA 01845 LESLIE Hp,NNON ©1988-2010 A ORD CORP)RATION. All rights reg The AC ORD name and logo are registered marks of ACORD ACORD 25(2010105) Fax: E-Mail: Phone: Of NORTH 1y 7136 Town of North Andover HEALTH DEPARTMENT '�SSACHUSt� CHECK#: (J1 � DATE: IAI LOCATION: H/O NAME: CONTRACTOR NAME: f U - T_yye of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DW C) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ Other:(Indicate) 1 $ I_ J Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer 1 ' �WAL -1 dy TOWN OF NORTH ANDOVER Permit Number NORTH ANDOVER,MASSACHUSETTS 01845 ! w� Date Issued Expiration Date SSAC6lUS� RECEIVED Ift a 12015 TOWN OF NORTH ANDOVER Jackie's Law — Permit Application HEALTH DEPARTMENT Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant Cornerstone Land Developers, LLC Phone Cell Street Address 61 Main Street- Box 657 (978) 433-8100 (978) 835-0102 City/TownMA ZIP Pepperell 01463 Name of Excavator(if different from applicant) Phone Cell Street Address Heider Construction (978) 606-1435 City/Town MA ZIP Tewksbury 01876 Name of Owner(s)of Property Phone Cell Street Address AIMCO North Andover, LLC 50 Royal Crest Drive (617) 639-6052 City/Town MA ZIP North Andover 01845 Other Contactoan Milinazzo Permit fee Received No Yes Description,location and purpose of proposed trench: Please describe the exact location of the proposed trench and its purpose(include a description of what is(or is intended)to be laid in proposed trench(eg;pipes/cable lines etc..)Please use reverse side if additional space is needed. Excavation for the installation of electrical conduit at Building 23. Insurance Certificate#: CL1561150214 Name and Contact Information of Insurer: W.E. Noyes & Son Insurance Agency, Inc. - (978) 425-9595 Poticy Expiration Date:6n0rz016 Dig"" :2015-211-5783 Name of Competent Person(as defined by 520 CMR 7.02): James Heider Massachusetts Hoisting License#HE-033993 License Grade: 2A Expiration Date:4/l/2016 BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE WORK, WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,G.L. c. 82A,520 CMR 7.00 et seq.,AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW. THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO, FOR THE DURATION OF CONSTRUCTION,AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERING SUCH WORK. THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED NECESSARY BY THE MUNICIPALITY. THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,INDEMNIFY,AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM ANY AND ALL LIABILITY,CAUSES OR ACTION,COSTS,AND EXPENSES RESULTING FROM OR ARISING OUT OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. APPLICANT SIGNATURE DATE EXCA ! TOR SIGNATURE DIFFE NT) DATE /5 OWN R'S SIGNATURE(IF DIFFERENT) DATE: --- -...._......--.._..__._.. -- -------_ ---...__.....__.-._._.......-.. —------ -- ---............ ..... _._._.....__,_.-..._..._...._ 2 1 P a g e ^ .mrr..,.- `;UI' .�: ft $E"EY +..' ,.c,. . J t, r -rpl_ * 4 r - .. ms`s ✓ s f L CONDITIONS AND REQUIREMENTS PURSUANT TO G.L.C.82A AND 520 CMR 7.00 et seq. (as amended) By signing the application,the applicant understands and agrees to comply with the following: i. No trench may be excavated unless the requirements of sections 40 through 40D of chapter 82,and any accompanying regulations,have been met and this permit is invalid unless and until said requirements have been complied with by the excavator applying for the permit including,but not limited to,the establishment of a valid excavation number with the underground plant damage prevention system as said system is defined in section 76D of chapter 164(DIG SAFE); ii. Trenches may pose a significant health and safety hazard. Pursuant to Section 1 of Chapter 82 of the General Laws,an excavator shall not leave any open trench unattended without first making every reasonable effort to eliminate any recognized safety hazard that may exist as a result of leaving said open trench unattended. Excavators should consult regulations promulgated by the Department of Public Safety in order to familiarize themselves with the recognized safety hazards associated with excavations and open trenches and the procedures required or recommended by said department in order to make every reasonable effort to eliminate said safety hazards which may include covering, barricading or otherwise protecting open trenches from accidental entry. In. Persons engaging in any in any trenching operation shall familiarize themselves with the federal safety standards promulgated by the Occupational Safety and Health Administration on excavations:29 CFR 1926.650 et.seq.,entitled Subpart P"Excavations". iv. Excavators engaging in any trenching operation who utilize hoisting or other mechanical equipment subject to chapter 146 shall only employ individuals licensed to operate said equipment by the Department of Public Safety pursuant to said chapter and this permit must be presented to said licensed operator before any excavation is commenced; V. By applying for,accepting and signing this permit,the applicant hereby attests to the following:(1)that they have read and understands the regulations promulgated by the Department of Public Safety with regard to construction related excavations and trench safety; (2)that he has read and understands the federal safety standards promulgated by the Occupational Safety and Health Administration on excavations:29 CMR 1926.650 et.seq.,entitled Subpart P"Excavations"as well as any other excavation requirements established by this-municipality;and(3)that he is aware of and has,with regard to the proposed trench excavation on private property or proposed excavation of a city or town public way that forms the basis of the permit application,complied with the requirements of sections 40- 40D of chapter 82A. vi. This permit shall be posted in plain view on the site of the trench. For additional information please visit the Department of Public Safety's website at www.mass.aov/dns 3.IPage Summary of Excavation and Trench Safety Regulation(520 CMR 14.00 et sea.) This summary was prepared by the Massachusetts Department of Public Safety pursuant to G.L.c.82A and does not include all requirements of the 520 CMR 14.00. To view the full regulation and G.L.c.82A,go to www/mass.gov/dps Pursuant to M.G.L. c. 82, § 1, the Department of Public Safety,jointly with the Division of Occupational Safety, drafted regulations relative to trench safety. The regulation is codified in section 14.00 of title 520 of the Code of Massachusetts Regulations. The regulation requires all excavators to obtain a permit prior to the excavation of a trench made for a construction-related purpose on public or private land or rights-of-way. All municipalities must establish a local permitting authority for the purpose of issuing permits for trenches within their municipality. Trenches on land owned or controlled by a public(state)agency requires a permit to be issued by that public agency unless otherwise designated. In addition to the permitting requirements mandated by statute, the trench safety regulations require that all excavators,whether public or private,take specific precautions to protect the general public and prevent unauthorized access to unattended trenches. Accordingly,unattended trenches must be covered,barricaded or backfilled. Covers must be road plates at least 3/o"thick or equivalent;barricades must be fences at least 6'high with no openings greater than 4" between vertical supports; backfilling must be sufficient to eliminate the trench. Alternatively, excavators may choose to attend trenches at all times,for instance by hiring a police detail,security guard or other attendant who will be present during times when the trench will be unattended by the excavator. The regulations further provide that local permitting authorities,the Department of Public Safety,or the Division of Occupational Safety may order an immediate shutdown of a trench in the event of a death or serious injury;the failure to obtain a permit; or the failure to implement or effectively use adequate protections for the general public. The trench shall remain shutdown until re-inspected and authorized to re-open provided, however,the excavators shall have the right to appeal an immediate shutdown. Permitting authorities are further authorized to suspend or revoke a permit following a hearing. Excavators may also be subject to administrative fines issued by the Department of Public Safety for identified violations. Summary of 1926 CFR Subpart P-OSHA Excavation Standard This is a worker protection standard,and is designed to protect employees who are working inside a trench. This summary was prepared by the Massachusetts Division of Occupational Safety and not OSHA for informational purposes only and does not constitute an official interpretation by OSHA of their regulations,and may not include all aspects of the standard. For further information or a full copy of the standard go to www.osha_aov. Trench Definition per the OSHA standard: o An excavation made below the surface of the ground,narrow in relation to its length. o In general,the depth is greater than the width,but the width of the trench is not greater than fifteen feet. • Protective Systems to prevent soil wall collapse are always required in trenches deeper than 5',and are also required in trenches less than 5'deep when the competent person determines that a hazard exists. Protection options include: o Shoring. Shoring must be used in accordance with the OSHA Excavation standard appendices,the equipment manufacturer's tabulated data,or designed by a registered professional engineer. o Shielding(Trench Boxes). Trench boxes must be used in accordance with the equipment manufacturer's tabulated data,or a registered professional engineer. o Sloping or Benching. In Type C soils(what is most typically encountered)the excavation must extend horizontally 1 '/:feet for every foot of trench depth on both sides, i foot for Type B soils, and%foot for Type A soils. o A registered professional engineer must design protective systems for all excavations greater than 20'in depth. continued _._..--------_.._.....------- —--------,_...._...._..._._.._—..__. ---- - -----------–--..__.. 4Page • Ladders must be used in trenches deeper than 4'. o Ladders must be inside the trench with workers at all times,and located within 25'of unobstructed lateral travel for every worker in the trench. o Ladders must extend 3'above the top of the trench so workers can safely get onto and off of the ladder. • Inspections of every trench worksite are required: o Prior to the start of each shift,and again when there is a change in conditions such as a rainstorm. o Inspections must be conducted by the competent person(see below). • Competent Person(s)is: o Capable(i.e.,trained and knowledgeable)in identifying existing and predictable hazards in the trench,and other working conditions which may pose a hazard to workers,and o Authorized by management to take necessary corrective action to eliminate the hazards. Employees must be removed from hazardous areas until the hazard has been corrected. • Underground Utilities must be: o Identified prior to opening the excavation(e.g.,contact Dig Safe). o Located by safe and acceptable means while excavating. o Protected,supported,or removed once exposed. • Spoils must be kept back a minimum of 2'from the edge of the trench. • Surface Encumbrances creating a hazard must be removed or supported to safeguard employees. Keep heavy equipment and heavy material as far back from the edge of the trench as possible. • Stability of Adjacent Structures: o Where the stability of adjacent structures is endangered by creation of the trench,they must be underpinned,braced,or otherwise supported. o Sidewalks,pavements,etc,shall not be undermined unless a support system or other method of protection is provided. • Protection from water accumulation hazards: o It is not allowable for employees to work in trenches with accumulated water. If water control such as pumping is used to prevent water accumulation,this must be monitored by the competent person. o If the trench interrupts natural drainage of surface water,ditches,dikes or other means must be used to prevent this water from entering the excavation. • Additional Requirements: o For mobile equipment operated near the edge of the trench,a warning system such as barricades or stop logs must be used. o Employees are not permitted to work underneath loads. Operators may not remain in vehicles being loaded unless vehicles are equipped with adequate protection as per 1926.601(b)(6). o Employees must wear high-visibility clothing in traffic work zones. o Air monitoring must be conducted in trenches deeper than 4'if the potential for a hazardous atmosphere exists. If a hazardous atmosphere is found to exist(e.g.,02<19.5%or>23.5%,20% LEI,,specific chemical hazard),adequate protections shall be taken such as ventilation of the space. o Walkways are required where employees must cross over the trench. Walkways with guardrails must be provided for crossing over trenches>6'deep. o Employees must be protected from loose rock or soil through protections such as scaling or protective barricades. 5 Page 11 Date.......�......��...� ..... d OF NONT#j ao� TOWN OF NORTH ANDOVER PERMIT FOR WIRING 88ACMU5� This certifies that .......!...!.'-a � ...............................................................' ............... ............. has permission to perform .................:.. ........... ........................................ wiring in the building of....... !r4 �lC�T ......................... 5OkoY�Qy- - y. -�. at .,.,..�U.� a3 � .....�,.` ;North Andover,Mass. Fee.....: �`-.."Lic.No. .1.0.',�7.................. .���7 -�f�! �......... /gLECii rCAL INSPEcrq Check# 2Z 12095 epp// f Official Use Only- , omrnontvsaC�h o f�a:lAaclt.rc3eEf� O ryry,, Permit No. -Llepartrnent 015Ire 3ervlces Occupancyand Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 /cove biniik APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance Nvith the 1v a:�. achusetls Electrical Code(NEC),527 CMR 12.00 (PLEASE.PRhVT IN INK OR TYPE ALL INFO.RWTTOIV) Dater January 13, 2014 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) 50 Royal Crest Drive Buildi # 23 Apt 1 Owner or Tenant Royal Crest Apartments Telephone No. 978-681-1822 Owner's address 50 Royal Crest Drive North Andover, MA 01845 Is this permit in conjunction with a building permit? Yes ❑ No Q (Check Appropriate Boxy Purpose of Building Commercial -Apartment Buildings Utility Authorization No. /6 3 5R 100 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: Replace Meter Socket Completion n.'the fi)lloiving table neat-be waived by the Inspector n Tl fres. t No.of Recessed Luminaires No.ofCeil.-Susp.(Paddle) Vans No.of Total Transformers KVA No.of Luminaire Outlets No.of MCI Generators KVA rl No.of Luminaires Swimming Pool Above ❑ I n- 1:1 o.o Emergency Lighting rnd. rnd. Batter 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 Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat ump umper ons . o.of Self-Contained Totals: Detection/Alertin2 Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Connection No.of Dryers Heating Appliances KW Security Siystems No.of Devices or Equivalent No.of WaterKN, No.o No.of Data Wiring Beaters Si ns Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No,of Motors Total IIP Telecom inumcationsirivalent No.of Devices or E ui f OTHER: �4 Attach additional det6il if desired, or as requires(ht:tire.Inspector of lFires. Estimated Value of Electrical Work: $722,QQ (When regtured by municipal policy.) Work to Start: 01/14/2014 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,udder the pains and penalties of perjury,that the information on this application is true and conydete. FIRM NAME: The Electricians & Co. inc. LIC.No:: A10737 Licensee: Michael J. Parziale Signature Q, LIC.NO.: E20269 (lfal)plicable,enter "exemplj°in the license number line.) Bus.Tel.,No.: 781-322-9344 Address: 50 Branch Street Malden, MA 02148 Alt.Tel.No.: 7111-322-21oo "Pcr M.C.L.c. 147,s.57-61,security work requires Dcpv-ttncnt of Public Safcty"S"Liccnsc: Lic.No. 33C000102.1 OWNER'S INSURANCE WAIVER: l 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. d am the(check one)❑owner ❑owner's a gent. Owner/AgentrPERALIT FEE. $ Signature Telephone No. 7-3-�vy 32 1 > Datel.�..�..� ... -^ �aOR7M TOWN OF NORTH ANDOVERi ' PERM-IT FOR WIRING ��SSACNUS� This certifies that ,p� SY fir' ...�J.... .. .................................. .......................... has permission to perform .........../,....S . `" ?............ wiring in the building of......... .............................. at....Z,3........, N. ....�.Z...... ..t {�.. ` ..... North Andover Mass. Fee. �.5............" Lic.No(..3/ . .... . .... .. ELECTRICAL INSP ,. Check # �f 7 10574 "W 'W ffJ� PC-mil No. .. _,(J¢pGr(,►urut o��irs �irvicv 'I Occupancy and Fee Chccked BOARD OF. FIRE PREVENTION REGULATIONS Rev. 1107.1 (iearc bianit) N` APPLICATION FOR, PERMITTO PERFORM ELECTRIL.'Ai- WORK VA All xvorf;to be perr.ortntd in tccordancewith the Mlossachusc'as Eleecriczl Code(MEC),.527 CMR 12.00 (PLEASE 1PdtLVT IN 1XK OR Tt FE.4LL I,VFORIITATIOA9 Tate: ate: City or T.o)vn of: n �,1 7 To the b7spect-or of Wires: = Rv this application the undersigns ewes notice of his or her in�cntion�topperform the cicctricai wor);described below. Location (Street & Number) l �� S` O-wricror Tenant Telephone No(. Owner's Address Is this permit in conjunction with a building ptrmit? Yes O No (Cheek.appropriate Box) Purpose of Building Utilii.j Authorization iti`o. Existing Service amps / Z�'01U . Overhead E] U ►d-rd El ,N,5.of meters New Service .- ,.Amps / Volts Overhead Uridord No. of Mcicrs Number of Feeders and Ampacity Location and Nature of Proposed Elccericxl Work: t-�Z� "- Completion ofdX rottowing table,navbewarved hi,.tlre tnmtcrorat,l ires. No. of Recessed Lumin3irrs No.of Ceil.iSusp.(Peddle)Fans, No.of ormcrs ToL2 No. of Luminaire Outlet's No"of Hot Tubs. Generators K A .Above In_ 1 o.of mergence]Lighting Luminaires f Sr'imming Paul grad. grnd. I;aftery Units No. of Receptacle Outlets `fo-of Oil B urners F1 ALARMS .INo.of Zones No.of etection.and No. of Svritchcs f No.-of'Gas Burners InitiatinE,Devices No. of Ranges 1'o.of Air Cond. Tons No.of Alerting Devices No_oCWaste Dia oasis Heat ump. Number ons Kw o.o e. antaint P Totals: I)eteetion/Altrtingbcrices il No. of Dishriashers S acdArea Heating K`V Local _ Co n echo 0 Other A a � Connection ' . Heatin;Appliances ecurty estems No. ofDrYera <4Y No,of Tltvuxs.or E uivaltnt Jho.ofWatcr IQ. o o. o, Data Wiring:CY SrQns' $allxsts No-of Devices or Equivalent Heaters No.Hydromassage Bathtubs No.ormotors T.-ox'i Hf', eiccotnmuntcations icing: No.of Devices orF1jUjY2lCV1t OTHER: y _ - ,brad;addirlgnat r'ercit ifeslred,or as required by the Impecrar of 13'ir&T- Estimated Valuc of Electrical Work: t- C,Nhcn required by rriutiicipal paltry*.) Work to Start: p q -�� Inspections to be re ucstrd in accordance with 1`fEC RulelU,and upon completion- INSURANCE COVERAGE: Unless waived by the owner,no permit for the performznce of'clectrical work may issue unless the licensee provides proof of liability insurance including-completed operation"coverage or its substantial equivalent. The undersigned certifies that such coveraet is in force,and:has exhibited prcafofsame.to the permit issuing office. CHECK 0�,T: IN-SURANCE [Z HC?i�rD D OTHER. Q (Specify.:) St'7_f insured I teFiVy,'ynder 11;-pains or.dprnalrias ofpzrjuq; thar!h,-- ution ori this application is true anal Complete. FIRM NAf1^_E: PDT Secur�.6 �er�rices _ l~IC.N0 � �1/� Licensee: Mirk A . RrophV _Sic4aturillc-- t= LIC.NO.: C--45 (lf t vplkablt;enter "erenfp:"in rlrt ticeirtx'lium ger tine 1 Bus.Tel.NO.'. 6 0 3-5 94"5 9 Address: 18 Cl ir•to+n Qrive Ho ?a.s� 1`71:I ___ Alf.Tel.No_: 'Per M.G.L. c. 147, s.57-b 1,security work requuc,l?cpar ;rent ofI'ublic Safety.,Sr"'License: Lie.No. 00953 0NVNER'5iNSURAt4C F,NV. &'VER: i an aware-that the Licenser_'d6es not have"the liability-insurance coverage narrhally required by law. ty my, signatum'bclow,l-ht.rcby waivr,this rcquirctneni. [am (ha'(chtck one)C1 ovrncr [j owner's went_ OwncrlAtie, PENT FEE: ;Q �' `— i f Department of P blic Safe One Ashburton Placer Rm 1301 . Boston, Ma 0210.8-1:618 License: S-License- Number. icenseNumber. SS CO 000953 Expires:02107fL0II Restricted To: 00 MARK A BM)IINY SR Tr.no: 117 1) Keep sop(or roceips and change of address noiihration a �.:.,ir::N-L'E!cl,.bCj^�:e.•-:,::1r Vt ' [.s+twaA+nrvrl� r?._ a�,j.n• n3./fa ` DEPARTMENT OF PUSUC SAFETY ti Number: SS Co UtBJ"_-.53 ' 8xpirds: pr'Q>:_t)f,. .• _Tr,,ra: I`>7.:, .� f S-License: A DT-jECURITY.SERVICE JFK A 3ROPHY Sq I h4ORS=ST ,-- At 003. MA Qn62DIG SAFE CALL CENTER : (888)344=7231 ' Cwnnusarcmer�_wC _. Fold.Thm avtzh Ak1V ng POdl-60- CMMGNWE ALTH OF MASSRCHttWUT BOARD FA A REMSTERED.SYSTEM C®NTRI�CT[3FI. -• f5SU6S Tl1E{18ClVE l +tSE 7+tx i g I I ► TYPE AD3 .SE.CURITY SERVICES, I1IC= MARK'-•.-A BROP Y SR -C 410 UHIV.ERSITY AVE 'N :WESTWOOD MA 42090-•ZSll s 849174 45 C 07/31/13 849.174 t i E.. � Fa�.'fbangnta�a �Pei'.aallans � - z ' 9971 Date.... ............................. ' pORT1� TOWN OF NORTH ANDOVER °t p PERMIT FOR WIRING ��Ss�cNusE� This certifies that . T2rc has permission to perform .. . �" �- ��� �� r LT wiringin the building of � - at... �'�..!� U. .. 'orth Andover,Mass. .. .... ........ ........................ .. © 16'737,,51 J O Fee 1..Z ........ Lic.No.............. ............... .. . ... . L E CTRICALINSPECTOR Check # to 3 (fommonwea&o f Wamac4u6ettj Official Use Only REM@ Permit No. eLJeParlment o��}ire �ervice� —'—�' Occupancy and Fee Checked 1W 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: March 14, 2011 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) 50 Royal Crest Drove Building # 96 Owner or Tenant Royal Crest Apartments Telephone No. 978-681-1822 Owner's Address 50 Royal Crest Drive North Andover, MA 01845 Is this permit in conjunction with a building permit? Yes ❑ No 0 (Check Appropriate Box) Purpose of Building Commercial -Apartment Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters t Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: InStall 6 Gell Packs! Completion of thefiollowing table may be waived by the Inspector of b4rres. 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.of Emergency Lighting rnd. rnd. Battery Units 6 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 No.of Alerting Devices Tons g No.of Waste Disposers Heatum Number Tons KW No.of Self-Contained Totals " " .. .. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Connection No.of Dryers Heating Appliances KW Security Svstems:* No.of Devices or Equivalent Heaters No.o Water Kit No.of No.of Data Wiring: e 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 if desired, or as required by the Inspector of 14'ires. Estimated Value of Electrical Work: $ 600.00 (When required by municipal policy.) Work to Start: 03/14/2011 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no pen-nit 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 and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: The Electricians & Co. Inc. LIC.NO.: A10737 Licensee: Michael J. Parziale Signature LIC.NO.: E20269 (If applicable, enter "exempt"in the license number line.) t Bus.Tel.No.: 781-322-9344 Address: 50 Branch Street Malden, MA 02148 Alt. Tel. No.: 781-322-3100 *Per M.G.L. c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. SS CO 001021 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: $ 125.00 Signature Telephone No. Date. . z: 490 w TOWN OF NORTH ANDOVER of ,.•��.�ao PERMIT FOR PLUMBING SSACHUS� �-9n � This certifies that .L"/�!�. . . . . . f. . . . . . . . . . . . . . .`. . . . . . . t has permission to perform . . . � / � . . . . . ?!� . . . . . . . .,� S. le plumbing in the buildings of at . . . . ./. . . .,,North An, Mass. Fee.�-F4.0.Lic. No.. fd/�'�7. �ch4r �.f''!'. . . . . . . . . . . . PLUMBING INSPECTOR Check # _� 2 AZ�11 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY i of I� 19,17CI-)'l!l' MA DATE �c' �.1 PERMIT# JOBSITE ADDRESS y< ,�o,y< C� OWNERS NAME K/&tffT74t OWNER ADDRESS c/2,2 2, TEL 2�Y'a��-�1 ��c FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[ EDUCATIONAL ❑ -RESIDENTIAL❑ PRINT- CLEARLY RINTCLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANSSUBMITTED: YES❑ NO❑ 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/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 SERVICE/MOP SINK .TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: / I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES O ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY fgr0000 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 El OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application ar and accurate to th best of my knowledge and that all plumbing work and Installations-performed under the permit Issued for this application will complia i all-Peru nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME paniel Huntress ,,_/LICENSE# 1 097 SIGNATURE MP[]� JP❑ 10977 CORPORATION L1#2 5 4 9 PARTNERSHIP❑# LLC❑# Roto- COMPANY NAME Nurotocoof ma d/b/a Rc oter ADDRESS 175 Maple Street CITY Stoughton STATE MA ZIP _ 02072 TEL781 -297-7049 FAX 781 -341 -8817 CELL781 -603-54.1 2 EMAIL dan.huntress@rrsc.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMR ❑+�'[��§ r� 1 ` FEE: $ PERM S t PLAN REVIEW NOTES 11 A E t Date. �y��P.f/.2.- . . 9470 VAORTM TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING t y w y k _ sSACNUSE� This certifies that . . . . . . . / has permission to perform . . .. . . "��"��.. . . . .Q plumbing in the buildings of . . . � . . y . . .�.�- . , Isco Andover Mass. Fee-?0, 5 .L/ic. No.�d �7 PLUMBING INS ACTOR Check #�/dd3 CITY .(/�/"7'Ll /rte 1�r7y fid- MA DATE PERMIT# JOBSITE ADDRESS 1'0 �� Ile, OWNER'S NAME P OWNER ADDRESS_ �; >< -a 3 TEL °S-OUT- 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 6 7 8 9 . 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 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 tELL. 1 --7—r LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK. .TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER f INSURANCE COVERAGE: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES LY' NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY jg000' 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 accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this applicationI1anoe 11 Perti provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �n PLU�M,BEER''SNAME Daniel Huntress LICENSE# 10977:_; SIGNATURE MP v JP❑ 10 9 7 7 CORPORATION�2 5 4 g PARTNERSHIP❑# LLC❑# COMPANY NAME Nurotocoofma d/b/aRo�to- cuat,'r ADDRESS 175 Maple Street CITY Stoughton STATE MA ZIP 02072 TEL791-297-7049_ FAX 781 -341 -8817 CELL781 —603-5412 EMAIL dan.huntress@rrsc.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ FEE: $ PERMR# PLAN REVIEW NOTES r y a 7 6 l3 Date..q),I.q .1.1. ...... NpRTM 3? TOWN OF NORTH ANDOVER p P • PERMIT FOR GAS INSTALLATION �9S SACHUSEt This certifies that . . l (3r�1Yr► ',4.� v� `�. has permission for gas installation . Tx . in the buildings of . . . .U.�.I� at . . . . . . «1Z. . . . . . . . . ., North Mdover Mass. N Fee. 35. . . . . . Lic. No.. . 3/03. . . . . . . . . . . . . . GAS INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: //114VM 4C MA. Date: e-/-7-// Permit# Building Location: /f-C- 6266 6tJ'W E Owners Name:_ 96DIr- Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential New:❑ Alteration:❑ Renovation:❑ Replacement:® Plans Submitted: Yes❑ NoZ FIXTURES TFDEDICATED LU z YSTEMS F- z w H O LU z t,h a � Z H Y of U w Q Wa' z W z C !n z Q Q H z Q � Ln x in Q W F- W 1' to N (ncc n W p Q h 0 Q z C C D: z to Vf Z U a LL x J_ Q 3 a x x o 3 x o o W w a x w w ot( O H 3 w W U F- CL 0 to N O H U > > O a z z N F I- w 1 1 a } F- C Q a m m o o LL °x Y 3 3 o°e y N 3 3 3 o aLn 3 ;Installring SMT. MENT x OOR OOR OOR OOR OOR OOR OOR OR lin Company Name: %%��E eo Check One Only Certificate# g p y y /�tYli�1 �/ L�/�F-�? Sy .. Address: l-� O4-�Fffi f l JT City/Town: ��-�2rf�'�C State: 1 jet Corporation ❑Partnership � Business Tel: ���Zs y yy�7 Fax: ❑Firm/Company Name of Licensed Plumber: F,I RANCE COVERAGE: e a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes ❑ No❑ 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 Signature of Owner or Owner's Agent Owner 1:1 Agent E:1 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 L ws. FAPPROVEE��D-(—OFFICE / Type of License: ❑Plumber Signature of Licensed umber ❑Master USE ONLY Journeyman License Number: 7 CG`MIITIOIVIIVEi4LTIi OF`MA9SAC.F4USES''rt x PLUMBERS AND GASFITTERS LICENSED AS A JOURNEYMAN P UMBER ISSUES THE ABOVE LICENSE TO .TIMOTHY R FOLEY 3'10 POWELL ST r STOUGHTON MA 02072-393 31.607 _ 05/01/12 800768 Peerless STEW BUSINESS Insurance® . - - Mcmbcr of Libcny Mutual Group EFFECTIVE DATE: 12/23/2010 �licy Number: GL 5432321 Prior Policy: Billing Type: DIRECT BILL Coverage Is Provided In PEERLESS INSURANCE COMPANY-A STOCK COMPANY Named Insured and Mailing Address: Agent: TIMOTHY FOLEY SMITH, BUCKLEY& HUNT INSURANC 152 OLDHAM ST E AGENCY, INC L C/O COMMERCIAL BOILER SYSTEMS 500 FOREST AVE PEMBROKE MA 02359 BROCKTON MA 02301-5749 Agent Code: 6201120 Agent Phone: (508)-586-5432 COMMON POLICY DECLARATIONS In return for the payment of premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. POLICY PERIOD: From : 12/23/2010 To: 12/23/2011 at 12:01 AM Standard Time at your mailing address shown above. FORM OF BUSINESS: INDIVIDUAL BUSINESS DESCRIPTION: PLUMBING CONTRACTOR r"Is policy consists of the following coverage parts for which a premium is indicated.This premium may be subject to adjustment. PREMIUM Commercial General Liability Coverage Part INCLUDED Total Premium for all Liability Coverage Parts $ 1 , 157. 00 Terrorism Risk Insurance Act of 2002 and 2005 Coverage $ 15. 00 Total Policy Premium $ 1 , 172. 00 FORMS AND ENDORSEMENTS Forms and Endorsements made a part of this policy at time of issue: Applicable Forms and Endorsements are omitted If shown in specific Coverage Part/Coverage Form Declarations Form Number Description CG2170 -0108 CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM CG2176 -0108 EXCL OF PUNITIVE DAMAGES RELEATED TO CERTIFIED ACT IL0003 -0907 CALCULATION OF PREMIUM IL0017 -1198 COMMON POLICY CONDITIONS ,.__:i21 -0702 NUCLEAR ENERGY LIABILITY EXCLUSION (BROAD FORM) 17-57 (06/94) INSURED COPY 2/2�/2n1n 5432321 NN195291 2912 p('-nnnnann .lIan01 0nA=DN nnn4s-e)r Pano 94 C�Rt�7 "05/17/10 ATE(MM/DDIYYYY) ® CERTIFICATE OF LIABILITY INSURANCE �o 3 05 17 10 RooucER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Imith Buckley & Hunt Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE enc Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR CJ y r ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 100 Forest Avenue Irockton MA 02301-5749 NAIC# ?hone: 508-586-5432 Fax:508-587-4935 INSURERS AFFORDING COVERAGE ISURED INSURER A: Tha Charter oak Fire ins Co 25615 INSURER B: The Phoenix Insurance Co 25623 Commercial Boiler Systems, Inc INSURER C: Twin City Fire Ins Co 29459 152 :Oldham St INSURER D: Travelers Indem Co of Amer 25666 Pembroke MA 02359-2522 INSURER E: :OVERAGES 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. NSR TY SK POLICY NUMBER DATE MMIDD/YYYY DATE MMIDD/Y TR PE OF INSURANCE LIMITS YYY GENERAL LIABILITY EACH OCCURRENCE $1000000 ' /10 05/24/11 A X COMMERCIAL.GENERAL LIABILITY 16808466B288COF09 05/24PREMISES(Any o one $300000 CLAIMS MADE �OCCUR MED EXP(Any one person) S 5000 PERSONAL&ADV INJURY $1000000 GENERAL AGGREGATE $2000000 tOLICY AGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG. $2000000 JET LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1000000 B ANY AUTO 6243C10009 05/21/10 05/21/11 (Ea accident) ALL OWNED AUTOS BODILY INJURY $ (Per person) X SCHEDULEDAUTOS X HIRED AUTOS BODILY INJURY $ (Per accident) X NON-OWNEDAUTOS PROPERTY DAMAGE $ k (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ ' ; EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $10000000 D X OCCUR EI.CLAIMSMADE ISFCUP4275Y889-IND- 005/24/10 05/24/11 AGGREGATE $10000000 $ RDEDUCTIBLE $ X RETENTION $5000 WGTTATU7T $ WORKERS COMPENSATION ITCRY LIMITS I I ER AND EMPLOYERS'LIABILITY C ANY PROPRIETOR/PARTNER/EXECUTIV�j OBWECIW8489 05/21/10 05/21/11 E.L.EACH ACCIDENT $500000' OFFICER/M(Mandatory In NE) EXCLUDED? L_l E.L.DISEASE-EA EMPLOYEE $500000 (Mandatory In NH) If yes,describe under SPECIAL PROVISIONS below. E.L.DISEASE•POLICY LIMIT $500000 OTHER ESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS :ERTIFICATE HOLDER 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 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL — IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUT ORIZED R PRE ENTATIVE CORD 2S(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD