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Miscellaneous - 407 MARBLERIDGE ROAD 4/30/2018 (2)
407 MARBLERIDGE ROAD 210/038.0-0079-0000.0 J Date .:.to ....... ........................ I&ORrs, TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION gs+cHu ...........This certifies that z ......" e- has permission for gas installation .. ..... in the buildings. Pf -4- 00-Acti ................................ .... ................................................................. at 4 ....... ... I UA�.... ..... )�� ................. North Andover, Mass. ................ .. ........................... .. ...0... Fee�h�'b....... Lic. NoJ....fl.%P.... ....N.Pr................................................. GAS INSPECTOR Cheqk# rs P) 9458 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK F CITY N.Andover MA DATE 7/31/2014 PE IT# (� JOBSITE ADDRESS 407 Marble Ridge Rd Floor 1 OWNER'S NAME GOWNER ADDRESS Same TEIFAXI TYPE OR OCCUPANCYTYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIALQ PRINT CLEARLY NEW:❑ RENOVATION:El REPLACEMENT:® PLANS SUBMITTED: YES[j NDE] APPLIANCES 7 FLOORS- BSM 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 COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER I UNVENTED ROOM HEATER WATER HEATER i OTHER -------------------------------- Re lace 1 Gas Meter s) x c -------------- and Associated Pi inq INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I Joseph Marino LICENSE# 8736 VSIGNATURE MPF-1-1 MGF® JP® JGF® LPGI® CORPORATION EJ# 32850 PARTNERSHIP®# LLC®# COMPANY NAME:j RH White Construction Co ADDRESS 141 Central St _ k CITY(r Auburn STATE MA ZIP 01501 � TEL 508 832-3295 I 8- FAX 508 926-4347 CELL 508-832-4614 EMAIL JMarino@RHWhite.com I �I i i ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 4 - S 1�Upi}1!O'iVillf�AL.TH OFF MASS,4`C. —= -P1UIl?YBERS AND GAS FI T-M--'AS.A--M-AaF-TER PL -__ 15SUES THS'%IBQUE LIGEfVSE l`E5 ="' :•ti_-•_`-;=` ,t' - _ _ w�WUf?_ ESTR ' MA 0 e ��131Qr _ 14 Po MR= • t YYI9LlH OF lViASSI6ii7o ;7 _ ` ►NIBSRS AND GASFIV-T-' AS A JQU.RNEYM-AN-f?l.U 14 _ ''=TSSUES THE ABOVE LICENSE - - y FRRTNGfON ST- NA 01 05/01/14 _ ' ^p ;" ' - • jug, -.r i • i ,--,MON ACORD® Lam-- • CERTIFICATE OF LIABILITY INSURANCE Page 1 of 1 08/29/203' TFT 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 COVE RAG R 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 certifleate does not confer rights to the certificate holder in lieu of such endorsement(s). PROpUCER CONTACT 97illiq pf Maesmcbuaetta, Inc. hmp PHONE FAX c/o 26 eQxntnzy Blvd. No_Exn. 877-945•-7376 No): 886-467-2378 R. 0. 305191 Dpi Sfi Cex��f1cat2�9(c�Wi11�e.GOH1 NngkAvillele, TN 37230-5191 INSURERS AFFORDING COVERAGE NAIL rt INSURED INBURERA: The Chaxt9s Oak IizA Ineuran" Company 25615-001 R. B. White Construction Company, Ino, INSURERS.Tr—OlAzei Property Casualty C4mtpany o£ Am 25674-003 41 Ca,ntral Street INS Auburn, Union Fire lnsuranca Company o£ 19445-001 P. 0. Box 257 Auburn, MA 01501 INSURER D;Travelers Indam ity company 25658-001 INSURER F; INSURER F; COVERAGES CERTIFICATE NUMBER:20187680 REVISION NUMBER, THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 16SUED 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 TYpE0FINSURANCE 4D' SU6 POLICY NUMBER POLICYEFF POLICY EXP LIMITS A GENERAL LIAMILITY VTC2000 977X9940-13 9/7./2013 9/1/2014 EACHOCOURRENCE E_ 2,000,000 $ COMMERCIAL GENERAL LIABILITY TO RENTF,p ' 5'Tz1Eaeecbrt— 300,og0 CLAIMS-MADE OCCUR MEDEXP(Anyone areon 1p�004 PERSONAL&ADV INJURY S 2 DQf),000 GENERAL AGGREGATE s 4,040 000 GEN'LAGGREGATFLIPMRTOAppLIESPER; PRODUCTS-COMPIOPAGGJL-J'0Q0 000 POLICY LOC AUTOMOBILELiABILITY VTJCAP 977R955A,=7.3 9/1/20x3 9/7./2014 OMI3IEDSINGLEI,IMIT 2,000,000 acs stent X ANY AUTO BODILY INJURY(Perpemon) S ALIT08 ED AUT08ULED EODILYINIURY(Peraociden!) 5 S HIRFDAUTOS X AUTO NED AUTO eraccldant S OPER -E % Co Ded X Cv11 Deg 95 C UMBRELLALIAB IX OCCUR SIy8766140 /1/2013 9/7./209.4 EACH OCCURRENCE $ S,004,000 EXCESS LIAB CLAIMfi-MADE AGGREGATE $ 51000,000 DED F RETENTIONS 10,000 S D WORKERS EMPLOYIRVLI COMPENSATION `�TRKUB B205A185-13 9/9./207.3 9/1/207,4 X 0 - ANDEMPLOYER&'LIABILITY To LI D ANY PROPRIETORIPARTNFRIFXECUTIVEY N VTC2KUB A203�71A-13 ((OFFICERi,VyEMSEREXCLUDED7 NIA 9/1/2013 9/1/2014 E.L.FACHACCIDENT .Qi 1,000 000 Ifinee deaErlbeun�dar E.L.DI2EA9E-EAEMPI,OYF.E S 1,000,000 U�csUKII+nON 01 UPFRATIONS Below F L,DISEASE-POLICY LIMIT S 1,000,000 )FSC RIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Auech Acord 101,AddlionPl Remarks Schedula,H more opeco la roquired) :IERTIFICATE HOLDER CANCELLATION SHOULD ANY OF TWE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORILLfD REPREME'NTATNE Zvxdence of =nmuxance I Co0,1:4197604 Tp1:1694012 Ce7:t:20287680 ©1988-2010ACORD CORPORATION.Alf rights reserved, CORD 25(2010105) The ACORD name and logo are registered marks of ACORD Date....0�e.(A...................... of TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION HU .. This certifies that .................. ...................... ..... .. ......................................... has permission for gas installation C1 AS- Vv-j- P I i...... in the buildings of.............r ..................................................................... ......................................................... at...40......... + korth Andover, Mass. Fee W'�..... Lic. No�.T�. .......... GAS INSPECTOR Check# 9459 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK F CITY I N.Andover MA DATE 7/3112014 PERMIT# JOBSITE ADDRESSI 407 Marble Rid a Rd Floor 2 OWNER'S NAME GOWNER ADDRESS I Same 1 TEL IFAXI ----I TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIALEJ PRINT CLEARLY NEW:[] RENOVATION:El REPLACEMENT:® PLANS SUBMITTED: YES[j NDE] APPLIANCES 7 FLOORS- BSM 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 [ I FRYOLATOR FURNACE GENERATOR i GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER Replace 1 Gas Meters x and Associated Piping INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY (] OTHER TYPE INDEMNITY 0 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 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 co iance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - PLUMBER-GASFITTER NAME Jose h Marino LICENSE# 8736 SIGNATURE MP 0 MGF❑ JP❑ JGF❑ LPG/® CORPORATION Q# 3285C PARTNERSHIP®# LLC®#� COMPANY NAME: RH White Construction Co ADDRESS 141 Central St CITY I Auburn I STATE LED ZIPI 01501 TEL 508 832-3295 FAX 1508-926-4347 347 CELL 508-832-4614 EMAIL JMarino@RHWhite.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES � r i � t TH OF MASS. 9 MAN BERS AN GAS Fl-r.—f UC SF® AS•A,.M-PjTr;R -J�DS�E`P�H,`D •P�•A-RIh!•D ..-:- _ --• `� • ST V. _ - = 86 05/ /14 ti OMI] iIEALTH M /�C$H�_ - - WQFASS :`P'LU711I ERS AND GASFIT--NIAf-IERSw; o A, ��® CERTIFICATE pATE(mmIDONYWI 4F LIABILITY I� SURANCE page 1 of A 08129/2013 THIS'CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLYAND 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 POHOY(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 notconferrights to the certificate holder in lieu of such endorsement(s), PRODVCEft CONTACT MAUF willim of MaaadchuaHtta, Ina. PHONC c/o 26 Coxltury Blvd. �Io Fes+ 877-9 5 47378 PAX w), 889-46772378 P. 0. Hox 305191 oDMA S -ce Gifiaate r�w•il�i9.�om Ntsgkviy]e, TN 87230-5191 INSURER(3AFFORDINGCOVERAGE NA10it INSURERA! The Char'tAT Oak Firo Ineuranpg Company 25615-001 INSURED R. H. White Constraotion Company, Inc. INSURERS.Tr13VOIArS property Casualty Co any of Am 25674-003 41 0. Boil 5treet: INSURER C:Natiolnal. Union Piro Inouranco Company o£ A9445-001 P. 0. Boa 257 Auburn, MA 01501. INSURERD;Travelers Ind&=ity Company 25658-D01 INSURER F; INSURER F; COVERAGES CERTIFICATE NUMBER:29287680 REVISION NUMBER; THIS IS TO CQRTIFY 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. INSRTYPE OF INSURANCE DD' SUB NARFPOLICYNUMBER POLICY EFF POLICY EXP LIMITS A GsENERALLIA9ILITY VTC20C0 977109946-13 9/1./2023 9/1/2014 EERENCE F 2,000,000 X COMMERCIAL GENERAL LIA9II.ITY RENTF,D $CLAIMS-MADE�ODOURone ereon 51p 000 ADV INJURY00,000 GREGATE S 4L__00'000 GFJI'LAGGREGATFLIMITAPPLIESPER; PRODUCTS-COMP/OPACsG $ JQQ0,000 POLICY FRO LOC $ AUTOMOBILE LIABILITY VT.3'C,AP 977K955A-13 9/1/2013 9/1/2014 'ME31 DSINGLF,I.IMIT S 2,000,000 X ANYAU70 BODILYINJURY(Perpereon) S ALI,OWNED SCHEDULED AUTOS AUT08 BODILY INJURY(Peracddent) X HIREDAUTOS X NOWOWNED AUTOS Dr accident S X Co Des X Coll Ded $ i C UMBRELLALIAB X OCCUR 1348766140 11/2D13 9/1/2014 EACHOCCURRENGF $ $ 000,000 X EXCESS LIAR CLAIMS-MADE AGGREGATE $ $,000,000 DED }; RETENTIONS 10,000 $ D WORKERS COMPENSATION VTRKUB 820SA185-13 9/1/201.3 _9/1./'201,4 g U - ANDEMPLOYERS'LIABILITY NMI,N JJrd,YU D ANYPROPRIETORIPARTNFRIFXECUTIVE NIA VTC2ECiJG A203A71A-13 9/7/2023 9/1/a01+� E.L.FACHACCIDENT F 11000,000 OFFICERIMEMSEREXCLUDED? LJ fMandef=InNH) E.L.DI8EA9E-EAEMPIOYF.E S 1,000 000 I 0456 IIV II ION W-OftRATIONS balm F_,I.,DISEASE-POLICY LIMIT S 1,000,000 7ESC RIPTION OF OPERATIONS I=A770N3I VEHICLES(Atrech Acord 101,Addltonel Rernerke 37h_7.117,It more ep eee Is roqulrad) tRTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THERE-OF, NOTICE: WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZ0 AePREaWNTATNE Evidence of Inlauxance Col1:4197604 Tp1:1694012 Cext::20267680 ©1988-2010ACORD CORPORATION.All rights reserved, CORD 25(2010105) The ACORD name and logo are registered marks of ACORD North Andover Board of Assessors Public Access Page 1 of 1 �•9 'wwno���� MIProperty Record Card Click Seal To Retum Parcel ID :210/038.0-0079-0000.0 FY:2014 Community :North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge Search for Parcels S. . w' . Search for Sales X' " Summary t is x Residence m Detached Structure Condo 407 MARBLERlDGE ROAD l 3 Commercial Location:. 407 MARR.1•ER1D(:E ROAD Owner Name: FAUCHE FAUCHEIi Owner Address: 407 MARI City: NO�. �� t Neighborhood:7-7 Use Code: 101-SNGL-F j I ASSESSMENTS Total Value: -------- ' 11 Building Value: Land Value: Market Land Value: Chapter Land Value: I 0-4 Sale Price: 1 Arms Length Sale Code:F-LON VN1EN1"Grantor: RAYMOND Illi Cert Doc: Book 1125 Page: 326 I i l I http://csc-ma.us/PROPAPP/display.d6?linkld=2433981&town=NandoverPubAcc 8/6/2014 North Andover Board of Assessors Public Access Page 1 of 1 ypR7/r Nor°th-l_ , ndlgv .--r Board of Assessor 3?d�;f. •.•e pG •o ti�� .SSACHOS� 1 4 roperty Record Card Click Seal To Recum Parcel ID :210/038.0-0079-0000.0 FY:2014 Community :North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge r V k � ' Search for Parcels Search for Sales ` Summary Residence Detached Structure Condo 407 MARBLERIDGE ROAD Commercial Location: 407 MARBLERIDGE ROAD Owner Name: FAUCHER,THOMAS FAUCHER,KRISTY ANN Owner Address: 407 MARBLERIDGE ROAD City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood:7-7. Land Area: 0.70 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 2715 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 418,300 429,300 Building Value: 204,100 204,100 Land Value: 214,200 225,200 Market Land Value:, 214,200 Chapter Land Value: LATEST SALE Sale Price: 1 Sale Date: 01/07/2008 Arms Length Sale Code:F-NO-CONVNIENT Grantor: CLEAN, RAYMOND Cert Doc: Book: 11025 Page: 326 http://csc-ma.us/PROPAPP/display.do?linkld=2433981&town=NandoverPubAcc 8/6/2014 956b s-- , Date........................... . � NoatM TOWN OF NORTH ANDOVER - PERMIT FOR WIRING SSACHUS This certifies that .... � L...... ............................. has permission to perform ...... ..... <..�. Z� .. ....�� ......................... wiring in'the building of.......wc... I—e.--an',.......................................... at.4/0.?..AM&,t4.0 � 3. ,No Andover,Mas . Fee... ........... Lic. ... �1. .. t ELECTRICAL INSPECTOR r� - Check # 2� Y �N a.wn►nw►wca►�n v► ria��ac,nuw«� Permit No. �r Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM EL CTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C,527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 8 t - 01C2 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to pefform the electrical work described below. tV/ Location(Street&Number) Y(J-) VqrU— Owner or Tenant y>\,6Telephone No. Owner's Address S 'F Is this permit in conjunction with a building permit? Yes KA"" No ❑ (Check Appropriate Box) Purpose of Building 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: ' hZc/ Ct�r" tZi� r � Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires g 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- ❑ o.o Emergency Lighting rnd. grnd. Batter 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. 1 TotaTons l No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: .......... .... Detection/Ale ting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* y No.of Devices or Equivalent . No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP 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 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 cove age is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE EZ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME,: LIC.NO.: Licensee: � £v;� �tQ Signature { LIC.NO.: (If applicable, enter "�,ex11mpt11 in t tcense f?•umber I ..) Bus.Tel.No.: Address: J�� OAC U^e P^ G' i 1'// PJV5 Alt.Tel.No.: *Per M.G.L c. 147,s. 57-61,s urity 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 Owner/Agent PERMIT FEE. $ Signature Telephone No. . � i f� i 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 Leizibly Name(Business/Organization/Individual): v�'n �° �' -t E �" �r e t 'l Address: ZK � . J . City/State/Zip: /��'* ����' j �ff j• Ql�3� Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.El I am a employer with 4. ❑ I am a general contractor and I * have hired the sub-contractors 6. F-1 New construction ployees(full and/or part-time). 2. I am a sole proprietor or partner- listed on the attached sheet. 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 area corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 11. Plumbing repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL ❑ g p 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 all 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. i Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: y 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 i 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 cert!y un#er the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 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#: 10159 • Date... ..... ..................... NORTH TOWN OF NORTH ANDOVER 3? e•,� OL PERMIT FOR WIRING ss^CHUSE� This certifies that .... �' / ....................... has permission to perform G r wiring in the building of........ ! ....... .C f� 07 �G 7 Zf�'w-:n / 'X� ,,�� at..... ........r� ...................... ............/ .(.... ,North Andover,Mass Fee..... ......... Lic.Nor' mf.... ., .. LECTRIC; INSPECTOR Check # Z1 Commonwealth of A�lassachusetts Official use only Department of Fire Services Permit No. fG • ,M BOARD OF FIRE PREVENTIONOccupancy and Fee Checked REGULATIONS [Rev. 1/07 (leave blank APPLICATIONI FOR PERMIT TO PERFORM ELECT AL iii RK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),52 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of NORTH ANDOVER4 . By this application the undersires gned gives notice of his or her intention to perform the To the electrical wordlescnbed below. Location(Street&Number) �Q` t® ' Owner or Tenant >_ /'t7 c C Owner's Address Telephone No. Is this permit in conjunction with a building permit? yes Purpose of Building NO ❑ (Check Appropriate Boz) g- /yam'" s�f -`d'ksVCf- Utility Authorization No. Existing Service Amps / volts Overhead 0 Undgrd Q No.of Meters New Service Amps ---L—Volts Overhead Undgrd No,of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: No.of Com letion of the, lowin table may be waived by the Ins ector of Wires. Recessed Luminaires No.of Ceil:Sus No.of t p•(Paddle)Fans TransformerTotal s No.of Luminaire Outlets No.of Hot Tubs KVA Generators ICVA No.of Luminaires Swimming Pool Above in- o.o mergency lg _ g No.of Receptacle Outlets No.of oil Burners d• nd. 11 Batte Units FIIRFFA-1AR1�IS No,of Wines No.of Switches No,of Gas Burners No..of Detection and No,of Ranges Initiatin Devices No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers' Heat Pump Number Tons KW _ No.of Self Contained Totals: __ ...._._.............._.... _....... No.of Dishwashers Deteciion/Alertin Devices Space/Area Heating KW Local❑ Municipal No.of Dryers Connection Other r3' Heating Appliances KW Security Systems:* No.of Water No.of No.of Devices or E uivalent Heaters No.of Data Wiring: Si s Ballasts. No.of Devices or E uivalent No.Hydromassage Bath s No.of Motors Total HP Telecommunications Wiring: t` OTHER• No.of Devices or Va.,;—lent r Estimated Value of Electrical Work: mach additional detail if desired,or as required by the Inspector of Wires. Work to Start: (When required by municipal policy.) 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 Iicensee.provides proof of liability incur ce including`°completed operation"coverage or its substantial equivalent. The undersigned certifies that such Covera s in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) Icertify, under thepains andpenalliesoefp rjury,that the information on this application is true and complete. FIRM NAME: 6?14 GC�2 r Licensee: LIC.NO.:, Z128''Cl (If applicable,enter "exempt"in the license number line) Signature �. LTC.NO.: Address: _ s 41C►-&A /YI/C, �/.2 Cl_ i y�:h� /tJ Bus.Te1.No.:1� *Per M.G.L c 147,s 57-61,security work requires D Alt.Tel.NO.:97$ f30 it/96 OWNER'S INSURANCE W q Department se ubhc Safety"S"License: Lic.No. 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 requirem Owner/Agent ent. I am the(check one) (]owner El owner's agent Signature Telephone No. PERMIT FEE:$ �� ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR-DOUG SMALL , I.ROUGH INS TION: Passed—[ Failed—[ ] Re-inspection required($50.00) Inspectors'comments: G (Inspectors'Signature-no initials) ' . Date Z.FINAL INSPECTION, Passed— Failed [ ] Re-inspection re uired 5 - Inspecto s'comments: q ($ 0.00) [ ] (Inspectors'Signa ure-no initials) • Date 3.UNDER GROUND INSPECTION: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: (Inspectors'Signature-no initials) Date 4.INSPECTION—SERVICE: - DATE CALLED NATIONAL GRID: NAYIE: Passed—[ ] Failed—[ ] Re-inspection required($50.00) Inspectors'comments: (Inspectors'Signature-no initials) Date 5.INSPECTION-OTHER: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: --------------- (Inspectors'Signature-no initials) Date DOOR TAGS ARE TO BE FILLED) OUT AND LEFT ON SITE IF TDA AREA TO BD+1 INSPECTED IS NOT ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED. I i The Commonwealth of Massachusetts Department of T11dustrial Accidents Office Of LnVesfigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print L e ibi Dame(Business/Organization/Individual): Address:_ City/State/Zip: / Oig�Y Phone e ou an employer?Check t propriate box: [2. am a em to er with q. Ty;New project(required):P Y ❑ I am'a general contractor and Iemployees(full and/or part-time).* have hired the sub-contractors 6. construction❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7• modeling ship and have no employees These sub-contractors have working for me in any capacity. workers' comp,insurance. . ❑Demolition [No workers'comp. insurance 5. ❑ We are a corporation and its 9' ❑Building addition required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL11.❑Plumbi employees. [No workers,ers' ng repairs or additions myself [No workers'comp. C. 152, §1(4),and we have no insurance required.] t 12.❑Roof repairs comp.insurance required.] 13.0 Other 'AnY applicant that o fill checks box Yl must also) cut the section below shoe=npoiicy _ f Homeowners who submit this affidavit indicating they are doing all work and then hireutside contractors must subminformation. t 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. am an employer that is providing workers'compensation i informatiom nsurance for my employees Below is the policy and job site Insurance Company Name: 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. I do hereby certify under the pains andpenalties ofperjury that the information provided above is bu and correc Si ature: Date.: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitlLicense# Issuing Authority(circle one): L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspecto:5P1::umbin:g1nsp:ect0]r 6. Other Contact Person• Phone#• Date.... 7..... /Z TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ .&I-I W. - ............................ has permission to perform ........ ...........DOS... jr. . ,........ . ............................. wiring in the building of............. ........................................ (. .. .......... ......... North Andove ,Mass. Fee.. ... Lic.No. ........ . . . .I.. . .............. LECTRICAL INSAL�CTOR Check # 10855 f commonwealth ofMassachusetts ofticialUse only Department of Fire Services Perm"O,_ /ez� BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev.1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK AM work to be performed in accordance with the Massachusetts Electrical Code WC),527 CMR 12.00 (PLEASEPAWTININKOR TYPE ALL.WFORMATIOA9 Date: V 5-- -215`— 2-0/2— 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) r- G� Owner or Tenant GQ r J� ;r 41r c Owner's Address Telephone No. Is this permit in conjunction with a building permit?g p Yes ❑ No ❑ CheckAppropriate PurposeofBuilding ( Box) Utility orization No._ /"2—�flj`� -7 Existing Service () Ams Z?c.Y !/a P _Volts . Overhead ndgrd❑ No.of Meters l ew Service Amps / Volts Overhead D-- Und grd [jNo.of Meters Z Number of Feeders and Ampacity 2 _ Location and Nature of Proposed Electrical Work: 1 N L�..✓ �}��ij�;:n 4s�/ ��s i i�� lam /�`- ���✓�c� 1=0 2 Com lesion o the ollowin table m be waived b the Inspector o Wires. No.of Recessed Luminaires ENE(Paddle)Fans No.ofTotal Transformers KVA No.of Luminaire Outlets Genera Generators KVA No.of Luminaires Swimm' Above In- o.o mer enc m Poo1 g y i m g nd. ❑ rnd. ❑ Batter Units g g No.of Receptacle Outlets No.of Oil Burners EFIRE ALARMS No.of zones No.of Switches No.of Gas Burners No.of Detection and No.of Ranges Total Initiann Devices No,of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons ' KW No.ofSelf-Contained Totals: _..._..._.._ _.._....._....Y._......__.........__. Detection Mu Devices No,of Dishwashers Space/Area Heating KW Local❑Municipal Connection F1 Other No.of Dryers Heating Appliances IOW Security Systems:*. A No.of Water No.of Devices or Equivalent Heaters KW No.of No.of Data Wiring: Signs Ballasts No.ofDevices orE uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or E juivalent Attach additional detail fdesired,,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 equivale t. The !� undersigned certifies that such cove rs in force,and has exhibited proof of same to the permit issuin office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties o era that the informatiory on this application i�ttd Coy,1' 2— FIRM NAME: /i}/tJ /w? �C � ��' p Licensee: LIC.NO. A 3 /7 8 Signature LIC.NO.: (Ifapplicable,enter"exempt"in the license number line.) ------_ Address: o- Bus.Tel.No.:y7 g 6 S6 0 a 'PerM.G.L c. 147,s.57-61,security work requires Department ofpublic Safe S License: fit'Tel.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/Agent ❑owner's a ent. Signature Telephone No. =PERZVffFEE:$ i �.1 ' Y TS7�"ECXO1EP� ' : - _. ELECTRZC.AL PERMT IST®. . �!—.Rorro�.x��ealCTpo�': passed: [_ +aiied--[ ) Tae-inspection xequzrecX($50.00) [ ] h8pectoxs'comments: (Xusp ectoxs'Signature-•xto knifjials) Pate lilt T'asse$•-- •T�afIecl�-•[ ) " � �texnspectioxtxec�ttirerl($50.00)-•[ � . auspectors'comments: � _ y (;i'iis&ctoxs'giguature•-xto Wfials) • 'Date 3.1JMVIR GROD"TNBPTJCTZON: passed-[ ] +ailed-[ ) Tae-9uspaction xetiufxed(S50A0)�[ J Inspectors'comments: i (inspectors'Signature x�o iuitiaTs) Tate A.. Passed.-[ ) Nned•-[ I k�e-uispectiouxequired( 50.00)�j � Inspectbrs'cowmeufs: (�xtspectoxsl ftaatuxa-io Wiials) bate 'assecl- [ ) WWI--[ ]_ �ie-fnspectiottxequized(�50.Od)-[ � a.spectoxs'comments: (baspectors' ]late D Q OR TAG9.AIDE TO BE P'B;EED Q TT.AND LEFT OX RITE W TIM APXA TO 3E INSPECTEID►1S NOT .A CCESSJBEE.AND,A.RE WSPECTION OF$50,00 18 TO BE CHARGED. � - \'• The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,AM 02111 www.massgov/iiia Workers' Compensation Insurance Affidavit:Builders/Contractors/ElectricianslPlumbers Applicant Information Please Print Lezibly Name(Business/OrganizationAndividual): ! lam/✓ �j G G/f-2 j/� ►� Address: City/State/Zip: Phone#: 7 ir 6 576 6 0 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ Ia employer with 4. ❑ I am a general contractor and I 6. ❑New construction ployees(full and/or part-time).* have Hired the sub-contractors i' 2. 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 i working for me in any capacity. workers'comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3111 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 outthe section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that checkthis 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 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 maybe forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do hereby certiry under the pains andpenalties of perjury that the information provided above is t ue and correct. - Signafore: ` Date: a 2 5 7i Phone#: 6� 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#: Informati®n and Instructions ' Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or 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-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 maybe 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 Compaoilwealth of massachmetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston}MA,02111 Tel,#617-727-•4900 ext 406 or 1-877-MASSAFB Revised 5-26-05 Faze#617^727;7749 WWW.Mass,gov/dia T:..�u.�l,yy:+;.¢�.�G.rr�•..s.r....u. . . s-,-•_ -...,,.r.�,.,..,,�,,=-,�,+7i��!'i3.a-"s-'P`�*`Ty`a�'`�=e�»=�'^`-�:.,r'ra*a+�lC +g.:. Date.. . /�s ',.TO 2010 - a ,ORTol TOWN OF NORTH ANDOVER - ' - 0 ° op PERMIT FOR GAS INSTALLATION t , s i • ♦ o °�s O�pp•••th tai SACMUSEt l This certifies that has permission for gas installation in the buildings of . ����/ ,( G.4 lL(.,c� ��- at 0( Vt t '; North Andover, Mass. Fee. J.�. ' Lic. No.. l��ia'�. . . . . . . . . . . . . . . . . . . . . . . C I�1 2512 t- 30.00 pA%S INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING 1 (Print or Type) NORTH ANDOVER Mass. Date 11-l" S _ Building Location e7Qj /�j,, �/f/� (////�// Permit # 1 O( 0 T� Owners Name 'I� /Lf, �q �✓ New 7-1 Renovation D Replacement Plans Submitted D �S FIXT, r0-c 0 � W N LISLU m a W6 C G Q = Q F to to w d to w O a to W 4 r01 C rQn ` W W W z W 0 W t ? U- —t l.- 0 j OO 5OW O t_ .s 0 Q GtW- o Stl$—aSTdT. BASEMEXT I I O I I M I ( I I I 'IST FLOOR I I I I I I ( ( I fI I I{ I 2ND FLOOR 3RQ FLOOR I I I I I I I ( I I ( I I I I I 4TH FLOOR I ( I ( I I I I I I STH FLOOR 6TH FLOOR 7THFLOOR I I I I I I I 8TH FLOOR ( I I I I (Print or Type) Check one: Certificate Installing Company Name /-7/0"nkA,/:�z Corp. Address Q. O� /�.- � Partner. Firm/Co. Business Telephone: c. Name of Licensed Plumber or Gas ttter Insurance Coverage: Indicate 11,::e type of insurance coverage by checking the appropriate box: Liability insurance policy (KI Other type of indemnity Q Bond Insurance Waiver: I , the undersicned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner = Agent i hereby certify that all of the details and information I have submitted (or entered)in above application are true and accurate to the best of my itnowtcdge and that atl plumbing work and tnstalUtions 7 rformed underPzrr.:it iuucd fo. this application wiil be in compliance with all eat Cs provisions of the Massachusetts State Cas Code and aptcr 142 of the GCnerat L►wa. By TYPE LICENSE: Plumber TitleGasfitter ature of Licensed City/Town: Master Plumber = Gasfitter journeyman ��� APPROVED (OFFICE USE ONLY] License Number • _ _ Date.... "l.L.... � T'D 2819 i%ORTH TOWN OF NORTH ANDOVER ' PERMIT FOR WIRING cmu s ; This certifies that has permission to perform .. .. �� r/1..��.?At, ................. wiring in the building of ..... 14 . �, �ll/y1,,.,,--"................ f K at..... ..h-le .f • North ' Andover Mass. I€ F e 7.... Lic.N0�-�. ... -6......r ......... ........ ............... .......... F ] (Q Z ELECTRICAL INSPECTOR 78.00 PAID � WHITE:Applicant CANARY: Building Dept . PINK:Treasurer GOLD: File Office Use Onj il � 0141 Tamm ium of s�E� Permit No. 14mritzim2 of pubiir *Ufidu Occupancy A Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 VAR 12:00 3190 peave blank) / APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date �i46 2 a& or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. 11 Location (Street & Numbers 7V 7 �1'l1�f72/3LC 9101qC Al Na. 4Ndover /LjASs' Owner or Tenant /fY l�hae!eQ,v Owner's Address Is this permit in conjunction with a building permit: Yes ✓ No (Check Approoriat Purccse of 6uildina S K9 CL-" rAM'Ly Utility Authorization No. Existing Service Amps Vcits Overhead Undgrnd r No. of Meters New Service 240 Amps `/oits C-verhead T� Uncg-r c r No. of Meters Numcer of Feeders and Ampacity 220 r Sr a.gLi P4 h.5 Lccaticn and Nature of Prcoosee Electricai Wcrx 7 rm/3261-6- Total No. of Lighang Outlets No. ct Hct '_-Cs I No. of'%anstarmers KVa Arcve.— 'n- — No. of Lighting =zxtures /p Swimming Pcci• yrr .o _ a Generators KVA q No. of Emergency Lighting No. of Receotac:e Cutlets G S No. of Cil turners I Battery Units No. of Switch Outlets /'L. No. at Gas surners I FIRE ALARMS No. of Zones Total No. of Ce!ecnon and Cy^c No. of Ranges No. at Air :cr.s I Initiating Cev ces i No.cf Heat, Tc:ai Toat No. of Disoosais P;-;,s 7ans 0;j No. -at Sounding Cevices No. at Sert Contained No. of Cishwasners ScaceiArea eacn'g K.•! De!ect:onrSouneing Devices ` Mumc:oat Na. at Drvers Heaunc Cev:ces KN Local _ Connecnon _Other No. at No. at I Law Vattage No. of Water Heaters KIN ! Sicns Eadas:s Winnc No 'Hvcro Massace u-s No. of `ictc-s =ata: ? I I CT HER: INSURANCc CCVERAGE. Pursuant :o the recutrements 11assachcse7:s ;ererai Laws NO I have a current Liadiiity Insurance Polic/ inc!t:cmg Ccmc:eted Gcera.:ens C..verage or its suestanual eeuivaient. YES _ YES coverage cv the 9 Of vc h x YES. ^lease indicate , have sudmtttea vaitC Arcot of same to the Office. YES _ NO _ !f you have c ec ec a. ,, type / checxtng the aorrodrtate cox. Z� 9b L INSURANCE = BOND = OTHER = (P!ease Scec:tv) /iuSuR4IJCE 'VUl / J t 20 D 11 (Exciration Datet Estimated Value of E:ec:ncal WorK 5 WcrK :d Start D AN 2 24/4?6 Inscecnon trate Recues:ec: Rough Finai Signed uncer:he Penalties of perjury: WILL CaU ight NAME r- ,4v'J 0 i S LIC. NO. E 2329 b Licensee A� Z//3�� 2 ?&" 726-yr izLin 5 S;gnat::re - tom/ UC. NO. 2Z lrD►ttLt/�#ntf �(/f/��t/f;( /(l�rt�l aus. =el. NO. Address Alt. :el. . o. OWNER'S INSURANCE WAIVES: I am aware trial Ire t_censee toes not Lave the insurance coverage or its suostanual eeutvalent as re- outrea oy Massachusetts Generat Laws, ana :nat my s:grature on -.ms .ermtt aeptication waives this reeutrement, r Agent (P!ease cnecK �)4JAA-�_j� 6_ g4 =etecrcne No. PERMIT FEE (Signature of Owner or Agent) *,1565 .. r COMMONWEALTH OF MASSACHUSETTS DIVISION OF ELECTRICIANS AS A REG JOURNEYMAN ELECTRICIAN ISSUES THIS LICENSE TO DAVID B DUBOIS 22 COACHMANS LANE cn HAVERHILL MA 01832-1086 23296 E 07/31/98 007601 i