Loading...
HomeMy WebLinkAboutMiscellaneous - 119 MOODY STREET 4/30/2018 / == 1 OM ODY STREET 21010800000.0 J , I I I I r Date....s Z. .....w a t HORTM q TOWN OF NORTH ANDOVER A PERMIT FOR WIRING �,SSACNUS� This certifies that .. TAT !l1 ... L T/1��.I/7L....... has permission to perform ......��� wiring in the building of..!V.��.'..QD U /�9/l/ .... .......... . .................................................... at...I. p ......... ....................... .. ...... .North Andover,Mass. n Fee.�� oa.... Lic.No.� .y C. . 10ELECTRICAL INSP*C'COR Check // a 3 k Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 0 V BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev. 1/07] Oeave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: '' City or Town of: NORTH ANDOVER pector o /C By this application the undersigned gives notice of his or her intention to perform the ele electrical work dies nbed below. Location(Street&Number) I h t) l� I S Owner or Tenant 5AN-gD 9%A 11kk4J Q Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes El No (Check Appropriate Box) Purpose of Building � Utility Authorization No.19 03 107- Existing Service !—()U vw Amps "j40 Volts Overhead /�,,� �­Undgrd❑ No.of Meters New Service � Amps I LO Yo Volts Overhead Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: M e✓Tett, d Completion o the ollowin table may be waived by the Inspec o_f Wires. No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fanso.of Total L No.of Luminaire Outlets Transformers KVA No.of Hot Tubs GeneratorsKVA No.of Luminaires Swimming Pool Above In- o.o mergency ig g d. ❑ a. ❑ Batte Units --, No,of Receptacle Outlets No.of Oil Burners .FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No..of Detection and No.of No.of Air Cond. Ranges Total Initiatin Devices Tons No.of Alerting Devices No.of Waste Disposers eat Pip Number Tons KW o.of Self-Contained Detection/Aler(in Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other No.of Dryers Heating Appliances Connection KW Security Systems:* o.of Water No.of No.of Devices or E uivalent I{�' Heaters No.of Si s Ballasts. Data Wiring; NNo.of Devices or E nivaient o.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or E uivalent /� Gv Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of�,WL)10 ' k: a41 Work to Start: (��required by municipal policy.) Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation"coverage or its substantial equivalent. The undersigned certifies that such covera m force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the ains andplulaides of perjury,that the information on this application is true and complete. FIRM NAME: I elliris EL M c_–r tt L C 4 4, Licensee: ��',f� �a�ji�ty�i l• Si LIC.NO.:1T gg2A I a licable,enter -exempt,,in the license number line.) Signature LIC.NO.: �y�v (f PP Address: _[f(j r`�. /��� oto �T f��? �y drN Bus.Tel.No.:A&A/ *Per M.G.L c 147,s 57 61,security work requires D Alt.Tel.No.: OWNER'S INSURANCE WAIVER; I am aware that theDepartment a does afety hav'e,t Ei ase. Lie.No. required by law. By my signature below,I hereby waive this requirement. I t the(check one) ❑owner rance coverage oo owner normally ent Owner/Agent Signature Telephone No. PERMIT FEE:$ J The Conurionwealth of Massachusetts Department of Industrial Accidents Office of Investigations 7 600 Washington Street J � Boston, AM 02111 � ►vww.mnss.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers lease Print Legibly Applicant Information Name (Business/Orllanization/Individual): 41616- Address: /l� ;AC T ` City/State/Zip: � I Phone#: t�f lby z -53?�' FEII employer?Check the appropriate box: Type of project(required): 4. ❑ 1 am a general contractor and i 6. New construction employer with ❑ees(full and/or part-tune).* have hired the sub-contractors ❑ Remodeling listed on the attached sheet.sole proprietor or partner- Demolition ship and have no employees These sub-contractors have 8• ❑ working for the in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5• E] We area corporation and its 10 'Electrical repairs or additions lw required.] officers have exercised their right of exemption per MGL I I.❑ Plumbing repairs or additions 3.❑ 1 ata a homeowner doing all work c gl 52, §1(4),and we have no 12.❑ Roof repairs myself.[No workers' comp. insurance required.]; employees.[No workers' 13.❑ Other, comp. insurance required.] *Any applicant that checks box H I must also tilt 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. rContraclors that check this box must attached an additional sheet showing the name of the sub a ontractors and their workers comp.policy information. I am nn employer that is providing workers'compensation insurance for my employees. Below is the policy card job site infi7rination. _ ' Insurance Company Name: WB VSiJA ee x04JA L n _.7 Policy#or Self-ins. Lic.#: �`r jf y ,� Expiration Date: y 6 /©' �,CP t 0 Job Site Address: 11R ` Kbkl)� S1 t N> w;z)Qyes VU _City/State/Zip: OU 1 16 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 ftp to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA f r insurance coverage verification. I do herekv V fine pains and penalties of perjury that the information provided above is true and correct. //Sionature Date: 5-25—zolo V Phone#: (z 9) —v 3 E,,,eDonly. Do not write in this area,to be completed by city or town official. n: Permit/License# hority(circle one):Health 2. Building Department 3.City/Town Clerkt. Electrical Inspector 5. Plumbing inspector rson: Phone#: Date..�a.�.�.�� � . .. TH Of o� TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION SSACHUSES vThis certifies that . :!/q v e N 5� w has permission for gas installation . . .7w r v A c ti �n the buildings of . . �!v " u ti at . . . `T. . . !�bo Y. . . . . . . . . . . ., Northdover, Mass. Fee. . .3.0. . . Lic. No.. ). .1 �rn2?� /U!U. . . . . . . . GAS INSPE TOR Check# 3 4255 MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT'TO DO GAS FITTING (Type or print) Date2--- NORTH ANDOVER,MASSACHUSETTS Building Locations r 01 0 N S 0 Permit# Amount$ N, /4 !U idsy ,�1S Owner's Namep New❑ Renovation ❑ Replacement Plans Submitted ❑ V 0 y F a CY. F O z O �r W Q Oz 94re H w a O ,.., w O w H w x zW H z O a z d O w z O w Ex- r o x w 3 a c� v a SUB-BASEM ENT BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR - 6TH. FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type) Check one: Certificate Installing Company Name 04 U Ito 4+ L--7,f/2 WS-144� LiCorp. Address 36 +Y C rL K-,—f-Yz Lz-:;-1 ❑ Partner. 7'we 1. Business Telephone 5 7 k 6d-7 112Kirm/Co. Name of Licensed Plumber or Gas Fittery� t//jj J? L�,y tV j A1-At-j INSURANCE COVERAGE Check one: I have a cugrent liability Insurance policy or it's substantial equivalent. Yes ❑fir,. No❑ Ifyou have checked yes,please indicate the type coverage by checking the appropriate box. Liability insurance policy 0---- 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 ofthe 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 hereb3Akartify 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 S e and Ch er 14 General Laws. By: Signature of Licensed Plumber Or Gas Fitter Title L'Plumber Is-QS-ir City/Town ❑ Gas Fitter Icen Number ❑ Master APPROVED(OFFICE USE ONLY) Journeyman