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HomeMy WebLinkAboutMiscellaneous - 457 BOSTON STREET 4/30/2018 457 BOSTON STREET / 2101107 0000.0 I ` fI � I I I I I I i I I I� �If I �I I , II II i I 1 Date 2.14-4.y.......... 16 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING CHU %AV Thiscertifies that ..... ..... i ..................................................................... has permission to perform..... plumbing in the buildings of ... ....... ........................................................... at.......ks.i............ ............. North Andover, Mass. Feelt'56...Lic. No.1%11....... ................................................................................. PLUMBING INSPECTOR Check 1' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY vt MA DATE a ( PERMIT# JOBSITE ADDRESStJ 00s OWNER'S NAME POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL ® RESIDENTIAL�f] PRINT CLEARLY NEW: RENOVATION:© REPLACEMENT: © PLANS SUBMITTED: YES 0 NO FIXTURES-1 FLOOR--D 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/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM [ -_ { __ __.E DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN I _...._J INTERCEPTOR(INTERIOR) _ I _.__._I _ _ __ ___, ! I _____f _..__..-I _._,-__I KITCHEN SINK _—I 1 —J .__( f J 1 __. E _._( I _ b JI -J= LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK _ .I I J 1 _—Al TOILET _ .I -_ ___ _ _.. ^_.I _,._.._I .___.1 ____ .T_ ___-_-f _.._. _-i URINAL —JE.- I ___ _._._ ___.J _.__.I -_ i .._f __._. 1 j WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING _ 1 -� - . I ___.._._. .... I I OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES% NO D1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 6 OTHER TYPE OF INDEMNITY D BOND 0 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 Q AGENT I® SIGNATURE OF OWNER OR AGENT 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 installations performed under the permit issued for this application will be in m fiance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ J LICENSE# SIGNATURE MPI�L JP CORPORATION Q1#©PARTNERSHIP®# _ ;LLC Dl# COMPANY NAME ADDRESS CITY - - - -'STATE ZIP d TEL FAX 97�l��_( CELL 7_0-'T77 EMAIL �o�-� .._/ __. .. _.......------...... ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTIO NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES w The Commonwealth of Massachusetts z Department of IndustrialAccidents r N. =- 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legib Name(Business/Organizationffndividual): /f Address:ap City/State/Zip: b Phone#: Are you an employer?Check t. appr6oriate box: Type of project(required): l ra employer with employees(full and/or part-time).* 7. F1 New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t ❑ 4.F1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. - 12.E]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no,employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submif this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-corilractors have employees,'they must provide their workers'comp.policy number. 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 required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verific ' I do hereby crtify hd the pains n enalties peijuiy that the information provided above is true and correct. Signature: Date: Z Z 2- T Xt _ Phone#: 7-2 30 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#: ,I 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 b6 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 fbi 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE Fax#617-727-7749 Revised 02-23-15 wWw.mass.gov/dia 9 ' COMMONWEALTH OF MM�SACHUSTT.S • • i • ME c BOARD.:O PLUMBERS' N GASF:ITTERS ISSUES THE FOLLOW I I�iG L f CENSE 1 s ICEN � LS @ AS A MASTER P,+BE {' Ia Q AV 1 D F MU L I K 'b OZ 12 27 H0BS0N"AVE I W.iLMI'NGT0N , MA 01887-2059 15871 OK/01/16 232749 _ 6 Date .r ..A.g ..1.. .................. OF NORT►�,� TOWN OF NORTH ANDOVER o s . PERMIT FOR WIRING s$ACHUS� This certifies that !� -P n O has permission to perform ..., �...! � � �� �{,. .wiring in the building of.... ' at ..............h............... k. ,North Andover,Mass. 1*21 Fee.. ..-...........Lic.NO. ................. n�n ELECTRICAL INSPECTOR Check It F comaw weahk 4 Mdd.AWA Official Use 01 cc77 n{� Permit No. 2epartment o�,}dre J mkw Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 eave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with-the Massachusetts Electrical Code(MEC),527 CMR 12.90 (PLEASE PRINT IN INK OR YTPF ALL INFORMATION Date: ��/�'�/6 City or Town of: OJT-{-k g d 8 Vhf' To the Inspector of Wines: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) &5+b Owner'or Tenant Wilhowo Anti Telephone No. 7 —70?7R Owner's Address S1 e Is this permit in conjunction with a building permit? Yes No ❑, (Check Appropriate Box) Purpose of Building lost Utilhity Authorization No. Existing Service v►0 Amps / l a`16 Volts -Overhead Undgrd❑ No,of Meters 1 � New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters \ Number of Feeders and Ampacity. Location and Nature of Proposed Electrical Work: , Com tenon o the o!lowin table maybe waived by the Ins actor of Wires. No,of Recessed Luminaires 3 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 mergency g d, d. Batte Units No,of Receptacle Outlets No.of Oil Burners FIRE ALARMS ENo.of Zones No.of'Switches No.of Gas Burners o.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total Tons No:of Alerting Devices No.of Waste Disposers HeatPump ails: _Number ons _.____._.. Detect o ofon/Alertin ned Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ElConnection Other No,of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent Heaters No.of Water K� No.of No.of Data Wiring: Signs Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No,of Motors Total HP Telecommunications Wiring: No.of Devices or uivalent OTHER: C ja"tlVhn ` Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: _, 00 (When required by municipal policy.) Work to Start:l , 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 Iiabili insurance including"completed operation"coverage or its substantial equivalent, The undersigned certifies that such 1!v age is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE N BOND ❑ OTHER ❑ (Specify:) r I cern, under the pgins and penalties ofperjury,that the information on this application is true and complete, FIRM NAME: L'IC.NO.- Licensee:- O.:Licensee: Cj j 5,�0 Signature �, a, LIC.NO.c�j_� (If applicable, enter"exempt'in�the license dumber tiny.) ff vv �- Bus.Tel,No.: ,3 Address: _ ly f IJ �r�)V2 h1'i d( 'fOn ©i R 9 Alt.Tel.No.:�l �O *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 by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owne 's agent. Owner/Agent Signature Telephone No. PEMIT FEE: $ .,,� i �� ����/�'2 �2� � � The Commonwealth o,f•.Massachusetts rn Department o,f gn Wd Accidents Office o,fDivestigations 600 Washington Street Boston,M4 02111 www.fr:ass gov/dia WorkersCompensatioq bmurance Affidavit: Builders/ContractorslEleetr%zians/Pinmbers APTYUcant Information Please Prim Le "-in Name(Business/o ahizaatiowbdividual):• c , Address: City/State/Zip: Are ou an employer?Check the appropriate bog: ]. I am a employer with 4. ❑ I m a etieral coAtra:tor and' of project(required): employees(full and/or part-time).* have hired the sub-contractors 6' []New COnstructian 2.M I am a sole proprietor or partner- fisted 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'com .insurance 5. g- ❑Building addition P ❑ Weare 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 I L❑Plumbing repairs or additions myself.[No workers'comp, e. 152,§1(4),and we have no 12, Roof insurance required.] t repairs employees.[No workers' ❑ comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing thekwoiken'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contraetois must submit a new affidavit indicating sunt. tContracton that check this box Ynust attabhed an additional sheet showing the name of the sub.contractors and the WorIMM 'comP•P0lia3'i»MetiM I am an employer that is providing workers'compensation insurance for my employees Below is the policy and' b site information. Lt Insurance Company Name: 4A'n� Policy#or Self-ins.Lia /�57r-� n Expiration Date: Job Sits Address:_ 7 / g D Si oy,) 24j City/State/Zip: /fir Attack a copy of the workers'compensation policy declaration gage(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 ane-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 bf Investigations of the DIA for insurance coverage verification. Ido hereby cern under the p is and penalties of perjury that the information provided above is true and correct. Si afore Phone Oficial 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): L Board of Health 2.Building Department 3.City/Town Clerk 4,Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i (�3 COMMONWEALTH OF MASSAC'HUSETM".... AW I A ril • olel 9 relkini ::s.BOAFfiD'�F ISSUES ZHE FOLLOW t G .LICENSE : ASA REG ;lOURNEYMA�1 ELECTRI�C��AN �` ! SIR I STOPHER A 0two Ljr tf F Z t. J `:.:.i`.4b D L ETO;N ::>>::..:>:;>:::MA 01949-24 . 07/3 10629'. 1 .,: »> :::>/> b; ;>><_ 50775 990 Date.. .W- NORTi{ °t'"`° '•�"° TOWN OF NORTH ANDOVER PERMIT FOR WIRING �Ss4cwUS This certifies that .... ........ ................. has permission to perform .... '7-L ..!. .............................................. wiring in the building of.......... 0 G f.! ................................................... �s,� s�- n at............... .... .�?.....�........ ....D......................../- North Andover,Mass. Ll I Fee..��8 "... Lic.No.5.......... � ............ ....... ECMINSPECTOR r Check # 3 Commonwealth Of Massachusetts Official U se Onl Department ®f Fere Services P ermit No. BOARD OF FIRE PREVENTION REGULATIONS ancy and Fee Checked 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 (PLEAS'EPRINTIN WKOR TYPEALL 1WNF0 TION) Date: City or Town of: � By this application the undersi ed gives no ' e of his or her intend11 o perform the electrical wk dTO the Inspector of escribed below. Location(Street�&Number) �' f Csc3 Owner or Tenant 6 Owner's Address Telephone No. Is this permit in conjunction with a building permit? yes Purpose of Building � No � BLDG PERNIIT# Utility Authorization No. � Existing Service,-_.266 Amps 20/ O Volts Overhead Undgrd❑ No.of Meters l New Service Amps _/ _Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Gn ernd I Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Sus . No.of p (Paddle)Fans Transformers Total, ' No.of Luminaire Outlets No.of Hot Tubs -KVA Generators KVA No. of Luminaires Swimming Pool Arnd.e ❑ Elo.o mergency ig tmg No.of Oil Burners No.of Receptacle Outlets �� rnd• Batte Units FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and No. of Ranges Total Inrtiatin Devices No.of Air Cond. Tons No.of Alerting Devices No. of Waste DisposersHeat Pump Number Tons Totals: """"'"""""'""'••"' �........... No.ofSelf-Contained Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local❑ Municipal No. of Dryers Connection ❑ Other rY Heating Appliances KW Security Systems:* No. of Water No,of No.of Devices or Equivalent Heaters KW No.of Data Wiring: Si s Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of MotorsTotal HP Telecommunications Wiring: OTHER. No.of Devices or E uivalent Estimated Value of Electrical Work: flltach additional detail tf desired, oras required by the Inspector of Wires. Work to Start: (When required by municipal policy.) Inspections to be requested in accordance with AMC Rule 10,and upon completion. 'NNURANCE 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 equiv lent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuingo CHECK ONE: INSURANCE BOND ❑ OTHER ffce. d cert, render tlae pains and enaldes o er as that the information on this application is trace and cone lete; .fP 1 a7', FIRM NAM: � - e , C_' P Licensee: �enteempt- Si afore LIC.NO.: (If applicable, e license tuber line.) LIC.NO.: Address: Bus.Tel.No.: *Per M.G.L.c.147,s.57-61,security work req ' Department of public Safe "S"Licen Alt.Tel.No.: OWI�TER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liabilityLIC.rance cove required by law. $y my signature below,I hereby waive this requirement. I am the(check on ❑ownerco❑ownerr's Gent. Owner/Agent g Signature Telephone No. PE RMIT FEE:$ ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR-DOUG SMALL 1.ROUGH INSPECTION: Passed— Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: (Inspectors'Signature-no initials) Date 2.FINAL INSPECTION; Passed—b4 Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors'comments: (Inspectors'Sign ure-n initials) Date 3.UNDER GROUND INSPECTION: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: (Inspectors'Signature-no initials) Date 4.INSPECTION—SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed—[ ] Failed—[ ] Re-inspection required($50.00)- [ ] Inspectors' comments: (Inspectors'Signature-no initials) Date 5.INSPECTION-OTHER: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: (Inspectors Signature-no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED. y The Commonwealth ofMassachusetts Department of Industrial Accidents Office ofInvestigations 600 Washington Street t Boston,MA 02111 �''� 5,,.q vww.massgov/dia Workers' Comp ensationInsulraneeAffidavit: Buildelrs/Contractors/JElectricians)Plumbers Applicant Information Please Print Legib NaM0(B.usiness/Organization/Individual): y � j Address: /6� a�de / City/State/Zip: /Cc- Phone#: 1 '2 Are you an employer?Check the appropriate box: Type ofproject(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 solo proprietor or partner listed on the attached sheet.? 7. ❑Remodeling . ship andhave no employees These sub-contractors have 8. ❑Demolition l working for me in any capacity. workers'comp.insurance. g, (�Building addition. [No workers'comp.insurance 5. ❑ 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 11.0 Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs insurance required.]f employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#Z must also Ell out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurancefor my employees Below is the policy and job site information. Insurance Company Name: 1-&�� Xfi Policy#or Self-ins.Lic.#: 4�TL57Q06 7 e;7,r,2' Expiration Date: Sob Site Address: �co �O �1 � City/State1Zip:A1A>d'f1�1�� 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 ORDBR and a fne 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 certify under• hep ins andpenalties ofperjury that the information provided above is true and correct. Si ature: Date: P f Gi y 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): X.Board ofHealth 2.BuildingDepartment 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other C ontactPerson: hone N: 7 J Date. . .. . .... . HORTh� 4, TOWN OF NORTH ANDOVER 4401 PERMIT FOR GAS INSTALLATION u•O qh SACHUSEt This certifies that . . . . IT t J�� has permission for gas installation . . . . . .q . . . . . . . . . . in the buildings of . . . . .:�: at . . . . . ?. . • .&5 !'. . • • . .'• .. North Andover, Mass. Feel d(� Lic. No.. .���. .S . . . . . .... . . . . �.�:':? ?l! 2 =•�; z GASINSPECTOR Check# ��� SW-d'D C1 It led C ' MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) T NORTH ANDOVER JAN. 26, 11 ,Mass. Date 20 Permit# Building Location 457 BOSTON ST. Owner's Name WILLIAM ROGERS Owner Tel# 978-989-0002 Type of Occupancy RESIDENTIAL New Fv—(] Renovation❑ Replacement F] Plan Submitted: Yes❑No❑ FIXTURES x w J U z W w W a O 0 � F x x� ^rA Y Z J �" F Q z z O F WOOP m W d w W w w W -. x A > z (� J O W z -1 — z F w w o o > O H u a (n w ` z c w Q x F �. v, a, z o z 0 w x w 2 0 C7 2 w 3 A CQ7 a OU oa' > A a H O w SUB-BSMT BASEMENT 1ST FLOOR 2"D FLOOR 3RD FLOOR 4T"FLOOR 5T"FLOOR 6T"FLOOR 7T"FLOOR 8TH FLOOR Installing Company Name Eastern Propane & Oil, Inc Check one: Certificate Address 131 Water Street Corporation Danvers, MA 01923 Partnership Business Telephone# 800-322-6628 Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE: I have a cures liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. Yesl ✓ I No El If you have c ecked yts,please indicate the type coverage by checking the appropriate box. A liability insurance policy Fv 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: 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 work and installations performed under the permit issued 1prAis application willpon compliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen al By Type nse: -K9umber Signature of Licensed Plumber or Gas Fitter Title t-Ga ter -MVIaster License Number �i �C3 3Cf City/Town •-Journeyman APPROVED(OFFICE USE ONLY) 7 5 / 2 Date.Z � .. . ........ ,40RT/, 3? a° TOWN OF NORTH ANDOVER O 9 ' PERMIT FOR GAS INSTALLATION SS C04 This certifies that has permission for gas installation . . . . . . . . . . . . . . . . . in the buildings of . . . . -c .7 ?: f:.�. . . . . . . . . . . . . . . . . . . . . . . . . . at [l�. . . . .� {`.:. . s . . . . . . . . . . . ... ort�h_Andover, Mass. Fee. . . . . . Lic. No/-/-t.,/ .).. . . . . . . . . . . . .v �l / GASINSPECTOR Check# 6 y a, 1 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING -U'r City/Town: 6rr'' r'I"'`'�`I'��� M 'VA. Date:``°'07 3/r 7-L'( Permit# Building Location: "—/y 7 Owners Name: w` i`lop, Type7AIteration: pancy: Commercial ElEducational ❑ Industrial ❑ Institutional F] ResidentialNew: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES WM Ca ui 1 / Z Q y N V = H m 2 O W W V N H O = W W 0 z J } W F) W Lu z U) 0 W W LU w UJ m 0 a a o w x > z w Q W x Lu a W w w z 9 = w � W z W > V w Z O J H H O Z J O LLW 3: W W w Z W N Q Q m w O z 0 ~ > z V o LL (Q9 (�7 = z O 0 o. W H > > > O SUB BSMT. BASEMENT F 1 FLOOR 2 FLOOR 3 FLOOR 4 THFLOOR 5TH FLOOR 6 TH FLOOR VH FLOOR 8 FLOOR Check One Only Certificate# Installing Company Name:—, ❑Corporation AddressF City/Town:94n V tpState: Z3 Z 1C'7-6�L 37/ / � �� C9• �E;] Partnep Business Tel• Ax: - rm/Company Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: I have a current liabiflly insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 Yes No❑ If you have checked Yes,please indi to 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 Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑;1 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 installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State bing Code and Chapter 142 of the eneral Laws. B Type of i e e. By ❑ Plu+fiber Title ❑�as Fitter i nat a of Licensed Plumber/G -iffier Master City/Town ❑Journeyman icense Number: APPROVED OFFICE USE ONLY ❑ LP Installer Date. .`-� : � � J "0*':�4, TOWN OF NORTH ANDOVER 40 F PERMIT FOR PLUMBING -� SSACMUS� ` This certifies that ((. . : . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . ! �. . . . . . . . . . . . . . . � 5 plumbing in the buildings of . . . . ... ... . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . . . . . . . ., North Andover, Mass. Fee.7i. Lic. No.l cry✓ 1. . . . . . . . . . . -41. J PLUMBING INSPECTOR Check * MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: /vim iZ el+%-2/�' MA. Date:•J/ 1 �/ Permit# BuildingLocation: ' j-S j34 5,k I Mi, I I I `7 � Owners Name: Type of Occupancy: Commercial❑ Education I❑ Industrial❑ Institutional❑ Residential / New:❑ Alteration:❑ Renovation: Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES DEDICATED Z SYSTEMS W Z H Z H O N O ( W Y 7 > Z LA J X FL- W O ^ W I c z a C Z = Y Q N Q a 0 Z n Q. Q oc W Z w � Vl Z a 3 H x tA <to In w vZ—i ~ W Q v~i Ln OJ a x Q r- Q 0 -i S Q W 0 Q Z W O = W Z W z U d LL = J W Q 3 Q LL Y 2 3 O 3 W 0 ~ LL H J Q 2 w w oi! O w �S Z 3 Y W I r- W = a O U Q a Z H H Q Y U �- O O v� Q Q In w O O F > > O 2 O Q Q Q Q u Q z = Q a m m c o LL x Y 5 g In 3 3 3 o w SUB BSMT. BASEMENT 1'FLOOR 2ND FLOOR 3RD FLOOR 4T"FLOOR 5T"FLOOR 6T"FLOOR 7T"FLOOR 8T"FLOOR Check One Only Certificate# Installing Company Name: S 1��i�vvSC\ t �� �`_ -,y h��� ❑Corporation Address: T�.�/ 1 City/Town: � 5 State:AAA— ❑ Part ship Business Tel: / �� /J Z� S�J �1G Z—3 irm/Company Name of Licensed Plumber: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes o❑ If you have checked Yes,please Indic a the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemni ❑ Bond indemnity ❑ 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 ❑ 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 installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws By /ypee5ense:� uTitle er Si ture f Licensed Plumber Citys APPROVED OFFICE USE ONLY []journeyman i ense Number: r Date..%.. ... . .. pt Na oT a 1A'O 3r o� TOWN OF NORTH ANDOVER PERMIT FOR WIRING SACINU 311 This certifies that ......:.:.!f.:.......:.. .......................-:......................................... has permission to perform .:-%. P'.' s- - '. ............................................ ( �r wiring in the building of -� ., ......................... .................................... ! at.... .......:......:.................- ......:........................... ,North Andover,Mass. Fee... /.IV.... Lic.No.&�:'?4 ELECTRICAL INSPECTOR / * Check # 7216 Commonwealth of Massachusetts Official Use Only Permit No. Z)X0 I Department of Fire Services Occupancy and Fee Checked ,M 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: 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. • 1 C�. Location(Street&Number) rf u Owner or Tenant t i Q Telephone No. g14 76 5-60&1 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 Amps ` Volts Overhead Z Undgrd ❑ No.of Meters _Z New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 4- a E Q /f �a del Completion of the followin table may be waived by the Inspector of Wires. No. of Recessed Luminaires j� No.of Ceil.-Susp.(Paddle) Fans Tr o 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. Battery Units No.of Receptacle Outlets 3S No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches6 o.oas No. GBurners No.o -Detection and �J InitiatingDevices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices — Heat Pum Number Tons KW No.of Self-Contained No.of Waste Disposers Totals Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection g pp KW No.of Dryers Heating Appliances Security Systems: '- No.of Devices or Equivalent No.of Water KW No.o No.o 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 OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work. emV (When required by municipal policy.) Work to Start: a — 13-6 7 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 4 undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE g] BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: bev, ) C-7,4k9 LIC. NO.:' C Licensee: ,? f F Gm Signature LIC. NO.: (If applicabl er xen pt"inlicense numb line.)line.) G� Bus.Tel. No.:ISI "2533-1�7th Address: /Z an. ft'e 6l�9", k2lCef ��/�� 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: $ - 1 -7 � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 qu www mass.gov/dia I Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /� Please Print Legibly Name(Business/Organization/Individual): �Q�'Yrts - Ck/�,eti, ,74 �- Address: City/State/Zip: 42,T4z&,a� C/f'O( Phone#: 7��� 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. P1 Remodeling 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 required.] officers have exercised their 10.V]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. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' comp.insurance required.] 13.❑ Other *Any applicant that checks box 41 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. $Contractors 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: &;e'V71 Policy#or Self-ins.Lie. Expiration�[ Expiration Date: IS - 8 Job Site Address: tJ 63's/cn. � City/State/Zip: �� d(,�E�, YYJ 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 certify under the pains and penalties of perjury that the information provided aboveistrute�and correct Signature: ��,�L.x) � Date: Phone#: t� I{� D V 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#: Date.?! NORT„ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACNUS� This certifies that .SQ.h].0 1. '. . .f`. .� . . . . . . . . . has permission to perform plumbing in the buildings of . �i���I. .1�0 {�0. ... . . . . . . . . . . . . . . . . .at . . . . . . . ., North Andover, Mass. Fee.8a"` . . .Lic. N o.��065. . . _ PLUMBIN INSPECTOR Check # 729 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS S� i3a�t'�� � VI_ Date � 1Building Location Owners Name � Permit# T e of Occu an �'"� G — ount New Renovation 0 Replacement [3 Plans Submitted Yes [3 No FIXTURES y A A A SLB)E M MiSEW C M Iffm 2MF 2 3MFUXR t 4MROCR 5MRDM 6MRDM MFUM 9MFIOR (Print or type) /� � � Check one: Certificate �v` Installing Company Name S Z a / ❑ Corp. Address Pathe . Business Telephone c) 7_17 Firm/Co. Name of Licensed Plumber. &theo - sus H.. Insurance Coverage: Indicatsurance coverage by checking the appropriate box: Liability insurance policyOther type of indemnity ❑ Bond ❑ insurance Waiver. I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature OwnerEl Agent I hereby certify that all of the details and information I have sub?erf (or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work din tallatioormed under ermit sued for this application will be in compliance with all pertinent provisions of the M sachu efts Sta I g C d C ptet 142 of the General Laws. By: igna o Ivens um er of Plum7-4c ense Title CI PRO (Cense NumDer Master Joumeyman ❑ APPROVED(OFFICE USE ONLY R.A.M. ENGINEERING 0 ROBERT A. MASYS, P.E. 160 MAIN STREET HAVERHILL, MA 01830 TEL : 978-372-0449 FAX: 978-372-7183 February 16, 2007 re : 457 Boston Street, North Andover, MA. TO WHOM IT MAY CONCERN: I have inspected the framing for the addition at the above address. I found the framing to be conforming to the proposed design plans, to be of good worksmanship, and in accordance with standard industry practice. If I can provide any additional information, or answer any questions, please call me. Ver trul yours �►��`tN OF,�,����c ( r !t /� ROAB� ` MASYS No.29174 e a At" '�S�ONALE� 3 i J J Date..IV ..... ........ A „ORTPI TOWN OF NORTH ANDOVER \ OF4..ao ,s1ti0 '0 " `p PERMIT FOR GAS INSTALLATION ,SSACHUSEA ..a J �* A This certifies that . . :. . : .- —.� ,.�4`. ;. : .�. . . . . . . . . has permission for gas installation, . . . . . . . . in the buildings of . �.: . .:' -��. . . . . . . . . . . . . . . . . at . :' '. . . :k'` "� . • .. . . . . • • • . •, Nortli Andover, Mass. Feed. . . . . . . Lic. GAS INSPECTOR WHITE:Applicant CANARY:Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Prigt or Type) Mass. Date 19 Permit# ' Building Location 1� Owner's Name Map: Lot: Zone: Type of Occupancy —Ep New Renovation J Replacement 1:3 Plans Submitted: Yes❑ No Fee: e, y ¢ N Y W vi N N U GW c ¢ O ¢ y = ¢ O W ¢ O 0 �' s to z J ¢ W ~ m Z ¢ a O W Q ¢ z O z W 2 m w �' W W O O o 0 W ¢ to7 W Q = Z I �n O > W W jrW y N Z U W 2 N W Q ¢X LU UJ J F z F W W. U O > LL F W J H W Z Q W _ Q Q _ � > N m Z. -O Z M O N = Q W > Q W Z Q Q Q Q O O W O W H ¢ S O (7 2 W 3 O C7 J v > o a O /�. SUB-BSMT. ! BASEMENT 1ST-FLOOR ` 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing LO Company Name- � 1 � _. Check.one: 'Certificate - Address 13\ x�te� 2—>r. � � m 1 1 �P Corporation i Estimate Value of Work: ZI Partnership Business Telephone 6:' "" —��� -66—S D Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE: ~ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yesb4 No If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy�d 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: Owner O Agent D 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 work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By Type of License: njl6l Plumber Signa ure of Licensed lu er or Gas,Fitter Title Gasfitter Master License Number hQ City/Town RJourneyman APPROVED (OFFICE USE ONLY) f 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 19 OAS INSPECTOR i