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Miscellaneous - 170 PLEASANT STREET 4/30/2018 (2)
170 PLEASANT STREET 210/070.0-0020-0000.0 __ . ,� _:�yz—.,.•-., ..i,_y -�" - '-cam- �+ -- ) .r -.. .. .+- t r gg � y Date......71,, '//do ° 373 8 HORTN � TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �Ss�cHusf� fl ; i� This certifies that / 4 has permission to perform .....�{.1 T...,�. .f. '.. . e.j....... N wiring in the building of..... ..�..........5...................................................... at...... J�. .(J,...�..�. Q.S4 .f...S ..•.................. North Andover Mass. r. 997 ' Fee! ..APUJ..�. Lic.No.f 1f. ol. .......................................................... � ELECTRICAL INSPECTOR d' Ck t4 5"3kv c WHITE: Applicant CANARY: Building Dept. PINK:Treasurer (�, }} Office Use Only - ull� (�QTIIriIIITIIU>'c�l If �155ar lugettg Permit No. Id r �elra tmerit cf f uhlit —56dEtU Occupancy& Fee Checked a" - 3/90 (leave blank) _3 BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 q f (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date ri Z- ' fb QM or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) owner ° r Tenant Owner's Address Is this permit in conjunction with a building permit: Yes V No ❑ (Check Appropriate Box) Purpose of Building DQ215 OCFtG--s Utility Authorization No. (Q(3 4: Existing Service v0 Amps Umo—j 10Volts Overhead Undgrnd ❑ No. of Meters New Service Amps __J Volts Overhead ❑ Undgrnd ❑ No. of Meters Number of Feeders and Ampacity17� f Location and Nature of Proposed Eieakipai Work' gegII � 1G�. 12, JkM44 . Total No. of Lighting Outlets No. of Hot Tubs00, No. of Transformers KVA �0 Abover-, In- No. of Lighting Fixtures I Swimming Pool grnd 'i grnd. !J I Generators KVA No. of Emergency Lighting No. of Receptacle Outlets I No. of Oil Burners I Battery Units No. of Switch Outlets i I No. of Gas Burners FIRE ALARMS No. of Zones 1 Total No. of Detection and No. of Ranges I No. of Air Cand. tone •�� Initiating Oevices Heat Total Total No. of Oisposals No.of P;,mps Tons KW No. of Sounding Devices — I — No. of Self Contained No. of Oishwashers Space/Area H��oting KW Oetection/Sounding Devices Municipal r- Other No. of Dryers Heating C)av ces wV Local W Connection I No. of No. of Low VoltaQ9 •.. _ . Nu. o.' Water Heat-ars sWiring rs K . _I Sign , _ Ballasts g No. Hydro Massage Tubs I No. of Motors Total HP ` OTHER: a ;' INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws — 1 have a cu ' nt Liability Insurance Policy including Completed Operations Coverage or its substantia tsl equivalent. YES1 N0 I have submitted valid proof of same to the Office. YES NO — If you have checked YES. please indicate the type of coverage by checking theapp priate box. INSYfANCEBONO = OTHER . (Please Specify) (Expiration Oate) s � Estimated Value of Ele�cltrical Work S 11 92 � Final Work to Start `�` Z?J It. Inspection Oate Requested: Rough Y► s Signed under the Penalti;sof perjury: _4 � �A FIRM NAME ��rr ta3 LIC. NO. Signature LIC. NO. Licensee OL konus. Tel. No. W Address L��� It. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Own r Agent nt(Please check one) Telephone No. PERMIT FEE z (Signature of Owner or Agent) Date. . . . . . . . . Vit! S�A(;HUSETTS UNIFORM APPLICATIO(4 FOR PFzRNIIT TO DO GASFITTING t (Print or Type) FORTH ANDOVER Mass. Date (3 �uilding Location ( ]() � eOLS'6z S' Permit ��+ax Owners NameOV New `-1 Renovation Replacement �] Plans Submitted �] FIXTIM! IF v scW yr rn U z Q °' rn x m x o � a i lx- W �- a f- x d tII N t' O O W Cr W rC W W F i.. N � N V W vs JA' 4 Q O A y W W W to W z a x tz x wa w }" W I' x 0 tx a t- z f= z F, w W o a tz f- w ..a > a W z Q a a < o o W v w t- rr > a a t- v SUR—EISIMT. BASEMERT 1ST FLOOR 2RDFLOOR 3RDFLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR (Print or Type) Check one: Certificate Installing Company Name MA- t-d e C� 0.,,i C�vw (� Corp. Address ( .d Glc I(S 5 Partner. -Sau!�us r-, allob Firm/Co. Business Telephone: /� 17 - A33 2!j Name of Licensed Plumber or Gas Fitter (( cj @ S cz- Insurance Coverage: Indicate the type of insurance 4verage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond 17j + 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 coverages. Signature of owner/agent of property Owner Agent 1 hereby certify that all of the dctuils and information I have submitted (or entertd)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations peeformcd under Permit itwed to: this spl,lication wW be to compliance with all patlnent prorisions of tho Massachusetts State Gas Code snd'Uraptes 14I of tho Genual laws. By "YPE LICENSE. Plumber Title Gasfitt-er Signal re of Licensed Master Plumber or Gasfitter City/Town: q �3 .7ourry`ytnan �y _ APPROVED (OFFICE USE ONLY) I�,icerise IJut*tLcr Ta 2250 Date... . ..?. .' .yfa... A �-r NORTN TOWN OF NORTH ANDOVER _PERMIT FOR GAS INSTALLATION �9SSACHUSES[y 1!'1 This certifies that (�. . . . . . . ! . . . . M has permission for gaWins llation�. . . .in the buildings f . ,) . . . . . . . . . . . . . . . . . . . . . at .�.v. .llcl . . . . . . . ., North Andover, Mass. 3. ` Fee . . . . . Lic. No.. Q yJ ! GAS INSPECTOR WHITE:Appclf"ant 3Q%ARY:Building Dept. PINK:Treasurer GOLD:File MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) t NORTH ANDOVER Mass. Date *6 'Alk, 6 w i building Location t d OeC,SG,w/ Permit # 2250 .• Owners Name �0 ►-2 . CSS. I3_z- ? r New Renovation Replacement p Plans Submitted FIXTUF?=5 YW (!) U1 Q! O V ltl f S N 'r daC N ama "' < W No 4 a z U�44 Wd t- at x Q Y W w ,`i 0 � z a = x � a Q w � m i z a W e r< y- o z Uj CC 0 uFi z Q = v c1 U. n 3 a ra .1 v ct > o n h- o SUQ—BSWIT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR S T H FLOOP. 6TH FLOOR 7TH FLOOR STHFLOOR (Print or Type) Check one: Certificate Installing Company Name ( cQc10 t.4 P10 _)V,\,Oe. Corp._ Address C�. �b� � ) _ l---j Partner. Firrn7Co. _.. Business Telephone:.Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:. Liability insurance policy Other type of indemnity Q Bond lnsuraAce Waiver: 1 , the undersigned, have been made aware that the licensee of this Spplication does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner u Agent El 1 hereby certify that all of the devils and information I have submitted (or entered)in above application are true and aocurate to the best of my knowledge and that all ptumbin; worst and tasr Liations performed under'Permit issued for this application will-be-in compWence with ell pertinent provisions of the Massachusetts State Cas Code and Chapter 142 of tho General Laws. — By TYPE LICENSE: lumber Title FeGafitter S gnature of Licensed City/Town- ter Plumb�er o G fitter ourneyman APPROVED (OFFICE USE ONLY) License Number TOWN N O NORTH ANDUVE.R NowrH Office of the Building Department �raQ tto,6 +tea` Cornmtmity Development and. Sei--ices 27 Charles Street. # North Andover,Massachusetts 0.1845 4F�R,7�o.� � 9SS�CHU4�< D. Robert Nicetta, Telephone('97811688-9545 uiir ng Commissioner 3T-AX(975)683-9542 April 4,2003 Dr. Alberto Sobrado CoMedPro 170 Pleasant Street 1 , North Andover,MA 01845 Dear Dr. Sobrado: I am in receipt of your letter dated March 24,03 in regards to your reply to the signage replaced at your place of business. Please be aware that any alterations to existing signs in any way must conform to the zoning regulations at the time of the alteration. It has been observed that a new canopy has also been added which has advertisement on it which is considered signage as well. I will need permits and photos and sizes of all the signage on the structure in order to determine as to your conformance to the zoning regulations. I look forward to your fast response to this so that we may put this issue behind us. Respectfully, Michael McGuire Local Building Inspector Cc file i CoMedPro Community Medical Professionals INTERNAL MEDICINE ALBERTO SOBRADO,M.D. 170 PLEASANT STREET Medical Director NORTH ANDOVER,MASSACHUSETTS 01845 508-685-4925 EG"' E EWE MAR 2 7 2003 L.BUILDING DEPT. March 24, 2003 Mr. Michael McGuire Town of North Andover Division of Community Development and Services Building Department. 27 Charles Street North Andover, MA 01845 RE: Permit Dear Mr. McGuire: My office manager, Doreen McDonald, explained to me that you had come by our office and told her that we needed to apply for two sign permit applications. Our building currently has two main signs, the one that is attached to the building has been in place for at least 10 years. In the summer of 2002, we took it down temporarily to paint the building, the sign itself was replaced with the exact same sign except that it had a different color to match the building. The other sign, that is larger, has been part of this property since at least 1970. The letters on the sign were changed to reflect the nature of our business, however the sign itself and the color was not changed. If there is a fee that needs to be paid to the town to change the letters or the color of the sign, I certainly apologize and this was oversight in our part for lack of knowledge of the town regulation. I would appreciate if you could let us know this position, since these signs have been permanent structures of the building; one for over 10 years and the other one for at least 30 years. If you could let us know at your convenience, it would be appreciated. j ncerels��be Sobrado, MDS/jt / I Date.. ............. NONTIi 3? aaoL TOWN OF NORTH ANDOVER PERMIT FOR WIRING • This certifies that ..... ................ has permission to perform ............................................................ wiring in the building of... .............................. at ........ ........�.ee.j..............?!oh Andover,Mass. ... .. R Fee..27��......L i c.No. ..... ....... ......�m6r ' ELECTRICAL FOR Check# (()139 Commonwealth of Massachusetts Official Use my Permit No. � I Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK G All work to be performed in accordance with the Massachusetts Electrical Code( C),5 7 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: '`� City or Town of: NORTH ANDOVER To the Ins ectd of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant Telephone No. 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 New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 1"4 A-rd A-4cl7-e (,?) Completion o the followingtable ma be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above n- o.o mergency Lighting No.of Luminaires � Swimming Pool rnd. ❑ rnd. ❑ BgtteEX Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.o etection an Initiatin Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers eat um um..er ons o.oSelf-Contained Totals ' .""""'""'"" Detection/Alerting Devices ^ No.of Dishwashers Space/Area Heating KW Local❑ un'ctpa [IOther Connection No.of Dryers Heating Appliances KW Security ystems: No.of Devices or Equivalent No.of Water KW o.o o.o Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP a ecommunicationsurmg: No.of Devices or Equivalent OTHER: Attach additional detail ifdesired, or as required by the Inspector of Wires. Estimated Value of Electr'cal Work: aQd. 00 (When required by municipal policy.) . Work to Start: / 7 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE O RAGE: 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 pains and penalties of perjury,that the information on this application is true and complete. 16-6774 FIRM NAME: F ,-GT/ 1 T , LIC.NO.: S Licensee: LAr�t�f �ri�h Signature LIC.NO.: (Ifapplicable, enter "exempt"in the lice a number line.) Bus.Tel.No.: —� Address: 1'0 Clld"741 Alt.Tel.No.:M✓ 7 *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,l hereby waive this requirement. I am the(check one)❑owner ❑owner's agent, Owner/Agent PERMIT FEE. $ Signature Telephone No. The Cornnionwealth of Massachusetts C+ASw.Y tirl. Department of Industrial Accidents Office of Investigations 600 Washington Street G! Boston, MA 02111 wtt�w.m(Iss.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Flectricians/Plumbers Applicant Information Please Print Legible Va111e (Business/Organization/Indkidual):_C, Address:_Z/ City/State/lip: / _�` \ ' r Phone #: f�j �j� ' ��� , 7 .Are you an employer?Check the appropriate box: p !. ❑ 1 am a general contractor and [ Type of project(required): I.Q I am a employe with 6. [_] New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.-' 4. E] Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. tNo workers' comp. right of exemption per MGL §1 i 2.F-1 Roof repairs insurance required.]' c 15_�. ti O,and we have no employees. [No workers' 13 Other. comp. insurance required.] *Am applicant that checks box#1 must also fill out the section hclo%N shoving their\korkers'compensation polio information. 1 I lomeowners 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 must attached an additional sheet showing the name of he sub-contractors and state whether or not those entities have employees. If the sub-contractors have entplopees.they,Hurst provide their workers'comp.policy number 1 tint an emph ver that is providing workers'compensation insurance for mp emphovees. Below is the policy and job site , formation. Insurance Company Name:_ UE__ZA.!, R A ~Policy 4or Self-ins.l.ic. : �C, _. Expiration Date:-17/1 5/2013 lob site Address: 170 Pleasant Street City/State!Zip:I North Andover, MA 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 oi'a tine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of S"rOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and peitalties;of perjun,that the information provided above is trite and correct. Signature: < C----^°� \ Date: 2/6/13 Phone 0: 9 7,5'- '5'- Official 'Official race on/r. Do not ivrite in this area, to be completer/bt•citt,or town uJJicial. City or Town: Permit/License# issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Tow•n Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#.: COMMONWEALTH OF MASSACHUSETTS ELECTRICIANS ASA RsEuOs3'pURNEYiVIgNELECTRICIAN CHARLES E DENDRON 2 BOX CAR BLVD TEWKSBURY 1-7 Primary License COMMONWEALTH OF�IVIASSACHU��E�- S S C s,R D .R:7.7x -rte. ELECTRICIANS REGISTERED MASTER ELECTRICIAN SSUES THE ASOvE L10EIySE TO C C ELECTRIC INC f' WILLIAM J COLANTUONI - 2 BOXCAR BLVD STATE OF MAINE T E bl K S$U R Y �$ DEPT OF PROFESSIONAL&FINANCIAL REGULATION o° t'f A 0 18 7 G- ^,uRELECTRfCIANS'EXAMINING 80A,Rp LICENSE#MS60019301 C • A �^^tio STEVEN G. GENDRON ` MASTER ELECTRICIAN ISSUED Dec 0-1, 2008 EXPIRES Nov 30, 2010 AFLG!'\Lw \I�1.1CL\S1\CiC1:;Til if�';;l.1i N )I;v� ' �:ttiSTENrE\ G CENnRU\ i I .... .. ..t ::�...` L\.\8L:C :l:u.i.;♦ '_= `.� •- ,$i:�F\Si:i� iS.Cll:\�T1CIL L'Lk!'"I'!:lCI\\?`~i?;?�-\a:tid' 1'2'y_•1 11162 1'C M.11-ch 31, 2011 Date . ? . . . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . . . . .!?2:! . . �!�- ` �`? � /. 7. has permission for gas installation C.�? /.✓� .A�.� in the buildings of. ? G'.ew . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . ./..7(—) . . . /0/-P?.j 44 . �- . . , North Andover, Mass. Feer?/.. . . . Lic. No.7/-13 . . . IV- 4 ..... . . . . . . . . . . . . . . . . . . GAS INSPECTOR Check# 6N/ 8536 � - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY /7 A!9 MA DATE l / PERMIT# JOBSITE ADDRESS D /�i9 �J-/�GOWNER'S NAME /kel— 7.01 �41J OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENTA PLANS SUBMITTED: YES❑ NOX APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ® NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑ 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 [:1 AGENT E]SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this 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 r i ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f PLUMBER-GASFITTER NAME Michael H. HouseLICENSE# 7173 SI A RE MP R1 MGF B JP❑ JGF❑ LPGI❑ CORPORATION # 3377C PARTNERSHIP❑# LLC❑# COMPANY NAME MERRIMACK VALLEY CORP. ADDRESS 15 AEGEAN DRIVE, UNIT#3 CCITY METHUEN STATE MA ZIP 01844 TEL 978-689-0224 FAX 978-689-2206 CELL 978-815-4523 EMAIL 1 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 23-h 3 The Commonwealth of Massachusetts Department of InduaWd Accidents Office of Invadgations 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit: uilders/Contractors/Electricians/Plumber Applicant Information 5 Please Print Lee1b1 Name(Business/Organization/Individual): �jj7�! � z lo Address: �, �� .�ll`� City/State/Zip:�!��/I� �/� Q�B�,�' Phone#•_ �8`� �� Are ou an employer?Check the ropriate box: 1 I am an employer with 4. 0 I am a general contractor and I Type of project(required): employees(full and/or part time).* have hired the sub-contractors 6 New construction 2. 0 I am a sole proprietor or partner- listed on the attached sheet. ?•0 Remodeling ship and have no employees These sub-contractors have working for me in any capacity. employees and have workers' 8'I'Demolition [Noworkers'comp.insurance req comp.insurance.$ 9. C Building addition required] 5.0 We are a corporation and its 10.O Electrical 3. n I am a homeowner doing all work officers have exercised their repairs or additions myself [No workers'com , 1 1. 0 Plumbin insuranceurance required]]trightP of exemption perm MGL g repairs or additions c. 152,§ 1(4),and we have no 12.0 Roof employees.[no workers' comp.insurance required.] 13 of *Any aPPlicant that checks box#1 most also Lll out the section blow sh tHomeownen who submit this affidavit indka m►�S their workers compensation pokey information. bug they are doing all work and theu hire oubide contractors mast sabmit a new a indicating such. t Contactors that check this box must attach an additional sheet the sub contractors have em showing the name of the-sub-contractors and state whether or not those entities have empbyeea, if ees.th mast Provide their workers'oo number. 1 am an employer that is providing workers'compensadon insurance or information. f my employees Below is the policy and Job site Insurance Company Name: / al Policy#or Self-ins.Lic.#: /�,J[f�/�f� Expiration Date: /3 Job Site Address:_/'� ���� � City/Stete/Zip:nz �f 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 152 can lead to the imposition of criminal up to$1,500.00 and/or one year imprisonment as well as civil penalties of a fine $250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the ffice ORDER a STOP WORK e�gatio Invof estigations the DIA for coverage verification. I do herby cern nde t pal a ofperjury that the info ' n provided above is true and correct Si re: `�/ tBl of Date: / Print Name: �/ �L'ti/ Phone#: 70ffixialse only Do not write in this area to be completedby city ortownofficial wn• se#• hority(circle one): 1.Board of Heath 2. Building Department 3.City/Town Clerk 6.Other 4.Electrical Inspector S.Plumbing Inspector Contact person: Phone#: i rn r` v, 01 0 N PLUNDERS AND OASFI'f7Of LICENS D AS A MASTER PLUMBER 1" io s�'t;G AR('1VF I.IC;frts i o M X:'f:HAE.L..H HOUSE ti , 63.:MARSH, LN t I 88*Et:MEE TWP MS O4414--6137;� ti? - :7173 05/01/14 a) 0 IeD CL r` N N O , N � f O ' a3 ; VIFroficient Buiiders; Inc. "Building the Future" Tim Gagne Supervisor 100 Conifer Hill Park(Suite 308) Danvers,MA 01923 Tel:978.774.7200 Cell:978.995.6882 TimGagne f Proficient-Builders,com 09816 Date . 0 bYq+[tR,t17q�; TOWN OF NORTH ANDOVER to PERMIT FOR PLUMBING This certifies that . .� . �. . has permission to perform . . . l . . . . . . . . . . . . . . . . . . . plumbing in the buildings . . . . . . . . . . . . . . . . at . . I U. . .�IG S."'k , North Andover Mass. Fee'� 'f1 ry . . Lic. No. �S� �. . !"I ��. /.l. . . PLUMBING INSPECTOR- Check#3 _ c r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY U�>1 Q)t I MA DATE L 11 PERMIT# i tie JOBSITE ADDRESS Ic7h - 11 OWNER' NAME P OWNER ADDRESS _I �� TELFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL Q PRINT CLEARLY NEW: Q RENOVATION: REPLACEMENT:©{ PLANS SUBMITTED: YES© NO© FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM l __._J II __! .___._1 ____. _( .____J _____J .._._J _.._____1 -_._.._► _ ! �i DEDICATED GAS/OIL/SAND SYSTEM _I DEDICATED GREASE SYSTEM _I I —{ __.-.._( DEDICATED GRAY WATER SYSTEM { ____J I ______E __.__► ___ _( ! ____�P=jj DEDICATED WATER RECYCLE SYSTEM _DISHWASHER I _I __...._i ._._ ____.__! _-._._I ..__.__ I I__.._;E____J DRINKING FOUNTAIN _ I ..._.. - -( -- -I --J --( ---I -.....-i - _._.._-I FOOD DISPOSER FLOOR/AREA DRAIN 1 1 _.-._ ( _..�I I __J INTERCEPTOR(INTERIOR) I _i I y ..__,1 KITCHEN SINK LAVATORY I --1 -- ----i ---1 _.._._.__I _Al ------ ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION i -_ _! I - .. ._ I I I , ! ' t WATER HEATER ALL TYPES iT WATER PIPING 1 INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ! IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW k LIABILITY INSURANCE POLICY ( OTHER TYPE OF INDEMNITY Q BOND D OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Cha ter 142 of the, Massachusetts General Laws,and that my signature on this permit application waives this requirement. " '1 CHECK ONE 0 W ER AGENT _( SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application 5pdtri 1dolaw d a6curate`to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will bei. c Iia with aIr Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � PLUMBER'- NAME , . _ _ LICENSE# /� SIGNATURE m MP JP CORPORATION # PARTNERSHIP 0# i LLC COMPANY NAME .0 -- -' ADDRESS CITY Or 1 STATE Vy ZIP ( 6 _ - TEL -FAX CELQ. ... EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# 94/J PLAN REVIEW NOTES �`'/ AV t The Commonwealth of Massachusetts Gz Department of Industritrl 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 Name(Business/Organization/Individual): Address: 0 City/State/Zip: Y� Y I Phone Are you an employer?Check the appropriate box: Type of project(required): 1.Vlayemployer with 4. ❑ I am a general contractor and I 6. ❑New construction oees(full and/or part-time).` have hired the sub-contractors 2. 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. El We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3111 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 they ire 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 Name:. Policy#or Self-ins.Lie.#:/1 �` Expiration Date: Job Site Address: City/State/Zip: Attach a copVe �fhe workers'compensation policy dec ation page(showing the policy number and expiration date). Failure to seccoverage 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 tear imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day a sor. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the f an coverage verification. Ido hereby ce er th andpenalties ofperjury that the information provided bove s true and correct. L� Sip-nature: Date: Z Phone - Officia use only. Don t 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#: r 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 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 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. 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 permittlicense 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 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 Office o£Investigations 600 Washington Street Boston,MA,02111 Tel.#617-727-4900 ext 406 or 1-877rM.ASSAFB Revised 5-26-05 Fax#617-727-7749 wwwmass.gov/dla -COMMONWEALTH OF MASSACHUSETTS pL'U.�.IBERS AND GASFITTER LICEN�+ED AS A.MAS_TER PLIV ISSUES THE ABOVE LICENSE TO PWit A FREEMAN MAIN ST NO'RT0N M'A .02766.-23.1_ 15139 05/01/14 158487 Da . . ..<........... .0,!* TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING C.0 This certifies that ..........All.......9L�..b,,o....................................................... has permission to perform . ............................................................. wiring in the building of ..9 .....RV ..77 at ............ r, r.......................................North A zg�N Mass. Fee..Ak..f.. ......Lic.No. fi...................... .................... Check# ' 00 TA Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leaveblank 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 ININK 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) ZO rt-C-f SfiA)7T v Owner or Tenant A40/t) y t`it//LD��C �^o G+O,� AeP Telephone No. Owner's Address • Is this permit in conjunction with a building permit? Yes :K No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps 1 Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: /.VSTAI.I, �L�4G ri G ti CTP I� >�"�S'N�[ A&P Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- Elo.o mergency Lighting rnd. rnd. Battery 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 No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent t No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as regzdred by the Inspector of*rhes. Estimated Value of Electrical Work: N �SO4t3 (When required by municipal policy.) Work to Start: 6/'9• /Y 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 pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: _ / �- G`GL-'C%iCr l_ LIC.NO.: I/Z i// .99 Licensee: Ajyg4w +1144_ Signature LIC.NO.: (If applicable,enter "exempt"in the license nzzmber line) Bus.Tel.No.•4P-3 -7A i•3 t7J Address: �',p.BdX <t,< L 9.y00No0&iP,�/ , /�J+s/ � _3 Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,sec rity work requires DepartrAent 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 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 shallbelimited 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 conceming 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 "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 0 Failed 0 Re-Inspection Required($.)❑ M Inspectors Comments: Inspectors Signature: nn Date: S SPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPEC ON: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com * COMMONWEALTH OF MASSACHUSETTS . * o • BOARD OF ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS A REGISTERED MASTER ELECTRICIAN (� z AARON R HILL W 21 L DERRYFIELD ROAD DERRY NH 03038-4360 l•.LP19►C7- �