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HomeMy WebLinkAboutMiscellaneous - Great Pond Road (5)II� � o z„ o v o � o y '' o J 970 7 / 0- f'-'...1 6) Date........................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING —r (1-e'k f c-, P 6 , � -/' � e -, r ....... This certifies that ................................................................ has permission to perform ..... ........ ...... wiring in the building of .............................. .......................................... 39�at ..... ..... ................ , North Andover, Mass. -7 Fee ... Lic. No... ..... —r4;-)521 ............ .. ... ... ....... r -r- I �-" Check # /?z -,c> E Ei�CTMR I L I r: LwUJJJJJJUJ1VVUa1&11 U1 Department of Fire Services �M BOARD OF FIRE PREVENTION REGULATIONS Permit No. �T_ 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 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: A')- lg p2 0 10 City or Town of. NORTH A"O`6/lER 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) :39 `y% 14,q zolD5-1- Owner or Tenant `,/,L Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building /�-/-}n t� (,, Utility Authorization No. Q �,/ - G0A- I Existing Service %A1 m Amps o?Yo Volts Overhead ® Undgrd ❑ No. of Meters New Service a5 G Amps 9.0 Volts Overhead Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: o - Completion ofthe 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 mergency 1g mg Battery 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 Totals: Number .......................................................... ""' Tons KW No. of Self-Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of ' No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: //_ aZo�o Inspections to be requested in accordance with NEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in'force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 0 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: C_ Cwc LIC. NO.: 1'7555A Licensee: �„��,��liec'� Signature LIC.NO.: (Ifapplicable, enter "exenspt" in the license number line.) Bus. Tel. No.: "C'12 '. 536-val7 Address: t T_;XDL c O! �6 Alt. Tel. No.I(Q LhRff13 *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 th6 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 Signature Telephone No. PERMIT FEE: $ a The Commonwealth of Massachusetts Department of Industrial ,Accidents Office of Investigations 600 Washington Street t Boston, MA 02111 �'� ,• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LelZibly Name (Business/Organization/Individual): 122 A/ Address: City/State/Zip: 0 [ 9 CD � Phone #: rW — S36 - G 6 ( 7 Are you an employer? Check the appropriate box: 1.9—I -am a employer with (j/ 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. t 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. 1 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. 1 1'. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: 1,-2-17— 90 ( d Job Site Address:2 �(/ �1 a(� 4r City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 1 4 --, rGam'te- Date... ".Rr:��a TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .... /�!!SG ....../,/) '/ has permission to perform ......IU4 /1, .... t/ ........... plumbing in the buildings of .... �r "� S .................... . at ... .. /� x)11. S .... ok, . T . �...... , North Andover,. Ivy ss. FJ 3P.- 4... Lic. No. .. S6Cl... ....... 1 � .. ! .... . PLUMBING INSPECTOR Check .", J/% 8355 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS `��,(� Date - Building Location !q( )ni�r •t\dtp d �, Owners Name �� rp�S Permit # " Amount Type of Occupancy S New Renovation ® Replacement Plans Submitted Yes ® No - FTXTTIR F (Print or type)� � Check one:Certificate Installing Company Name Corp.'11 Address ��^"� \Ca M El Partner. Business Telephone Firm/Co. Name of.Licensed Plumber: \5 J Insurance Coverage: Indicat_q&e type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above threeinsurance Signature Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are. true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Pl!m e Chapter 142 of the General Laws. City/Town APPROVED (OFFICE USE ONLY Type of Plumbing License icense um er Master Journeyman '�' .d MOWN MMMMMM= `9 1 .....--..0..M.....-..--- NMM mom MEMO ON MW MMMMM ON ---MONO -..-......-...-... No 0 No No No 0 No MOON 1: ' MIMMEMMMM No 00100000 :I e.' MMOMMMON ON MMMMMNMMMMMM (Print or type)� � Check one:Certificate Installing Company Name Corp.'11 Address ��^"� \Ca M El Partner. Business Telephone Firm/Co. Name of.Licensed Plumber: \5 J Insurance Coverage: Indicat_q&e type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above threeinsurance Signature Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are. true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Pl!m e Chapter 142 of the General Laws. City/Town APPROVED (OFFICE USE ONLY Type of Plumbing License icense um er Master Journeyman '�' Date.... 210.0....... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...4.5-e...... / t has permission for, gas installation .... 4aq....... %q-� .�^... . in the buildings of . J . ........................ at /... !1���! ... /%!�:. .. �...... , Nogh 4ndover, Mass. Fee o..... Lic. No.:�� ��... f.��:!.... . f GAS INSPECTOR Check # /16 f 7266 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date r d NORTH ANDOVER, MASSACHUSETTS Building Locations L' �: 4\ Permit # Amount $ Owner's Namer ; S New ❑ Renovation r Replacement ❑ Plans Submitted ❑ (Pant or type)+! , Check one: Certificate Installing Company Name vSEI T� ❑ Corp. Address 172' ❑Partner. v usmess Te ep one 5-17- _ 7l-1 r ' 4 75a,❑ Firm/Co. Name of Licensed Plumber or Gas Fitter -%za� J INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No If you have checked yes, please mdicate the type coverage by checking the appropriate box. Liability insurance policytmOther type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the -� �- .uy �_, w. us, a I%A WaL all Yiuinotng worx ana mstauanons pertormed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber ❑ Gas Fitter 1-lcense Number ❑ Master EpJourneyman d x H wo a oa M z V1 N coJ ] F z H x w a w ^ w H y� c x>WD w. zd� d wtr, w Q z c F U .a 0 Na eL O x tom, a Cal U a > a F SUB-BASEM ENT O B A S E M ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8.TH. - FLOOR (Pant or type)+! , Check one: Certificate Installing Company Name vSEI T� ❑ Corp. Address 172' ❑Partner. v usmess Te ep one 5-17- _ 7l-1 r ' 4 75a,❑ Firm/Co. Name of Licensed Plumber or Gas Fitter -%za� J INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No If you have checked yes, please mdicate the type coverage by checking the appropriate box. Liability insurance policytmOther type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the -� �- .uy �_, w. us, a I%A WaL all Yiuinotng worx ana mstauanons pertormed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber ❑ Gas Fitter 1-lcense Number ❑ Master EpJourneyman Date. . U TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ......./ 6? 4......` .n.....�.,.•../ ......... . has permission to perform ......t � !.'�?..... !�/.`6."t ........ Z plumbing in the buildings o_f...../3/''� ................... Tjo at .....7..... ell ..> ../......+ ...... ,North And/over, Mass. Fee .Q� .. Lic. No..30 41.. ....... /.�.. ......... PLUMBING INSPECTOR Check ;x 8356 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS �p Date —7 Q %- Building Location' - i �- "acold ,� • Owners Name %'K-\ Permit # " Amount Type of Occupancy � S 41 New ri Renovation El h Replacement FTYTTTR FN Plans Submitted Yes ❑ No n (Print or type) Check one: Certificate Installing Company Name 3 `� 0 Corp. Address ` m r-�'` ` ca M a er a-1 � Partner. Business Telephone Ct ']g - $ t G — '-1 a ,S Firm/Co. Name of.Licensed Plumber:�� Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above threeinsurance Signature Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are. true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the MassachusettsiE2t a and Chapter 142 of the General Laws. By: igna o ns _ um er Type of Plumbing License Title _;056 a rVII City/Town License Numoer Master Journeyman APPROVED (OFFICE USE ONLY i • � .p M • ....W---------------mmmmml � -D�j oelm.-....--.n-.m-..-....-..mI i /' mmmmmmmmmmmmmmmmmmmmmmmmmI I: / /' .....-..-.M ..............' (Print or type) Check one: Certificate Installing Company Name 3 `� 0 Corp. Address ` m r-�'` ` ca M a er a-1 � Partner. Business Telephone Ct ']g - $ t G — '-1 a ,S Firm/Co. Name of.Licensed Plumber:�� Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above threeinsurance Signature Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are. true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the MassachusettsiE2t a and Chapter 142 of the General Laws. By: igna o ns _ um er Type of Plumbing License Title _;056 a rVII City/Town License Numoer Master Journeyman APPROVED (OFFICE USE ONLY Date... �/,//.o....... D TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ........ has permission for, gas installation ....I! in the buildings of ................................. at .. `��...,.� f ... !�h ..a ..., North Andover, Mass. Fee OW :10. . Lic. No..L, GASINSPECTOR Check # 7237 �4 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FUTING (Type or print) Date NORTH ANDOVER, MASSACHUSETTS tt Building Locations '-U tiaQa-+nor-oka�T • Permit # Amount $ Owner's Name '36zZ 5 NewElRenovation Replacement ElPlans Submitted ❑ (Print or Name— Check one: Certificate Installing Company `— A ❑ Corp. Address C7 YY4rny, i ` r A N- ❑Partner. Business a ep one c] y$-_ g� _4 ® Firm/Co._ Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check ne: I have a current liability Insurance policy or it's substantial equivalent. Yes, No❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnityElBond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one:Owner ❑ Agent 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas�odeand Chapter 142 of the General Laws. own (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber 5 -CO -7 ❑ Gas Fitter License Number ❑ Master upJourneyman d µ U w w a O O U x O C � p0 W C Z F < w ° H z x W a a� °w F w x a W a z F W C7 , o W °o U o x x o x 3 c w SUB -BASEM ENT a U a> c 0 o B A S E M ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8.TH. FLOOR (Print or Name— Check one: Certificate Installing Company `— A ❑ Corp. Address C7 YY4rny, i ` r A N- ❑Partner. Business a ep one c] y$-_ g� _4 ® Firm/Co._ Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check ne: I have a current liability Insurance policy or it's substantial equivalent. Yes, No❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnityElBond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one:Owner ❑ Agent 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas�odeand Chapter 142 of the General Laws. own (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber 5 -CO -7 ❑ Gas Fitter License Number ❑ Master upJourneyman Date .. �' '(' "fv ... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ..0 ..... f ....... .... has permission to perform .... plumbing in the buildings of L ..%�..................... . / J at ..�.....�9( ..... .............. . North Andover, Mass. Feet301. ..Lie. No.,3/-�611... .............................. / PLUMBING INSPECTOR Check w l Co 8354 MASSACHUSETTS UNIFORM APPLICATION ICOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date A? Building Location- k is o\�, 9V Owners Name Permit --#--/-- Amount Type of Occupancy New Renovation to Replacement 'VYVrrTTD' C Plans Submitted Yes ® No n (Print or type) Check one: Certificate Installing Company Name Corp. Address tn�'rn"� �E ca Partner. Business Telephone Firm/Co- Name of Licensed Plumber: Insurance Coverage: Indicate th type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity F1 Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above threeinsurance Signature Owner 0 Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are. true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts StaPlumbinge C Chapter 142 of the General Laws. A1LIV City/Town APPROVED (OFFICE USE ONLY Type ofPlumbing License 0 -�-' co icense ul�m6ei Master ri Journeyman i .......-.©--M..-........ MI-linum MM NN No W mom W W711UNIMMM .Now .mom ............mom MMMNo W'1111100- No Now MMMMIMMMMMM M110012990300 MMMMMMMMMIMM .-.-.W-..■ N 10 a e : MONO 0 ON 0 0MWMMMIMM is 1 M.....-.-....� MMMMMMMMMN ..■ 1 71 ...O.-...... ....... -- (Print or type) Check one: Certificate Installing Company Name Corp. Address tn�'rn"� �E ca Partner. Business Telephone Firm/Co- Name of Licensed Plumber: Insurance Coverage: Indicate th type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity F1 Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above threeinsurance Signature Owner 0 Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are. true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts StaPlumbinge C Chapter 142 of the General Laws. A1LIV City/Town APPROVED (OFFICE USE ONLY Type ofPlumbing License 0 -�-' co icense ul�m6ei Master ri Journeyman 1. , The Commonwealth of Alassachusetts Department o f fradusfr al Accidents Office ofI-MVesfioQtions 600 Washinclon Street Boston, M4 02111 v www. rnas,.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ lectri 3Dlicant InformCianS/Plumbers ation Name (Business/Organization/Individual): Address:L�aa v\n ,,,--,.. � City/Stale/Zip >,��c -a /y�/� I?r�-1 Phone #: q •Are you an employer? Check the appropriate box: n I. ❑ I am a employer with 4. ❑ I am a beneral contractor employees (full and/or part-time).* 2. ZI am a sole and I have hired the sub -contractors proprietor or partner- listed on the attached sheet. t ship and have no employees These subcontractors have working for mein any capacity. [No workers' comp. insurtnCe workers' comp, insurance. 5. ❑ We are a corporation and its 3. [1required.] am a homeowner doing work officers have exercised their .1 all Myself [No workers' comp. right of ex:Cmption per MGL C. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required_] '°.=.try ti♦♦,�.,Tir"rtt t3Pi Ch.�"�...b� boy. -t m�_sE _Iso %ui cut• f c ' ^n � Homeowners w' ..ece_ =ow F.n.Q :'^n9 7iY^-..'v,CiCO2II..en Type of project (required): . 6. ❑ Neu, construction 7. Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other os L thu af6davrt indicating they ar ✓ de;_gall w, ;k and r . n ir—zy ; o -u. +Contractors that check ;; bQx M- q a ached an additional sheet showing the mea himoutside sub contractors tfiuct ;u;r it a new amoavit indicating such. acme of the sub -contractors and their workers' comp. Policy, in{'�d(m i' am n employer that is providing workers' compensation insurance for my employees BeloW is the policy and job site inform¢tzon. Insurance Compiny Name: Policy # or Self -ins. Lic. #. Expiration Date: Job Site Address: City Attach a copy. of the workers' compensation policy deciarafion page (showing the policy number,and expiratiori Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ane 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 o fstatement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification this I do hereby certify under the pains and pena&ies of perjure thizt the information provided above is true and correct 7-'? 1 S-,L{a^�� Official use only. Do not write in this area, to be completed by city or town ofricia( City or Town: issuiaa Authority (circle one): P ermitucense a - Board of Health 2. Rading Department 3. City/Town Clerk 4. EIectrical Inspector S. plumb 6. Other uig Inspector Contact Person: Phone'#: Information an- d .Instructions r Massachusetts General Laws chapter 152 requires all employers to provide workars' compensation for their employees. Pursuant to this statute, an employee is defined as "...every peon in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnetship, associattion, corporation or other legal entity, or a..ny two or more of the foregoing engaged in a joint enterprise, and including t3ae legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association ox- other legal entity, employing employees. However the owner of a dwelling house having not more than three apartnz eats and who resides therdin, or the occupant of the dwelling house of another who employs persons to do mainte;mance, construction or repair work on such dwelling )iou.5e or on the grounds or building appurb=znt thereto shall not be, --a lse of such, employment be deemed to be an employer." 'I, 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 builaings in the commonwealth for any applicant who has not produced acceptable evidence of colanpiiance 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.perfonnance of public work uml:ff 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 Lisability Partnerships (LLP) with no employees other than the members or partners,. are not required to carry workers' comp ensation 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 confumaiion of insurance coverage. .Also be stye to sign and date the affidavit The affidavit should be rvtuued t0 the vity yr toKTi that the auvhca.`uon iur the �erFanit'oT l:Ce''se 4� being req w�+, not f:, a ;�}ep —eZlt OI Industrial Accidents. Should you have any questions regardii=b the law o if you = reYh'ircd 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 peri it/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 f6r your cooperation and should you have any questions, please do not hesitate to give us a call The Deparunent'.s address, telephone.and,fa number.__.. The Commonweal h, of Massachusetts Department ofFndustrial Accidents fliice of 1nresttaafioas 600 Washina-tan street Boston., MA 02111 Tel # 617-727-4900 ext 44Q6 or 1-g—7-MAS.SAFE Revised 5-26-05 Fax # 6.17-727-7749 vrvm, mass._c,v/dia Date .... ....... ,0PT)j TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... / .?Xf,r. ...... .................. . ... has permission for. gas installation ..... A in the buildings of at ...?'� ...... .....:S' ........... North Andovq,, ass. Fee. Lic. No.. ....... ...... GAS INSPECTOR Check # )16 7265 MASSACHUSETTS UNIFORM APPLICATON FOR PERMU TO DO GAS FITTING (Type or print) Date Q Q NORTH ANDOVER, MASSACHUSETTS Building Locations Permit # Amount $ Owner's Name New ❑ Renovation Replacement ❑ Plan=s Submitted ❑ (Print or type)`� ` 1 Check one: Certificate Installing Company Name 1�vSo� �Y ❑Corp. Address 'C0. MYV14. 1 ke C Hca /AA- O Jia. l ❑ Partner. usmess Te ep one r S s- ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check ne. I have a current liability Insurance policy or it's substantial equivalent. Yes No❑ If you have checked ,yes, pleas indicate the type coverage by checkin qappriate box. Liability insurance policy Other type of indemni Bond ❑ Owner's Insurance Waiver: I am aware that the -licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent 7 hr:rrhv—P f-fko+mil.,fN,e,7va..a..__ac_r_— --- �'•.=u..,�.... " �"""Iu, dor emerea) m above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code an .Chapter 142 of the General Laws. City/Town (OFFICE USE ONLY) bIgnature of Licensed Plumber Or Gas Fitter ❑ Plumber 0 Gas Fitter License Number ❑ Master Journeyman d rA w U o x s w a o m 0 o W V2 iWW- F d p z z E• W Q GCw7 04" vO� a H z x O ; W U a a W a W �. z o FQW+ z � �" Z o z 3 a U ° > ° WM o SUB -BASEM ENT xo B A S E M ENT 1ST. FLO O R 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type)`� ` 1 Check one: Certificate Installing Company Name 1�vSo� �Y ❑Corp. Address 'C0. MYV14. 1 ke C Hca /AA- O Jia. l ❑ Partner. usmess Te ep one r S s- ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check ne. I have a current liability Insurance policy or it's substantial equivalent. Yes No❑ If you have checked ,yes, pleas indicate the type coverage by checkin qappriate box. Liability insurance policy Other type of indemni Bond ❑ Owner's Insurance Waiver: I am aware that the -licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent 7 hr:rrhv—P f-fko+mil.,fN,e,7va..a..__ac_r_— --- �'•.=u..,�.... " �"""Iu, dor emerea) m above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code an .Chapter 142 of the General Laws. City/Town (OFFICE USE ONLY) bIgnature of Licensed Plumber Or Gas Fitter ❑ Plumber 0 Gas Fitter License Number ❑ Master Journeyman r h The Commonwealth of Massachusetts Department o f Industrial Accidents Office of Investigations ..600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legubly Name (Business/Organiza6on/Individual): Address:M rn City/State/Zip t 1I& e fd„1 Phone #: Type of project (required): 6. 11 New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other Homeowners who submit this ahaffidavit indicating they are doing all work and then hire outside contractors ore must submit a new affidavit indicating such. Conctors 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. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify undr the pains enalties of perjury that the information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: _ P'ermit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 6. Other Contact Person: 2 4. Electrical Inspector 5. PIumbing Inspector Phone #: Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I MA employees (full and/or part-time).* 2 I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp, insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No workers' comp. C. 152, § 1(4), and we have no insurance required] t employees. [No workers' comp. insurance required.] :.Any applicant that checks box o fi #1 must alsll cut the sectiea belmv showin• t:. ., v„n ,�> Type of project (required): 6. 11 New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other Homeowners who submit this ahaffidavit indicating they are doing all work and then hire outside contractors ore must submit a new affidavit indicating such. Conctors 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. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify undr the pains enalties of perjury that the information provided above is true and correct Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: _ P'ermit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 6. Other Contact Person: 2 4. Electrical Inspector 5. PIumbing Inspector 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 pe=rson 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 orother 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 coxnpliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall v enter into any contract for the performance of public work until acceptableevidence 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 tawn that the application for the pe=rmit 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 permittlicense 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. °Ibe Commonwealth of Massachusetts Department of Indusirial Accidents Office of Investigations 600 Washington Street Boston, MA 021.11 Tel. # 617-72.7-4900. ext 4406 or 1-8 77-NIASSAFE Revised 5-26-05 Fax # 617-727-7749 vrwu'.mass._govfdia