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Home My WebLink AboutMiscellaneous - 453 JOHNSON STREET 4/30/2018 (3) 453 JOHNSON STREET 210/098.A-0069-0000.0 e- a W Date.......... .................. NOR71{, 4,, TOWN OF NORTH ANDOVER PERMIT FOR WIRING SACMUS� i This certifies that ..................... �P.-- haspermission to perform ... . 'a.... ._.............................. . .... ...: �,' wiring in the building of..... ^...r.... ...............................................................—� . ......... .............. ......North Andover,Mass. t Fee?................... Lic.No .............. .. --- ELECTRICALINSPECTO Check # 7gr- r Commonwealth of Massachusetts Official Use Only Permit No. 179S29 Department of Fire Services \VtVOccupancy and Fee Checked c% 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(M C),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 10,6 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives noticeofhis or her intention to perform the electrical work described below. Location(Street&Number)_45:tj �!o ,j g0.00 31— sor Tenant - �TpNp,u�y y) Telephone No. P 9,-4'r 7z S 3303 Owner's Address rrt Is this permit in conjunction with a building permit? Yes ❑ No Cg (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service loo 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: luSnau d;e�LdTS � LdlZgnaL ' Completion of the ollowin 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 J KVA /d No.of Luminaires Swimming Pool Above ElIn- E3 o.o mergency ig g 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 InitiatingDevices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g 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❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of No.of No.of Devices or Equivalent Heaters KW Signs Ballasts Data of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of lectrical Work: 3Qbi3•d7' (When required by municipal policy.) Work to Start: pe Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE OVERAGE: 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 the pains andpenalties ofperjury,that the information on this application is true and complete. FIRM NAME: (/ LIC.NO.:- ✓�� Licensee: Signature LIC.NO.: (If applicable, enter"exempt"in the license number line) Bus.Tel.No.: Address: Alt.Tel.No.: *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 byIa . By my signs a elow,I hereby waive this requirement. I am the(check one)❑owner Elowner's agent. Owner/Ag t Signature Telephone No.(ob�- �c-�0,a PENT FEE. $ °% i The Commonwealth of Massachusetts , f Department of Industrial Accidents �..�,ct AOffice of Investigations �.t� ; , 600 Washington Street i� Boston, MA 02111 i www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Le Print�p V Name (Business/Qrganization/individual): A J IW" V 14 C-0L(25W Address:_ 4L City/State/Zip: 172A.u6lhe5rrwx ,V Phone#: . Are you an employer?Check the appropriate box: Type of project(required): I-❑ i am a employer with 4. F1I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors b. ❑New construction I 1� am a sole proprietor or partner- listed on the attached sheet.t 7• ❑ Remodeling 2. 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 10.❑Electrical repairs or additions required.] officers have exercised their P 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 repai insurance required.]t employees. [No workers' svv�Lc comp. insurance required.] 13'�'Other 2, *Any applicant that checks boi#I 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. $Cont actors that check this box must attached an additional sheet showing the name of the subcontractors 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: Srw '142rn Policy#or Self-ins. Lic.#: !2r 134 6,712--Z- Expiration Date:_ Job Site Address: City/State/Zip: ) ofAo X, ration page(showing the policy number and expiration date). Attach a copy of the workers' compensation policy decla 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 certify under the pains and penalties of perjury that the information provided above is true and correct Suture: Date: Phone#: Official use only. Do not write in this area,to he 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 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_ot 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 cavy 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 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 Revised 5-26-05 Fax#617-727-7744 www.mass.gov/dia Date.3.:c .. . . NpRT/, pE �.ao o? 6 TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION 4 to h SAC'HUSEtIC _ This certifies that .� . . . . . . has permission for gas installation . .D 4T- 4-- in the buildings of . . qs,3 �- .k . . . . . . . . . . . . . . at . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. North Andover, Mass. Fee, ,D.�. Lic. No.. �` 7 -1 :'�. .......:1.� `� V GAS INSPECTOR Check# /�7�� u 56 . 0 - %ACHCSETCS LjNU0D',I APMCATON FOR PE LNffrTO DO GAS Fn MG (Type or print) Date CC NORTH ANDOVER,MASSACHUSETTS X5.3 Building Locations Permit# Amount S () G.a d rl �N SGS Owner's Name Newt] Renovation a Replacement Plans Submitted D WWF >0G C p C a W F ` ZZ d z 3 °� °' °x o° o FU- B •BASEMEN T r BASEM ENT �r QST, FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR STH . FLOOR 6TH . FLOOR 7TH . FLOOR IS FLOOR (Print or type l one: Certificate Installing Company Mame - \" S� �Sa<`c1S� L�. Corp. �q :address \s��d, S Partner. usiness a ep one al's 'Z"��!-"l�'j0 Firm/Co. Name of Licensed Plumber or Gas Fitter IN SURANCE COVERAGE Che one: I have a current liabilityurance policy or it's substantial equivalent. Yes Noll If you have checked yes,plL se indicate the type coverage by checking the appropriate box. Liability insurance policyIn Other type of indemnity 1:1 Bond 13 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 13 Agent 13 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,ill plumbing work and installations performed under Permit Issued for this application will be in inpliance with all pertinent provisions of the�1. is Sta as Cu nd L apt of the General Laws. Signature of Licensed Plum er Or Gas Fitter B tle Plurnber 3-�35 Citv;Tcwn Gas Fitter License Number er Master APPROVED,CFFZCE I.SE CNLY; Joumeyrnan Date.. . /r NORTH 3? y` L TOWN OF NORTH ANDOVER O 9 • PERMIT FOR GAS INSTALLATION �,SSACMUSEt This certifiesthat:. . r c``'' . . . '. . . . . . . . � � 1 has permission for gas installation U�' . . ... .' !. . . . . . . . . . . . . in the buildings of � .- . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . .. North Andover, Mass. Feev. . . . Lic. �+ GAS INSPEC70f#� v c� Check# �3 5291 MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) Date NORTH ANDOVER,MASSA7bCHUSETTS Building Locationsq ST F Permit# Amount$ Owner's Name New Renovation Replacement ❑ Plans Submitted Ua a o w PW rAC a O a z w z u w z OF a D x w ►ten C7 F Z F d x W 5 w w F W F �+ C h W > w a �' m z o G Z , z w C F w 7 W) x x o x 3 c .da o c 11Q, > c a° H o SUB -BASEMENT B A S E M ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 13TH . FLOOR (Print �i or e) Check one: Certificate Installing Company Name ELcI J64AAO 4, Z-zu 6?txex X r D Corp. Address yti Irig7Ci-�211,— •O• O Partner. au0 D&r-4% Av 7Y d 3653 El Business Telephone C— — ZZ Firm/Co. Name of Licensed Plumber or Gas Fitter?iay 6W46,0p%J INSURANCE COVERAGE Check o I have a current liability Insurance,policy or it's substantial equivalent. Yes rM No� If you have checked Les,please indicate the type coverage by checking the appropriate box. .ti Liability insurance policy M Other type of indemnity D Bond Owners 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 13 Agent 13 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 M sachus State Gas ode and Chapter 142 of the General Laws. of Licensed Plumbe�,Or Gas/jitter By: Sign'Title Plumber 7`7 City/Town,. Gas Fitter License Number Master APPROVED(OFFICE USE ONLY) Journeyman