HomeMy WebLinkAboutMiscellaneous - 35 CIDERPRESS WAY 4/30/2018 (2)S�
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Date.....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........ -Ze Z�7—
............ .......... ..........
has permission to perform ....... .................................
wiring in the building of ........ /-It7t-7
...........
..........
a t . G. -5-S ...... North Andover, Mass.
- PE�LEC�7�MCA�LN�SPECC;7i�D�R
Fee. Lic. No..7�2.6!4�� .........
Check # ?—
I 10529
Commonwealth of Massachusetts Official Use Only
+ ,
- Department of Fire Services Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]/07] (leaveblank
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 t- I ,j ii
City or Town of. NORTH ANDOVER To the Inspector JWires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) �S Gf (,1�► t �Z s (��4-ti.1
Owner or Tenant
Owner's Address
- ftti DO v
Telephone No. LE 7 _ L63, S:-
Is this permit in conjunction with a building permit? Yes Q No ❑ (Check Appropriate Box)
Purpose of Building ��t CvJTut� Utility Authorization No.
Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: W1 K,
Completion of the following table may be waived by the In ector o Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets I
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑In- ❑
rnd. grnd.
o. of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of SwitchesNo.
of Gas Burners (
No. of Detection and
Initiatin Devices
No. of Ranges (
No. of Air Cond.Tonal
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Number
.Tons
W
. . ....... ... ...
.......................
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers (
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers l
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (l Dc7 O,. `� (When required by municipal policy.)
Work to Start: 1 Z I I l 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 forc nd has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE 2"' OND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: ti,c .vLq LIC. NO.:
Licensee: AA CCtk 4t Signature V LIC. NO.: e Z-) lrrpS�
(If applicable, enkr "exempt" in the license number line Bus. Tel. No. �r�3 3 L zoi-
Address: 1 t�wS �Jt�k .p 1p,45 ^'(�S� f.�,t.( Alt. Tel. No.: 37 K- C*6 'I,_
*Per M.G.L c. 147, s. 57-61, curity work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required
by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's
Owner/Agent PERMIT FEE: S
Signature Telephone No.
M
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): b A-, n� 4r
Address:
City/State/Zip: A.') &1(4 p3 jr -L _ Phone #: g 7 3 7 C-0?�6
Are yop an employer? Check the appropriate box:
1. I am a employer with _k
4. ❑ I am a general contractor and 1
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. [�iew construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
1 I.❑ Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
*Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 4,A/00 L A6 .
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: s ESS City/State/Zip:
Attach a copy of the workers' compensation policy d claration 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 cerffy under the pains and penalties of perjury that the information provided above is true and correct.
7
Phone #: 3
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 #:
Date.. ........
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ... l.� ..leelK!". �''.............
has permission for gas iinsta7..,
ion . ,/ S t ............ .
in the buildings of .........!.. / ' ... �a ?!3'a H,. .....
at .. ' .4-� r,��!� f........... N/or h nd ver, .
Fee.AL•1/�/Lic. No.. �S/S7.zr
GAS INSPECTOR
Check # /&.3
7958
9230 Date ..�Z��/. .
TOWN OF NORTH ANDOVER
' PERMIT FOR PLUMBING
This certifies that ../ ! . ! .. !`-.PE'er . � .......... .
has permission to perform .lviq� !
plumbing in the buildings of
at ..>- C-!!�?.............. . North Andover, Mass.
'
PLUMBING INSPECTOR
Check # &3
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a
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town: 9�1 l MA.
Date:- Permit#
Building Location:
Owners Name: J ��
PType of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
New. h!!j Alteration: ❑ Renovation:
FIXTURES
Plans Submitted: Yes n No
Installing / VV � Check OnO-F,
Address:f City/Town: -C �, ElCorporation
State: ' (/
Business Tel:1,�Q 3 �) / Fax:
�El Partnership
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Nam /
Marne of Licensed Plumber: Y h,'.1 /, ❑Firm/Company
INSURANCE COVFRa�Fa
DEDICATED
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-SUB BSMT.
BASEMENT
.1' FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6' FLOOR
7TH FLOOR
3' FLOOR
Plans Submitted: Yes n No
Installing / VV � Check OnO-F,
Address:f City/Town: -C �, ElCorporation
State: ' (/
Business Tel:1,�Q 3 �) / Fax:
�El Partnership
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Marne of Licensed Plumber: Y h,'.1 /, ❑Firm/Company
INSURANCE COVFRa�Fa
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1 have a current liability insurance policy or its,substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑
If you have checked Yes, please Indic the type of coverage by checking the appropriate box below.
A liability insurance policy. Other type of indemnify ❑ 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
Si nature of Owner or Owner's A ent Owner ❑ Agent ❑
hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate ti
Knowledge and that all plumbing v: or k and installations performed under the permit issued for this application will be in compliance with all
Pertinent provisio of the Massachusefts State Plumbing Code and Chapter 742 of the General Laws, a lian a t,.� best of ry
-A us
3y
fty/Town
Type of License:
PIPIumber
Master
❑Journeyman
SignAure of Licensed Plumber
License Number:
v
AO
The Commonwealth ofMassachusetts
Department oflndustrialAccidents
Office oflnvestigations
600 Washington Street
5
Boston, AM 02x11
www.mass gov/dia
� Iicant Information
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name
Address:
City/State/Zip:,
Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
2. ❑employees (full and/or part-time).*
I am a sole proprietor or
have hired the sub -contractors
listed
partner-
ship and have no employees
on the attached sheaet. t
These sub -contractors have
working for me in any capacity,
[No workers' comp, insurance
workers' comp, insurance.
5. ❑ We are a corporation and its
3. ❑required.]
I am a homeowner doing all
.officers have exercised their
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 red
Type of project (required):
6. ❑ New construction
7. [❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. El Electrical repairs or additions
11 -E1 Plumbing repairs or additions
12.0 Roof repairs
Homeowners who submox #1 must also fill out the sectquire ] 13.0 Other I
*Any applicant that checks bion below showing their workers' compensation policy information.
it 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
information. my employees Below is the policy anti job site
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Job Site Address:
Expiration Date:
Attach a copy of the workers' compensation policy declaration page (sho— City/State/Zip-
wing thepolicy 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 a
Of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forand a fine
warded to the Office a
Investigations of the DIA for insurance coverage verification.
"0 itereby certify under the pains and penalties ofperjury that theinformation provided above is true and correct.
Official use only.
Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
'.i
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
Of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three aparfinents 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 (ifnecessary) and under "Job Site Address" the applicant should write "
town)all locations in (city or
" 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 CO of Passacl�i,setts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston} 1 A. 02111
Tol. # 617.727-4900 ext 406 or 1-877-MASS.A.FE
Revised 5-26-05 Fax # 617,727-7749
www.mass.�ov/dia
N,1A%ACHGSEI'IN LINUORM APPLICATON FOR PERINIlT TO DO GAS FMING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations
Owner's Name
New Renovation ❑ Replacement ❑
Date ld /J, — / /I41
Permit #
Amount $
Plans Submitted
(Print or type) �� J < Check one: Certificate Installing Company
Name ,?-�
El Corp.
Address rl Partner.
Busmess fe ephone C) Firm/Co.
Name of Licensed Plumber or Gas Fitter /M1s+Xi,,, Y k A -
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes No
If you have checked �, pleasclte the type coverage by checking theappropriate box. ❑
Liability insurance policy Other type of indemnity Bond
Owner's Insurance Waiver: I am aware that the licensee does not have the .Insurance coverage required by Chapter 142 of the
Mass. General Laws. and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent
I hereby certify that all of the details and information I have submitted ("or entered) in above application are true and accurate to the-
bcst of mN knowledge and that all plumbing work and installations performcd under Permit Issued for this application will be in
compliance with all pertinent provisions a�the N1la8sachusctts State Gas Codeand CIppter 14;.4f the,*jyneral Laws.
By: � A . ��� . �V
Title
City/Town
APPROVED (OFFICE USE ONLY)
0
�v
Signature of Licensed Plumber Or Gas Fittcr
Plumber �j'l,S 7
itter I case Number
er
Master
® Journeyman
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SUB -BASEMENT
B A S E M ENT
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4T 11. FLOOR
5 T H. F L O O R
6TH. FLOOR
7 T H. F L O O R
8TH. FLOOR
(Print or type) �� J < Check one: Certificate Installing Company
Name ,?-�
El Corp.
Address rl Partner.
Busmess fe ephone C) Firm/Co.
Name of Licensed Plumber or Gas Fitter /M1s+Xi,,, Y k A -
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes No
If you have checked �, pleasclte the type coverage by checking theappropriate box. ❑
Liability insurance policy Other type of indemnity Bond
Owner's Insurance Waiver: I am aware that the licensee does not have the .Insurance coverage required by Chapter 142 of the
Mass. General Laws. and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent
I hereby certify that all of the details and information I have submitted ("or entered) in above application are true and accurate to the-
bcst of mN knowledge and that all plumbing work and installations performcd under Permit Issued for this application will be in
compliance with all pertinent provisions a�the N1la8sachusctts State Gas Codeand CIppter 14;.4f the,*jyneral Laws.
By: � A . ��� . �V
Title
City/Town
APPROVED (OFFICE USE ONLY)
0
�v
Signature of Licensed Plumber Or Gas Fittcr
Plumber �j'l,S 7
itter I case Number
er
Master
® Journeyman
The Commonwealth of Massachusetts
It's 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 Le6bly
Name (Business/Organization/Individual):
Address:
City/State/Zip:
Phone #:
Are you an employer? Check the appropriate box:
i. ❑ I am a employer with 4. ❑ I am a general contractor and
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
-[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
workers' comp. insurance.
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
1 l .❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mustssubmit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct.
Signature: Date:
Phone #:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #: