HomeMy WebLinkAboutMiscellaneous - 15 WOODBERRY LANE 4/30/2018 (2)7527
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TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATIOI
This certifies that.. .���! �...,� �/t. c>,' ... .. .
has permission for gas installation ...`b .. ,-/ ................
in the buildings of .. �. jam. �.:l............................
at P.:! . ....... , North Andover, Mass.
Fee ..3v...... Lic. No. 3P. J . ? ... .. U � ..r................ .
1GAS INSPECTOR
Check # i ,5
G
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
NORTH ANDOVER ,Mass. Date DEC. 22, 2010 Permit #
Building Location 15 WOODBURY LN
Owner Tel# 978-681-5672
Owner's Name JANICE BICKLEY
Type of Occupancy RESIDENTIAL
New Fv—(] Renovation❑ Replacement Plan Submitted: Yet No[]
FIXTURES
I
-Gas fitter
30
• -Master
License Number
_
g 3
• -Journeyman
�
1!
Installing Company Name Eastern Propane & Oil, Inc
Address 131 Water Street
Danvers, MA 01923
Business Telephone # 800-322-6628
Name of Licensed Plumber or Gas Fitter BENEDICT BREITUNG
Check one: Certificate
ZCorporation
Partnership
Firm/Co.
INSURANCE COVERAGE:
I have acur liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑
If you have c ecked yes, please indicate the type coverage by checking the appropriate box.
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
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 m
knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all
City/Town
APPROVED (OFFICE USE ONLY)
Is State Gas Code and Chapter 142 of the G�T>)eral Laws. RrQ,—>,
Ty a of License: IISS�
Plumber Signature of Licensed Plumber or Gas Fitter
-Gas fitter
30
• -Master
License Number
_
g 3
• -Journeyman
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BOARD OF HEALTH TEL. 688-9540
NORTH ANDOVER, MASS. 01845
APPLICATION FOR SOIL TESTS
DATE.
TIO
LOCAN OF S[011 I TESTS: 1,S Wo Q-,2 L.dw _ N. &UabuFtZ
Assessor's map & parcel number: lm,4p PWci%1. /,V/
OWNER: : � h 04 TEL. NO.: - 6,81-
- �
ADDRESS: L,jy
ENGINEER: e,^-
TEL. NO.:
q78- 6 eU
-!%68
CERTIFIED SOIL EVALUATOR:%
gA-
7.���
Intended use of land: residential subdivision, single family home, commercial
Repair testing Undeveloped lot testing
N. A. Conservations Commission Approval:
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM:
1. Proof of land ownership (Tax bill, deed, or letter from owner permitting
tests)
2. Plot plan
3. Fee of $275.00 per lot for new construction. This covers the minimum two deep holes
and two percolation tests required for each disposal area. Fee of $75.00 per lot for
repairs or upgrades.
GENERAL INFORMATION
1. Only Certified Soil Evaluators may perform deep hole inspections.
2. Only Mass. Registered Sanitarians and Professional Engineers can design septic
plans.
3. At least two deep holes and two percolation tests are required for each septic system
disposal area.
4. Repairs require at least two deep holes and at least one percolation test, at the
discretion of the BOH representative.
5. Full payment will be required for all additional tests within two weeks of testing.
6. Within 45 days of testing, a scaled plan (no smaller than 1 °-100'): shall, oe-spb rotted t�o4-
the Board of Health showing the location of all tests (including abor�e��te-Sj,g,, OF HEAL H
7. Within 60 days of testing soil evaluation forms shall be submitted._
WOOL 43;E,
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LOC
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EOL vel 1 NESS. -
C==( -OL ^TION TEST = _
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Town of North Andover, Massachusetts Form No. 1
NORTH BOARD OF HEALTH /J
19�
o
APPLICATION FOR SITE TESTING/INSPECTION
Applicant
Site Locat
Engineer
Test/I nspection Date and Time
00.1
CHAIRMAN, BOARD OF HEALTH
Fee YO Test No.
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
Town of North Andover, Massachusetts
NORTH BOARD OF HEALTH /]
'0 6 m
�tiRAo� ..Ew,ap APPLICATION FOR SITE TESTING/INSPECTION
Form No. 1
19
Applicant
NAME % ADDRESS / TELEPHONE
Site Location
r t/
Engineer
NAME ADDRESS TELEPHONE
r
Test/Inspection Date and Time -111) A/l>
Fee_
C -HAI BOARD OF HEALTH
Test No.
S.S. Permit No. D.W.C. No.C.C. Date Plbg. Permit No.
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Date...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...........
has permission to perform�—� - .:t--' ......................................
wiring in the building of .......... ...... ...........................................
..... ...... . .................. V?. North Andover, Mass.
Fee �/
Lic. No . .........
............... .
t;o? . ... . . .. ..........
ALEC�MICAL INSPECTQ
Check #
7677
commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. 7G,77
log
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked /off
[Rev.l/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 DV INK OR TYPE ALL INFORMATION) Date:
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
Location (Street & Number) t30 D gU (2
Owner or Tenant GA {' f` Telephone No.
Owner's,
Is this permit in conjuncron with a b�ding permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building P P A 6 I Utility Authorization No.
Existing Service 0?00 Amps 12-0 17—W Volts Overhead ❑ Undgrd No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Ele ical Work: 445
r 01 6j
No. of Recessed Luminaires
�.. ...cwuvwert
No. of Ceil: Susp. (Paddle) Fans ,r
aaie may De waived byy the Ins ector Of Wires.
No. of Total
`
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators
::
Z
No. of Luminaires l
Swimming Pool Above ❑ In- ❑
o. o mergency i
o
rnd. rnd.
Ba- Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches ��
No. of Gas Burners
No. of Detection an
Initiatine Devices
No. of Ranges
No. of Air Cond. Ton �
Tons
No. of Alerting Devices
No. of Waste Disposers
eat Pump
Number
-........................._.........................._.
Tons
KW
No. of Self -Contained
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area HeatingKW
Local ❑ Municipal
ElOther
Connection
No. of Dryers /
Heating Appliances KW
Security Systems:*
No. of Water
No.
No. of No. of
No. of Devices or Equivalent
Heaters KW
SiBallasts
Data itin
Devices or E uivalent
No. Hydromassage Bathtubs No. of Motors Total HP com
elemunications 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: 1-5, JOd (When required by municipal policy.)
Work to Start: p� %-(I % Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify, under the atns fnilpenalties ofpe jury, that the information on this application is true and complete.
FIRM NAME: /% /f'Cc^i G 1 i% LIC. NO.: 4,25
Licensee: 0 b&17 6qR r C /C Signature LIC. NO.:.357WE
(If applicable, enter "exe pi" i the 4�rense numh r lin Bus. Tel. No.:�7k
Address: L,QU S=n P�4 &br c P �/ , X40 ezj /?l /f- 6,/7/,9 Alt. Tel. No.: So Sl-Ps8-gFel �
*Per M.G.L c. 147, s. 57-61, secaty work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the Iiability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE. $%�
F,,J e A, jz _ (7- - o .l PAJ
n
i
41
The Commonwealth of /Ylassachusem
>wt !
Department of Industrial Accidents
6 F1 New construction
7. ❑ Remodeling
Office of Investigations
These su&contractors have
600 Washington Street
working for me .in any capacity,
[No workers' comp, insurance
Boston, MA 02111
1 www.mass.gov/dia .
Workers' Compensation ImiRrance Affidavit: Builders/Contractors/Electricians/plumbers
Name
Address: l00
IN
t�2_
Citystate/Zip:.6 lCd c c, . v
d� 11n l i U (� l �% Phone #:. c% 7�_ 5?,z .3 � C� or9
Are you an employer? Check -the appropriate box:
1. I- am a employer with 4. ❑ I am a general contractor and I
Type of Project (required):
employees (full and/or part-time).*
2. [] I am asole proprietor. or partner-
have hired the sub -contractors
listed on the attached sheet t
6 F1 New construction
7. ❑ Remodeling
ship and have no employees
These su&contractors have
8. (] Demolition
working for me .in any capacity,
[No workers' comp, insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
g, Q Building addition
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
Electrical
10. ❑ repairs or additions
11.Q Plumbing repairs or additions
myself. [No -workers' comp.
c. 1.52, § 1(4),' and we have no12.(]
Roof repairs
insurance required.] t
employees. [No workers'
13.Q Other
comp. insurance required.]
JF oa,r,1.64n� , nn=Ks oox 8 t 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 mustattached an additional shwtshowing the name of the sub -contractors and their workers' comp. policy information.
1 ant an employer that is providing:workers' mp nsatian insurance for my enployem Below is the policy and job site
information.
Insurance Company Name: ' 4
Policy # or Self -ins. Lie. #: Expiration Date: j
Job Site Address:_ 4z7 - City/State/Zip: /!dr/ve/' .
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.
rnar we injormanon provided above is true and correct.
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 #:
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 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, nofthe Department of
Industrial Accidents. Should you have any questions regarding the lawor if you are required to obtain a workers'
compensation policy, please call the Department at the numberlisted 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 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 1-8.77-MASSAFE `
Revised 5-26-05 Fax # 617-727-774
www.mass.gov/dia
I
N
P
Date.
,40
TOWN OF NORTH ANDOVER
PERMIT FOR PLUM
Ad
This certifies that 13 I -0 ......................
has permission to perform ... a. k ...............
plumbing in the buildings of .... v ..................
at. 11 v ..
North Aridover, Mass.
Fee .... Lic. No.. /.;.-V .. ........ .
PLUMBING INSPECTOR
Check# 7 L( L( ) .
7493
1
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date '7X/�-.1
Permit # 2510/ 1
Amount to 7 4='
New Renovation Replacement Plans Submitted Yes No
FIXTURES
(Print or type) Choe: Certificate
CInstalling Company Name&eAizp
� a---
Partner.'
Firm/Co.
Name of Licensed Plumber..,Ji9/�%G.pd'%
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy 17 Other type of indemnity 11 11
❑
Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
threeinsurance
Signature Owner
I hereby certify that all of the details and information I have submitted (c
best of my knowledge and that all plumbing work an jt Mations
compliance with all pertinent provisions of the M 5 unl
;D (OFFICE USE ONLY
Agent 11
xed) in above application are true and accurate to the
under Permit Issued for this application will be in
Gade,and Chapter 142 of the General Laws.
r
,,,,�ype 6fPlumbing License
PG/507-/-/
icense um er Master
Journeyman ❑
Date.....................
TOWN OF NORTH ANDOVER
PERMIT FOR GASANSTALLATI(
This certifies that ... 7' M, �.�.� �... !.. I. �......... .
has permission for gas installation .� .... .�.�."�.. r? e? f.':. .
in the buildings of ..... r %�!'� `�
at ............ North Andover, Mass.
Fee.. -:7. Lic. No— - o IINSPECTOR
.. ............
Check # 3 Y V 3
6129
MASSACHUSETTS UNIFORM APPUCATON FOR PERIVII'T TO DO GAS FITTING
(Type or print) Date g�Gt/G -7
NORTH ANDOVER, MASSACHUSETTS
Building Locations
I J IV �� //�Y
—�—
Permit # L 5
Owner's
Name
4J%ilk
Amount $
New Renovation
Replacement
D
46�1
Plans Submitted
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SUB-BASEM ENT
A a F
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B A S E M ENT
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
8TH. FLOOR
(Print or type j0
Che ne: Certificate Installing Company
Name--orp.
C
Address �� .�� �� Partner.
Business I a ep one — ppm ElFirm/Co.
Name of Licensed Plumber or Gas Fitter,
INSURANCE COVERAGE Check o
I have a current liability Insurance policy or it's substantial equivalent. Yes NoO
If you have checked ves, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ;i 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
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 13 Agent 0
1 hereby certify that all of the details and information I have s (or entered) in ove application are true and accurate to the
best of my knowledge and that all plumbing work and ins ations p ormed un
en Issued for this application will be in
compliance with all pertinent provisions of the Massa setts St a as Code hapter 1 the General Laws.
Title
City/Town
(APPROVED (OFFICE USE ONLY)
Si ure of L�sed Plumber Or Gas Fitter
Plumber IDG/347_�
Gas Fitter L cense Number
Master
Journeyman
Date
HORTM
Of „ao ,°1ti0
�2 �` °p TOWN OF NO THjANDOVER
• PERMIT FOR GAS INSTALLATION
This certifies that f ...........
has permission for gas installation ..6?14. .........
in the buildings of . V' G ............................
at . `-_ ....... �, North Andover, Mass.
Fee... ... Lic. No.. 1,!G z r ... ... .....
4GAS INSPECTOR
Check # g -i 3
6167
TTJ
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Fria or Tm)
^� -4/. &D21jLfK Mass. Date 16 at�z
#
Building Location p / i CC` f E
Owner Tel# �� 3 3 1) % Type of Occupancy 1
New 0. Renovation Replacement ❑ Plan Submitted: Yes ❑ No
FIXTURES
11
Installing Company Name Jul f/ C�T���L._!�71a Check one: Certificate
Address l q c) Soo -rm // l Al N S%- ❑ Corporation
1)DC,E7oN Hifi - 019
❑Partnership
p,
Business Telephone �9 7 9 � aa3 —130 .,r Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
have a current II&M Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
YesNo a
n you have Led n}, please Indicate the type coverage by dwddng the appropriate box.
A ttabiaty Irmnnos pok7 * Other type of indemnity D Bond o
OWNERS INSURANCE WAIVER I am aware that the licenses don M hm the insurance coverage required by Chapter 142 of the
Mesa. General Laws, and that my signature on this permit appkatIon wWMes this requirement•
Owdt one:
Owner 0 Agent o
Signature of Owner or Owner's Agent
I hereby certify that ah ve of the details and information I hasubm (or enbm
knowledge and that all plumbing worts and Installations performed under the per
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of t
BY
Title
City/town
APPROVED (OFFICE USE ONLY)
m"and accurate to the best of my
issued for Ufb op0atl6ff wM be In- mpffsnos with all
Type of Ucense:'
•
-Plumber Sign re of Ucensed Plum Rter
4as fitter
-Master Ucense Number�� d�
• �Joumeyman
a
...,:
■■■■■�■■■■■■■■■■■■■■■■■■■■
Installing Company Name Jul f/ C�T���L._!�71a Check one: Certificate
Address l q c) Soo -rm // l Al N S%- ❑ Corporation
1)DC,E7oN Hifi - 019
❑Partnership
p,
Business Telephone �9 7 9 � aa3 —130 .,r Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
have a current II&M Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
YesNo a
n you have Led n}, please Indicate the type coverage by dwddng the appropriate box.
A ttabiaty Irmnnos pok7 * Other type of indemnity D Bond o
OWNERS INSURANCE WAIVER I am aware that the licenses don M hm the insurance coverage required by Chapter 142 of the
Mesa. General Laws, and that my signature on this permit appkatIon wWMes this requirement•
Owdt one:
Owner 0 Agent o
Signature of Owner or Owner's Agent
I hereby certify that ah ve of the details and information I hasubm (or enbm
knowledge and that all plumbing worts and Installations performed under the per
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of t
BY
Title
City/town
APPROVED (OFFICE USE ONLY)
m"and accurate to the best of my
issued for Ufb op0atl6ff wM be In- mpffsnos with all
Type of Ucense:'
•
-Plumber Sign re of Ucensed Plum Rter
4as fitter
-Master Ucense Number�� d�
• �Joumeyman
N' ' 3846
Date. /0—�A- j7
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
...., ........ , ...at ..,!!?fir? !y`.4/9./t. ................... .
has permission to perform ... D.t-. :................. ........ .
plumbing in the buildings of .....................
at. ............ North Andover, Mass.
Fee. Lic. No.. . ............................. .
PLUMBING INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
Date'/?.�
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
.at ....................
has permission to perform .....`............................ .
plumbing in the buildings of ....................... .
at. ! ' ............. North Andover, Mass.
Fee. Lic. No.. . ............................. .
PLUMBING INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DOrPLUMBING
(Print or Type) /y
Mass. Date l 19 01 � #
Permit f;
Building Location Owner's Name !iS�P.sA/f
Type of OccupancTI A
UW
New ❑ Renovation ❑ Replacement R Plans Submitted: Yes ❑ No ❑
FIXTURES
Installing Company Name P1 o f3EeT 'Am M A T A e 7 Check one: Certificate
Address L'(; RC hi / t4k) p , ❑ Corporation
/r E TW o_ n- YO t4 0 t NL/ ❑ Partnership
Business Telephone 1 f L -i9-7 I 2-Arm/Co.
Name of Licensed Plumber '- f` r3 F?- T fry-
INSURANCE
ry
INSURANCE COVERAGE:
I have a curre;'jability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
i Yes No ❑
If you have checked yes, please
/indicate the type coverage by checking the appropriate box.
Qa liability insurance policy 1d 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 ❑
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 issu for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plum ' g Obde and apter of the eral Laws.
BY �sL
Title SLOAre of LicensedPlum r
Type of License: Master % Joumeymab ❑
APPROVED OFFIC U ONL License Number Y33 5 �'p
•
Y
•
•
•
•
0P4j
ONE
Installing Company Name P1 o f3EeT 'Am M A T A e 7 Check one: Certificate
Address L'(; RC hi / t4k) p , ❑ Corporation
/r E TW o_ n- YO t4 0 t NL/ ❑ Partnership
Business Telephone 1 f L -i9-7 I 2-Arm/Co.
Name of Licensed Plumber '- f` r3 F?- T fry-
INSURANCE
ry
INSURANCE COVERAGE:
I have a curre;'jability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
i Yes No ❑
If you have checked yes, please
/indicate the type coverage by checking the appropriate box.
Qa liability insurance policy 1d 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 ❑
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 issu for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plum ' g Obde and apter of the eral Laws.
BY �sL
Title SLOAre of LicensedPlum r
Type of License: Master % Joumeymab ❑
APPROVED OFFIC U ONL License Number Y33 5 �'p
r
c
O
m
m
z
O
u
9
Date.....
.......
Al- ..0-3....... .............
IAORTN
°t<•�"° TOWN OF NORTH ANDOVER
i� • - e o�
lip PERMIT FOR WIRING
', - ;
This certifies that
has permission to perform -�
....:............................... -L-?: ;.. n-1 .................
wiring in the building of ....-':.�"'
T �� 1'-'-�'....................................... 4, i�"�'" . .. ,North Andover, Mass.
Fee ...( .. Lie. No.. /`i..... %.°... G.�..................
ELECTRICAL INSPECTOR
Check # 2;�o � V
4 7 u 7
l.Ccomnwnw.al� o/lla.0eac/iW���!
1JeParinunl o`�lr. sirVit.1
BOARD OF FIRE PREVENTION REGULATIONS
OMciul Use Only
Permit No; L170
Occupancy and Fee Chcckcd
Rev, 11/99) Ieove blank)
APPLICATION FOR PERMIT TO PERFORM'ELECTRICAL WORK
All rvvrk to be perrornicJ in occordmice with the Mutsachusctts C1,xifical Cole (M 52 CAIR 12.00
('L EASE NRJ,vT /N INK 0/t TYPE ALL INFOI-l7/ON) Date: 17�,�' 03
City or 'Foirn of: Not A v!b v v E 2 To the hupector• 6ftvires:
Dy ;!:!s application die undersiyncd 5ivcs notice of las or her intention to perform the electrical work described
Locvivrt (Sired & Number) /S LUoa
Kyj
Owner or Tcnalit V'ArytC, Q If -At,
� rC U Telephone N �o�/ S�
Owner's Address S A M^ IC— r
is !Itis permit In conJunctivn irllh n bullding pernlll?
Yes El
No.•Q, (Check r pproprla(c 13ox)
I'ur!,usc or UuilJtuK UIDIty Aulhorizativn Nv,
Ealslln; Scnlrc Amps 1 110113 Ovcrlscad ❑ UllderJ ❑ Nu, of �Icicrs
LL, "I S—Cr I'iIC Anips / Yv113 Overhgatl ❑ Undgrd ❑ No, of Meters•
N,vmocr ur FccJers and Ampacltr
Locative a:tJ No lure of Proposed Elcclrlcal Worg:
CuurnlrNon u/III r (o/lawing ruble Oita v bf u•ar. ml 6.• ,1,, L..—l— nr lyl.. J
�0 0' Recc scu Fi.tlures
No. of Cull.-Susp, (I'addic) FatuTransformers
KVA
or Lig!,ting Oullcls
No. of Hut Tubs
Ccncralors KVA
�o. of Lig!!ting Flxlure3
ore I)•A
Srrlmniiug Poul end. 0 endB0'
o. o mergutcy g i ug
0 Units
c! Receptacle Outlets
No. of 011 13urrim
FIRE ALARMS No. of Zones
o, o e cc ou an
liddullng Devices
c' S Yitc!:es
No. of Cas Burners
1. c.' Ringcs
No. of Air Coag.Tons
No. of Alerting Dcvlccs
o! �1 as:e Jispnscrs
cal PumpNumber
Totals;
ons
o. o c on a nc
Dclecdoil/Alerlln Devlces
•
Ds!:nYaslIcrs
Spacdrlrea Heallitg KlYLocal
O CoCD clan CD Olher
Drycrs
HenlIng Appllances IC1Y
ccur ly y3tcnu:
No: of Devices or E ulvalelit
:ter
ltc,lcrs KNY
o. o I o. 0
Sly'lls 13ai1u313
Dain WWIIgg;
No, of Lim or E ulvolenl
+o. Hn .ro passage Dalhlubs
t`lo. ofMolors Total F1P
c ccommun cal ons r ng:
No. of Dcvlccs or Equivalent
rTH`R --
_ i
rftroeh oddldouol driall Vduirrd, or of req,,;rrd oy rite r„sprcror o/ bier,
�S � N_tiNCE C0VEJU10E: Unless wzivcd by the oN'vner, no permit for the perfornunce of ciccrricol work )•stay issue unless
c ;:cense^, provtic s proof of liability insurance including "conipleted operation" coverage or its substantial equivalent. The
r.ccrs:3nc: ;c:: ries that such covcmge is in force, and has exhibited proofofsame to the permit issuing ofrice,
NSURnNCE []—DOND 9—OTHER ❑ (Specify:) �iyAG'Q,��edry/�,e�lo /2 3l o
of Electrical Work: 1 61vr (When required by municipal policy.) (E.tptratfon Dalc)
ry Sar; 3 D ` hQpcctiom to be rcquesled bi accordance Nvidi MEC Rule 10, and upon comple(ion.
r/,r l,ni„s 0111/ pelInlrics olperjur)-, that the lnjormalloit on thl3 ap licallun IS true and coniplrty,
Z�<<i9ti G�� o LI C. NO.
see �( ,t,> �tJr•yp,� �igisaturc LIC. NO.:
T
Uus. Tel. No.:
A..ress^ I a 9 AIAll. Tel. No.: 5D�'�6'/-6/1/
O ER'S !NSJRAINC E; NYAIVLII: I ani await that the Licclisce elves not havir the liability insurance eoncrage normally
C ,y U*, 11iy sisnaturc below, I hereby waive this requirement. I ons the (check Otte) Q owner ❑ omier's a%�cm
J, ;e... I'cicphunc Nu.
FlIll?"IT FCC; S �O oti
RD U C I PT HA.L