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HomeMy WebLinkAboutMiscellaneous - 430 MAIN STREET 4/30/2018 430 MAIN STREET 210/057.0-0003-0000.0 1 Date.k......r7 0 ;L TOWN OF NORTH ANDOVER PERMIT FOR WIRING SS^ ....................... This certifies that ... ....... ....................................... has permission to perform .4-4CI.......................................... . ............ wiring in the building of ................................................................................... at..--7/20 ...... 4t. North Andov�f�,Mass.. ...... ..... Fee�2©............. Lic.No���,14 ................. .. .. . . ..... 'ELECTRICAL INSPE Check #C-1! 8462 Official Use only Commonwealth of Massachusetts :.. Department of Fire Services Permit No. ��3� Occupancy and Fee CheckeQA BOARD OF FIRE PREVENTION REGULATIONS [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: /® — j' -(—c> 8- 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) �3O N1.+ltu 5 r Owner or Tenant �-Je le*,u AJ Telephone No. Owner's Address 15- —nM IF Is this permit in conjunction with a building permit? Yes ❑. No (Check Appropriate Box) Purpose of Building 0<re.l1`.'f' 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: Az^ ��� Completion of the following table may be waived by the Inspector of N%ires. 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 ❑ n- ❑ o.of Emergency Lighting rnd. grnd. Battery 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 Initiatin2 Devices No. of RangesTotal jl No. of Air Cond. Tons No. of Alerting Devices No, of Waste Disposers Heat Pump Number Tons KW No. of Self-Contained i1 Totals: Detection/Alerting Devices II No. of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection ' No. of Dryers Heating Appliances KSecurity Systems:*KW No.of Devices or Equivalent No. of Water No. of No.of Heaters KW Data Wiring: Signs Ballasts No.of Devices or Equivalent No. hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent ®_MER: ;t ttach additional detail if desired, or as required by the Inspeclor of[Vires. 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 forthe performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The :A14 undersigned certifies that such covera e is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Q BOND ❑ OTHER ❑ (Specify:) I certify,under 1 ai s auc Penalties oYIIV rjury,that the information Ord ids application i true and coillplete. FIRMNA lC`!S /lefµ}� , a LIC. NO.: Licensee . A75 tr rVivv& Signatur LIC. NO.: �''9-77 (Ifopplicable Inter '�c>�c upt"in the license mrmblr line.) Baas. Tel. No. ,Address: G. �c � (!� 1-1-0'1 �tdxa c'-R� fVt q O(W9 Alt.Tel. No.:n 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 cloes 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 [Jowner's agent. /Agent Signal FPERMIT FEE: Signature Telephone No. s The Commonwealth of Massachusetts „= Department of Industrial Accidents c .. Office of Investigations 600 Washington Street Boston, MA 02111 ii www-rrtass,gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leaibl Name (Business/organization/Individual) Address:-p - City/State/Zip:_N(7- (�00 Xi- / Phone #: 7 F/— rS/q— 7 9 �9` Are you an employer?Check the appropriate box: l.El I an a employer with 4. ❑ I am a general contractor and[ Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.RI—ant a sole proprietor or partner- listed on the attached sheet. $ 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. 9• ❑ uilding addition ' p ❑ We area corporation and its ,-.y� required.] officers have exercised.their 10 L1 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.7 Plumbing repairs or additions myself. [No.workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' 12.7 Roof repairs comp, insurance required. 13.[] Other ] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. +Homeowners who submit•this aE%Edavit inciicatiEw Gee-,ase doiEr--eEE::•��- - _.contractors b ) b ..ti{GLI tohire, $Contractors that check this box must attached an additional sheet showing the name of the outside ub-contractors and their workers'comp.policyavit dicating such. information. 1 am an employer that is providing workers'compensation insurance for mJ'employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date; Job Site Address:-73L,-) City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. I do hereby cern and a pain and penalties o erjury that the information provided above is true and correct SiQrtature ' Phone#: `7tr/— y t,/_ Ps—5L 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#: w 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 cant'workers' compensation insurance. If an.LLC LLP does have _ employees,a policy is required. Be advised that this affidavit may submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit(license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to 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 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 4.06 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7744 www.mass.gov/dia Date./ T ,14, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMUSE� This certifies that has permission to perform . . . . ./`,!�.- .�/ � . . . . . . . . . . . . . . ( 4 t plumbing in the buildings of . . . . . . . . . . . . . . at . . . . .t(' . . L9. !.,� . . . . . . . . . . . . . . .. North Andover, Mass. Fee. .' Lic. No:./?. . . i I. . . . . . . . PLUMBING INSPECTOR Check # 7883 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) n ' MUMbE2 , Mass. Date !O !y 4 t _ O � Building Location �3 0 /�i'�-/P S' 7 Owner's Name /7,(.teb 1�L�r Type of Occupancy K ES'l2) New❑ Renovation❑ Replacement[ Plans Submitted: Yes❑ No[:] FIXTURES z y z Z Z J 0 � (' Z W LU Z y Z IQ _ Z ~ W �- O m W c7 lW- co >- Z yn LJi. IY in Q W Z Q W G 0 0 W [/� J —� Q' fY 4 Y x -j CL = a Z 0 cx) Z Q 3: Is Y Z cxn _ a a o y it 1 0 1= a�Q o = Q m m m m 0 0 0 LL x Y J F� y N O SUB-BSMT. BASEMENT 1 FLOOR 2 FLOOR 'y 3Ru FLOOR 4 FLOOR Installing Company Name A-c- Check One: Certificate Address 7 f i�EI—IL ,,�- % /, ❑f orporation I `4 �J�`���6.�E-11 N J-V Q t N(L ❑Partnership Business Telephone C4 t3 S'' ❑Firm/Co. Name of Licensed Plumber !- i= 14 L>-ri,; INSURANCE COVERAGE: I hay e a current liabilih ' surance police or its substantial equi�-alent which meets the requirements of MGL Ch. 142. es ❑No If you have checked ves.please indicate the type of coverage by checking the appropriate box. A liability Insurance Polio-[� Other type of LidelrinitvF] Bond[] OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insuralnce coverage required by Chapter 142 of the Mass. <Teneral Laxvs_and that my signature on this permit application rn air es this requirement. Check One: ❑(:)N`nner [:]AgentSignature 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 o my knowledge and that all plumbing work-and installations performed under the permit issued for this application will be ui compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General I31' TYPE of LICENSE: r-,TIBER SION.3 c . ICENSED PLUMBER M(3ASI7TTER TITLE ❑(TASFITTER r� BMSTER 1, � CITY TowN ❑J(ATRNE11LAN LICENSE NUMP,ER APPROVED(OFFICE(TSE ONLY) I Date,,! �y/�V�e ... . . .. . it HORTM - 3� ° TOWN OF NORTH�AND. VER 0 9 J i > PERMIT FOR GAS INSALLATION ' CHUSES This certifies that ( .�.t.�?�� . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . in the buildings of .�d!L! ��h. �.:':'. . . . . . . . . . . . . . . . . . . . . . . . at .3 P. /hI41.:-% . . : . . . : . . . . . . . .. North Andover, Mass. Fee. 3.U. . . Lic. No./ -- . . . . . . . . . GAS INSPECTOR Check# 'I t 6577 MASSACHUSETTS UNIFORM APPLICATION FOP.P 1RMIT TO DO GASFITTING i 1/" ,Mass. Date 101NI& 20 d& Permit# Building Location Loo h&/V ,Sr Owner's Name Type of Occupancy S> New ❑ Renovation ❑ Replace nt Er"'Plans Submitted: Yes❑ No❑ z GQ ¢ za ¢ �xw ° o oE_ U X00 IU' PR 1 SUB-BASEMENT BASEMENT FIRST(1ST)FLOOR SECOND(2ND)FLOOR THIRD(3RD)FLOOR FOURTH(4TH)FLOOR FIFTH("5TH)FLCX:)R SIXTH(6TH)FLOOR SEVENTH(7TH)FLOOR EIGHTH(8TH)FLOOR histalling Company-Name � �1.. ILLU�i.r �- .� -�f Address .171 I Q' -' j'-� °i Check one: Certificate I+4.)OVEI A- 6 f 4�E ' corporation ; Business Telephone IT-> S` &"?rfef ❑ Partnership Name of Licensed Plumber or Gasfitter � � - 14 o l—k(c„� ❑ Firm/Co. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes ,p— No❑ If you have checked yes,please Indic e the type of coverage by checking the appropriate box. A habilih-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 MGL,and that my signature on this permit application waives this requirement. Signature of Owner or 01x-ne6s A ent 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 the permit issued for this application will be in compliance with all pertinent provisions of th e"sachus'tts State Gas Code and Chapter 142 of the General Laws. / '1 By Type of License: Title ErlTumber P-Master Sig#rj f Licensed Plumber/Gasfitter City/Town ❑ Gasfitter ❑ Journeyman Li se number APPROVED OFFICE USE ONLY)