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HomeMy WebLinkAboutMiscellaneous - 15 WOOD AVENUE 4/30/2018r N Date ...... 5..�:... L..:...��..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .........ZI) .. 4........2.:..1 .... .......//..��................../.................... has permission to perform .... ...'.. -� %'v Xi X...�i ( f,,,..... ............................................ wiring in the building of ....... 7�.. �.........1.... r ................................................. at.. �y�� �'✓a -5- ................................. North Andover, Mass. ....................... ........... Fee... . � f - . < �-. Lic. No./ p 33 ................... .. ..................... .... a . ...... ,_ � GG .............. . ELECIRICAL INSPECTOR Check # /3 1/, 2 r- 12329 I 1: � Commonwealth of Massachusetts Official Use only Efflom Department of Fire Services Permit No. f2 -" 2 - BOARD BOARD OF FIRE PREVENTION REGULATIONS APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Bieeirical Code (NEC), 527 CMR 12.00 (PLEASE PRINTININK OR TYPE AW INFORMA770M Date: City or Town oh 1i/�, z� .,v Z . To the Inspector of Wires: By this application the undersigned gives notice of his or h intention to perform the electrical work described below. Location (Street & Number) /S1'� �✓� a� Owner or Tenant /� /' c i leo G Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ Building Permit # Purpose of Building Z fft . / Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters New er ce Amps 2l/ f z. LCL Volts . Overhead Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �✓ ��- % S' z.�� BGG Completion of the following table may be waived by the Inspector of Wires, No. of Recessed Fixtures No. of Cell.-Susp. (Paddle) Fans r o ata Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA Na. of Lig3tt#ng Fixtures Swimrxiiaag Pond Above ❑ d. ❑ Rum Unif Emerts g No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No-57No-57 Detection an Initiating Devices No. of Ranges No. of Air Coud. Total No. of Alerting Devices No. of Waste Disposers p Heat Plam_ um _er „•ons _ Totals:""` o. o Self -Contained DetectionlAlerti Devices No. of Dishwashers Z Space/Area Heating KW Local ❑ Connemunlection [I other No. of Dryers Heating Appliances KW ecur tpSystems: No. of Devices or Equivalent No. of Water KW Heaters o. of NO. of signs Ballasts Data Wiring: No. of Devices or Uuivalent No. Hydromassage Bathtubs No. of Motors Total HP a eNo of Devices orEquivalent OTHER: 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 in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify.-) 7— IX (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: f-- z Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the paths and penalties of perjury, that the information on this appUcation is true and complete. Current Insurance certificate must be on flte in our v#ke andar sdavlrmuWals» hefsiled out,r*k dank appliaatiom FIRM NAME: P F e S H / �� LIC. NO. Licensee: Ae,o 41 ' fr, , L Signature LIC. NO.:�32 ({J'applicable, a er "exempt " in the license number line.) Address: OWNER'S INSURANCE WAIVER: I am aware that the Licd6see does required by law. By my signature below, I hereby waive this requirement. Owner/Agent Signature Telephone No. Bus. Tel. No.: — Alt. Tel. No. insurance coverage normally ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL 3. UNDX*R GROUND INSPECTION: Passed - I I Failed — f I Reins on required ($50.00) - 13 Inspectors' comments: - no Date S 4. INSPECTION — SERVICE. DATE CALLED NATIONAL GRID: NAME: Passed —I Failed — t ] Re -ins tion r nixed (�SO.Op) _ j I . Inspectors' comments: (Ins actors' Signatnre - no initials) Date S. INSPECTION - OTHER: Passed — l Failed - (I Reins action r aired ($50.00)-f Inspectors' comments: (Inspectors' Signature - no initials) Date DOOR TAGS ARE TO BE F;RI" C UT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A REINSPECTION OF x.00 IS TO BE CHA GF . 104.019 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING gB�CHU This certifies that 10P.1 ....... 40-�re //0 ................................................................ has permission to perf6rm4d1.14(4A0.;.L'r ... plumbingin the buildings of ............................................................................................. ..... 4s� ...... North Andover, Mass. .. OF6.7. .-*�*'.'.*d'-.-1"'�.1.e ............................................ Fee. .90 ... Lic. No.3 ;zILI (-)' PLUMBMG INSPECTOR Check , �- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY '(/� ° _ MA DATE PE-R 1IT #--� JOBSITE ADDRESS 115 �' fiG (qh'�-� OWNER'S NAME POWNER ADDRESS TEL IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL ® RESIDENTIALA PRINT CLEARLY NEW:[] RENOVATION: ® REPLACEMENT: 14 PLANS SUBMITTED: YES Q NA FIXTURES I FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE _► _ I ( } _ __ ( _ 1 �_ �_! .,_._�.! —___.; -_,___ I DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIL/SAND SYSTEM ! _-„_, _ __ E _ —} _ __ } ___► _j .__ _t ____ ► ._-___ ( _ _f DEDICATED GREASE SYSTEM �} } _ � _ � _ _} } I -_I DEDICATED GRAY WATER SYSTEM I DEDICATED WATER RECYCLE SYSTEM 1 _-_-____J -_- .__► __—► _ .___( —_J —..__1 ..-_� ._.___._E _..____I _.___( _i �I DISHWASHER _ i ._ I _ . _ _6 , ._—J I _._J --- --- ___.__1 _._-_ _4 ._-... } F-7 I DRINKING FOUNTAIN FOOD DISPOSER i .--___.1 ___.__.---._._► -___ f �__ ._.___.l--____.I ___ l _______! ..__.- -_ _ ► ...___J FLOOR /AREA DRAIN1 INTERCEPTOR (INTERIOR) C� J _._-_! _.____._ �__. __._._ ( i 1 .------ j KITCHEN SINK LAVATORY (I _..._.__.} _ ---._._..I ____.__( __.-.--..I ROOF DRAIN SHOWER STALL SERVICE/ MOP SINK TOILET URINAL ...._._ I .__r _.._._ } --(_._-1 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER .,_ � I I I ._......_._. --- -- _ _ I '-_--__i .__._.._E ..-_.__I ► .._._.._._( I f -._ _ 1-.___.._ ____I .__.__-►------.J 1 _____.1 ___ -_I I ---.__ _ I ► �_._J -__-_I _.._! INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES t&NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY © BOND Q 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 L] AGENT 10 SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true andacc ate 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 ith all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME to __LICENSE# - SIGNATURE MP © JP 0 CORPORATION 0 �PARTNERSHIPQ#®LLCQk COMPANY NAME o.n� �j �, e„ f� ADDRESS CIr ___..__..._.---- _STATE ZIP � j TEL FAX CELL JVMAIL O O H U y w orl z Nrl O H vs p W O W a Z w ~ CO K�+ W O � a W a uJ a O o W F- . � U J a IL B U) ui x w H O O W a a Q�j 05 f The Commonwealth of Massachusetts Department of Industrigl Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information nn J Please Print Legibly Name (Business/Organizationlindividual): Address:) rzku N yJ Gy c) City/State/Zip--T }'1/45 P""- A k 61620 Phone #: qA 90 / 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. ❑ New construction employees (full and/or part-time).* 2. [ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7. ❑Remodeling ship and'have no employees These sub -contractors have S. ❑ Demolition working for me in any capacity. workers' comp. insurance. g Building addition [No workers' comp. insurance 5. El We are a corporation and its 10.❑ Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required] t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showingtheir workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then.hire outside contractors must submit anew 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. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company N 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 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 ofup 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. Ido hereby �c-erYt� under li ins and penalties ofperjury that the information provided above is trueandcorrect. Sianafirrw V 14 bate. + �l J1 l 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: Information and Instructi®ns 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 -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 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 "lob 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 Off"itce of Investigations 600 washingfion street Boston? MA 02111 Tel, # 617-727-4900 ext 406 or 1-877rMA-MSAFE Revised 5-26-05 Fax # 61.7-727-7749 wwwanass.govMia ..,Division of Professional Licensure: License Search 4� a ,R The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Home State Agencies A -Z Topics Home > Division of Professional Licensure > Check A Professional License By the Division of Professional Licensure LICENSEE Name: THOMAS M. ANDELLA TEWKSBURY, MA I ilf�hll7'Wie117 **This Licensee has additional Licenses click here to view them.** Licensing Board: PLUMBERS it GASATTERS This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Tuesday, April 22, 2014 at 9:19:44 AM. © 2007-2011 Commonwealth of Massachusetts Page ] of 1 Mass.Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATEDINFO Disclaimer Regarding Website License Searches Glossary of License Status Codes More... { * Commonwealth of Mai�sachus.�tts division of RegK4ration�,. � Board of Phlmbiog'_Ex�irie a f THOMAS),M54NDELLA�__ , 28 FF2EDEf2I - `+- i TEWKSBUtY; NF =0178 , JoumeymaAPlu.rntier PL30858-J 05/0:112008 ' _� 002197 } ! i arise No. Ex ation Date. _ aerie,. No:.. hitn'//11nPncP rec ctntP mn nc/nnhlir,../nnhT iPanea0 ncn9linarr1 rnrlP=PT.kt-vnP .Tc4Llic... 4/22/2014 License Type: JOURNEYMAN PLUMBER License Number: 30858 Status: SELECTED FOR AUDIT Expiration Date: 5/1/2014 Issue Date: 6/12/2007 Exam Date: 6/12/2007 ISchool: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Tuesday, April 22, 2014 at 9:19:44 AM. © 2007-2011 Commonwealth of Massachusetts Page ] of 1 Mass.Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATEDINFO Disclaimer Regarding Website License Searches Glossary of License Status Codes More... { * Commonwealth of Mai�sachus.�tts division of RegK4ration�,. � Board of Phlmbiog'_Ex�irie a f THOMAS),M54NDELLA�__ , 28 FF2EDEf2I - `+- i TEWKSBUtY; NF =0178 , JoumeymaAPlu.rntier PL30858-J 05/0:112008 ' _� 002197 } ! i arise No. Ex ation Date. _ aerie,. No:.. hitn'//11nPncP rec ctntP mn nc/nnhlir,../nnhT iPanea0 ncn9linarr1 rnrlP=PT.kt-vnP .Tc4Llic... 4/22/2014 Division of Professional Licensure: License Search The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Home State Agencies A -Z Topics Home > Division of Professional Licensure > Check A Professional License By the Division of Professional Licensure LICENSEE Name: THOMAS M. ANDELLA TEWKSBURY, MA ltl \o I , .71 **This Licensee has additional Licenses, click here to view them.** Licensing Board: PLUMBERS £x GASFITTERS License Type: JOURNEYMAN PLUMBER License Number: 30858 Status: SELECTED FOR AUDIT Expiration Date: 5/1/2014 Issue Date: 6/12/2007 Exam Date: 6/12/2007 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Tuesday, April 22, 2014 at 9:19:44 AM. 02007-2011 Commonwealth of Massachusetts Page 1 of 1 Mass.Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATED INFO Disclaimer Regarding Website License Searches Glossary of License Status Codes More... Site Policies Contact Us http://license.reg.state.ma.us/public/pubLicenseQ.asp?board code=PL&typeclass=_J&lic... 4/22/2014 0 2014/04/23 14:12:27 1 /3 OEastern Insurance 233 West Central Street Natick, MA 01760 To: Company / Insurer: Contact Fax Number: Contact Phone Number: AR WC COI Liberty Mutual 978-688-9542 From: Marie Kelleher Direct Fax Number: 5086515198 Direct Phone Number: 508-620-3360 Notes: Date and time of Fax transmission: 4/23/14 2:11:20 Number of pages including this cover sheet: 3 The information contained in this facsimile message is privileged and confidential. It is intended only for the use of the individual named above. If you are not the intended recipient, you are hereby notified that any distribution or copy of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately at the above listed phone number. Thank you. 2014/04/23 14:12:27 2 /3 MASSACHUSETTS ASSIGNED RISK POOL REQUEST FOR CERTIFICATE OF INSURANCE Use this form to request a Certificate of Insurance from an Assigned Risk Pool Carrier. Please provide all of the requested information, including the facsimile number(s) of the person or persons to whom the Certificate of Insurance should be issued. If this form is fully and accurately completed, the Certificate of Insurance will be issued and distributed by facsimile to each fax number provided below, within two (2) business days of the carrier's receipt. This Form may be mailed or faxed to the Assigned Risk Pool Carrier. To obtain each carrier's contact information refer to the Certificates of Insurance section located in the Producer Community section of the Bureau's website (www.wcribma.org). 1. Name, address, telephone number and facsimile number of the INSURED: Name: Thomas Andella Mailing Address: 28 Frederick Circle , Tewksbury, MA 01876 Physical Address: Phone: (978)804-2237 Fax: (978)858-0987 2. Name, address, telephone number and facsimile number of the CERTIFICATE HOLDER: Name: Town of North Andover Mailing Address: 1600 Osgood St. Bldg 20 Ste 2035 Physical Address: North Andover, MAO 1845 Phone: Fax: 978-688-9542 3. Name, address, contact person, telephone number and facsimile number of the PRODUCER: Name: Eastern Insurance Group LLC Mailing Address: 233 West Central Street, Natick, MA 01760 Contact Person: Select Department Phone: 800-333-7234 opt.3 Fax: 508-653-8089 4. Policy Number, Policy Effective Date and Policy Expiration Date If a Certificate of Insurance is needed for more than one policy term, provide the Policy Number, Effective Date and Expiration Date for each policy term. Policy Number: WC531S359318054 Effective Date: 4/10/2014 Expiration Date: 4/10/2015 5. List any special requests for optional coverages /endorsements (see Page 2 for listing of coverages available in the pool and the conditions of availability) or additional information (including changes in exposure not yet reported to the carrier) that will assist the carrier in the issuance of the Certificate of Insurance. NOTE: An additional insured(s) shall not be listed on any Certificate of insurance unless such additional insured(s) is a named insured on the policy. 2014/04/23 14:12:27 3 /3 } Date. . a NORTH TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING SSACNUS�tb This certifies that ..... ........ .. ...... has permission to perform 1�//i . . plumbing in the u' dings of r...... . at /. <Z/ 1....... �.. .. .... , North Andover; Mass. '? /�� �. Fe -41' ( . Lic. No.. A.P . PLUMBING INSPECT. . Check � ! I �� � � t t. SI is l MASSACHUSETTS UNIFORM APPLIL FOR PERMIT TO DO PLUMBING (Print or Type) Q�� ,S /�•���� ��6I,ellGtass. � Permit # � � ' s Building Location Owner's NamlgLd— Il'r��/`) 1 !Q Type of occupancy, Residential New ❑ Renovation ❑ Replacement N Plans Submitted: Yes ❑ No ❑ FIXTURES Installing Company Name Heritage Htg. &Pig. Co. Inc. Address _ 35 Pleasant Street Stoneham, Ma 02180 Business Telephone . 781 —438-7776 Name of Licensed Plumber Gordon Switzer Check one: Certificate EX Corporation 714 [] Partnership 171 Firm/Co. 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 indicate the type coverage by checking the appropriate box. A liability Insurance policy I; 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: Sinnalnro of ('aunn1... n,.,...,:. e....... Owner ❑ Agent ❑ i nereoy 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 Stale Plumbing Code and Chapter 142 of the General Laws. By Si�orensember Title City/Town Type of License: Master Journeyman ❑ APPRovEo (WICE SE ONLY) License Number 8322 X to � r—{ J o Ne X ,r••W-�� W n x r v a f = O Z O w wO Q WO et fn_ rt Q r- Cr¢ UUJ y W e ` 0. Z X aXCr <- J3a ++ 1ro+ �Qro w a T W O O yO C ~ JZ O3: G f] W i?u4} iQii .?uT�I Q r- � ►- O a N X � S � r' X Z a O O O yr Y Y _ W W -c W ?�LL-l'i 3 x m N O ca 3= ai U. 0 D a 3 v: m ro 3� ro ro 33�ri' ro SUB—BSMT. BASEMENT IST FLOOR 2NDFLOon 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name Heritage Htg. &Pig. Co. Inc. Address _ 35 Pleasant Street Stoneham, Ma 02180 Business Telephone . 781 —438-7776 Name of Licensed Plumber Gordon Switzer Check one: Certificate EX Corporation 714 [] Partnership 171 Firm/Co. 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 indicate the type coverage by checking the appropriate box. A liability Insurance policy I; 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: Sinnalnro of ('aunn1... n,.,...,:. e....... Owner ❑ Agent ❑ i nereoy 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 Stale Plumbing Code and Chapter 142 of the General Laws. By Si�orensember Title City/Town Type of License: Master Journeyman ❑ APPRovEo (WICE SE ONLY) License Number 8322 a Z 0 J D in LL O -z O p Q U O J m 1 0 z w a m 6 LL J � J z a O Y O W p N � O r LL � LL w O M z a O IY LL O LL O z O W co a Z 0 J D in LL O -z O p Q U O J m 1 d V J w a W 6 LL W Y Vol, a Z 0 J D in LL O -z O p Q U O J m 1 iCA tY' Date ... ;�/. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that...............G- Q . ...5..../c �c> ...... has permission to performP�A wiring in the building of.......... !° `t ! .'�.`. .. ...... .................................................... at ............. ��✓L%.C% �! U ....... . North Andover, M�s -Fee....�4 .�.J.. Lic. No. /J�.�Q .............te.'••• ll� ELECTRICAL INSPECTOR Check # f 4393 The Commonwealth of Massachusetts FOR OFFICE USE ON � Permit No. Department of Public Safety Occupancy &Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work will be performed in accordance with the Massachusetts General Code. 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) -- - Date -,;Lv-a3 City or Town of 4 .01/� To the inspector of Wires: The undersigned applies for a permit to perform the electrical work described below: Location (Street and Number) Z,5-- zt b 1' ?Vr P/ 0,Z_7 _ Owner or Tenant Owner's Address (aSC l/iFti%-/p/ Z - L O Is this permit in conjunction with a building permit? Purpose of Building /05/,b �-7 y ee— Existing Service Amps / New Service Amps Dumber of Feeders and Ampacity Location an Nature of Proposed Electrical Work ,W i1v 239 F194 --2--k Volts Map: Lot: Zone: Yes ❑ No 2 (Check Appropriate Box) Utility Authorization No. Overhead ❑ Underground ❑ No. of Meters Volts Overhead ❑ Underground ❑ No. of Meters S N6'�E 16 Lr >�?.eCA4IFFe5 No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures I Swimming Pool Above gmd. ❑ In-grnd. ❑ Generators KVA No. of Receptacle Outlets I No. of Oil Burners No. of Emerg. Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self -Contained Detection/Sounding Devices No. of Ranges No. of Air Cond. Total Tons No. of Disposals No. of Total Total Heat Pumps Tons KW No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Devices KIN No. of Water Heaters KW No. of Signs No. of Ballasts Local ❑ Muncipal Connection ❑ Other No. of Hydro Massage Tubs No. of Motors Total HP I Low Voltage Wiring OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including C,gp��n �oeted Operations Coverage or its substantial equivalent. YES ❑ NO 111 have submitted valid proof of same to this office. YES tEJ'NO If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE 03"BOND ❑ OTHER ❑ (Please Specify) , (Expiration Dale) Estimated Value of Electrical / ork/,$ Work to Start d� O Inspection Date Requested: Rough Final Signed under the penalties of perjury: FIRM NAME LIC. NO.! 1 Licensee`//,y y i g 4H�)A{i95 Si naturLIC e �— g NO. Address A-6-0 J sc"-D S77/�O t�dl��,P� �/1tt D / 0 45 Bus. Tel. No. 9 7 Alt. TeL No. 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)/ I (Signature of Owner or Agent) Telephone No. PERMIT FEE $ NEW ENGLAND D CLAIMS SERVICE, INC. ReplyTo ❑ P.O. BOX 345 MANSFIELD, MA 02048 TEL. (508) 337-8058 FAX (508) 339-5835 Reply To ❑ 100 CONIFER MILL DRIVE, SUITE 308 DANVERS, MA 01923 TEL. (978) 777-9900 FAX (970) 774-9296 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 3D TO: Building Commissioner or Inspector of Buildings TUw- t. 1. addresses Reply To ❑ P.O. BOX 578 SHREWS BURY;:11>iA:,01545 'STEL. fi5U8) 'S42-3995 - FAX (508) 842-7510 w -12003 Board of Health or Board of Selectmen f— JAMG RE: INSURED PROPERTY ADDRESS --� I.s --1� ay2_L�1_U� ___.._-----•--..._....__.. POLICY NO.:3 �� ��^ •" ��'�"�•�"`�°`� tea' •G�.9 L3 LOSS OF: 0 o a3 FILE OR CLAIM NO.: $ . _.(o=_°� Claim has been made involving loss, damage or destruction of the above -captioned property which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139 Section 3U is appropriate, please direct it to tyle attention of the writer and include a reference to the captioned insured, location, policy number, elate of loss and claim or file number. C L A i rn S. AJ,,'T 0 :. , E 2. TITLE __.__ On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. SIGNA RE AND DATE cc: Fire Dept.