HomeMy WebLinkAboutMiscellaneous - 30 IRONWOOD ROAD 4/30/201880
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ............ V11 1.
................
has permission to perform ......... .... Wv, .......
plumbing in the buildings
..................................
at .................. :� ............ I'X. ..................... North Andover, Mass.
Fee..�o .............. L i c. N o .. ..................................................................................
PLUMBING INSPECTOR
Check # 20A
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
POWNER
TYPE OR
PRINT
CLEARLY
CITY MA DATE /0/'JPZ/.-2C PERMIT #
JOBSITE ADDRESS Ir%^wW0J- ft�- OWNER'SNAME Gre�
ADDRESS SA. -I Z-- TEI-60-351-/0,00- FAX
OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL Ej RESIDENTIAL
NEW: RENOVATION: El REPLACEMENT: PLANS SUBMITTED: YES E] NO
FIXTURES -1 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/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR / AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOPSINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current !jg�insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [K] OTHER TYPE OF INDEMNITY El BOND El
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER [I AGENT
SIGNATURE OF OWNER OR AGENT /-1-)
I hereby certify that all of the details and information I have submitted or entered regarding this application are tru an accura to the Vestof y knowledg
and that all plumbing work and installations performed under the permit issued for this application will be in co lian?el �h Pertine provi on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Peter G. Viens LICENSE # 12116 SIGNATURE
MP M ip F-1 CORPORATION # 3631 C PARTNERSHIP [-I # LLC E:1 #
COMPANY NAME Merrimack Valley Corp ADDRESS 15 Aegean Drive Unit#3
CITY — Methuen STATE Ma ZIP 01844 TEL (978)689-0 24
FAX CELL EMAIL pviens@mvalleyco[p.com
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Date .......
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TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
'A e—A— V, -
This 'certifies that ......... p ........................ 1 0 --,1-)
...................................................................................
has pennission for gas installation ..... �N� .......................................
in the buildings of .............. -a�
%J-0 North Andover, Mass.
at ........................................
.......................
Fee ;�2 . . ....... Lic. No. ...... .....................................................................
............
Check #2kkoA GASINSPECTOR
10233
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY kOIA,41�014141- MA DATE & _71
/j I //S— PERMIT# 101z
JOBSITEADDRESS60 lcOv',Ludu� f2 OWNER'S NAME ka-elm 6- Jt 0-4--4—
GOWNER
ADDRESS TEL& 7-331- POV FAX
TYPE OR
OCCUPANCYTYPE COMMERCIAL [I EDUCATIONAL El RESIDENTIAL E9 --
PRINT
CLEARLY
NEW: RENOVATION: El REPLACEMENT: El� PLANS SUBMITTED: YES F] NO [j;�
;A I
APPLIANCES FLOORS— esm 1 2 3 4 5 6 7 8 9 10 11 12 �'A 3 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
'4
LIABILITY INSURANCE POLICY 91 OTHER TYPE INDEMNITY BOND
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER [-] AGENT Ej
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 u te to the best of my 4'0�e
and that all plumbing work and installations performed under the permit issued for this application vAll be in complianc " all Pertin( ision C�
t e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. tr
PLUMBER-GASIFITTER NAME Peter G. Viens LICENSE # 12116 SIGNATURE
MP El MGF F-1 JP [_1 JGF E:1 LPGl CORPORATION R] # 3631 C PARTNERSHIP [] # LLC #
COMPANY NAME Merrimack Valley Corp — ADDRESS 15 Aegean Drive Unit # 3
CITY -Methuen STATE MA ZIP 01844 TEL (978) 689-0224
FAX CELL EMAIL pviens(@_mvaIIeycorp.com
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I�te Commonwealth of Massachuseles
Department of IndustrialAcciderets
Office of In vestigatioKs
600 Washington Street
Boston, MA 02111
www.m ass.gov1dia
0 Wo*rkersl Compensation Insurance Affidavit: Build erslCarg tra c�ars/Electricia ns/flumbe rs
Please Print Legibly
Name (Business/organization/indi�,idual): Ile,
Address:.
City/Stale/Zip: 7111-?.;- //" C,,�A��Xl Phone
A reyou an employer? Check the zppropriate box:
I am a employer with —
4. R I am a general contractor and I
ernployees (full and/oi- part-tirne).*
have hired the sub -contractors
2. C1 I am a sole proprietor or partner-
listed on the atlached sheet.
ship and haveno employees
These sub -contractors have
working for ine in any capacity.
employees and have worl<ers-,
[No workers' COMD. insurance
comp. insuranceJ
required]
3. 0 1 am a horneowner doing all work
myself [No workers' comp.
inswranCe required.] T
F] We are a corporation and its
officers have exercised their
Tight of exemption per MGL
c. 152, § 1 (4), and we have no
employees. [No workers'
comp. insurance MqUired.]
Type of project (required):
6. D New construction
7. E] Remodeling
8. F� Demolition
9. Building addition
10. Electrical repairs oi- additions
l ].[] Plumbing repab-s OT additions
12.El Roof repairs
13. Lt�-Other_er��- A�J..
*A_ny 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 all work and then hire outside contractors Must SUbmit a new affidavit indicatir.- such.
1, -
,ont(aciors th2t check this box must attached an additional sheet showing- the narne of the sub -contractors and state whether or not those entities �ave
they Must provide their workers' comp. policy number.
A,bn employer that isproviding workers' compensation insurancefor my employees. Below is thepolicy andjob site
information.
In s i. i r a n c e C o m p a n y N a m e:
Policy # or Self -ins. Lic. fl: .10"A4411—)z 416�,41 31 Expi�ration Date: 1�-
Job Site Address:,10 Ir4bV%&J" A City/Slate/Zip:_AL. /41 ur—It , Mf, Do-vi—
Attach 2 copy of the workers' compensation policy declaration page (showing the policy number and expiration d2te).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the 11-riposition of criminal penalties of a
fi-ne up to S1,500-00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WOU ORDER and a fine
of lip to S250.00 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.
1 (70 44zi_eb
� y certify under thepnirts andpenallies ofpejuiy that the information provided above is tride and correct.
sip -nature: mse._,- rwa�X �/, / 6 11.Y
_VlLk�*Z Wate:
Phone 4:
Ofjleial use only.. Do not wrile in this area, to be completed by city or town official.
c
City or Town: Perm it[License 9
-7
Issuing Autho)-ity (circle one):
V 7Plumbing I
1. Board ofHealth 2. Building Department 3. City/Tomi Clerk 4. Electrical Inspector- S. Plumbing Inspector
Ot her
,;act Phone
COMMONWEALTH OF MAM- ACHUS "T
v TA,
BOARD, OF
PLUMBER$ AMD GASF.ITTE�A.S..
'Ll'CENSE
ISSUES THE F 0 L L OW [N -G
L I C� ENSE01- AS A JOURNEYMAN P L U MB E 'R'..
PETER G VIENS
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9' BLUEBURD LAN:E
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ATXfN ON W O�3911-2362
0 M M 0 N)�%� 1 0 F M
M 9141 3W.,J01 2 W15,
ARD OF
P L UMB EAS A NO G A S F I TT EALS
ISSUES THE F OL L O'd I� LICENS
.:Lftffl--S810 AS A MASTER PLUMBER
PE T E:R G VIENS
9 BLUEBIRD LAN�E
-ATKIN5ON ItH 038 11-2302
12 1 T�!&
FKRWM -
Commonwealth of Massachusetts
Department of Public Safety
Hoisting Engineer
4
-110323
License:HE
PETER G VIENSP-
Peter Viens 9 BLUEBIRD LN
Cert # 1023121001-12 ATKINSON Nff 03, 4
Expires: 10/23/2015 tit
Certification g"4, Expiration:
N. F. P.A. 99-2012 ed. commissioner 11/113/2015
ASSE 6010 InstaRer & ASME IX Brazer
State of Now Hamiishire
State of MECHANICAL IDENTIFICATION
*,.Hampshire
GAS FITTER E
PETER VIENS
NAMEi PETER V,11 NAME:
4
ENDORSEMENTS:- P
LICENSEREGISTRATION #:
DATE ISSUED: 10/1512013
SERVICE GFE0700587
DATE -EXPIRES: 1113012015 MASTER 3249 7 3 #
LICENSE #:GFE0700587
.1113012016
RATIO�5: 2
commonwealth of Massachusetts
Department of Public Safety
OSHA 600316337 License: PMU-001088�
Pipefifter Unrestric�ted Master
U.S. Department of Labor
Occupational Safety and Health Administration Peter G Vi ens
9 BLUEBIRD 1A.E
Atkinson NH 0361,11 W.14
Peter Viens
has successfully completed a 30 -hour Occupational Safety and Health
Training Course in
Gonstry tion Safety & Health Expiration:
11113f2016
commissioner
(4407R—Ice 6071
Date................ ..... . ..........................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ..... f k H
....................................................... ....................... ..... jp ............
has permss . ion for gas installation A -�� 42
....................................................................
D
in the buildings of .......... (
......... ............... ...................... . North Andover, Mass.
Fee ... Lic. No. .�ND
GASINSPECTOR
Check #
.1;1
it
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY '11164_1 MA DATE 111�9e�))
lz;:�VtV P E R M I T # G_
/
JOBSITEADDRESS OWNER'S NAME
GOWNER
ADDRESS TEL 9X 101—eg_5� FAX
TYPE OR
PRINT
OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RE S I DENT IAL// -t
CLEARLY
NEW.' RENOVATION: REPLACEMENT -I\/ PLANS SUBMITTED: YES NO
APPLIANCES I FLOORS— 4 5 6 —7 _10 13 14
BOILff
BOOSTER ---
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/ SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES �(NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY �( OTHER TYPE INDEMNITY . BONDi
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER AGENT
SIGNATURE OF OWNER OR AG:_NT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to t e best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complia ith Perti
all Zent rol* n of the
Massachusetts Slate Plumbing Code and Chapter 142 of the General Laws. &;
PLUMBER-GASFITTER NAME , Peter G. Viens LICENSE # 12116 SIGN URE
MP K MGF JP JGF LPGI CORPORATION <# 3631 C PARTNERSHIP #, LLC #:
COMPANY NAME: Merrimack Valley Corporation ADDRESS 15 Aegean Drive, Unit #3
CITY Methuen STATE MA ZIP 01844 TEL 978-689-0224
FAX 978-689-2206 CELL 978-807-2819 EMAIL pviens@mvalleycorp.com
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The Commonwealth of Massachusetts
Department offnidustrialAccidents
Office of Investigations
600 Washington Street
Boston, AM 02111
www.mass.govldia
Workers' Compensation Insurance Affidavit: Build ers/C ontra eta rs/Electri cian s/Piu M be Ts
AlMlicant Information Please Print LegLbly
Name (Bu sin ess/Organizati on/Ind ivid ua 1).* /1
Address:
City/State/Zip: 1,/", li� -x J11W Phone #: LJ171j'_ 611_.;0 V
Are you an employer? Check the appropriate box:
].%lama employerwith 4. E] I am a general contractor and I
Type of project (required):
employees (full and/or part-time)."
have hired the sub -contractors
6. D New construction
2.0 1 am a sole proprietor or partner-
listed on the attached sheet.
7. 0 Remodeling
ship and have no employees
These sub -contractors have
8. R Demolition
workm"- for me in any capacity,
employees and have workers'
9. R Building addition
[No workers' comp. insurance
required.]
coinp. insuranceJ
5. EJ We are a corporation and its
10. 0 Electrical repairs oi- additions
3. El I am a homeowner doing all work
officers have exercised their
I L E] Plumbing repah-s or additions
myself [No workers' comp.
right of exemption per MGL
12.Ej Roof
insurance required.) T
c. 152, § 1(4), and we have no
4repair
13.0.Otl 11AZAPr Ztclo
employees. [No workers'
comr). insurance reouired.]
A�4
*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 all work and then hire outside contractors Must submit a new affidavit indicating Such.
lContractoTs that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub-contraCtOTS have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurancefor my employees. Below is th e policy andjob site
information. I-- —
/ ?,/ / V5
eh�, _"90i
Insurance Company Name: 4, L �,7/jv
7
Policy 4 or Self -ins. Lic. 4: Expiration Date:
Job Site Address:.. City/State/Zip:/V-/54&W-,/49
Attach .9 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 ii-nposition of criminal penalties of a
fine tip to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the forrn of a STOP WORK ORDER and a fine
of tip to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verfication.
I do h ereby cerh nd i ep s and iy that the information provided above is trite and correct.
Sianature:
Official use only. Do not write in this area, to be completed hy city or town official
City or Town:
Perm it/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
BOARD QF C�
PLUMEIE-R$`AN:IJ G::ASFITT.E.----RS
ISSUES THE FOL LOW INS LICENSE
L I ��-E N.SSED As A JOURNEYMAN PLUMEIE*
P E T E.....R G VIENS
9 BLUEM:111): LAN'E
0
.A TO N SO N :.:,N'H 0381l-2302
2 10,3,5 05/Q.11"16. 21�5 6
Commonwealth of Massachusetts
Department of Public Safety
Hoisting Engineer
License: HE -110323
PETER G VIENV'
9 BLUEBIRD 1ji !'F�j
-j
ATKINSON MHT 038 1
Expiration:
Commissioner 11/13/2015
State of ".6, ampshim
I,,
441 -
GAS IFITTERio E
NAME: PETER VI
ENDORSEMENT !P
DATE ISSUED: 10/151-2013
DATE EXPIRES: 11/30/2015
LICENSE #:GFE070 587
:erlity that I have examined
ncawo'dance with the Fede5'.MoPT0r-'f.-'�.'S 'y and with knowledge
of the driving duties, I find this person is qualified; and, it applicable, only when:
C] wearing corrective lenses 0 driving within an exempt intracity zone (49 CFR 391.62)
El wearing hearing aid 0 accompanied by a Skill Performance Evaluation Certificate (SPE)
E] accompanied by a 0 qualified by operation of 49 CFR 391.64
waiver/exemption
The information I have provided regarding this physical examination is true and complete. A complete examination
form with any attachment embodies my findings completely and correctly, and is on file in my office.
SIGNATURE OF MEDICAL EXAMINER
EP
DATE
ME9MAL EXAMINER'S NAME (PRINT)
OMD
E] Chiropractor
0 DO
dvanced
)elplractice Nurse
MEDICAL EXAMINER'S LICENSE OR CERTIFICATE NO.
ISSUING STATE
0 Physician
Assistant
0 Other
Practitioner
NATIONAL REGISTRY NO.
1'4-
ef4j
SIGNATUR OF71VER
INTRASTATE
CDL
irzle�— &—,
ONLY
—Q
0 YES
Y(N 0
0 YES A6 0
DRIVER'S LICENSE NO.
STATE
/ / V -S /0
N171
ADDRESS OF DRIVER
—9—/a��
MEDICAL CERTIFICATION EXPIRATION DA I t:
-,*,
/ OA�� a /
PLY 1 DRIVER PLY 2 MOTdR CARRIER
26520 (5/13)
BOARD OF
PLUMBE 411 9 A S F I TT ERS I
ISSUES THE FOLLOWNG�LICENS
L I"tth-S. tb AS A MASTER PLU14BEW
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Pf TEA G VIENS
W
9 BLUEBIRD LANE i'Z
N:
.-A.TK I NSON -H 03811-236�
121 . O/R.1/1-6 213585
Commonwealth of Massachusetts
Department of Public Safety
Pipefitter Journeyman
License: PJ -028388 W*
I
PETER G VIENS
9BLUEB
ATKINS4:=)3811
Expiration:
Commissioner
11/13/2015
STATE OF NEW HAMPSHIRE
BUREAU OF BUILDING SAFETY & CONSTRUCTION
PLUMBING SAFETY SECTION
NAME: PETER G VIENS
LIC #: 3249 M
EXPIRES: 11/30/2014
mom
Peter Viens
Cert # 1023121001-12
Expires: 10/23/2015
Certification
N. F. P.A. 99-2012 ed.
ASSE 6010 Installer & ASME IX Brazer
OSHA 600316337
US-&PrU=r1Cflt.Mb0
01151=411011:111111W Way aw He=m Adrjiil�
Peter Viens
110buftudom Sat*& "Mm
rAVOIRTI(Ice wVVj 7M/2#,Wj—
I
Date.
"ORTH
TOWN OF NO RT, ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that. /2-1 ........ .........
has permission for gas installation .............
in the buildings of . . :-.5 .......... ......... I .........
at ... 3.Q ... U -. . L.A.-. 0. .0. . North Andover, Mass.
Fee. 3.1 Lic. No../ 5� 7
ASINSPECTOR
Check#
6576
.1
FIXTURES
LLI
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
G
City/Town:T Date: Permit#
Building Locatic,3��.. Owners Name:
xiType of Occupancy: Commercial' Educational,__,' Industrial lnstitutional� Residential
New:� Alteratlon:'�__ Renovation,�; Replacement: Plans Submitted: Yes: No'
FIXTURES
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6' FLOOR
fWFLOOR
-i'FLOOR
Check One Only Certificate #
Installing Company Name:,,J�'
Corporation
Address: own:, ta MA
a—icity/T S
Partnership
.. . ..... ... k . .... .
.. .........
Business Tel-,, Fax:
�Firm/Companyi
--------------- . . .. .......
Name of Licensed Plumber/Gas Fitter:, 16w
INSURANCE -COVERAGE:-
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes jNi
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy Other type of indemnityi_j Bond
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
C ' heck One Only
Owner i� A ent
9
Sionature of Owner or Owners Aaent
By checking this box []; I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and
accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be In
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
in Of License:
Byi
um4er
44
Gas Fitter
Title� : V,,, "Signature'of Licen Plumber/Gas Fitter
Master
Journeyman 'r
Cityrrown License Number:
LP Installer
APPR
A ��l 60
109
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This certifies that ....... C. v ..... 7/ ...............................
has permission to perform ..... el-Alerk, �- ..... ......
wirin in the building of ........
S'C)/L
9 .......
at.... . 7.6 ....... ..... N h
Fee...... Lic. No./,�F./`�`Iv3 ...........................................................
ELECTRICAL INSPECTOR
�VHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
Date 7;
71 TO 2524
.... ...... ............
,&ORT"
TOWN OF NORTH ANDOVER
6 0
PERMIT FOR WIRING
$$A US
.. ...... ........... .... . .....
This certifies that ....... C. v ..... 7/ ...............................
has permission to perform ..... el-Alerk, �- ..... ......
wirin in the building of ........
S'C)/L
9 .......
at.... . 7.6 ....... ..... N h
Fee...... Lic. No./,�F./`�`Iv3 ...........................................................
ELECTRICAL INSPECTOR
�VHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
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Office Ue Only rid
The Commonwealth of Massachusetts Permit No. 5-9-1
Occupancy & tee Checked
Department of Public Safety 3/90 (leave blank)
BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 12:00 RULE 8 Etfective 1/1178
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
City or Town, of A)n AA)dnier To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number)
CK.-ner or Tenant Ltp,; 1/-6�,Vvl aj )0-0 sp/1)
Owner's Address -3tp --��t-OA)Lc-qwoc4i
Is this permit in conjunction with a building permit: Yes[] No (Check Appropriate Box)
Purpose of Building, Utility Autborization NO.
Existing Service Amps Volts Overhead R UndgrdE] No. of Meters
New Service Amps Volts OverheadEl Undgrd El No. of Meters
Number of Feeders and Ampacity
z
Cn
W
J
:3
M
IL
IL
0
Location and Nature of Proposed Electrical Work
P -Q
7) V
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws , , , " i .
I have a current Liability Insurance Policy including Completed Operations Cov�rage or its substantial
equivalent. YESC] NOE] I have submitted valid proof of same to this office. YESO NO F1
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
INSURANCE [] BOND [] OTHER r-� (Please Specify) --CExpiration Date)
6- ---'
Estimated Value of Electxical Work S
I-) Inspection Date Requested: Rough
Work to Start
Signed under the penalties of perjury:
P!Fdi NAME , L k etp a L,->, zy-,VC-4
Licensee Signature
Final
LIC. /L30/*3
LIC. No.,ie le o 13
g 0 0 (�%- Bus. V1. No.
Address -%2-1- �m g. �-, 11 -Alt. Tel. No. /72 9
OWNER'S INSURAtXE WAIVER: I am aware tvlt the Licensee does not have the insurance coverage or its SUD-
stantial ed by Ma?"chu tts General Laws, and that my signature on this. permit
,___�,e
applicat rement er Agent (Please check one),,
MEE�� elephone No. PERMIT FEE 1, dO
CTignature of Owner
( t4l--- 6-3,&
--V i )%, f L) Y- meA3
No. of Lighting Outlets
No. of Hot Tubs
Total
No. of Transformers KVA
No. of Lighting Fixtures
Above in -
Swimming Pool grnd. gr-nd
Generators KVA
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting
Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection and
Initiating Devices
No. of Sounding Devices
No. of Self Contained
Detection/Sounding Devices
Municipal Other
Local 11 Connection[]
No. of Ranges
Total
No. of Air Cond. tons
No. of Disposals
Heat Total Total
No. Of Pumps Tons KW
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
Heating Devices KW
-T -
No. of Water Heaters KW
N
No, of 0. o
Signs Ballasts
Low Voltage
Wiring
No. Hydro Massage Tubs
I No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws , , , " i .
I have a current Liability Insurance Policy including Completed Operations Cov�rage or its substantial
equivalent. YESC] NOE] I have submitted valid proof of same to this office. YESO NO F1
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
INSURANCE [] BOND [] OTHER r-� (Please Specify) --CExpiration Date)
6- ---'
Estimated Value of Electxical Work S
I-) Inspection Date Requested: Rough
Work to Start
Signed under the penalties of perjury:
P!Fdi NAME , L k etp a L,->, zy-,VC-4
Licensee Signature
Final
LIC. /L30/*3
LIC. No.,ie le o 13
g 0 0 (�%- Bus. V1. No.
Address -%2-1- �m g. �-, 11 -Alt. Tel. No. /72 9
OWNER'S INSURAtXE WAIVER: I am aware tvlt the Licensee does not have the insurance coverage or its SUD-
stantial ed by Ma?"chu tts General Laws, and that my signature on this. permit
,___�,e
applicat rement er Agent (Please check one),,
MEE�� elephone No. PERMIT FEE 1, dO
CTignature of Owner
( t4l--- 6-3,&
