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Home My WebLink AboutMiscellaneous - 15 CIDERPRESS WAY 4/30/2018 C1 '\ �� \ �� V �- Date....... ......................... o� No°TM�ti 3: ,�`. `:-••'•°o� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,SS^CMUSE� This certifies that ........... l/yJ �....... ? 'GT..fz�..�........... has permission to perform .......... 1 Q /�.. NSCw....J...� `.. ............................. wiring in the building of........4....�.`.`"`. �f r�U .0. �lf' �'-la..:. l C, S at /,1! ?l rJ/�F SS w / ,North Andover,Mass. I PSS'- /Z5 a Fee.. .. .......... Lic.No..M............ ............... .. .............................. ......... ELECTRicALINSPE�TOR Check # / _ -Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical CodeC), 27 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date' 3 Z4 City or Town oh NORTH ANDOVER To the—lip- ctor of Wipes: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) j � 1AES S Owner or Tenant (� '1 „q, Telephone No. Z S. Owner's Address 1 Is this permit in conjunction with a building permit? Yes 9-'No ❑ (Check Appropriate Box) Purpose of Building r2-C,5 ,�T _ Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No.of Meters New Service -off Amps t to / 1-!-t( Its Overhead❑ Undgrd C?--'No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: L1 F ,� kc1J5G� Completion of the followin table may be waived by the Inspector of Wires. No.of Recessed Luminaires L.p No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires p Swimming Pool Above El o.o mergency Ig tingrnd. rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches 30 No.of Gas Burners etection and Initiating Devices No.of Ranges No.of Air Cond. Tonsl 3 No.of Alerting Devices No.of Waste Disposers ( Heat Pump Number .Tons KW No.of Self-Contained Totals: ................... Detection/Alerting Devices No.of Dishwashers ( Space/Area Heating KW LocalMunicipal ❑ Connection EJ other No.of Dryers 1 Heating Appliances KW Security Systems:* No.of WaterNo.of Devices or E uivalent Heaters KW No.of No.of-- Data Wiring: signs Ballasts No.of Devices or E uivalent 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 o Electrical Work: G v �� (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VE GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability. ance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cover a is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: q L �- �L�- LIC.NO.:� Licensee:N(,( 3.1ArF .�- IC.NO.: L 8D sz- [ ignature (If applicabl ent "exempt"in the license number line.) Address: I�us� �y� S Bus.Tel.No.: Zr *PerM.G.L c. 147,s.57-61,sec ur work requires Department of Public Safety"S"License: Alt. c.No.:l. �2" 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/Agent ❑owner's agent. Signature Telephone No. PERMIT FEE. $3r5:! ELECTRICAL PERMIT NO. ELECTRICAL INSPECTOR-DOUG SMALL PORT: Mhspectors,�comm'ents: TION: Failed—[ ] Re-inspection requiredT($50.00)-[ ] ectors'Signature-noAltials) Date 2.FINAL INSPECTION; Passed—[ Failed—[ .] Re-inspection required($50.00)-[ ] Inspectors'comments: (Inspectors'Signature-no initials) v , Date• � . 3•UNDERGROUND INSPECTION: Passed—[ ] Failed—[ ] Re-inspection required($50.00) Inspectors'comments: (Inspectors'Signature-no initials) Date 4.INSPECTION—SERVICE: - DATE CALLED NATIONAL GRID: NAlVID: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors'comments: (Inspectors'Signature-1io initials) Date 5.INSPECTION-OTHER: Passed—[ ] Failed—[ ] Re-inspection required($50.00) Inspectors' comments: (ruspectors'Signature-no initials) Date D 0 O TAGS ARE TO BE FILLED OUT AND LEFT ON SITE.W THE AREA TO BE INSPECTED IS NO ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED. T The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,AM 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legiblv Name(Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 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 sh%et. # 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for mein any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 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' comp.insurance required.] 13.0 Other Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. 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 fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date• Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Per # 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#: 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 filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia Date. .�i��? � TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING • i ,SSACMUS� . . . . . . . . . .This certifies that . . .//� . ./ . . . . . . . . . . . 1 has permission to perform . . . . . . ,i� . . . �l`liS(. . . . . . . . . . . . plumbing in the buildings of . . �... . 1. . . at . . .. . . . . . , North Andover, Mass. Fee. Lic. No.1 . . . . . . . . . . . . . .i!. . . . . .. . .... . . . . . . . f ."PLUMBING INSPECTOR Check ." '� ,d ` MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: /1�Iri1 �11 MA. Date: Permit# T Building Location: I C1,�Q/t� 1,/''CS Owners Name: �+�r Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential[[ New:Ni(Alteration:❑ Renovation:❑ Replacement:❑ Plans Submitted: Yes❑ No❑ FIXTURES DEDICATED � z SYSTEMS W Y 0 > Z LA 2 H Vf p 0 Uj Uj LA cc LA LA Z H &A Q of Q W C7 C C Z a °c H Z V) W F Q 3 m Cn W z LA > Q Y v, W OJ a X Q Q W C O c W W cc Z W J Z C' o:0. W oil W W I- OC 0 I U. !A J a' {A W W U H 'n O ~ U ; O Q a Z Z LA H H = w W Q H V1 a m m c c LL i x 5 5 W L 3 3 3 o a ID 0 W 3 SUB BSMT. BASEMENT 1ST FLOOR 2ND FLOOR / 3RD FLOOR 4T"FLOOR 5T"FLOOR 6T"FLOOR 7T"FLOOR 8T"FLOOR ++ Check One Only Certificate# Installing Company Name: (/ I i / ❑Corporation Address: �' iJ� City/Town: 11/✓VL State: K z a/y El Partnership 3 Business Tel: C4�� J 7� Fax: ❑ Firm/Company Name of Licensed Plumber: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes o❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's 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 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 142 of the General Laws. By Type of License: Title lumber Signature of Lic nsed/Plumber Cityrrown Master License Number: � APPROVED OFFICE USE ONLY ❑Journeyman —A 7� it, u Date... ...... .. .y f HpRTM 3? �` TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION th �,SSACMUSEt This certifies that . . F,. :.f. . . .� !�. . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . l:'.q. . . . . . . . in the buildings of . . at . . . . . . . . . . . :_. .'. '� .��?�� . . . . .. North Andover, Mass. /5��'s % Fee. .r. Lic. No.. . . . . :. . . . . .. . .. . . . . . . . GAS INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: MA. Date: 7 10 Permit# Building Location: { Owners Name: Y 5 Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: Q� Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES U) w n a Q caca V O rn rn m = 0 J } W Z U) 0 2 w w p z 9 Z 0 ~ n w a DO Q ~ w Co w m 0 a a I— o w x W w Z I— w < W = LL F rn v w W z = w W ~ a > 0 W Z 0 J i— H 0 Z J 0 LL co = W H w Z W >- M N J Q Q m W 0 Z 0 ~ � � W 0 o a LL 0 cW7 z z O a > > > O SUB BSMT. BASEMENT 1 FLOOR -i'FLOOR 3 FLOOR 4 FLOOR 5TH FLOOR 6 FLOOR 7 FLOOR 8 FLOOR / Check One Only Certificate# Installing Company Name:�I��ice) Qyi ❑Corporation Addressa KA6 dr City/Town: State: ❑ Partnership Business Tel: 5/ 1 '�J'`7� Fax: ❑ Firm/Company Name of Licensed Plumber/Gas Fitter: 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 have checked Yes,please in cate the type of coverage by checking the appropriate box below. A 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 ❑ Signature of Owner or Owner's Agent By checking this box❑;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 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 142 of the General Laws. 4 44 Type of License: By ❑Plumber Title as Fitter Signature of Licensed Plumber/Gas Fitter Master Cityrrown ❑JourneymanLicense Number: � 7 APPROVED OFFICE USE ONLY El LP Installer