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HomeMy WebLinkAboutMiscellaneous - 43 MARBLEHEAD STREET 4/30/2018 43 MARBLEHEAD STREET 210/008.0-0020-0000.0 i f NORTH q - Q �S�ao gas tip lir "~ � ••, a pL ,., Town of North Andover �o D.B.A. —Zoning Compliance Form 'rap * 978-688-9545 �9SSgCHus��'c`� This form must be reviewed with the Inspector of Buildings. Office Hours are Monday-Friday 8-10 am,and 1-2 pm Monday-Thursday. Alicant Name: Name of Business: Address of Business: -/,3M a4-" If, 49-� Zoning District Map $ Lot Phone: 9 7 ?'- _27/ - Email 3p I Nature of Business: S r_'-Q a-n6 rl r-11 n�"—l 4?--z �� r .. J, Do you own this property? Yes No If no, written permission is required from your landlord. Will you have clients coming to this property? Yes No \I Will you have any employees? Yes No Will you have any major deliveries? Yes No Description of Business Activity(MustbeCompleted) / Signature of Applicant For Signage Refer to North Andover Zoning Bylaw Section 6 The proposed us i an allow e in this zoning district. Issued By (.- Date d/ e4, Date...... ............... OF %OR TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Thiscertifiesthat ............................................................................................. .................. has permission for gas installation ..AP.(.14tL... Al in the buildings of AUI.4-0-4—.......... ............................................... at.......................................................I......................................—, North Andover,Mass. FeeJP- S... Lic. No7- .. .... ......................... 4//G A INSPECTORS Check# 93915 Date.7WKV......... 10616 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING g8•�cMus� �,� This certifies that:`-....4!(e�........ . ........... .................................................:........... has-permission to perform..... il¢ .... ''...................................................... t`plumbing in the buildings of............... f:................................... at.....4 3.....� !a r'....1 .. .......`�� .. .............t North Andover, Mass. Fee .:,/,U...Lic. No.�. - .. .... .................... FCUMBING INSPECTOR Check# v�, f MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE '7 ( PERMIT# " JOBSITE ADDRESS WNER'S NAME POWNER ADDRESS TEL IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: M RENOVATION:® REPLACEMENT: ( PLANS SUBMITTED: YES 0 NOD 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 ! _ J .._._ _.--� 1 I J I ..-_.._.J .:. ( ..__.._ Ji= ROOF DRAIN SHOWER STALL SERVICE/MOP SINK = TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 64 OTHER TYPE OF INDEMNITY i BOND M 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 0 AGENT (I SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to t best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in c mplia with all P nt ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# GNATUR MP X JP 0 CORPORATION MJ#=PARTNERSHIP 0# ;LLC COMPANY NAME t ¢- ; ADDRESS CITYf STATE ZIP / �i TEL 03 --- FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES l The Commonwealth ofMassachusetts " Department oflndustriglAccidents Office of Investigations 600 Washington.Street Boston,MA.02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers, Applicant Information Please Print Legibly r Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(fall and/or part-time).` have hired the sub-contractors 2.KI am a sole proprietor or partner- listed on the attached sheet.I 7• F1 Remodeling ship and'have no employees These sub-contractors have 8. E]Demolition working for me in any capacity. workers'comp.insurance. g• [J Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.El am a homeowner doing all work right of exemption per MGL 1111 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 41 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they gie 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 anal job site information. Insurance Company Name% Policy#or Self-ins.Lic.#: ExpirationDate: 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 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 maybe forwarded to the Office of 'Investigations of the DIA for insurance coverage verification. I do hereby cert under the pains and penalties of perjury that the information provided ab Ove 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.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person:- , Phone#: Information and Instruction*8 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 ofits political subdivisions shall enter into any contract for the performance ofpublic 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 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(ifnecessary)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 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 orpermit 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 CaMmaORMalth ofMamachusetts Dopartmoat ofladustdal.Accidents Office ofIavestigatio.0 500 Washixt&a Street BostonMA02111 TO,A 517-727-4900 ext 405 ox 1-877�,MASSAFE Revised 5-26-05 Fax#617-727-7749 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY __ MA DATE PERMIT# b 6 JOBSITE ADDRESS L kf-R OWNER'S NAME OWNER ADDRESS TE FA TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL El PRINT CLEARLY NEW:Q. RENOVATION:El REPLACEMENT:ha PLANS SUBMITTED: YES 0 NO E] APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER _ _I ._ C+ ._ L�- - ED -�- - CONVERSION BURNER COOK STOVE DIRECT VENT HEATER + DRYER - FIREPLACE FRYOLATOR ---- FURNACE GENERATOR J � GRILLE INFRARED HEATERS _ - _. LABORATORY COCKS MAKEUP AIR UNITI- OVEN POOL HEATER ROOM/SPACE HEATER _ __ __ ► __ _ ROOF TOP UNIT ` TEST UNIT HEATER _ UNVENTED ROOM HEATER I WATER HEATERI~- OTHER — .-- -----_ - --- -- - - �� ---F771 - INSURANCE COVERAGE -- I have a current liability nsurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY P OTHER TYPE INDEMNITY © BOND -11 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 0 SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and urate to th st o my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co plian all Pe ' p ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME v LICENSE# Z0 9IGNATURE MP Ea MGF El JP ® JGF LPGI -j CORPORATION Q# PARTNERSHIP®#=LLC D#= COMPANY NAME: ADDRESS _ �) CITY _ STATE ZIP O TEL FAX —�_ CELLEMAIL� ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No 7'`7p"� THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES �► The Commonwealth of Massachusetts - - Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organi'zatiordlndividual): Address• City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2!�I am a sole proprietor or partner- listed on the attached sheet. �• Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. -1 9. ❑Building addition [No workers' comp.insurance 5. El We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box N must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then.hire outside contractors must submit a new affidavit indicating such. 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.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 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 certify under the pains andpenalties ofperjury 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#: 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 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 j oint 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-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 may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. AIso 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 I policy information(ifnecessary)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 ciuestions, please do not hesitate to give us a call. The Department's p s address,telephone and fax number: The Commonwealth ofMassachwotts Department of Judustriai.Accidents Office of havestigations 6.00 Washington Street Boston,MA 02111 Tel,#617-727-4900 ext 406 or 1-877:MASSAM Revised 5-26-05 FaY,#617-727-7749 www.Mass,gov1dia Date....— V ............................ e TOWN OF NORTH ANDOVER PERMIT: FOR WIRING This certifies that ................ ... ......... ......................... has permission to perform ........65-4F..... wiring in the building of....... ............ Ar . ........................................ at.. / ....../.. .....R.A e, ........6........5.......... .North Andover,Mass. ............. Fee..:*.��............. Lic.No.J.?11�1 ;`. 7 Check # 66b3 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 0 Occupancy and Fee Checked lug BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/051 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: ' City or Town of: To the Inspector of Wires: By this application the undersigned giv s notice of his or her intention to perform the electrical work described below. Location(Street& Number) ' Le ru Owner or Tenant Telephone No. Owner's Address VY� Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building / , Utility Authorization No. p g le _ L -o s Y 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: 0 e d'e Po o L 06 J Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires ] No.of Ceil.-Susp.(Paddle) Fans No. of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Batter 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. Total No.of Alerting Devices Tons g No. of Waste Disposers Heat Pump Number Tons K No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications firing: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: / O6 — (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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [6- BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: ` 1)� LIC. NO.:1K/yg Licensee: VA w b-e 0�rjo Signature LIC.NO.. B (if applicable, enter "exempt"in he license number line.) / _ Bus.Tel. No.. Address: �, �G.U1eis^S �� NV /�!/l C�Ub��l� Alt.Tel. No.: *Security System Contractor License required for this work; if applicable,enter the license number here: 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. $ Commonwealth of Massachusetts Official Use Only Permit No. (Ct 6 a Department of Fire Services Occupancy and Fee Checked r� BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] 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: ' Z - 06 City or Town of: To the Inspector of Wires: By this application the undersigned givs notice of his or her intention to perform the electrical work described below. Location(Street& Number) (�f 6 Le N da � 1 Owner or Tenant S S Art i 1`7 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building 4&Q Cyt) 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: O t ire Po D L 06 d-oe t Completion of the ollowin table ma be waived b the Ins ector of Wires. No.of Recessed Luminaires `` � No.of Ceil.-Susp.(Paddle)Fans o.o ota �P Transformers KVA t No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. El Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.o Initiating n an Devices No.of Ranges No.of Air Cond. TotaTonal No.of Alerting Devices Heat Pump Number Tons o.oSelf-Contained No. of Waste Disposers Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other C No. of Dryers Heating Appliances Kms, Secrlo.of yDevic s or Equivalent No.of Water0.o o..o Data Wiring: Heaters Signs Ballasts No.of Devices or E uivalent No. Hydromassage Bathtubs No.of Motors Total HP a ecommunications firing: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: _/ pd �- (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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 0�- BOND ❑ OTHER ❑ (Specify:) I certify,under the pains anti penalties of perjury,that the information on this application is true and complete. FIRM NAME: ` Ud 14 CJ4b2QLIC. NO.:Ig/sr5Gt Licensee: `' d w ,.p OoiQ Signature LIC.NO.: Q (If applicable, enter "exempt"in he license number line.)e / �] Bus.Tel. No.V�5 E,. J 6. Address: �'.Z. 515kl)r)WY2i('S ,�5 7— d'l� 1214 C b��l� Alt.Tel. No.: O *Security System Contractor License required for this work; if applicable,enter the license number here: 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 yr r f 2 7— c, f)P--Y • T s_ • Date. . .z.. .. ©... .. .. z ,,ORTI, { 3?0�..ao �ti�L TOWN OF NORTH ANDOVER • - PERMIT FOR GAS INSTALLATION �9SSACHUSESS This certifies that . . .� ? ?-z • All k „ has permission for gas installat/lio1*,-*--i!4--&�-:.-t%. ��s�. _ . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . at North Andover, Mass. Fee-. 3:.` Lic. No.. � A �r . . . . . . . . . . . '-GAS INSP eTOR ` Check# 5526 * $ . .-.FTTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) , Mass. Date Z 20� Permit# Building Location Y3 /77,4t6j,/ 671' Owner's Name 5 'SvrlhG'r✓ s"mi -J Telephone 975f-6,Y:' r-. 3 $ 7 Z Type of Occupancy A e-5 Jj, New M Renovation o Replacement Plans Submitted: Yes E] NoEl m Y F m °' L L 12 0 O yyr d d 0 12w U m = E 2 W 12 a) lQ mN d O Q. W d d 12 O > a) aNi N c 2 12 0 `�' > w = N r+ C a+ O r d O C O w O O + d im O =ILL o 89 .moi 0 W m D CL m O SUB-BSMT. BASEMENT 1 ST FLOOR 2ND FLOOR 3RD FLOOR ► , 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name EnergyUSA Propane,Inc. Check one: Certificate Address 100 Myles Standish Blvd.,Suite 101 X❑ Corporation 132 C Taunton,MA 02780 El Partnership Business Telephone (800)822-1300 Manager-Bob Olander X8055 El Firm/Co. Name of Licensed Plumber or Gasfitter William Kent Corson(800)822-1300 X8051 Cell (508)294-6660 ..... ...... r INSURANCE COVERAGE: EnergyUSA Propane;Inc:_ has a current liability insurance policy or its substantial equivalent,which meets the requirements of MGL Ch.142. Yes X❑ No If you have checked yes,please indicate the type of coverage by checking the appropriate box. A liability insurance policy X❑ 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. t Check one: Owner El Agent Signature of Owner or Owner's Agent 1 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 Code and Chapter 142 of the General Laws. Type of License: By aPlumber Title -MGasfitter Signature of Licensed Plumber or Gasfitter City/Town X Master IIIAPPROVED(OFFICE USE ONLY) nJourn.eyman License Number 3707 BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING NAME &TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIC. NO. PERMIT GRANTED DATE 20 a" GAS INSPECTOR