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HomeMy WebLinkAboutMiscellaneous - 35 ROYAL CREST DRIVE 4/30/2018Date ---.).. .-D........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ! This certifies that ......... 1....!.'.....1.U��............................. ....................... has permission to perform ..... . ............:.... ��p. Gc- ., .............................. wiring in the building P ............................................................................. at .. .........1 :.a... .1... �.. �P.. a? ..................... zo nFee.........lpZ...... Lic. No.196 ELECTRICAL INSPECTOR Check # au e J, � Z) M 1 anamonraeaf ti o� ///ueecech�ad offluial Use Only Permit No. ..1JA�1ehNblaaRlt6 o�,.JBrR �sraicab - -- — --- Occupancy and Pee Chocked a� BOARD OF FIRE PREVENTION REGULATIONS (Rev, 1/07) (icaveblaljk) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be perlbrincd in jC00rdancC with the Mamiehusco.9 I ICctr'ical C'odo (MEC), 527 CMR 12,00 (PLEASE PRINT 11V .INIC OR TYPE ALL INT'ORMAT1ON) 1)01e: City or Town of: PQY'�r Fs>.�� � _ 7'0 ll�e lras�iecJor of Til es: — Sy this application the undersigned gives notice of his or her intention to perform the electrical jwork described below, Location (Street & Number) (0p.&\,- c` sn VVI%ff' "i -0v, Ally mex- �DV�xU\10q �'r ?j� Owner or Tenant 'MC.lb v �T'clephone .No. Owner's Address 5:10 fknva L c ve.S-T 1Dr\,4S ►.ro7i1n 14NA�,c pjdA — B this permit in conjunction with a building permit? Vey 0 Purpose of Bttildiaag?PQN t>,. �Ltvl"i Existing Service Amps /_ Volt's Overhead ❑ New Service _ Amps / Volts No K (Check Appropriate Box) Utility Authorization No. _--- Number of T'ceders and Ampacity Overhead EI Undgrd ❑ No. of Meters Undgrd ❑ No. of Meters Location and Nature of Proposed Electricai Work: �*u� '�r.f3l�'t1��.�w►r. �ot� -Co �R.�.cu. dt� �x�C oe�-��.�.,.�!�d��.� �� �'1,�s w�l,� �.c,_y�tru �L� ASS Cnnaplellan nl'Ihe.1r�llavinp tcthle mnv Ge Nraived by the 1r7sneclor njGYb•es, i.►S�Qt No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) panso. of Total Transformers ICVA, No. of Luminaire Outlets Y No. of Hot Tubs Y~ Generntors KVA No. of Luminaires Swimming Pool Above El❑ rnd. rad. mgency Ug ani o. 5f , er Batterl Unit No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No, of Cas Burners f I)n nnd o• o Iaiti t ng Devices Devvices No. No. of Ranges No. of Air Cond. Totl nsNo. of Alerting Deviceg N0. of Waste Disposers eat um Totals um er 'fans tCRN o. o Sell-Contnine ]Detection/Allerting Devices No. of Dishwashers Space/Areas Heating KW Local ❑ un'C'rpal M COther Connection No. of Dryers Heating Appliahces Rte, stem: 9 Security Sys No. of Devices or E uivolent No. of Water KW Heaters No. of R-0-01! signs Ballasts Data Wiring. No. of Devices or Equivalent No. Hydromassage Bathtubs No, of Motors 'Total HP Telecom mun Cationsm ar: No, of devices or E uivakent _ OTHER: Allach additional detail if desired, or as required ley the Impector of R�ire,s, Estimated Value of Electrical Work: CC* (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no pci'ntit for 1.he performance of electrical work may issue unless the licensee provides proofof liability insurance including "completed operation" coverage or its substantial equivalent, The undersigned certifies that such coverage is in foree, and has exhibited propf'of same to the permit iser.ling office, CRECIC ONE: INSURANC LL [xj BOND ❑ OTHER ❑ (Specify;) J certify, under the pains and penalties of perjuni, that the infbrmjjtir111 oil this application is true and complete. FIRM NAME: NowportEloctric LIC. NO.: A20803 Licensee: David McMullen Signature _ _ LiC. NO.: 1160813 (Ifapplic[rhle, enter "exenyx" in the Iicei7sc manlier line,} Rus. Tel. No.. 40127 Address: 200 F igtoint Ave, Portsmouth, RI 02871Alt. Tel. No.: 617-908.1193 'a Per.M.G.L. c. 147, s, 57-61, security work requires Department of Public Safbty "S" License' Laic, No. OWNER'S iNSURANCE WAIVER: i am aware that the Licensee does nol have the liability insurance coverage normally required, by law. By my signature below, I hereby waive this requirement, 1 an, the (check ons) x owner 0 owner's agent, Owner/Agent Signature _ Tcleplamae No, 1PEYM1T,rEE.,$ /C? Af - -- /-3 -- ": �/ � 7 Date TOWN OF NORTH ANDOVER PERMIT FOR WIRING I P This certifies that ............. ..................................................................�i +� q - u has permission to perform .Q.....{a?�ctf,, „ ............. .....'.M �a wiring in the building of......l!vmC?. ....... ................................................................... `,.,,�..`a.!. 5.... �.C�:'j. ..-12-North Andover, Mass. Y A � Fee.... '.7A. ....... Lic. No.2 03 .......I"I ............... ELEC�'PR CAL INSPECTOR , y Check # i� i/ Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS se Permit No, Occupancy and Pee Checked (ev. 11/991 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 PRINTW INK OR TYPE' AL4 INF, O TION) Date: City or Town of: NO'f_l-k ANIADVO-y- Bythis application the undersignedTO the gives notice o :s or er rntentton to perform enelectrical work des Location (Street & Number)cribed below,. Owner or Tenant �� �'� r� (Urp�y (Si4, rata Naomi Owner's Address L'l � Telephone No, 9 7� 6�c�. 7d OC _c) L cYeS Is this permit in conjunction with a building permit? Yes Nd�v Q 3 Purpose of Building_No [g,"_ -� (Check Appropr a1 to Box) �iUJ�.LI Existing ServiceAm s Utility Authorization No, N v p ______/ ___Volts Overhead ❑ Undgrd ❑ No, of Meters Amps ---,- Voits Overhead Number of Feeders and Ampacity Undgrd ❑ No, of Meters Location and Nature of Proposed Electrical Work: it rf r ► �/�iJC���\lf' h A / t NrCP A1C1 21,2", 1'', (WckCK C�5 lesion o 'the ollowin table ma be waived b the Ins ecior o Wires. No. of Recessed Fixtures No, of Cell. -Stns , 0.0 p (Paddle) Fans Transformers KVq No. of Lighting Outlets No. of Hot 'Pubs Generators KVA No, of Lighting Fixtures Swimming Pool rnd e ❑ rnd°• ° mergency g ng [No, of Receptacle Outlets ❑ Bette Units No. of Oil Burners . FIRE ALARMS No, of Zones No. of Switches No, of Gas Burners 0.0 etec on an No. of Rangesotal InitIatin Devices No. of Air Cond. No, of Alerting Devices No. of Waste Disposers Tons ea um Totals um er ons o, o e - onta ne No, of Dishwashers Detection/Alertin Devices Space/Area Heating KW ❑ un►c a No. of Dryers Heating Appliances Lecur yy��onnecption ❑ Other o• o ater KW No.rNo. f Devices or E ulvalont floaters KW o. o o, o Signs Ballasts Wiring No, Hydromassage Bathtubs No. of Motors fl ne �ic o10'rE uinvgalent Total FTP No. of Devices uivalent%� f h^e.J7' OTHER: CS�-----INSURANCE COVERAGE: Unless waived by the owner, no permitfor the performance of er as r Ma STS' �llach addlfionat data!! !f deafred, or as required by the Inspector oJ'rYires, to licensee provides proof of liability insurance including `bompleted operation" coverage or its substantial % electrical work may issue unless undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing officeuivalent. The CHECK ONE: INSURANCE P]' BOND ❑ OTHER ❑ (Specify;_ Estimated Value of Electrical Wor (Exp ,, tratton Date) Work to Start: . (When required by municipal policy,) Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties o er ur that the Information on this application Is true and complete, FIRM NAME: N�, fP 1 G Licensee: LIC. NO.: 0 (If applicable enter "exempt "in the licet'.re number Iine,) Signatur Y,YC NO,; (0 0 Address: D y� Bus. Tel. No.- a OWNERS INSURAN E WAIVER: I am aware that the I icen Licensee does no have the No. - required bylaw. 13y my signature below, I hereby waive this requirement. I am the Alt' Tel. No•v - 3 Owner/Agent (check oninsurance coverage normally Signature owner owner s agent, Telephone No, PERMIT FEE; $� �tj 11MY (.01ttttt'o,ttN)etalth 0014,5sachccsetts MYkI Departm-ent. ofIndrestrialAccidents Office o, fbivestigativrrs X Congress Street, ,Smile 100 Bostom, MA 02114-2017 www, rttassgovldia Workers' Cor;<apensatiioln Insurance Affidavit. )dui.Xders/ContJractors/Electri<cians/Plumbers �nlie�nt Tnfnr.r.o�;,.., A4il,7�C ,� A"Jll aI11e (Business/Organization/Individual):Nfwr-,.r4� .,�ID o /S Phone #v: Aryyou an employer? Check the appropriate box.- I.JN 1. an, a employer with? 4. (1 I am a. general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2, ❑ 1. am a'sole proprietor or partner, listed on the attached sheet, ship acid have no employees 'hese sub -contractors have working, for me in any capacity. Cnrtployees and have workers' [No workers' comp. insurance comp. insurance.I required.] 5. We are a, corporation and its 3.0 1 am a homeowner doing all work officers have exercised their myself [No workers' Comp. tight of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. (No workers' comp, insurance re uir-17 — 05 Type of project (required): 6, New construction 7• Remodehg $. [] Demolition 9, Building addition 1011 10 Electrical repairs or additions 11.© Plumbing repairs or additions 12.0 Roof repairs 13. © Other "Any applicant that chocks box M must also till out the section below showing thcir workerg' compensation policy inform�ltl0n. J' Homeowners who submit this affidavit indicating they are doing all work and then hire outside cgntractorg must submit a new affidavit indicating such, $Cenp•acfors that cheplc this box i; b4 attached an additional sheet showing the name of the sob-cohtractors and state whether or not those cntitiei have employees. It the sub-wntrectors have emPJoyees, they must provide their workers' comp, policy number, I aln an ert'ployer that i's providing workers I corirpensation insurance for my employees. Below is the policy and job site information. Insurance Company Name; 4& _ —11 Policy # or Self -itis. Lic. 4: �^ � Expiration Date: tyI Job Site Address:�a�/c `—" City/State/Zip:. wri, Veg 61 sis 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 imprisotxmen.t, as well as civil penalties in the foam of a STOP WORD ORDER and a fine Of up to $250.00 a da.y against the vibla.tor.. Be advised that a copy of this statement may be :forwarded to the Office of. 111vestigatlorls of the DIA for insurance coverage verilf cation. I do here cervi y :Trader tli ar.n nd Lena/Wes o ' ler irr , that the lit nrnaativn provided above is true and correct. ry -.I 7-7-- —.r" -A --- - Ofcial use only. Do riot write in dais area, to be completed by city or town officlal. City or Town: Permit/I L --Se # 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: 'hone; I 4 N PO13 OP ID: LS CERTIFICATE OF LIABILITY IN �TE(DiYYYYY, THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 0!/0$12014 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED TE THE POLI BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),MgU HOLDER. THIS REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. CIES IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy les) must be endorsed. If SUBROGATION IS WAIVEDORIZED the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights certiflt:ate holder In Ileu of such endorsements . ,htosubject to PRoouceR ghts to the )F Dwyer A an 38 Bellevue kvenue D.F. Dwyer Insurance At�enc Newport, RI 02840 P E"' -4 I�� 401.846-9629 -�,�—_ Daniel F. Dwyer III A ; dfd dfdw encom Iac No��401-846.9629 INSURE 8 AFFORDING COVERAGE INSURED Newport Electric Construction INSURERA : Foremost �NA10—" Corp iNSURERB:Scottsdale Insurance Com an Portsmouth, RI 02871 High Point Ave, Suite BS INSURERc: Beacon Mutual Insurance 41297 Portsmouth, — INSURER -11 ll THIS 13 TO CERTIFY THAT THE POLICIES UIRE ENT TE �L SREb BELOW HAVE ,BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER OCUME11 ..11�11111111111... ONN WUM RESPECT TO W CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. RICH THIS TYPE OF INSURANCE --..-...._.._.____..--_---•- -� S, GENERAL LIABILITY POLICY NUMBER LIMITS- A X COMMERCIAL GENERAL LIABSCP006 ILITY EACH OCCURRENCE 046448 g 12/30/2013 12/30/2014 000'01 CLAIMS -MADE � OCCUR PREMI4Fcrae GEML AGGREGATE LIMIT APPLIES PER: rcrcOUNAL A ADV INJURY g 1,001 POLICY I I PRO- �l GENERAL AGGREGATE g — 2,001 LOC AUTOMOBILE LIABILITY PRODUCTS - COMPIOP AGG g 2,001 .4 7 ANY AUTO S OMB ALL NED X SCHEDULED AUTOS SCP005046448 7 2/30/2013 12/30!2014 NED SINGLE LI 1 E acct on 1,00( AU TOS BODILY INJURY (Per person g , HIRED AVTOS X NON -OWNED AUTOS BODILY INJURY (Per accident) g PR PERTY 0 GE ------ UMBRELLA UAe X OCCUR b X EXCESS UAB g CLAIMS -MADE D B80019698 12/3012013 EACH OCCURRENCE $ D ETENTI N wOFtICERe OOMMNSA71ON 12/30/2014 AGGREGATE g 6,000 ANO EMPLOYERS, LIAeIUTY C $ ANY PROPRIETOR/PARTNERIEXECUTIVE Y / N ED 68861 WC S7ATU- 0TH• $ NH)OFFICER/MEMBER In NIA (,ndatoryIn 01/18/2014 01/18/2015 —'—"""--- If es dtory If yea dee I W under and DE GI NOF E.L. EACH ACCIDENT g 600 PERATIONS below I- A Empl Prac Liab E.L. DISEASE - EA EMPLOYEE g b00, SCP006048448 12!3012013 12/30/2014 E.L. DISEASE - POIICY LIMIT g C00 60, DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORO 101, Addltlonsl Rs Aft Schedule, It more *Psoe Is required) LD ANY THE UEXPIRATIION H DATE ABOVE THEREODESCRIBED F, N0710E POLICIES WISE CANCELLED DELIDELIVERED BEFORE IN InsUred'8 Copy ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE Daniel F, Dwyer III ACORD 26 (2010/06) The ACORD name and logo are registered marks 2of CORD D CORPORATION. All rights reserved. r F NORTH ANDOVER BUILDING DEPARTMENT 1600 Osgood Street North Andover Tel: 978-688-9545 Fax: 978-688-9542 BUSMESS F0l?M FOR TOWN CLEFS DATEP10 /20i 4 NAME: ADDRESS: � S gomt c ES ( ptew ZON NGDISTRITOT: TYPE OF13USINES :_ r(OM ( a( -Ft (i GAME Cll/A)Cj,e fOC<f/? ` BUILDING LAYOUT PROVIDED: YES NO . AVAILABLE PARKING SPAMS: ZONING BYLAW USAGE: YES NO BUILDING INSPECTOR. SIGNATUM BUSINESS FORM POP TOWN CLERK 2.40 Home Occupation (1989132) An accessory use conducted within a dwelling by a resident who resides in the dwelling as his principal address, which is clearly secondary to the use- of the -building. for living purposes. Home occupations shall. 'include, -bit not'limited to the following uses; personal services such as furnished by an artist or instructor, but not occupation involved with motor vehicle repairs, beau4, parlors, animal kennels, or the conduct of retail business, or the manufacturing of goods, which impacts the residential nature of the neighborhood. 4. For use of a dwelling in any residential district or multi far ily district for a home occupation, the following conditions shall apply. a. Not more than a total of three (3) people may be employed in the home occupation, one of whom shall be the owner of the home occupation and residing in said dwelling, b. The use is carried on strictly within the principal building; c. There shall be no exterior alterations, accessory buildings, or display which arc not customary with residential buildings; - d. Not more than twenty-five (25) percent of the existing gross floor area of the diveliing unit. so used, not to exceed one thousand (1000) square feet, is devoted to -such use. In connection with such use, there is to be kept no stock in trade, commodities or products which occupy space beyond these limits; e. There wilt be no display of goods or wares visible from the street; f. The building or premises occupied shall not be rendered objectionable or detrimental to the residential character of the neighborhood due to the exterior appearance, emission of odor, gas, smoke, dust, noise, disturbance, of in any other way become objectionable or detrimental to any residential use within the neighborhood; g. Any such building shall include no features of design not customary in buildings for residential use. Signature f / Date North Andover MIMAP January 29, 2014 �B4t 133 ' •- , SaD draLane� WWaieOP' otecffon 114 125 API IS f � d 114 I .% 125 A1� O L t B2� /sotot Andover • 125t1��e°R�-- l .... - d _. tn1 R aCRJS i c :DDl — Rail Line -. Wetlands Intemlates 0 Exempt Lands Zoning 0 Busine I Busine s 1 District s 2 District Hon—tal Datum: MA Stateplane Coordinate System, Datum NAD83, — SR G Busine D Busine s 3 District s 4 District pORT/� Meters Data Sources: The data for this map was produced by Merrimack Valley Planning Commission (MVPC) using data provided by the Town of Roads 1:i Easements ® Genera �Planne I= Corrido Business District Commercial Dev Development Dist Of p 'a� ��� �e = be 'e O North Andover. Additional data provided by the Executive Office of Environmental Affairs/MassGIS. The information depicted on this map is 0 MVPC Boundary C3 Municipal Boundary Zoning Overlay D Corrido D Corrido ' Industri Development Dist Development Dist 0 1 District O -- —: 1e ♦ ; for planning purposes only. It may not be adequate for legal boundary definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY e Adult Entertainment o Downtown Overlay District © Historic District C•F Industri C Industri O Industri 2 District 3 District S District + _ ^ # i * p Yy� . �. 7 �p'��t�p OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION ® Water Protection Reside ce 1 District 7S ❑ Parcels C : Reside O Reside ce 2 District ce 3 District SACHUSE ❑ Hydrographic Features 1" = 691 ft . de •q }rde ce4 District -5 District -- streams YYY de ce fi District -a esidential District Date.......... 9542 NORtM TOWN OF NORTH ANDOVER. �? 0.w _....'. pL PERMIT FOR PLUMBING This certifies that ... 6%s 11,x' has permission to perform plumbing in the buildings o 9....... ........ s..... . at.../�i.. i" .. .....�I...... ...!' .....�.., Vo A Dov ,Mass. Fee......... Lu. No. ............................. . PLUMBING INSPECTOR Check p 7/z-5-7 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY Du t;� MA DATE 7 . / PERMIT # JOBSITE ADDRESS OWNER'S NAME) e %<f &,,y -A &3 7q e1 P OWNER ADDRESS de `1(f 1t, TEL7,?oa FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL F1 RESIDENTIAL PRINT CLEARLY NEW: [—I RENOVATION: ❑ REPLACEMENT: 1 PLANS SUBMITTED: YES NO[_] FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM _! DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN ; SHOWER STALL SERVICE / MOP SINK TOILET - URINAL _ WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER v wZ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I .! :ia OTHER TYPE OF INDEMNITY F! BOND II 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 L] AGENT L SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information 1 have submitted or entered regarding this application are true and acc rate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in lance h II Pelinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME; Bradford Piesco ;LICENSE # ;10512 SI NATURE MPI! I JPI1II CORPORATIONh,, 1#110512 IPARTNERSHIPII 1#I �ILLCI I#fe COMPANY NAME I Nurotoco of MA d.b.a Roto -Rooter I ADDRESS i 175 Maple Street CITY; Stoughton ; STATE MA; ZIP02072 ; TEL 781-297-7049 FAX 1781-341.8817 1 CELL 1774-259-2439 1 EMAIL I Bradford.Piescodrrsc.com I ROUGH PLUMBING INSPECTION NOTES I BELOW FOR OFFICE USE ONLY Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERM 8 y PLANl REVIEW NOTES FINAL INSPECTION NOTES 4-1 vhf" v/ tnve.7• 9anons 600 Washington Street lw Bostok 1119 OZIlI www-MaMgov/dia Workers' Compensation Insurance Affidavit: Builders/ContractorsMect � pl��e� p�licant Information ame ity/Statel p: Stoughton MA; 02072 _ phone #: 781-297-7049 YOU an employer! Check tbrappreprl,e bon `I am a emp%r wide -'-)n_ 4. (] 1 am a general esomracW and I aPloYm {fan anwor pus dump I am i sole pioprieaor or 'have bired the anb-eontracoozs listed partner- for—me on the audod sheetfor-i These smb-con�acto� have snY capacity. (NO imsurance vmkcng comp. msaraaoa s. 13 Wei neaemy6tion and its ant P, Icomp. 1 am ao homeowner doing all work . have wed them right ofeaemptian per MGL .nWuK +Comp. c. 152, jI ft and Wehaveno ' awb ms. (No wodm.. SPP dwAOC6b= it ame deo epi auto eewn wow eonrae�adho aaAmtad..t8ea�►Q ' Type ofproject owph d): — 6. ❑ New consemtion 7. 13ReroodeNag L'13 Demob 9. 0 Haildigg addidoa 1613Electrical repairs Qr addidona 11•0 Btapairs Or additions 12.13 Roof MAE 13.Q Other ' �°i►��OSaSt�artdQientffisoa�dde •-»-, rdofi Qist �beel�my boa � attee3ed oro ad�eiamea r6eet �ow�.me aeras Dime � tit a aeM e�drv$ aQeh end4us wroAoea� �p� pew. Qn emPlvY6r dWis provlding workers' eompearatlorr lnaw�anee or rmrlos J !�' u4Aloyu�• Below Ie- tlieool�yy � job aIle' InOQ/NaQle_�Vtarah rTea '. . 6 or Sew --ins,. Lit P: EXpftd= Date: 4/l/2012 ReAddress' 6 a copy oftheworken' eo mpensatlon poHey declaratlon page (showing the polio' number and aplratl'on date e to seaae eovoage se- required under Se con 25A of MGL c.152 can lead to pie ofd P�altiex of s P to $1,500.00 and/or one-year nm�pnsmumt m wen n civil.sullies is the form of a STOP Ofah ORD b MOM a day against the violaitor. Be aftbad dw a EIt and a fmo �a m of the DIA for f � . �P% ®f t� ea1t maybe forwarded to the OWWC of 'd coo wrdirthepalnt and pcnahles 009dw 'tlratdw b Jorrnatton provJded above 4 tree orad eorrteft lelal are o* Do not write In d* area, robe eoarpleted a or town o F or Town: otHePermit/Llcense � owd alth LBWldtn� De . ►flier g Partment 3. CYty/i'own Clerk 4. Eledrtcal Inm rtes a Ud Person: . Phone ft MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) _ NORTH ANDOVER Mass. Date 71 building Location Permit # (�f Owners Name- ? _ New -7 Renovation D Replacement Plans Submitted D FIXTURES u (Print or Type) Installing Company Name ANDOVER PLG. & HEATING CO. , Address 573-1/2 SO. UNION ST. LAWRENCE, MA. 01843 Business Telephone: 508 685-8383 Check one: Certificate NN . Corp. 2122 Partner. Firm/Co. Name of Licensed Plumber or Gas Fitter rFORaF PROSE Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Q Bond ED 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 17 Agent 0 I hereby certify that aU 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 aU plumbing warts and installations perforated un der' Permit issued to. this app6eation will -be in compliance with an perttaent ! provisions of the Massachusetts State Gas Code and Chapter 14: of the Genera! Laws. .. 9 By PE LICENSE: r2M,4.a umber Title �p� I Inns sf itter- Sig ature of Licensed 90'v Plumber or Gasfitter City/Town: sterurneyman 998 APPROVED (OFFICE USE ONLY) License. number ANSI ISE MOSSIMME yffin EMMONS (Print or Type) Installing Company Name ANDOVER PLG. & HEATING CO. , Address 573-1/2 SO. UNION ST. LAWRENCE, MA. 01843 Business Telephone: 508 685-8383 Check one: Certificate NN . Corp. 2122 Partner. Firm/Co. Name of Licensed Plumber or Gas Fitter rFORaF PROSE Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Q Bond ED 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 17 Agent 0 I hereby certify that aU 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 aU plumbing warts and installations perforated un der' Permit issued to. this app6eation will -be in compliance with an perttaent ! provisions of the Massachusetts State Gas Code and Chapter 14: of the Genera! Laws. .. 9 By PE LICENSE: r2M,4.a umber Title �p� I Inns sf itter- Sig ature of Licensed 90'v Plumber or Gasfitter City/Town: sterurneyman 998 APPROVED (OFFICE USE ONLY) License. number `ATO 2169 Date."/ -/1.-.5; c ....... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION A ff °S� S N This certifies that !............... . has permission for gas installation ... L4 .. t �................. r.. in the buildings of ...Je 410. -...cam ................... atCl) nj.�.. . 3 , No Andover, Ma Fee.. Lic. No.. GAS INSPECTOC Rl WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File 1,0379 ..Date.jv ......................... TOWN OF NORTH ANDOVER ) PERMIT FOR WIRING w 1 e - This certifies that ............ S.T.t-fA. Pu ..... �z L< J—ze 'c ... ..... ... ... ...... ...... has permission to perform ...... , K ........... . ........... wiring in the building of .... .................... at ...... rth Andover, MW. 57 .......................... ......... ..... Fee..L?��." .. Lic. No. 6 ........... .. ......... .. .... ELE RICAL INSPECTOR. Check # 7,-Z— Commonwealth of Massachusetts Official Use Only • Department of Fire Services Permit No. to BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked u,p [Rev. 11/991 (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: 10-13-2011 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) 50 Royal Crest Drive Building # ,3 5 Owner or Tenant Royal Crest Estates Telephone No. Owner's Address 50 Royal Crest Drive Is this permit in conjunction with a building permit? Yes No X (Check Appropriate Box) Purpose of Building Apartment Buildings 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: Upgrade Emergency Lighting Completion of the following table may he waived by the Insnertnr of Wirvc No. of Recessed Fixtures No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑ In- El o Emergency ig ting 6 rnd. rnd. Battery Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number ............................... I s Ton ........... . KW. . ............ No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. 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 x BOND ❑ OTHER ❑ (Specify:) 3-21-12 Estimated Value of Electrical Work: (Expiration Date) Work to Start: 10-17-11 Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: Stilian Electric, Inc 108 Tenney St. Georgetown, MA 018 LIC. NO.: A11067 Licensee: Karl Gonsiorowski Signature LIC. NO.: E31598 (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 978-352-9994 Address: 108 Tenney Street Georgetown, MA 01833 Alt. Tel. No OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $125.00 Signature Telephone No. dAK I//- Z�V- 4� X", ---- ,, 4 10090 6 6 0 Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .............. .... ........ has permission to perform( .... le�ra' Af. ........ 1,r1K.1 ...... wiring in the building of ...... .. 4 .. ......... A ............. at ... ...............V North Andover, Mass. .... Fee.... .......... Lic. No.,Pe .7,,;?7 ......... LECTRICAL INSPC:`I'OR Check # do-- `v C,ommonwea& of Majjac4u,4eth Official Use Only Apartment of7ire Services Permit No.%,/O rJ D Occupancy and Fee Checked r BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: May 12, 2011 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)_ 50 Royal Crest Drive Building # 35 Apt 4 Owner or Tenant Royal Crest Apartments Telephone No. 978-681-1822 Owner's Address 50 Roval Crest Drive North Andover. MA 01845 Is this permit in conjunction with a building permit? Yes ❑ No X❑ (Check Appropriate Box) Purpose of Building Commercial - Apartment Building 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: Replace Burnt Baseboard Heat with new as directed. Completion o the followingtable ma be waived b , the Ins ector -f Wires No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Tota Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ n- ❑ rnd. rnd. o. o Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detoction and Initiating Devices No. of Ranges No. of Air Cond. Total Tons g No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: """"" IKW """'' . No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ unicipal ❑ Other Connection No. of Dryers Heating Appliances KW ecurity Systems: No. of Devices or Equivalent No: of ea 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: $372.00 (When required by municipal policy.) Work to Start: 05/12/2011 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 ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: The Electricians & Co.. Inc. LIC. NO.: A10737 Licensee: Wayne Morganti Signature LIC. NO.: E28407 (If applicable, enter "exempt" in the license number line) Bus. Tel. No.: 781-322-9344 Address: 50 Branch Street Malden, MA 02148 Alt. Tel. No.: 781-322-3100 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. SS CO 001021 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 /'moi Telephone No. PERMIT FEE: $ UU f--, - //- Fold, Then Detach Along All Perforations CONTROL # H 0 4 5 0 2 6 IMPORTANT If this license is lost or destroyed, notify your Board at the: Division of Professional Licensure, 1000 Washington St., Suite 710, Boston, MA 02118-6100. If your name or address shown is changed, notify your board of correct name or address to insure proper mailing of next Renewal Application. Always refer to your license number. This license is subject to the provisions of the General Laws as amended. It is a personal privilege, and must not be loaned or assigned to any other person. Keep this license on your person or posted as required by law. Fold, Then Detach Along All Perforations The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations U9 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): The Electricians & Co., Inc Address: 50 Branch Street City/State/Zip: Malden, MA 02148 Phone #: (781) 322-9344 Are you an employer? Check the appropriate box: Type of project (required): 1. ® I am a employer with 15 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 6. L1 New construction 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9• ❑Building addition [No workers' comp. insurance comp. insurance. P• required.] 5. ❑ We are a corporation and its 10. ® Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work officers have exercised their l I. El Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] + c. 152, §1(4), and we have no 13.7 Other employees. [No workers' comp. Insurance requirecl.] *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Hanover Insurance CornDanv Policy # or Self -ins. Lic. #: WHN 6055762 01 Expiration Date: Job Site Address: 50 Royal Crest Drive City/State/Zip:-N. Andover. MA 01845 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 ofperjury that the information provided above is true and correct. Phone #: (781) 322-3100 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 #: ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDrmY) 08/25/2010 PRODUCER 978. 922. 2288 FAX 978. 922. 2731 Appleby & Wyman Insurance Agency Inc. 152 Conant St . Beverly, MA 01915 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED The Electricians & Co., Inc. 50 Branch Street Malden, MA 02148 INSURERA: Hanover Insurance Company 22292 INSURERB: INSURER C: INSURER D: INSURER E: %1Vvr_rwur0 THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRDD' LTR IN TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM1DD/YYYY POLICY EXPIRATION DATE (MMIDDNYYYI LIMITS GENERAL LIABILITY ZBN6055947 09/01/2010 09/01/2011 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 300,000 CLAIMS MADE [K] OCCUR MED EXP (Any one person) $ 10,000 A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 X POLICY PRO LOC JECT AUTOMOBILE LIABILITY AWN6286430 09/01/2010 09/01/2011 COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) 1,000,000 ALL OWNED AUTOS X BODILY INJURY $ A SCHEDULED AUTOS (Per person) X HIREDAUTOS X BODILY INJURY $ NON•OWNEDAUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY UHN6280480 09/01/2010 09/01/2011 EACH OCCURRENCE $ 2,000,000 X OCCUR E� CLAIMS MADE AGGREGATE $ 2,000,000 A $ DEDUCTIBLE $ X RETENTION $ 10,000 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY WHN6055762 09/01/2010 09/ 01/2011 LIMITS ER TORYANY A Y / N OFFICER/MEMBER EXCLUDED? PROPRIETOR/PARTNER/EXECUTIVEEl E.L. EACH ACCIDENT $ 500 ,000 E.L. DISEASE - EA EMPLOYE $ 500 QOQ (Mandatory in NH) If yes, describe under - E.L. DISEASE - POLICY LIMIT I $ 500,000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS v"" r rrron r c r1VL.ur_M CANCFL I ATIAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Town of North Andover NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Attn : Wire Inspector IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 1600 Osgood Street REPRESENTATIVES. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Marciano/Fitz erald ACORD 25 (2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. 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