HomeMy WebLinkAboutMiscellaneous - 118 MEADOWVIEW ROAD 4/30/2018 (2) 118 MEAD8=Wf ROAD w) pA D '
210/103.0-0061-0000.0 --
z Date. (...�.v..f........
NOR7M
Of t,.ao; 44O
�r �•,� -- "�• O� TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
,SSACMUS�
This certifies that
has permission to perform �C.vI/Qd "
................`. ..........................................
wiring in the building of ? .... .. c. 'f� ----.......................
at.....1..1.k, d� 0Cl,J
.......... .............: ,North Andover,Mass.
^� Fee. ...... Lic.No. 7,11A........... .....
ELECTRICAL INS;E
Check
88 '17
Commonwealth of Massachusetts Official Use Only.
Department of Fire Services Permit No. -2
BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked
[Rev. 1/07] (leave blank
APPLICATION FOR PERMIT TO PERF
All work to be performed in accordance with the MasORMCELECTRICA 527 CMR o WORK
Massachusetts
(PLEASE PW%7LV INK OR TYPE ALL INFORMATION) Date: W j 1;709 .
City or Town of: NORTH ANDOVER
To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) f _)O jNC,,�Ul"
Owner or Tenant � �Y\1 C
Owner's Address Telephone No.
Is this permit in conjunction with a building permit? Yes
Purpose of Building NO ❑ (Check Appropriate Box)
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:
Completion of the ollowin table maybe waived b the Inspector of Wires,
No.of Recessed Luminaires No.of Ceil:Sus No.of Total
p. (Paddle)Fans
Transformer
No.of Luminaire Outletss KVA
No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool AboveElIa_ o.o mergency ig g
d d• " Batte Units
No.of Receptacle Outlets CT No.of Oil Burners
FIRE ALARMS
No.of Switches No.of Zones
No.of Gas Burners No.of Detection and
No.of No.of Air Cond. Total
Ranges Initiatine Devices
Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump Number ons
p of Self-Contained
Detection/Alertiner Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal
No.of Dryers HeatingA Connection ❑ ��
Appliances K W Security Systems:
No.of Water No.of No.of Devices or E uivalent
Heaters KW No.of Data Wiring;
Si s Ballasts .
No.Hydromassa a Batlitubs No.of Devices or Equivalent
Hydromassage No.of Motors Total HP Telecommunications Wiring:
OTHER: No.of Devices or E uivalent
Estimated Value of Electrical Work:
Attach additional detail if desired, or as required by the Inspector of Wires.
(When required by municipal policy.)
Work to Start Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE OVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and enalties o p )
FIRM NAME. f perjury,that the in ormation o%is application ' true and complete.
nes c�) '�,rl,,cam) ,w
Licensee: •NO.:
4'y Signature LIC.NO.:
(If applicable, ter"ez pt"in the license numb-
umb �n
Address: /02=`�YC1� ity1 A) 6��g Bus.Tel.No.4� `J 7 E.
I
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does
*Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"!License: Alt.TeLicl No.:� )t o
required law. By my signature below,I hereby waive this requirement I not am tile have the liability insurance(check one) ❑owner [I coverage normally
gent.
Owner/Agent ent
Signature Telephone No. PERMIT FEE. $ •j
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` Date.
"ORrM
TOWN-OF NORTH ANDOVER
10
PERMIT FOR PLUMBING
,SSACMUS�
This certifies that 1
rt has permission to perform :.. . . . . . . . . . . . . . . . . . . .
plumbing in the buildings of . . . . . . . . . . . . . . . . . .
.North_Andover, Mass.
. . . / . . . . . . . . . . . . .
PLU[WIBING INSPECTOR
Check # �? �
8107
ry•�
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print) f
NORTH ANDOVER,MASSACHUSETTS I /
Building Location I� MPALA y, A � Date
Y.'�/ .Owners Name �1/� ^ I� Cj Permit—# f We
Amount
Type of Occupancy
New Renovation Replacement �� Plans Submitted Yes ❑ No ❑
FIXTURES
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(Print or type) Check
� on Certificate
Installing Company Name C�W S' Corp. Ti)`7 '7
Address t��tCJ 1:1 Partner.
ft (g D.
BusmessTelephone, cy28—Rost• Firm/Co.
Name of Licensed Plumber: �-
Insurance Coverage: Indicate the jygof insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond ❑
Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner Agent
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Ch r 142 of the General Laws.
By J1bI1dLUIC U L1CL��r�tumoer
Type of Plumbing License
Title l —1
City/Town icense um er Master Journeyman ❑
APPROVED(OFFICE USE ONLY
d C.J
The Commonwealth of Massachusetts
k
"14r
Department o Industrial Accidents
tr
Office of Investigations
600 ff,ashincg ton Street
ti ,� Boston, M4. 02111
c-: www_nzass.gov/dia .
Workers' Compensation Insitrance Affidavit: Builders/Contractors/Electricians/Plumbers
Apulicant Information
Please Print Le-qbly
Name (Business/orpnirdtion/individual):
Address: g D,C7 SO, jV)
City/State/Zip:— Phone#. .
Are you ane ployer?Check the appropriate box:
1• am a em to et with 4, T °f Pref(required):
P ❑ I am a general contractor and 1
em fu ttd/or part-time).* have hired the sub-contractors b ❑Naw construction .
2.E3 I am.a-sole proprietor.or partner. listed on the attached sheet,t 7. Q Remodeling
ship and have no employees These suit-contractors have 8. Q Demolition
working for me in any capacity, workers' comp.insurance.
[No workers comp. insurance 5. 9. ❑ Building addition
' P ❑.We are a corporatism and its
required.] officers have exercised their 10.El Electrical repairs or additions
3.❑ 1 am a homeowner doing all wont right of exemption per MGL 11.Q Plumbing repairs or additions
myself.[No•workers'comp, c, 152, §1(4),*and we have no �I
insurance re uiretL t 12•❑Roof repairs
q ] employees. [No workers' 13 ❑.Other
comp. insurance required.]
'Any applicant tient checks bot(#l M=81111)fill out the section below showing their workers'Compensation policy information
r Homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such.
4Contlactnts that check this box must att shred an addr'tiatuil shcaet shoving tf a name of the sub-contractors and their workers'mm...polim.it fonnsgon.
J am an employer that is prl?Wding workers'compensation insurance or a to em Below is the o ' and'ob site .
informador. f �' mP Y . P Acy I
Insurance Company Name: «GG
Policy#or Self-ins. Lic.#:
Expiration Date: /O
Job Site Address: �; Jt' !,tA) 4 Ci /State/Zi
ty n '
Attach a co of the worke '
P
ftr�
ver
Py
is compensation
policy declaration page(showing the policy Dumber 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
i fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be
advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and rormct
Si tore: Date: �9 [
Phone—#: _(-V-Rz>y• z> ?�_
Official use only. Do not write in this area,to be completed by city or town.ofcial
City or Town; Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person• Phone#:
Information a nd Instructions
Massachusetts General Laws chapter 152 requires all emp;}oyers 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 emplayer 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 includirig the legal representatives of a deceased employer,or the
receiver or bustee of an individual,partnership,assocratiohn 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 anothenwho 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 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 t3he 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 cordracting authority."
Applicants
Please fill out the workers'compensation•affidavit complertely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),addresses).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
mem'uers 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 numberlisted below. Self mmired mmpmniec Should pntPrtnPir
self-insuranoe-license number on the appropriate dine.
City or Town Officiais
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 permitflicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/licarm applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should writo"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 affidaviL
The Office of Investigations would lice to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give its a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Sth�eet
Boston, MA 02111
TeL#617-7274900 eat 406 or 1-8.77-MASSAFE
Revised 5-26-05 Fax#617-727-7744
www.mass.gov/dia
4004 Date... ,tea. ... .........
f kORT"1
TOWN OF NORTH ANDOVER
o
PERMIT FOR WIRING
,SSACHUSE�
This certifies that .........:�... ...... ..�.ft.. .�r..:.S...........�.:...................
has permission to perform .... !........,�.<..?%�....................................
?wiring in the building of....... .SPC?.�1.6...`...................................................
at.... � � cflX�!.(/z..t :�`�.. ,North Andover,.Mass.
r -
. ....... .. . ....... .XE
Fee...G�l`.i�.... Lic.No. !:., 1.......... . ........LECTRICALINSPECTOR
Check #
vrnciaiuseuniy
Permit No. �' do _
aefrsy�t eat 4;D.R.Sa y Occupancy&Fee CheckecdL—V
BOARD OF FIRE PREVENTION REGULATIONS.527 CMR 12:00
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00
(Please Print in ink or type all information) Date ;�L
✓
To the Inspe r of Wires:
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below. I
Location(Street&Number I !) �I n1 L/I 0W
Owner or Tenant �/ � t tT l fi r✓✓c- 0s
Owner's Address 5
Is this permit in conjunction with a building permit Yes No ❑ (Check Appropriate Box)
Purpose of Building l Utility Authorization No.
t
Existing Service Amps Voits Overhead ❑ Undgmd ❑ No.of Meters
NevSgq(;e Amps Voits Overhead ❑ Undgmd ❑ No.of Meters
Number of Feeders and Ampacity (04 U./�! r 1�G+� -U C��(VM [� l�I�
Location and Nature of Proposed Electrical Work
4
Total
moi.of Li htin Outlets No.of Hot fuse No.of Transformers KVA
Above ❑ In
�.of Lighting Fixtures Swimming Pool grnd ❑ grnd / Generators KVA
No.of Emergency Lighting
No.of Receptacles Outlets No.of Oil Burners Battery Units
No.of Switch Outlets No of Gas Burners ! FIRE ALARMS No.of Zone
Total No.of Detection and
No.of Ranges No of Air Cond Tons Initiating Devices
Heat Total Total
No.of Di osal No. Pumps Tons KW No.of Sounding Devices
No./of Self Contained
No.o Dishwashers S ace/Area Heating KW DetectionlSounding Devices
❑ Municipal ❑ Other
No. Heng Devices KW Local Connection
No.of No.of Low Voltage
No.of Water Heaters KW Signs Bailases Wiring
No.Hydro Massage Tuds No.of Motors Total HP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES= NO =
have submitted valid proof of same to the Office YES= No = N yqu have check YES please indicate use type of coverage by checking the appropriate box
INSURANCE = BOND = OTHER =.(Please Specify) ( / �l,Ja f
(Expiration Date)
Estimated Value of Electrical Workb
Work to Start Inspection Date Resquested Rough Final
Signed under the Penalties of pequry:
FIRM NAME GuA 17/11C LIC.NO.
Licensee Signature LIC.NO.
Bus.Tel No. �
Address / Alt Tei.No.
OWNER'S INSURANCE WAIVER: I am aware that thb Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) (�Telephone No. PERMITTEE $ �-d_ (Signature of Owner or Agent)
3054 /
Date.
f
00RTti 4. TOWN OF NORTH ANDOVER
1-ep•,,•w ,e• Op .
PERMIT FOR GAS INSTALLATION
,SSACMUSES
d
This certifies that . .,. A-1 • • • • • • • • • •VL
m
has permission for gas installation . �
in the buildings of . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .
at . ��` ?"�'`�°t `'L--. . P J: . . . . . . ., North Andover, Mass.
` /!�
Lic. No......J .—
?..� .. . ..
• AS I�NSPECTCT OR
WHITE:Applicant CANARY:Building Dept. PINK:Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DOVAA /IT7T111NqG �
(Print or Type)
NORTH ANDOVER Mass. i Dates/� 6
t uilaing Location Permit #_ 0S-
'� Owners Name 4j�-,r�l
New "1 Renovation D Replacement IB"" Plans Submitted D
�9 FIXTUo-c
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us W m J = d = W s W a W �- W W x C3 it
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-d
0! 4 2 U40 O N =
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rz z o v r u. a to s y a omn. tw- o
SUQ—SSMT.
BASEMENT
1ST FLOOR .
2NO FLOOR
3RD FLOOR I
s 4TH FLOOR
STH FLOOR
GTH FLOOR
7TH FLOOR
STH FLOOR
(Print or Type) .?:.. f. Check one: Certificate
Installing Company,"Name ANDOVER PLBG. & HTG. CO. , INCM Corp. 2122
Address 573• 'S0. UNION .STREET Partner.
LAWRENCE, MA. 01843 Cf Firm/Co.
Business Telephone: 978 685-8383
Name, of Licensed,? {Plumber;: or Gas Fitter GEORGE_ LAR()SE
IhsUu anc,%'Coverage Indicate the type of insurance coverage by CheCking the
appropriate box:
Liability insurance policy EFJ Other type of indemnity F__j Bond
Insurance Waiver: I , the undersigned, 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 17 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
knowted&c and that all plumbing work and Installations performed under Permit issued for this application wW be in compliance w(tlt all pesttamt
provisions of the Massachusetts State Cat Code and Q►apter 142 of the General Laws, —'
By YPE LICENSE:
Plumber -
Title Gasfitter' Signa are of Licensed
Master Plumber or Gasfitter
City/Town: Journeyman 9983 _
APPROVED (OFFICE USE ONLY) License Number