HomeMy WebLinkAboutMiscellaneous - 437 SUMMER STREET 4/30/2018 437 SUMMER STREET
210/107.A-0083-0000.0
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;;';�~�o� TOWN OF NORTH ANDOVER
410 M- PERMIT FOR WIRING
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S`rACHUS�
This certifies that .:...........� . ............. ...��.�.'4;..i.�.�.........................:....
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has permission to perform ...... ,.?....... t-f........... ?... 1... ..........
wiring in the building of...................: C !.. .. .. .....................................
.....
at r,.7 ................�T..................:North Andover,Mass.
.............................................
oo— 70C
E (04#RICAL INSPECTOR
Check#
12499
Commonwealth of Massachusetts Official Use Only
Permit No.
`- - Department of Fire Services
Occupancy and Fee Checked
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(NEC),527 CMR 12.00
(PLEASE PRINT IN WK OR TYPE ALL INFORMATION) Date:
City or Town of. NORTH ANDOVER To the Inspector of Noires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) sc/ mit E
Owner or Tenant ��/ f o,ei cc�Q 2 d l e SeaAa4V& Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
- Existing Service-f�— Amps C;d / OVolts 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: e f,.`y�� �` Se�e,C �'`i e C7co,
Completion of thefollowing table may be waived by the Inspector of Wires.
No. of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total
I Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
o.of Luminaires Swimming Pool Above ❑ In- El Battery
o mergency ig ting
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
No. of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: - ""' ......"""............. Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local El Municipal ElOther
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 Wiring:
No.of Devices or Equivalent
QTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (Wen required by municipal policy.)
Work to Start: 7 Z /c Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: nless waived by the owner,no pennit 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 cover e is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains a d penalties of perjury,that the information on this application is true and complete.
FIRM NAME: . oo( of LIC.NO.: nn
Licensee: �/ r f4 Signature LIC.NO.: f TI
(If applicable,enter " L pt"in th��nqe number er line.) ����!` Bus.Tel.No.•
Address: p( (�r Alt.Tel.No.: ?
*Per M.G.L c. 147,s.57-61,security work Kquires 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 PERWIT FEE.$
Signature Telephone No.
❑ 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 throughout the Commonwealth,and applications shall be filed +
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an
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 shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he
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 of the Acts of 2010 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 certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012.
❑ Rule 8-Permit/Date Closed: ***Note:Reapply for new permit ❑
❑ Permit Extension Act-Permit/Date Closed:
Trench Inspection
Pass 0 Failed Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass Failed Re-Inspection Required($.)❑
Inspectors Comments: .
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass Failed 0 Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
ROUGH INSPECTION:
Pass n? Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments:
L�
.-
Inspectors Signature: Date:
FINAL INSPECTION:
Pass 0 Failed Re-Inspection Required($.) ❑
Inspectors Comments:
0—/
I Inspectors Signatu e: ate:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
The Commonwealth oflMlassachusetis
Department of IndustrialAcclkhts
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): q6f a ccl 14,
Address:
City/State/Zip: 11'a"v-Pf k l� /V& Phone#: 7,1( ZS--
Are you an employer?Check the appropriate box: Type of project(required):
1.[ 1 am a d I t
l 4
employer with . ❑ I am a generacontractor an `
� 6. EJ New construction
employees(full and/or part-time).* have liired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
p•insurance.' comp.working forme in any capacity. workers9. ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
r myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]i employees. [No workers' 13.[i Other
k comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
-Homeowners who submit this affidavit indicating they ate 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.#: 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
ofu'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.
1 do hereby certd rider the pains an dpe7eftl ofperjury that the information provided above is true and orrect.
Si afore: 4 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 an two or more
. . Y
of the foregoing engaged in a omt enterprise,and including J rp dm the legal representatives of a deceased g g P employer,or the
receiver v r 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 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-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 tho,
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 law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or ,
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachmetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
TeX,#617-727-4900 est 406 or 1-877,MASSABB
Revised 5-26-05 Fax#617-727-7749
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Sys �te. m .. Mon De .11,re"`s �
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Indoor Nigh Dater Alarm with Battery Bach-Up
•Durable Nerna 1 thermoplastic enclosure rated for indoor use
•Red'alarm'fight,green'on"light and 85 deabel hom at 10 feet
•Mechanial alarm float syAtch included(15'cord)
•Alarm test and ham silence button with auto reset—120 VAC R
•The alarm win continue to work even when the primary power fad dire to our battery back-up feature
•Auxiliary dry contacts are standard05
•External quick conmei terminal block for easy float installationTIPo
•Two-year limited warranty
Dimensions 6"X 3-3/4'X 2-112'
Enclosure Nema 1 thermoplastic(external mounting feet)
Ham 85 db at 10' 1
Weight 2.5 His with float
Voltage Primary 120 VAC,9 VAC secondary,60 Hz(alarm condition
2.5 watts max)
Power Cord 6 feet,120 VAC
float Switch 15'mechanical float with tie Strap(normally Open)
Moat Switch Connection Ouldc conned float comedian.Do not apply power.
Class two output,12 VAC °
Standard Auxiliary Contacts 240 VAC,5 amp max resistive/60 HzOw
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1OA200 SMD-21H 120 Indoor alarm with audible and visual alarm, 15' 1X 4 tbs. $93.00
mechanical alarm float,battery back-up,6 foot'power
cord,auxiliary dry contacts,and quick snap terminal
connections.(High Level)
1OA201 SMD-21L 120 Indoor alarm with audible and visual alarm, 15' 1X 4 lbs. $93.00
mechanical alarm float,battery back-up,6 foot power
cord,auxiliary dry contacts,and quick snap terminal
connections.(Low Level)
10A202 SMD-21N 120 Indoor alarm with audible and visual alarm,battery 1 X 2 tbs. $83.00
back-up,6 foot paver cord,auxiliary dry contacts,
and quick snap terminal connections.(No Float Switch)
1 OA204 SMD-21 HM 120 Indoor alarm with audible and visual alarm, 15' IX 4 lbs. $93.00
mercury alarm float,battery back-up,6 foot power
cord,auxiliary dry contacts,and quick snap terminal
connections.(High Level)
10A206 SMD-21HM PC Indoor alarm with audible and visual alarm,1S 1X 4 tbs. $97.50
mercury alarm float,battery back-up,6 foot power
cord,auxiliary dry contacts,SST pipe damp and quick
snap terminal connections.(High Level)
6 Call or in as your order today. Phone:601-939-2966 Fax:601-939-3526 E-mail:joeeenviro-flo.net
System.. Monitoring De vi-ces
Indoor High Water Alarm With Battery Back-Up
Installation information
0
PROM oa 98HOVaN 2 0 0
31 9V BATTERY 3
0 32 BACK-UP 2-
0
e
ALARM UNIT
FLOAT CORD COS
71 63 0~ o LIST®
PUMP POWER CORD s
S0
AUXILARY DRY
OBSERVER 200CONTACTS
0
0
6-POWER CORD
QUICK CONNECT TABSJ
FOR FLOAT SWITCH
(CLASS 2 OUTPUT)
a120V PLUG
0
& ALARM TEST
TIE STRAP SILENCE ALARM ALARM LIGHT
HORN
0
FLOAT SWITCH
ALARM POWER ALARM POWER
LIGHT CORD W/PLUG
ALARM FLOAT
DL
QUICK CONNECTC US ALARM FLOAT
CORD
o ( AUXILIARY CONTACTS
W/COVER REMOVED
O
NORMALLY CLOSED
USE TO TURN SOMETHING
'OFF"DURING HIGH WATER
CONDITION
COMMON MUST HAVE
HOT LEG FROM POWER
SOURCE CONNECTED
NORMALLY OPEN TO POWER CONTACTS.
USE TO TURN SOMETHING
'ON'DURING HIGH WATER
CONDITION
Call or fax us your order today. Phone: 601-939-2966 Fax: 601-939-3526 E-mail:Joeeenvlro-flo.net
7803 Date. �7!./ A . . . . .....
NpRTM
14,,
TOWN OF NORTH ANDOVER
f � 9
• PERMIT FOR GAS INSTALLATION
�1SSACMUSESt -
j� -T
This certifies that /`.�`!.'. . . 5�.�"`.h?.17.4.1
has permission for gas installation . . . . . . . . . . . . . . . .
in the buildings of . 5.0 !'� Q 0 R. P. . . . . . . . . . . . . . . . . . . . . . .
at 7. . u.(4i.tq l ill. . . . . . . ., Nort Andove Mass.
all
GAS INSPECTOR
Check# !U
C 71. Fltyffown.'
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
y /�- �Uv�t c. , MA. Date: �� Permit#
Building Location: 3 "Z C U hl vy ,04 <-t Owners Name: Si2d A-11)() P
Type of Occupancy: Commercial❑ Educational❑ Industrial ❑ Institutional ❑ Residential[�
New: ❑ Alteration:❑ Renovation: ❑ Replacement: Plans Submitted: Yes ❑ No'❑
FIXTURES
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V M D t=i 0 U1' 2 = O a IW > > > 5' O
SUB BSMT.
BASEMENT
1 FLOOR
2 FLOOR
3 FLOOR
4 FLOOR
5 FLOOR
_6TIFFLOOR
7 FLOOR
8 FLOOR
Installing Company Name:_tf` , Check One Only Certificate# h
564 fs'J!�'1 ��t _
/► ❑Corporation
Address:to 0 IJ0 X ,S�Cj (f City/Town:.--h0,0,__h-,,z11---state:
c ❑Partnership
Business Tel: dFax: -e
❑Firm/Company
Name of Licensed Plumber/Gas Fitter: ,S ,.Q v „Q f{/ , f f
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YesVo❑
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy [� Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Signature of Owner or Owner's Agent
Owner ❑ Agent ❑
By..checking this box❑;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 install ns performed under the permit issued for this application will be in
compliance with all Pertinent provision of the Massachusetts State Plumb' g odea d Chapter 142 of the General Laws.
=—(O—FFICE
Typ f License:
Bylumber
[BEl Fitter Signature of Licensed lumber/Gas Fitter
aster
Journeyman License Number:
❑LP Installer
4.�
Date.�/. �`l.�J.. .. �Ie
a NORTH
f 3j a1•,.ao e,41
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
9SSAcMUSES
This certifies that . . . . . . . . ... . . . . . . . . . . .
has permission for gas installation . .�'? �.,�. . . . . . . . . . . . . . . .
in the buildings of . . e!? . . . . . . . . . . . . . . . . . . . . . . . . . .
3 .S'� _
at . ./. . . . . . . . . G?L. . . : . . . . , North Andover, Mass.
Fee...!2j. . . . . Lic. No..`--7 3.�. . . . . . .� - .. .
GAS INSPECTOR
f� Check# G
5327'\
MASSACHUSETTS UNIFORM APPLICATION FOR'PERMIT TO
DO GASFITTING �
(Print or T e1
Vol ass. Date 20 Permit A lSr 2, 7
Building Location owners me j
Ai, e of Occupancy
New❑ Renovation❑ Replacement/ Plans Submitted: Yes❑ No
❑
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O = $ �
WAN low
Ze�� � aaE � � � z � - � W
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= O O = O C7 ce p 0 .'
SUB-BSMT a
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR .
' STH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
Installing Company Name Check one: Certificate
kd dress 1
❑ Corporation
3usiness Telephone j,,V- ---U ❑ Partnership
dame of Licensed Plumber.or 62S Fitter 1rmlCo.
INSURANCE COVERAGE:
'I have a current 11 billty Insurance policy or its substantial equivalent, which meets the requirements
No ❑ Of MCL Ch. 142.
Yes t
If you have checked yes, please indicate the type of coverage by checking the a
ppropriate box.
A liability Insurance policy G/' Other type of indemnity ❑ Bond
OWNERS INSURNAiCE 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 ffils7—permit applicationv'- Ives this requirement
signatureafowner or Owners Agen Check one:
Owner ❑ Agent ❑
iereby certify that all of the details and Information I have submitted(or entered)In above application are true and accurate to the best of
y knovNedge and that all plumbing work and Installations performed under the permit Is lzur this application be In compliance wlth
I pertinent provislons of the Massachusetts state cas Code and Chapter 142 of the Ce
By
Type of License:
Title
[i Plumber S Signature 91zi
re of L cerued PI
ber or Gas F tter
City/Town
❑Casfltter
APPROVED(OFFICE USE ONLY) ume License Number /}
. ❑joourneyman
BELOW FOR OFFICE USE ONLY
FINAL INSPECTIONS lKQTCMES PROGIIESS INSPECTIONS
FEE
Na ,
APPLICATION FO11 PERMIT TO 00 PLUMBING
NAIL i TYPE OF BUILDING
LOCATION OF BUILDING
PLUMBER
PERMIT GRANTED
DATE �1 f
PLUmmeINsPECT011