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HomeMy WebLinkAboutMiscellaneous - 34 HARKAWAY ROAD 4/30/2018L This certifies that ... ?a:y�`...... I ........:( has permission for gas installation.. ' lt......; in the buildings of ... .�.:.. C. .................. at ..,3Li .. M 6"�..ST7...... , North Wover, Mass. Fee Lic. No. K6 .. ..... GASINSPECTOR Check # FD 8769 1 MASSACHUS-E--TTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY _ 0d O St II MA DATE - PERMIT # JOBSITE ADDRESS -_5 F.. OWNER'S NAME f° �e C� N s� .._ _ GOWNER ADDRESS rr_ e TEL _ I�FAXI__— TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONALRESIDENTIAL PRINT CLEARLY NEW: Ej RENOVATION: � REPLACEMENT: 0 PLANS SUBMITTED: YESF-1 NO® APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 1 8 1 9 10 11 12 13 14 BOILER �.,,.-.T�.. _� ..._.�:�- BOOSTER _ _��I_ _ _ _ _. _ _- 1 _ CONVERSION BURNER --.._. COOK STOVE DIRECT VENT HEATER.—� DRYER J I 1 _ FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE ==L1 -.--I= 7— INFRARED HEATER INFRARED LABORATORY COCKS (f MAKEUP AIR UNIT OVEN l: —1 --- POOL HEATER a- ROOM / SPACE HEATER 1 �_ �I-_T, 1 -- -.•.- .--- C-- �__,«_ __ . _ �_ �f — :- - , .: : . :=== ROOF TOP UNITr-- TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER — INSURANCE COVERAGE MGL. Ch. 142 YES NO 0 have a current liability insurance policy or its substantial equivalent which meets the requirements of -_._ 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAG BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY EJ] 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 CJI SIGNATURE OF OWNER OR AGENT 1 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 'th all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ) PLUMBER-GASFITTER NAMEI LICENSE #8 SIGNATUREK� .p, _ .tJ___,T w/�� MPMGF 01 JPJGF [I LPGI CORPORATION [�# �a PARTNERSHIP(#_- LLC [,#�I COMPANY NAME:�„��,ry ADDRESS I CITY..,.. _i!► _--._..._..__._-... ..._ .. I STATE ZIP _ __TEL FAXCELL EMAIL c - _Cp r -- . 17-/-L ?_c) WCI �v- v N, ,e'/L.••1 �••"�� - Y��. C..��! moi, . on z y ❑ U w *k a � � } ° a < LU M j a j Cd w N The Commonwealth ofMassachusetts - Department of IndustriqMccidints Office of Investigations 600 Washington Street Boston, MM 02111 www.mass.gov1d1a Workers' Compensation Insurance Affidavit: Builders/Con TractorsfElectriciansfPlumbers Name (Business/Organization/Individual): Address: U 5 r C City/State/Zip:1 a �� Md 0M; Sr Phone #: / %6-� � 6 .S�7a) f 0 Are yop an employer? Check the appropriate box: ❑ Type of project (required): 1, am a employer with 4. I am a general contractor and I 6. ❑ New construction employees (full and/or part- nue).'° 2. ❑ I am a sole proprietor orpartner- have Hired the sub -contractors listed on the attached sheet. x 7. ❑ Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for mein any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp, insurance 5. ❑ We are a corporation and its 10.[] Electrical repairs or additions required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12,❑Roofrepairs insurance required.] t employees. [No workers' 1311 Other comp. insurance required.] 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they a're 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. lam an employer that 1s providing workers' compensation insurance formy employee. Below is thepolicy and job site information. Insurance Company Name:. Policy # or S elf -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 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 file form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Xdo Hereby undtliepains qntdpenadties ofperjury that trite information provideriabove is true and correct. W (! 111_ Date: 7-9— Official -9_ 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): I. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - 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 employeY is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more ofthe 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.,, r 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 ofits political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapterhave 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 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. 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 -andprintedlegibly: The Departmerithas 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 oz permit not related to any business or commercial venture (i.e. a dog license orpermit 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 shpuld you have any questions, please do not hesitate to give us'a call. The Department's address, telephone and fax number: The Comxzaouwcajth of A4assacl?usofts Dep.ari ez�t ofXndustdal .Aocidonta Office of Westigatio.m 600 Washingto_u Stzeet BOAMIMA02111 TO, # 617-727-4900 W406 or 1-877-MASS.A.M, _.__-- Mu i X17- M7 17r7n n COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND.GASFITTERS LICENSED AS A MASTER PLUMBER , i ISS4ES THE ABOVE LICENSE TO: f I PAUL W DONOVAN SR.' c.;f 131 BUNKERHILL AVE LOWELL MA 01850-1933 n 11285 ..05/01/14 183517 This certifies that . /�' / . , iU^' 0 V ............................. eA has permission to perform ...... s/ ."r x., %�� a.•�7,,,, , , , , , , , , , ,, plumbing in the buildings of.. .'/.-� Z- ,,,, , , , , , , , , , , at ...... J� `y A . �2 � �:wJ , , , , , . , .. , North Andover, Mass. Fee . /. �. Lic. No. �� � -�.. .114 ............... .. . PLUMBING INSPECTOR Check# �2y�J�\���� \Z MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY � � �' _ j MA DATE� ���_ � I PERMIT# JOBSITE ADDRESS OWNER'S NAME P 11 OWNER ADDRESS q j! TEL FAX L___11 TYPE OR OCCUPANCY TYPE COMMERCIAL © EDUCATIONAL 0 RESIDENTIAL ®� PRINT CLEARLY NEW: Q RENOVATION: REPLACEMENT: 0I PLANS SUBMITTED: YES[] NO© FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I I ( I ( ( I _ _1 i I CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM (__..., DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM _ (____._...I ._._._..J _._ 1 .._._.._1 ! (( ! ...._..__( ._.__..._I ._._._...._1 J __lL_.__J DISHWASHER _i ._.._I ___..._I __-.. .�I ._ _J J � _.,i _I _..1 ; .___._! = __._-..._I DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR INTERIOR _I -! a 1 ._�i i J ..__-._1 ( _...__._i 1 _I i _.__.i KITCHEN SINK ___-._-!ROOF LAVATORYIF—, DRAIN._...___iSHOWER STALL I _.-_� _'_-..._( _-__j ......._._ I _.._._ISERVICE _!TOILET I MOP SINK _—._-_-(VF_ _ i —___(URINAL _____..1 _._.__.JWASHING MACHINE CONNECTION _ I __f _ WKIERHEATER ALL TYPES d f i --..___. _ . __i .. - .; .._ -_ 1 WATER PIPING _i ._._ (1 - --.__..I i _ ( ! ( .... _-[ I i O'��dER __—I INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES*N' O IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Er", OTHER TYPE OF INDEMNITY © BOND [_f 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 01 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be ' lianc ith all P& .nent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME w o, r� c� ✓ 01/ --. LICENSE # -. - SIGNATURE MP [R"* --JP D CORPORATION ..I # 3-)_�a PARTNERSHIP P#=LLC U COMPANY NAME `&pj Qj l� �S ;ADDRESS ?�j }� �.✓ d ��L CITY L ©eve �— j STATE !t- ZIP TEL (% 0 FAX L _ t CELL I.-­­­­­_­1EMAIL The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 � www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lea bly • e Name Address: nc r G I l City/State/Zip: % �� �� e ! l , J1%� t le S Phone #: ! /0 J cC Are you an employer? Check the appropriate box: 1. EKani a employer with -3 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. [1 We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside 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 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 Investigations of the DIA for insurance coverage verification. I do hereby cert under the pains and penalties of perjury that the information provided above is true and correct. Phone #: / 7O d b S-- d 10 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 Instrnctions 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 ofhire, 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 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 lndustrial .Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877rMASSAFB Revised 5-26-05 Fax # 617-727-7749 www-Mass,gov/dia i COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS LICENSED ASA MASTER PLUMBER _ ISSUES THE ABOVE LICENSE TO: PAUL. WDONOVAN SR ,.. I z s t '.131: BUNKERHILL AVE' LOWELL' MA 01850 1933 n, 11285 05/01/14 -183517 COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS ICENSED AS A JOURNEYMAN PLUMBER ISSUES THE ABOVE LICENSE TO ; P -AUL-` W D0N0VAN SR 131.BUNKERHILL AVE ' LOWELL MA 01850-1933 22043 05/01/14. j: i Date . I7..I►�.�.� . TOWN OF NORTH ANDOVER PERMIT FOR WIRING .► � l l 1- I I This certifies that has permission to perform J. �! .-.- wiring in the buil ing of .:: lye ........... {3s es .............. at ....... �.. � . 9i�l.�4-�.� ...�.C�........ ,North Andover, ass. Fee .�. .. Lic. Nol"- Nl..... . ELECTRICAL INSPECTOR Check # Q &0 Z—, 11310 4 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use On'I_v Permit No. 111.3 10 Occupancy and Fee Checked :ev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance vtith the �N/lassachusetts Electrical Code (MEC). 527 CMR 12.00 (PLEASE PRINT IN INK OR �T�YPE ALL 1 NFOR -4 TIO 1- j Date: 17 -hi I -, City or Town of 10 r44, "vim To the Insp CtofOf Wines: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number ) G1V Owner or Tenant Z Tde"6hone No. Owner's Address Is this permit in conjunction with A building Purpose of Building es id _e cG Existing Service 10G, Amps it? Yes ❑ No (Check Appropriate Box) Volts New Service Amps Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work —1 .,V IL Z'A- (2 - it? 2 Utility Authorization No. i T r' 17 7 5 Overhead ,� Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Completion of the following table n,,aly be waived b?v the Inspector of Pl,fres No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Tons Transformers KVA No. of Luminarie Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above ElIn-11 Swimming Pool No. of Emergency Lighting No. of i-nd. arnd. Battery Units No. of Receptacle Outlets No. of Oil Burners j FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and No. of Devices or Eauivalent Initiating Devices No. of Ranges No. of Air Cond. Total No. of Alerting Devices Tons Connection No. of Waste Disposers Heat Pump Number ............................................. Tons KW ............ No. of Self -Contained No. of Totals: Data Wiring: Signs Ballasts Detection/Alerting Devices No. of Dishwashers No. of Dryers No. of Water KW Heaters No. Hydromassage Bathtubs OTHER: Space/Area Heating KW Local ❑ Municipal ❑ Other Connection Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of No. of Data Wiring: Signs Ballasts No. of Devices or Equivalent No. of Motors Total HP Telecommunications Wiring: No. of Devices or Eauivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of lec ica l Work: (%N'hen required by municipal policy.) Work to Start 2 Inspections to be requested in accordance with NIEC Rule 10. and upon completion. INSURANCE C V RAGE: 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:) GENERAL ACCIDENT INS. 7/31/13 (Expiration Date) I certify, under the pan:s and penalties of perjury, that the information: on this application is true and complete. FIRM NAME: REILLY ELECTRICAL CONTRACTORS. INC LIC. NO.: Licensee: JAMES J. REILLY Signature / Y 1tf!�, LIC. NO.: 16666 A (If applicable, enter "exempt" in the license number linea F V I Bus. Tel. No.: 508-230-8001 Address: 14 NORFOLK STREET; EASTON.. MA 02375 Alt. Tel. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature bel v, I her v waive this requirement. I am the (check one) ❑ owner [owner's agent. Owner/Agen Signature Telephone No. 603 74-16 t o -166 _ PERMIT FEE: I l7 //Z- � �... �` s-�-�.� �. /e,- Iv)4— 'r-- 12 -2(n-(L t -, piw4 &,x i - 1- 7 5)9-p� `lam' f;gqL-Z- L- L--V,13Ptit raus 0A tv - 2 7-/ 3 P/7-7 4 Date.. ... 3..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............................... �............., ...... has permission to perform ....is4 . ............ ................................................................ wiring in the building of..�.-ft ..... ......... .................... ...... & .................... --vorth Andover Ma ... ........... .. ... -3, Fee. 111C. No . ................. . .............. . ......................... "J;%�L �INP�iW Ch ck # 1 452 Y cam, ,� �,�,,, � � r--114 O 54- lrom.monweahk o f Ma�JacL,u tb 2epartment ol.}ire Jervice� BOARD OF FIRE PREVENTION REGULATIONS 17 2Z -+f4L Official Use Only [�Reev.ml rit No. cupancy and Fee Checked /07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 7 C 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFO TION) Date: 3111 City or Town o€: To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the ectrical work described below. Location (Street & Number) 3'2,-3V �1 A/Zk- f 1 l,(1Vc4 Owner or Tenant Owner's Address Telephone No. ?46 --3( b -776--T Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No.—./ Z Existing Service 10 Amps /bVolts Overhead Undgrd ❑ No. of Meters New Service aw Amps lit t / a (Volts Overhead Und-rd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: r'...- -. 1...: _r, r__ —n Attach additional detail if desired, or as required by the Inspector of Wires. 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 c�ove ,e is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE LU BOND ❑ OTHER ❑ (Specify:) I cert, under thepains andpenalties ofperjury, that the inform tion on this applicati n is true and complete. R FIRM NAME: () i( - e L LIC..NO.: 3 l Licensee: �d�� �, 8A�l2 Q V et Signa ure LIC. NO. (If applicable, enter, e.xem t" in the I'. ense umbei,� line Address: • �� )( � M� ©Z t7 r Bus. Tel. No.: I VJ *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. 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 El owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ �«� w r �uuuwtn mole moy ae warved 6y the Ins ector 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 ig ting 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 Initiatin Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pum Number..Ton....... KW "' No. of Self -Contained Totals ""'""' " Detection/Alertin Devices No. of Dishwashers Space/Area HeatingKW Municipal ED Other Connection ESec±uriSystem No. of Dryers Heating Appliances , s:*No. of Water Devices or E uivalent No. of No. of Heaters KW Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage BatlitubsNo. 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 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 c�ove ,e is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE LU BOND ❑ OTHER ❑ (Specify:) I cert, under thepains andpenalties ofperjury, that the inform tion on this applicati n is true and complete. R FIRM NAME: () i( - e L LIC..NO.: 3 l Licensee: �d�� �, 8A�l2 Q V et Signa ure LIC. NO. (If applicable, enter, e.xem t" in the I'. ense umbei,� line Address: • �� )( � M� ©Z t7 r Bus. Tel. No.: I VJ *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. 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 El owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ Norkers' C licanr t_ Y=O T le (Business/C fess:-_ /State/Zip:, Hou an emplc [ am a emplc IMPloyees (1 I am a sole p ship and hav 'working fol [No worker: required.] [ am a horn( Myself. [No insurance r( )Iicant that ch, wners who.su I ors that cheel It employee ation. ice Compa # or Self -i 'e Address i a copy o i s to secure to $1,50( 'D $250.00 gations o' ireby cer �4Z 3 ficial use y or To, ling Au 3oard o e )they ntact P .✓ l ne L.-ommonwealt/t of .Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 kEl�w F www.massgov/dia orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers (Business/Organiza6on/Individufal): I V -A 3s: tate/Zip: Phone )u an employer? Check the appropriate box: am a employes with _ 1 4. ❑ 1 am a general contractor and 1 mployees (full and/or part-time).* have hired the sub -contractors am a sole proprietor or partner- listed on the attached sheet. I bip and have no employees 7orking for me in any capacity. Vo workers' comp. insurance squired.] am a homeowner doing all work tyself. [No workers' comp. Lsurance required.] t These sub -contractors have workers' comp, insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4),, and we have no employees. [No workers' comp. insurance required.] . �-C Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other nt that checks box #1 must also fill out the section below showing their workers' compensation policy information. rs who,submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. employer that isproviding workers' compensation insurance for my employees Below is thepolicy and job site Company Name: or Self -ins. r �� Lic. #:_ � b` o 0 S Expiration Date:_. r� Address:_ -A A 0191W City/State/Zip:-Not UUco 1J e(L t / ° `a• a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). to secure coverage as required under Sectionr26A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of rations of the DIA for insurance coverage verification. certify under the pains nd penalties of perjury that the information provided above is true and correct: _ Date: 31if�3 use only. Do not write in this area, to be completed by city or town official or Town: Permit/License # g Authority (circle one): rd of Health 2. Building Department 3. City/Town Clerk. 4. Electrical Inspector 5. Plumbing Inspector er. tact Person: Phone uo J . Ci {'N' Lu Z: LLJ Cl) Cl) � CO 11;k z z2w eC i LL i 0 W -m0 = j0 LLI •w 0 ULL), 4 W W JV. C/) CL 31 4 _ Date..Z-1- )-..s..s..... a: "ORTI{ TOWN OF NORTH ANDOVER pf ao ,x11.0 32 PERMIT FOR GAS INSTALLATION p � 1- 9 This certifies that .. .1!. !4. / "r ...d l ............. has permission for gas installation ... f ?1'q, N. I. - C ............. in the buildings of 1.F .......................... at . �� .. ,!�l?!? . :'` • !° :.� • • • • • •.. , North Andover, Mass. Lic. NO Fee...?t� .../.?.L.?� ��--.`.�1�U:. ... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer IASSACHUSETFS UNIFORM APPUCATON FOR PERMIT TO DO GAS FMING or print) IvvnfH ANDOVER, MASSACHUSETTS Date 2 A21, _ 19 ?— Building Locations �I G— Permit # 3 l 2— Amount Amount $ J' Owner's Name w- S New ❑ Renovation ❑ Replacement 0--�Plans Submitted ❑ (Print or Address usiness Telephone CAD b , V -% n kot i Name of Licensed Plumber or Gas Fitter one: Certificate Installing Company W- � rA,d C eck I Corp. �� ❑ Partner ❑ Firm/C o. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑ If you have checked ves'pie ase mdic e type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installatiffG ed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Ste e and Chapter 142 of the General Laws. By: Title fCity/Town OVED (OFFICE USE ONLY) S7Wqature o Licensed Plumber Or Gas itter Plumber . �'� ❑ Gas Fitter (cense 1 umber aster ❑ Journeyman � x W W =< C C W W z C _ Cn SUB -BASEM ENT BA SEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4T 11 . F L O O R 5T H. F L O O R 6T 11. FLOOR 7T 11 . F L O O R KIN. F1,00 R (Print or Address usiness Telephone CAD b , V -% n kot i Name of Licensed Plumber or Gas Fitter one: Certificate Installing Company W- � rA,d C eck I Corp. �� ❑ Partner ❑ Firm/C o. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑ If you have checked ves'pie ase mdic e type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installatiffG ed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Ste e and Chapter 142 of the General Laws. By: Title fCity/Town OVED (OFFICE USE ONLY) S7Wqature o Licensed Plumber Or Gas itter Plumber . �'� ❑ Gas Fitter (cense 1 umber aster ❑ Journeyman