HomeMy WebLinkAboutMiscellaneous - 172-174 WATER STREET 4/30/2018J
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...... ......................
has permission to ........................................
Z,
wiring in the building of4.
.. .... ............ I . .. . . ...........
........... North AnddVer�Mass.
... Lic. No
Fee .... ..........
iLiE��MICAL �INSPE R
Check#
.8112
commonwealth of Massachusetts
V000 Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
eJ
Official Use Only
Permit No.
Occupancy and Fee Checked O�
[Rev. 1/07] (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical CodT(M ), 527 CMR 12.00
(PLEASE PRINT EV INK OR TYPE ALL INFORMATION) Date: a Y�o
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) 1-7 L/ Jcx..=yam c �—
Owner or Tenant" Cala _. yy!✓
Owner's Address , l0�`tT
IMAM
Telephone No.
Is this permit in conjunction with a building permit? Yes ❑ No
❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts
New Service Amps / Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Overhead ❑ Undgrd ❑
Overhead ❑ Undgrd ❑
No. of Meters
No. of Meters
n•.—, uuuuzunui aezau y aesirea, or as required by the Inspector of Wires.
Estimated Value of El trical Work: C�fl .(When required by municipal policy.)
Work to Start:_ V� B 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 xhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER (Specify:)�'ejP)/z,_ W,, -- f ��
I certify, under the pains and penalties of perjury, that the inform ' n n this appkcahon is true and complete -1
FIRM NAME• LIC. NO.:
Licensee: v �� — � Sign
LIC. NO.:
(If applicab , en{� ex in the 1' a nu er�fiive)
T ' c4,4 BU JLm. No.:
Alt. Tel. No.:
s epar went of Public Safety "S" License: Lic. No.
that the Licensee does not have the liability insurance coverage normally
waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
_ Telephone No. PERMIT FEE: $ 4j ��
Address: h
*Per M.G.L c. 47, s. 57-61, security work re
OWNER'S INSURANCE WAIVER: I=
required by law. By my signature below; I ht
Owner/Agent
Signature
-V
Ik
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.m=s ffov/dia
Workers' Compensation Insurance Affidavit Builders/Contractors/Eiectricians/Piambers
Name (Business/OrgaiiiZation/indi
Address: -) 0
City/State/Zip:
A
ridual): VUA&
0247) Phone 9:_ .% 0--
M
re you an employer? Chew ✓the appropriate boz: `
1 •�"�' am a employer with 4. ❑ 1 am a general contractor and 1
employees (full and/or part-time).*
2. ❑ . I am: a.sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet
ship and have no employees
These subs -contractors have
working for mein any capacity,
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required-]
3. E] I am a homeowner doing all work
officers have exercised their
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.]
"Any applicant that cheeks bot: # I must also fill out the sed b t h
Type of project (requires[):
6. ❑ New construction
7. ❑ Remodeling
8. Q Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.0 Plumbing repairs or additions
12.F] Roof repairs
13.Q Other
c on a ow s owing their workers compensation policy information,
r Homeowners who submit this efi'rdavit indicating they are doing all wont and then hire outside contractors must submit a new affidavit indicating such.
1Conttactors that check this box mustatrached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information.
14M an employer that_is providing workers' compensation insurance for my employees: Below isthe policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: 7 2 UP -.-- 4ff-�X � / D� E_%Tiration Date: „ [ f
Job Site Address_ e.�Jt � �'fi-" City/stateop: %U ' �NbC � R -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 insurance coverage verification.
I de hereby certify under the pains and penalties of perjury .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/ own Cierk 4. Electrical Inspector 5. Plumbing Inspector
L.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 -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 cant' 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 pem' it or license is being requested, nofthe Department of
Industrial Accidents. Should you have any questions regarding the law or if you am 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 numbers on the appropriate line.
City or Town Officials
h
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 f
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 parson is NOT required to complete this affidavit
The Office of lnvestiga#ons would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give as 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, N4A 02111
Tel. # 617-727-4900 ext 406 or 1-8.77-bfASSAFE
Fax # 617-727-77451
Revised 5-26-05 www.mass.gov/dia
Date ../.... 3 G
� f NORTH 1
TOWN OF' NO H ANDOVER
o
PERMIT FOR PLUMBING
,SSACNUS� 11
'This certifies that ...` G/.G.`1 .C/....16 ...................
has permission to perform ... s?!n �4 �'.�: -s .. .... .
plumbing in the buildings of ... ."':. / .. ................ .
at. /7 V.. I..��..�� � . `............:.... . North Andover, Mass.
Fee. �J`L .. , .. Lic. No.. ./0. ? .... .......
P UMBING INSPECTOR
Check #
r
f %7G
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location 1-7,
Date ~- 02 2 —�(J
)wners Name Permit # —7707 .
Amount7ts y, t7
of Occupancy .o_ , �� �---
New ri Renovation Replacement
FIXTUR FN
Plans Submitted Yes❑ No
(Print or type) Check one: Certificate
Installing Company Name / p jl /%pj� !� GO .� 1-1 Corp.
Address _1 t� we 3 Partner.
jz rz gee- - r_� -! /�-t n o -2- 1 i? L4-
uusmessTelephone ,,1"/ 7 —.,,09:3 —g5� Finn/Co.
Name of Licensed Plumber: "mile
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy E Other type of indemnity ❑ Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature IOwner ❑ Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By: igna ure U1 Ocensecu
Type of Plumbing License
Title /0 75 o
APPRwnOVED (OFFICE USE ONLY cense um er Master Journeyman ❑
PPRu
Date. ` 3G y
TOWN OF NO
PERMIT FOR GA
This certifies that .r .lI y . y.... I M :.. Lo/
has permission for gas installation'`''
in the buildings of ..................... ..... .
at . %7y..' H..�f........ .. ., North Andover, Mass.
Fee.. 2':.. Lic. No..f P.?r: .. .... ., .�.... c*j,�...... .
GAS
INSPECTOR.
Check # 3 (r 1
: � s
MASSACHUSETTS UNH ORM APPUCATON FOR PERM TO DO GAS FITTING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations J %//- }.W�.� S'
Owner's Name
New D Renovation Replacement 0
Date
Permit # F Y
Amount $ -7
�G�irl � Glin -
Plans Submitted U
(Print or type)
Name Lt7.
Check one: Certificate Installing Company
�U/%/Y�r %�� ,�-
11 Corp.
Address Partner.
Business Telepnone 1<1/ -7 0z ��' ' / Firm/Co.
Name of Licensed Plumber'or Gas Fitter PF— CCS -r—
INSURANCE COVERAGE Check one:
1 have a current liability Insurance, policy or it's substantial equivalent. Yes ED`, NoO
If you have checked Les, please in icate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity 13 Bond 13
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 0 Agent
1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By: .
Title
City/Town,
VED (OFFICE USE ONLY)
Signature of Lic ed Plumber Or Gas Fitter
Plumber f 6 7 -4-8
Gas Fitter (cense Mumer
ED -master
13 Journeyman
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SUB-BASEM ENT
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BASEM ENT
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7 T H. F L O O R
8TH. FLOOR
(Print or type)
Name Lt7.
Check one: Certificate Installing Company
�U/%/Y�r %�� ,�-
11 Corp.
Address Partner.
Business Telepnone 1<1/ -7 0z ��' ' / Firm/Co.
Name of Licensed Plumber'or Gas Fitter PF— CCS -r—
INSURANCE COVERAGE Check one:
1 have a current liability Insurance, policy or it's substantial equivalent. Yes ED`, NoO
If you have checked Les, please in icate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity 13 Bond 13
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 0 Agent
1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By: .
Title
City/Town,
VED (OFFICE USE ONLY)
Signature of Lic ed Plumber Or Gas Fitter
Plumber f 6 7 -4-8
Gas Fitter (cense Mumer
ED -master
13 Journeyman
Date ....... �/- .. ..0.9. ......
.......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....
..... ..................................................................................
has permission to perform ...... 7. ......................
wiring in the building of .... ...........................................
...... Z2.y ..... ......... , North Andover, Mass.
Fee....Lic. No1,?K'I40.(—..
............
ELECTRICAL 4.1s" P**E' c**,'rO'* RWL
V
Check #
7295
(flmmonwea(Ut o/ Madlac%je
uee(
2eparintenl of7ire service]
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. A C r2
Occupancy and Fee Checked
[Rev.(1/99] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (NIEC), 527 CNIR 12.00
(PLEASE PRINT IN INK Oil TYPEAL[ GVI`yRM-17I0N) Date: `1 —2 —d 7
City or 'Town of: �kt6 c,jc��e P,_ To the Inspector of Wires:
By this application the undersigned gives notice oflus or her untentiou to perform file electrical work described below.
Location (Street S Number) y J -l(el-
Owner or Tenant Telephone No.
Owner's Address Qe
Is this permit ill conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
1'urp0se of Building (, �n�; f!v k >( i► Ulilily Authorization Nv. G�6
Existing � Service Amps (,j/ Polls Overhead Und rd
>; ❑ 1\v. of Meters .
New Service o Amps q �(� t 2c:AFO is Overhead Undord
1-�-n--
00"
b ❑ No. of nllctcrs �_
Number of Feeders and Ampacity o� 4P"A/-f
Location and Nature of Proposed Electrical Work:
-Dec. l
C,
J t r P I
Transformers KVA
Generators KVA
Na of Lighting Outlets
•
Colrinletion Of the lottnuinn
fnl.lo ......, 1 ........:.....1
L...l. _ r.. __. __. _ _ _ ..,• —
No. of Recessed Fixtures
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
Generators KVA
Na of Lighting Outlets
No. of Hot "Pubs
No. of Lighting Fixtures
Stivinin ing Pool Above ❑ 111 ❑
0.0 ulergency lg plug
rlld, rind.
Batte Units
FIRE ALARNIS No. of Zones
No. of Receptacle Outlets
No. of Oil Burners
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alertina Devices
o
!!\'o. of Waste Disposers
fleat Punlp
Number
_lbns__.....
K� ___
No. of Self -Contained
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW.
Local ❑ Municipal ❑Other
C011llectnoll
No. of Dryers
Healing Appliances KW
Security Systems:
No. of Water
No. of IV o. of
No. of Devices or Equivalent
Healers K
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total h11'
1' elecommunications Wiring:
No. of Devices or E uivalellt
OTHER:
Attacn adanionai detail J desired, or as required by the Inspector of ;Vires.
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 cov rage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) &O
'
Estimated Value of Electrical Work:' (When required by municipal policy.) Expiratton Date)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I cerlifj•, under thins 171111penalties of perjurj•, that the htforntatiotr on this application is true and complete.
FI101 NAME: C- LIC. NO.: 1;
Licensee: Signat>.
(If applicable. enter "exempt - in 11d a license num er lin
Address: r� �-Llo-f 0_r 12?- A"'I /-/
OWNER'9I�ISUVANCE �YYA1VE72: I arilawarc thatilie Licetlscc oes
required by laxv. By my signature below, I hereby waive this requirement.
Owner/Agent
Signature Telephone No.
LIC. NO.:
Bus. Tel. No.:V=&Z-Oyd
gZ/ Alt. Tel. No.:
not have the liability insurance coverage normally
I am the (check one) ❑ owner ❑ owner's agent.
1'isRMIT FET::. VCS "%
ot" ye� I e, --O -7 /)Ij
E
Date. Z 2— c -2e - j /,
............................
.
TOWN OF NORTH ANDOVER
0
0L
PERMIT FOR WIRING
1 114
This certifies that ...... 1....................... ....... . ...............................
has permission to perform ..... .1..XL9 . .. ..................................
............ ..
wiring in the building of .....
at/.,7r
... c.;2
........................................................ ) ........... ,North Andover, Mass.
Ar e,'4
Fee/.%/J... ........ Lic. No . ...162 .....
,1!�.f
... ....."4....—
...
.... . ... ..I ...
ELECTRICAL INSPECTOR
Check#
7112
Is
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. - _ 7�/ �
Occupancy andFee l p ` v
Zev- 9/051 n.". hl.nkl /ly .. -/.-A, -
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical CodeE7(04
527 CMR 12.00
(PLEASE PRINT ININK OR TYPE ALL INFORMATIOA9 Date:
City or Town of: To the lnlpedor of Wires:
By this application the undersioned gives notice of his or her intention to perform the electrical work described below.
Locstion (Street & Number) e,, er 51 .
er or Tenant Mor
Own kS'I f C o e• i (' eft I Telephone No,�j( �/ -/�
Offer's Address
Is tdis permit in conjulnetioill with a building permit? Yes ® No ❑ (Check Appropriate Box)
Purpose of Building V Ide,t' `Utility Authorization No.
Existing Service Amps Vdtz Overhead ❑ Undgrd ❑ No: of Meters
Amps / Volts Overhead '
New Service Am
p ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampselty
Location and Nature of Proposed Electrical Work: rPwt1`Q O -F LC f%�on _ C wo ��4 e
No. of Recessed Luminaires
No. of Cell: Susp. (Paddle) Fans
o. o otal
Transformers KVA
No. of Luminaire Outlets 1
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool ove ❑ - ❑
rnd. grnd.
No. of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
o. of Detection an
Initiating Devices
No. of Ranges
No. of Air Cond. Total Tons
No. of Alerting Devices
No. of Waste Disposers
eatump
Totals:
um er
I
ons
o. o e - on
Detection/Alertins Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ municipal❑ Other
Connection
No. of Dryers
Heating Appliances KW
echo. of ysteDevm : or Equivalent
No. o ea KW
Heaters
o. o o. o
Signs Ballasts
Data Wiring:
No. of Devices or E uivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
a ecommu ca onsWiring:
No. of Devices or Equivalent
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 liabili urance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such co v ge is in force, and has exhibited proof of same to the pern4t issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) /Vis 0I certify, under th f4ains andpenalties of perjury, that the information on this licado
FIRM NAME: I eC C S P m S - LIC. NO.: %K Y
Licensee: tyea no (y Signature LIC. NO.: JO C 4/6
(Ifapplicable, enter "eMe" in t e license tuber lin Bus. Tel. No.'. �-La�'�i`�Address: �t �( Q /Y
. (a/fry / Alt. Tet. No.:
*Security Sys ein Contractor License required for lis Work; if applicable, enter the license number here:
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)E] owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE:
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