Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 26 WEST BRADSTREET ROAD 4/30/2018
2] 1� ! Date t 1 ' .., `�.............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING ssACNUsot This certifies that ....'......�........ .!......-!..... - e. - l`' .................... ..... has permission to perform ..1 .........: �.`.:`..1. .... wiring in the building of.... P.F.. e. atFe�.....Psi....� ..... ..................I1 North Andover, Mass. ............... .. Lic. No.:Z.1 .......... ..... ............... EICAL INSPECTOR C16eck # Commonwealth of Massachuseffs Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy. 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 (MEC), 527 CMR 12.00 (PLEA SE PRINT IN INK OR TYPEALL INFORMATION) Date: / City or Town of. NORTH ANDOVER To the Ins ect�Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) tO H w , Owner or TenantTelephone No. KQJ 7K—)875 Owner's Address Is this permit in conjunction with a building permit? Yes NJ No ❑ (Check Appropriate Box) Purpose of Building t1l 1-k�ettl/ 3--&,4�51 6!, Vc Utility Authorization No. Existing Service Amps 0_2 /1)0 Volts Overhead KI Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity 5_1�#Ie. A v-- zinc A%,7� and Nature ofProposed Electrical Fork: ' Xf Lky // 16, l� 3 Cnsnntaffn" n{fln { 77 .. •..L.. «.. . 7 L,,. ,..7 L.. sL_ r_____ No. of Recessed Luminaires __ V No. of Ceil: Susp. (Paddle) Fans .YINo'. Of VG YYl[[YGU V L/[G l�TOtal r u YY IrCJ'. Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires - . Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets /® No. of Oil'Burners FIRE ALARMS No. of Zones No. of Switches 7 No. of Gas Burners No. f Detection ti tin Devices es i No. of Ranges g / � � • Total No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons KW •'' "" IDetection/Alerting No. of Self -Contained Devices No. of Dishwashers r Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers No. of Water Heaters KW Heating Appliances KW No. of No. of Signs Ballasts Security Systems:*. No. of Devices or Equivalent Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail ifdesired, or as required by the Inspector of Wires. Estimated Value of 1e trical Work: 7 ® (When required by municipal policy.) Work to Start: % Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C RAGE: 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 g BOND ❑ OTHER ❑ (Specify:) I certify, under the ins (indpenalties ofperjury, thn_t the information on this application is true and cor7iplete. FIRM NAME: LIC. NO.:V5,� A Licensee: Al-', 4a I� � r�yAyt . Signature IC. NO.:5P"T- (Ifapplicable, enter "exempt" in the lice a number line.) Bus. Tel. No.��� 3a0 }i f,S Address: Alt. Tel. No.: 17 —S' / -/ yeah *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. 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. $ l �� -- 19LJL'tLL..d.Li1CHL.CERl%ffJ. lel®. ylyJ..etCJIJ.�JL�Ju��J.: ELEC7tMCAL INSPECTOR •-. Fatted-•[ 7 Re -inspection regnirecT($50.00) - r j Inspectors, co en : - r (Xusp ctoxs' Sig�ea itiaTs) Date All T1�K TZO t�% k'assed— [ Failed r ] Re -Inspection required ($50.00) -- [ Inspectors' comments: (pzispectors' Signature •• no initials) Date G F ROUND E\T�I'CTxOJY: Faced- [ ] Re -inspection, required ($60.00) [ J omments: (iuspectors' Signature -• no iuitials) Date D ® OR TAGS APX TO BE I+JOr i=ED 01—UT AND LEFT ON SITE IF THE ARES. TO 3E INSPECTED IS NOT ACCESSIBLE AND A RE 7USPECTION OE X50.0 0 IS TO BE CHARGED. - O The Commonwealth of Massachusetts - Department of jndusfj,1g1Acc!6nts office of Investigations 600 Washington. Street Boston, MA 02111 -www.mass gov1d1a Workers' Compensation Insurance Affidavit: Builders/Cont ractors/Cl ri PleasePrint Leb r gly EpplieaniC Tn£ormaiion Arf—l" Name (Business/Organizationfbdividud): GIW) �/L G �%✓ C G., r . Address:. C� City/SfaielZip:1i�'r� �1l�aj Phone Are you an employer? Check the appropriate box: 1. VT -I am a employer with 4• X am a general contractor and I have hired the -contractors employees (fall and/or part-time)-* 2111 am a sole proprietor or paxtner- listed on the attached sheet.These ship and'have no employees sub -contractors have working for me in any capacity. -workers' comp. insurance. 5. El are a corporation and its [No workers' comp. assurance officers have exercised their required.] 3111required.] a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no employees. DNoworkers' nsurascexequired.] i� comp. insurance required.] Type o£project (required): 6. New construction F 7. Remo doling S. [] Demolition 9. ❑ Building addition 10.[] Electrical repairs or additions ILE] Plumbing.repairs or additions 12. ❑ Roof repairs 13.[( Other 'Any applicant that checks box#1 must also fill outthe section below showingtheir workers' compensation. policy information. Tiomeowners who submit this affidavit indicating they Re doing all work and then hire outside contractors must submit a new affidavit indicating such. t6atractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. X am an employer that is p�ovicXing workeYs' compeitsation insurance fol' my employees: below is the�olicy and job site information. J Insurance Company Name:. 670,W V' //77G� Expiration Date: "/ li Policy 4 or Self -ins. Lic. #: !� �� W e �a'1,Y � job Site Address*. Attach a copy of the workers' compensatioxt-Policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o.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 WORD ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the AIA for insurance coverage ver'if'ication. X do Hereby certi ei' tlae pa' penalties ofpetjury that the information provided alcove is iru a d correct - 1 �� Date: 'o/'d3 ) 3a Official iise only. Do not vrjte !a this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): Y. Board of Health 2. Building Department 3. City/Town Clerk �. 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 biro, - express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two ormore of the foregoing engaged in a joint enterprise, and including the legal representatives of a•deeceased employer, or file receiver or trustee o£ 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 dowelling 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 lie -easing agency shalt 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), addresses) 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 cant' workers' compensation insurance. Tian LLC or LLP does have employees, apolicy is required. Be advised that this affidavit maybe 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 ifyou 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 Deparimenthas 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 permitToonse 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 (ifnecessary) and under "fob Site Address" the applicant shouldwrite "alllocations in (city or town)" A copy ofthe 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. Anew affidavit must be filled out each year. Where ahome owner or citizen is obtaining a license ozpermit not related to any business or commexcial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOTrequired to complete this affidavit. The Office of Investigations would like to thank you in advance for your co operation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone anal fax number: The Cox m. onwalth ofMassarhusetts - • _ Department o£fiatdwtdal Acoldents,� Qfte offAvesiigat< 0m 60 Waftgoa ftxe t: Boston, MA. 02111 TO, 4 617-727_4900 at 406 ox 1-877•:MMSAFE Revised 5-26-05 Fax 0 617-727-7749 v ww'ams,,gov/dj . / '101 !SRI Illy GAN Date ..... /-2 ................................... TOWN OF NORTH ANDOVER This certifies that '04 cl PERMIT FOR WIRING �Z.l ............ has permission to perform ............. ........................................... wiring in the building of .................. nal ................................................... at2 .......... 1, . .... ............ ....... North Andover, Mass. X) . ......... ... . �Fee 5�.4! ... .... Lic. No. ......... 317 .... .. ....... EE� ��i�'2� INSPECTOR ff Check # 13089 k C,ccommonwea[th o�a�ace Official Use Only eCJepariment o��ire �ewice� Permit No. (] Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 C 12.00 (PLEASE PRINT IN INK OR TYPE LL INFO A ION Date:!� / \/ City or Town of: QV To the Inspector of Wires: By this application the undersigned Aives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Q vie -ST - Owner or Tenant iV Owner's Address Our\ Is this permit in conjunction with a buibling permit? Yes ❑ Purpose of Building Telephone No. 9'� 41? No J& (Check Appropriate Box) Utility Authorization No. Existing Service Amps / Volts Overhead ❑ UndFrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Un+d ❑ No. of Meters Number of Feeders and Ampacity / n Location Nature of Proposed Electrical Work: J/ Completion of the followink table 10ay be waived by the In ector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above E]In- 1:1 Swimming Pool rnd. rnd. o. o 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 andInitiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump I Number Tons I KW No. of Self -Contained Totals: Detection/Alerting Devices No. of DishwashersMunicipal;. o Space/Area Heating KW Local ❑ Connection ❑Other 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 T elecommunications Wiring: No. of Devices or Equivalent OTHER: 1— fV V G l/✓J v Attach additional detail if desired, or as required by the Inspector of Wires. 1 Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: p, 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 cover is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: a " G LIC. NO.: -0/7 -?7-7+ Licensee: / S -f-1 (4 J�/\ �]%� J,��,Signature IC. NO.: S (If applicable, ent r�"exem t lice a number line.) ^ (y /� Bus. Tel. No.: �/7 Address: �(% li 41 /- %/fi ill A / ti � F% �—c� � � � , . Alt. Tel, No. - *Per M.G.L. c. 147, s. 57-61, sec nu ty work requires Department of Public Safety "S" License: Lica No. .= a 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 agen. . 1 Owner/Agent Signature Telephone No. ( PERMIT FEE: $ �� a i V -- � "" 1� ti`', is ._s : �.. ".1 � , .....,�., � J\.. \�� ��._a, cHmy s&/®_ z . 7EBS»� oRACUT A5 \ ': »QK« 0«1203 ~'.. 008890 Date ..•.••• pORTM OjOya,.ao ,e ltiOOp TOWN OF NORTH ANDOVER "PERMIT FOR -GAS INSTALLATION This certifies that .. f 4'� .. 5& ..... ... /..... !fl. - has permission for gas installation . tX!?�R?..�r✓�l .�`!?. . in the buildings of ...l�' ..e!%T' ................. at . Z. �['? !. ........ . , North Andover, Mass. Fee,?7,:Sq. Lic. No.Z!�,?7. /,c GAS INSPECT 1(91 Check # \7977 NAASSACHLSEM UNIFORNI APPUCATDN FOR PERM TO DO GAS FITMG (Type or print), Date / NORTH ANDOVER, MASSACHUSETTS Building Locations Permit # LA () wner'S Name Amount $ New M/ Renovation ❑ Replacement ❑ Plans Submitted (Print or type) Q Check one: Certificate Installing Company Mame V J a % 1' — �� ® Corp Address & L4, i Ave�� dt L;e �� �!'l�t, . D/�(G�GJ ® Partner. Business Te ephone C� 2 k— _ —y� —Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 0— No If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy ®/ Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter I42 of the :glass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 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 m� knowledge and that all plumbing work and installations performed under Perinit Issued for this application will be in compliance with all pertinent provisions of the NJUSSachuSCUS Stat (.odt and pter I42 of the General Laws. By: Title City/Town :APPROVED (OFFICE USE ONLY) Pi.gnature of Licensed Plumber Or Gas Fitter lumber �' ) 0 Gas Fitter tc,ense i um�� 11 Master [aJOurneyman c� c4 n � UO ai F F a O z E" ya W W C7 �0� W W E Q v� .� eV 2, �: :7 Ems+ F z c a °� z' o F O 3 a a U z > o SUB -BASEM ENT a a a H C : B A S E M ENT 1ST. FLOOR r 2ND. F L O O R 3RD . F L O O R ---- 4T H. FLOEOR 5TH. FLO 6TH. FLO 7TH. F LO 8TH. FLOOR a (Print or type) Q Check one: Certificate Installing Company Mame V J a % 1' — �� ® Corp Address & L4, i Ave�� dt L;e �� �!'l�t, . D/�(G�GJ ® Partner. Business Te ephone C� 2 k— _ —y� —Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 0— No If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy ®/ Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter I42 of the :glass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 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 m� knowledge and that all plumbing work and installations performed under Perinit Issued for this application will be in compliance with all pertinent provisions of the NJUSSachuSCUS Stat (.odt and pter I42 of the General Laws. By: Title City/Town :APPROVED (OFFICE USE ONLY) Pi.gnature of Licensed Plumber Or Gas Fitter lumber �' ) 0 Gas Fitter tc,ense i um�� 11 Master [aJOurneyman } The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: h,l� City/State/Zip: MAR -f, lYla, Dl � Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ 1 am a general contractor and 1 ployees (full and/or part-time).* have hired the sub -contractors 2. I 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.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 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.❑ Electrical repairs or additions 1 I [J Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #t 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 mustssubmit 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. #: Expiration Date: Job Site Address: 026 Pelo6 t2&A' S City/State/Zip:,V,11,7 ,6W/l 1- 4 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 ujW the pains anApenalties of perjury that the information provided above is true and correct. . ./a Phone #: cl -7 Z/- 7j6 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 #: OF MASS I Date..../ ./ TOWN OF NORTH ANDOVER PERMIT 'FOR WIRING" This certifies that .................... Dz4.1.?4zj.4,.57 ... has permission to perform ..... ...................................................................... ,I wiring in the building of ........... vl:�7�ml ............................................... ✓ ,North Andddov r, Mass. at.. ... LAA3� ...... AF Fee .... . . Lic. No. -V. 7e z ............. ........... 0C ELECTRICAL iMN )ELEcrRICAL I S2ECTOR7 Check J/-..__ 10467 Vii - Commonwealth of Massachusetts Official Use only Permit No. Department of Fife Services Perm -- Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] 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 (PLEASEPRINTIN)7K OR TYPE ALL INFORMATION) Date: 1 City or Town of. A r 7�, 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) pZ 6 Owner or Tenant S-1 i, V:L4,/-e M7r"_ Telephone No. Owner's Address �Sa,Jh2 Is this permit in conjunction with a building permit? Yes ❑ No W (Check Appropriate Bog) q v Purpose of Building /VV mi' , Utility Authorization No. t O Existing Servici f t Amps ®aZc' Volts Overhead Undgrd ❑ No. of Meters l — - New Service J� Amps A / fU Volts Overhead,, Undgrd ❑ No. of Meters —� Number of Feeders and Ampacity Jr� pZ�r� R,yyll p J j J�y(U - I "j- G . Location and Nature of Proposed ElectricalWork: ���� lev✓t �� COmnletinn nfthe fnllnwino inhlo mnv hn wnivod by tho ["c tnr nfWir No. of Recessed Luminaires No. of Cell.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- E] d. d. No. o Emergency i g Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection an Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers eat Pum Totals: Number ons ----.•. No. -of Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑umcipal [IOther Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water Heaters' No. o o. Of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage BathtubsNo. of Motors Total RP Telecommunications W' No. of Devices or EquivaTent OTHER: Attach additional detail ifdesireg or as required by the Inspector of Wires - Estimated Value of Electrical Work: o2U 0 U (When required by municipal policy.) Work to Start: /l/ fl /I J 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 0 BOND ❑ OTHER ❑ (Specify:) I cet7lfy, under thepains andpenaMes of erjkuy, that the information on this application is true and complete, FIRM NAME: Vj een.7- a 2Cei LIC. NO.: Licensee:h e m 7"&,tA Signature _ LIC. NO.:��X (If applicable, enter " empt" in the license number line.) Bus. Tel. No.: �7iPcS'� 7�Y �3 Address: i"I. u� J�✓ /fie,-nt ,r La eLjGf Alt. Tel, No.:27,E —t,7 p *Security System Contractor License required for this work, if applicable, enter the license number here: 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. J PERMIT FEE. $ r O -Z v The Commonwealth of Massachusetts Department of Industrial Accidents Office of InvaWgations 600- Washington Street Boston, MA 02111 www.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Blectriciaus/Plumbers _Applicant Information Please Print Legibly • dame (Business organization/Individual): Address:.U City/State/Zip: ,Kt i1Ge U/ r Phone M Pd 96W / �,3 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ 1 am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction mployees (full and/or part-time).* have hired the sub -contractors listed on the attached sheet. ; 7• ❑ Remodeling 2. am a sole proprietor or partner - ship and have no employees These sub -contractors have 8. ❑ Demolition worldng for we in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑ Building addition [No workers' comp, insurance have exercised their 10-❑ Electrical repairs or additions required.] . ❑ I am a homeowner doing all work _officers • right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12.❑ Roof repairs insurance required] t employees: [No workers' ME] Other comp. insurance required.] Any applicant -that checks box #1 must also fill out the section blow showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional ahcet showing the name of the subcontractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. 'Belo w is the policy and job site information. Insuriinee Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Joh Site Address: City/State zip: jattach 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 ORDERd a fine of up to $250.00 a day against the violator. Be advised that a copy ofthis statement stay be forwarded to the Office fn Investigations of the DIA for insurance coverage verification. I do hereby certify u i the airs t penalties of perjury that the informati64,provided above is true and correct Date._ J Oficial use only. Do not write in this area, to be completed by city or townzoffcial, City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. other Contact Person: Phone M k Date ...... A` .:2- / Z- TOWN OF NORTH ANDOVER (0' � PERMIT FOR WIRING This certifies that .................... ! .. Z.... / ...... ........ f/I� .C... has permission to perform .......................................... .............................. wiring in the building of .. VE. -ru 2 4 WL -57— c at............................................................................. . N%th Andover, Mass. Fee-:-..�.............. Lic. No......... . 2'o..... .:... %',_. ELE ICAL DWECTOR Check # ~-1 '3 ZS 1064A C1Mn jZWea1tA o/ PY/aelac�icseifd officialU�sey/Only c� c�77 [,Rem1,,77,o it N.: el yarlmznl� ar051"e serviced - ccupancy and:;+ee Cfiecked BOARD OF FIRE PREVENTION REGULATIONS (leave blank) APPLICATION ION FOR PERMIT TO PERFORM EL�CTRJCAL. V1.0p, All work to be performed in accordance with the Massachusetts Electrical Code (MEQ, 527 Ci 1R 12.00 (PLEASEPRINT 7V01XORTYPEALLINFORIYMTIO9 Date: §fnl, ;�CityorTowAof: � ��✓ � +� To the Inspecto o By this application the itndersignicr Yes notice of his or her intention to perform the el ctrical work described below, Location (Street &Number) C9 - Owner or Tenant { rjpk_wj yQ Telephone No, Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Bos) Purpose of Building Utility Authorization No, Existing Servic 00 Amps /)Volts Overhead, Undgrd ❑ New Service Amps / Volts Overhe ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Work: No, of Dieters No;,of Meters Cam ledon of thefibllowin,q table may he waived by the Cnspector of Yrires, No, of Recessed Luminaires No. of Cell. Susp, (Paddle) Fans No. of Total Transformers.. KVA No. of Luminaire Outlets No, of Hot Tubs ' Generators 17A �ar� No, of Luminaires a Swimming Pool Above In- rnd. grad., Elo, oz meriency zg hng Batte . Units No. of Receptacle Outlets No. of Oil Burners P , FIRE ALARMS No. of Zones ' No, of Switches No. of Gas Burners Detection and itiatin DevicesNo,-of Ranges No. of AirCo*ud. `TotalfAlertin Tons VNI,of g Devices No, of Paste Disposers Heat PumpNumber Totals; Tons£1Y No, of Sel#=Contained "'-. "........ Detection/Alert!) Devices No. of Dishwashers Space/Area Heating I{W L nl ❑ Municipal ❑Other Connection No. of Dryers Heating Appliances Kyy No, Security Systems;*. of Devices or Equivalent No. of Water KWNo. Heaters of No. of Si Ballasts - Data Wiring: No, of Devices or Equivalent Na. Hydromassage Bathtubs No. of Motors Total HP. Telecommunications Wiring; No. of Devices or E uivalent OTHER; Attach additional detail if desired, or as required by the Inspector of Mres. Estimated Value of Electrical Work: (When required by municipal policy,) Work to Stam 6 A Inspections to be requested in accordance with NIEC 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 coverage is in force, and has exhibited proof of same to the permit issuing office, CHECK ONE: INSURANCE $ BOND ❑ OTHER ❑ (Specify:) I cert, under the pains andpenalties of erjury, that the information on this application is true and complete FIRNI NAME: � X LIC. NO,: >b --d Licensee; �� �. i/n + Signature _ LIC. NO," (If applicable, enter "exempt" in the license number line.) $us, Tel, No.: Address: / ��Ar� �� , ,1.1?rCf'1 , �1� Alt. Tel, No,: � �� *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 laws. 'By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. flwner/Agent 7 Signature Telephone No. PHJU--11T FEE; � - The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UT www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): tY l ie11'f („/L La✓�y 1. i D� Address: ,; on JO y” City/State/Zip: -e LL !, r), M& p t rilq Phone #: 4?7f J6 % �? Are you an employer? Check the appropriate box: L ❑ 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. ❑ I 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.] ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 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.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 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 Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: 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. I do hereby certify under t pains anal penalties of perjury that the information provided above is true and correct Phone #: 7,y - 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 'J 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 a_ny 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 F Information and Instructions 'J 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 a_ny 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 Date.lA .7 ... TOWN OF NORTH ANDOVER PERMIT FOR. GAS INSTALLATION SACHUS This certifies that.. .................................. has permission for gas installation ...................... in the buildings of J*........ ..................... .. at .2 .6 J? It (5�k I North Andover, Mass. ... ..��:Fee. ...Lic. No. .......... G INSPECTOR Check# 6683 MASSACHUSETTS UNN ORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Logationsh / Owner's Name New ( Renovation . D Replacement ❑ u (Print or type) Name Address Name of.Licensed Plumber'or Gas Fitter /712 Z ,' Date�� Permit # Amount S _ YG �d ey e Plans Submitted Check one: Certificate Installing Company Corp. 'ElPartner. Elf;im/co. INSURANCE COVERAGE I have a current liability Insurance policy or it's substantial equivalent Check one: If you have checked Yes, please in ' e the type coverage by checking the aiate boxYes . NoO Liability insurance policy Other type of indemnity the D Bond Owner's Insurance Waiver. Lam aware that the licensee does nat_ have the Insurance coverage required by C:::j Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: ner Agent t hereby certify that all of the details and information I have submitted (or ennterred) in above application0best of my knowledge and that all plumbing work and installation compliance with all pertinent provisions of the Massachuse r ode under Pe Issued for this application will be in as Code and C e 42 of the General Laws. By: Title City/Tovvn•. _ APPROVED (OFMCE USE ONLY) S1 re of Licensed Plumber Or Gas Fitter Plumber14— GC ED Gas Fitter � 'ense I IUIjlurF Master ourneyman Location ;?� No. © Dated NORTh TOWN OF NORTH ANDOVER OOt...o ,1h•0 `a Certificate of Occupancy $ o Building/Frame Permit Fee $ J.�GMSt U Foundation Permit Fee $ Other Permit Fees $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector 3U-40 04/08/99 04:37 31.00 PAID Div. Public Works Lz; n I m cJ i N z (e _� C3 - O UQ UQ � (iV � V Q i _N 9 r" x Z U- 9 � 9 V w * w LO " LU n H J Q * < z 3 W LU .-. L - Ln w Z p _ z � tm n Z � s - �? \ ✓� a G w u e� \� 4 m- cv-J _ < < ^ z N a Z z fc s W L z_ L ^ d < J w Z m (e _� C3 - UQ UQ � (iV V 9 r" x U- 9 � 9 V � . ' w LO " m �ilie "Coana�raaarau�eczLC�, o`�� : ��a4vcrr�udeCl�i DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE Number: Expires: Birthdate; CS 046636 0610211999 0610211948 Restricted JO; 1G RAYMOND E DAMPHOUSSE JR 75 BUTTERNUT LANE METHUEN, MA 01844 HOME IMPROVEMENT CONTRACTOR Registration 101862 Type - PRIVATE CORPORATION Expiration 061/29/00 RAYMOND E. DAMPHOUSSE, JR. & Raymond E. Oamphousse, Jr. 75 utternut Lane � ADMINISTRATOR Methuen MA 01844 I 9 s.� I w w o a Q o ro w° U w O x° cn w O v w W °D C40 u V) ro w a Go ao c�° � w z w w w v m z cin I Q x o � .. o : m c g c � o � C H O C A O _V V G C R O 0 C L C O Cc 0 Ee :� c 'mom L G) o c N O GD CL.+ O O Ucm ECO c a N �O CD CD CD d. N N CD 3 L m N C m m O W .= N N O O E m 0 m CL C-) L� CD N m L Of m co m cc Z o` C Of CD O d C N C .O CD O N N •O+ ® (D L m ru O c A CO C C.3 'O C0.1 .N CD O - C O s 0 E Z co CL O y ® C Ico Om C � O •� � ® Z3 CL)•S •E- c CD © co �.+ CL CD CS Loft C13 CD cc O cm< y C ® caC Cc ¢_J J .0 .Q ® CD co c C c CLy o � • _0 U) LLI U) IrW W cr W. w U) Q 2 � O GO W_ C � H � W WE C.3 V 0. CL S2 N co H .. o : m c g c � o � C H O C A O _V V G C R O 0 C L C O Cc 0 Ee :� c 'mom L G) o c N O GD CL.+ O O Ucm ECO c a N �O CD CD CD d. N N CD 3 L m N C m m O W .= N N O O E m 0 m CL C-) L� CD N m L Of m co m cc Z o` C Of CD O d C N C .O CD O N N •O+ ® (D L m ru O c A CO C C.3 'O C0.1 .N CD O - C O s 0 E Z co CL O y ® C Ico Om C � O •� � ® Z3 CL)•S •E- c CD © co �.+ CL CD CS Loft C13 CD cc O cm< y C ® caC Cc ¢_J J .0 .Q ® CD co c C c CLy o � • _0 U) LLI U) IrW W cr W. w U)