HomeMy WebLinkAboutMiscellaneous - 4 JOHNSON STREET 4/30/2018 (2).10
I
Date ..... . ....... / .. ..... / -,/ ........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that // , ."c)
.......... d .......... 5 ....... ............................................................................
has permission to perform
.. . ................... ...... ..... .............
wiring in the building of ..... .......... // ............. f ................... el ............................
.at .... !�� ........ z "I ,�, -f - , L-
........................................ I ...........
Fee./............. Lic. No./���!
......... ...
Check #
1 12 21 6 ".",
........................ . ...... . North Andover, Mass.
................. . ...........
TIIC��CAL ii;�PEcrdR
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Commonwealth of Massachusetts Official Use 0 ly
Department of Fire Services Permit No. Z-
Occupancy and Fee Checked
aM 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 WINK OR TYPE ALL INFORMATION) Date: // — / -- / �/
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) f/ JGI Y S�
Owner or Tenant /�,., G _ Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building r/ /-- /--, 4-�- � 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: /XX
Completion ofthe following table may be waived by the Insnector of Wires.
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans V
No. of Total
Transformers KVA
No. of Luminaire Outlets
No, of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- ❑
rnd, Rrnd.
No. of Emergency Lighting
Battery 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
p
Heat Pump
Totals:
Number
........................................................................
Tons
KW
No. of Self-Contained
. . .
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
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: (When required by municipal policy.)
Work to Start: - - Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAG : 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 covert in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify, tinder the pains and penalties ofperjury, that the information on this application is true and complete.
FIRM NAME:. Z% /,- LIC. NO.:
Licensee: Signatur LIC. NO.:
(If applica le, en r "exempt" in the license number line) Bus. Tel. No. -
Address: Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Departmodt 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 agent.
Owner/Agent �-
Signature Telephone No. PERMIT FEE. $ Z S r
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass IN
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
"
Pass M
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH ]INSPECTION:
Pass 0 X
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comme
.-
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
tv—
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
Department ofIndustrial Accidents
Office of Investigations
VV 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):
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
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. [1 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.
Y Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit 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
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.
X do hereby cert under the pains and penalties of perjury that the information provided above is true and correct
Signature: Date:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
PermitUcense
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical 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 employeiis 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 -contractors) 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 ou file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office ofInvestigatious
600 Washington Street
Boston} MA. 02111
Tel # 61.7-727-4900 at 406 or 1-877rMASSAFF,
Revised 5-26-05 Fax # 617-727-7749
wWWjnass,9oV1dla
Date.,� ... . .... /.5� ...... ......
... .... ... ... . ...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
..... .. . . ... . ...
has permission to perform ..... I ........................... ;.I..' ............. /" ......................... -5./ ..........
wiring in the building of ......... ............ .............. I ............... ( ....... .
at ..... Ll
.................................................................................. . North Andover, Massi
Fee(�� .... Lic. No)"�Zj ................................
ELEcnucAL
Check # 0
Commonwealth of Massachusetts Official Use Only
Department of Fire Services permit No. % Z- 2 -
BOARD OF FIRE PREVENTION REGULATIONS
APPLICATION FOR PERMIT TO PERFORM ELEC`TRIC-AL
WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALI. INFO MATIOA9 Date: 3 — /9 — ./ y
City or Town of: ��Xv v IT - 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) �z lel „ s o Sfi
Owner or Tenant :r, � A, s - el Telephone No.
Owner's Address
AC
Is this permit in conjunction with a building permit? Yes E3��No ❑ Building Permit #
Purpose of Building IL c 61 -ed 1 Z4 o2, Utility Authorization No.
Existing Service Amps / Vol Overhead ❑ Undgrd ❑ No, of Meters
New Service ykjl- Amps /2 v 12 G fVolts Overhead ❑ Undgrd ��No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
e. u w, SXo
Completion of the following table may he waived by the Inspector of Wires.
No. of Recessed Fixtures
No. of Ceil.-Susp. (Paddle) Fans
o. of Total
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Above n-
Swimming Pool d. rnd.
o. o Emergency Lighting
BaWery Units
No. of Receptacle Outlets U
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
o. oDetection an
Initiating Devices
No. of Ranges
g
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
p
umber
eat Pump ..
Totals:
ons
o. o e - ontame
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
al [:3 Other
Local Q Connection
No. of Dryers
No.
Heating Appliances KW
ecurity ystems:
No. of Devices or Equivalent
No. of Water KW
Heaters
o. of No. Of
Signs Ballasts
Data Wiring:
No. of Devices or E uivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
a ec o m nicatis s E uivalent
OTHER:
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 coverapwm force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) l —/l
(Expiration Date)
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 3 - 2- —�y Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the pains and penalties of perjury, that the information on this application is true and complete Current
Insurance certificate must be on fife in our office and affidavit must also be filled out with each application.
FIRM NAME: O £' S'�.k // %�/� , -I-- LIC. NO.:�
Licensee: Signature Y 1` LIC. NO. :_T 3
(If applicable, enterlexempt " in the license numb r line) Bus. T Ir§o.:_ r-7 -iia �
Address: 0,y vrrl - Alt. Tel. No:
OWNER'S INSURANCE W : 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. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $
ELECTRICAL PERMIT NO. INSPECTION REPORT:
ELECTRICAL INSPECTOR - DOUG SMALL
I. ROUGH INSP CTION:
Passed — I ) Failed - I ] Re -inspection required ($50.00) - [
Inspectors' comments:
- no initials)
2. nN , _ PECTION:
paw — I ) Failed —
kiluspecwrs- aignature no
3. UNDER GROUND INSPECTION:
Passed — I I Failed — [ )
Inspectors' comments:
(Inspectors' Signature - no
4. INSPECTION —SERVICE:
DATE CALLED NATIONAL GRID:
Passed — I I Failed — I I
Inspectors' comments:
ka„spcY:wrs- aquature - no
5. INSPECTION - OTHER:_
Passed — [ ) Failed I )
Inspectors' comments:
(Inspectors' Signature - no
Date
Date
Date
LUL -
Date
.....a�� Date
DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT
ACCESSIBLE AND A RE -INSPECTION OF $50.001S TO BE CHARGED.
W. I
Date...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Thiscertifies that ............................ ..........................................................
has permission to perform ... �40c) .............................. r .............................
......... ...
wiringin the building of ...................................................................................
at .......... t-1 ..... T "5-1 ............ North Andover, Mass.
zv'� ..............
Fee ... Lic. No.
ELECrRICAL iNsncrm V
Check # 2-3 o9�v
7938
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No.
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: 12_ -2 & -7
City or Town of: NORTH ANDOVER To the Inspector f Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) h S p vk
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts
Overhead ❑
Undgrd ❑
No. of Meters
New Service LI b 0 Amps 120 / Z -I-0 Volts
R
Overhead ❑
Undgrd
No. of Meters 1
Number of Feeders and Ampacity
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
' Location and Nature of Proposed Electrical Work:
CUJ on ck-2f5
�ouAd
52t'VjfCe
t
�Gc
No. of Air Cond. ons Tot
No. of Alerting Devices
No. of Waste Disposers
1L ✓� S (� cBv im/'
T2 t� v7[nc i�U
-t-
KW
........................
No. o Self -Contained
Detection/Alerting Devices
Cmmnlotin Anfth, fn lln,.
d,.,.. t„h t.>.... .A-..,,.:.,,,,71...
q- - r._--__._ _rnr___
4
No. of Recessed Luminaires
--
No. of Ceil: Susp. (Paddle) Fans
u' aic i L a Jur U rr tres.
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑In- ❑
rnd. rnd.
o. o Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
N-5.51 Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. ons Tot
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Number
......
Tons
R
KW
........................
No. o Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal El other
Connection
No. of Dryers
No. o Water
Heaters KW
Heating Appliances KW
No. o o. of
Signs Ballasts
Security Systems:*
No. of Devices or Equivalent '
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No, of Motors Total HP
TelecommunicationsWiring:
No. of Devices or E uivalent
OTHER: ' G�
Attach additional detail j desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: ( When required by municipal policy.)
Work to Start: 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 J BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: Gr Clh:e - ( YOdra dch LIC. NO.:
Licensee: S}C 1) �pyA I N crdaO Signature_ LIC. NO.• A i 1 ro G.1
(If applicable, enter "exempt" in the license number line) Bus. Tel. No.: 7 81-31 ol 1�1
Address: 0 (D W I h pN � ("e _J - 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 i
Signature Telephone No. PERMIT FEE: $ / 2 5
�-.K,
0
16,
30�
Date. . -1 .........
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .. fl/vx yll;olr .... P .� ...............
has permission for gas installation ... 1-'t . .'k. � -r /'I
in the buildings of - ren ". / � t, . . P <..A 7 .......... :*****'
at ..... 1/.-. A x, t ....... North Andover, Mass.
Fee. ..... Lic. No.. 7
G INS
Ai .' E��OR
Check #
5706
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO
(Print or Type)
r�
GASFITTING
00 &),WV6k- . Mass. Date 9 17 111G Permit # 6 6
?'. —
Building LocationY—BTU HO S/ o ST Owner's Name CES) E"k, k6AG7`/ T"j
ti D Rte) o0vG21 i'IA Type of Occupancy
New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑
Installing Company Name BAY STATE GAS COMPANY
Address 55 MARSTON STREET
LAWRENCE, MA 01840
Business Telephone 9 7 b— 6 8.7 -110 5
Name of Licensed Plumber or Gas Fitter Francis X. Corkery
Check one:
17 Corporation
❑ Partnership
❑ Firm/Co.
Certificate #
1862
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes K No ❑
If you have checked res, please indicate the type coverage by checking the appropriate box.
A liability insurance policy X 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 I Owner❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in abo pplication are true and accu jAte to the best of my
knowledge and that all plumbing work and installations performed under the permit iss f r this application willWnt6mplianoe with all
Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S. (/ /
T e of License:
Plumber Signature of Licensed Plumber or Gas
Title Gasfitter
City/Town Master License Number _374'5
APPROVED O ICE S -ONLY) Journeyman
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Installing Company Name BAY STATE GAS COMPANY
Address 55 MARSTON STREET
LAWRENCE, MA 01840
Business Telephone 9 7 b— 6 8.7 -110 5
Name of Licensed Plumber or Gas Fitter Francis X. Corkery
Check one:
17 Corporation
❑ Partnership
❑ Firm/Co.
Certificate #
1862
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes K No ❑
If you have checked res, please indicate the type coverage by checking the appropriate box.
A liability insurance policy X 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 I Owner❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in abo pplication are true and accu jAte to the best of my
knowledge and that all plumbing work and installations performed under the permit iss f r this application willWnt6mplianoe with all
Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S. (/ /
T e of License:
Plumber Signature of Licensed Plumber or Gas
Title Gasfitter
City/Town Master License Number _374'5
APPROVED O ICE S -ONLY) Journeyman
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COMMONWEALTH OFMASSACHUSETIS
TOWN OFNORTHANDOVER
1600 OSGOOD ST
APPLICATION FOR CER TIFICATEOFINSPECTION.
W
J
Date �- ) Fee Required (Amount)__ _______
No Fee Required
Accordance with the provisions of the Massachusetts State Building code, Section 108,15, I hereby apply for Certificate c
Inspection for the below -named premises located at the following address:
Street and Numb(
Name of Premises
Purpose for which _ ._....
Used -4V � l�
Licenses (s) or Permit
v,
Required for the Premises by Other Governmental Agencies:
License or Permit
Agency
Certificate to be issued to /. , /'',
Address-------��l�u----(OiVG1�'"`�------------- Telephone �'�lt
Owner of Record of Building
Address C P.-i-rz '
Name of Present Holder of Certificate
Name of Agency, if any
SIGNATURE OF PERSONS TO WHOM CERTIFICATE
IS ISSUED OR HIS AUTHOIRIZED AGENT
INSTRUCTIONS:
1) Make check payable to: Town of North Andover
TITLE
DATE
2) Return this application with your check to: Building Dent.
1600 Osgood ST, North Andover MA 01845
PLEASE NOTE
Application form with accompanying FEE must be submitted for each building or structure or part thereof to be certified.
3) Application and fee must be received before the certificate will be issued.
4) The building officials shall be notified within ten (10) days of any change in the above information
CERTIFICATE # EXPIRATIONDATE:
CERTIFICATE OF INSPECTION WORKSHEET
REVISED 3.2006 jmc
INSPECTION REPORT FORM
CLASSIFICATION PASSES INSPECTION yes no DATED
OWNER
BUILDING NAME OR NO.
STREET LOCATION
TYPE OF OCCUPANCY - Day Care
School Common Victualer's
Auditorium. Restaurant Cafe
Liquor
Place of Assembly
Gym Apt.
OPERABLE
EXIT SIGN yes no
LIGHTED EXIT SIGNS yes no
NUMBER OF GRADE FLOOR MEANS OF EGRESS DOORWAYS
NUMBER OF SEPARATE STAIRWAYS ACCESSIBLE PER STOREYS
EMERGENCY LIGHTING SYSTEM
dry cell wet cell
operable
SPRINKLER SYSTEM
operable gage pressure :
yes
no
SMOKE DETECTOR
operable
yes
no
FIRE ALARM SYSTEM.
expiration date
yes
no
ANSUL SYSTEM
......
yes'
no
FIRE ALARM SYSTEM
operable municipal
yes
no
ELECTRIC EQUIPMENT VIOLATIONS
yes
no
FIRE RESISTANT CURTAINS OR DRAPERIES
EGRESSES LAWFULLY DESIGNATE unobstructed yes no
HANDICAP ELEVATOR yes no
STAIRS PROPERLY RAILED yes no
HALLS AND STAIRWAYS LIGHTED yes no
UTILITY ROOM - CLOSETS
RADIATOR GUARDS yes no
COMPLIES HANDICAPPED PERSONS LAWS
yes no
HOW HEATED NO. FIREPLACES yes no
BOILER ROOM CONDITION
1 ST FLOOR SEATS
1ST FLOOR BAR SEAT OTHER LEVELS
OCCUPANCY NUMBER (INCLUDING STORIES # AND OCCUPANCY PER FLOOR USE REVERSE SIDE
J
N2 3 - " 0
Date ..... /
4 F11 -all -
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ... A...,l ....... . .... ... :Z�
..............................................
or has permission to perform ........ 9; f..81 ................................................
wiring in the building of .............................................
lk e
v — fe, "', d,(-1
at ........ It ...... ...................... North Andoyer,,Mass-.-
�72�
Fee .... Lic. No. ......... .......
ELECTRICAL INSPECTOR
Check #
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
111/iV%."1MVA%X1TyrA;"• ltlVl lrllJlJA ,-.A,111- IA All
DEPARTIV ENTOFPUBLICS4MY
BOARD 0FFIREPREYEW0NREGUL4TI0AN527CMR 12.00
Permit No.
Occupancy & Fees Checked
PPUCATIONFOR PERMIT TO PERFORM ELECTRICAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL. INFORMATION) Date f I �L fes`
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) ll_ k^,� J
Owner or Tenant - —X- c_(s cam. P— /jf, 0./ { "
Owner's Address S C—\ -A
Is this permit in conjunction with a building permit: Yes [Z] No (Check Appropriate Box)
Purpose of Building A-R-�( Utility Authorization No.
Existing Service Amply / Volts Overhead 1:3 Underground
New Service Amps�Volts Overhead l:3 Underground M
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work' -A.,x CA ¢.7
No. of Meters
No. of Meters
1 No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Total
KVA
No. of Lighting Fixtures
Swimming Pool Above
Below
Generators
KVA
ground
ground
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 Ranges
No. of Air Cond. Total
Tons
No. of Detection and
No. of Disposals
No. of Heat Total Total
Pumps
Tons
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. of Self Contained
�..�
Detection/Sounding Devices
Local Municipala
Other��
No. of Dryers
Heating Devices KW
ID Connections
of Water Heaters KW
No. of No. of
�No.
Signs
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
OTHER
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wSvRa+rrcE Bono o OTI �x (PteaSptaicy)
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sighed unda�ie P ofpajtey.
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FIRMNAME , V. L-,,-� ,
z,
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Lita�eNo
BusimTdNa
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OWNER'SPgRJRANCEWANFR,Iatnatmdr,ttheidcesmtti�etheitstxatneoovetageaAssul �ialec�Iivakttkastec dbyMassad7SOZ5
Laws
mddmtmy*mWm,mthspwritappkadmwainthis Iac�stxnL
(Please check one) Owner a Agent ❑ /' )6)
Telephone No. PERMIT F r v v
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTtNG
(Print or Type)
NORTH ANDOVER Mass. Date�%.,y p y
4uildin Location
i 9.Q Permit # ON Ll
H
Owners Name.a.�r4,fl
New 77 Renovation D Replacement �] Plans Submitted
FIXT IRDS
lid
(Print or Type) I -k.,,-,,17 Check one: Certificate
Installing Company Name,'�C.r'- ��,ti,�h,5,,,,r� �lv.r�l�i� [] Corp.
Address �� �CJr/Ct.(/adLr° _/� Partner.
'504,11,4 '3'd5' [�irm/Co.
Business Telephone:,,-) G 7 -3 S -..q
Name of Licensed Plumber or Gas Fitter
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy "Other type of indemnity Q Bond E]
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.
ignature o owner/agent of property Owner r Agent El
I hereby certify that all of the deuils 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 perforated under Permit isseed for this application will -be In compliance with all pattnent
provisions of the Massachusetts State Cas Code and Qupter 142 of the General I.Aws. — '
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
TYPE LICENSE:
Plumber
Gasfitter Signature of Licensed
Master Plumber or Gasfitter
Journeyman / Q -; U
License slumber
Y
Y
•
I
■sEREPREN
oamsoni��os����/
.. -
■�t�■�11■/�///fin/n■/�����'
.. -
WAtifflar
■OO■/nom■■■
IKENEEM■■ESE■■
(Print or Type) I -k.,,-,,17 Check one: Certificate
Installing Company Name,'�C.r'- ��,ti,�h,5,,,,r� �lv.r�l�i� [] Corp.
Address �� �CJr/Ct.(/adLr° _/� Partner.
'504,11,4 '3'd5' [�irm/Co.
Business Telephone:,,-) G 7 -3 S -..q
Name of Licensed Plumber or Gas Fitter
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy "Other type of indemnity Q Bond E]
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.
ignature o owner/agent of property Owner r Agent El
I hereby certify that all of the deuils 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 perforated under Permit isseed for this application will -be In compliance with all pattnent
provisions of the Massachusetts State Cas Code and Qupter 142 of the General I.Aws. — '
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
TYPE LICENSE:
Plumber
Gasfitter Signature of Licensed
Master Plumber or Gasfitter
Journeyman / Q -; U
License slumber
qw-%
TO Date. . ;> .......
241S � /. .. /. -9� �
T TOWN OF NORTH ANDOVER
0 PERMIT FOR GAS INSTALLATION
This certifies that ... .............
has permission for gas installation ... .........
in the buildings of ........
at (,(,-
....................... North Andover, Mass.
Fee.5�f'�—... Lic. NoJ.'?�1KKj6..1
1.0,
97 .1 . ......
I; NS
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
Location
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
S CHU Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL
Check #
Building Inspig4or
Loc at io,4n/7'
No. Date
TOWN OF NORTH ANDOVER
At
At Certificate of Occupancy $
ho
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 1030
14163 �'�Uildi ng Insprx-or
Date
TOWN OF NORTHANDOVER
27 CHARLES ST
APPLICATION FOR -CER TIFICA TE OF INSPECTION
l/
() Fee Required (Amount)
() No Fee Required
Accordance with the provisions of the Massachusetts State Building code, Section 108,15, I hereby apply fog
Certificate of InspvxVon for the below -named premises -located at -the foll-0wangass'
Street and
Number `l ::ro I Al `tom
Name Of
o -FPg ut ' �es�a ur, u,�, � o V%e. o F � �
Pro m i.co.c
Purpose for which Premises is
Used 'JR -es 4-a \j r .An+— c,g'C-e�
Licenses (s) or Pex-mit{s) Required far -the Premises by-0Cher-Governmental Agencies:
License or Permit
FW
Certificate to be issued
Address Li -11
v()nr°C- w 5'
U
Owner of Record of Building
Addressn�
Name of Present Holder of Certificate rep o E t
Name of Agency, if any
SIGNATURE OF PERSONS TO WHOM CERTIFICATE
IS ISSUED OR HIS AVTHOIRIZED AGENT
INSTRUCTIONS:
A en
018.
r _ ^
1-5
Telephone(OE'(— FS $ I/ S�':
TITLE
DATE �f
1) Make check payable to • Town of North Andover
2) Return this application with your check to: Building Dept
27 Charles Street, North Andover MA 01845
PLEASE NOTE:
Application form with accompanying FEE must be submitted for each building or structure or part thereof to be cert
3) Application and fee -must -be received before -the -certificate will -be -issued.
4) The building officials shall be notified within ten (10) days of any change in the above information.
CERTIFICATE # EAPIRATIONDATE: '
FORMSBCC-3-74 REWSED 1199-jmc
TOWN OF NORTH ANDOVER INSPECTOR'S NAME
OFFICE OF THE INSPECTOR OF BUILDINGS MICHAEL MCGUIRE
INSPECT40-N-REPORT -FORM
CLASSIFICATION PASSES INSPECTION yes o no 0
OWNER
BUILDING NAME OR -NO.
STREET LOCATIO
DATED
TYPE OF OCCUPANCY Day -Car-e-Center fl Aud. 0 -Ca E -Gyre E -Apt. 0
School 0 Common Victualer's 0 Liquor 0 Place of Assembly 0
Other
OCCUPANCY NUMBER -f+�-steries # -and7occupancy iwAoor - use -reverse side
EXIST SIGN
LIGHTED EXIT SIGNS
EMERGENCY LIGHTING SYSTE M
SPRINKLER SYSTEM
SMOKE DETECTOR
FIRE ALARM SYSTEM
ANSULSYSTEM
FIRE ALARM SYSTEM
operable 0
operable 0
operable 0
-expiration-late
dry cell 0 wet cell
gage pressure
operable 0 municipal 0
ELECTRIC EQUIPMENT PROPERLY PROTECTED
EGRESSES LAWFULLY -DESIGNATE unobstructed 0
EXISTINGS
yes n 0
-yes -0 -ne -0
0
yes 0 no 0
yes 0 no
-yes -0 -o E
yes
0
no 0
yes
0
no 0
yes
0
no 0
-yes
-0
-no 0
STAIRS PROPERLY RAILED yes 0
HALLS AND STAIRWAYS LIGHTED yes 0
RADIATOR GUARDS yes 0
COMPLIES HANDICAPPED PERSONS LAWS -yam
FIRE RESISTANT CURTAINS OR DRAPERIES
HOW HEATED NO. FIREPLACES yes 0
BOILER ROOM CONDITION
VENTILATION
UTILITY ROOM - CLOSETS
NUMBER OF GRADE FLOOR MEANS OF EGRESS DOORWAYS
NUMBER OF SEPARATE STAIRWAYS ACCESSIBLE PER STORY
SHOPS
no 0
no 0'
no D
-no 0
no
FOR INSPECTOR USE ONLY Revised 2i99 JMc