HomeMy WebLinkAboutMiscellaneous - 39 VILLAGE GREEN DRIVE 4/30/2018Date% ;2.:... 7.......
•`,'..�+''ryppL TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
has permission to perform .........`�
wiring in the building of.(..................y..// r
at .................... �.�............ .... ...............
........,.... , North Andover, Mass.
Fee's<%........... Lic. Nol7ld�....................................................
ELECTRICAL INSPECTOR
Check #G�� ,
7692
The Commonwealth of Massachusetts Office Use Only� qa-
G- 1?,�
;j Department of Public Safety Permit No. r
Occupancy & Fee Checked C 3_
jr BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90
(leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date September 21, 2007
North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) 36 Village Green Drive
Owner or Tenant Property Management of Andover
Owner's Address P.O. Box 488
Is this permit in conjunction with a building permit: Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building Residential 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 _Li ghting _in
boiler room
No. of Lighting Outlets
No, of Hot Tubs
Total
No. of Transformers KVA
No. of Lighting Fixtures
Swimming Pool Agog Elgmd. ❑
Generators KVA
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting
Battery Units
No. of Switch Outlets
No. of Gas burners
FIRE ALARMS No. of Zones
No. of Detection and
Initiating Devices
No. of Sounding Devices
No. of Self Contained fs
Detection/Sounding Devices
Local ❑ Municipal Connection [:]Other
No. of Ranges
Total
No. of Air Cond. tons
No. of Disposals
Heat Total Total
No. of Pumps Tons KW
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
Heating Devices KW
No. of Water Heaters KW
No. of No. of
;Signs Ballasts
Low Voltage
Wiring
No. Hydro Massage Tubs
No. of Motors Total HP
OTHER:
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.
I have submitted valid proof of same to this office. YES IR NO ❑.
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
INSURANCE N BOND ❑ OTHER ❑ (Please Specify)
Estimated Value of Electrical Work $
Work to Start Inspection Date Required: Rough
Signed under the penalties of perjury:
FIRM NAME CROWE & SONS ELECTRICAL CORP.
Licensee JAMES B. CROWE Signature
YES ® NO ❑
(Expiration Date)
Final
LIC. NO. 17168A
LIC. NO.1716 8A
576 MIDDLESEX STREET LOWELL, MA 01851 Bus. Tel. No. T978) 453-6�
Address � Alt. Tel. No. 9 7 8 2 b i —
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage or its substantial equivalent as
required by Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Owner ❑ Agent ❑ (Please check one)
(Signature of Owner or Agent)
Telephone No.
PERMIT FEE $ 55.00
Date. 16 -e)
.�� TOWN OF NORTH ANDOVER
PERMIT FOR -PLUMBING
This certifies that . ...`.""`" ... ... ......! ``-Y•--Gr'"a. .... .
r has permission to perform-�?.-.
plumbing in the buildings of'. �t ..-..................... .
at "`�. �% �° `' � : North Andover, Mass.
/o
............. .... LicNo.�y.�PLUNPECTOR
Check # /� D
8042
4 MASSACHUSETTS UNIFORM ,APPLICATION FOR PERMIT TO DO PL
(Type or print) UMBIlNG
f
NORTH ANDOVER, MASSACHUSETTS
Building
New Q
Renovation
of
Replacement -rz
Date ► o
Permit # v
Amount—,�
Plans Submitted Yes No `" 1
Installing.Company Name QY'\\\JRASCl Check one:
Certificate
Address Corp.
4� �'Q ���1 Q ❑ Partaer.
usmess. elephone
Name of Licensed PlumberFmn/co.
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indenlni
tY n Bond
Insurance Waiver I, the undersigned, have been made aware that the licensee of this application does not have any one of the
three insurance
above
Signature ❑
Owner Agent El
hereby certify that alJ of the details and information I have submitted
best of my knowledge and that all plumbing work and installations(or entered) in Wove application are true and accurate to the
compliance with all pertinent provisions of the Massachusetts Statelamb-performed under Permit Issued for this application will be in
n Plumb � Code and Cha ter ] 42
By: P of the General Laws.
1gIlaLLL Ol 1 tcrnch e
Title Type of Plumbing ,License
City/ own ) )N i
APPROVEDlicense vumoer
(OFFICE USE ONLY Journeyman ❑
e� \
t�;bl>Jd
1. i
tar r
c:
ne c,omrnOnwealth ofAfi?Ssachusetts
Department of Industrial Accidents
Off1ce of .£nvestigations
600 Washin,,Street
Foston, M4 02111
w"' -"lass-, 0i)/&a
Workers' Compensation Insurance.A:€Fidavit, Builders/Contrartors/Electric
Aca.nt Iaforaiation 4ans/Plumbers
Name (Business/Organization/Individual):
Address:
S5
kr-
City/State/Zip:
Phone #:
Are you an empioyer? Check th
e appropriate
1. ❑ I an a employer with
box:
4. ❑ I am a tr
employees (frill and/or part-time).*
I am a
=eneral contractor and I
have hired the sub -contractors
sole proprietor or partner -"Ste
ship and have no employees
d oza the attached sheet $
working for me in any capacity.
These sub -contra
workers°,ctrs have
comp, insurance,
NO workers' comp. insurance
p
5. ❑ We are .a corporation
re uired_
q ]
3. ❑ [ am a homeowner doing
and its
officers have exercised. their
all work
myself. [No. workers' comp.
insurance
right of exemption per MGL
c. 152 , 1(4), and we have
required.] t
no
'employees. No .workers'
comp in
Type of Project (required):
.6•. ❑ New construction
7• ❑ RernodeIing .
g• ❑ Demolition
9. ❑ Building addition
10:❑ Electrical repairs or additions
I 1 Plumbing repairs or additions
12.[] Roof repairs
surance regtnred ] 13 ❑Other
*Any rowiean th;iTwho checks box #I .must also fill out the section below showing their workers' com nation o
t f'iUmCOWner$ who Sublttll.tl)iS ariidavit indicating lite-' arc Lioill. '•'•' _. ,. t
mron:sahon.
XConuactors that check this box must L t'd Enrn himcuiae cone
attached an additional sheet showing the name of the s • at ruts muni submit IL new am`davit indicating such.
r ,. _ _ Lb"eG•<u�CLots and fnr r w� ;,—,
• • •. .,wa ycl J'ZLU U pr0VWzne workers`' c0 ensatioiz i -•- -..•••N. P., is 1nn7rmatlon.
information. �zsurance for '' employees. Below is the oft
_ P cy and job site
Insurance Company Name:
Policy # or Self -.ins. Lic. #.-
Job
:
.rob Site Address:
Expiration Date:
Attach s copy of the workers' compensation .po➢icy deciaration Q City/Stat✓/Zip:
.Failure to secure coverage as required under Section 25A of ode (showita; the policy number and expiration date),
fine up to $1,500.00 and/or one-year imprisonment; as well MGL C. 152 can lead to the imposition of criminal penalties of a
of up to .5250.00 a da against as civil penalties in the form of a STOP WORD ORDER and a fine
Y � Inst the violator. Be advised that a copy of this
Investigations of the DIA for insurance coverage verification, statement may be forwarded, to the Office of
PLLMV aka penalties of perjurf' that the information Provided Iabove is true and correct
N
Of ficial use onip. Do nor write in this arell, to be completed by city or town ozr-
City or Town:
Issuing Authority (circle one): Permit/Lricense #
I. Board of Healtb 2. Building Department 3
6. Other
ylifol � 1
C"3/ own.Cierk 4. Electrical Inspector 5. PFumbing Inspector
Contact Person:
Phone 4_
Date..e?7....
WORTH /
Of` „ao ,e 1tiO
TOWN OF NORTH ANDOVER
9
PERMIT FOR—GAS INSTALLATION
This certifies that�" " . -- �-.
has permission for gas installation �' ............
in the buildings of:
O .,,,.�.
at ,,,_ 6 ....... ... ✓ = IVort Andover, Mass.
Lic. No. .IA`11... --
✓ GAS INS PEG OR
7 U
Check # 1,..3 6 O �'
6763
S
ap
MASSACHUSETTS UNDORMAPPUCATONFORPERMTO DO GAS RrrJNG
(Type or print)
NORTH ANDOVER, MASSACHUSETTS Date L4)0q
Building L . ations j 6— 5 �
Permit #
Owner's Name Amount S
New ❑ Renovation
Replacement � Plans Submitted ❑
G
RSU B-BASEM ENT
(BASEM ENT
ItST.
FLOOR
1N D:
FLOOR
3RD.
FLOOR
4TH.
FLOOR
STH.
FLOOR
6TH.
FLOOR
7TH,
FLOOR.
BTH.
FLOOR
(Print or type)
Name
q Name of.Licensed Piumber'or Gas Fitter
Check one: Certificate installing Company
Corp.
0 Partner.
Firm/Co.
- - ••���� arw LIME au plumbing work and installations performed under Permit Issued forth are
true and accurate
c u to o the
Corn
with all pertinent provisions of the Massachuse S e Gas Code and Chapter 142 of the General Laws.
. r
By: Sign re of Licensed Plumber Or Gas Fitter
Title Plumber my A
City/Town � Gas Fitter
License Number
Master
APPROVED (OFFICE USE ONLY) 0 Journeyman
�a
w
W
a
a
c
a
w
o
u
m
N
v,
F
Q
g
a
z
z
p
H
t -
w
w
`�
=
d
x
W
Z:
d
w
<
a
:;
F
W
C�
o
>
Z
W
U x
4
s
'o
s
E
3
v
c
W
%
*.��
o
no
q Name of.Licensed Piumber'or Gas Fitter
Check one: Certificate installing Company
Corp.
0 Partner.
Firm/Co.
- - ••���� arw LIME au plumbing work and installations performed under Permit Issued forth are
true and accurate
c u to o the
Corn
with all pertinent provisions of the Massachuse S e Gas Code and Chapter 142 of the General Laws.
. r
By: Sign re of Licensed Plumber Or Gas Fitter
Title Plumber my A
City/Town � Gas Fitter
License Number
Master
APPROVED (OFFICE USE ONLY) 0 Journeyman
Workers' Compensation Insurance .Affidav=gfldP s/Contr-Act
Acant Info, nation orslEleetricians/plusnbers
Name (Business/drganizabon/Individuai)-:
Address:
1
City/State/ZipUO
Phone #:
Are you an employer? Check the appropriate box:
I an. a employer with 4. ❑ I am a general c
employees (frill 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. ❑ l am a homeowner doing all work
myself. [No. workers' comp.
insurance required.] t
ontractor and I
have hired the sub-contracto,-s
listed ozi the attached sheet 1
These sub -contractors have
workers' comp. insurance.
5.. ❑ We are a corporation and its
ofiieers have exercised.their
right of exemption per MGL
c. 152, § 1(4); and we have no
errtployeeS. [No workers'
camp. insurance remlirPrl 1
M
Type of project (required):
6. ❑ New construction
7• ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10:❑..Electri.cal repairs or additions
i 1.0 Plumbing repairs or additions
1210 Roof repairs
13.❑ Other
_Ily appilw4mi mai cneacs box #1 .must also fill out the section below sho---------------
wing their workers' compensation Inoii
l onme tors th who check
this
box Fsiideatt inr;icatiug iitey' er= c:oing Er': V`C'1 r wid Ehcrt hire outside cunirsu turn must su'mni ansa amdavi[ incl in oc� .
Conmu tars Thal ehccl; this box.mrisi attscned an additional sheet showing the Warne of the sub cc ,sactors a d their woricen 'com , oil
s ..n
I am an. enrplo}ger tl:X is providine workers' co ensotion i P P �7 miotmation.
informado►L mP assurance for ng' employees. Below is the policy, and job site
Insurance Company Name:
Policy # or Self -.ins. Lic. #:
Expiratim Gate:
Job Site Address:
Attach a copy of the workers' compensation Policy declaration City/state/Zip:
Page (showing the policy number and expiration state).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposirion 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 WORM ORDER and a fine
of up to 1250.00 a day against the violator. Be advised that a copy of this statement may f forvvP W to the Office ORDER
Investigations of the DIA for insurance coverage verification.
4 J., t_ ___t
..�, � � "Ji auger rase patnc and penalties of perjurJ' that the inf
V
vided above & true and correct
y\\��0I
Official use only. Do nor write in this area, to be completed by city or town ofcia[
City or Town:
Permit/License 4
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town
6. Other Clerk 4. Electrical Inspector S. Piumining Ictspector
Contact Person:
Phone
The ComnWn wealth of Alassachusetts
l
Department o
f Industrial Accidents.
�~
Office of .�.f fnvestigQitions
600 Washingon Street
Boston, AIA 02121
r-
Workers' Compensation Insurance .Affidav=gfldP s/Contr-Act
Acant Info, nation orslEleetricians/plusnbers
Name (Business/drganizabon/Individuai)-:
Address:
1
City/State/ZipUO
Phone #:
Are you an employer? Check the appropriate box:
I an. a employer with 4. ❑ I am a general c
employees (frill 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. ❑ l am a homeowner doing all work
myself. [No. workers' comp.
insurance required.] t
ontractor and I
have hired the sub-contracto,-s
listed ozi the attached sheet 1
These sub -contractors have
workers' comp. insurance.
5.. ❑ We are a corporation and its
ofiieers have exercised.their
right of exemption per MGL
c. 152, § 1(4); and we have no
errtployeeS. [No workers'
camp. insurance remlirPrl 1
M
Type of project (required):
6. ❑ New construction
7• ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10:❑..Electri.cal repairs or additions
i 1.0 Plumbing repairs or additions
1210 Roof repairs
13.❑ Other
_Ily appilw4mi mai cneacs box #1 .must also fill out the section below sho---------------
wing their workers' compensation Inoii
l onme tors th who check
this
box Fsiideatt inr;icatiug iitey' er= c:oing Er': V`C'1 r wid Ehcrt hire outside cunirsu turn must su'mni ansa amdavi[ incl in oc� .
Conmu tars Thal ehccl; this box.mrisi attscned an additional sheet showing the Warne of the sub cc ,sactors a d their woricen 'com , oil
s ..n
I am an. enrplo}ger tl:X is providine workers' co ensotion i P P �7 miotmation.
informado►L mP assurance for ng' employees. Below is the policy, and job site
Insurance Company Name:
Policy # or Self -.ins. Lic. #:
Expiratim Gate:
Job Site Address:
Attach a copy of the workers' compensation Policy declaration City/state/Zip:
Page (showing the policy number and expiration state).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposirion 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 WORM ORDER and a fine
of up to 1250.00 a day against the violator. Be advised that a copy of this statement may f forvvP W to the Office ORDER
Investigations of the DIA for insurance coverage verification.
4 J., t_ ___t
..�, � � "Ji auger rase patnc and penalties of perjurJ' that the inf
V
vided above & true and correct
y\\��0I
Official use only. Do nor write in this area, to be completed by city or town ofcia[
City or Town:
Permit/License 4
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town
6. Other Clerk 4. Electrical Inspector S. Piumining Ictspector
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 ofhire
express or implied; oral or written."
An employer is defined as "an individual; partnership, association, corporation or, other legal .entity, or an), two or more
of the foregoing engaged in a joint enterprise, and includi-no, the legal representatives of. a deceased employer, or the
receiver or trustee of an individual. partnership, associati on or other legal entity, employing employees. However the
owner of a dwelling house having not more than .three als artments 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 o r local licensing agency shall withhold the issuance or
renewal of a license or permit,r;o operate a business or to construct buildings in the commonwealth for any
applicant who has not prodncad acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, 925C(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 contraeting authority."
Applicants
Please fill out the workers' compensation affidavit compl-etely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contraztor(s) name(s), address(es) and phone number(s) along with their ce„ mdfficate(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 carryworkers' compensation insurance. If an LLC or LLP does have -_
employees, a policy is requirec Be, advised. that this affici;a.vit maybe submitted to .the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the. affidavit:. The,affidavitshould
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 reg�.-dirg the iam, or. if you are required to obtain a workers'
compensation policy, please call the Department at the nu�mmber,Iis+.ed below. Self-instrzd insured companies should enter their
self-insurance license number on the appropriate line. .
City or Town Officials
Please be sore that the afiidavit.is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit foryou to fill out in the event the Office of Investigations has to contact you regarding the appii=L
Please be sure to fill in the pennit/iicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permitnieeme applications in arty give; 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 licens- or permit not related to any business or commercial venture
(i.e. a dog license or permit to burnleaves 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 far, number:
The Commonwealth of Massachusetts
Department of L-ndustrial Accidents.
Office of l vestiatilons
600 Washington Street
BQston, MA 02111
Tel # 617-727-4900 e) -t 406 or 1-877-MASS.4FE
Revised 5-2645 Fax 4 617-727-7749
''.mass.govldi:a
.1.
Date.!. .r�.
No
4, TOWN OF NORTH ANDOVER
' PERMIT FOR PLUMBING
SSA�NUS�
This certifies that .../ ................... �............ .
has permission to perform ........... -a J ...............
plumbing in the buildings of .+'��??�''-4—< ,c.,r✓ ..... .
at . �,..n1 .. �%, Q.!�-f19! .... . ....... . North Andover, Mass.
o�
Ft'`!)... < . Lie. No...... ... ... �.�.. �J.. . �
ee
PIUMBINGfNSp TOR
Check # 4o0
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
0
d
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH.ANDOVER, MASS CHUSETTS
44rvill
DateBuilding Location �' /Zeit ers Nam /�omit # i 3.Q
� Amount
Tvoe of Occupancy
New M Renovation F1 Replacement
Yes 11 No 11
(Print or type)
Installing Company Name
Address R-6 L,
S.
Check one:
Corp. _
Partner.
Firm/Co.
Certificate
Name ofLicensed Plumber.
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy �� Other type of indemnity ❑ Bond
Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
.V
three insurance
Signature Owner Agent F
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. . la 'ons performed r Permit Issued for this application will be in
compliance with all pertinent provisions of the Mas siett tate P bing e and Chaptee e General Laws.
Title
City/Town
APPROVED (OFFICE USE ONLY
Type of Plumbing License
icense um er Master L._1�/ Journeyman
W-773 �31
% / . • -=..--.-�
..............�-
•. ..-• ---..---�...-.---���.--..
(Print or type)
Installing Company Name
Address R-6 L,
S.
Check one:
Corp. _
Partner.
Firm/Co.
Certificate
Name ofLicensed Plumber.
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy �� Other type of indemnity ❑ Bond
Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
.V
three insurance
Signature Owner Agent F
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. . la 'ons performed r Permit Issued for this application will be in
compliance with all pertinent provisions of the Mas siett tate P bing e and Chaptee e General Laws.
Title
City/Town
APPROVED (OFFICE USE ONLY
Type of Plumbing License
icense um er Master L._1�/ Journeyman