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HomeMy WebLinkAboutMiscellaneous - 23 OLD FARM ROAD 4/30/2018 23 OLD FARM ROAD r-12 210/035.0-0071-0000.0 1 I I I I i I i i Date.... .... i12 T".,��o TOWN OF NORTH ANDOVER O? * i PERMIT FOR PLUMBING +neo ,sSgCHU9�Sjj ! This certifies that...1..!'!.!. I....60.ki t -......................................................... has permission to perform............. / t�.!E � �..................................................... plumbing in the �-b-u-ildin s of............................................................................................. ...t e-II'V4 &L.............................. ..,No h Andover, Mass. FW&.�.....Lic. No. .�?...... PLUMBING INSPECTOR Check# } MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY I NORTH ANDOVER 01845MA DATE 07/22/15 PERMIT#-11. i�t7 JOBSITE ADDRESS 23 OLD FARM ROAD OWNER'S NAME SAME POWNER ADDRESS I SAME TEL FAX NIA TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW:® RENOVATION:Q REPLACEMENT:® PLANS SUBMITTED: YES[j NOD FIXTURES 7 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _ CROSS CONNECTION DEVICE i ! DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM AI _ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM I DEDICATED WATER RECYCLE SYSTEM DISHWASHER ! 3 DRINKING FOUNTAIN FOOD DISPOSER _ FLOOR/AREA DRAIN s INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY - -- 1 ROOF DRAIN EE SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION t WATER HEATER ALL TYPES WATER PIPING i OTHER , INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E] OTHER TYPE OF INDEMNITY ❑ BOND Q 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 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to th st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianc with all Pe ' nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I MICHAEL L.CROMBIE LICENSE# 12742 SIGNATURE MP[3 JP 0 CORPORATION Q# INC PARTNERSHIP F-1# LLC[�# COMPANY NAME I CROMBIE PLUMBING AND HEATING INC ADDRESS 155 MOORE STREET CITY I WINTHROP STATE MA I ZIP 02152 TEL 617-846-8668 FAX 617-846-3676 CELL 617-719-8783 EMAIL crombieplumbing @aol.com ROUGH PLUMBING INSPECccT��I//OW�N NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT El 1:1 FEE: $ PERMIT# ^ PLAN REVIEW NOTES o� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 1 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): CROMBIE PLUMBING AND HEATING INC Address: 55 MOORE STREET City/State/Zip:WINTHROP, MA. 02152 Phone#: 617-846-8668 Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 5 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. R Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.t 9 E] Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical 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.] f c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#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 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: HARTFORD FIRE INSURANCE COMPANY Policy#or Self-ins. Lic. #:08 WEC CR3905 Expiration Date:9-1-15 Job Site Address: 23 OLD FARM ROAD City/State/Zip: NORTH ANDOVER, MA. 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. Ido hereby certify under the pa' andpenalties ofperjury that the information provided above is true and correct. Sijznafore: Date:07-22-15 Phone#: 846-8668 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 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 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 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 burn 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 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE Revised 7-2013 Fax # 617-727-7749 www.mass.gov/dia Date..7/2//iT........... OF T TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING CHU This certifies that ..... ... ..... ........ ...............bz.r 9.......... *U- e vin u has permission to perform .......................................................................................................... wennin the building of...... ,I. .............................................................................. at ......Z-�)...d.4-1-Al I ............. ...... ........................................... ....... ...............N h Andover,Mass. .... Lic.Not: 0 Fee �W 4?- i� ..... ..... .......... ELECTRICAL INSPECTOR Check# Or Commonwealth of Massachusetts Offic'al Use Only 7. L510 a ire Services Department of FPermit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07j (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT IN MK OR TYPE ALL INFORMATION) Date: -7 - 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) a'�> 0 16 � C M ?-D Owner or Tenant /A'k ire lC CL—t--Z— Telephone No. Owner's Address bo— MQ-Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) ti Purpose of Building 2)�Q a x&• Utility Authorization No. - Existing Service Amps / 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: �>—O V�"N a) se ����D M Completion of the following table maybe 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 S No,of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ NO-7-OTEmergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets 3 No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No. of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices No.of Waste Dis osers Heat Pump Number Tons KW No.of Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other P g Connection No.of Dryers Heating Appliances KW Security Systems:Y Y No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications No.of Devices or E u valent OTHER: Attach additional detail if desired,or as required by the Inspector of 07res. Estimated Value of Electrical Work: c?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. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) X certify, under the sins and penalties ofperjury,that the information on this application is true and complete. FIRM NAME �(' C C'1� I t(C� Z� LIC.NO.:�0-S9,QA ,C- Licensee: ; ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed • on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166, §32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑ Permit Extension Act—Permit/Date Closed: Trench Inspection r Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP CTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: M6, k 4j Date: 7-- FINAL INS CTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents „ . I Congress Street,Suite 100 Boston,MA 02114-2017 Hwww.mass.gov/dia G.M 5.. Wol;kers'Compensation Insurance Affidavit:�uilder�lContractors/Electricians/Plgm els. TO BE FILED WITH THE pE12MITTING AUTHORITY. please print LtcFihlv A '•licant Information Name(Business/OrganizationAndividual): CG r� Address: l�"�— CCC� S��Q ��/ / • City/State/Zip: U one#: Are ou an oyer?Check the appropriate box: Type of project(required)' Y I am a employer with_�employees(frill and/or parE time).* 7. Q New'constra'otlon 2.Q I am a sole proprietor or partnership and have no employees working for me in $. Q Remo deliiig any capacity.[No workers'comp.insurance required.] 9, Q Demolition 3.Q I am a homeowner doing all work myself;[No workers'comp.insurance required.]t 10E]Building addition 4.Q I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repaixs or additions ensure that all contractors either have workers'compensation insurance or are sole 12 Plumbing repairs Or additions proprietors with no employees. 5.Q I am a general contractor and T have hired the sub-contractors listed on the attached sheet. 110 Ro6f repairs These sub-contractors have employees and have workers'comp.insurance t 14.Q Other 6.Q 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-] *Any applicant that checks bbx#1 must also fill out the section below showing their workers'compensation policy information. fi Homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such T1 Homeown 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. X am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. C � S Insurance Company Name: dC� - `3e 1—t � (� Expiration Date: Policy#or Self-ins.Lic.#: a3 O( (AA9 D City/State/Zip: �� V fob Site Address: compensation policy declaration page(showing the policy number and expiration.date). Attach a copy of the workers' Failure to secure coverage as require as civer il may penalties in the form of aaSSTOP violational punishable ORDER Iand a fin of up to $250.00 a and/or one-year imprisonment,as P may be forwarded to the Office of Investigations of the DTA for insurance day against the violator.A copy of this statement coverage verification. X do hereby cert u ��a ties of pe ' that the information provided above is true and correct. _ ate: Si ature: /- Phone#: official use only. Do not write in this area,to he completed by city or town official Permit/License# City or Town: Issuing Authority(circle one): 3.City/Town Clerk 4.Electrical Inspector 5.plumbing Inspector 1.Board of Health 2.Building Department 6.other Phone#- Contact Person: 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 ofthe 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 b6 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 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 be returned to the city or town that the application for the permit or license is being requested,not the Department of IndustrialAccidenis. 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•"a11locations 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext.7406 or 1-877-AIASS.AFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia l .f ° COMMONWEALTH OF MASSACHUSETTS ■Em 0", . • • BOARD OF 1 E.L E:CTR I C I A N;S>-,:-,,' ? >€ =1 SSUES THE.: FOLLOW NG LI'CEN'SE AS A: R1=G`t.STER.ED MAST.E:R. ELECTR'I-C-[.A. W I Ra CHARD C P I CARD I JR n 1W 14 GREYSTONE RD f' �� Lu, S A UG Us MA 0190 6-211'-6' 20520'AJ'; 07/31/16 39607 ' CLCOMMONWEALTH OF MASSACHUSETTS BOARD OF ELECTRICIANS ISSUES THE FOLLOWING Lt CENSE. AS A REG JOURNEYMAN .ELECTRIC'L-AN R1;:CHARD C P I CARD I' JR i 114 GREYSTONE RD J AUGUS MA o1906-2116 ' 39029E 07/31/16, 277x'' 4 9 8 : : -� Date....1.—..31- 11... .... �, �10RTM °�,�``°;•1"° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING . a• ,S"r CHU This certifies that has permission to perform ..... �L rT� S`�' wiring in the b 'Iding of......... -.................................................. at....... .,ti?.. /1 tyl....... �........... ,North Andover,Mass. Fee....41'G. Lic.No.VS.L... ............... ...LECfRICAL.IrrsPEcroai� / Check # 33V Z31 r . 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.p.143,§3L the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of ongoing construction acti*il j,and rpay be-deemed-by the.:inspector-of-Wires abandoned.and-invalidaf he--. _ or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entitystated on the permit application. n The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending-through August 15,2012. Rule 8—Permit/Date Closed: a � Dote:Reapply for new permyt� 0 Permit Extension Act—permit ate Closed: C'1mmonwaa19 o f Ma.33ac4usaf Official Use Only •;'� �t-'yy�� ] nn Permit No. op 'artmant of Jira Servica9 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in acc rdance with the Massachusetts Electrical Code(NEC),527 C 12.00 �(,p / (PLEA SEX PRINT IN INK OR TYPE ALL INFORMATION) Date: // / City or To't'irn of: n,-1-7f &,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) _ Q,„L �q�ii1 Owner•or Tenant Si'�P�/ ,, f' J41-e Telephone No.q 74l--,20f f- 74Z_ Owner's Address / Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑l No. of Meters iC:"y� .Amm-s i �•�c!tG v'r'2r::�""S n !,Tn.?.r-� ! Nc..of ryll&ers L� p Number of Feeders and Ampacity .Location and Nature of Proposed Electrical Work: Completion o the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Sus addle Fans o. of Total p ) Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimmin Pool Above ❑ n- o.o mergency ig ng g rnd. rnd. Batte .Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No,of'Switches No.of Gas Burners o. of Detection and Initiating Devices No.of Ranges Na.of Air Cond. Tonal No. of Alerting Devices Heat Pum umber Tons•_•_•• KW No. of Self-Contained No.of Waste Disposers Totals -� Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ther Connection No.of Dryers Heating Appliances KW Security of Devices yyte s orEzrVivalent No.of Water KW No.of No. of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent � trim No. Hydromassage Bathtubs No.of Motors Total HP elecommunicationsNo.of Devices or E uivalent e OTHER: 0'7—O/q �� I ZD Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: Zq, (When required by municipal policy.) Work to.Start: S _Inspections to be'requested in accordance with MEC Rule 10, and upon completion. INSURANCE CE: 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 W BOND ❑ OTHER ❑ (Specify:) 1•cert, under the pains and penalties ofperjury,that the information.on this application is true and complete. FIRM NAME: E c-,u n Se LIC.NO.:_�i�SL' Licensee: i L eGz Signatur LIC.NO.:JdZ, (If applicable, enter "exemp 'in the license number link ,/_ Bus.Tel.No.:_t� Address: 1 L /�7"� C/)� /T�� �s )4 96r-7 Alt.Tel.No.: *Per M.G.L. c. 147, s.57-61,security work requires Department of Public Safety"S"License: Lic.No, 0006-/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(check one)❑owner ❑ owner's agent. Owner/Agent PERMIT FF. $ dz Signature Telephone No. ���J COMMONWEALTH OF MASSACHUSETTS ELECTRICIANS A REGISTERED SYSTEM TECHNICIAN ISSUES THE ABOVE LICENSE TO: ARTHUR W PIERCE ` I UPHAM ST SALEM MA 01970-251 1024 D 07/31/13 874092 ✓�e C�ar�cinanurealC� a��..`lizi,lac�uaP.lZ3 DEPARTMENT OF PUBLIC SAFETY Certificate of Clearance Number: SS CC 000517 Expires: OEM/2012 Tr.no: 91.0 S-license: ADT • ARTHUR PIERCE 18 CLINTON DR HOLLIS, NH 03049 commissioner 1 , � �n Date...........-�. .... ........... °'.«•° "� TOWN OF NORTH ANDOVER ° p PERMIT FOR WIRING + SSACMUS� •This certifies that ..................... r`..... �............... -"?o...:..:.................. haspermission to perform ...,............................................................................. wiring in the building of.... .......? ......................................................... at......:.................................................................. .. .. .North Andover, ass. Fee% ry ....:......... Lic.No:?� ��!' ............ . .. .... ............ :... .. LEcTrmcAL INSPE I t Check # G 1 896 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank u,p- APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical (J MFQ,527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date: U ()1 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigns Ives n tics of his or her intention to perform the electrical work described below. Location(Street& umber) Owner or Tenant z Telephone No. r Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. I Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity )n Location and Nature of Proposed Electrical Work: Completion of the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA i No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- El o Emergency Lighting rnd. rnd. BatteryUnits No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. a Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number I Tons I KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water , No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: UQ Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value(°f/le trical Work: (When required by municipal policy.) Work to Start: 1( (O o9 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. CHECK ONE: INSURANCE J0 BOND ❑ OTHER ❑ (Specify:) I certify,under the ainsand penalties o`f,�erjury,that the information on this application is true and complete. FIRM NAME: �l .NO.: w me— Licensee: �(� ��'j�hlhQ,Q_,&— Signatur LIC.NO.: 13-3e (If applicable, nter ' empt"in the.licena nu4 ber line)( /' " Bus.Tel.No.: Address: �����° / �LL"1J1�1�� — Alt.Tel. *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety "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. $ 0 , �„o Location` No. Date NORTH TOWN OF NORTH ANDOVER A Certificate of Occupancy $ 41 s ; Building/Frame Permit Fee $ cNUS Foundation Permit Fee $ s� usE Other Permit Fee $ 3� Sewer Connection Fee $ Water Connection Fee $ �J TOTAL $ i / i Building InspecUr I O L:'6/27/99 14:55 25.00 PAI11 Div. Public Works Pr RM IT NO. zy �Y APPLICATION FOR PERMIT TO BUILD** `*****NORTH ANDOVER, MA MAP N0. i �/ 3 LorNo../ OO 2. RECORD oFOWNF1,S1 m DATE E3(>nK PACE ZONE SU 13 DIV. LOT NO. LOCATION PURPOSE.OF BUILDING CJS O! i /t'�' �.� � � � • oWNFat's NAME e/ 69 NO.OF STORIES SIZE OWNER'S ADDRESS BASEMENT OR SLAB ARCIIiTECT'S NAME SIZE OF FLOOR TINI13ERS ] 2ND 3RD BUILDER'SNAME �/GC SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET DIMENSIONS OF POSTS DISTANCE FROM LOT LINES-SIDES REAR DIMENSIONS OF GIRDERS AREA OF LOT FRONTAGE 11EIGHTOF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITICN MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEIVER .� IS BUILDING CONNECTED TO NATURAL GAS LINE INSTUCTIONS 3. PROPF,RTY INFORMATION LAND COST EST. BLDG.COST 0466 PAGF,I FILL OUT SECTIONS I-3 EST.BLDG.COST PER SQ. FT. EST. BLDG.COST PER ROOM ELECTRIC METERS MAST BE ON OUTSIDE OF BUILDING SEPTIC PERMIT NO. ATTACHED GARAGES MUSTCONFORM TO STATE FIRE REGULATIONS 4. APPROVED BY: PLANS MUST BE FILED AND APPROVED Bl'BUILDING INSPECTOR BUILDING INSPECTOR DATE FILED OWNERS TEI.II jn75 OoV Q CONTR.TEL# a3y�� SIGNATURE OF OWNER OR AUTIIORIZ_ED AGENT � "� CONTR.LIC# FEE $ a� m II.I.C.# y PERM IT GRANTED�� 19 ti '00e Revised 5/5/99 .IM -<,. eel 67 (Policy Provisions: WC 00 00 00 (NM ONLY) , WC 00 00 00 A) 29 VM INFORMATION PAGE-WCIP WZ WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY HARTFORD PLAZA, HARTFORD, CONNECTICUT 06115 NCCI Company Number: �1= THE Company Code: 6 HARTFORD m 0 0 0 Suffix CD LARS RENEWAL oPOLICY NUMBER: F- n� Previous Policy Number: 1. Named insured and Mailing Address: NORMAN GAY DBA ALL UNDER ONE r` (No.,Street,Town, State,Zip Code) ROOF/PEST IN PEACE C CD 0 70 JEFFERSON STREET FEIN Number: 028349269 NORTH ANDOVER, MA 01845 State Identification Numboos): The Named Insured is: INDIVIDUAL Business of Named Insured: ROOFING zsw Other workplaces not shown above: 7 0 JEFFERSON ST. , NORTH ANDOVER, MA 01845 2. Policy Period: From 11/0 9/9 8 To 11/09/99 : 12:01 a.m.,Standard time at the insured's mailing address. Producer's Name: MASS WORK COMP A R DIRECT _ LEtv'NOX INSURANCE AGENCY PO BOX 462 ...r LYNNFIELD, MA 01940 Producer's Code: 083477 Issuing Office: THE HARTFORD 4801 NORTH WEST LOOP 410, SUITE 200 SAN ANTONIO TX 78229 .= (800) 852-7991 ffi i no poucy Is not atnoing w..646 cy aur authorized representative. 7?7 Authorized Representative Form WC 00 00 41 A Printed in U.S.A. Page 1 (Continued on next page) �. _ _ .. _ __ s�l�..C..�1��7�� Rte... n• .n n ,n n 1 • :'.� +� ••✓1e iao�r»inzaru�sea,C� a����r�taa�uoetlJ ' 1 DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE Number: Expires: Birthdate: CS 834288 89J3eJ1999 69J38J1945 f f Restricted To: 88 j NORMAN GAY 19 JEFFERSON ST { N ANDOVER, NA 81845 �. _I