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HomeMy WebLinkAboutMiscellaneous - 148 MAIN STREET 4/30/2018 (58) .�..� ��- G -� _ �- . �� Date.........t.........1....................... OORT#4 °� •�tia TOWN OF NORTH ANDOVER PERMIT FOR WIRING $B,�cMu5� This certifies ?..... .I.r `i� ..�.,:L1.... �f ............................... has permission to perform .. . . .!....:.UTA..JA............................................... wiring in the building of.......... vta w�.�/5........................................... MA, + ,�- 2 p5 ++�a' n `-e at .... ...... ...............-....................................!-'..............................,;c�rfhAndover,M ss. Fee,��� ..........Lic.No.�.1���.. .........'U................`....�.........................��...... � ELECTRICAL INSPECTOR 9 Check# A commonweaffh of Massachusetts Official usro�y of Fire Services Per=mft No. BOARD OF FIRE PREVENnON REGU A-noNS j Occupancy and Fee Checked ev. 11/991 Cleave btaJc) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the?vtassaci�s�Inspecto ricrl Code (PLF.�4SE PR11VT IYINK OR TYP 14LL INFOR1�477019 Date: C):''`%CSR I2.00 City or Town of: _ � Z tus e✓ To the of es: �BY�,,y,�applicationpt��e( jI,� ped g�n�o # s or her intention to perform tine eieetrica;work described below. Locafta(Street&Number) f n S�-� 0 r 1 11�#,aiy, Lot: Owner or Teuast _S !C�'� C r- nn e ✓ Telephone No. owner's Address 1;L Is this p011e9t is c0103ct4a with a bufiftg pees Yes 52 Noi j Building Permit# R Pale of Utility Authorization No. Eng Service Amps ! Volts Overhead ElUndgrd[D No.of Meters Now Savice kmpsi Volts Overhead ❑ U udgrd❑ No.of?Meters Ntemher of Feeders and Ampae ty Location and Nature of Proposed ELecanicat Rork: of 3 1 0.Of Recessed Futures Com patio N0.offollowin labia be waived by the Inspector of Win No.of Cel}.-Susp.(Paddle)Fans T Trtpsformers KVA S. N0. Na of Hot Telma Generators KVA No.of Lig Fixtures Above Pool Above ❑ In- Q o.a cy d. tiairts N0.of ROMptaeie Outlets No.of OR Burners FIRE ALARMS No.of Zones N0.of No.of Gras garners No.of Detention and In" . Devices N0.of Ranges No.of Air Cond. Tota No.of Alerting DevicesTons _ No:of Waste ffigmm Hest Pomp Number Tons KW No.of Self-Contained � Totals- Dgte on/ Devices No.of Dishwashers Space-/Area Heating KW Local II connection II Other No.of Dryers Heating Appliances KW f or si�ale$t 0.of ester KW No.of No.of Data Wiring: Semis signs Ballasts No.of Devices or eat Na Hydromassage Bathtubs No.of Motors Total HP Tepecomat�ications Wiring: r No.o€Ikwices or aivdea# OT' �R: Attach additional derail if desire or as-gr&ed by the hapeator of W INSU� CE 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 s coverage is in force,and bas exhib' proof of same to the permit issuing office. CHECK ONE: INSURANCE EsOND ❑ OTHER ❑ S U d c l��'-) F.s&aawd Valnac of Elect tioai Work Dafe) ���, (When required by municipal policy.�, WO&to Start inspections to be requested in accordance with MEC Rule 10,and upon completion. I cer#y,under the pmns mid pend ies of pesjury,that the hiiformation on this application is true and conVlete_ FIRM NAME: f r 1 S L 2l: ti , �i'1 LIC NO.: L.ieeasee:1.1J/�1Q�][� �1 nt5 Sigaa#are 1C.NO.: (If�plicable,ernes" •in th¢licence nranber Iine. $us.Tel.No.:��-�t�}''�OWNER'S TNS3RANC,'L WALVER lam aware that a Licensee Maes nor have Etre IiabilHy insurance coverage normally rec{uyred by 1 $y my sigsRtdre below,I hereby waive this requirement, I am the(check one)❑ owner Ll owner's agAWL. Owner/refit Telephone No- 1312-71 o PERMIT FEE: $ '�j� 1312-7 `� .t. C i� `mint Q r s 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): ,L )Y)icy F) r 4-aeOz� Address: f d. City/State/Zip: A Ant. Phone #: S-3)•W-7i Are you an employer? Check the a propriate box: 1.R'I am a employer with� 4• ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g• ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.* 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10. '✓❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13•0 Other comp. insurance required.] *Any applicant that checks box#I 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 employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 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: l7 y 00in t,�/- '�'a©I 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certifv under the pains and penalties of perjury that the information provided above is true and correct Simature: U#_ Date: 2/ Phone#: ?S - Lint Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: 0 i I 1lLTH.OF M°< J► N�S ::;„ I AP arts:<:,:�> �: O L L OW I N GAs..-.A ; <jSSUES Tff. D MAST. LECTRICIAN'`':<>' :' ELECTRIC ,i'NC t Po;Kx. 3955 'A 9p.t. 61-39 ... .. .: P)SA abY 45416 07/11 ` t i.; s �60MMON WF.A—Ltk OF M. 2-Mu THE FOLLOWII1l: `��'�CES.E;:::<> ,� > SSU S,` :hz URNEY A >< A �4;yfi ELEC1RICIdI.'':..:. °t:JQ. I?�A • . I I TOWN OF NORTH ANDOVER „ PERMIT FOR PLUMBING 41 o » •• r -$BACHU`3� TVs certifies that..................`.......:`t"............JQ.............`..� {j has permission to perform...........1 �!`rcrUe-, r".e✓v, Q J-e-(.... .................................................................... . plumbing in the buildings of.......k f.......... ....................... ..................... �� M� �� o s a �An at.....�.............................. ................................. ( ..(�.........�North ndover, Mass. Fee4...............Lic. No.ZO 10...... .....1....iu.............................................................. PLUMBING INSPECTOR Check# 6'P J MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE ZZ PERMIT# OM JOBSITE ADDRESS _ q f OWNER'S NAME POWNER ADDRESS e. _ TEL jFAX��— TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL®� PRINT CLEARLY NEW: M RENOVATION:® REPLACEMENT: PLANS SUBMITTED: YES Q NO2.. FIXTURES 1 FLOOR- BSM 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _IL J I L___..I CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM _.�f �j � .___.,...j l - - _. _I -__I __-. I ( k DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM __._ ......_ ! ___1 I DEDICATED WATER RECYCLE SYSTEM 1 _._. .__1 ...._.i DISHWASHER . _� DRINKING FOUNTAIN FOOD DISPOSER -.l i _.._.-1 FLOOR/AREA DRAIN .____.1 _._-- [ __..-_.j ---_-_1 . INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY f ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET I __ .___f URINAL --------- ..._..._( ___._.. .__..._.; 1 ......__.�ED f ......._...I __. WASHING MACHINE CONNECTION _f ! __._. r —_.-_1 _ __# - _► _ _! ! 1 WATER HEATER ALL TYPES I ( ._ . i ! 1 f .— ( __.._-_I _.-.._ WATER PIPING OTHERI ...._._.-._.f __J ____I ..--...__.1 ! ---- ! _ I INSURANCE COVERAGE: _ 1 have a ;..current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TY F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND 0 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 _i AGENT I© 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 best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co h all e ntprovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. — ::—_�7 �v PLUMBER'S NAME o h LICENSE# SIGNATURE MP Elf JP CORPORATION 0#=PARTNERSHIP 0# _ q LLC U� COMPANY NAMEmM�s D.g_ -- ,j -LC ADDRESS CITY � __...._.._...._I STATE °C _� ZIP C7 (�B'� —� TEL S'3_ FAX ( CELL��EMAIL �"� ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No c 1, THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES �, d i The Commonwealth of Massachusetts Department oflndustrlalAccidents Office of Investigations 600 Washington Street Boston,MA.02111 qu www.mass.gov/ilia Workers' Compensation Insurance Affidavit: Builders/ContractorslElectricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): _T�a aaS Q_-LQ= i't�t.`Z Address: City/State/Zip.�c-> S���- (2 VA 'FT , . 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. E�_Wew construction em gees(full and/or part-time).* have ned the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet.t 7• modeling ship and'have no employees These sub-contractors have 8. [J 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.❑Electrical repairs or additions required.] officers have exercised their 3111 am a homeowner doing all work right of exemption per MGL 11.E]Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have,no 12.❑Roofrepairs insurance required.]► employees.[No workers' 13.❑Other comp.insurance required.] x ny applicant that checks box#1 must also fill out the section below showingtheir workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they tie 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. I am an employer that is providing workerscompensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Sel-Mus.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 requiredunder 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 maybe forwarded to the Office of 'Investigations of the DTA.for insurance coverage verification. I do hereby cert! er a pain enalties ofperjury that the information provided above is true nand correct - Signature: Date: Z C Phone#: C z J 7 f 2_6 Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermitUcense# 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, Q 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, j 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 maybe 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 he. 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(ifnecessary)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 maybe 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 orpermit 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 Gaxozweatth of Massarhusetts Depafteiat of fadusWal.Accldonts ofaee of 111vestigatlow 604 WuMagtou Street Boston?X4.021 X Z TQI,#f X 7-727-4900 0Yt 406 ox 1.-877,1MASSAF.E Revised 5-26-05 Fax#617µ727-7749 '{A1WW_m a c.e crn'tzfrl;a yyOMMONW�L H OF MASSk&k SETTScogtA . « » o R Af > P UMBE $W AS,I ISSU THE FOLLOW : ENSE }c - I E$ AS A JOU /KA `§ T 4m S u DE FROKZO ~k CAS/R/R I : > , � » > 0 -SME §� 0198331 7 ^ 2 ® 20/0»® 0/ \ 2 �. , �\�! ;