HomeMy WebLinkAboutMiscellaneous - 171 GREENE STREET 4/30/2018 171 GREENE STREET
210/045.A-0033-0000.0
Date.. .y /v2.........
� µORTq
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
40
�,ssACHUs��
This certifies that
�PR_ OJ�
has permission to perform tR.QIVIC .lAAI n........k
wiring in the building of..... ..!..!` ..... .� 00c.�.. .............................
�Q.� P .. North Andover Mass.
Fee.k ?.t .. Lic.No Z10` ..1......... .rP/.. . . F .
( EIDE A INSPECTOR
Check # v
�► 0758
commonwealth ofMassachusettts Official Use only -
a ,
Department of Fire Services Permit No. I, 7
BOARD OF FIRE PREVENTION REGULATIONS fey
Occupancy blank) ed
(leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PANT INK OR TYPE ALL NFORMATION) Date: L /f!
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)
Owner or TenantTelephone No. ��� Q —�7 S/L
Owner's Address s
Is this permit in conjunction with a building permit? Yes NoPPeck Chroriate B' A o
❑ ( P x)
Purpose of Building // i D Pn)C Utility Authorization No.
Existing Service /IOd Amps Ido / O Volts Overhead❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
4 Number of Feeders and Ampacity
Location and Nature/of P o os
Electrical Work: ' y��,
Completion o the ollowin table maybe waivedby the Inspector o Wires.
No.of Recessed Luminaires No.of Cell.Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of LuminairesSwimming Pool Above ❑ In- ❑ o.o Emergencyugng
rnd. grnd. BattervIbuits
No.of ReceptEicle Outlets �� No.of Oil Burners FIRE ALARMS No.ofiJones
No.of Switches No.of Gas Burners No.ofDetectiing Devices
No.of—Ranges Tons l No.of Alerting Devices
No.of Air Cond.
FNo.
of Waste Disposers HeatTPomp Number _Tons :_ KW No.of Self-Contained
Detection/Alertin Devices
of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances r Security Systems:*-
No.of Water
Heaters KW signs
No.of Devices or E uivalent
No. Bal Data Wiring:
Si s Ballaass ts No.of Devices orE uivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.ofDevices orE uivalent
OTHER:
_ Attach additional detail iif desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: ' ,5 t.7�� hen required b municipal policy.)
- �—.------ � q • Y P P Y•)
Work to Start: `� o nspections 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 c,�ovesis in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE 11YBOND ❑ OTHER ❑ (Specify:)
I certify,mider the pains and penalties ofperjury,that the information on this application,is true and con,piece.
FIRM NAME: LIC.NO.: A 9 1,6
Licensee: �r (Ld'O COffO Signature LIC.NO.:
(Ifapplicab e,en er`exempt"in the license nu ber,lin ) , / Bus.Tel.No- 7(0�"
Address: o� f_[4
517 2n,y A A V7 a�0� Alt.Tel No-CO— 7�
*Per M.G.L c. 147,s.57-61,security work requires epartment ofP blic 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.$
MEcCT&ALP
Re-iuspectioza xegW ef'($50.00)~[ ]
3'nspectors'comnxe�afs:
gappeetors'6 Signature 40?ri " s) Date
2t.tsFpIeNcALI xn'AmCex3tfIsO:N,
Passe$ -
- Re-xnspectiott
ocxeruixe ($ 0.00)- [
(Inspectors'i9'ignature no fait als) Date !
3.MD=GROUND lNgROICTZON. ,
3'assed-[ Failed--[ ) ?�2e-inspectiott xet�ufxect( 50.00) [
Inspectors'comments:
(mspectors',Signature-no initials) Date
• 0
4.)NSPECI'ION-- VjCE:
ATE CA Y TMER-0 NITUTONA1,ODu
Passed--[ ) I+'aiM•--[ Re-fnspectzonrequired($50.00)-[ �
Inspectors'eommeufs:
(Inspectors,isigaature-Bio;initials) Date
�.It�t�PECT'XO�1"-•OTR.: '
'assed-•[ ) I+•ailer��-•[ �. '�Le-inspection xec�uix'ed($50.OD)�[ ]' -
sspectors'Comments:
S
(Lispectors' ignatnre uofnitia7s) Pate
D 0O TAGS ARE TO 13E MMED OUT AO IEPT ON)SITE IF TBE.ARVA TO DE)U PECTED Y NOT
A.CCESSIBUAND A.M USPECTIONOF$50,00INTOBE CDUGED. � .
The Commonwealth of Massachusetts
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 Le0bly
Name(Business/Organization/Individual):
Address: ��/�1'26
City/State/Zip: A1,9SAG Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
em yees(full and/or part-time).* have hired the sub-contractors
2. am a sole proprietor or partner- listed on the attached sheet. �• [�-Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. E]Building addition
[No workers'comp.insurance 5. El 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.
Homeowners who submit this affidavit indicating they a're 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.
I am 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.Lic.#: Expiration Date:
a
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby cero under thepains andpenalties ofperjury that the information provided above is true and correct. -
Signature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other - -
Contact Person: Phone#:
1
_ y
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 ofhire,•
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-contractor(s)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 he.
City or Town Officials
0
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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The ComMonwealth.of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston?MA 0.2111
TeX,#617-727-4900 ext 406 or 1-877,7MASSAFE
Revised 5-26-05 Fax#617-727-7749
v vvwanass,gov/dia
9274 Date. //Z-?, /Z. . .
p'."•O°7M,�'p TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
,SSACMUS�
This certifies that .-�� !!PM. �."�r//�. . . . . . . . . . . . . . . . . .�. . .
has permission to perform . K�holr��`�a�-r. .�Jll/!''�?�h, . . . . . . . . .
g! n
plumbing in the buildings of . . . . �. 5 . . a�l0��' . . . . . . . . . .
at./.17,� .1104ree. . ST. . . . . . . . . . /. ., North Andover, Mass.
Fee. ?'7 .Lic. No.
PLUMBING INSPECTOR
Check # �Y
2�v
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
WCITY 1 AX0w rN 4jvl�v vc--� MA DATE //Z�i 2 PERMIT#
EI P
JOBSITE ADDRESS /%� �2c�L`�lJ S'j J OWNER'SNAMEJ
P OWNER ADDRESS 1121 6,o-0e-,W S,, TELT �29-y79-3 f 7Y IFAXI I
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ( RESIDENTIAL
PRINT
CLEARLY NEW.( ( RENOVATION:K REPLACEMENT: ( PLANS SUBMITTED: YES j I NOI
FIXTURES-1 FLOOR BSM 1 2 3 F4 5 6 7 a 9 10 11 12 13 14
BATHTUB t
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM _
DEDICATED GAS/OIL/SAND SYSTEM r
DEDICATED GREASE SYSTEM 9
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM —
DISHWASHER
DRINKING FOUNTAIN
W .............._ l
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK i
LAVATORY
ROOF DRAIN _—
SHOWER STALL -
SERVICE/MOP SINK _1 I
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER I
- - -- -- —
s
INSURANCE COVERAGE:
I have a current liab_ ility 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 OF INDEMNITY BOND I
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 illy signature on this permit application waives this requirement.
CHECK ONE ONLY: WNER AGENT
SIGNATURE OF OWNER OR AGENT
-T-hereby certify that all of the details and information I have submitted or entered regarding this application are true and ptculAte to the best of my knowledge
and that all plumbing work and Installations performed under the permit issued for this applicalion will be in complianqOryalt Pertinent provision of the
Massachusetts Stale Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAMEj.s'7,4✓e,,J Ct?Z/L. 'LICENSEIII/rY6(i SIGNATURE
Mp A JP1 I CORPORATION1 l#! 1PARTNERSHIP1 I#i �LLC� I#�
COMPANY NAME L'f►c ADDRESS 1Z eo"cult O Sr
CITY /-lerwve%✓ I STATE' /,, J ZIP J TEL
FAX 1928008-1-084 CELL IVS-Si5--3qj�EMAIL � _V,-CAV(g)
I
i
I
_ROUGH PLUMBING INSPECTION NOTES (BELOW FOR OI-FYCE USE:ONLY FINAL rNSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERmrr ❑. ❑
FEE: PERMIT 9
PLATI 'rVMW.NOTES
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tnvest'Vaa'tions.oflheJ)11EC I lice coverngeveriGcalibn.
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Ceitifcict.E'Fiasott:. 1'Iiott�ll':
rM9001ul 'nd Instrait ong
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Date....
NORTH
0 ,,*- ,, -0
TOWN OF NORTH ANDOVER
PERM4T FOR WIRING
CHUS
This certifies that ............ ........ r................
has permission to perform .....4PLx--I—,(4zv........................................
wiring in the building of........ .......................................
at... .......5..................... North Andover,Mass.
Fee Lic.Nolq.q6-W..........
Check # 36 ALEI�ZINSPEet
10624
R
CommeaweaX of Vamac"Uii Official
Use Only
Aparhnanf of- iira Swvicae Permit No. V G Ll
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS Rev. 1/07j leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: / Z-7— / -2—
City
City or Town of: g2/ 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) %7 /' Cto�(C(�W ?�
Owner or Tenant 1A44 Telephone No. ^
Owner's Address
Is this permit in conjunction with a building permit? Yes [ ] No ❑ (Check Appropriate Box)
Purpose of Building 5*N6Le Fj0i-MIL 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: c4ISE .
Completion o the ollowin blemaybewaivedbythe/ns ector of Wires.
No.of Recessed Ltiminaires No.of Cell.-Susp.(Paddle)Fans r o ora
Transformers KVA
No.of Luminaire Outlets No..of Hot Tubs Generators KVA
No.of Luminafres Swimming Pool Above ❑ n- ❑ o.o mergency Lighting '
rad. rnd. Batte Units
No.of Receptacle Outlets '2 i No.of Oil Burners FIRE ALARMS. No.of Zones
No.of Switches1 *7No.of Gas Burners o.o etection an
Initiating Devices
No.of Ranges No.of Air Cond. Total ons No.of Alerting Devices
No. of Waste Disposers eat ump ._ um er _ ons o.oSelf-Contained
Totals: Detection/Alertin Devices
No.of Dishwashers Space/Area Heating KWLocal❑ Municipal ❑ Other,
Connection
No.of Dryers Heating Appliances KW Security ystems:*
No.of Devices or Equivalent
No.of ti aterKWo.o o.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wirin /_
No.of Devices or Equivalent p
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 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 of perjury,that the information on this a lication is true and complete.
FIRM NAME:-A\J 4 C> CLEo-rRi CA L iaNrg.Aclrwci LIC.NO.:
Licensee: DAV 10 14R 66AP, Signature e LIC.NO.: t 4 9 tP 3 A
(If applicable enter"exempt"in the license number line.) Bus.Tel.No.:q'S•6932.6322 "
Address: 87 5FLi»0t4- • 1 r NOVO ANDOV6P. III g 5' Alt.Tel.No.670:3759-a673Lf
`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. 1 am the(check one)❑owner ❑owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $