HomeMy WebLinkAboutMiscellaneous - 45 HERRICK ROAD 4/30/2018 c----
/ 45 HERRICK ROAD
J210/015.0-0055-0000.0 `
� I
i
i
I
1 k
Ef
I
I
I
�f
I
Date..... �i ......�.....
� NORTM
or °.:�•'."o°� TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
SSCHU E�h
Thiscertifies that )-w..... ................ . .....................................................
has permission to perform ........... .........K-- ^^ "e ..................
wiring in the building of..........
at. 7---3........ ..... .... ........................... . orth Andover,Mass.
D' Fee . Lic.No 3 .�ZS.......... .i -
C 1 ZINSPBCTOR
Check #
8944
Commonwealth of Massachusetts Official Use Only —
_ Department of Fire Services Permit N°._ y�
t ' kip BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/07]
Qeave 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 WINK OR TYPE ALL INFORMATION) Date:
City or Town of: NORTH ANDOVER To the Inspector of W' es:
By this application the undersigned gives notice of his r her intention to perform a electrical work described
=On
(Street&Number) C &
011
below.
ll' �
r Tenant 2
� Lt4Z Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes
No ❑ (Check Appropriate Boa)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Und d
;�' ❑ No.of Meters
New Service Amps / Volts Overhead
❑ Undgrd ❑ No.of Meters
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work:
� )
t � � ,�(1✓1��
Completion o the ollowin table m be waived b the Inspector o Wires.
No.of Recessed Luminaires No.of Ceil-Soap.(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
Id. d. ❑ Batte Units
A —. No.of Receptacle Outlets No.of Oil Burners
FIRE ALAMMS No.of Zones
No.of Switches No.of Gas Burners o..of Detection and
Initiating Devices
�
No.of Ranges No.of Air Cond, Total No.of Alerting ming Devices
No.of Waste Disposers eat Pump Number Tons ICW No.of Self-Contained
Totals: __._._._..._.__.___ ._. _.___.
-
Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW cal❑ Municipal
Connection ❑ Other
No.of Dryers Heating Appliances KW Security Systems:*
No of Water No.ofo.oNo.of Devices or E uival mt
Heaters KW Si s Ballasts Data Wiring:
No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total Hp Telecommunications Wiring:
OTHER:
No.of Devices or E uivalent
Attach additional detail tf desired, or as required by the Inspector of Wires.
Estimated Value of lectijcal Work: (When required by municipal policy.)
Work to Start:, r0 O Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVE GE: 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.
f CHECK ONE: INSURANCE [0 BOND ❑ OTHER
I certify,under the pains and enalties o ❑ (Specify:)
p f perjury, that the information on this application is true and complete.
FIRM NAME:
LIC.NO.:
Licensee: ( pt )rV Signature
(If applicable, enter�z mpt"in the ' ens numb-ep l ne.) LIC.NO.:-36
Address: (' /V p r l �,C f� 16(g&4( us.Tel.No.:
*Per M.G.L c. 147,s. 57-61,security work requires DepartMent of P lic Safety"S"License: Alt.L cl.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: $
t . The Commonwealth of Massachusetts
Department of Industrial Accidents
Dice of Investigations
* `E'dl; 600 NMashington Street
Boston, MA 02111
t' www.massgov/dia .
workers' Compensation Insurance Affidavit: Builders/Con
Applicant Information tractors/Eieatricians/Pil>mbers
Please Print Leeibl
Nalie (Business/OW.izadongndividual): C
Address:
City/State/Zip: #1k0C 96)J Phone#:_
Are you an employer?Cheek.the appropriate box:
1.❑ I:aro a employer with 4, Type of project(required):
❑ I am a general contractor and T
employees(full and/orpart-time),* have hired the sub-eornsactors 6 New construction
2. I am.a:sole proprietor or partner- listed on the attached sheet t I 1 7. ❑Remodeling
'ship and have no employees These sub-contractors have 8. ❑Demolition
working for mein any capacity, workers, comp.insurance.
[No Wod=S$Comp.insurance 5. 9• ❑Building addition
p ❑ We are a corporation and its
'required.) officers have exercised their 10.❑Electrical repairs or additions
3.❑ 'I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No-workers'comp. c. 1.52, §1(4),'and we have no 12. Roof
insurance required.] ❑ repairs
nq ] .employees. [No workers' 13.7Other
comp. insurance required.)
"may appiiceirtt that ishecks bob#l must also fits 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 connectors must submit a new affidavit indicating such.
4conttactors that check this box mustattsehed an additional sheet showing the name of the sub-
!` contractors and their workers'comp.polite i.^.fcrnL.daci.
I ant an employer that is prgvidcng:workerscompensation insurmweformy.employees; Below is the o ob site
inform doiL P &7'and'J
• Insurance Company Name: '
Policy#or Self-ins.Lie..#: Expiration Date:
Job Site Address:_ l`Ee.�i�(G /�.'( CitylState2ip. /
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ex iration (J
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.
Ido hereby certify er the airs and alti of perjury that the information pro7dev is-oue correctSi ture: Date: / 0
Phone
Official use only. Do not write in this area,to be completed by city or town official
City or Town: PermitUcense#
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 emp 11oyers 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 tnmstee 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 bo 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 conformation 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 Officinis
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/]ic=e 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 starnped 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 parson 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 1-8.77-MASSAFE
Fax#617-727-774
Revised 5-26-05
www.mass.gov/dia
Date.
NORTH TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
,SSACMUS� }�
This certifies that �.�12,ri�`" : . . .00 ?. �"l�'���� '. . . .
has permission to perform ? !. � F d`'L .& 1. -
plumbing in the buildings of . . .`�
TJ..... . . . . .. . . . . . . . . ., North Andover, Mass.
Fee. . f. ".Lic. No.. / . . .5 . . . . . . . . . . . . . . . . . . . . . . . . . .
PLUMBING INSPECTOR
Check .N
8177
MASSACHUSETTSUNIFORM U ORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type)
,Mass. DateQK(0 Cf 20 o q Permit#
Building Location Owner's Namel A 900 �O tJ
� n 5
Owner Tel# Type of Occupancy ke 5
New ❑ Renovation Replacement ❑ Plan Submitted: Yes ❑ No R
FIXTURES
P1
z
y
y W x F
04 rn tr;
04 w
win � 3 � m
2 9NDFLW_R
ao FMR
41""FLOOR
1- R
>A
m
Installing Company Name '?� >I PC-) oJ6 Check one: Certificate
Address y N 10 1 J ST Z P Corporation 6 Z
I
❑Partnership
Business;Telephone# 60 - 1 ❑Firm/Co.
Name of Licensed Phimber MA I71'0 PIZ Z C7
WSURANCE COVERAGE:
I have a curie"
bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 66 No ❑
If you have checked Ms,please indicate the type coverage by checking the appropriate box.
A liability insurance policy a---- Other type of indemnity ❑ Bond ❑
I
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.
General Maws,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 wort: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.
By a&t4j /.22 0
Si cute of Incensed Plumber
Title
Type of License:Master 011 Journeyman ❑
Cityrrown
APPROVED(OFFICE USE ONLY) License Number 46 l
—' Department of Industrial Acridents
�=
Office
Investigations
7 600 Washingtan Street
Boston,MA 02111
Workers' Compensation Insurance Affidavit: Builders/C.ontraetors/Electricians/Plumbeft:•
Applicant Information Please Print Le 'blv
Name (Businessiorpuization/Individual): A Q'4 PC-M:A 1 :2L U 1A.g JC
Address: J 0 >J 1 0 ►J S .... -
City/State/Zip: P4t 2 t-"`'J IJ — ►'�� `Q02' Phone #:_6 t �U4
Are you an employer? Check the appropriate box:
I . . Type of project(rewired):
1. I am a avloyet with�_ 4. C] I am a general.contractor and I
employees(ftill and/or part-time).# have hired the subrcontracrors �. Q Rem delinnction
?.C❑ I am a sole proprietor or parmer- listed on the attached sheet t 7: Remodeling
ship and have do employees These sub-contractnrs.have _ S. Q Demolition
working for me in any capacity. workers' comp..insurance. g, Q Building addition
(N?woitets' comp. instt ce- 5. ❑ We are a corporation and its .
reElectrical"quu•ed.] I officers have exercised their 10. repairs or additions
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
12.0 Roof repairs
insurance required.] t employees. (No workers'
comp. insurance required.] 13.M Oter
Any applicant that checks bot*t muse also fill out the section below showing their workers'compensation policy infommdm
Homeowners who submit this affidavit indicating they are doing all work and then bite outside=Mctm must submit a now affidavit indicating such,
Cantracmts that check thin box must attached as additional sheet showing the i ken of the sub-contractm and their workers'roe;.policy inforrnatialL
!ane an employer that is providing workers,compemadon , esf Qr.in em 1 ee& Bdvw is the policy:artd job site
.f Y P o3'
'nformation. ' ;::::rtirn:
Insurance Company Name: ( WAPIt fo �:.
Policy#or Self-ins.Lic. #: -1,6 \)J e( \Jn Expiration DAM: ] o
Job.Site Address: City/Slatemp:+ Afikye ✓ _MA , 01945
Attach a copy of the workers' compensation policy deciaradoa a(showing the policy number and
Pa8 ( 8 P c}' etpiration 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 51,500.00 and/or one-year imprisonment; as well as.civU penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 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 cerci i4er the pants and penalties of perfury that the information provided above is true and corn ,
act
Siznattire: Date 08
-Phone T: 61 - 5 O� Z Z
Oficial use only. Do not write in this area,to be completed by city or town=offer
City or Town: Permit/ icense;*
Issuing.Authority (circle one):
I. Board of Health L Building Department 3. Citv(Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: Phone 4:
Date. .... ..
TOWN OF NORTH ANDOVER
PERMIT FOR GASINSTALLATION
Io
o"4.
CHU
This certifies that . . ..... . . . . . . . . . . . . .
has permission for gas installation . . .
in the buildings of . . . . . . . . . . . . . . .
at . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . .. North Andover, Mass.
Feer . . ... . Lic. No.ZZ// . . . . . . . . . . .
GAS INSPECTOR
Check A 6
6723
AiA S,AMUSEMUNIFORMAPPUCA'PONFORPERNWTODOGASFITTING
(Type or print) Date
NORTH ANDOVER,MASSACHUSETTS
J
Building Locations /�� Permit#
+ Amount$
Owner's Name R d&
New 0 Renovation Replacement Plans Submitted 0
ac
wz a
a C 04 F OG
P4 F z O w
wd GC d >
1 d tx W C4 A F
Gh F x F W 94 U w w w C7 p0
o x 3 A a a > A w [w-
SUB-BASEM ENT
B A S E M ENT
1ST. FLOOR
2ND . FLOOR
3RD . FLOOR
4TH . FLOOR
5TH . FLOOR
6TH . FLOOR
7TH . FLOOR
8TH . FLOOR
(Print or type) D _ C k o e: Certificate Installin Company
Names (-,��1� -3 ��7 f(��-E �/�/C. Corp. /Ifo
Addrass R`7 C l oL.> �5 T Partner.
f mac)M2R v-i-we M/t
Tusiness Telep one Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
I have a current liabi1 'ty Insurance policy or it's substantial equivalent. Yes EY No
If you have checked yes,please in Cate 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: 13Signature of Owner or Owner's Agent Owner 13 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 G o e d Chapter ener ws.
By:
ey Signature of L' ensed Plumber Or Ga Fitter
Plumber g 9 J 7
City/Town Gas Fitter License Numner
aster
APPROVED(OFFICE USE ONLY) Journeyman
f