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HomeMy WebLinkAboutMiscellaneous - 32 LINCOLN STREET 4/30/2018 (2)/ 32 LINCOLN STREET 210/070.0-0041-0000.0 1 Date WY` TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . . . . . w. .P4 7 �—. So yv, , , .LPR/I has permission to perform . . . . . wiring in the building of . . . .L:. F.v . . . . . . . . . . . . . . . . . . . . . . . at . . . .3 2 C,rR/. . . . .S ,No h Andover, Mass. d Fee . .��O.-�'ic. No. . . ,� 2...�_S". . . . . . . . . . . . ELECTRICAL INSPECTOR 'heck # 3 b3�3 11239 l.om.monwea&of Maiyachubetti Official Use Only c7 Permit No. _3G Apartment � -1 partment ol5ire Serviced Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 1 I-15 City or Town of: fJ 14 c^Jo. r'�1 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) 3,�/ y Owner or Tenant "S pl > Telephone No. Owner's Address " Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. 132&n Ste'J Existing Service iZ Amps /.�iO 1,,2qb Volts Overhead ® Undgrd ❑ No.of Meters �( New Service � Amps l /vtyt; Volts Overhead ❑ Undgrd ❑ No.of Meters _ 3 Number of Feeders and Ampacity `` 4A C. r,C e Location and Nature of Proposed Electrical Work`" Completion of the llowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- Elo.o mergency Lighting rnd. rnd. Batter 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 Initiating Devices Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number ITons JKW No.of Self-Contained Totals: Detection/Alerti'la Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other K Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water K`,�, No.of No.of Data Wiring: Heaters Si ns Ballasts No.of Dvices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipalolic . p Y) Work to Start: I+- I S22- 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 certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: 1J it((I Irv-�� ���,� Z�� ,u Si natur g LIC.NO.: E37,�c(S (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.: 75s1'9o2. -�b21o9 Address: Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.No. OWNER'S INSURANC WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law my i atu below,I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent. Owner/Agent �.p� Signature Telephone No. 3 � 75� PERMIT FEE: S it The Commonwealth of Massachusetts Department of Industrial Accidents - Off ce of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: L1 a=. KL)rl So S-7- City/State/Zip: City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 4�S Remodeling have ave ship and have no employees These sub-contractors8. ❑ Demolition o working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. E] We are a corporation and its 10.❑ Electrical repairs or additions t q ] ` 3.JS� I am a homeowner doing all work officers have exercised their I L❑Plumbing repairs or additions myself. o workers' . right of exemption per MGL Y � comp 12.❑ Roof repairs insurance required.] t c. 152; §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *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. tContractors 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-contractors have employees,they must provide their workers'comp:policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 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 the patq a�penalties of perjury that the information provided above is true and correct. Sign ture: L.�.J�� � " Date: Phone#: 7 ` Official use only. Do not write in this area,to be completed by city or town official - City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions 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-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy'is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to,obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 11-22-06 www.mass.gov/dia Date..... ........................ AORTN TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING AT 0 ACHUS This certifies that .................................. ......................... ...... has permission to perform wiring in the building of......... I!F............................................... ............ .North Andover,Mass. Fee..Z-35...:`� Lic.No.3.72�5�......... ... . .. ..... ... PE /OLiM ' ICA�LiNSI ECTO Check # 4� 0705 I l.ommonuieahk o f Madjac4a9ettd Official/Uyse�Only 7 nl € c� Permit No. �(.� / x 2epartment ol3ire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank) i 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 PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: 16ki 79n,,,4y"ft— To the Inspector of Wires: t By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) � �,0o Owner or Tenant llt`+�r�Py ���?u� Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes Fk No ❑ (Check Appropriate Box) Purpose of Building Llpel__- Utility Authorization No. //, I F -3 4 6 Existing Service Amps / Volts Overhead ® Und rd g ❑ No.of Meters " New Service Ams / Volts Overhead P ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: I w I_ Completion of the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. grnd. Patter No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of SwitchesNo.of Gas Burners No.of Detection and Initiatin Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of elf-Contained IQ Totals: Detection/Alertin2 Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection 1 No.of DryersHeating Appliances KW Security Systems:* No.of Devices or Equivalent r No.of Water No.of No.of KW Data Wiring: Heaters Si ns Ballasts No.of Dvices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent i OTHER: 11 Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 7606 (When required by municipal policy.) Work to Start: S 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 certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: r Licensee: 01L,11Q.fi Signature LIC.NO.:Ems'7,4 s (If applicable,. r " xempt"in the license number��+*+e.) Address: OU G % t Alt.Tel.No.:6 6 Bus.Tel.No.: - 26 *Per M.G.L.c. 147,s.57-61,security work requires Dep&rtment of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability it surance coverage normally required by law. B" y sign e below,I hereby waive this requirement. I am the(check one)EN owner ❑owner's a ent. Owner/ t Signature Telephone No. ?7 '375 �? ERMIMT FEE: $ ✓ �� 3q' A - l �I P. r i A� Y I y Y+ I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia j Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers j Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: yo2' 9J dso N S City/State/Zip: a Q d &506V Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g• ❑Demolition i working for me in an capacity. employees and have workers' ( g y ' [No workers' comp. insurance comp. insurance.,- 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10. Electrical repairs or additions officers have exercised their 3. I am a homeowner doing all work 11.rl Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152; §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *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. tContractors 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-contractors have employees,they must provide their workers'comp:policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �. olicy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under thepains andpenalties ofperjury that the information provided above is true and correct. Signature: 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 Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of 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 names address es and hone numbers along with their certificates of pP Y ( ) ( ), address(es) p ( ) g certificate(s) insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the.affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext.406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 11-22-06 www.mass.gov/dia Date. !,�� / .�. . .. .. NORTH pF Sao ,°110 o? y` TOWN OF NORTH ANDOVER F p ' 'PERMIT FOR`GAS INSTALLATION SACMUSEt :r This certifies that . . ✓.�l�h�= ('. . ©!�vIJ'v. _ . . . . . . . . . . . has permission for gas installation in the buildin s of . .4,�:ka4e.l . ./� h. . . ."!-e. . . . . . . . . . . . . . . . . at . . . . . . . j? a�. .S.7. . . . . . . . . ., North Ando /Muss. : Fee. . �7 da Lic. No.:,�/. .Z3� ./7 4!K:�. .aj�r ��? . . . GAS INSPECTOR Check# SO 8016 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: W 1/m Z rV-41 MA. Date: / aO Permit# Building Location: 3,� ,vii Q//1 ST Owners Name: V i n c LJ 1T- 4'j) �D/V-2 Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential [ New: ❑ Alteration: ❑ Renovation:t�( Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES Lu co z C6 m s 0 � W v co o = co w z Z z p � W z W o aa� Z5 w CO W m 0 Q a Fw- 0 0 W X W F m v w w Z = cn W Lu o F o x w > V w z —I l— F- O z -j 0 u- F = w F w W Z W } W CD J Q Q . m w O z 0 L > z F- _ V o o t=i. CQ7 = z � O a. H > > > O SUB BSMT. ' BASEMENT I IaltjI r 1 5T FLOOR ' 2 FLOOR f 3 FLOOR 4 FLOOR 51HFLOOR 6 FLOOR 71HFLOOR 8 FLOOR Check One Only Certificate# Installing Company Name: 14,•c��-e j'4 • �n ,.,-rte ❑Corporation Address:— / .3 A /. -P/L-PR City/Town:_E„e/ItJ-1- State:_ El Partnership Business Tel: (�7- 7 f 7 - 0 9 Fax: ❑Firm/Company Name of Licensed Plumber/Gas Fitter: 95S v 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 have checked Yes,please indicate the type of coverage by checking the appropriate box below. 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 c usetts�Gaws,and that my signature on this permit application waives this requirement. V Check One Only Owner F-1 Agent ❑ Si natur of Owner or Owner s A ent 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 an Cha d pter 142 of the G eral Laws. liZ�� Type of License: By — DJ-Plumber �' 0 Title El Gas Fitter Signature of Licensed Plumber/Gas Fitter Master Cityrrown ourneyman License Number: 3 3 APPROVED OFFICE USE ONLY LP Installer The Commonwealth of Massachusetts Department of Industrial Accidents Office ofinvestigations 600 Washington Street Roston, AM 02111 www mass:gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organization/Individual): /1?/' c4/ 1Q SS 0 Address:_ % �I ( k City/State/Zip:_ 6,V n e {l- t/ 02/1 Phone#: 0/2 - 7 9 7 - f2i 7 Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4. Type of project(required): ❑ I am a general contractor and I employees(full and/orpart-time).* have hired the sub-contractors 6• ❑New construction 2%n I am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling ship and have no employees These sub=contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. [No workers'comp. insurance 5. 9• ❑Building addition p ❑ 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 boy:#1 must also fill out the Section belong Eho;=.,ir. ei works,'eoWpb•sauon 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: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby ce underand penalties of perjury that the information provided above is true and correct: Si atur . Phone#: E only: Do not write in this area, to be completed by city or town official n: Permit/License# ority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspectorson: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of 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 coimpliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es) and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retueued to the city Cir town.that the app%rcat-i n f he � liCed.e 2,.being requested Department of i'y t� 4hr a or t4 p :anis or s s g P�� ,not the Depa nt 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 homeowner or citizen is obtaining a license or permit not related to any business.or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would'like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 east 406 or 1-8.77 MASSAFE Revised 5-26-05 Fax#617-727-7749 wvm%mass..gov/dia 9268 Date. 9/. !sf?vii TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSAGMUS� ? c t This certifies that . . . .SPL . . . . . . . .USSU . . . . . . . . . . has permission to perform . .e)?f-'.�t��_ ./ ��C .�l��. S. . . . . . . �!e? plumbing in th buildings of . . !?I . /�? "`� at. : .�. . . . .1 60..�✓/. .5.7. . . . . orth Andover, Mass. � &PE PLUMB NN R Check # o MASSACIIUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Building Location 4o L 6 4 S 1 Date p 0/ a Permit# Owner V t C e Yl j n!–o — Amount New 0 , Renovation Replacement Plans Submitted Yes No FIXTURES S[I�EF�VIC R8EMENT IST ELOOR 3REk IIDQt 4IH EL" 6TH FLOM 7M HOM SIH NJ" 01�ririt or type) Check one: Installing Company Namer17 i ,QJ�,4. S 5 QCorp. Certificate Address /9 /A-, I r r dL �e� / , ba/y Partner. Business Telephone 7 7 _ -7 Firm/Co. Name of Licensed Plumber: / � . Insurance Covera Indicate the type of insurance coverage by cher the appropriate Liability insurance policy Other f indemnity Bond insurance Waiv I, der three signed,have been made aware that the licensee of this application does not have any one of the above 'V � Signa Owner ❑ Agent I hereby certify that all of the details and information I have submitted(or,entered)in above application are true and a best of m knowledge an accurate to d that the Y g tall lamb' p ing work and installations ormed der Permit Is compliance with all pertinent provisions of the Massachusetts S d for this application will be in b' ode er 142 of the General Laws. By: D ignauire o rcense um er Title Type of Plumbing License City/Town 1239 APPROVED(ocEusEONr Y dense um-_" _— Master n Journeyman L...� Irew/Z � Z. r r �- The Commonwealth of MaNsachuselts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Pr><nt Legibly Name (Business/Organizafion/Individual): /�p,t �i fSl� Address: City/State/ZiP:_�y&�e a- Phone#:- /7 - 7 g 7 - rf'd,97 Are you an employer?Check the appropriate box: 1.El am a employer with 4, Type of project(required): ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. I am a sole proprietor or partner- listed on the attached sheet � 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. com . insurance 5. 9• ❑Building addition [No workers p.p ❑ We are a corporation and its required.] officers have exercised their ME]Electrical repairs or additiops 3.❑ I am a homeowner doing all work right of exemption per MGL .11 T- Plumbing repairs or additions myself. [No workers' comp, c. 152,§1(4),and we have no 12,0 Roof repairs insurance required.] t eq ] employees. [No workers' a comp.insurance required.] 13.❑Other Any applicant that checks bot:i-i must also fill out the section below sho«ng theirworkcris _ 'ey inform on _ comm f Homeowners who submit this affidavit indicating they are doing all work and then hireutside contractors io-utst submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contactors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address:__ � �-i�C��n - �1` _ City/State/Zip:gZl}iW J 6V-1 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 co Investigations of the DIA for insurance coverage verification.copy of this statement maybe forwarded to the Office of I do hereby certify under the s and nal ' perjury that the information f mation rovided above ove rs true and correct Signature: i- a f o7 Date.: / Phone#: Official use only.. Do not y write an 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#: i r. 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 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 apartruents 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 w cessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their cerdficate(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 lie returned to the city or town that.the application the e artolicense is be mg requested,not the Department of r 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 aspace 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 permittlicense 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,IIIA.02111 Tel. # 617-727-4900 ext 4.06 or 1-877-MASSAFE Revised 5-26-05 Fax##617-727-7749 mmm,.mass-gov/dia - A i . .yIa77 , Date. . .. HORTq o� TOWN OF NORTH ANDOVER F D • PERMIT FOR GAS INSTALLATION SACMUSEt This certifies that .. . .o..? . . .�(.tl . . . has permission for gas installation . . li?��. . . . . . . . . . . . . . . . . . in the buildings of . . . . . . . C),� _. . . . . . . . . . . . . . . at . . . :.:` . . . .� � 1.%z. . . . 1� . . . .. North Andoveer`, Mass. f�'e.2S..c4. Lic. No.,AO.)31. GASINSPECTOR Check# �(� N MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Towni'' 11,��t�-�., , MA. Date: - l l �PermiW�_�� Building Location: /<,'66A,) Owners Name: Type of Occupancy: Commercial❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES wco co m Cd r F-Lu ZCd m CO U = a ca 0 z z W v z m p 2 w W O 0 � Lu O Q H w m w m o a. 0 U) rn v W Lu Z ~ = N UJ 0 W W o = > 0z LU w Z JW U) F— IQ— O Z —1 0 LL U) = W H w W V D D LL (7 (7 2 = O a H > > > O SUB BSMT. BASEMENT isT FLOOR 2 Nu FLOOR Vu FLOOR 4 FLOOR 5TH FLOOR 6 FLOOR 7 FLOOR 8 FLOOR l Check One Only Certificate# Installing Company Name: /)�_ �r/C`— w✓ /y �yj '4I s�J Elorporation 6' C l J Address:/ �� D City/Town: � � State:�� // El Partnership Business Tel:6035�S��b Fax: ❑Firm/Company Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes L?rNo❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy V 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent 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 he General Laws. By Type of License: ❑Plumber Title ❑Gas Fitter Vgnat�urZeof Licensed Plumber/Gas Fitter ❑ler Citrneyman �� APPROVPROVououED OFFICE USE ONLY EJ LP Installer License Number: I Location _52 --3 C! /,Iti 40 S �- No. 5 a ) Date Of "ORT" TOWN OF NORTH ANDOVER 1t`�° ,�,1•C ` Certificate of Occupancy $ Building/Frame Permit Fee $ 8 Ss+c14 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # r)l 6 '16345 �G- Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: �a n DATE ISSUED: vD 3 SIGNATURE: Building Commissioner/I for of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Prop y Address: 1.2 Assessors Map and Parcel Number: .3 Map umber Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning DisUid Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 0 1.7 Water Supply M.GL.C.40. 54) 1.5• Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ '?One Outside Flood Zone 0 Municipal ❑ On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Ow�Jer of Regprd 1, Name Print Address for Service: �N (Print) tce �1 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Z rn Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construe n Supe Not Applicable ❑ Licensed Cons ction Su rvisor: e &3 C F License Number nn Address Expiration Date Si afore Telephone 'aa� 3.2 gpgistered Home Improvement Contypctor Not Applicable ❑ v ompany Name rn 4yRegistration Number r ��� AcWess r � Expiration DateI'S ^ i nature Telephone V ' I 1 r SECTION 4-WORKERS COMPENSATION(M.G.L.C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check allapplicable) New Construction ❑ Existing Building 0 Repair(s) 0 Alterations(s) ❑ Addition 0 Accessory Bldg. 0 Demolition 0 Other ❑ Specify Brief DescFiption of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be E(INLY Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction (9 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC D 5 Fire Protection 6 Total (1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN it OWNERS AGENT OR CONTRACTOR APPLIES FOR BUR DING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf;in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER,/AUTHORIZED AGENT DECLARATION r 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief � I Print ame Si Anature of Owner/A 9ent Date '717:.• NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1ST2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS -HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE i 1 INFORMATION &INSTRUCTIONS Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law" an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. i 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 section 25 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, 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 in the workers' compensation affidavit completely, by checking the.box that applies to your situation and supplying company names, address and phone numbers as all affidavits 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. City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for your cooperation and should you have any s lease do not he ' questions, p sitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street b Boston, MA 02111 Fax# (617) 727-7749 Telephone# (617) 727-4900 ext. 406, 409, or 375 �17se Commorcweaftfi of 912assacftusetts a Department of Ind=Tia[Accidents Of,=ofInvestigations s ��• 600 Washington Street Boston, %tg 02111 Workers'Compensation insurance Affidavit A.PPLICA.NT LNFORMA N Please PRINT Legibly Name: � �1 Location: CMry: d : �WTelephone#: ❑ I am a homeowner performing all work myself. ❑ I am sole proprietor and have no one working in my capacity ❑ I am an employ, r provisling workers' compensation for my employees working on this job F / Company Name: 2'L&C11W 0 Address: C.2 1 CTelephone City: Insurance Company: C�I olicy#: P ❑I am(circle one) sole proprietor,general contractor or homeowner and have hired the contractors listed below who have the following workers' compensation policies: Company Name: Address: City: Telephone#: Insurance Company: Policy#: Company Name: Address: City: Telephone#: Insurance Company: Policy#: Attach additional sheet if necessary Failure to secure coverage as required under Section 25A of MGL 15B can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I t a of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. understandtha . co Y PY 1 do here rtcfy under the ains a penalties of perjury that the information above is true and cor ct. Signature: Date: S�t� Print Name: Q Phone# _ Official Use ONLY-Do not write in this area ❑Building Department Permit/License#: ❑Licensing Board City or Town: a Selectmen's Office C)Health Department 13 Check if Immediate response is required o Other ti r ' INFORMATION &INSTRUCTIONS Massachusetts General Laws chapter 152 section'25 requires all employers to provide workers' compensation for their employees. As quoted from the "law" 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 section 25 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, 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 in the workers' compensation affidavit completely,by checking the.box that applies toour situation and supplying toy company names, address and phone numbers as all affidavits maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city,or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are required to obtain a workers' .compensation policy,please call the Department at the number listed below. I City or Towns 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 t o fill out in v y 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Fax# (617) 727-7749 Telephone# (617) 727-4900 ext. 406, 409, or 375 NORT#q Town of And = O -" dower Mass. %6'6"9400 o COC 1K w CQ > > A11 DRATED C-1 BOARD S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System "&*A#A0 AS 0 BUILDING INSPECTOR THIS CERTIFIES THAT...... ...... ................................................................ Foundation I.p............ buildings on ..4�*-; Y /V C v�Id ...IF- Rough has permission to erect... ' .R g . ...................................5 to be occupied as..` ....R e.1.00..0.......... �.N.t4�w C. ..................................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Lawsr lating to the nspection, Alteration and Construction of Buildings in the Town of North Andover. f JII so 0000� PLUMBING INSPECTOR i VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARS ELECTRICAL INSPECTOR C Rough ....................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. �'� L.anuxartweat�{t a f f~f���iicdo�! •` For Office use only 199) p �v w'�errictd (Rev.t Num ..Us ��• Permit Number. BOARD OF FIRE PREVENTION REGU IONS Occupancy&Fee 3c�ZJ APPLICATION FOR PE TO PERFORM ELECTRICAL WORK (ALL WDaxro eE PERF0 wrrx MASS=Z )Sl M ELECrMCAL CODE 527 cMR Ixoo) PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date: City or Townof: v To the Inspector of Wires: By this application the undersigned gives notice of his o h intention to pertorm the electrical work described-below:, 7 zz�, Location:(Street& �Number) .�;/� C o „ - sem-- L4 Owner or Tenant: h { Owner's Address: yJ% Is this permit in conjunction with a Building Permit? Yes o No 1-�(Check Appropriate Box) Purpose of Building: 2_ /—ice,- U014 Authorization# Existing Service: 2liv Amps • ad Underground � � #of Metersere _ New Service: Amps / Volts Overhead D Underground.❑ #of Meters: Number of Feeders and Ampacity: Location and Nature of Proposed Electrical Work: No.of Recessed Fixtures No.of Cell:Susp.(Paddle)Fans No. of Transformers Total KVA : * Of Lighting Outlets O No. of Hot Tubs Generators KVq of Lighting Fixtures Swimming Pool: Above ground 0 In Ground 0 #of Emergency Lighting Battery Unitsof Receptacle Outlets rj No. of Oil Burners d Fire Alarms #of zones #of Detection&Initiating Devices Of Switches No.of Gas Burners #of Sounding Devices: #of Self Contained "gam No, of Air Conditioners TOTAL TONS: Detection/Sounding Devices of Waste Disposals Heat Pump Totals: Local o Municipal Connection o Other o Number. TONS: KW: Security Systems: No.of Devices or Equivalent Dishwashers Space/Area Heating: KW Data Wiring,No..of Devices or Equivalent f Dryers __ Heating Appliances KW Telecommunications Wiring:No of Devices or Equivalent: f Water Heaters KW No. of Signs: #of Ballasts: OTHER; ydro Massage Tubs No. of Motors Total HP NCE COVERAGE:Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance g`completed operation'coverage or Its substantial equivalent undersigned certMes that such coverage is In force,and has exhibited proof of same to the permit CO. CHECK ONE: INSURANCE d BOND a OTHER a Please specify: d Value of Electrical Work (When required by municipal policy) Start: / '/G — ;S 1 carflfy,under the pains and pens/fleas to be requested In accordance with MEC Rule of perjury,that the information on this application is true and complelte10,and upon completion. :��L�/ .s /�• �ty l / Signature, J O _ (if applicable,ant r 'ax n the 11 ns , u or line) LIC.a� 9 S 3 Address: Bus.1 el,# —2/G AIL Tel.# OWNER'S INSURANCE WAIVER:I am aware that the Licensee does not have the Habillty insurance coverage normally required by law. By my signature below,i waive this requirement I am the(check one) Owner 0 OR Agent a Signature of Owner/Agent Telephone# , PERMIT FEE:S Date.17z�................ VkORTFf TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHU This certifies that B. .........,` .......IL-1 ............. .......................................... .has permission to ....................................... Miring in the building-of........� , a,"-� !J....................................... . .... .... .......................................................... -North Andover,Mass. Fee��f7........... Lic.No.............. ....... ELECTRICAL INSPECTOR V Check # 5521 L.onusioruveai�o �� For Office Use Only c�� c'7 (Rev.11/99) 290arLnaud o�}ira�mica Permit Number, BOARD OF FIRE PREVENTION REGU TIONS °�upancrr�Fee APPLICATION FOR PE TO PERFORM ELECTRICAL WORK (AL L WORK TO BE PERFORMED W17}i MASSACiiC1SETt S ELScrXICAL CODE 527 CMR 1200) PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date: City or Town'of: y , To the Inspector of Wires: By this application the undersigned gives notice of his o h r intention to perform the electrical work described below, Location: (Street&Number) 3-2— .�;h eSJ— Owner or Tenant:_ (' s ; Owner's Address:__ Is this permit in conjunction with 1 a Building Permit? Yes o No — Che ( ck Appropriate Box) Purpose of Building: Utility Authorization#' Existing Service 2G / Amps/Z v/2_�_cVolts Overhead . Underground #of Meters _ New Service Amps / Volts. Overhead 1 Under round,❑ 9 #of Meters: Number of Feeders and Ampacity: Location and Nature of Proposed Electrical Work: No,of Recessed Fixtures No.of Cell:Susp,(Paddle)Fans No, of Transformers Total KVA No.Of lighting outlets No. of Hot Tubs , Generators KVA No. of Lighting Fixtures Swimming Pool: Above ground a In Ground o #of Emergency Lighting Battery Units 3 �`, No.of Receptacle Outlets Y f% No. of OII Bumers Fire Alarms d #of Zones #of Detection&Initiating Devices No,of Switches No.of Gas Burners #of Sounding Devices: #of Self Contained No.of Ranges Detection/Soundin Devices No. of Air Con 9 Ices dl Uoners TOTAL TONS: Local o No. of Waste Disposals Municipal Connection o Other o Heat Pump Totals: Number. TONS: Security Systems: No,of Dishwashers KW' No.of Devices or Equivalent Space ce!Area Heating: KW Data Wiring,No..of Devices or Equivalent: No.of Dryers .�. Nesting Appliances KW Telecommunications Wiring:No of Devices or Equivalent: No. of Water Heaters KW No. of Signs:-#of Ballasts: OTHER; #of Hydro Massage Tubs No. of Motors Total HP I)JSURANCE 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. a undersigned certifies that such coverage is In force,and has exhibited proof of same to the permit Issuing office. CHECK ONE INSURANCE 6- BOND p OTHER a Please specify: Estimated Value of Electrical Work$ (When required by municipal policy) Work to start: Ins ctions to be requested In accordance I card fy,under the pains and penalties of perjury,that the In onnatlon on this application is true tm complete,0,and upon completion. I Firm Name: S,., / LIC.# �/ Licensee: Signature, applicable,ant-r 'eze in the l/ ns e u er line) LIC.# Address: S� bus el,#��7 —Z/o yAlt.Tet.# OWNER'S INSURANCE WAIVER:1 am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I waive this requirement. I am the(check one) Owner o OR Agent a Signature of Owner/Agent: _ Telephone# PERMIT FEE:S