HomeMy WebLinkAboutMiscellaneous - 10 FRANCIS STREET 4/30/2018 (2)Fl ("I zy. Date... ....... ........ NORTH °f�"•�:•�"� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING R i SAC14U This certifies that.............���///!!%!................................................... has permission to perform ......... LTt/.......6!1L .............................. wiring in the building of ........ m2*�.................................................. at .....�/XI..f.... C..;E.` ................................... . Nofth Andover, Mass. Fee... Lic. No.............. ................. /Y�t... ..�;..,...�.:... ELECI ICAL INSPECTOR . i Check # � 71/�� i"Li4I J• Commonwealth of Maijac"m Official Use Only EEEREEW Iffm cc�� cc77 [[�� Permit No. 1JeParfinent o/,}ire Jervice� Occupancy and Fee Checked $rl 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), 5277 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: !7-- 30 — j,7 City or Town of: /Vb - Awcq,- To the Inspector of Wires: By this application the undersigned gives notice of his or her inte tion to perform the electrical work described below. Location (Street &Number) Owner or Tenant Owner's Address Telephone No. Is this permit in conj on with a building permit? Yes ❑ No � (Check Appropriate Box) Purpose of Building e/ C&AC ti° 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: lVjL,0tj r %l [ lete Co nfltin fn/Inwino fnhlo .. ho l A.. sb 7 < fA7 No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans o. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- Elo, rnd. nd. Batteo m ergency Lighting 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 Tons No. of Alerting Devices g No. of Waste Disposers Heat Pum Total% Number„ '' ' " Tons "'" KW """"""""'"" o, of elf -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Si ns 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: A. 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 in ce including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cover a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under th ai s and pe alties of jury, that the information. on is application , true and complete. FIRM NA LIC. NO.:rjgfjy — Licensee: Signatur LIC. NO.: (If applicable, ent "ezem " in the license number line.) Bus. Tel. 1Vo. Address: UC Alt. Tel. No.:' *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 a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ,97 i 0 Dat/ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies ies that :�;; .... ...... /.: '�e. /% . . .... .. 7t ....... r-5- r -.1 has permission to performS. 9114--Xem-vop . ....................... wiring in the building of.,- L .. l..-..... ................................................. at./O ... ....... . . .................. North Andover, Mass. 09 Fee.,517. Lic. No.. ....... 1) .................... IIE-CTRICAL INSPECM" Check # J 6.UI11111U11F1NCQld11 U1 ' Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (ME , 527 Cr2.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: j b d /0 City or Town of. NORTH A"OVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intentionto pqrform the electrical work described below. Location (Street & Number) © AJ Owner or Tenant, TD ry I / Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Apropriate Box) Purpose of Buildinggk iYly ✓� �� raa �� 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: �/ �- /p7,� ✓ 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 Above Ei In-NO-50-rEmergency Swimming Pool rnd. 2rnd. El Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Detection and No. of Switches No. of Gas BurnersTot Initiating Devices No. of Ranges No. of Air Cond. Tons No. of Alerting Devices Number..Tons HeatTotals: KW " ' 'Detection/Alertin No. of Self -Contained No. of Waste Disposers Devices No. of Dishwashers Space/Area Heating KW Municipal Local ❑ Connection El Other No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW No. of ' No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or Equivalent OTHER: --i •Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of E ctnca ork: 4�0"-D, (When required by municipal policy.) Work to Start: 101P O fd 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 suchcov rage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the ain and enalti s ofperjury, that the inform tion on this application is true and complete. FIRM NAME: d'7/ IC. NO.: r Licensee: ,r G Signature LIC. NO.: (If applica le, ter "exempt" in the license nu ber line.) J C Bus. Tel. No.: Address: d O >o ,5, -lJQ nyi / lq, F - % 1 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Depahmeiit of Public Safety "S" License: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have th6 liability ins ..c coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one wner ❑ owner's Owner/Agent I P RMIT FEE.-'$ Signature Telephone No. 9 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 `'4 s�• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers lmlicant Information I Please Print Legibl, Name (Business/Organization/Individual): Z2 7�� z Address: llq� - 6b--, r,2 3a^ City/State/Zip: ,!/Q /1 /l ( ,/l/ r Phone #: �� Are you an employer? Check the appropriate box: 1 ` I am a employer with 4. ❑ I am a general contractor and I r 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.] i 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. F1 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. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. Iain an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under thepains andpenalties ofperjury 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 8 7 6b Date. J()/, (/ o TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .............. ......... has permission to perform plumbing in the buildings of .................... at,I .......... (UAC 7Yk ..N..... North A d.ovev,A ass. FeP�PP.Lic.No.3NA.. ..X/ .../ PLUMBING INSPECTOR Check #r2.1 0 1 r' w 10 .MASSACHUSETTS U NORM APPLICATION FOR PERWRT TO 3) O PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Buildinglacation D- 'r I Dated��1� Amount Type ofOccupancy P Renovation lacement E] Plans Submitted Yes No New � � Re �� vC'C�iuc�KV Check one: Certificate (print- or type) n n Cozp. . Installing CompanyName l inl 7E�� ` � • L-€ II Partner. Address _ lr t f �j oo—irm/Co. Business Telephone -Name ofLicensedPlumber: Insurance Coverage: Indicatff the o£msuzance coverage by checking appropriate box: Liability insuraace policy Other Type o£indemnity ;Insurance Waiver I, tho undesiigaed,have been made aware thatthe licensee of this application does not hale any one o£the above three insurance - ignatuze - - Owner Agent L__1 I hereby certify that all ofthe details and information) have submitted (or entered) is above application aretrae and accurate to the best of myjmowledge and that all plumbing work and installations performed under Pm t Issued for this application will be in compliance with all pertinent provisions of the Mas ahusetts Statta 1umb' Code and Chapter l 42 ofthe General Laws. r%d_t✓/ 't--•�'�' - - Title City/Tomm AAPPROVED (OFFiCEUSE ONLY Type oulumbing License )cense um er Master Journeyman The Comrazonx emIth of fa,ssachusetts Department. °f•£ndastrialAccidents 0fface ref _&Pesti-ations 600 Wasizington street BOStOrz, -41M 0211-1 w��v.aazczs�gox�,�dia - . Workers, Compensatiozz Jtns rance Affclav t: BnUders/Contract:ors[Rleet is ags/t���xmbexs knpEcant•Informstion t TY aa7 e (Business/Oro niTz±ion/Individual); (. S p 0- / • Address: _ f � ✓ I � . City/State/Zip; u Phone #: - ?o /77 t Are you all employer? Check the appropriate box; I. 0 I am a employer with _ 4. [] I am a gcheral contractor and I Type of Project (required): ��nployees (full and/Or pazt iime): - 2. (�T have hired the sat)-confrantors 6• ❑ e�' constTuciion am a sola proprietor orpartn.er- 'listed on tb.e attached she -rt 1 7. pl] of emodeiing ging ship and have no employees These sub -contractors have &' El worI�ng forme in any capaciti3; O PJOIlCeIS' COIIIp. 7n�aranCe workers' comp• insurance, 5. ❑ We are a 9. El BmIdmg addition 3-[]required.) am ahomeowner doing corporation and its officers have exercised their 10 Q Fleck cal*repairs or additions •I all work myself jlQo workers' comp, ria t of ex emptonperMCrL c. 152, §_1 (4), and we have II•[] Plumbing repairs or additions insurance required.] t no employees. [No workers' 17•❑ Roofrepairs comp. insc�ranc� required J ..�' :Va. Tiir ± f.SP.±bo x•' l 1 t• .SCt 111... *V+E.RO:;^..^.•-,• 13 ❑ Other r � Hot-ni:OWnetS who SlI[7fII7t ffiL afdavlt i -a -ti g th � ar✓ .r?C:,z ^_';r.� -..^.moi vi�'L`r':C•,.ES' CCL^t^�`:.'�•�'�'•,o.^. rvCJ .•.i'yRuic:+.�uC":t Coutracbrs _t cu:G'� t ? _.. _. • eY u u2ai ad c3 o3I ii and ;glen hireflu±side cou*�c±c s _t a- uii a new at$aaviE incicafing such. for c' ditioiral sheet Showing fh'P - hum an errtplayer that isproviding workers' aame'of ffle sub cantrac±ors and theirworkers' compensation comp- policy informatim inform�faon, irzsurance for rrzy errzplayees: 13eXoit, is rize policy and job site. Insurance Company Name: ?OIicy # or Self ins. Lic. 9— V • E7;piration Date: Job Site Address: City/State/Zip: Attach. a copy -of the workers' compensation. poEcy declaration page (shovng the policy Ann ber•and expiration date). Failure to secure coverage as required under Section 25A ofMGrL c. 152 can lead to the imposition of criminal penalfias of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form az a STOP WORK ORDER and a rine Of up fa $250:OD a day against the violator. Be advised that a copy of statemeni may b e forwarded fp Phe Office of Investigations of the DIA. for insurance coverage verification Ido hereby certify under thepains ¢ndpennlffes ofperjaoy thserthe irz• formaizon.provided• above is true and correct. Official zzse 0111y. Do not wr*e in this area, to be completed bar city or toren offzciaL City or Toym: P erzaiflLicense # r,: Essng A.utbor!" (circle one)• X. Board of Health 2• Bttilain , Dapartment 3. City/Town Clerk; 4. Ec lectricaI inspector S. Plumbzng � error 6. Other p Contact Persuiz: Date..'... ............... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...... 11 . -1� .............. has permission for gas installation ........ in the buildings of ........................................... at ..................... I North Andover, Mass. Fee.�.-. Lic. No.. ........... .......... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type)�1 Q q A2N DO 1) �, Mass. Date �/ 19 7 / Permit Building Location_ , o �Ip��G15 S/ Owner's Name Type of Occupancy /Res Id eo �, pa) New V Renovation ❑ Replacement ❑ Plans Submitted: Yes[] No ❑ Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Check one: �❑ Corporation ❑ Partnership Business Telephone 508-68,7-1105 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery Certificate # 1862 INSURANCE COVERAGE: have. alcusrrenntt liability insoura❑nce policy or its substantial equivalent which meets the requirements of MGL Ch. 142. If you have checked yes, please indicate the type coverage by checking the appropriate box. A liab„,;ty insurance policy X( Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. 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 abo pplication are true and accuWe to the best of my knowledge and that all plumbing work and installations performed under the permit Iss f r this application will n mplianoe with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. T e of License: Plumber Signature of Licensed Plumber or Gas Title r—fiM er Master License Number 8697 City/Town Journeyman APPROVED OFFICE SE ONLY pAw MEMO OMNI TIT lime ME MW NEW Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Check one: �❑ Corporation ❑ Partnership Business Telephone 508-68,7-1105 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery Certificate # 1862 INSURANCE COVERAGE: have. alcusrrenntt liability insoura❑nce policy or its substantial equivalent which meets the requirements of MGL Ch. 142. If you have checked yes, please indicate the type coverage by checking the appropriate box. A liab„,;ty insurance policy X( Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. 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 abo pplication are true and accuWe to the best of my knowledge and that all plumbing work and installations performed under the permit Iss f r this application will n mplianoe with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. T e of License: Plumber Signature of Licensed Plumber or Gas Title r—fiM er Master License Number 8697 City/Town Journeyman APPROVED OFFICE SE ONLY Nv) wW X I w x N coCL Z m n a n a Q U. z U z- a o W0 , O � t - w N J n 2 O . O . N O a h W F- U � 4 • Q n Oz 0 a z . _ 0 a cc 'J O O u.LL � n 3 z O O a. F o .1 a v J a a a wl w LL z Nv) wW X I w x N coCL Z m a n a Q U. z U a o W0 , O �