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HomeMy WebLinkAboutMiscellaneous - 24 STACY DRIVE 4/30/2018I This certifies that. .��"" Q ....... . . .. . . . . has permission to perform�.��� .'�� .��'?.......... . wiring in the building of ..... , ... , . at ..... - ... C�.� . �r........ , No ndover, M s. Feej.`��.... Lic. No.7A� L.O... ......... ,� ELECTRICAL INSPE OR f Check t10913 Commonwealth of Massachusetts ,i Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS ,i1 A ,of Official Use Only Permit No. Occupancy and Fee Checked [Rev. 1/071 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 IN INK OR TYPE ALL INFORMATION) Date: _ f — (Q— (-a- City -a-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) Owner or Tenant A-Iit Telephone No. 4iot— 3 5-3�o Owner's Address -J iAyo I ---- Is 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 ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: f tT- Iq geK po �F ` L i (;. t4 TS'-' Mt t✓d2o Completion of the following table may be waived by the In ector of Wires. No. of Recessed Luminaires No. of Ceil: (Paddle) Fans of Total TransSusp. Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires '5J Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o Emergency Lighting BatteryUUnnisits No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Detection and No. of Switches No. of Gas Burners Initiating Devices No. of Ranges No. of Air Cond. Tons Tot No. of Alerting Devices Heat Pump Number. Tons KW No. of Self -Contained No. of Waste Disposers P Totals: ........... ....................... Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal El Other Cyyonnection No. of Dryers Heating Appliances KW uri Sec Not 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 Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: e5d (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 62 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: �J F -, &ftV `Z f --7t 1, cx-& C- e4ey- LIC. NO.: Licensee: `Tt=Qf/'C Signature LIC. NO.: (If applicable, enter "exempt" it a license number line.) Eeirt, Bus. Tel. No.: Address: i l °/ /4 e Lt- 5'-(- lJ i t1 AGS Gt Alt. Tel. No.: *Per M.G.L c. T47, s. 57-61, security work requires Department of Public Safety "S" License: Lie. No. X 9 - OWNER'S OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage norma ly required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent rPERMITFEE.- $ Signature Telephone No. i J - _ y' �'1,ry�T/-'�'—��•/': A � • '�t'�'�jj y'( '�j' • - �Y r(•ji—�' 7�Y ��j ��] �T • y • ._ �.AJ1(Uu.+l..0i-1.�V.C'��'�(t/�''.(��'QJT�%�i1%i'JJ.� 1Y1�®�j��y . �'( /'� , �Iy��j�.1LJ.�J.V Jle.a�JG ®�•*• � _ �!Me;)x xs'copts: ' (.Cuspec$axs' �tgnatuxe ••xto �.i�aTs� .- date _ Z.101MAL lXNS'PE C tIOI I; 3.'asse�•-• �'aile[I--�') � �c-�ns,�ecizoxtxee�uixe� ($0.00)-• [ � _ nsp ectax S' coxum eztts: (Ms ctors',5tgna -)a0' ' OS) Slate �.'assecl�-•j' � �+`ai�ecl-•j � ?ate-fnspeciio�xecluiret�($�D.UD)�[ � • .iTnspectozs' coxamextts: , (.tnspectoxs' Signature-• m initialls) pate I asseci--[ � ispectbxs' comamwAs. p'afied-- (�ttspectoxs',�tgn2tuxe wrio f '3�7�'EC2'�O�r7 -• 0�:' ' Le-auspectiou xequi sect• --F' +'aile�(� [ )- ate xnspectionrpauiz'ea ($50.00) [ pectorie coziim.eds: Date " �1�; sp ectoxs"tgnairzre xto xnittaTs) Pate The Commonwealth of Massachusetts Department of IndustriqlAccidints Office of Investigations Uf 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 8� Please Print Legibly �^ Name (Business/Organization/Individual): a C7 &/y F ,,c- (2Cc,a x-!' Address:_ Z a Cf 14 C S City/State/Zip: CV l� C7 / !`e5U r L L i 0- Phone #: 114 39- lC Are you an employer? Check the appropriate box: 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 2.0-I am a sole proprietor or partner- listed on the attached sheet, I ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] f employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors 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:. Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: ar Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). %Failure to secure coverage as requiredunder 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 do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct. )1::,-.( -- C.' k , -- ? Z l 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 r w 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, §256(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 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. Goarnux>,o>l Malth of Massachusetts Department of Industrial Accidents Office of Iavestigatioans 600 Washington Street Boston, M.A, 02111 Tel. # 617-727_4900 o t 406 or 1-877rMASSAFB Revised 5-26-05 Fax ## 617-727-7749 www.mass,govfdia Date. Of "0RTk TOWN OF NORTH ANDER 0 A PERMIT FOR GAS lt,!STALLATION This certifies that... . Xe'��................... . has permission for gas installation . F . ........... .......... . in the buildings of .. .............................. .at........... I North Andover, Mass. Fee.l? ..... Lic. No../ k I.. � .. ....A ...... T -is INSPECTOR Check# 6545 I MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS F rn7e�� (Type or print) Date , ° �NORTH ANDOVER, MASSACHUSETTS Building Locutions /,\" I/)/—, Owner's Name New ❑ Renovation E] Replacement G Ji -� SU B-BASEM ENT BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOO 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR STH. FLOOR (Print or type) Name Address Permit # ry )-- Amount Amount $ f JZ!! Plans Submitted ❑ Check one: Certificate Installing Company Partner. Firm/Co. Name of Licensed Plumbeior Gas Fitter INSURANCE COVERAGE Check one: [ have a current liability lnsurance•policy or it's substantial equivalent. Yes ❑` If you have checked es lease indicate the No ❑ L� p type coverage by checking the appropriate box. Liability insurance policy ❑� Other type of indemnity 13 Bond ❑ 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. Signature of Owner or Owner's Agent Check one: Owner 13 Agent 13hereby certify that all of the details and information 1 have submitted (or entered) if above application are true and accurate to the best of my knowledge and that all plumbing work and installations pe or de d Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State d and Chapter 142 of the General Laws. 1 By: Signatu , o ensed PI er Or Gas Fitter Title 13-71umber City/Town. Gas Fitter ❑ aster i. ., moe„s� umber APPROVED (OFFICE USE ONLY) ❑ Journeyman zw Z E, W d w U W x C w z d w F z F w w V Check one: Certificate Installing Company Partner. Firm/Co. Name of Licensed Plumbeior Gas Fitter INSURANCE COVERAGE Check one: [ have a current liability lnsurance•policy or it's substantial equivalent. Yes ❑` If you have checked es lease indicate the No ❑ L� p type coverage by checking the appropriate box. Liability insurance policy ❑� Other type of indemnity 13 Bond ❑ 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. Signature of Owner or Owner's Agent Check one: Owner 13 Agent 13hereby certify that all of the details and information 1 have submitted (or entered) if above application are true and accurate to the best of my knowledge and that all plumbing work and installations pe or de d Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State d and Chapter 142 of the General Laws. 1 By: Signatu , o ensed PI er Or Gas Fitter Title 13-71umber City/Town. Gas Fitter ❑ aster i. ., moe„s� umber APPROVED (OFFICE USE ONLY) ❑ Journeyman zw C C > W oC Check one: Certificate Installing Company Partner. Firm/Co. Name of Licensed Plumbeior Gas Fitter INSURANCE COVERAGE Check one: [ have a current liability lnsurance•policy or it's substantial equivalent. Yes ❑` If you have checked es lease indicate the No ❑ L� p type coverage by checking the appropriate box. Liability insurance policy ❑� Other type of indemnity 13 Bond ❑ 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. Signature of Owner or Owner's Agent Check one: Owner 13 Agent 13hereby certify that all of the details and information 1 have submitted (or entered) if above application are true and accurate to the best of my knowledge and that all plumbing work and installations pe or de d Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State d and Chapter 142 of the General Laws. 1 By: Signatu , o ensed PI er Or Gas Fitter Title 13-71umber City/Town. Gas Fitter ❑ aster i. ., moe„s� umber APPROVED (OFFICE USE ONLY) ❑ Journeyman Date HORTp pit..° .1tip TOWN OF NORTH ANDOVER o _ � PERMIT FOR PLUMBING- 4 SA This certifies that .. G. has permission to perform ... 7.. ..................... c LfG plumbing in the buildings of .. h7 ...........:...... .......... at .... :........ ,North Andover, Mass: Fee:�(?.T'_'... Lic. No...�.? PLUMBING INSPECTOR Check # Z j � � �- 7853 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS (^� Building Location �Date Owners Name Permit # a Type of Occupancy ,t<'S Amount New Renovation El Replacement' / P � Plans Submitted Yes1:1No ❑ FIXTURES (Print or type) ', //II / Installing Company Name l//,L/l.– L -�Check one: CertificateL Address LU Partner. Business 1 elephone Firm/Co. Name of Licensed Plumber. �t— Insurance Coverage: Indicate the type 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 lic three insurance ensee of this application does not have any one of the above Signature Owner 13 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 ands Ila s performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachu e tate and Chapter 142 of the General Laws. By. bigkens um er Title aTZel flumbing License City/Townum er Master © ❑ APPROVED wFicE usE oNLY Journeyman