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HomeMy WebLinkAboutMiscellaneous - 31 PHILLIPS COURT 4/30/2018 -31 PHILLIPS COURT 210/095.0-0040-0000.0 .J . Date.3 ...... .. ....... r°.prwp*N�tioc TOWN OF NORTH ANDOVER p PERMIT FOR WIRING 88�c►nis� This certifies that ................. .. .......... ............................. .................. has permission to perform ...R�_.1 1'�P.J �Z r 1 .- wiring in the building of...... i < <?- at.... �...... 'l!L^. ►.�S l (�\nn�".........>North Andover,Mass. Fee. �4 J Lic.No.`�}0 �... .......................................... .................. ..... . ............ ELEcrRICAL INSPECTOR Check# 11' i C' i' 11473 M Commonwealth of-Massachusetts husetts Official Use Only ` Department ®f Fire Services F1,No- PermiBOARD OF FIRE PREVENTION REGULATIONS ancy and Fee Checked07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PMT.ININKORTYPEALLINFO TION) Date: City or'Town of: � �.: — � 2 2,— i3 To the Inspector of Wires: By this application the undersi ed gives not' of his or her intention to erform the electrical work described below. Location(Street&Number) V. �� ov 'Owner or Tenant \ Owner's Address Telephone No. Is this permit in conjunction with a building permit? yes No ❑ BLDG PERMIT# Purpose of BuildingUtility Authorization No. Existing Service ago Amps IdQ /2,V6 Volts Overhead � ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd [] No.of Meters Number of Feeders and AmpacityT/�� JvI Location and Nature of Proposed Electrical Work: Completion of the following table maybe waived by the Ins ector of Wires. No.of Recessed Luminaires /(� No.of Ceil.-Susp.(Paddle)Fans Z. No.of Total. No. of Luminaire Outlets No.of Hot Tubs Transformers KVA Generators KVA No. of Luminaires Swimming Pool Above ❑ In- o.o mergency rg rng rnd. rnd. ❑ lo:, Units No. of Receptacle Outlets D No.of Oil Burners FIRE ALARMS No.of Zones ��' No. of Switches C C) No.of Gas Burners No.of Detection and No. of RangesInitiatin Devices No.of Air Cond. Total r Tons No.of Alerting Devices ai No. of Waste Disposers He Pump Number Tons I£W No.of self-contained Totals: " ......' ' No. of Dishwashers Space/Area Heating KW Detection/Ale-tin DevicesLocal❑ l�Iunicipal No. of Dryers Heating Appliances KW Security Sys Connection ❑ Other No. of Water No.of No.of Devices or Equivalent Heaters �' No.of Si ns Ballasts Data Wiring: No.Hydromassage Bathtubs No.of Devices or E uivalent No.of Motors Telecommunica Total tionsW rri ' No.of Devices nJ OZ�R; or E uivalent Estimated Value oflec ical Work: Attach additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start: ®/ Inspec ions to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VE GE: 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 cert,under the pains and penalties of perjury,that the in orm IRM NAM, f atron on this application is true and complete. Licensee: LIC.NO.: Signature LIC.NO.: (Ifapplicable en r "eke pt"in th is number line. Address: Bus.Tel.No.:lA%7.3/(� *Per M.G.L.c.l 7,s. 7-61,security work requires Department of Public Safety" Alt.Tel.No.:S"Licen LIC.NO.: � OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability ` required by law. $y my signature below,I hereby waive this requirement. I am the(check onD owner normallygent. 1` Owner/Agent Signature El Telephone ne No. P ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR-DOUG SMALL F P ION: Failed—[ ] Re-inspection required($50.00)-ments: (Inspectors'Signature-no initials) Date J — 2 e 2.FINAL INSPECTION: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors'comments: 1110/Z7 (Inspectors'Signature-no initials) Date 3.UNDER GROUND INSPECTION: Passed—[ ] Failed—[ j Re-inspection required($50.00)-[ ] Inspectors' comments: (Inspectors'Signature-no initials) Date 4.INSPECTION—SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed—[ ] Failed—[ ] Re-inspection required($50.00)- [ ] Inspectors'comments: (Inspectors'Signature-no initials) Date 5.INSPECTION-OTHER: Passed—[ ) Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: (Inspectors Signature-no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED. The Commonwealth of Massachusetts Department of industrialAcczdents Office of-1nvestigations 600 Washington Street Boston,MA 02111 Uvww.mass.gov1dia W017-kers' Compensation JCnsulrazlce Affidavit: BuiIdexs/Cont�ractoxs/JEXeciriciazzs/Pluznbers A licant Information Please Print Leazblv NaMe,(B.usiness/Organization/Individual): } Address:Y 36ca4- City/statelZip: _A), A,,X 8 o)j4_r n/1 A a t9Ll - Phone#: you an employer?Check the appropriate box: 1[6. ype ofproject(requ:ired): [Are I am a employer with 4. ❑ I am a general contractor and I ❑New construction employees(full and/or part-time).* have hired the sub-contractors.❑ I am a sole proprietor or partner- listed on the attached sheet.s . 0 Remodeling . ship and have no employees These sub-contractors have 8. []Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp,insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.F1 Electrical repairs or additions 3.❑I am a homeowner doing all work 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' comp.insurance required.] 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 contractorsmust submit a new'af idavit 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 isproviding workers'compensation insurauce for my employees Below is the policy and job site information. Insurance Company Name: � r � i e Policy#or Self-ins.Lic.#: J j s6," L -01- I Expiration Date: ` f Sob Site Address: '��j`�e� 1', (90')E` City/State/Zip:� ��_.erM Vj 0 l rt/S; Attach a copy of the workers'compensation policy declaration page(showing the policy number and expirations 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 maybe forwarded to the Offica of i Investigations of the DIA for insurance coverage verification. I do Hereby certify under the gains andpenaldes ofperjury that the information provided above is rue a d eorr eet. Si ature• Date: Phone#: - [6. ial use onl. Do not write in zrt this area to e c Y b om lefed b city or town o acia p y � ff t or Town: Permit/License# ng Authority(circle one): I. ard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing fnspector heractPerson• Phone#: Date . . . . . TOWN OF NORTH ANDOVER is PERMIT FOR GAS INSTALLATION This certifies that . . 9 , 0"t has permission for gas installation in the buildings of. . . . at . . . . L . . . . . . . . . . . . . . . . . . . . . .North Andover, Mass. �. Fee . ..IbO. . . . Lic. No. I Q.:�)Q.t. . . MC). . . . . . . . . . . . . . . . . Otttt GASINSPECTOR Check# � 8608 r i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I Nu V�Qdd '-C-' MA DATE PERMIT# JOBSITE ADDRESS „( hV� )1 (' �—II OWNER'S NAME C GOWNER ADDRESS TEr FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIALO- PRINT CLEARLY NEW: A RENOVATION:JjKREPLACEMENT:® PLANS SUBMITTED: YES 0 NOQ APPLIANCES 7 FLOORS- BSM 1 1 2 3 4 5 6 7 8 9 10 11 12 13 1 14 BOILER [ BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR _J j _ _ ( f FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT _,r:..1: —. �. OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST ! _- -1 _. _ [ _ -. _ _ I ) _-_-- [ -T_I= 1 ._Tf Q, UNIT HEATER LINVENTED ROOM HEATER 1VV� ATERHEATER ,_. _-__ r �` OTHER E J(_- ===I- INSURANCE COVERAGE -- -�-- - — --- �--- --- -- --- � have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES �_I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I OTHER TYPE INDEMNITY ©I 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 requ' en a CHECK ONE ONLY: 0 _! NT �I SIGNATURE OF OWNER OR AGENT t''? hereby certify that all of the details and information I have submitted or entered regarding this applicatio d ac t es f y kn ledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance i erti n ro ' ion o the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. \( PLUMBER-GAS ti FITTER NAM S --W� �r _ LICENSE#-16G/� S ATURE MP MGF JP D JGF LPGI 0 CORPORATION PARTNERSHIP # � � _11 LLC[ # COMPANY NAM : _�__-.- 3 _I ADDRESS CITYSTATE • _.._ _ _..- — ---_—_..._r._...__—____ _ . ZIP . Of RE? TEL _ Z'T, CELL[.( EMAIL.---- I ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# C %�1�✓ PLAN REVIEW NOTES G Y' F � l Lf S The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations UV 600 Washington Street Boston,MA. 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Organization/Individual): V Address: 3 City/State/Zip: 00, Phone#: Ary an employer?Chect e appropriate box: Type of project(required): 1 I am a employer with 4. ❑ I am a general contractor and I 6. E]New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. �• E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work 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' comp.insurance required.] 13.0 other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. � n 1 n V,, Insurance Company Name:. ►" t�V Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: N w' City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$ . and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine j of up to 50.00 a day ains a violat e dvised that a copy of this statement maybe forwarded to the Office of Invest' ations oft he D for uranc cov g verification. I do li eby cert! and a al es ofperjury that the information provided above is true and correct 5Y,naturel Date: ` Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: I 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 hire, express or implied,oral or written." An employeiis 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-contractors)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 Comraonwealth,ofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Stye.et Boston}MA 02111 Tel,#617-727-4900 eA 406 or 1.-877:MASSAFE Revised 5-26-05 Faze#617-727-7749 wwwmass,go dia Di Xision of Professional Licensure: License Search Page 1 of 1 The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES ........................................................................................._......................................................................................_...........:................................................................... Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency More... LICENSEE Name:TIMOTHY A. GIARD REFERENCES& NO ANDOVER,MA RELATED INFO Disclaimer Regarding '_'This Licensee has additional Licenses,ctick here to view them." Website License Searches _ ._. —a Enforcement Process Glossary Licensing Board: PLUMBERS ti GASFITTERS � Glossary of License Status License Type: MASTER PLUMBER Codes. License Number: 10301 # More... Status CURRENT Expiration Date. 5/1/2014 Issue Date: 6/18/1986 Exam Date: School: i This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Wednesday,February 27,2013 at 10:35:33 AM. ©2007-2011 Commonwealth of Massachusetts Site Policies Contact Us htt ://license.re .state.ma.us/ ubLic/ u _ — p g p p bLlcenseQ.asp.board_code PL&type class—_M&1... 2/27/2013 09826 Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . . . ha:s permission to perform . . . . ! �?,S./ !� 'N,6'jc,` t.. . plumbing in the buildings of. ! . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . .` 3 . ' 1:�.�.� .0. . . . . . . . ,North Andover, Mass. t � Fee .(,:"it:). . Lic. No. P-.:�P\ . A.. . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check# �� 4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY C Ir— MA DATE D PERMIT# JOBSITE ADDRESS � OWNER'S NAME jr OWNER ADDRESS TI TEL FAX j TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL Q RESIDENTIAL,, PRINT CLEARLY NEW: 01 RENOVATION;0 REPLACEMENT:M,I PLANS SUBMITTED: YES 0 NO© FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _I _ M_I CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM } ( ! _..__I __. _( ._ _.._.,I __I DEDICATED GREASE SYSTEM _J DEDICATED GRAY WATER SYSTEM I _. f DEDICATED WATER RECYCLE SYSTEM DISHWASHER } __L DRINKING FOUNTAIN _-_I ...__...-_..f __.._.._l .___..._f FOOD DISPOSER FLOOR/AREA DRAIN _i 1 i ...__.__..I ._.__J ( ---_.._...._f f } INTERCEPTOR(INTERIOR) KITCHEN SINK ____..__} __...f ____j LAVATORY _f /_..1 .- --_I .__._._.1 _-_-- J J f 1 .,' � f ( f ( ROOF DRAIN SHOWER STALL SERVICE/MOP SINK �} � I —_f ! f f a ._._.._ _..___.! ..____1 _ .._.__.__I f 11) TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING _} . ! _. I _._._..__f } . I _. � __..__._ OTHER - _ _ I I I f .__..._l --— INSURANCE COVERAGE: I have a current liability 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( OTHER TYPE OF INDEMNITY 0 BOND M 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 0 Y: 0 R . A ( "° SIGNATURE OF OWNER OR AGENT 6 hereby certify that all of the details and information I have submitted or entered regarding this a plication are true and cur e t e t y kn ledge ` and that all plumbing work and installations performed under the permit issued for this application in com iri t o ' ' the K) Massachusetts State Plumbing Code and Chapter 142 of the General Laws. L\ PLUMBER'S NAME C + / =LICENSE# l6 0_/ S I G)fAf URE FVIP JP nCORPORATION V# y 3 j PARTNERSHIP D# f LLC COMPANY NAM j&o 14 oe.1 l-"- ; ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES y , The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA. 02111 UV www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: �1-- 1 ' City/State/Zip: Phone#: 1 l WV J"���J �® Aretarn employer?Check he appropriate box: Type of project(required): 1 I a employer with 4 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.# �• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers'comp.insurance. Y p tY• 9. F1 Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3111 am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roofrepairs insurance required.]t employees.[No workers' comp.insurance required.] 13.0 other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. nTV Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: P \ ' U t` 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 itnprisonments ell as civil penalties in the form of a STOP-WORK ORDER and a fine of up to against the viol r. Be iseA that a copy of this statement may be forwarded to the Office of Invest i ations of the D insura a er eve tcation. I do hereby c under p nalti o perjury that the information provided above is true and correct. - Signature: �_- Date: �—2 6 Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: r Informati®n 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 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-contractors)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 bum 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 Commonwoalth of Massachusetts Department of lndustrnial,Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877:MASSAFB Revised 5-26-05 Fax#617-727-7749 wwwMass.gov1dia Division of Profes-ional Licensure: License Search Page 1 of 1 � a The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES .......... ................:.............................................................._...._......_......................................................................... ......._........... Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency LICENSEE More... Name:TIMOTHY A. GIARD REFERENCES& NO ANDOVER,MA RELATED INFO Disclaimer Regarding "*This_Licensee has additional Licenses,click here to view them.'" Website Lioense Searches Enforcement Process Glossary � Licensing Board: PLUMBERS 8 GASFITTERS Glossary of.License Status License Type: MASTER PLUMBER l Codes License Number: 10301 . More... Status: CURRENT Expiration Date 5/1/2014 Issue Date: 6/18/1986 i Exam Date: School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. i The page above has been generated by the Division of Professional Licensure web server on Wednesday,February 27,2013 at 10:35:33 AM. ®2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg.state.ma.us/pubLic/pubLicenseQ.asp?board_code=PL&type class=_M&1... 2/27/2013 Date..4!f+b z.. . ... . F HOFTIy . TOWN OF NORTH ANDOVER . PERMIT FOR GAS INSTALLATION . 1 : . �9SSACH 5Et This certifies that . . I� . . . . . . . . . . . . . . . _. .. . . . has permission for gas installation /�� in the builfdings of S( /4*47el. LQ. .. . . . . . . . . . . . . . . . . . . . at Norah over, ass. Fee. -p Lic. No.:-? $/�. . . . GASINSPECTOR Check# '8280 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASF;TTING (Print or Type) ` Af OlfLrfM AP1DbUEQ Mass. DateZIN ZOJ Z Permit # Building Location X113.3 PHILLIPS T Owner's Name h _ _ NOREP) ANQbUE►'Z- MIA. Type of Occupancy Z FQNIL�/ New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑ N N a W N N (1) U � ¢ N Uf a N M W O N s r J F 0 W O U m ~ Z n z p W ~ a CC z � C F- w at `� m N H du O O C F- to W d N a N (7 V W S z f- N a0 > W W W N a Z M a W � W F- W I- X Y F. W W tl O > U. }- W J W X d W a r' r c>! aC z C z W C v S a W a W z, a c= a p ¢ '.S 1 1 O 0 Y LL a 3 o tl � 0 Off' y o L F- O SUB—BSMT. BASEMENT 1 1ST FLOOR N2ND FLOOR N, 3RD FLOOR 4TH FLOOR OSTH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name COL.UMRIA G&S GF MASSACHUSETTS Check one: Certificate # Address 55 MARSTON STREET �O Corporation 1862 LAWRENCE, MA 01841 - 2312_ ❑ Partnership Business Telephone 9 7b-691- 640 6 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked res, please Indicate the type coverage by checking the appropriate box. A 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 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.- Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ hereby certify that all of the details and information I have submitted(or entered)in abo knowledge and that all plumbing work and installations performed under the permit iss f rr tthisapplication on are rwill ue d a n r4mpl ante wcur ith all my pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. T e of License: Title Plumber Signature of Ucensed Plumber or Gas Gasfitter City/Town Master License Number_3745 APPROVED OFFICE SF ONLY Journeyman I BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION ' I FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING " NAME & TYPE OF BUILDING LOCATION OF BUILDING i PLUMBER OR GASFITTER LIC. NO. - PERMIT GRANTED DATE X19 GASINSPECTOR 4113 Date.2c.7-0 .. .... ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHUS This certifies that XI/ ..... .ya�.. .. ............................... r. has permission to perform-..L... wiring in the building�D Of... ............................. at ...... . c........... ...... North Andover,Mass. `f Fed-4�S................ Lic.NAe��4 A--L-Ii N--S-P--E-C--T-0--R.................. ELECTRIC Check # TBE COMMONWEALTH OFMASS4CHUSETTS Office Use only DEPAR7M&l TOFPUX1CSAFEIY BOARDOFFIREPREVEIW0NRBGMH0NS527CNIRI2(i19 Permit No. Occupancy&Fees Checked APPLICA71ONFOR PERMIT TO PERFORMELECMCAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover The undersigned applies for a permit to perform the electrical work described below. To the Inspector of Wires: Location(Street&Number) �' , - P Owner or Tenant Owner's Address )1 C. Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Building -.� L,, , i v Utility Authorization No. Existing Service Ams / Volts ------- Amps Overhead Underground � No.of Meters New Service Amps Volts Overhead Underground � No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work v., V C, No.of Lighting Outlets No.of Hot Tubs No.of ransformers Total No.of Lighting Fixtures Swimming Pool Above BelowKVA Generators round KVA round No.of Receptacle Outlets No.of Oil Burners No.of Switch Outlets No.of Emergency Lighting g Batte ry Units No.of Ranges No.of Gas Burners No.of Air Cond. Total FIRE ALARMS Tons No.of Zones No.of Disposals No.of Heat Total � Total No.of Detection and No.of Dishwashers Pumps Tons KW Initiating Devices Space Area Heating KW No.of Sounding Devices No.of Self Contained No.of Dryers Detection/Sounding Devices Heating Devices KW Local Municipal Ode-� No.of Water Heaters KWNo.of [3 Connections No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP ;OTHER. FnArtatloeCove�Ptust�txtotllelegttit�r�sof'MLaws [have aamJLiabtkh=arxeFblicyi rkdT `, ] Cocritsmbs4ntial vitt •.'haw submilledvaWptoofcfsarnetod1eOffice YES YES NO i>ac3drlgdr lox. � ff �lacl�dYES,Plea9eirdethetypeofooreageby NSURANCE BOND ftaseSPecify) F,#atiollD& volktostalt 0 bTeC iMD*Ra�d W fl L )l mtEdvalueofF lwolic$ ignadtmder'TieFt cfpefjuT �L, - t`' Final IRMNAME ry� � f GV � .�, ticertseNo. 3 7 7 iam9ae 5�.w-e.. Sigr>attne _�/lN' LimmNO ! ►1 m ss. /� 0 1 U e � � /� V eve M c� ��� BusQtessTel No. oZ- (5 0 AMIRSINSURANCE WAIVFR,lam aware thatthe Lxmsedoesnothavetheumuanoccoverage ori At Tel No. — '�714y16i dd ntmysignahueonftpmnitaME�tivsretlt urartalt wbsMrtdegtnvalerttasto*mdbyMa� l msetCt erallaws 'lease check one) Owner Agent Telephone No. Igna re o wner or gen PERMIT FEE$ �� 3051 Date..l� a ..... Q CE l 'P M0RTM TOWN OF NORTH ANDOVER 3?�44��ao 1ti�L O +: o 0 PERMIT FOR GAS INSTALLATION �,SSACHUSES M M J This certifies that . . .s. . . . . . . . . . . . . . . . . . . . . ..... . CL has permission for gas installation . C:.f . . . . • . • • • • • • • • 'cu• in the buildings of . /t/ . . . . . . . . . . . . . . . . . . . . . . . • at . .j! �' : �1.�a:. . . !_ . . . . . . . . . . . . . .. North Andover, Mass. Feer.}j.'. . . Lic. No..r .3:. . . . §INSPECTOR WHITE:Applicant CANARY:Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING t (Print or Type) _ NORTH ANDOVER . - Mass. Date 1huilding Location -311 ��Za� dwew— Permit #_ ?r Owners Name 9�) � T� _ New 77 Renovation D Replacement Plans Submitted �] s FIXTUR_- D7 W N K : tL trf oyc rn ¢ o a I— a W Qf J V f0 r N C. O tW C4wC Z O m N N O W _ y CC LW7 rF– :µ j - < a W W 0 C W V J W o O woN > G W O 010 U W >1 =1 <1 � SU$—QSt.IT. BASEMENT I + 1ST FLOOR 2NO FLOOR 3110 FLOOR 4TH FLOOR 5TH FLOOR 6THFLOOR 7TKFLOOR BTHFLOOR (Print or Type) Check one: Certificate r Installing Company Name ANDOVER PLG. & HEATING CO. Corp. 2122 Address 573 112 SO UNION ST. _ Partner. LAWRENCE , MA. 01843 Firm/Co. Business Telephone: 508 685-8383 Name of Licensed Plumber or Gas Fitter GF^KrFAQncF Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy co Other type of indemnity 0 Bond Insurance Waiver: 1 , the undersigned, have been made aware that the licensee o1' this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner ElEl 1 hereby certify that all of the details and information 1 have submitted (or entered)in above application are true and accurate to the teat of my knowledge and flat all plumbing work and 4utallations performed under'Fetmit itsued lo: this application will-be in compliance with all Vertl�cnt Provisions of tho Massachusetts Stale Cas Cuda and Chapter 14:of the Genera!Lawa. By TYPE LICENSE: Plumber umbe �— r Si lure of Licensed G� Title sfitter 5 n � Master Plumber or GasfitY�er City/Town: Journeyman APPROVED (OFFICE USE ONLY) License Dumber 'MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 GASFITTING I (Print or Type) _ C NORTH ANDOVER , Mass. Date . 'I �uilding Location �j/ 4?11 it # Owners Name � �a5 • Y New —7 Renovation Replacement Plans Submitted D C,t� FIXTUP=S to x w vi y a at I -I¢ .v � y = F W0 us 11 h G1 M cyst d W W F N d a y 4 U) N a V W z �7 4 Q O, O W W W to j z C a tot a a W k-" W v = c) Cr Z _ r z r W y o ? o h W o to z z 4 W G M .r tti z Q Ls > C W O z Q G d < O O W O W h Q z O t7 z W d c7 ,t U tr } Q a h 01 1 1 1 1 1 SUR—aSMT. t BASEMEMT l ' 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR (Print or Type) /� ?rz Chec -one: Certificate Installing Company Name d4�/ "'�. Corp. i9� Address yc/ - if/ii /O Partner. Firm/Co. Business Telephone: fE`/6— Name of Licensed Plumber or Gas Fitter ter iGyjt�- Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity 1_=_.t Bond Insurance Waiver: I , the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner 17 Agent El 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 ill plumbing work and Installations perforated under Permit issued to; this application will be mpliance with all Mtlncnt provisions of the Massachusetts State Gas Code and ChApter 141 of tho General Laws. By YPE LICENSE: C rGasfitter lumber Title Sign lure of Licensed City/Town- aster P�G� �laer mor Gasfitter ournevan APPROVED (OFFICE USE ONLY) License Number MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER Mass. Date building Location Permit # Owners Name New 77 Renovation D Replacement ID Plans Submitted �] FIXTURES w W 34 z tz tr; Cy z CC F- Q O 1.. w Z m H H W w O O a W F- r to c > �„ W w z x a V' W 4 °C t- z Lu 07 "i t- z W w a oLd 7 U. Y d W .4 tC f }- to W " O2 O N Z d Lr y C tis O z Q G d d O O W _ O W F- a z ou. z n O ., z > ci a f- o SUA—BS,MT. BASEMENT ISTFLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR TTI{ FLOOR STH FLOOR (Print or Type) Check one: Certificate Installing Company Name Q Corp. Address - - Partner. Firm/Co. Business Telephone: Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Q Other type of indemnity Q Bond E] Insurance Waiver: I , the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner 17 Agent H I hereby certify that all of the details and information 1 have submitted (or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations pe formcd under Permit irseed for this application will-be in compliance with all pertinent provisions of the Massachusetts State Cas Code snd Chapter 142 of the General L►ws. TYPE LICENSE: By \` - Plumber Title Gasfitter Signature of` Licensed } City/Town: Master Plumber or Gasfitter Journeyman APPROVED (OFFICE USE ONLY) License Number ' Date..A. .?.. NOrrTM TOWN OF NORTH ANDOVER pf «aD ,s1hp 0 � `p PERMIT FOR GAS INSTALLATION , t SS CH - f This certifies that 3. � . . . . . . . �t has permission for gas-installationA ! . . 4 in the buildc ing-ings of. : . . . . . . . . . . . . . . . . . . . . . . . . . . r at h �� . . . . . .. . . . . . ., North Andover, Mass. Fefj-. ,- Lic. No.. e5"-�. . . . . . . . . . . . . . . . . . . . . .. . . . . 2.50 PAID GAS INSPECTOR. WHITE:Applicant CANARY:Building Dept. PINK:Treasurer GOLD: File Date,/�A? N2- 3903 NORTH TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING ' SSACNUS� 'Al l This certifies that has permission to perform . . H . : . plumbing in the buildings of . . . . . . . . ' . . . . . . . . . . . . . . . . . . at. . J. .N.1 . . . . . . : . . . . . . . . .. North Andover, Mass. Fee. Lic. PLUMBING INSPECTOR WHITE:.A0ja Vt9 i4,?h4NARY: B.APMTDept�ID PINK:Treasurer �.•.....,o�..a sv a ia urrnru"Nl ANt'UUAIIUH hUN lrr-IiMi a 1%, W%J s •-•.tl..• ... (Prini a TW41 / NORTH ANDOVER, . Mau. Dale BulldlnaPermN * t, / 3 Location h-0�. s� � 4jat� Owner's t� Na/me New ❑ neno.atlon p neplacemerA [vJ Plans Submitted: Yes❑ No p FIXTUAE3 x W » « 0 x W J se ►- u t 0 0 e x K M a 00 t X 4 M O = et K 1 h r K 4 J a at es a K °w i « h 0 to s lot s i o sue-9SMT. SASKMSNT 1ST FLOOR 2010 FLOOR 3AD FLOOR ITN FLOOR aTN FLOOR IT" FLOOR YTN FLOOR •Tit FLOOR EE Check one: Certlnule Installing Company flame ANDOVER PLG . & IIEAT I NG CO. , I NC . (Corp. 2122 �+ Aridresa- 573 112 SO IIN T ON ST p Partnership LAWRENCE , MA. 01843 ❑Firm/Co. ©urine» Telephone 508 685-8383 Nerve of Licensed Plumber GEORGE LAROSE INSURANCE COVERAGE: ChecK I have a current IlabAlty Insurance polity or Its substanII&I equhralerd. Yes No D It you have checked yam, please Indlcale the type coverage by checking the appropriate box. A IlablRy .Insurance policy l� Other type of Indemnity 0 Bond O OWNER'S INSURANCE WAIVER: I am aware that the licensee dont not have the Insurance coverage required by Clupter 112 & the Mass. General Laws. and that my signature on thla permit application waives this requirement. Check one: Omer p Agent ❑ nattxe o er a Omer s ent 'i I haraby c-lify that alt of the detalls and Information t have submitted br onto(ed)in above sppkAtion out true and accurate to the best of my knowledge and that as plumbing wak and Installations Wormed under the parmA laund for We applkalkm will be In compRancs with alt per0noni provisions of the Massachusetts Slate Plumbing Code and Chapter 112 of due GNV4LAN" lata _ we of Ucinii�� aty/Town Ucmte Number 9983 Type of I'tumbing IJoanse: Master [t�^/ AI't'1"wTO ICYEK:E USE 01101 Journeyman l� r Date. . . . . . . . . .. . ,4ORTN . TOWN OF NORTH ANDOVER • - PERMIT FOR GAS INSTALLATION �1SSACMU5Et - This certifies that. . . . f . . . . . . . . . . . . . . . has permission for gas installation in the buildings of . . ! !i?' . f .. . . . . . . . . . . /... . . . . . ., North ndover, Mass. Fee.:Jl/ Lic. No.. . . . . . . . . . . . . . . GASINSPECTOR Check# G 4610 MIASSACHUSETTE UNIFORMS APPLICATION FOR PERM rr TO DO CiASFITTING tPrurt or Type Mass. t?ate�/C !/��S2G Permit v--4v_ ng 1 1 Owners Nam%LdL JCA741 e,ddl)er Lip vr� Building Location I / 19 'fl Type of OccupancY.�E�I New ❑ Renovation ❑ ReAr -Vpla-Invent Plans Submitted: Yes❑ No❑ AY IsW Y W b! A a z C C7 < W 02-1 gi Z < m W < M W r N Or 'C < O er Z _ < ¢ r p h = Y < s• Z F' > p 0 > k h w 1 W Ac Z O O X us z 3 Q 7 J 0 W > Q d � O SUB—aSMT. BASEMENT 1 ST FLOOR IND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 8TH FLOOR 7TH FLOOR ' i STN FLOOR installing Company Name—At; t2 T A . Am MA T A Check one: Ceto Address 00,4(N/w 14 rl) L-M ❑ Corporation - -- M,e 7-q U F tj Al rl ❑ Partnership Business Telephone • 'R ra l2—2 -q-71 2-1inn/Co.Nameof Ucensed Plumber or bias Fitter J?r?!A E c2 T A 5 A m Al A 7A i!?(-) INSURANCE COVERAGE: I ave aY urrent tJabfl ty N policy Or Its substantial equivalent which meets the requirements of MGL Ch. 142. es E2If you have checked,fes, please indicate the type coverage by checkMg the appr is box A liability Insurance policy 0"' Other type of Indemnity❑ Bond ❑ 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. 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 my knowledge and that all plumbing work and installations performed under theed for this application be in compliance with all Pertinent provisiOns of the Massachusetts State Lias Code and Chapter 142 of tA7 By T katUfteense:Tileer re n u or er er City/Town License Number V32) M BELOW FOR OFFICE USE ONLY FINAL, INSPECTION SKETCHES PROGRESS INSPECTION FEE, NO. i APPLICATION FOR PERMIT TO DO GASFITTING NAME A TYP£ OF BUILDING LOCATION F BUILDING PLUMBER OR OASFITTER LIC. NO. PERMIT GRANTED DATE OASINSPECTOR Date. J TOWN OF NORTH ANDOVER m PERMIT FOR PLUMBING 4 •o•,.,o•••"t5 ,SSACMUS� This certifies that e.. . . . . . . . . . . . . . . . . . . . . . has permission to perform . . ..\ ... . . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . j xq.y.c(` .... . . . . . . . . . . . . . . . . . . at. .3. .�.�'./.l. . . . . . . . . . . . . . . . . . . . . .. North Andover, Mass. Fee. L t! Lic. No..``1. 3. . . . . . . . . r -? y... . . . . . ULU MBIN INSPECTOR t C G Check # 5245 T°MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) f� 'ew , Mass. Date P milt# ., — Building Location 9 3 Owner's Nam_ f ' / 4Leic/4�� Type of Occupancy S i 17 E IJ tl New ❑ Renovation O Replacement P""' PI ns Submitted: Yes ❑ No 13FIXTURES P Z N N Z Y • h- .N N N O Z � ? N W Y J N ?' V Q N W W 4C cc 0 a x Z o ¢ N W ¢ S s W Z D a (a Z .¢ a ¢ O W ¢ W W d N W ¢ J W = < S 3 O Y S x IL 0 d Y J m S V1 N d d O a J j a ¢ OC m a O < F- H o ,x SUB-BSMT. ;r BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing.Company Name "ki'�E -r Q• c',Am m P4-rA 0 Check one: Certificate Address ) ❑ Corporation IY) E TN 0 ie-Ai YO A 01 AVL/ ❑ Partnership Business Telephone �� -�� P �/Co. i -7 Name of Licensed Plumber INSURANCE COVERAGE: I have ayes currenatflabillty insurance ns ra ce policy or its substantial equivalent which meets the requirements of MGL Ch. 142. No If you have checked Les, please indicate the type coverage by checking the appropriate box. A 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 142 of the Mass. 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 my knowledge and that all plumbing work and installations performed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plu"ge and apter of the eral Laws. 7 Titre re of Licensed Plum er City/Town Type of license: Master % Journeyman❑ APPFidVED OFFICE USE ONLY) License Number 3 5 f BELOW FOR OFFICE USE ONLY FINAL INSPECTIONS SKETCHES 1 PROGRESS INSPECTIONS FEE NO. APPLICATION FOR PERMIT TO DO PLUMBING NAME &TYPE OF BUILDING r" LOCATION OF BUILDING 's /- PLUMBER • f PERMIT GRANTED f ; DATE 19 r PLUMBING INSPECTOR 3902 Date A-.'?4�................- 3 HORTM o TOWN OF NORTH ANDOVER '° PERMIT FOR WIRING �$3ACH S This certifies that % ..:a. ........... has permission to perform . �.`...... �. ..:. ................ wiring in the building of.... .............:. ..................................................... at... , .... ......rte .... .......... ,North Andover,Mass. Fee.... .......... Lic.No. /. /�c5 .... ./ .<.< --.................. 7 ELECTRICALINSPECTOR Check # Q 00 Mn / I� 7j--d, //�� 3�.a3 C ommonweallk of/I'/aeeacliueells Official Use Only c� p?� _ a.UeParlmenl 013ire �ervicej Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(,VIEC),527 ChIR 12.00 (PLEASE PRINT IN INK OR 7-Y1` -:ILL iNI-'ORAL I7'ION) Date: b - City or 'Town of: � dt�yez ' To the Inspector of GYires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number)3 3 Pk 1 Owner or Tenant y ,\ ii Telephone No7 6 Owner's Address w. Is this permit in conjunction with a building permit' Yes No ❑ (Check Appropriate Box) Purpose of Building a �0.�t Iy Utility Authorization No.d�� " 7! 5j Existing Service /00 Amps Ids / g,Slb Volts Overhead Undgrd ❑ No. o(tlieters Neiv Service O6 Amps /aS/ Q50 Volts Overhead Undgrd ❑ No. ofNleters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: /ll Pw vC t)i t- Corn lesion of the following table nra,be ir•aived by the Ins cctor of Wires. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No'of Total Transformers KVA No. of Lighting Outlets No.of blot TubsGenerators KVA No. of Lighting Fixtures Swimming Pool o hove ❑ Li- ❑ o.o uergency Lighting ntd. rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones of Detection aid No.of Switches No.of Gas Burners No. Initiating Devices No.of Ranges No.of Air Cond. Tons TotNo. of Alerting Devices No.of Waste Disposers Heat Pum Number Tons KW No. of Self'-Contained P Totals: Detection/Alerting Devices No. of Dislnlvashers Space/Area Heating KW Local 0 Municipal El Connection Other Heating Appliances KW Security Systems: No. of Dryers No.of Devices or E uivalent No. of Vater KW Signs of No. of Daia Wiring: HeatersSigns Ballasts No.of Devices or Equivalent No.HAlromassage Bathtubs No.of Motors Total IIP Telecommunications Wiring: No.of Devices or.Equivalent OTHER: Attach additional detail ifdesired•or as required by the Inspector of Wires. INSURANCE COVEiU1GE: 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 suc coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ 0"11-IER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: O-d-, Inspections to be requested in accordance with MEC Rule 10, and upon completion. Icer•tifj, under the pains acrd penalties of perjmy,that the information on this application h true and complete. FI ILII NANIE: y�eo cs � `� LIC.NO.:A ru Licensee: SG,,,•.¢- Signature LIC.NO.: 37 3o-�E (If applicable e iter •e.vempt..in th licensc 1111jer line.) s� Bus.Tel.No. Address: Z/ n I !V-(, � 7" 0-'V t��, /-/rte (���i o�� :27 / � v '1 -Alt.Tel.No.: I� 6' ' OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my si-nature below, 1 hereby waive this requirement. I am the(check one) ❑ owner ❑ ov,•ncr's agent. Owner/Agent Signature Telephone Nv. FPERAll T FEl:: $�� PLEASE FILL OUT BACK SIDE t ADDRESS ELECTRICIAN PERMIT # i