HomeMy WebLinkAboutMiscellaneous - 29 SECOND STREET 4/30/201801
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AP, Date...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .... V....
..............................
has permission to perform ? 46 r, I/ .. W
wiring in the building of ....... 1.9 .. ..... . ...................
at ....... ..................... ....... . NorthAmdover, Mass.
..........
Fee. Lic. No. )*U ...... ......
Check 7 :3*9 ELECTRICAL INSPECTO
,7052
T -A
Commonwealth of Massachusetts Official Use Only
Permit No. 7PS-2—
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/051 0,a,eblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (M Q, CMR 12.00
(PLEASE PRINT IN INK OR 7-YPE ALL INFORMATION) Dat X�A,6
City or Town of. NORTH ANDOVER To the Inspectorlof Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & NWn�er) '21 -s'e-e-AVI
Owner or Tenant Vck�l-t(-k-q can�-t� Telephone No.
Owner'sAddress R& 4V-ki05dY-\-AR
Is this permit in conjuaction with a building Yes [jj� No (Check Appropriate Box)
r
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permit?
Purpose of Building awe� Utility Authorization No.
Existing Service = Amps Volts Overhead 0'--- UndgrdE:l No. of Meters
New Service Amps
Number of Feeders and Ampacity
Volts OverheadEl UndgrdEJ No. of Meters
Location and Nature of Proposed Electrical Work: balk ��41ocje(
Completion of thefollowing able may be waived by the Inspector of Wires.
No. of Recessed Luminaires /C?/ -z
4%E I
No. of Ceill.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above Ei in- —1Vo--5-rYm—e-rgency
Swimming Pool grnd. grnd. r 1
Lighting
B ttery Units
No. of Receptacle Outlets 2
No. of Oil Burners
FIRE ALARMS
INo. of Zones
No. of Switches -a
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
HeatPu pINumb,erlTons
Totamis:
KW
I
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers If
Space/Area Heating KW
Local F1 Municippi El Other
Connection
No. of Dryers
Heating Appliances KW
Security Svstems:*
No. of f3evices or Equivalent
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
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: (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 [I BOND OTHER F-1 (Specify:)
I certify, Under ql!�j andp4�na i Of i
perypi tat the informatio,"n isYplicationis heandcomplete.
FIRM NAME: tc 1--7)r- L-101r7f LIC. NO.:
Licensee: CXe(ne1JQt Signature Z ZY LIC. NO.:
(If applicable, enter "e.kempt " in#he license number line.) Bus. Tel. No.:
Address: Alt. Tel. No.:
*Security System Contractor License required for this work; if applicable, enter the license number here:
OWNER'S INSURANCY WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
y la
required b, m. y in ig ure beloV. I hereby waive this requirement. I am the (check one) 0 owner
y 1-1 owner's agent.
.79'1 L1dS-6V6FPERMIT FEE.- $
Owner/Agent
Signature Telephone No.
Ra4t �t - &h f — 3 o.— cq -7 — P41
j — 0 -1 04%
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114 �LThe Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Ledbly
Name (Business/Organization/Individual):
Address:- 2,tse cc)rld sf:
City/State/Zip: 6_� AJO-1114-4- 0/4Phone#:_n1 Y(15� &,n6
Are you an employer? Check the appropriate box:
1. M I am a employer with
4. El I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2.E1 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. El We are a corporation and its
;equired.]
officers have exercised their
3.92"'1 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.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. R New construction
7. E];4te-5odeling
8. R Demolition
9. F1 Building addition
I0.E1 Electrical repairs or additions
ILE] Plumbing repairs or additions
12.R Roof repairs
13.R Other
*Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy infon-nation.
f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
I
+Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workets' comp. policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjoh, site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:fi�:,-,?H-tiAnc&-)g--
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 'he 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 celify un
.LLhepins#ff ea6lties ofperjury that the information provided abqvejs
!�p_ ,�rye and correct.
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 #:
Date
-7
,ORTk
Oz.
TOWN OF NORTH A D -OVER
I
PERMIT FOR GAS UN17TALLATION
%-It-
This certifies that ... .............
has permission for gas installation .1 .................
in the buildings of e. � j ..............................
at .......... I North Andover, Mass.
Fee.?Q��. Lic. Nojt(�?-.�.. . . . !4:-. . .....
"GAS INSPECTOR
Check #
6174
MASSACHUSETrS UNIFORM APPUCATON F`OR PERNUF TO DO GASffrnNG
(Type or print) Date A la -7
NORTH ANDOVER, MASSACHUSETTS
Building Locations Se- e & t�l ko
W— Permit #
A) 4AJ VIVC4, k-" ,7r C.- Owner's Name Amount $
Newp Renovation Replacement Plans Submitted
(Print or type) Check one: Certificate Installing Company
Name - 0 A L/I 49 /Z -?V 0114 4V .. 0 Corp.
Address a /I I/ e, �–/z L--Z�- r — 1:1 Partner.
Business Telephone 4417a<- —
2 77J- 6k7 1jJC- - Firm/Co.
Name of Licensed Plumber or Gas Fitter D400 it ".)
INSURANCE COVERAGE Check one:
I have a current liability Insurance, policy or it's substantial equivalent. Yes M NoO
If you have checked ves, please indicate the type coverage by checking the appropriate box.
Liability insurance policy rM Other type of indemnity Bond
LOGIk 13 13
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 Check one:
Owner 13 Agent 13
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 and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachuseq&SWe Gas Code W Chapter 142 of the General Laws.
e— - —S
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
[3 Plumber
[3 Gas Fitter License Number
Master
Joumeyman
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(Print or type) Check one: Certificate Installing Company
Name - 0 A L/I 49 /Z -?V 0114 4V .. 0 Corp.
Address a /I I/ e, �–/z L--Z�- r — 1:1 Partner.
Business Telephone 4417a<- —
2 77J- 6k7 1jJC- - Firm/Co.
Name of Licensed Plumber or Gas Fitter D400 it ".)
INSURANCE COVERAGE Check one:
I have a current liability Insurance, policy or it's substantial equivalent. Yes M NoO
If you have checked ves, please indicate the type coverage by checking the appropriate box.
Liability insurance policy rM Other type of indemnity Bond
LOGIk 13 13
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 Check one:
Owner 13 Agent 13
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 and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachuseq&SWe Gas Code W Chapter 142 of the General Laws.
e— - —S
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
[3 Plumber
[3 Gas Fitter License Number
Master
Joumeyman
Date.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBINGZ
This certifies that ... /f. ....... P.
has permission to perform .... A .<- y .' t..
.................
plumbing in the buildings of ........................
at ... )..5 ... �� C'. .'. , . . . � .................... " North Andover, Mass.
Fee.6-3. Li c. No.. ..........
- hw� M-BING INS C OR
Check#
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."� ff`�
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enw2d Laws. rn:1 that M�l zignature or, this permfl aPP11cation walv= this requir
.err.
Check one:
P.
Ch
-ener Agent,
hfireb)'-M6'ffizt M11 Of the MWL� and infamlafion I have =b
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rriftied (or enters�,,.� above Appficaflon. are irlp- 2nd th-
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Chtmk one:,
Certricate
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Name of Li=rlsed Plumb --r
PLS.M:�,CE COVERACE.
"nt habitity Imu Por1cy Or fts subst2ntial eQuIvalerif
yes mr1m
which mLLets
9L No the requireLmeft of MGL Ch. 142.
If YOU have checked.=
--P. ;*=L, indicate the. b,;>-- coverage ty ch=king the appropriate b=
liElAity in'Eurance, pojjc�, Other bq>-- c;,. irjda=jty ED .
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enw2d Laws. rn:1 that M�l zignature or, this permfl aPP11cation walv= this requir
.err.
Check one:
P.
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-ener Agent,
hfireb)'-M6'ffizt M11 Of the MWL� and infamlafion I have =b
Pelli
rriftied (or enters�,,.� above Appficaflon. are irlp- 2nd th-
Aw chapter 142 of lk Generaf Lawr. COMPliance wffh all
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TOWN OF NORTH ANDOVER
PERMIT FOR
This certifies that /C .......................
has permission for gas installation ...... A,. ..........
in the buildings of ... 14., ................................
....... . North Andover, Mass.
at
Fee. .3 tc,.� . Lic. No..) e-! J. i ......
GASINSPECTOR
Check#
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Building Loaatior;
6e(fo�?d -S�, Owner's Name
TYPe of Occupan-y-J?-cs-
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kddress 4
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New 0 Rencivati6n 4 Replacement 0 Plans Submitted: Yes[D NoR
certificate
NSURANCE COVERAGE:
lhave a current liability insurance Policy or its substantW equivalent which m
Yes, W- No 0 eets the requirements of MGL Ch.
VyOU have.checked yes, Please Indicate the type coverage by checkingthe approprkife box.
Aliability insurance policy 0
Other type of indemnity 0 . Bond 0
142.
ICWNER*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 �er�Wappjication waives this requirement.
Check one:
k-vmef Or Lmner S Agent OwnerO Agent
I hereby certify that all of the deWls and information I have submitted (or entered) in above PPlication are true and accurate to the best of my
kAovAedge and that all Plumbing work and installations Performed under the permit iSSU a
Pertinent Provisions of the Massachusetts State d lot this appliration M11 be in compliance with all
13y . Gas Code and Chapter 142 of the Gener:l Laws.
----------- of License 6
Title -------------- Pl.:nbe �Yjjdlure of Ucensed Plumber Or Gas --ritter
'EG ;filter
aty'rTown M. I., License Number
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Location
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No. t -111 —
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Date q It *,"
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Feef?eldy $
Sewer Connection Fee $
Water Connection Fee $
TOTAL $
Building Inspector
Div. Public Works
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