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HomeMy WebLinkAboutMiscellaneous - 401 STEVENS STREET 4/30/2018 (3) f- ti__� -- - - I �, 1 Date TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . . . . . � . . ��. Lo . . . . . . . . has permission to perform . . .!tom- . . C4 wiring in the building of . .kI.1vD . , at . . . . . . . . . . . . . . . . . 5 7. . . . . . . . . . .Xorth Andover, Mass. Fey . . . . ic. No. ©a r �3. . . . . . . . . . . . . . . . . ELE TRICAL INSPECTOR Check# 11057 Commonwealth of Massachusetts Official Use only * Permit No. 1(��r -7 Department of Fire Services —� Occ upanc} and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/991 cave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK -ll work to be performed in accordance with the Massachusetts Electrical Code(NEC) 27 CMI 12.00 (PLEASE PRINT IN INK OR TMP,ALL INFORMAIYON) Date: f� �/j City or Town of: O r-4 ,l -ee- 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) q11 LL�+ a & STek--)ens ST. Owner or Tenant e•$ Telephone No. q7,'-a(o s- -7(9 Ll Owner's Address P,0, !9nK q fS , N- /9t iitr /i/1 6/t-d— Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building j✓�C,�2 a WliA✓ Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service d Amps -I Zo! 14OVolts Overhead Undgt^d ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: (trl � Akuj 1-\wS e Completion of the folio table may be ivaived by the In ector 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 Swimming Pool Above ❑ ❑ o.of Emergency Lighting rnd. Md. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.of etection an Total Initiating Devices No.of Ranges No. of Air Cond. Tuns No.of Alerting Devices No.of Waste DisposersHeat Pam I Number ons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems: No.ofDevices or E uivalent No.of Water KW o.o o.o Heaters Signs Ballasts Data Wiring: No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP TelecommunicationsWiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner,no permit fir 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 cov ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)#11? go)o 4rt r `7 6 t Estimated Value of Electrical Work:J]2 t (When required by municipal policy.) (EYpiration Date) Work to Start: 1 Z Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify,under the ns and penalties of perjury,that the infornradon on this application is true and complete, FIRM NAME: rt� t e>W C-4 LIC.NO.: 100 1-7 a Licensee: 141(CNcra,/ Signature � LIC.NO.: aD q3,7 (If applicable,enter" t"in thice •e nianber line.) Bus.Tel No.:47k- 7t.,7-07115Address: -q S,luer &rousctI-e&N iA114 030-7q Alt.Tel No.: OWNER'S INSURANCE WAIVER I am award 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. $ /b --1 -- r�, (9 l !-- 26- cam fS��L� Date TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION f—1,,e ky,, �� -L� This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . in the buildings of. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . SIPS .. . . . . . . . . Nrth Andover, Mass. fib 117A Fee . . . . . . . . . Lic. No. . . . . . . . . . . .M GASINSPECTO Check# '1/0/ 8412 Mr . 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 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 l 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. rThe 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 r 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www,mass.gov/dia r 9 LIbE'l.:SED AS A r,,nASTE'R PLUMBER - r ISSUES THE ABOVE LICENSE TO 14'NIEL C FLSEMILLER GtD YANKEE RD c a VIA I7RHIL MA 01:83Z 10:G7 1288 05/01/14 14:7729 [� elm ��Z� a N° 9647 Date.�� Z�-- . . TOWN OF NORTH ANDOVER A PERMIT FOR PLUMBING ,SSACMUS� j This certifies that ./���?? 1/ . . . . . . . . . . . . . . . . . . . has permission to perform . . per-1 S!t. )70-1. . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings o�f .y/ , . .���rJ.GZ.&41 . . . . . . . . . . at. . . ��• Xr "° �.�,, 5 .� j... . . . . . . . . . . . .. North And-over, Mass. Fee�'77. . . .Lic. Nol f21•!4 . . . .1YA. . . . . . . . . . . . QPLUMBING INSPECT-OR Check # 3 WHITE: Applicant CANARY: Building Dept. PINK:Treasurer n MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORM _.. : CITY iii/ .0..v ,. MA DATE //. � _. PERMIT# F ` JOBSITE ADDRESS OWNER'S NAME acs sr—1 7-.. g? OWNERADDRESS TELFAX LL I TYPE OR OCCUPANCYTYPE -COMMERCIAL Q EDUCATIONAL RESIDENTIAL r[� PRINT CLEARLY NEW: ENOVATION: REPLACEMENT: PLANS SUBMITTED: YES FJ NOE] FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER _ E2 _'�_— DRINKING FOUNTAIN FOOD DISPOSER �;� ?�����- FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL �l, l�- [. _ I _...__ E-7) SERVICE/ SERVICE/MOP SINK ..... ...._.' -I1 TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING I . (-_��I�-�1�-1(-RIS^ OTHER _,.z.....1�'i�,-1 �, f_ �f ( !(-' ;f�hl(-1M11 7f-f 1 -1[ 1 . . _.. i( ( � 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 'OTHER TYPE OF INDEMNITY EJ 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 F-1 AGENT Q SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information 1 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 permit issued for this application will be in pliance Pertinent pro ' ' of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME 112,,p4l � ,Q LICENSE# !l d'$ SIGNATURE MP CORPORATION 0# PARTNERSHIP -�#j LLC[ --� COMPANY NAME ADDRESS G/ r CITY STATE® ZIP 6 TEL S C'9 7 FAX CELL &6y7fEMAILR , c <'e— 1—7 — 2 y. -VL Axg-� ?f 1 3f� } 1 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 r Name (Business/Organization/Individual):��i,��f/ Address: City/State/Zip: �1.�.v ,�.�i Phone#: 9 F"/ 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. L 41Kw construction employees(full and/or part-time).* have hired the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet. t E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑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.]i 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. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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: Ac :.v Policy#or Self-ins.Lic.#: C ✓� /Q 'fid ��/� Expiration Date: 9 �i'.. Job Site Address: 10,6 Or :� City/State/Zip: M da,, �1,iJ 13/ ) 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. 1 do hereby certif under t/zepains �ndpenalties erjury that the information provided above is true 'dcorrect. 5i nature: Date: ^tD &Ya Phone#• 6'7 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#: r 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 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www,mass.gov/dia i �� wNIC1NWE��T�ry - . ':`llCE '3SED AS A �JIASTER P:LljMbCR - � ISSUES THE ABOVE LICENSE TO' 14NIEL .0 ELSEMILLER 67 ' O.LB.-YANKEE RD tom. A.`A P_R H I L M A. 0 ].8 3;2„ 7.1288 05/01/14 147729 M I , Y CAS ' Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 318,0100.00 m $ - $ 3,816.00 Plumbing Fee $ 477.00 Gas Fee 100 comm. $ 100.00 j Electrical Fee $ 477.00 Total fees collected $ 4,870.00 I 411 Stevens Street 108-13 on 8/8/12 New Home Location f No. a�/ Date Z' • - TOWN OF NORTH ANDOVER m Certificate of Occupancy $Abd Building/Frame Permit Fee $. // Foundation Permit Fee $ ®� r, Other Permit Fee $ t rc n TOTAL sy, Check# a 25591 A60ding inspector Y