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HomeMy WebLinkAboutMiscellaneous - 8 CiderpressSAI, 0;;'1 11 aF OR qti 0 ID 32 oG o m Date.h��' i�... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... (�.:c il.G e l 't .p 1 f has permission to perform ... plumbin in the buildings of .. !V) P Q. �. ��: Y`S C-' L Y` -q mit .� r at .... . ` ! . �� e.�?. ,� �.SS .... ,North Andover Mass. Fee . 21 �5.. Lic. No. � � .. .. �.................. ... PLUMBING INSPECTOR Check # '? G-� 11, tMASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE J PERMIT # JOBSITE ADDRESS Ci S OWNER'S NAME _ L ff POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0f EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ® REPLACEMENT: D PLANS SUBMITTED: YES[] NOF -11 FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM I _J1 __._,! _.---J DEDICATED GREASE SYSTEM I= L.___._I DEDICATED GRAY WATER SYSTEM f ! f { I 1 _ _ ...1 i f _! _J =jt DEDICATED WATER RECYCLE SYSTEM DISHWASHER _! ..._FJ -__.. _) DRINKING FOUNTAIN _ _I ____...I 1 f-! FOOD DISPOSER FLOOR/AREA DRAIN I __-.__...J ._ ._ I _____..( INTERCEPTOR (INTERIOR) ! . t .-----._i KITCHEN SINK —9 _ -- -_1 ___I LAVATORY ROOF DRAIN SHOWER STALL I -- _-_► ` 1 _.. _ _f ._ __ _) _-____.( .. _ _. I ..__ __ T ( _ SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION IrWATER HEATER ALL TYPESF T" WATER PIPING OTHER [L___ED INSURANCE COVERAGE: 1 have liability NO a current insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [ g' 0 IF YOU CHECKED YES, PLEASE INDICATE THE YPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND Q 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 R 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 ofmy knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all.Pertinent prov' on of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ LICENSE# /S/57 SIGNATURE MPNK JP 0 CORPORATIO—N 0# _ PARTNERSHIP EJ# i LLC D i COMPANY NAME "ADDRESS CITY -- STATE ZIP_ I�,�6�Z. i1 TEL FAX_ p CELL 117a -P711 MAIL . --.---_ ___._._..._ -- ---------- 11, F z° 0 F U N tAw E o rl z Nn } O W LU Z uLU_ E 5 a W a W W a W � Oz a a � w a as C.) I a as a D x w I-- LL tA w H °z o � � V W a C7 a O a I-iy The Commonwealth of Massachusetts ` Department of Industrigl Accidents Office of Investigations kvi 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): City/State/Zip: Phone #: 6,0-3 Are Y9u an employer? Check the appropriate box: 1. I am a employer with ! 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. I ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] r employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. E] Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Phone #• �� Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone Information and Instructions . µ Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced. acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial .Accidents Office of111vestigations 604 Washington Street Boston} MA 021 It Tel. # 617-727-4900 ext 406 or I-877, MASSAEE Revised 5-26-05 Fax ## 617-727-7749 www.mass.govfdia COMMONWEALTH OF MASSACHUSETTS' o . . , • - . . 111Ter�f�'ilrra s c . • .. ' ,, �. PLUMBERS AND CASFITTERS LICENSED AS A MASTER PLUMBER I ISSUES THE ABOVE LICENSE TO: - I "!TCf AEL V1 KELLEFz {� '! I )0 KENT EDY DR. N f PE-LHAM 1,41!_03076-2605 15157 lF5/U't !).. 1.74161 gpuomwfi@ r .,z i r This certifies that has permission for gas installation in the buildings of. j .J . , North Andover, Mass. Fee ..,�� ` . Lic. No... �.� � . iV ................... ... GASINSPECTOR Check # . /./0 00 i f.N- IV..ASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE ]:] PERMIT # � JOBSITE ADDRESS - _ _ _ SS OWNER'S NAME y GOWNER ADDRESS _ TELL_ TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL ® RESIDENTIAL CLEARLY NEW: [I RENOVATION: 0 REPLACEMENT: PLANS SUBMITTED: YES F-11 NO Q APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 BOILER BOOSTER J14 CONVERSION BURNER COOK STOVE DIRECT VENT HEATER W DRYER FIREPLACE -J FRYOLATOR — I, rt _ FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKSMAKEUP AIR UNIT =-T _ l .. T _.I _ _ -.. T( _... ( _1 OVEN- __ POOL HEATER =M / SPACE HEATER -�_ _ I - .-..-J .- J _ . - ;OOF TOP UNIT '"EST .UNIT HEATER UNVENTED ROOM HEATER - i _ L _ -- - ;.- ?. I . _ . �. _ - -WATER HEATER I _ j INSURANCE COVERAGE have a current liab_ ility insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 102/NO 0 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERA E BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of tl ,Massachusetts General Laws, and that my signature on this permit application waives this requirement. I _ CHECK ONE ONLY: OWNER L� AGENT 0 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all P rtine provi Massachusetts State Plumbing Code and Chapter 142 of the General Laws. SFITTER NAME v LICENSE # 1S/ ( SIGNATURE PLU7MGF MP _ I JP J JGF. _ LPGI f CORPORATION 0# PARTNERSHIP __(# LLC .__i# COMPANY NAME:CADDRESS - -- CITY L .L= _. 1'''l s �-. , �. STATE ZIP l� TEC.� .�I.I FAX CELL AIL 0 z 0 F U W W W a � o z W } � W o LU °z U w �* 3 w � � ~ W < w co a O LU > w � w c a 0 a a a U J Ei a a a c ui x w E- a H z° o � U � Q W a .S C�7 C7 a t The Commonwealth of Massachusetts Department of IndustriqlAccWnts Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/individual): Phone #: Are ygu an employer? Check the appropriate box: 1. V1 am a employer with / 4. ElI am a general contractor and I _ - employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they aie 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. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lic. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties er' tl:at the information provided /_/boove is true and correct. .Qi"whira• �1� nntp..' 7 /& 7/ /l V P-605 - 6 S -/ l Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: Information and Instructions - Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington. Street Boston, MA, 02111 Tei. # 617-727_4900 ext 406 or 1-877:MASSAFB Revised 5-26-05 Fax # 617-727-7749 www.tmass.govfdia N .COMMONWEALTH'OF MASSACHUSETTS ,.., % P. LU . BERS AND GASFITTERS L CEN ;E MASTER PLU S DASA MBER ISSUES SSUES THE ABOVE LICENSE TO: MTCHAEL V1 KE'LLE, "T_-0 KENNEDY DR. PELHAM 63076-2605 15.157 Im Date ..... ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... L .,.r ..................... ............................................................................... .. lk"' .4 has permission to perform .... 6�&g ..... *V,5m-- ...... L L wiring in the building of......... M.E .. . ................................... at ..... F ....... ........ 4A,.l ............... North Andover, Mass. Fee .... , . Lic. No. .............. P .... . ...... ........ L Check # I 13 -73 -rAkF ��Fp Pe -RR 477- 11� Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS (�reg OfficialUseOnly Permit No. I I z 3 Z' Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASEPRINTWINKORTYPEALLINFORMATION) Date: ZZ 13 City or Town of: NORTH ANDOVER To the Ins ector V Wires: By this application the undersigned givesotice of his or her intention to perform the electrical work described below. Location (Street &Number) � -11, �'�- -SS (,v Owner or Tenant /�/� 1vd (rte J S �L �"VC3✓S Telephone No. c�jf % 263 Owner's Address 0 - Is -Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building �5 Gf�L,v`tM4-C — 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: L,/ L 0,1E7 CO,,�6-0 Completion nfthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans Total Trsformers KVA Trans No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires CIO Above In- Swimming Pool rnd. ❑ rnd. ❑ o. o Emergency ig ting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ARMS No. of Zones No. of Detection 2ndInitiating No. of Switches Lto No. of Gas Burners Devices No. of Ranges TWO No. of Air Cond. Tons 3 No. of Alerting Devices [ ` Heat Pump Number Tons KW .... No. of Self -Contained Disposers No. of Waste Dis P Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Municipal Other Local ❑ Connection ❑ No. of Dryers L Heating Appliances Security Systems:* No. of Devices or E uivalent No. of WaterKW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or E uivalent Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or Equivalent OTHER: YYt Attach additional detail f desired, or as regttzred by the Inspector of res. Estimated Value o Electrical Work: �6 9 J 0 `� (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such er is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE co[BOND ❑ OTHER ❑ (Specify:) I certify, tinder th ains and penalties of perjury, that the information on this application is true and complete. FIRM NAME:. O,L M Yk-C— LIC. NO.: Licensee: tAjq n/` Al ignature .-�IC. NO.: -CL-? (If applicabl enter "exemp " in the lice a nztmber Iine.J Bus. Tel. No.: 3 g Address: t(.� � 11 �i 1'41-"A', �� "' Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, sec iiy work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAVER: 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: $ Cionntnre Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: * ** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROU H SPECTION: Pas ? Failed Re- Inspection Required ($.) ❑ Inspectors Com nts: Inspectors Signature: Date: FINAL INSPECTIO Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Sig ature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold(@townofinerrimac.com P l The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers _Applicant Information Please Print Lezibly Name (Business/Organization/Individual): CAAAA AZIe Address: hs.4__ i-e- K� City/State/Zip: V_L 9"-jVN q b 3 k L1Phone #: Are y u an employer? Check the appropriate box: 1. L41 am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors listed on the attached sheet. � 2. ❑ I am a sole proprietor or partner- These sub -contractors have ship and'have no employees working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their required.] 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no employees. [No workers' insurance required.]r comp. insurance required.] Type of ect (required): 6. ew construction 7. [1 Remodeling 8. ❑ Demolition 9. [] Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other, *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy infomtation. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: k.�t SVS Policy # or Self -ins. Lic. #: Expiration Date: C��C'k „� City/State/Zip: PO ,4ti�a�� ��� Job Site Address: �i I t Attach a copy of the workers' compensation policy decla ation page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. j Ido Hereby cernl under the pains and penalties of perjury that the information provided a ove is true and correct. k ,. 1, Q t 0 n n��o• � ZZ�I Phone #: I) -�— 3 ,) S — M& Z Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple pennit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, ` please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth. of Massa( Department oflndustrial .Accidents Office of Investigations 600 Washington Street Boston} MA 02111 TO, # 617-727-.4900 eyd 406 or 1-877rMASSAFE Revised 5-26-05 Fax # 617-727,7749 www.mass,govma Date....?'../ 9. /0 ................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......... ...... kwwk.m" Pw ............. has permission to perform .........1.. -P ............................... wiring in the building of ..... .............. at ... ..................... Y� orth Andover, Mass. Fee .... No. ......... ELECTRICALINSPECTOR'­� Check# -� a.wnrnunwCan.11 vi 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 (MEC), 527 CMR 12 00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 7;6 City or Town of: NORTH ANDOVER To the Inspecto of Wird: By this application the undersigned gid notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant ItIlr Owner's Address n Telephone No. Is this permit in conjunction with a building permit? Yes �-- No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. VX y� Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters New Service 1ILI� Amps v / Volts Overhead ❑ Undgrd No. of Meters Number of Feeders and Ampacity Y "4A-? cl!9 Zy-1 V1 XM /' Location and Nature of Proposed Electrical Work: 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- ❑ rnd. rnd. o. o Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW No. of Self -Contained p Totals: Detection/Alertin Devices No. of Dishwashers Space/Area Heating KWConnection Local ❑ Municipal El Other No. of Dryers Heating Appliances KW SecNoto Devic s 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 No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: ;?(I' (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ILBOND ❑ OTHER ❑ (Specify:) I certify, under the p ins and penalties of perjury, that the information on this application is true and complete. FIRM NAME: </, : e- C . LIC. NO.: Licensee:���y, �.� �g%��� Signature LIC. NO.: s (If applicable, enter "exempt" in the license number line;) Bus. Tel. No.: T WJC Address: '_ 4I/ Alt. Tel. No.: J - *Per M.G.L c. 147, s. 57-61, security work requires Department of2u i "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 Owner/Agent PERMIT FEE. $ Signature Telephone No. f s 5 61 69/-L ,�_ry.(t7/� c-� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 h www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ADDlicant Information Please Print Legibly Name (Business/Organization/Individual): Address: oT( — 4 ye!' City/State/Zip:/rte Phone #: / 7e Are you an employer? Check the appropriate box: 1. am a employer with % 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] employees. [No workers' comp. insurance required.] Type of project (required): 6. construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. / r Insurance Company Name: ,--a Policy # or Self --ins. Lie. #: ��tJ`/6 Expiration Date: Job Site Address: (.�� of �/ Q /2" S S 1. �� City/State/Zip: la ljez,-- Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify undey th0ains and penalties of perjury that the information provided above is true and correct. D ) w 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 #: Meetinghouse Commons LLC 115 Carter Field Rd. North Andover, MA 01845 Phone: 978-687-2635 Fax: 978-689-2310 March 14, 2011 Mr. Peter Murphy, Electrical Inspector Town of North Andover Building Department, 1600 Osgood Street North Andover, MA 01845 RE: Electrical Contractor at 6 Cidernress Way Dear Pete, As discussed, we are releasing the previous electrical contractor at 6 Ciderpress Way (building permit #124-2011), which was Kevin Warren Electrician. This work was completed and inspected through the rough stage as of September 20, 2010. We will now continue with the finish portion of the work at this location with Brimac Electric. 4 Please feel free to contact me with any questions or concerns, or to address any administrative items. Sincerely, D. Zahoruiko, Manager • o f 9 ,SSACMUS� Date.. . .......... TOWN OF 7RTH ANDOVER PERMITR PLUMBING This certifies that l..... r... f ....... ..�............. . has permission to perform .... % 4 plumbing in the buildings of ..,.'-.! ......... .........."....... . at ............................. ........... North Andover, Mass. Fee ... Lic. No..../..) �/ /. n . . PLUMBING INSPECTOR Check # I A CIlTJ>� TT TTNUORM MpLICATION FOR PERIMT TO ]D O PL�IlNG MASS(Type or print) NOIZIHANDOVER, MAS SACHUSETM Date d - �SS Owners Name raS' Permit BuildingLoaatidn Amountt e of Occu ancy r . n - New � Renovation Replacement Plans Submitted Yes No - Check one: certnIcate (Print'ortype) �fl'1 Q Corp. Installing Company Name Address v cb Partner. Name oflicensed Plumber: "l " Insurance Coverage: Indicate the of insurance coverage by checking the appropriate box: Bond II Liability insurance policy � Other type of indemnity J11 y-1 'Insurance Waiver: I, the undersigned, have been Made aware that the licensee of this application does not have any one ofthe above three insurance _ t Owner n Signature. Agent ,• i I hereby certify that all of the details and information I have submitted (or entered) in above application are.true and accurate to the best of mylmowledge and all plumbing work and installatitoants performed under Permiha tere142 fthfor se Generalon"WillLaws. be in compliance with all pertinent provisions of the Mass achu� Ste. 1? bing C p T Y' Type ofPlumbing Licens e ,�,/ Citfyl�own L-� umber — Master ?oumeyman APPROVED (OFFICE USE ONLY The E'omnZonWealth of [V assachusetts Depattment o f rndustf iaiAccidents Dfjace 0-fbivestigrztions 60.0 Washington Street BO&Oi2, li 1U 02111 xnw_,rncrsagouldia Workers' Compen.gafaon lasuran.ce .fid -alit: PuUCIers/Cosi ract0rs/FlectXclang/Plumbers ------------------------------------ Dame (Business/Oro nization&dividml): ------------------ Address: City/State/Zip: _ Phone #: -A-re you an employer? Check the appropriate box: 1 • �] I am a employer with 4. ❑ I am age_ ural contractor and I employees (full and/or part-time).* 2. Q' I have hired the sub -contractors am a sola proprietor or partner- listed on the attached sheet ship and have no employees These sub—contractors have working for me in any capacity workers' comp, insurance. [No workers' comp. inGitrance 5. [] We are a corporation and its required.] 3 • ❑ I am a homeowner doing all work afncros have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, §_I (4), and we have ,no insurance required.] f employees. [No workers' comp. 7n e, Y,-a„c�, required.] Type of project (required): 6.. ❑ Near construction 7. [] Remodeling 8. 0 Demolition 9. E] BniIding addition 10.[] Bleciricalrepa re or additions .11.[] Plumbing repairs or additions 12.E] Roofrepairs 13.❑ Other M._s: also Ml ou:• i �c ee 'ceaatr 1 Rome, 3wners who suomif'his affidavit indicatin fh , d g e1 o�g sI1 •„ ng and when hireouffiiBe contractors L�&_t "u usi a new aifi&vii indicating such. • +ConfraetOrs •moi c?•�,r the hor MM -t a ocied an additional Sheet showing the . aame'of the sub contactors and theirwarkere' comp. policy information. Pam'zn employer that is providing workers' compensadon insurance for my employees Bel is ilze policy and job site. iPlf07?1tdtZpn Insm-ance Compiny Name: Policy # or Self -ins. Lic. #: E piraiion Date: J'ob Site Address: City/State/Zip: Attach a copy -of the workers, compensation policy declaratf on page (shavdng the policy ttumber.and expiration date). Failure to secure coverage as required under Section 25A of M* GrL c. 152 can lead to the imposition of c 'mina. penalties of a fine up to S 1,500.00 and/or one year imprisonment; as well as civil penalties in the form of a STOP WORK ltal P= and a fine of up to 5250:00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. _ Ido hereby cerdfjv under the pains and p -*antes ofperjury thuf the inforraaifon provided above iv true and correct Si�aature: ' Date• .._ . Phone #: Official use only. Do not writd in this area, to be completed by cLz , or town official City or Toym- hsuin Autbority (circle one): P'ermftUcense 1. Board of Health 2. Building Department 3. Cityll'own Clerlr 6. Other Contact: Person: 4. ElectricaI.Iuspector 5. Plumbing lnspector Phone'#: 13 Date.. 1� //......... . o� °� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �,SSACHUSE4 This certifies that ...� �u has permission for gas installation ....a in the buildings of .... Z".6 (d. r :1..:t�r��,. '....Adi. 4'A at ... �... �. . �.�._...�! (� .............. North Andover, Mass. c Fee..'. Lic. No..I S1*67.... .... ....l...-:... ...... GASINSPECTOR Check # ` + HASSAa SEITIS L)NDDRM APPUCATON FOR PERNff r TO DO GAS FITTING (Type or print) Date L16 Aa - NORTH ANDOVER, -MASSACHUSETTS Building Locations Permit # Amount'G Owner's Name Vew ❑ Renovation Replacement, Plans Submitted (Print or type)� �� X Check Con� Certificate Installing Company Name) / Address ary�G K �'i-� FlPartner.. . J r6 :z 6 BUsmess Te ephone (, G _ ff 3 — `) Firm/Co.- Name irm/Co:Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check on I have a current liability Insurance policy or it's substantial equivalent. Yes No o If you have checked yes, please iijoiciate the type coverage by checking the appropriate. box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: lam. aware that the licensee does not have the: Insurance coverage required by Chapter 142 of the Mass. General Laws; and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 0 Agent 0 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the - best of m} knowledve and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Cky Code and Cl y JoAf the General Laws. By: Title City;To�vn — - VPROVED (OFFICF USE ONLY) Signature of Licensed Plumber Or Gas Fitter rl Plumber 4t IL2 as Fitter Eicense Numuer Master Journeyman U �. a O �D C H o d H x z ] o w G tn 9 H H W W �' ca c4 tW7 Z z C�7 xf O W A U` ..7 U x y A A4 tW-� O SUB-BASENI ENT BASEiVI ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR . 4T II. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR t 8TH. FLOOR (Print or type)� �� X Check Con� Certificate Installing Company Name) / Address ary�G K �'i-� FlPartner.. . J r6 :z 6 BUsmess Te ephone (, G _ ff 3 — `) Firm/Co.- Name irm/Co:Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check on I have a current liability Insurance policy or it's substantial equivalent. Yes No o If you have checked yes, please iijoiciate the type coverage by checking the appropriate. box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: lam. aware that the licensee does not have the: Insurance coverage required by Chapter 142 of the Mass. General Laws; and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 0 Agent 0 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the - best of m} knowledve and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Cky Code and Cl y JoAf the General Laws. By: Title City;To�vn — - VPROVED (OFFICF USE ONLY) Signature of Licensed Plumber Or Gas Fitter rl Plumber 4t IL2 as Fitter Eicense Numuer Master Journeyman