HomeMy WebLinkAboutMiscellaneous - 32 STONINGTON STREET 4/30/2018 32 STONINGTON STREET r 210/019.0-0051-0000.0 A Date... .............. 00 TOWN OF NORTH ANDOVER . PERMIT FOR WIRING s3ACH This certifies that 9,,-,-o -b', Pe-Ayz .......................................................................................................................... has permission to ............................... wiringin the building of.............. ................................................................................ at ...... ....................................... -,-Vorth Andover,Mass. Fee..,.� its V4 ......Lic. o. ..... E TR'ICAL CTOR Check# f � i - - Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. �- Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] leave blank APPLICATION FOR PERMIT TO PE FORM .ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 C 12.00 (PLEASE PRTNTW INK OR TYPE ALL INFORMATION) Date:, (,- l City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice =hi her intention toyerform the ectrical work described below. Location(Street&Number) ( / Owner or Tenant AckA Telephone No. Owner's Address I h3�'fi a Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service� Amps / olts Overhead Undgrd 1:1No.of Meters _ New Service C�,00 Amps /o�4(.kolts Overhead©Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: L)P G P--Ab F S Z-P—J ( C-9—TZ7 flM Com letion o thefiollowing 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 mergency Lighting nd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: '. .To........"....""'.""""""" Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical ork: (When required by municipal policy.) Work to Start: j-(p— / ? Inspections to be requested in accordance with MEC Rule 10,and upon completion. �f INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability ins nee including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cover is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I cert,under the pains and enalties ofperjur -that the information on this application is true and complete. FIRM NAME:Gi tity� , /i=.�E' 1 [;1�1 l7 i i LIC.NO.:14 4 ?7 Licensee: J ' Q Signature ,LIC.NO.: ygl�7� (Ifapplicable,enter mpt"in the license ember line.) ` Bus.Tel.No.• O Address: j W412Q gur JL �4A-81nCN AX () %48 Alt.Tel.No.: 9-�4 r *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE. S Signature Telephone No. (` ►D SQL ?3 it ELECTRICAL INSPECTOR .SOU .XNP CTIO_N . Passed--[ ) Failed-( ] Re-imp ection required($50.00)"r j -inspectors'comweAts: - L {X. •' . _ • a ti t'. �a 8. (Gasp ectors'Signature-no initials) pate 1 FXN•AL INSPE TION; Passed—L1 ) V Failed.-[ ] Re-inspection required($50.00)"[ j inspectors'co nis• spectors'8lgnaiuf&4 no initi Is) Date I MINDER GROUND INgRECTION: , passed--j ] Failed- [ ate-inspection required($50.00)"[ J Inspectors'comments: f (Inspectors'Sfgnature"no initials) Date t.'.I�I'SPECTION-�Ekt�XCE: - . DATE,CK(,E>ED NATIONAL GIRD, : NA1�•. Passed-[ ) Failed-( Re-inspection required($50.00)-[ ] Inspectbrs'commends: (Inspectors'Siguature-no initials) Date S.INSPECTION•-OTHER: Passed-[ ] I+.siled--[ )_ 'Pe-inspectiou required($50.00)••17 Inspectors'cmnm.ents: +` 'Qhspeetors'Signature••no initials) Date DOOR TAGS.ARE TO BE FIGLED—OUT AND LEFT ON SHE IF THE AREA.TO BE INSPECTED IS N'OT, .ACCESSIBLE AND ARE MBPECTION OF$50.00 zS TO DE CHARGED. 1 The Commonwealth of Massachusetts Department of IndustrialAccidents ,� tl X Congress Street,Suite 100 '< Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Iudividual): ((,-�(� �l l tJ (�►J( C� Z- C a C C Address: City/State/Zip: P Phone#: _?f� L!389-(00 at-k Are you an employer?Check the appropriate box: Type of project(required): 1. a employer with employees(full and/or part-time).' 7. ❑New construction I am a sole proprietor or partnership and have no employees working forme in $. Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑B ' mg addition ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. 12.F1 Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.❑Roof repairs ' These sub-contractors have employees and have workers'comp.insurance.$ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] 1 , `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 neve affidavit indicating such #Contractors 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. Iain 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.Lip.#: Expiration Date: Job Site Address: 0 a-T6 \2— —City/State/Zip:yQ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verific tion. I do hereby rt y u derthe ins andpe lttes ofperjury that the information provided above is true and correct. ` telSi afar : Date:5 Phone-o"' <( _� ©fl f Lr 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#: 1 r � 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 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-lias 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 bum leaves etc.)said person is NOT required to complete this affidavit. v The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia a l� kj &COMMONWEALTH OF MASSACHU'SETT BQARD � 4 ELEGTR I C PANS L =$ UES THE F,,OLLOWING LICI<N'SE A5 A S t ° REGI;STERD MASTER ELECTRI\GIAN;� h,G I NO Da P I ETRANTON'I'O ELECTRI tGINO DIP.IETRANTONIO I 19 WARREN AUE' N MA oz�"48-5617 "Blo84 C � � >:t <COMMONWE; `LTH . • • . • OF MA SACHUSE:TTS,:> !! aoaRWdIr ELECTRICIANS ISSUES TIDE FOLLOWING. L:ICENSVE ? AS RSG JOURNEYMAN: TELECIR 1 4~�f IYCRI;ANi� I G.>I:NO D I P `• ... I ETRANTON'j'p � 3 . w1c1 19 WAR REN''" =� p I 1 \ 02148- 6 294 78 `E:;' 5 1..7 4 '07/31; X7278 - - ....................... NORTH TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING This certifies that., A i�.�.............. ..a,4........................................ has permission to perform 64An)z-,*I............................................. .............. wiring in the building of..........V.-U........................................................................................ .:3 ... ......2 . ,Mass. V-,4",-" at -I"U"V:- ..... ...... ... ...................................................:...North Andover,Mass. Fee ..........Lic.No. ........Z !�C�TRI�CAZ INSPECTOR _r Check# (0 11 ? 7 / 6p 4S_ .2 3 w - - Commonwealth of Massachusetts Official Use ]Only 60 Department of Fire Services Permit No. 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),5 7�12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:_ City or Town oh NORTH ANDOVER To the I ector bf Wires: By this application the undersigned gives notice of his or her' tention to perfopn the electrical work described below. Location(Street&Number) 3a- S+vo/t3 - Owner or TenantL� Telephone No. Owner's Address ►L 3 yU Is this permit in conjunction 1VT ilding pe it? Yes No ❑ (Check Appropriate Box) Purpose of Building� egpy(�, Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: W)Q 011- N P LZ Completion o the ollowin table may be waived by the Inspector o 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.of Emergency Ligliting nd. grnd. Battery Units No.of Receptacle Outlets Zt No.of Oil Burners FIRE ALARMS JNo.of Zones No.of SwitchesNo.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Cl Totals: """"''"...""............... Detection/Alerting Devices o` No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:3 No.of Devices or Equivalent No.of Water , No.of No.of Data Wiring: Heaters Si ns Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as rega+ired by the Inspector of Wires. Estimated Value of Elect ical Work: (When required by municipal policy.) Work to Start..-40 Inspections to be requested in accordance with MEC Rule 10,and upon completion. +f 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 en ies of perjury,that the information on this application is true and complete. 0 FIRM NAME: f LJR— (0 (Z(L- LIC.NO.: /& OMsee:, Signatur IC.NO.:8CP-19 (If applicable,enter"exempt"in the cense number line. _n Bus.Tel.No.; -7-P 1 3qJ i't O 0 Address: �l-�?���21 �y� �NLD E Uv ` t�/C�� Alt.Tel.No.:=7�1 ,iaG *Per M.G.L c.'147,s.'5-7-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE.$ i _. 7EX,lEcCTRXM PEpjvff's'Ro. WSPECUONREPORT. ELEMICALINSPE -TOR 1.ROUGE.. SP CTION; l Passed [ V+ailed-•[ l Re-inspection xequlreft($50.00) [ ] + ikspectors'comments: (Cnspecto f atuxe-no�nffials) Date 2.FXIV'.A7G IP7SP�CTZON'; Passed--[ ) \ Failed--[ j ate-fnspectionrequized($50.00)-•[ � ];asI tors'comments", (f*ectors'Signa a-no' 'als) Jute 3.UIeIDER GRODM INSPECTION: Passed- [ ] F+afled -j ] ?fie-iuspection,required($50.00).[ ] inspectors'comments: (Inspectors"Signatare-no initials) Date � [4. NSPECTION—SERVICE: J�asei -ctbrs pec 'commeufs: l Ged r—i�[; J2eN-in'A1sp�ect•i. onxec�uired($50.00)• [ ] (Inspectors'Siga*xe••io initials) Date 5.ZNSPECTION-OMER. Passed—[ ] Failed [ ) lte inspection required($50.00) [ Y � Inspectors' cobiMents: E, (&apedors'Signature-no fifflals) Date DOOR TAGS.APS TODE FILLED OUTAND LEFT ON SITE IF THE AREA.TO BE INSPECTED IS NOT ACCESSIBLE AND A RE WSPECTION OF$50.00 IN TO BE CHARGED. The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 021142017 SO www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): j���1 ) ¢J7 1 (J () > (L� Address: City/State/Zip 0 Phone#: Are you an employer?Check the appropriate box: Type Of project(required): 1.❑I employer with employees(full and/or part-time).* 7. ❑New construction 2. I am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.(No workers'comp.insurance required.]t 10❑Buddition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.ffElectrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.❑Roof repairs • These sub-contractors have employees and have workers'comp.insivance.$ 6.0 We are a corporation and its officers.have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *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 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 state whether or not.those entities have 1 employees. If the sub-co' Tactors fiave employees,they must provide their workers'comp.policy number. I ail 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: 070 f-� City/State/Zip:0 80A00°2-- t 'A t Attach a copy of the workers'compen ' n policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verif ation. I do hereby rtif un r tli p=ofperjury that the information provided above is true and correct. Si n e: Date: �o �- /rr ! 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-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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia z COMMONWEALTH OF MASSACHUSETTS: : 101 LING12 • q 14 Lei:1 klmll E' .EC:TR`I C I ANS:::. - 1 a ISSUES„ THE FOLLOW I NG:. L I CENSE I itE13�JOURN EYMAN ELECT40-019-W-- GP I ETRANTO,N"f0 19 WARREN'"E s x 02148—561..7 r: 1.:; 29.478 <`E =-> V' 97 2 7 7f31:1..16<:.. 8 1 ,.�. ... , • COMMONWEALTH OF M ' • • ASSACHUSE1: • •.BOARD' • El"E;CTR.1'C I`A N S.,; 'S'SUES THE REGISTERED MASTER ELECTRI C-I�A NSE AS A PIETRAN TON L>0E L`E / a ,, ETRANTON I p CTRII C a 1 w:. 19 WARREN 'EINE :rv�.. a�. `MALDEN`. 15274 021 61 �.-..:. , '''Oj31/J.6:<, >81084 SUBURBAN ADJUSTMENT 226 LOWELL STREET, SUITE B5 WILNIINGTON,MA 01887 978-988-5959 FAX 978-657-8969 Form of Notice of Casualty Loss to Building Under Mass. General Laws Ch. 139, Sec. 3B TO: Building Commissioner or Board of Health or Fire Department or Inspector of Buildings Board of Selectmen Arson Squad City or Town Hall City or Town Hall City or Town Hall North Andover,MA 01845-3620 North Andover,MA 01845-3620 North Andover, MA RE: Insured: Amy Lu ����,�: Property Address 32-34 Stonington Street APR 0 0 . 014 j Policy No.: CP 022702 f TOWN OF NORTH ANDOVER 1 HEALThi DEPARTMENT Loss of: 03/31/2014 _ — — File or Claim No.: 14062 Claim has been made involving loss,damage or destruction to the above captioned property;which may either exceed$1,000.00 or cause Mass. Gen.Laws,Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen.Laws,Ch. 139 Sec.3B is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured,location,policy number,date of loss and claim or file number. Dana M.Akers Property Adjuster On this date,I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. 04/03/2014 Signature and Date > t IV SUBURBAN ADJUSTMENT 226 LOWELL STREET, SUITE B5 WILMINGTON,MA 01887 978-988-5959 FAX 978-657-8969 Form of Notice of Casualty Loss to Building Under Mass. General Laws Ch. 139, Sec. 3B TO: Building Commissioner or Board of Health or Fire Department or Inspector of Buildings Board of Selectmen Arson Squad City or Town Hall City or Town Hall City or Town Hall North Andover,MA 01845-3620 North Andover,MA 01845-3620 North Andover, MA RE: Insured: Amy Lu Property Address l 32-34 Stonington Street-- Policy No.: CP 022702 Loss of: 03/31/2014 File or Claim No.: 14062 Claim has been made involving loss,damage or destruction to the above captioned property,which may either exceed$1,000.00 or cause Mass. Gen. Laws,Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws,Ch. 139 Sec.3B is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured,location,policy number,date of loss and claim or file number. Dana M. Akers Property Adjuster On this date,I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. 04/03/2014 Signature and Date Y ) Date........`..... .a.7..� N°prh °� "'° '•�� TOWN OF NORTH ANDOVER PERMIT FOR WIRING CMUS This certifies that . ............................................................................................................................ has permission to perform ... rF........—, wiring in the building of.............. G .. ' .:........................................................... at ....... .. 3.7......... � �.JV.'.` '/. . ....... ........:North Andover,Mass. Fee.... '5...........Lic.No.J� ���1 :............ . . .,: ........... 'tCE ICAL INSPECTOR // r t bio Check# ; 12117 i Commonwealth of Massachusetts Official Use Only Permit No. 17-11`7 Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS .[Rev. 1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Z7 City or Town of. NORTH ANDOVER To the Inspector f ices: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) e-5L-ZJ J Owner or Tenant Telephone No. Owner's Address &41 Is this permit in conjunction wit a building permit? Yes ❑ No (Check Apprrp��Box) Purpose of Building Utility Authorization No. / /J 1 Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: -4PJ�7� m P,�z --C {� Completion o the following table may be waived by the Inspector of Wires. of No.of Recessed Luminaires No.of Ceil: TransSusp.(Paddle)Fans Total Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- Elo.o Emergency 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 No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices No.of Waste Dis osers Heat Pump Number Tons J.KW No.of Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other P g Connection No.of Dryers Heating Appliances KW Security Systems:* y No.of Devices or Equivalent No.of WaterKW No.of No.of Data Wiring: Heaters - Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent � OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Ylectrical Work: (When required by municipal policy.) Work to Start: IZI I y 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 ins ance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such covera is in force,and has exhibited proof of s/"'e"thrmit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Speci (/` I certify,under the pains an tp nalties o erju that ilte inf/#t�ntati.a"n this application is true and complete. FIRM NAME: . `- ,, f , 1 C "U 4-A LIC.NO.: ,� Licensee: V I�/J Signature / , / LIC.NO.: (If applicable,enr "e em " 'n the li ense number line.) VWO Bus.Tel.No.: Address: !1 / elAlt.Tel.No.: L *Per M.G. c. 1 7,s.57-61,security work req I 3iffty"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. 4 r �. I�JJu�tili.l..Ei.�.�I,XJ.!_f��.1[i.lF'JJ.J.ISI®'. .•- .l.J.`�IJ7l.Ju�.kJ.®�3C�'J�V�1.: ._ r ' � ...?�V til ♦.-..i��i�:J V�®�~S• , .. r, , r , � R r` x.Plo"r x'ns ectors'eco ,� znmmfs: (Xnspe�oxs? zgxatuxe�x!oifiaTs) Date �.�V�,TN'�l'� ION; • PasseaL j I V rave$--j T �ius�ectio�xe0uixe ($ 0.00)- j xnectol s' (Deats: { !isliectozs' ignafuz oxnitiaiS Slate , 3.UNMER GROTMD)NgR CT`ZON.- �'asse8•-j ] �'a�1et�-•j � �e�inspectxonxe�uire�(��0.00)�j � • Tnspectozs'comments: (Inspectozs'aignatUxe�ao�nitiaTs) Pate &AM,CALTMRWNIUIONM�C-90-131 : NAME: assecT--j � �'aile�..-j � �.e-5nspectzonxequirer�(�50AD)�j � ' !sJ?ectoxs9 comme3its: ' (�uspectoxs',�zgn2tuze��aojnftza�s) bate !sed--j � �'azte�f•-j �- 'Ite�ns�action xegtux'ed($ 6.00)-•[ � pectoxs' co�um.enfs: _ . (Rap ectoxs'slinawe-)10 xiutialls) Date 31 OR TAGS AM TO 13E MLED AMLEFT OX RITE IF THE.A_P. +tea.TO 3E INU TED Xg NOT I ' The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Uf www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name(Business/OrganizatiorAndividual): a o Address: 05 C/k1 a(_el(2 Gam( City/State/Zip: al Phone#: 9'7k 6 �3—M I V- 04 Are y an employer?Check the ap ropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. WFINe -construction employees(full and/or pa - ' e).* have hired the sub-contractors2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7• odeling 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 o 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' 13.❑Other comp.insurance required.] !Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policyinformation. 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 their workers'comp.policy information. I am an employer that is providing wor ers'compensation insurance for my employees. Below is the policy and job site information. 'nn I ,�y Insurance Company Name:. W Policy#or Self-ins.Lic.#: > YI � Expiration Date: q11(0,11( Job Site Address: Z� lL'lL° 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$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 ,�vestigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties 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#: Y� 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)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.ado license or 'ermit to bum leaves etc. g P )said person is NOT required to coinP Tete 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 Com onwealth.ofMossachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston.,MA 0211.1 Tel,#617-727-4900 ext 406 or 1.-877,MASSAFB Revised 5-26-05 Fax#617-727-7749 www.Mass.govfdia Date......... ........ .. .. ...... ...... 14ORTH TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING Hu — 0 This certifies that .......— 1 .................................................................................................................... has permission to perform ........1..............: wiring in the building of............ . at ...... .. /....S7-.6....q...l..l.* .. . .... ................... North Andover,Mass. • Fee... ..........Lic.No ............. ...................... .... / ELECTRICAL INSPECTOR Check# 12093 Commonwealth of Massachusetts Official Use Only o Department of Fire Services permit No. Z D Occupancy and Fee Checked �M s, 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(M1"i ),527r/V 12.00 (PLEASE PRINT IN NK OR TYPE ALL INFORMATION) Date: /js City or Town of: NORTH ANDOVER To the Inspe for ofMires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 3 2--3 S th Owner or Tenant Cv -2 C 9'r') Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building 1L Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No,of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: '— &y o kLC Itclw Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No.of Total r Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- El o mergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiatin Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained ................................................... Totals: . Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wtres. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: ,�� Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove e 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 tins application is true and complet zz FIRM NAME: t LIC.NO.: Licensee: S'T- H Signature LIC.NO.: (If applicable,enter `exempt"in a icense number line.) UBus.Tel.No.: Address: /l 1 Alt.Tel.No.: *Per M.G.L.c. 147,s. 7-61,security work requireg Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE:$ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed " on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of.ongoing construction activity,and may be.deemed-by the.Inspector of Wires abandonedand.invalid ifhe or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass F?1 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 x ail ' Re-Inspection Required($.) ❑ Inspectors Comments: 4 41 rA14 U Oq Inspectors Signature: vS7' MOT- Q ROUGH INSPECTION: Pass IN Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: `— 2-f Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com ` Date./. .. . .. y F, o'<" RT" TOWN OF NORTH ANDOVER - PEAMIT FO`R PLUMBING This certifies that . . . '. . t�. . . . r. .�. .� . . . . . . . . . . . . . . . . . . . . has permission to perform. . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , North Andover, Mass. Fee. v Lic. No.&7 P. . . . . . . . . !`.` "� . . . . . . . . '. PLUMBING INSPECTOR Check ff V ? 7634 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS �f 2Cl"�,/� /� ` Date Building Location 516%,4,11.4 5 wnersName v` Pe.-r-k44. Permit# 70 Amount Type of Occupancy �2S• '/�i� New Renovation Replacement �/ Plans Submitted Yes ❑ No FIXTURES 3 a o w w o w A a bo a A A a x x a. H x W A a a a1 SL MME ISI:HIM 2M it" I' M �)NIDC[t 4II3HIM SII3)NLOCl2 s1FI>FI�t - 7M FLOL�2 SIH)bI10C]�I2 (Print or type) '1 1, ,(f S f_ Check one: Certificate Installing Company Name V W('1 hf ❑ Corp Address ��� ��'`�`{ SN U"'f i< ❑ Partner. Business Telephone 21?2 frSa— 9y Firm/Co. Name of Licensed Plumber: 0 Vza Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy r]/ Other type of indemnity ❑ 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 Signature Owner ❑ ��� I hereby certify that all of the details and information I have submitted en red)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations pefformne4nder P it Issued for this application will be in compliance with all pertinent provisions of the Massachusetts StatPlu in d Chapter 142 of the General Laws. By: igna ure 01 LicelisFEWUM577 Type of Plumbing License Title City/Town License lNumBer Master Journeyman El(OFFICE USE ONLY HORTm pf �,.o ,g1ti0 TOWN OF.FNORTH ANDOVER O ,•; p • PERMJT,FOR GAS INSTALLATION 9SSACHUSEt T�.�' f, 4,.1 - t.._ .� . . . . . . . . . . . . . . . . . . . . . This certifies that . . ..f.. .�:. has permission for gas installation . . . . . . . . . . . . . . . . . . . . . in the buildings of . . ': f'` F . f. . .: . . . . . . . . . . . . . . . . . . . . . . . . . . . at ... . . . . . . . . . . . . . . .. North Andover, Mass. Fee. . :.`. . Lic. No. <. . . . . . . . 'GAS INSPECTOR, f Check# I/ MASSACHUSETTS UNIFORM APPLICATON FOR PERVIlT TO DO GAS FITIING (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building LQgations J10', Permit# 5` 4,17 Amount$ 3 Owner's Name New Renovation Replacement Plans Submitted To � a cli W w 0 i¢ . a W m x O W w O O O z FW a U w x Z F °+ a > d W W !A .zr Q T. �" C W � � O G x Z Q W Q F. F" } h m Z O W > W z C Q d O O W O x a x o x F m > o °a o SUB-BASEM ENT BASEMENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR "1 (Print or type) n �l i '/ T �.- Check one: Certificate Installing Company Name_ Corp. Address �7/ � 11 Partner. �nIPIA n 1 -Business Telephone 0 _ 13-+irm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: 1 have a current liability Insurance policy or it's substantial equivalent. yes13 No� If you have checked yes,please indicate the type coverage by checking theappropriate box. Liability insurance policy �-� Other type of indemnity D Bond 0 Owner's Insurance Waiver: 1,#m aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and tha ignatu on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner I hereby certify that all of the details and information I have submitted(or entered)in above application are true an curate to the best of my knowledge and that all plumbing work and installations performed under Permit Is ued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and C er neral Laws. i By: Signature of Licensed PI r as Fitter Title �Irumber /1-/_/e 0 S City/Town, Gas Fitter ricense Num5er Laster _ APPROVED(OFFiCE USE ONLY) Journeyman Office Use Only The Commonwealth of Massachusetts Petwlr b. Department of Public Safety Occupancy a Fee Checked/,Jn BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 1200 3/90 (leave blank) ktol APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK AH work to be performed In accordance.v4$h the Ma"schusetu Electrical Code. $27 CMR 12:00 q (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date II Y I� G?h,Ey o Towb of �)N 6YCr To the Inspector of Wires; The undersigned applies for a permit to perform the electrical work described below. Location (Street g Number) 2' 3 14 Owner or Tenant I�Le &b�lr c Owner's Address Is this permit in conjunction with a building permit: Yes ❑ No (Check Appropriate Box) Purpose of Building 1 `' Utility Authorization NO. Existing Service Amps 0 / 2 a Volts Overhead Undgrd No. of Meters „J New Service Amps / Volts Overhead ❑ Undgrd❑ No, of Meters Nmmber of Feeders and Ampacity2 ers 1°J K f Al o,. Location and Nature of Proposed Electrical Work Vti p rt`nA S. X11 S\,-4 f 64 W ��l No. of Lighting Outlets NO. of Hot Tubs No. of Transformers Total KVA No. of Lighting'F. ixtures Swimming Pool Above In- rnd. ❑grnd. ❑ Generators , KVA is No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units ! No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones 1 No. of Ranges No. of Air Cond. Total No. of Detection and tons Initiating Devices Heat Total Total No. of Disposals No. of Pumps No. of Sounding Devices Tons KW No. of Dishwashers Space/Area Heating KW N4 of Self Contained Detection/Sounding Devices No. of Dryers Heating Devices KW Local❑Municipal ❑Other Connection No. of No. Of Water Heaters KW Sig sf Ballasts Wirinoltage No. Sydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES❑ NO[] I have submitted valid proof of same to this office. YES❑ NO ❑ If you have checked YES, please indicate the type/off coverage by checking the appropriate. box. INSURANCE ® BOND ❑ OTAER❑ (Please Specify)`.[L.iVYI 14I2,319 J -2 p rat on ate Estimated Value of Electrical Work $ Work to Start I v� S Inspection Date Requested: Rough Final WIAC6• Signed •o.Aer the penalties of perjur•: i FIRM NAME e: -L 1"►/k: Licensee 17--le-(�(�� KuL tYa�—z�►C y P/e�signature Y ti, LIC. 110: - Address nol " ,SL:T �C� gc3f Bus. 1. No. S 8'`-I Alt. 1. No.A4 hf R71� , X!_Q OWNER'S INSURANCE WAIVERt I am aware'that the Licensee does not have the insurance coverage or its, su - stantial equivalent as required by Massachusetts General wsTa ,annd that my signature on this permit j application waives this requirement. Owner" Agent (Please check one) yNo. ."J 'Telephone `� a° �b-q 1�+qCJcB. PERitIT FEE s ! Signature of Owner or gent Date...�' ....... �aORTF, °ft"` TOWN OF NORTH ANDOVER k O A PERMIT FOR WIRING r °,,r—o [ SSACMl15� I Gi cc This .. {" 'p tr e' CL,G s certifies that � ' has permission to perform .. .1'r .....P �f' � � ? ........ r {t ....'.' . . wiring in the building of........ 1....,. ,.4. ........ ....� .....:'.� ,J �/P/ :. .K..,..... .;v.�. .North Andover,Mass. !4; Fee..�.::�.........r. Lic.No:��.�.��':..�.�'............... ............ ......... .. .. .. ..... .. . . �j ECTRICALINSPE TO� CT s WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File