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HomeMy WebLinkAboutMiscellaneous - 204 MILL ROAD 4/30/2018�\ i N r O � Aj D � �Z7 i D i g v , b Date....2:7./ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........................................................................ has permission to perform ....al ...F wiring in the building of ........... .................................... at ...... ..7..... !'! iLL....!?D ......................�, North Andover, Mass. Fee..: S. - e' ... Lic. No. s.!. ............. ..�.. �1. ....... r LECMICAL INSPECTOR Check #� ✓/ Commonwealth of Massachusetts 5-ffi—cia- 09M Department of Fire Services Permit No. Oc BOARD OF FIRE PREVENTION REGULATIONS [Rev.l 07] upancy and Fee Checked 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 W INK OR TYPE ALL INFORMATION) Date: _�,J 16, d City or Town of: NORTH ANDOVER To the Inspector f Wires: By this application the undersigned gives notice of his or her intention to erform the electrical work described below. Location (Street & Number) Lo (-/,/ �I t I l �y Owner or Tenantj/�yj �� /��j �,9- Telephone No. Owner's Address Is this permit in conjun�on with ab g per t? Yes Purpose of Building , �7 l / fjyd? t No ❑ (Check Appropriate Box) Utility Authorization No. Existing Service Amps _ Yolts 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: �yy16 Z� �� n Yl d%iA. nom_ Com letion o th e 11 bl No. of Recessed Luminaires o owin No. of Ceil: Susp. (Paddle) Fans to a may be waived 2E the inspector of Wires. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. grnd. o. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and InitiatingTotaDevices No. of Ranges No. of Air Cond. Tons l No. of Alerting Devices No. of Waste Disposers eat Pump Totals: Number -Tons No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal El Other No. of Dryers No. of Water KW Heaters Heating Appliances KW No. of No. of Signs Ballasts Sectio. oSystems Devices s or E uivalent Data Wirin No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: <sriacn additional detail if desired, or as required by the Inspector of Wires. Estimated Value of E ctrical Work: (When required by municipal policy.) Work to Start: 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 cove ge is in force, and has exhibited proof of same/e. permit issuin 7�� CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) ���LI certify, under the pains and penalties of perjury,th/at'th' formation o this aplication is true a dceNO �^FIRM NAME: ) 6A e�%1ZtC (,rJ LIC. Licensee: 1,p, Signature LIC. NO.: (If applicable, �enter "`exe� pt-' in the icensember Ii..)) Bus. Tel. No.: Address: l/ L✓ Alt. Tei. Ne.:_ *Per M.G.L c. 147, s. 57-61, security wor requires Department of Public afety "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. $ 7-17-ellj, 7 +� 2�A� Date. Tol + TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .. ...................................... has permission to . perform ... —r2,,,4 f a Nit—, vie kj plumbing in the buildings of ...� .................. at .. rt h77A—n&W6r-, Mass. Fee yf SO...Lic. No. ........... I ............... PLUMBING INSPECTOR Check 8147 MASSACHUSETT§ UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Z j�ZDate Building Location Owners Name � Permit # Amount Type of Occupancy New0 Renovation 12fRenovationPlans Submitted Yes ❑ No ❑ LOWMIRES -71, MMMMM IN MIN IMMMEM MINE!� Y Y .--- IMMIME IM---------M---- MIMMaMM®MMMMM IIMMMMMMMMMMMMW MEN 5 ,.:M MMMNMMNMM IMMMMMMMMM mom ME MMMMMOMMMMMM ME ..' nn�nnnn-n�nnnnnnnnn�� ,.' nnMMMIMMM n IN ..' Wilaill, nnnMnnnnnn�nnnnnnnanMnnnMW ,,'nnnMnnnnnnMInnnnnnnnnMMMMMM (Print or type) Check one: Certificate Installing Company Name �FUMCQA�—�1U4V&I Corp. Address I �) 1(A4e`r\ 0 • Partner. 2e,ymt OZ l S 1 Business Telephone Col 4 - -3-11 ZI2S' � Firm/Co. Name of Licensed Plumber: /� �r (� I (.}ZtN`Q^' Insurance Coverage: Indicate the Wpe of insurance coverage by checking the appropriate box: Liability insurance policy 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 M Agent n 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 installation erfo under Pe t I ed fo is application will be in compliance with all pertinent provisions of the Massac sett e '1 g Cod r 142 of the General Laws. By: na ure or Mceupeaum tle Type of Plumbing License Ti Cit /Town I Sl B 6 F -1y =se um er Master Journeyman I tt' APPROVED (OFFICE USE ONLYL_I The COMMUnwealth of Massachusetts j 1 Department of Industrial Accidents Office of Investigations Md tiv f 600 ATashinoon Street Boston, MA. 02111 i WWW HWS&gov%dia Workers' Compensation I.Mbr=ce Affidavit: Builders/ContractorsMieetriciens/Pfambers Applicant Information Please Print Let-qbl NaM a (Business/Organizationtlndividual);_ c71/p�r P—I t�,l Address: 1 C, r-, 14�.- City/State/Zip: Jkke Jy\rA s o-7 VC L Phone #:. CP 1q ree u an employer? Check -the appropriate box: LI i am a employer with 1 F2. 4. ❑ 1 am a genet contractor and I T�ofPro1� (required):employees (full andlor part- etxrrt .* I am.a.sOle proprietor or have tarred the sub-aontracors6• ❑New construction❑ listed partner_ ship and have no employees on the attached sheet, i 7• ❑ Remodeling These suit -contractors have 8. Q Deildingoirt working for me in any capacity, [No workers' comp. insurance n workers' comp. insurance. 5. ❑ We arc a corporation and its 9 ED Building addition required.] 3. ❑ i am s homeowner doing officers have exercised heir 10.0 Electrical repairs or additions all work myself. [No-worken' comp, right of exemption per MGL 1 I.❑ Plumbing repairs or additions Q 152, § 1(4), and -we have no required.].t 12.[] Roofinsurance —employees [No workers' repairs COMP, insurance required_] 1317 Other 'Any applicam that checks boa'# t must also fill out t ers who submit this affidavit indicating they Homeownthe section below showing their workers' bompensati,, poiioy information. doing are all work and then hire outside contractors must -submit _ 4Contn>ctors that check this box must auaohed an additional sheat a new affidavit indicating such showing• ehe name of fhe sub -corn tractors and their workers' comp. polite information. t arr an employer that is pr?"nr workers I compensation ir+suranee or a to informaliom f mr )W yee : Below is the Policy and job srte Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Hate: ------------ Job Site Address:_ 7 U4 A flA 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 $ I,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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to Investigations of the DIA for insurance coverage verification. the Office of I do hereby certify mat the information provided above is true and ronrXi Date: Zt —a G Of}°Icia1 use only. Do not write in Phis area, to be completes! by city or town of cid City or Town: Permit/License # Issuing Authority (circle one): L Board of Health 2. Snilding Department 3. City/Tovve Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: t Information a nd Instructions Massachusetts General Laws chapter 152 requires all employers to proviae 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 enbcrprise, and includirig the legal representatives of a deceased employer, or the receiver ortnrstee of an individual, partnership, association or other legal entity, employing employees. *However the owner -of a dwelling house having not more than three apa..i-anents and who resides therein, or the occupant of the dwelling house of another who employs persons to do mai-ntenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment bo 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 1to 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 tate commmrwealth nor any of its political subdivisions shall enter into any contract for the perfornmrice of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presarted to the car dracting authority." Applicants Please fill out the workers' compensation• affidavit compif--tely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) mind phone number(s) along with their certificates) 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' cornpensation 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 nw-ober listed below. Self ++rsr�+pd c annaniPs chrn�i.t P.nrP.t�,P;s 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 this event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which wiII be used as a reference number. in addition, an appiicant 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 frrture 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 flog 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 Massachuse= Department of FndustciW Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TeL # 617-727-4900 cxt 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.masss.gov/dia Date.. • ~. % :.. ©.( ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......... :::S�............. �:a%........................................... r has permission to perform ......,.,.......-��-�...... wiring in the building of ..... .............. ................................. at �:°. �!...... ... .... ........... .North Andover., Mass. �� Fee* ?.............. Lic. N �? ........ ��` .... ... ELECTRICAL INSPE R V Check # y , t Commonwealth of Massachusetts Official Use my NEW Department of Fire Se rvices Permit No. BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEG), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: -� % To the Insp City or Town of. NORTH ANDOVER �/ ' Wires: 6 f Wres: By this application the undersigned gives notice of his or h tents n to pWorm the electrical work described below. Location (Street & Number) 2-o` hA�I Owner or Tenant Telephone No. Owner's Address 01 Is this permit in conjunction with �DuH7�g r 't? Yes ❑ No ® (Check Appropriate Box) Purpose of Building j ' Utility Authorization No. C `y Existing Service 10 Amps 1 bo / O Volts Overhead Und rd g ❑ No. of Meters New Service -,—bj Amps Z) / 't�yVolts Overhead ® Und rd g ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Estimated Value o y ueazrea, or as requtrea by the Inspector of Wires. of/Electrical Work: (When required by municipal policy.) Work to Start: Z2— Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE(OVERAGE: 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 s to CHECK ONE: INSURANCE D BOND Permit i suing office. ❑ OTHER ❑ (Specify.) �` /�� I certify, under the pains and penalises ofperjury, that the inform ion on this application is true and complete. �U o �" (- FIRM NAME: _ L- G (( LIC. NO.: J Licensee: Signature (If applicably nter "rbpt" i license number ne.) �q / r �" �_ J LIC. NO.: Address: /�q ` �� /(/� r Bus. Tel. No.. *Per M.G.L c. 147, s. 57-61, security ork requires Department of Public Safety "S" License: Alt. Licl. No .7 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 (c Owner/Agent heck one) ❑owner ❑owner's agent. Signature Telephone No. PERMIT FEE: '` 5 �r-� �'� t i c ! 'w N° 2417 Date .....{.1..///1..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING S .........�—............ r cThis certifies that eJ 5J�... ........................ has permission to perform . C...... W , 2 • n ........ ............... ............................... wiring in the building of ....... +.v .k. ............................................... at ........rh .T.......lN!..1..�.�....... ....... ............. Orth Andover, Uv G / Fee ............. Lic. No...�.�J. (17............... ,?... 1 ....... ............ ELECTRICAL INS ECTOR Check # / o e WHITE: Applicant CANARY: Building Dept. PINK: Treasurer .i C 1n%r4ontuea[lh o` ///ae�ae�ett 1at'1� Official Use Only `7 cc� cc77 Permit No. �CJ¢parinu;nl o`.}ira �aruiced BOARD OF FIRE PREVENTION REGULATIONS [ROccupancy and Fee ed ev. 11/99] , leave blanlank)k) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Elcctricnl Code (MEC), 527 ChIR 12.00 (PLCIISC PRIiVT IN INK OR TYPC:ILL 1tVFOkVM7101V) Date:_� City or Town of: /��1iC/>�� To the Inspector of 1,Vil•es: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Nuntber) _ _n��? Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building, permit? Yes ❑ No (Check Appropriate Bos) 1'urliose of Building- /, % Utility Authorization No. Existing Service Amps / Volts New Service Anips / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters' A No. of Recessed Fixtures -_. ------- _....,, �,,.........� No. of Ceil.-Susp. (Paddld) Falls ...u.c "Illy uc nurvca a1. 111C t!!S ccror of irtres. No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑ in- ❑ rnd. rnd. o. o mergency Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARNIS No. of Zones No. of Switches No. of Gas Burners i o- o Detection and Initiating Devices No. of Ranges No. of Air Cond. Tons Tot No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: umber Tons _ K\V No. of elf- ontained Detection/Alerting Devices No. of Dishivashers Space/Area Heating KW Local ❑ Mut►icipaI ❑ Other Connection No. of Dryers No. of Water Heaters KWi Heating AppliancesKW i o. of o. of Signs Ballasts Security ystems: No. of Devices or Equivalent Data Wiring:No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total IIP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Altach additional delail if desired, or as required by the Inspector of ;Vires. INSURANCE COVERAGE: Unless waived by the o' ner, 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�tBONDEI is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSUIL\NCE 0 -1 -HER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: I certify, corder FIRM NAnIE: Inspections to be requested in accordance with MEC Rule 10, and upon completion. airs and penaltiesu perjury, that the information on this application is trite and complete. ESTI �r6rT1Z,f L fiA I-4/zM CD, LIC NO: A 1391 % Licensee: Signature (If applicable, enter ren 1 • in a licence j71,e ae. Address:o tTe t -z `/ i F C�%�6a! OWNER'S INSURANCE WAIVER: I am aware that the Lice& oes required by law. By my signature below, I hereby waive this requirement. Owner/Anent Signature I'clephtinc No. LIC. NO.: 3�i3S1 Bus. Tel. No.: Alt. Tel. No.: not have the liability insurance coverage normally I am the (check one) ❑ owner ❑ owner's agent. Pi:Rt111T FEE: S