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Home My WebLink AboutMiscellaneous - 4 STACY DRIVE 4/30/2018 :.�.-_ . .,�,. 4 STACY DRIV 210109 000.0 Date..41.. .!. .............. Of NONTM,� TOWN OF NORTH ANDOVER PERMIT FOR WIRING 8s�caus� � This certifies that ..................................... ( � �.................. .......................... Q�— o �C. J�.P has permission to perform ................................................................�.. t'..........1.. �!'........ wiring in the building of........bl.6- ............................................................................ at ._...... ...!:... . '..� ............................................. orth Andover,Mass. obFee� "' Lic.NO`7 ................ .........:...... . ..... ...1 E ECTRICAL INSPECTOR Check# I V Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] eave 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: 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) (-,, 1)r Owner or Tenant Ter1M Telephone No. '761- y2Y- 2 2 Owner's Address CA Is this permit in conjunction permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service JLTD Amps ;ZO / 2q0 Volts Overhead❑ Undgrd� No.of Meters 7 New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity j Location and Nature of Pr osed Electrical Work: upOATc k 1rcweN REcoCATU PNIFa Fol OdPL,A NCCS Completion o the followingtable may be waived by the Inspector of Wires. 1 No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires — Swimming Pool AboveElIn- Elo.o Emergency lighting 91`11d. rnd. BgfteM Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches 2 No.of Gas Burners o.of etection and Initiating Devices No.of Ranges 1- No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers 1 Heat Pump umber Tons I FKW No.of Self-Containe Totals: I Detection/Alerting Devices No.of Dishwashers 2 Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KWo.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. Estimated Value of Electrical Work- (When required by municipal policy.) Work to Start: 94o 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 thepains andpenalties ofperjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: vta ASS,KA<L Signature '�� LIC.NO.: 2SS� 'SR (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.; Address: J� 3"grz-,-060 C,,r Saye,-" O1 Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INS CE WAIVE I am aware that the Licensee does not have the liability insurance coverage normally required by law. si e b waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent o Signature Telephone No. 70 l-921-06 2 Z PERMIT FEE:$ / ,J J COMrV10MWEq�TH;OFp_MASSAGHUSETT Y, , T- �, . . A 1 14 Zy s AS`A;REG'.JOURNEYMAN ELECTRICIAN= 1 ISSUES THE OVE'LICEPISE TO ^ 'a S7EVE'N ?m,,/ lAJJAR 2-5 SHERW00U Cl.R SALEM- -2555-JR ALEM 2555JR 07%3I/L3 836Q49 �; 0 i Date • TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . . . 1?a . . 1 !V has permission to perform . . . . ! .v �.,^. . . . . . . . . . . . . . . . . . . . Kz — plumbing in the buildings of. . s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . . . . . .North Andover, Mass. Fee�' ... . . . Lic. NVX 2. .cr:!`'."l! —n` .... . . . . . . . . PLUMBING INSPECTOR n Check# W o 4 �. r. ;sem MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY '/ _ MA DATE _� PERMIT# - 9M JOBSITE ADDRESS y _ OWNER'S NAME POWNER ADDRESS j TEL _ FAX j TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL Q RESIDENTIAL] PRINT CLEARLY NEW: MI RENOVATION:fa REPLACEMENT:Q PLANS SUBMITTED: YES Nodi] FIXTURES 7 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 GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM ___..-l ._._- DISHWASHER _[ ._-- -; __.._ ._. [ _ [ .__..J -. DRINKING FOUNTAIN { } ----..-_[ I i ___..._1 __J FOOD DISPOSER i - } _I . f I [ I __J _[ _► } ( _.._.__f FLOOR/AREA DRAIN ! _- I } �1 [ __._.I _._.__} ..____..[ i . .__._i _ ._.-_ i L__I , INTERCEPTOR(INTERIOR) I ._ -I _--_-_ KITCHEN SINK _- LAVATORY ROOF DRAIN _ [ ! I _ _ l [ ._ _J __.J 1 � _._.__I _. � ! �__.� SHOWER STALL [ _.._._� _.__.._I ,____1 ____.� .._ _} ._ _► _._..__} _._[ .______I _.___[ -_-_ ___. TI [ SERVICE/MOP SINK _ I -_-.__-) __._J TOILET I I _ _.J [ _1 _J J J _jI I __._ } ____I -------I _._-. l URINAL [ ..__- 1 _-..-._[ I .__._. J _....-.._I _.._._.. [ 1 ' f [ _.... } I .__--- WASHING MACHINE CONNECTION —i _. ? . I I .__.# WATER HEATER ALL TYPES d ! i _I !- 4 . i ._._ __._..1 _ .I ._. . } WATER PIPING OTHER INSURANCE COVERAGE: 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 jo OTHER TYPE OF INDEMNITY Q# BOND Q 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 —I AGENT _+ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of m p dw ge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinen sion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ A/ LICENSE# i SIGNATURE [VIP JP Q CORPORATION n# _ PARTNERSHIP 0# _ LLC Z COMPANY NAME_RC�f'PJ ��-ItI ADDRESS 1V _ CITY y 1 STATE ; ZIP TEL 9 FAX CELL EMAIL _ �- ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES J w The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizatiorvindividual): ,A f_�� N A J Address: City/State/Zip:,SA le,t j "14 0307 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.P I 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. workers'comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing alt work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lie.#: 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 requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certnder the pains andpenalties of perjury that the information provided above is true and correct Signature: Date: az6z Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants a. Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Goonweakth of Massachusetts Department of Industrial Accidents Ofiree of Investigations 600 Washington Street Boston,MA 02111 Tek,#617-727-4900 ext 406 or 1-877:MASSAFB Revised 5-26-05 Fax#617-7.27-7749 www.Mass.govfdia Division of Professional Licensure: License Search Page 1 of 1 ri The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> _ ONLINE SERVICES ........... .......-..........................................._.......................................---........................................_........................................................._............ ......... Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency LICENSEE More... Name:JAMES P. GREENE REFERENCES& SALEM, NH I RELATED INFO I Disclaimer Regarding "This Licensee has additional Licenses,ctick here to view them.* � � Website License Searches Enforcement Process Glossary Licensing Board. PLUMBERS£t GASFITTERS Glossary of License Status License Type: MASTER PLUMBER Codes License Number: 15152 I More... Status: CURRENT Expiration Date: 5/1/2014 j Issue Date: 9/18/2006 i Exam Date: 9/18/2006 School: t This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Wednesday,February 06,2013 at 9:26:02 AM. O 2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg.state.ma.us/pubLic/PubLicenseQ.asp?board_code=PL&type_Class=_M&li... 2/6/2013