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HomeMy WebLinkAboutMiscellaneous - 105 HIGH STREET 4/30/20181` Date ....21111 .......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that !74.za ....... ..................... has permission for gas installation ..... &11 -en - in the buildings of at ... A)-,677- .14 ::::.:� :::::::::::::: ...ic. No. Check # /W 9005 ............................................. I ........................... ................. North Andover, Mass. GASINSPECTOR DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER ,-ABORATORY COCKS MAKEUP AIR UNIT OVEN `FOOL HEATER ROOM / SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES IM NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY E] BOND (� OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER © AGENT El SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate tot best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian Rh all Pe t vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME j� w,�� _ LICENSE # 1 J e4 MGNATWE MP OQ MGF EI JP ® JGF LPGI�_ CORPORATION ©#-- PARTNERSHIP ®#= LLC [J# COMPANY NAME: ADDRESS 11, /� STATE ZIP TEL CITY r� .cc.�-tam. _ _ �L�R - FAX!_ CELL IL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY o . a MA DATE F T' PERMIT # JOBSITE ADDRESS _ OWNER'S NAME �Z(SA GOWNERADDRESS TEL- IFAXI TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL [ EDUCATIONAL RESIDENTIAL CLEARLY NEW: Q RENOVATION:E] REPLACEMENT: PLANS SUBMITTED: YES E3" NO Q APPLIANCES 7 FLOORS -BSM 1 2 3HE 4 5 6 7 8 9 10 11 12- 13 14 BOILER BOOSTER CONVERSION BURNER I�( COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER ,-ABORATORY COCKS MAKEUP AIR UNIT OVEN `FOOL HEATER ROOM / SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES IM NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY E] BOND (� OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER © AGENT El SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate tot best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian Rh all Pe t vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME j� w,�� _ LICENSE # 1 J e4 MGNATWE MP OQ MGF EI JP ® JGF LPGI�_ CORPORATION ©#-- PARTNERSHIP ®#= LLC [J# COMPANY NAME: ADDRESS 11, /� STATE ZIP TEL CITY r� .cc.�-tam. _ _ �L�R - FAX!_ CELL IL H O Z O H U W a w � �q o a z 00 y� W } F- W EO-+ a Z a* � a w CO w o. O w w w w � a g a a Q U J H °- a CO w x w F LL V) H z 0 H U a a The Commonwealth of Massachusetts - Department of IndustYud Accidents Office of Investigations quo 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly NaMe (Business/Organization/Individual): N I MA 4L44 Address:_ City/State/Zip: L� #YA)til Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees and/or part-time).* have hired the sub -contractors 6. F1 New construction 2. (] I am a sole proprietor or partner- listed on the attached sheet. 7• ❑ Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.E1 Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12.E] Roof repairs insurance required.] i employees. [No workers' comp. insurance required.]13.❑ Other !Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. i -Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby cert& u r the pain enalties ofperjury that the information provided above is tr�uee and correct Sienature: Date:' o�/ Y /� '% Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitUcense # Issuing Authority (circle ane): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. AIso be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of ,Musach- wetts Department of Industrial Accidents Office of Investigation& 600 Washington Stroet Boston., MA, 02111 Tel, # 617-727-4900 ext 406 or 1-877,MSS.AFB Revised 5-26-05 Fax # 617-727-7749 www.mass.gov1dia From: Nancy Greenwood Fax: +1 (978) 794.5409 To: N Andver RE: Jim Hu! Fax: +1 (978) 688-9542 Page 2 of 2 0113112014 9:36 A00rx,c►CERT'IFICAT`E Off' LIABILITY INSURANCE DATE(N�JI/DLY1 CERTIFICATE MAY B1= r",SUCD OR MAY PERTAIN, THE INSURANCE AFFORDEI:) BY -rFE POLICIES UESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_. 1/31//'14 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE H THIS CER71FICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OI. ALTER THE COVERAGE. AFFORDED BY THE POLICIES BELOW. THS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORMED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORT'AN'T. If the certificate holder is an ADDITIONAL INSURED, the policy(fes) must Ise endorsed. If SUBROGATION IS WAIVED, subject tothe feigns and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such end®rsemepgs), PRODUCER CONTACT NAME: — Nancy Greenwood Ins. Agency —_ FAX — PHONE 11 Haverhill $treef ( xQ14�(978) 683•-7676 Nn (978) 794-5409 '- - Mathuen, MA 0184 •ma ADDRESS; 1`fancy,@Nan YGreenwood. con �'�— ��_ INSLIMMS)AFFORDING COVERAGE I NA(C* DAMAGE TO RENTED �REMI$ES �e occurrence INSURERA.-Nor Mand InsurahCe MED EXP {Arryoneperson) --._._.. _.. ...�....__.... •---•—_.......... —...... ...-... .. INSURED �— ..__. INSURER B. _ James M Hurley dba _ _ Hurley -,Plumbing 6 Heatincj PO Bos 396 INSURERC: fNsuRIERn: -- N Andover, MA 01845 1NSURER E: __ _ -'—` _$ 1 , 000, QOO INsuRCRF. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY B1= r",SUCD OR MAY PERTAIN, THE INSURANCE AFFORDEI:) BY -rFE POLICIES UESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_. LTR TYPE OFINSURANCE INSR SUBR PQLICY EYF Pl)l1CY ET(Fi IN R PQIJCV NUMBER MMIDON MmwioG YYW LIMITS A GENERALLIABILITY WS194595 � 3.2/16/13 1.2/16/14 EACH OCCURRENCE - 11000,000$ $ XCOMMERCIAL GENERAL LIABILITY CERINS MADE ON OCCUR I DAMAGE TO RENTED �REMI$ES �e occurrence i S 00, 00 MED EXP {Arryoneperson) JI $ 5.000 PERSONAL & ADV INJURY _$ 1 , 000, QOO GENERA.LAGGREGATE $-2 r 00� 0©0 GEN'LAGGREGATELIM!T'APPL!ESPER PRODUCTS-COMNOPAGG $ 2 000,000 ...._ _. PRO- LOC POLICY Is AUTOMOBILE LIABILITY 1 COMBINED SINGLE LIM . Ea accirJan! _ - $ � — I ANYAUTO BODILY INJURY (Per porsan) $ ALLOWI,ED SCHEDULED I _ AUTOS AUTOS ; BODILY INJURY (Per ( ) $���— NON -OWNED LHIREDAUTOS AUTOS I _ PROPERTY DA?6%, GE eracaderr $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE OCCUCLAIMS-MODE $ FICCESS UAB � AGGREGATE ` $ T ( DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ( WC 6rATU= I OTH- Y -LIMITS --- -EJR-- Y 1 N L_EACH ANYPROPRIEMR/PARTNERIEXECUT(VE EXCLUDED? �N/A E.L. DISE %$E -EA ENIPI.OYE aMEMBER In NH) II s,descrlbeunder $ E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS below ! I &SCRFPTIONOFOPERATIONS / LOCATIONS IVEHICLES (Adacth ACORD 101, AcKtional Remarks Schedule, if Mona space isrequired) Town of North Andover 120 Main Street North Andover, MA 01845 t, AW 4C LLA 1 I U N SHOULD ANY OF THE ABOVE DESCRIBEDPOLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTI•IORIZED REPRESENTATIVE 1988-2010 ACORD CORPORATION, All rights reserved. ACORD 25 (2010105) The ACORD name and Ingo are registered marks of ACORD Phone: (978) 688-9500 Fax; (978) 688-954.2 E -Mail: v i Location f No. c;23 J Date �� a ,l i Check # \6- g .i 765U TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ �• �/ Building Inspe6r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATf2 OR DEMOLISH A ONE OR TWO FAMILY DWELLING d' BUILDING PERMIT NUMBER: C:22 z DATE ISSUED: SIGNATURE: 11a -Pjj Bulldin Commissione for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: ' WAN 1.2 Assessors Map and Parcel Number: i 1 1 1 Map Number Parcel Number N • 131' �.� V `''�' 1.3 Zoning Information: Zoning Distridl Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS 00 Front Yard Side Yard Rear Yard Required Provide Required Provided Rered Provided 1.7 Vater Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SE�.TION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT ! s ;71c District Yr NO 2.1 bwner of Record Name (Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Si nature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 1;A -ensed Construction Supervisor: Licensed Construction Supervisor: Ad ess � (Jz,,�- Telephone Not Applicable 0 License Number t-7 aQ Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature_ Telephone 0 z M 90 0 mn ic aas rn r _r rz a SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes ....... No ....... ❑ SECTION 5 Description of Proposed Work check as a Ucable New Construction 0 Existing Building ❑ Repair(s) Alterations(s) 0 Addition 0 Accessory Bldg. ❑ Demolition ❑ Other 0 Specify Brief Description of Proposed Work: �C (� r I WCTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Completed by permit applicant OMCUL USE ONLY 1. Building (a) Building Permit Fee Multi lier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) // (p.� 4 Mechanical HVAC 5 Fire Protection 6 Total (1+22±DCheck Number IOWNEN AGENT,OR CONTRACT( J APPL9S F UILDING PERMIT i I, __ , as Owner/Authorized Agent of subject property K.y>behal byriz _ to act on matt o w rk auth y build ng permit application z , /0 Si i re of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief -eA �'J G P J Print me � � � �A Signature—of—Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS i S7 2 ND 3Fw SPAN DINIENSIONS OF SILLS DIlVIENSIONS OF POSTS DM ENSIGNS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND _ IS BUILDING CONNECTED TO NATURAL GAS LINE North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: �� r� -?- A �r6ility Signat e07; Applicant Date NOTE:. Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector E o R M h N coo `o x W O _ .�`. h 0. C U, dZO M Q U co o i. n j� m rn o LL cn ,i k O Z to00 o LO it U 0 +k m Z aZ� �J) J m Quo j- =�Q :.. •, Im- �0 sh, Q M ^ A ACORDM CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YY) 09/21/2004 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION M . P . ROBERTS INSURANCE AGENCY INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 060 OSGOOD STREET HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. ORTH ANDOVER MA 01845 978-683-8073 INSURED ARTHUR ALLEN CONSTRUCTION 369 WAVERLY ROAD NORTH ANDOVER, MA 01845 COVERAGES INSURERS AFFORDING COVERAGE INSURERA: UNDERWRITERS AT LLOYDS INSURER B: INSURER C: INSURERD: APPLICATION MADE TO: MWCARP INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR I TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DDIYY POLICY EXPIRATION DATEMM/DDIYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE � OCCUR LGL045009 05/28/04 05/28/05 EACH OCCURRENCE $1,000, 000 FIRE DAMAGE (Any one fire) $ 50, 000 MED EXP (Any one person) $ 5, 000 PERSONALBADVINJURY $1,000,000 GENERAL AGGREGATE s2,000, 000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC JECT PRODUCTS - COMP/OP AGG s2,000, 000 AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per person) HIRED AUTOS NON -OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS LIABILITY OCCUR ❑ CLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ $ DEDUCTIBLE RETENTION $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY TO BE ASSIGNED T / B / D T / B / D STATUTH- ORY L MITS X OTR E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 OTHER nF_q :RIPTlnfJ nC nPFRATln.Ql. ----...... CERTIFICATE HOLDER ADDITIONAL INSURED; INSURER LETTER: CANCELLATION TOWN OF NORTH ANDOVER BUILDING INSPECTOR 27 CHARLES STREET NORTH ANDOVER MA 01845 ACORD 25-S (7/97) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR © ACORD CORPORATION 1988 CONTRACTORS INVOICE WORK PERFORMED AT provided for the above work and was.completed in a substantial workmanlike manner for the agreed sum of Dollars {$ Thisisa OPartial 11. FulU invoice due and payable by: Month Day. Year in- accordance, with our El Agreement. Proposal No. Dated Month Day Year IiN., CJ822' CONTRACTOR'S INVOICE -79q 3 S 3 provided for the above work and was.completed in a substantial workmanlike manner for the agreed sum of Dollars {$ Thisisa OPartial 11. FulU invoice due and payable by: Month Day. Year in- accordance, with our El Agreement. Proposal No. Dated Month Day Year IiN., CJ822' CONTRACTOR'S INVOICE y m x m m y m CO) F, Cl W C � CO) CM) 10 0 CD n Z y E; O �• � � O C. y aCc "oo d C C:j CD CD o �F CLQ CD CD CD C CD V�• �. CD C. 0 y �• O �C C S v CO)10 O CD z O CD CCD LUA MC O m m Ml 0 O y Cl) rn it rn CA _ t I �m m 3 m N 4 m oCL H z p7 CO) _� Q .� a �CD m IE m N z n O m % O 9 4 CW z n b z � � vz N M v z 0 0 omi 0 0 c No 2671 Date......... /... �o- TOWN OF NORTH ANDOVER 00 PERMIT FOR WIRING This certifies that 'b ... qS 2 ....................... S ............... ......om...e ................... G........ has permission to perform..... ....... 1.SS................................... wiring in the building of 1�."........... e f J ........� . I ................................................ �, s� at w.s..............'..� orth And KS /.... .................. . ��i� Fee ....�5.... ... Lic. No. l � 1 .............. !!........................ C/ �) ECTRICAL INSPECTOR Check # .� J �v WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Commonwea& oladjac�nujejfs Official use Only c� e7 Permit No. 9 / k� _LJepart?ncenf o�,}ire-erviczs BOARD OF FIRE PREVENTION REGULATIONS [ROccupancy and Fee Checked —_ ev. 1 1, 99] t}cave blank) -- APPLICATION! FOR PERMIT TO PERFORM ELECTRICAL WORK Ail work to be pert'ormed in accordance with the Massachusetts Electrical Code (j.tEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYP t :t L itV('OR 'l710N) Date: `0D City or "Town of: To the IIIS12 to of Wires: By this application the undersigned gives noticeql77his or her intention to perform the electrical work described below. Location (Street & Number)_ C�� a ( 4. Owner or Tenants/ VIL Telephone No. Owner's Address Is this permit in conjuuctioi with n building, permit? Yes ❑ No (Cluck Appropriate Box) 1'urliosc of 13uilding1' Utility r\uthorizatiou No. Existing Service Amps / Volts Overhead ❑ Und2rd ❑ No. of Meters . New Service Amps / Volts Overhead ❑ Undgrd ❑ i\'o. of tileters ,a Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: con !e inn n%x.. rho � 11,....:..,. 1.1 No. of Recessed Fixtures -- - , ...1-1111 No. of Ceil.-Susp. (Paddle) Fans --. ,,,« • ue- nu:vea ov urc Ills ccror of No. of 'Total Transformers KVA No. of Lighting Outlets No. of Hut Tubs Generators KVA No. of Lighting Futures Swimming Pool Above ❑ In- ❑ b grad. arnd. t o. o inergeIlcy Ib lllllg Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARi•IS No. of Zones No. of Switches No. of Gas Burners NO. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Tota] Tons No. of Alerting Devices a No. of Waste Disposers Heat Pump Totals: Number Ions K1V _ I - No. of Self -Contained Detection/Alerting Devices No. of Dislii'Yasllers Space/Area Heating KIV Local ❑ Municipal Connection 0 Other No. of Dryers Heating Appliances K1V Security Svstems: No. of Devices or Equivalent No. of Water Kly. Heaters t`'o. of r\o. of Suns Ballasts D:, t:r ;firing: No. of Devices or Equivalent No. Hydromassage Bathtubs INo. of Motors Total HP I'eleconmiunications Wiring: No. of Devices or E uiv-lent OTHER: Ifttacll additional detail if desired, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the license-, provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is iii force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ 0.1•I-JER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: IQ apd0 Inspections to be requested in accordance •.with ivIEC Rule 10, and upon completion. I certify, tinder the pains and penalties of perjury, that the information air this application is trite and complete. FIRM[ NAME: 8 i nks tiome, SeC LIC. NO.: C , l Licensee: Ha( K J sw I ✓ts-f-r SignatureP L1C. NO.: �,SCI)'�QOSgS (If applicable. enter 1 e. empt - i1 the license number line.) Bus. Tel. No. l8 - 1C 5�' DU 4 3 Address: 155 AIt.Tel.No.: �DR"81.-- 8q OWNER'S INSURANCE WAIVER: I am awaM that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, 1 hereby waive this requirement. I am the (check one) ❑owner ❑owner's anent. Otivncr/r\ycnt Signature Telephone No. Fp7ii�fIT FLL: S