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HomeMy WebLinkAboutMiscellaneous - 43 LISA LANE 4/30/2018 (2) 43 LISA LANE / 210/098.A-0050-0000.0 L 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§,3L,the permit application form to provide notice of installation of wiring shall be uniform throughoutthe Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant tom.al,c. 166,§32,as a electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits sha Lbe limited as to the timjof_on�ing construction.activity,and maybe.deemed by-theJnspector_of_Vii,-es abandtmed_anddavalid.ifhe—. or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the.permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 ofthe Acts of2010 and extended by Sections.74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job;growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certaiwpermits and licenses concerning the use or development ofreal property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effector existence"during the qualifying period beginning on August 15,2008.and extending'through August 15,2012. .r les—PermitriDate Closed: * Note:Reapply for new permit ❑Permit Extension Act—Permit/Date Closed: �- � Date..�1.-. ..:.Z 42........ el O�,,OaoT stip 3? ,� TOWN OF NORTH ANDOVER PERMIT FOR WIRING c"usf This certifies that .................. ...� X.... J.S. '............................ ......... . ....... has permission to perform .... P` ....................................... wiring in the building of......../�Jr` .!-v..�.. : ............................................. at..MY....4-.!..5.d..G ....................................7An,North Andover,Mass. 'u Fee,P .a'..... Lic.No.A.<�.-.... -f.li?�......i...... .............. ELECTRICAL INSPECTOR Check # 9274 . Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WOR All work to be performed in accordance with the Massachusetts Electrical Code(MEC), 27 CMR 12.00 (PLEASE PRINTININK OR TYPE ALL INFORMATIOA9 Date: l U City or Town of: NORTH ANDOVER To the Inspect r of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 0 Owner or Tenant y c Telephone No. Owner's Address �{ c.S� Is this permit in conjunction with a building permit? Yes Purpose of Building NO ❑ (Check Appropriate Box) 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: ��, ©l� �;�•` + Completion of the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of CeiL-Sus No.of Total p.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming PoolAbove In- o.o mergency g d• ❑ d• ❑ Batte Units -—, No.of Receptacle Outlets No,of oil Buy-Hers -E ALARMS No.of hones No.of Switches No.of Gas Burners No.of Detection and No.of RInitiatingDevices anges No.of Air Cond. TOS Tons No.of Alerting Devices No.of Waste DisposersHeat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No,of Dishwashers Space/Area Heating KW Local❑ Municipal No.of Dryers Heating Appliances KW Security Connection El Other Systems:* _ No.of Water No.of Devices or E uivalent No.of a Heaters KW Si s Ballasts Data Wiring: - No.of Devices or Equivalent No.Hydromassage Bathtubs . No.of Motors Total HP Telecommunic;1, Wiring: OTHER: No,of Devices or E uivalent g�}(� �Q Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of El trical Work: (When required by municipal policy.) Work to Start: D Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO RAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ fP1u OTHER ❑ (Specify:) I certify, under the pains and penalties o er' that the information on this application is true and complete. FIRM NAME: r_ pp Licensee: LIC.NO.: (If applicable, enter `, empt"in tlf�lice e n :ber lin Signature LIC.NO.: Address: �(��{ l��� � \ c�- �A Q l� � Bus.Tel.No.: a -11F� *Per M.G.L c 147,s 57-61,security work requires D "S" Alt.Tel.No.: h6l= 16s'j OWNER'S INSURANCE WAIVER: I am aware that the Licens e does nothave the lliabili Lic.No. required by law By my signature below,I hereby waive this requirement. I am the check one insurance coverage normally Owner/Agent - ( ) ❑owner El owner's aeent Signature Telephone No.!JPERMIT FEE.S 4' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investig ations 6 600 Tf,ashingion Street Boston, ALL 02111 www.marsgov/dia . Workers' Compensation Insurance Affidavit: Alicant nfarn:ation B ilders/Coetractors/Eiectriciaas/Pfambers I Please Print Lm-'bl Nie (Business/Drganization/individuai): . — tt �1L 1✓� v Address: City/State/ZsF: �G� �0c �t• (3(C Phone#: . 1 _ — � l Are you an employer?Cheek.the appropriate box: i•❑ I am a employer with 4. Tof prep(requirm): ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-coTtttactors 6.7[]New construction 2.❑ I am.a:sole proprietor or partner- Iisted on the attached sheet t 7• ❑Remodeling ship and have no employees These sub-contractors have working for me.in any capacity, g ❑Demolition workers' comp.insurance. [No workers'comp. insurance 5. ❑ We are a corporation and its 9. ❑Building addition 3.❑ required_] officers have exercised their 10.ED Electrical repairs or additions 1 am a homeowner doing all wont right of exemption per MGL 11.(] Plumbing repairs or additions rrayself, [No-workers'comp, c. 152, §1(4),and we have no insurance required,]t employees. [No workers' 12•❑Roof repairs comp. insurance.requiretL] 13 ❑.other `�Y applicant that checks bo>L ti f must also fail out the section below showing their workers'oompmsation policy information. t Homeowners who sabmit this affidavit indicating they are doing all work and than hire outside contractors must submit anew affidavit indicating such Icontractors that check this box Must attached an additional sheet showing the name of the sub-cop trU-10TS�r submit t--, f __„ ap.policy.inmmistion. !am an employer that is providing workers'compensation insurance for M employees: Below is the policy andyab site information. Insurance Company.Name: • LC A Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: �"\ ��� '�•—�vl� - City/State/Zip:�At,-A�� f),, 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. l do hereby c 'y under the pains lid enalties o er' P /P l�Ym the information provided above la true and correct Sit�natrnr: _ Date: Phone 9: A 1g �1 — [Li 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 Z. Building Department 3.City/Towa Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person Phone#: 09978 Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . . /� has permission to perform . . .f�'. r��e Iti , .�� s } � v/LC_ plumbing in the buildings of. !.P. ,, lis- , , , , • , , , , . . . . . . . . . at . . . . . . . VZ . . Lr-sl. . . . , . . , . . . . ,North Andover, Mass. Fee .t'xY . Lic. No. . U..3 4!. . . . . . . . . . . . . . . . . . . . . . . . ^� PLUMBING INSPECTOR J Check# r f�T�C 3 Date..�.. .....(..I.f�............... A �►ORTIy TOWN OF NORTH ANDOVER p PERMIT FOR WIRING mu`3� t This certifies that ...... I. has permission to perform ....................................................... ( .M.�. ............................... wiring in the building of.........N. ?.m. 1 ......................................................................... at ........ ...... .1..�.!2.Ar.....!.-:G..Ij e—............................North Andover,Mass. Fee.J.?................Lic.No. .. ... ...... "1. ............................................................... ELECTRICAL INSPECTOR Check# —� C4%11� - I-�> n17x,�,3 `• a Official Use Only Commonwealth of Massachusetts Official 1/ Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C,527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date:— /,, /7/-/3 City or Town of. NORTH ANDOVER To the Ins ec or of Wires: By this application the undersigned gives notice o his or her' tention to perform the electrical work described below. Location(Street&Number) I Y Owner or Tenant Y5 C {;t Telephone No. Owner's Address P1 Of Is this permit in conjunction with a building ermit? Yes No ❑ (Check Appropriate Box) Purpose of Building '51 n5 /•e 9 l Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead laudgrd ❑ No.of Meters < Number of Feeders and Ampacity [ )D �`►"1` Location and Nature of Proposed Electrical Work: ICe+r7d JPs I Ylch�T�'1 - Completion of the following table may be waived by the Inspector of Wires. No.of Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Batter Units b No.of Receptacle Outlets Z, No.of Oil Burners FIRE ALARMS No. of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons J.KW No.of Self-Contained �\ P Totals: Detection/Alerting Devices Municipal ❑ Other No.of Dishwashers Space/Area Heating KW Local❑ Connection Heating Appliances KW Security Systems:Y A I No.of Dryers No.of Devices or E uivalent -� No.of WaterKW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent b 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 Wtres. 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 c�MB ge is in force,and has exhibited proof of same to the permit issuing office. n CE CHECK ONE: INSURANOND ❑ OTHER ❑ (Specify:) I certify,cinder ticepacn n penalties ofperju ',that the 'formation on this application is true and complete. r FIRM NAME: . J UkOA C/�'1/ LIC.NO.: Licensee: -C 41, \Ju& Signature LIC.NO.: (If applicable,ent� xe t'ii zn the jicense number�li+�e.) l /�� Bus.Tel.No.: Address: S 6 4 , , 1C IL *Per ccs( 1 C N0/ t c 111 �l Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Departm nt 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 PERMIT FEE: $ Signature Telephone No. 72�ssec�.-�[ , --�,aj�eQ-•j' ] �e-�ttspeet�oxt xequiz'e�'{$�O.OD}�� � Asp Betas c eats: 14 (lCnspse$ozsyzgn Luxe� tonitiaTs) .r Pate •6+•.4JJ-1�,lI,Y=.7JC,wlr.fC lYt - �'asse$--[ � �'aile�--j � �te�s�leetton.xe�uixec�(��0.00}-•j �` . �it5�ectoxs'comm• fs• • (nsectoxs�,�`ignatu oto fst• 'aTs) date 'assed--IazIec�--jtefnseetzo�xecuixe {�sD.OD)�[ as.Vectoxs'moments. d i (�nspectoxs�aignatuxe��oi 7UEITs) Date 00TCAI LIE,—0X. dam.+OX'.��t03I1 . NA- :. v We'll.-j � �e-anspectton required(�50.OD}�{ � �eetbxs9 eoinm.ept'ts; . i (Aspectoxs,Mguatuxe-io�Atgaxs) Data f actoxs'coxc+.m.cats: 'psp eecoxs°Szgnature no liOials) date ' O The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): CJ 'a✓fi /[' �� Address: q3 Lt c>A 1_#nnx City/State/Zip: V q�h iPhone#: 9 7 6 ��.� r .J Are yy6 an employer?Check the appropriate box: Type of project(required): 1,94 am a employer with 4. ❑ I am a general contractor and I employees and/or part-time).* have hired the sub-contractors 6. El New construction 2.❑ I 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 10.0 Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing 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. 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.Lic.#: b �V Expiration Date: G t Job Site Address: q3 Yj 4,oiz ( City/State/Zip: v 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 )f 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. do hereby certify ii ler the pain n e alties of perjury that the information provided 7ve s true and correct. 3i nature: n Date: 13 ?hone 4: 17 ��03'0c�i( Official ztse 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#: a Y� O 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 law1 or if you are required to obtain a workers' compensation policy,please call the Department at the number listed b low. 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 1,1877-MASSAFB \\Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dih s r ' 4 FaK Th�D•tmch Aft q N PwftraWns COMMONWEALTH OF MASSACHUSETTS BOARD ELECTRICIANS EL REGI M ABOVE ST WTOELECTRICIAN TYPE S-TE-PttEN M JUBA III .o -A 555 SALEM ST =: ` mokTH ANDOVER. KA 01845-3109 ?. 855786 855786 fold.nm n. a Almy N Pmiarasxn � n F—� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE L_-_i PERMIT# 1 JOBSITE ADDRESS ` OWNER'S NAME f � (tir *A--' POWNER ADDRESS S �" f _ 1 TELFAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL Ell RESIDENTIAL©' PRINT CLEARLY NEW: RENOVATION:Q REPLACEMENT:Ee PLANS SUBMITTED: YES® NOQ FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE —_ —_J_ l I DEDICATED SPECIAL WASTE SYSTEM _1 _.____( .._..._...[ i _I I DEDICATED GAS/OIL/SAND SYSTEM ( __ DEDICATED GREASE SYSTEM _ ___._._..( _-_-( I ._......__.( ---_._-) 1 _.77-1 DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER -J _---____1 ._..771 ___-____} -j DRINKING FOUNTAIN FOOD DISPOSER l . _.! _._.-_-- ...-__-( _._._._( ( _-__ -_...___._1 ..._.._.__I .-.._-___I _..__._ I __......_I FLOOR/AREA DRAIN _) ___.__.1 E-_.__1 -._.___.) ___.._! .._ ( _--.._..J ___.__1 __._-.._P INTERCEPTOR INTERIOR k € I i ._.__( _( I ..._771 ._._...-J=1=1 KITCHEN SINK ._..__.._1 ----__-._� _._._.._J ___ { ! .._._._ ._.I _ LAVATORY ROOF DRAIN .—.___j __.._-_..) I _......... SHOWER STALL SERVICE/MOP SINK __._-__1 _-__--1 -____J __-_.__I ._._-__� —_f - _I ... .—! .-- A _( J __J= URIN _._-._� ___._._I ...__.._.1 ._.._.._.._( .._...___3 ...... i _..... WASHL G MACHINE CONNECTION 1=== l _.1 J=== _ WATER HEATER ALL TYPES --( _l _I _. _ _P PING _._. WATER PI OTHER -----..._J INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESEO NO .I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY © BOND MI 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 _I 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 c Massachusetts State Plumbing Code and Chapter 142 of the General Laws. pp PI nce hall Pe ant pro sion of e PLUMBER'S NAME _ , , _ el-f (LICENSE# c SONATURE MPO JP 0 CORPORATION R# 3 3 Y- ___i PARTNERSHIP P# _ {LLC COMPANY NAME �`T S/'{ �,,,�..w�-_/ ADDRESS CITY dJ ��f ✓,.t` —STATEZIP U! �'�{r it TEL14 9 7�vG 0 z FAX ; CELI)kT ��5.] EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ C � FEE: $ PERMIT# PLAN REVIEW NOTES `f t The Commonwealth of Massachusetts Department ofIndustrigl Accidents Office of Investigations kvi. 600 Washington Street Boston,MA.02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legib� Name(Business/Organization/Individual): At " Address: GSD /� x S�S`f City/State/Zip:_1-'l 0. y-2 /'h✓/Phone#: 9 7 1 G d 2 c� Are you an employer?Check the appropriate box: Type of project(required): 1.9 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.El am a sole proprietor or partner- listed on the attached sheet.# ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. E]Building addition [No workers'comp.insurance 5. ElWe are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]f employees. [No workers' ' comp.insurance required.] 13.❑Other *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 aie 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. Insurance Company Name:. '--P1 c) 00 Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: S �`CH �--- City/StateMix-2, Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby er ' u er thepans and pe allies perjury that the information provided above is true and correct. Si afore: Date: Phone#: � d F � 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' 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 contrasting authority." Applicants 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'compelasation 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 confnmation 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 permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any givlen year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"I he 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 maybe 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 bum 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 604 Washington Street Boston}MA.02111 Tel,#617-727_4900 ext 406 or 1-877,7MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia j r � N°RTM °f'"`°;•�"� TOWN OF NORTH ANDOVER PERMIT FOR WIRING ' AcmUs�� iThis certifies that ....... ....... ...................................... has permission to perform ........ .................................. wiring in the building of....A1 c..I waa4........................................................ at.....li(.3..... .l..sly...... 11.,............................... ..... , orth Andover,Mass. Fee.. . 1... �L......... Lic.No..1Z.. Y .............r. ELECTRICALINS PECTOR Check # S S 8 Lk 2 Commonwealth of Massachusetts Official Use only ROMP LYDepartment of Fire Services Permit N°. Y Z 'L. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [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: 10- 2-6- 0 8 City or Town of: NORTH ANDOVER To the Inspector of Wire's: By this application the undersigned gives notice of his or her intention to perform.the electrical work described below. Location(Street&Number) LAi,-= Owner or Tenant L vr%I c t yvt p.N Telephone No. Owner's Address 14 Is this permit in conjunction with a buildin permit? Yes Q No ❑ (Check Appropriate Boz) a Purpose of Building bAservne.,+ sv� „Utility Authorization No. Existing Service Zdb Amps 12,0 /2 Yo Volts Overhead ❑ Und d gr No.of Meters New Service Amps / Volts Overhead❑ Un d dgr ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �y44cJ Completionof the followin table may be waived by the Inspector of Wires. No.of Recessed Luminaires 12 No.of Ceil:Susp. (Paddle)Fans No'of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA ` No.of Luminaires Z Swimming Pool Above in- ❑ o.o mergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets I 0 Nc.of Oil Buy Lers FIRE AI,ARIVIiS No.of Zones No.of Switches (p No.of Gas Burners No. of Detection and Initiatin Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump umber Tons No.of bell-ContainedTotals: ­­—I*­­­­­ _ Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of WaterNo.of Devices or Equivalent Heaters KW No.of No.of Data Wiring: t Signs Ballasts No.of Devices or E uivalent No.Hydromassage BathtubsNo.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent 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: (D-20-00 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 r9i BOND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenalties ofpeerjury'1 that the information on this application is true and complete. FIRM NAME: 1Z1'<-e- ]r T ;e cy.•, LIC.NO.: 1,7, 3 01 12 Licensee: iRwr e,.>cc b2;c c Signature(IfLIC.NO.: f 2 3/H� Adadress:bleF0er"exempt"in the ^e�iymbUr I ti,*115 1 Bus.Tel.No.:�b "g ZZ c 3 l��X 12 6 l t^ 0 3 Ss t(�/ Alt.Tel.No.:(ob3- 9 va - CoS97 *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 agent. Owner/Agent Signature Telephone No. PERMIT FEE: S J^ s The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www-mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �v 2 Address: eb !�>&K 12 (o City/State/Zip:\A"e�aN 7 N\+ �qu Phone#: L63-(2 3c, 1 Are you an employer?Check the appropriate box: l.❑ 1 am a employer with 4. Type of project(required): ❑ I am a general contractor and l employees(full and/orpart-time).* have hired the sub-contractors 6.. ❑New construction 2.511 am a sole proprietor or partner- listed on the attached sheet 1 ?• ❑ Rem.odeiing aship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. [No workers'comp. insurance 5. ❑ We are a corporation and its 9• ❑ Building addition required.] officers have exercised.their 10:❑ Electrical repairs or additions 3.❑ I an 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 insurance required.] t employees. [No workers' 12.❑ Roof repairs comp. insurance required.] 1.3.❑ Other *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who subutit this affidavit indicating tliey arc doinio ail work and then hire outside contraciors rust submii a new affidavit indicating such. 4Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. I am ann employer that is providing workers'compensation insurance information for mJ'employees. Below is the policy and job site Insurance Company Name: Policy#or Self-.ins.Lic.#: Expiration Date: " Job Site Address: City/State/Zip: t Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). 1 .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. !do hereby certi nder the pains qn_dpenaldes of perjury that the information provided above is true and correct Signature: f °1-� "�"`ems 16 / p ' Date: Phone it: Official use only. Do not write in this area,to be.completed by city or town officiaL City or Town: IPermit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5- Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,associati on 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 ort 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 l� 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 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 thell permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the lava or if you are required to obtain a workers' i 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 j 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 permitliicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit1hcense applications in atiy 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 T applicant as proof that a valid affidavit is on file for futur� 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 iInvestigations 600 Washington Street Boston, MA 02111 Tel. 4 617-727-4900.6,-t 406 or 1-877-MASSAFE Revised 5-26=05 Fax 4 617-727-7749 www.mass.gov/dia Date........Z —........r..... f &ORT" 3?;•'�``�-:°'�.�pp� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,SSACMUS� - This certifies that ......... ........................................................EG nn ��.�... has permission to perform .........:5.... l c / ................................... wiring in the building of...........!?tl-1 ......................................... L .......................... North Andover,Mass. .= /� Q Fee.3:�......... Lic.No. �3.�? .............. - r.. l LE ICAL INSPE R Check # 895 Commonwealth of Massachusetts Official Use 0� Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev. 1/07] (leaveblank 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 WINK OR TYPE ALL INFORMATION) Date: 7�Z 3 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) 3 •S/-\ N N 1= Owner or Tenant e 4 m t4 " Telephone No. Owner's Address L.3 L.C S P' L 1k.r.-I Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building SV N 126or,. Utility Authorization No. Existing Service Z,60 Amps (20 / 24oVolts Overhead [ Und rd g ❑ No.of Meters New Service Amps / Volts Overhead❑ Und rd g ❑ No.of Meters Number of Feeders.and.Ampacity Location and Nature of Proposed Electrical Work: Completion of the followin table may be waived by the Inspector of Wires, No.of Recessed Luminaires e> 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 mergency ig g d d. ❑ Batte Units No.of Receptacle Outlets (p No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches 2 No.of Gas Burners No..of Detection and Initia ' Devices No.of Ranges No.of Air Cond. Tons l No.of Alerting Devices No.of Waste Disposers Heat Pump Number ons KW__ o.of Self-Contained Totals: _._.._.___...._. Detection/Alerrfin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal other Connection E] No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of No.of Devices or Equivalent No.of Data Wiring: Heaters ' Sigrns Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total Hp Telecommunications Wiring: OTHER: No.of Devices or E uivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) v Work to Start_21Z � ?j 6`f Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [( BOND ❑ OTHER ❑ (Specify:) I certify,under thepains and penalties f perju that the information on this application is true and complete FIRM NAME: C — F Ie=1 c e�v1 e-e LIC.NO.: LZ 3 R Licensee: tskirtN<-e K<e--r— Signature _ _ $�; (If applicable nter"exempt"in the liipee numbers line.) LIC.NO.: LZ VIi( Address: 6 IZ 1Pt»1 6Y1 �►4��5 y Bus.Tel.No.: 6 *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Alt.L cl.No. e3' 8 w97 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: $ I �7n i y i 7f �-�� i 0 4" The Commonwealth of Massachusetts k t Department of Industrial Accidents Office of Investigations V600 FT,ashington Street 4 i Boston, MA 02111 {' www.nzass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anolicant Information PleasePrint Le�bly Name (Business/Organizafion/Individual): in 1 e— Address: FQ l7aX )Z 4- City/,State/Zip:_ L 1}-y�v e kw PA 115 D-3'4L#: . G o!!>-9 Z 40 - 3,0-<,j Are you an employer?Cheek.the appropriate box: 1.❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.K I am.a.sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me.in any capacity, workers' comp.insurance. [No workers'comp.insurance 5. ❑ We are a corporation and its 9' Building addition aired 10.❑Electrical required.) officers have exercised their repairs or additions 3.❑ 1 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 insurance required.]t ❑ repairs 9 I .employees. [No workers' comp. insurance required.] 13.❑.Othtr t`ADY applicant that checks borf#t must also fill out the section below showing their workers'compensation policy information homeowners who submit this affidavit indicating they ata doing all work and then hire outside contractors must submit a new affidavit indicating such. 3Carttractors that check this box must attsebed an additional sheet showing the name of thesub-contractors and their workers'comp.po►i_;iafnr cnction. 1 ant an employer that is.providing:workers r cowpensatwn insurance for nw 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. if do hereby certif der the pains a pen of perjury that the information provided above is true and correct Si ture: =j 8 �' Phone#: G b 3 ' Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every.person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the'foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. 'However the owner.of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do mai-ntenance,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 I local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business ort'a 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 ti:ie 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-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 requiredto 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 1 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 numberlisted below. Self-insured companies should enter their self-insurance Iicense number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided asp ace 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 mt liil be used as a reference number. In addition,an applicant that must submit multiple permit/licenw applications in any given year,need only submit one affidavit indicating current policy'information(if necessary)and under"Job Site Add less"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 bum 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 f1industrial Accidents Office of investigations 600 Washington Street Boston„MA 02111 Tel.#617-7274900 e'xt 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#61;7-727-77451 www.mass.gov/dia a - Date. .... . ". . .y. . . . ".o ft'r" +o TOWN OF NORTH ANDOVER ° PERMIT FOR PLUMBING ,SSACMUS -This certifies that . . . - . . . ... jhas permission to perform . . . . . ... . `.. ....`.`. . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . at . . 7 . . . . . . . . . . . . . . .„North Andover, Mass. Feel`!. . Li c. No.. . �. . . . . . . . . . . . . . �- PLUM IN�G INSPECTOR t� Check .N 7 ( 14.0 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Building Location 3 << S ✓iJ Owners Name /V -e c� Permit /J Amount Type of Occupancy New Renovation Replacement 1:1 Plans Submitted Yes ❑ No ❑ FIXTURES az w U ZZ r w Q 3 w � �Iz A a w x >aASEVIENr inM E 3MK" 4MFL" sIH FLOOR 6M FLOOR 71H FLOQt 91H HJO I2 (Print or type) Check one: Certificate Installing Company Name {G eee P nn El corp. Address 1, X �U�L — h ElPartner. Business Telephone 7 -Zv Q—Firm/Co. Name of Licensed Plumber: UJ e) �c Insurance Coverage: Indicate the type of insurance coverage by checking theappropriate box: Liability insurance policy `I Other type of indemnity 0 Bond ❑ Insurance Waiver: 1, the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information 1 have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and i itallatio s performed under Permit Issued or this application will be in compliance with all pertinent provisions of the MasS c sett tate lambing C e and Chapt 42 of'the Gep 1 Laws. . c� --� By: SignalUre 01 LICenSeaum Title Type of Plumbing License �n City/Town icense um er Master1 r1 Journeyman 1. El ❑ APPROVED(OFFICE USE ONLY CJ Date.......,`,.?'I.:.............. + NORTI{ °`, :•�"° TOWN OF NORTH ANDOVER ° PERMIT FOR WIRING N p �,SSACMUS� This certifies that .........� ! C. .... .... ............ has permission to perform ... �� ....'? wiring in the building of........N.T.A1. ................................................ R at....a.3...... ............................. .North Andover,Mass. AA oma,,,.".. f� Fee.l.P.... ..... Lic.No. �..�............... 'C. +' V EL CTRICALINSPECrOR . Check # -5-37Z 67 Commonwealth of Massachusetts ! [ :�c()IIIN Permit No. 745 6 Department of Fire Services Occupancy and Fee Checked F-T BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9 051 !lege blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK ,\I I .pork to lie pertornied in accordance\\it I'(the\Llsszic h Usetts I:I cc trical Code(\IFC). 527(AIR 12.00 iftLISE PRL\T IN INK OR TYPEALL INFORM.1TIO,Vj Date: 5- a Y—O(o City orTown of: A&4�, 'To the h7.s'j?eL'/0/' 0/ MITS.' By this application the undersigned,)i,,cs notice ot'his or her intention to perform the clecti-ic,,Il work described below. Location(Street& Number) 413 Owner or Tenant _j% /1au.at/ Telephone No. 6,92-35-u Owner's Address 5)412;% Is )+11,F— Is this permit in conjunction with a building permit? Yes F] No (Check Appropriate Box) Purpose of Building j F;4w t-/y Utility Authorization No. 6 3Q(. qr Existing Service /PT Amps IdLO/ J-4iO Volts Overhead � Undgrd E] No. of Meters New Service &4VO Amps (jo / ;WDVolts Overhead Eg"' Undgrd F-1 No. of Meters Number of Feeders and Ampacity, Location and Nature of Proposed Electrical Work: S,,0t/;U (4,2 &e44A� 141C 61k I Ar Cmilplelioll(?/111(,/i)Iloll big able mat be 11:1111LI/by Win- 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 F--1 No.of ergency Lighting iBatter Units No.of Receptacle Outlets No. of Oil Burnersof Zone s FIRE ALARMS No.of Switches No. of Gas Burners o•of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total.2 Tons 7 2 INo.of Alerting Devices No.of Waste Disposers Heat PUT p N.umher Tons J-KW, If-Contained Totals: etection/Alerting Devices MuniciNo.of Dishwashers Space/,Area 1 rea Heating KW (Local 0 Other Connection— ecurit,, .S sterns:* No.of Dryers Heating Appliances KW ---T5�� 7� No. of Water No.of No-'of Devices or Equivalent Heaters KW No.of Data Wiring: Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total VIP I elecommunications Wiring: No.of Devices or Equivalent OTHER: F-stinlated\,'alue of Electrical Work: hen rquired by municipal policy.) kk ork to Start, Liq<o 111SI)CLItions to be requested in accordance with MEC Rule 10, and LIP011 completion. INSLRANC 1RACE: L,nIess waived by tile omivr• no pe!-mit for the perlonnance of clectrical wvork may i'-:SLIC tile licensee provides proof of liability insurance inclUdill'-,-coniplctcd operation"coverau-c Or its All"AJ116ill "I)(' cel-tiric', that such co�era,,�,e i,. in 101*cc. Jild has c:,Jlibitcd Iwoof ot,;arle to the- -(:I,Illlt office. I IECKONE: INS( RA\0,-- 130ND El ()HILR ❑ (Spccily:) wider.the prints rind pemdties:)1'peql'iij,, •/1/!1/the infi)17)1ationoll;114,ipplication IJ 11we il,r-fd cowplete. f,'I 11 N11 NAME: Ael".C(c Licensee: --Bus. Tel. No Address: OfM-- Alt. Tel. :SCCLI-ity System Contractor LicenseLicenserequired fol-t1liS work; if;lppliCLible, LlItCl'the license number IltA-L: I (OWNER'S INSURANCE WAIVER: I ;.un mvare that file Li,.cllsec do,.!.:;7()/have the liability illSl-ll-aHlCe COV,-ill L e 11CI-111,11k, iquired by law. By my:::,,nature below, I 110'Lln waive this requirt:imnt. I ;mi the(check one)0 owner [-] - - -,C'l i t. Owner/Agent D,, Date....... a. .... ... f NORTH TOWN OF NORTH ANDOVER PERMIT FOR WIRING ;,SSACHUSEt This certifies that .................� '. .y......4::r¢ .............................. has permission to perform ..........�t P.b.e- �''� Vis........................ wiring in the building of...........1 t/E '/ !1/......................................... at........11..3... .................................North Andover,Mass. ad 1 Fee.., .. LIc.No3.��................. ?..............„.... ).........,1..... ELECTRICAL INSPECTOR Check # j P2 r )i� Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. �dC-- x - BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/99] 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 (PLEA SE PRINT IN INK OR TYPE ALL INFORMA TION) Date: 7/17/2006 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) 43 Lisa Lane Owner or Tenant Laurie Neyman Telephone No.682-3354 Owner's Address same Is this permit in conjunction with a building permit? Yes X No ❑ (Check Appropriate Box) Purpose of Building:Kitchen Remodel/Addition 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: Remodel Kitchen?Kitchen Addition Completion o the ollowin table ma bewaived b the Ins ector o Wires. No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above ❑ In- ❑ o.o mergency ig mg rnd. rnd. Batte Units No.of Receptacle Outlets No.of Oil.Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tonsl No.of Alerting Devices No.of Waste Disposers Heat Pump Number ITons KW....... No.of Self-Contained Totals: "' "' Detection/Alertin gy Devices No.of Dishwashers Space/Area Heating KW Local ElMunicipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Water No.of Devices or Equivalent of No.of Heaters KW Si ns BallData Wiring: No. ,. Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent Attach additional detail if desired, or as required by the Inspector of Wires. 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 X BOND ❑ OTHER ❑ (Specify:) On File Feb/2007 Estimated Value of Electrical Work: (Expiration Date) (When required by municipal policy.) Work to Start:7/1.7/2006 Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: Kelly M.Casey Signature (I �, LIC.NO.: 37200 (If applicable,enter "exempt',in the license number line) Address: 700 Robbins Ave Unit 3 Dracut Mass 01826 Bus.Tel.No.: 978-697-4453 Alt.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's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ �- ky 7 - -2- i i �e t i Date. ,AORTPI 3?0 y,,,.o ,e1tiOL TOWN OF NORTH ANDOVER FO P . PERMIT FOR GAS INSTALLATION SAC NUSE�C This certifies that . . c. . . f `. . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . .� r.;l .!!! . . . . . . in the buildings of . . l.e y.' . . ..'. .. . . . . . . . . . . . . . . . . . . . . . • . . at . .�!.? . . . . . . . . . . . . . .. North Andover, Mass. Fee. ?. . Lic. No..` '. . .'. . e. . .�.- ? . . . GASINSPECTOR Check# ? ' c 474 MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations 43 Li sa Lane Permit# Y(f ? `� Amount$ Owner's Name Eric Mevman New❑ Renovation ❑ Replacement Plans Submitted ❑ 0 0 PQ a �, o � � ° F U a° a w o SUB-BASEMENT BASEMENT / 01 1ST. FLOOR 2ND . FLOOR y 3RD. FLOOR ~ 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH . FLOOR (Print or type) - CAWone: Certificate Installing Company Name Andover Mg. & Htg. Co., Inc. Corp. 2122 Address 20 Aegean Dr. Unit 110 ❑ panne.. MPthnpn Ma (11 RQa Business Telephone (g]S) 6Sgi_S3S_j ❑ Firm/Co. Name ofLicensed Plumber or Gas Fitter George LaRose INSURANCE COVERAGE Check on I have a current liability Insurance policy or it's substantial equivalent. Yes M No[] If you have checked ye_s please indicate the type coverage by checking the appropriate box. 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 Mass.General Laws,and that my signature on this permit application waives this requirement. Check one. Signature of Owner or Owner's Agent 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 knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State GasWe and Chapter 142 General Laws. By: ignature of Li ed Plumber Or Gas Fitter Title 011luinber 9983 City/Town ❑ as Fitter incense um r L.rJ Master APPROVED(OFFICE USE ONLY) ❑ Journeyman Location No. Date NORT" TOWN OF NORTH ANDOVER Ot�t�ao a'�1. Os ♦' a00� Certificate of Occupancy $ Building/Frame Permit Fee $ �,sACMU Foundation Permit Fee $ �/t �r Permit Fee - $ �410' UG?6 q Sew V nection Fee $ .44 • ter Connection Fee $ V �o�i9rco�� TOTAL $ .t 19'1 f0> J Building Inspector now Div. Public Works �- APPLICATION FOR PERMIT TO BUILD — NORT` ANDOVER, MASS. /PAGE I MAP d-40. LOT NO. 2 RECOR OF OWNERSHIP '.DATE (BOOK '.PAGE ZONE I SUB DIV. LOT NO. 11 1 1 LOCATION ? �'� A 2 1 c- PURPOSE OF BUILDING. A-4feal5- +.s Illoi- OWNER'S NAME T yn p,i!�1,T ®// )7/. 1v /� ,A NO. OF STORIES SIZE O 2 /�J�{t�.Gl,s� OWNER'S ADDRESS GJ�t S.�VZ 4-7_eT BASEMENT OR SLAB - ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAMED ' SPAN -- DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES-SIDES REAR " " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 - 12- SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILE BOARD OF HEALTH v SIGNATURE OF OWNER OR AUTH RIZED AGENT All FEE U / J �J z PERMIT GRANTED OWNER TEL.# v'�` _ f('?J PLANNING BOARD CONTR.TEL.# j 75=/2-22 CONTR.LIC.# a t.1-6 9? CoN�+e•?��1_ 93 BOARD OF SELECTMEN a f� BIALDING IN15PECTOR i BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY r�O R1ES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY FFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE 3 1 2 13 CONCRETE BL K. PINE BRICK OR STONE HARDW'D PIERS PLASTER _ DRY WALL _ UNFIN. 3 BASEMENT 11 AREA FULL FIN. B M AREA _ '/, 1/1 '/ FIN. ATTIC AREA _ N_O B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARDNWD _ ASBESTOS SIDING COMMCN VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY _ - ATTIC SIRS-.-8 FLOOR BRICK ON FRAME CONC. OR CINDER ELK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLEHIP BATH (3 FIX.) f' GAMBREL MANSARD TOILET RM. (2 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st 13rd I NO HEATING w. ,-. 4SERVATIO _ FINAL PLANNING . FINAL SEW RIWATER _FINAL own of 6,. OL n over NO. 393 RIVEWAY ENTRY PERMIT 4 1■.(a`KAP er, Mass. a 19 �� CLIC HEWICK A �V R M �Sq E i BOARD OF HEALTH PE I LD THIS CERTIFIES THAT....... �0.4 IA ...... '�x ..................•. �. BUILDING INSPECTOR has permission MWIt! .o"e,,..pwl k •• Rough .�.. .. , .. ............................ Chimney to be occupied as....... .. ••••• ••••••••••••• Final provided that the person accepting this permit shall in every respect conform to the terms of the application on file in PLUMBING INSPECTOR this office,and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Rough Buildings in the Town of North Andover. Final VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR Rough UNLESS CONSTRUCTION STARTS Service Final .. ... .. . ............ BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Final Display in a Conspicuous Place on the Premises FIRE DEPT. Do Not Remove Burner No Lathing to Be Done Until Inspected and Approved by Smoke Det. e,01/ Building Inspector Date. ./ell�l .� r t HpRTM TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that i . . . . . . . r . . . . . . . . . . has permission to perform plumbing in the buildings of �fE �-!• . . . . . . at . �, �� l:r �� �. -`. . . . . . ., North Andover, Mass. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . heck # O� PLUMBING INSPECTOR 6,209 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO PLUMBING (Print or Type) L y-aca Aoda I/r'!' , Mass. Dae rL7 Permit # 61 Building Location / Owner's Name IS — 6 X—q — 2k& q Type of Occupancy Residential New ❑ Renovation ❑ Replacement Plans Submitted: Yes ❑ No ❑ FIXTURES NN cn o Z W ►- o b V, z W Y J N Q V Fa- N V) 2 v� 4 rr ¢ y N Z G 2 H a O — W F- W N F U W cc X Z O � ¢ N W C 2 ,c W - D a N Z K S O rtf aC W W a N Zr -JN rY J Z O O x x H U j F„. O W 6 > N Y 4 O Z X .( ►- 0 � a ~ a a r c' `� a a o a � a cc cc X a o a N 3 Y J m N O O J 3 Z f- 0 W Lt 7 0 a t. fu J VJ SUB—BSMT. BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name Heritage Htg. &Pig. CO. Inc. Check one: Certificate Address 35 Pleasant Street IX Corporation 714 Stoneham, Ma 02180 ❑ Partnership Business Telephone 781---4a8.—7 7 7 6 l-7 Firm/Co. Name of Licensed Plumber Gordon Switzer INSURANCE COVERAGE: I have a current liability 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 coverage by checking the appropriate box. 1 A liability Insurance policy IN 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent❑ Signature of Owner or Owner's 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 knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all . pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Title �na ure oLicensed mer City/Town Type of License: Master[X Journeyman❑ APPROVED(OFFICE USELicense Number 8 3 2 2 j BELOW FOR OFFICE USE ONLY FINAL INSPECTIONS SKETCHES PROGRESS INSPECTIONS FEE - NO. APPLICATION FOR PERMIT TO DO PLUMBING NAME&TYPE OF BUILDING LOCATION OF BUILDING __---.- _ --PLUMBER - PERMIT GRANTED DATE 19 PLUMBING INSPECTOR e10 oDate......... .. ....... s NORT►{ TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,SSACMUS� ... .... .........t................... ... ............... .......certifies that=: l.&/j has permission to Pe/form 4'Kw �` Q ' ��f� . ..L .J ............. ........... ................ .... ............ wiring in the building of ( .2)/.///L- .................. ................................... at.....�J..... ...._:................�...............(./�/(.�.'.................. ,North Andover,Mass. Feel G�.:. .. Lic.Noe I- ..�. .... . � . ! i i ...... �........./ j' tLECTRICAL INSPECTOR L Check # &q Y Pcr[Tljt NIL) 15W�5 BOARD OccvPWICY and Fee Checked OF FIRE PREVENTION REG C>�, Rev. I 1190) APPLICATIOiNJ FO.R Pl---RMI'F T RFORM ELECTRICAL WORK I work 10 be perl ormcd in 3(_C0rLh1lCC M01), s Pcr,iricni Cojjc S2 7 C.%I R 12,00 ,A. FP E TYPE'.,ILLINVOP,�[ lioly) INK 01? Dn t c: City or 'Yowl, of: BY this appl TO (h C b1sp qf J-Vil es. 1-ition (lie uiider.st�,,- j Q 14�_ eclol Cf ki(vCS noilcc -)C her Location (Street & Number) Owner or Tenant Owner's Address Telep 0 11 e Is this permit in coi,juitctitit, Ivilh :I titlildi#14" perjllif*� Yes m A I' liuse Of l3ujjjilj� _q F❑J (CheckApprnp,iaje Bo,) h UlilitY Aufhoriz.,iliuii No. Existing Service Amp's ❑ No. of INIcler.-, Amp� Lid-rd Number of Feeders and Anip.icity of)Ieters Locitimi and Nature of Proposed Electrical Work, v(djeolu, Ifible may be irnived bi.,I/, o(wires. NO. of Recessed Fixtures No. of Ccil-Slisp- (P-idd;c) o• f No. of Lighting Ontlels No. of 1 lot Tul)s Kv,k K N'A '60-------------- No. Or Ughlitio Fixtures A eve III _i7T . 0GeneIliergelT T L a er Units Receptacle Outlets No. of Recept, No.of Oi�l�Bu�ynm FIRZ ALARMS No. of Zones No.ofSwifelies No.of -et Fo I-I u,i n e r s t Initiating Devices Ii n No. of Ran aes No.of Air Cond. r o Toils No. OfAlerthip 11c3it JPu _�T � Devices No. of Waste Disposers I I-P �ber F.0n­S.­. fN, T—N<I-—0f zones 11�es No.Of U�_(_ect d Tota S: No, oFS1lf-CGntTn�_c_d - -N u Defec(ioll/Alertir)o Devices of Dishw3sliel-S Sp,3C6,l,re.1 heating K —-—------ Local "" ' P" _E collpleclioll Other No. of Dryers )Icnling�Applialices Security �Systems: 'o. Do _C�or E _ f -"ir N-6 —IvY-T(e_r No-ofDevices or Equivalent NoIIcatcrs . OF­­­­ No. cl�__ S Ballastsf�a �rhlg: No.�ofDevi(es or Equivalent t> Telecomn) No. Hydromissae Bathtubs N I o to r.s Total I ions g I OTHER: or Equivalent '(11001 oddilional demi(ffdei,e(4 or as rrq�jtfired�b­lfhe Inspector of Wires. S U P--\-N CL. C 0 N.E I Z,1 GL: Unless less'waivcd by the 0 N\lief, no permit for the per fo r the licensee providesMan- ol'electrical work may issue unless Procif'of h3bility insuralice includim! "cowpleted operalloll,,coverage or its substantial equivalent. The undersigned cerlifies that such coyera s in force, and has exhibited proof orsame to the permit issoill,,, ofi-ice. CHECK ONE- IN�R_ANCE DOND ❑ OvIll-R - z f 'I IsIff-Efl), I 4(6A k-_\,50)W� - 1-1 (STx­ifY:) q c .- ___ yl _S 2- E-Shiji-iled Valite ofUjcCjI-ic.jI W " ol k. (Whr)ere uired by nimlicip,)l polio) (E\p1ro6on Di1c) Volk. to Start I 111specili011s to be 11c(1uMC'J in accordance with iMEC Rule 10,and Uj)0f1 LOMPletion. (711,11iclinhies vfpeJJ*l1rj"Illat Me Info If oil this nliplicativil 4C li-jee FJ 10 1 N A 1\It,. r LIC. ,\O. .Addr To I, iN'o.: -7-1 u S. .1/c- , 4. 1 01VtTO. No.: > CL R: 13Tuts irol 1CCIIIIN'd by la.t. lizibikiy ins' 4'l-9 c normally �=�� 13\ lily Si cc era�w I cwllcr s autill. goa(mc below, t licicby w�xfve l!6S oil,(110(check mic) F Telcpholle 11 T]--'E-T': S