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Miscellaneous - 143 SANDRA LANE 4/30/2018 (2)
143 SANDRA LANE 2101097.9"0000.0 JI 7226 Date. .141,�'� . . NpRTF; p TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACNUS� / This certifies that . . . 44-s has permission to perform . . . . . . /� plumbing in the buildings of . . `ti b. ! . . . . . . . . . . at `,?,;,# . . ., North_Andgo er/,Mass. Fee. .`�'�-1 Lic. No..2p.6:- . PLUMBING INSPECTOR Check # A A J � I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING �U. City/Town: 0( l0�'r MA. Date: Permit# Building Location:_ L q:3 anip ra )jye Owners Name: kQ �ra�rr �a Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential New:❑ Alteration:❑ Renovation:( f Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES DEDICATED LU x o SYSTEMS Z w Ln w U v� O d Ln mv� rz rx in �n In d Q rx w ❑� F Q ❑ Q Z 0 Z vNi C7 na X ¢ H d d z O o: w ❑ ❑ w w Z LL r _j Q Uj Cd Q 0 = JO O H ❑ 9 O O Oa Z 2 y H H w df N a m m o ❑ �. x 5oxin 3 3 o ¢ 3 -SUB BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4T"FLOOR ; 5T"FLOOR 6'FLOOR 7T"FLOOR 8T"FLOOR (its MiiirgOrtiip2,r }r foam= (" �U fir' D. �' f:P, f Oners`il.: cz.?�ioi 1 c +tv ir. Address: Pike fB S'1'city/Town: I�le I"f ❑Corporatior� C'1'� state:,��� Business Tel:._ 9/ 967 9U El Partnership Name of Licensed Plumber: CAQ11—/� �irm/Company r INSURANCE COVERAGE: 1 have a current Ii . ability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes ❑ No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnify ❑ 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 Si nature of Owner or Owners Agent Owner ❑ Agent ❑ 1 hereby certify that all of the details and information 1 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 742 of the General Laws. 3y Type of License: �Plumb�er ��� itle � Si nLtil"Plumber 9 ature of Licensed itylTownaster EyiP n / PPROVED OFFICE USE ONLY) aM ourney an License Number: t�f�(Cj3to The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 'Y www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers _Applicant Information Please Print Legibly Name(Business/organization/Individual): Address: c JSTT City/State/Zip: Phone#: °, � 98��- of Are you an employer?Check the appropriate box: _ Type of project(required): 1.❑ I am aP J employer er with 4. p Y ❑ I am a general contractor and I mployees(full and/or part-time).* have hired the sub-contractors 6 El construction 2• I am a sole proprietor or partner- listed on the attached sheet.t �• [ Remodeling ship and have no employees These sub-contractors have 8. Demblitio working for me in any capacity, workers'comp,insurance. ❑ n [No workers comp. 5. 9• El Building addition ' p ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.A52 umbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no insurance required.]t em to ees. 12•❑Roof repairs employees. [No workers' comp- 13.❑Other insurance e required.] !An' applicant pplicant 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 hew workers'comp.policy information. I am an employer that is providing workers'compensation insurance for information. my employees. Below is floe policy and job site Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: { ,,� S aY1.3 rei (,jnf City/State/Zip: Attach atopy of the workers'coNI, mpensation 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. fP j Y1' , t do Izereby certify under the pains and penalties o er u that the information provided above is true and correct. 9i nature: Bate: . ':none#: FCfi:J0r'T0SWe0nn1Y- ao not write in this area,to be completedby cityor townofficial• 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#: • M Information and Instructions tions 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 ofpublic 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 Depaitment 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 beenofficially 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 for 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, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Com-nonwealL1 oa t4assach se s Department of Industrial Accidents ®ice of InVestigatioms _ 600 Washington Street Boston;UA,0211 X T01.#617.727-•4900 ext 405 or 1-877-MA SS.AFE* Revised 5-26-05 Fax#61.7-727;7749 W.roass.9-ov7dia > COMMONWEALTH OF MASSACHUSETTS , /. mill LICENSED AS A JOURNEYMAN PLUM R •, ISSUES THE'ABOVE LICENSE TO: rj MON- 2k 3 j #1 71 BERKELEY ' STx co BT::LLERICA MA 0'1862- 19 85/01/12 80606A- Date.... r NORTH 3r .� 0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING ;,SS�CMUSE� . This certifies that ............ ... ... .. ��`���... .... ..... ...�...................... has permission to perform ........... -4Z.sRf t..... f/ .......... wiring in the building of.................... -.�c� .G /�-�f� .................. at..... .7.. ...>��4?t!� L�...,V................... . rth Andover,Massz f� o� � Fee........7;SI LIc.No. /IX................. . . .!. .. EL RICAL INsncro Check # 6__7_ '�`� Sg 10501 "�" rnrr>+tiuc�� H J 3�aciut Offi ul I�_�.niv Pemlit io. l � � .. Occupant alio Fee Ch 1-:ed 3t .ARD OF SIRE PREVENTION REi�iJLAT1Gf3� �l�te�t. l,t�t] ale ;e b? l.; r! P PLICATION POR PERMIT TO PERFORM ELECTRICAL WORD A11><orl t ite pe- imed in alccc?rdance Electrical Code CNIEC),527'r?:m 12.08) E (PLE4SE; pp—TINT LT�I'OP, 71pEI zL I,'F-OPLIfAl7 011, Date..: Tuesday, November 15, 2011 Cfth°or Tonru of North Andover To 311:t:''•lrgp€ctor ti iT tt-es.- 3 By=tliis application the undCrsrgneed gives,notice of his or her intention to perforin the:electriml wor1 devcnbed bels v,,-. Location(street&- umber)' 143 Sandra Ln. Garner o3=Teliatrt Franco Graceffa Telephone No. 9787941449 Clwrrerr's Address SAME A Is this permit in con utrctio with.a buildi3rgei Alit' I e^r '�a t lrtc3r:� t o 3l3 to Boi;i It rp ,�] ❑ { pp` p,, Purpose of Building Utility uthw izatiou o. Existin,seratce Amps l IT01 s OverheadEl1nclgr•tl ❑ '-Nlo. of meters __. 9 New 5e1"a=ice Amps � Volts €verheaad❑ Undgrd ❑ of Meter i- Number-of Fretlers and mparit-,> Location and,Nature of Proposed Electr kal.Wargil:. rte �9AFFII�6F?DYra.7Q.�'t:artYTs 173x'fc7t�?l�C'F,till' 'S'1'>'C."7e£. '1',S>s'sTt3S-'EfrfiI"tl;<c}'dd'S�. f No.of oit. No..of Recessed Luminaires of C erL-Su.>>p.(?adtllejarm Ir°awfor.iners K A -74 3_ rn No,.of Lumitlair e,Outlets -No.of Dort Tubs Generator KI'A Above E] - ❑ t-b.0 m.tr-pm z' itrrlg rn No.of Lumfitair�es Swi l3minm Pool �rnd, Qrntt. Battery Units No.of Receptacle Outlets Ya.of Oil Burners FIFE ALAICANIS o. oaf Zones :'tri.of Slviu:hes No,of Gas Burners t'o,ba eteetlr�rl 3.n IltItiaalinz Dei-ices' ! No.of Ranges o.of Air CodCodd. Ton, No. of Alertin-Device,: ftP eat impurll ,el 0315 !No,0 fie' - orltmiie{ Vo.of��mte Disposer' Total:: s )1ft2cti0tl':Sclt'tiIlDevices 'lo.of Dishwasher-, Spa cel-Area:Heating I T��` Loral❑ u3uclpa ❑ t?tlrer C o rul et tie"11 Heating, P?iirntes ��� `ecunt =stens-"qt.of Diwer \a ofTle�r es or£"tti�alr.nt 2.00 "( o.of 3 ter `o.o o.o �. Herpes r ]3all as#5 Data Wir•in, Signs o,of)Dikes or Equivalent 0.00 Q' n lay.ofMotors Total EF eeconimu?iicati€:n will- 'No. tin : C» o.Hgrl;t otxtass rge Bathtubs No. of De,.ices or E_uiva]ent 0.00 OTHER: trach ad,hrioar1 deta7,1,if dr--;,I-Ai 0 '7 t'equit C?i�1:"tha h1 . •yl"E,tT l Estimated ilue of Elertriul Work: (51e,requrxed bl y i micipal policy.' . , woll,to Start: Inspeetions to be requested in acce:rdaance.ivith'MEC,RAIe 10,:arta;.par)completion. ENSUR.AiN CE COVERAGE: Lh-des,- wa?ivett lx; Ile owner,no pemut for=:lie;perfaym- ace of eiecmcai wok m.-tr:-me u ales.; the-licensee prot:�ides proo=ofl Ibiiit_�:ulmrauce iichiding`'cor lrieted operatiar.i'ca�veiaaa or its substaiiti:il e ur alen? . The midersru-rled certrfies that.mcli coverage-is nl f�ICtx.find lla,:e�lrl>�t#ed pl ti tof.ume,to the pemail s4 uui4 C ffice_ C2EC'I ON, E INSUKA.NC'E ❑ .BONKID ❑ OTHER ❑ Spetif:; I c°er ifi ratr.rirer file pairrs:alyd Pettalhes crf pep juP-y, that the riifor-arr hoa on this aMilrc:rzhon res that mtd c-vrtpl'ed€:. F.IRXI NA.NIEs}lrrrerica n Marin&..C;rrrt.rrirl3ni:artirtrls..f tre= LIC<',NO.; I = 1 ' _4 N-I A Licensee: R i ch a r d L, S a ru p s ro r3, S r. Signature . LIC=.N,0 ; 5 ft 2 [ afamuiicr,f,7mmw -extyt r-117 ihe Ti£:en e-nfmb'rRim,! Bur, Tel.�o,. 7,t-,. l-� ttf Address: '29 r Broad .; a y. Ar°linr ton, 1ylA 0" 4'74 .alt, Tel,No.- 'Pel'`aI.C�_L. l4 _ 1 Gi..'?'Cllr'litr work Fe?t�1113�'. Department of Prll?llceaf-'r License: 1 rC.._ SS C4}0100000 uU t::1 OWN'-'ERS INSURA.NC`E itlrABJTR. I im mare that the License dors ray?r?'I'avn dle li-ebf1it; in urance cat-,3Re requiledby fii'.'k`. By m xl mantre below,I hereby �hrect21iremeni. 1 3111 Nl?e W1eC1 lrte;l ❑0,3ne:•" ❑�'"'t?t ;'err;.. €:}tix'rrer'r�.geni Sigrr;rtuee Telephone`to. PERS T FFF.' S45.00_ Date.....!Z- 22 - ...................... Ot.40RTjj TOWN OF NORTH ANDOVER PERMIT FOR WIRING *AT This certifies that ........JO........ ...Y................................. ........................................ has permission to perform ......... ................................... .. wiring in the building of......... .................................... � / �... Nor h Andover , ass.. 5 FeeLic.No. Y/*a5 ............ . ........ ....... ..... . ...... ........... .ELECTRICAL INSPE R Check # 0553 Commonwealth o`cc77i�aachu�e( Official Use Only — — - ---• -- __ .. _ Apartm¢nt o�.}ire�ervice! Y_ Permit No-- BOARD OF FIRE POccupancy and Fee Checked PREVENTION REGULATIONS y [Rev. 1/07] 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:j -• a Q 1 City or Town of: A) &Li R /}n:J a w rL 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)_j Y3 '�A N d &^ L N Owner or Tenant A c-0 r- t? e,+-F.4 Telephone No. Owner's Address 4 J 5Ak k a L Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 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: Com letion o the ollowin table maybe waivedbuyy the Ins ector o Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)FansNo.of Total 1 Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ O.o mergency ig ing rnd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones J No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tonal No.of Alerting Devices No.of Waste Disposers f Heat Pump Number...Tons.... KW.......... No.of Self-Contained Totals: Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Water No,of Devices or E uivalent No.of No.of Heaters KW signs Ballasts DatNo.of Devices or E u�ivalptNo.Hydromassage Bathtubs No.of Motors Total HP Telecommunications WNo.of Devices or E OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 406to (When required by municipal policy.) Work to Start:/p/-aa `)J it 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,under the ains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: ho. - , - { t LIC.NO.: - Licensee: 6Dj�} �� Signature LIC.NO.: (Ifapplicable,enter "exempt"in the license number line.) Bus.Tel.No.: Address *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Alt.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 Signature Telephone No. PERMIT FEE. $ u f The Commonwealth of Massachusetts I Department of Industrial Accidents t Office of Investigations __ _ ___ _7 ky 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): � � b' f"I E Ji [�A Address: 9� L"-f { City/State/Zip;-_b,1 S /`7J b ,6 q Phone#: 9 `2 Y �'6 t-/-7� V-1 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 employees(full and/or part-time).* have hired the sub-contractors 2. 1 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. 9. ❑ Building addition [No workers' comp. insurance 5• ❑ We are a corporation and its required.] officers have exercised their 10.❑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.F-1 Roof repairs insurance required.]t employees. [No workers' 13.0 Other comp: insurance required.] *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. a :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. 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 criminalP enalties 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 pain dpenalties ofperjury that the information provided above is true and correct. Si nature: Date: 1;2 Z `f" 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#: Gomm HMO Professional�nglneer �eylew 15 limited to structural desicr and ' I I member sizing, IIIIIIIIiI � , . . . . . . . . . . . . . . . . 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Profe55ional engineer review 15 limlted to Structural cle5icgn and member 51zinci I I I � EXI511NG � I FND1N IF AN MR 01;AN GM159ON 15 I Iy5ccyr1?l;D IN iFE5�FLANS V'.C.I.WILL CQWCf IT AT NO Aign-noN&Ewa,G.C.1.15N0f P'c ON51M FOI ANY CONSiaICTION C05f5 Rf TO FLOOR ADS , %0 MOp5 On OMM159GN5. 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