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HomeMy WebLinkAboutMiscellaneous - 193 COTUIT STREET 4/30/2018 193 COTUIT STREET 210/023.0-0011-0000.0 Date....�.�.b. .............. cF Nonrh,� TOWN OF NORTH ANDOVER c PERMIT FOR WIRING • � I This certifies that .......`.C.� .. ........... ` ... .......................................................... has permission to perform .......SPR v U C► �/i _ ......... . .................................... .................................... wiring in the building of. at ..........�.....! l 0 U� t . ...................North Andover;Mass. ............................................................... � Fue� ... .......Lic.No?� ......*:�� Gt'..........(...... ............ T ii (IRICAL INSPEC,(09 1 iepk# V /i tfoinmonwea&o/Ma-Mac4tMef Official Use On W �-7 / Permit No. c� l - / partment of_%,Senlice6 I BOARD OF FIRE PREVENTION REGULATIONS �vu/0a7cy and Fee Checked °'" � j (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 (PLEASEPRiMINEff OR TYPEALL INFORMATI011) Date: 6 -l3 - R013 City or Town of: /k jf T/c/ /,1,2 1)0 Line 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&Dumber) Z 93 (-or f y T 5 7—Ane7l— Owner or Tenant �t C/' 5 Telephone No.9709_ Owner's Address / �tT ST/�ctE'T Is this permit in conjunction with a building permit? Yes ❑ No Q" (Check Appropriate Box) �. N,, Purpose of Building Utility Authorization No. /56 9 3 Q 7 d � 1 Existing Service 00 Amps Q / qo Volts Overhead 0"-' Undgrd❑ No.of Meters / New Service / 00 Amps /2/ Volts Overhead� Undgrd❑ No.of Meters Q, Dumber of Feeders and Ampacity I Location and Nature of Proposed Electrical Work: )CS S 0 o.Q v;T eA\� J Com etion of the following 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- ❑ o Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I 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 Pumplvumber 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 Hsi Security Systems:* No.of Devices or Equivalent No.of WaterHW No.of No.of Data Wiring: Heaters Si ns Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: /` •> Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 0 (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. 7 CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I cert,tinder thepains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: L LIC.NO.:?k�)0Pz Licensee: — Signature LIC.NO.:a 01?6' (Ifapplicable,enter `exempt"in the license wnber line.) Bus.Tel.No.-%,,Q_20q_9207 g Address: 6-5-3 Lo CC s r 'Ou (0/91v/ Alt.Tel.No.: *Per M.G.L.c.147,s.57-61,security work requires De artment of Public Safety"S"License: Lie.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. $ a � _ � /� f l�� S�� `� r � jf -13-/3 G� l � •c. � -1 G�,�� �' �- The Commonwealth of Massachusetts Pnnt:oh Department of Industrial Accidents y Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Legibly Name (Business/Organization/Individual): lgz a�2zlcy Address: tjr< S City/State/Zip: 4ti&� /&P / Phone#: 9Y0_ 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 I employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2.al 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' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.1 required.] 5. ❑ We are a corporation and its 10.[R<Iectrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no 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. tHo meowners 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 the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 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: 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. Ldo hereby certify under the pains and penalties of2erLug that thein ormation provided above is true and correct. Signature: _ _. _ .___-- _____.._ .__.__`Date: .:/3... 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#: 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 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 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 penmit/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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigatioiis would like to thank you in advance for your cooperation and should you have any questions, i please do not hesitate to give us a call. i j The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA.02114-2017 Tel. # 617-727-4900 ext.406 or 1-877-MASSAFE Fax#617-727-7749 Revised 7-2010 www.mass.gov/dia i 'COMMONWEALTH OF MASSACHUSETTS;." ELECTRICIANS AS A R"EG JOURNEYMAN ELECTRICIAN r` ISSUES THE ABOVE LICENSE TO: UR EY e MICHAEL J C L G5 L,OWELL ST LAWRENCE :.,,_- ,MA 01,8 280:1': E 07/31/13 S;G8187; LICENSE NO. . . . EXPIRATION 1 Date.. . ate'.. NpRTM TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION SAC'NUSEtty This certifies that . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . -t% 'm the buildings of . _, �-*r'^.'a''! . . . . . . . . . . . . . . . . . . . . H �'�. . . . ., North Andover, Mass. Fee.. Lic. No�R�w.4J . / ' . . . . . . . . . . . (� GAS INSPECTOR Check# 3© MASSACHUSETTS UNIFORM APPLICAT/10N R PERMIT TO DO GASFITTING (Print orType) l/ No_ /-�Ijouer Date �O-I� Receipt# Permit# '7 IFBuilding Location 9 �- S 3Ow L �/C�1111 Map: Lot: Zone Type of Occupancy New ❑ Renovation ❑ VRepiacement O Pians Submitted: Yes❑ No ❑ Fee: N � N Y W ¢ 7! y N N U z ¢ W ¢ V1 ¢ O ¢ N = ►- 0 W ¢ O U �' S N J o W F. m ¢ O uj LU ¢ ¢ z O z Or m N H W W o C a ¢ W N pr 0 V W S N z t M O C > W W W N H z ¢ F H S ¢ ¢ W ¢ ¢ J - t S O W W V N z < W :� < ¢ - t-Z LU > w rp z O z ¢ O CM = Q S O O S U. 3 10 V J V ¢ > O d F O SUB-BSMT. BASEMENT 1ST FLOOR KI r 2ND FLOOR 3RD FLOOR 4TH ,FLOOR r STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR _rj___J__=±� Installing Company Name Townsend Propane Services, Inc. Checkone: Cerdficate Address 27 Cherry Street,' Danvers, MA 01923 O Corporation EstimateValueofWork: O Partnership Business Telephone 978-777-0700 O Firm! Name ofUcensedPlumber orGasFitter INSURANCE COVERAGE: I have a curren liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yeana No O If you have c ecked M please indicate the type coverage by checking the appropriate box. A liability insurance pollcyA Other type of Indemnity O Bond O 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. Checkone: OwnerO AgentO Signature of Owner or Own6es 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 the 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 Type of License: Plumber ignature of-ocanse0lumberor Gas Fitter. Title Gasfitter Master license Number City'lTown Journeyman' APPROVED (OFFICE USE ONLY) Rwood 0&17/00 Ia�O? Office Use Only � uhe LIIIIIIItIIII1uralt1 of Musaourm Permit No. Elepartmetit of Puh11t —Aafetq Occupancy&Fee Checked JJ BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00X90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 91-3r'�-J T& or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to erfor the electrical work described below. Location (Street & Number) S Owner or Tenant Owner's Address is this permit in conjunction with a building permit: Yes No ❑ (Check Appropriate Box) Puroose of Buiidina Utility Authorization No. Existing Service Amps —J Volts Overhead ❑ Undgrnd ❑ No. of Meters New Service Amps _� Volts Overhead ❑ Undgrnd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets i No. of Transformers Total No. of Hot Tubs I In- No. of Lighting Fixtures Swimming Poci -,rna. — grnd. _. Generators KVA No. of Emergency Lighting No. of Recectacie Outlets I No. of Oil Burners I Battery Units No. of Switch Outlets I No. of Gas Burners FIRE ALARMS No. of Zones Total No. of Detection and No. of Air Cono. No. of Ranges I tons Initiating Devices No. of Disposals I No.of Heat Total Total Pumos Tons KW No. of Sounding Devices No. of Seif Contained No. of Dishwashers I ScacerArea Heating KW Detection/Sounding Devices -!I Municioal r Other No. of Dryers Heating Devices KW Local Connection i No. of No. of Low Voltage No. of Water Heaters KW I Signs Sa:lasts Wiring yd o Massage No. H r M a Tubs No. of Motors Total HP a g OTHER: --------------------- INSURANCE COVERAGE: Pursuant to the recuirements ct Massacnusetts general Laws ** I have a current Liability Insurance Policy inctuctng Com.p:e;�ac Oceranons Coverage or its substantial equivalent. YE5 YNO = I have submitted valid roof of same to the Office. YES - NO = If you have checked YES. please indicate the type of coverage by checking the appr riate box. INSURANCEBOND - OTHER = (Please Scec:fy) - - (Expiration Date) Estimated Value of Electrical Work $ /`5 ac Work to Start Insoecaon Date Recuestea: Rough Final Signed uncer the Penalties of perjury: FIRM NAME LIC. NO. �/� Licensee Signature LIC. NO. Z1V /fn��L/ .CSO Bos. Tel. Address D, �-s�� �Z AJ� o �cJ 4�.' Alt. Tel. No. OWNER'S INSURANCE AIVER: 1 am aware that the L: ensee toes not have the insurance �dverage or its substantial equivalent as re- quved by Massachusetts General Laws. and that my signature on :nis permit abpiication waives this requirement. Owner Agent (P!ease check one) .eieonone No. PERMIT FEE 3 tSignature of Owner or Agents x-5565 257 Date......� ..�.�.. ..1S _ Ct NORT1{ TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACNUSES a 4. This certifies that ..... .. '-.. . ., `c, . ...r . c, has permission to perform ..... .. ... lewr✓.�:...........� ........... wiring in the building of........ .... .. . .... ...................................................... at... ` ...... we .. �1r.... .:...........Yg"�AnMeM-., Fee....3.)..... Lic.No. .-7.4�OJIC.......................................................... ELECTRICAL INSPECTOR 09/�0/99�5:13 35.00 PAID WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File