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HomeMy WebLinkAboutMiscellaneous - 40 MAYFLOWER DRIVE 4/30/2018 lal'7 BUILDING HLE Date Ylem i?', TOWN OF NORTH ANDOVER „ PERMIT FOR PLUMBING '88'�CHUS� / r This certifies that............................ lcv+r(' [............................................................. has permission to perform............ .........v cam¢ Plumbing in the buildings of.................... ................................................. at... ...�................ I.. .�'..�.'................................. �., orth Andover, Mass. Fee.."TY�'.. Lic. No.�5.%........ .... ......►.. -4.J ................................................ PLUMBING INSPECTOR Check# 7f'97, V MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 9CITY f't. ' MA. DATE Z^ PERMIT# JOBSITE ADDRESS qQ OWNER'S NAME'6 POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NE . RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ElNO El FIXTURES Z FLOOR- BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB t CROSS CONNECTION DEVICE I DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIUSAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER FOOD DISPOSER 1 FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN 4 SHOWER STALL [ SERVICE 1 MOP SINK TOILET URINAL WASHING MACHINE CONNECTION 1 WATER HEATER ALL TYPES y WATER PIPING � Y OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which,meets the requirements of MGL Ch.142. Yes R No❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Z 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE BOX ONLY: OWNER [I AGENT F1Si nature of Owner or Owner's 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 my Knowledge and that all plumbing work and installations performed under the rmit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Cha 42 of he General Laws. PLUMBER NAME STEPItCO C- GALIPS14Y SIGNATURE LIC# I O34 S MP 2 JP❑ CORPORATION X# -31910 PARTNERSHIP ❑# LLC ❑# COMPANYNAME 6AWIJSKI( PLUMgitjb * 1+64nlI ADDRESS: P.O. NIX 1701 CITY NIAyEftltuL STATE rn•A- ZIP 01831 EMAIL wyyW, t'►' rp1ymbentow CAM TEL q79-3?y- OR 3 CELL - 0t-5f0'4-5g01A FAX0176591-L113i i ! ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No S �7j' THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES Date.:..'f/ .���........................ N0, TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION SS.�CNUS� * This certifies that .. has permission for gas installation . .. v1� .................................... inthe buildings o ................... ... ... ................................................................................ at.../ Q... 14-&-e-1.7.. I'I �C� .......... ....... NLhAndover, Mass. /V�Fee./046V.... Lie. No. ... ................. ... ..... ................ ................................. GASINSPEC R Check# 0i Jf u r — MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: MA. DATE: PERMIT# JOBSITE ADDRESS: �id ! d OWNER'S NAME: GOWNER ADDRESS: TEL: FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENT1Al' PRINT CLEARLY NEW:11 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCESZ FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE 1 have a current iiabil insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [ NO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY 9 OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted(or entered)regarding this application are a and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application I b 'n compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER/GASFITTER NAME: STEPHEN C. C—ALINSKY LICENSE# 10314'6 SIGNATURE COMPANYNAME: GAL1i SK14 PLOWS10C 14C1�rIIJ& ADDRESS: P.Q. WX 1701 CITY: aAVd=iLNi1—L STATE: In•A ZIP: 0i$31 FAX: q78- 6al-14I31 TEL: 9715-37'1— l7y3 CELL: 5'C4- 6tA- 5goy EMAIL: w-yyW, mr tDMbe03XA0� carte MASTER[ JOURNEYMAN❑ LP INSTALLER❑ CORPORATION[�# 319is PARTNERSHIP❑# LLC❑# i ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No Z THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# — PLAN REVIEW NOTES Date... .. :.. .... i I r►ORT 4, TOWN TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,ssACMUS�S This certifies that ............. ..lq..(/—..4.... ...C./............... .*': ................. I has permission to perform ............. .. .....N, '?�f. ................................. wiring in the building of.............. r.c*..�.1. ..�.! .......... .... ............... at ............1(.1 ....il...,North Andover,Mass. Fee Lic.No. o }� // ELECTRICAL SPEPTOR Check# 2 SO Commonwealth of Massachusetts Official Use only MEWIfflow Department of Fire Services Permit No. MW Occupancy and Fee Checked 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: 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) L10 �Lkv,,,,r-r 0. Owner or Tenant, v t.A '1 . Telephone No. Owner's Address \O �,r• %I, "ytr MN. mv-k< Is this permit in conjunction with a building permit? Yes [& *`�No ❑ (Check Appropriate Box) Purpose of Buildings ja,,,,��\� V-,wSe Utility Authorization No. I 2:a6l V'7,5 Existing Service Amps / Volts Overhead ❑ Undgrd❑ o.of Meters Q New Service UO Amps \W /`).Vo Volts Overhead El Undgrd No.of Meters t Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �cv �UvSC Completion of the folloivingtable may be waived by the Inspector of Wires. 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 Above ❑ In- El o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones t No.of No.of Detection and Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: I I I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security stems:* 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. Estimated Value of Electrical Work: ,f�0 (When required by municipal policy.) Work to Start: 1-13.-15 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 covera 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: U6,I G-i 3:vac. LIC.NO.: 10I?6A Licensee: �r Q \,�/f, " Signature ' n. LIC.NO.: (If applicable, enter"exem t m the lice a number line.) Bus.Tel.No.: C 7 e- � -7 30 Address: g. aN �. ( ,�f=�n� I�,{�� OIQ3s Alt.Tel.No.: Q7b-3)6- I6') *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: .I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's a ent. Owner/Agent 7 Signature Telephone No. PERMIT FEE. $ � ^� ` 1 1 I i J Y'J �� �, / �� ACOORO° CERTIFICATE OF LIABILITY INSURANCE DATE 121011/201412014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Phone: 978-6884474 Fax: 978-327-6558 CONTACT DEGNAN INSURANCE AGENCY DEGNAN INSURANCE AGENCY PONE FAx 85 SALEM STREET ac No Ext): 978-688.4474 ac No: 978-327-6558 E-MAIL naninsurance.comdenan Cd@ LAWRENCE MA 01843 ADDRESS: g @ g INSURER(S)AFFORDING COVERAGE NAIC 4 INSURERA :MOUNT VERNON FIRE INSURANCE COMPANY 26522 INSURED VALLEY ELECTRIC INC. INSURER 21 HYATTAVENUE INSURER HAVERHILL MA 01835 INSURERD: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 24908 REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBERMMIDD MMIDD LIMITS A GENERAL LIABILITY CL 2651542A 11/14/14 11/14/15 EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES(Ea occurenoe) $ 100,000 I1 CLAIMS-MADE OCCUR MED.EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO--JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ I ALL OWNEDSCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE UTOS (per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION VJC STATU- OTH AND EMPLOYERS' LIABILITY TORY LIMITS ER $ ANY PROPRIETORIPARTNER(EXECUTIVE YIN E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? F7NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESPRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) d CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 120 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Andover,MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE (Mew. ��) Attention: Electrical Inspector Carla M.Degnan ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACC)MY CERTIFICATE OF LIABILITY INSURANCE DATE ( 12/011/2011201YYYY) 4 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER Phone: 978-688-4474 Fax: 978-327-6558 CONTACT NAME: DEGNAN INSURANCE AGENCY DEGNAN INSURANCE AGENCY PHONE O No Fxt: 978-688-0474 FAX 978-327-6558 85 SALEM STREET (6L No): E-MAIL naninsurance.comdenan cde LAWRENCE MA 01843 ADDRESS: g @ g INSURER(S) AFFORDING COVERAGE NAIC# INSURER :NORFOLK AND DEDHAM INSURED VALLEY ELECTRIC INC. INSURERS 21 HYATTAVENUE INSURER HAVERHILL MA 01835 INSURERD: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 24907 REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADO'L SUER POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER MM/DD (MMIDD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES(Ea occurence) $ CLAIMS-MADE Il OCCUR MED.EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ PRO- POLICY JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE UTOS (per accident) $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ A WORKERS COMPENSATION WE132614A 11/13/14 11/13/15 V&STATU- OTH AND EMPLOYERS' LIABILITY TORY LIMITS ER $ YIN ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 100000 OFFICERIMEMBER EXCLUDED? (Mandatory in NH) NIA E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 120 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Andover,MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE n y Attention: Electrical Inspector � / 11) bC, Caria M. Degnan ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD I COMMONWEALTH OF MASSACHUSETTS. ' • • - • LECTRIC'IANS 'ISSUES THE FOLLOWING LICENSE AS IEC"1 STARED MASTER ELECTR I CLAN �4 :LEY ELECTRIC. INC a' ,m I RR I AN A:.:WR 1 SLaE; i y 21 HYATT. AVE' ') �p ORD;::.. 01835-822: � .,1,/.:<i::6:<:>;> 163131 R Date....... .� ...�. 5 OF NORT#i,� 3�; ooL TOWN OF NORTH ANDOVER o s PERMIT FOR WIRING S `S3tCHU5� ��F'• This certifies that .......t4J). ............. �.�---. .................................... has permission to perform ....... .......I.. ........ .` ....................................... wiring in the building of.............. ,. ../, ......... ..✓��' r` ` � .................................................. at ........0...Ai1w.(.�!�1.!i��.....��..:. .... .............N h Andover,Mass. Fee... ....,....Lic.No. /.Q ( .........t! X - ^..�!�-...... ......................... ELECTRICAL INSPECTOR Check# fir% Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked 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: 418M '7— 9 —/�'- 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) Owner or TenantTelephone No. Owner's Address jl7eor�[��U Af. �), Qr �e✓ Is this permit in conjunction with a building permit? Yes 15ANo ❑ (Check Appropriate Box) Y Purpose of Building_S� ,�,��� Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service � Amps JW / a4C) Volts Overhead❑ Undgrd� No.of Meters _X Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the ollowin table may be waived by the Inspector of Wires. 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 Above ❑ In- El o Emergency Lighting rnd. rnd. Batte Units No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of SwitchesNo. of Gas Burners No.of Detection and �. Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: I I Detection/Alerting Devices ,f No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security No Systems: f Devices or Equivalent No.of Water KW No.of No. of Data Wiring: Heaters Signs Ballasts No.of Devices or E uivalent 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: f1,000 (When required by municipal policy.) Work to Start: '7-1 f7.-1 S 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 9, BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury,that the information on this application is true and complete FIRM NAME: yjf!� lC c r` LIC.NO.: -20 1 80A Licensee: �.1�,, ;Q, ;S�c Signature .via k-) LIC.NO.: (If applicable, enter "exempt"in t license number lineN Bus.Tel.No.• q78-8q 1•-7(3U Address: �4\ Irv_ Avr. R-r. Fzrd MA, otsS5 Alt.Tel.No.:-q7&--376- (LCA *Per M.G.L c. 1.47,s. 57161,security work requires Department of Public Safety "S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ III` I t C i c COMMONWLTH OF _. • . . • MpSSACHSErr BOARD OE ELECT ISSUES THE .F RICIANS REG fiTERE.p OLLOWiNG `L 1 CENSE MASTER ITIECTRIAS, A VALLE'y CIAN E BRIAN, LECTRiC.: INC . 21 HYA7V` COPY E3.RADFOiiD , 201 MA 018 A _ 0:'% .L/.l.� 1631 1 f i Date.... ............................................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �s�cHus� i This certifies that ....... . . .!1 �....'�` . 9.'�`z t.?ADS 11"e vim,.✓.IJ......... has permission for gas installation i v inthe buildings of................:.. ..... -!. -'..................................................................... at...�ftQ.....MG. +z _ ............................ North Andover, Mass. VI- Fee...I.P.D.=.... Lic. No. ......3.............. ....................................................... GASINSPECTOR- Check# Il� 537 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK / CITY: NORTH ANDOVER DATE: PERMIT#w11 JOBSITE ADDRESS: 40 MAYFLOWER DRIVEI OWNER'S NAME: KEYLIME INC GOWNER ADDRESS: TEL: 508-328-4630 FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: Z,- RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED:YES ❑NO 9 APPLIANCES FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE LJ INFRARED HEATER LABORATORY COCK ' MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER r- WATER HEATER INSURANCE COVERAGE A I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES E NO❑ If you hav& checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY FZ] OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted(or entered)regarding this permit application is true and accurate to the best of my Knowledge. I certify that all plumbing work and installations performed under the permit issued,will be in compliance with all Pertinent provisions of the Massachusetts Uniform State Plumbing Code,and Chapter 142 of the General Laws. PLUM BER/GAS FITTER NAM �iSL� �I '��0� LICENSE# SIGNATURE COMPANY NAME:OSTERMAN PROPANE LLC ADDRESS: 321A Merrimack St I t CITY: Methuen STATE:MA ZIP:01844 FAX:978-738-0118 1 TEL: 800-368-9956 CELL: EMAIL: INFO@OSTERMANGAS.COM MASTER 0 JOURNEYMAN ❑LP INSTALLERORPORATION ❑# PARTNERSHIP ❑# LLC 0#45-326-3311 t t f r r The Commonwealth of Massachusetts - M Department oflndustriglAccidents y 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 usiness/Or anizatiorgndividual. 1 ✓ ) Z,��e /J Address: 5 - Ciiy/State/Zip:i moi} e�/9�Y/ Phone#: 199 9-- 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.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling ship and'haveno employees These su tractors have S. ❑Demolition j working for mein any capacity. w ers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. LM are a corporation and its ce e e 10.El Electrical repairs or additions officers ffI rshav exercised 3.E11 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.[]Roofrepairs insurance required.] employees.[No workers' comp.insurance required.] 1311 other 'Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. I-Homeowners who submit this affidavit indicating they a're 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. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and jolt site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: e) 4-1% ZV17L Ci /State0 , 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 oneuyear 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 o£ Investigations of the DIA for insurance coverage verification. Xdo Hereby certfy under tepall s=ndpenaftlesofperjury that the information provided above is 7fre and correct. - Signafore: Z it, Date: Phone#: Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit/License# --- —- i 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#: I ' I J r ------ - --- g COMMONWEALTH OF MASSACHUSETTS PLUMBERS.BWff- SFITTERS ISSUES THE::; EOLLOWIN61*1 GENSE � LICENSED AS AN LP GAS `INSTALLER {w MICHAEL A BRYSON. SR $ ARBOR CT I�f W lYNNt MA 01902-1110, a 933 a5o1/16 ,:223720 4