HomeMy WebLinkAboutMiscellaneous - 34 WILD ROSE DRIVE 4/30/20180
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that....Y..'4... .. ....................
/' r �.............
has permission to perform...<.?�.:�...........:........-�....
plumbing in the buildings of .......,
at , .. ..... 7...........
Fee °;!. .��... Lic. No. /A5P..
Check # / D 6
............... i .......... , North Andover, Mass.
...........:..............:.....................................
UPLUMBING INSPECTOR
N
P
TYPE OR
PRINT
CLEARLY
MASSA
CrUSETTS UNIFORM APPLICATION
- FOR A PERMIT TO PERFORM PLUi1>9BING V110R1�
i' CITYI�I
MA• DATE
JOBSI I E A,DDRES..
OWNER APERtvIIT r
�� I OWNER'S NAM :v-/jl.
DDRESS:
OCCUPANCY TYPE I tL: FAX
COh9MERCiAL
ElRENOVI TION � p� C cDU'CATIONAL 71RESIDENTIALACEi�/Ei�l i : ❑
FiX'v'TRES' F1 CORS—
BATHTUB
CROSS CONN DEVICE
DEDICATED SPECIAL VVASTE SYS
I DEDICATED GAS/OIL'S,AND SYS
DEDICATED GREASE SYcTEM
f DEDICATED GRAY WATER SYS
DEDICATED WATcR RE" SE S" S
DISHWASHER
DRINKING FOUNTAIN
FOOD WASTE GRINDER UNIT
11 FLOOR I.AR=A GRAIN
INT ERCEPTOR INTERIOR
ERIOR
KITCHEN S1NK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE /MOP SINK
011 ET
URINAL
WASHING MACHINE CONNECTiOn'
INA I ER HEAT ER ALL TYPtS I
WA T ER PIPING
RSMI
PLANS SUBMITTED: YES ❑ NO ❑
LNEMMWM�
INSURANCE COVE 1 I i 1
I have a current !iabffih� insurance policy -RAGE
L —,1 otic or its substantial equivalent whici; meets the requirements or MGL,
Ir you have checked 1'ES I Ch. 142 YES �0
— p -as„ l.ndicate `ie t pe of coverage by checking the appropriate box below.
LIABILITY IN'SURAN^E POLICY 1 -
OWNER'S
OWNER'S INSURANCE WAIVE OTHER TYPE INDEMNITY
R: I am awa-e ` BOND
Massachusetts General Laws, and that m e that the license doesap application w-'
licensee does not the insurance coverage required by Chapter 142 of the
Y'PeFMit p
aloes this requirement,
SIGNATURE OF OWNER O,R AGENT
CHECK ONE ONLY: OWNER-�
❑ AGENT u
I hereby verify t,iai all 0f the d2- s
Knowledge =iork a Inforc,aliJn I rave submitted or en12r2d� regarding this a c
g and that ali plumbing work and ins =,Ilalions periorm2d under ±h2 9 ppli a[i and of file MassachuseCs State Plumbino Ccce and Cha ; r n , ue and accurate to the best of my
permit issued for this ap 'anon wi e ir, camplian with all Pero
p'° 2 0. ,ne Genera! Law
PLUh�SE.R nlAi�` �"� s.
- ._L.0 / 1�►,� LICENSE r
COMPANY NAfgE; LgC'J SIGNATURE- 'j + ADDRESS:
CITY_ /_111) �.�
_ R `9A-)�
1 STATE: G.TE; ) R
'EL '!P O
✓IAS T ERT .;Ol RN=Y!v1AN i 1 •v nJ ST i
PAR T NERSHi:
Is
4
................
Date.
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that L Z]��ee �LA-
..............................................................................................................
has permission to perform %--,.......cr e.......................................................................
wiring the building of .... '.) ...................... 1
.........................................................................
►
L e ..te 0 C- '�),e .
-.,P— .., orth Andover, Mass.
........................................................................................
Fee..66�. ........... Lic. No. b-31 M
.... ................. ....................... ........... .. .. ..... .
L RJI C INSPECT
.1 . ECT
Check it U -k (D
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 1
Occupancy and Fee Checked
[Rev. 1/071 (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: I Z i Ll < 114
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) -3--Y- W I L D
Owner or Tenant V,J+ rsk 6 Telephone No.
Owner's Address
Is this permit in conjunction with a uilding permit? Yes C9" No [:1(Check Appropriate Box)
Purpose of Building S I �o a, ekt Utility Authorization No.
Existing Service240 Amps (;D / Z14e Volts Overhead ❑ Undgrd 5J --
New Service Amps / Volts Overhead ❑ Undgrd ❑
Number of Feeders and Ampacity
No. of Meters
No. of Meters
Location and Nature of Proposed Electrical Work: w \ �. N 1r -J 0% Q 4- V�\ , f-evnej r.YQA
ie -.► .<a ►VC'y�}l. ►"Ag1L ��� la 4,�► r� Q.
('.mm�]otinvr nftT,o nllnwiv.n f..A10 .,, . I,., ...7 A,. •L.,. T r.�
No. of Recessed Luminaires O�
--
No. of Ceil: Susp. (Paddle) Fans
i1 --J 6wvl u rr{r GJ.
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- ❑
rnd. rnd.
No.o- mergency ig ing
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
g
No. of Waste Disposers
Heat Pump
Totals:
Number
Tons
_....._..•.......
KW
" '
No. of Self -Contained
Detection/AlertingDevices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
No. of Water KW
Heaters
Heating Appliances KW
No. of No. of
Signs Ballasts
Security Systems:*.
No. of Devices or E uivalent
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER: VC i At� V�j >v� \ S� �t 1 C�� ,.Jaw e � sr ve.v
N�Att additional detail if de ired,, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: -I, �� (When required by municipal policy.)
Work to Start: 17► L( - I LI Inspections to be requested in accordance with NEC Rule 10, and upon completion. rE
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:) A�GtA Q\ 6� Pj d-•1 `Q
I certify, under the a' and p ties ofperju_ry, that the information on this applicc ti i�Ac�,ipddfcr }l p c c
FIRM NA �-A� (r` C �- Q LIC. NO.: /634A TQ
Licensee: U, .i S Signaturei�2L LIC. NO.: "( w, -K
(Ifapplicable, enter `exempt" in the license number line.) Bus. Tel. No.*,
Address: PF,Ci—�lGj�- !-�d. r� �` % r-► 1X e �r�
Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. No.
OWNER'S 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
_ ELECMCAL)NSPFCTOkt_-1,...'
k�nsjpectors,
O•UMINSPNCTION;
sed-- [ ] -Failed•-[ 7 De -inspection �requireci($50.00) - j j
comm ts: -
(iin ectors" Sign e • o fnftials) _ Date
Z. 70MAL 7NSPACKTOX; -
rasse$— Z j wiled—[ ] R&bspedlon. required ($50.00) -1 j
Xuspectors' comments:
A.
�'—
QH4actors' Signature • no ' tials) Date
3• '[iMIR GRODM 7zeT UCTION:
Passed- ] Failed-- [ Re -Inspection required ($50.00) - [ a
Xnspectors' comments:
(Inspectors' Signatare •- no initials) Date
. y
�. MSPECTION-- MEER:•
�.'assed — [ � �+.azzec� �- [ ]- • ?�.e-xnsp ection z'equired ($�O.O D) •• [ �
nspeetors' comments:
( iespedors'Signatare-•noiiutials) Date
DOOR TAGS .ARE TO BE FMLED ODTAAND LEFT ON ffM IF THE APXA TO BE INSPECTED IS NOT
.ACCESSIBLE AND ,A. RE WSPECTZON OF X50.00 IS TO BE CHARGED. -
I =
Z. 70MAL 7NSPACKTOX; -
rasse$— Z j wiled—[ ] R&bspedlon. required ($50.00) -1 j
Xuspectors' comments:
A.
�'—
QH4actors' Signature • no ' tials) Date
3• '[iMIR GRODM 7zeT UCTION:
Passed- ] Failed-- [ Re -Inspection required ($50.00) - [ a
Xnspectors' comments:
(Inspectors' Signatare •- no initials) Date
. y
�. MSPECTION-- MEER:•
�.'assed — [ � �+.azzec� �- [ ]- • ?�.e-xnsp ection z'equired ($�O.O D) •• [ �
nspeetors' comments:
( iespedors'Signatare-•noiiutials) Date
DOOR TAGS .ARE TO BE FMLED ODTAAND LEFT ON ffM IF THE APXA TO BE INSPECTED IS NOT
.ACCESSIBLE AND ,A. RE WSPECTZON OF X50.00 IS TO BE CHARGED. -
The Commonwealth of.Massachusetts -
- Department of Indifstrigl Accidents
Office of Investigations
600 Washington Sheet
Boston, MA 02111
-www massgov/dia
orker$, CompensationImuranceAfidavit: Buffders/Cont°actors/Electirxexansl�'Xumbe s
bYn�no vw,,, r .pn:hr,
Name (Business/OrganizaiaonlTndividual):^ U�L C
Address L(A 0. .
City/State/Zip: w� �Arr� , i..� Phone Lfq o '::Fs—b 7-6
Are you. mployer? Check the appropriate box:
S d•• ❑ I am a general contractor and I
1 I am a employer with
employees full and/or arEtime} *
have hired the sub -contractors
2. El am a sole proprietor ox partner-•
listed on the attached sheet.
These sub -contractors have
ship and'have no employees
working forme in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We area corporation and its
officers have exercised their
required.]
3. El X am a homeowner doing all work
right of exemptionperMGL
myself. [No workers comp.
c, 152, §1(4), and we have no
employees. o workers'
insurance required.] t
comp. insurance required.]
Type of project (required):
6. [] New construction F
7. aarmodeling
8. [( Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ plumbingrepairs or additions
12. ❑ Roof repairs
13.❑ Other
Mny applicant that checks box#1 musteso fill outthe section below showingtheir workers' compensationpolicy informat! 0n.
I Homeowners who submit this affidavit indicatingthey tine doing allwork and then hire outside contractors must submit a new affidavit indicating such.
?(�ontractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. Policy information.
X am an employer that is providing workers' compensation insurance for my en2ployees: Below is the policy ancd job site
information., \�
Insurance Company Name: 4 fl —77d
Expiration Date:
policy # or Self ins. Lic. #:
Job Site Address:, 3 4 N&.1. ► t t > City/State/Zip: ti' I
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as xequiredunder Section 25A of MGL o,152 can lead to the imposition of crfi final 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 WORD ORDER. and a fine
of uTto $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.
X do hereby certify uncle ins ancd penalties ofperjury tilat the information provicdecd aboveiss true and correct.
[-
Phone #:
official vse only. Do not write in this area, to be completed by city or town official.
O f �
City or Town: Perznit/License #
Issuing Authority (circle one):
3. CSty/Town Clerk d. )Electrical inspector 5. Plumbing Inspector
1. Board of health ?. Bufdjng Department
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 ormoxe
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 Weal 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 required2'
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), addresses) and phone numbers) along with their certificates) 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, apolicy 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 aff davit. ']'hie 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 whichwill be used as a reference number. In addition, an applicant
that must submitmultiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "fob Site Address" the applicant shouldwrite "all locations in (city or
town)." A copy of the affidavit that has been offlciaily stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on isle for future permits or licenses. A new affidavit must be £tiled out each
year. Where ahome owner or citizen is obtaining a license oxbermitnot 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 should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
Tho GQrowcaxt ofit�tassachUsPtf
Dopa i ont Qff dmidal Accidents
OfiRce OURVONiigatim
60a gtw Strut
Bostw, 02111
TO, 4 617-7-217_4900 est 406 ox 1-877-MASSAM
Revised 5-26-05 Fax # 617427-7749
wv�w..�a�s,g4vf�ia
4
Date.. q1Z?
9552
.�� TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
�SACNUSc- �/ _ /�
This certifies that ..././!. •S!� . i.id�!��=..f'/i4. ,
has permission to perform
plumbing in the bildings of ../ . Z. �/sIrl ......... .
at .. 1V. .Wr./c f.1 ...P ...... .. , North Andover, Mass.
Fee.Lic. No. ! 194........
PLUMBING INSPECTOR
Check ." 'C.I
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY L L&I-Kn MA DATE 7 PERMIT #
JOBSITE ADDRESS L✓, /q/ 7/OWNER'S NAME �4 .
POWNER
ADDRESS i TEL = FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY
NEW: RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES ; NO
FIXTURES 7 FLOOR- BSM 1
2
3 4 5 6 7 8 9 10
11 12 13
14
BATHTUB
CROSS CONNECTION DEVICEI
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND SYSTEM
DEDICATED .. , . F�
FW- FF1MiWFW-i,FMFW-F
FW- FFW-F�F_
..,.WATER RECYCLE F
i FMFWF
F F•NFW,F FM-
FW-
WMFW-FW
• iWWF
F FW-FW-FWF
F�aF®FW—F=—MF=—FM—
M
DRINKING
••.DISPOSER
•-F�iM-F®F�F-F-FM-F®I-F®F®F®i-
..• ..•.
F
FFF-FFF-FM[-FFMFFM-FFM-FF-FFM-FF®FF-FFM-FM
®m
INTERCEPTOR (INTERIOR) F•-F®FM—FM—F=FM—FM—FM—F®F®F®FM—F
FM—FW—A—EFM—FM—F—�FM—�F®FFM—F®FM
•oma
•. F�F�F®F�F�F�F�F�F�F�F�F®F�
__..y
ROOF DRAINFF�®r®r®rF®r®r®r®
SHOWER►��FFF®�FrrF®
• • SINK
F®r��F®F®r®rF
• FBF-FM-FM-F®F-FM—FM-[M-F®F
F®
• F
F®F®r-FM—�FM—FM—FM—FM
F=—F=—F®
WASHING MACHINE CONNECTION F
F F-FM—F=—FM—F
FM—F-FM—FM—FM—F=—FM—FM—
F
�F
FOOM
MF�MF
F
F F
F F
... FW-F0FFFFFF
FW-
F
FW- FW-
FF•
I��rlr.��rl��r�lr�I-r�rlr��
INSURANCE COVERAGE:
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YE No D
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW �-
LIABILITY INSURANCE POLICY i OTHERTYPE OF INDEMNITY F� 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 0 AGENT
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 P rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME _ v 5 /� �_�_ LICENSE # /' _ _ j' ( SIGNA
MP JP Q CORPORATION# _( PARTNERSHIP_I # i LLC D�
COMPANY NAME [ ;ADDRESS 7 !
CITY STATE ZIP%%?J II TEL %
FAX ]CELL I EMAIL
10
W
CL
ui
LU
LL
. The Commonwealth of Massachusetts
Department of IndustriqlAccidints
Office of Investigations
quo 600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leafty
Name (Business/Organization/Individual):
Address:
City/State/Zip:
Au an employer? Check t ppropriate box:
1 am a employer with
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. ❑ 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 lumbing 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 anew 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
Policy # or Self -ins. Lic. #: / Expiration Date:
Job Site Address: � ZVJ e— City/State/Zip: Cip✓Y�
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 certify under the pains and penalties ofperjury that the information provided above is true and correct.
Sion RfII i�� �� nate-
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other - - -
Contact Person: Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence of compliance with the insurance coverage required"
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth, of Massachmetts
Department ofzndustrial Accidents
Office of Investigations
600 Washington Street
Boston? MA. 02111
Tel, # 617-7274900 ext 406 or 1-877:MASSAFB
Revised 5-26-05 Fax # 61.7"727-7749
ww�v.zl�ass,govfdla
Date ..$...`... .
This certifies that .....
has permission to perform .....................
wiring in the building of .... pr '�',' : !� ....................
rat ...... orth Andover, Mass.
�
-D°O
Fee ..... ..Lic. No .......... ...... ................ ...
ELECTRICAL INSPECTO
Check # S007
1 `f 0 x.17
t_.olnlnoluoea�h o�cc�ad4achu9e�
al Je� o��ire .�ervicel
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 1 ICY7
Occupancy and Fee Checked
ev. 1/07] leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEQ, 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATIOA9 Date: g
City or Town oh v., #-k ' A4 L ve.., To the Inspkto of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 3N LA ->,-IA Rosc_ Ort ✓e
Owner or Tenant i Telephone No.
Owner's Address 14 I.JCL& K.osr_
Is this permit in conjunction with a budding permit? Yes
No ❑ (Check Appropriate Box)
Purpose of Building Q e_3 r`d nn cr_ Utility Authorization No.
Existing Service 2 o o Amps 12-01 2y6 Volts Overhead [g- Undgrd ❑ No. of Meters
New Sdgrd-❑die:-ef meters—
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
f'nrnnlalinn r f&. lnllnwina /ahem maw he waived by lite Insnwwr of Wires
No. of Recessed Luminaires_ or
No. of CeiL-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
Ln cY
No. of Luminaires y � 6; w� F Es
Above In-
Swimming Pool Xrnd. ❑ ffnd, ❑
o. o Emergency g
Butte Units
No. of Receptacle Outlets o2
No. of OR Burners
FIRE ALARM
No. of Zones
No. of Switches
No. of Gas Burners
No. of InitiatinDevices and
evices
No. of Ranges f �'
No. of Air Cond. Total
Tons
No. of Alerting Devices
Disposers
No. of Waste Dis P 1
Heat Pump
Totals:
umber
Tons
No. of Self -Contained
Detection/Merting Devices
I
I
I
No. of Dishwashers / t1
S acdArea Heating KW
P g
Local ❑ Municipal ❑ O&W
Connection
No. of Dryers
Heating Appliances KW
No. of evices or Equivalent
No. of WaterKW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications W" ""ng
No. of Devices or Egulmvalent
OTHER
•�1__r___J �JL..L.. B. ..m.. n/LUirno
-
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start F 2 Inspections too be requested in accordance with MEC Rule 10, and upon completion
INSURANCE C GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
Aersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE [0" BOND ❑ OTHER ❑ (Specify.)
I certify, under the pains and penalties o, fFedury, that the infonwadon on this application is true and complete:
LIC. NO.: 0617 �
LIC. NO.- LQt7 /=
TeL No.; ? 8 � - G 3J —0 37
TeL No.: 791- 39'- l75f L
*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 hoes 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 ent.
Owner/Agent Telephone Na PERMIT EEE. S
eP
Signature
FIRM NAME:
Licensee: AQo�'».-� 17 Signature
(If applicable, emer "exempt " in the (tome member line.)
Address•
Bus
Alt
leg- as—rZ77
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
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): a.1"r%S n +- s A n
Address: 2 b -
City/State/Zip: ,. di ,� d, aha a r g q5— Phone #: 7 1 631 — o 3
Are you an employer? Check the appropriate box:
l', ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
listed the attached sheet. t
2. P- am a sole proprietor or partner-
on
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
5. ❑ We are a corporation and its
[No workers' comp. insurance
officers have exercised their
required.]
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
employees. [No workers'
insurance required.]
A
comp. insurance require .]
Type of project (required):
6. ❑ New construction
7. [a le'emodeling
8. ❑ Demolition
9. ❑ Building addition
10. El 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.
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 their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:
T-1, Si't Address
Expiration Date:
City/State/Zip:
e
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is trite and correct.
Phone #: 9 /' 6,31 - o
Official itse 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
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required"
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. ## 617-727-4900 ext 406 or 1-877-MASSAFE
evised 5-26-05 Fax ## 617-727-7749
Date . ./-.
No 4 r
�- 1y J
-�'.",0 RT :14�o TOWN OF NORTH ANDOVER
10'li On
PERMIT FOR PLUMBING
,SSACMUS�
This certifies that ........... .... ........... .
has permission to perform ...: J� '............. .
plumbing in the buildings of.�:.;.-.!- .z�....j qtr!✓_ ...... . . . . . . .
at ...... .............. . North Andover, Mass.
Feer....... Lic. No..14.Vr ...
PLU1vl G INSPECTOR
Check # 9�
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
I&
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
fPr'it or Typ&4e)
l
�'�W
Mass. Date Il Permit # �f
Building Location Owner's Name/u� Z&��r!/`: O
/U, D A64�!rn/e f Type of Occupancy
New EK
B.P.#
Renovation ❑ Replacement ❑ Plans Submitted: Yes ❑ No ❑
SEWER# FIXTURES SEPTIC#
Installing.Comp4reA Name,
Business Tele
Flame rf I_Icen.s. �t Number
Check one:
❑ Corporation
❑ Partnership
ahrm/Co.
Certificate #
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 49[ No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability Insurance policy ❑ Other type of Indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application wolves this requirement.
Check one:
Owner ❑ Agent C3Signature of Owner or Owner's Aaent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations rf e e permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plum ' e and ChWer 142 of the General Laws.
Stg o Plumber
Title
Gty/Town
Type of License: Master Journeyman E](;
APPRO VED 0 FI US ONLY) License Number !?a.4
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Installing.Comp4reA Name,
Business Tele
Flame rf I_Icen.s. �t Number
Check one:
❑ Corporation
❑ Partnership
ahrm/Co.
Certificate #
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 49[ No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability Insurance policy ❑ Other type of Indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application wolves this requirement.
Check one:
Owner ❑ Agent C3Signature of Owner or Owner's Aaent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations rf e e permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plum ' e and ChWer 142 of the General Laws.
Stg o Plumber
Title
Gty/Town
Type of License: Master Journeyman E](;
APPRO VED 0 FI US ONLY) License Number !?a.4
Oftice Use On Y
The Commonwealth of 19 Massachu tts
PermitB 1A
_ Deportment of Public Safety
Occupancy b Fee Checked
BOARD OF FIRE PREVENTION REGULATION CMR 1200 3/90 (leave blank)
APPLICATION FOR PERMIT TO PPRFORM ELECTRICAL WORK
All vmrk to be performed In accordance with the Maesaehuserts Electrical Code. $27 CMR 1f2::00
(PLEINT ASE PRTN INK OR TYPE & 7
INFORMATION) i Date - ` %8
City or Tows of a . ) AD La i— To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) C/ I)" If) X01n c()
m I/
Owner or Tenant 1 f'! 1 Q i� T O
Owner's Address
Is this permit in conjunction with a building permit: Yes No ❑ (Check Appropriate Box)
Purpose of Building a Pus A 6 a I �, t U Q Utility Authorization NO.
Existing Service Joy Amps /,4) YO its Overhead a Undgrd ❑ No. of Meters��
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Namber of Feeders and
Location and Nature of Proposed Electrical Work 6 �' / b L fi k"ad 1)7 '
OY1 Pk4inc; A" A",,A
No. of Lighting OutletsNo.
of Hot Tubs
No. of Transformers Total
RPA
No. of Lighting Fixtures 3
Swimmin Fool Above In-
g rnd. ❑ grnd. ❑
Generators . RVA
No. of Receptacle Outlets D
No. of Oil Burners
No.
Battof er Emergency Lighting
Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection and
Initiating Devices
of Sounding Devices
No. of Self Contained Detection/Sounding Devices
Local ❑ Municipal []Other
Connection
No. of Ranges
No. of Air Cond. Total
tons
No. of Disposals
No. of Yeats Total ToKtWWl JQnNo.
No. of Dishwashers
Space/Area Heating 1 IW �. S
No. of Dryers
Heating Devices IW
No. of Water Heaters IW
No, of No. of
Signs Ballasts
Low Voltage
Wiring
No. Hydro Massage Tubs
No. of Motors Total HP
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 0 I have submitted valid proof of same to this office. YES ❑ NO [I
If you have checked YES, please indicate the type of coverage by checking the appropriate. box.
INSURANCE 16] BOND ❑ OTHER ❑ (Please Specify) -
(Expiration ate
Estimated Value of Electrical Work $
Work to Start Inspection Date Requested:
Signed a..Aer the
FIRM NAME J tI1
Licensee
.acs ..e .mamma......
Rough Final
LIC. N0. S
LIC. NO. F ? D..d-D
Address US- JCdG /( � j (/i1 i LDwB// v nus, aei. moo. vs - i� iv
Alt. Tel. No. t-,6
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub-
stantial equivalent as required by Massachusetts GeneralwsT.a , and that my signature on this permit
application waives this requirement. Owner Agent (Please check one)��/
Telephone No. PERMIT FEE S
Signature of Owner or Agent
GATE{MM/DDrYY1
.. 06/08/98
i`'3;UED AS A MATTER OF INFORMATION
140 t -TIGHTS UPON THE CERTIFICATE
't DOE'S NOT AMEND, EXTEND OR
""DED BY THE POLICIES BELOW.
TDING - ;OVERAGE
�•113TllAL INS CO
COMPANY
Cai T'iC POLICY PERIOD
FL.�F'cGl
TO WHICH THIS
7'l
,ALL THE TERMS.
,r 0;)0 000
,L r7
i.I 'I, 000
::,�.�,:•,<F
�1 , 000, 000
a•A,;r? art r „
rj i ; ; "000
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00
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1CO3 000
500, 000
f•.(«,t•G•E.k !'h.11' C YE'F.
1. 0 0, 0 0 0
,'' °i` t-[. ,t Thr• •,r - — —
ABOVE. DtzjCt't,3EL{ POt.?VES Be CANCELLED BEFORE THE
'ti`"Fv'.)F 0.,h 15SUI G OOMPANY WILL ENDCAVOP. TO MAIL
I)A'i ri'^i` tE •f •P„ h: TO 4riL CE:F:"FICATE HOLDER NAMED TO THE LEFT,
110',K'. °,• ALL IMPOSE, NO OBLIGATION OR LIABILITY
:-N I':; (.U4A= .r1.,_ ITS AGENTS OR REPRESENTATIVES.
F I
rw A
(..l'
° r r' Date.....�/�... ...............
., .
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
........ 7 ?;� ...n....'�!:�.�..!....� .........
has permission to perform :'z..r.,..1................................................
wiring in the building of ........... ,...fes:':1................................
at ....... ......L. `.:..!:.. -v.:...... ... , North Andover, Mass.
Fee..:moi.....`...... Lic. No;-�.: ..?:0 ...............................................................
ELECTRICAL MpECTOR
06/08/98 13:19 25.00 RAID
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
n..nuam f
(Print a Type)
NORTH ANDOVER, , Mass. Date _Ig
Budding
Location 71-
Permit #
Owner's
Name
New d Renovallon ❑ Replacement ❑ Plans Submitted: Yes ❑ No.12
�iXTUAE3.........
J 1� Check one: Certificate
Installing Company Name f� ❑ Corp.
Address 19 Partnership
77,17 ❑ Firm/Co.
Business Telephone
Name of Ucensed Plumber Leo I i2z!-Ca7741e
INSURANCE COVERAGE: L;hack one
I have a current liability Insurance policy or No substantial equivalent Yes AQ No ❑
It you have checked yq}, please Indicate the type coverage by checking the appropriate box
A liablily Insurance policy Other type d Indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: 1 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:
Owner ❑ Agent ❑
Signature o et a owner s en
1 hereby certify that all of the deteAs and Information I have submftled (or entered) In above application are true and soauate to the best of my
knowledge and that all plumbing work and Instalattons performed under the �m>il Issued for We appikatlon will be In compliance with aft
pertinentprovisions of C
a Massachusetts State Plumbing odan
e d Chapter 12 d the
IDY
This of Ucensed Plumber
gty/Town license Number �l %
Type of Plumbing Ucense: Master
AP IUWD (OFFICE USE ONLY) Journeyman ❑
����������I1
�������//111111111■
U.
J 1� Check one: Certificate
Installing Company Name f� ❑ Corp.
Address 19 Partnership
77,17 ❑ Firm/Co.
Business Telephone
Name of Ucensed Plumber Leo I i2z!-Ca7741e
INSURANCE COVERAGE: L;hack one
I have a current liability Insurance policy or No substantial equivalent Yes AQ No ❑
It you have checked yq}, please Indicate the type coverage by checking the appropriate box
A liablily Insurance policy Other type d Indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: 1 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:
Owner ❑ Agent ❑
Signature o et a owner s en
1 hereby certify that all of the deteAs and Information I have submftled (or entered) In above application are true and soauate to the best of my
knowledge and that all plumbing work and Instalattons performed under the �m>il Issued for We appikatlon will be In compliance with aft
pertinentprovisions of C
a Massachusetts State Plumbing odan
e d Chapter 12 d the
IDY
This of Ucensed Plumber
gty/Town license Number �l %
Type of Plumbing Ucense: Master
AP IUWD (OFFICE USE ONLY) Journeyman ❑
1
Date ..... .I.. �...
+ftHpRT:, o TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
l,'•O•r° �4h
S
SACHUS /
This certifies that ........................................ .
has permission to perform .......r ............!. (............
plumbing in the buildings of .................. ...................
at .. `......... I ......................... 1 orth Andover, Mass.
Feer. 1.. _ Lie. No../'.4 '. .
WHITE: Applicant CANARY: Buildina Dept.
PLUMBING INSPECTOR
60. Ci �P'.L
PINK: Treasurer GOLD: File
'location_
No. / 7/
Date 7,
pORTN
TOWN OF NORTH ANDOVER
• O
O?
�
�A
A
Certificate of Occupancy
$
z"
Building/Frame Permit Fee
$
cNu��'
s�sE
Foundation Permit Fee
$
Other Permit Fee
$
Sewer Connection Fee
$
Water Connection Fee
$ 4'
4
TOTAL
$
Building
Inspector
Mw
Dahlin W-6.
Location
No.
Date
"ORT"
TOWN OF NORTH ANDOVER
• • OR
O?
+ ;
Certificate of Occupancy $
Building/Frame Permit Fee $
CHUst��
Foundation Permit Fee $ C7,
Other Permit Fee $
A
fl
Sewer Connection Fee $ ='
Water Connection Fee $
TOTAL $
,-
Building Inspector '
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and ^apartments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements,
APPLICANT FILLS OUT THIS SECTION
APPLICANT , vj r`�,' u.c�+.� �,/�,./( � T— PHONE 76— 8q-3+4
) k 7
LOCATION: Assessors Map Number Ct PARCEL
SUBDIVISION ` I��n-c Lr,. LOT (S)
STREET Li L L 0 S C ST. NUMBER
OFFICIAL USE ONLY
VDATIONS OF O N AGENTS:
9VL4 6
ATION ADMINISTRATOR
S
TOWN PLANNER
DATE APPROVED I al 4 `Q
DATE REJECTED
11
DATE APPROVED
DATE REJECTED
I& lc
FOOD INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
4 n n \n /1P / Ido A
SEPTIC INSPECTOR -HEALTH
COMMENTS
DATE APPROVED
DATE REJECTED
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR
DATE,___.__
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a MASSACHUSETTS UNIFORM APPLICATION FOR, PERMIT TO 00 GASFITTIN
(Print or Type)
<� NORTH ANDOVER Mass. Date -'7/
-%
building Location /77� �a/, j�G Permit # (�
Owners Name
• Y New Renovation D Replacement Plans Submitted r]
FIXTUP=c
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(Print or Type) Check one: Certificate
Installing Company Name �7�/T Q Corp.
Address// // Partner.
Firm/Co.
Business Telephone:
Name of Licensed Plumber or Gas Fitter 0
Insurance Coverage: Indicate the type of i-isuragce coverage by checking the
appropriate box:
Liability insurance policy M Other type of indemnity r--7, Bond
C
Insurance Waiver: I, the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner 0 Agent 0
I hctcby ccray that all of the details and infotmation I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that aU plumbing .writ and InsaUations performed under Permit iueed fo: this application wilt be in compliance with ail pertinent
provisions of the Massachusetts Slate Cas Code and Chapter 142 of the General Laws.
TYPE LICENSE:
Plumber
Gasfitter Si ature of Licensed
Master Plumber or Gasfitter
Journeyman
License slumber
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
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8TH FLOOR
(Print or Type) Check one: Certificate
Installing Company Name �7�/T Q Corp.
Address// // Partner.
Firm/Co.
Business Telephone:
Name of Licensed Plumber or Gas Fitter 0
Insurance Coverage: Indicate the type of i-isuragce coverage by checking the
appropriate box:
Liability insurance policy M Other type of indemnity r--7, Bond
C
Insurance Waiver: I, the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner 0 Agent 0
I hctcby ccray that all of the details and infotmation I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that aU plumbing .writ and InsaUations performed under Permit iueed fo: this application wilt be in compliance with ail pertinent
provisions of the Massachusetts Slate Cas Code and Chapter 142 of the General Laws.
TYPE LICENSE:
Plumber
Gasfitter Si ature of Licensed
Master Plumber or Gasfitter
Journeyman
License slumber
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
It Date .............:.......
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ............ .. ... ................... .
has permission for gas installation ........:....... ...... .
in the buildings of .................... f.
.......................
at .. ... .... ................... . North Andover, Mass.
Fee..... ..- Lic. No............. ..................
r� r, ii; "ICD cW INSPECTOR
WHITE: Applicant ` CANARY Building Dept. PINK: Treasurer GOLD: File
• Date .. .. �-. •
1
TOWN OF NORTH ANDOVER
O � D
PERMIT FOR GAS INSTALLATION
c✓'•q9
SSAC NUSEt
This certifies that ...< ... ^ '...G' .....�...+...: �----
has permission for gas installation.1...... t..�.:............
in the buildings of ...................
�- at .. :.! •s, r. ' •= �� .� North Andover, Mass.
Fee—J �,.`. Lic. No...�.�-
/ - GAS INSPECTOR
Check # /,'– i
4-
4 -� /
MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FrrrING
(Type or print) Date \
NORTH ANDOVER, MASSACHUSETTS `
Building Locations SL i �•\\� 'SSL Permit #
QN��y 2O
l Cc .� cx S`:\ Amount
Owner's Name
Newt Renovation ❑ Replacement ❑ Plans Submitted ❑
(PrintName � --�' 7�5�N`�'' �AS �y �-�—� �" �eck C� Ce� installing Company
Address��� ��" S` Partner.
c 1`ZA 0��a-3
Business Telephone q'1 '"�'"�`� -•i'O ❑ Firm/Co.
Name of Licensed Plumber or Gas Fittery
INSURANCE COVERAGE Check e_
I have a current liability Insurance policy or it's substantial equivalent. Yes No❑
If you have checked M, plAse indicate the type coverage by checking the appropriate box.
Liability insurance policyrKI Other type of indemnity 11Bond❑
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.
Ch -:k one:
Signature of Owner or Owner's Agent
Owner ❑ Agent ❑
i hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the IvMr=hr_tts StatQas Coge and Chapter 142 of the General Laws.
(Title
VED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber 3"1 `3 S
Gas Fitter License Number
Master
❑ Journeyman
5TH. FLO OR
(PrintName � --�' 7�5�N`�'' �AS �y �-�—� �" �eck C� Ce� installing Company
Address��� ��" S` Partner.
c 1`ZA 0��a-3
Business Telephone q'1 '"�'"�`� -•i'O ❑ Firm/Co.
Name of Licensed Plumber or Gas Fittery
INSURANCE COVERAGE Check e_
I have a current liability Insurance policy or it's substantial equivalent. Yes No❑
If you have checked M, plAse indicate the type coverage by checking the appropriate box.
Liability insurance policyrKI Other type of indemnity 11Bond❑
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.
Ch -:k one:
Signature of Owner or Owner's Agent
Owner ❑ Agent ❑
i hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the IvMr=hr_tts StatQas Coge and Chapter 142 of the General Laws.
(Title
VED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber 3"1 `3 S
Gas Fitter License Number
Master
❑ Journeyman
No.. 76
3 2 ,(d
Date � vS CI ,y
TOWN OF NORTH ANDOVER
o BUILDING DEPARTMENT
� e
Building/Frame Permit Fee $
pDgATlD '�M
SSACMUSE
Foundation Permit Fee $
( ef-Permit Fee
Building Inspector
i
Location �'
4
No. Date
or-
NORTH TOWN OF NORTH ANDOVER
`p Certificate of Occupancy $ Z
y , z
Building/Frame Permit Fee $
cMusEth Foundation Permit Fee $ I c8
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL
".'("TiS7"4 (/ 7,6
6781
$ e-,
Lx
Jt-�- Building Inspector
Div. Public Works
A q
Locati&r 3 V G% -A /.a-•c.�-e
No.- /7'.79 Date A9
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ , g �•U
Building/Frame Permit'Fee $
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection-Fee9 $
Water Cc rk*tiot 6e40 $
TOTAL O� $ ,(SQ•t� U
Building InsF
6638 obi
n u 3 8 Div. Public w
Location :3d � f iJ� ' J � z
Ado. y % Date'
40RTpf TOWN OF NORTH ANDOVER
b t,.ac '. 6
* Certificat 9ccupancy $
+ i; + _ BIA9l rame Permit Fee $
CMU5
CHU Et Foundation Permit Fee $
1A
Other Permit Fee $
it s 7 Sewer Connection Fee $ ate
?O�o Water Connection Fee $
TOTAL $ > L
__.Building Inspector,
►'-641.76 Div. Public Works
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FORM U - LOT RELEASE FORM A
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicanfills
out this
section*****************
APPLICANT: b
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Phon� i& �Uo - q6 \
LOCATION: Assessor's ap Number
Subdivision osz L A
StreetV\41 il 3 015 VVIL
Parcel
Lot (s) .2,
St. Number
************************Official Use Only************************
RECO DATION. OF TOWN AGENTS:
Cons rvation Administrator
Comments
I �a1.-' 1
Comments
Food Inspector -Health
Septic Inspector -Health
Comments
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Public Works - sewer/water connections -�-g-3
PJIV-driveway permit ` Z�-
Fire Department
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