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Miscellaneous - 34 WEST WOODBRIDGE ROAD 4/30/2018 (2)
tea, Date�2-- ,.,,; TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that. f/ has permission to perform ./.49 ...6?.. ,.!......./ wiring in the building of C1.2. i.-A...................... at ... -.... , No Andover, Mass. Fee *... Lic. No. 3 T% . r ELECTRICAL INSPECTOR Check # 11277 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. I 2-7) 7 Occupancy and Fee Checked [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: /,2Z yV/oZ City or Town of. NORTH ANDOVER To the Inspecto ofWires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street& Number) 3L+ Ir16-61- t --t 00D1$X'IQ&C 12040 Owner or Tenant IZO WA LO C, A2 96,M, -J--0 Telephone No. (o1-1- -1q7- C,017 10 Owner's Address -j 4 Vii ES T W u 00 Gal 0 G L- aD , h) 0aT14 A -NO 6 LC-tL v"11- Is this permit in conjunction with a building permit? Yes Q No ❑ (Check Appropriate Box) Purpose of Building Za tCet-36,ly Utility Authorization No. Existing Service 2,0L) Amps J ZU / 2-LJO Volts Overhead Undgrd 0 New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 1<rCj-� QCMc�®�L No. of Meters No. of Meters Completion o 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 bove ❑ In- ❑ rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets `' No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches 1. No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pum P mber Nu Tons KW - No. of Self -Contained P Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ElMunicipal ❑Other Connection 1010. 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 Wires. Estimated Value of Electrical Work: i`{OU #' (When required by municipal policy.) Work to Start: JaJS JJ&_ 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 9 (Specify:) NU t�SUXAW" I certify, under the pains and penalties of perjury, that the information on this pplicadon is true and complete. FIRM NAME: DA�1/ iii r --/?,0 % ----)GAUW , /�-7 /LIC. NO.:A 2 Licensee: DAAA0 A1tQ6J&1LLQ Signature LIC. NO.: (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: q?i? f S?? 27�Z Address: O I U Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security worTcc requires Department of Publ Sa ty "S"�!License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee do n t have the li bility,,,insyrance coverage normally required by law. By signature below, I hereby waive this requirement. I am the (check one)Xowner ❑ owner's agent. Owner/Agent Signature Telephone No. L Q 7 J 1 S7) 6 1 PERMIT FEE. $ RWA I.- V3 ���� � _ �3 -i3Q� w ©9806 / rate TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... Gv412.1) /V.. .... ............ . has permission to perform ....�... .... ......... .. . plumbing in the buildings of 7-/ ...... ., North AndoverMassFee,5 .. Lic. No.3.1-2%'� U� PLUMBING INSPECTOR Check # .��' ��.-a„�.�Q_ Vi -�1�. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE , J PERMIT At 1 JOBSITEADDRESS 13 cl VJ eS b,�wo a &4j &I OWNER`S NAMEI Ri Cq IL.P It'i OWNER ADDRESS IFAX I I TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ( 1 RESIDENTIAL PRINT CLEARLY NEW. ( E RENOVATION: I 1 REPLACEMENT: PLANS SUBMITTED: YES 1 1 NOI. 1 FIXTURES -1 FLOOR-' BSM 1 2 3 6 7 0 9 10 It 12 13 14 BATHTUB CROSS CONNECTION DEVICEDEDICATED T4� SPECIALWASTE SYSTEMDEDICATED GAS(OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREADRAIN INTERCEPTOR INTERIOR KITCHEN SINK _i ! LAVATORY _. ROOF DRAIN SHOWER STALL SERVICE/MOP SINK i - - 1 I - — •! •-w- -.� .. ._ .L_ �.._ j - ", TOILET _ I URINAL —_ WASHING MACHINE CONNECTION, _ I WATER HEATER ALL TYPES. WATER PIPING _ ...OTHER I INSURANCE COVERAGE: 1haveactirr6allabiliLy iisifralice policy.or its substantial equivalent which meets the requirements of MGL Ch.142. YES 1&I NO I I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1011 OTHER TYPE OF INDEMNITY! BOND +• I OWNER'S INSURANCE:WAIVER: I ani aware that the ficensee.does not have th6liSlirance coverage required by Chapter 142 of the Massachusetts General Laws, and that nay signature on this pennit application waives this requilminent. CHECK ONE ONLY:- OWNER AGENT - SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and irifonnalion I have submitted or entered regarding jhis application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under fie permit issued for this application W11 be in compliance mith all Pertinent provision of the 142 of the General Laws. . Massachusetts State Plumbing Code and Chapter th .�G t 1.��'1�' PLUMBER'S NAME Sft ( (SGL 2 A -d ! LICENSE /i I `�b'� Y SIGNATURE MPI 01 JP 1 CORPORATION 1 . 111! (PARTNERSHIP' 111j ( LLC 1' .1# COMPANY NAME I.5'iI C-2,'Z,he P /9 (ADDRESS( �c� �3�n �_G06 I CITY( j1��. �� ltii.^� I STATE I r }� /i ZIP �b I �i `( Q TEL I `% 4 P % � 2 - FAX I CELL 5-919 (EMAIL ��.-a„�.�Q_ Vi -�1�. E-( 0 z z OIJ Oil p LU CL LU x O lu 44 Lu LLI LL. Ao4re., v z Sv y elkeelt (Ile 41)0,0111.fate bd-%: ap it imployerwhii_ Bill a Kelleftil Int bflt(ojcet�ici uTee ): Dfell( ORM, of1whish olAccl(feha, Heiv wiforue- (oil Slilp alliflievotto cluployco BOOM; MU 02111 Ao4re., v z Sv y elkeelt (Ile 41)0,0111.fate bd-%: ap it imployerwhii_ Bill a Kelleftil Int bflt(ojcet�ici uTee ): Heiv wiforue- (oil Slilp alliflievotto cluployco 7llesc Sub-66fl(roblors Bova xiorlkdog -for wo IB, any oppit6try wopre a oi-poration gild Its! .0 0111 1 WhIgAdditiolt crocidietons: -311 0oradd,iffout 11!YkIf' [No.�Yorkcrsl collip. c9lop. 11surtincore-quire(f.1 17(w), f r,: (IONR fill wo- tund thin L%iv I, III I tn'.fur.-M n a djitlopl tteej tbhint? Ins(Iraucc:Conrl?au}�l�iuhc� ,. .Polioy, trot telPfusa:10. 3.6 06 6t, r . Mjk4ftaa SUCII. xvo*ktcdis,ot)iillldllsklloilil*olj ttetjjrjtf,[�,' 7- - oil tingp(Shoiiing xf, .99 010 hillml [oil rc edit b int p pi ulfacs, p ra-. fiito up to:SitSQO t10 nndfoi oiiGyenr Puiprisouuienl,. as ueil ns cts; pewildes. III ill& tonit. o*f R STOPAVORK 6f (o Ifteoffice-of 1.!fqAqAefij! ivalry wifter OJIWOOW640. Po not fnrhL N dils area, to he congetett4p �r do �v (muo.0cm, Cio, .61-1,00kz 1-99-111140rl`101111 2-RuildfugDolvOload 3.Clft�jrb 6. 911wr Cuons le�assachuseits.General,Lit�s�s c�tapfer X52 requites Wkt!Ant kgvlce ofailoe 'receh!O -.Flllstee;ofa7t� rn cWldijl al., pa tiles, outer. legal:clllilr"t!�fityfng.,Qmploy rds. d7iereWj: or the occupant ofthe pairw,ori: oi such ctit�lliugltoiise tltdJs e or Perillittoogerilte. a blWhiesslor to- dolls ItItict buildings !it Me contlifoillyci ttl:Wr Iky ,npplkallf WAO-has If0tPrOduced acceptable eEjilel' a I a Additibftall M*G'L"b'li'k)to'rl-52.,4256(7)' 0!!tP'into alyconYacHortho Please A] f siluallidu likidi if sob-contradoi(s) jimue(i),addtess(es)jq IYO�fs) alongg with theirceilibicale(s) of fNiftalim. Unikedtiabilify Compatlies (LLC) -OiMibers oiParniersi are itot required foilEllice. insU . INit LLC orLLP does have, -OPAOYM, aPolicy Is required.lamittilay li,edibinitted to theDepartilientof industrial - Acoidp,iif&forcoitriminti(illofilisilt-allce.cdveyage. h6besilretosl 9A nit . d(Inte-thenradnift. The 6fft7daV;c-qholljd bareturitecrto the city or town tillat (lietipplicatiou for thopet-unt or licemP is being req,jestcd, lloflli--Dapirtmiellf of bdp-dit" is teglrdfil.410 Iffir ify6ll are reqtivedto.-obfabtin workers, "Or-falkoionpolicyplease call tlle*paoineItthemimbefh9tedbefo%y.'solf-1(surcil.compai, *dIOkldenter theirfiice IicensenumbcrOlLtl�e4pprolrlate.line. City or TbIql, Officlals Mutp rintedleggib1y. T. DePA Iftfielit hasproWed a ppacpat ft boltdill Af IA V, -a ff -1d fl %I! I fOt Y 0 it td filI b if 6a f h"V61 I t th e 0 f rl c 6 of T) ive s t ika t i 0) 1 11 a s f 0 co I Eta, 0 fyo u reg ti cling I be f IPP I ica ut. Ple' ase -be surd (o fill in xvill.b.- x ' 1;1111 b Inad(IftiounitapPliclat Policyy InfOrillatiOn (iFMMSSATY) anduldef"Ibb Sifo:Address"the applicalit should wrille 'fall I Vi%ih)2'A copy afflie afridavit t1lathlsbeel .1offi-crallyslanipedokiiiat-k-46dbyi (fie cilY or towil.may be -provided to tile bliP]icantesproofthaEavaffd!iffidfLt,itlliofifit6:forfitttire-perniitsoflicense.s. AlielyliMidavit niusftafilfed ow each ilitEigalicense shiess orconinieroial votituio O.e- adog license Gejeenukto burn leaves etc) said person. is XOTnquired to coniple-tottds,affidalit. t pt itse do not Imitate to - give tib A ocill, D6pamneilt ofIt>dut !" 600,1vashingtoll Stma BoStO101A.01111 TPA. 61'7-727-4poD W40 -ot 1A 77-MASsgr-B itetis it 2G -t14 V-49 Y1 07,727 7749 IA%,!VARSS.govI(IIa .S/�! / Date. . ........... is TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ................ has permission for gas installation k0l)MIIIAW.I�IZ4. in the buildings of ...... . 744 ........ at ............... ass. Fee Lic. No. 4Q?;3 GAS INSPECT -R Check# jo 8143 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES 1111 NO D I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY W OTHER TYPE INDEMNITY 0 BOND [1-]J 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 [__J] AGENT El SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTERNAME Lt%rllii7m gAZff?WLICENSE# 20'%3 SIGNATURE MP [� ]J MGF 01 JP X JGF [] LPGI Q CORPORATION [�I# ��( PARTNERSHIP _(#[— LLC �_1#= COMPANY NAME: ----r`1/ .P�ZI`�2_A'+F/'..__...__._..___.IIADDRESS -x--#�4� S%•---__-_.._--------.-_---._______._.u� CITY c'%c�ge�— — - - - -_ STATE�ZIP 0��5!r/�.u��'1TEL �,�97�7 2 - - --2- FAX CELL r EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY®-- 6 MA DATE S --S-2-01 PERMIT # JOBSITE ADDRESS 3q W 7`'cud�� 2`1 _ OWNER'S NAME GOWNER ADDRESS 11 TEL_0l� gZR-7/ JIFAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL D RESIDENTIAL CLEARLY NEW: ® RENOVATION:�jl REPLACEMENT: PLANS SUBMITTED: YES E-11 NO FA APPLIANCES -1 -. FLOORS—► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER ..,.: - - I.I�. DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES 1111 NO D I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY W OTHER TYPE INDEMNITY 0 BOND [1-]J 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 [__J] AGENT El SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTERNAME Lt%rllii7m gAZff?WLICENSE# 20'%3 SIGNATURE MP [� ]J MGF 01 JP X JGF [] LPGI Q CORPORATION [�I# ��( PARTNERSHIP _(#[— LLC �_1#= COMPANY NAME: ----r`1/ .P�ZI`�2_A'+F/'..__...__._..___.IIADDRESS -x--#�4� S%•---__-_.._--------.-_---._______._.u� CITY c'%c�ge�— — - - - -_ STATE�ZIP 0��5!r/�.u��'1TEL �,�97�7 2 - - --2- FAX CELL r EMAIL The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ..600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: ]Builders/Contractors/Electricians/Plumbers MlirAn Tnfnrmai-; " Name (Business/Organization/Individual): City/State/Zip:A , 6Lotacs, e),,8"9'y' Phone #: g-7 -:2 7 2-9 Are you an employer? Check the appropriate boa: _ — L ❑ lam" a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).' 2. ®I am a sole proprietor have hired the sub -contractors listed or partner- on the attached sheet t ship and have no employees 'These sub=contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ am a homeowner doing officers have exercised their .I all work myself. [No workers' comp, right of exemption per MGL C. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] *Any £ppLcant that checks box M must also fill Out the section b low T Type of project (required):' 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.EgPlumbing repairs or additions 12.❑ Roof repairs 13.❑ Other PensaL Homeowner; who submit this affidavit indicating they are doing all work and then hire outside contraMn ctors must submitnew 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 Compiny 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. Ido hereby certify under the pains and penalties ofperjury that the information provided above is true and correct -3 -- a-00,2 Official use only. Do not write in this area, to be completed by city 0, town official City or Town: Permit/License if 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 erson: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 bb returned to the city or tovm. that the aplicatio' for the pmm&t- or li1;en8e is be,ng req'ues*..eT� d, not the Jep art. crit 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 dumber. In addition, an applicant that must submit multiple permit/license applications in any given year, need only.submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business. or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would'like to thank you in advance for your cooperation and should you have any questions, please do not -hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth GfMassachusetts Department of Industrial Accidents Office of Investigations 60:0 Washington Street Boston, IFA 0211.1 Tal. # 617-727-4900 ext 406 or 1-8.77 MASSARE Fax # 6.17-72.7-7749 Revised 5 -26 -OS uv.Tn asc _ ssnv/rTi a 09 Date.. ........... 0* Try 6 4. 0TOWN OF NORTH ANDOVER X— PERMIT FOR GAS INSTALLATION N This certifies that--)'-"' has permission for gas installation ............. in the buildings of ...... ........................ . at North-, Andover, Mass. Fee-. D.`..... Lic. No--:,, ...... GAS INSPECTOR Check 4 12-1,9y 6941 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date �. NORTH ANDOVER,, MASSACHUSETTS Building Locations v �" '�c Permit # ! .'Amount $ Owner's Name \ Ne�S Renovation 1 Replacement E-1 Plans Submitted QSi l (Print Name Address �' i Mame of Licensed Plumber or Gas Fitter eck one: Certiic Installing Company Corp Partner. Z� Firm/Co. INSURANCE COVERAGE Chec ne: I have.a current liability Insurance policy or it's substantial equivalent. Yes No ❑ If you have checked ,es, p1wise indicate the 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 El Agent I hereby certity that all of the details and mtormation 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permi Issued for this application will be in compliance with all pertinent provisions of the Massachusetts aiat_e Gas Cede and-Obapter k2 of the General Laws. IAPPROVED (OFFICE USE ONL ) Signature of Licensed -Plt4nber 600as Fitter Plumber Gas Fitter License Number Master Journeyman �a U o F W F 0 F d x W U w ZH F F w. o > 0 x o 3 °a x a U a° > c F o SUB-BASEM ENT BASEM.E.N.T 1ST. FLO O R 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR ELL (Print Name Address �' i Mame of Licensed Plumber or Gas Fitter eck one: Certiic Installing Company Corp Partner. Z� Firm/Co. INSURANCE COVERAGE Chec ne: I have.a current liability Insurance policy or it's substantial equivalent. Yes No ❑ If you have checked ,es, p1wise indicate the 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 El Agent I hereby certity that all of the details and mtormation 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permi Issued for this application will be in compliance with all pertinent provisions of the Massachusetts aiat_e Gas Cede and-Obapter k2 of the General Laws. IAPPROVED (OFFICE USE ONL ) Signature of Licensed -Plt4nber 600as Fitter Plumber Gas Fitter License Number Master Journeyman .. T-UJI&AIZverwerof 1i'zft =achatsetts • �, r DTortrrrent of Ind=rid Acci&e '. Q.i1ice of Insti; afiorry 60V glasilbTtnn Street 1 BOSMO ,MA 02111 ' WarkeW Compensafioa iasitraaee-�zQs�,�vvldiu . 'giant IafflrtBafioa Aftc�avit: Bu ers/Cuatractars/nectricia as/Fimmbers Name Please Print L 'bF `~�, Sz�'1 Address: C Ccr.SL Citysta&Z7-igPhme \A,.re�you an emplOYer? Cheek.the a . co j`9J I•am a em i � PP Pete �bo�: • employees (fun ani r � * Q I am a goneral rmt.maaw and I T ype °`f P�l�t (regoiredj par€-time). iiavo bared the sub-contractors 6• ❑ Now conr&ucbm . 2• Q T am .a.sole proprietor or partner. Iisted on the attac}red dieet t 7. Remodeling snip and have no empioy�' _ Thome Q working far me in sc% eonactors have [No worm, . M ��ty. wot-kers' comp. ffimz nc 8' Q Demolition comp• iasruarrce .. 3• Q We are a co oration and its 9' Q $wldirg addition required-] rP 3 • Q I am a homeownerdoingo�� have exercised their. i O.Q Electrical r aPairs or additions all work right of exemption per MOL 11.�] Plurrub' myself '[No wank + mg cepa n or additions insutw •re imp, c ISS+ § 1(4),'and•we have no required.]. .t .empioy�& (No war3 d Roaf repairs `` BPP1lcerati�er clerics` MMP. �usaheo require ] I•Other tom# l must also fm =tf= seat+on below oho , _ D O vino smolt this of w.+ iadicabng they att6ein ail N!mg thetrworkert amuPeosefron policy in CoaftMr; that rbeck Ws bm muat•at>Boi sn adrF.�fieasi doing a owl end th= hide outa(de � 0a �'+aig• the nems dfew sidtQ m nibmit n 0.W AfrWavit radios* sum 1 oe etsPfoyer ftra7 �rnti%otn :�etr. timir work=' M- •,„•_. mon. ilzmr� f.M- M, ,M* Be�reeu.'.*F.e va;lab rare+ Insurance Comparry Name: Porn # or Self--ins. Lie. #• Job Site Address �' WDate: �® Attach a copy of the workere'Com �xY��eJZip; C d lb PenM ioc Policy decbai-at on oe showin. Failure m sem" covets a as PO ( titer poiicY number sad e fine g required under Seddon 25A of MciL c. 152 can xpis�tioa dat6e . . up i;1,5D0 00 and/or one-year anpnsonrnerrt, as woll as civil Fuad to � imposiiion of =,hirW p=ahi s c f a Of UPtD ti $250'00 a day againstthe violator. Be advised that a copy. o fp es in the form of a MP Wpfu{ ORp ME a fine Investigations of the DIA for insurance coverage veriflowicM. this sdtement may be forwarded to diel pffce of I do hereby certify der th s nd penalties a e ' fP rlmy that the urformodour P vkded above i • Si awe and Qorred Dom. C�C�` . � p C . Phone #: � 8� ^ri O ietcl rose only. Do not wriL, in this arra, m !ic aomPlel--d by aJ or town. offrcia[ Gly or Towns; Issuing A Permit/Limuse # d afhoriiy (circ3e ones: L Other Board ofBeaitb 2 Suilefing Depzrtment 3. City/ToA,u'Clerk 4. Electrical Inspector 5. Pinm6iug Ilea f. Pyr Contact Person: Phone #: tntormatlon a- ltd lnstructions Massachusam Cameral Laws chapter IS2 requires all emp Ioyers to provide workers' compensation for their empioye:es. ' Pursuant to this statin, an vg6yer is defirked as "..:every person in the service of another under arty contract Aim, express or implied, oral or written," An enpfa are is defined as "an individual PwtnecshiN LMc)1 saiion, corporation or other legal entity, or any two crmor of the'foregaing engaged in a joint entraprise, and inciudi"s the legal rcpresertafives of a d6cmad employer, orIbe receiver orrtristc•of an individual, partnership, associatic>m or other legal •crmtity, employing employ-- 'Howe=thc owner•of a dwelling house having not mor than three apm3rtmonts and who resides therein, or $e occupeat..of the dwelling house of another who employs persons m do mR-:i7U==ce, contraction or repair we* on such dwcibnghot= or on the grounds or building appurtenant thereto shall ndst b=m= of sucb employment bre d.,-med to be are, ednployr." MOL chapter 1 SZ §25C(6) also states that "every state ar local 6caasiug agency shall withhold the issaaaceor renewal of irliecom or permit to operate a business or to construct buMmgs in the commonwealth for nap applicant who has not produced amceptable eviden m ma -t compliance witfm tie.insarance 6overaaQe r cquir�ed.„.. Addidonal;iy, MOL chapter I S2, §25C(7) rft f s "Neither tilt commrmwed& nor any of its polifical subdivisions shall enter irmo any contract far the perForc, ce of public wane mmmrtil accepitalile evidence of comnPliaiux with fire insiamamdx rsmluntmemmts .of this chapter have been presented tD-the ccot rmtraz ft mdwrity.” Applicants Please fill out the workers' ,compensation, affidavit compiem-tely, by checking the boxes that appiy m your situation and, if nay, MI5' zu�s) name(s), M9): fold phone nurnber(s) along with their cartifim*s) of insurance. Limited'Liability Companies (LLC) ar LimmFi(ad Liability PartnersHips (LLP) with no.ernployees of er$um the members orpart;=%, are notrequiral,to carr work=' cdsrrrpensdion h,u,,, ce. ifan LLC or LLP does.have employees, a policy is required. Be advised mat this affidevit may be submitted tins the Department of Industrial Amxidemrts fur ron5arrhatian of inpmhraihcc coverage. Ake Eye sure to. sign and -date the afbdavit, The affidavit should be returned to tiro: city are town that tine appTic:ation for fine per¢ or ficxnse is being requested, natibe Department of Industrial Acaidmta. Should you havz any questim. regarding tine .taw or if you are required tD obtain a workers' nompensation polipy, please -•rail the Dcpartmcnt atthe -nuomber.listed below. Self-insured mingmies should eniertheir self insh== ficrmac nurnbW an 6z,appropi• m mm= City or Town Officials Please be sane that tiho afndavit is cornplae and Fk trd i-R;bly. 'Ihe Depaitnent ties provided a spa= at fire botrom of the affidavit for you to fill out in tim event the Off= of Investzpa6cffm has to contact you regarding fim applicant Please be MU= to fill in the permitAicense nunmberwhid W III be used as a referm= number.' In addition, an applicant 1fip pw►� RPp Y given year, need. only submit one affidavit indicating eumrmn that incest submit mu !c remise iiratiomms in art policy •informafion (if necessary) and hmdcx "Job Site Addr-els" fhr applicant should write "all locations in (city or tovrfm)." A Dopy of c affidavit that has bei► officially stamped are mrmarimd by t3 a city or town maybe provided to the applicant as proof fint a valid affidavit is on file for futurm permits or licenses. A now affidavit muk be filled out each year. Wheal a home owner or citirn ii obtaining a li=sr or pMrmit not related tD airy business or commercial vsmmtUM (i.e. a dog license or permit tD bum leaves etre.) said parson is NOT_tnquu-ed to'compietz this afndaviL The O tf ice of invesfi�#ions would 3mica to thank you fn advance {nr your cooperation :,mid:shouid you have any questions, please dw not. hesft air to give us a caul. The Departmeumt's address, telephone and fax nwnber. The Commonweflth of Wmssachuseti= Deparmcni oflsatzstrW Accidents Office -Of InvZotivaiions " 600 Washir.-ton Street Boston, MAA (12111 Tel * 617-727-4900 eiz--t 406 or 1 _&77-IviASSAFE Fax #til 7-727-7741 R viscd 3-26-(}S Www.>aass.aov{dia P V Date ..... 0O,TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING E This certifies that ....... ................................. S .............. has permission to performSt letA, nF A'IV ......................... .................. wiring in the building of ..................41.. 77/�' .................41.77�.................................................. Wat -.3Y...66 . 644 . ....... North Andover, Mas. Fee....... �.a...Lic. No..J3-4 ........ TOR' 'i�- E.- 9-- IkCAL iN�S-P/E' C - Check # le 3 94/1 9035 _4�N Commonwealth of Massachusetts Official Use Only Permit No. �(✓ �S 1W Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS Rev. 11/99] leave blank APPLICATION! FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: -7 City or Town of: 4hl To the Insof Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) cY y,, &Ve—%%—(�(i ,t�rL <c X-ep rte Owner or Tenant � � �. �,;i* �l'( Telephone No. �/� ?7 Owner's Address f��O r77 Is this permit in conjunction with a building permit? Yes ❑ No Ej-- (Check Appropriate Box) Purpose of Building,rld� Utility Authorization No. 7j�?� �15r� Existing Service %O= Amps 1/Volts Overhead 9— Undgrd ❑ No. of Meters / New Service J.m- Amps lo� /�K0 Volts Overhead ®� Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Co letinn nfth,, Mllnx»no table may be waived by the Inspector of Wires. ff Attach additional detail tfdesired, or as required by t e -spec or a 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 lam' BOND ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical Work: -7 r?/1 (When required by municipal policy.) Work to Start: •l rf Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under hep ins and penalties ofperjury, that the information on this application is true and complete. FIRM NAMELIC. Licensee: _(� 7 ' .z— �Cc s � Signaturer� LIC. NO.: e'� (If applicable, en r "exempt " in the licensle number line.) Bus. Tel. Address: r 22 6CLi� ' o Alt OWNER'S INS RANCE WA"�IV R 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: $ g6 Signature Telephone No. �5'f35�.� No. of Total No. of Recessed Fixtures No. of Cell: Susp. (Paddle) Fans Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Above n- Swimming Pool md. ❑ rnd. ❑ o. o Emergency Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Detection an No. of Switches No. of Gas Burners Initiating Devices No. of Ranges No. of Air Cond. Ton No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained Disposers No. of Waste Dis p Totals: Detection/Alertiniz Devices No. of Dishwashers Space/Area Heating KW Municipalr-1 Other Local ❑ Heating Appliances KW Security Systems: No. of Dryers No. of Devices or Equivalent o. o ater KW No. o o. o Data Wiring: Heaters Signs Ballasts No. of Devices or E uivalent Telecommunications No. Hydromassage Bathtubs No. of Motors Total HP oiring: No. of Devices or :E uivalent .ofDevices OTHER: h ! t f Wires ff Attach additional detail tfdesired, or as required by t e -spec or a 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 lam' BOND ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical Work: -7 r?/1 (When required by municipal policy.) Work to Start: •l rf Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under hep ins and penalties ofperjury, that the information on this application is true and complete. FIRM NAMELIC. Licensee: _(� 7 ' .z— �Cc s � Signaturer� LIC. NO.: e'� (If applicable, en r "exempt " in the licensle number line.) Bus. Tel. Address: r 22 6CLi� ' o Alt OWNER'S INS RANCE WA"�IV R 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: $ g6 Signature Telephone No. �5'f35�.� EL BOARD OF ELECTRICfA REGISTERED M AS T E RE CT ELECTRICIAN RI CIAN TYPE ER ELECTRICAL SERVICES -A .INC MICHAEL L DEMEO 108'TENNEY STREET GEORGETOWN' M _ A 0 18 33 18 309505 16366 A 07/31/10. 309505 V Commonwealth of Mash Division of Registration�� '- $ f Board of ElectricaLExarS�,` , JOSHUA' ` (1R r — .�a 15 Fa�rwax Derry, W939 = i Joumeyman`8ect£r�t�a 13349-6 07/31/2010 " License No, Expiration Date. 005707 Serial No.