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Home My WebLink AboutMiscellaneous - 25 Maple Street911� c rim 9697 Date............ .. ...L...../ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............ -7� 1314 ...... �'—e /- ..... ........ ........ !�7 ....................................... has permission to perform ......... ......... U/zio: ..................... wiring in the building of ........... D4'vwlt & ................................................. at ...... A*1Z ............................... . ...... . North Andover, Mass. ;27A . ................. Lic.No. LECTRICAJANikcrok Check # j t�apillu)ltwnaLt/c a�%addacfarr�a�! Official Us? Only cr�� cc77 Permit No. aCJnParfnwlst o�..tira �nralcad ' V Occupancy and Fee CheckedBOARD OF FIRE PREVEI�fT10N REGULATIONS [Rev.l/071 Oravebiank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with lite Massachusetts Electrical Code C), 5.2„7 CMR 12.00 (PLErlSEPRlNTININIL'ORTYPE.r FO ATXON) Date: City or Town of: ® To the Xns cto of lTfires: By this application the undersigned g ves notice of his or �her intention to pprfibrin the electrical work described below. Location (Street & Number) , 2-5 Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building: p6mit? Yes ❑ No ❑ (Checic Appropriate Box) Purpose of Building ` Utility Authorization No. Existing Service Amps ! Volts New Service Amps ! Volts '%. Number of Feeders and Ampocity Location and Nature of Proposed Electrical Wnrlc Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters 17 ., 1.#J'A .. rd... r-11 . .....A1-. r-_. ..__ .. No. of Recessed Luminaires No. of Ceil. Susp. (Paddle) Fans Na. °f T°fal Transformers INA No. of Luminaire Outlets No. of Hot Tubs Generators ICVA No. of Luminaires Swimming Pool Above ❑ In- ❑mergency rnd. d. Lighting Batte Units No. of Receptacle Outlets10 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection nn Initlatine Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No, of Waste Disposers HentPump Totals: Number TonsK o. of elf- ontained DeterAon/Alarting Devices No. of DistnvashersSpacelArea Heating KW Local E] municipal ElOther Connection No. of Dryers No. of Water ICW Heaters Heating Appliances Iov No. of No. of Si ns Ballasts Security Systems: No. of Devices or Equivalent Data Wiring: No. of Devices or 1r uivaIcnt No. Hydromassage Bathtubs No. of Motors Total HP Telecommunicntions Wiring: No. of Devices or E uivalent OTHER-__ t nrractt aadrtionai detatt ►J desired, or as required b}r [lie Inspectar. ajA Tres. Estimated Value of Electrical Work. (When required by municipal policy.) Work to Start; .71 !fi) Inspections to be requested in accordance with MEC Rule 10, and upon completion_ = ==INSURANCE -C MAGE:-Unless-waived-bythe=otivner� Fin=peimit=fdr tIie=performniict ofelec�ical=vvoclt=may=issue unless the Iicensee provides proof of liability insurance including "completed operation” coverage or its substantial equivalent_ The undersigned certifies that such cove a is in force, and has exhibited proof ofso a to th ermit is ng frice_ CHECK ONE: INSURANCE BOND ❑ OTi�ER ❑ (Specify:) ji�,� �L 3/�/p f certify, render tha p and pena 'e of erjtrty, Ilia the in a tion art tlt� licatian is Imre arrrt7! lel FR M NAME: L Lk a PP LIC. NO�gtL-� Licensee: c .P,to�,ft QUbA Signature LIC. NO.: (IJappllcable, eater' rpt" in icense{lunrberline.) 1 Bus. Tel. No.t Address: t rC c UAx Alt. Tel No: *Per M.G.L. c. 147, s. -61, senircurity work regDepartment of Public Safety "S"License: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance en rage normaily 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: S r Date. . 7/!4/4........ . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... tf- ................... has permission for gas installation in the buildings of ... ka!? 4? �!� # .1 ........................... at ... Z57. ,�-........ North n dover mass. � Feev�? Lic. No..9VG ... GASINSPECTOR Check # /Zefl' 8239 GRILLE E_j INFRARED HEATER LABORATORY COCKS I —J MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ...... . . . . . . . . . . ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER..., LF ::: 711 IL_ L—AL—I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES ('NO Ej I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ey- OTHER TYPE INDEMNITY Ej BOND ED 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 E3 AGENT [:11 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 acciorate to the best of knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co a e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. v4f all P3eT' ent prol�o PLUMBER-GASFITTER NAME . . . . . . - LICENSE ONATURE IMP El MGF 01 JP JGF LPGI CORPORATION [H#=: PARTNERSHIP [--I#= LLCF'I#= COMPANY NAME: 12 ADDRESS CITY STATE =ZIP [ &jTEL FAXMAIL __11 c4c: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY [_11y -Ali 0 MA DATE PERMIT # JOBSITE ADDRESS Y' OWNER'S NAME GOWNER ADDRESS TEL TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW:E1 RENOVATION: E] REPLACEMENT: PLANS SUBMITTED: YES Ej NO F_J APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE L_j —1 GENERATOR iJ 1IL GRILLE E_j INFRARED HEATER LABORATORY COCKS I —J MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ...... . . . . . . . . . . ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER..., LF ::: 711 IL_ L—AL—I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES ('NO Ej I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ey- OTHER TYPE INDEMNITY Ej BOND ED 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 E3 AGENT [:11 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 acciorate to the best of knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co a e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. v4f all P3eT' ent prol�o PLUMBER-GASFITTER NAME . . . . . . - LICENSE ONATURE IMP El MGF 01 JP JGF LPGI CORPORATION [H#=: PARTNERSHIP [--I#= LLCF'I#= COMPANY NAME: 12 ADDRESS CITY STATE =ZIP [ &jTEL FAXMAIL __11 c4c: w M The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UT. www mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): / .-N1 �►�•� --e Address: /V Q 13 o u ti -5 V City/State/Zip: -yl p itA L/,,--, Phone #: S -2 F& J -Z, o r--�D Are you an employer? Check the appropriate box: 1. LK 1 am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. # 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.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. [3 -remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F1 Electrical repairs or additions 11.0 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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. iContractors 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. n Insurance Company Name: 'ZL 0, CA--, JKL-G-5 Policy # or Self -ins. Lic. #: fob Site Address: Expiration Date: City/State/Zip: kttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a .me 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 )f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. ' do hereby cer ' u er the pains and pe Ities perjury that the information provided above is true and correct. ii nature: Date: 7 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 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 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia 87 ; 6 Date. .IQ/I-/./!() MOR, • o TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING �1 This certifies that ! '`�.' ... /'�. !+� h!�r' ... )�.14 has permission to perform ...�`r�! P� ......... I ' x �� -v-.j plumbing in the buildings of .. cT� V V *f -V ................. at . a .5 .04.!!''�-......... , North Andover, Mass. Fee J 1.3..... Lic. No..li ,t). 3-G. PLUMBIN 4INSPECT Check # SSA C tT TT U UopM APPLICATION FOR PERWT TO JD 0 pL�7I OING (Type or print) / / _(� NORTH ANDOVER, MASS.A.CHUSETTS Date f U / t1 Owners Name .� 01A e)// �'✓ Permit #__L_ _ Building Locatidn Amount Type ofOccupancy w •e f ti' ( New r Renovation ReplacLJ No ement Flans Submitted Yes _ Check one: (print•ortype) ! s�r�c -'� �9L 1� Corp. Installing CompanyName �l �p L� D Eadner. Address - 0/ 74b 1, Business Telephone NameofLicensddPlnmber: Insurance Coverage: Indicate the tYP e of insurance coverage by checking the appropriate box -Bond Liability insurance policy Other type of indemnity. �[ I, the undersigned, have been made aware that the licensee of tbis application does not hale any one of. the above ,Insuzance Waiver three insurance _ r Owner Agent ignatuze . - I hereby certify that all ofthe details and informatio d hav mss• moor deunde Bred) in abo tissued for this applic tionwill be inte to best of Amy jm owledge and that all plumbing work. p N Code d Chapter,.42 of the General Laws. compliance with all pertin ent provisions of the lvSas c s tate Plum mg sr Type of numbingLkense Title MasterET Joumeymau CitylTowzt icense um er -APPROVED (OFFICE USE ONLY U a J The ComnaorzNvea&h of!Massachusetts • �3epat�ment. of£radustriczX�ccidents - OJJ-Ice ofX- Vesta -a ons ' 600 WasizinbatpnStreet .$ostara, AM 02X.Z1 '.Masagovidia Workers' Compensratiou Insurance AffIcTaviEt: Builders/Contracio s/ +iecfrxc az s/Plrxmbers Name (Business/drd nizaEon/Individ ml): Address: City/state/Zip: _ Phone #: Are you an. employer? Check the appropriate box: I- [] I am a employer with 4. ❑ I am a gt_-heral contractor and I employees (full andlorpart-time)* 2. Q -I have hired the salt -contractors am a sole proprietor or partner- •Iisted on'the attached sheet t ship and haveno employees These sub -contractors have working for me in any capard4,r Mo ins�nce, workers' comp, insurance. 5• ❑ workers' comp. We are a corporafi.on and its zequired.] 3.0 I am a homeowner doing all work Ofncers have exercised their right of ex_empiiou per MGL myself. [No workers' comp. • c. 152, 6-1 (4), and we have no insurance required-] t employees. [No workers' c.Omp. mstx -anti; required-] Type of project (required): 6. ❑ Neer constauction 7. 0 Remodeling S. [] Demolifion 9. [] Building addition IO.Q Blecirical'repairs or additions I1,[] Plumbing repairs or additions 12.[] Roofrepairs 13.[] Other 4 .t Elso a, CII:' �..0 � .. _ tjOv. ,;T `�' « _..S � 1.'^..0 Ser'LQ±+ �'n�r c rin .. • Elamabwners who suamif ibis affidavit indicating h , ?� a - .• " v'crY� s comY s�os, cs u a� tei e ug all w� ani rhea hire nu#sida Corr _ctors �J'&_t M uit a new 2Hi&vit indicating such. .+Contrgcforsth.:iciegkt�hox.*_^.•.:.�•Yatta�,;-.edauaddiuouaiSheetshowingthe - - name'of the sub -contractors and theirwcrkers' comp, policy informafi_m dam an employer that isproviding workers' corpzpensauon irzsurance for my employees B910h; is the polkv and job site. irzformatzan. _ Insurance Compiuy Policy # or Self -ins. Lic. #: Expiration Date: J'ob Site Address: City/state/Zip: Attach a copy -of the workers' compensation policy declaratifM page (shove ng'thepolicy number•and expiration date). Failure to secure coverage as required under Section 25A ofM' C3L c. 152 can lead to the imposition of criminal penalties of a E00 up to $1,500.00 and/or ane yeariroprisgnm.ent; as wallas civilpenalties 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 stafement may be forwarded to the Office of Inve: igations of the DIA for insurance coverage verification _ I do hereby cernfp under the pains andpeiuz des afperjury thrrtthe inform aizon. provided above -'is true ¢nit correct Phone #: Official zcse only. Do not write in this area, to be completed by cite or toren official City or `Z'ovvw. P'ermzf license hsuing Authority (circle one): x. Board of Health 2, $uiIriinb Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Fnspector C. Other Contact Person;: Phone'#: