HomeMy WebLinkAboutMiscellaneous - 157 SUTTON HILL ROAD 4/30/2018 (2) 157 SUTTON HILL ROAD
210106_00000.0
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Date.�.:..I?n-13.........
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NcnrH�� TOWN OF NORTH ANDOVER
9
PERMIT FOR WIRING
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This certifies that .............BlzloevlfLc—
. ..... ........................................................................................
has permission to perform Zl 4.s .f.l��f..........................................................
wiring in the building of.t, a?t
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at ...... f !'1 ....H/ I;nS............... ...............North Andover,Mass.
Fee �� Lic.No. :;"
ELV rox
c Check*
7 �+ ;�
Official Use Only
Commonwealth of Massachusetts /
Department of Fire Services Permit No. ( �
o p
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev.1/071 (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical CodeC),527 CMR 12.00
(PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: i ( 3
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) TTV �.Uw iti c
Owner or Tenant Telephone No.
Owner's Address S
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate]Box)
Purpose of Buildings c�p,A;-7 I/t�C_, Utility Authorization No.
- Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
— A/�, CQ A F-L-A r-i% S y ✓�lR 1(]'L i�JrL LCL`
Completion of the followin table may be waived by the Inspector of Wires.
of
No.of Recessed Luminaires No.of Ceil: TransSusp.(Paddle)Fans Total
Trsformers KVA
No.of Luminaire Outlets ,j No.of Hot Tubs Generators KVA
No.of Luminaires 3 Swimming Pool Above ❑ In- ❑ o.of Emergency Lighting
rnd. grnd. BatterV Units
f No.of Receptacle Outlets O No.of Oil Burners FIRE ALARMS No. of Zones
No.of Switches No.of Gas Burgers No.of Detection and
Initiatin Devices
No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump I Number Tons KW No.of Self-Contained
Totals: "" """""'"""'" """.............. Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of Water KWNo.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
{ Estimated Value of Electrical Work: `�`0 pn (When required by municipal policy.)
A Work to Start: '& Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVE ( GE: 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 cover e is. force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
X cert,tinder the aims and penalties ofperjury,that the information on this application is true and complete.
FIRM NAME: . L C, -t C— LIC.NO.: At�jZ(o
Licensee: ,/V( tr( ,q{�L /� ��,�,4� Signature 9— LIC.NO.:
(If applicable ente "exempt"in the license number line.) Bus.Tel.No.: 3
Address: tl-L t k0- A-,; Alt.Tel.No.:
*Per M.G.L c. 147,s.57-61,security work requires Department of PublicSafety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent.
Owner/Agent PERMIT FEE. $
Signature Telephone No.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c. 143,§3L,the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c.143,§3L.
Permits shall-be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any Permit or approval that was
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"in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012.
❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑
❑ Permit Extension Act—Permit/Date Closed:
Trench Inspection
Pass M Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
i
Pass❑' Failed Re-Inspection Required($.) ❑
i
Inspectors Comments:
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
ROUGH INSPECTION:
Pass Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments:
I
Inspectors Signature: Date: Y
FINAL INSPECTION:
Pass❑' Failed 0 Re-Inspection Required($.) ❑
Inspectors Commen :
Inspectors Signature: U Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
Department of IndustriqlAccWnts
Office of Investigations
klip 600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lelsibly
Name(Business/Organization/Individual):
�I
Address:-8-
City/State/Zip;
ddress: 8-
�-
City/State/Zip: c`,10..�� .�Q v3 Phone#: �r 7 J_�zu Sr-IS 4—
Are
—Are ygiran employer?Check the appropriate box: Type of project(required):
1.Ul am a employer with 4. ❑ I am a general contractor and I `
6. ew construction
employees(full and/or part-time).* have hired the sub-contractors
2.F1 am a sole proprietor or partner- listed on the attached sheet. 7 emodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. F1 BuildiYng addition workers' comp.insurance 5. El We are a corporation and its
required.] officers have exercised their 10. lectrical repairs or additions
3.❑ I 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.❑Roof repairs
insurance required.]t employees.[No workers'
comp.insurance required.] 13.❑Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
1Homeowners who submit this affidavit indicating they aie 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.
am an employer that isproviding workers'com ensation insuranceformy employees. Below is thepollcy andjob site
information.
Insurance Company Name:.
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: y t-�``� ��e— �� City/State/Zip: kO
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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
do hereb cerci under,the pains and penalties of perjury that the information provided Bove is true and correct. -
c ature: Date: l2-
Phone#: 7 CS
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other - - -
Contact Person: Phone#:
I
I
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
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renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
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applicant who has not produced.acceptable evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants ,
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
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. t^
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 multiplepermit/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: 7
Tho Commonwealth of Massachusetts
Department of of Industrial Accidents.
Office of Investigations
600 Washington Street
Boston,MA 02111
1 Tel,#617-727-4900 ext 406 or 1-877,TMASSAFB
Revised 5-26-05 Fax#617-727-7749
wwW mass,gov/dia
Date. ./G„G `�. .. . .
WORTH
pf Sao 'stip
0 °p TOWN OF NORTH ANDOVER
' PERMIT FOR GAS INSTALLATION
SACHUSEt
This certifies that . . lr ,�9. ( �L ��,( -7/
has permission for gas installation . . . . . . . . . . . . . . . . . . . . . . . .
in the buildings of . ,1`Jcc Ute- �. . . . . . . . . . . . . . . . . . . . . . . . . . .
at ./S.?. . .��-. .f 6 . . �?��. .t. . . . . . ., North Andover, Mass.
Fee. :.0 ' Lic. No.. . . . . . . . .
^ G SINS CTOR �~`
Check# /
4766
MASSACHUSETTS UNIFORM APPUCATO/FOPFRMNU TO DO GAS Ff nI iG
(Type or print) DateNORTH ANDOVER,MASSACHUSETTS1 Building Locations v`� `' H( �� Permit# Ll �ts
Amount$ ?p-
Owner's Na e
New❑ Renovation ❑ Replacement ��--� Plans Submitted ❑
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U a
a rA x o rA x H
y� a
zi Cry o z OH g OF a
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Fa W ¢ M F.
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cn a z U g W 4 W H A H
CW7 H z WWF z F,, FW+ W p O z W a4 P a
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I1S
UB -BASEM ENT
BASEMENT
T.. FLOOR
2ND . FLOOR
3RD . FLOOR
4TH . FLOOR
5TH . FLOOR
6TH . FLOOR
7TH . FLOOR
STH . FLOOR
(Print or type) / / Check one: Certificate Installing Company
Name Z 1�i ® Cop.
Address P' U v l Y ' �`
❑ Partner.
Business Telephone 47 7 7177376 , ❑4MIC-0•
Name of Licensed Plumber or Gas Fitter rz CU ,L
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes Q__ No❑
If you have checked yes,please indicate the type coverage by checking the appropriate box.
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
Mass. General Laws,and that my signature on this permit application waives this requirement.
Check one: ❑
Signature of Owner or Owner's Agent 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 der Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Co a h Chapter 142 of the General Laws.
Sigpiature of Licensed Plumber Or Gas Fitter
By.
Title M_Ilumber 1111d
City/Town ® Gas Fitter License Number
�ster
APPROVED(OFFICE USE ONLY) ❑ Joumeyman
I
I
Date.41_/c
04."� -1 4,a TOWN OF NORTH ANDOVER
14
p PERMIT FOR PLUMBING
SSACMUS�
This certifies that �.�.��/-��-. .?� . . . . . . . . . . . . . . . . . . . . . . . . . .
has permission to perform . . .1. . . . . . . . . . . . . . . . . . . . . . . . . . .
plumbing in the buildings of .
at . . . . .(... . . . . . . , North Andover, Mass.
Fee. . Lic. No.. �C' . . . . . . . �'t...-.
PLUMBING INSPECTOR
Check # l
6 , 54
MASSACHUSETTS UNIFORM A LICATION FOR PERMIT TO DO PLUMM
(Type or print)
NORTH ANDOVER,MASSACHUSETTS 'f, /
Date Cv /
Building Location 4�5 S�ow /2bwnersame < <'/�s/elf Permit# `y
Amount &%-Q —
Type of OccupancyT.S
V
Replacement /� 11Plans Submitted Yes No
New Renovation 1:10
❑
FIXTURES
F
cc
r
SCBM
�i EVE*4r
M FLOOR
M FLOOR
�FIDOR I
41H FLOOR
51H FLOOR
61H FLOOR
ZII°I FLOOR
SIH FLOOR
i
(Print or type) �j Check one: Certificate
/
Installing Company Name e- 2, Corp.®
Address rG G ` `f ° p F1 Partner.
Business Telep onej 7 B GI7S G-Z.5—,F �"irm/Co.
Name of Licensed Plumber: L'v
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity Bond ❑
Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above
threeinsurance
i
Signature OwnerF1Agent
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 Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plu i Code and Chapter 142 of the General Laws.
By igna ure or LicenSea-FIUMDer
Type of Plumbing License
Title
City/Town License 1,411mDer Master Journeyman ❑
APPROVED(OFFICE USE ONLY
Date.. . . . .. . .... . .. .. .. ..
Y f „O RT H ,
�'-o?�` °^ TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
s a
SACHU .
�f / 1w
This certifies that
has permission for gas,installation . G!! l
in the buildings o /.P�-IU� —1 . . . . . . . . . . . . . . . . . . . . .
at/ 7 � ��. f. f�, -North Andover, Mass.
Fee.Z.�P.*.'�-'.O. Lic. No.
~ GAS INSPECTOR
Check# 0
5070
MASSACk1USETTS'.UNIFORM AR�C-ATtCM.
VNW«T TO DO GAsFFlTiNG.
• �Aassr Date a 2 Permit�!
6 o ba owners Namw C
New ❑ Rerwoation<-O R f �/ Pfans<Submitted:-ed. Yesp : { O:O
b W _ V N p D W
Z.
Ci
0. . p
Sua�=BSfiAT.
JASEMENT
'1ST FI.QOq
=ZNO FL-OGA �
9R0 fLO:OR.
j 4TH FLOOR._ -
STN#LOOK .
STH•1<fr00R
TTH:FLOOR-
STHfLOOR..
in"Ing OompOW: ,.
Address N Check;Ow; Com:
rt.[
❑ Qxporation-
1 i ❑ Partriaship.
Business Tdephon
Firm/Co.
Name of Licensed Plumber or°Casa Fitter:. �VA7 T A44:6 Q
i SURANCE:COVERAGE:. -
f ave aV tiabiity
Yes No ❑ ent'which meets.the requicemerrts.ef_INGt.C 142-
If Y�have:
0°d a4Ype=vMge-by. the e,box.:
A fiabiltY. :
Ottiec type�Liny p . Bond ❑
OWNER'S 1NSURAt CE yr R;1 amLLawane:
ttwe --mss'not`have-_the coverage r
Chapter 1.42"of-the Nass_-Gener�tl-tiwa,-sod�: 9 equired by.
mY signature-an 1-di PM*APPiication waives_this requirement
Check one:
Siynatae dAwn•r�r�Owilers AgMt . def❑ Agent,O
hereby�Y that so of
the deta�s and infonnafion t ha�ee subnyttad(or enter in.abo�ee
edkw 9P�that ap.he Maw h and hstadations application as trop and aocurate.to:the beat.of my_
vel aorisions a fhe Massachusetts state Gas.code and°rmed under the pem*issued p be aNn
Chapter 142 of the �t a
T of
G-
MeSigGasfittet _natu we at °f,
CKY/Town WUoense Number 314(0.
OELOW AOR OIsFICE'IJ'stE"OILY,
FINAL INSPECTION SK•ETCNIRB j PRb.Op€'SS INS.PE.CTION
PER
APPLICAT1.00 FOA I►ERMIT TO DO OA-SPITTING
NAME j TY.PE.Ol�'Alu .bfNO.
1
lw
s 1'
LOCATIOf OR aU+iLbill
a ,
P4UMtlER Oft>OASFI:rtTEl1 .�. '." i
20
OAS IHSPSCT64 ..
x 7>
'
Date.
.D,S._....
R
- a
H0°'��41 TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
,SSACHUS� ,
This certifies that t ;t :. . ...
has permission to perform . /4 r. .I�/1.. .. . .. �..�.. .
plumbing in the buildings of .'t.:: �I. . . . . . . . . . . . . . . . .
at !_ .--,., N
/� �j/ orth Andover;Mass.
Fee '. . . . .Lic. No.. .!.;l1l.!C� / :�. . a
PLUMBING INSPECTOR
t Check #
637 )
.:�.
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lot
SL
'+ WATER CLOSETS
KITCHEN SINKS a
LAVATORIES _
a
BATHTUB
.� �. I SHOWER STALLS
DISHWASHERS $
•� �� � DISPOSERS O -
St LAUNDRY TRAYS •p
WASH. MACH. CON r
N.
HOT WATER TANK
T TANKLESS
�( SLOP SINKS Z
FLOOR DRAINS O
OAS TRAPS o �O
1'I � O O URINALS
DRINKING FOUNTAIN
i6 AREA DAA
IN
WATER PIPING
ROOF DRAINS
BACKFLOW PREV,
3
SL OTHER FIXTURES:
SOTLER MATE
GREASE TRAP f"
Q C
rz SCULLERY .SINK .
g1 . 5HOWER VALVE w