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HomeMy WebLinkAboutMiscellaneous - 147 FRENCH FARM ROAD 4/30/2018 (2) 147 FRENCH FARM ROAD 210/035.0-0084-0000.0 - ` Date..6!4..�o............... 16 2 7 TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING that 1%Ar,-A L.This certifies th .............................................. ..... ha�permission to perform..Uc t14,J C,-,b ................................................................................................ plumbing in the buildings of... ..... ........................................................... C- "-p- at..... .........(^! .....................1.....0.14.........., North Andover, Mass. Fee... . Lic. No. . ................................................................................. PLUMBING INSPECTOR Check# L4 D MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY /V ����✓ ' /� MA DATE v PERM" JOBSITE ADDRESS .110,y/- OMER'S NAME�L�+r�/,� 0 Wv jr OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATIONY REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES Z FLOOR BSM t 2 3 4 5 6 7 a 9 10 1 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND 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 INSURANCE COVERAGE: `� I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES< NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW / ` LIABILITY INSURANCE POLICY 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 E]SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this applicah are true and accurate to the best my knowledge and that all plumbing work and installations performed under the permit issued for[his application I be i comp a with all Pe ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME////,4W)e�J04�0 LICENSE# 51G ATURE Mo$� JP❑ CORPORATIOY# /J PARTNERSHIP El LLC❑# COMPANY NAtu{�� �� /17�y ,e.�_ ADDRESS CITY,C�� t - � — STATO!W_ ZIP �/� TEL ''�6�'Ffy FAX <«� CELL EMAIL EMAIL Z _ li 1� `/LQc • 1Y1� t\�\ Y , i . The Commonwealth of Massachusetts M Department oflndustrialAccidents I Congress Street,Suite 100 Boston,MA 02H4-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LeZibly Name (Business/Organization/Individual): �aA ftm c W pat t rL4 G. Address: (3 (,t)_p 5 S+. City/State/Zip: &*V 2b t h&P, D lg Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.�am a employer with t�. : employees(full and/orpart-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. F Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself[No workers'comp.-insurance required.]t ❑4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. • 12.[dumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ t 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.F-1Weare a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have no,employees.[No workers'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. #Contractors that check this box must-attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have ntractors have employees,they must provide their workers'comp.policy number. employees. If the sub-co* I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: M [tr,ltc, /' t-p,r Policy#or Self-ins.Lic.#: W C V O Ma 000 Expiration Dater f t a-4 t to Job Site Address: 1(4:) Ftr2nc Fx aw Q<C9. . City/State/Zip: No &—A (mA ot?g5 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.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 correct. Signature: Date: q- b- ((p Phone#: a�, -1 q5-D 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#: r r 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. 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 fired 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia A r � I OP ID:JT ) CERTIFICATE OF LIABILITY INSURANCE DATE(MMl1 015Y) 05/29/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: J.T.O'Neill Durso&Jankowski Ins Agcy LLC PHONE 978-688-7000 FAx 11 Saunders Street AIC No Ell:: _ (AIc978-688-7001 North Andover,MA 01845 ADDRESS:jtoneill@dursojankowski.com Durso&Jankowski Ins.Agcy. -- PRODUCER KANNA-1 CUSTOMER ID#: - --------------- _ INSURER(S)AFFORDING COVERAGE I_ N_AIC_# INSURED Kannan&Pricone Plumbing& - — - —- msuRER A:Liberty Mutual Insurance ' Heating,Inc. - -- -- 3West Ayer Street iNSURERa:Atlantic Charter Insurance Co. - - --INSURER C:ACE/USA Methuen,MA 01844 INSURER D INSURER E.: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR---- -- -- - ------ ADDL SUBRi -- -- POLICY EFF I POLICY EXP - ---- -"----- ----- ------ -- LTR TYPE OF INSURANCE IN R IWVD POLICY NUMBER MM/DD/YYYY MMIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE I�S 1,000,000 DAMAZ`iE T RENTED !S 300,000 A X ; COMMERCIAL GENERAL LIABILITY ! BK$56003225 ! 04/O1/2015 04/01/2016 I PREMISES Ea occurrencej_ --i CLAIMS-MADE Ex]OCCUR ; MED EXP(Any one person) s5_ 1$,00 — PERSONAL&ADV INJURY 1,000,000 ! - I GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I PRODUCTS-COMP/OP AGG 15 2,000,000 i- E -A LI - — y---- ---- POLICY PR0 LOC ! is AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) S 1,000,000 A X X 1 ANY AUTO BAS56003225 04/01/2015 04/01/2016 ALL OWNED AUTOS BODILY INJURY(Per person) S _ ice_-- - --- --- — SCHEDULEDAUTOS j BODILY INJURY(Per accident)_S PROPERTY DAMAGE X ! HIRED AUTOS (PER ACCIDENT) S X NON-OWNEDAUTOS IS is UMBRELLA LIAR X I OCCUR EACH OCCURRENCE S 5,000,000 EXCESS LIAR I CLAIMS-MADE i AGGREGATE S A ------ ---- US056003225 04/01/2015'04/01/2016 DEDUCTIBLE - ! X ! RETENTION S 10000 WORKERS COMPENSATION X WC LIMIT iOTH- ANDEMPLOYERS'LIABILITY I TORY LIMITS_ ER_ -_ B i ANY PROPRIETOR/PARTNER/EXECUTIVE YDN ,N/A �WCV01161700 06/0112015;06/0.1/2016 I E.L.EACH ACCIDENT S _ -_ 11000,000 I OFFICER/MEMBER EXCLUDED? I"I - -". C (Mandatory in NH) 6S62U62E24978014 06/01/2015 i 06/01/2016;E.L.DISEASE-EA EMPLOYEE S 1,000,000 If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMITf S 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Plumbing&Heating CERTIFICATE HOLDER CANCELLATION NORTH13 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 384 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE Durso&Jankowski Ins.Agcy. ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD KANN&PR-01 JONEILL ,acoRO CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDD/e `-� 4/6/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Durso&Jankowski Insurance Agency PHONE - FAX 11 Saunders Street (A/c No,E J_�9�8)688-7000 (q/� Na):(978)688-7001 North Andover,MA 01845 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE ___ NAIC# INSURER A:Concord Group Insurance INSURED INSURER B:Safet-y Insurance Company_ _ _ 33618 Kannan&Pricone Plumbing& INSURER C:Markel Insurance Co Heating,Inc. —- --- - - - .. - - 3 West Ayer Street INSURER D: Methuen,MA 01844 SURERE:______ INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR - ADDL SUBR - - POLICY EFF POLICY EXP- ---- - - LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDDIYYYY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _ _ S 1,000,000 CLAIMS-MADE � X OCCUR 20009105 04/01/2016 04/01/2017 DAMAGE TO RENTED -PREMISES(Ea occurrence)_ S MED EXP(Any one person) S 5,000 PERSONAL&ADV INJURY_ S GEN'L AGGREGATE LIMIT APPLIES PER: __GENERAL AGGREGATE S 2,000,000 X POLICY _ JET - LOC PRODUCTS-COMP/0P AGG S 2,000,000 OTHER: S AUTOMOBILE LIABILITY COa BIKED SINGLE LIMIT S 1,000,000 B ANY AUTO 6237590 04/01/2016 04/01/2017 BODILY INJURY(Per person) S ALL OWNED X SCHEDULED BODILY INJURY Per accident S AUTOS AUTOS ( ) NON-OWNED PROPERTY DAMAGE - S X HIRED AUTOS X AUTOS (Per accident) - S UMBRELLA LIAB X OCCUR -EACH OCCURRENCE S 3,000,000 C X Excess uAB CLAIMS-MADE MKLVIOLE107332 04/01/2016 04/01/2017 AGGREGATE S DED RETENTION S S WORKERS COMPENSATION PE vim- ,AND iH- AND EMPLOYERS'LIABILITY YIN .. STATUTE _ ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N I q E.L.EACH ACCIDENT S (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under — ------- - - - --- - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover Bldg 20 Ste 2-36 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Date.. of Nowrk,� 3r;` :• �oL TOWN OF NORTH ANDOVER t ' PERMIT FOR WIRING �ss,+cNuSE This certifies that ... has permission to perform ....... ... . 1 ....... c ✓2� wiring in the building of.....B F�1 ..................................................... at ................................�►- '�. !..:!.......... .:,North Andover,Mass. Fee...140.x............Lic.No�fl�5 t - ELECTRICAL INSPECTOR Check# 1(PSO 4 k 4 stela� MBEi 55UES !�€ fflW�ifi _TrfE t It Ab AS A MkST �D I i 10 B G:RIAM U f€W RD Y t Syt 7 1 � 1 J R Commonwealth of Massachusetts Official Use Only Permit No. ' '17 Department of Fire Services ' Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [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 17VNK OR TYPE ALL I7VFORMATIOA9 Date:_AVOO&/-/ 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. �a 1 Location(Street&Number) WW Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with buildi g permit? Yes kr No ❑ (Check Appropriate Box) Purpose of Building__ &/U Utility Authorization No. y - 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 Pro osed Electrical Work: / Completion of the following table may be waived by the Inspector of Wires. No.of Recessedo.oT Recessed Luminaires No. Cel Susp.(Paddle)Fans Trans Total (� Trsformers KVA No.of Luminaire Outlets No,of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- El o.o Emergency Lighting rnd. rnd. Batteryits No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and InitiatingDevices Ranges o.o g Tons No.of Ran No. Air Cond. Total No.of Alerting Devices � No.of Waste Dis osers Heat Pump Number Tons KW No.of Self-Contained 1� p Totals: -" ' "" " ' Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal F1 other p g Connection No.of Dryers Heating Appliances KW SecN t o.o Systems:* ev cls or Equivalent \ No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Bathtubs No.of Motors Total HP Telecommunications Wiring: No.Hydromassage No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: L (When required by municipal policy.) Work to Start: A Z Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO RAGE: 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;age is in force,and has exhibited proof of same to the permit issuing office. A� CHECK ONE: INSURC BOND ❑ OTHER ❑ (Specify:) I certify,under thepains andpenalties ofperjury,that the informatio n this application is true and complete. L� FIRM NAME• . LIC.NO.:A/6 2 / 6 ' Licensee: , ��14,� Signature LTC.NO.: (If applicable,enter "exenpt�"in nth licens urmbe ine.) Bus.Tel.No.: Address: --A- /,/ ttt b/ it�P� Alt.Tel.No.: *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 [Pi�MIT FEE:$ Signature — Telephone No. 1 ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the 1a 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 concerning 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[N Failed IN Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INECTION: Pass 0 V Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: 44, Inspectors Signature: Date: Z Jill FINAL INSP TION: Pass 0 IJ Failed Re-Inspection Required($.) ❑ Inspectors Comments: 19 Inspectors Signature: Date: . 1 . Ito DEB WEINHOLD ...TOWN OF MERRIMAC,MA. ...:...dweinhold@townofinerrimac.com ,J The Commonwealth of Massachusetts M Department of IndustrialAceldents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/OrganizatioiAndividual): Address: City/State/Zip: Phone#: Are you an employerlh__ heck the appropriate box: Type of project(required): I am 1. a employer employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working forme in 8.4( 1' emodelitig any capacity.[No workers'comp.insurance required.] /`� 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'compAnsurance required.]t 10 [:1 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.# ' 14.❑Other 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have ne.employees. [No workers'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 tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is piovidiizg work s'compensation insurance for my employees.'Below is the policy and job site information. / Insurance Company Name:77/ AA— Policy#or Self-ins.Lie. l#:- e `C. Expiration Date:: Job Site Address: ' I f R ° 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 MGL c. 152,§25A is a criminal violation punishable by 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.A c y of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Idohereby certify nd the p s d penalties o ��zatthe information provided bone' true and correct. Si nature: Date: 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#: i r 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'liire, 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-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' compensatiod 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia a.' :COMMONWEALTH OF MASSA&&'*SETTS, BOABQ OF EL€CTRICIAN:S ISSUES-344E FOLLOWING- Ll ClNSE . ASA RV,6; JOURNEYMAN ELECTR SAN. URT 1 FORBES � 1 ' , �t 10 NORTH E`ND RD y �,4_ 1.r 'W TD:WNSEND,.... ..- MA 01469 1125 37854E oANIMIP l%31/16<: =99369 OMMONW OF MASSACH SETT:. M ELE:CTaICIANS J ��SUES THE FOLLOWING LIGENSt A l¢ RE- '—. TEI�ED MASTER. E ECTRI C'I A C; L Ft�RBES ELECTRIC r `_ CURT L F0R8ES. 10 NORTH TOWNSEND MA 01469 5 ,...0 � ;; 0 10072 Date........................ NORTH Ot t�.•o;�1ti0 TOWN OF NORTH ANDOVER o PERMIT FOR WIRING SACMUS� — This certifies that ...........�J.............L.t:. GSNf�...... .............................. has permission to perform 4 / &� 677Z .................... wiring in the building of /3CLl VEL V v at..... ............................ ......... }........... ,North Andover,Mass. ��11 m o Fee.dJ�.......... Lic.No..�� .�7 7.. SPE........... . . ....... ........... ... .. ..4 (� /� ELE CAL INCTOR Check # `� " 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the 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 ofongoing 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 flia precedurg 12-month period.Upon written application,an extension of time O'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 puipose by establishing an automatic four-year extension to certain permits and licenses concerning 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. ule 8—Permit/Date Closed: _—� �/ *t*Note:Reapply for new permrC>� 0 Permit Extension Act—Permit/Date Closed: l.ommonwea&olcc//tamac"tb Official Use Only aLJeParEmenE o/.}ire eruice� Permit No. 1-00-72— Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [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 INFO TI,O Date: V"07� A/ �lC�� e -- To the Inspector of Wires: City or Town of: 4)0, By this application the undersigned gives notice of his or her intention to perform the electrical workdes below. Location(Street&Number) h d077 Owner or Tenant p P Telephone No. Owner's Address q A -e Is this permit in conjunction with a build' g permiit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building iZ es ekir - 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 an Nature of Proposed Electrical Work: re 611 re e Aceal-,1 PBL Completion of the followingtable may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans TransTotal Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires S Above ❑ In- Elo.o Emergency Lighting nd. rnd. Battery Units No.of Receptacle Outlets .of Oil Burners FIRE ALARMS No.of Zones of No.of Switches No.of as urners No. InDetection and Initiatin Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Dis osers 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 1 P g Connection No.of Dryers Heating Appliances KW Security Systems:* i'Y Na of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts I No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: ��V (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 co erage is in force,and has exhibited proof of same to the permit iss�g office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) �v(/r G --/n,Sf,((I ? I certify,under thepains and enalties ofperjury,that Oe information on this app 1"c tion is true and complete FIRM NAME: �w- 0" LIC.NO.: S)9 Licensee: Signature LIC.NO.: (Ifopplicable,enter "exempt"i the license number line.)�j �/ `Bus.Tel.No.: 7 Address: Q� `t "f t�'�l `"(� D L/ Alt.Tel.No.: �'7-5 3 el *Per M.G.L. 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 a ent. Owner/Agent Signature Telephone No. PERMIT FEE. $ Date.q/ 7/1*( . 8941 4 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SCHUSf� f j �! '. � This certifies that . . . . . • . . . . • • • • • • • • • • • • • has permission to perform . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . _ 1?�!'t '.`'' . . . . . . . . . . . . . at �.y Irf� . . . . . . . . . ., North Andover, Mass. Fee.._ . . . PLUMBING INSPECTOR F Check F MASSACHUS""ETTS UNIFORM �-\ (Print or Type.) .` . APPLICATION FOR PERMIT TO DO PLUMBING Mass. Date l� Building_ 7 Permit # _ g,Locatiori� X78Owner's Na 01 New [, Type of Occupancy Residential s...;,,,t Renovation O Replacement Plans Submitted: Yes❑ No _ FIXTURES N O Z F •� r--f i } ¢ of i O _ Z �, Q S4 S4 Q4 x y 1 v :_ ¢ m y ¢ V `n u- _ I ¢ W O :3 w f- �n <~ c a c7 a a P 3 x m r'7 0 0 3 x y u a 3 o a N •'� BASEMENT IST FLOOR' 2ND FLOOR 3RD FLOOR - .- 4TH FLOOR STH FLOOR. 6TH FLOOR I 7TH FLOOR STH FLOOR E. ? Installing Company Name Herlitage Ht I g. &P1g. Co. Inc.. Address Check one: Certificate int street t$Corporation 714 Stoneham, Ma 02180 Business Telephone ❑ Partnership 7sI -q?:g-.?776 Name of Licensed Plumber f l Firm/CO. Gordon Switzer ----- r,[NSURANCE COVERAGE: ve a current Liability insura.n.ee policy or its substantial equivalent which meets the requirements ofYes No ❑ou have checked yes,.pjease indicate the type coverage b checking the MGL Ch. 142. YR g Y g appropriate box. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass..General;Laws,. and that my signature on this permit application waives this requirement. Signature of Owner or Owner_'s AgentCheck one: Owner ❑ Agent❑ I hereby certify that all of the details and.information I have submitted(or entered)in above application are true and accurate knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massact;usetts State Plumbingto the best of my =By_ Code and Chapter 142 of a General Laws. Signa ure of Ucensed Plum erType of license: Master Journe yman❑License Number 83,22 %z" Waits 9D bCp_o11 water line to water-boiler BELOW FOR OFFICE USE ONLY r PROGRESS INSPECTION$' , FINAL INSPECTIONS SKETCHES FEE N0:___ APPLICATION FOR PERMIT TO DO PLUMBING NAME A TYPE OF BUILDING, LOCATION OF BUILDING PLUMBER PERMIT GRANTED DATE 19 PLUMBING INSPECTOR 1 8 9 U ; Date r' � NORTH r �',, •� ,.!� TOWN OF NORTH ANDOVER 3: •`_" ' 0 AL PERMIT FOR PLUMBING This certifies that .- �— !, has permission to perform . . '�l>.r . 1, o,-.tit , .`.J k . . . . . . . . plumbing in the buildings of . . . �Qs11.U!/?�.G. . . . . . . . . . . . . . . at . . . . 147. . . (,4/n.11f.QL. ., North Andover, Mass. Fe O. .Lic. No..� a.dam . . . . .. . . . PLUMBING INSPECTOR Check MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) tn,�Cl-2�h ZqQd,2 V&/ Mass. Date Pe--r'�mit # Building Location 7 ('e_n,,_ /' wner's Nam.'. ,n J) FYI V-,--/ �IS q 7 R (G J �� Type of Occupancy Residential New 0 Renovation ❑ Replacement IN Plans Submitted: Yes❑ No ❑ FIXTURES Z N Q r�1 o = F O LU Q C7 CC �4 34 34 N ¢ _ ¢ ur O z —< a s vy W y ? LL az CC z CC cc LLI Q Rf (tS rif 1 i ¢ W W a N a J N ¢ 2 J z O OLU LL LL i ~ v > tz- o = a V) F- z o a = z w o 0 v N Q� Q r a a = 'W a a o a J J a ¢ ¢ M a 0 a -4-) 4-) d-) 4-3 �4 3 )[ J m cn o o J 3: = r m u a 3 ¢ m b rd rd rd SUB—BSMT. 1 BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name Heritage Htg. &Plg. Co. Inc. Check one: Certificate Address 35 Pleasant Street EX Corporation 714 Stoneham, Ma 02180 ❑ Partnership Business Telephone 781 -43 8-77 76 (-7 Firm/Co. _ Name of Licensed Plumber Gordon Switzer INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 91 No ❑ If you have checked Vis, please indicate the type coverage by checking the appropriate box. A liability insurance policy IN 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent❑ Signature of Owner or Owner's 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 the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code andJChapter 14 f the General Laws. By C Signature of Licensed Plumber Title Type of License: Master[X Journeyman❑ City/Town $3 2 2 APPROVED(OFFICE USE ONLY) License Number L/ocation / No. Date �oRT� TOWN OF NORTH ANDOVER AL n Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ s4CHuse Other Permit Fee $ Sewer Connection Fee $ v Water Connection Fee $ TOTAL $ Building Inspector 1 2 6 fJ15/98 09:19 117.04 pA�rD Div. Public Works l I location No. Date TOWN OF NORTH ANDOVER A Certificate of Occupancy $ + + Building/Frame Permit Fee $ � , , 1'�s''•° '<� Foundation Permit Fee $ s�cHust Other Permit Fee $ Sewer Connection Fee $ x Water Connection Fee $ TOTAL $ Building Inspector 07/15/98 09:19 117.01 nr)rn Div. Public Works �... > >, , PERMIT ******** I CRM IT NO. R7 � AI I LIGATION (,OIZ I I'RMI`i' TO I3U1L1) NORTII ANDOVER, MA AI 11•NO. O 3 T. O LOf.NO. o 2. RECORD 01OWNERSHIP DATE BOOK PAGE 7/)hE Still DIV. LO"F NO. LO( AIION Yr-) / PIINPOSE(A:HI I)IN(1 OWNER'S NAME ( NO.OF S-TO RIES SIZE: OA OWNER'S ADDRESS A V"�- BASEMENT Olt SLAB ST ND RD AR(III 1 EC-I'S NMME �_� SIZE OF KOOR 1 IMBERS I 2 3 Bl 111 DER'S NAME l , SPAN DISI ANCE TO NEAREST BUILDING DIMF.NSIONNS OF SILLS DISTANCE FROM S'rREE I" DIMENSIONS OF POS IS DISTANCE FROM LOT LINES-SIDES REAR DIMENSIONS OF GIRDERS ARBA OF LUT ` A FR(NJIAGE IIEIGIIT Of:F(x)NDATION THICKNESS IS L0111-DIM;NEW N[/ SIZE OF FO(YIING X IS BUILDING ADDI TI(NJ AJ 0 , MATERIAL OF CI IIMNEY IS BOILDING ALTERATION L)e-J IS BUII.I)IN(i(NJ SOLIDO R FII I.EDLAND I 1191 1.BUILDING CONFORM TO RE(�I1REMENTS OF CODE IS BUILDING C(NJNECI ED'I O TOWN WAFER e-S ,4;O.gRD(N APPEALS ACTION, IF ANY IS DUILDINGC(NJNECIED101OWNSEWER e-S IS BUILDINGCONNECIL•DTONATURAI.GASI.INE IINSIII('I'IONS 3- PROPER IX INFORNIA7"ION I.ANDC'OST ESI. BI.IXi. COST UU PAGE I FILL ON IF SEC]IONS 1-3 ESI. BLIXi.COS f PER So. FT. -� ESI'. BLDG. COS I PER ROOM ELECFRIC METERS MUST BE ON OOTSIDE OF BI)II DING SEI'lIC PERMI 1 NO, A Fl ACHED GARAGES MUST CONFORM*FOS rATE FIRE REGULATIONS �. .►I'1'ItO�'F.D B1': PLANS MUST BE FILED AND APPROVED BY BI IILDING INSPECTOR Bl II I.DI .INSI' . :7011 DA I E FII I:U ( OWNERS I FIN Z S t L 2,J COHIR.IEI.a 16f�,�9 -S-33 7 COM R.LIC'a SIGNA I'1IRI?Of-OWNER OR All"I 1 NN2IZI:D AGLN"T ��1-1:11 PFRKIII GRANFIiD 19 NOR T/y Town of O L �� m No. , * - - - * z _ c7 j 19 �� * � � . � dower, Mass., 0 LAKE '9A_COCHICHEWICK _ V '9A DgA'rED J"9 `J v ` BOARD OF HEALTH Food/Kitchen PERMIT T Septic System BUILDING INSPECTOR THISCERTIFIES THAT........................................... ............... .�� ................................................................ Foundation has permission to erect .......K ..�f .l.i�--.. buildings on ........ ......:F. i�10 C.... ......... .G .,...... Rough to be occupied as.......................................:............ .:... ...� ze.-s ... .................................................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Guildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION ST Service T ELECTRICAL INSPECTOR Rough ...................................... L G INSPECTOR ........... Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final r No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. � Burner Street No. Smoke Det. 3041 N° 3 u 4 1 Date...... �Z. ........... • NOR7M 3?°;t„``°.:•_�"°0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSAcmUSE� This certifies that ��`"rt..::+.r......... { fi E......... ..................................... has permission to perform lj..A T wirihl in the building of � ...C?�.���.!!.'- �` at.........i.. ?.....C..Q.F..!�.C. ...... .!t..f�`l....0 North Andover„Mass. �7 - �� Fee.. ..;.. ?.... . Lic.No.. ..�. �� ......... .. ... .. .................... LECMCALINSPECTOR Check # ��� WHITE:Applicant CANARY: Building Dept. PINK:Treasurer V lug Pelmit# Department of Public Safety BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Effective: 1/98 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) 1J. 4 AJ t SoVi 2 DATE �� G To the Inspector of Wires,TOWN of GRINOWThe undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) 1 Y 7 F-R—elJ611 6 Owner or TenantP14uJlT L + E LLK 6,f /�/Vic r/ Owner's Address(if different) S/f til . Is this permit in conjunction with a building permit (Check Appropriate Box) Yes NoE Purpose of Building I 9 4 0q t'7V Utility Authorization no. Existing Service- P-cc-, Amps ( aF, 3 p Volts Overhead a Underground #of Meters NEW SERVICE- AMPS VOLTS OVERHEAD UNDERGROUND[] #OF METERS Number V+eeders and Ampacity I Location&Nature of Proposed Electrical Work (�(� ( RF- G U 7- 7-0/2 #Lighting Outlets #Hot Tubs #Transfomiers Total KVA #Lighting Fixtures Swimming Pool ABOVE./IN -ground #Generators KVA #Receptacle Outlets #Oil Burners #Emergency lighting Battery Units #Switch Outlets - #Gas Burners FIRE ALARMS: #Zones #Ranges #Air Conditioners - Total Tons #Detection&Intiating Devices #Sounding Devices #Disposals #Heat Pumps Total KW #Setf-Confd Detection/Sound Devices #Dishwashers Space/Ama Heating KW Local❑ Muni.Connection R Other #DrYers Heating Devices KW Connection Location #Ylfater Heaters KW #Signs #Ballasts Low Voltage Wiring El Hydro Massage Tubs #Motors Total HP OTHER: INSURANCE COVERAGE:Pursuant to the requirements of Massachusetts General taws, I have a current Liability Insurance Policy Including Completed Operations Coverage or its substantial equivalent YES a/ NO I have submitted valid proof of same to this office. YES rl NO If you checked YES,please indicate the type of coverage by checking the appropriate box. INSURANCE Er BOND ❑ OTHER r-1 (Please Specify) xpira ion a e Estimated Value of Electrical Work $ Work to Start Inspection Date Requested- Rough:LV I L L LiQL L Final: Signed under the penalties of perjury: FIRM NAME (7 v h -r-E t_, c I L uc.# .S'A Licensee t C-l fin, Lo„ C A V ��� Signature ��jU �LL� Lic.# Address !� !� R b ie, C/T /�1J!/T D / b Bus.Tel.# 9 7e'aSl'3 L AIL Tel.# OWNER'S INSURANCE WAIVER: I am aware that the licensee 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) Tel.# cash CIC I PermitFee 3�Y-- GG