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3? �•_�� "�o� TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
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SSACMUSE�
This certifies that .�rl S
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has permission to perform ..f5 /-0,
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wiring in the building of ...............................
Fee.... Lic. No ..............
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Commonwealth of Massachusetts
Official Use Only
Department of Fire Services Fpancy
t No.BOARD OF FIRE PREVENTION REGULATIONS and Fee Checked
[Rev, 1/071 iiravPl.1�,.L1
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 WINK OR TYPE ALL N'ORMATION) Date: *`7- ( `7 ,
City or Town of: NORTH ANDOVER To the
By this application the undersigned gives notice of his or her intention to perform the ele electrical workpector ofles nbed below.
Location (Street & Number) (
Owner or Tenant 0 . ._ID "�� a� (� � ��
C-0 r -%C
Owner's Address
Telephone No.
Is this permit in conjunction with a building permit? Yes
Purpose of Buildin 5j— NO ❑ (Check Appropriate Box)
g -A ��y, Qn Utility Authorization No.
Existing Service i i7Q Amps /�4()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:
No, of Recessed Luminaires T
No. of Luminaire Outlets
No. of Luminaires ift /
No, of Receptacle Outlets
FNo.
ESwitcEhesEE,s
f Waste Disposers i
No, of Dishwashers j
No. of Dryers
o. of water )ice'
Heaters
No. Hydromassage Bathtubs
OTHER:
No. of Ceil.-Susp. (Paddle) Fans
No. of Hot Tubs
Swimming Pool Above
d. ❑ d. ❑
No. of Oil Burners
No. of Gas Burners
No. of Air Cond. I°tal
Tons
eat =,17!���
TSpace/rea Heating KW
Heating Appliances KW
No. of No. of
Signs Ballasts
No. of Motors Total HP
table may be waived b the Inspector of Wires.
o. of Total
Transformers KVA
Generators KVA
IRE ALARMS INg of Zones
J.....
o. of Detection and
Initiating Devices
o. of Alerting Devices
O. of Se f- nn*o:nod
gal ❑inumcipal
Connection ❑ Other
.unitySystems:*
No. of Devices or Equivalent
to Wiring:
No. of Devices or Equivalent
ecommumcations Wiring:
No. of Devices or Eanivnir nt
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of ]ec ' al Work: Q Q (When required by municipal policy.)
Work to Start 5' I / (_ Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE C GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE .Iia'—BOND ❑ OTHER
❑ (Specify:)
I certify, under th pains and Eenalties of perjury, that the information o
FIRM NAME: lication is true and complete
-
\j V
Licensee: LIC. NO.: NO.:. 3ci -5 R
(If applicable, enter " t in the license number line.) Signature LIC. 1'�
Address: O �� 1 Bus. Tel. No.: 0 3qTel. No
S -^b
*Per M.G. c. 147, s. 57-61, sec rity work requires Departmen of Public Safety "S" License: Alt LIC. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally 70
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. S
59
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of investigations
Ut 600 Washington Street
Boston, MA 02111
www.mass govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual):
Address:
City/State/Zip: phone #:
1S
CaO!5 `4100 5�-C67(�
Areyo employer? Check the appropriate bog:_
1. I am a employer with k4 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet x
ship and have no employees These sub -contractors have
working for me in any capacity. workers' comp. insurance.
[No workers' comp. insurance 5• ❑ We are a corporation and its
required.] officers have exercised their
3. ❑ I am a homeowner doing all work right of exemption per MGL
myself [No workers' comp. c. 152, § 1(4), and we have no
insurance required.] t employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10 -0 Electrical repairs or additions
11.7 Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
t .:a� _: V uu UU1 min
Lae section oeur shelving thetheirwoq,—,' COmpa,...SatlOn
Hpolicy information'
omeowners who submit this affidavit indicating they are doing all work and thea hire outside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employee& Below is the policy and job site
information.
Insurance Company Name:
` Policy # or Self -ins. Lic. #:_ 1
1 — Expiration Date:
Job Site Address:_ %� t �� �j City/State/Zip: DJ 1P1 NJ '00-e M
VIN
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.
I do hereby ceilkfy under th pains ndpenalties of perjury that the information provided above is true and correct
Phone #: Q 3 `-o o � ( —7 t)
11 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):
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: Phone #:
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-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
bereturned to the city or town that the application for the pe rnit 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 permit/license 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 02111
Tel. # 617-72.7-4900 ext 406 or 1-877-N .IASSAFE
Fax # 617-72.7-7749
Revised 5-26-05
www.rnass..gov/dia
OFFICE OF BUILDING INSPECTOR
°+ TOWN OF NORTH ANDOVER
CONSTRUCTION CONTROL
PROJECT NUMBER: A1. i Pim • i o 10 . D
PROJECT TITLE: f' 15 >}CR V E51DGNCE 14C—M ORE U N6
PROJECT LOCATION: l Z CASM UT 5t.. UN -11-4 8 YOM ArPI)O 0,
NAME OF BUILDING:
NATURE OF PROJECT: V4TC.O" 9fWPEL.I IJ G
IN ACCORDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE BUI DING CODE,
+,D L REGISTRATION NO. 611
BEING A REGISTERED PROFESSIONAL E44601 ER/ARCHITECH HEREBY CERTIFY THAT I
HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS,
COMPUTATIONS AND SPECIFICATIONS CONCERNING:
ENTIRE PROJECT 0 ARCHITECTURAL 0 STRUCTURAL 0 MECHANICAL 0
FIRE PROTECTION 0 ELECTRICAL CJ OTHER (SPECIFY) 4PI>E PIEVIEW fiPQ--
LIN6 Lie, : raxjv9V
FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEGrI P -Fu% 0, ��L
COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS
STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRATICES.
AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY.
I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND B
EPRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT
THE WORK IS PROCEEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING
PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.0
1. Review, for conformance to the design concept, shop drawings, samples and other submittals
which are submitted by the contractor in accordance with the requirements of the construction
documents.
2. Review and approval of the quality control procedures for all code -required controlled materials.
3. Be present at intervals appropriate to the stage of construction to become, generally familiar
with6the progress and quality of the work and to determine, in general, if the work is being
performed in a manner consistent with the construction documents.
PURSUANT TO SECTION 116.2.2 1 SHALL SUBMIT WEEKLY, A PROGRESS REPORT
TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDING INSPECTOR.
UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE
SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR O)Q9uPANCY.
SIGNATUR
SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF —19—
NOTARY
9
NOTARY PUBLIC
MY COMMISSION EXPIRES
Date.........
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that,:� �G .�. L
. J.
has permission for gas installation/ lr '/. � ; ( �
in the buildings of .. /1 r.. .��.^ -.f !..'!............. .
at ����!�� �. �. t Lam. -. f... , North Andover, Mass.
Fee.... Lic. N ....... ... ..........................
' Check # , //
GASINSPECTOR
MASSACHUSETTS UNIFORM APPUCATION FM PERMIT TO DO GASFITTING.
(Print or Type).
Date L Q__ Permit
G�
BuldkV -- I I l _�
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New ❑ Renovation..p
Owner's Name
Type of Occupancy 0i
Replacement, Plans Submitted: Yesp No p
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Business T
Name of Ucensed Plumber or Gas Fitter
Check one.: Cer#tficete:
❑ Qxporation-
❑ Partnership
P Firm/Co.
INSURANCE COVERAGE:
I have aYecuffcrvLlLlblltY i Once 'pdky or Its substar>�t equivalent- -meets the requirements of. MGL Ch: -142.
If you have ..backed et4g n*Wkaie*a"e—=nmge-by checking theaPpWxlst� box
liability insurance policy X Other.type cf._indemnity [1 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 thts permit application waives this requirement
Check one:
Signature of owner.or-lOwrwis Agent;. Ownw❑ Agent ❑
I hereby cw* that all of the details and information 1 have submitted (or entered) in above application are true and accurate to.the best of my
knowledge and that all plumbing wodk and installatiora performed under the permit issued for this application will be in compliance with ail
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General
Tj of License:°:-.
Plumber SignetwWof Ucense mer or Gas RW
Title Gasfitter
ma ter license Number 310(0,
an
V
most,
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Business T
Name of Ucensed Plumber or Gas Fitter
Check one.: Cer#tficete:
❑ Qxporation-
❑ Partnership
P Firm/Co.
INSURANCE COVERAGE:
I have aYecuffcrvLlLlblltY i Once 'pdky or Its substar>�t equivalent- -meets the requirements of. MGL Ch: -142.
If you have ..backed et4g n*Wkaie*a"e—=nmge-by checking theaPpWxlst� box
liability insurance policy X Other.type cf._indemnity [1 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 thts permit application waives this requirement
Check one:
Signature of owner.or-lOwrwis Agent;. Ownw❑ Agent ❑
I hereby cw* that all of the details and information 1 have submitted (or entered) in above application are true and accurate to.the best of my
knowledge and that all plumbing wodk and installatiora performed under the permit issued for this application will be in compliance with ail
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General
Tj of License:°:-.
Plumber SignetwWof Ucense mer or Gas RW
Title Gasfitter
ma ter license Number 310(0,
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
SSACMUS� i I
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This certifies that _ !�..�... �.�.'. .!� /.. �(... ...
has permission to perform ....'.'.:.. ..............
1 � ,
plumbing in the buiilld;ings o c.. l :.-.r....... r.... ............ .
d. .......- ......:.......... North Andover, Mass.
Fee ��11...... Lic. No../%� ........... ................
// / PLUMBING INSPECTOR
Check 9 /!�
,5661
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(print or T
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,Mass. Datef E Permit
Building Location s Owner's Name C e - a u 1) 171iu'�
_ Type of ocxupanay A/( � / l''
New 0 Renovation o Replacement 0"� Pians Submitted: Yes O No C
FIXTURES
Check one: Certificate
Installing Company Name AdAr e,e3 � V1
O Corporation
Address 5-14L4 - w%AP ino C{- 13 Partnership
Business Telephone 1- ,2
Naeae of Licensed PlL= _�L,,Pvx .S
M URANCE COVERAGE:
1 have Y current liability o icy or its substantial equivalent which meets the requirements of MGL Ch. 14L
If you have checked yes, please indicate the type coverage by checking the appropriate bout.
A liability insurance policy -9 Other type of indemnity O Bond G
OWNERS INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required
by C2fapter 142 of the Mass. General Laws, and that my sign on this Wrrutappication warm this meWffwnent
Check ne:
Soloure of Owner or Owners Agent Owner Agent 0
I hen:by certify that all of the details and intro nation I have submitted (or erMw" in above apl3fication are mre and accurate to
the best of my w owie0ge am that all plumbing work and installabom Perf ruled order the perrnft issued fpr this app*=ion will
be in compliance with all pertinent Previsions of the k4assachusetts s2oi �- "Cater 1g of the GCneral Laws.
at Licensed
Type of Ucense MM& X Joumeyman i
License Number _ /-3/019
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Check one: Certificate
Installing Company Name AdAr e,e3 � V1
O Corporation
Address 5-14L4 - w%AP ino C{- 13 Partnership
Business Telephone 1- ,2
Naeae of Licensed PlL= _�L,,Pvx .S
M URANCE COVERAGE:
1 have Y current liability o icy or its substantial equivalent which meets the requirements of MGL Ch. 14L
If you have checked yes, please indicate the type coverage by checking the appropriate bout.
A liability insurance policy -9 Other type of indemnity O Bond G
OWNERS INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required
by C2fapter 142 of the Mass. General Laws, and that my sign on this Wrrutappication warm this meWffwnent
Check ne:
Soloure of Owner or Owners Agent Owner Agent 0
I hen:by certify that all of the details and intro nation I have submitted (or erMw" in above apl3fication are mre and accurate to
the best of my w owie0ge am that all plumbing work and installabom Perf ruled order the perrnft issued fpr this app*=ion will
be in compliance with all pertinent Previsions of the k4assachusetts s2oi �- "Cater 1g of the GCneral Laws.
at Licensed
Type of Ucense MM& X Joumeyman i
License Number _ /-3/019
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