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HomeMy WebLinkAboutMiscellaneous - 107 MILLPOND 4/30/2018 - - - - - 107 MILLPOND !. - - 210/095.A-0107-0000.0 �- 1 Date..... S.................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION sSgCHU This certifies that ................... has permission for gas i t np 11 ation ... ......................... inthe buildings of ........................................................................ at.......A..7...... .... . f North Andover, Mass. ................................................ J Fee.!?v.......... Lic. No. /Ip .......................... ..................................................................... GAS INSPECTOR Check# 10168 '00000,00,11�� d MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GASFITTINGWORK CITY MA DATE s, PERMIT# JOBSITE ADDRESS OWN R'S AME L&1 C( � GOWNER ADDRESS TEL — _ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIA PRINT CLEARLY NEW:[ RENOVATION: REPLACEMENTS PLANS SUBMITTED: YES Q NO E3 APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER =1I�a a I BOOSTER __ — - --- --- ----- -- L- - - CONVERSION BURNER COOK STOVE DIRECT VENT HEATER . DRYER _A--- e FIREPLACE -I L_ 1= �- FRYOLATOR FURNACE - GENERATOR _i GRILLE _ - _---.N.--- -.� - INFRARED HEATER [ I l..—-� -_=_—r LABORATORY COCKS __ MAKEUP AIR UNIT POOL-JAEATER ROOM 7 SPACE HEATER ROOF. OP UNIT —----- TEST 1 _ - _ _ -- — -TEST _JL_---=I . _ _ _ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER . — OTHER I .. INSURANCE COVERAGE — have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I rNO D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianc with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME�� C--- II LICENSE# 5 M SIGNATURE MP�MGF E11 JP E3 JGF 0 LPGI® CORPORATION[�]__J# PARTNERSHIP[3#E _=LLC®# � COMPANY NAME: r,.-ST/ i S, _ ADDRESS CITY Q �� __ STATE ZIP d?;/�... . J TEL �.� FAX CELL=�REMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION CTION N TES Yes No G �� THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES •' The Commonwealth of Massachusetts F Department oflndustrialAccidents X Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers,Compensation Insurance Affidavit.Builders/Contractors/Electricians/1'lumbers. ORITY. TO BE FILED WITH THE PERMITTING AUT ( ,)Please Print Le 'bl A '•11---i-Information Name(Business/OrgariizationAndividual): Address: y LA-,. v v /Lj & S g, JM Phone#-. City/State/Zip: �' h..,: Are you an employer?Check the appropriate box: Type of project(required): em to ees full and/or part-ti, e).* 7. ❑New`donstYuation 1. I am a employer with�. . P y or artnershi and have no employees Working forme in 8. []Remodeling , 2I am a sole proprietor p P any capacity.[No workers'comp.insurance required.] 9• ❑Demolition 3.Q I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical xepavrs or additions +'° 12T[]Plumbing repairs or additions proprietors with no employees. 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13°.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance. t 14.' Other 6.❑We are a corporation and its.officers have exercised their right of exemption per MGL c. 152,§1(4),and We have no employees:[No workers'comp.insurance required.] *Any applicant that checks box#1_must also fill out the section below showing their workers'compensation policy information. 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 attaclied an additional sheet showing the name of the sub-contractors and state whether or not(hose entities have employees. If the sub contractors have employees,they must provide their workers'comp.policy number. X am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: L)C./"j 1`` S L `2Z Expiration Date. Policy#or Self-ins.Lic.#: 1 �j 7 l`�► , / J O n City/State/Zip: A, Al d D,�r Job Site Address: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a S'T'OP WORK ORDER and a fine of up to $250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby certify under•tliepains andpenalties ofperjury that the information provided above is true and correct. Date: Signature: Phone#: Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 4.Electrical Inspector 5.Plumbing Inspector 3.Ci /Town Clerk P 1.Board of health 2.Budding DepartmentCity /Town Contact Person: Phone#: i 06 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 hlxye, express or implied,oral or written." An employer is'd'efuied as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enferprise,and including the legal representatives of a deceased employer,or the receivef'6r trustee 6f an individual,partnership,association or other legal entity,employing employees..Howeverthe owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant-who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractors)name(s),address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. B e advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of IndustrialAccidents. 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia Date.2//:: . . . ...... .. NORTH Of o X41 o� TOWN OF NORTH ANDOVER E p . PERMIT FOR GAS INSTALLATION } �9SS/1CMUSEt F Y This certifies that . . . .�:1 . . . . ip `5. . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . )C!!'.r�. ?c . in the buildings of C. /?!q (-c/'. �. . . . . . . . . 4' at .�4.7. . .�??� .t. 1. ��ti . . . . . . . . . forth Andover, Mass. Fee. .�7�. . . . Lic. No. t ���. . . . . . . I <!4sr�/L . . . . . . GAS INSPECTOR n Check# / ) V Y 7'129 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date 2 ,1�;tA NORTH ANDOVER,MASSACHUSETTS el Building Locations _/0 /',/I ! / �Q� Permit# 7 jr 9 Amount$ !�U Owner's Name ��t /� New Renovation ❑ Replacement ❑ Plans Submitted ❑ z U a a o 6. F x x c. w a a z zF w W W O .. y O > Q F Cw7 F Z .Z d x C a W F O F w d z F" F EW W C7 O > W F U .a M W Q ? F a w > w a ca z o z o x z x a a O o w x ox O U U a > SIB -BASEMENT BA SEM ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR ( 5TH . FLO O R 6TH . FLOOR 7 T H . F L O O R 8TH . FLOOR --+-f-. FF. Name or type) n )/ Q J f �ZeL / G Check one: Certificate Installing Company Address CoX 6Firm/Co.Partnusiness a ep one 117/ Name of Licensed Plumber or Gas Fitter �? D INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No❑ If you have checked ms,please in ate the type coverage by checking thee appropriate box. ❑ 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 Agent 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 installation o ed under P it Issued f this application will be in compliance with all pertinent provisions of the Massachusetts at ode and er a General Laws. By: Signat of icense lum r Or as Fitter Title ❑ Plumber f` Ci own G❑ Fitter I.,icense NuMer EaMaster APPROVED(OFFICE USE ONLY) ❑ Journeyman The Commonwealth of Massachusetts Department of 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 Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are y an employer?Check the appropriate box: 1. I am a em to er with�_ 4. TyE f project(required): P Y ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 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. [No workers comp.insurance 5. 9. Building addition p ❑ We are a corporation and its required.] officers have exercised their 10.❑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 insurance required.]t 12•❑Roof repairs Q ] employees. [No workers' comp.insurance required.] 13.[1 Other "-.rev ap t Hplicant that checks box*1 must also Ell out the section below Show Wg th v�orkea'compensation policy infor.:,adore. omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new $Contractors that check this box must attar affidavit indicating such. bed an additional sheet g ch. showing the,name of the sub-contractors;and their workers'comp. Ii information. policy >s. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can Iead 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. 1 do hereby cerizfy under the pains and penalties of perjury that the in formation provided above is true and correct. Si ature: 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#: Information an d 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 notbecause of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability partnerships(LLP)with no employees other than the y� members or partners,:are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials.. Please be sure that the affidavit is complete and printed legibly. The Department has provided a-space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to than you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 east 406 or 1-877-MAS.SAFE Fax#617-72.7-7749 Revised.5-26-05 www.mass..gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING L`'J (Ptlni or Typel NVRTH ANDOVER, . Mass. D 6uata O►'l t 10 �7 - ,- Bundlna /�!7 l /� - Permit # Location / ?' Owner's h _ Name Ar,I f i'L� New Renovation ❑ Replacement ❑ Plans Submitted: Yes 91 No.❑ PIxTURE6 �. a so w Z w e ! 0 s w C t 31 w s a u ar • • • w t• < r. • � w a < a �0 16o az r r < • < J " at • s {�{ • a er p < • vii V � � v i � s at • • 7• Oee s • t o -A < e s r < 0 < h c s sa � • • o p s y s ►• w L' • a as < f et • o sua—eeuT. sastarENT 1sT FLOOR IN* FLOOR 71110 FLOOR ITH FLOOR aTH FLOOR ITH FLOOR. tTH FLOOR •T)i FLOOR — l f Check one: Certwicate Installing Company Cl Corp. Address-,Z4 ,�' .7 ❑Partnership Aylk t Firm/Co. Business Telephone ' Name of Licensed Plumber WE - / INSURANCE COVERAGE: Cbecx one I have a current liability Insurance policy or Its substantial equivalent. Yes No ❑ II you have checked y . please Indicate the type coverage by checking the appropriate box. A liability Insurance policy Elff Other type of kxiemndy ❑ 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 thia permit appiicatlon waives this requirement. Check one: Owner ❑ Agent ❑ stars o Owner a 1Jwner a ens I her cwUfy that aR of the detalls sed informallon I have subr Ailed for entered)in above appkatlon are true and accurate to the best of my knowledge " that all plumbing work and insiallationa performed under the pemN Issued lqtNs pikallon rn7 be In pertinent provisJons of the Massachusetts State Plumbing Code and Chapter N2 of tf p.. al compliance with a!1 By ��e�r Signahne .. TriN License Number City/Town Type of Plumbing ticanse:Master Mf IDWED(OFFICE USE ONLY) Journeyman ❑ t Date. 2801 NORTH of •'�c TOWN OF NORTH ANDOVER 04. P- PERMIT FOR PLUMBING 1SSACMUS� l This certifies that . . .. . . ... . . 14?/..r�?.�. . . . . . . . . . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . at. v.7 . .�'1?.���.�./.'.6.� . . . . . . . . . . . .. North Andover, Mass. Fee. . Lic. No.././ . . . . . . . . PLUMBING INSP CTOR 01/31/96 08:53 25.00 PAID WHITE: Applicant CANARY:Building'Dept. PINK:Treasurer GOLD: File MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITT1P1G � (Print or Type) NORTH ANDOVER Mass. Date i Building Location=f�� �G r� �Q Permit # CY Owners Name/,G,m New Renovation II Replacement Plans Submitted m -- c m ur c 40 to oa v c c m s mt- tu W II -.1 o a = as Q UA F— I .t C = O W I G1 Z m u7 r Uj w o o C m s W � — � H O o. G � 4 (/t C W Z (J C (I L W < C �, G I-- 111 W W < — O tt W W — C7 C C7 F— F- F. W ++ O ? ts. t— ..i �— W E a C ' UA u O C _. a: O 3 G Of L7I C� Y O o.� H O SU&-3S?.1-, � I I I I I 1 t 1 i I i I ( I � ( { •I I I SASE14SEtlT I I I ( I I ( 1 I I I I I I I I f ( I I j tS- FLOOR I f l f l ► I i 1 I i I I l f f I I i l l i i __1La FLOOR I l l i I I ► I I I I I 1 I ► I I i I I I I{ I i t 13Ra FLOOR 4TH FLOOR ST H FLOOR I I I I I ( I 1 I I I I f I I I I I ( I I I I 6TH FLOOR I I I I I I I I I I I I I I I I I I ( ( I I( 8TH F .0oR I ( ( I E I I I I I I I I (Print or Type) Check one: Certificate Instailing Company Name,f���� �C'� Q Corp. Address � �v - - � Partner. - Z. 7Firm/Co. Business Telephone:s©ep-t:��,F• 61Y Name of Licensed Plumber or Cas Fitter �� C In,surancr- Coverace: Indica;_ :na ;ipe of insurance coverage by checking the appropriate box: Liability insurance policy CL^er type o; indemnity = Bond Insurance Waiver: 1 , the undersic.n.ed, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner = Agent Q I he.,cby certify that all of the details and information I have submitted (or entered)in&Note application are true and&cassate to the best of my Lnowtcd;e and tttat su pturnbin; work and tnsrAdauo= ;=ormed under ftermit i..seed for this appiiation wdl be in aomptianoa with all pertinent provisions of Lhe Massachusetts State Cas Cade and t3aptcz Is.ct t:a ckncr:i Laws. kms?= LIC�VSE By Title I Gasiitter Signature of Litensed C'_ty/Tcwn: Maste= Plumb asfitter Journeyman APPROVED (OFFICE USE ONLY} L cense NC=ber 41 < ++v+i.-e�;i:�`rw�ar`.�".xfiYt- _�i.,...._ .. _�_.—�,...hy�„�y„y - -• .--.-..--....:+.,�n;:eu..-��cy.�.r.,��.. .+moi "I Date.2 0 8 Date. G;� .�.:. . t t NaR7H TOWN OF NORTH ANDOVER A. cF to ,,,tia 0_. op PERMIT FOR GAS INSTALLATIOIf . y SSA US This certifies that ,��. 4-. . . . . . . r, has permission for gas installation . . /fir. tQ h -� in the buildings of . . . . . . . . . . . . . . . . . . .. ry at . /4)7 . f??t� C.1%.� .4 . . . . . . . . . . ., North Andover, MaM Fee. 7 ?i:. . Lic. No. !/.�.� .G. . .`�' 1�-. . . . .. . . GAS INSPECTOR WHITE:Applicant CANARY:Building Dept. PINK:Treasurer GOLD:File J ] 1 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING Z J (Print or Type) NO .ANDOVER ,MA Mass. Date ar - 19 PermitF3 - 64. _=_= a Building LocationAPZ_ M-ILLPOND Owner's Name NO.ANDOVER,MA Type of Occupancy ' RES New ® Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ ' No ❑ r= � W N Y Cr (n y N U y 2 N rt O N r }a a 0 Uj W N 5 O U © = n C: �c '' z .O t- w < m N FW- W O d C a � N V W < = F- N O � W < W Q w = rz < O O W 2 > O < W -j U C y o a F- O SUB--BSMT. BASEMENT i 1ST FLOOR 2ND FLOOR SRo FLOOR I_ 4TH FLOOR I j STH FLOOR 6TH FLOOR I I I I 7TH FLOOR STH FLOOR Installing Company Name CALLAHAN AIR CONDITIONING Check one: Certmcate r Address 91 BELMONT STRFFT ❑ Corporation NO.ANDOVER,MA. 01845 ❑ Partnership Business Telephone 508-689-9233 ❑ Firm/Co. Name of Ucensed Plumber or Gas Fitter JOSEPH KEVIN CALLAHAN INSURANCE COVERAGE: I have a current IlabAtty Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142- Yes 42Yes RJ No O If you have checked ys, please Indicate the type coverage by checking the appropriate box. A liability Insurance pcllcy ZI Other type of Indemnity O 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: Owner❑ Agent ❑ Signature of Owner or Owner's Agent I herebycertify Information have submitted or entered (n ove a ricallon are true and rate to the best of m b that all of the details and inform l I h ( ) PP accurate Y knowledge and that all plumbing work and Installations performed under the permit sued for this appl(catl will b In pllance with all .pertinent provisions of the Massachusetts Stale Gas Code and Chapter 142 of the neral Law BY T e of Ucense: umber 9natur o c nse um a or Gas liter rue rifler aster Ucensa Number M-3440 City/Town Journeyman PfX7VF--.(5(0FF1C0 . TQ c� Date.!,/� Jt�>' . . .... _ l / ;t ,AORT1y TOWN OF NORTH ANDOVER , Of,....p ,s,41 0 y� ° op PERMIT FOR GAS INSTALLATION SS S1 This certifies that . `9�Lf`��! . . . . .e. . . . . . . . . has permission for gas installation . . . �. . . . . in the buildings of . . If.Y--. !i. . . . . . . . . . . . . . . at .Ae L Po. . . . . . . . . , orth Andover, Mass. Fee. . :. . . . Lic. No..?.Y Y . . . . . 01/29/9613%44 '25.00 INSPECT A. WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD:Pile � �}rc ��>Irtorriatuurglt}� a� �i�>I�,a��i�u)�ettl� � talGct Oce only � .// Vepartrnent Of Public solly Pernill No. BOARD CSF !`IRE PREVENTION REGULATIONS 527 C&AR 12:00 (1ccupanty a Foe Chocked .»�. A 3/90 (leave blantW APPLICATION FOR �ERMI TIO PERFORM ELECTRICAL WORK All work to be At �e I, � � e (PLEASE PRIN1 IN INK Ok IY1'E All INFORMATION) -Dale t p A'All ��r- `u.- T--_ _ Inspector of Whes>(;Icy or Town of ` ---- The undersigned.appiles fora Permit to peeleculcal work described below. ,.,.location IStrem & Number) Lg0wner or Ten•7n1 D(Ownei's Address ._.a.�_ .t,.l_�.11�3..1�.�' Is ,,is Pcrrnit in conlunctinn with s building FRIIPlit' Yes �� PIn— -''� _---•- (Check Appropriate Box) C _lJtllity Authorisation No. •-�-----'---'-" Purpose of nuilding -------- 1 D Existing Service Amps J_ `d. Volts Overhead ❑ Undgrd No. c.1 Melers .�- .�- New Service _ ---;-_Amps— ---Volts Vveihead Untlgrd Na. nl Meters Location and Nature of Pro weed Electrical Work'_ Number of F(-.e and Arn)vitl — -- - ,._---- -- TOTAL p�•_ No. of Hot Tubs No, of 1 rdnvlurmcrs _�.�,,, No, of Lighting Outlets _- Above n. in t r trr in Puul md, Ca md. ❑ Generators __- k r ane ting No. of Ltgl,trrt� Oil Durners Y ullets ._. No. of ._.--.-•-- No. of Receptacle (') " .;_ �..—, � Outlets A No. of Gas�� 1 Butner&r FIRE ALARMS No. of 7_ones No. of Switch —-- fo a No, of Delecoon and 11 No_:__of Alr Conditioners Tons Initiating Devlcel, No.,.of Ran a ------- -— — eat otal Tote No, of Sounding Devices No of Pum res Tone�"' KW No. of gulf Contained �- — - No. or Uii+H>srals .------ �-- -r t)electionjsnunding Devices No. ishwashErs �� _�. _ ?c�Area Ileadn --„ KW Munlclpal Noof D --p—�-�-- __...�.— locsil_.J' Connecuon ❑Ocher Healing UevlcEs KW No. of '-�--" o oY. _ ow o tags 'T•To o wlrtn No. of Water Heaters _ KED' Si --- �� IJo. of motors wa! - - '- OTHER: ---_---•+-^--`_� -- -�, h r�ulrEments a(�assarhusttes C,enorai laws-----_--------�--y-- ------�-_v strbn,ltlRd valid root COVERAGE; Pursuant tr t o eq ulvalent. Y[5 C)NU U l l a e P I have aNCF . I have a current LlabllUy Insurance Policy Including Completed Ol,erallons Covuagc or rty subslanua eq NO LI If same to this ck ce, YES Ir 9e Indicate the type of coverage by checking the apprOprlate box If you have chec7�k��ed���, P ' INSURANCE �Ge! BONp ❑ OTHER❑ (Please Spec)ty) --.• --- -- -"" (Expiration Date) Fstimaied Value of Eletaricill %V011: s -- Work to S1,3111 Insr,ection (late Requested: Rough --•-..__-_- Final ------ Signed under the penalties of perjury: P.R5213 _ lIc• Ivo. fIFtM NA E _..X 1A S_ci[-X�� - .•..l �w—i_ .—ice __.. -- �_ 1',2 _Signature le -�,-..�' --IIC. NCO. �{ p Licensee 1�Yl G:� I�L�r --1 -� Bus, Tel. No. Address _- C:�.—�-�-1��_'L. � _._ •-- -- substantial a ulvalent as requlredbY frlaseachusetts —--- --,• e,ro-A�d.CE_yVAIVEK:I am aware tical the Licensee doll not hate the Insurance cuvt:rage ur cls q , .:.T_:t uyohcatlon waives this requirement. Owner Agent (Please check one) PERM11 FEE t � ` �a •. 1 i :S �1�,r ,.ca-z�;;..r.sc.:...-^...-* ,;,�,�"�.`�.1`""h '";�-.�i;.,.:;.=.a. "+�tf`•-21'+^�jit'y.3.+..rs"+^^'.:.,,--.'-•ti. '. Date. NTO 2704 3 is �� HORT11 "` - 3g pe_';r``•`-:°',1e�ppL TOWN OF NORTH ANDOVER PERMIT FOR WIRING �Ss�cHusf� i -�. ti. This certifies that ....... C.s�.. .5........ .-....f:�:...' ..`.............................. N ,I has permission to perform ....... .......(r('j5.. ................... wiring in the building of......1 .c(fj:1.........C.Y1 ................... .* at �. ..... .�..j(. �1, � ' ,North 7/0 ter,..........'..�........ ........ t /t Fee.....b".*J. Lic.No.ffl�.;-.�./............... . �.., . I //ELECTRICALINSPECTOR /7 i l(� 95 11:23 1500 PAID WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File `�4, c \_ Y