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HomeMy WebLinkAboutMiscellaneous - 20 STACY DRIVE 4/30/201814 r t M Date . � . .!�;.1...............- z� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............D. -Y............. n.� 5�..................... C.( .. 4 tJ (� .................... has permission to perform .............k'i..7-c,. ................................................ wiring in the building of..........'.................................................. at ...... ©... ?��/ .Y 1).2 ...................................... , North Andover, ass. F-� J ! Z Fee...u�1 a...� Lic. N .................. fes................... ......... ........... LECTRICAL INSPECTOR Check # 0 L 6 a v C'ommonweaR of //%amackudefd Official Use Only cc� cc77 n Permit No. 2 _ ep.d.d o/.}ire Serviced Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (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 IN INK OR TYPE ALL INFORMATION) Date: B - — /ys 9# -ox -Town of: �/ . 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'orTenant �,g� Owner's Address —T"`"' Is this permit in conbuilding permit? Yes I Purpose of Building=Aopl' P Overhead ❑ Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Telephone No. No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Undgrd ❑ No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: ,, Ifk- Completion of the lbllowinz table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of CeSusp. (Paddle) Fans il: No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming -pool Above ❑ In- ❑ rnd. nd. o. o Emergency Lighting . Battery Units No. of Receptacle O ttets ' No. of Oil Burners FIRE ALARMS No. of Zones No, of'Switches No. of Gas Burners o. of Detection andInitiating Devices No. of Ranges Tot No. of Air Cond. Tons No. of Alerting Devices Heat Pump Number Tons No. of Waste Dis oser .. _ _ _.-..........._......-. .......... Detection/Alerting Devices No. of Dishwashers K,� S ace/Area Heating KW P g Local ❑ Municipal ❑ Other Connection No. of Dryers r3' Heating Appliances KW Security Systems:* No. of Devices or Equivalent No., of Water KW No. of o. of Data Wiring: Heaters Si ns Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications firing: 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 liability insurance including "completed operation" coverage or its substantial equivalent, The undersigned certifies that such cove ge is in force, and has exhibited proof of same to the permit issuing office, CHECK ONE: INSURANCE X BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information. on this application is true and complete. FIRM NAME: LIC. NO.:11 Licensee: / ,' �/./ni9© Signature _ 11C. NO.: (If applicable, enter "exempt" in the license number line.) Bus. T Address: f� �ihiAlt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Departmenfof Public Safety "S" icense: 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 a ent. Owner/Agent PERMIT FEE: $ Signature Telephone No. t cL The Conttttonivealth of Massachusetts Departntcttt of Industrial Accidents Office of Investigations 600 ff,ashitngtotn Street Boston, .MA 02111 www.niass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): jJrj,C�O`GG��Z6 Address: // City/State/Zip: MAVi..w iA'Jg aol-gly f Phone M K_ 96 Are you an employer? Check the appropriate box: I. ❑ I am demployer with � 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. El am a sole proprietor or partner- listed on the attacbcd sheet. $ ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), .and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9.❑ Building addition IO.Ylectrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box iE I must also Fill out the section below showing their workers' compensation policy information' t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors 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- Ora-l/GR i4 e2b is y/ `zff o, Z5�9. Policy # or Self -ins. Lic. M m//© z,z_4f_z Expiration Date:' - Job Site Address: - �z D 4�7.o,_O;e ,moi City/State/Zip:A g&ppyl Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). t Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of critrrinal 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 certify under the pains and penalties o petjury that the information provided above is true and correct Si ature: Date: Phone M e;.�� Ofcial use only. Do not write in this area, to be completed by cit), or town official. City or Town: Permil/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5..Plutubing Inspector 6. Other Contact Person: Phone #: k Date.., /. .L " o ,. TOWN OF NORTH ANDOVER o0, 0R' ••�ao PERMIT FOR PLUMBING This certifies that • .....�... • • • /'��l �• has permission to perform ..... '. r .L , ;,• .f ��. , • , . •.,({ S• • . • . plumbing in the buildings of ..... ,. ,::.....i� !. <./'._:.....�!...... . at North Andover, Mass. 4)... Lic.FNo.. .. PLUMBING INSPECTOR Check ti 66:: MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING r City/Town: MA. Date: O�� /� Permit# Jre ii/ Building Location: Q Owners Name: V �il�El1 Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: U Alteration: U Renovation: U Replacement:)Q Plans Submitted: Yes U No 10141111:4*y INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YeskNo ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy K Other type of 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 ❑ Agent ❑ gnature of Owner or Owner's Agent I herebv certifv that all of the details and information 1 have submitted for entered) reaardina this aoolication are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the pe it issued foris application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 1 of the Gener Lawy By tie City/Town APPROVED (OFFICE USE ONL Type of License: tuber of License Number: DEDICATED SYSTEMS � z Z IW- z 4A O N W 1.1 .n 'n Y Q in > `� u ~ � 0 Z Z a. W Z D: Z M Z Q Q H Z Q�Q N H W � a D: O Q WU- Q Z D: O C Q 0: W Z V7 Z W U a LL = W a 0C a 0 Q Q y o c 0 g i g O = Q Q 3 a 3 a 3 3 a Co m LL s x o: 0 1- 0 a 0 0 0 SUB BSMT. BASEMENT 1ST FLOOR -2 U FLOOR 3 ° FLOOR 4T" FLOOR ST" FLOOR FT" FLOOR T" FLOOR 8T" FLOOR Check One Only Certificate # Installing Comp ny Name: ' ` Corporation Address:%,- City/Town: A' State:j�� 'Z ❑ Partnership ,{s Business Tel: s U (/��o� Fax: �} '7 20 - &D7- ©ta � ❑ Firm/Company Name of Licensed Plumber: . INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YeskNo ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy K Other type of 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 ❑ Agent ❑ gnature of Owner or Owner's Agent I herebv certifv that all of the details and information 1 have submitted for entered) reaardina this aoolication are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the pe it issued foris application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 1 of the Gener Lawy By tie City/Town APPROVED (OFFICE USE ONL Type of License: tuber of License Number: k z O H U W a . CIO t7 O a C7 F - a� O vwi o 0 co a a (i O Q o Q a i ° a z C7 q m z a w F z w m a w ¢ ❑ o H U z z � W U W z 0 F U W 06. z x U a z w k 73;7 q/w . �.. Date... .... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �_. This certifies that Adlw.lme. has permission for gas installation in the buildings of...6.41, ......AVi.y R-- .............. at ....��-� ...f!�.{....... , NortAn over, Mass. Fed' . Q, � . Lic. No.. a�./.�... ,� * GAS INSPECTOR Check # FIXTURES UJI MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town:t/�—, MA. Date: Permit# Building Location. 1710 s �[� Owners Name: Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ ResidentiaA-- New: ❑ Alteration: ❑ Renovation: E] Replacement: Plans Submitted: Yes ❑ No FIXTURES UJI W Y N H Z QL) It N O x IY �' x rn MX H O F' W W O J} v fn W z to O O 1%W E W W 0 F W W W z 0 9 m o W Q a H W o O 1-- w � X W > z I- a W W W z W x W� z �°, W x > z 0 W z i� J W >- J H H Q Q O m z W J 0 0 z N 0~ W W W F. W Q W F O- v fY Q o o W W W Q> O 0 a¢ O z R P>>> z O SUB BSMT. BASEMENT / 1 FLOOR 2 Nu FLOOR 3 FLOOR 4 1H FLOOR 5 FLOOR 6 1H FLOOR -i'm FLOOR 8 FLOOR Check One Only Certificate # �"4--, Installing Com any Name: r Q Corporation AddressCity/Town: 4W11M State: El Partnership n Business Tel: 9l���.� f% Fax: 7 —�j- c �, ❑ Firm/Company Name of Licensed Plumber/Gas Fitter: t' INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YesX No ❑ If you have checked Yes, please indi to the type of coverage by checking the appropriate box below. A liability insurance policy [,7 Other type of 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 ❑ Agent ❑ Sionature of Owner or Owner's Aoent By checking this box ❑; 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 underlhe permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Cocjejihc4,Chapter 14,Z f the Qeneral Laws. By Title of License: umber 3s Fitter City/Town I Ll,lourneymanI License Number: APPRAviin inprir F' i ICF nmi v1 F]LP Installer Fitter