HomeMy WebLinkAboutMiscellaneous - 163 CANDLESTICK ROAD 4/30/2018 163 CANDLESTICK ROAD
210/106.-q 0000.0
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Date.... '„Z-
HORTM +
3:°,•� ``°-:'�"°� TOWN OF NORTH ANDOVER
PERMIT FOR WIRING }
�Ss�cHusf�
''J'
This certifies that ..........1.... .4�.....
�U.�..�(!G..�.........�..�.......... �
has permission to perform ......... !TG i S�!!y ... ,
........................ ............
wiring in the building of.............. . .TLS.................................................
i at.... ....... . ,North Andover,Mass.
33L a
Fee..................... Lic.No. ............. ..... ......... ..........
-CTRICAL INSP R
Check 11 r
8317
} Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No,
3� 7
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),5J7 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:
City or Town of: NORTH ANDOVER To the Inspecto 'of Wires:
By this application the undersigned gives notice of his orher intention to perform the electrical work described below.
Location(Street&Number) 43
Owner or Tenant L Telephone No.
Owner's Address 43 cc,, J1, S f C-IC
i
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service ✓BOO Amps / Volts Overhead ❑ Undgrd Q"--No.of Meters
it
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
t
Completion of thefollowing table may be waived by the Inspector of Wires.
No.of Recessed Luminaires „Z(_? No.of Ceil.-Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets G No.of Hot Tubs Generators KVA
No.of Luminaires a7 6 Swimming Pool Above [I In- ❑ o.of Emergency Lighting
rnd. grnd. Battery Units
No.of Receptacle Outlets /6 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 No.of Alerting Devices
Tons g
No.of Waste Disposers 1 Heat Pump INumber I TonsKW No.of Self-Contained
Totals: ""..........
"' Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal E] Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent
No.of WaterKW No.of No.of Data Wiring: j
Heaters Si ns 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 Elec ical Work: (When required by municipal policy.)
Work to Start: 0 6 6� Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE CO RA E: 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: INSURANCEn BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties ofperjures,that the information on this application is true and complete.
FIRM NAME 0^ el&&c L e r:C LIC.NO.:
Licensee Rol dt-c- Signature LIC.NO.: 3
(If applicable,enter"exempt"in the licennu ben line.) Bus.Tel.No.•&-?-AK"G79P
Address: Alt.Tel.No.: 1W-6
*Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"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
Signature Telephone No. PERMIT FEE: $
f
2
s
The Commonwealth of Massachusetts j
• Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
NameBusiness/Or anizati u c !� (✓
( g on/Individual): 70"-,
Address:
City/State/Zip: .41 o3cL�-3 Phone #: c1>03 - y3 �62 3
Are you an employer? Check the appropriate bog: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
e loyees(full and/or part-time).* have hired the sub-contractors
tam a sole proprietor or partner- listed on the attached sheet. E] Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in 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.F1 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' 13.❑ Other
comp. insurance required.]
*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 the are doing all work
and then hire outside contractors
$ g Y g 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: Tc> rµ
Policy#or Self-ins. Lic. #: Expiration Date: �IlAe
Job Site Address: �E 4�z X/, k City/State/Zip: /j/d� �
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 insurancd coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Si nature: f �/`� Date: 7 0�
Phone#: 6'4 3-- e{37—6%2 3 3
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#•
to. . . . . . . . . . .
"°RTM TOWN OF NORTH ANDOVER
'• o
PERMIT FOR PLUMBING
F SgAC14USE�
This certifies that T"7?? . . . �f !
.�-. . . . . .'^. .
. . . . . . . . . .has permission to perform .
plumbing in the buildings of .�4' -•`'�a.• "
. . . . . . . . . . . . . . . . . . .
v
I at . . . . . .-. . . . . . . . : . . . . . . . . . . . . . .,. .: North Andover, Mass.
Lic. No. . . . . . . . .
. . .
PLU B.NG INSPECTOR
Check # �yS
7856
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER,MASSACHUSETTSDate 9
j
Building Location J� Car Owners Name
� Permit# �
!rj
Type of Occupancy Amount
New ri Renovation ri Replacement L,:..f Plans Submitted Yes No
FIXTURES
o
0 0
A a a
SIMM A Cie
oa
BE FIDCIR :Z. ,
M FLOOR
m moaz
4HI FLOCK
M F)<fM
6M RDM _
7I)<i FIDOR
gm FIIJQR
(Print or type) Check one:
Installing Company Name Certificate
L ❑ Corp.
Address ri
Partner
Business lelephone Finn/Co.
Name of Licensed Plumber: rYl '� �� al /V 6
insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy ❑ Other type.of indemnity ❑ Bond ❑
s
Insurance Waiver. I, the dersigned,have been made aware that the licensee of this application does not have any one of the above
Vk"uranc
ature Owner 13Z 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 Mass huset to Plurq} Code an apter 142 of the General Laws.
By:
Signature n hens u7"ai�iDujJ e
Type of Plumbing License
Title .r
City/Town tcense um er Master ❑ journeyman
APPROVED(OFFICE USE ONLY LJ
i
Date. �l. . . ./.
i
,,OR°':�tic TOWN OF NORTH ANDOVER
+ PERMIT FOR PLUMBING
s o� ,�•'a
b 'O,,r�o•I�`t•i
,SSACMUS�
J
This certifies that . ./ c
has permission to perform . . .P.1N. . . . . . . . . . . . . . . . . . . . . . . . . . .
plumbing in the buildings of . . l.Y. f l
'/ . . . ... . .. North Andover, Mass.
Fee. Lic. No.. e1.`. . f. . . . . . ;t;_. .C.
;�: . . . . . . .
/ PLUMBING INSPECTOR
Check #
5021
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING 2 `'
` (Print or Type
NW , Mass. Date AJ12 0 2CO3- Permit #_ ,S
Building Location��P Namep/-,
h� ,s Type of Occupancy 2t 5 C--
New
New ❑ Renovation ❑ Replacement P Plans Submitted: Yes ❑ No ❑
FIXTURES
Z �
z
N 2 Y a
O Z
W Y J N } U a N W W
O Z N Q ¢ a ~ z O _ 2 N a ¢
W F W ¢ _ ¢ N _
LL, t0 �' `_ x
U Z ¢ m N y W } a N z a O Q a �, 0 x
¢ W o O ¢ a N ¢ > Q W — o a v1 Z .¢ a ¢ O U.
I- r W a 0 ¢ J _ o c
JU.
W S C x W
� O f- Q Y
F- U a Z = C, 2 = Y d O a W W Y W
> F- O of r' 2 O N — Z F O
~ < a a o a J ° a ¢ ¢ a Q o a ►_-
Y W 0 z O d S a @ O
SUB—BSMT.
BASEMENT
w
IST FLOOR
2ND FLOOR
C 3RD FLOOR
4TH FLOOR
I
STH FLOOR
6TH FLOOR
7TH FLOOR
STH FLOOR/
Installing Company Name Lt?w m A T A e 0 Check one: Certificate
Address_ r� C(:AC hi mr3n 1 /' , ❑ Corporation
l'FA vr1 A • y t NL/ ❑ Partnership
Business Telephone_ /� _i9 2irm/Co
Name of Licensed Plumber 2 r3 Fe"T f>> SA rn vlrq rK fir"
INSURANCE COVERAGE:
I have a current!' bility insurance policy or its substantial equivalent which meets the requirements nts of M
. }a q GL Ch. 142.
Yes Q' No ❑
If you have checked rtes, please
/indicate the type coverage by checking the appropriate box.
A liability insurance policy Ind" 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:
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 nerformed under the permit issu for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plum ' g e and apter of the oral Laws.
'tii,L���i
re o Licensed lum r
Title •
City/Town Type of License: Master % Journeyman ❑
APPROVED OFFIC U ONL License Number
BELOW FOR OFFICE USE ONLY
FINAL INSPECTIONS SKETCHES PROGRESS INSPECTIONS
FEE
NO.
APPLICATION FOR PERMIT TO DO PLUMBING
NAME do TYPE OF BUILDING
LOCATION OF BUILDING
PLUMBER
PERMIT GRANTED `
DATE 19
PLUMBING INSPECTOR
I
Location f 0�
No. Date
NaRTM TOWN OF NORTH ANDOVER
Certificate of Occupancy $
t
Building/Frame Permit Fee $
s'4TIG t� Foundation Permit Fee $ -
�ORT �_ Other Permit Fee $ t' /
Connection Fee $ "
Waiio Connection Fee $
�PR TOTAL $
z ® <� Building Inspector
Div. Public Works
gERi:IT NO. U 97 APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1
MAP d40. LOT NO. 2 RECORD OF OWNERSHIP (DATE BOOK " —
PAGE
ZONE I SUB DIV. LOT NO. 1
LOCATION PURPOSE OF BUILDING t er '
OWNER'S NAME NO. OF STORIES Z SIZE - 1
OWNER'S ADDRESS or
BASEMENT OR SLAB
f _
ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAM vWV' !!�k ./9�_1 ,', SPAN ---
DISTANCE TO NEAREST BUILDINGC'� DIMENSIONS OF SILLS
DISTANCE FROM STREET POSTS
DISTANCE FROM LOT LINES-SIDES REAR " GIRDERS
AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW SIZE OF FOOTING X
IS BUILDING ADDITION MATERIAL OF CHIMNEY
IS BUILDING ALTERATION { 5 i�i_� IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE "l IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS 3 PROPERTY INFORMATION
LAND COST
SEE BOTH SIDES EST. BLDG. COST Us=
PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT.
COST PER ROOM BLDG.
PAGE 2 FILL OUT SECTIONS 1 - 12 EST. I
SEPTIC PERMIT NO.
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
D ILED J
of
cgag WARD OF HEALTH
SI N URE OF WNER OR AUTH ZED GENT
FEE •D �
i
(,.�
PERMIT GRANTED OWNER TEL.# v PLANNING BOARD
CONTR.TEL.
19 -� CONTR.LIC.#-0-L QJ�
Qs-V WARD OF SELECTMEN
t� B ILDINO INSPECTOR
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA-
APARTMENTS I RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
CONSTRUCTION
2 FOUNDATION 8 INTERIOR FINISH
CONCRETE 3 1 2 13
CONCRETE BL K. PINE
BRICK OR STONE HARDW D
PIERS PLASTER
_ DRY WALL
UNFIN.
3 BASEMENT
AREA FULL FIN. B'M'T' AREA _
1/1 1/2 l/, FIN. ATTIC AREA _
N_O B M T FIRE PLACES _
HEAD ROOM MODERN KITCHEN
4 WALLS I 9 FLOORS
CLAPBOARDS B 1 2 3
DROP SIDING CONCRETE �_
WOOD SHINGLES EARTH _
ASPHALT SIDING HARD",('D _
ASBESTOS SIDING _ COMtACN
VERT. SIDING ASPH.TILE _
STUCCO ON MASONRY _
STUCCO ON FRAME
BRICK ON MASONRY ATTIC STRS. & FLOOR _
BRICK ON FRAME
CONC. OR CINDER BLK.
STONE ON MASONRY WIRING
STONE ON FRAME _
SUPERIOR Ij POOR _
ADEQUATE NONE 11
$ ROOF 10 PLUMBING
GABLE HIP BATH Q FIX.)
GAMBREL MANSARD TOILET RM. (2 FIX.)
FLAT SHED WATER CLOSET _
ASPHALT SHINGLES LAVATORY
WOOD SHINGES KITCHEN SINK
SLATE NO PLUMBING _
TAR 8 GRAVEL STALL SHOWER _
ROLL ROOFING MODERN FIXTURES _
TILE FLOOR
TILE DADO
6 FRAMING 11 HEATING f
WOOD JOIST PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. &COLS. STEAM
STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR
WOOD RAFTERS _ AIR CONDITIONING
RADIANT H'T'G
UNIT HEATERS
7 NO. OF ROOMS GAS
OIL
6'M'T 2nd _ ELECTRIC
1st 13rd NO HEATING
54, a condition of
In accordance with the provisions ofMCL
40s
isthatthedebris resulting from
BuildingPermit Number
waste
osed of in a properly licensed solid
this work shall be disp P ,
disposalde
Y
fined b HCL c 111, S 150A.
facility as
4 The debris will be is ose of in which City or Town
O STREEI ADDR SS
At Tiv 0 'l
'S
C0 'ILA
TYPE SC,::O�NTAINER
FOR
TRANSPORTATION
Signatur of Permit Applica
Date
it
i
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,R�'y`' .` 0.1 �^r'+ � ls ,�",�^' � e� �"" �� ,�'^ ''�t,•>_,�;5'�.�.x,*s�''�. }ti`�"�i'��+c�c: .w +r'����',±_ .;^,., � ,, j���t�l��.��+� •,�!_ .�;+a�:Y�r`�'���•y,�` ti3.,+
; �,t .c` x'�'���`r�.', +r.'�'..�` ..��'.t'``�"`.'�` .��a��; ��i�i�fa�,.����_T,1i 4+.,����,. ,Y. ! ..y,, a. ��. ,.�,� ,.,�•. '.-, t. ,. .. �Y� �.:
A,"1I ,r^.11111 -GIJT
uf-tt t ;.:jTIGf;
i.J.... iA %U i.. ii ri= Fc,&ci 1ations and StaTldacr J
Uri A�whbil-i-ton 1ac1: r 1301
t-to tort I'�£1 uCii11;3 v�i1J `• [��
;i.); 17- I?'Ir''F•OVEi'lENT CuiNTr;+CTu;< t
'f•1 a',.%i. 0 _ r C a f a t i o'n IJ E,i i b/9 cj
T I ,;V _ riI'1r+yT(_ �Ji�i '�) (1I l)I'`: 07ie�ammaiuueall�a�/l�auvett
HOME BPROVENENT CONTRACTOR
Registration 100502
s=�h1E I�ICr N T✓ve - PRIVATE CORKRATiON
COOK Expiration 06/18/94
Nut=<1"1 .T(WI"M0 1\1 5
AMERICAN REMODELTNG INC
✓ii
' CHARLES COOK
8585 NORTH STEMMONS X5102
ADMINISTRATOR DALLAS TX 75241
c t �+• .ti,. �' l tt y� .< .p,.`r S Ynf i•�;.},"h:`t.•..t
.,t" rRY '3. Y'• .7.r t fy. Y �.1. .,;. 4 1,..i. �'. .�'i
:✓k ..11'�`�.wy � I T.k � . 4 •J,i.{:p•1h.. �.'�` "'S w �1t"^♦ ..4ipi✓
}. 7L� .}. + }at^ x, ,� )•' r' s+ y7 .i?M ".p ,qt: .t;'..a f:+'B,ic+.:Y•.. fJ,dd o:b>„ 'a}a / .'�,,, J`
{ t � 9., r•.. ,,fit eY.S�•,. 1 r.�.y f 9:' •r.i .r — .,5xr s..y...,
Suggested Allldavil for IIonte Imptovemcnt C:utmaclul 11clmll Appilcatluu
for office Use only 14AN1 '' P Cl' 'y/11
N
1'erurll No. /`I if l _
Dole
AFTIUAVIT `
lluule Inllrl urrurcul (:unlluclor I,IIw
Supplement to Petmll Application
MULe.112Arcqultesnlal the'recon+ ruclIon.eUernIon,rcnuvnlle , ainlvovnl�d�emo,-lh
m � onoemIon•
rcoomirucllon of an oddhion lo_nnLtne rat 11��owucf.e.ccuhlcJ hulldin�conlnlulnr.sl Icml one bol 1101"Bole 1IIBII 1Quf dW111/...0
o/lruclurc+which arc polncall lopuch 1c/IJcsocc ur bulldlot be dune by rcSIslacd cuuUsclul/,"life urlslu aapllwu,nlons wilh olhcc
IcgYllcnlcul/.
Type of Work: Est. Cost
Address o[,''yYurk
Owner Name:
Date of Pctmil Appllcatlun:
I hereby certify that:
Rcgisttallou Is nut teyulted fur lite following lcasun(s):
Wo1 k excluded by law
_Job under 3I,000 ,
Llullding nol uwncr-occupied
_Owner pulling own permit
_Other (specily)
i
Notice Is hereby given lit-it:
OWNERS PULLING THEIR OWN Pf RMIT OR DEALING WITH UNREGISTERED j
CON'I*ItAC1'OltS fOlt API'LICAIILr I(on11= INII'ItOVFNIEN'I'WOItK UO NO'1'1IAVE
ACCL'SS TO'11 IF.ARBITIUV11 PROGRAM OltUAR '1'Y FUND UNDER MGL
c. 142A.
Slgued udder pcnalllcs of perjury: /f,
r
1 hcteby apply for a perh►it as the agcul of lite uwncr:
Dale CuuUactut Name Reglsltatlutt No.
i
Olt:
Notwithstanding the above nullec, 1 hereby apply fur a permit as lite owner of lite above ptopetly:
Dale Owncr Name
a COMMONWEALTH-OF MASSACHUSETTS-
' E� DErAR MENf OF INDUSTRIAL ACCIDENTS
600 WASHINGTON STREET
� 9
fames., Campoel; BOSTON, MASSACHUSETTS 02111
_omm ssione-
WORKERS' COMPENSATION INSURANCE AFFIDAVIT
(licensee/permittee)
i
Will a principal place of business/residence at:
' (City/State/Zip)
do hereby certify, under the pains and penalties of perjury, that:
[] I am an employer providing the following workers' compensation coverage for my employees working on this
job.
Qf M 1 7 2_
Insurance Company Policy Number
i
[] I am a sole proprietor and have no one working for mc.
[ ] I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below
who have the following workers' compensation insurance policies:
Name of Contractor Insurance Company/Policy Number
Name of Contractor Insurance Company/Policy Number
Name of Contractor Insurance Company/Policy Number
Q I am a homeowner performing all the work myself.
NOTE: Please be aware that while homeowners who
employ Persons to do maintenance construction or repair work on adwelling of not more than three units in the homeowner
also resides or on the grounds appurtenant thereto arc not generally
Yconsidered to be employers under the Worker Compensation Act
(GL C. 152,sea. 1(5)),application b a homeowner
or er i PP Y for a license
permit evidence the legal status of an employer under the Workers' Compensation Act
1 understand that a copy oFkizis.statement will be forwarded to the Department of Industrial Accidents'Office of Insurance for coverage
verincuion and r_�at failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties
cotnsisa:cg of a fine of up to $1500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fine of S 100.00 a day against me.
Signed this day of
9
Licensee/Permittee Licensor/Permittor
The Commonwealth of Massachusetts
Prrm(t So.
Department of Public Safety
"
BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 12.00 3/90 occupancy S Fee Checked
(leave blank)
APPLICATION aFORmP)ERoMIT TOdance with � PERFORMMauachusertsa�ELECode. ZCTRICAL WORK
All work CMR 12:00
(PLEASE PRINT IN INK OR EpO�R RHA/T�IIONN) Date --�f
City or Town of V V.1 y To the Inspector of Wires:
The undersigned applies for a permit to performl elec icalfwork descri d below.
Location (Street & Numbe 05fi � .
Owner or Tenant
Owner's Address
Is this permit in conjunction with'a building permit: Yes No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization NO.
Existing Service Amps / Volts Overhead ❑ Undgrd❑ No. of Meters
Nev
Service Amps / Volts Overhead ❑ Undgrd❑ No. of Meters
Number of Feeders and Ampacity
Location and Nat a of Proposed Electrical Work
AA
No. of Lighting Outlets No. of Hot Tubs No. of Transformers
Tot
jAl
No. of Lighting Fixtures Swimming Pool Above In-
grnd. ❑ grnd. ❑ Generators KVA
No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting
Battery Units
No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zoll.-s
No. of Ranges No. of Air Cond. Total No. of Detection and
tons Initiating Devices
No. of DisposalsNo, of at Total Total
pmps Tons KW No. of Sounding Devices
No. of Dishwashers Space/Aria Heating KW No. of Self Contained
Detection/Sounding Devices
No. of Dryers Heating Devices KW Local❑ Municipal Dot
her
Connection
No. .of Water Heaters KW No,
nof Ballasts LowWirVoltage
Signg
No. Hydro Massage Tubs No. of Motors Total HP
OTHER:
I
I
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a currentCLbilly Insurance Policy including Completed Operations Coverage or its ubstantial
equivalent. YES6❑ I have submitted valid proof of same to this office. YES�OIf you have checYES, please indicate the type of coverage by checking the propriate bo
INSURANCE [)40ND ❑ OTHER ❑ (Please Specify) LM.
-e Vr �i✓LS 62 ZO��
Date
Estimated Value of Ele tr al Work S
Expiration
Work to Start cs < IInspection Date Requested: Rough Final
Signed under the penalties of perjury:
FIRM NAME ' e LIC. N0.':Z:
Licensee G Signet L 1 (3IC. N0 `7 d
Address S� Bus. Te . No.
A
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does. not hit. Tel. No.ave the insurance 7q e7 or its sub-
stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit
application waives this requirement. Owner Agent (Please check one)
Telephone No. PERMIT FEE S
Signature of Owner or Agent
From M&W T4WKSBURY PHONE No. 508 851 7601 Mar. 19 1993 3:57PM P01
,_• . . . . . . : . . . . . . • . . . . -�-1SSllf ORIF (NN/DU/YY)
CERlIfICATE Of 1NSURANCI --- '
i i 03J00/93 -�
PRODUCCk - - - • -
........................................
- • - -
-- THIS CCRTIr1CATEISISSUEDAS AMATTER OF INFORMATIONONLY.AND CONFERS
NO RIGHTS UPON TNF CERTIFICATE HOLDER. THIS C RIIFICAIE DOES NO] AMEND,'
MAH NEYALiL WRIGHT IHS.of TENKS• IEXIEND OR•W EI( THE-COVERAGE-AFFORDED'BY-101 PR IC1ES-BELOW-- lbwk&bury;
MA 01016 ---CONPAHIES AffDROING COVERAGE
- (508) P51-9004 -------------- •-------------------- (COMPANY-- -- "Commerce lilt. Co......---------------.. ......-------------i
------------------- -I 11 A -----
INSURED TT µµ
Kcnnclh Wink dba
Wink Electric
5 North Strut • I 1
AAdaYB( Mn olBlo ILEIAlf......__�_____�_____.---- -- w--t
CDVERACEw __...----..:..:. - .....-•------- ' -=---=--'I.CTIER....E--------------=-- --•. :.::__::_.::-------.. ......... I
THIS 18 10 CERTIFY THAI 111E POLICIES OF INSURANCE LISTCD bLLOW HAVE DEEM 15SUED 10 THE INSUkED NAMED ABOVE FOH INE PULIVY PtN100•1
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION Of ANY CONIACT OR DIHER DOCUMENT WITH RESPI-C1 TO WHICH THIS �
CERTIFICAIC MAY BE ISSUED OR MAY PER1AlH- 16E INSURANCE AFFORDED BY TIIt POLICIES DESCRIttO HEREIN IS SUBJECT 10 All THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICR S, I,111ITS.SHOHN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1
------------
-w__. --- -------------------- .i._ I
---� . Vbl1CY.-i--PpI.ICY-- ----....-._ ---------------------------
I
LIRI TYPE OF INSURANCE I POLICY NUMBER EFFECTIVE IEXPIRATIONI LIMITS 1
DALE , DATE 11 -�
---
--------------------------------+------------..---_-----a----------t---.._...... i, -------------------------------------------
' GENERAL LIAUILITY ' ' (i(HERAL AGGREGATE. S00 000_)
A l I C33245 1 03/20/93.1 03/20/94 I PR(�ItOUC gg CbF�]�!j� At;6REGAT�t •'-SG .000 I
1(X) COMMERCIAL GENERAL LIABILITY' II I-PER 96R�C�6`AOVFRTTS�[R6�I�RY""+ � 66`b66_I
( ) CLAIMS MADE jKj OCCUR. ( I I I EA6RM6F11 FE
I OYWNER o L CONTRACTO 'S PROT.I I I I- E-6A117C _ 4��J�Gj�"`t - •S6`6R0_�
----------------- --•-------+--------... .---------)--------._:.....__---)-ML6l��C"fR-E --Any-one-person
AUTOMOBILE LIAOILIIY COMBINED SINGLL
II I I I-LIMIT------- ,t
ANY AUTO - - ---------i--••--
I ALL OWNED AUTOS I I I I BODILY INJURY
I SCHEDULED AUTOS 1 i I I (Per parson) �i I
1 HIRED AUTOS l I I I-- - ---•-•-------------------4---------------�
I NON•ORNED AUTOS I I I ( BODILY INJURY
I GARAGE LIABILITY I I I 1 (Per.accident) I; I
1 I I j PROPERTY UAMAUL
-
.............................. ) _. _.-------i----------J---------- - - --------------------- ...............
' EKCCBS LIADILITY OCCURENCE
..]umbrella
rm
Other Than Us brella-.f..or.a_-----1i------------------ I I (_AC M _.-__- -- ------ ---�--
WORKER 9 �II
COMPENSATION ' ' ' ` �IATUTOKY LIMITS '
I
AND I I 1. I"ESR IST EI6ETlT" -------I
I EMPLDYERS' LIABILITY I I I I-DISFAS - OCT / L li 1
FF
I I ;�6TSE`ASC- ACR EH YEE"-------•t ---I
---+....... ...............•------..;..._-•-•------------- -..... - -t-------------------------------------------------
.
----- -------,--- ----------------------------
. ............................ - - ---- -- + ---- - �-- -�---------------------------- - •------------I
DESCRIPTION OF OPERATIONS/IOCAIIONSJVEHICLES/SPECIAL-TIEMS-
, I �
CERTIFICAIC HOLDER ------ CANCELLATION
' SHOULD ANY OF THE ABOVE—DESCRIBED POLICIES BE CAMCEItED-BEFORE TILL I
. I EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
AMR1, 1 MAIL 10 DAYS WRITTEN NOTICF 10 THE CERTIFICATE HOLDER NAMED TO THL 1
57 TEED D K. I LEFT BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION 09
I ItABfLITT F ANY KIND UPON INE COMPANY IT'S AGENTS OF REPRESENTATIVES. 1
RANDOLPH.- . MA I--- ---•- • •-- ------•-•• '---- --- -------- -1
--
ISSUE DA"I
PRODUCER
THIS CERTIFICATE ISSUED 11/12./92
eacon Insurance Agency AS MATTER OF INFOR-
BL
MATION ONLY AND CONFERS NO RIGHTS UPON )THE
22 Middlesex Street CERTIFICATE HOLDER; 11' DOES NOT AMEND *,EX-
TEND OR ALTER COVERAGE-- AFFORDED BY THE POI.-.
N. Chelmsford MA 01863ICIES BELOW. COMPANIES AFFORDING (.',OVERQ&jEj
COMPANY
LEI rE.R A
INSURED COMPANY
LETTER B
KENNETH WINK DBA WINK ELECTRIC COMPANY
780 SHAWSHEEN STREET LETTER C
COMPANY
TEWKSBURYj MA 01876 LETTER D USF&G INSURANCE COMPANY
COMPANY
E
: COVERAGES: THIS CERTIFIES THAT INSURANCELETTER POLICIES BELOW HAVE BEEN
ABOVE INSURED FOR POLICY PERIOD INDICATED ISSUED TO THE ;
- NOTWITHSTANDINO ANY REQUI.REMENT, TER�
OR CONDITION OF ANY CONTRACT OR DOCUMENT TO WHICH THIS TERMSFOFASUCHABE ISSUE[
'- OR MAY PERTAINI THE INSURANCE HEREIN IS SUBJECTTO ALL PCC) TYPE OF POLICYPOLICIES'.
ILT INSURANCE POLICY POLICY LIA LIM IN THOUS
GENERAL LIABILITY NUMBER EFF DATE EXP DATE EA OCC AGGREG
COMPREHENSIVE FORM BODY
PREMISES/OPERATIONS INJ $ $
UNDERGROUND EXPLOSION & COLLAPSE HAZARD PROP
$
PRODUCTS/COMPLETED OPERATIONS DOM $
CONTRACTUAL BI
INDEPENDENT CONTRACTORS PD $ $
BROAD FORM PROPERTY DAMAGECC, COMB
PERSONAL INJURY
PERSONAL $
AUTO LIABILITY
INJURY
ANY AUTO B I
ALL OWNED AUTOS (PRIV PASS) PERS $
ALL OWNED AUTOS (OTHER THAN PRIV PASS) B I
HIRED AUTOS ACC $
NON-OWNED AUTOS PROP
GARAGE LIABILITY DAM s
BI&PD
EXCESS LIABILITY COMB $
UMBRELLA FORM BI &
OTHER THAN UMBRELLA FORM PD s
,'ERS '
D WORI' $
0713345926 11/06/92 COMB
COMPENSATION AND 11/06/93 STATUTORY
EMPLOYERS ' $100 EACH ACC
LIABILITY
OTHER do $500 DIS-POL LM
$100DIS-EA EMP
,ESCRIPTION OF OPER
ATIONS/LDCATIONS/VEHICLES/SPECIAL ITEMS
ELECTRICAL WIRING
ERTIFICATEHOLDER CANCELLATION
SHOULD ANY POLICIES ABOVE BE CANCELLED=B=E=-===
FORE EXPIRATION, COMPANY WILL ENDEAVOR TO
MAIL 10 DAYS NOTICE TO CERTIFICATE HOLDER,
BUT FAILURE IMPOSES NO COMPANY OBLIGATION.
AUTHORIZED REPRESENTATIVE
DEBORAH A GRIMSHAW
�y
.i yr
•
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♦-etc'.
N
y� !
I
_ e
O
Z __
z COMM QF SAS A�
G �
a OF ELECTRICIANS
EGISTED MASTER ELECTRICIAN
ISSUES THIS LIGASE TO
KENNE J ,WINK ,
780 SWSHEEW.-STREET..
TEWK9RY`,'' • ,• 'MA, 0.1876-2362
uJl 1348A 07/31/95 243952
N
J
CL
W
J
G`
ti.
f
NORTH
� � 1
Town of And
O
h Pl�/L 19 Aj
�y �-�?" � dower Mass.
Oc Nic c.�( 1 ,
C
ADRATED
'9S H BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
��
THIS CERTIFIES THAT.........X&A.. ......... ....e••v..�^•0 BUILDING INSPECTOR
""""" Foun anon
has permission to erect.$J..J0/...W4.... buildingsRo on .�..`., 'A►� , 5'f1� ./ i ugh
to be occupied as.........1I�.. ..... 'PA .... ................... Chimney
provided that the person accepting is permit shall in every respect conform to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
PERMIT EXPIRES IN 6 MONTHS Final
UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR
X V1 Rough
wemtm-
a-00"... Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove Rough
Final
No Lathing or Dry wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector.
Burner
PLANNING FINAL CONSERVATION FINAL Street No.
CG1A/FR /1A/ATFR I � DRIVEWAY ENTRY PERMIT Smoke Det.
FINAL .�'� � ti