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Home My WebLink AboutMiscellaneous - 26 PHILLIPS COURT 4/30/2018 (2)�f� Date ... ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... .. ..... has permission to perform .......... ......... wiring in the buildmj� of ...... '41 .... ..... . . ......................................... ar-:4�5 .............. .......... 'IN North Andover, Maass. o Fee.�.,'P .. . ...... Lic. No(... V. R AL INSP o Check 7788 Commonwealth of Massachusetts Department of Fire Services Yt BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. / / G Occupancy and Fee Checked CDC�::, [Rev. 7 �— �R1 /0� (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:.N o i/ - f� O City or Town of. NORTH ANDOVER To the Inspector of'Wires: By this application the undersigned gives notice qf his or her intention to perform the electrical work described below. Location (Street & Number) 0-5 Pit li fa s Co Ltrf Owner or Tenant D1c-&E DQAaVv!—A-J Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ Purpose of Building /C25►0eAC e— No Appropriate Box) 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 ��---- Locati� d Nature of Proposed Electrical Work: S (� �� 90 j�u5 �S r'�� Completion of the.following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No..of Ceil.-Susp. (Paddle) Fans NO. of Tota Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. grnd. o, 011 Lmergency Lignting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners ( o Detection and No. Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pum Totals Number Tons KW No. o Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances Kms, Security Systems: No. of Devices or E uivalent No. of Water KW Heaters No. of No. of ' Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP elecommunications Wring: No. of Devices or Equivalent OTHER: Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. (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 insu ce including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cover is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ff BOND ❑ OTHER ❑ (Specify:) I certify, under the ins nd pnalr►es of perJ�N'r�rrA�, that tTI, e information on us application ' true and complete. FIRM NAIV)JE� r►srcaol�er L/'0 t1019- LIC. NO.: Licensee: Un-tS'i�he` Signatu e LIC. NO.:�� (If applicable, enter "exempt" in the license nu er line.)Bus. Tel. No. X7%'69 0c4.3 Address: �0 . d�y'•Gi M� 01 Alt. Tel. No.. L*Per M.G.L c. 147, s. 7-61, 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 FPERMIT FEE. $0,9>°� SignatureturaTelephone No. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual) Address: /D.5 IRrrW006 IW City/State/Zip: SAT _ &XlkeC KA* Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a emplo er with 4. ❑ I am a general contractor and I e ees (full and/or part-time).* 2. l am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. t These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. []Building addition 10.0 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 are doing all work and then hire outside contractors must submit a new 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. #: Job Site Address: Expiration Date: 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 $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 cer ' under t<z a�� peroti� of jury that the information provided above is true and correct. ,P, D Phone #: 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 #: .`, 939 Date. ...... a w NORTH TOWN OF NORTH ANDOVER py` ��ao ,e,tiOL PERMIT FOR GAS INSTALLATION: D � Z— l, 4 V7 SwrwUSE N n fr .� :_ This certifies that . F - .:�... ... .. has permission for gas instillation - �f • �-f� in the buildings of.. '� • .............. • • • • •. f at �-'�P�^ ... ` '/- U. •r�? ? • • • • . , North Andover, Mas tri ` Fee�4. Lic. No. ........ ........................... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Building New SUB-SSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Mass. ®ate 9P-, % > L.L;CoS C--7— Renovation ❑ Replacement ❑ 19 Permit # 9J, er"s Name Type of Occupant &S) 0 Installing Company Name . BAY STATE GAS COIKPANY Address 55 MARSTON STREET Plans Submitted:, YesO No ❑ Check one: Certificate # LAWRENCE ; MA 0I 8 4 0 CorPoraiion 10.2 Business Telephone 508-68.7-:1105 ❑ Partnership Name of Lkxnsed Piumber or Gas Fitter Francis X. Corkery ❑ Fi Co INSURANCE COVERAGE: r~ have a carr liab8ity kSurance poky or its substantial ,. Yes No O equivalent which meets the requirements of MGL Ch. 142. ff you have checked es. please indicate the type coveragey checking bthe appropriate box. A IfaUibr Insurance poQcy �( OUM type of Indemnity O Bond ❑ OWNER'S. INSURANCE WAIVER: I am aware Chapter 142 of the Mass. General Laws. and that t t that the licensee not have the Insurance coverage required by signature on this permit application" waives this requirement Check one: Owner or Owners AGWd Owner[] Agent ❑ all IM *Pft"anWd s a atlle Massachawnttatb rmatim 1 hM tions p� wAma d (a kation are true and setts State Gas Code � Ch 142�of tfle application U to tom wffh allmY T of Lkense: Title - Gaer � ° or /Town Master License Number 3745'- Journeyman .1 (A NOC W U N 1— W z Q h m a t h< tC cC 0 :. 01 CC W WW N W oG t- O 43 z w J w w >u i Hx VW> w 40 j' V1 x <<viYpaxoozu.M3c Installing Company Name . BAY STATE GAS COIKPANY Address 55 MARSTON STREET Plans Submitted:, YesO No ❑ Check one: Certificate # LAWRENCE ; MA 0I 8 4 0 CorPoraiion 10.2 Business Telephone 508-68.7-:1105 ❑ Partnership Name of Lkxnsed Piumber or Gas Fitter Francis X. Corkery ❑ Fi Co INSURANCE COVERAGE: r~ have a carr liab8ity kSurance poky or its substantial ,. Yes No O equivalent which meets the requirements of MGL Ch. 142. ff you have checked es. please indicate the type coveragey checking bthe appropriate box. A IfaUibr Insurance poQcy �( OUM type of Indemnity O Bond ❑ OWNER'S. INSURANCE WAIVER: I am aware Chapter 142 of the Mass. General Laws. and that t t that the licensee not have the Insurance coverage required by signature on this permit application" waives this requirement Check one: Owner or Owners AGWd Owner[] Agent ❑ all IM *Pft"anWd s a atlle Massachawnttatb rmatim 1 hM tions p� wAma d (a kation are true and setts State Gas Code � Ch 142�of tfle application U to tom wffh allmY T of Lkense: Title - Gaer � ° or /Town Master License Number 3745'- Journeyman .1 ora Mme F ml .I x a O z I t= - !C H ` u. N •. _i a , N _z � N W N . W 0 a a - a 0 0 � c p O a ora Mme F ml .I x a z I t= - !C H ` u. N •. _i .moi � t - W 0 D a - a � z p O W Q m 0 .J ' a O. Q ' w W ora Mme F ml .I x !C z