HomeMy WebLinkAboutMiscellaneous - 14 High Street 1
BUILDING FILE
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Date....3.-. .6..`/5-
11050
r►ORTM
o�,.�•• ..�ti TOWN OF NORTH ANDOVER
o'��. �, '• °off
.* PERMIT FOR PLUMBING
HU
This certifies that.........--��.......
............6' 12 i t t-r.`...............................................
.................
has permission to perform....P1w�A.! -..... `'�"�""+°:....'��`�.c
plumbing in the buildings of.... .C. '.... ....L -.................................................
at..... ...� .�6!i....�> dl ............................................... No Andover, Mase.
Fee...1 ......Lic. No. 5 1 s...... ...............................L............ .......................... ..
PLUMBING INSP TOR
Check#
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MASSACHUSETTS ACHUSETTS BJNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
1
CITY N N bV MA DATE 3 t� ,�5 PERMIT# I(Y t/
JOBSITE ADDRESS LI HI G S`f OWNER'S NAME C
OWNER ADDRESS :S 72� ydS TEL FAX '
TYPE OR OCCUPANCY TYPE COMMERCIAL EX EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK /
TOILET /
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
I
INSURANCE COVERAGE:
i have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES® NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 14 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I 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 al plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the F
MassachuseZ State Plumbing Code and Chapter 142 of the Genera Laws.
PI.l1MBFR'S NAME /4 G
✓1 LICENSE ff /J�JSIGNATURE
MP 90 JP❑ CORPORATION❑# PARTNERSH'P❑# / LLC❑#
COMPANY NAME_ V f�M e 5 �"� clU _/�-f ._ ADDRESS---- y--- j/ 5-),-
---- ---------
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j CITY— 12i`% STATE IV' ZIP �.30 g TEL
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j FAX CELL97.9— y�3� 76y EMAIL
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. COM ONWEALTH OF MASSACHUSETTS
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ME no e • • •
BOAROf
f ,PLUMBERS :AND GASFITT:
ISSUES :THE FOLLOWING LIC ENSE
L I Cl;NSEtI AS A JOURNEYMAN�PLUMB'ER
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J4E5 P GREENE
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4 BRIDGE `ST.
SALEM N o3a7. 3�73�
Date..j445-
...........
OF NORTN,�
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
,83 CHU
This certifies that ....t..1/� —t
..............
has permission to perform ................. ..........................
. . ................ ..................................
w in the building of.,.,.,..,. `�/�- �S- �f
/ f ...............................................................;..............
wiring
at
.......................................................... ..North Andover,Mass.
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Fee......... Lic. No. 136
.............q....7
...........................
ELECTRICAL INSPECTOR
�heck# -32 0
131 7 �
Commonwealth of Massachusetts Official Use Only
rs ?? Ijq
Department of Fire Services Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00
(PLEASE PRINT IN HK OR TYPE ALL INFORMATIOA9 Date: 3Ar /V,-- n
City or Town of: NORTH ANDOVER To the Inspector 6f Vires: 3
By this application the undersigned gives notice of his or her intention to perform the electrical work described below. (P
Location(Street&Number) �f f a F,
Owner or Tenant Telephone No. .
Owner's Address
Is this permit in conjunction with a building permit? Yes2q No ❑ (Check Appropriate Box)
Purpose of Building 00/�/� 4& 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: -��� � �� ✓per
Completion of the following table may be waived by the Inspector of Wires.
IF
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
J No.of LuminairesSwimming Pool Above ❑ In- ❑ INO.of mergency ig ting
rnd. grnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones l�
No.of Detection and
No.of Switches No.of Gas Burners Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices Z
g Tons
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
p Totals: Detection/Alerting Devices
No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other
p g Connection
No.of Dryers Heating Appliances KW Security Systems:*
y f No.of Devices or Equivalent
No. of WaterNo.of No.of Data Wiring:
KW
Heaters j ofns Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
` f OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
I 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 coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify, cinder the pains and penalties of perjury,that the in or t lin on lieation is true and complete.
FIRM NAME: _ f® .1& -*P- LIC.NO.:
Licensee: 10111MSignature LIC.NO.:
(If applicable,enter "e empt"in the license numb r ' .) Bus.Tel.No.:
Address: � Alt.Tel.No.:
*Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No.
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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.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with,the provisions of M.G.L.c.143,§3L,the i
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an �+
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c.143,§3L.
Permits shall-be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses conceming the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012.
❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑
❑ Permit Extension Act—Permit/Date Closed:
Trench Inspection
Pass M Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass(] Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
ROUGH INSPECTION:
Pass M Failed Re-Inspection Required($.) ❑
Inspectors Comme s:
L
Inspectors Signature: V Date:
FINAL INSPECTION:
Pass 0 Failed Re-Inspection Required($.) ❑
Inspectors Comments:
11 4
^ z _�
Inspectors Signa re: Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
Department ofIndustriq[Accidents
Office of Investigations
kvi. 600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information O�Please Print Legibly
Name(Business/Organization&dividual):
Address: �jGt/cIQO��J
City/State/Zip:_ _4/1o?w Phone#: &7�e'?l �
Are you an employer?Check the appropriate box: Type of project(required):
1.[KI am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(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
required.] officers have exercised their 10.E1 Electrical 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.]t 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 aie doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. n
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 lead to the imposition of criminal penalties of a
4-me up to$1,500.00 and/or one=year imprisonment,as wellas 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
tlnvestigations of the DIA for insurance coverage verification.
I do hereby cert underdWains and penalties ofperjury that the information provided above is true and correct.
Si ature: 4p/Z2? Date:
Phone#: ��� "l `�D
Off elal use only. Do not write in this area,to be completer)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.PIumbing Inspector
6.Other - - -
Contact Person: Phone#:
i
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 employeils 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-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
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy*information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, v
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
Tho Commonwealth.ofMossachusetls
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA,0211.1
TO,#617-727,4900 ext 406 or 1-877r1ASS.AFE
Revised 5-26-05 Fax#617-727-7749
WwW=ss,govfclia
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SETTS
x>GOMMONWE LTH OF MpSSgOHU >.
LEC R71 Cl ANS
LSUES
THE. FOLLOWING LIC1<iSE, "A` A
T
REISTf=REO MASTER ELECT�RaCIAN
'O ,K, & SON ELEC".,RI C C0
=1R20SLAU ..;;MLADY
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BLOSSOM
101;':;::;::»:
OUR.
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MA 01801-5
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13847 .A 01%31/16. 39013
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1-2 h4•t` • �4,yG At
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NORTH ANDOVER SUI ING DEPARTMENT
'RsrEo q5 1600 Osgood Street
�SSAC}9LlS� � ,
_
North Andover .
Tel: 978-688-9545
Fax: 978-688-9542
BUS.�117�',S,�'FORM FOR TOWN C EEK
DA.T.P:
NNANM
ADDRESS;
,ONINGDISTRIOT: 's �dCfJ t'►1 bCcJ
TYM OF BUSINESS:
BUII,DTNGLA.Y'OTJT PROVIDED: KYEDS , NO
A7VAIL..E BLEPAR9 fiiG SPACES:
ZONING BY LAW USAGE: (ZYE NO
liDING IMPECTOR SIGNA.'TUPX
.BIISWSS FORM FORMWN CLERK
2,40 Home Occupation(1989132)
An accessory use conducted within a dwelling by a resident who resides in the dwelling as his principal
address, which is clearly secondary to the use.of the building for living piuposesr Home occupations shall
'iiicIude,"but riot'limited to the following uses; personal services such as funrished by an artist or instructor,
but not occupation involved with.motor vehicle repairs, beauty parlors, animal kennels, or the conduct of
retail business,or the manufacturing o£goods,which impacts tlae residential nature of the neighborhood;
d. For use of a dwelling in any residential district or multi-fhmily district for a home occupation,the
following conditions sha11 apply:
a. Not more than a total of three (3}people may be employed-in,thq.he o occupation, one of
whom shall be the--owner of tha home occupation and residing im said divellmg;
b. The use is carried on sixietly-Whinthe principal building;
c. There shall be no exterior alterations, accessory buildings, or display which are not customw
with residential buildings, -
d. Not more than.tvvm ,-five (25) percent of the existing gross floor area of the divelling unit.
so used, not to exceed one thousand (1000) square feet; is devoted to'such use. 7n
connectionwith
such use,there is
-to be kept no stock in trade, commodities or products which occup3T space
beyond these limits;
e. There will be no display of goods or wares-visible from the street;
f The building or premises occupied shall not be rendered objectionable or detrimental to the
residential character of the neighborhood due to the exterior appearance, emission of odor,
gas, smoke, dust; noise, disturbance,,or in any other way become objectionable or
detrimental to any residential use withk the neighborhood;
g. Any such building shall include no features of design not customaq in buildings for residential
use.
Signature Date