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HomeMy WebLinkAboutMiscellaneous - 1600 OSGOOD STREET 4/30/2018 (19) Date. 7.1?f"�G ".O RT TOWN OF NORTH ANDOVER ° PERMIT FOR PLUMBING SACNus This certifies that A 41A. l. . . . . . . . . . . . . . has permission to perform . . . k !'-Z �. . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. North Andover, Mass. Fee Lic. No.lq.`. ... . . . . . . . 9... . .-:� . . . . . . . . PLUMBING INSPECTOR Check # 71. 52 J� MASSACHUSETTS UNIFORM APPLICATION FO PERMIT TO DO PLUMBING (Type or print) NORTH AND VER,MASSACHUSETTS , I (��� !f Date Building Location Owners Name �� �� Ili`!�' Permit# ?V Amount �D.1 Type of Occupancy E�S/1i►es-5 New Renovation Replacement 13 Plans Submitted Yes No FIXTURES rf En rA 1zF H SLRHM BF�4IVIINI' 1ST 112 ZrD FIDQt �]T1XIt 4M ROIR �•t 5IH 1I0� 6M HBM 7IH HDD SIH H-om (Print or type) L� T Check one: Certificate / ` Installing Company Name i� ! *7 C,• J r �� �./'1 [],,Corp. Address '� ���yt ' '�4- � Partner. Business Telephone _ C}` Firm/Co. Name of Licensed Plumber h-C lef Insurance Coverage: Indicate the "f insurance coverage by checking the appropriate box: Liability insurance policy LVW J 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 three insurance Signature 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State t mbing Code and Chapter 142 of the General Laws. By: 'Signalure of Eicenseaum er Type of Plumbing License Title f 00 -23 Ci /Town t3' icense NumBer Master �'''�Journeyman ❑ APPROVED(OFFICE USE ONLY ,t Date..Z.� ...�/.......... f pORTM ° "f-4.,"° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ♦ °1 � .`mow �,SSACNUSE� Thiscertifies that ................................................................. ........................... has permission to perform'-' ..................................... wiring in the building of.. -.. W.................. ........................................ atNorth Andover Mass. Feet s ..�+.... L c.No/ ........ '.... '�r!'e:-. ..... . ... . ..... . f iLCMICAL I ECfo Check # D:J�� 7637 J t Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 7ro y� BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked kv [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Cope(MEC),527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: / b 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) 1600 0OOc' St- Owner orenan � ``{ , e l.t(c� e�,,ayl�- Telephone No. Owner's A ess (-00 pd S � bvi l t L Z'ed �Lou'� Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Boz) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead [:1Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 1'U o�h4 FLoc� �i1aR'{ Ee i SWI L2> Ae-4-C<teJ QOV66 1 2_oop'fp 1�rccrR Completion of the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans o.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA t No.of Luminaires Swimming Pool Above ❑ In- 0.o mergency ig g rnd, rnd. Batte Units „ No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers eat Pump Number Tons o.of Self-Contained Totals: "" Detection/Alerting Devices No.of Dishwashers Space/Area HeatingKW Municipal Local❑ Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No.of WaterNo.of No.of No.of Devices or Equivalent Heaters KW Signs Ballasts . Data Wiring: No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP ITelecommunications Wiring: OTHER: No.of Devices or E uivalent �•yy�� Attach additional detail if desired, or as required by the Inspector of Wires. J Estimated Value of Electrical Work: 5 W (When required by municipal policy.) Work to Start: z O 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 1i bill insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cov ge 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: M t [--L R-e rJ6 L CO. XP C LIC.NO.: 1503 Licensee:VJ 13.1 f kH W, SP r6n Signature W•S LIC.NO.: 6S�3 (Ifapplicable, enter"exempt"in the license nun er line.) Address: 1^13 FrPa y A-ve, �(.0" {V•H. �-1 q Bus.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Alt L cl.No..(go3-7b S-c(baa 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 Signature Telephone No. PERMIT FEE: $ The Commonwealth of Massachusetts 4 Department of indusbid Accidents Off ice of Investigations . ' • 600 Washington Street Boston, MA 02111 r www massgov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers Applicant Information Please Print Legibly Name(Business/ izadonlindividu Co . Address: CitylState/ZiP: :,:�� eH 03 )1 Phone#:_L3` 76,5—S— q /d 2 Aan employer?Check a appropriate box: Type of Project(repaired): ' 1.Fam a employer with 4. ❑ 1 am a general contractor and i employees(full and/or part-time),* have hired the sub-contractors 6• ❑New con struction 2.❑ l;am.a.sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling ship and have no employees These stili-contractors have $. Q Demolition working for me in any capacity, workers' comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required] officers have exercised their 10.[3 Electrical repairs or additions d 3.❑ I ain 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 } insmance required.]'t employees.[No workers' 12.❑Roof repairs comp.insurance required.] 13.❑Other 'Any applicant go checks/loll#1 must also fill out the section below showing their workers'bompensatioo policy infonnetion. t Homeawnap who submit this affidavit indicatting they ars doing all work and lien him outside contractors must submit a new affidavit indicating such. 4Contraetons that check this box must attached an additional sheet•showing the tarn of the sub-contractors Bad their workers'comp policy information. I ant-an employer that is providutg:workes'compensation inswwwefor my eMloyeM- Below is the polky and fob site information: _ ( Insurance Company Nam • .V erfe dt tSi,a IN t"CQ CUM " Policy#or Self ins.Lie.#:_ Ifil Expiration Dom. f t j 2(� ©13 c32-v�t>}-oo —�1-=k- Job Site Address: r�c� S�. �`at�c, a.0 t 2hd FL J.M.MIL City/stst op:I i, Avis of-er Qk 845 Attach a copy of the workers'compensation policy deciaratioa page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL e. 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 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. jI do hereby c under the pains and petab es of per,/uty that the infornsadon provided above is kue and eotred a Si A� VV, ti Date- Phone#: k3- 7(5 Official use Only. Do not write in this area,to be completed by ayy 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 S.Plumbing Inspector 6.Other Contact Person: Phone#: