HomeMy WebLinkAboutMiscellaneous - 42 UNION STREET 4/30/2018Date.L5Wb�15......
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
Thiscertifies that........................................................��'A................................................
............... �.,.. ..T,..............
has permission to perform .....�..!`��....... ! a � �o
plumbing in the buildingsof.......J,�c�t..w...`!�-.J............................................
at ...... ......................................................... North Andover, Mass.
W
Fee.. rMe...... Lic. No... 6(6..................................................................................
PLUMBING INSPECTOR
Check #
UCITY
POWNER
TYPE OR
PRINT
CLEARLY
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
!N)A 1 A80\ K MA DATE S� �'� S� PERMIT #lu
JOBSITE ADDRESS 2 �� I a� $ OWNER'S NAME KVil t S0Vxj 'A;'
ADDRESS 23 TEL 10 7J 0 IU 4Q FAX �
OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL
NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ NO
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/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/ AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER Gat,R
A0416% NC o
INSURANCE COVERAGE:
I have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO [:1
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ 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 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 ' nce with all Pertine rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME AYN111VV W 06-C!r: GA LICENSE # 33005 SIG TURF
MP ❑ JP 2' CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ #
COMPANY NAME�Yl�r"C1/� 1P 1A ADDRESS WO-7 L GV4lI ST
CITY L4W'[-Q h C-0 STATE ;_ ZIP 0 14 4 I`` TEL
FAX CELL 19 7 b+ 9S S `1 EMAIL nhl Y VJyA la 3 3
YC
M
The Commonwealth of Massachusetts
Departnient of Inrlllstrial Accldeltts
Office of Investigations
600 Ulashingtoit Street
Boston, MA 02111
mv9v.nias&gov/dia
Workers' Compensation Insurance Affidavit: Build ers/Contractors/EIectricians/Pluuabers
Applicant Information Please Print Legibly
Name (Busines s/organization/lndividual): DndreW
Address: 20 7 1. owt It 54
City/State/Zip: LaW,14 h G -C ivkA Phone #: 6? 7 F -2t
Are you an employer? Check th'e'appropriate box:
1. ❑ Tani a'employer.with. 4• ❑ I am a general contractor and I
�I7lployees (full arid/or part-time have hired lhesnb-contractors
2. [�'I am a sole proprietor or partner- listed on the attached sheet. t
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required]
3. ❑ I am a homeowner doing all work
myself [No workers' comp.
insurance required.] t
These sub -contractors have
workers' comp. insurance.
❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c, 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required]
Type orproject (required):
6. ❑ New construction
7. [] Remodeling
8. ❑ Demolition
9. [l Building addition
.10.0'Electrical repairs or additions
I I.0 Plumbing repairs or additions
12.[] f repairs '
13. Other
'Any applicant that checks box ii t must also 5.11 out the section bclow 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 aflidavit indicating such.
XContraclors 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 Ii orkers' compensation insurance for my employees. Below is the policy and job site
infori nation.
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address: �2 U r !/� • A,yle'o" r— City/Stale/Zip: o) �-q
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 e. 152 can lead to the imposition of cruninal penalties of a
fine up to $1,500.00 and/or one-year imprisormient, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against die violator. Be advised that a copy of thus statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby ceifify I�er the pains aiz adjlties of perju>7, that the infol•nnationprovided above is true and correct
Phone #:
Oficial use only. Do not write in this area, to be co tplefed by cif, or town offciaL
City or Town:
Perinit/License #
5--M-/S—
Issuing Authority (circle one):
1. Board of IIealth 2. Building Department 3. City/Tbwn Clerk 4. Electrical Inspector 5..Plulabing Inspector
6..Other
Contact Person:
Picone #:
O
m
0
C,
r
�D
O fD
IV N
00
a0
N
CT �
� A
=
v`0
O A
.a o
0
'00 A
3 fD
N N fD
o
N
o
N .«
3 t5oi O
<m
(QO
3 10
C
N
CQ �
N
O
tD
tD •B
cr 50
tD O
o O
! su rr
m
m
m
D
cn
C
0
r
0
Z
0
D D D
n O a
m (D CD
N U) N
0 0 0
O O O
O O O
O Q O
� a �
CD N M
Ca O
O
Q.
tQ O
n
o �
Q.
M
a)
w
o
CL
<D
S
lD
O'
m
W
O
�nw
O
C
O
Q.
O
m
(D X 0
_\ �
;
CT (D
�I»w
\<0§
00
\ j 03 k
/0
�®
\\
\�
k \
n
\
/
]
7
%
/
�
/
\
/
K
0
/
ƒ
0
0
#
_
r+
ƒ
]
f
E
0
]
2
J
]
�
�
St
/ °
F o
-W
_ #
0 E
_ =
a
0
f
U) m o m 7
§
■ m .. ..
ap��E
903
/27ƒ/
Ln
(D
i
/ 2 po
ai q \
2
G/
(Ln
>
5�
]
¥
/
LM
§
CL/
0
M
§
7
d
9
%
CD
iv
N
m
0
0
0
N
CL
CD
3
CD
7
0.
(D
fD
3
CD
CD
a
s
iv
3
0
N
CD
3
T.
c
0
3
c
0
v
0
CD
co
N
N
7
a
0
v
N
411
(D
C
a
0
0
0
a
N
fR
(D
0
H
CD
m
0
(D
51F
,v
N
N
0
O
c
N
x
(D
0
v
0
v
m
0
3
0
m
0
3
v
o'
v
(D
m
CA
CD
m
m
0
*m-nv
(D3 X S
cr _ O
a Ioj
!D pD V
m m 00
1-1
v 00
oD i. 00
3 (D
A Ul
Oh
0 N
O
� 7
D o
Iz o
0
S
n O
O 0
3
Z r --i o A
O 0) O :;-i
T 00 7 n
y O O o
o- o Z n G7
0Q43cD
N 3 41
3 v
D o < n
O rD O (D
N M D
'O �
3
v
o'
n
rD
s = v
rD N =
-s
Q. Ln
d
rD
O — -fi
" (D p
a 3
-< Z-
0 (D
c : c
O O
5F 3
d
1+ rD 3
O (D
0-
z
O r C
y �
v 00
=rLn
V
rn O
00
`aG O O^
� Y
s N O
O (D
iii
G t
O 3
Q
O O
N
(D rr
(D m
rt
r+ y
3 =
(D Q
OUQ
�
rte+ r
rD
S
0-
0 t
O O
(D
7
O
(D
O C n O (D cn -
D s .... 3
4535
Date... �f... '.......:�'.. ......
TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
This certifies that
............:............................................:: �.............................
has permission to perform
wiringin the building of .............. ......................................................................
at .......` :...... ll ........ ................................................. , North Andover, Mass.
Fee. ................. Lic. No.:......... ............... .....,!.. F:'........................
ELECTRICAL INSPECTOR
Check #
Official Use Only
Permit No.
att °aF Satiety Occupancy & Fee Checked—3f,5
BOARD OF FIRE PREVENTION REGULATIONS.527 CMR 12:00
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 522277 CMR 12:00
(Please Print in ink or type all information) Date U Z 2-1 O Z
To the Inspector of Wires:
Town of North And
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number �.Z.
Owner or TenantLi, I' � S4.,?O M x/161
Owners Address
Is this permit in conjunction with a building permit Yes ❑ No CSI' (Check Appropriate Box)
Purpose of Building b �i G i�A/1 / �2_'" A c re ,I Ublity Authorization No.
F)tisting Service %PO Amps //0 XYZ O Volts Overhead ❑ Undgmd ❑ No. of Meters
New Service Amps Voits Overhead ❑ Undgmd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
i
OTHER:
% — V,, -4 /,, L
,VSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I rive a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO =
have submitted valid proof of same to the Office YES = NO = If you have checked YES please indicate the type of coverage by checking the appropriate box
INSURANCE = BOND = OTHER = (Please Specify) (Expiration Date)
Estimated Value o Electric I Work$ / D o p ra
Work to Start 2 0 Z ins 'on Date Resquested Rough Final
Signed under the enalties of perjury:
FIRM NAME LIC. NO. !}
Licensee Ze 0i✓ Ze W, AS Signature LIC. NO. ! 0 7
4, jif/a4 v e✓
Address /V� Alt Tel. No.
OWNER'S INSURANCE WAIVER: I am aware t at the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws. And that my signature on this permit application waives this requirement Owner Agent (Please Check one)
Telephone No. PERMITJFEE $
(Signature of Owner or Agent)
Total
No. of Lighting Outlets
No. of Hot fuse
No. of Transformers KVA
Above ❑ In ❑
No. of Lighting Fixtures
Swimming Pool
grnd ❑ grnd ❑
Generators KVA
No. of Emergency Lighting
No. of Receptacles Outlets
No. of Oil Burners
Battery Units
No. of Switch Outlets
No of Gas Burners
FIRE ALARMS No. of Zone
No. of Detection and
Total
No. of Ranges
No of Air Cond
Tons
Initiating Devices
Heat Total Total
No. of Di sal
No.
Pumps Tons
KW
No. of Sounding Devices
No./ of Self Contained
No. of Dishwashers
Space/Area Heating
KW
Detection/Sounding Devices
❑ Municipal ❑ Other
No. of D rs
Heatina Devices
KW
Local Connection
No. of
No. of
Low Voltage
No. of Water Heaters KW
Signs
Bailases
Wiring
No. Hydro Massage Tuds
No. of Motors
Total HP
OTHER:
% — V,, -4 /,, L
,VSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I rive a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO =
have submitted valid proof of same to the Office YES = NO = If you have checked YES please indicate the type of coverage by checking the appropriate box
INSURANCE = BOND = OTHER = (Please Specify) (Expiration Date)
Estimated Value o Electric I Work$ / D o p ra
Work to Start 2 0 Z ins 'on Date Resquested Rough Final
Signed under the enalties of perjury:
FIRM NAME LIC. NO. !}
Licensee Ze 0i✓ Ze W, AS Signature LIC. NO. ! 0 7
4, jif/a4 v e✓
Address /V� Alt Tel. No.
OWNER'S INSURANCE WAIVER: I am aware t at the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws. And that my signature on this permit application waives this requirement Owner Agent (Please Check one)
Telephone No. PERMITJFEE $
(Signature of Owner or Agent)
3/07
Date...../ ............................
TOWN OF NORTH ANDOVER
3? �. ,� ..., •. °c
00
p PERMIT FOR WIRING
l 01 ♦.p
Thiscertifies that..........................................................................................
has permission to perform.........:I.....:....................° ...-.................................
wiring in the building of
at ' / I North Andover Mass.
Fee' �... ....... Lic. No.� ..' ' e,7 ............. � �.'r.!.. +r, -� ............'...........
r ... .
! ELECTRICAL INSPECTOR
Check #
Permit No. (15
-
V*40- r °� s Occupancy & Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS. 527 CMR 12:00
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 e7 _
To the I specto of Wires:
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Numb�ejr//d
Owner or Tenant h t/ ✓ / sd/10 M AA/N
Owners Address /
Is this permit in conjunction with a building permit Yes 2 No C4 (Check Appropriate Box)
Purpose of Building Utility Authorization No.
E)dsting Service Amps Vats
New Service Amps Voits
Number of Feeders and Ampacity :L� D lP 0
Location and Nature of Proposed Electrical
Overhead ❑ Undgmd ❑
Overhead ❑ Undgmd ❑
Irv.'
No. of Meters
No. of Meters
�2-0
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO =
have submitted valid proof of same to the Office YES = No = it you have checked YES please indicate the type of coverage by checking the appropriate box
INSURANCE = BOND = OTHER = (Please Specify) (Expirafon pate)
Estimated Value of El,9/P,,-,
ct 'cal Work$ So, 10
Work to Start 7/-Z 90 mr Inspection Date Resquested Rough Final
Signed under the Penalties of perjury:
clou aeMv UC. NO.
PAN
NO/!E� 190
p IV Bus. Tel No.
Address �S� lr4ye/%%l fl /(/a/ �i/1 dVt/ AItTel.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws. And that my,signature on this permit application waives this requirement Owner Agent (Please Check one)
Telephone No. PERMITTEE $
(Signature of Owner or Agent)
Total
No. of Lighting Outlets
No. of Hot fuse
No. of Transformers KVA
Above ❑
In ❑
No. of Lighting Fixtures
Swimming Pool gmd ❑
gmd ❑
Generators KVA
No. of Emergency Lighting
No. of Receptacles Outlets
No. of Oil Burners
Battery Units
No. of Switch Outlets
No of Gas Burners
FIRE ALARMS No. of Zone
No. of Detection and
Total
No. of Ranges
No of Air Cond
Tons
Initiating Devices
—
Heat Total Total
No. of Di sal
No. Pumps
Tons
KW
No. of Sounding Devices
No./ of Self Contained
—
No;fofDshwashers
SceArea Heating
KW
Detection/Sounding DeviesMunicipal cOther
No. of Dryers
Heating Devices
KW
Local Connection
No. of
No. of
Low Voltage
No. of Water Heaters KW
Signs
Bailases
Wiring
No. Hydro Massage Tuds
No. of Motors
Total HP
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO =
have submitted valid proof of same to the Office YES = No = it you have checked YES please indicate the type of coverage by checking the appropriate box
INSURANCE = BOND = OTHER = (Please Specify) (Expirafon pate)
Estimated Value of El,9/P,,-,
ct 'cal Work$ So, 10
Work to Start 7/-Z 90 mr Inspection Date Resquested Rough Final
Signed under the Penalties of perjury:
clou aeMv UC. NO.
PAN
NO/!E� 190
p IV Bus. Tel No.
Address �S� lr4ye/%%l fl /(/a/ �i/1 dVt/ AItTel.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws. And that my,signature on this permit application waives this requirement Owner Agent (Please Check one)
Telephone No. PERMITTEE $
(Signature of Owner or Agent)