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HomeMy WebLinkAboutMiscellaneous - 104 MILLPOND 4/30/2018r� Date.l� ..G.� �...... a TOWN OF NORTH PERMIT FOR GAS IN; This . certifies that ..Cry has permission for gas installation .Tr.. ....................... . in the buildings of...&iA,� .......................... ... . at ..p. �(../�!�. �. �..��.' . �.. ....... , North Andover, Mass. Fee. r Lic. No9' 'GAS INSP Check # 26 pq /-/- 6621 6621 =lVTl 10=0 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town:, Nb , r1� Jar Date: Permit# tj G 1 I J Building Locatic 10 Ll Owners Name:. 3i_.6,40 Type of Occupancy: Commercial Educational Industrial Institutional Residential New:, Alteration: Renovation; Replacement: Plans Submitted: Yes No O =lVTl 10=0 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ✓ No If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy I/ Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner Agent By checking this box ❑ 11 hereby certify that all of the details and Informal I have submitted fo42f tered) re rding this application are true and accurate to the best of my Knowledge and that all plumbing work and Instal t ns perfo uhe pe Issued for this application will be in compliance with all Pertinent provision of the Massachusetts State P bi de and ha to 1 the eneral Laws. Type of License: By Plumber Title Gas Fitter Master Signature o Licensed F4u er/Gas Fitter City/Town Journeyman License Num er: , 15137M APPROVED OFFICE USE ONLY) LP Installer x x CO) � Q x ® O W 0 U O 1— x x W Z I- ® O O 0. w x 2 p a- W y W W Z m O ~Q d H G W O x W pn X W F- x Q W U) W W 0h- z 9 to a W O W H Z G x L. W x � x w J Q B W O Z O W 2 x V a 0U' (x9 = Qm = J ® a Q x w IW— Z > � O SUB BSMT. BASEMENT 1 FLOOR }2 FLOOR 3 FLOOR 4 FLOOR WH FLOOR 6 FLOOR 7FH FLOOR 8 1HFLOOR Installing Company Name:: Central Cooling &Heating, Inc. Check One Only Certificate # Corporation 2806C Address:; 9 North Maple Street City/Town:. Woburn State:. MA Partnership Business Tel:. 781-933-8288 Fax: ' 781-932-9017 Firm/Company Name of Licensed Plumber/Gas Fitter:<_Mike Bemasconi INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ✓ No If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy I/ Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner Agent By checking this box ❑ 11 hereby certify that all of the details and Informal I have submitted fo42f tered) re rding this application are true and accurate to the best of my Knowledge and that all plumbing work and Instal t ns perfo uhe pe Issued for this application will be in compliance with all Pertinent provision of the Massachusetts State P bi de and ha to 1 the eneral Laws. Type of License: By Plumber Title Gas Fitter Master Signature o Licensed F4u er/Gas Fitter City/Town Journeyman License Num er: , 15137M APPROVED OFFICE USE ONLY) LP Installer z / \ \ $ \ / � � 3 w \ ) 0 \ ) \ \ ) § . m [ ZR @ o 2 \ \ ^ � § § \ E z 0 IT, § $ $ § ..I k . The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Map # Lot # 600 Washington Street Address: Boston, MA 02111 Permit # www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Cie ntf& I (Cv\,i r+±i ng! 71r Address: ly Sn F City/State/Zip:- \1,16Sa to l�,p� 618 ► Phone #: Tl lb 1- 933 - € a g J3 Are you an employer? Check the appropriate box: 1. E0 I am a employer .with 4. E] 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. ship and have no employees 'These sub=contractors have working f6r me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. required.] 5. E] We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL t insurance required.] t c. 152, §1(4), and we have no employees. [No .workers' -- - comp. insurance required.] Type of project (required): 6. ❑ New construction 7. 0 Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.0 Roof repairs 13.El Other CgQ C *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 state whether or not those entities have employees. ff the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: LO 1 I�NSUR.ndCE NEI-06kkt TNC Policy # or Self -ins. Lic. #: QT66U `2 (2� , r Expiration Date: (1 36 1,7- 00�' Job Site Address:—/ -6 �% Ill /I �'l1) City/State/Zip: Ald , ItrL6rr 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 I doereby i.0 under the pains and penalties of perjury that the information provided above is true and correct. 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) alsor. 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 nuinber(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 carryworkers' compensation 'insurance. If an LLC or LLP does have employees, a policy is required. Be.advised that this affidavit miy be siibmitted 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 Industria.TAccidents. Should you have any questions regarding'the law or if you are requited 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/licen'se'e' 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. Anew 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 io give us a'call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Omee of Invest gat ons 600 Washington Street Boston, MA 02111 Tel. # 617-727-49Qo ext 406 or `1-877-MASSAFE Revised 11-22-06 Fax # 617-727-7749 - www.mass.gov/dia r x Date . .. G1' '. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .��..`" !`......... 6.L`...Z l has permission to perform...r.!�......................... . !©��v plumbing in the buildings of .. �� ........ ...................... at ... c� .. '/?! .0 . �...%�p ............. ,North Andover, .Mass. Fee.62 .... Lic. No../ ).l 3.?. ..........�....:.. . PLUMBING I�CTOR Check # 7925 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING L (Print or Type) - City/Town:.Nd' r Permi# Building Locatic .. _ �__ i_ ....._ .._. _ __ Owners Name::.. Type of Occupancy: Commercial; Educational` Industrial! Institutional r Residential' New:j Alteration:; Renovation,` if Replacement:; V` Plans Submitted: Yes No, ® ' SUB-BSMT. BASEMENT 1ST FLOOR 2ND FLOOR i 3RD FLOOR 4TH FLOOR 4 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Check One Only Certificate # Installing Company Name Central Cooling & Heating, Inc. Corporation ' 2806C --- Address:,: 9 North Maple Street City/Town:i Woburn { State.: MA , ! c M _ Partnership Business Tel: ; 781-933-8288 Fax: ; 781-932-9017 Firm/Company`. Name of Licensed Plumber/Gas Fitter Mike Bernasconi n INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes' ± No If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy' �/' Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner Agent Sionature of Owner or Owner's Aaent k By checking this box LJ; I hereby certify that all of the details and accurate to the best of my Knowledge and that all plumbing work compliance with all Pertinent provision of the Massachusetts Stat I have submitted (ore red) regarding this application are true and Ionspe�fo d and the rmit issued for this application will be in :ode . n hap r 1 2 of thib General Laws. z; Type of License: f By- .:. .. ., . i t Plumber Iii V Title C Gas Fitter i ignature f Licensed Plumber/Gas Fitter Master City/Town',_Journeyman �3� � . _�,- j License Nu ber. 15137M APPROVED (OFFICE USE ONLY) LP Installer -,-4 FIXTURES z PWoz w .J M : i Q (n IQ - D 0 W W N R Z rn H W . 9 x w z O Z CL z W O M W Q� M Q Q W D a J Z QQ Q a O X LL w x Q `_ = O z x Y a Op I— Q Y Q w° LL W I— �25m U> O n®o5�=IQ- N a n rn H Z O i�<Woa O to z z w l- p °�< V= o SUB-BSMT. BASEMENT 1ST FLOOR 2ND FLOOR i 3RD FLOOR 4TH FLOOR 4 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Check One Only Certificate # Installing Company Name Central Cooling & Heating, Inc. Corporation ' 2806C --- Address:,: 9 North Maple Street City/Town:i Woburn { State.: MA , ! c M _ Partnership Business Tel: ; 781-933-8288 Fax: ; 781-932-9017 Firm/Company`. Name of Licensed Plumber/Gas Fitter Mike Bernasconi n INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes' ± No If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy' �/' Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner Agent Sionature of Owner or Owner's Aaent k By checking this box LJ; I hereby certify that all of the details and accurate to the best of my Knowledge and that all plumbing work compliance with all Pertinent provision of the Massachusetts Stat I have submitted (ore red) regarding this application are true and Ionspe�fo d and the rmit issued for this application will be in :ode . n hap r 1 2 of thib General Laws. z; Type of License: f By- .:. .. ., . i t Plumber Iii V Title C Gas Fitter i ignature f Licensed Plumber/Gas Fitter Master City/Town',_Journeyman �3� � . _�,- j License Nu ber. 15137M APPROVED (OFFICE USE ONLY) LP Installer -,-4 v c z z CO 'v m A -- _o -a n m Q, z z � o m T p W T C a) O F z v G7 z D, m � m r n O Z O � Z O v 0 r C W. Z <� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFiTTING lt!✓� (Print or Type) Mass. Date zz1dU Permit* Building Location l / C h Owner's Name i /r9 Type of Occupancy G New k Renovation ❑ Replacement ❑ . Plans Submitted: Yes❑ ' No ❑ Ins`alling Company Name Check one: Certificate u Address ❑ Corporation 7 G i Q ❑ Partnership Business Telephone G - S Firm/Co. Name of Licensed Plumber or Gas Fitter =s��/^'C' 'CGI�/rl�lii INSURANCE COVERAGE: I have a curr t liability insurance policy or its substantial equivalent which meets the requirements of MGI_ Ch. 142. Yes I& No ❑ It you have checked ye, please indicate the type coverage by checking the appropriate box A i)abiilty insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 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 best of my knowledge and that all plumbing work and installations performed under the permit issued for Ws application will be in compilance with ail pertinent provisions of the Massachusetts Stale Gas Code and Chapter 142 of the G79t;e� Fvlt'6; T e of Ucense: Plumber S ature o cense er at Gas, ,iter Gasritter Master Ucense Number cwn Journeyman (A NW N N N V. V — s „1 U3 W C N H O eJ d W0 C Q O. .O O1- C O tau N t7 ar 4= f- H p W W C7 ... }• T J J �- F' 1• }• W S W Q G O sl ur W f V W us W < s< i O O W a• O t}ot tL 3 O O J 0 C > o a F- O SUB—BSMT. BASEMENT I I I ST FLOOR , I 2N0 FLOOR 2R0 FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR I i I ( I STH FLOOR I i I I Ins`alling Company Name Check one: Certificate u Address ❑ Corporation 7 G i Q ❑ Partnership Business Telephone G - S Firm/Co. Name of Licensed Plumber or Gas Fitter =s��/^'C' 'CGI�/rl�lii INSURANCE COVERAGE: I have a curr t liability insurance policy or its substantial equivalent which meets the requirements of MGI_ Ch. 142. Yes I& No ❑ It you have checked ye, please indicate the type coverage by checking the appropriate box A i)abiilty insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 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 best of my knowledge and that all plumbing work and installations performed under the permit issued for Ws application will be in compilance with ail pertinent provisions of the Massachusetts Stale Gas Code and Chapter 142 of the G79t;e� Fvlt'6; T e of Ucense: Plumber S ature o cense er at Gas, ,iter Gasritter Master Ucense Number cwn Journeyman a. Date . .y 2443 ,LORTIy TOWN OF NORTH ANDOVER OF tao ,^gti0.t PERMIT FOR GAS INSTALLATION Xy. } /. r This ce=rtifies that .... .. . . a has permission for gas in talla 'on . in the buildings of li 1. < ..t! t j'• ........ ... . n: L at . �D. . .... . ..... , North Andover, Mass. Fee.. Lic. No. r i7 15:06 �3p (� .... . c / F GAS INSI; C(!%A WHITE: plicant CANARY: Building Dept. PINK: Treasurer GOLD: File MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO•DO PLUMBING (Printf or Type))- , / 2614i/&Z�� , Mass. Date 01 020 19 18 Permit #V<-�wxl_3 Building Location 16 y %Lii/� /'Dii6� Owner's Name ( )h Ike ;y Type of Occupancy kj New ❑ Renovation ❑ Replacement 19 Plans Submitted: Yes ❑ N01 FIXTURES Installing Company Address_ q6 I e 9_ MA. Ol4 $3 Business Telephone Sog- n7- aa& Name of Licensed Plumber `nC ` Check one: Certificate -Corporation aQ 89 ❑ Partnership ❑ Firm/Co. INSURANCE COVERAGE: have a current I- bility Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checkedrimes, please indicate the type coverage by checking the appropriate box. A liability Insurance policy )2< Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter. 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Anp.nt 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 the permit issued for this ap lication will be in compliance with all pertinent provisions of the Massachusetts State PI mbingCod Chapter 14Z of the Cerner gy L/l Title ig ature of Wensed Plumber City/Town Type of License: Maste� Journeyman APPROVFr) nFFI(F i KP fW vi 1 od.... __ r/0 " Y • • ■NAREENEENEENnIOtEENInne®■ ■EEMINNsEnn NONE on mom EK4j.. ••• W®oNININIn mom n0■ mom NONE . ... ■■SEEMEN®a® on ONEENEnnIOn■ .. ■■®��o��■®®��ol��������NON■ Installing Company Address_ q6 I e 9_ MA. Ol4 $3 Business Telephone Sog- n7- aa& Name of Licensed Plumber `nC ` Check one: Certificate -Corporation aQ 89 ❑ Partnership ❑ Firm/Co. INSURANCE COVERAGE: have a current I- bility Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checkedrimes, please indicate the type coverage by checking the appropriate box. A liability Insurance policy )2< Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter. 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Anp.nt 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 the permit issued for this ap lication will be in compliance with all pertinent provisions of the Massachusetts State PI mbingCod Chapter 14Z of the Cerner gy L/l Title ig ature of Wensed Plumber City/Town Type of License: Maste� Journeyman APPROVFr) nFFI(F i KP fW vi 1 od.... __ r/0 " m o y X m 0 m y D In V m v m .r A � o z o 0 ((� (v�' ,n m z D 0 - r v 0 V r c N N Z O v m n 0 z N m o y X m 0 m y D In V m v m .r A � o z o 0 ((� (v�' m m 0 v 0 V r c N Z O V w O O m N N z N V m A -•i O z N C13 m r- 0 0 w O 'n -n A m c N m 0 Z r -c '3613 Date ���� . / � ` TOWN OF NORTH ANDOVER A PERMIT FOR PLUMBING Vro d g SgACMUSi t /�� N This certifies that.y ............. /.... ..... . has permission to perform ... . . .... plumbing in the buildings of ti at .. y?-'............. ,North Andover, Mass. 0 Fee%gf ..... Lic. Nc O I/.. ....... 0 PLUMBING INSPECTOR C WHITE: Applicant CANARY: Building Dept. PINK: Treasurer j. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Punt or Type) • — © e , Mass. Date 19 Permit # Building Location AT e/ %VJf/l/' G'� a Owner's Name Type of Occupancy h., New Ig• Renovation ❑ Replacement ❑ Plans Submitted: Yes ❑ No ❑ B.P.# SEWER# FIXTURES SEPTIC# Installing. Company Name ��Ui� ,�oL�•�� Business Telephone ill- l5 X-- 7e/ f/ Name of Licensed Plumber .,r/2;L Check one: ❑ Corporation ❑ Partnership 5' Firm/Co. Certificate # INSURANCE COVERAGE: I have a currQrlt liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142- Yes 42Yes ® No ❑ If you have checked Yes, please indicate the type coverage by checking the appropriate box I A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Aaent Owner ❑ Agent ❑ I hereby certify that all of the details and information 1 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 der the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing � Chap r 142 of th ral Laws. Title Si ure of Licensed Flumbeir CRY/Town Type of License: Master [a Journeyman ❑ APPfiOVED O FIC US ONLY) License Number Z6 2 Z t17 Y Q • y O N f— Vf N N O Z >0 1a CL �= V N Z � N Cf S � W r UQ W < N = � a Q N t7 Q ¢ a a �, ¢ 3 Q E •r{ Cs UJ O O ¢ W a cc W —° Z C W t- > tz- o s - o a y z z w {6 o m Y -s o a Z, a s s. M a C a u SUB—BsMT. BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing. Company Name ��Ui� ,�oL�•�� Business Telephone ill- l5 X-- 7e/ f/ Name of Licensed Plumber .,r/2;L Check one: ❑ Corporation ❑ Partnership 5' Firm/Co. Certificate # INSURANCE COVERAGE: I have a currQrlt liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142- Yes 42Yes ® No ❑ If you have checked Yes, please indicate the type coverage by checking the appropriate box I A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Aaent Owner ❑ Agent ❑ I hereby certify that all of the details and information 1 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 der the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing � Chap r 142 of th ral Laws. Title Si ure of Licensed Flumbeir CRY/Town Type of License: Master [a Journeyman ❑ APPfiOVED O FIC US ONLY) License Number Z6 Date l .. 7 I Tly 3236 ,%ORTFI TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING S 5 This certifies that ...... . . .......... has permission to perform ......... Plumbing in the buildings of .. �) . .. ........................ at. . . .......... North Andover, Mass. Fee�?� ..... Lic. No..../. -45i4 ........................... PLUMBING INSPECTOR 02120AW16�17 25.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer �.� Date.................................. TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that ..0.. i- r ............................... ........ ............................... has permission to perform ...... A V e � �`PP f A ('W -A OA.. .............................................................. wiring in the building of ... . 7��."i m e I A n.) 2 'E C A' ................................................................... b at ...... �.I /I I. ............................. ,North Andover, Mass. n Fee .�....... Lic. No. o� `i ..........., ..............................:.:.......................... ELECTRICAL INSPECTOR Check # jm-2r 5287 J THE COADIOA HEALTHOFAlASS4CHUSE7TS Office Use Only DEPARTMEAT0FPUBLICS4FL7Y1 Permit No. BOARDOFFMEPREVE MONREGULW NS527CM 12.VO Occupancy & Fees Checked APPLICATTONFOR PERMFFTO ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE D (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Town of North Andover The undersigned applies for a permit to perform the electrical Location (Street & Number) Owner or Tenant r� FORMELECTRICAL WORK JSSTS ELECTRICAL CODE, 527 CMR 12:00///,z Date �sy To the Inspector of Wires: below. Owner's Address s --- 5� /Y®� Gir'✓>.�a�►'ry�'Y / /� �%/may!: Is this permit in conjunction with a building permit: Yes r-711 No r1 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service % Arhp§ Volts OverheadUnderground No. of Meters New Service %y Amgs�®S/%%C�Volts Overhead Underground �/ No. of Meters —�-- Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA round 2round No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners No. of Ranges No. of Air Cond. Total FIRE ALARMS No. of Zones Tons No. of Disposals No. of Heat Total Total No. of Detection and Pumps Tons KW Initiating Devices No. of Dishwashers Space Area Heating KW N9. of Sounding Devices N.' of Self Contained Detection/Sounding Devices No. of Dryers Heating Devices KW Local Municipal Other Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP THER;,. uw=Covaage. Pananttothe oTmetnentsofMassachu�sGenerallaws aveaamentImbhtyhmua=Fbhcyiw xhngComp CoverageoritsatsMdalegivalax YES NO avEsubmitrodvalidploofofsametothe Ot YES r Ifyouhavec11ec1�dYES,p thetypeofmvtrageby �g the bo SURANCEE BOND MIM F-1 ( Specify) EVirationDate Edd ValueofEleddcal Wolk $ xktoStart y hispewonDateRNuested Rough Ffflal ZZ0 wdunderTiePalaltieso perjury: MNA E l f �� Lioasf--No. i% �Jl� /4%l7UU/� Signahuz LiemseNo ��'•�0�5'/' BUWk-SSTelNo. y� A37� `;*-URANCEW(- I am awaethat tbeLicene doesnothave the uiam=cowrageorits abstantialegtu4entaslagnaedbyMassachusenGefletalLaws that my signahue on this permit application waives this It ;ase check one) Owner = Agent ® �� Telephone No. Igna ure 7T Owner or Tgent PERIMITT FEE $ The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. ComDanv name: Address City: Phone #: , Insurance. Co. Policv # Company name: Address 1. Cily: Phone #: Insurance Co. Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years' imprisonment_as welLas_civil.,penattiesjn.lhe%rm of-a_STOP WORK ORDER.,w.d_a.fine.of_(.$1DO.DD)_aliayagainst..me. understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name P.hone.# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing ❑ Building Dept ❑Check if immediate response is required ❑ Licensing Board ❑ Selectman's Office Contact person: Phone #: ❑ Health Department ❑ Other, i i4t( 0mmaweat of Massa us wf ����rtts Office Use Only "" `J "`w""PUW Welty Permit No. , BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy 6 Fre Checked MW (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK MI work to be performil in accordance with the Massachusetts Electrical Code, $27 CMR 11:00 (PLEASE PRINT IN INK OR TYPE ALL INFORAAATIOPQ Date_ Y*') A ,� / /�, ✓1/?lfl r 1/2 ,i - City or Town of / /[J/ / / / / ✓ / /%,J C, The undersigned applies for a permittoperi, doe electrical work Location IStreel d Number) M IW D Owner or -Tenant rJA Owner's Address / Is this permit in conjunction with a bun permit Yes 0 No To the Inspector d Wires) (Check Appropriate Box) Purpose of Building I Utility Authorization No. Existing Serdce 1 -Ir i v Amps J1h0J�&ZVolts Overhead U Undgrd LJ No. of Meters New Service --Amp / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity /� /� /�� /% �j� Location and Nature d Proposed Electrical weak l tY� (;lJf / ZQI -�l:lien Sze sJ OTHER: FEB 2 4 1997 INSURANCE COVERAGE: Pursuant to the requi- metes of Massachusttes General Laws I have a current liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES n NO f_l 1 have submitted valid prod ut same to this office. YES U NO U If you have checked ES, please indicate the type of oowrap by checking the appropriale box. INSURANCE U BOND ❑ OTHER❑ (Please Specify) ,(Expiration Date) Estimated Value of Electrical Work S Work to Start Sianed under the oenaltfes of cerium. FIRM Llcens( lddres Mtspection Date Requested: Rough Final LIC. NO. 7-3 LIC. NO. No. L _ & Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts ,eneral laws, and that my signature on this pwn* application waives this requirement. Owner Agent (Please check one) Tdephoht No. ! PERMIT FEE f (Signatwe of Owner or AgmW TOTAL No. of lighting Outlets No. of Hot Tubs No. of Transformers KVA AboveIn- No. of Lighting Fixtures Swimming Pool grnd. 1:1md. El Generators KVA No. ol Emergency Lighting No. of Receptacle Outlets No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Total No. of Ranges No. of Air Conditioners Tons Initiating Devices of Sounding Devices No. of Self Contained DetectiordSounding Devices Municipal Local❑ Connection ❑Other No. of Disposals Heat Total totalNo. No. of Pumps Tons KW No. of DishwashersSpace/Area HeatingMunicipal KW No. of Dryers Heating Devices KW No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. H dro Massae Tubs No. of Motors Total HP OTHER: FEB 2 4 1997 INSURANCE COVERAGE: Pursuant to the requi- metes of Massachusttes General Laws I have a current liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES n NO f_l 1 have submitted valid prod ut same to this office. YES U NO U If you have checked ES, please indicate the type of oowrap by checking the appropriale box. INSURANCE U BOND ❑ OTHER❑ (Please Specify) ,(Expiration Date) Estimated Value of Electrical Work S Work to Start Sianed under the oenaltfes of cerium. FIRM Llcens( lddres Mtspection Date Requested: Rough Final LIC. NO. 7-3 LIC. NO. No. L _ & Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts ,eneral laws, and that my signature on this pwn* application waives this requirement. Owner Agent (Please check one) Tdephoht No. ! PERMIT FEE f (Signatwe of Owner or AgmW :-rl;r°'Yi..ra�+r'+:lyM1t�ri,(".gt"'>,�1,Fly-4,{�'v.".-•"'�.'ay�v�r':'.--4- - -....- "t-�::�r--- ctid...�} _,r-_ �' T ,���I Date.. 142 756 31 Cs Ho �T °,�'poG TOWN OF NORTH ANDOVER. " a ' PERMIT FOR WIRING •l 1ySACMUSE< - - This certifies that........7.c, CO 5.............................�c,`� ...... has permission to perform ..... ..I.R �...... .i'.t .... wiring in the building of .......... . j at ..... Q.. .... .t....%...Y?............................ .North Andover, Mass.: 3 Fee....Lic. No../. =...3 ............: E RICALNSPECT r4 C , 03/03 2a., 25.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer .. _ t..f - ,� _� ��_.!`--'°-'.'r,�-y-•-_-�"''+-:•tet--�.�'s`'� .�.c;�r.y_�,.�:-may ,---.-.3,:,t�� LZ