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Home My WebLink AboutMiscellaneous - 295 BRENTWOOD CIRCLE 4/30/2018 (2)Date ..... yr .... Y/.`/" n ..... 11372 40RT TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING CHU &This certifies that ..... .. .... ...... ...................... ..................... ha s pe rmission to perform ... ............................................ plumbingin the buildings of ......... ................................................................................... at ......... North Andover, Mass. J . . ........ . Fee<;5) . . ...... Lic. No. ..... .................................. ECTOR Check INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGIL Ch. 142. YES P-15-0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY R--" OTHER TYPE OF INDEMNITY D BONDE I 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. I CHECKONEONLY: OWNER 0 AGENT IR -1 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 and accurate to the st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be 17� ,, �e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 2 all Pe * nt ovision of the PLUMBER'S NAME LICENSE# SIMAT6RE MP WK'jP [JI CORPORATIONEI#=PARTNERSHIP I # LLC COMPANY NAME )L V,_ x 5;, ADDRESS 47 CITY STATE ZIP TEL FAX CELL EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK c1TY[M MA D E 11PERMIT# JOBSITE ADDRESS OWNER'S NAME LA4" P OWNER ADDRESS TEL FAX TYPE OR OCCU PAN CY TYPE COMMERCIAL EDUCATIONALE] RESIDENTIALQ— PRINT CLEARLY NEW: RENOVATION: F1 REPLACEMENT: PLANS SUBMITTED: YES[] NO FIXTURES -4 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIIJSAND SYSTEM I DEDICATED GREASE SYSTEM ZE DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREADRAIN L. _j INTERCEPTOR (INTERIOR) — — - - - - I ___j; —1 KITCHEN SINK —A _1_A _j LAVATORY ROOF DRAIN HOWER STALL ERVICEIMOPSINK JOILET URINAL L_j ___j _-_ j ___1 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES L-1 WATER PIPING OTHER I J F-7-1 ___j _J I F_ III Ill Ill I I I I I I I F-1 I III I 7=11=1 I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGIL Ch. 142. YES P-15-0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY R--" OTHER TYPE OF INDEMNITY D BONDE I 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. I CHECKONEONLY: OWNER 0 AGENT IR -1 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 and accurate to the st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be 17� ,, �e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 2 all Pe * nt ovision of the PLUMBER'S NAME LICENSE# SIMAT6RE MP WK'jP [JI CORPORATIONEI#=PARTNERSHIP I # LLC COMPANY NAME )L V,_ x 5;, ADDRESS 47 CITY STATE ZIP TEL FAX CELL EMAIL .R z 4) >(n El LLI M 6i LLI LL I The Commonwealth of Massachusetts Department of industrialAecidents I Congress Street, Suite 100 Boston, KA 02114-2017 www.mass.govIdia etors/FlectricianslPhIpibers. Worke& Compensation Insurance Affidavit: Builders/Contra, 1. . I TO BE FILED WITEL TEIE PEF-WTT�NG AUTi[ORITY- Name (B,siness/bigali�,.iiowbdivid,,al): 1-�_ Address: �s 17 City/State/Zip:_ Are you an emp�oyer? tfic approPriate box: ^?jfh-one # - �e 7 r— 9 1 r , I-0 I am a employer -with ___ . _.�emPloy' `3 (W and/or part-time).' 2.1ar— asole proprietor or VartnershiP and have no employees vvoiking for me in any capacity. [go workers' comp. insurance 1equired.] 3.E] I am a homeowner doing all work myself [No workers, comp. insurance required.] 4. r] 1 am a homeowner and vAU be hiring contractors to conduct all work on my property. I WEI ensur e that all contractors qi�her have workers' compensation insmance or arc sole proprietors with and I have hired the sub -contractors listed on the attached sheet. S.F] I am a general crmtr4ctP�,, - .. - ' These sub-contractois bav6 employees and have workers' comp. insuranceI 6.FJ We are a coI and its, Officers have exercised their right of 'exemption per MGL c. 11�1) RJ(Al andwe ha�b r� emPldydes. [No workrrS7 CoMp. insurance requ=d.] Type of project (�equlrell)* 8. kemodelli,19 9. El Demolition JOE] Building addition I I.L] F 9 _ ,lectri al rpp.*s or additi9ps 12, 1 airs or additions ,E]PIpmbingrep 11 Lj Robf re*� 14. n Other ----- so irwo-rkers'rompensationpoRoyffifo-atiOn-' *Any applicant that cbeial�g IpMxYF�l st ;a 1 M out the section below showing the hire outside contractors must submit a Em affidavit indicating such his affideAt indicating they are doing all work PnElfaell or not those prrtiges� haVc 'i 11craeowneis who subn4.t. _ - - sub -contractors and stat9whetheT d. hn additional sheet showing the name Of the lContractors that checkthis box must attache -ve emploYccs, they must provide their workers' 00I Policy nbr- employees. If the sub -contractors ha Ivorkers, compensation insurancefor mY MPIOYees- Relow is thepolkey andyob sit� I am an eMployer that is providing information. fnsurance Company Policy # or Self -ins. Lic. Expiration Date' City/State/Zip- fob Site Address compelasation policy declaration page (showing the policy number and expiration date). Attach a copy of the workers' on punishable by a fiftb up to $1,500-00 pailure quired under MGL c. 152, §25A is a criminal violati , to secure coverage as re e form of a STOP WORK ORDER and a fine of up to $250.00 a and/or one-year imprisonment, as well as civil penalties in th th 1A for insurance day against the violator. A copy of this statement may be forwarded to the Office of fnVestigatiOns Of a D coverage veriflcation��,: ! ��) , �I I,= :: , �, �� , 11 , 15 � : ,, , I ��: ation provided above is true and correct ,1JI ''' ,I 1 11111 0,644erjurythatthein fdo hereby cei Y or town Official 0 f _ft ia, Se 0.1 Y. Do not write In t1lis area, to he completed by cit Permit/License City or Town: issuing Authority (circle 01 1. Board of Health 2. Building Department .3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone Contact Information and Instructions Massachusetts General Laws chapter 152 requirM all employers to provide workers' compensation for their euiObyl�es. Pursuant to this statute, an employee is defmcd as every person in the s ervic e of another under any contract of hii�, express or implied, oral or written.,, An employer is' deffied as "an individual', Partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in ajoint enf6rprise, and including the legal representatives of a deceased employer, or the receivbf,6r, trustd6 6f an individual, partnership, association or other legal entity, employing ernployee�., However the owner of a dwelling house having not more than three apartments and who resides therein, or the oco'up- �.nti 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 bd 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 op6rate a business or to construct buildings in the commonwealth for any applicant whd has not produced -acceptable evidence of compliance with the insurance coverage r I eq : uired." Additionally, MGL chapter 152, §25C(l) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acce p'table evidence of compliance with the insurance requirements of this� chapter have been presented to the contracting authority." Applicants Pleasb fill out the Workers, compensation affidavit completely, by checking the boxes that apply to your qituation and, if nec6sary, supply sub'contractor(s) name(s), address(es) and phone number(s) along with their cartificate(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 anLLC oALP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confumation 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 requ�sted, not the Dep'artment of IndustTial-Accidenis. §hould you have any' questions regarding the law or if you are req*d . to obtain aw''o'rkers' compensatiori policy, please, call the Department at the number listed below. Self-iusurod companies should enter their Self-insuraric-e license number on the appropriate he. 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 me to fill in the permit/license number which will be used as a reference number. lu 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 ity or town)." A copy of the affidavit that has been officially stamped or -(c marked by the city orto m.may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A now 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 bum leaves etc.) said Person is NOT required to complete this affidavit. The, Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 Tel. -# 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia I..kijtOMMONWEALTH OF MAW6USETTS F— _57 _ c) ^ Date............................... 6 TOWN OF NORTH ANDOVER PERMIT FOR WIRING A US This certifies that ............... .......................... has permission to perform .................. ........................................... M /9 C AMa �'.' wiring in the building of ........... j ........................... at ...... Aort An over, Mass. h d Fee ... �57�7� Lic. No—V ................ il�� . .. ...... PICAL �IN�SP�E�C�MR ,;7t Check # 8282 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Z 2? 2 - Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS I [Rev. 1/07] Qeav, 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 PRJNT ININK OR TYPE ALL INFORMATION) Date: a. 05-- 0a 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) 2 C/ 5- ;Y d,ec..v 7, z, Owner or Tenant tA g, " 4) � 114 1 Telephone No. Owner's Address /rCt, r A VZ Is this permit in conjunction with a building permit? Yes U- No [:] (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead F1 Undgrd [I No. of Meters New Service Amps Volts OverheadEl Undgrd El No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ComDlelion of the following, table may be waived hy the In ectornfWires No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers K -VA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above Ei In- grnd. grnd. f 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 and Devices No. of Ranges No. of Air Cond. Total Tons —Initiating No. of Alerting Devices No. of Waste Disposers Heat P Totals: umber ............... I Tons I ....................... I KW .......... ........... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local [] Municipal Connection ElOther No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water Heaters KW 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: e17 110 (When required by municipal policy.) Work to Start: G) 0, — 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 [-] BOND [-] OTHER [] (Specify:) I cetWft, under the pains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: J( Signature LIC. NO.--k-�- J 14Z (If applicable, enter "exempt " in the license number line.) Bus. Tel. No.: 4v j� 9 7 0 11 � 9 Address: L' ? /-14 X L' 0 ct V� X d IV, --,'f- - 0' 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 law. By my signature below, I hereby waive this requirement. I am the (check one) F] owner Elowner's agent. Owner/Agent Signature Telephone No._ EE: $ __[PERMITF f- .5 , 06. m .� 44 I r Ll The Commonwealth ofMassachusetts Department ofIndustrial 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 Legibly Name (Business/Organization/Individual): �ddress: k //4j C1 .ty/State/Zip: 10-e �V /V, /-/, o Phone #: e o z Are you an employer? Check the appropriate box: 1. El 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. ElVam a sole proprietor or partner- listed on the attached sheet. t 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 required.] officers have exercised their 3.0 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. F New construction 7. Remodeling 8. Demolition 9. [] Building addition l0.F1 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.F Roof repairs 13.F Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information, � Homeowners who submit this affidavit indicating they are doing 0 work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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"insurancefor my employees. Below is the policy andjob 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. I do hereby certify under thepains andpenalties ofperjury that the information provided above is true and correct. Signature: Date: elf—a5— —0 Q Phone#: w' S- a 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.'7F .-. ��. N2 4724 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Wile f This certifies that ................... has permission to perform ................... /?4 - — '— ................ plumbing in the buildings of .... . at . ...... North Andover, Mass. Fee,'��. ... Lic. No .......... ....... ........... PLUMBING'INS ECTOR Chbck # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer A— lVLASSACHUSETTS nL TFORM APPLICATON FOR PE RMIT TO DO'dAS F=(; i, ype or print) t e -2- NORTH ANDOVER, MASSACHUSETTS , V,11,0� Building Locations Permit# A), 1197 -,Da, -C New Ell/ Renovation Owner's Name Replacement Plans Submitted Amount S (Print or type) 1(la ' &�2( . . Check one: Certificate Installing Company Naine c- k )L/� L-4 Corp. V Address "XI—le) F-1 Partner. Business Telephone Fq-F4r`miCo. Niame oFLic.-n5ed Plumber or Gas Fi fNSUPLANCE COVEKAGE Check one- — I have a current liability Insurance policy or it's substantial equivalent. Yes Nom I rvou have checked ves. p lease indicate the tv pe coverage by checking the appropriate box. Liabilitv insurance policy Other ty pe of indemnity Bond 71 F7 'a Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the iMass. General Laws.. and that my signature on this permit application waives this requirement. I Check one: Sianature of Owner or Owner's A-ent Owner A2ent I hereby c,,-,ziN that all of the details and intbi-maiion I have submitted (or entered) in above application are true and ac --urate Lo the best ofmy knowledge and that all plumbing work and installations pe�brmed under Permit Issued For this application will be in complianc.- with all pertinent provisions oFtht!-.Ivlassachusetts St t Q s Code aqd Chapter 142- ofthe General Laws. a Bv: Title City/Town �kPPP OVED (ovricl- USE !)NLY1 SiQnature of Lic,-msed Plumberl6r Gas Fitter ED--rfurnber :�6t ( , q 2- 7 Gas Fitter Uc--Fise Fiurrioe- F-1 Master F7 kumeyman N2 2018 A Mus Date//—.��—.'59P .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that A.a. ................................... has permission to perform .......................... ......... 7 ............................... ....................................... wiring in the building of., ....... ! ............ North Andover, Mass. at-....),.) ............. .......... ................ Fee ...... Lic.No/ ........... i-a 0 '--ELEcrRicAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 4 Office Us:45,nly 01 4e (Iotntnonwtal� of fiassa0lioetts Permit No. Elepartintnt of Public buftti;l Occupancy A Fee Checkedlk-w— (leave blank) BOARD OF FiRt PREVENTION REGUUTIONS 527 CMR 12 -.W APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 11/10/99 City or 'Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform the electirlical work described below. Location (Street & Number) 295 BRENTWOOD CTRCLE_ Owner or Tenant JULIA LAMPHAM (978) 689-8902 Owner's Address Is this permit In conjunction with I% building permit: Yes C3 No (Check Appropriate Bok) Purpose of Building Utility Authorization No. Existing Service Amps Volts overhead C3 Undgmd C3 No. of Meters Now Service Amps volts Overhead 0 Undgmd 0 No. of Meters Number of Feedem and Ampacity �Ocatlon and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tube Total No. of Transformers KVA No. of Lighting Fixtures Swimming Pool AbOveo In - grnd. grnd. C1 ..nerators KVA No. of Emergency Lighting No. of Recoplacle Outlets No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones Tbtal No. of Detection and No. of Ranges No. of Air Cond. tons Initlating Devices No. of Disposal* No.of Heat Pumps Total Total Tons KW No. of Sounding Devices No. of Sell Contained No. of Dishwashers SpacWArea Meeting KW Detection/SoundIng Devices No. at Dryers Nestling' Devices KW Municipal 0 Other Local 13 Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Mnrfng BURGIAR ALARM & DEVICES No. Hydro Massage Tubs No. of Motors lbtal HP OTHER: THREE SMOKE DETECTORS INSURANCE COVERAGE: Pursuant to the mquirements of Massachusetts general Laws I have a current Liability Insurance Policy Including Completed Opgrations Coverage or Its substantial oQuIvalent. YES 0 NO 0 1 have submitted valid proof of same to the Office. YES 0 NO 0 it you have chocked YES. please Indicate the type of coverage by checking the appropriate box. INSURANCE 0 BOND. 0 OTHER 0 (Please Specify) (Expiration Date) Estimated Value of Electrical Work 3 726.00 Work to Start - 11/9/99 - -- Inspection Date FlOqU63ted: Sough Final 11 Signed under the Penalties Of P*du(Y: FIRM NAME ADT Spnurity Servicea . Tnr-. —LIC. NO. —LIC. NO. .1231C- Uciinsee_nnnald A- IRrnnkq Signature M3 Bus. Tel. No. -) '741�4008 Address 111 Morse Street, Norwood, MA Ali. Tel. No. -42ZJ,)- )38-1 13L - OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have ft Insurunce coverage or Its substantial equivalent as (0- quited by Massachusetts General Laws. and that my signature. on this permit application waives this riliquirement. Owner Agent (Please Chock one) % ... Telephone 14o._— PERMIT FEE S - 35.00�