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Home My WebLink AboutMiscellaneous - 12 SAMUEL WAY 4/30/2018 i 3 11 A, _ Date ./ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . -? �< °�. . . . . . . . . . . . has permission for gas installation . . .,. 2rv2rca ?!2 in the buildings of. . Q"1 . . . . . . . . . . . . at . A2, tYtA�e.�. Gt. ` . C �. Rc?,North Andov r, Mass. Fee . .bD . Lic. No.5.5n1. . . ., �. . . . . . GASINSPECTOR Check#. H 6 99 s� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY _ _A�Q _ MA DATEID ltl�/z I�PERMIT# JOBSITE ADDRESS OWNER'S NAME ------------- __. _ -.. OWNER ADDRESS _ _2 SiAlN1U T �uA TYPE OR OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL 01 RESIDENTIAL PRINT // CLEARLY NEW:V RENOVATION: REPLACEMENT:E:J1 PLANS SUBMITTED: YES NO APPLIANCES-1 FL ORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE ®r— FURNACE DIRECT VENT HEATERDRYERFIREPLACE LJ I � I (LI1 1 .I1 L—A - _jFRYOLATOR GENERATOR _ . 1 —[I- L1 1 = I GRILLE _____l _.______ _-. INFRARED HEATER _ T. LABORATORY COCKS MAKEUP AIR UNIT ! . — Jl 1 ._.--J L_ .. F-7:7) OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER —AL-1 f WATER HEATER r. OTHER INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES;dNO El 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY rV OTHER TYPE INDEMNITY BOND ��_[ OWNER'S INSURANCE WAIVER:I am aware that the Icensee 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. t CHECK ONE ONLY: OWNER .___i AGENT C_IJ 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 co liance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. • PLUMBER-GASFITTER NAME "tlX { II LICENSE# -I SIGNATURE MP MGF E_1 JP n JGF[_]_-( LPGI CORPORATIONJ$# PARTNERSHIP D# LLC # - --- CO PANY NAME: ,AP ADDRESS I CITY f STATE ZIP TEL FAX L; CELL_ -. Q1- EMAIL � � I�,-- -i L01AA ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ n ^4 4aex—e FEE: $ PERMIT# PLAN REVIEW NOTES r , p �Q l� t 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):(a in., D� �.� �� (Age Address: Ro 60)c7z City/State/Zip: No. & M, Phone#: q7$ - $f s%20 fD Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with—yL-- 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 1011Electrical repairs or additions 3.❑ I 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. Roof repairs insurance required.] i employees. [No workers' 13.❑Other comp.insurance required.] *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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I aim an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: tt •• --CMLMZL, �NS•(/ mco,4, / Policy#or Self-ins.Lic.#: W V4t. Expiration Date: Job Site Address: 575- OS64&oC� 15V City/State/Zip: p Am� wM p18gS 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 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 tree and correct. Si nature: �L—AbD Date: 10 •1! , 12— Phone 2— Phone#: ! hj• gig, -20 /o Official itse 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#• b. i , J 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 tliat"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." f 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 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. 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 s'> 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,nurimber which will be used as a reference number. In addition,an applicant". 10 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 thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call.t s 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 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia i .. f COMMONWEALTH OF MASSACHUSETTS S A GA LI:GENSE'D AS A MASTER PLUMBER 'ISSUES THE ABOVE LICENSE TO- PR T OPRT B RLANCHETTE O: B`O'X728 NO` T_H A.NDOVE'R •MA '0.1845-'0728 85.9.7 05/01/14 14:7813, # , 9 CONTROL# H356028 IMPORTANT If this license is lost or destroyed, notify your Board at the: Division of Professional Licensure, 1000 Washington St., Suite 710,Boston,MA 02118-6100. If your name or address shown is changed, notify of correct name or address to insure proper mailing of board Renewal Application. Always refer to your license number. This license is subject to the provisions of the General Laws s as amended. It is a personal privilege,and must not be loaned or assigned to any other person. Keep this license on your person or posted as required by law. WARNING THIS DOCUMENT HAS ENHANCED SECURITY FEATURES Y t i' 1 �+1 h • htt�Jtmvben com.,'ma eopte Search[Whde.. Q Bm9 Mao x ti,•* CI+X WelcometoNorthAnd_.X Fre P Ede Edit Yta : X.�Convet NSelectFamaes FooHet f .iJ?� -t..'43^K•*;h. rr a3.a:c nF a (�".N„'z.. , 45€EB WAGES VtOEOS MAPS MORE tDing i p Sign m Read Aetia€ : - Traffic' Fuliscre i 8 Punt Shaer }j} �+ 1 Aff c' z- w r' Alow x ' u x i , #- r y x Y �' v1 r 'JR• x. e i yy x C 1 / Thursday,Oct 11,2012 09:59 AM I .;z j, ,i y Date . ��—�Z.` 1Z— TOWN OF NORTH ANDOVER �a PERMIT FOR WIRING This certifies that . . . . .. . has permission to perform . . . . . . . . . , wiring in the building of . . . . . . . . . . . . . . . . . . . . . . . . at . . . .ti. .Sd Aq U ,North Andover, ass. . . Fee 7. Lic. No. . i ELECTRICAL INSPECTOR�r Check# 11145 Official Use Only Commonwealth of Massachusetts Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leaveblank M 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 ININK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives otice of his or her intention to perform the electrical work described below. Location(Street&Number) I a ��fI�� al/r1 Owner or Tenant RAZQ Al rte•,n Telephone No. Owner's Address C�^ Is this permit in conjunction wit a b t*W* g permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building ' i Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters } New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters .t Number of Feeders and Ampacity Location nd Nature of Proposed Electrical Work: NJ Completion of the following table maybe waived by the Ins ector of Wires. No.of Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA AboveIn- o.o Emergency ig ting No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices No.of Air Cond. Total No.of Alerting Devices No.of Ranges Tons No. of Waste Disposers Hear talp Number....Tons....._,.,KW....,. No.of Self-Contained Detection/Alerting Devices Municipal Other No.of Dishwashers Space/Area Heating KW Local❑ Connection El Heating Appliances KW Security Systems:x No.of Dryers No.of Devices or E uivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 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 cove e is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,Under tl pains and penalt' s of p rjuty,that the information on this application is true and complete. FIRM NAME: . 1 e�- 'P 1 L- LIC.NO.: 4 Licensee: �' Z Signature LIC.NO.: (If applicabl,ent�t xempt"in thg�license number li e.) p� (, Bus.Tel.No.: Address: 1"Q �L�C� �1J7'1' � �� 1Jb Alt.Tel.No.: RM *Per M.G.L C. 147,s.57-61,security work requires Department of Public Safety"S"License. Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)[]owner ❑owner's agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. --------------------------------- x. ao�rrspo logs Osseo -�� 'aileflH� e-xnspeeo�xettuxetT{��4.OD)�� ns,�ectoxs'�apaztte�ufs: .. (lCnspeetoxsyzgaatuze�uo.nifiaTs� .r Pate Vassaa ailed- { ate- s ectzo�xec txixe ( 0.0 0}r[ ' �n�iecto�-S'comzneufs: s ( isiectozs',ignature� lo 'tiaTs) ))ate 'assets--j J �'ailet�—j � ate-xns�eetto�xec�uixet��O.UO)�[ � , aspectoXs'eoxn�ents: [lnspectozs�aignatuxe��o�nias) ))ate ' F ssec.—[ ailed--je anspec�io�xequixe { 50.OD} ,')?adbxs'eopnmepfs: - {lTxtspectozs'�ign�tuzeK7aojbitZaxs) 3la$e e t�`•[' � �+`ailer�� . '�e�nsp ec�ort x'egu7x'et�{$50.0 D)-•[ S ecto?'s'coz�im.l;7�ts: _ , —s eci o xs' dateMgnature-310 xndals) �1 a 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 Le ibl Name (Business/Organization/Individual): j 4 Ftp Address: ,G City/State/Zip: �J� (� �f- - 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 6. ❑New construction VI (full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet.1 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10. lectrical rep airs or additions requtred.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 1111 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑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. t 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 attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insur nce Company Name: Policy#or Self-ins.Lic.#: Expiration Date: .I 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 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. Ido here rtify under the . s-and penalties ofperjury that the information provided above is true and correct. Si nature: - Date: 1� J Phone#: �� 3 Official itse 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#: i P a 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 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 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. y` 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 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 Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Zevised 5-26-05 Fax# 617-727-7749 4� Date..�..ZK°f......... pORT1� °f,"":•�"° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,s$ACMUs C Y This certifies that ...J.��............ ...... i has permission to perform � wiring in the building of....... at./ ....... ....................... . ............ ,North Andover,Mass. Fee G'.�2...r...... Lic.No.'s)..... .... ......... : ::. A.... ...... ELEMUCAL I SPE Check # 7�Y 6 4"L Commonwealth of Massachusetts Official Use Only Permit No. Jos Department of Fire Services Occupancy and Fee Checked "- BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/051 (leave 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 IN INK OR TYPE ALL INFORMATION) Date: dr) I 0 9 City or Town of: IJ0 4114 fi iJ'Rj*O V9Z To the Inspe for f Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) , SAyN 'VEL WI AY Owner or Tenant CAMJM t')-)(1J Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes R, No ❑ (Check Appropriate Box) Purpose of Building ELI J 0 Cr Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No. of Meters New Service 1 Amps 2p`l Volts Overhead❑ Undgrd No. of:Meters i Number of Feeders and Ampacity `1(3o a Location and Nature of Proposed Electrical Work: L)]q,(r 1)f131 �;JKJGLJE' i'Am]L� Completion of the following table nsay be waived by the Inspector of Wires. No.of Total No. of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators K-VA Above No.o mergencytg ting No.of Luminaires Swimming Pool rnd. ❑ 6rnd. ❑ Batte Units s No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones to No.of Gas$urners No.of Detection an No.of Switches Initiatin Devices !' Total No. of Ranges No.of Air Cond. Tons No.of Alerting Devices Heat Pump Number Tons KW No.of Self-Contained No.of Waste Disposers ...................... g P Totals: Detection/Alerting Devices--A2 Municipal No.of Dishwashers Space/Area Heating KW Local❑ Connection El Other Heating Appliances Security Systems:* No. of Dryers No.of lbevices or Equivalent No.of Water �) KW No.of No.of Data Wiring: Heaters / Siens Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs. No. of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail ifdesired, or as required by the Inspector of Wires. Estimated Value of Pectrical Work: (When required by municipal policy.) Work to Start: / Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO 'ERAGE: 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 penalties of perjury,that the information on this application is true and complete. FIRM NAME: Interstate Electrical Servi , s rporat '. LIC.N .:A-5217 Licensee: Pasquale A. Alibrandi Signature I (If applicabl rater "exe n t"in the license number line.) Bus.Tel.No.:9 7 8-667-5200 Address: Treb�e Cove Rd. , N. Billerica, MA 01862 Alt.Tel.No.: *Security System Contractor License required for this work; if applicable,enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑ owner ❑owner's agent. Owner/Agent PERMIT FEE: S Signature Telephone No. i X32- 1l'i'VO W-62 r I� 1 Date.... ... .... Of WORTH-1 TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING ,SSACHU This certifies that ............... ...... ..................... Ifas permission to perform ........Sz--Cwki7.-�t, SvS. .. .................. ...I................ .. ........ wiring in the building of............... at............. ..----....... ,North Andover,Mass. ILI:Fee..................... Lic.No". 2P................(I- .... EcrRICAL INSPECT& Check B 6 5 S), Commonwealth of Massachusetts Official Use Only Department of Fire Services Pe'n'is No. { BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked ev. 1/07] Qeave 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 IN INK OR TYPE ALL INFORMATION Date: City or Town of. NORTH ANDOVER — a g By this application the undersigned gives notice of his or her intention to perform the ele electrical wpector ork ddies n-bed below. Location(Street&Number) ja f in lay tel, Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes Purpose of Building �,PSs�,� /�5 Q No ❑ (Check Appropriate Boz) Utility Authorization No. Eristing 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: S, p Com lesion o the ollawin fable may be waived by the Insvector of Wires. No.of Recessed Luminaires No,of CeiL-Sus o.of Total p.(Paddle)Fans Transforme Formers KV No,of A Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ _ o.o niergenry �A d Batte Units " --- No.of Receptacle Outlets No.of Oil Bu1'Itlprc FIRE ALARMS No. of Zones 77 No.of Switches No.of Gas Burners o..of Detection and No.of No. °� Ranges Initis i Devices of Air Cond. Tons No,of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW o.of e . ontained Totals: _ Detection/Ale Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ �� No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of No.of Devices or E uivalent Heaters KW No.of Data Wiring: Si s Ballasts . No.of Devices or Equivalent i� No.Hydromassage Bathtubs No.of Motors Telecommunicatio Total HP ns OTHER' �,p L u� �.� '1 No.of Devices or E �ent Estimated Value of Electrics]Wo Attach additional detail if desired, or as required by the Inspector of Wires. ZtZ 0• t` y (When required by municipal policy.) Work to Start ,� ZJ'-� 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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 62� BOND ❑ OTHER ❑ (Specify:) I certify,under the ain andpenaldes ofperjury, that the information on this application is true and complete- FIRM NA2:&�& ALicensee: / LIC.NO.:�//S ��1�J1 t/A Signator tv`/ LIC.NO. �C/7P (If applicable, enter emgt' �he''eryepumberline.) Address: G/ �/ �q `evil tY /��/j Bus.TeL No.:�7d �r *Per M.G. c 147,s 57-61,security work requires D License: Alt:Tec.No.: OWNER'S INSURANCE WAIVER: I am aware thatt tthe Livens a does notehavl e I theliabili mi sur nc No. required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑ owner ce coverage normally Owner/Agent ❑ owner's agent Signature Telephone No. PERMIT FEE: $ � .. . �, N c��r �� -. �� y The Commonwealth of Massachusetts k- 1 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ' www.n=s gov/dna . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anoiicant Information Please Print Lea- bly Name (Business/Orgenization/individual) 5D///1/0, /}l APnIV, Address: ,.Z 7 City/State/Zip: LLo-,"re lie—, f Phone#: . l 7J- G 4) -6 Y 7X Are ou an employer?Check.the appropriate box: 1.�I am a employer with 1 4, Type of Project(required): ❑ I am a general contractor and I 6. ( ew construction employees(full and/or part-time).* have bred the sub-contractors 2•❑ I am a sole proprietor or partner_ listed on the attached sheet 2 7. ❑Remodeling ship and have no employees These sub-contractors have $. Q Demolition working for me in any capacity, workers' comp.insurance. [No workers' co m . 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 I I,Q Plumbing repairs or additions myself.(No-workers' comp, c. 152, §1(4),and we have no 12.[] Roof insurance required.]t employees, [No workers' repairs comp• insurancerequired.] 13•0.Other *Any applicant that checks hoz#t must also fi[t out the section below show' mg their work='compensation policy ir&rmation, Eiotracto rs who submit this affidavit indicating they ars doing'all work and then hire outside connctom must submit a new afrxlavit indicating such. #Contractors that check this box mustanachea an additional sheer showing the name of the sub-conttauton and their wort' . F pol' ir.`tsastion. t ant an employer that is protriding:workers'compensation insurance for my employees: Below is the policy aid job site information. Insurance Company Name: G ra n Policy#or Self-ins. Lie.#:_W6- -9 Expiration Date: Job Site Address: City/State2ip:y.. .4A�0eUz '� Attach a copy of t6e_workers' compensation.polis declaration -e sho PA.-e wing the Policy number and expiration date], Failure to secure coverage as required tinder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a f 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and pea of perjwy that thein ornrationProvided f above is true and correct Siemtta e: o _ Date: Z S^ Phone#: 9 7 1�- G-PZ— . (p V 7 y 7e�r only. Do not write in this area,m be completed by.city or towLida Town: PermitUcens hority(circle one): Health Z Building Department 3.City/Town Clerk 4.Elector 5. Plumbi]Jnspector on: Phone - Date. ".0RT:��a TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SS�cHUS This certifies that .. . . .! . . . . . . . . . . . . . . ./. . . . ... . . . . . . . . . . . . . . . . has permission to perform . . . ./ti. . . . . . . . . . . . . . . . . , . . . . . . . . . . plumbing in the buildings of . . . . . . . .f at . .f . . . �«r `/ . . . . . . . ., North Andover, Mass. Fee. .�'t/t. -Lic. No. . . . . . . . . , ... . . . . PLUMBING INSPEC OR Check # C� a 8020 AM DRAINS - SATNTUIS • DISHWASHERS DISPOSER$. FLOOR DRAINS ' "amps ❑ s NOT WATER TANKS KITCNEN SINKSNANNIN _ IN ILAUNDRYTRAYS 190 NINON C3 off BOOP DRAINS ❑ SNOWER STALLS ❑ SLOP SINKS TANKLESB .N I k URINALS WASHING MACK CONN. ❑ ❑ C3,. 11 WATI N CLOSETS ❑ T � WATER PIPING a I ) ` OTHER-rIXTURN C3 ' C3 �to ❑ a'Zi n r 7 Date.. Y....f:.r`.. . ... .. NORTH o= TOWN OF NORTH A OVER F PERMIT FOR GAS INSTALLATION h gs,SSAC MUSE�t This certifies that . . . . . . . . . . . . . . . . . . . . has permission for gas insta-l'lation �: . . . . .. . . . . . in the buildings of . . = 1'",- ar �. . . . . at ./,., .5 . �` 'f. : . . ., North Andover, Mass. Feld. 'Lic. No `��~ ",/-, �. . . :. . . . . . . �+ GAOR Check# `7fo� f 6756 CONVERSION BURNER -� DIRECT VENT HEATERS � a m DRYERS FURNACES a e ❑ OAS GENERATORS GRILLES ., n HEATER RANGE ❑ (� a HEATING BOILERS i " LABORATORY COCKS , OVENS � C �► � POOL HEATERS '� R ❑ °' a � .. RANGES w y ROOF TOP UNITS A C N 7� ❑ .::.,,:. �:!.. TESTS ❑ s, UNIT HEATERS z i UNVENTED ROOM HTRS. CL �-�► $ i,1 VENTED ROOM HTRS. ❑ '` m �' ❑ r ` WATER HEATERS 31• °' OTHER FIXTURES:M 011 S, co e O 3 D ° g