HomeMy WebLinkAboutMiscellaneous - 50 ROYAL CREST DRIVE 4/30/2018 (4) �� �� ,�j �:��
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• Town of North Andover
HEALTH DEPARTMENT
,SS�CHU
CHECK#: ( ,D DATE:
LOCATION: ,
e .
H/0 NAME: J
CONTRACTOR NAM i V
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
Other. (Indicate) 4 $�
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
t
TOWN OF NORTH ANDOVER Permit Number
NORTH ANDOVER,MASSACHUSETTS 01845
�yORT►f., Date Issued / 21,,3
Expiration Date
�1 swC1W`�i�
Jackie's Law - Permit Application
Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant Pre 1 b.Ez Phone Cell
Street Address i 1�`z -5 1QA�� Sr. -78 861 8� ORS L&
City/Town " MA ZIP '
T6 GDS /43,S cec.c_
Name of Excavator(if different from applicant) Phone Cell
Street Address
City/Town MA ZIP
Name of Owner(s)of PropertyPhone Cell
Street Address `/��_ ,,,., �J I G�52
/Town MA ZIP
er be.W=.* "me- W4 otMG -
Other Contact Permit Fee Received No Y QQ
Description,location and purpose of proposed trench:
Please describe the exact location of the proposed trench and its purpose(include a description of what is(or is intended)to
be laid in proposed trench(eg;pipes/cable lines etc..)Please use reverse side if additional space is needed.
Insurance Certificate#:
Name and Contact Information of Insurer: r1. ACbON (QjW6
taa l�-t1�tW St'- P.o.3ox �f2$ NoeT# A o�re��Na ams Owls S. CAULUS
Policy Expiration Date: 9 D
Dig Safe#:
Z615 5`7 105(!)
Name of Competent Person(as defined by 520 CMR 7.02):
.Sa-K.t eS . l #ltd eL
Massachusetts Hoisting License#
" - 01530A 3 Al j 2a /5
License Grade: :lExpiration Date:
BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE
AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE
WORK, WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE TO
WORK PROPOSED,INCLUDING OSHA REGULATIONS,G.L.c. 82A,520 CMR 7.00 et seq.,AND ANY
APPLICABLE MUNICIPAL ORDINANCES,BY-LAWS AND REGULATIONS AND THEY COVENANT
AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WILL
COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW,
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND
THE EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND
ALSO, FOR THE DURATION OF CONSTRUCTION,AUTHORIZES PERSONS DULY APPOINTED BY
THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND,INSPECT THE WORK
FOR CONFORMITY WITH THE CONDITIONS ATTACHED HERETO AND THE LAWS AND
REGULATIONS GOVERING SUCH WORK.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY
TO REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY
THE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED
THEREUNDER,INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE
LAW AND CONDITIONS OF THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE
THEREWITH,AND MEASURES TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC
WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH
INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED NECESSARY BY
THE MUNICIPALITY.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY
TO DEFEND,INDEMNIFY,AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS
AND EMPLOYEES FROM ANY AND ALL LIABILITY,CAUSES OR ACTION,COSTS,AND EXPENSES
RESULTING FROM OR ARISING OUT OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY
PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT.
APPL CANT SIG 't
DATE Ls
EXCAVATOR SIGNATURE(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(IF DIFFERENT)
DATE:
21Page
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CONDITIONS AND REQUIREMENTS PURSUANT TO G.L.C.82A AND 520 CMR 7.00 et seq.
(as amended)
By signing the application,the applicant understands and agrees to comply with the following:
i.
No trench may.be excavated unless the requirements of sections 40 through 40D of chapter 82,and any
accompanying regulations,have been met and this permit is invalid unless and until said requirements
have been complied with by the excavator applying for the permit including,but not limited to,the
establishment of a valid excavation number with the underground plant damage prevention system as
said system is defined in section 76D of chapter 164(DIG SAFE);
ii.
Trenches may pose a significant health and safety hazard. Pursuant to Section 1 of Chapter 82 of the
General Laws,an excavator shall not leave any open trench unattended without first making every
reasonable effort to eliminate any recognized safety hazard that may exist as a result of leaving said
open trench unattended. Excavators should consult regulations promulgated by the Department of
Public Safety in order to familiarize themselves with the recognized safety hazards associated with
excavations and open trenches and the procedures required or recommended by said department in
order to make every reasonable effort to eliminate said safety hazards which may include covering,
iii. barricading or otherwise protecting open trenches from accidental entry.
Persons engaging in any in any trenching operation shall familiarize themselves with the federal safety
standards promulgated by the Occupational Safety and Health Administration on excavations:29 CFR
1926.650 et.seq.,entitled Subpart P"Excavations".
iv.
Excavators engaging in any trenching operation who utilize hoisting or other mechanical equipment
subject to chapter 146 shall only employ individuals licensed to operate said equipment by the
Department of Public Safety pursuant to said chapter and this permit must be presented to said licensed
operator before any excavation is commenced;
V.
By applying for,accepting and signing this permit,the applicant hereby attests to the following:(1)that
they have read and understands the regulations promulgated by the Department of Public Safety with
regard to construction related excavations and trench safety; (2)that he has read and understands the
federal safety standards promulgated by the Occupational Safety and Health Administration on
excavations:29 CMR 1926.650 et.seq.,entitled Subpart P"Excavations”as well as any other
excavation requirements established by this municipality;and(3)that he is aware of and has,with
regard to the proposed trench excavation on.private property or proposed excavation of a city or town
public way that forms the basis of the permit application,complied with the requirements of sections 40-
40D of chapter 82A.
vi.
This-permit shall be posted in plain view on the site of the trench.
For additional information please visit the Department of Public Safety's website at www.mass.gov/dns
3 1 P a g e
Summary of Excavation and Trench Safety Regulation(520 CMR 14.00 et seg.)
This summary was prepared by the Massachusetts Department of Public Safety pursuant to G.L.c.82A and does not
include all requirements of the 520 CMR 14.00. To view the full regulation and G.L.c.82A,go to www/mass.gov/dps
Pursuant to M.G.L. c. 82, § 1, the Department of Public Safety,jointly with the Division of Occupational Safety,
drafted regulations relative to trench safety. The regulation is codified in section 14.00 of title 520 of the Code of
Massachusetts Regulations. The regulation requires all excavators to obtain a permit prior to the excavation of a
trench made for a construction-related purpose on public or private land or rights-of-way. All municipalities must
establish a local permitting authority for the purpose of issuing permits for trenches within their municipality.
Trenches on land owned or controlled by a public(state)agency requires a permit to be issued by that public agency
unless otherwise designated.
In addition to the permitting requirements mandated by statute, the trench safety regulations require that all
excavators,whether public or private,take specific precautions to protect the general public and prevent unauthorized
access to unattended trenches. Accordingly,unattended trenches must be covered,barricaded or backfilled. Covers
must be road plates at least 3/4"thick or equivalent;barricades must be fences at least 6'high with no openings greater
than 4" between vertical supports; backfilling must be sufficient to eliminate the trench. Alternatively, excavators
may choose to attend trenches at all times,for instance by hiring a police detail,security guard or other attendant who
will be present during times when the trench will be unattended by the excavator.
The regulations further provide that local permitting authorities,the Department of Public Safety,or the Division of
Occupational Safety may order an immediate shutdown of a trench in the event of a death or serious injury;the failure
to obtain a permit; or the failure to implement or effectively use adequate protections for the general public. The
trench shall remain shutdown until re-inspected and authorized to re-open provided, however,the excavators shall
have the right to appeal an immediate shutdown. Permitting authorities are further authorized to suspend or revoke a
permit following a hearing. Excavators may also be subject to administrative fines issued by the Department of
Public Safety for identified violations.
Summary of 1926 CFR Subpart P-OSHA Excavation Standard
This is a worker protection standard,and is designed to protect employees who are working inside a trench. This
summary was prepared by the Massachusetts Division of Occupational Safety and not OSHA for informational
purposes only and does not constitute an official interpretation by OSHA of their regulations,and may not include all
aspects of the standard.
For further information or a full copy of the standard go to www.osha.gov.
Trench Definition per the OSHA standard:
o An excavation made below the surface of the ground,narrow in relation to its length.
o In general,the depth is greater than the width,but the width of the trench is not greater than fifteen
feet.
• Protective Systems to prevent soil wall collapse are always required in trenches deeper than 5',and are also
required in trenches less than 5'deep when the competent person determines that a hazard exists. Protection
options include:
o Shoring. Shoring must be used in accordance with the OSHA Excavation standard appendices,the
equipment manufacturer's tabulated data,or designed by a registered professional engineer.
o Shielding(Trench Boxes). Trench boxes must be used in accordance with the equipment
manufacturer's tabulated data,or a registered professional engineer.
o Sloping or Benching. In Type C soils(what is most typically encountered)the excavation must
extend horizontally 1 �/:feet for every foot of trench depth on both sides, 1 foot for Type B soils,
and-1/,foot for Type A soils.
o A registered professional engineer must design protective systems for all excavations greater than
20'in depth.
continued
• Ladders must be used in trenches deeper than 4'.
o Ladders must be inside the trench with workers at all times,and located within 25'of unobstructed
lateral travel for every worker in the trench.
o Ladders must extend 3'above the top of the trench so workers can safely get onto and off of the
ladder.
• Inspections of every trench worksite are required:
o Prior to the start of each shift,and again when there is a change in conditions such as a rainstorm.
o Inspections must be conducted by the competent person(see below).
• Competent Person(s)is:
o Capable(i.e.,trained and knowledgeable)in identifying existing and predictable hazards in the
trench,and other working conditions which may pose a hazard to workers,and
o Authorized by management to take necessary corrective action to eliminate the hazards. Employees
must be removed from hazardous areas until the hazard has been corrected.
• Underground Utilities must be:
o Identified prior to opening the excavation(e.g.,contact Dig Safe).
o Located by safe and acceptable means while excavating.
o Protected,supported,or removed once exposed.
• Spoils must be kept back a minimum of 2' from the edge of the trench.
• Surface Encumbrances creating a hazard must be removed or supported to safeguard employees. Keep
heavy equipment and heavy material as far back from the edge of the trench as possible.
• Stability of Adjacent Structures:
o Where the stability of adjacent structures is endangered by creation of the trench,they must be
underpinned,braced,or otherwise supported.
o Sidewalks,pavements,etc.shall not be undermined unless a support system or other method of
protection is provided.
• Protection from water accumulation hazards:
o It is not allowable for employees to work in trenches with accumulated water. If water control such
as pumping is used to prevent water accumulation,this must be monitored by the competent person.
o If the trench interrupts natural drainage of surface water,ditches,dikes or other means must be used
to prevent this water from entering the excavation.
• Additional Requirements:
o For mobile equipment operated near the edge of the trench,a warning system such as barricades or
stop logs must be used.
o Employees are not permitted to work underneath loads. Operators may not remain in vehicles
being loaded unless vehicles are equipped with adequate protection as per 1926.601(b)(6).
o Employees must wear high-visibility clothing in traffic work zones.
o Air monitoring must be conducted in trenches deeper than 4'if the potential for a hazardous
atmosphere exists. If a hazardous atmosphere is found to exist(e.g.,02<19.5%or>23.5%,20%
LEL,specific chemical hazard),adequate protections shall be taken such as ventilation of the space.
o Walkways are required where employees must cross over the trench. Walkways with guardrails
must be provided for crossing over trenches>6'deep.
o Employees must be protected from loose rock or soil through protections such as scaling or
protective barricades.
5 Page
OP ID:SHHE
A�oRo
CERTIFICATE DATE(MMIDD/YYYY)
OF LIABILITY INSURANCE 09/04/13
THIS CERTIFICATE ISI SUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NC T AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFI ATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE ORP RODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the cert ficate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditiont of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in(leu of such endorsement(s).
PRODUCER Phone:978-688-6921 CONTACT
Macdonald&Pangione Insurance NAME: Jim Helder
P.O.Box 428 Fax:978-688-5350 ti/c°Ne Ext:978-851-8544 FAX
104 Main Street E-MAIL A/c No
North Andover,MA 01845 ADDRESS:
Craig S Childs CRO UCER ID k:HEIDE-1
INSURED Heider Building Associates LLC INSURERS AFFORDING COVERAGE NAIC N
143 Marshall St INSURER A:Peerless Insurance Company 24198
Tewksbury, FAA 01876 INSURER S:
INSURER C:
INSURER D:
INSURER E:
INSURER F
COVERAGES CERTIFICATE NUMBER:
THISREVISION NUMBER:
IS TO CERTIFY THAT HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTA 4DING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSI IED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NAUTOMOBILE
TYPE OF INSURA CE POLICY NUMBER MM/DD1YYYY MIOWLDI DIYYYY LIMITS
ABILITY
EACH OCCURRENCE $ 11000100
RCIAL GENERAL (ABILITY GL4339740 09/10/13 09/10/14
PREMISES Ea occurrence $ 100,00
AIMS-MADE X OCCUR
MED EXP(Any one person) $ 5,00
PERSONAL 8 ADV INJURY $ 1,000,00
GENERAL AGGREGATE $ 2,000,00
EGATE LIMIT APPLIES PER: I PRODUCTS-COMP/OP AGG E 2,000,00
PRO LOC
LIABILITY $
COMBINED SINGLE LIMIT $ 1,000 0O I I (Ea accident) ,
ALL OWNED AUTOS I BODILY INJURY(Per person) $
A X SCHEDULED AUTOS BA 8812479 11/01/12 11/01/13 BODILY INJURY(Per accident) $
X HIRED AUTOS I PROPERTY DAMAGE
X NON-OWNED AUTOS (Per accident) $
EDEDUCTIBLE
LU1BT $
OCCURU\B EACH OCCURRENCE $
CLAIMS-MADEAGGREGATE $
N $
WORKERS COMPENSATION $
AND EMPLOYERS'LIABILITY X WC STATU- OTH-
A ANY PROPRIETOR/PARTNER/EX CUTIVE Y/N ;WC4339804 09/10/13 09/10/14TOR LIMIT, ER
OFFICERNEMBER EXCLUDED? ❑ N/A E.L.EACH ACCIDENT $ SQQ,QQ(Mandatory In NH)If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 500,00DESCRIPTION OF OPERATION belowA Inland Marine 882 E.L.DISEASE-POLICY LIMIT $ 500,00
12/02/12 12/02113 55,000 Ded$100
Rented Equipmen
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more apace Is required)
Additional insured: AIMCO North Andover, LLC, 50 Royal Crest Drive, North
Andover MA 01845.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Conerstone Land Consultants THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
61 Main Street tCraigS
CE WITH T�POY PROVISIONS.
Pepperell,MA
PRESENT
lds ZI
ACORD 25(2009/09) The ACORD name and logo are registered mars of ACORD ACORD CORPORATION. All rights reserved.
ORNERSTONE
9-
Land Consultants, Inc. Letter Of Transmittal
P.O. Box 657 - Pepperell, MA 01463
1794 Bridge St. - Unit 17B - Dracut, MA 01826
Delivered by:
❑ Regular Mail a Hand Delivery ❑ Fax to.: Job No.:2011-244 Pa e 1 of 1
❑ Client Pick up ❑ Email to:
Date: December 5,2012
To: Gerry Brown, Inspector of Buildings Subject: Royal Crest Estates
North Andover Building Department Bldg 48 Foundation Drainage
1600 Osgood St. Location : Royal Crest Estates
North Andover, MA 01845 50 Royal Crest Drive
North Andover, MA 01845
The following items are enclosed:
Item Oty. Type Description ID No. Dated Revised
1 Ltr Rir`Construction om letion Affidavit 12/5/12
2 1 Plan Idg 48 Foundation Drainage Plan—Reduced 9184 03/1512 06/15/12
opy
3 - Photos g 48 Repair Photographs Varies
I
Kenn th Lania,E.I.T.
ken@comerstoneland.net
I
CORNERSTONE Land Consultants,Inc. Pepperell, MA • (978) 433-8100
wmvxornerstonela nd.net Dracut, MA • (978) 455-7960
r �
61 Main St. '"`C O Rte E RST O N E 1794 Bridge St.
P.O. Box 657T Consultants,
Unit 17B
Pepperell, MA 01463 .and Consultants, Inc. Dracut, MA 01826
Phone: (978)433-8100 Civil Engineering•Land Surveying•Land Planning Phone: (978)455-7960
°ax: (978)433-8125 (� __ Fax: (978)433-8125
www.cornerstoneland.net
December 5, 2012
Gerald Brown, Inspector of Buildings
Town of North Andover Building Department
1600 Osgood Street
North Andover, MA 01845
RE: Construction Completion Affidavit
Building 48 Foundation Drainage
Royal Crest Estates
North Andover, MA 01845
Mr. Brown,
Accompanying this Construction Completion Affidavit, please find photographs of the installation and
backfilling of the foundation and roof drainage repair and installation completed at Building 48 located on
the Royal Crest Estates property. Photographs included show the foundation waterproofing system
installation, foundation drainage installation and completed construction.
As you are aware, Cornerstone Land Consultants completed a plan entitled "Foundation Drainage Repair
Plan Bldg. 48", Dwg No. 9184 dated August 29, 2012 (last revised October 2, 2012)detailing the repair.
Based on field inspections conducted during and after the repair, the work completed is in substantial
compliance with the plans referenced in this letter and on file with your office.
Should you have any ques ns or require additional information on this matter, lease don't hesitate to
contact us in our Pepper I, MA office.
ArtN OF M'A
F JOHN qc
S
A.
Z VISN EWSKI
Sincerely, o crva
No.2 75
o I T
Kenn h M. Lania, E T. John A. Visniewski, P.E.
ken@cornerstoneland.net jack@cornerstoneland.net
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A
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type) • ,
• NORTH ANDOVER , Mass. Date - .old •96
k§uiIding Location 4j/// Permit t ,z 2. X d
Owners Name ? fl7; / °y
New 71 Renovation r] Replacement =✓j"
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WATER HEATERS
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GAS GENERATORS
LABORATORY COCKS
CONVERSION BURUERS r
ROOF TOP UNITS
VENTED ROOtA HTRS.
DIRECT VENT HTRS.
POOL HEATERS
TESTS -
OTHER •
sua—eswT.
•
BJSEMEHT
1ST FLOOR
2HD FLOOR
3RQ FLOOR
4THFLOOR
STH FLOOR
6TH FLOOR
7TK FLOOR
STH FLOOR
(Print or Type) Check one: Certificate
Installing Company Name ANDOVER PLG. & HEATING CO., Pg. Corp. 2122
Address 573 i/2 SO. UNION ST EJ Partner.
Business Telephone:
LAWRENCE, MA. 01843 El Firm/Co.
508 685-8383
Name of Licensed Plumber or Gas Fitter GEORGE LAROSE
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy Other type of indemnity n Bond 1 ,
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 coverages.
Signature of owner/agent of property Owner El Agent f
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 aU plumbing work and Installations perforated under. Permit issued for this application will be in .. pliance with all pertinent
prov.siona of the Massachusetts Slate Cas Code and Chapter 141 of the General Lawn.
By
r
(1.. L U V, .•
Title
City/Town:
5 i996
APPROVED (oFF.ICE.IISE a-NCY)
YPE LICENSE:
lumber
Gasfitter
Master
Journeyman
Sign ure of Licensed
Plumber or Gasfitter
9981
License Number
Date.:....'
TOWN OF NORTH ANDOVER fi
PERMIT FOR GAS INSTALLATION8
This certifies that 4 f: �� ^ yap
has permission for gas installation .. F , -.'',': o,/, `��`� ` % ' 4•
in the buildings of ../.. /!2. f r..... /- r`=,-
at .`... G . / j,V.4'.4 .. C E.(''. .... , rth Andover, Mass.
Fee.? 4 Lic. No.. . (2:r. 3. .
GAS INSPECTOR "
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: Flle
M
4,4
M
a
05b8
This certifies that
Date
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
has permission to perform
wiring in the building of
at 56 gte-
Fee
/
C
57- -11..tr Z/f6.7'
Lic. No.
Check # g 4'12'42
, North Andover Mass.
ELECTRICAL INSP CTO
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 1 3
Occupancy and Fee Checked
[Rev. 11/99] (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: 10-13-2011
City or Town of: North Andover To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 50 Royal Crest Drive Building #
Owner or Tenant
Owner's Address
Royal Crest Estates
50 Royal Crest Drive
Telephone No.
Is this permit in conjunction with a building permit? Yes No X (Check Appropriate Box)
Purpose of Building Apartment Buildings
Utility Authorization No.
Existing Service Amps Volts Overhead Undgrd No. of Meters
New Service Amps Volts Overhead Undgrd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: ilpgrade Emergency Lighting
Completion of the followine table may be waived by the Inspector of Wires.
No. of Recessed Fixtures
No. of Ceil: Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Swimming Pool Above
grnd.
No. of Emergency Lighting
Battery Units
6
■ In-
■
grnd.
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
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Number
Tons
KW
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local • Municipal • Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:
No. of Devices or Equivalent
No. of Water
Heaters
KW
No. of No. of
Signs Ballasts
Data Wiring:
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.
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 undersigned certifies that
such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE x BOND ❑ OTHER ❑ (Specify :)
3-21-12
(Expiration Date)
Estimated Value of Electrical Work:
Work to Start: 10-17-11 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: Stilian Electric, Inc 108 Tenney St. Georgetown, MA 0183
Licensee: Kari Gonsiorowski Signature
(If applicable, enter "exempt" in the license number line.)
Address: 108 Tenney Street Georgetown, MA 01833
LIC. NO.: A11067
LIC. NO.: E31598
Bus. Tel. No.: 978-352-9994
Alt. Tel. 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: $125.00