HomeMy WebLinkAboutMiscellaneous - 53 WAVERLY ROAD 4/30/2018_ �z `2. S f 7,/ 0.q - Date................................ TOWN OF NORTH ANDOVER 0 - PERMIT FOR WIRING This certifies that..0-v) / � et-br— .......................................................................................... has permission to .... le-t.h.".. / ... e4 /Z— ...... ......... . . .............. wiringin the building of .............................. 4 ........................................ at . E.164 -P .... /7-7-:�,!S .... ........ .... . North Andover, Mass. .......... Fee.K ........ Lic. P2 Check #13tr- 7626 v commonwealth of Massachusetts Official Use only -� Department of Fire Services Permit No. V1 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] 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 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 47— /0- 7 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) Jr -3 /.Aq l/e r Y 4 A91 Owner or Tenant Owner's Address 115-1 P- Tele hone No. E,ey Is this permit in conjunction with a building permit? Yes � No ❑ (Check Appropriate Box) Purpose of BuildingItlir C 9r6le N 'r- &-,1/�A-1 Unity Authorization No. Existing Service 60 Amps l Zv/ 17--7e--'Volts Overhead 9'**'/ Undgrd ❑ No. of Meters 4( -- New Service 14ZJ Amps elk� / ZA�' Volts Overhead EJ-- Undgrd ❑ No. of Meters_ Number of Feeders and Ampacity :!'— I /�—�'4-7oep Location and Nature of Proposed Electrical Work: �3 ,C��uJr✓.� ILS Pu Com I,,*;- h ll No, of Recessed Luminaires e on o t e o oxen No. of Ceil: Susp. (Paddle) Fans_ table may oe waivea by the Inspector of Wires. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above El In- El o. o mergency ig g rnd. rnd. Bj t 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 InitiatingTotaDevices No. of Ranges No. of Air Cond. Tons l No. of Alerting Devices No. of Waste Disposers Heat Pump Number _� ......_........................................__. Tons No. of Self -Contained Totals: ...' Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local Municipal ❑ El other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Water Heaters KW No. of No. of No. of Devices or Equi valent DataNo. Signs Ballasts ofitinDevices 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: �'' !►,(When required by municipal policy.) Work to Start: `� --/ d � O'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 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 and penalties ofperjury, that the infortgation on this application is true and complete. FIRM NAME: G-' yr LWc- P-"4<-- �a�J"T�� N� 114 LIC. NO.: �JO�� � Licensee: 9q -1C f e. Signature IC. NO.: .9 p --le t - (If applicable, enter mpt " in the license number h e.)/ , e Bus. Tel. No.: IT8 '64- 7S-ok— Address: -, t GtcJ $ /'y�+.Se- AJ 4/0 7 % Alt. Tel. No.: )'79'- 61 - 7r'ov *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 ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ sem. 4 4 S�v PA, IV The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 e l www.nzass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Ayylicant Information Please Print LeQibiv Name (Business/Organizafion/individual):u r L `�(e P -Mw- (E!, ivt� Address: /,19- I ,19- City/State/Zip:__ Are you an employer? Check the appropriate box: Type of project (required): L ❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. New construction — �yees (full and/or part-time).* have hired the sub -contractors 2. I am.asole proprietorr or partner- listed on the attached sheet 1 7. ❑ Remodeling ship and have no employees These suit -contractors have 8. 0 Demolition working for mei any capacity. [No workers' comp, insurance workers' comp. insurance. 5. ❑ We are a corporation and its q, ❑ Building addition required.] officers have exercised their 10. F1 Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions myself. [No -workers' comp. c. 1.52, § 1(4),'and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required_] �"J, -PP 641a uiac cu=Ks Dox 8I must also tit[ out the section below showingtheir workers' compensation policy P� p cy information, t 14omeownen 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 antan employer that is providing:workers' compensation insurance for mY employees. Below is -the policy and job site information. 0 Insurance Company Name:_ 11�64� Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: Ve— Y %�� City/State/Zip:__ Attach acopy of the workers' compensation policy deciaration 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 cerci/ er th � airs and penalties of pe 'usy # information provided above is true and correct. Phone #: ell Z — Y` Official use only. Do not write in tris 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 6.Otber Contact Person -- /-"a —d 4. Electrical Inspector 5. Plumbing Inspector Phone #: C ^7 JN Date . �� 0.... . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING `� This certifies that .4!' <► (j(./k.... �t-Y ....... ....... . has permission to perform ... plumbing in the buildings of .. ! % A ..................... at. .....!/4� 12� V . , North Andover, Mass. FeLic. No.. . ........d . �.. f!............ . PLUMBING INSPECTOR Check # u� 7477 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date l9't%YySTo2i;o2oo�' Building Location e,d� Owners Name /Y�e S/ Permit # Amount Type of Occupancy S/%1 g4! ,,/ New Renovation Er Replacement Plans Submitted Yes No FIXTURES -�:111-1614 177- 31 M ce. CI• , F0• isI J1I• Wl"Urks• WWres :1 W• (Print or t)rpe) Check one: Certificate Installing Company Name�sR 1lY&I' e- /� a. •n TD . Corp. Address Partner. Business Telephoneg j ��9 •�96�� Firm/Co. Name of Licensed Plumber. Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ® Other 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 Owner 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 Massachusos State Plumbing Code d Chapter 42 of the General Laws. n Y By: Ale Signature or Llcensea Plumber Type of Plumbing License Title ��/4. 9, City/Town �'1GuinSer '� Master Er Journeyman APPROVED (OFFICE USE ONLY Date. ....... ` TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION h ,SSACHUSE� This certifies that ..(������.... .......... ........... . has permission for gas installation .../`..� . ........ in the buildings of '// ............................ ? �A �.6,-'/ . North Andover, Mass. at ��?^ ......... .... GAS INSPECTOR Check # 2r1 7 � MASSACHUSETTS UNIFORM APPUCATON FOR PERNIIT TO DO GAS FITTING (Type or print) Date 7 NORTH ANDOVER, MASSACHUSETTS Building Locations S.3 GUAv+e�e. �Pe� Permit # Amount $ Owner's Name MARkEV New Renovation ® Replacement 1:1 Plans Submitted (Print or Name Name of Licensed Plumber or Gas Fitter S Che k one: Certificate Installing Company Corp. ElPartner. 0 Firm/Co. INSURANCE COVERAGE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 13 NoO If you have checked Les, please indicate the type coverage by checking the appropriate box. Liability insurance policy Ey Other type of indemnity D 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 Agent 13 I herehv certify that all of the ei P,n;6 —A :.,4 ... «: I L .... ... I--'— � - - - - - - ».,......,,u kVI V11LOCUI .n aoove 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 as Code and Chapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas fyitter Plumber ! /R 9 Gas Fitter License Number In Master Journeyman U a x F w �, v m m z Q d O Z z a� w w x U W v, z OF v, a > d w z x x a w w l°. A F x z d w d 'd F > °m z o z w o F x a� x o x f' 3 a a u a> o a SU B-BASEMEN T H O BASEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH..FLO0R 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or Name Name of Licensed Plumber or Gas Fitter S Che k one: Certificate Installing Company Corp. ElPartner. 0 Firm/Co. INSURANCE COVERAGE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 13 NoO If you have checked Les, please indicate the type coverage by checking the appropriate box. Liability insurance policy Ey Other type of indemnity D 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 Agent 13 I herehv certify that all of the ei P,n;6 —A :.,4 ... «: I L .... ... I--'— � - - - - - - ».,......,,u kVI V11LOCUI .n aoove 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 as Code and Chapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas fyitter Plumber ! /R 9 Gas Fitter License Number In Master Journeyman